Bilateral Ulnar Deviation Supination Stress Test to Assess Dynamic Scapholunate Instability


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


      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.


      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.


      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.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Salva-Coll G.
        • Garcia-Elias M.
        • Hagert E.
        Scapholunate instability: proprioception and neuromuscular control.
        J Wrist Surg. 2013; 2: 136-140
        • Hagert E.
        • Lluch A.
        • Rein S.
        The role of proprioception and neuromuscular stability in carpal instabilities.
        J Hand Surg Eur Vol. 2016; 41: 94-101
        • León-López M.M.
        • García-Elías M.
        • Salvà-Coll G.
        • Llusá-Perez M.
        • Lluch-Bergadà A.
        Muscular control of scapholunate instability. An experimental study.
        Rev Esp Cir Ortop Traumatol. 2014; 58: 11-18
        • Salva-Coll G.
        • Garcia-Elias M.
        • Lluch-Bergada A.
        • Esplugas M.
        • Llusa-Perez M.
        Kinetic dysfunction of the wrist with chronic scapholunate dissociation. A cadaver study.
        Clin Biomech (Bristol Avon). 2020; 77: 105046
        • Wolfe S.W.
        Scapholunate instability.
        J Am Soc Surg Hand. 2001; 1: 45-60
        • Kitay A.
        • Wolfe S.W.
        Scapholunate instability: current concepts in diagnosis and management.
        J Hand Surg Am. 2012; 37: 2175-2196
        • Lawand A.
        • Foulkes G.D.
        The “clenched pencil” view: a modified clenched fist scapholunate stress view.
        J Hand Surg Am. 2003; 28: 414-418
        • Ramamurthy N.K.
        • Chojnowski A.J.
        • Toms A.P.
        Imaging in carpal instability.
        J Hand Surg Eur Vol. 2016; 41: 22-34
        • Pliefke J.
        • Stengel D.
        • Rademacher G.
        • Mutze S.
        • Ekkernkamp A.
        • Eisenschenk A.
        Diagnostic accuracy of plain radiographs and cineradiography in diagnosing traumatic scapholunate dissociation.
        Skelet Radiol. 2008; 37: 139-145
        • Sulkers G.S.I.
        • Schep N.W.L.
        • Maas M.
        • Van Der Horst C.M.A.M.
        • Goslings J.C.
        • Strackee S.D.
        The diagnostic accuracy of wrist cineradiography in diagnosing scapholunate dissociation.
        J Hand Surg Eur Vol. 2014; 39: 263-271
        • Salva-Coll G.
        • Garcia-Elias M.
        • Leon-Lopez M.T.
        • Llusa-Perez M.
        • Rodríguez-Baeza A.
        Effects of forearm muscles on carpal stability.
        J Hand Surg Eur Vol. 2011; 36: 553-559
        • Esplugas M.
        • Garcia-Elias M.
        • Lluch A.
        • Llusá Pérez M.
        Role of muscles in the stabilization of ligament-deficient wrists.
        J Hand Ther. 2016; 29: 166-174
        • Schimmerl-Metz S.M.
        • Metz V.M.
        • Totterman S.M.S.
        • Mann F.A.
        • Gilula L.A.
        Radiologic measurement of the scapholunate joint: implications of biologic variation in scapholunate joint morphology.
        J Hand Surg Am. 1999; 24: 1237-1244
        • Sulkers G.S.I.
        • Strackee S.D.
        • Schep N.W.L.
        • Maas M.
        Wrist cineradiography: a protocol for diagnosing carpal instability.
        J Hand Surg Eur Vol. 2018; 43: 174-178
        • Demehri S.
        • Hafezi-Nejad N.
        • Morelli J.N.
        • et al.
        Scapholunate kinematics of asymptomatic wrists in comparison with symptomatic contralateral wrists using four-dimensional CT examinations: initial clinical experience.
        Skelet Radiol. 2016; 45: 437-446
        • Kakar S.
        • Breighner R.E.
        • Leng S.
        • et al.
        The role of dynamic (4D) CT in the detection of scapholunate ligament injury.
        J Wrist Surg. 2016; 5: 306-310
        • Patel R.M.
        • Kalainov D.M.
        • Chilelli B.J.
        • Makowiec R.L.
        Comparisons of three radiographic views in assessing for scapholunate instability.
        Hand (N Y). 2015; 10: 233-238
        • Lee S.K.
        • Desai H.
        • Silver B.
        • Dhaliwal G.
        • Paksima N.
        Comparison of radiographic stress views for scapholunate dynamic instability in a cadaver model.
        J Hand Surg Am. 2011; 36: 1149-1157
        • Eraktas İ.
        • Ayhan C.
        • Hayran M.
        • Soylu A.R.
        Alterations in forearm muscle activation patterns after scapholunate interosseous ligament injury: a dynamic electromyography study.
        J Hand Ther. 2021; 34: 384-395
        • Said J.
        • Baker K.
        • Fernandez L.
        • Komatsu D.E.
        • Gould E.
        • Hurst L.C.
        The optimal location to measure scapholunate diastasis on screening radiographs.
        Hand (N Y). 2018; 13: 671-677
        • Andersson J.K.
        Treatment of scapholunate ligament injury: current concepts.
        EFORT Open Rev. 2017; 2: 382-393
        • Kani K.K.
        • Mulcahy H.
        • Chew F.S.
        Understanding carpal instability: a radiographic perspective.
        Skelet Radiol. 2016; 45: 1031-1043
        • Dornberger J.E.
        • Rademacher G.
        • Mutze S.
        • Eisenschenk A.
        • Stengel D.
        Accuracy of simple plain radiographic signs and measures to diagnose acute scapholunate ligament injuries of the wrist.
        Eur Radiol. 2015; 25: 3488-3498
        • Özçelik A.
        • Günal I.
        • Köse N.
        Stress views in the radiography of scapholunate instability.
        Eur J Radiol. 2005; 56: 358-361
        • Sikora S.K.
        • Tham S.K.
        • Harvey J.N.
        • et al.
        The twist x-ray: a novel test for dynamic scapholunate instability.
        J Wrist Surg. 2019; 8: 61-65