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LUNOTRIQUERAL (LT) LIGAMENT INJURY, WRIST

Introduction

Injuries to the lunotriquetral interosseous ligament (LTIL)—including sprains, tears, and instability—are considered an unusual cause of ulnar-sided wrist pain. Compared to injuries of its counterpart, the scapholunate interosseous ligament (SLIL) and other forms of dissociative carpal instability, LTIL injuries are less common and not as well understood. The LTIL is most often injured from a fall on an outstretched hand (FOOSH), although some high-energy sports and other mechanisms may also be responsible. LTIL injuries can occur in isolation, but are usually part of a complex injury and associated with other wrist trauma, such as distal radius fracture or perilunate dislocation. Treatment depends on the degree of stability, time elapsed since injury, and several other factors, but typically includes mobilization. Surgical intervention is reserved for certain chronic cases and patients who fail to respond to conservative treatment.1,2,3,4

Pathophysiology

  • The most common mechanism of LTIL injury is trauma to the wrist caused by a FOOSH, usually with wrist hyperextension, extension and radial deviation, or volar flexion1
  • LTIL injuries may also result from twisting, pulling, pushing, catching, or striking, as well as high-energy or impact sports like football, hockey, rugby, or basketball1,5
  • Degenerative etiologies for LTIL injuries have also been described: positive ulnar variance leading to ulnocarpal impingement can alter wrist intercarpal mechanics and lead to subsequent LTIL degeneration1,4
  • LTIL injuries range from incomplete tears to complete dissociation, with either dynamic or static carpal instability; “dissociation” is used clinically to describe static instability, while “sprain” describes predynamic and dynamic instabilities, but not all injuries are unstable1,3
  • Complex LTIL injuries that also involve trauma to the wrist are more common than isolated injuries6
  • Volar intercalated segmental instability (VISI) deformity is a type of carpal instability that can be caused by advanced LTIL injury3

Related Anatomy

  • The LTIL is a C-shaped intrinsic ligament that stabilizes the LT joint and works with the SLIL to stabilize the proximal carpal row; stability of this row is associated with an equilibrium of forces on the lunate, between the extension moment of the triquetrum and the flexion moment of the scaphoid4
  • The LTIL is made up of three regions: dorsal, intermediate, and volar
    • Unlike the SLIL, where the dorsal aspect is the most critical, the volar segment is the most stout and is considered the major constraint to LT motion
    • Several extrinsic ligaments help to further stabilize the LT relationship, including the palmar radiolunotriquetral ligament and the dorsal radiocarpal ligament4,5
    • Normal wrist mobility and stability require an intact LTIL that fixes both the lunate and triquetrum bones into a single mechanical unit and determines the position of the lunate throughout wrist range of motion(ROM)1

Incidence and Related Conditions

  • As a group, ulnar carpal injuries—which include triquetrohamate (midcarpal) and LT instability—are about one-sixth as common as their radial counterparts1
  • Relative to other ligamentous injuries of the carpus, symptomatic and isolated tears of the LTIL are not commonly reported7
  • Carpal bone injuries
  • Carpal ligament injuries
  • Triangular fibrocartilage complex (TFCC) injuries
  • Distal radius fracture
  • Perilunate dislocation1,3

Differential Diagnosis

  • Entrapment of the dorsal branch of the ulnar nerve
  • TFCC tear
  • Ulnocarpal arthrosis
  • Midcarpal instability
  • Kienbock’s disease
  • Extensor carpi ulnaris (ECU) subluxation
  • ECU or flexor carpi ulnaris (FCU) tendonitis
  • Distal radioulnar joint (DRUJ) subluxation
  • Pisotriquetral (PT) arthrosis
  • Fracture of the hook of the hamate, ulnar styloid, or triquetrum
  • Ulnocarpal impingement
  • Chondromalacia of lunate or distal ulna
  • LT synostosis
  • Calcific tendinitis1,2
ICD-10 Codes

