Surgical Techniques for the Treatment of Acute Carpal Ligament Injuries in the Athlete

The treatment of athletes with carpal ligament injuries provides many challenges. Our initial goals remain to make a timely and accurate diagnosis, provide treatment options, and create an environment for shared decision making. To optimize outcomes and facilitate return to play, early surgical intervention may be warranted. This article reviews common carpal ligament injury patterns in the athlete with a focus on both classic and newer surgical techniques.

Key points

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The treatment of carpal ligament injuries in athletes is highly individualized, sport specific, and requires an open discussion between the athlete, family, coaches, trainers, and the physician.
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Early recognition and treatment of carpal ligament injuries is essential to ensure optimal outcomes.
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A short trial of immobilization for occult injuries often improves symptoms, followed by early surgical treatment if symptoms persist.
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Acute dynamic and static injuries should be treated early for the most predictable outcome, even if this requires forfeiting the current season.

Introduction

The normal wrist involves a complex, balanced synchrony between the carpal bones and rows. These bones are stabilized by intrinsic and extrinsic carpal ligaments. Disruption of these ligaments can result in pain, instability, and loss of function. Untreated, or inadequately treated, these injuries can lead to progressive degenerative change that may be career threatening. With athletes, our initial goals remain to make a timely and accurate diagnosis, provide options, and create an environment for shared decision making. Restoring their unique skill set can be challenging. An appreciation of the nuances of patient wishes, risk tolerance, and demands of the sport allows an individualized treatment strategy to be provided.

Athletes of any discipline involving violent contact with the ground or other players are prone to carpal ligament injury. ^, This injury is often related to a fall or impact resulting in forced hyperextension of the wrist. Patients often present with dorsal wrist pain and swelling and may complain of decreased motion, grip strength, and the feeling of sudden shifts or clunks. The most commonly injured carpal ligaments are the scapholunate interosseous ligament (SLIL) and the lunotriquetral interosseous ligament (LTIL) ( Fig. 1 ), with SLIL injury occurring at a rate of about 6 times that of LTIL injuries. Injuries to the carpal ligaments occurs on a spectrum and can range from partial tear with occult instability to complete tear with injury to associated secondary ligamentous stabilizers. Without treatment, these injuries often progress to arthrosis. These injuries may be ignored by athletes for weeks or years, which creates a treatment dilemma, as outcomes of operative treatment for chronic injuries are less predictable. In this article, we focus on surgical treatment of carpal ligament injuries in athletes who are identified in the acute phase.

Physical examination

For any athlete presenting with acute wrist pain, a comprehensive physical examination is performed. Specific clinical findings that may suggest an SLIL injury include tenderness over the carpus, particularly dorsal and radial, prominence of the scaphoid proximal pole, and in some cases, an enlarged gap between the scaphoid and lunate. Dorsal wrist pain that seems out of proportion or is not responsive to a brief course of immobilization should raise suspicion for a carpal ligament injury. Specific provocative maneuvers may be limited initially owing to pain and swelling, but may be more appreciable upon repeat examination. The scapholunate ligament injury is tested with Watson’s test. With the wrist in ulnar deviation, the scaphoid is stabilized in extension with the examiners thumb on its tubercle and index finger on the dorsal proximal pole. As the wrist is radially deviated, the scaphoid’s natural tendency is to flex. This action is limited by the surgeon’s thumb on the tubercle. If the SLIL is incompetent, the patient may experience pain or a painful dorsal clunk as the scaphoid is displaced dorsally. Additionally, pain with resisted index and long finger extension with the wrist partially flexed is a sensitive finding for injury or insufficiency of the dorsal SL ligament. The SLIL may also be tested with the scaphoid lift test. With the elbow on the table and the forearm fully pronated, the lunate is stabilized in one hand and the scaphoid tubercle is pushed upward in an attempt to extend the scaphoid in relation to the lunate, with pain indicating the test is positive. LT ligament injury and instability can be evaluated with the shuck, ballottement, and shear tests, with the shear test being most specific. The shuck test is performed by stabilizing the lunate to the radius and attempting to translate the triquetrum in a volar and dorsal direction in relation to the lunate. A test is positive when pain or increased laxity is noted. With the ballottement test, the examiner uses his or her thumb to push the medial body of the triquetrum radially against the lunate in a rocking or balloting manner. For the shear test, the examiner steadies and supports the dorsal body of the lunate while a firm load is applied on the LT joint through compressing the pisiform against the triquetrum. A positive finding for the ballottement and shear tests is the presence of pain.

