Wrist sprains

1. High-Yield Summary

Wrist sprain is an imprecise clinical descriptor that frequently obscures high-energy ligamentous disruption of the carpus, predisposing to chronic mechanical instability and progressive joint degeneration:

• Spectrum of Carpal Disruption: Traumatic wrist injuries encompass damage to intrinsic stabilizers (primarily the scapholunate interosseous ligament [SLIL] and lunotriquetral interosseous ligament [LTIL]), extrinsic radiocarpal/midcarpal ligaments, and the triangular fibrocartilage complex (TFCC). Dismissing acute wrist pain as a benign sprain without rigorous assessment risks missing progressive carpal dissociation.
• Primary Biomechanical Restraint: The dorsal subregion of the SLIL is the principal stabilizer of the scapholunate articulation, possessing thick transverse collagen bundles capable of resisting tensile loads up to 300 N. The membranous subregion provides negligible mechanical constraint.
• Diagnostic Triad & Stress Imaging: Standard resting radiographs are frequently normal in early or dynamic instability. Definitive evaluation requires bilateral clenched-fist stress views to unmask dynamic scapholunate diastasis (>3 mm, Terry Thomas sign), lateral measurements for Dorsal Intercalated Segment Instability (DISI, scapholunate angle >60°), and diagnostic wrist arthroscopy as the reference gold standard.
• Stage-Specific Management Paradigm: Acute repairable tears (6 weeks) without arthritis require soft-tissue reconstruction, such as Three-Ligament Tenodesis (3LT). Fixed malalignment or arthritic change mandates motion-sparing salvage (Proximal Row Carpectomy vs Four-Corner Arthrodesis).
• Natural History of Neglected Tears: Complete SLIL disruption inevitably advances along a predictable degenerative pathway termed Scapholunate Advanced Collapse (SLAC wrist stages I–III), characteristically preserving the concentric spherical radiolunate articulation.

2. Anatomy

Scapholunate Interosseous Ligament Complex

The scapholunate interosseous ligament (SLIL) is a true C-shaped intra-articular structure transfixing the proximal margins of the scaphoid and lunate. Anatomically and biomechanically, it is partitioned into three distinct subregions:

• Dorsal Subregion: The thickest (2 to 3 mm) and mechanically dominant component. Composed of densely packed, transversely oriented collagen fascicles, it exhibits an ultimate tensile failure load of approximately 300 N. It serves as the primary restraint against scaphoid flexion, lunate extension, and carpal rotatory subluxation.
• Membranous (Proximal) Subregion: Composed of thin fibrocartilage with sparse vascularity and disorganized collagen architecture. It provides negligible biomechanical resistance (failure load <50 N). Age-related central perforations in this zone are common and do not provoke carpal instability.
• Volar Subregion: Approximately 1 mm thick, with an average tensile strength of 150 N. It provides secondary rotational constraint, resisting excessive extension and external rotation moments, and is intimately blended with the radioscaphocapitate ligament.

Lunotriquetral Interosseous Ligament & Carpal Kinematics

The lunotriquetral interosseous ligament (LTIL) mirrors the C-shaped geometry of the SLIL but possesses reversed biomechanical polarities. Its volar subregion is the thickest, stiffest, and strongest portion, providing the primary mechanical barrier against abnormal triquetral motion. The proximal portion is membranous, while the dorsal subregion confers secondary rotational restraint.

In the intact wrist, the lunate functions as an intercalated segment lacking direct muscular insertions. Its spatial orientation is governed by opposing rotational vectors: the scaphoid possesses a natural tendency to flex under axial compressive loads, while the triquetrum has an inherent tendency to extend via its helicoidal articulation with the hamate. The intact SLIL and LTIL equilibrate these antagonistic rotational forces, maintaining the lunate in neutral alignment.

