SL ligament rupture (scapholunate instability)

What is the SL band and why is it important?

The scapholunate ligament (SL ligament) connects the scaphoid to the lunate. It consists of a strong dorsal portion, a volar portion, and an interosseous portion. The dorsal part in particular contributes significantly to stability.

• Function: Coordinates the movement of the proximal carpal row and keeps the scaphoid and lunate in sync.
• Stability effect: Prevents separation (diastasis) between the scaphoid and lunate.
• Consequences of an injury: Malposition (e.g. DISI deformity) and long-term increased risk of osteoarthritis (SLAC).

Causes and risk factors

The most common cause is a fall onto an outstretched hand (skis, bike, everyday life). Repeated overloading or twisting movements can also damage the band. Degenerative (wear-related) tears occur less frequently.

• Acute: fall trauma, sports injury, work accident.
• Chronic: Repeated overextension or heavy support loads.
• Risk factors: contact sports, wrist-heavy activities, pre-existing ligament laxity, previous hand injuries.

Typical symptoms

Complaints vary depending on the severity and time after the event. Pain and swelling predominate acutely; Later, the focus is on pain under strain, a feeling of instability and decreasing strength.

• Pain on the radius side (radial-dorsal) of the wrist, v. a. at pressure and load.
• Swelling, hematoma and restricted movement immediately after the accident.
• Snapping or cracking, feeling of insecurity (“gives”), loss of strength in the grip.
• Stress-related complaints, e.g. B. when supporting, turning or heavy lifting.

When should I seek medical advice?

Seek medical help promptly if pain, swelling or loss of function persists after a fall or overuse. SL injuries that are detected early can be treated in a more targeted manner.

• Significant swelling, severe pain or visible misalignment.
• Sensory disturbances in the hand/fingers, feeling cold, pale or severe restriction of movement.
• Persistent discomfort despite rest after 48-72 hours.

Diagnostics: This is how we proceed

The diagnosis is based on history, clinical examination and imaging techniques. The aim is to record the severity (strain, partial tear, complete tear), the dynamics of instability and possible accompanying injuries.

• Clinic: pressure pain dorsoradially, pain provocation during axial loading and flexion/hyperextension; special tests such as the Watson test (scaphoid shift) or the ballottement test.
• X-ray: Standard images in two planes as well as stress or fist-close images to show a scapholunate diastasis or DISI malposition.
• MRI/Arthro-MRI: Soft tissue diagnostics of the ligament and detection of accompanying lesions; Arthro-MRI can better define tears.
• CT: Detailed bone assessment, e.g. B. if small bony avulsions are suspected.
• Ultrasound: Supplementary for effusion and soft tissues, limited to the SL band.
• Arthroscopy: Minimally invasive joint endoscopy as the diagnostic gold standard and at the same time an option for targeted treatment of suitable partial tears.

Degrees of severity and progression

In simple terms, a distinction is made between strain/partial rupture and complete rupture. It is also relevant whether the instability only exists under load (dynamic) or permanently at rest (static).

• Partial tear/strain: Ligament fibers are damaged, but there is partial stability.
• Complete rupture: scaphoid and lunate separate; often measurable diastasis on x-ray.
• Dynamic instability: particularly noticeable in stress or fist shots.
• Static instability: deformity even at rest (e.g. DISI); increased risk of SLAC osteoarthritis.

Arthroscopic classifications (e.g. Geissler) grade the ligament injury according to patency and instrument penetration. What is crucial for patients, however, is whether a reliable reconstruction is possible or whether advanced secondary changes already exist.

Conservative therapy: first check, then operate

Not every SL ligament injury requires surgery. In the case of strains and selected partial tears, structured conservative treatment can relieve pain and stabilize function. A prerequisite is careful diagnosis and follow-up.

• Immobilization: Short-term using a forearm cast or a stable orthosis (typically 3–6 weeks), depending on the findings.
• Pain and inflammation management: Short-term NSAIDs, local cooling, elevation.
• Physiotherapy: Gradual mobilization after swelling, strengthening of the forearm muscles, proprioception, everyday strategies that are gentle on the joints.
• Occupational therapy: everyday training, advice on aids, workplace ergonomics.
• Taping/splint supply: Temporary to provide relief during peak loads.
• Infiltrations: Cortisone injections can calm accompanying synovitis, but do not heal the ligament. Reluctant indication and information.
• Regenerative procedures: PRP/ACP for wrist ligament injuries are discussed, evidence is currently limited. Use only after individual benefit-risk assessment and information.

