Scapholunate interosseus ligament tears in elite gymnasts.

Gymnastics requires conversion of the upper limb into a load-bearing extremity, leading to upper extremity, especially wrist, injuries. The “gymnast's wrist” or the Madelung-like deformity involves repetitive excessive loading of immature bones leading to premature closure of the distal radial physis with associated ulna-plus variance and wrist pain.1–3 The significant physical demands of gymnastics and the frequency of injuries especially in elite gymnasts has led some to state that chronic gymnastic injuries should more properly be referred to as consequences of participation in the sport, implying the inevitability of chronic injuries.4 Up to 88% of gymnasts experience wrist pain.1 This is associated with older age, increased training hours and higher skill level.5 Elite gymnasts have a significantly greater rate of injuries than lower level gymnasts.6 Therefore they need to be considered as a separate group from casual participants in terms of sport-specific stresses and resulting injuries. The scapholunate interosseus ligament (SLIL) is involved in maintaining the stability of the complex structure of the wrist. Wrist injuries commonly involve the SLIL.7 However, there is no reported literature on SLIL injuries in gymnasts. It may be that these injuries have been overlooked in the past. The wrist pain associated with these injuries is usually chronic and is less severe than a fracture, so athletes may interpret it as a nonsignificant sprain and may not seek medical attention. Physicians may overlook these injuries for similar reasons. The mechanism of injury is generally believed to be impact loading with the wrist in extension and ulnar deviation,8,9 resulting in the capitate being driven between the scaphoid and lunate bones. This can occur with either a fall on an outstretched hand or repeated loading with weight bearing through the upper extremities. Clinical presentation is usually pain over the dorsal and radial aspects of the wrist with associated loss of motion or grip strength, or both. Radiologically, scapholunate diastasis is defined as greater than 3 mm with a normal scapholunate distance of 2 mm or less on the other wrist. Diastasis is present in static scapholunate dissociation but is not visible in dynamic instability unless elicited on stress views, which can be performed with fist clenching or ulnar deviation of the wrist. Additional radiographic signs include the cortical “ring” sign due to the volar flexion of the scaphoid, a scapholunate angle greater than 70° (normal 30°–60°), and a radiolunate angle greater than 5°, which indicates a dorsal intercalated segmental instability (DISI) pattern with a dorsiflexed lunate. Radiographs in most scapholunate injuries appear normal, the radiographic findings already described being seen mostly in complete ligament tears or chronic partial tears. Further evaluation can include MRI, which can better visualize scapholunate diastasis, ligament tears, occult fractures, and bone bruising. Arthrography has been used but often now is bypassed in favour of arthroscopy, which continues to be the standard method for evaluating SLIL injuries. We describe 3 patients who had tears of the scapholunate ligament.

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