Triangular Fibrocartilage Complex Architecture

The triangular fibrocartilage complex (TFCC) suspends the carpus on the distal ulna and serves as the primary stabilizer of the distal radioulnar joint (DRUJ). It comprises the articular disc (TFC proper), dorsal and volar radioulnar ligaments, the meniscus homologue, the ulnar collateral ligament, and the extensor carpi ulnaris (ECU) subsheath. The radioulnar ligaments split into two functional laminae:

• Superficial Fibers: Insert broadly onto the tip of the ulnar styloid process.
• Deep Fibers (Ligamentum Subcruentum): Insert directly into the fovea at the base of the ulnar styloid process, contiguous with the center of rotation of the DRUJ. Foveal disruptions decouple the radius from the ulna, inducing profound DRUJ instability.
• Vascularity Patterns: Vascular supply enters peripherally via branches of the anterior interosseous, posterior interosseous, and ulnar arteries. Only the peripheral 10% to 20% contains sufficient capillary beds to support primary reparative healing; the central 80% is avascular and relies on synovial fluid nutrition.

Extrinsic Carpal Ligaments & The Space of Poirier

Extrinsic carpal ligaments bridge the radius and ulna to the carpus. On the volar aspect, the radioscaphocapitate (RSC) ligament originates from the radial styloid and acts as an anatomical sling supporting the scaphoid waist. Medial to the RSC lie the long radiolunate (LRL) and short radiolunate (SRL) ligaments. The radioscapholunate ligament (ligament of Testut) is a neurovascular synovial fold rather than a structural mechanical restraint.

Between the volar radiocarpal ligaments and the midcarpal arcuate (capitotriquetral) ligament lies an inherent anatomical area of capsular weakness: the Space of Poirier. Located directly palmar to the capitolunate articulation, this zone is devoid of reinforcing ligamentous fibers. During high-energy wrist hyperextension, catastrophic failure of the Space of Poirier permits midcarpal dislocation and anterior extrusion of the lunate into the carpal tunnel.

Surgical Approaches, Internervous Planes & Neurovascular Hazards

Surgical access to the carpal ligaments demands exact anatomical precision:

• Dorsal Approach: Centered longitudinally over Lister’s tubercle. Dissection enters between the 3rd extensor compartment (extensor pollicis longus [EPL]) and the 4th extensor compartment (extensor digitorum communis [EDC] and extensor indicis proprius [EIP]). Because all dorsal extensor musculature is innervated by the posterior interosseous nerve (PIN), this represents an intertendinous interval rather than a true internervous plane. Capsulotomy should preserve the dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments via a ligament-sparing inverted-V or Berger flap.
• Posterior Interosseous Nerve (PIN) Danger Zone: Courses along the floor of the 4th extensor compartment on the dorsal radius. Resection of a 1.5-cm terminal segment (PIN neurectomy) is routinely performed to denervate the dorsal wrist capsule and reduce postoperative pain.
• Superficial Branch of the Radial Nerve (SBRN): Emerges beneath the brachioradialis tendon approximately 6 to 8 cm proximal to the radial styloid, arborizing into delicate sensory branches across the anatomical snuffbox. Vulnerable to traction injury, portal placement (1-2 and 3-4 arthroscopic portals), and neuroma formation.
• Palmar Cutaneous Branch of the Median Nerve (PCBMN): Originates 5 cm proximal to the wrist crease and runs in a separate fascial tunnel between the flexor carpi radialis (FCR) and palmaris longus tendons. At high risk during volar FCR harvesting for ligament reconstruction.
• Dorsal Cutaneous Branch of the Ulnar Nerve (DCBUN): Branches from the ulnar nerve approximately 5 cm proximal to the pisiform, curving dorsally around the subcutaneous border of the distal ulna. Endangers 6R and 6U arthroscopic portals and ulnar-sided exposures.

3. Pathogenesis

The predominant mechanism of acute carpal ligament disruption is high-energy hyperextension (>90°) coupled with ulnar deviation and intercarpal supination, typically sustained during a fall onto an outstretched hand (FOOSH) or high-velocity athletic collision. Impact energy drives through the thenar eminence, creating a violent rotational torque across the carpal rows.

