Imaging in carpal instability

Development and stability analysis of carpal kinematic metrics from 4D magnetic resonance imaging

OBJECTIVE

To develop MRI-derived carpal kinematic metrics and investigating their stability.

METHODS

The study used a 4D MRI method to track scaphoid, lunate, and capitate movements in the wrist. A panel of 120 metrics for radial-ulnar deviation and flexion-extension was created using polynomial models of scaphoid and lunate movements relative to the capitate. Intraclass correlation coefficients (ICCs) analyzed intra- and inter-subject stability in 49 subjects, 20 with and 29 without wrist injury history.

RESULTS

Comparable degrees of stability were observed across the two different wrist movements. Among the total 120 derived metrics, distinct subsets demonstrated high stability within each type of movement. For asymptomatic subjects, 16 out of 17 metrics with high intra-subject stability also showed high inter-subject stability. The differential analysis of ICC values for each metric between asymptomatic and symptomatic cohorts revealed specific metrics (although relatively unstable) exhibiting greater variability in the symptomatic cohort, thereby highlighting the impact of wrist conditions on the variability of kinematic metrics.

CONCLUSION

The findings demonstrate the developing potential of dynamic MRI for assessing and characterizing complex carpal bone dynamics. Stability analyses of the derived kinematic metrics revealed encouraging differences between cohorts with and without wrist injury histories. Although these broad metric stability variations highlight the potential utility of this approach for analyzing carpal instability, further studies are necessary to better characterize these observations.

Midcarpal Instability

Midcarpal instability (MCI) of the wrist represents multiple distinct clinical entities that all have in common abnormal force transmission across the midcarpal joint. This can be asymptomatic but can also result in painful wrist motion, a characteristic catch-up clunk, and symptoms of instability. The carpus is stabilized by numerous extrinsic and intrinsic ligaments. Dynamic joint reactive forces between the proximal and distal carpal rows help create reciprocal motion, which results in smooth, physiologic wrist mechanics. Diagnosis of MCI requires a thorough history, physical examination, and adequate imaging. MCI can be managed nonsurgically with activity modification, physical therapy, specialized orthotics, medications, and corticosteroid injections. A variety of surgical treatment options exists to treat symptomatic MCI. These include arthroscopic thermal capsulorrhaphy, ligament repair or reconstruction, radial osteotomies, and limited radiocarpal or intercarpal fusions. Capsulorrhaphy or ligament repair is favored for mild to moderate cases; osteotomies can be used for the correction of bony deformities contributing to instability, whereas partial wrist arthrodesis is indicated for severe or recurrent instability and fixed deformities.

Kinematic 4D CT case-control study of wrist in dart throwing motion "in vivo": comparison with other maneuvers

OBJECTIVES

To compare the diagnostic performance of scapholunate gap (SLG) measurements acquired with dart throwing (DT), radio-ulnar deviation (RUD), and clenching fist (CF) maneuvers on 4D CT for the identification of scapholunate instability.

METHODS

In this prospective study, 47 patients with suspected scapholunate interosseous ligament (SLIL) tears were evaluated from March 2015 to March 2020 with semiautomatic quantitative analysis on 4D CT. Five parameters (median, maximal value, range, and coefficient of variation) for SLG, lunocapitate angle (LCA), and radioscaphoid angle (RSA) obtained during DT maneuver were evaluated in patients with and without SLIL tears. CT arthrography was used as the gold standard for the SLIL status. The SLG values obtained were also compared with those obtained during CF and RUD maneuvers.

RESULTS

Significant differences in all SLG- and LCA-derived parameters are found between patients with and without SLIL tears with DT (p < 0.003). The best diagnostic performance for the diagnosis of SLIL tears was obtained with median and maximal SLG values (sensitivity and specificity of 86-89% and 95%) and with maximal and range LCA values (sensitivity and specificity of 86% and 74%). No significant differences were observed for RSA values (p > 0.275). The SLG range obtained with DT maneuver was the only dynamic parameter statistically different between patients with partial and complete torn SLIL (p = 0.037).

CONCLUSION

4D CT of the wrist during DT showed a similar performance than RUD and a better performance than CF for the differentiation between patients with and without SLIL tears.

