Chronic wrist pain: indications for wrist arthroscopy

Although arthroscopy represents a new and dynamic diagnostic technique for evaluating the wrist, specific indications for arthroscopic intervention in the wrist are not defined. To place this technique in perspective, we review our experience with 54 consecutive arthroscopies of the radiocarpal and midcarpal joints in 53 patients with chronic wrist pain. On the basis of this review, we believe arthroscopy is indicated for the diagnosis of wrist pain of longer than 3 months' duration. Defects of the triangular fibrocartilage and lesions of the articular cartilage, including loose bodies, are detectable and easily treated with wrist arthroscopy.     

TFCC-lesion. MR arthrography vs. arthroscopy of the wrist

In a blinded study from January to July 2000, 125 patients suffering from specific complaints of the wrist were examined with direct MR arthrography prospectively. Within 24 hours an arthroscopy of the wrist was performed. With the MR arthrography in 70 patients or 56% of all patients injury of the TFCC was diagnosed. In 65 patients this could be verified arthroscopically. In the remaining 55 patients no TFCC lesion was diagnosed with the MR arthrography. However lesions were found via arthroscopy in three cases,were MRI findings expected an intact TFCC. In the remaining 52 cases the MRT could exclude a lesion of the TFCC correctly. An agreement of the MRT and arthroscopic results could be determined in 93.6% of the cases (correlation). The diagnosis of a TFCC lesion by means of MRI was correct in 94% of the cases (sensitivity), the exclusion of such lesion in 89% (specificity). Positive or negative predictive values of 91% or 93% were achieved. Since neither a specificity nor a sensitivity of 100% can be reached at the moment, the MR arthrography cannot replace the arthroscopy. However it could be a potent additional tool for wrist diagnosis if intraarticular contrast is used. It can facilitate the diagnostics and the indication for surgery at the ulnocarpal wrist and help to reduce arthroscopic interventions that are only for diagnostic purposes and without any therapeutic consequences. With improvement of the technique of magnet resonance tomography we can expect further increase of accuracy and the clinical use of the MR arthrography in the diagnostic workup at the ulnocarpal wrist.     

桡骨远端骨折腕关节MRI和疗效评估的临床研究

目的 探讨桡骨远端骨折疗效欠佳的原因，及其与骨折伴发的软组织损伤的关系。方法 对65例桡骨远端骨折内固定物取出术后，经平均1．8年随访的患者，选择其中20例（评分为良4例，可11例，差5例）进行腕关节MRI检查，观察关节软骨和腕尺侧三角纤维软骨（triangularfibro cartilage，TFC）的损伤情况。结果 MRI检查发现，9例有明显的TFC损伤（占45％，其中评分为良1例，可3例，差5例）。8例有桡骨远端关节软骨的损伤（40％，评分为可3例，差5例）。结论 TFC损伤和创伤性关节炎可能是影响桡骨远端骨折疗效，造成术后腕部慢性疼痛的主要原因。     

Stellenwert der Handgelenkarthroskopie

Wrist arthroscopy has been the gold standard in diagnosing ligament, cartilage, or triangular fibrocartilage complex (TFCC) lesions of the wrist joint. One advantage of arthroscopy is the ability not only to see, but also to palpate the lesions using a probe. A disadvantage of arthroscopy is the low interobserver reliability of digital images or videos made during arthroscopy. Magnetic resonance imaging (MRI) is an alternative to wrist arthroscopy in diagnosing wrist lesions. Its reliability is enhanced by a limited, specific use, which should be founded on a thorough hand surgical clinical examination. MR images should be transmitted to the surgeon in an adequate quality.     

腕关节镜辅助可动力化外固定器技术治疗桡骨远端关节内骨折

目的采用腕关节镜辅助可动力化外固定器技术治疗桡骨远端关节内骨折,并初步评价其治疗效果。方法15例桡骨远端关节内骨折患者,采用腕关节镜辅助可动力化外固定器技术治疗。常规X线片检查结合腕关节镜观察,测量手术前后尺偏角、掌倾角、桡骨短缩、关节面“台阶”和关节内骨折缝隙。患者主观症状用疼痛标尺法测量,腕关节功能按Sarmiento改良的Gartland-Werley计分法评价。结果术后患肢掌倾角、尺偏角、桡骨短缩和关节内骨折复位情况除2例关节内骨折缝隙大于2mm外,均获得满意效果;患者疼痛计分平均1.2分;腕关节功能优10例,良4例,一般1例。结论通过本组病例观察,可动力化外固定器技术可以较好地维持桡骨远端关节内骨折的稳定。腕关节镜手术有助于精确恢复关节面的平整。两项技术的结合使用较好地解决了维持桡骨关节面高度和恢复关节面平整的问题。     

