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Modified Carpal Stretch Test as a Screening Test for Detection of Scapholunate Interosseous Ligament Injuries Associated with Distal Radial Fractures
Bong Cheol Kwon, MD, PhD1; Soo-Joong Choi, MD1; Si-Young Song, MD1; Sang Hoon Baek, MD1; Goo Hyun Baek, MD, PhD2
1 Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Pyeongchon-dong Dongan-gu, Anyang-si Gyeonggi-do, 431-070, South Korea. E-mail address for B.C. Kwon: bckwon11@gmail.com
2 Department of Orthopedic Surgery, Seoul National University College of Medicine, 28 Yongon-Dong, Chongno-Gu, Seoul 110-744, South Korea. E-mail address: ghbaek@snu.ac.kr
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Gyeonggi-do, South Korea

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 May 04;93(9):855-862. doi: 10.2106/JBJS.J.00361
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Intra-articular distal radial fractures are frequently accompanied by a scapholunate interosseous ligament injury, which may adversely affect the outcomes. Arthroscopy may not be appropriate as a first-line evaluation method to diagnose these injuries because of time, expense, and availability issues. The purpose of this study was to evaluate the effectiveness of the modified carpal stretch test for screening for scapholunate interosseous ligament injuries in patients with an intra-articular distal radial fracture.


The carpal stretch test is a radiographic evaluation in which disruption of the smooth arc of the proximal carpal row joint line indicates a lack of integrity of the scapholunate interosseous ligament. We modified the original carpal stretch test and prospectively performed the modified test on forty-eight patients with a total of forty-nine unstable intra-articular distal radial fractures. With the patient under anesthesia, the injured wrist was evaluated with the modified carpal stretch test with fluoroscopy. The wrist was then examined arthroscopically to classify the scapholunate interosseous ligament injury. Three observers independently determined whether there was disruption of the proximal carpal row joint line (Gilula's arc II), used as an indicator of a grade-III or IV scapholunate interosseous ligament tear, on fluoroscopic images. The fluoroscopic results were compared with the arthroscopic findings.


The average sensitivity of the modified carpal stretch test was 78%, the average specificity was 72%, the average positive predictive value was 60%, the average negative predictive value was 87%, and the average accuracy was 74%. The intraclass correlation coefficient (ICC) for interobserver agreement was 0.73, and the ICCs for intraobserver agreement were 0.86, 0.68, and 0.84 for the three observers.


The modified carpal stretch test was useful to rule out grade-III or IV scapholunate interosseous ligament tears associated with intra-articular distal radial fractures, but it was not as useful to confirm the presence of a tear. This test may reduce the necessity for arthroscopic assessment to identify scapholunate interosseous ligament injuries following distal radial fractures and may improve the rates of detection of important carpal ligament injuries accompanying intra-articular distal radial fractures.

Level of Evidence: 

Diagnostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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