Wrist and Hand
Indications and Goals: Wrist arthroscopy is becoming more widespread, with the realization that it is extremely valuable for a variety of diagnostic and therapeutic purposes. Indications include assessment of ligamentous injuries of the wrist, especially the scapholunate and lunotriquetral ligaments, debridement and repair of triangular fibrocartilage complex (TFCC) tears, assessment and debridement of chondral defects, removal of loose bodies, synovectomy, lavage of septic arthritis, arthroscopic-assisted reduction of intraarticular distal radius fractures, distal ulnar resection, and ganglion excision.
Procedure and Technique: A traction tower is used for positioning and distraction, with the index and long fingers in finger traps with 10 to 15 lbs of longitudinal traction applied. A small-joint 2.7 mm arthroscope is typically used. Portals are based on the dorsal wrist compartments. There are 10 described dorsal portals for the wrist: 5 at the radiocarpal joint, 2 at the midcarpal joint, 1 at the scaphotrapeziotrapezoid (STT) joint, and 2 at the distal radioulnar joint (DRUJ). The 3-4 portal (between extensor pollicis longus and extensor digitorum communis) is usually created first, 1 cm distal to Lister’s tubercle. The joint is insufflated with 5 to 10 mL of fluid, then a small superficial skin incision is made. A blunt trochar is used to access the joint to avoid transection of the extensor tendons and is angled to follow the anatomical 12-degree palmar tilt of the distal radius. The 4-5 portal (between the extensor digitorum communis and extensor digiti minimi) is usually created next. The 6-R portal is immediately radial to the extensor carpi ulnaris tendon, while the 6-U portal is immediately ulnar to it. These are often used as outflow portals. The dorsal branch of the ulnar nerve is particularly at risk for injury with creation of the 6-U portal. The 1-2 portal (between the extensor pollicis brevis and extensor carpi radialis longus), has limited utility due to its proximity to the branches of both the lateral antebrachial cutaneous nerve and the sensory branch of the radial nerve as well as the deep branch of the radial artery. The radiocarpal joint is inspected in a systematic fashion beginning radially and working ulnarly. Debridement is carried out as necessary, and ligamentous structures including the scapholunate ligament are inspected. The TFCC should be taut, with a trampoline-like effect when probed. Midcarpal arthroscopy is critical to evaluate the integrity of the scapholunate and lunotriquetral ligaments, and a probe pushed between the scaphoid and lunate can assess for laxity. The midcarpal radial portal is located 1 cm distal to the 3-4 portal, in line with the radial margin of the third metacarpal, while the midcarpal ulnar portal is located approximately 1 cm distal to the 4-5 portal, in line with the fourth metacarpal.
Post-surgical Precautions/Rehabilitation: The type of rehabilitation involved following a wrist arthroscopy depends upon whether or not tissue was repaired or removed. If the procedure involves removing or debriding tissue without any repair, then acute rehabilitation can focus on pain relief and scar management at the portal sites. A wrist splint is usually applied at the time of arthroscopy, and is removed at the first postoperative visit, at which time range of motion exercises can begin. A splint may be used for strenuous activity for approximately 4 weeks. If the procedure involved a repair, then care should be taken to avoid placing too much stress on the repaired tissue until adequate and safe healing has occurred. The timeframe for rehabilitation progression will depend upon the specific tissue that is repaired and the stability of the repair.
Expected Outcomes: Outcomes for wrist arthroscopy certainly vary based upon the procedure being performed. Overall, however, general benefits associated with wrist arthroscopy include minimal damage to surrounding soft tissue, less postoperative pain, shorter recovery times, and fewer surgical complications. Potential complications include injuries to the extensor tendons, radial artery, and the superficial branches of the radial and ulnar nerves. The tendon most at risk for arthroscopy is the extensor pollicis longus, with both acute and late rupture of this tendon being reported. Neurovascular complications are related to the more ulnar portals.
Return to Play: Return to activity is totally dependent upon the procedure done. If the structural integrity of the wrist is not compromised, return within weeks is possible. The majority of patients are able to perform activities of daily living by 2 weeks, and full recovery is anticipated by 6 weeks.
Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. [Set-up, portals and normal exploration in wrist arthroscopy] Chir Main. 2006;25(suppl 1):S131-S144. Review.
Chloros GD, Shen J, Mahirogullari M, Wiesler ER. Wrist arthroscopy. J Surg Orthop Adv. 2007;16(2):49-61. Review.
Culp RW, Osterman AL, Kaufmann RA. Wrist Arthroscopy: Operative Procedures. In: Green DP, et al., eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier; 2005:781-804.
McGinty JB, et al. eds. The Wrist, in Operative Arthroscopy. 3rd ed. Baltimore, MD: Lippincott Williams and Wilkins; 721-818.
Ricks E. Wrist arthroscopy. AORN J. 2007;86(2):181-188; quiz 189-192. Review.
Ruch DS, Poehling GG. Wrist Arthroscopy: Anatomy and Diagnosis. In: Green DP, et al., eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier; 769-780.
Scapholunate Ligament Repair
Indications and Goals: Scapholunate ligament disruption is a potentially devastating injury if left untreated, yet the initial injury is often unrecognized and dismissed as merely a “wrist sprain.” Scapholunate ligament injury can lead to significant alteration of normal wrist kinematics and resultant carpal instability, characterized by wrist pain, loss of motion, weakness, degenerative arthritis, and disability. Static instability shows abnormal carpal alignment on standard radiographs, while dynamic instability requires stress radiographs for abnormal carpal alignment to become apparent. Scapholunate ligament disruption leads to the dorsal intercalated segmental instability (DISI) type of deformity. Loss of the normal ligamentous constraints leads to scaphoid hyperflexion and lunate hyperextension. This is evident on lateral radiographs showing a scapholunate angle greater than 70 degrees (normal being 47 degrees). AP views may show a widened scapholunate interval (>3 mm), and bilateral clenched fist stress views can confirm a scapholunate diastasis. Pathologic scaphoid hyperflexion may also manifest as a “cortical ring sign” on the PA view. A positive Watson’s test is when a palpable clunk is felt while applying dorsal pressure to the volar scaphoid tubercle as the wrist is moved from ulnar to radial deviation. MRI has become more sensitive for the detection of scapholunate ligament disruption, but wrist arthroscopy remains the gold standard for diagnosis.
If left untreated, the injury will progress along a predictable pattern of degenerative arthritis, known scapholunate advanced collapse (SLAC). This stepwise degenerative process involves radial styloid and scaphoid arthritis early due to edge-loading, followed by proximal capitate migration, and finally pancarpal arthritis. The primary goal, therefore, is early diagnosis and treatment of this injury.
Procedure and Technique: Treatment depends on the stage and type of instability. In cases of partial scapholunate ligament injury and occult instability, arthroscopic debridement and a period of postoperative immobilization may be sufficient. Some authors recommend arthroscopic pin fixation for 6 to 8 weeks. Acute complete scapholunate ligament ruptures without evidence of arthritic degeneration may be amenable to primary open repair by passing nonabsorbable suture through drill holes. The scapholunate interval is then pinned with K-wires, and the primary repair is often augmented by a dorsal capsulodesis procedure, such as the Blatt capsulodesis or the dorsal intercarpal capsulodesis. Many other repair techniques have been described, such as tenodesis, bone-ligament-bone autograft reconstruction, and intercarpal fusion. Cases of chronic, static instability that have progressed to SLAC require a different approach. The radioscaphoid and capitolunate joints are affected, but the radiolunate joint is spared. Treatment is dependent on the condition of the capitate articular surface and the radioscaphocapitate ligament. Options include radial styloidectomy, proximal row carpectomy, scaphoid excision and four-corner fusion, and total wrist fusion.
Post-surgical Precautions/Rehabilitation: Postoperative protocols obviously depend on the procedure performed, with more involved reconstructive and repair procedures requiring longer periods of immobilization. However, for scapholunate ligament repair procedures, the wrist is immobilized in neutral position in an above elbow thumb spica cast for 8 weeks, following which time the pins are removed and active motion is initiated. Some follow the approach of using a long arm splint of 2 weeks and a Muenster cast for 6 weeks more. Once the pins are removed, a short arm cast is used for another 4 weeks. Range of motion should focus on regaining only functional movement that is necessary for activities of daily living, without aggressively forcing end range wrist flexion as it could adversely affect the stabilizing repair. Grip strengthening exercises should be delayed until satisfactory healing has occurred.