Under progressive loading, ligamentous failure advances sequentially around the lunate, as classified by the Mayfield perilunar instability stages:

• Stage I (Scapholunate Dissociation): Tensile failure initiates at the volar RSC and propagates through the dorsal SLIL. Decoupling of the scaphoid from the lunate allows the scaphoid to rotate into palmar flexion, while the lunate tilts dorsally under triquetral influence.
• Stage II (Capitolunate Dislocation): Propagation through the Space of Poirier leads to midcarpal joint disruption. The capitate separates from the lunate and subluxates dorsally.
• Stage III (Lunotriquetral Disruption / Perilunate Dislocation): The failure vector tears the lunotriquetral interosseous ligament and dorsal radiocarpal attachments. The entire carpus dislocates dorsal to the lunate, which remains seated within the lunate fossa of the radius.
• Stage IV (Lunate Enucleation / Dislocation): Complete dorsal capsular rupture allows the migrating capitate to push against the dorsal horn of the lunate, squeezing the lunate volarly through the Space of Poirier into the carpal tunnel (spilled teacup sign), while the capitate reduces into the lunate fossa.

4. Natural History

Wrist sprains represent up to 20% of all musculoskeletal injuries treated in emergency and sports medicine clinics. Scapholunate ligament disruption is the most common form of carpal instability, presenting in 10% to 30% of intra-articular distal radius fractures and disproportionately affecting active individuals aged 20 to 45 years.

Untreated complete rupture of the SLIL leads to persistent rotational instability and progressive joint failure through the Scapholunate Advanced Collapse (SLAC) pattern:

• Stage I SLAC: Chondral wear and styloid osteophyte formation limited to the articulation between the radial styloid and the distal palmar scaphoid.
• Stage II SLAC: Extension of full-thickness chondral loss across the entire scaphoid fossa of the distal radius.
• Stage III SLAC: Capitolunate joint degeneration with proximal capitate migration into the widened scapholunate interval.
• Radiolunate Preservation: The spherical geometry and congruent contact mechanics of the radiolunate articulation preserve its joint space throughout all stages of SLAC arthritis, serving as the biological cornerstone for motion-sparing salvage procedures.

Isolated LTIL disruption leads to Volar Intercalated Segment Instability (VISI), midcarpal subluxation, and secondary lunotriquetral advanced collapse. Chronic foveal avulsion of the TFCC culminates in persistent DRUJ instability, distal ulnar subluxation, and debilitating ulnocarpal abutment.

5. Clinical Presentation

History

Patients present following an acute hyperextension or twisting wrist injury. Common historical features include:

• Localized pain over the dorsal radial aspect of the wrist, immediately distal to Lister’s tubercle (anatomical location of the dorsal SLIL).
• Mechanical symptoms including painful snapping, clicking, or a sensation of the wrist “giving way” during loaded tasks.
• Marked weakness of power grip and inability to bear weight through an extended wrist (e.g., executing a push-up).
• Ulnar-sided pain exacerbated by forearm pronosupination, ulnar deviation, and lifting heavy objects, pointing to TFCC or LTIL injury.

Physical Exam

A methodical physical examination utilizing standardized provocative maneuvers is critical for localizing ligamentous pathology:

