Original
article
Scapholunate
interosseous
ligament
injury
in
professional
volleyball
players
Lésion
du
ligament
scapho-lunaire
interosseux
chez
les
joueurs
professionnels
de
volley-ball
R.
Mugnai
a,*
,
N.
Della
Rosa
b,
L.
Tarallo
aa
OrthopedicsandTraumatologyDepartment,UniversityHospitalPoliclinicodiModena,Modena,Italy
b
DepartmentofHandSurgeryandMicrosurgery,UniversityHospitalPoliclinicodiModena,Modena,Italy Received18February2016;receivedinrevisedform30May2016;accepted21July2016
Availableonline27August2016
Abstract
Injuriestothescapholunateinterosseousligament(SLIL)arethemostcommoncauseofcarpalinstability.ASLILinjurytypicallyfollowsafall onanoutstretchedhand,withthewristinhyperextension,ulnardeviationandintercarpalsupination.Wehypothesizethatrepetitiveaxialloading onthewristinhyperextension,duringthereceptionanddiggingmotionsofvolleyball,canleadtofunctionaloverloadingoftheSLIL.
Toidentifypatientsandtodeterminetheclinicalhistoryandsurgicaltreatmentperformed,weanalyzedhospitalrecords,X-rays,electronic databasescontainingalltheoperationsperformed,andimagefiles(includingbeforeandaftersurgeryandfollow-up).
WeidentifiedthreeSLILinjurycasesinnationalvolleyballteamplayers,alsoattheliberoposition,whoweretreatedatourclinicbetween2007 and2013forscapholunateinstability.OpenreductionandBergercapsulodesiswasperformedinallcases.Atameanfollow-upof3years(range, 22–50months),themeanpainlevelonVASwas0.3(range,0–1)atrestand1.7(range1–2)duringsportactivities.ThemeanDASHscorewas4 (range2–5).Themeanwristflexionwas608(range55–708)andextensionwas808(range75–858).
GiventhegreatersusceptibilityoftheseplayersfordevelopingaSLILinjury,ahighindexofsuspicionisneededwhenmanagingathletes presentingwithwristpainorinstability.
#2016SFCM.PublishedbyElsevierMassonSAS.Allrightsreserved.
Keywords:Scapholunateinterosseousligament;SLIL;Carpalinstability;Volleyball;Sport;Libero;Athletes
Résumé
Leslésionsduligamentscapho-lunaireinterosseux(LSLIO)sontlacauselaplusfréquented’instabilitéducarpe.UnelésionduLSLIOsuccède classiquementàunechutesurlamainétendue,aveclepoignetenhyperextension,eninclinaisonulnaireetensupinationintercarpienne.Nous avonsémisl’hypothèsequ’unemiseenchargeaxialerépétitivedupoignetenhyperextensionpendantlaréceptionetl’interceptionpouvaitêtre responsabled’unesurchargefonctionnelleduLSLIO.
Pour retrouver les patients et reconstituer l’histoire clinique et les traitements chirurgicaux réalisés, nous avons analysé les courriers hospitaliers,lesradiographies,lesdonnéesinformatiquescontenantlesprotocolesopératoiresetlesdossiersd’images(ycomprispréetpost opératoiresetpendantlesuivi).
Nousavonsidentifiétroiscasdejoueursdevolley-balldeniveaunational,spécialementdeslibéros,traitésdansnotreétablissemententre 2007et2013pouruneinstabilitéscapho-lunaire.UneréductionàcielouvertetunecapsulodèseselonBergerontétéréaliséesdanstousles cas.Aureculmoyendetroisans(22–50mois),ladouleursurl’échellevisuelleanalogiqueétaità0,3(0–1)aureposetà1,7(1–2)pendant l’activitésportive.LescoreDASHmoyen étaitde4(2–5). Laflexionmoyennedepoignet étaitde608(55–70),l’extension moyennede poignet étaitde808 (75–85).
Availableonlineat
ScienceDirect
www.sciencedirect.com
HandSurgeryandRehabilitation35(2016)341–347
*Correspondingauthor.
