29 Radiocarpal Pain and Stiffness
Abstract
Pain and stiffness of the wrist present a difficult problem which has significant implications. Several causes account for loss of range of motion (ROM) and pain following trauma to the distal radius and carpus. Extra-articular ones include heterotypic ossification and changes in joint geometry, and the intra-articular ones include malunion, steps in articular surface, carpal injuries, and instability. The method for treating stiffness and pain of the wrist depends on the needs of the individual patient, age, residual wrist mobility, level of physical activity, functional demands, and radiographic changes. Persistent pain is the main reason for dissatisfaction, so reduction should not be compromised to preserve mobility. Conservative treatment options include nonsteroidal antirheumatic drugs, steroid infiltration, splinting of the wrist, and hand therapy. If conservative intervention shows no improvement of ROM or pain, then several surgical treatment options such as wrist denervation, arthroscopic or open arthrolysis, partial wrist arthrodesis (PWA), total wrist arthrodesis (TWA), or wrist arthroplasty (WA) can be considered.
29.1 Introduction
Pain and stiffness of the wrist presents a difficult problem which has significant implications. Several causes account for loss of range of motion (ROM) and pain following trauma to the distal radius and carpus. These can be classified into extra-articular and intra-articular. Extra-articular ones include heterotypic ossification and changes in joint geometry, and the intra-articular ones include malunion, steps in articular surface, carpal injuries, and instability. 1 This chapter will focus on stiffness and pain after distal radius fracture (DRF). Carpal injuries and instability will be discussed in other chapters of this book.
DRFs are the most common fractures of the upper extremities with an incidence of approximately 190/100.000 per year. 2 , 3 , 4 Over the last decades, the trend has moved away from stabilizing DRF with Kirschner wires (K-wires) or external fixator, toward open reduction and internal fixation using volar angular stable locking plates. Dorsally displaced DRF can also be stabilized from volar aspect, which simultaneously reduces the risk of extensor tendon irritation when compared to dorsal plating. 5 , 6
Complication rates following surgically treated DRF are low and well-documented in the literature, 7 , 8 but stiffness of the wrist is seldom mentioned. 9 Early mobilization of the wrist after DRF leads to better functional results and, as reported in the literature, reduces the risk for restricted ROM. 5 As early as 1814, Colles warned his colleagues about prolonged wrist immobilization after DRF that could lead to potential impairment. 10 Nevertheless, some studies have demonstrated that the recovery period in the first 2 months significantly influence the ultimate functional outcome. 11
Wrist stiffness and pain after surgically treated DRF is often caused by loss of reduction, screw penetration into the radiocarpal joint, or malunion with an intraarticular step-off. Knirk and Jupiter have shown that a step-off greater than 2 mm in the radiocarpal joint has a higher risk for posttraumatic radiographic degenerative arthritis, leading to pain and functional impairment. Young patients are more prone to develop degenerative arthritis if the DRF heals with malalignment in the radiocarpal joint. 12
Routine daily activities require a ROM of at least 30 to 50 degrees of extension, 5-degree flexion, 10 degrees of radial deviation, and 15 degrees of ulnar deviation. 13 , 14 The method for treating stiffness and pain of the wrist depends on the needs of the individual patient. Conservative treatment options include nonsteroidal antirheumatic drugs, steroid infiltration, splinting of the wrist, and hand therapy. If conservative intervention shows no improvement of ROM or pain, then several surgical treatment options such as wrist denervation, arthroscopic or open arthrolysis, partial wrist arthrodesis (PWA), total wrist arthrodesis (TWA), or wrist arthroplasty (WA) can be considered.
29.2 Surgical Techniques
29.2.1 Denervation of the Wrist
Denervation of the wrist is an established procedure for treating chronic pain when conservative treatment fails. An advantage of wrist denervation is pain relief without the risk of stiffness. Should neurectomy prove unsuccessful, then alternative treatments options are still possible.
The concept of total wrist joint denervation (TWJD) was first described by Albrecht Wilhelm in 1966 15 and includes five skin incisions to access all ten terminal nerve branches of the wrist. Complete denervation has been considered to be the most effective method to achieve pain relief, while preserving the highest degree of mobility in the wrist. A disadvantage of this technique is the possible loss of skin sensitivity and protective proprioception. The literature describes many modifications of this procedure, but to date no definitive technique has been established. Although TWJD is very popular, partial wrist joint denervation (PWJD) is still performed more frequently.