  • LUNOTRIQUERAL (LT) LIGAMENT INJURY, WRIST

    Diagnostic Guide Name

    LUNOTRIQUERAL (LT) LIGAMENT INJURY, WRIST

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    LUNOTRIQUERAL (LT) LIGAMENT INJURY, WRIST S63.512_S63.511_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S61 AND S63
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • The L-T ballotment test is used to assess tenderness and instability. The examiner's left index is applying upward pressure on the pisiform (1) to indirectly put pressure on the triquetrum while the left thumb pushes the lunate volarly.
    The L-T ballotment test is used to assess tenderness and instability. The examiner's left index is applying upward pressure on the pisiform (1) to indirectly put pressure on the triquetrum while the left thumb pushes the lunate volarly.
  • The lateral X-ray shows the pressure points used during the L-T ballotment.
    The lateral X-ray shows the pressure points used during the L-T ballotment.
Pathoanatomy Photos and Related Diagrams
Anatomic Ulnar Wrist Dissection
  • The anatomic specimen shows the open ulnar part of the wrist. The lunate, the lunotruetral ligament and the triquetrum are on the left of the image. The triquetral pisiform ligaments have been cut showing the dorsal articular surface of the pisiform. The ulnar edge of the radius, the TFCC, the head of the ulna and the cut ECU tendon are also shown.
    The anatomic specimen shows the open ulnar part of the wrist. The lunate, the lunotruetral ligament and the triquetrum are on the left of the image. The triquetral pisiform ligaments have been cut showing the dorsal articular surface of the pisiform. The ulnar edge of the radius, the TFCC, the head of the ulna and the cut ECU tendon are also shown.
Symptoms
Swelling and tenderness over ulnar side of the wrist
Ulnar-sided wrist pain
Painful clicking or clunking with ulnar deviation
Grip weakness and/or a sense of wrist instability
Wrist Stiffness
Typical History

The typical patient is a 37-year-old, right-handed, male landscaper who tripped after accidentally pushing his wheelbarrow into a hole at a high speed and fell onto his outstretched right hand. After the injury, he experienced pain on the ulnar side of his wrist, which grew worse with any movements that required rotation or ulnar deviation, as well as stiffness, weakness, a clicking sensation, and tenderness over his LT joint. These symptoms limited his wrist ROM and prevented him from fulfilling all of his landscaping duties, but he waited until three months later to see a physician because he assumed the injury would heal on its own.3,6,8