E-mailaddress:raffaele.mugnai@gmail.com(R.Mugnai).
http://dx.doi.org/10.1016/j.hansur.2016.07.003
Etantdonnéelagrandesusceptibilitédesesjoueursàdéveloppercetypedelésion,nousconseillonsunhautdegrédesuspiciond’unelésiondu LSLIOquanddetellesathlètesseprésententpourunedouleurouuneinstabilitédupoignet.
#2016SFCM.PubliéparElsevierMassonSAS.Tousdroitsréservés.
Motsclés: Ligamentscapho-lunaireinterosseux;LSLIO;Instabilitéducarpe;Volley-ball;Sport;Libero;Athlètes
1. Introduction
Injuries to the scapholunate interosseous ligament(SLIL)
arethemostcommoncauseofcarpalinstability[1–3]andcan
be associated withother lesions such as secondaryligament
rupturesandwristor carpalbonesfractures[4,5].
The SLIL is part of a delicately balanced system of
intrinsicandextrinsicligaments,whichensurewriststability
andallowproperloadtransmission throughthecarpaljoints
[6–8].The complexityof thesecondary stabilizersexplains
why a SLIL lesion leads to a spectrum of instability [7,9],
rather than a unique clinical manifestation, depending on
bonecongruencyand,mostimportantly,additionalligament
damage. Along with static scapholunate (SL) instability,
whichcanbediagnosedbasedonplainradiographs,theterm
‘‘dynamicSL instability’’has been used todescribe milder
conditions, in which the integrity of secondary ligaments
requires forceful maneuvers and stress radiographs for the
instability to be detected [8,10]. Nevertheless, it is very
importanttorecognizethislesionbecauseaSLILdisruption
alterswristkinematics. Ifundiagnosed anduntreated,itcan
causeprogressivearthriticdegenerationovertime,leadingto
an end-stage condition known as scapholunate advanced
collapse (SLAC) [11].
Many studies have shown that this injury is common in
athletespronetodevelopingacuteandchronicwristinjuries, like football players [12], baseball players [13], basketball players[14]andgymnasts[15].Here,wereportonthreecases
of national volleyball team players (from two different
countries),allliberoplayers,whoweretreatedforscapholunate instabilityatourclinicbetween2007and2013.
2. Patients andmethods
To identifypatients and todetermine theclinical history
and surgical treatment performed, we analyzed hospital
records, X-rays, electronic databases containing all the
operationsperformed,andimage files (includingbeforeand
after surgery and follow-up). All patients gave informed
consentpriortobeingincludedinthestudy.Thisstudy was
performed in accordance with the ethical standards of the
1964 Declaration of Helsinki, as revised in 2000. The
postoperative clinical evaluation was performed by one of
the authors and included an analysis of passive range of
motion(ROM),functionalresultsbasedontheDisabilitiesof
Arm,Shoulder andHand(DASH)questionnaire,pain levels
both at rest and during sport activities with a 10cm visual
analogue scale (VAS).
3. Casesdescription
3.1. Case1
A 35-year-old right-hand dominant male libero player
presentedwitha4-weekhistoryofrightwristpainandpopping, followingafallonhisoutstretchedpalm.Hehadmisinterpreted
the injury and treated it as a simple sprain. Examination
revealed dorsal wrist swelling and tenderness over the
scapholunatejoint.Provocativeligamenttestingwashampered
bythepain.
Anterior–posterior (AP) radiographs appeared normal,
whereaslateralradiographsshowedabnormalscaphoidpalmar
flexion, with ascapholunate angle greaterthan 708. A
high-resolutionmagneticresonanceimaging(MRI)examshoweda
SLILtearandanassociatedavulsionofthedorsaltubercleof thelunate(Fig.1).
Anopen repairthroughadorsalapproachwasperformed.
Capsulotomywitharadial-basedtriangularflapwasperformed
accordingtoBergeretal.[16].Intraoperativesheartestshowed
Fig.1. High-resolutionMRIshowingaSLILtearandassociatedavulsionofthe dorsaltubercleofthelunate.
dorsaldislocationofthecapitateonthelunate(videoavailable
as a supplementary file). Surgical treatment consisted of
reduction and pinning of the scapholunate interval (two
scapholunate K-wires and one scaphocapitate K-wire) and
screwfixationof theavulsedlunatefragment(Fig.2).
The K wires were removed 6 weeks after surgery. Wrist
physical therapy exercises were prescribed; the patient’s
symptomsimproved and he was able to return to play after
4months(Fig.3).