• Watson Scaphoid Shift Test: The examiner applies direct thumb pressure to the palmar tuberosity of the scaphoid while taking the patient’s wrist from full ulnar deviation and slight extension into radial deviation and slight flexion. Constraining normal scaphoid flexion forces the proximal pole of the scaphoid to subluxate dorsally over the rim of the radius. Upon releasing thumb pressure, the scaphoid snaps back into the fossa with an audible or palpable clunk and sharp dorsal pain. Positive Finding: Subluxation clunk and localized dorsal pain [Sensitivity: 89%, Specificity: 98%].
• Kleinman Shear Test: The patient’s forearm is positioned in neutral. The examiner stabilizes the dorsal aspect of the lunate with one finger while applying an anterior-to-posterior shearing force on the palmar surface of the triquetrum with the thumb. Positive Finding: Reproduction of localized pain, crepitus, or excessive translation [Sensitivity: 86%, Specificity: 92%].
• Reagan Ballottement Test: The examiner stabilizes the lunate between the thumb and index finger of one hand, while the triquetrum and pisiform are translated dorsally and palmarly with the opposite hand. Positive Finding: Pain, crepitus, and gross intercarpal hypermobility indicating LTIL rupture [Sensitivity: 80%, Specificity: 88%].
• TFCC Fovea Sign: The examiner palpates the soft-tissue interval bounded by the ulnar styloid process, the FCU tendon, the palmar surface of the ulnar head, and the pisiform. Deep focal pressure into the fovea elicits exquisite pain. Positive Finding: Sharp localized tenderness corresponding to foveal avulsion of the TFCC [Sensitivity: 95%, Specificity: 87%].
• TFCC Compression / Ulnocarpal Stress Test: With the wrist placed in maximal ulnar deviation, an axial compressive load is applied while rotating the forearm through pronation and supination. Positive Finding: Deep ulnar joint line pain, mechanical clicking, or grating crepitation [Sensitivity: 84%, Specificity: 85%].
• Piano Key Test: With the forearm fully pronated, the examiner presses firmly downward on the dorsal aspect of the distal ulnar head while supporting the radius. Positive Finding: Excessive palmar translation and immediate spring-back upon release, reflecting rupture of the distal radioulnar ligaments [Sensitivity: 70%, Specificity: 90%].

6. Imaging and Diagnostic Studies

The diagnostic protocol begins with high-quality radiographs and progresses to dynamic stress views and cross-sectional imaging:

• Standard Radiographic Series: Posteroanterior (PA), true lateral (shoulder abducted 90°, elbow flexed 90°, wrist in neutral rotation), and 45° semi-pronated oblique views. Integrity of Gilula’s carpal arcs (Arcs I, II, and III on the PA projection) must be verified; step-offs signify disruption of carpal congruency.
• Clenched-Fist / Pencil-Grip Stress Views: Bilateral PA views taken under maximal clenched-fist isometric contraction drive the capitate proximally into the carpal rows, wedging open the scapholunate interval in dynamic instability that appears normal on resting films.
• Scapholunate Interval (Terry Thomas Sign): A clear space exceeding 3 mm between the scaphoid and lunate is abnormal; an interval greater than 4 to 5 mm establishes static dissociation with rupture of both primary and secondary restraints.
• Cortical Ring Sign: On PA radiographs, a flexed scaphoid appears foreshortened, projecting a circular cortical density (“signet ring”) over its distal pole, accompanied by a scaphoid length <22 mm.
• Scapholunate Angle (Lateral View): Measured between the longitudinal scaphoid axis and the mid-axis of the lunate. Normal: 30° to 60° (mean 47°). An angle >60° (frequently >70°) defines Dorsal Intercalated Segment Instability (DISI). An angle <30° with lunate palmar flexion defines Volar Intercalated Segment Instability (VISI).
• Radiolunate Angle: Normal is 0° ± 15°. Lunate dorsal tilt >15° confirms DISI; palmar tilt >15° indicates VISI.
• Dynamic Fluoroscopy: Evaluates real-time carpal kinematics during continuous active radial-to-ulnar deviation, detecting subtle carpal clunking, asynchronous scaphoid rotation, and midcarpal instability.
• Computed Tomography (CT): Multidetector 3D CT delineates occult bony avulsions (dorsal lunate or scaphoid rim fractures), quantifies rotatory subluxation, and details early articular chondromalacia in SLAC staging.
• Magnetic Resonance Imaging (MRI) & MR Arthrography (MRA): High-resolution 3T MRI demonstrates ligament continuity and capsular tears. Triple-compartment MRA (radiocarpal, midcarpal, DRUJ) achieves 90% to 95% sensitivity for full-thickness tears by displaying contrast extravasation across the scapholunate or lunotriquetral intervals.
• Wrist Arthroscopy (Gold Standard): The definitive diagnostic benchmark. Direct visualization and mechanical palpation via 3-4, 4-5, 6R, and midcarpal portals allow dynamic evaluation of ligament tension, probe pass-through, and articular cartilage mapping.