Imaging

Standard posteroanterior, lateral, and oblique radiographs are obtained routinely with contralateral views for comparison. These radiographs are scrutinized for incongruity of arcs, intercarpal distance abnormalities, and the intercarpal angles are measured using standard techniques. When static instability is absent but SLIL injury is suspected, a clenched pencil grip view provides the best method to evaluate for dynamic instability ( Fig. 2 ). Additional stress views of the carpus such as an axial loading view, ulnar deviation view, and distraction view may help to identify malalignment. Static findings such as SL diastasis, a positive ring sign, and dorsal scaphoid translation should raise suspicion for more significant ligamentous injury ( Fig. 3 ). Fluoroscopy, computed tomography scans, and MRIs can all provide useful information to supplement the clinical examination. We rely primarily on MRI to evaluate for intercarpal ligament injuries, with a 3 T magnet preferred because this has been shown to be superior to 1.5 T magnets ( Fig. 4 ). ^, The sensitivity and specificity of 3-T MR for SLIL tears has been reported between 70% to 90% and 94% to 100%, respectively. For LTIL tears, the sensitivity is lower from 50% to 82%, and specificity is comparable from 94% to 100%. ^,

General management

In the absence of radiographic abnormalities, many intercarpal ligament injuries improve with a brief period of immobilization, ^, whereas athletes with radiographic evidence of acute carpal ligament injury with static or dynamic change are indicated for early surgery. Significant ligament injuries may still be present even in the absence of static or dynamic instability on the initial plain radiograph. A high clinical suspicion is necessary to ensure timely diagnosis because the window of opportunity for repair is limited and early intervention is preferable to ensure optimal outcomes. We tend to offer surgical intervention in athletes because outcomes are more favorable when these injuries are addressed acutely and because of the concern about progression to scapholunate advanced collapse arthritis. It should be noted, however, that the true natural history of intercarpal ligament injuries is unknown; many acute injuries go undetected and are often written off as a sprain. Additionally, it has been observed in a small cohort of patients that partial ligament injuries may not in fact progress to static gap, dorsal intercalated segment instability deformity, or arthritis, although all of these patients reported some level of pain, decreased grip strength, and decreased range of motion after nonoperative treatment. Athletes with clinically suspected carpal ligament injuries but normal radiographs are immobilized and reevaluated at 1 and 3 weeks after injury. This schedule provides the opportunity to repeat provocative testing maneuvers once pain and swelling subside, as well as to confirm improvement in symptoms. Often elite athletes present with or request high-resolution MRIs, which can be helpful in evaluating the anatomic structures of the carpus and facilitate early injury identification, assuming adequate imaging protocol, radiologist experience, and sufficiently strong magnet. ^, However, this cannot supplant clinical evaluation because there is a high rate of asymptomatic tears found on MRI. ^, If the MRI is equivocal and a patient remains symptomatic after 4 weeks of immobilization, and suspicion for carpal ligament injury remains high, wrist arthroscopy for diagnostic and therapeutic purposes is indicated. Diagnostic arthroscopy provides the best means of assessing the intrinsic and extrinsic ligaments of the wrist. The Geissler classification is used to classify the degree of injury noted to the SL and LT interosseous ligaments ( Table 1 ) and the European Wrist Arthroscopy Society classification has also been described for the SL ligament. Garcia-Elias and colleagues proposed 5 questions to help guide treatment: (1) Is the dorsal SL Ligament intact and functional? (2) Does the ligament have sufficient tissue and healing potential? (3) Is the scaphoid aligned normally? (4) Is any carpal malalignment easily reducible? and (5) Is the articular cartilage normal? These questions help stratify stages of scapholunate injury and have been used to create stage-oriented algorithms for treatment. ^, In general, attempts at restoring bony relationships with a soft tissue repair or reconstruction is attempted when a wrist is without fixed bony deformity, as is often the case with acute carpal ligament injury. However, in the presence of fixed bony deformity, which occurs with chronic or neglected injury, this strategy is likely to fail and as such salvage surgical procedures are favored, such as a partial wrist fusion.

Table 1

Geissler arthroscopic classification of interosseous ligament injury

From Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. JBJS . 1996;78(3):357-365; with permission.

Grade	Description
I	Attenuation/hemorrhage of the interosseous ligament viewed from the radiocarpal space without midcarpal malalignment.
II	Attenuation/hemorrhage of the interosseous ligament viewed from the radiocarpal space with incongruency/step-off of carpal alignment. May have a gap less than the width of a probe.
III	Incongruency/step-off of carpal alignment viewed from the radiocarpal and midcarpal space and a probe can be passed through a gap between the carpal bones.
IV	Incongruency/step-off of carpal alignment viewed from the radiocarpal and midcarpal space with gross instability and a 2.7 mm arthroscope may be passed through the gap between the carpal bones.

