The Role of Dynamic (4D) CT in the Detection of Scapholunate Ligament Injury

Abstract

Background Scapholunate (SL) interosseus ligament injuries detected at an early stage could allow the surgeon to prevent progression through the spectrum of injury that leads to instability, and eventually osteoarthritis. We contend that early instability following injury can be detected by visualizing the relative motions and distances between the involved carpal bones (scaphoid and lunate) during wrist movement in vivo. The purpose of this study is to demonstrate the utility of dynamic CT (i.e., 4DCT) in diagnosing SL interosseus ligament injuries in two patients with clinical suspicion of SL interosseus ligament injury during flexion-extension (FE), radial-ulnar (RU) deviation, and dart thrower's (DT) motions.

Case Description 4DCT images obtained from two individual cases were analyzed to assess the proximity between the scaphoid and lunate during wrist motion using standard image processing techniques. Proximity maps representing the distances between the scaphoid and lunate bones during each phase of wrist motion were determined. These maps provide insight into the severity of diastasis (large separation) and location of diastasis at the SL joint. The patients' proximity maps indicated dorsal diastasis and subtle uniform diastasis.

Literature Review Complex musculoskeletal abnormalities, such as wrist joint instabilities, elude diagnosis during 2D fluoroscopy due to the 3D geometry of the anatomy and the inherent 3D nature of the bony kinematics. Even the most recent advances with MR arthrography lack good correlation with wrist arthroscopy. Wrist arthroscopy remains the gold standard for diagnosis to assess for intercarpal laxity. However, arthroscopy is an invasive procedure subjecting patients to the risk of infection, nerve injury, pain, and stiffness.

Clinical Relevance 4DCT allows noninvasive characterization of where ligament injuries likely occur; this may allow for a more selective surgical treatment directed at the specific location of the tear.

Keywords

scapholunate interosseus ligament - computed tomography - 4DCT

• References

• 1 Schmid MR, Schertler T, Pfirrmann CW , et al. Interosseous ligament tears of the wrist: comparison of multi-detector row CT arthrography and MR imaging. Radiology 2005; 237 (3) 1008-1013
• 2 Leng S, Zhao K, Qu M, An KN, Berger R, McCollough CH. Dynamic CT technique for assessment of wrist joint instabilities. Med Phys 2011; 38 (Suppl. 01) S50
• 3 Zhao K, Breighner R, Holmes III D, Leng S, McCollough C, An KN. A technique for quantifying wrist motion using four-dimensional computed tomography: approach and validation. J Biomech Eng 2015; 137 (7)
• 4 Choi YS, Lee YH, Kim S, Cho HW, Song HT, Suh JS. Four-dimensional real-time cine images of wrist joint kinematics using dual source CT with minimal time increment scanning. Yonsei Med J 2013; 54 (4) 1026-1032
• 5 Demehri S, Wadhwa V, Thawait GK , et al. Dynamic evaluation of pisotriquetral instability using 4-dimensional computed tomography. J Comput Assist Tomogr 2014; 38 (4) 507-512
• 6 Edirisinghe Y, Troupis JM, Patel M, Smith J, Crossett M. Dynamic motion analysis of dart throwers motion visualized through computerized tomography and calculation of the axis of rotation. J Hand Surg Eur 2014; 39 (4) 364-372
• 7 Garcia-Elias M, Alomar S X, Monill S J. Dart-throwing motion in patients with scapholunate instability: a dynamic four-dimensional computed tomography study. J Hand Surg Eur 2014; 39 (4) 346-352
• 8 Goh YP, Lau KK. Using the 320-multidetector computed tomography scanner for four-dimensional functional assessment of the elbow joint. Am J Orthop 2012; 41 (2) E20-E24
• 9 Halpenny D, Courtney K, Torreggiani WC. Dynamic four-dimensional 320 section CT and carpal bone injury—a description of a novel technique to diagnose scapholunate instability. Clin Radiol 2012; 67 (2) 185-187
• 10 Shores JT, Demehri S, Chhabra A. Kinematic “4 dimensional” CT imaging in the assessment of wrist biomechanics before and after surgical repair. Eplasty 2013; 13: e9
• 11 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. J Bone Joint Surg Am 1996; 78 (3) 357-365
• 12 Manuel J, Moran SL. The diagnosis and treatment of scapholunate instability. Orthop Clin North Am 2007; 38 (2) 261-277 , vii
• 13 Forward DP, Lindau TR, Melsom DS. Intercarpal ligament injuries associated with fractures of the distal part of the radius. J Bone Joint Surg Am 2007; 89 (11) 2334-2340
• 14 Jørgsholm P, Thomsen NO, Björkman A, Besjakov J, Abrahamsson SO. The incidence of intrinsic and extrinsic ligament injuries in scaphoid waist fractures. J Hand Surg Am 2010; 35 (3) 368-374
• 15 Laulan J, Bismuth JP. Intracarpal ligamentous lesions associated with fractures of the distal radius: outcome at one year. A prospective study of 95 cases. Acta Orthop Belg 1999; 65 (4) 418-423
• 16 Wong TC, Yip TH, Wu WC. Carpal ligament injuries with acute scaphoid fractures—a combined wrist injury. J Hand Surg Br 2005; 30 (4) 415-418
• 17 Hobby JL, Tom BD, Bearcroft PW, Dixon AK. Magnetic resonance imaging of the wrist: diagnostic performance statistics. Clin Radiol 2001; 56 (1) 50-57
• 18 Kuo CE, Wolfe SW. Scapholunate instability: current concepts in diagnosis and management. J Hand Surg Am 2008; 33 (6) 998-1013
• 19 Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am 1972; 54 (8) 1612-1632
• 20 Mak WH, Szabo RM, Myo GK. Assessment of volar radiocarpal ligaments: MR arthrographic and arthroscopic correlation. AJR Am J Roentgenol 2012; 198 (2) 423-427
• 21 Rimington TR, Edwards SG, Lynch TS, Pehlivanova MB. Intercarpal ligamentous laxity in cadaveric wrists. J Bone Joint Surg Br 2010; 92 (11) 1600-1605
• 22 Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am 2006; 31 (1) 125-134
• 23 Hirsh L, Sodha S, Bozentka D, Monaghan B, Steinberg D, Beredjiklian PK. Arthroscopic electrothermal collagen shrinkage for symptomatic laxity of the scapholunate interosseous ligament. J Hand Surg Br 2005; 30 (6) 643-647
• 24 Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears. J Hand Surg Am 1997; 22 (2) 344-349
• 25 Whipple TL. The role of arthroscopy in the treatment of scapholunate instability. Hand Clin 1995; 11 (1) 37-40
• 26 Del Piñal F. Arthroscopic volar capsuloligamentous repair. J Wrist Surg 2013; 2 (2) 126-128
• 27 Wahegaonkar AL, Mathoulin CL. Arthroscopic dorsal capsulo-ligamentous repair in the treatment of chronic scapho-lunate ligament tears. J Wrist Surg 2013; 2 (2) 141-148