Expected Outcomes: Results vary as reported in the literature. Grip strength deficits, range of motion deficits (wrist flexion and radial deviation), and ongoing pain up to 30 months postoperative with activities of daily living may persist. Decrease in symptoms of pain and clunking as well as improvement of functional status have also been reported. The most common complication of the dorsal capsulodesis involves limited wrist flexion. This loss of wrist flexion is inherently related to the procedure and not due to scarring after immobilization and attempts at regaining the last 12 to 20 degrees of wrist flexion could lead to disruption or weakening of the reconstruction.
Return to Play: Return to participation requires complete healing and restored stabilization of the joint(s) involved. This may take up to 4 to 6 months conservatively.
Dagum AB, Hurst LC, Finzel KC. Scapholunate dissociation: An experimental kinematic study of two types of indirect soft tissue repairs. J Hand Surg [Am]. 1997;22(4):714-719.
Deshmukh SC, Givissis P, Belloso D, Stanley JK, Trail IA. Blatt’s capsulodesis for chronic scapholunate dissociation. J Hand Surg [Br]. 1999;24(2):215-220.
Garcia-Elias M, Geissler WB. Carpal Instability. In: Green DP, et al., eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier; 535-604.
Walsh JJ, Berger RA, Cooney WP. Current status of scapholunate interosseous ligament injuries. J Am Acad Orthop Surg. 2002;10(1):32-42.
Wintman BI, Gelberman RH, Katz JN. Dynamic scapholunate instability: Results of operative treatment with dorsal capsulodesis. J Hand Surg [Am]. 1995;20(6):971-979.
Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving procedures in the treatment of scapholunate advanced collapse wrist: Proximal row carpectomy versus four-corner arthrodesis. J Hand Surg [Am]. 1995;20(6):965-970.
Wyrick JD, Youse BD, Kiefhaber TR. Scapholunate ligament repair and capsulodesis for the treatment of static scapholunate dissociation. J Hand Surg [Br]. 1998;23(6):776-780.
Indications and Goals: Wrist fusion is most commonly performed for patients with severe post-traumatic or degenerative arthritis that cannot be improved by another motion-saving procedure. Arthrodesis may also be performed in patients with joint destruction, bone loss, or contractures such as in inflammatory arthritis, infection, paralytic or spastic conditions, trauma, or tumor resection. Fusion may also be required in late stages of complex carpal instability or after failure of a limited intercarpal arthrodesis, proximal row carpectomy or arthroplasty. The goal is to provide predictable pain relief and a stable wrist for power grip.
Procedure and Technique: Current techniques favor rigid internal plate fixation, in an attempt to avoid prolonged cast immobilization and decrease rates of pseudarthrosis. Rod or pin fixation may be used for patients with inflammatory arthritis or a connective tissue disorder, but plates are becoming more commonly used in these conditions as well. A recent development is the precontoured, low-contact, dynamic-compression titanium plate, which was specially designed for wrist arthrodesis. It gives a lower profile to reduce the incidence of hardware prominence and resultant tenderness and extensor tendon irritation. It also eliminates the need for time-consuming precontouring of the plate into slight wrist extension and ulnar deviation. Bone graft is often used to increase fusion rates, and may be taken from the distal radius. Larger defects may be filled with iliac crest graft, but this involves significant donor site morbidity including persistent pain, hematoma formation, infection, and nerve injury.
