synovectomy and cheilectomy of hypertrophic mar-
gins that impinge during hyperextension. Return to
sport may not be possible in all cases, but relief of pain
generally occurs following treatment.CARPAL INSTABILITY
- Carpal instability can be seen in any athlete in a con-
tact sport following a collision injury, but may also be
a result of chronic repetitive loading in noncontact
sports. Carpal instability can be seen as a spectrum of
injuries ranging in symptoms and functional deficit.
Initial injury may present as something as innocuous
as an occult dorsal or intracapsular ganglion (men-
tioned above) and progress to dynamic instability,
then static instability, and ultimately to scapholunate
advanced collapse (SLAC). The dynamic instability is
not apparent on routine radiographs, but is reproduced
by manipulation and seen on stress radiographs
(pronated clenched fist views (Dobyns et al, 1975)).
Static instability can be seen on routine radiograph as
abnormal carpal alignment (Taleisnik, 1980). Carpal
collapse is seen following complete disruption ini-
tially of ligaments between the scaphoid and lunate,
and progressing to disruption between the lunate and
triquetrum and finally to the midcarpal joints.
SCAPHOLUNATE DISSOCIATION
- Scapholunate instability occurs as the ligamentous
support of the proximal pole of the scaphoid is dis-
rupted, and the scaphoid rotates into palmarflexion.
This can be reproduced clinically during physical
examination by performing the Watson maneuver
(Watson and Dhillon, 1993). Radiographically, this is
shown by widening of the scapholunate space (com-
pared to the uninjured wrist), an increase in the
scapholunate angle (>70°, normal 30°to 60°), and a
cortical ringsign in which the distal pole of the per-
pendicular scaphoid is seen end-on on the anteropos-
terior view of the wrist. - Successful treatment may consist of closed reduction
and percutaneous pinning if initiated within the first 3
to 4 weeks after injury. This may also be performed
under arthroscopic guidance. In most cases, open
reduction, ligamentous repair, and internal fixation
with Kirschner wires is the most reliable treatment in
the management of scapholunate ligament injuries in
athletes. For chronic scapholunate dissociation without
advanced arthritic changes, a dorsal capsulodesis and
ligament reconstruction as described by Blatt (Blatt,
1987) or when ligament reconstruction is not possible,
a scaphotrapezial-trapezoidal fusion as described by
Watson (Watson and Hempton, 1980) may be per-
formed. Postoperatively, the wrist is immobilized in
slight palmar flexion and pronation. Return to contact
sports is limited after treatment for carpal instability.LUNOTRIQUETRAL INSTABILITY- Injuries to the lunotriquetral ligaments may range
from sprain to partial tear to complete tear with or
without carpal malalignment. The carpal instability
associated with this injury is a volar intercalated seg-
ment instability (VISI) deformity. This complete
injury occurs rarely in athletes. Symptoms consist of
pain on the dorsoulnar side of the carpus with a posi-
tive lunotriquetral ballotment test as described by
Reagan et al (Reagan, Linscheid, and Dobyns, 1984).
Injection of local anesthetic to the lunotriquetral joint
usually relieves symptoms and restores grip strength.
Routine radiographic evaluation is able to detect static
instability as evident by volarflexion of the lunate in
neutral deviation. Midcarpal arthrography and MRI
may demonstrate incomplete or complete tears of the
lunotriquetral ligaments or radiocarpal arthrography
may detect a simultaneous injury to the triangular
fibrocartilage particularly in an ulna positive patient.
Ulnar variance has been shown to be associated with
the location of injury. An ulnar minus variance is
related with radial axis injury, while an ulnar neutral
or plus variance has been linked to ulnar axis injury.
•Treatment of acute or untreated chronic injuries with
no evidence of a tear consists of injection of a corti-
costeroid preparation followed by immobilization.
Surgical treatment is considered when disabling pain
continues and cessation from sport is not an alterna-
tive, and consists of lunotriquetral ligament repair
when possible. Arthroscopy may be valuable in stag-
ing and determining treatment, and may be used to
assist in reduction and pinning in both acute and
chronic ligament tears without advanced collapse
(Weiss et al, 2000). In patients with an ulna plus vari-
ance, ulna shortening is the treatment of choice.
Lunotriquetral arthrodesis has been performed, but
without uniform success (Taleisnik, 1992) and is
rarely performed in athletes (Weiss et al, 2000).
ULNAR TRANSLOCATION- Ulnar translocation is an extremely rare injury in ath-
letes, which is usually a result of a severe violent
impact, such as in motor sports. In order for complete
translocation to occur, complete disruption of both the
300 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE