Box 1 Wrist arthrofibrosis classification

Type I: Intrinsic (adhesions)

A. Radiocarpal joint (Fig. 1)

B. Midcarpal joint

C. Distal radioulnar joint (DRUJ)

D. Combination of above

Type II: Extrinsic (capsular fibrosis)

A. Dorsal

B. Palmar

C. Distal radioulnar joint (DRUJ)

D. Combination of above

Cancer Radius
Fig. 1. Fibrous bands (arrow) extend from the radius to the carpus (Type IA wrist arthrofibrosis). This ''spot welds'' the carpus to the radius.

through creep, or the permanent deformation of tissue when placed under constant stress for an extended period of time. Typical dynamic splinting regimens require 8 to 12 hours of splint usage per day. Static-progressive splinting produces plastic deformation through stress-relaxation, or the permanent deformation of tissue when held in a constant deformation. Both methods improve motion of contracted joints, but static-progressive splints require shorter treatment times and are generally better tolerated by patients [33,35].

Most cases do respond to nonoperative treatment. If after 3 months of noninvasive treatment, range of motion remains unacceptable, then intra-articular corticosteroid injection may be indicated, based on data from adhesive capsulitis of the shoulder [36]. If the range of motion has pla-teaued after 6 months of physiotherapy, splinting, and corticosteroid injections, and the range of motion is inadequate for activities of daily living, surgical treatment may be indicated.

Operative

Types IA, B, and D have intraarticular adhesions (Fig. 1) and are best approached arthro-scopically. Surgical arthroscopic treatment of arthrofibrosis has been successfully used for contracture of the knee, shoulder, and elbow [1,3,

9-12,37-39]. Hattori and colleagues [40] have recently reported on arthroscopic treatment of wrist intraarticular adhesions. In a series of 11 patients, they attained improvement in 91% of patients with an average increase of 22 degrees of range of motion.

Arthroscopic radiocarpal and midcarpal joint intrinsic adhesion release

Standard wrist portals are initially used (3-4, 4-5, 6R, 6U, MCR, MCU) and thorough resection of intraarticular adhesions is performed. A combination of shaver, thermal ablation, arthroscopic biters, and graspers are employed. Both radiocarpal and midcarpal joints are inspected and pathologic adhesions debrided. Additional 1-2 and palmar radial portals may be used to visualize and resect adhesions in the dorsal aspect of the joint. The palmar radial portal is made by making a 2-cm incision over the flexor carpi radialis (FCR) tendon at the level of the radiocarpal joint. The tendon sheath is incised and the FCR tendon is retracted ulnarly. The portal is made through the FCR subsheath [41].

Types IC and II C are best approached by the open procedure as described by Kleinman and Graham [42,43] (Fig. 2). Open dorsal and palmar capsulectomies of the distal radioulnar joint have been described by the authors for posttraumatic contracture of the distal radioulnar joint capsule limiting supination and pronation. They reported on nine patients who had average gains of 51 degrees of supination from 21 degrees preoperatively to 72 degrees postoperatively and 28 degrees of pronation gain from 54 degrees preoperatively to 82 degrees postoperatively [42].

Open distal radioulnar joint contracture release (Kleinman and Graham technique)

Palmar distal radioulnar joint release

Palmar capsulectomy is indicated for loss of supination [42]. It is performed by approaching the DRUJ through an interval between the ulnar neurovascular bundle and the flexor carpi ulnaris tendon. The neurovascular bundle is gently retracted ulnarly and the extrinsic flexor muscle mass is retracted radially. The space between the proximal aspect of the palmar radioulnar ligament and distal ulnar head is identified with an 18-gauge needle, which may be confirmed radio-graphically. The DRUJ arthrotomy is initiated

Mri Radioulnar Ligament Tear

Fig. 2. DRUJ ''silhouette'' capsulectomy. The palmar side is similar. Dorsal and palmar capsulectomies are performed by excising a portion of capsule ''silhouetting'' the ulnar head. The resection of the central portion of the thickened capsule preserves the critical ligamentous portions of the triangular fibrocartilage complex. (Adapted from Kaplan FTD. Stiffness and joint contracture. In: Friedman SL, editor. Complications in orthopaedics—distal radius fractures. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2005. p. 53.)

