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Arthroscopy of the wrist
ARTHROSCOPY
OF THE
WRIST
E. P. KELLYandJ. K. STANLEY From the Wrightington Hospital, Wigan
Endoscopy has developed steadily since its inception in the early part of the 19th century. In 1939, Dr Kenji Takagi of Tokyo University was the first to look inside a body cavity which had no natural portal, in that case the knee (Takagi, 1939). Nowadays arthroscopy of the knee has become accepted as a routine orthopaedic procedure for investigative and perathroscopic surgery. Arthroscopy of other joints has been slower to develop, hindered in part by instrument-makers’ concentration on arthroscopy of the knee but also by lack of knowledge of the precise anatomy of other joints and under-realisation of the potential of arthroscopy of those joints by orthopaedic surgeons in general. Arthroscopy of the wrist was described by YungCheng Chen (1979), Johnson (1981) and Whipple (1986) but it was not until recently, as the appreciation of carpal mechanics grew, that its relevance in the investigation of the painful wrist gained a new momentum. The ability to observe the inter-carpal movements and inspect the ligaments and joints directly, in the current awareness of their function, should give arthroscopy a definite place in the clinical investigation of the painful wrist. Material and method Arthroscopy of the wrist has been performed at Wrightington Hospital since 1984. Up to January, 1989, 120 arthroscopies had been carried out. The records of 98 of these were available at time of review. The referrals came from three sources : general practitioners in the locality: 27 cases (27.6%); other consultants both within and outside the region: 66 cases (67.3%); and other hand surgeons : five cases (5.1%) as tertiary referrals. 64 patients were male and 34 were female. Their ages ranged from 11 to 64 years, with a mean of 31.4 years, but two-thirds of the patients were aged between 20 and 40 years (Fig. 1).
Because there were so many secondary and tertiary referrals (72.4%), and because many of the referrals from general practitioners had been seen elsewhere in the past, the duration of symptoms was excessive in some cases (Fig. 2). It ranged from 1 to 360 months, with a mean of 30.27 months. 53 patients presented within a year of injury or onset of symptoms, but seven patients had had their symptoms for over ten years. 85 patients had a history of injury. Preliminary
assessment
The patients were first assessed in the out-patient department, where a record of their history and symptoms was made. Clinical examination endeavoured to identify the symptomatic area by ballottement of the inter-carpal joints. Another test which we found useful in the latter part of the series is the pseudo-stability test. This depends on a comparison of the injured wrist with the normal wrist. In the normal wrist, it is possible to elicit an anterior and posterior drawer sign as the radio-carpal joint is stressed (Fig. 3). On the abnormal side, antero-posterior stressing may demonstrate a similar picture to the normal wrist, increased laxity suggesting instability (Fisk 1984) or less laxity than the other wrist. In this last category, subluxation is not possible as these movements are resisted involuntarily by muscular spasm. Therefore a patient who has less laxity in the injured wrist is said to exhibit pseudo-stability. Many of the patients had been investigated elsewhere and brought with them special investigations such as scaphoid X-rays, technetium bone scans and arthrograms. Where instability was suspected, a further series ofX-ray films was taken which we call a “six-shot series”: P.A.in neutral position, P.A. with radial deviation, P.A. with ulnar deviation, clenched fist P.A. with radial
AGE OF PATIENTS
40.
DURATION OF SYMPTCHS
-
30.0
zi 30. 24.0 1
E 2 20.
G 18.0 :: "c 2 12.0
h 9 10. ii?
a 9 8
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20-30
30-40
40-50
236
Graph
showing
the distribution
-36 -24 MONTHS
Fig. 2 of the patients
-
>50
YEARS Fig. 1
6.0
by age.
Graph showing whole group.
the length
THE
of duration
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Fig.
