Arthroscopic Release of Wrist Contracture

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CHAPTER 52 Arthroscopic Release of Wrist Contracture

Joseph Bergman, MD, Gregory Bain, MBBS

Rationale and Basic Science Pertinent to the Procedure

Wrist contracture is a difficult problem with significant clinical implications. It has a variety of causes with trauma to the distal radius and carpus being the most common. The authors recommend that the wrist contracture be classified as extra-articular, capsular, or intra-articular. Extra-articular causes include heterotopic bone and changes in joint orientation, as might be seen after an extra-articular distal radius fracture; intra-articular causes include intra-articular distal radius or carpal fractures and carpal instability. Extra-articular and intra-articular pathology should be dealt with to address these sources of wrist stiffness.

Causes of capsular stiffness include fractures, surgery, arthritis, and immobilization to the wrist. In cases of capsular stiffness, initial treatment should include physiotherapy directed at stretching and splinting. In most cases, this regimen yields satisfactory results.

In refractory cases, surgical intervention may be warranted given the effectiveness of the technique when used with other joints.¹^–⁵ Open and arthroscopic techniques have been described for the wrist, although there is a paucity of literature regarding clinical outcomes. Nonetheless, for cases where conservative management is inadequate, there seems to be a role for surgical management. In cases in which the source of the restriction in motion is the capsule, release or resection of the capsule would provide an increased range of motion, much as it does in other cases of arthrofibrosis.

Anatomy

Numerous nerves and blood vessels traverse the wrist joint. Their proximity is important in choosing arthroscopic portals and during release of contractures. The ulnar and median nerves and the radial artery are most at risk during this procedure, and their proximity to the capsule is relevant to the safety of the release (Fig. 52-1).

FIGURE 52-1 Cadaver cross section showing the relative locations of the major neurovascular structures of concern, including the ulnar nerve (UN), the median nerve (MN), and the radial artery (RA).

Used with permission from The Journal of Arthroscopic and Related Surgery, Vol 16, No. 1 (Jan-Feb), 2000.

Ulnar Nerve

The ulnar nerve is at risk in many of its branches for portal selection and in its proximity to the ulnar volar joint capsule. It courses from beneath the flexor carpi ulnaris to the radial side of the tendon, and passes radial to the pisiform at an average distance of 6 mm (range 4 to 12 mm). Because the ulnar carpal ligaments are left untouched in this procedure, the ulnar nerve is principally of issue with respect to portal placement.

The ulnar nerve has two significant superficial branches, which originate approximately 10 cm proximal to the wrist joint—the dorsal cutaneous branch, and the volar cutaneous branches of the ulnar nerve. Placement of the 6R portal should be done using blunt dissection to avoid injury to the dorsal superficial ulnar cutaneous nerve. The portal should be placed in the proximal fifth (19%) of an imaginary line drawn from the ulnar styloid to the fourth web space.⁶

Median Nerve

The median nerve’s course on the central volar aspect of the wrist within the carpal tunnel places it away from the joint capsule. It is the most superficial structure within the carpal tunnel and sits 13 mm underneath the skin surface.⁷ It passes an average of 6.9 mm volar to the volar wrist capsule and at closest, 4 mm.⁸ The median nerve passes radially within the carpal tunnel and is, on average, 18 mm radial to the pisiform and 8 mm ulnar to the scaphoid tubercle. It is protected by the mass of the finger flexors during capsular excision.

Radial Artery

The radial artery is located radially to the flexor carpi radialis tendon and sheath. It is at least 3 mm away from the volar radial capsule (average >5 mm). During capsular release, the radial artery is the structure most at risk, but careful division of the radioscaphocapitate ligament and the long radiolunate ligaments avoids the artery.

Indications

An arthrofibrotic wrist in which stiffness is the principal presenting complaint is most appropriate for arthroscopic release of the wrist capsule. Patients for whom stiffness is not the dominant symptom are not ideal.

Ideal Candidate

The ideal candidate for arthroscopic capsular release is a patient with functional loss of range of motion and for whom conservative therapy, including splinting, has failed. There is no upper limit to timing, but the joint should have stabilized in terms of pathology and range of motion before initiating any surgical release. In practice, this should be at least 6 months from the time of injury.

Capsular contracture should be diagnosed as the origin of the stiffness, and bony architecture should be ruled out as a reason for limitation of motion. There should be normal articular cartilage with a normal anatomical joint surface. Stiffness should be the sole reason for the contracture, with a painless but limited range of motion. Lastly, there should not be a generalized arthropathy likely to lead to recurrence of stiffness.

Contraindications

Absolute Contraindications

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