The procedure is carried out by making a longitudinal incision from the distal third of the index-middle finger interosseous space, across Lister’s tubercle, and over the radial shaft to the proximal border of the abductor pollicis longus. Full-thickness skin flaps are elevated while preserving as many cutaneous nerves and dorsal veins as possible. The third dorsal extensor compartment is opened, and the extensor pollicis longus tendon is transposed. The second and fourth dorsal compartments are elevated subperiosteally. Dissection is then continued to expose the dorsal aspect of the third metacarpal, carpometacarpal, capitolunate, and radiocarpal articulations. Articular cartilage is removed with a curette, rongeur, or burr, and the joints are denuded to cancellous bone. The triquetrohamate, capitohamate, and scaphotrapeziotrapezoid joints may be included if indicated by preoperative examination or radiographs. Lister’s tubercle is removed, and the dorsal surfaces of the scaphoid, lunate, and capitate are decorticated to provide a flat surface for plate application. Cancellous bone graft is harvested from within the distal metaphyseal region of the radius through a cortical window created 2 cm proximal to the distal radial articular surface and radial to the intended plate position. One centimeter of subchondral and metaphyseal bone should be preserved during harvesting to prevent fracture. Bone graft is inserted into the prepared joint spaces that will lie beneath the plate. An appropriate plate is then selected and contoured, or the precontoured plates may be used. The plate is fixed to the third metacarpal shaft with bicortical screws. Alternatively, the plate may be fixed to the second metacarpal to position the wrist in slight ulnar deviation, thus enhancing power grip. The holes must be drilled exactly from dorsal to volar in the sagittal plane or rotational malalignment of the finger will occur when the plate is secured to the radius. The plate should be placed as far proximally as possible on the metacarpal shaft to avoid irritation of the overlying extensor tendons by the distal edge of the plate. An additional bicortical screw is placed into the capitate. The plate is fixed to the radius with bicortical screws in a compression technique. The extensor pollicis longus is transposed above the extensor retinaculum as the third dorsal compartment is closed.
Post-surgical Precautions/Rehabilitation: Postoperative rehabilitation will initially focus on pain management and incisional wound healing. No range of motion is expected to be gained at the site of the fusion. However, adjacent joints should undergo mobilization exercises as soon as tolerated by the patient, beginning with passive digital motion. Strengthening exercises were begun 6 weeks after surgery. Splinting is discontinued at 6 to 8 weeks, and full unrestricted use of the extremity is usually permitted by 10 to 12 weeks postoperatively when healing is complete and radiographs confirm successful fusion.
Expected Outcomes: Dorsal plating techniques with autologous bone graft have been shown to be superior to various other techniques, with fusions rates exceeding 90%. Wrist arthrodesis results in high subjective patient satisfaction with respect to pain relief and correction of deformity. Grip strength, digital range of motion, and forearm rotation do not significantly change from preoperative values. Improvements in pinch and grip strengths have been reported following wrist arthrodesis in patients with osteoarthritis, but not in those with rheumatoid arthritis. Most patients will be able to perform activities of daily living and return to work, though modifications may be required. The ability to achieve full supination or pronation may not be realistic and should be shared with the patient prior to the procedure so that a clear picture of functional abilities is understood. Maximum improvement may take over a year to achieve. Complications from this procedure include non-union, extensor tendon adhesions
or tenosynovitis, intrinsic muscle contracture, plate tenderness, carpal tunnel syndrome, infection, neuroma formation, ulnocarpal impaction, and distal radioulnar joint arthritis.
or tenosynovitis, intrinsic muscle contracture, plate tenderness, carpal tunnel syndrome, infection, neuroma formation, ulnocarpal impaction, and distal radioulnar joint arthritis.
Return to Play: Unlikely for most athletes. After complete bony fusion, return to activities as tolerated may occur within 4 months postoperatively.
Jebson PJ, Adams BD. Wrist arthrodesis: Review of current technique. J Am Acad Orthop Surg. 2001;9(1):53-60.
Hayden RJ, Jebson PJ. Wrist arthrodesis. Hand Clin. 2005;21(4):631-640. Review.
Honkanen PB, Mäkelä S, Konttinen YT, Lehto MU. Radiocarpal arthrodesis in the treatment of the rheumatoid wrist. A prospective midterm follow-up. J Hand Surg Eur Vol. 2007;32(4):368-376. Epub 2007 Jun 4.
Markiewitz AD, Stern PJ. Current perspectives in the management of scaphoid nonunions. Instr Course Lect. 2005;54:99-113. Review.