3
Demonstration of the examination of a wrist for pseudostability. This wrist had a positive test but the resistance has disappeared under anaesthetic.
deviation, P.A. with ulnar deviation, clenched fist P.A., standard lateral in neutral position and clenched fist lat,eral views. An image-intensifier was used to screen the wrists; on a few occasions, this was carried out under general anaesthetic. Arthrography, when indicated, was carried out using a triple-injection technique under anaesthetic and image intensification. Unlike Levinsohn (1987), we did not wait for the resorption of the dye between injections, but carried out the sequence of distal radio-ulnar, mid-carpal and radio-carpal injections in that order. Technique of arthroscopy
The patient is supine. General anaesthesia is not always necessary, as regional blocks and intravenous regional anaesthesia have been used and found to be adequate. In fact, as the examination is transmitted by camera to a television screen, it is possible and indeed may be useful, toa allow the patient to observe the procedure. We recommend the use of a video-camera. This allows the opportunity to teach, the participation in the procedure by an assistant and is more comfortable for the operator. In addition, there is some concern that the high energy light frequencies used may cause macular damage (Miller and Hollingsworth, 1986) during direct viewing. It is possible to install a video-recorder in the camera circuit and to record the arthroscopic examination; this allows the procedure to be re-appraised at leisure and with more discussion than is possible at arthroscopy. The hand is suspended using “Chinese finger traps” (Fig. 4) to maintain the hand and forearm vertical and the elbow at a right angle. The hand is best suspended from a device attached to the operating table (Fig. 5): a modified intravenous fluid stand leaves the limb too mobile and uncontrollable. In the method where the forearm is suspended from the theatre ceiling (Botte, VOL. 15B No. 2 MAY
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Cooney and Linscheid, 1989), it would appear necessary to use a hand clamp to steady the wrist. We have found that it is advantageous to be able to move the wrist around the arthroscope, rather than the reverse, at certain stages during the procedure. This is possible with our system, while still maintaining the required stability, due to the short lever arm in the suspension device. Counter traction (2 Kg) is applied through a sling applied to the upper arm beneath the sterile drapes. The bony landmarks used are the radial and ulnar styloids, the tubercle of Lister, the sulcus distal to the lunate and the third metacarpal. The soft-tissue landmarks in this area are the extensor retinaculum and its fibrous septa which form the six dorsal compartments (Taleisnik, 1985). The portals of entry to the wrist are named according to their relationship to these dorsal compartments: hence the 3/4 portal lies between the third and fourth compartments and the 6U portal lies to the ulnar side of extensor carpi ulnaris in the sixth compartment. Before insertion of the arthroscope, the radiocarpal joint is distended with approximately 5 ml of saline, usually through the 6U portal. The 3/4 portal has been found to be the most useful for comfortable access to the whole radio-carpal joint, although on occasions it is necessary to use the 6U portal. Access to the 3/4 portal is through a stab incision 1 cm distal to Lister’s tubercle. The capsular incision must be generous enough to prevent a traumatic procedure and render the use of the sharp trochar unnecessary. The arthroscope should be angled at approximately 20” in a proximal direction to allow for the volar angulation of the radio-carpal joint and to enable the tip of the arthroscope to be guided over the dorsal lip of the distal radius. Once in the joint, orientation is achieved by advancing the arthroscope to the anterior margin of the radius, where the fat pad in association with the radio-scapholunar ligament can be identified (Figs. 6 and 7). This is
Fig. 4
Steel mesh “Chinese
finger traps” are applied
to the fingers.