We particularly treat partial tears without demonstrable static instability conservatively. Regular checks are important. If there is persistent instability, significant diastasis or functional limitations, we discuss surgical options.

Surgical options: individual and stage-appropriate

Surgery is considered in cases of complete rupture, dynamic/static instability, failure of conservative therapy or advanced symptoms. The aim is to reduce pain, restore the best possible stability and delay arthritic changes. The specific procedure depends on the time of injury, tissue quality and accompanying findings.

• Arthroscopic treatment: Debridement of fresh partial tears, if necessary temporary transarticular wire fixation to support healing.
• Primary ligament suture/refixation: For acute complete ruptures (ideally within the first few weeks) using suture anchors; often temporary K-wire stabilization.
• Dorsal capsulodesis: Additional stabilization via the extensor side capsule, often as a supplement.
• Ligament reconstruction with tendon transfer: For chronic ruptures, e.g. B. Method according to Brunelli/“Three-Ligament Tenodesis”; The aim is biomechanical stabilization.
• Corrective osteotomies/screw procedures (special cases): Very individual depending on the deformity.
• Salvage procedure for osteoarthritis (SLAC): Proximal row carpectomy (row 1 resection) or partial carpal fusion (e.g. four-corner arthrodesis) - to reduce pain if wear and tear has already occurred.

Each procedure has advantages and disadvantages. A supposedly “perfect” recovery is not always realistic. We discuss options transparently, including expected follow-up treatment, limitations and risks.

Rehabilitation, healing process and everyday life

The follow-up treatment has a significant influence on the result. It requires patience and good guidance. Periods vary depending on the findings and surgical technique.

• Immobilization after surgery: Often 4–8 weeks using a cast/orthosis; K-wires are removed in a timely manner.
• Physiotherapy: Start after medical clearance with passive, then active mobilization; later strength and coordination training.
• Duration to stress: Easy everyday activities after 6-8 weeks, heavy physical work, depending on sports and work, often after 3-6 months.
• Expectation management: Temporary stiffness or reduction in strength is not uncommon; Consistent exercise programs support the process.

Complications are possible: persistent pain, limitation of movement, complex regional pain syndrome (CRPS), infection, wire/implant problems, or progressive osteoarthritis. Structured aftercare helps to identify risks early.

What you can do yourself (first aid and everyday life)

• Acute measure after a fall: protection, cooling (20 minutes, several times a day), elevation, compression without constriction.
• Adjust load: No heavy loads, no overstretching support; Use ergonomic aids.
• Splint/tape only according to instructions: Do not immobilize for too long without medical supervision.
• Painkillers only for a short time and after consultation; Pay attention to warning signs.

prevention

• Technical training in sports (e.g. fall technique), suitable protective equipment.
• Strength and coordination training of the forearm and shoulder girdle.
• Workplace ergonomics, breaks and alternating workloads.
• Early clarification for recurring wrist problems.

Your treatment in Hamburg

In our practice at Dorotheenstrasse 48, 22301 Hamburg, the focus is initially on precise diagnostics and conservative options. We discuss findings in an understandable manner, take into account your everyday and professional requirements and plan the therapy in stages. If relevant instability is suspected, we will promptly organize the necessary imaging. For surgical issues, we cooperate with specialist hand surgery centers; The decision is made jointly and without time pressure.

• Structured investigation and functional analysis.
• Individual information about the benefits and limitations of conservative and surgical measures.
• Therapy goals: pain reduction, stability, maintaining mobility and suitability for everyday use.
• Close follow-up and adapted rehabilitation concept.

Course and prognosis

The prognosis depends on the severity, time of diagnosis and appropriate treatment. Partial cracks detected early often have a more favorable perspective. In the case of complete ruptures, prompt, stage-appropriate therapy improves the chance of stability. Untreated instabilities can lead to a wear and tear process.

There is no general promise of healing. Realistic goals are pain relief, functional improvement and the best possible stability within the anatomical conditions.