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
L-T Tear Imaging Studies
  • Wrist arthrogram showing an intact L-T ligament
    Wrist arthrogram showing an intact L-T ligament
  • Wrist arthrogram consisted with a torn L-T ligament.
    Wrist arthrogram consisted with a torn L-T ligament.
  • Positive ulnar variance is often associated with L-T tears.
    Positive ulnar variance is often associated with L-T tears.
  • Gripping view done in neutral forearm rotation shows markedly worse positive ulnar variance.
    Gripping view done in neutral forearm rotation shows markedly worse positive ulnar variance.
  • Ulnocarpal abutment and L-T Tear treated with ulnar shortening osteoplasty.
    Ulnocarpal abutment and L-T Tear treated with ulnar shortening osteoplasty.
Treatment Options
Conservative
  • Several factors must be considered when deciding the optimal treatment plan for a patient, including the degree of stability, time elapsed since injury, associated injuries, ulnar positive variance, and patient goals1
  • LTIL injuries that occur ≤3 months are classified as acute
  • The initial management of most LTIL injuries without radiological changes—both acute and chronic, with or without dynamic instability—should be conservative and include immobilization2
    • Carefully molded cast with a supporting pad under the pisiform
    • Wrist splint with a lateral supracondylar extension
    • 6 weeks of immobilization should be followed by ≥6 months of observation before surgical intervention is considered
    • Immobilization is less likely to be curative for chronic injuries1,8
  • Nonsteroidal anti-inflammatory (NSAID) medications
  • Cortisone injections
  • Conservative treatment of acute LTIL injuries is unwarranted if static instability is present radiographically and irreducible3
Operative
  • For patients with acute or chronic dissociation or chronic tears that have not responded to conservative management, surgical treatment is usually necessary to realign the lunocapitate axis, reestablish the rotational integrity of the proximal row, and reduce excessive intercarpal motion1,7
  • The treatment of chronic injuries depends on the degree of stability and arthroscopic assessment1
  • Direct LTIL repair
    • Most appropriate in the acute setting before the torn ends of the SLIL atrophy
    • Multiple strand repair using bone tunnels or suture anchor implants is required in addition to K-wire fixation
    • Indicated for unstable lesions and dynamically unstable lesions not amenable to arthroscopic treatment1
  • LT arthrodesis
    • Indicated when SLIL repair is technically unfeasible
    • Considered the treatment of choice for chronic complete LTIL injuries
    • Can be accomplished by many techniques
    • Compression screw arthrodesis is straightforward and provides rigid internal fixation
    • One key to long-term success may be the ability to obtain complete fusion1,2
  • LTIL reconstruction
    • Reconstruction of LTIL with a distally based ECU reconstruction through bone tunnels with 8 weeks of transarticular pin immobilization
    • Indicated for unstable injuries
    • Should be weighed against LT fusion in patients with chronic injuries
  • Dorsal radiocarpal ligament capsulodesis
    • May be used in patients with chronic dynamic LT instability6
  • Arthroscopic debridement
    • Used to treat stable LTIL injuries
  • Arthroscopic debridement and pinning
    • May be used for acute, dynamically unstable LTIL injuries
    • It is important to debride only the fibrocartilaginous portion of the ligament to avoid producing iatrogenic instability
  • Ulnar shortening osteotomy (USO)
    • May reduce symptoms of traumatic LTIL tears without an intracarpal surgical procedure through tightening the distal extension of the TFCC and relevant volar and dorsal extrinsic ligaments7
  • LT fusion
    • Indicated for some cases of chronic LTIL instability
  • Tenodesis
Treatment Photos and Diagrams
  • Small acute L-T Tears can often be treated by arthroscopic debridement +/- L-T joint pinning.
    Small acute L-T Tears can often be treated by arthroscopic debridement +/- L-T joint pinning.
  • The set up for a standard ulnar shortening osteotomy using a AO plate and screws. Note the guide lines for a 4mm shortening (double arrow) and the etched line used to assess rotation after cutting the ulna (single arrow). One temporary screw in place.
    The set up for a standard ulnar shortening osteotomy using a AO plate and screws. Note the guide lines for a 4mm shortening (double arrow) and the etched line used to assess rotation after cutting the ulna (single arrow). One temporary screw in place.
  • Plate removed and first bone cut is 80-90% of the ulna width.
    Plate removed and first bone cut is 80-90% of the ulna width.
  • Second complete cut performed while an extra blade is held in the first cut. The extra blade provides a guide to the plane for the second cut.
    Second complete cut performed while an extra blade is held in the first cut. The extra blade provides a guide to the plane for the second cut.
  • Bone fragment has been removed and osteotomy closed and reduced with one screw, plate and a bone clamp.
    Bone fragment has been removed and osteotomy closed and reduced with one screw, plate and a bone clamp.
  • Completed internal fixation after ulnar shortening osteoplasty.
    Completed internal fixation after ulnar shortening osteoplasty.
  • 1. Plate being positioned on the ulna. 2. First cut of the osteotomy. 3.Second osteotomy cut. 4. Completed ORIF of osteoplasty.
    1. Plate being positioned on the ulna. 2. First cut of the osteotomy. 3.Second osteotomy cut. 4. Completed ORIF of osteoplasty.
  • Ulna exposed for ulnar shortening osteoplasty using a sliding plate.
    Ulna exposed for ulnar shortening osteoplasty using a sliding plate.
  • Sliding plate being secured to ulna with distal screws. Plate application volubly with holes for osteotomy guide visible.
    Sliding plate being secured to ulna with distal screws. Plate application volubly with holes for osteotomy guide visible.
  • Plate secure with distal screws and a proximal screw in the slotted hole and ready for adjustment after shortening. Oblique screw guide held in p[lace with k-wires.
    Plate secure with distal screws and a proximal screw in the slotted hole and ready for adjustment after shortening. Oblique screw guide held in p[lace with k-wires.
  • First osteotomy cutting guide in place on side of the sliding plate.
    First osteotomy cutting guide in place on side of the sliding plate.
  • Both osteotomy cuts have been completed (see arrows).
    Both osteotomy cuts have been completed (see arrows).
  • Bone fragment being removed to allow shortening (arrow).
    Bone fragment being removed to allow shortening (arrow).
  • Compression clamp in place and ready to close osteotomy defect. Screw in slotted hole loosened slightly.
    Compression clamp in place and ready to close osteotomy defect. Screw in slotted hole loosened slightly.
  • Osteotomy closed and internal fixation screws all in place in the oblique screw crossing the osteotomy.
    Osteotomy closed and internal fixation screws all in place in the oblique screw crossing the osteotomy.
  • Final X-ray showing completed fixation and slight negative ulnar variance.
    Final X-ray showing completed fixation and slight negative ulnar variance.
CPT Codes for Treatment Options