7. Classification

Three validated classification systems guide clinical and surgical decision-making in carpal ligament pathology:

8. Treatment

Medical / Nonoperative

First-line conservative management is indicated for low-grade partial ligament sprains (Geissler grade I/II, Garcia-Elias stage 1) without dynamic or static diastasis on stress radiography:

• Immobilization Parameters: Short-arm thumb-spica cast or rigid radial gutter orthosis for 4 to 6 weeks to minimize intercarpal shear across the healing ligament fibers.
• Pharmacotherapy: Short courses of oral nonsteroidal anti-inflammatory drugs (NSAIDs) and cryotherapy for acute pain and synovial effusion.
• Proprioceptive Hand Therapy: Neuromuscular re-education prioritizing the dart-thrower’s motion plane (radial extension to ulnar flexion), which maintains functional range of motion while minimizing scapholunate translation. Targeted strengthening of the flexor carpi radialis (FCR) and pronator teres creates a dynamic vector that supinates and stabilizes the distal scaphoid pole.
• Failure Thresholds: Persistent pain, progressive mechanical clicking, or emergent diastasis on follow-up stress radiography past 6 to 12 weeks represents failure of nonoperative care and warrants operative exploration.

Operative

Surgical intervention is dictated by chronicity, ligament repairability, carpal reducibility, and articular cartilage integrity:

• Acute Repair (<6 Weeks): Dorsal approach through the 3rd/4th extensor compartment interval. The torn dorsal SLIL is re-anchored to the decorticated bone footprint using mini suture anchors or transosseous sutures. Repair is augmented with a dorsal intercarpal (DIC) ligament capsulodesis or Blatt capsulodesis to resist scaphoid flexion. Dual 1.6-mm K-wires (scaphocapitate and scapholunate) are placed under fluoroscopic guidance and left for 8 to 10 weeks to protect soft-tissue healing.
• Chronic Reducible Reconstruction (>6 Weeks, Pristine Cartilage): Three-Ligament Tenodesis (3LT / Garcia-Elias Technique). A distally based strip of the FCR tendon is harvested, passed through an oblique drill hole in the scaphoid from the palmar tuberosity to the dorsal footprint, tensioned across the dorsal lunate surface into an anchor, and sutured into the dorsal radiotriquetral or DIC ligament. This construct simultaneously neutralizes scaphoid flexion, closes the scapholunate gap, and stabilizes the dorsal carpal row.
• Salvage: Proximal Row Carpectomy (PRC): Complete excision of the scaphoid, lunate, and triquetrum. The head of the capitate articulates directly within the congruent lunate fossa of the distal radius. This motion-preserving procedure eliminates carpal instability without relying on bony fusion. Strict Prerequisite: Cartilage of the capitate head and lunate facet must be entirely preserved (Outerbridge grade 0 or I).
• Salvage: Four-Corner Arthrodesis (4CA) with Scaphoid Excision: Complete excision of the arthritic scaphoid followed by articular decortication, bone grafting, and rigid internal fixation (circular carpal plate or headless compression screws) of the capitate, lunate, hamate, and triquetrum. Indicated for SLAC stage II or III arthritis where capitate cartilage wear precludes PRC. Preserves the unaffected radiolunate articulation.
• Total Wrist Arthrodesis: Rigid fusion from the distal radius to the 3rd metacarpal base. Reserved for end-stage pancarpal arthritis (SLAC stage IV), failed motion-sparing salvage, or high-demand manual laborers requiring permanent, pain-free stability.

Indications & Contraindications

Precise diagnostic metrics define operative thresholds:

• Acute Repair Indications: Dynamic or static SL interval >3 mm, Geissler grade III/IV arthroscopic instability, within 6 weeks of trauma.
• Three-Ligament Tenodesis Indications: Chronic SLIL disruption (>6 weeks) with fully reducible carpal alignment (normal passive reduction of scaphoid on lateral fluoroscopy) and absence of articular cartilage wear (Garcia-Elias stages 3 and 4).
• Tenodesis Contraindications: Fixed, irreducible carpal malalignment or radiographic/arthroscopic signs of osteoarthritis (SLAC wrist).
• PRC Contraindications: Chondromalacia or eburnated bone on the proximal capitate head or lunate fossa (SLAC stage III).
• Four-Corner Arthrodesis Contraindications: Radiolunate joint arthrosis (rare in pure SLAC; more common in advanced inflammatory or calcium pyrophosphate arthropathy).

9. Outcome

Clinical outcomes in carpal ligament reconstruction reflect a balance between pain relief, mechanical stability, and permanent loss of wrist motion:

• Acute Primary Repair: Restores average grip strength to 80% to 88% of the contralateral uninjured extremity. Mean flexion-extension arc reaches 100° to 110° (approximately 75% to 80% of normal). Validated Patient-Rated Wrist Evaluation (PRWHE) and DASH scores demonstrate significant lasting improvement, with low rates of early degenerative revision when performed within 6 weeks.
• Three-Ligament Tenodesis (3LT): Large prospective multicenter cohorts demonstrate durable pain relief and stabilization of the scapholunate angle. PRWHE scores improve by an average of 23.4 points, with grip strength recovering to 78% of the uninjured side. Average postoperative flexion-extension arc ranges from 85° to 95° (loss of 15° to 20° of flexion is typical due to dorsal capsular tethering).
• Proximal Row Carpectomy vs Four-Corner Arthrodesis: Both motion-sparing salvage techniques achieve high long-term survivorship (>85% at 10 to 15 years). PRC delivers a slightly superior total flexion-extension arc (mean 75° vs 65°) and eliminates nonunion risk. Four-corner arthrodesis yields higher ultimate grip strength preservation (75% to 80% vs 65% to 70% for PRC) and reliably arrests progressive radiocarpal collapse in young, high-demand laborers.

10. Complications

Surgical complications are structured chronologically across intraoperative, early postoperative, and late phases:

11. Pearls and Pitfalls

Key technical pearls and judgment traps optimize diagnostic and surgical execution:

• The Passive Reducibility Test: Prior to harvesting the FCR tendon for Three-Ligament Tenodesis, introduce a 1.6-mm joystick K-wire into the scaphoid under fluoroscopy. If manual joy-stick manipulation fails to fully reduce the scaphoid out of flexion and correct the DISI deformity, soft-tissue reconstruction will fail. A fixed deformity requires release of contracted volar structures or primary conversion to partial arthrodesis.
• The Dart-Thrower’s Kinetic Arc: Initiate postoperative rehabilitation along the dart-thrower’s plane (radial extension to ulnar flexion). In this oblique kinematic plane, midcarpal motion predominates while the scapholunate interosseous interval undergoes minimal translation, allowing early neuromuscular conditioning without stressing healing ligament repairs.
• Direct Magnification Inspection of the Capitate: In suspected SLAC wrists, never finalize the decision between PRC and 4CA based solely on plain radiographs. Inspect the proximal articular cartilage of the capitate directly under surgical loupes or arthroscopy. Any grade III/IV chondromalacia or subchondral eburnation on the capitate mandates Four-Corner Arthrodesis over PRC.
• The “Normal Radiograph” Junior Trap: Overlooking acute complete scapholunate rupture because resting radiographs appear normal. Always palpate directly over the dorsal SLIL (just distal to Lister’s tubercle) and obtain bilateral clenched-fist views.
• Missed Perilunate Dislocation: Confusing a Stage IV lunate dislocation on lateral wrist films for a simple sprain. Verify that the radius, lunate, and capitate sit in colinear alignment on every lateral radiograph; the lunate must not resemble a tipped or spilled teacup.