Fig. 2. DRUJ ''silhouette'' capsulectomy. The palmar side is similar. Dorsal and palmar capsulectomies are performed by excising a portion of capsule ''silhouetting'' the ulnar head. The resection of the central portion of the thickened capsule preserves the critical ligamentous portions of the triangular fibrocartilage complex. (Adapted from Kaplan FTD. Stiffness and joint contracture. In: Friedman SL, editor. Complications in orthopaedics—distal radius fractures. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2005. p. 53.)

with a transverse incision in this space. All the elements of the triangular fibrocartilage complex are spared. Complete excision of the palmar capsule is accomplished by first dissecting toward its insertion on the radius, paralleling the proximal margin of the palmar radioulnar ligament. The dissection continues proximally along the margin of the sigmoid notch of the radius to the edge of the proximal aspect of the ulnar head. The scalpel is then directed ulnarward, outlining the hyaline cartilage surface of the palmar aspect of the ulnar head. By following the contour of the distal ulna in this manner, a palmar ''silhouette '' resection of the DRUJ capsule is accomplished to completely excise the thickened elements of the capsule while protecting the articular surfaces of the distal ulna and distal radial sigmoid notch.

Dorsal distal radioulnar joint release

Dorsal DRUJ capsulectomy is indicated for loss of pronation. The capsule is approached by retracting the extensor digiti quinti from the fifth dorsal compartment. The floor of the fifth compartment either can be elevated from the underlying dorsal DRUJ capsule or can be included in the silhouette capsulectomy, which is preferable for surgical efficiency. Like the palmar procedure, the space between the proximal aspect of the dorsal radioulnar ligament and the distal ulnar head is identified with an 18-gauge needle. A transverse incision is then made in this space toward the radius, remaining parallel to the distal radioulnar ligament. Incise proximally along the border of the sigmoid notch to the proximal aspect of the ulnar head. Then incise ulnarly, outlining the ulnar head to make a window in the dorsal capsule, which ''silhouettes'' the ulnar head (Fig. 2). The stout inferior aspect of the capsule is maintained in all cases. Once either the palmar or dorsal capsular resection is performed, any intra-articular adhesions can be lysed with a Freer elevator.

Types IIA, B and D usually do not require surgery; if they do, both open [14] and arthroscopic [44] methods have been described. Watson and Weinzweig [14], using both open dorsal and palmar approaches, have described surgical release of extrinsic joint contracture.

Open wrist extrinsic contracture release (Watson and Weinzweig technique)

For contracture limiting wrist flexion, the dorsum of the wrist is approached through a longitudinal or transverse incision at the level of the radial styloid; it is rarely necessary to completely open any of the extensor retinacular compartments [14]. The tendons are retracted to provide exposure of the wrist joint and dorsal cap-sulotomy is performed, releasing the dorsal capsule radial to Lister's tubercle and the dorsal radiocarpal ligament (dorsal radiolunotriquetral ligament), which is originates ulnar to Lister's tubercle (Fig. 3). Following release, it is important to analyze wrist motion by fluoroscopy. If the wrist is hinging open dorsally and the radiocarpal motion is not congruous, then a palmar approach is needed to release the proximal row and allow translation until flexion occurs while maintaining normal articular contact. Combined denervation of the posterior interosseous nerve (PIN) and anterior interosseous nerve (AIN) may be performed at the same time to augment pain relief.

For contracture limiting wrist extension or for incongruous radiocarpal motion, a palmar

Dorsal Radiocarpal Ligament

Fig. 3. Dorsal extrinsic release of the radiocarpal joint. Dorsal capsule is incised radial to Lister's tubercle. The dorsal radiocarpal ligament (DRC) is incised ulnar to Lister's tubercle. DIC, dorsal intercarpal ligament. Arrow and dashed line = incision. (Adapted from Kaplan FTD. Stiffness and joint contracture. In: Friedman SL, editor. Complications in orthopaedics—distal radius fractures. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2005. p. 53.)