KEY POINTS

• Four-dimensional computed tomography can dynamically assess scapholunate instability. • The best results for differentiating between patients with and without SLIL tears were obtained with SLG median and maximal values. • The dart throwing and radio-ulnar deviation maneuvers yielded the best results for the dynamic evaluation of scapholunate instability.

Radiographic Evaluation of Carpal Mechanics and the Scapholunate Angle in a Clenched Fist with Dynamic Computed Tomography Imaging

Purpose

The long-term consequences of injuries to the scapholunate joint can severely limit hand function, and the potential for posttraumatic deformity makes early recognition of these injuries important. The purpose of this study was to evaluate the motion of the scapholunate joint in normal wrists through the radial and ulnar deviation using novel dynamic computed tomography (CT) imaging.

Methods

Fifteen participants consented to have their uninjured wrists scanned. A protocol was designed to ensure adequate time, yet limited exposure, for volunteers. Participants began with the hand in a relaxed fist position and then proceeded to clench the hand in a full fist and relax. Once relaxed again, the wrist was maximally ulnarly deviated and then maximally radially deviated in a fluid motion. Dynamic CT imaging was captured throughout the range of motion.

Results

The scapholunate angle was measured on dynamic wrist images. The mean range of the scapholunate angle that the wrists moved through was 37.2°-45.9°, and the mean midpoint angle was 41.2° ± 0.4°. All wrists had small, measurable differences in the scapholunate angle when moving from the maximum ulnar deviation to the maximal radial deviation. The average maximum angle change through the range is 11.7°, whereas the average minimum angle change was 0.9°.

Conclusions

In this study, scapholunate angle calculations using dynamic wrist CT scans were within the range of accepted normal for the angle in uninjured wrists. With the increased focus on dynamic imaging for wrist motion, it may be possible to derive a standardized protocol for mapping the carpal motion that is clinically applicable and reproducible.

Type of study/level of evidence

Diagnostic IV.

Bilateral Ulnar Deviation Supination Stress Test to Assess Dynamic Scapholunate Instability

PURPOSE

We describe a new radiologic test to assess the integrity of the scapholunate ligament in dynamic scapholunate dysfunction.

METHODS

A bilateral forearm-holding device was designed to perform a comparative radiographic assessment of the scapholunate joint gap during resisted isometric contraction of the extensor carpi ulnaris muscle with full supination of the forearm. The concept is based on the known scaphoid pronation effect of this muscle. Clinical data from 12 patients were collected retrospectively and used to analyze the patients' symptomatic and asymptomatic (contralateral) wrists with a newly developed test called the Bilateral Ulnar Deviation Supination (BUDS) test. A wrist arthroscopy was performed in all cases as a reference standard for the radiologic test.

RESULTS

The test was positive in 7 patients, with a mean scapholunate joint gap of 4.8 mm. The mean differences in the scapholunate joint gaps between both wrists were 2.6 mm in BUDS-positive patients and 0.2 mm in BUDS-negative patients. A Geissler stage III or IV scapholunate ligament rupture was confirmed in all BUDS-positive patients; by contrast, BUDS-negative patients exhibited either no lesion or a Geissler stage I injury.

CONCLUSIONS

The BUDS test is a new radiologic test based on proven biomechanical effects that is able to accurately assess dynamic scapholunate dysfunctions. The analysis carried out found a correlation between radiographic and arthroscopic findings. Further research is needed to confirm the validity and reliability of the test.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

[Establishing a standardized diagnostic Procedure for sonographic Imaging and Evaluation of the scapholunate Ligament]

BACKGROUND

Ultrasound has not yet been established in the diagnostic workup of scapholunate ligament lesions. We aimed to develop a standardised examination procedure to visualise and evaluate the SL ligament.

PATIENTS AND METHODS

Forty patients (70 hands) were examined prospectively with ultrasonography and the results were compared with arthroscopy and MRI findings. We studied the visibility of the SL ligament and the SL distance on side-to-side comparison and performed a method comparison between MRI/arthroscopy and ultrasound, testing for distinction and accordance. Cut-off values for the SL distance indicating a lesion were determined and all parameters were used for developing a score.