3.2. Case2
A 23-year-old right-hand dominant male libero player
presentedwithpainfulclickingandlossofgripstrengthinhis rightwrist.Hecouldnotrecallaninjuryeventandwasbarely
abletoremembertheonsetofthesesymptoms,whichhesaid
was approximately 3 months prior. Local steroid injections
wereperformedbytheteamdoctorwithoutsubstantialbenefit.
Physical examination revealed tenderness over the dorsal
aspect of thewrist atthe lunatefossa. The Watson scaphoid
shifttest[17]waspositive,asapainfulclunkwasevokedwhen pressurewasappliedonthevolaraspectof thescaphoid,into radial deviationof thewrist.
OntheX-rays,anincreasedradiolunateangle(greaterthan 158)indicatingaDISIpatternwasvisible,butneitherabnormal
scapholunate angle nor SL diastasis were found (Fig. 4).
Imaging studieswerecompletedwithMRI,whichconfirmed
the DISIdeformity,suggestiveofaSLILlesion(Fig.5).
ClinicalsuspicionofaSLILinjurywasconfirmedwithan
arthroscopic evaluation, which revealed the presence of a
chronic GeisslergradeIII lesion.The scapholunate jointwas
stabilized through open reduction, pinning and Berger
capsulodesisprocedure[18].
Three months after the surgery, the patient was fully
recoveredandabletoresumetraining.
3.3. Case3
A 33-year-old right-hand dominant male libero player
presentedwitha4-month historyof snappingsensationsand
pain of his right wrist. He could not recall falling on a
hyperextendedwrist.Localsteroidinjectionswereperformed
bytheteamdoctorwithoutsubstantialbenefit.Onexamination, painwaselicitedduringpalpationoverthedorsalSLinterval
andtheSLshifttestwaspositive.RadiographsshowedaDISI
pattern, which was confirmed by an MRI. No other
abnormalitieswere detected.Ahighindex of suspicionfor a
SLIL lesion, based on clinical presentation, images, and
Fig.2. Post-operativeX-raysshowingreductionandpinningofthe scapholu-nateinterval(twoscapholunateK-wiresandonescaphocapitateK-wire)and screwfixationoftheavulsedlunatefragment.
Fig.3. Clinicalevaluation3monthsaftersurgeryshowingnearlycomplete recoveryof wristextension, which isof primary importancefor someone playingtheliberopositioninvolleyball.
Fig.4. LateralX-raysshowingascapholunateangleof538.Thearrowpointsto evidenceoflocalsteroidinjections.
positivevolar drawer test,led us tocomplete the evaluation withwristarthroscopy.
Wrist arthroscopyshowed aGeisslertypeIII partial SLIL
tear associated with rotational subluxation of the scaphoid.
Scapholunate anatomic position was restored and stabilized
withK-wirepinning.TherepairwasreinforcedwithaBerger
capsulodesis(Fig.6).
Afterthreemonthsofrehabilitation,thepatientwasableto returntoplay.
3.4. Clinicaloutcome
For these three athletes, at a mean follow-up of 3 years
(range 22–50 months), the meanpain level onVAS was 0.3
(range0–1)atrestand1.7(range1–2)duringsportactivity.The
meanDASHscorewas4(range2–5).Themeanwristflexion
was608(range55–708)andextensionwas808(range75–858).
4. Discussion
A SLILinjury typically followsa fall on an outstretched
hand, with the wrist in hyperextension, ulnar deviation and
intercarpalsupination [19].
TheliberopositionwasfirstintroducedbytheInternational FederationofVolleyball(FIVB)in1996[20].In1998,itwas internationallyrecognizedandin2002,theNationalCollegiate
Athletic Association (NCAA) rules were changed toinclude
this new role. The libero is a player specialized in serve
receptionanddefensive tasks.Receptionanddiggingactions
are performedby the libero to save the ball. Digging is the
ability to prevent the ball from touching one’s court after a
spike,particularlyaballthatisnearlytouchingtheground.A playersometimesperformsa‘‘dive’’,i.e.,throwhisorherbody
intheairwithaforwardmovementinanattempttosavethe
ball, and land on his or her chest. We hypothesize that the
repetitiveaxialloadingonthewristinhyperextension,required bytheseactivitiestogetupfastorpushthebodyforwardonthe ground,cancausefunctionaloverloadingoftheSLIL(Figs.7
and 8). Since the libero role has been introduced relatively
recentlyinvolleyball,therearenootherreportedcasesinthe scientific literature, but we believe that more will be in the
comingyears.
