Open release of stiff wrist: a medium to long term case series and literature review

BACKGROUND AND AIM OF THE WORK

The authors reported a personal case series of open release of stiff wrists performed after previous internal osteosynthesis of distal radius fractures.

METHODS

From a series of 16 patients operated by a single surgeon, 12 were evaluated at a mean 7.1 years follow-up (range 2.25 to 19 years), while 4 were lost at follow-up. The ROM in flexion-extension achieved at the final control was measured with a goniometer and compared to that recorded before surgery. The PRWHE questionnaire was administred at the last follow-up.

RESULTS

The mean flexion improved from 25.5° to 42.3° and the extension from 15.75° to 43°. The mean PRWHE value was 32.9.

CONCLUSIONS

Although arthroscopic release is increasingly used in clinical practice for its minimal invasinevess and warranty of fast recovery, open arthrolysis in post-traumatic stiff wrists appears to be an effective procedure, adaptable to all types of stiffness, that lets get good long lasting functional results.

Wrist Arthrolysis: A Systematic Review of Open and Arthroscopic Techniques

Background  Wrist arthrolysis is a viable option in wrist stiffness and can be performed via open or arthroscopic techniques. Purpose  The aim of the study is to describe and evaluate the available techniques of open and arthroscopic arthrolysis of the radiocarpal joint and the distal radio ulnar joint (DRUJ) in posttraumatic wrist stiffness. Methods  A systematic literature search was performed in PubMed to identify studies reporting on open and arthroscopic wrist arthrolysis. Key words included "open wrist arthrolysis," "arthroscopic wrist arthrolysis," "post-traumatic wrist stiffness," and "DRUJ arthrolysis." Data were extracted independently by a pair of reviewers. Results  Overall, 637 studies were identified; 13 additional articles were found through previous publications (total 650 articles). A total of 612 records resulted after duplicates was removed. Fourteen studies were selected and only eight respected the inclusions criteria. One study focused on volar open arthrolysis and four studies on arthroscopic arthrolysis of the radiocarpal joint; two studies reported on open arthrolysis and two studies on arthroscopic DRUJ arthrolysis. Range of motion following open and arthroscopic wrist arthrolysis improved in all studies. Conclusion  Both arthroscopic and open arthrolysis can lead to similar and satisfactory results in radiocarpal joint and DRUJ stiffness.. Level of Evidence  This is a level 3a study.

Evaluating Viscoelastic Properties of the Wrist Joint During External Perturbations: Influence of Velocity, Grip, and Handedness

In this study, we designed a robot-based method to compute a mechanical impedance model that could extract the viscoelastic properties of the wrist joint. Thirteen subjects participated in the experiment, testing both dominant and nondominant hands. Specifically, the robotic device delivered position-controlled disturbances in the flexion-extension degree of freedom of the wrist. The external perturbations were characterized by small amplitudes and fast velocities, causing rotation at the wrist joint. The viscoelastic characteristics of the mechanical impedance of the joint were evaluated from the wrist kinematics and corresponding torques. Since the protocol used position inputs to determine changes in mean wrist torque, a detailed analysis of wrist joint dynamics could be made. The scientific question was whether and how these mechanical features changed with various grip demands and perturbation velocities. Nine experimental conditions were tested for each hand, given by the combination of three velocity perturbations (fast, medium, and slow) and three hand grip conditions [self-selected grip, medium and high grip force, as percentage of the maximum voluntary contraction (MVC)]. Throughout the experiments, electromyographic signals of the extensor carpi radialis (ECR) and the flexor carpi radialis (FCR) were recorded. The novelty of this work included a custom-made soft grip sensor, wrapped around the robotic handle, to accurately quantify the grip force exerted by the subjects during experimentation. Damping parameters were in the range of measurements from prior studies and consistent among the different experimental conditions. Stiffness was independent of both direction and velocity of perturbations and increased with increasing grip demand. Both damping and stiffness were not different between the dominant and nondominant hands. These results are crucial to improving our knowledge of the mechanical characteristics of the wrist, and how grip demands influence these properties. This study is the foundation for future work on how mechanical characteristics of the wrist are affected in pathological conditions.

Manual passive rehabilitation program for geriatric distal radius fractures

Limitation of wrist range of motion (ROM) is a common complication of distal radius fractures (DRFs) in geriatric patients. The present study aimed to evaluate the effectiveness of rehabilitation in the restoration of wrist ROM after geriatric DRF. Eighty-eight geriatric patients with DRF, 59 women and 29 men aged 71.69 ± 6.232 years participated in the study. The time from wrist immobilization to rehabilitation was 12.89 ± 5.318 weeks. Daily rehabilitation was performed 30 minutes a day for 8 weeks. Active wrist ROM was measured before and at 2, 4, and 8 weeks after rehabilitation. Data were analyzed by the repeated measures multivariate analysis of variance (MANOVA), one-way MANOVA, and analysis of variance (ANOVA). Repeated measures MANOVA suggested a significant time effect for ROM (Wilks Lambda = 0.002, F = 7500.795, P < .001). Compared with before rehabilitation, each wrist ROM was significantly improved at 2, 4, and 8 weeks after rehabilitation. The one-way MANOVA demonstrated that changes in ROM were significantly different between groups (Wilks Lambda = 0.007, F = 559.525, partial eta square = 0.993, P < .001), indicating that patients in the short-term stiffness group (≤3 months) had a significantly greater increase in ROM than patients in the long-term stiffness group (>3 months). The results of this study suggest an 8-week daily rehabilitation program for geriatric patients with limited ROM <3 months after DRF.

