What is the recommended treatment for a patient with a possible scapholunate ligament injury and age-related changes after a FOOSH injury?

Treatment for Scapholunate Ligament Injury After FOOSH Injury

For a patient with borderline widening of the scapholunate joint indicating possible ligament injury following a FOOSH injury 3 weeks ago, the recommended treatment is functional support with a wrist brace combined with early exercise therapy to restore joint functionality.

Diagnostic Considerations

The borderline widening of the scapholunate joint on X-ray suggests a possible scapholunate interosseous ligament (SLIL) injury, which is the most commonly injured ligament in the wrist 1. When evaluating scapholunate injuries:

• Standard radiographs may have limited sensitivity (46%) for detecting scapholunate injuries 2
• MRI without contrast is valuable for detecting ligamentous injuries that may not be visible on X-ray 3
• CT arthrography has the highest sensitivity and specificity (nearly 100%) for detecting scapholunate ligament tears when there is high clinical suspicion 3

Treatment Algorithm

1. Initial Management (Weeks 1-4)

• Functional support with a wrist brace rather than immobilization 3
• Begin early exercise therapy to restore joint functionality 3
• NSAIDs may be used to reduce pain and swelling 3
• Avoid RICE (Rest, Ice, Compression, Elevation) as it is not recommended for ligament injuries 3

2. Intermediate Phase (Weeks 4-8)

• Continue with supervised rehabilitation focusing on:
  • Proprioception
  • Strength
  • Coordination
  • Function 3
• Manual mobilization techniques in combination with exercise therapy 3
• Gradual increase in range of motion exercises

3. Advanced Phase (Weeks 8-12)

• Progress to more challenging exercises
• Functional activities specific to patient's needs
• Return to work planning with a specific schedule to minimize work absenteeism 3

Special Considerations

Surgical Options

Surgery should be considered only in cases where:

• Conservative treatment fails to resolve symptoms
• Patient requires quick recovery (e.g., professional athletes) 3
• There is evidence of static instability or significant functional impairment

Surgical options include:

• Primary ligament repair (for acute injuries)
• Reconstructive procedures (for chronic injuries without arthrosis)
• Salvage procedures (for cases with cartilage loss) 4, 5

Monitoring and Follow-up

• Regular assessment of wrist stability and pain levels
• Follow-up imaging (radiographs) at 6-8 weeks to evaluate healing
• Consider advanced imaging (MRI or CT arthrography) if symptoms persist despite treatment

Evidence Quality and Considerations

The evidence for treatment of scapholunate ligament injuries is primarily based on expert opinion and clinical experience rather than high-quality randomized controlled trials 4. The British Journal of Sports Medicine guidelines provide the strongest evidence for functional support over immobilization 3.

Pitfalls to Avoid

1. Delayed diagnosis: Failure to recognize scapholunate injuries can lead to chronic instability and degenerative arthritis 1
2. Prolonged immobilization: This can lead to stiffness and delayed recovery 3
3. Inadequate rehabilitation: Insufficient focus on proprioception and strength can result in persistent instability
4. Overlooking associated injuries: Scapholunate injuries often occur with distal radius fractures 2

For this patient with a 3-week-old injury and borderline widening of the scapholunate joint, functional support with a brace and early rehabilitation offers the best balance of promoting healing while preventing stiffness and functional loss.