Indications and Goals: The triangular fibrocartilage complex (TFCC) is a meniscus homologue in the wrist at the distal end of the ulna, and acts to stabilize the distal radioulnar joint (DRUJ). It is bordered and anchored by the dorsal and volar radioulnar ligaments that run from the sigmoid notch to the base of the ulnar styloid. It is a load-bearing structure and in patients with neutral ulnar variance the TFCC bears about 20% of the load across the wrist. Patients with ulnar positive variance will have relatively more load placed on the TFCC and thinning of its central portion. The central and radial aspects of the TFCC are relatively avascular and are amenable to debridement, whereas the ulnar and peripheral portions are more vascular and amenable to repair.
Injuries to the TFCC can be either traumatic or degenerative. Acute traumatic injuries will present with ulnar-sided wrist pain after a rotatory injury and are classified according to the location of the tear. Chronic degenerative tears are usually a result of ulnar positive variance, which can be idiopathic or post-traumatic, such as in malunion, growth arrest, or radial head excision.
Procedure and Technique: TFCC tears are usually evaluated and repaired arthroscopically. Palpation of the TFCC is important, because it normally has a “trampoline” effect when probed. In the acute traumatic setting, central tears without instability can be debrided as long as 2 mm of the peripheral rim remains to maintain stability. Peripheral tears at the base of the ulnar styloid are often associated with DRUJ instability and should be repaired. If there is an associated ulnar styloid fracture, it should undergo internal fixation or excision of the fragment followed by TFCC repair. Peripheral repairs can be performed either through an inside-out or an outside-in technique. The outside-in technique may have a lower incidence of irritation of the dorsal ulnar sensory nerve. A 1 cm incision is made just volar to the extensor carpi ulnaris and distal to the ulnar styloid. The tendon is retracted ulnarly, and two needles are passed through the capsule and across the tear under direct arthroscopic visualization. A wire loop is passed through one needle to grab a 2-0 nonabsorbable suture introduced into the joint through the other needle. The suture is then tied over the dorsal wrist capsule, securing the tear. If the TFCC is avulsed from the ulnolunate or ulnotriquetral ligaments or from the sigmoid notch (as in distal radius fractures), repair can be carried out either open or arthroscopically.
In the chronic setting, ulnar positive variance must be treated in addition to the TFCC pathology. The ulnocarpal impaction may be addressed either through an open extraarticular ulnar shortening osteotomy, or arthroscopically with a wafer procedure, where a burr is used to remove the distal 1 to 4 mm of the ulna through an associated central TFCC tear. Wearing of the TFCC without perforation can be treated by ulnar shortening osteotomy alone. If there is perforation of the TFCC with associated lunate chondromalacia, the TFCC can be debrided and an ulnar shortening procedure can be performed.
Post-surgical Precautions/Rehabilitation: For debridement procedures, range of motion exercises can be initiated relatively early after a short period of immobilization. For repair procedures, a sugar-tong splint for 2 weeks followed by a short arm or Munster cast for 4 weeks can be used. Range of motion has begun thereafter with strengthening started at 10 weeks. For ulnar shortening osteotomies, the area must be protected until there is evidence of healing across the osteotomy site on radiographs.
Expected Outcomes: Outcomes following a TFCC repair depend upon the size of the tear, the ability to accomplish a repair, and the age-related degenerative change in the wrist. A majority of patients experience a reduction in pain after surgery, with improvement in grip strength and daily activities. Acute tears repaired within 3 months of the injury usually regain about 80% of their range of motion and strength. Arthroscopic repairs usually have better recovery of range of motion and strength than open repairs. Loss of wrist rotation, loss of grip strength, and an ulnar positive variance are factors that are correlated with poor outcomes. Stiffness is a common long-term complaint.
Return to Play: Return to participation varies upon whether debridement of repairs performed, and is usually between 6 to 12 weeks.
Chen AC, Hsu KY, Chang CH, Chan YS. Arthroscopic suture repair of peripheral tears of triangular fibrocartilage complex using a volar portal. Arthroscopy. 2005;21(11):1406.