For athletes with acute carpal ligament injuries, we generally treat partial SL ligament tears (Geissler grades I–III) with arthroscopic debridement and capsular shrinkage and temporary pinning of the SL joint depending on the amount of instability (Geissler grade III). We immobilize the patient for 6 weeks after surgery and then initiate hand therapy with return to play allowed when athletes can tolerate the activities of their sport and when grip strength is at least 50% of the contralateral side, often at 12 weeks. In those with complete tears (Geissler grade IV), an open dorsal approach is made and the ligament is repaired primarily or acutely reconstructed if insufficient tissue is present. When rotatory instability of the scaphoid is also observed, a dorsal capsulodesis is also performed to address the sagittal plane instability. After ligament repair with or without capsulodesis, the wrist is immobilized in a short arm cast for 6 to 8 weeks. Pins are then removed and the athlete is transitioned to a removable splint for 4 additional weeks and dart thrower’s range of motion exercises are begun. Return to play is typically allowed at 4 to 6 months postoperatively after these parameters are met. For those who present in the chronic phase, reconstruction is considered in the off season with an understanding that results are less predictable and salvage procedures may be necessary at the end of an athlete’s career. Operative treatment of LT ligament tears is less well-studied, but largely mirrors SL treatment algorithms and is detailed elsewhere in this article.

Surgical techniques

Diagnostic Arthroscopy

Wrist arthroscopy remains the gold standard for the diagnosis of carpal ligament injury. Both the radiocarpal and midcarpal joints are evaluated using standard techniques. The 3-4, 6R, and midcarpal portals are marked. The radiocarpal joint is insufflated with saline through the 3-4 interval. Distension of the midcarpal joint may be palpated during injection of the radiocarpal joint in the presence of interosseous ligament injuries. The skin is sharply incised and a small curved hemostat is used to bluntly spread down to and then enter capsule. The blunt trocar with arthroscopic cannula followed by the arthroscope is inserted through the 3-4 portal. The 6R portal is then made under direct vision. The radiocarpal joint is evaluated in a systematic fashion noting the presence of synovitis and the quality of the articular surface and intrinsic and extrinsic ligaments. A shaver and/or thermal probe is used to address synovitis and remove debris to improve visualization. The SLIL, LTIL, and triangular fibrocartilage complex are probed for structural integrity. The 3-4 portal provides the best view of the SLIL, where it should have a concave appearance ( Fig. 5 ). The arthroscope is then transitioned to the 6R portal, where the LT ligament is better visualized. The normal ligament should also be concave in appearance between the lunate and triquetral articular surfaces ( Fig. 6 ). From the 6R portal, the camera is then directed dorsally to evaluate for dorsal capsular injury. Typically, communicating fibers of the dorsal intercarpal ligament insert onto the SLIL and a dorsal bow of the capsule will be observed. When injured, this arch or septum will be absent and when probed no resistance will be felt as the probe moves dorsally toward the midcarpal joint ( Fig. 7 ).

The midcarpal–radial and midcarpal–ulnar portals are then created, located approximately 1 cm distal to the 3-4 and 4-5 portals. When there is an SLIL injury, we typically create the ulnar midcarpal portal first given the displacement of the scaphoid, which can make the radial midcarpal portal more challenging to create. A volar radial portal may be added to better visualize the volar SL and the dorsoradiocarpal (DRC) ligaments. The midcarpal radial portal is used to evaluate the scapholunate interval, followed by the midcarpal ulnar portal for the LT interval, and presence of instability is noted and graded as described by Geissler. The arthroscope is usually started in the midcarpal radial portal, except in smaller wrists where the midcarpal ulnar portal may be easier to enter or if the patient is suspected to have a large SLIL tear with scaphoid displacement. Individuals with a normal interval will have tight apposition of the scaphoid and lunate, without step off or the ability to get a probe between the bones ( Fig. 8 ). As level of injury worsens, coronal plane instability is first observed with gapping between the carpal bones, followed by sagittal plane instability in the presence of associated extrinsic ligament injury, with articular step-off observed in the midcarpal joint as the lunate flexes or extends in relation to the scaphoid and triquetrum.

