Hand Surgery Source

Scapholunate (SL) Tenderness

Test, Exam and Signs

Historical Overview

  • Scapholunate (SL) tenderness is indicative of injury to the scapholunate interosseous ligament (SLIL).
  • Luxation of the scaphoid and “semilunar” carpal bones was first described by Hessert in 1903.1 He cautioned that these injuries had previously been ignored or misdiagnosed as Colles’ fractures, leading to inappropriate treatments and poor outcomes.

Description

  • On the palmer side, the SL joint is covered by the long radiolunate ligament and the carpal tunnel, rendering palpation ineffective.
  • On the dorsal side, the SL joint is covered by the dorsal radiocarpal ligament but can be effectively palpated.

Pathophysiology

  • The SL joint is the most frequently injured joint in the carpus, and can occur after a fall on an outstretched hand, impact to the hypothenar region, forced extension in ulnar deviation and supination.2
  • The SLIL is an intra-articular structure (ie, synovial) composed of three elements:
    • Volar ligament
    • Dorsal ligament
    • Proximal fibrocartilage
    • The dorsal structure is twice as strong as the volar and about nine times stronger than the proximal structure.3
  • The elements of the SLIL can be injured in isolation or combination.

Instructions

  1. Take patient history
  2. Apply pressure to the dorsal side of the SL joint, which is located just distal to the dorsal radial tubercle (Lister’s tubercle)

Related Signs and Tests

  • Scaphoid tenderness
  • Watson’s scaphoid shift test4
Presentation Photos and Related Diagrams
  • Palpating scapholunate ligament for tenderness. Arrow at lister's tubercle which is palpatedfirst to help identify S-L ligament position.
    Palpating scapholunate ligament for tenderness. Arrow at lister's tubercle which is palpatedfirst to help identify S-L ligament position.
  • Lister's tubercle being palpated with arrow at S-L ligament location.
    Lister's tubercle being palpated with arrow at S-L ligament location.
Definition of Positive Result
  • A positive result occurs when there is tenderness and increasing pain with pressure.
Definition of Negative Result
  • A negative result occurs when pressure does not elicit tenderness.
Comments and Pearls
  • SL tenderness is a straightforward test in subacute cases, where tenderness is localized, but it can be difficult in acute cases because of pain and poor localization of tenderness.2
  • In more severe cases, or when secondary supports have degenerated, separation of the scaphoid and lunate can be seen on plain x-rays.
  • Stress x-rays, CT, or MRI imaging studies may be helpful in determining the severity of injury and deciding on surgical treatment.
  • Because many acute injuries are not diagnosed, it is not known whether progression always occurs, but it does appear to happen frequently. Symptoms can become worse as secondary structures fail.
References
  1. Hessert W: Dislocation of individual carpal bones, with report of a case of luxation of the scaphoid and semilunar. Ann Surg1903;37:402-13.  PMID: 17861263
  2. Kitay A, Wolfe SW. Scapholunate instability: Current concepts in diagnosis and management. J Hand Surg Am 2012;37(10):2175-2196. PMID: 23021178
  3. Pappou IP, Basel J, Deal DN. Scapholunate ligament injuries: A review of current concepts. Hand (N Y) 2013;8(2):146-156. PMID: 24426911
  4. Watson HK, Ashmead D, 4th, Makhlouf MV. Examination of the scaphoid. J Hand Surg Am 1988;13(5):657-660. PMID: 3241033