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Wrist Arthroscopy William B. Geissler, MD Professor and Chief, Arthroscopy and Sports Medicine, Professor, Division of Hand and Upper Extremity Surgery, Director, Hand/Upper Extremity Fellowship Program, Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi Editor Wrist Arthroscopy With 217 Illustrations in 321 Parts, 44 in Full Color William B. Geissler, MD Professor and Chief, Arthroscopy and Sports Medicine Professor, Division of Hand and Upper Extremity Surgery Director, Hand/Upper Extremity Fellowship Program Department of Orthopaedic Surgery and Rehabilitation University of Mississippi Medical Center Jackson, MS 39216 USA Cover illustration: xxxxxxx xxxxxx xxxxxxxxx xxxxxxxxxx xxx xxxx xxxxx xxxxx xxx xxxx xxx xxxx xxxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxxx xx xxx xxx xxx xx xx x xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxxx xx Library of Congress Cataloging-in-Publication Data Wrist arthroscopy / [edited by] William Geissler. p. ; cm. Includes bibliographical references and index. ISBN 0-387-20897-6 (h/c : alk. paper) 1. Wrist—Endoscopic surgery. 2. Wrist—Surgery. 3. Arthroscopy. I. Geissler, William. [DNLM: 1. Wrist—surgery. 2. Arthroscopy—methods. WE 830 W95512 2004] RD559.W7514 2004 617.5Ј74—dc22 2004041828 ISBN 0-387-20897-6 Printed on acid-free paper. © 2004 Springer-Verlag New York, LLC. All rights reserved. This work may not be translated or copied in whole or in part without the writ- ten permission of the publisher (Springer-Verlag New York, LLC, 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in con- nection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of go- ing to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed in the United States of America. (MP/MVY) 9 8 7 6 5 4 3 2 1 SPIN 10941881 Springer-Verlag is a part of Springer ScienceϩBusiness Media springeronline.com 24 Clinical Approach to the Painful Wrist Andrea Atzei and Riccardo Luchetti ain localization of the wrist is the most common CLINICAL EVALUATION cause of referral to consultation in the office of Pmany hand and wrist surgeons. In many cases, History a patient’s complaints are readily recognized as typi- cal symptoms and the history pathognomonic of de- The steps in taking a patient’s history are well defined fined disorders. Accurate physical examination, sup- (Table 24.1). The patient’s general history should be ➟ T1 plemented by standard x-rays, often yields a prompt collected first; age and sex are important as they cor- diagnosis during the first patient visit. relate with joint wear.5,6 Special attention should be However, cases of chronic wrist pain, in which paid to occupational and avocational activities in- exact diagnosis is difficult even after several con- volving the wrist; previous injuries or surgery, and sultations, are not infrequent. This is not surprising other systemic illnesses and/or rheumatologic dis- if one considers the anatomic and biomechanical eases. Details of wrist complaints, whether they fol- complexity of the wrist joint. Within that small area, low injuries considered trivial and therefore initially there is a concentration of intimately related struc- underestimated, or result from slow progression of tures, including more than 20 radiocarpal, inter- nontraumatic conditions, must be obtained by specific carpal, and carpometacarpal joints, as well as the dis- questioning during a thorough clinical history. tal radioulnar joint (DRUJ), 26 carpal ligaments and The most common causes of acute or chronic wrist the triangular fibrocartilage complex (TFCC), each pain7–9 can be divided into 7 main categories (Table of which can be source of intra-articular pathology. 24.2): traumatic injuries (including acute injuries and ➟ T2 In addition, the 24 tendons, 2 main vascular trunks, posttraumatic conditions), degenerative and inflam- and 6 nerves crossing the joint are all sources of matory disorders (local or systemic conditions and extra-articular pathology. repetitive trauma disorders), infections, tumors, con- Thorough clinical evaluation of the painful wrist genital and developmental disorders, neurological dis- should include routine steps of taking the patient’s orders, and vascular disorders. Categorizing the pa- history and performing a physical examination, fol- tient’s wrist complaints according to these 7 general lowed by appropriate imaging studies. During the last causes is an important step to identify a specific dis- decade, arthroscopy has confirmed its role as a valu- order or to formulate a differential diagnosis to guide able tool in helping the clinician in the diagnosis of physical examination and further investigation. wrist disorders.1–4 Direct visualization of intra-articular structures al- Physical Examination lows early diagnosis and treatment of selected cases. However, limitations of arthroscopy include the fact Continuous advances in our understanding of wrist that only intra-articular pathology can be assessed, and anatomy and kinematics have increased the impor- not all abnormalities identified by arthroscopy are tance of physical examination as the basic diagnostic necessarily responsible for the patient’s complaints. tool, over imaging techniques, whose most valuable Therefore, diagnostic arthroscopy is indicated only fol- contribution is in differential diagnosis in selected lowing a thorough clinical examination, during which cases.10 Examination should be extended to the entire the anatomic structures responsible for the patient’s upper extremity, including the cervical spine and all symptoms should be located with the greatest accu- other joints or areas of symptomatology. racy and all extra-articular causes of pain excluded. A Evaluation of the painful wrist begins with an ac- systematic approach is suggested for the diagnosis and curate inspection for specific areas of swelling or ob- management of the conditions or disorders that cause vious deformities, erythema, warmth, nodules or skin wrist pain. lesions, and prior surgical scars. Assessment of pas- 185 186 ANDREA ATZEI AND RICCARDO LUCHETTI TABLE 24.1. Steps in Taking a Patient History. impairment,11 especially when the rapid exchange grip 12 Patient’s general history Wrist complaint history technique is used to detect submaximal effort. Palpation is the next step of physical examination. 1. Age 1. Classification of chief complaint 2. Handedness 2. Onset, location, and nature of Diagnostic ability depends essentially on a thorough 3. Occupation symptoms knowledge of both soft tissue and bony topographic 4. Avocational activities 3. Symptom’s relation to specific anatomy of the wrist: recognition of underlying soft 5. Previous wrist injuries activities 6. Previous wrist surgery 4. Factors exacerbating or tissue and bone structures as sources of pain is a fun- 7. Other orthopedic/ improving symptoms damental step towards diagnosis, as it allows correla- rheumatologic disorders 5. Frequency and duration of tion of clinical complaints with anatomical damage.13 8. Other medical/ post-activity ache dismetabolic disorders 6. Subjective loss of wrist motion A systematic approach to correlating the pain symp- 7. Abnormal sounds or sensations tom to topographic anatomy of the wrist can be with wrist motion achieved by dividing the dorsal and palmar aspect of 8. Efficacy of prior treatments 9. Current work status the wrist surface into 3 areas: radial, central, and ul- 10. Involvement of worker’s nar (Fig. 24.1). A total of 6 areas are defined by using ➟ F1 compensation claim prominent bony landmarks and easily palpable ten- dons as reference points. Proceeding from radial to ulnar on the dorsal sur- sive and active range of motion of both wrists usually face of the wrist, the following landmarks are located follows. A loss of motion is consistently associated (Figure 24.1A): the dorsoradial border of the compart- with a disorder primarily affecting the wrist joint, ei- ment for the abductor pollicis longus (APL) and the ther posttraumatic or degenerative. Measurement of extensor pollicis brevis (EPB) tendons—i.e., the first grip strength has proved to be a reliable index of wrist extensor compartment of the wrist, a longitudinal line TABLE 24.2. Most Common Causes of Wrist Pain. Chondritis/Osteochondritis/ Post-traumatic arthritis Fracture and Malunion Nonunion SNAC Radius—ulna Scaphoid SLAC Scaphoid Capitate Piso-triquetral arthrosis Other carpal bones Hamate Hamate-triquetral arthrosis Traumatic Hyperextension Radioscaphoid impingement Disorders (Gymnast’s wrist) Ulno-carpal impingement Ligamentous Injuries and Instability Perilunate (scapholunate, lunotriquetral) Midcarpal (intrinsic, extrinsic) Radiocarpal (ventral or dorsal subluxation, ulnar translocation) Extensor Carpi Ulnaris Dorsal
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