Wrist Contracture After Distal Radius Fractures

Key Points

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The origin of a posttraumatic wrist joint stiffness can be either extra-articular, intraarticular, or both.
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Surgical arthrolysis is a viable option that can be performed via open or arthroscopic surgery.
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A poor articular surface may be responsible for failure or recurrence of painful stiffness after arthrolysis
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Arthroscopy of the DRUJ can be challenging.

Panel 1: Case Scenario

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Case 1: A 24-year-old male manual worker presented with a painful stiffness of left wrist. He had an extra-articular distal radius fracture (DRF) treated with reduction and above elbow to hand cast with the wrist flexed and pronated. One month later the cast was removed. Rehabilitation was done for 3 months without satisfactory results ( Fig. 1 A–F): wrist ROM (FE = 15 degrees/PS = 0 degrees) and pain 8 according with VAS scale 0–10.

Fig. 1

33-Year-old male presents with painful stiffness in the left wrist after a distal radius fracture treated in a cast. Preoperative clinical function of wrist extension (A), flexion (B), supination (C) and pronation (D) and preoperative radiographic imaging of the wrist (E, F).
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Case 2: A 33-year-old male presented with right wrist stiffness after ORIF (volar plate) for an intraarticular DRF. Rehabilitation was done for 4 months but wrist stiffness persisted ( Fig. 2 A–F).

Fig. 2

36-Year-old male with painful stiffness to the right wrist after a distal radius intraarticular fracture treated with palmar plate fixation (A–F) in association with ulnar fracture and ulnar styloid fracture. Clinical function of the wrist flexion (A), extension (B), pronation (C) and supination (D) and preoperative radiographic imaging showing the position of the palmar plate to the distal radius with healing of all fractures (E, F)

How can you come to an evidenced-based decision in the management of these two similar cases?

Importance of the Problem

Wrist contracture can be a disabling complication after trauma or surgical procedures. Intraarticular and capsular injuries as well as prolonged immobilization may cause arthrofibrosis. This could lead to a limited range of motion (ROM), pain, and long-lasting disability. Usually a good rehabilitation program of the wrist is the first treatment. In case the rehabilitation regime fails to increase wrist ROM, wrist manipulation under general anesthesia or peripheral regional blocks may be attempted with a potential risk of ligament or bone avulsions.

Main Question

What is the best surgical method for wrist stiffness after distal radius fractures (DRFs) treated by cast or volar plate fixation?

Is the same question valid for stiffness of the DRUJ?

Current Options

Surgical arthrolysis is a viable option that can be performed via open surgery or arthroscopy. Arthrolysis of the radio-carpal (RC) joint can be useful in flexion-extension stiffness, while distal radio ulnar joint (DRUJ) arthrolysis is indicated in cases with limited pronation-supination. The aim of this chapter is to compare the results of open and arthroscopic arthrolysis of the radio-carpal (RC) joint and DRUJ in posttraumatic stiffness of the wrist.

Finding the Evidence

A comprehensive search strategy was created in collaboration with an independent research librarian and was designed to capture all relevant articles relating to wrist arthrolysis. The search strategy was applied to the Pubmed-MEDLINE databases from database inception until 15th January 2020 with the following keywords: “open wrist arthrolysis,” “arthroscopic wrist arthrolysis,” “posttraumatic wrist stiffness,” “arthroscopic wrist capsular release,” “DRUJ arthrolysis.”

Quality of the Evidence

We followed the graded ranking proposed by Sackett concerning the studies obtained through the literature search. Five levels of degrees were considered from Level I to Level V ( Table 1 ). Each accepted study was evaluated according with the Schünemann and also graded based on the quality of evidence on the Grade Working Group system ( Tables 2 and 3 ).

Table 1

Level of Evidence.

Level of Evidence
I	Large randomized controlled trials
II	Small randomized controlled trials
III	Cohort and case-control studies
IV	Case series
V	Expert opinion

Table 2

Assigning Grades of Evidence by GRADE Working Group.