237
E. P. KELLY AND J. K. STANLEY
often found to be damaged in association with ruptures of the scapho-lunate ligament. Once the fat pad has been identified, withdrawal of the instrument will allow visualisation of the scapho-lunate joint. When this is done, then the sweep across the scaphoid fossa of the radius can begin. Radially one is limited by capsular attachments to the non-articular area of the scaphoid. Returning to the scapho-lunate joint, one can then move across to the triquetro-lunate joint. By rotation of the
arthroscope, the radial attachment of the triangular fibrocartilage complex can be seen as the arthroscope moves on into the ulnar compartment, the limit of which is the ulnar recess, lying anterior and distal to the ulnar styloid. During radio-carpal examination the condition of the intercarpal ligaments, the triangular fibrocartilage complex and the articular surfaces of the scaphoid and lunate fossae of the distal radius can be seen. Evidence of ligamentous injury, the presence or absence of synovitis and degenerative change can be recorded. Entry to the mid-carpal joint is through a stab incision in the sulcus just distal to the lunate in the line of the third metacarpal. This can best be identified by tracing the line of the third metacarpal vertically down through the carpus across the capitate. Again the arthroscope must be directed proximally. As in the radio-carpal examination, the capsular incision must be generous enough (approximately 5 mm) to allow easy insertion of the arthroscope sheath. Once in the joint, the superior surface of the scapho-lunate joint may be identified by the presence of an anterior triangle of fat which is a continuation of the anterior fat pad seen in the radiocarpal joint (Fig. 8). This finding is consistent. The midcarpal joint is a joint within a joint: it is a space within the wrist joint and is maintained by the intrinsic and extrinsic ligaments of the wrist joint as a whole. The intercarpal ligaments which bind the periphery of the carpal bones together are not now in evidence and the intercarpal movement can be observed and tested. The range of vision usually extends from inside the triscaphoid joint on the radial side of to the triquetrohamate joint on the ulnar side. The fact that the observer is looking down into a concavity (as compared with looking up at a convexity in the radio-carpal joint) allows
Fig. 6
Fig. 7
Fig. 5
238
The hand is suspended
from a device attached
Arthroscopic picture showing a normal with the fat pad below and anterior to it.
to the table.
scapho-lunate
joint
Arthroscopic picture showing a disrupted scaphohmate joint with an associated tear of the radio-scapho-lunate ligament. THE JOURNAL
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Table l-Showing the list of all diagnoses foond at arthroscopy. Scapholunate injury alone indicates those cases in which no other pathology could be identified Arthroscopic diagnosis Scapho-lunate injury Scapho-lunate injury alone Triangular fibrocartilage injury Synovitis Luno-triquetral injury Osteo-arthritis Peri-lunar injury Scaphoid fracture Loose body Hypermobile joint Ganglion Normal
Fig. 8
A midcarpal arthroscopic picture joint with the anterior fat pad.
showing
the scapholunate
the examiner an unimpeded view of the distal surfaces of the scaphoid, lunate, triquetrum and their intervening joints. Apart from assessing the condition of their articular surfaces and that of the opposing dome of the capitate, it is possible to ballotte the proximal row and make a qualitative assessment of the stability of the joints. (This does not apply to radio-carpal examination, except in cases of complete disruption of the carpal ligaments). Fractures of the scaphoid are more readily seen and assessed from the mid-carpal approach. No per-arthroscopic procedures, except for removal of loose bodies, have been attempted so far. However, the introduction of a fine blunt probe through the 6R portal, with simultaneous insertion of the arthroscope through the 3/4 portal, allows triangulation and assessment of the size and quality of the chondral surfaces. Results It is not entirely correct to use the term results in relation to the findings at arthroscopy. What we have endeavoured to do is to collate the findings in such a way that they may be of use to the prospective arthroscopist. Table 1 lists all the diagnoses made in order of frequency. It is obvious from the totals that there is considerable overlap and often several diagnoses were found at the same examination. The most frequent site VOL. 15B No. 2 MAY
1990
No. of cases 31 21 11 7 6 6 3 2 1 1 1 5
