INTRODUCTION

Dorsal perilunate synovitis was the term that we used in the late 1960s and early 1970s for patients presenting with wrist pain who had clinical findings consistent with a syndrome that the senior author (HKW) now calls dorsal wrist syndrome (DWS). The patients with chronic and more severe wrist pain underwent surgical exploration. At the time of surgery, an abnormal ridging on the dorsum of the scaphoid and lunate was noted in all cases. The ridge occurred most prominently at the dorsal distal aspect of the proximal pole of the scaphoid. A lesser ridge was usually present on the dorsal, distal, and radial aspects of the lunate. The ridging bone was pink to purple, representing reactive fibrocartilage material, and was always soft and easily removed with a dental rongeur. One could readily tell when the denser bone was in contact with the rongeur. As rotatory subluxation of the scaphoid became a clinically recognized entity in hand surgery, the senior author began to look more closely at the relationship of the ligamentous supports between the scaphoid and the lunate ( Fig. 45-1 ). Tears of the volar aspect of the scapholunate interosseous ligament (SLIL) were identified in the more symptomatic patients with dorsal wrist syndrome. Evaluation of the SLIL to look for tears became a standard part of the surgical procedure. It became evident that SLIL tears usually begin volarly and extend dorsally as the severity of the injury increases.

Scaphoid instability produces a sequence of events that creates a spectrum of disorders ranging from wrist sprain and dorsal wrist syndrome (DWS) to rotatory subluxation of the scaphoid (RSS) and a scapholunate advanced collapse (SLAC) wrist. The findings of carpal tunnel syndrome (CTS), ganglia, and post-activity ache (PAA) are often indicators of more severe underlying wrist pathology. Note that the development of ganglia seems to require a more intact joint; ganglia are absent with major joint displacement and destruction.

(Illustration created by Steve Criado.)

DIAGNOSIS OF DORSAL WRIST SYNDROME

Physical Examination

Physical examination first reveals a positive finger extension test ( Fig. 45-2 ). This test is performed by passively flexing the wrist, then asking the patient to actively extend all four fingers against resistance. If the test is positive, the patient is unable to maintain extension because of pain in the wrist. The finger extension test is an extremely effective part of the evaluation. In the senior author’s experience, a negative finger extension test all but excludes the possibility of any radial-sided wrist pathology such as rotatory subluxation of the scaphoid, dorsal wrist syndrome, Kienböck’s disease, carpal boss, scaphoid fracture, scapholunate advanced collapse (SLAC) wrist, or any other abnormality in the load column of the index and middle finger metacarpals, capitate, scaphoid, lunate, and radius. A positive finger extension test is usually associated with a positive articular-nonarticular (ANA) test ( Fig. 45-3 ), which is synovitis and tenderness at the articular, nonarticular junction of the scaphoid. Scaphotrapeziotrapezoid (STT) joint synovitis is not usually present in dorsal wrist syndrome. A positive scaphoid shift ( Fig. 45-4 ) may or may not be elicited, depending on the degree of synovitis at the time of the examination and the degree of instability or tearing of the SLIL tear. There is tenderness over the scapholunate joint dorsally. Carpal boss testing is negative when forcibly malaligning the index and middle metacarpals; either depressing one while extending the other or vice versa. There is no evidence of symptoms arising from tenosynovitis of the first or second extensor compartments. The patient may or may not have pain with forced wrist flexion or extension.

Finger extension test . The patient’s wrist is held passively in flexion; the examiner then resists active finger extension. Radial wrist disease causes pain and prevents powerful finger extension.

Articular-nonarticular test (ANA) . The articular-nonarticular junction of the scaphoid is acutely painful when palpated with the examiner’s index finger firmly against the radial aspect of the patient’s wrist just distal to the radial styloid with the wrist in ulnar deviation. Pressure in this area with the wrist in radial deviation is distal to the ANA and not symptomatic.

Dorsal wrist syndrome tenderness at the thumb .

Imaging

Radiographic examination of dorsal wrist syndrome is usually normal but may demonstrate osteophyte formation on the distal dorsal ridges of the scaphoid and lunate in the lateral projection with or without evidence of rotatory subluxation of the scaphoid ( Fig. 45-5 ). Contralateral wrist films may be useful in identifying inconsistencies for comparison.

Dorsal bony ridging . An oblique x-ray of the wrist may demonstrate the ridging that occurs on the dorsum of the scaphoid and lunate.

Magnetic resonance imaging results are typically negative or may indicate minor abnormalities in other parts of the wrist.

CLINICAL STAGES

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  Three-day injury : A minimal sprain, such as falling from a chair on the dorsiflexed wrist, will produce pain from stretching of the synovium with or without minor tearing of synovium and joint edema. In this case, no significant tear of any major support ligaments occurs. The injury usually clears in about 3 days.

  
  
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  Three-week injury : A more severe dorsiflexion injury ruptures blood vessels in the synovium and may cause a partial SLIL tear with or without injury to the volar radioscaphocapitate or long radiolunate ligaments or other volar extrinsic ligaments. The main ligamentous supports of the scapholunate joint remain intact, but hemarthrosis occurs. Clinically, this manifests as a wrist “sprain” that usually requires about 3 weeks to clear, but without any lasting sequelae. The repair activity in the tissues lasts a good deal longer than the symptoms. Because the ligament tears are partial—that is, incomplete—healing of each ligament is expected with or without treatment.

  
  
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  Three-month injury: A significant forced dorsiflexion injury ruptures the SLIL with or without concomitant tears of extrinsic ligaments such as the radioscaphocapitate or long radiolunate ligaments, and tearing of synovium results in a hemarthrosis and soft tissue swelling. This is the injury described by Mayfield and colleagues, which may result in different combinations of ligament tearing as the injury load pattern is dispersed through the wrist. The healing process is associated with a painful and unusable wrist joint for the first month. This is usually followed by significant residual symptoms for the second month and low-grade symptoms during the third month. Depending on the degree of tear and the type of immobilization, the patient’s wrist may heal and become asymptomatic and fully usable. More commonly, there is some residual scapholunate instability of varying degrees, which in turn influences the incidence of recurrent wrist pain under loading. Twenty-five percent of normal adults demonstrate some tearing of the SLIL and clinical laxity of the scaphoid support. The wrists of 1000 people who were not patients were examined bilaterally by the same three hand surgeons. Twenty-one percent demonstrated unequivocal unilateral positive scaphoid shift (Watson test). Thirty-seven percent of these “normal” people had some symptoms. Bilaterally positive scaphoid shift wrists were excluded. From this study, we have felt comfortable saying that nearly 25% of normal adults have sustained some permanent injury to the scaphoid support system.