Introduction

Wrist contractures can occur following any type of wrist injury, but are most prevalent following distal radius fractures. Ganglion excision, carpal dislocation or fracture, previous wrist surgery, reflex sympathetic dystrophy, and prolonged immobilization may all lead to a loss of wrist motion. Watson has previously described a release of the volar and dorsal wrist capsule through open capsulotomies.¹ A similar approach has been described for the distal radioulnar joint.² Arthroscopic release of wrist contractures has been reported by a number of authors, with encouraging results.^3–5

Indications

A biomechanical study performed by Palmer et al. defined functional wrist motion as being flexion of 5 degrees, extension of 30 degrees, radial deviation of 15 degrees, and ulnar deviation of 10 degrees.⁶ Patients lacking a functional arc of wrist motion who have failed a trial of dynamic/static progressive splinting are candidates for this procedure. Volar capsulotomies are less risky and are indicated to regain wrist extension. Dorsal capsulotomies are necessary to regain wrist flexion but they may require use of a volar arthroscopy portal and are technically more difficult.

Contraindications

Contraindications in this case include all of those general to wrist arthroscopy, including active infection, large capsular tears (which can lead to extravasation of irrigation fluid), bleeding disorders, neurovascular compromise, marked swelling (which distorts the anatomy), inadequate or marginal soft–tissue coverage of the wrist, and the inability to withstand anesthesia. Division of the radioscaphocapitate (RSC), long radiolunate (LRL), and short radiolunate (SRL) ligaments should be performed with caution in patients who are at risk for ulnar translocation (such as those patients with rheumatoid arthritis and those who have undergone previous radial styloidectomies).^7,8 A frank carpal volar or dorsal carpal instability pattern is another contraindication because release of the volar and/or dorsal extrinsic ligaments would likely exacerbate this condition.

Relative contraindications include an unfamiliarity with the regional anatomy as well as abnormal bony anatomy due to a distal radius mal–union. Patients who cannot comply with postoperative dynamic/static progressive splinting due to low pain threshold or psychological disorder are not appropriate candidates.

Equipment

A 2.7–mm 30–degree angled scope along with a camera attachment is used, although a 1.9–mm scope is useful in tight wrists. A 3–mm hook probe and Freer elevator are needed for palpation of intracarpal structures and for release of adhesions. An overhead traction tower greatly facilitates instrumentation. The use of a motorized shaver is needed for debridement, along with a selection of suction punches and arthroscopic straight and curved knives. Some type of diathermy unit may be useful if cautery is desired for lysis of adhesions.

Surgical Technique