DiagnosingaSLILtearcanbeverychallenging.Intheacute setting,painandswellingarecommon,butalesssevereclinical
presentation than the one experienced with fractures and
particularly non-traumatic lesions frequently mislead the
patients to underestimate the injury and to seek medical
assistanceweekstomonthslater,becausethepainhasnotgone away[6,10].
Theclassicmanifestationsofsub-acuteor chronicinjuries
comprise weakness during gripping movements, catching,
popping and pain in the wrist [2,8]. Steps must be taken to
diagnoseaSLILlesionevenwiththemildestsymptoms.The
bestapproachincludesphysicalexamination,whichshouldaim
Fig.6. IntraoperativeviewoftheBergercapsulodesisprocedure.
Fig.7. Axialloadingonthewristinhyperextension,duringservereceptionand digging,causingfunctionaloverloadingoftheSLIL.
Fig.5. High-resolutionMRIconfirmedtheDISIdeformity(radiolunate an-gle=428),butwasnotabletodetectanyapparentsignsofSLILdisruption.
toexcludethepresenceofgeneralizedligamentouslaxity[2], carryingoutprovocativemaneuvers(i.e.Watsonscaphoidshift test)[17]andanaccurate radiologicalassessment.
On the X-rays, scapholunate diastasis (>3mm), the ring sign(flexionofthescaphoid)andascapholunateanglegreater
than 608 are all criteria indicative of static scapholunate
instability.HowevernormalX-raysarenotsufficienttoexclude aSLILinjury[2].Lackofintegrityofthesecondaryligaments
cangiverisetodynamicinstability,whichcan beuncovered
onlyonstressX-rayviews.MRIaddsmoreinformationtothe
plain X-rays studies, as it provides better sensitivity and
specificityinrecognizingligamentandothersofttissuestears
[21].
Acadavericstudywasperformedtocomparethesensitivity,
specificityandaccuracyofCTarthrography,conventional3-T
MRI,andMR arthrography indetecting SLIL,lunotriquetral
ligament,andtriangularfibrocartilagecomplextears[22].The
accuracyofCTarthrographyandMRarthrographywasabout
90–100%,while thatof conventionalMRI accuracywas 70–
90%.Inparticularthesensitivity,specificityandaccuracywere
66%,86%, and80%,respectively, for conventional3-TMR;
100%,86%,and90%for MRarthrography;and100%using
CT arthrography in detecting SLIL tears. Overall, injected
exams,andinparticularCT arthrography,areabettermethodto
identifySLILtears thanconventionalMRI [22].
However, arthroscopy is currently considered the gold
standard for evaluating ascapholunate lesion, as it provides
directvisualizationoftheinjuredstructures[6].Inthecurrent
study, we used the classification proposed by Geissler [23],
which did not correlate the degree of SL jointlaxity to the
specific tissue injury site. Several cadaveric studies have
focusedontheroleofextrinsicligamentsinmaintainingcarpal
stability [24]. This finding led to the development of new
arthroscopic classification systems that include an in vivo
assessmentof theextrinsicligamentsof thewrist[25].
Arecentstudyexamined therelationshipbetween
arthros-copicGeisslergradesandspecificanatomiclesionsof theSL
supportingligaments.Theauthorsdemonstratedthatsequential sectioningoftheSLsupportingligamentscausedaprogressive
increase in the Geissler grade, suggesting that the Geissler
gradecorrelateswithdamagetodistinctanatomicalstructures. Inparticular,GradeIIwasidentifiedwithlesionstotheSLIL,
particularly inthe volarandmembranous portions.GradeIII
followedsectioningofthedorsalSLILandthevolarextrinsic
ligaments (radioscaphocapitate and long radiolunate
liga-ments). Sectioning of the dorsal extrinsic stabilizers was a
keycomponentinthe progressionfrom gradeIIItogradeIV
wrists[26].