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CPT Code References

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Complications
  • In one study,6 patients who were complication free at 5 years:
    • Reconstruction: 69%
    • Repair: 14%
    • Arthodesis: 1%
  • LT fusion: 41% developed nonunion and 23% developed ulnocarpal impaction6
  • Ulnocarpal impingement
  • Reoperation
Outcomes
  • Acute LTIL injuries are usually responsive to 6 weeks of immobilization, and subsequent arthroscopy is warranted to assess the injury if no significant improvements are made2
  • Most studies suggest that SLIL repair, SLIL reconstruction, and LT arthrodesis resolve pain symptoms in a majority of cases, but with high complication and reoperation rates7
    • One study reported 5-year reoperation rates of 31% for SLIL reconstruction, 77% for SLIL repair, and 78% LT arthrodesis, as well as an overall complication rate of 82%
    • Thus, SLIL repair or reconstruction was recommended as the treatment of choice for chronic isolated LTIL instability3
  • Ulnar Shortening Osteotomy may be an effective primary treatment option for addressing traumatic LTIL tears, but further research is needed7
  • Arthroscopic debridement and pinning provides very good results in most patients1
  • LT fusion provides less satisfactory results with higher reoperation rates compared with LTIL repair and reconstruction6
  • Arthroscopic debridement: 78–100% resolved/improved symptoms1 and excellent results in 93% (13/14) of patients with scapholunate or LT ligament tears2; however, one study showed that 80% of patients had poor results3
  • Arthroscopic debridement with pinning: 80% of patients reported complete pain relief4
  • Dorsal capsulodesis: after 3 years’ follow-up, 64% (23/36) of patients had good-to-excellent results5
Key Educational Points
  • Patient history and physical examination are essential for correctly identifying LITL injuries, because most patients present several weeks or even months after the acute injury1
  • Arthroscopy
    • The gold standard for diagnosis
    • The most definitive modality for evaluating LTIL injuries, as it allows for definitive treatment of many soft-tissue injuries and permits evaluation of SLIL tears before undertaking open surgical treatment
    • Necessary for assessing dynamic instability and for grading instability1,9
  • The relative scarcity of isolated LTIL injuries reported in the literature may be due – at least in part – to underdiagnosis7
  • The optimal treatment of LTIL tears is still uncertain because the available literature is limited to a few retrospective case and comparative studies, often from an advocate of a specific surgical treatment; the indications for surgery are therefore variable and unclear8,9
  • Complication rates and reoperation rates are high for LT repair and even higher for LT arthrodesis.
  • The diagnoses of “instability” and “complete tear” are poorly defined and potentially unreliable terms; LTIL injuries are often dismissed as wrist sprains and may also be missed because of this diagnostic difficulty7,8
  • The major contsraining portion of the LT ligament is the volar segment of the LT ligament.
References