of pathology is in relation to the lunate and/or the scapholunate joint. With the experience we now have, we feel that these findings can perhaps be interpreted as various stages of the peri-lunate injury described by Mayfield (1984). Post-traumatic synovitis was the only diagnosis in two cases. Similarly, triangular fibrocartilage complex injuries were found in isolation in only three cases. Some degree of triquetro-lunate injury (attenuation and partial rupture) was seen in association with scapho-lunate ligament ruptures in two cases, but these were not considered to be complete peri-lunate injuries which have been recorded separately. In reviewing these cases, we became aware that there were two groups of patients, differentiated by their relative indications for arthroscopy. Group I : ‘investigative
group”
In these patients, arthroscopy was carried out to assist in making a diagnosis. There were 64 cases : 37 male and 27 female. The age range was from 11 to 64 years, with an average of 3 1.7 years. The range of duration of symptoms was from 1 to 360 months, with a mean of 26.6 months. The source of referral for this group was : Primary-16 cases, Secondary-46 cases, Tertiary-2 cases, Clearly the lack of diagnosis was the main problem, as 75% of these were consultant referrals. Of the 64 in this group, 60 gave a history of trauma. 18 were off work because of their wrist pain. Although this group were considered to be undiagnosed before arthroscopy, some form of provisional diagnosis had been recorded. This was shown to be incorrect in 29 patients: approximately 40% of the total in the group, though this improved as the series continued. 239
E. P. KELLY
AND
The largest group of patients in whom a provisional diagnosis was made fell under the umbrella term “nonspecific carpal instability”. The patients in this group gave a history of an injury which had failed to resolve fully, with symptoms of pain and loss of grip. In all, 52 patients had been diagnosed as having non-specific carpal instability. 38 patients were considered to have normal x-rays in their pre-arthroscopic assessment. The decision to proceed to arthroscopy was made on persisting symptoms of pain and weakness of grasp. Table 2 lists the final diagnoses in the patients in the investigative group, while Table 3 shows the final diagnoses in those patients within that group who were considered to have a normal radiological examination. Group 2: “Assessment group”
These patients had already been diagosed and were undergoing arthroscopy to assess the condition of the wrist joint. There were 34 patients : 27 male and 7 female. The age range was from 18 to 58 years, with a mean of 3 1.7 years. 11 patients were referred primarily from general practitioners in the area, while 21 were secondary referrals from other consultants. The vast majority of referring consultants were orthopaedic surgeons, but a small number were rheumatologists. 26 gave a history of trauma (76%). The duration of symptoms ranged from 3 to 360 months, with a mean of 38.97 months. Seven patients were off work because of the pain in the wrist. Table 2-Showing
the artbroscopic diagnoses in group 1 or investigative
J. K. STANLEY
Table 4 gives the diagnoses made at arthroscopy this assessment group.
in
Treatment groups The results of the arthroscopic diagnosis have been recorded not only in respect of the pathological abnormality found, but also with regard to the planning of further treatment following the arthroscopic examination and diagnosis. Accordingly the patients can be categorised into three treatment groups (Table 5). Treatment group A Those
recommends arthroscopy.
patients for whom one surgery as a result of the findings at
Treatment group B Those patients for whom surgery can be recommended should persisting symptoms warrant further surgical intervention. Treatment group C Those patients for whom conservative treatment is recommended.
Previously negative investigations
There is one group which merits further scrutiny. There is nothing more frustrating for a clinician than to be faced with a patient who continues to complain despite a series of normal investigations. In addition, this is the sort of patient who might eventually be considered a little less than reliable subjectively. There were 38 patients who, in the face of persisting symptoms and previously normal investigation, were arthroscoped because of a high index of suspicion of the presence of pathology in the wrist joint. Many of these had had arthrography, six-
group Arthroscopic diagnosis Scapho-lunate injury Triangular fibrocartilage Triquetro-lunate injury Synovitis Peri-lunate injury Hypermobile Ganglion Normal
Table 3-The investigations
No. of cases 26 9 5 3 2 1 1 5
injury
Table &The
diagnosis io the assessment group Arthroscopic diagnosis
Scaphoid non-union Healed scaphoid fracture due to deformity Kienbock’s disease Scapho-lunate dissociation degeneration Loose body O.A. secondary to fracture Ganglion
14 with
instability 2 9
with
secondary 6 1 1 1
diagnosis in those patients who had normal radiological Table 5-Distribution Arthroscopic diagnosis
Scapho-lunate injury Scapho-lunate injury alone Triangular cartilage injury Ganglion Hypermobile Normal
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No. of cases
of patients in the treatment groups (see text)
No. of cases 21 16 8 1 1 5
Treatment Grp.