Conca M, Conca R, Dalla Pria A. Preliminary experience of fully arthroscopic repair of triangular fibrocartilage complex lesions. Arthroscopy. 2004;20(7):e79-e82.
Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy. 2007;23(7):729-737, 737.e1.
Gupta R, Bozentka DJ, Osterman AL. Wrist arthroscopy: Principles and clinical applications. J Am Acad Orthop Surg. 2001;9(3):200-209.
Ruch DS, Papadonikolakis A. Arthroscopically assisted repair of peripheral triangular fibrocartilage complex tears: Factors affecting outcome. Arthroscopy. 2005;21(9):1126-1130.
Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair. Arthroscopy. 2007;23(12):1357.e1-e4.
Indications and Goals: Tenosynovitis should be insersene of the second and first compartment typically involves the first dorsal wrist compartment (APL and EPB) (de Quervain’s syndrome) and the intersection of the second (ECRL and ECRB) and first (APL, EPB) compartments (intersection syndrome). The diagnosis of de Quervain’s syndrome is confirmed with Finkelstein’s test (thumb is place in the fist and the wrist is ulnarly deviated) and pain with resisted thumb metacarpophalangeal joint extension. de Quervain’s is six times more common in women than in men, and often affects the dominant hand in middle age. It is worsened by repetitive activities involving simultaneous thumb abduction and wrist ulnar deviation. Over time this can cause narrowing of the fibro-osseous canal through the extensor retinaculum. A subset of patients who will have new onset but self-limited disease is pregnant and lactating women.
Intersection syndrome is commonly diagnosed in rower’s (“oarsman’s wrist”) and golfers, and presents with a history of wrist pain and crepitance or “squeaking” approximately 5 cm proximal to Lister’s tubercle. Both conditions are initially treated conservatively with activity modification, nonsteroidal anti-inflammatories, injections, and thumb spica splinting. Intersection syndrome is more likely to respond to these conservative measures than de Quervain’s. Surgical intervention is indicated in patients who have failed a prolonged trial of nonoperative measures.
Procedure and Technique: For both procedures, the patient is placed supine on the operating table with a hand table. For de Quervain’s, a 2 cm transverse incision is made over the first dorsal compartment, 1 cm proximal to the radial styloid. Branches of the lateral (should be lateral antebrachial cutaneous) antebrachial cutaneous and superficial radial sensory nerve are identified and protected. The sheath over the APL and EPB is incised in a longitudinal fashion. The APL may have multiple slips (2 to 4), and the EPB is in a separate compartment in many individuals. A small portion of the dorsal retinaculum is excised. For intersection syndrome, a 4 cm longitudinal incision is made proximal to the wrist and the second compartment is released and the bursa at the intersection of the two compartments is debrided.
Post-surgical Precautions/Rehabilitation: Range of motion for the thumb started early while the wrist is splinted in 10 degrees of extension for 2 weeks to prevent a volar tendon prolapse. Sutures will be removed between 1 and 2 weeks, at which time gentle hand and finger strengthening exercises can be initiated. Supervised rehabilitation should emphasize scar management and tendon gliding to prevent against postoperative scarring. Full recovery could take several months. Pain and symptoms generally begin to improve after surgery, but tenderness in the area of the incision may last for several months.
Expected Outcomes: Surgical release of tendons of first dorsal compartment of the wrist has excellent results in patients with de Quervain’s tenosynovitis. However, patients may have incomplete relief or persistent pain if a separate EPB compartment is not identified and released intraoperatively, or the superficial radial sensory nerve is irritated or injured. Debate exists regarding the type of incision. The use of a longitudinal incision may be associated with complications such as poor cosmesis, superficial radial nerve injury, and poor wound healing. Advantages of using a longitudinal incision versus a transverse incision include ease in recognition of compartment variations and superficial branches of the radial nerve.
Return to Play: A return to basic activities of daily living can occur within 3 to 4 weeks. More involvement with resistive type work and sport activity may take up to 3 to 4 months.
Gundes H, Tosun B. Longitudinal incision in surgical release of de Quervain disease. Tech Hand Up Extrem Surg. 2005;9(3):149-152.