The treatmentstrategydependsonseveralfactors,suchas thegradeofthedisruption,conditionofsecondarystabilizers,
reducibility of the scapholunate joint and the patient’s
functional needs. When dealing with professional players,
the aims of treatment are to relieve the symptoms, prevent
progression to osteoarthritis and allow the athlete toresume
trainingassoonaspossible;asaconsequence, anon-surgical
approach may not be sufficient to achieve the patients’
expectationsintermsof recovery.
Earlydiagnosisiscrucialasthereisasignificantdifference betweentreatmentstrategiesforacuteorchroniclesions,and
functionaloutcomesareimprovedwhensurgeryisperformed
early on [27–29]. Numerous surgical procedures have been
describedtotreatthiscondition.
Patientswithacutepartialtears(GeisslergradesI,II,III)can
be treated successfully with arthroscopic debridement and
temporary K-wire stabilizationof the SL andscaphocapitate
joints [8,30]. Acutecomplete lesions(Geisslergrade IV)are betteraddressedwithopenligamentrepair,reinforcedbydorsal capsulodesis[8,25–27,30–32].
Treatment of chronic lesions (more than 6 weeks old) is
consistentlyinfluenced bythepresenceof secondary
osteoar-thritis. In chronic partial tears (Geissler grades I, II)
arthroscopic debridement andpinningcan stillbe attempted.
However,anintensedebateexistsonhowtobesttreatchronic
lesions (especially Geissler grade III, IV), with many
techniques proposed such as capsulodesis [18,30,32–34],
arthroscopic-assistedtechniqueswithdorsal
capsulo-ligamen-tousrepair[35]orbone-ligament-bonegraft[36],tendongrafts
[8], tenodesis [37,38], induced pseudoarthrosis (RASL
pro-cedure) [38],andnewtechniques includingthe scapholunate
axis method (SLAM) [39] and the scapholunate intercarpal
(SLIC) screw[40].
Chroniclesionscomplicatedbyarthritisrequireadifferent approach.Theavailableoptionsinclude:denervationandradial styloidectomy[41,42],proximalrowcarpectomy[43], arthro-desisandtotalwristarthroplasty[8,42].
In our series, postoperative management consisted of a
physical therapy program, and all the athletes were able to
resume fulltraining.
SLIL lesions are the most frequent cause of carpal
instability. Besidesacuteinjuries, veryoftenthe patient,and particularlytheathlete,tendstomisinterpretthisconditionasa
simplesprainandonlyseeksmedicaladviceweeksormonths
later,when thepainhasnotgoneaway. Inaddition,dynamic
instabilitiesneedimagingmodalitiesbeyondsimpleX-raysto
beuncovered.Ifleftuntreated,theseinjuriescaninterferewith activitiesandprogresstoosteoarthritis,soitisveryimportantto recognizeandtreatthemappropriately.Wewouldliketostress
Fig. 8.Photo of a libero player showing how thehyperextended wristis undergoingaxialloading.
theimportanceofearlydiagnosis.Thisallowsthesurgeonto
perform less invasive techniques such as arthroscopy and
pinning,andleadstobetterfunctionaloutcomes[28,29],which
is particularly important when dealing with demanding
professionalathletes.
Ontheotherhand,inchroniclesions(notablyGeisslergrade IIIandIV),theoutcomesofalltheavailableprocedurestendto deteriorateovertime,leadingtovariablegradesofstiffnessand
residualpain,especiallyinthosewhoplacehighdemandson
their wrists [44–46]. In such cases, it is very important to
discusstherisk–benefitratiowiththeathleteandpossiblydelay surgicaltreatmentuntilthe endof hisprofessional career.
5. Conclusions
Given the greater susceptibility of volleyball players
(especially the libero) to developing this kind of injury, we
advisehavingahighindexofsuspicionforaSLILlesionwhen managingathleteswhopresentwithcomplaintsofwristpainor
instability. We have also treated some teenage volleyball
playerswithpartialtearsinourclinic;webelievethateducation
onhowtocorrectlyperformcertainmovements,fromthevery
beginning of their training, may play an important role in
preventingtheseinjuries.
Disclosureofinterest
The authorsdeclarethattheyhavenocompetinginterest.
AppendixA. Supplementary data
Supplementary data associated with this article can be
found,inthe onlineversion,at doi:10.1016/j.hansur.2016.07. 003.
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