Basics of diagnostic wrist arthroscopy

Minimal access surgery has considerably progressed in recent years. This has also led to advancements in the area of wrist arthroscopy, which has gained widespread acceptance. The complex nature of the carpus poses particularly difficult diagnostic dilemmas in the management of chronic wrist conditions and injuries of the wrist joint. Arthroscopic procedures involve less surgical dissection, better visualization and classification of lesions, less post-operative pain and a shorter recovery time for the patient. This article focuses on the indications, pre-operative assessment, theatre protocol and complications of wrist arthroscopy.     

Diagnostic and operative arthroscopy of the wrist

The evaluation and diagnosis of wrist disorders has traditionally been difficult and problematic. Ligamentous wrist sprains and their associated carpal instabilities, triangular fibrocartilage complex disruptions, and cartilage injuries have been virtually impossible to fully assess because of the inadequacy of current diagnostic techniques. Arthroscopy of the wrist allows a thorough evaluation of the soft-tissue structures and cartilaginous surfaces within the radiocarpal and midcarpal joints. In selected cases, wrist arthroscopy can be employed to surgically modify the intraarticular lesions and to assist in the planning of reconstructive operations.     

Fractures and ligamentous injuries of the wrist

Rapid diagnosis, appropriate management, and sport-specific rehabilitation are important in the management of any wrist injury in the athlete. The addition of technetium scans, CT, arthroscopy, and MRI in the evaluation of the athlete's wrist has provided valuable and powerful diagnostic tools. The versatility and relatively low invasiveness of arthroscopic intervention and the subsequent early return to activity make this technique especially attractive in the high-performance athlete. Suspicion of potential injuries, complete knowledge of wrist mechanics and anatomy, and a careful physical examination are still the most important tools in the evaluation of wrist injury. It is important to approach each athlete in a patient-oriented manner, taking into account the fact that many of these injuries have the potential to be career ending. Treatment that will provide the best possible long-term wrist function must be the physician's ultimate goal. In addition, the importance of appropriate and activity-specific rehabilitation cannot be overemphasized.     

关节镜治疗创伤后慢性腕关节疼痛

目的：探讨关节镜在创伤后慢性腕关节疼痛的治疗效果。方法：回顾分析2007年2月至2010年6月收治的12例创伤后慢性腕关节疼痛的病例,男9例,女3例,年龄19～47岁,平均35.6岁,经查体及MR检查有异常者行关节镜检查和治疗。其中8例三角纤维软骨复合体（TFCC）中央型部分撕裂,行镜下边缘部分切除;2例腕骨间韧带部分损伤后松弛者行射频皱缩;1例下尺桡关节不稳行腕关节清理后克氏针横穿远端尺桡骨于前臂旋转中立位,长臂石膏固定6周;1例尺骨撞击综合征行腕关节清理,三角软骨盘边缘修整后,磨钻部分切除远端尺骨。用改良Mayo腕关节评分进行疗效评价。结果：术后平均随访10个月,Mayo腕关节评分术前平均（51.67±15.27）分（25～75分）,术后平均（77.92±10.54）分（65～95分）,术后评分高于术前。11例恢复原来工作。结论：对创伤后慢性腕关节疼痛病例,关节镜可以明确诊断并行镜下治疗,疗效良好。     

Imaging of Articular Cartilage

Since the advent of arthroscopy and MRI, clinicians have been able to directly image articular cartilage. Significant strides have been made to improve MRI technology to permit nondestructive imaging and assessment of articular cartilage. Development of new cartilage-specific MRI sequences and MRI techniques to evaluate cartilage matrix composition permit earlier diagnosis of cartilage injury and degeneration. Although the current standard for articular cartilage assessment continues to be visual assessment through arthroscopic surface imaging and probing, introduction of novel cross-sectional imaging technologies such as OCT will similarly augment the diagnostic capacity of arthroscopic assessment of articular cartilage. Continued development of new methods to image articular cartilage will enhance the ability of clinicians in identifying potentially treatable areas of early cartilage damage. Improved early diagnosis and treatment may lead to methods to prevent or delay the onset of disabling osteoarthritis.     

A comparison of the findings of wrist arthroscopy and magnetic resonance imaging in the investigation of wrist pain

Between 1996 and 1999, 54 patients with wrist pain had magnetic resonance imaging performed using a 1.5 Tesla scanner without a wrist coil. Wrist arthroscopy was performed using a standard technique. The findings were then compared. Magnetic resonance imaging had a low sensitivity for the detection of triangular fibrocartilage complex injuries (0.44) and scapholunate ligament injuries (0.11) when wrist arthroscopy was used as the standard of reference.We conclude that when a magnetoresonance technique that does not employ a dedicated wrist coil is used, a negative magnetic resonance imaging scan does not exclude these two significant injuries.     