Fig. 3. Dorsal extrinsic release of the radiocarpal joint. Dorsal capsule is incised radial to Lister's tubercle. The dorsal radiocarpal ligament (DRC) is incised ulnar to Lister's tubercle. DIC, dorsal intercarpal ligament. Arrow and dashed line = incision. (Adapted from Kaplan FTD. Stiffness and joint contracture. In: Friedman SL, editor. Complications in orthopaedics—distal radius fractures. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2005. p. 53.)

approach is performed through an extended carpal tunnel incision with a 45 degree zig zag incision across the proximal wrist crease in line with the ulnar aspect of the palmaris longus, avoiding injury to the palmar cutaneous branch of the median nerve. The flexor tendon mass and median nerve are gently retracted radially and the ulnar neurovascular bundle is gently retracted ulnarly. The radiocarpal joint line is then identified and motion-limiting scar tissue is incised. This scar tissue lies superficial to the important palmar wrist ligaments, the radioscaphocapitate, long radiolunate (radiolunotriquetral), and short ra-diolunate ligaments (Fig. 4). The offending scar tissue tends to run longitudinally where the important palmar ligaments run obliquely. The palmar ligaments should be preserved if possible. Intraoperative gains in range of motion should be documented.

Studies on cadavers have demonstrated the safety of arthroscopic capsular release in the shoulder [39] and more recently in the wrist [44]. Verhellen and Bain [44] described arthroscopic

Fig. 4. Palmar extrinsic release of the radiocarpal joint. Scar tissue is incised (arrow and dashed line), which lies superficial to the important palmar wrist ligaments: ra-dioscaphocapitate (RSC), long radiolunate (LRL), and short radiolunate (SRL). These ligaments are preserved in the open palmar release as proposed by Watson and Weinzweig.

Fig. 4. Palmar extrinsic release of the radiocarpal joint. Scar tissue is incised (arrow and dashed line), which lies superficial to the important palmar wrist ligaments: ra-dioscaphocapitate (RSC), long radiolunate (LRL), and short radiolunate (SRL). These ligaments are preserved in the open palmar release as proposed by Watson and Weinzweig.

wrist capsular release. This relatively radical release should be approached with caution, because there is one single report of two cases of its use and no other verifying studies. Verhellen and Bain base their technique on the work of Viegas and colleagues [45], who demonstrated in a cadaveric study, that sectioning of numerous ligaments (Fig. 5) did not result in ulnar or palmar translation. With the addition of ulnar carpal (UC) sectioning palmar translation of the carpus occurred. The addition of sectioning of the dorsal ulnar (DUL) and palmar ulnar (PUL) ligaments led to ulnar translation as well. However, there were pressure centroid shifts in the palmar direction of both the scaphoid and lunate when only two ligaments, radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments, were sectioned. It is unclear how this would affect carpal wear patterns in vivo.

Verhellen and Bain [44] performed an anatomic study on 10 MRIs and two cadaveric specimens and reported that the average distance from the radiocarpal joint capsule to the neurovascular structures were 6.9 mm to the median nerve, 6.7 mm to the ulnar nerve, and 5.2 mm to the radial

Scapholunate Distance

Fig. 5. Ligaments resected in the arthroscopic capsular release as proposed by Verhellen and Bain. Ulnar ligaments (depicted in black) should not be sectioned (DUL, UC, PUL) to prevent instability. DC, dorsal capsule; RLT, radiolunotriquetral; DRC, dorsal ra-diocarpal; DUL, dorsal ulnar; UC, ulnocarpal; PUL, palmar ulnar; SRL, short radiolunate; RSL, radio-scapholunate; LRL, long radiolunate; RSC, radiosca-phocapitate. (Redrawn from Verhellen R, Bain GI. Arthroscopic capsular release for contracture of the wrist: a new technique. Arthroscopy 2000;16:108; with permission.)