Scapholunate Interosseous Ligament Injuries

Occult instability

Partial SL ligament tears may result in occult instability and often improve with a brief course of immobilization followed by dedicated therapy. Strengthening the flexor carpi radialis, abductor pollicis longus, and extensor carpi radialis longus after cast removal may improve scaphoid stability and gradual return to play is allowed if the activities required for their sport are tolerable and grip strength is at least 50% of the contralateral side. Specific rehabilitation protocols for partial SL ligament tears, which include dart-throwers motion and/or proprioception training have been described with promising early outcomes. In those patients who remain symptomatic, or in skill position athletes such as quarterbacks and basketball and baseball players who require wrist motion to perform, we favor early surgical treatment with arthroscopy, debridement, and thermal shrinkage. After arthroscopic confirmation of stable partial SL tear (Geissler grades I–III), a shaver is used to debride the unstable tissue flaps, preserving the healthy intact fibers. A monopolar or bipolar radiofrequency probe is then inserted into the midcarpal joint and used to perform thermal shrinkage of the distal volar SL ligament and the dorsal SLIL as needed. This maneuver is performed using the cauterization setting and the ligament and volar capsule is spot welded at the palmar junction of the scaphoid and lunate until a color change is noted from pearl white to golden yellow/light brown without ablating the tissue ( Fig. 9 ). The probe is applied in bursts of a few seconds while maintaining adequate fluid outflow and irrigation to decrease the risk of heat buildup and thermal injury. If present, redundancy of the membranous and dorsal portion of the ligament is also addressed with thermal shrinkage through the radiocarpal portal. After thermal shrinkage, the scapholunate joint is again probed to confirm stability. In Geissler grades I and II ligament injuries we immobilize the wrist for 6 weeks but do not transfix the joint, whereas in Geissler grade III injuries, two 0.045-inch K-wires are used to transfix the scapholunate joint and protect the ligament for 6 weeks, after which the short arm thumb spica cast and K-wires are removed. Therapy with motion in the dart throwers plane is started immediately after discontinuation of immobilization and activity is advanced to full active range of motion as tolerated thereafter. Full return to activity is allowed at 12 weeks.

Occult instability of the scapholunate has also been described to occur with dorsal intercarpal ligament injuries, without associated SL ligament tear. ^, Loss of the normal arch of the dorsal capsuloscapholunate septum is observed through the radiocarpal joint and minimal to no resistance is encountered as a probe is passed from the radiocarpal to the midcarpal joint. Often abundant synovitis is encountered. Repair of the dorsal capsuloscapholunate septum to the SLIL has been described by using a needle to pass a 3-0 PDS suture through the capsule at the 3-4 portal, advancing it through the capsule and dorsal SL into the midcarpal joint and tying this down over dorsal capsule with the wrist in extension. ^, When we have encountered this pathology in practice, we have used either debridement alone followed by immobilization or a single suture anchor placed on the dorsal aspect of the lunate to perform a capsuloplasty, depending on whether the patient’s complaints were pain or instability. Postoperatively the patient is placed in a short arm cast for 4 weeks, followed by therapy and return to full activity at 12 weeks.

Isolated injury of the DRCL without associated SLIL tear has also been observed to result in occult and dynamic instability. The ligament is visualized through the volar radial portal. This is created through a 2-cm longitudinal incision at the proximal wrist crease over the flexor carpi radialis tendon. The sheath is incised and the tendon is retracted ulnar after which a 22-gauge needle, followed by blunt trocar and cannula are introduced through the floor of the flexor carpi radialis sheath into the radiocarpal joint. The ligament is captured using an outside in technique with a horizontal mattress stitch passed through the ligament using the 3-4 and 4-5 portals. The tails are then passed under the extensor tendons and tied over the capsule at either the 3-4 or 4-5 portal.

Outcomes

Outcomes data after arthroscopic treatment of occult SL instability are limited to case series and expert opinion, typically involving chronic injuries with normal carpal alignment after failure of nonoperative measures. Ruch and Poehling performed debridement alone of membranous SL tears in patients with at least 6 months of mechanical symptoms with satisfactory improvement and no progression to instability in all 7 of their patients with at least 2 years of follow-up. Weiss and colleagues reported on debridement of partial tears in patients with symptoms refractory to a minimum of 6 weeks of nonoperative treatment, with satisfactory improvement in 11 of 13 patients at a mean follow-up of 27 months. Debridement is thought to address any mechanical symptoms and associated synovitis related to unstable tissue flaps.