PWJD was first described by Berger in 1998 16 in a single-incision technique with complete neurectomy of the anterior interosseous nerve (AIN) and the posterior interosseous nerve (PIN). Studies have shown that a neurectomy of the PIN and AIN may influence the proprioception of the wrist. 17 The PIN sends fibers to the central part of the dorsal wrist and is the primary dorsal innervator. The AIN innervates the volar capsule, periosteum, and ligament insertions as shown by Van de Pol et al. 18
The PIN and AIN are accessed via a 3 to 4 cm longitudinal dorsal incision between radius and ulnar one finger-breath proximal the ulnar head. The PIN is identified after the dissection between the extensor digitorum communis and extensor indicis proprius overlying the interosseous membrane. After longitudinal incision of the interosseous membrane, the AIN is presented. Neurectomy is performed by resecting 2 cm of each nerve.
Weinstein et al 19 described outcomes after PWJD as did Hofmeister et al. 20 Both studies reported pain relief between 50 and 80% and a reduced DASH score. Of note, 85 to 90% of the patients were satisfied with the result. However, the success rate after 28 to 31 months dropped to 68 to 85%.
The diagnostic value of preoperative diagnostic nerve block remains unclear. Many authors describe and discuss a diagnostic nerve block prior to surgery, but the outcome remains controversial. No strong correlations between diagnostic pain relief and severity of postoperative pain can be proved. 16 Two possibilities could explain the differing results in literature. Either the anesthetic injections failed to block the affected nerve or the interosseus branches were missed during surgery.
29.2.2 Wrist Arthrolysis
Both open and arthroscopic wrist arthrolysis is not very frequently documented in the literature. Surgical intervention is indicated if patients present with persistent, disturbing ROM restriction despite a minimum of at least 6 months conservative treatment. Capsular contracture should be the main criteria for restricted ROM, and other reasons such as radiocarpal malalignment should be excluded. The resulting stiffness in the wrist should also be painless in the restricted ROM.
If pronation and supination are affected, then open or arthroscopic arthrolysis of the distal radial ulnar joint (DRUJ) is preferred. Del Piñal et al 21 reported about arthroscopic arthrolysis of the DRUJ in six patients with a posttraumatic loss of supination of at least 90 degrees. Only the adherences between the volar capsule and the ulnar head were released. At the follow-up after 3 years, mean supination was 76 degrees and the mean improvement in supination was 80 degrees. Kleinman and Graham 22 showed in an anatomical and clinical study that DRUJ capsulectomy can markedly improve forearm rotation.
Kamal and Ruch et al 23 reported the open volar capsular release after DRF in eleven patients and a mean follow-up of 4.5 months. Wrist extension, flexion, and DASH score improved after surgery, but were lower than the minimal clinical difference. Pain according to the visual analogue scale was not affected as a result of the arthrolysis.
Arthroscopic arthrolysis has the advantage of small skin incisions, which lowers the risk of tissue scarring. Verhellen and Bain 24 performed an anatomical study on two patients with posttraumatic wrist stiffness. They found a mean distance of 6.9 mm from the capsule to the median nerve, 6.7 mm to the ulnar nerve, and 5.2 mm to the radial artery. ROM improved in both patients, in extension as well as flexion. Luchetti et al 25 performed an arthroscopic release of the wrist in 22 patients after DRF and reported an increase of ROM from 84 to 99 degrees in extension/flexion. Osterman et al 26 reviewed 54 patients with an arthroscopic release of the wrist and DRUJ, or both. At a mean follow-up of 62 months, ROM in extension and flexion improved from 35 to 41 degrees, but a loss of wrist motion of 30% was noted over time. Hatorri et al 27 retrospectively analyzed 11 patients with posttraumatic wrist contracture and a mean follow-up of 13 months. They found a mean improved ROM in extension by 9 degrees and flexion of 13 degrees. Mean arc of wrist extension/flexion improved significantly from 76 to 98 degrees.
Arthrolysis of the radiocarpal joint is only applicable under specific criteria. Patients should present with no anatomical malalignment and a painless wrist, which is reduced in extension/flexion. Literature suggests an improved ROM, but simultaneously this gain lessens over time. Nevertheless, this ROM improvement should be critically addressed. Does this minimal clinical difference become a recognizable improvement for the patient?
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