Level of Evidence
1A	Systematic review of randomized controlled trials
1B	Individual randomized controlled trial
2A	Systematic review of cohort studies
2B	Individual cohort study
3A	Systematic review of case-control studies
3B	Individual case-control study
4	Case series
5	Expert opinion without explicit critical appraisal or based on physiology or bench research

Table 3

Overall Quality by GRADE Working Group.

Quality
High	Further research is very unlikely to change our confidence in the estimate of effect
Moderate	Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low	Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low	Any estimate of effect is very uncertain

No randomized controlled trials, systematic reviews, or metaanalysis were found which specifically answered to the initial questions. Overall the studies on wrist arthrolysis were selected for the outcomes of a single technique: open or arthroscopic surgery. Only eight studies of some importance related to the surgical technique of wrist arthrolysis were found. All but one of these studies had an evidence of Level IV (GRADE 3B). The final study was Level V (GRADE 4).

Findings

Evidence From Level IV–V Studies

In eight included studies, three reported results on open technique (two articles on open DRUJ arthrolysis and one article on open volar wrist (RC) capsulotomy) ( Table 4 ). Five articles studied the results of the arthroscopic arthrolysis (four on RC joint, and one on DRUJ arthrolysis) ( Table 5 ).

Table 4

Studies With Open Arthrolysis.

No.	Author	Year	Journal	Technique	No. of Cases	Age (yr)	Sex	Dominant hand	Follow up	Previous Surgeries	Measurements	Results
1	af Ekenstam	1988	Scandinavian Journal of Plastic and Reconstructive Surgery	Capsulotomy DRUJ	18	44 (17–67)	15 Women and 3 men	10 Dominant, 8 nondominant	1–6 years	15 Patients in 5 of whom the radius previously had been osteotomized. In the other 3 cases the TFCC was injured. In one case the ligament Injury was combined with an epiphysiolysis of the ulnae and in another it was combined with a complex transscaphoid perilunar dislocation.	Forearm rotation, pronation, supination. Grip strength, pain		Preop	Postop
												Forearm rotation	92 (40–125)	138 (70–175)
												Supination	45 (0–80)	66 (20–90)
												Pronation	46 (15–90)	71 (50–90)
												Grip strength	50%	70% (injured/uninjured hand)
												Pain: improved in 15, unchanged in 2, worse in 1.
2	Kleinman and Graham	1998	The Journal of Hand Surgery	Capsulotomy DRUJ—“Silhouette” resection	9	40 (25–48)	5 Women and 4 men	6 Dominant, 3 non dominant	Not reported	Eight of the 9 patients sustained displaced fractures of the distal radius and underwent open reduction and internal fixation. In 6 of these 8 patients, the original radius fracture extended into the sigmoid fossa of the distal radius.	Pain, extension, flexion, pronation, supination	Wrist extension and flexion improved approximately 20 degrees. Likewise, radial and ulnar deviation increased 5 and 9 degrees, respectively. Grip strength improved from an average of 36% of the contralateral side to 55%. Postoperative VAS was 3. The surgery was rated successful by all patients.
3	Kamal and Ruch	2017	J Hand Surg Am	Open Volar Capsular Release	11	45 (21–62)	6 Women and 5 men	Not reported	4.5 years	Volar plating for a distal radius fracture.	DASH, wrist flexion, extension, pronation, supination, VAS, ulnocarpal translocation		Preop	Postop
												Flexion	35.9 ± 9.2	62.7 ± 18.8
												Extension	24.8 ± 15.5	58.6 ± 13.4
												Pronation	61.5 ± 12.6	75.9 ± 9.2
												Supination	49.3 ± 16.8	72.3 ± 13.1
												DASH	45.9 ± 15.5	9.6 ± 12.9
												VAS	2.6 ± 1.0	2.2 ± 1.2