Diagnosis

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Clinical symptoms of pain, restricted wrist range of motion, swelling, and a plateau in the improvements after at least 6 months of intensive physiotherapy should be considered suspicious for arthrofibrosis. There is frequently a hard endpoint to range of motion.

Before a diagnosis of arthrofibrosis can be made, other causes of loss of motion and pain must be ruled out in the differential diagnosis. This includes bony incongruity, arthritis, complex regional pain syndrome, carpal instability, loose bodies, malunion, nonunion, avascular necrosis, soft tissue (tendons, skin) contracture, spasticity, and skin or subcutaneous scarring. Loss of motion and pain are more commonly caused by one of these entities, and not arthrofibrosis.

The evaluation begins with a thorough history and physical examination. Particular parts of the physical examination include a detailed account of wrist range of motion: flexion, extension, radial deviation, ulnar deviation, supination, and pronation. The quality of endpoints (hard versus soft) and whether there is pain at the endpoints, should be noted. Anesthetic block of the posterior interosseous nerve, anterior interosseous nerve, and distal radioulnar joint with a local anesthetic agent, or examination under anesthesia, can help determine if the limited range of motion is due to pain or structural mechanical pathology.

Wrist radiographs should be evaluated for bony incongruity, arthritis, malunion, nonunion, loose bodies, and carpal instability patterns. If there is a question of bony pathology, which is equivocally seen on radiographs, CT may help elucidate the diagnosis. Dynamic radiographic sequences or fluoroscopy can be useful to assess the motion of the radiocarpal and midcarpal joints in flexion, extension, ulnar, and radial deviation. MRI may be helpful to confirm or deny suspicions of intraarticular fibrous adhesions, ligament injury, or avascular necrosis. Special MRI cartilage sequences with 3D gradient and echo (fat saturated) or fat saturated proton density are taken in coronal or sagittal planes to assess the cartilage status. These studies can also demonstrate capsular thickening.

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