Ilyas AA, Ast M, Schaffer AA, Thoder J. de Quervain tenosynovitis of the wrist. J Am Acad Ortho Surg. 2007;15(12):757-764.
Jackson WT, Viegas SF, Coon TM, Stimpson KD, Frogameni AD, Simpson JM. Anatomical variations in the first extensor compartment of the wrist. A clinical and anatomical study. J Bone Joint Surg Am. 1986;68(6):923-926.
Mellor SJ, Ferris BD. Complications of a simple procedure: de Quervain’s disease revisited. Int J Clin Pract. 2000;54(2):76-77.
Wolfe SW. Tenosynovitis. In: Green DP, et al., eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier; 2005:2137-2158.
Yuasa K, Kiyoshige Y. Limited surgical treatment of de Quervain’s disease: Decompression of only the extensor pollicis brevis subcompartment. J Hand Surg [Am]. 1998;23(5):840-843.
Wrist Ganglion Excision
Indications and Goals: Ganglion cysts are the most common soft tissue tumors of the hand. These mucinfilled cysts are usually attached to the adjacent underlying joint capsule, tendon, or tendon sheath, and can cause pain from compression of surrounding structures. They are most prevalent in women and usually occur between the second and fourth decades of life. Patients usually seek medical attention due to cosmetic appearance of the mass, pain, weakness, and concern of potential malignancy. A specific antecedent traumatic event is present in at least 10% of cases, and repeated minor trauma may be an etiologic factor in their development. A one-way valvular mechanism has been postulated to connect the wrist joint to the cyst. Ganglions usually occur singly and in very specific locations but have been reported to arise from almost every joint of the hand and wrist. The dorsal wrist ganglion accounts for 60% to 70% of all ganglions of the hand and wrist. The main cyst is most often directly over the scapholunate ligament, but may protrude elsewhere between the extensor tendons and can be connected to the ligament through a long pedicle. Failure to identify this pedicle and excise its scapholunate ligament attachment increases the likelihood of recurrence. Transillumination or aspiration confirms the diagnosis preoperatively. Aspiration and injection may provide long-term relief and has been reported to be effective in 20% to 30% of patients. Volar wrist ganglions may be in close proximity to the radial artery, so aspiration should be done with extreme care or simply avoided. Surgical excision of ganglions is performed for persistent pain.
Procedure and Technique: Most dorsal ganglions may be approached through a transverse incision over the proximal carpal row, but a modified incision or second transverse incision may be necessary for ganglions not directly over the scapholunate ligament. The diagnosis of ganglion cyst should be confirmed before commitment to a transverse incision because this type of incision is not readily incorporated into a limb-sparing incision in the event of a subsequent diagnosis of a malignant soft tissue tumor. Typically, a dorsal ganglion appears between the extensor pollicis longus and extensor digitorum communis tendons, which are retracted radially and ulnarly, respectively. The main cyst and its pedicle are mobilized down to the underlying joint capsule. With the wrist in volar flexion, the joint capsule is opened along the border of the radius and proximal pole of the scaphoid. The capsule is elevated and retracted distally to expose the capsular attachments to the scapholunate ligament. Smaller intraarticular cysts are often seen attached to the scapholunate ligament. The capsular incision is then continued around the ganglion, but all capsular attachments to the ligament are left intact. The ganglion and its capsular attachments are then tangentially excised off the scapholunate ligament. Arthroscopic dorsal wrist ganglion excision is becoming more popular with lower recurrence rates and smaller rehabilitation.
Post-surgical Precautions/Rehabilitation: A bulky dressing extending from the proximal forearm to the MP joints is applied and the hand elevated. Early finger motion is encouraged. The dressing and sutures are removed between 7 and 10 days postoperatively. Wrist motion should be initiated and encouraged, especially volar flexion. Hand therapy is continued until a full range of motion has been obtained. Essentially no restrictions need to be placed on the individual apart from assuring adequate wound healing and a gradual increase in activity level and usage of the wrist.