Investigative
Assessment
A B C
25 20 19
19 11 4
Total
64
34
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shot series of wrist X-rays and/or stress X-rays. Some were referred from other centres because their investigations to date had failed to show any abnormality. There were 22 males and 16 females with an average age of 27.3 years. 36 gave a history of injury and the average length of duration of symptoms was 15.7 months. As regards the decisions taken following arthroscopy, it was again possible to allocate them to the three treatment groups. Treatment group A. 12 patients, Triscaphoid fusion was recommended in eight cases. A luno-triquetral fusion was recommended in one patient and the operative procedure was not specified in three cases. Treatment group B. 13 patients, Triscaphoid fusion was suggested for four patients. The procedure was not specified in nine cases. Treatment group C. 13 Patients were treated conservatively. Of these, five had a normal arthroscopic examination, and eight patients had some form of identifiable pathology at arthroscopy. Of the latter, four had scapholunate injuries: two were in isolation, one in association with a triangular fibrocartilage tear and one associated with a marked synovitis. There was one patient with an isolated triangular fibrocartilage tear and one with evidence of a triquetro-lunate injury for which surgery was not recommended. A further patient had a marked post-traumatic synovitis but no other pathology. Pseudo-stability Pseudo-stability was recorded in 36 patients. Of these patients, 27 (75%) were found at arthroscopy to have a scapho-lunate dissociation. Only two cases in whom pseudo-stability was found at the clinical examination had normal arthroscopic findings and in these two only radiocarpal arthroscopy was performed, not mid-carpal arthroscopy which is more sensitive to instability patterns. Of the patients who exhibited pseudo-stability and were found to have a scapholunate dissociation, 15 (55.6%) had a normal radiological examination. Discussion As long as arthroscopy of the wrist is performed in special centres and as long as we are on the early, steep and upward swing of the learning curve, we must look critically at its value and constantly re-appraise its relevance to the patient. It is obvious from our experience and that of other centres that there are pitfalls in the investigation of chronic wrist pain. Wrist pain has been described as the “low back pain of hand surgery” (Brown and Lichtman, 1984): there is therefore a natural desire to develop a VOL. 15B No. 2 MAY
1990
OF THE WRIST
technique which will allow the clinician the best possible chance of making a precise diagnosis. In our series of 98, only five patients had a normal arthroscopic appearance, yet 64 (the “Investigative group”) had complained for a long time, without a firm diagnosis being made. Although these patients were seldom off work, pain, interference with leisure activities and being labelled as undiagnosed chronic wrist pain were problems. Even the few normal examinations were of some value. It is important, as Dandy (1986) pointed out, to take complaints seriously and to the limit of reasonable investigation, particularly when dealing with the often highly-charged situation of a young person and his or her parents. The reassurance that there is no major or sinister pathology inside the joint is sometimes enough to make the situation acceptable to the patient and to allow the commencement of rehabilitation. However, we must admit that this is not always the case. By far the most common diagnosis made at arthroscopy was an injury involving the scapho-lunate joint, though frequently it was found in association with other pathology. As pointed out previously, these injuries may, in the future, be demonstrated to be all part of a spectrum of injury which is proportional to the severity of the trauma involved (Mayfield, 1984). Triangular fibrocartilage lesions were rarely found alone. They provide a particular problem, because it is not clear whether the discontinuity is due to an injury or is an incidental finding which may be within normal limits. Of the seven young adults with triangular fibrocartilage tears, only three complained of pain on the ulnar side of the wrist. There is a preponderance of males in our series, as in others, and it has been suggested that this is due to the type of activities commonly associated with wrist injuries : football and motor-cycling accidents. Although women rarely present with painful non-union of the scaphoid, we suggest that it may occur but that their subsequent activities are not sufficient to render it painful. There are two interesting features about the categorisation of the patients in this series. The first is the division according to indication for arthroscopy. The 64 patients who had “done the rounds” and had not yet arrived at a diagnosis, seemed on occasions to be driven as much by dissatisfaction as by symptoms. Clinically they clearly present a problem, but it is our impression that as experience grows so does one’s clinical sensitivity to the location of the problem. It is possible to ballotte the intercarpal joints individually and become more precise in one’s diagnosis. The non-specific diagnoses were more common in the early part of the series and we hope to show in later publication that accuracy improves with experience. However, this clinical development runs parallel to the ability to make confirmatory accurate arthroscopic diagnoses. Although we have not, as yet, undertaken any 241