Cited

  1. Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears. J Hand Surg Am 1997 Mar;22(2):344-9. PMID: 9195439
  2. Ruch DS, Poehling GG. Arthroscopic management of partial scapholunate and lunotriquetral injuries of the wrist. J Hand Surg Am 1996 May;21(3):412-7. PMID: 8724471
  3. Westkaemper JG, Mitsionis G, Giannakopoulos PN, Sotereanos DG. Wrist arthroscopy for the treatment of ligament and triangular fibrocartilage complex injuries. Arthroscopy 1998;14(5):479-83. PMID: 9681539
  4. Osterman AL, Seidman GD. The role of arthroscopy in the treatment of lunatotriquetral ligament injuries. Hand Clin 1995 Feb;11(1):41-50. PMID: 7751330
  5. Antti-Poika I, Hyrkäs J, Virkki LM, et al. Correction of chronic lunotriquetral instability using extensor retinacular split: a retrospective study of 26 patients. Acta Orthop Belg 2007 Aug;73(4):451-7. PMID: 17939474
  6. Shin AY, Weinstein LP, Berger RA, Bishop AT. Treatment of isolated injuries of the lunotriquetral ligament. A comparison of arthrodesis, ligament reconstruction and ligament repair. J Bone Joint Surg Br 2001 Sep;83(7):1023-8. PMID: 11603516

New Articles

  1. Wagner ER, Elhassan BT, Rizzo M. Diagnosis and Treatment of Chronic Lunotriquetral Ligament Injuries. Hand Clin 2015;31(3):477-86. PMID: 26205709
  2. Nicoson MC, Moran SL. Diagnosis and Treatment of Acute Lunotriquetral Ligament Injuries. Hand Clin 2015;31(3):467-76. PMID: 26205708
  3. Sachar K. Ulnar-sided wrist pain: Evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. J Hand Surg Am 2012;37(7):1489-1500. PMID: 22721461
  4. Wagner ER, Elhassan BT, Rizzo M. Diagnosis and Treatment of Chronic Lunotriquetral Ligament Injuries. Hand Clin 2015;31(3):477-86. PMID: 26205709
  5. Nicoson MC, Moran SL. Diagnosis and Treatment of Acute Lunotriquetral Ligament Injuries. Hand Clin 2015;31(3):467-76. PMID: 26205708
  6. Omokawa S, Fujitani R, Inada Y. Dorsal radiocarpal ligament capsulodesis for chronic dynamic lunotriquetral instability. J Hand Surg Am 2009;34(2):237-43. PMID: 19181224
  7. Mirza A, Mirza JB, Shin AY, et al. Isolated lunotriquetral ligament tears treated with ulnar shortening osteotomy. J Hand Surg Am 2013;38(8):1492-7. PMID: 23849735
  8. Atkinson CT, Watson J. Lunotriquetral ligament tears. J Hand Surg Am 2012;37(10):2142-4. PMID: 22633232
  9. Slutsky DJ, Trevare J. Scapholunate and lunotriquetral injuries: arthroscopic and open management. Sports Med Arthrosc 2014;22(1):12-21. PMID: 24651286

Reviews

  1. Vezeridis PS, Yoshioka H, Han R, Blazar P. Ulnar-sided wrist pain. part I: Anatomy and physical examination. Skeletal Radiol 2010;39(8):733-745. PMID: 19722104
  2. Watanabe A, Souza F, Vezeridis PS, et al. Ulnar-sided wrist pain. II. Clinical imaging and treatment. Skeletal Radiol 2010;39(9):837-857. PMID: 20012039

Classics

  1. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J Hand Surg Am 1984;9(4):502-514. PMID: 6747234
  2. Ritt MJ, Linscheid RL, Cooney WP 3rd, et al. The lunotriquetral joint: Kinematic effects of sequential ligament sectioning, ligament repair, and arthrodesis. J Hand Surg Am 1998;23(3):432-445. PMID: 9620184
  3. Pin PG, Young VL, Gilula LA, Weeks PM. Management of chronic lunotriquetral ligament tears. J Hand Surg Am 1989;14(1):77-83. PMID: 2723372
  4. Butterfield WL, Joshi AB, Lichtman D. Lunotriquetral injuries. J Hand Surg Am 2002;27(4):195-203.
  5. Shin AY, Weinstein LP, Berger RA, Bishop AT. Treatment of isolated injuries of the lunotriquetral ligament. A comparison of arthrodesis, ligament reconstruction and ligament repair. J Bone Joint Surg Br 2001;83(7):1023-8. PMID: 11603516
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