Study finds that early treatment results in better outcomes
According to the results of a study presented during the 2016 annual meeting of the American Association for Hand Surgery, early diagnosis and surgical treatment of scapholunate (SL) ligament injuries in patients younger than 18 years results in better outcomes, compared to patients who underwent surgery a year or more after the injury.

SL injuries may result from a fall or a sudden load on the wrist. They are not uncommon in athletes, but are rarely diagnosed in pediatric patients. Some symptoms of an SL tear include pain on the dorsal side of the wrist, swelling, bruising, and a snapping or popping in the wrist. A torn SL ligament can mean a painful loss of grip strength. Nonsurgical treatment options include prescribing anti-inflammatory medications such as ibuprofen and splinting or casting.

This Institutional Review Board-approved retrospective review involved 21 patients (14 females and 7 males; average age: 15 years, range: 11 years to 17 years) with surgically documented SL injury. Researchers reviewed pre- and postoperative radiographic data, injury classification (using the Geissler scale), and postoperative treatment. Postoperative outcomes were evaluated based on the Mayo Wrist score.

Preoperatively, of the 21 patients, 20 had dorsal wrist pain, and 7 had a positive Watson's shift test. All patients had radiographs taken; 15 of the 21 patients underwent MRI, and the radiologist's interpretation indicated an SL injury in just 7 of these patients. Patients not diagnosed with MRI were diagnosed at the time of arthroscopy.

The authors note that arthroscopic visualization was valuable in determining the extent of the injury in the 18 patients in which arthroscopy was performed. Based on the Geissler scale, 1 patient had a grade II injury, 12 patients had a grade III injury, and 5 patients had a grade IV injury.

The other 3 patients underwent open surgery for complete SL tears that were obvious based on physical exam, radiographs, and/or MRI.

Analyzing results
At an average follow-up of 28 months, patients reported the following:

• pain-free—eight patients
• pain only with heavy activity—three patients
• mild pain with daily activities—seven patients
• moderate pain—two patients
• daily pain, medication required—one patient

Based on the modified Mayo wrist score, which was available for 16 patients, 8 patients had excellent or good results and 8 had fair results.

In terms of motion and strength, the mean wrist flexion-extension arc was 111 ° and the mean grip strength of the affected side was 81 percent of the unaffected side. Patients treated more than 1 year following injury had significantly decreased grip strength and Mayo wrist scores (Fig. 1). The difference in the average Mayo wrist score was statistically significant at 69 in the late treatment group versus 83 in the earlier treatment group (P = 0.004).

"A high index of suspicion is necessary to detect an SL injury in this age group," wrote the authors. "SL injury should be part of the differential diagnosis in all children with persistent dorsal wrist pain, localized tenderness over the dorsal SL joint, and/or a positive Watson's test." Although MRI may assist in the diagnosis, it is not always sensitive; in this series, MRI failed to identify SL injury in more than half of the patients who underwent imaging.

Coauthors of AAHS Paper 65, "Long-Term Outcomes Following Operative Management of Pediatric Scapholunate Ligament Injuries" are Paige M. Fox, MD, PhD; Robert J. van Kampen, MD; Heather L. Baltzer, MD; and Steven L. Moran, MD. Disclosure information for the authors was unavailable.

Bottom Line

• Researchers reviewed pre- and postoperative radiographic data, injury classification, and postoperative outcomes of 21 patients (14 females and 7 males; average age, 15 years) with surgically documented SL injury.
• Of the 21 patients, 18 underwent arthroscopy and 3 patients underwent open surgery for complete SL tears that were obvious based on physical exam, radiographs, and/or MRI.
• Patients treated more than 1 year following injury had significantly decreased grip strength and Mayo wrist scores. The difference in the average Mayo wrist score was statistically significant at 69 in the late treatment group versus 83 in the earlier treatment group.
• The investigators concluded that early diagnosis and surgical treatment of SL injuries in patients younger than 18 years may result in better outcomes, compared to patients who undergo surgery a year or more after the injury.
• Although MRI may assist in the diagnosis, it is not always sensitive; in this series, MRI failed to identify SL injury in more than half of the patients who underwent imaging.