RESULTS

An intact ligament appears as a hyperechogenic, fibrillary structure and shows discontinuity or a hypoechogenic space when injured. An intact ligament was visible dorsally in 89.6 % and palmarly in 83.3 %. The SL distance for an intact ligament was 5/2/5.1 mm for the dorsal/middle/palmar aspect (range 3.2-6.7/0.9-4/3.1-7.8 mm) and 6.4/3/6.3 mm (range 5-9.4/2-6.2/4-9.3 mm) for a lesion. The difference between the right and left hand with an intact ligament was a maximum of 2.1/1.1/1.8 mm, an average of 0.4/0.2/0.2 mm; in case of an injury, the maximum difference was 1.2/0.9/1.1 mm. Distance values for radial and ulnar deviation were physiological but partly unpredictable. The cut-off values determined for a lesion are 5.05 mm for the dorsal aspect (sensitivity/specificity 0.95/0.60), 1.95 mm for the middle (1/0.62) and 6.15 mm for the palmar aspect (0.55/0.85). The created sonographic SL ligament score has a high AUC (area under the curve) of 0.93, a sensitivity of 85 % and a specificity of 90 %.

CONCLUSION

The parameters, especially when combined to a score, allow to state whether the SL ligament is intact or not. Ultrasound can, therefore, be recommended as a diagnostic and screening method for an SL ligament lesion und should be used as a routine tool. The criteria must be checked from a perspective with high case numbers.

Osteoarthritis of the Wrist: Pathology, Radiology, and Treatment

Osteoarthritis (OA) is a degenerative disease that can manifest in any synovial joint under certain conditions. It leads to destruction of articular cartilage and adjacent bone, as well as formation of osteophytes at the edges of afflicted joint surfaces. Regarding the wrist, typical degenerative arthritis affects particular joints at a specific patient age, due to asymmetric load distribution and repetitive microtrauma. However, in the presence of instability or systemic diseases, early-onset degeneration can also impair the range of motion and grip strength in younger patients. Although advanced stages of OA display characteristic signs in radiography, the detection of early manifestations frequently requires computed tomography or magnetic resonance imaging (in some cases with additional arthrography). If a wrist becomes unstable, timely diagnosis and precise treatment are essential to prevent rapid disease progression. Therefore, close collaboration between radiologists and hand surgeons is obligatory to preserve the carpal function of patients.

Deep Learning-Based Post-Processing of Real-Time MRI to Assess and Quantify Dynamic Wrist Movement in Health and Disease

While morphologic magnetic resonance imaging (MRI) is the imaging modality of choice for the evaluation of ligamentous wrist injuries, it is merely static and incapable of diagnosing dynamic wrist instability. Based on real-time MRI and algorithm-based image post-processing in terms of convolutional neural networks (CNNs), this study aims to develop and validate an automatic technique to quantify wrist movement. A total of 56 bilateral wrists (28 healthy volunteers) were imaged during continuous and alternating maximum ulnar and radial abduction. Following CNN-based automatic segmentations of carpal bone contours, scapholunate and lunotriquetral gap widths were quantified based on dedicated algorithms and as a function of wrist position. Automatic segmentations were in excellent agreement with manual reference segmentations performed by two radiologists as indicated by Dice similarity coefficients of 0.96 ± 0.02 and consistent and unskewed Bland–Altman plots. Clinical applicability of the framework was assessed in a patient with diagnosed scapholunate ligament injury. Considerable increases in scapholunate gap widths across the range-of-motion were found. In conclusion, the combination of real-time wrist MRI and the present framework provides a powerful diagnostic tool for dynamic assessment of wrist function and, if confirmed in clinical trials, dynamic carpal instability that may elude static assessment using clinical-standard imaging modalities.

Interdisciplinary consensus statements on imaging of scapholunate joint instability

Objectives

The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique.

Methods

Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of ‘0’, ‘5’ and ‘10’ reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of ‘8’ or higher for 80% or more of the panellists.

Results

Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available.

Conclusions

Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability.

Key Points

• Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability.

• Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability.

• Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Evaluation of Four-Dimensional Computed Tomography as a Technique for Quantifying Carpal Motion

Delayed diagnosis of dynamic carpal instability often occurs because early changes in bone alignment and movement are difficult to detect and manifest mainly during a dynamic/functional task. Current diagnostic tools are only able to examine the carpal bones under static or sequential-static conditions. Four-dimensional (three dimensions + time) computed tomography (4DCT) enables quantification of carpal mechanics through 3D volume sequences of the wrist in motion. A comprehensive understanding of carpal mechanics is needed to define normal function and structure and provide targets for treatment of carpal injuries. In this study, measurements of scaphoid translation and joint congruency were taken by creating models from the CT scans of the carpals in extreme frames of motion, registering those models to the neutral position, transforming the models into a local coordinate system, and using software to calculate the joint surface areas (JSA). Results indicated that the centroid of the scaphoid translated 6.4 ± 1.3 mm and extended from extreme radial to extreme ulnar deviation. Results are consistent with the literature. An additional study was performed to measure the responsiveness of the 4DCT technique presented. Bone models from each frame of motion for radio ulnar deviation (RUD) and flexion extension (FE) were created and distinct differences between their JSA were measured qualitatively and quantitatively. The results show that there was statistically significantly different JSA within carpal joints between RUD and FE. These studies provide the first step in developing the methodology when using 4DCT scanning to measure subtle abnormalities in the wrist.

Imaging of Carpal Instabilities

Background The term “carpal instability” describes different debilitating wrist conditions, in which the carpus is unable to maintain its physiological range of motion and load transfer. Depending on the cause and location of the dysfunction, four groups can be defined: dissociative, non-dissociative, complex, and adaptive carpal instability. As the most common form by far, dissociative carpal instability can further be categorized as dorsal or palmar intercalated segment instability, contingent on the afflicted interosseous ligament.

Method This review article outlines the different entities of carpal instability, their pathophysiology, and their clinical presentation. It further discusses the diagnostic significance of different imaging methods as well as the established treatment options for each form of instability in context with the current literature.

Results and Conclusion Early detection and treatment of carpal instability are essential for preventing carpal osteoarthritis. Traumatic lesions of the scapholunate interosseous ligament are the most frequent cause of instability. They can occur in an isolated fashion or in context with other carpal injuries. While stress imaging and fluoroscopy facilitate the differentiation between dynamic and static forms of carpal instability, only MRI and CT/MR arthrography can directly reveal the extent of ligament discontinuity.

Key Points:

Citation Format

Ultrasonography for Dorsal-Sided Wrist Pain in a Combat Environment: Technique, Pearls, and a Case Report of Dynamic Evaluation of the Scapholunate Ligament

Ultrasonography is a commonly utilized tool in orthopedic surgery for the diagnosis and treatment of a variety of musculoskeletal conditions, including pathology about the wrist. Its value should not be underestimated when other diagnostic resources are unavailable - such as in a combat setting where ultrasounds, but not X-ray, are a standard equipment item. An active duty soldier presented to an orthopedic provider in an austere environment with chronic dorsal wrist pain due to a previous fall. Physical examination and dynamic ultrasound examination allowed the deployed provider to diagnose a scapholunate ligament injury. The patient was appropriately evacuated to a higher level of care without the need for X-ray or other advanced imaging modalities. Making this readily available resource a standard tool for providers deployed to a forward location could be beneficial for efficient and appropriate patient evacuation for musculoskeletal injuries. It can also rule out injuries that would otherwise have required unnecessary soldier movement through hostile territory for diagnostic tests such as X-rays. In addition, a simple technique and pearls for ultrasonography of the wrist are provided.

Management of Nondissociative Instability of the Wrist

Nondissociative carpal instability is instability of an entire carpal row and can lead to vague ulnar-sided wrist pain as well as a clunking wrist. The etiology of this process is most often generalized ligamentous laxity; however, it can infrequently occur as a result of trauma or malalignment of the radiocarpal joint. Whereas treatment remains controversial, the literature supports nonsurgical management and includes patient education, dynamic placement of orthoses, proprioceptive therapy, and extensor carpi ulnaris strengthening. If extensive nonsurgical therapy fails, surgical intervention includes soft tissue and bony procedures, all with high complication and failure rates and limited long-term outcome data.

