Wrist Arthrofibrosis
Section snippets
Etiology and pathophysiology
Stiffness and decreased range of motion are common following trauma or surgery to the wrist. This usually resolves with physiotherapy. Arthrofibrosis is defined as pain and stiffness that does not allow functional range of motion and is due to adhesions or contracture of the joint. The etiology of contracture of a joint can be classified into either intraarticular or extraarticular [21]. Arthrofibrosis is due to an excessive fibrotic response during the repair process, which leads to fibrotic
Clinical manifestations
The clinical diagnosis of arthrofibrosis is often one of exclusion. Classic symptoms appear after surgery or trauma, especially after prolonged period of immobilization of greater than 6 weeks. The disorder is characterized by a limitation of both active and passive range of motion of the wrist joint that is not primarily due to arthritis or other underlying conditions. Swelling and pain are invariably accompanying symptoms, and often lead to sleep disturbance.
Despite intensive physiotherapy,
Diagnosis
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,
Classification system
For optimal treatment and planning, we have classified wrist arthrofibrosis based on location of disease and functional limitation (Box 1).
Nonoperative
The most common cause of arthrofibrosis is traumatic injury. Therefore, the first step in treatment is prevention. Because protein-rich edema fluid is eventually replaced by scar tissue, edema control is paramount in prevention. This is achieved by strict elevation, compression, and finger exercises.
Once the diagnosis of arthrofibrosis has been made, treatment starts with a dedicated program of therapy to stretch scar tissue. In addition to active, active-assist, and passive range of motion
Operative
Types IA, B, and D have intraarticular adhesions (Fig. 1) and are best approached arthroscopically. Surgical arthroscopic treatment of arthrofibrosis has been successfully used for contracture of the knee, shoulder, and elbow [1], [3], [9], [10], [11], [12], [37], [38], [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
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
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 radiographically. The DRUJ
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 capsulotomy is performed, releasing the dorsal capsule radial to Lister's tubercle and the dorsal radiocarpal ligament (dorsal radiolunotriquetral ligament), which is
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
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
Discussion
Arthrofibrosis is an acknowledged cause of pain, limited motion, and disability in multiple joints, including the knee, ankle, shoulder, and elbow [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [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
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