Safety of Releasing the Volar Capsule During Open Treatment of Distal Radius Fractures: An Analysis of the Extrinsic Radiocarpal Ligaments' Contribution to Radiocarpal Stability

PURPOSE

The contribution of the extrinsic radiocarpal ligaments to carpal stability continues to be studied. Clinically, there is a concern for carpal instability from release of the volar extrinsic ligaments during volar plating of distal radius fractures in which the integrity of the dorsal ligaments may be unknown. The primary hypothesis of this study was that serial sectioning of radiocarpal ligaments would lead to progressive ulnar translation of the carpus.

METHODS

We studied the stabilizing roles of the radioscaphocapitate (RSC), short radiolunate (SRL), long radiolunate (LRL), and dorsal radiocarpal (DRC) ligaments. We sequentially sectioned these ligaments in 2 groups of 5 matched pairs and measured the motion of the scaphoid and lunate with the wrist in passive neutral alignment, radial deviation, ulnar deviation, and simulated grip. Displacement of the lunate in the radioulnar plane was used as a surrogate for carpal translation. The groups differed only by the order in which the ligaments were sectioned.

RESULTS

In the intact state, the lunate translated ulnarly during simulated grip and radial deviation, whereas radial translation, relative to its position under resting tension, was observed during ulnar deviation. With serial sectioning, the lunate displayed increased ulnar translation in all wrist positions for both groups 1 and 2. The magnitude of ulnar translation exceeded 1 mm after sectioning the LRL plus RSC along with either the DRC or the SRL.

CONCLUSIONS

Sectioning of either the DRC or SRL ligaments along with release of the RSC and LRL ligaments leads to notable although minimal (<2 mm) ulnar lunate translation.

CLINICAL RELEVANCE

Isolated sectioning of individual radiocarpal ligaments, such as for visualization of the articular surface of the distal radius, leads to minimal ulnar translation. Because prior clinical work found no clinical complications after volar capsule release, it is posited that translation less than 2 mm creates subclinical changes in carpal mechanics.

Shi's Yi-Qi Bu-Shen Tong-Luo decoction combined with manipulation in the management of wrist stiffness after distal radius fracture: Study protocol clinical trial (SPIRIT Compliant)

INTRODUCTION

Wrist stiffness is a common sequela of distal radial fractures. Manipulation is generally used and effective, but problems exist, such as intense pain, swelling during the process of manipulation and long treatment period. Therefore, a combinative therapeutic strategy is necessary to benefit rehabilitation after distal radius fracture. Shi's Yi-Qi Bu-Shen Tong-Luo decoction (BTD) combined with wrist manipulation has been used in the Shanghai Ninth People's Hospital Huangpu Branch in last few decades. BTD has potential therapeutic effects on rehabilitation after distal radius fracture, which should be evaluated by rigorous clinical trial.

METHODS/DESIGN

A randomized, double-blind, placebo-controlled clinical trial will be conducted to determine the efficiency of BTD in relief of wrist stiffness and pain and function rehabilitation. A total of 80 wrist stiffness patients with or without pain and edema will be enrolled, and treated with wrist manipulation plus BTD or placebo for 4 weeks. The primary outcome measure is the Cooney wrist score. The second outcome measures include pain numerical rating scale, patient rated wrist evaluation, 36-item short form health survey questionnaire, and side effects.

DISCUSSION

Although BTD has shown effects on rehabilitation after distal radius fracture in the Shanghai Ninth People's Hospital Huangpu Branch for decades, the universality of this efficacy needs evaluated. The results of this trial will provide a convincing evidence.

TRIAL REGISTRATION

ChiCTR2000029260, January 19, 2020.

Volar Capsular Release After Distal Radius Fractures

PURPOSE

Loss of full wrist range of motion is common after treatment of distal radius fractures. Loss of wrist extension limiting functional activities, although uncommon, can occur after volar plating of distal radius fractures. Unlike other joints in which capsular release is a common form of treatment for stiffness, this has been approached with caution in the wrist owing to concerns for carpal instability. We tested the null hypothesis that hardware removal and open volar capsular release would not lead to improved upper extremity-specific patient-reported outcome (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire).

METHODS

We conducted a retrospective chart review of patients who underwent a tenolysis of the flexor carpi radialis tendon, removal of hardware, and subperiosteal release of the volar capsule (extrinsic ligaments). The primary outcome measure was patient-reported outcome on the DASH. Secondary outcomes included wrist flexion, extension, pronation, and supination, visual analog scale for pain, and radiographs/fluoroscopy for ulnocarpal translocation.

RESULTS

Eleven patients were treated with a mean follow-up of 4.5 years. Mean DASH scores improved after surgery. Mean wrist flexion, wrist extension, pronation, and supination improved after surgery. Mean visual analog scale scores did not change. The radiocarpal relationship on radiographs/fluoroscopy was normal.

CONCLUSIONS

Open volar capsular release to regain wrist extension after treatment of distal radius fractures with volar locking plates is safe and effective. Patients regain wrist extension in addition to improved DASH scores. There were no radiographic/fluoroscopic or clinical signs of ulnocarpal translocation after release of the volar extrinsic ligaments.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.