Perilunate injuries: biomechanics, imaging, and classification

Perilunate injuries are uncommon injuries that are often misdiagnosed. Although conventional radiographs can underestimate the severity of the perilunate injuries, assessment with cross-sectional imaging can be complex, and terminology is inconsistent in the scientific literature. The aim of this paper is to describe the biomechanics, anatomy, and classification of perilunate trauma in order to provide a systematic approach to the description and diagnosis of these injuries.

The Role of Cone-Beam Computed Tomography (CBCT) Scan for Detection and Follow-Up of Traumatic Wrist Pathologies

Emergency diagnostics demand fast, easily available, and cost-effective procedures. The higher the accuracy of radiological imaging, the better it supports the surgeon in decision-making for further treatment. Cone-beam computed tomography has been proven to be a reliable tool in diagnosing fractures of the hand and distal forearm. It can be easily installed, has a high spatial resolution, and a potentially lower radiation dose when compared with multislice computed tomography or a series of plain x-rays. This review focuses on the value of conventional radiography, cone-beam computed tomography, and multislice computed tomography for diagnosing traumatic wrist pathologies.

Real-time three-dimensional MRI for the assessment of dynamic carpal instability

Background

Carpal instability is defined as a condition where wrist motion and/or loading creates mechanical dysfunction, resulting in weakness, pain and decreased function. When conventional methods do not identify the instability patterns, yet clinical signs of instability exist, the diagnosis of dynamic instability is often suggested to describe carpal derangement manifested only during the wrist’s active motion or stress. We addressed the question: can advanced MRI techniques provide quantitative means to evaluate dynamic carpal instability and supplement standard static MRI acquisition? Our objectives were to (i) develop a real-time, three-dimensional MRI method to image the carpal joints during their active, uninterrupted motion; and (ii) demonstrate feasibility of the method for assessing metrics relevant to dynamic carpal instability, thus overcoming limitations of standard MRI.

Methods

Twenty wrists (bilateral wrists of ten healthy participants) were scanned during radial-ulnar deviation and clenched-fist maneuvers. Images resulting from two real-time MRI pulse sequences, four sparse data-acquisition schemes, and three constrained image reconstruction techniques were compared. Image quality was assessed via blinded scoring by three radiologists and quantitative imaging metrics.

Results

Real-time MRI data-acquisition employing sparse radial sampling with a gradient-recalled-echo acquisition and constrained iterative reconstruction appeared to provide a practical tradeoff between imaging speed (temporal resolution up to 135 ms per slice) and image quality. The method effectively reduced streaking artifacts arising from data undersampling and enabled the derivation of quantitative measures pertinent to evaluating dynamic carpal instability.

Conclusion

This study demonstrates that real-time, three-dimensional MRI of the moving wrist is feasible and may be useful for the evaluation of dynamic carpal instability.

Evaluation of a Quantitative Method for Carpal Motion Analysis Using Clinical 3-D and 4-D CT Protocols

For wrist complaints related to motion, a 2-D radiograph or CT scan of the static wrist may not always be considered diagnostic. 3-D motion imaging, i.e., multiple 3DCT scans in time (4DCT), enables quantifying carpal motion and comparing motion patterns of the affected wrist with those of the healthy contralateral side. The accuracy and precision of the method, however, is limited by noise and motion artifacts. Although, the technique is considered promising in existing literature, the accuracy and precision of carpal motion analysis has never been investigated systematically. In this paper, we introduce and evaluate a semi-automatic segmentation- and registration-based method for 3-D carpal motion analysis. We investigate the accuracy and precision of the method, and its dependency on motion and scan parameters (angular velocity, dose, gantry revolution angle for image reconstruction, and scanner type) using a wrist phantom. During standstill the positioning error was ≤ 0.23 mm and ≤ 0.78°. A partial gantry revolution for 3-D reconstruction introduced image deformation, contributing to a positioning error of approx. 0.8 mm. This error increased with reduced dose, and with increasing angular velocity of the wrist phantom. In cases where the phantom was rotating about an axis parallel to the rotation axis of the gantry, and in a direction opposite to the gantry, the positioning error increased, probably because of the apparent increase in angular velocity with respect to the gantry. Slow carpal motion 4DCT analysis is feasible using a regular CT scanner. A partial gantry revolution angle for 3-D reconstruction may introduce image deformation, which decreases the accuracy of carpal motion analysis. Knowing the positioning error in 4DCT imaging with the proposed method is considered valuable when investigating wrist injury since it enables discrimination of actual motion from apparent motion caused by methodological error.

