scapholunate ligament injury
In my opinion, this is probably one of the more challenging issues that we face as wrist surgeons at present. The scaphpolunate ligament sits between the scaphoid and the lunate bone, two of the cornerstones of movement in the wrist. The complexity of movement of the wrist, the anatomy of the jumble of bones in the wrist and the interplay between ligaments and tendons means that the techniques that we use to repair or reconstruct scapholunate ligament injuries do not routinely provide good outcomes.
Injuries of the scapholunate ligament can involve a partial tear or a complete tear of the ligament, imparting a spectrum of clinical problems. Some people rapidly develop arthritis, while others will have minor instability symptoms in their wrist and will only be troubled by the wrist in 20 to 30 years time. So how do we treat scapholunate ligament problems?
If the injury is only minor and there is little displacement between the two bones (scaphoid and lunate), these can most commonly be treated non-operatively. If there is a more significant injury, then it is probably best investigated with a wrist arthroscopy. This involves a small procedure to make four or five stab incisions over the back of the wrist to allow insertion of an arthroscope (small viewing device) into the joint. We can then directly observe the appearance of the ligament and make inference about stability.
If the injury is fresh and only mildly unstable, several wires (smooth stainless steel pins) can be inserted through the bones of the wrist to hold the bones in position while the ligament heals. If there is significant displacement between the bones at the time of arthroscopy then it is probably best that the wrist be opened (cut on the back of the wrist) and the ligament formally repaired (i.e. holding the ligament back onto the bone with sutures). This will give the ligament the best chance of healing back in appropriate position and length. Debate currently surrounds whether it is better to repair the ligament or to augment the ligament with extra tissue taken from elsewhere in the body to give the ligament better chance of healing.