LRL RSL

Fig. 5. Ligaments resected in the arthroscopic capsular release as proposed by Verhellen and Bain. Ulnar ligaments (depicted in black) should not be sectioned (DUL, UC, PUL) to prevent instability. DC, dorsal capsule; RLT, radiolunotriquetral; DRC, dorsal ra-diocarpal; DUL, dorsal ulnar; UC, ulnocarpal; PUL, palmar ulnar; SRL, short radiolunate; RSL, radio-scapholunate; LRL, long radiolunate; RSC, radiosca-phocapitate. (Redrawn from Verhellen R, Bain GI. Arthroscopic capsular release for contracture of the wrist: a new technique. Arthroscopy 2000;16:108; with permission.)

artery. Distances to the closer tendon structures were not reported. They reported on two cases with average improvements in range of motion of 30 degrees of flexion and 40 degrees extension. There was no clinical or radiographic evidence of carpal instability postoperatively in either case.

Arthroscopic extrinsic wrist contracture release (Verhellen and Bain technique, modified)

The arthroscope is placed in the three to 3-4 and an arthroscopic, hooked electrocautery device is introduced into the working portals of 6R and 4-5 to cut the palmar capsule and ligaments. The ligaments are cut until extracarpal fat and the flexor carpi radialis tendon are visualized. Division of the palmar capsule includes the short radiolunate ligament, the radioscapholunate ligament, the long radiolunate ligament, and the radioscaphocapitate ligament. The ulnotriquetral and ulnolunate ligament are left intact. The dorsal capsule and dorsal radiocarpal (dorsal radioluno-triquetral) ligament is then divided from the sigmoid notch to the radial styloid with the hooked electrocautery device. The dorsal ulnar ligament complex is left intact. The 1-2 and palmar radial portals are useful to visualize and work on dorsal aspects of the radiocarpal joint. The final ligamentous transections are depicted

(Fig. 5). The arthroscopic instruments are removed and gentle closed manipulation is performed to achieve maximal improvement in range of motion, which is documented.

Postoperative treatment

The postoperative treatment should consist of full, unrestricted mobilization of the wrist. Postoperative pain relief is generally well controlled with a wrist block or pain pump indwelling catheter regional block using 0.5% bupivacaine in the immediate postoperative period, followed by oral analgesics. Intensive physiotherapy and splinting should be used to maintain range of motion gained intraoperatively.

Illustrative case

A 22-year-old woman injured her left wrist in a motor vehicle collision (Fig. 6A,B). The fracture was fixed by open reduction internal fixation with a palmar fixed-angle plate and DRUJ pinning (Fig. 7A,B). The fracture healed, but despite 9 months of intensive postoperative physical therapy, the patient developed a painful left wrist and restricted range of motion to 10 degrees of extension and 30 degrees of flexion (Fig. 8A,B). Supination was minimally affected with lack of 10 degrees versus the contralateral side. Pronation, radial, and ulnar deviations were symmetric. Standard radiographs showed good reduction and complete healing of the fracture. MRI showed multiple adhesive fibrous bands from the distal radius to the carpus, which were tethering motion (Fig. 9).

The patient was diagnosed with Type IA wrist arthrofibrosis that had failed nonoperative treatment. Arthroscopy confirmed intraarticular radio-carpal adhesions (Fig. 10). Arthroscopic resection of the adhesions was performed through standard portals (Fig. 11). Postoperative range of motion improved to 70 degrees of extension (increase of 700%) and 80 degrees of flexion (increase of 267%) (Fig. 12A,B). Grip strength improved from 15 kg preoperatively to 50 kg postopera-tively (increase of 333%).