Dynamic CT Scan of the Normal Scapholunate Joint in a Clenched Fist and Radial and Ulnar Deviation

BACKGROUND

Injuries to the scapholunate can have severe long-term effects on the wrist. Early detection of these injuries can help identify pathology. The purpose of this study was to evaluate the motions of the scapholunate joint in normal wrists in a clenched fist and through radial and ulnar deviation using novel dynamic computed tomography (CT) imaging.

METHODS

Fifteen participants below 40 years of age consented to have their wrist scanned. Eight participants were randomized to have the right wrist scanned and 7 the left wrist. Volunteers were positioned at the back of the gantry with the wrist placed on the table, palmar side down. Participants began with the hand in a relaxed fist position and then proceeded through an established range of motion protocol. Dynamic CT imaging was captured throughout the range of motion.

RESULTS

The movement in the healthy scapholunate joint through a clenched fist and radial and ulnar deviation is minimal. The averages were 1.19, 1.01, and 0.95 mm, representing the middle, dorsal, and volar measurements, respectively.

CONCLUSIONS

This novel dynamic CT scan of the wrist is a user-friendly way of measuring of the scapholunate distance, which is minimal in the normal wrist below 40 years of age.

Long-Term Functional Results of a Wrist Exercise Program for Patients with Palmar Midcarpal Instability

Background  Patients with palmar midcarpal instability have symptoms of pain, combined with clinical signs of abnormal mobility on stressing the joint, an unpredictable blockade feeling, and a noticeable clunk, in the absence of an underlying trauma. No data are available on the effect of conservative treatment for these patients. Purpose  The purpose of this study was to evaluate the effect and the long-term functional outcomes of a wrist exercise program in patients with palmar midcarpal instability. Patients and Methods  All patients diagnosed with palmar midcarpal instability between 2005 and 2011 were included. Patients completed the Patient-Rated Wrist and Hand Evaluation (PRWHE) and the Short Form-36 health (SF-36) questionnaires, scaled their perceived pain before and after treatment, and indicated the effect of the received treatment. Results  A total of 119 patients diagnosed with palmar midcarpal instability were included. The median follow-up time was 6 years (IQR 4.5-7.0). The median PRWHE score after hand therapy was 35.5 and the median mental component of the SF-36 score was 53.9 and the physical component was 45.2. The median perceived pain reduced from eight to four and the median therapeutic effect of the wrist exercise program was five. Conclusion  Although palmar midcarpal instability remains to be a chronic disease, the effectiveness of our wrist exercise program is promising with acceptable long-term functional results and a good quality of life. Level of Evidence  Level IV, retrospective cohort study.

Scapholunate dissociation; diagnostics made easy

Scapholunate dissociation (SLD) is a form of carpal instability, caused by rupture of the scapholunate ligament (SLL) the secondary stabiliser of the scapholunate (SL) compartment. SLD can cause osteoarthritis of the wrist. Recently a study was published that shows cineradiography to be an excellent radiological imaging technique for diagnosing SLD at a tertiary centre for hand and wrist surgery [1]. As the quality of these results can be influenced by the expertise of the operator and observer of the cineradiographic studies, the aim of this study was to determine if these results were reproducible at a secondary centre for hand and wrist surgery with less expertise in wrist cineradiography. All cineradiographic studies carried out during a 10-year period were obtained. All patients who underwent the gold standard procedure (arthroscopy/arthrotomy) after cineradiography were included, a total of 50 patients. The diagnostic accuracy of detecting SLD by both cineradiography and conventional radiography was calculated. Cineradiography had a high diagnostic accuracy, while the accuracy for conventional radiography was average. When all wrists with an SL distance ≥3mm were excluded (static SLD), diagnostic accuracy for conventional radiography dropped even lower, while accuracy for cineradiography remained high. These results are comparable with published accuracy rates and show that cineradiography has a high diagnostic value for detecting SLD and do not seem to be influenced by the operator or observer of the cineradiographic studies.