腕关节镜辅助下修复舟月韧带治疗腕关节不稳定

目的分析腕关节镜辅助下利用骨锚修复腕舟月韧带的疗效。方法自2008年10月一2011年4月,对6例腕关节损伤患者通过腕关节镜探查舟月韧带,确定损伤部位后,应用Mitek骨锚重建舟月韧带,术后石膏托固定腕关节于功能位4周后开始患腕被动活动,6周后开始主动运动。术后随访6个月,测定患腕术前及术后的握力、应用改良Mayor评分法对腕关节功能进行客观评分、患者源性调查表（disabilityofarm-shoulder-hand,DASH）问卷法进行主观评分,以及术前与术后的x片检查对比。并与健侧腕关节x片进行对比。结果术后6例患者腕关节疼痛均有缓解．握力明显改善。按照改良Mayor评分：优2例,良3例,可1例,优良率为83．3％,与术前评分的差异有统计学意义（P〈O．01）。术后DASH分值平均为（14．6±7．0）,与术前评分差异有统计学意义（P〈O．01）。结论舟月韧带损伤是导致腕关节不稳定的重要原因之一,在腕关节镜辅助下利用骨锚修复舟月韧带是一种微创、实用的方法。     

Complications of wrist arthroscopy

PURPOSE: To determine the incidence and nature of complications after arthroscopy of the wrist joint. METHODS: The outpatient records and surgical reports of 211 patients who had wrist joint arthroscopy were reviewed to determine type of procedure, type of anesthetic, portals used, and incidence and nature of postsurgical complications. RESULTS: We identified a total of 11 complications in our patient group (5.2%). Of these, 2 patients (0.9%) developed major complications and 9 patients (4.3%) developed minor complications. Five complications 45% were identified in the immediate postsurgical period and 6 (55%) were delayed complications. All of the minor complications resolved at latest follow-up evaluation with conservative care. CONCLUSIONS: Wrist arthroscopy is a safe procedure with a low rate of major and minor complications. In spite of its limitations wrist arthroscopy remains an invaluable tool in the diagnosis and treatment of wrist joint disorders.     

Evaluation of chronic wrist pain: Arthroscopy superior to arthrography: Comparison in 39 patients

39 patients with chronic wrist pain underwent arthrography and arthroscopy to reveal disruptions of the triangular fibrocartilage complex (TFCC) and/or interosseous ligaments. TFCC disruption was diagnosed arthroscopically in 15 cases of which arthrography revealed the disruption in only 7. in 3 other patients, arthrography showed rupture of the TFCC: however, arthroscopy showed no defects. Rupture of an interosseous ligament was diagnosed arthroscopically in 6 patients in all of whom it was also revealed by arthrography. in 6 other patients, arthrography showed disruption of an interosseous ligament not verified by arthroscopy.

We conclude that arthroscopy is superior to arthrography for diagnosing chronic wrist pain.     

Evaluation of chronic wrist pain: Arthroscopy superior to arthrography: Comparison in 39 patients

39 patients with chronic wrist pain underwent arthrography and arthroscopy to reveal disruptions of the triangular fibrocartilage complex (TFCC) and/or interosseous ligaments. TFCC disruption was diagnosed arthroscopically in 15 cases of which arthrography revealed the disruption in only 7. in 3 other patients, arthrography showed rupture of the TFCC: however, arthroscopy showed no defects. Rupture of an interosseous ligament was diagnosed arthroscopically in 6 patients in all of whom it was also revealed by arthrography. in 6 other patients, arthrography showed disruption of an interosseous ligament not verified by arthroscopy.

We conclude that arthroscopy is superior to arthrography for diagnosing chronic wrist pain.     

Cost description of clinical examination and MRI in wrist ligament injuries

Objective: The total number and cost of wrist MRIs in the catchment area of the Västra Götaland Region in Sweden (population 1 723 000) during 1 year was analysed, together with the number and content of referrals.

Methods: Six radiology departments reported the numbers and rate of all MRI investigations intended to diagnose wrist ligament injuries (n?=?411) and other injuries to the wrist.

Results: The additional cost of the difference between MRIs and a clinical examination by a hand surgeon, plus indirect costs for patients with suspected wrist ligament injuries, was calculated as 957 000 euros.

