The origin of a posttraumatic wrist joint stiffness can be either extra-articular, intraarticular, or both.
Surgical arthrolysis is a viable option that can be performed via open or arthroscopic surgery.
A poor articular surface may be responsible for failure or recurrence of painful stiffness after arthrolysis
Arthroscopy of the DRUJ can be challenging.
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.
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).
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.
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?
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 ).
|Level of Evidence|
|I||Large randomized controlled trials|
|II||Small randomized controlled trials|
|III||Cohort and case-control studies|
|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|
|5||Expert opinion without explicit critical appraisal or based on physiology or bench research|
|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).
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 ).
|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|