Early results for arthroscopic debridement and thermal shrinkage for partial tears with normal carpal alignment have also been favorable. Darlis and colleagues reported improvement in pain in 14 of 16 patients with a minimum of 3 months of symptoms, with complete resolution of symptoms in 8 of 16, without evidence of instability at a mean of 19 months. Lee and colleagues reported on 16 wrists with isolated partial SL or LT tear and a minimum of 3 months of symptoms, with significant improvement in pain at rest and with activity, as well as excellent functional scores in 13 of 16, and good in 3 of 16 at a mean of 53 months of follow-up. No radiographic instability or arthritic change was noted in their follow-up period. Battistella and Taverna similarly reported improvement in patients with Geissler grade I injury treated with debridement and thermal shrinkage alone, and in those with grades II and III change treated with arthroscopic reduction, k-wire fixation, and thermal shrinkage. Thermal shrinkage is thought to improve symptoms of instability by tightening the ligaments through heating and denaturing of collagen, which is followed by tissue repair with vascular invasion and fibroblastic activity. ^, Additionally, pain symptoms may be alleviated through ligament denervation.

Patients may benefit from arthroscopic reduction and K-wire fixation, without thermal shrinkage. In a series of 40 patients with less than 3 months of symptoms and 3 mm or less of side-to-side difference in the scapholunate interval, 83% had maintenance of reduction and symptom relief. Stability was observed to be maintained for 2 to 7 years of follow-up. Arthroscopic dorsal capsuloplasty for isolated dorsal capsuloscapholunate septum tear as performed by Binder and colleagues had significant improvement in wrist range of motion, grip strength, functional scores, and pain scores in 10 patients with a history of at least 7 months of chronic dorsal wrist pair that was refractory to nonoperative measures, with a mean follow-up of 16 months.

Complications

Heat-related complications including collagen necrosis and chondrolysis are concerns with thermal shrinkage. Although these complications have not been reported with wrist arthroscopy, issues with thermal capsulorrhaphy of the glenohumeral joint including recurrent instability, deficient anterior capsule, and chondrolysis have decreased its frequency of use. ^, Strict attention to maintaining adequate outflow and using the probe in a pulsed manner for no longer than a few seconds at a time help to ensure adequate heat dissipation and may decrease the risk of heat-related complications. ^,

Complete scapholunate interosseous ligament tear amenable to repair

Complete disruption of the SLIL alone results in dynamic instability and is only apparent on stress examination. With additional injury of the scaphotrapezial and dorsal intercarpal ligaments, static SL interval diastasis can occur. When this includes scaphotrapezial trapezoid injury, the scaphoid will flex and rotatory subluxation will occur. When this is observed, it is important that surgical repair or reconstruction stabilizes the carpus in both coronal and sagittal planes to ensure optimal outcome. Arthroscopy will demonstrate instability of the scapholunate interval with step off in the radiocarpal and midcarpal joints (Geissler grades III and IV). In the acute (<1 week) and subacute phases (<6–8 weeks), repair is preferable if tissue quality is of adequate quality. Arthroscopic reduction and fixation may be adequate in Geissler III injuries, and techniques to reduce and repair a complete SLIL tear (Geissler grade IV) with dorsal capsulodesis have been described. Our preference for athletes is to perform an open reduction and dorsal ligament repair and K-wire fixation, with or without capsulodesis when the injury is sustained within 8 weeks of presentation.

A dorsal approach to the carpus with a radially based ligament-sparing capsulotomy is performed. The capsulotomy runs from the radial styloid along the dorsal rim of the radius to the center of the lunate fossa, extending in line with the dorsal radiotriquetral ligament to its insertion, and then from the triquetrum to the scaphotrapezial trapezoid joint in line with the fibers of the dorsal intercarpal ligament ( Fig. 10 ). Two 0.062-inch K-wires are inserted into the lunate and scaphoid as joysticks to assist with reduction at the planned insertion site of a suture anchor. The carpus is stabilized with two 0.045-inch K-wires through the scapholunate and scaphocapitate joints and then a dorsal ligament repair is performed using suture anchors ( Fig. 11 ). Most commonly, the ligament has avulsed off of the scaphoid, followed by a tear in the midsubstance, and then the lunate. The suture from the anchor is left intact and half of the dorsal intercarpal ligament, which was maintained on the distal scaphoid, is brought over and attached to the dorsal scaphoid and lunate reinforcing the SL repair and completing the capsulodesis ( Fig. 12 ). The capsulotomy is then closed to the dorsal radiotriquetral ligament, the pins are cut beneath the skin and the wrist is immobilized in a short arm cast for 6 to 8 weeks. Pins are then removed and the athlete is transitioned to a removable splint for 4 additional weeks and dart thrower’s range of motion exercises are begun. Return to play is allowed at 4 to 6 months postoperatively.