Conclusions: It is recommended that MRI should only be used in patients in whom there are clinical difficulties in terms of diagnosing wrist ligament injuries. It is suggested that patients with suspected wrist ligament injuries should be referred directly to an experienced hand surgeon, capable of performing a standardised wrist examination and, when needed, diagnostic arthroscopy and final treatment. The proposed algorithm for the diagnosis and treatment of suspected wrist ligament injuries presented in the present study could save time for the patient and for the radiology departments, as well as reducing costs. The ability to implement the early and appropriate treatment of acute ligament injuries could be improved at the same time.     

Visualisation of the pisotriquetral joint through standard portals for arthroscopy of the wrist: a clinical and anatomical study

Disorders of the pisotriquetral joint are well recognised as the cause of pain on the ulnar side of the wrist. The joint is not usually examined during routine arthroscopy because it is assumed to have a separate joint cavity to the radiocarpal joint, although there is often a connection between the two. We explored this connection during arthroscopy and in fresh-frozen cadaver wrists and found that in about half of the cases the pisotriquetral joint could be visualised through standard wrist portals. Four different types of connection were observed between the radiocarpal joint and the pisotriquetral joint. They ranged from a complete membrane separating the two, to no membrane at all, with various other types of connection in between. We recommend that inspection of the pisotriquetral joint should be a part of the protocol for routine arthroscopy of the wrist.     

Arthroscopic resection of volar wrist lipoma: a case report

We present the case of a patient who showed a volar radiocarpal mass confirmed to be a lipoma by the ultrasonographic examination. The whole procedure was done by arthroscopy, using portal 1-2 for the shaver and 3-4 for the arthroscope. The patient returned to daily activities within a few days, with a mobility of the operated wrist identical to that of the contralateral wrist, with no pain and only two little dorsal scars.     

非创伤性尺腕撞击综合征的诊断和治疗

目的 探讨无明确创伤病史且X线片表现不典型的尺腕撞击综合征的特点及诊断标准和治疗方法.方法 回顾性研究2003年10月至2010年10月明确诊断和治疗的55例尺腕撞击综合征患者中没有明确创伤病史且X线片表现不典型的25例,在Kostas诊断标准基础上,观察尺腕压力试验、动态尺骨正向变异、MRI检查的阳性率和腕关节镜检查,分析观察指标对诊断结果的影响和临床意义.治疗采取尺骨短缩手术,截骨方式中16例采用水平截骨(Darrow法),9例采用斜行截骨(Rayhack法),加压钢板螺钉内固定.采用Darrow标准作为疗效评价标准.结果 本组25例患者中尺腕压力试验阳性比率为84％,动态尺骨正向变异的发生比率为52％,MRI检查发现腕骨信号改变的比率为82％,以月骨尺侧部近端和三角骨腰部最为常见,腕关节镜检查三角纤维软骨复合体(TFCC)退变及尺骨头和月骨的软骨退变比率为100％.随访时间4～48个月,平均26个月.25例骨折均愈合,水平截骨的平均愈合时间为4.5个月,斜行截骨的平均愈合时间为2.5个月.优7例,良15例,中2例,差1例;总优良率为88％.术后未发生严重并发症,治疗结果满意.结论 非创伤性尺腕撞击综合征由于缺少明确的创伤病史,尤其当X线片表现不典型时同其他引起腕关节尺侧疼痛的病因较难鉴别,应用尺腕压力试验、动态尺骨正向变异检查和早期MRI检查可早期明确诊断,有效提高诊断率.腕关节镜检查可作为诊断困难和鉴别诊断的补充手段.应用尺骨短缩手术可明显改善症状,斜行截骨是值得推荐的截骨方式.     

Arthroscopic diagnosis of posttraumatic disorders of the wrist

Arthroscopy of the wrist is a helpful diagnostic procedure in cases of painful problems that cannot be diagnosed by clinical and radiological examination. Arthroscopy of the wrist was done in 32 patients, who could not be diagnosed by clinical and radiological examination. During arthroscopy, lesions of the fibrocartilaginous disc and of the cartilage, synovitis of the joint capsule, scaphoidlunate dissociations and a loose body were detected. As a result of arthroscopic findings, 10 operative procedures were necessary. Resection of a torn disc, local synovectomy, reconstruction of the torn scaphoid-lunate ligament and removal of a loose body were done by open arthrotomy (8 patients). In 2 patients shaving of chondral ulcers on the radial joint surface was performed, which obviated the need for an explorative arthrotomy. Arthroscopy is a simple method that enables new diagnostic possibilities in rare but difficult cases of posttraumatic pain of the wrist.