Expected Outcomes: While ganglion excision appears to be an effective treatment method with minimal to no impairment of wrist motion and function, it is not without complications. Volar ganglia resection complication rates are significantly higher versus dorsal, including damage to the superficial radial sensory nerve, the palmar cutaneous branch of the median nerve, and the radial artery. Early recurrences, the most common complication of ganglion surgery, are usually due to inadequate and incomplete excisions. Stiffness of the wrist can be avoided by early motion, physical therapy if necessary, and splinting of the wrist in slight flexion in the immediate postoperative period. It is imperative to stress early volar flexion. To avoid keloid or hypertrophic scars, longitudinal incisions across the wrist joint should be avoided. Awareness and respect for the sensory branches of the radial and ulnar nerves prevent neuroma formation, which often defies effective treatment.
Return to Play: Under optimum circumstances, return to participation should occur between 6 and 8 weeks to minimize the likelihood of a return of the cyst. With some athletes, functional ability may be restored much sooner than this timeframe.
Athanasian EA. Bone and Soft Tissue Tumors, In: Green DP, et al., eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier; 2211-2264.
Dias J, Buch K. Palmar wrist ganglion: Does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes. J Hand Surg [Br]. 2003;28(2):172-176.
Dias JJ, Dhukaram V, Kumar P. The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. J Hand Surg Eur Vol. 2007;32(5):502-508. Epub 2007 Aug 6.
Geissler WB. Arthroscopic excision of dorsal wrist ganglia. Tech Hand Up Extrem Surg. 1998;2(3):196-201.
Ho PC, Law BK, Hung LK. Arthroscopic volar wrist ganglionectomy. Chir Main. 2006;25(suppl 1):S221-S230. Review.
Carpal Tunnel Release
Indications and Goals: Carpal tunnel syndrome is the most common type of compressive neuropathy. The median nerve is impinged in the carpal tunnel by direct trauma, repetitive use, or anatomic anomalies. Paresthesias result from early microvascular compression and neural ischemia. Large sensory fibers (light touch, vibration) are affected before small fibers (pain and temperature). Continued compression may lead to structural changes such as demyelination, fibrosis, and axonal loss. These changes may cause weakness or paralysis of the motor nerve. Abnormal two-point discrimination may also be evident after prolonged compression. Patients report paresthesias and pain (often at night) in the palmar aspect of the radial 3½ digits. Weakness and loss of fine motor control are late findings. The most sensitive provocative test is the carpal tunnel compression test (Durkin’s test). Other provocative tests include the Tinel and Phalen signs. Semmes Weinstein monofilament testing is sensitive for diagnosing early CTS. Thenar atrophy may be present in severe denervation. It often affects cyclists, racket sport participants and wheelchair athletes. Risk factors include female sex, obesity, pregnancy, diabetes, hypothyroidism, chronic renal failure, inflammatory arthritis, storage diseases, smoking, alcoholism, advanced age, and repetitive wrist flexion during occupational activity. Electromyography and nerve conduction studies are not necessary for diagnosis of CTS, but they may help to confirm the diagnosis in equivocal cases. Acute CTS occurs in the setting of high-energy trauma, such as distal radius fractures and fracture-dislocations of the radiocarpal joint. Nonoperative treatment includes activity modification, night splints and nonsteroidal anti-inflammatory drugs (NSAIDs). Steroid injections yield transient relief in 80% of patients; only 22% of patients are symptom-free at 12 months but 40% are symptom-free for more than 12 months if symptoms have been present for less than 1 year and they have normal two-point discrimination, no thenar atrophy, less than 1 to 2 ms prolongation sensory/motor latencies, and no denervation potentials on EMG. Failure to improve after corticosteroid injection is a poor prognostic factor, and surgery is less successful in these cases.
Procedure and Technique: The patient is placed supine with the hand on a hand table. An incision is made along a line extending from the radial side of the ring finger, usually in a palmar crease. Structures within Guyon’s canal can be injured if the incision is too ulnar, and the recurrent motor branch of the median nerve can be injured if the incision is too radial. The subcutaneous tissue and palmar fascia is dissected to expose the transverse carpal ligament. Typically, a retractor is placed into the tunnel to protect the nerve and the ligament is released on the ulnar side of the nerve (to protect the recurrent motor branch). Endoscopic carpal tunnel release is an option as well for those experienced with this technique.