Discussion

Arthrofibrosis is an acknowledged cause of pain, limited motion, and disability in multiple joints, including the knee, ankle, shoulder, and

Distal Radius Fracture Radiograph
Fig. 6. Preoperative injury films of a severely comminuted distal radius fracture with DRUJ instability. (A) Posteroan-terior wrist radiograph. (B) Lateral wrist radiograph.

elbow [1-12]. Theoretically, no diarthrodial joint is immune from this poorly understood pathologic process, and its incidence in the wrist may be greater than realized [14,15].

Stiffness of the wrist had previously been attributed to capsular thickening and contracture, although evidence to support this conclusion is limited [44]. Intraarticular adhesions characteristic of arthrofibrosis have been observed and reported, but the true incidence is unknown. MRI, especially scans obtained using special cartilage-imaging sequences, may demonstrate intraar-ticular bands or adhesions. The sensitivity of MRI is, however, unknown and a negative scan does not necessarily exclude arthrofibrosis. Cine fluoroscopy examination may provide additional

Open Reduction Internal Fixation Wrist
Fig. 7. Status post open reduction internal fixation of the distal radius fracture and distal radioulnar joint pinning. (A) Posteroanterior wrist radiograph. (B) Lateral wrist radiograph.
Kienbock Disease Wrist
Fig. 8. Clinical range of motion 9 months postoperatively despite aggressive physiotherapy. Painful, restricted range of motion in extension (A) and flexion (B).
Arthrofibrosis Wrist
Fig. 10. Arthroscopic view from the 3-4 portal of radiocarpal adhesions (Type IA wrist arthrofibrosis). (C, carpus; R, radius; arrow: adhesions).

information. Examination should be performed in both the posteroanterior (PA) and lateral planes with the wrist moving in flexion-extension and radial and ulnar deviation. Lack of combined motion through both the radiocarpal and midcarpal joints is suggestive, although not necessarily diagnostic, of arthrofibrosis, as the proximal carpal row is being "fixed" and restrained. The examiner will note motion through the midcarpal joint only

Mri Images Fibrosis Sarcoma
Fig. 9. MRI appearance of arthrofibrosis. Fibrous bands (encircled) extend from the radius to the carpus (Type IA wrist arthrofibrosis).
Kienbock Disease Wrist
Fig. 11. Status postlysis of adhesions debridement. The radiocarpal joint has been freed of the "spot welding'' effect. (C, carpus; R, radius; arrow: free space after lysis of adhesions debridement.)
Fig. 12. After arthroscopic release, range of motion improved dramatically in both extension (A) and flexion (B).

on flexion-extension in the lateral view. This is confirmed by the absence of reciprocal motion of the proximal carpal row with radial and ulnar deviation of the PA examination.

For radiocarpal and midcarpal adhesions (Types IA and IB, respectively), the definitive diagnostic study and treatment is wrist arthros-copy. With arthrofibrosis, one notes discrete, thick, fibrous bands ''spot welding'' the radius to the scaphoid or lunate. These can be resected through conventional 3-4, 4-5, 6R, 6U, MCR, and MCU portals. However, capsular thickening, analogous to adhesive capsulitis of the shoulder, may also be present. If so, resection of the affected tissue done in an open manner as advocated by Watson and Weinzweig [14], or done arthroscopi-cally as advocated by Verhellen and Bain [44], may be performed. If performed arthroscopically, the surgeon must be prepared to access the wrist by means of a palmar radial portal to adequately visualize and resect the dorsal capsule. The open technique may permit preservation of the important palmar ligaments, but does not permit resection of intraarticular adhesions. Arthroscopic release is excellent for intraarticular adhesions. Therefore, in select cases, a combined approach may be helpful. Midcarpal arthroscopy should also routinely be included in the procedure.

Persistent limitation of motion after wrist trauma may be treatable. Most patients will respond to aggressive therapy, splinting, and cortisone injections, and improvement may continue for 12 to 18 months after injury. However, for the recidivistic wrist, a nihilistic approach is not, necessarily, warranted in a properly motivated patient with demonstrable arthrofibrosis. Aggressive debridement of arthrofibrotic tissue and, if necessary, thickened, scarred capsule, may be beneficial.

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