12. Controversy

Several major controversies persist in the literature regarding wrist ligament management:

• Arthroscopic vs Open Acute Repair: Arthroscopic-assisted reduction and percutaneous pinning (with or without transosseous capsuloligamentous plication) has gained significant adoption. Advocates cite reduced capsular scarring, preservation of dorsal vascularity, and diminished postoperative stiffness. Conversely, proponents of open repair argue that direct anatomical visualization and rigid suture anchor placement into decorticated bone footprints provide superior, more durable biomechanical constructs.
• The Critical Time Window for Direct Repair: While textbook consensus delineates 6 weeks as the boundary between acute repair and chronic reconstruction, histological investigations confirm that intrinsic ligament stump healing capacity diminishes substantially after 4 weeks. Conversely, several contemporary series document successful open direct repair up to 8 to 12 weeks post-injury provided robust ligament remnants are present.
• PRC vs Four-Corner Arthrodesis in Stage II SLAC: Long-term comparative trials show equivalent subjective pain relief and satisfaction between PRC and 4CA in SLAC stage II. PRC avoids the risks of nonunion and hardware complications and offers faster return to activities. However, critics highlight concerns regarding progressive radiocapitate degeneration over 15 to 20 years, favoring 4CA for young, active patients despite its higher initial complication profile.

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

14. References

• Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980. doi:10.1016/s0363-5023(80)80007-4 [Level V (Biomechanical Investigation): Experimental Cadaveric Biomechanical Investigation]
• Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am. 2006. doi:10.1016/j.jhsa.2005.10.011 [Level IV (Therapeutic / Technique Description): Clinical Cohort & Operative Technique Guide]
• Wessel LE, Wolfe SW. Scapholunate Instability: Diagnosis and Management – Anatomy, Kinematics, and Clinical Assessment – Part I. J Hand Surg Am. 2023. doi:10.1016/j.jhsa.2023.05.013 [Level V (Expert Systematic Review): Comprehensive Anatomical, Kinematic & Diagnostic Review]
• Wessel LE, Wolfe SW. Scapholunate Instability: Diagnosis and Management – Classification and Treatment Considerations – Part 2. J Hand Surg Am. 2023. doi:10.1016/j.jhsa.2023.06.016 [Level V (Expert Systematic Review): Comprehensive Classification & Evidence-Based Management Algorithm]
• Blackburn J, van der Oest MJW, Poelstra R et al. Three-ligament tenodesis for chronic scapholunate injuries: short-term outcomes in 203 patients. J Hand Surg Eur Vol. 2020. doi:10.1177/1753193419885063 [Level IV (Therapeutic Prospective Cohort): Multicenter Prospective Cohort Study]

15. Master Class Pro-Tip

When evaluating a patient with persistent dorsal radial wrist pain following a fall, never accept the provisional diagnosis of a “simple wrist sprain” without rigorously excluding an occult scapholunate dissociation. In the acute setting, standard static radiographs are frequently completely normal because intact secondary ligamentous restraints (specifically the radioscaphocapitate and dorsal intercarpal ligaments) mask the underlying interosseous disruption. You must order bilateral clenched-fist stress radiographs and compare the scapholunate interval directly to the uninjured contralateral wrist. If the patient exhibits focal tenderness over the dorsal scapholunate interval directly distal to Lister’s tubercle and a positive Watson shift test, treat the injury as a dynamic scapholunate disruption until proven otherwise with advanced imaging or diagnostic arthroscopy. If operating on a chronic injury, always insert temporary 1.6-mm joystick K-wires into the scaphoid and lunate to test passive reducibility under fluoroscopy before dissecting an FCR tendon graft; attempting a soft-tissue reconstruction on a fixed, non-reducible carpus is doomed to rapid failure and recurrent DISI deformity.

Master Class Surgical Pearl: Scapholunate Ligament Disruption and Carpal Instability