E. P. KELLY AND J. K. STANLEY
arthroscopic surgery of the wrist, we still see two clear roles for arthroscopy of the wrist. In the investigative group, 38 of 64 patients had normal X-rays; others had varying degrees of abnormality in their pre-arthroscopic assessment and therefore required arthroscopy to make or complete the diagnosis. We have used other parameters of assessment, such as single-phase radio-carpal arthrography, progressing to three-phase arthrography (Levinsohn, 1987) in the latter part of the series. In addition, the patients have been subjected to the “six-shot” radiological series of X-rays, plus stress testing with and without anaesthesia. This still leaves a significant number of patients without a proper diagnosis. Arthroscopy therefore gives one the opportunity to make a more precise diagnosis. The “assessment” group of patients are those in whom one can add to the pool of clinical information for a particular complaint. At the time when a silastic replacement was considered a suitable treatment for Kienbock’s disease, it was possible first to assess the lunate fossa with the arthroscope. Similarly in non-union of the scaphoid the condition of the radio-carpal joint can be assessed. The fracture can be identified directly through the mid-carpal joint and even be entered on occasions: the whole length of the scaphoid, except the tubercle, can be visualised. In patients with established abnormality and some degenerative change, it is possible to examine the wrist joint before deciding whether to carry out a limited wrist fusion. The decision made after arthroscopy seems to depend as much on the patient as on the pathology. The disorder is not life-threatening, so it is interference with work, hobbies and leisure activities will determine both the surgeon’s and patient’s willingness to proceed to further surgery. As the commonest presentation is in young males, it follows that the young adult group had the highest number of patients recommended primarily for a surgical procedure. Treatment group B (those patients for whom surgery could be deferred) contains a spectrum of patients including those who had sought a diagnosis but were not sure that their symptoms required surgical intervention. It also includes those patients who were sure that they did not wish for further surgery, but because of our findings, it was felt that they would require some intervention in the future. This is reflected in the rather large numbers of patients for whom no operative procedure was specified. Young patients who have been treated for an injury to the wrist and fail to get better, even when the fractured
242
scaphoid has united (but flexed and shortened), cause a considerable diagnostic problem. Physiotherapy usually makes them worse. All investigations may be normal, Arthroscopy would appear to have a considerable advantage. It can be carried out as a day case, general anaesthesia is not always necessary and the morbidity is low. These patients fall into the classification recently put forward by Watson (1989) which he described as “the dynamic instabilities”. His first type includes patients who have no abnormality radiologically. The second consists of patients who demonstrate abnormality in some special X-rays e.g. arthrography. The third is those patients who have identifiable instability patterns on plain X-rays (“static instability”). In our hands, arthroscopy of the wrist has proved to be a safe, and reliable investigative tool. It has allowed us to make a diagnosis in approximately 95% of patients. It is well-tolerated by the patients, even under local anaesthesia. Increased familiarity with the injury patterns of the wrist will help us achieve a more complete understanding of the functional anatomy of the wrist.
References BOTTE, M. J., COONEY, W. P. and LINSCHEID, R. L. (1989). Arthroscopy of the wrist: Anatomy and technique. Journal of Hand Surgery, 14A: Z(1): 313-316. BROWN, D. E. and LICHTMAN, D. M. (1984). The Evaluation of Chronic Wrist Pain. Orthopedic Clinics of North America, 15: 2: 183-192. DANDY, D. J. (1986). Arthroscopy in the Treatment of Young Patients with Anterior Knee Pain. Orthopedic Clinics of North America, 17: 2: 221-229. FISK, G. R. (1984). The Wrist. Journal of Bone and Joint Surgery, 66B: 3: 396 407. JOHNSON, L. L. Diagnostic and Surgical Arthroscopy, 2nd edn. St. Louis, C. V. Mosby, 1981: 400. LEVINSOHN, E. M., PALMER, A. K., COREN, A. B. and ZINBERG, E. M. (1987). Wrist Arthrography: the value of the three compartment injection technique. Skeletal Radiology, 16: 539-544. MAYFIELD, J. K. (1984). Wrist Ligamentous Anatomy and Pathogenesis of Carpal Instability. Orthopedic Clinics of North America, 15: 2: 209-216. MILLER, R. A. and HOLLINGSWORTH, T. R. (1986). Rigid Endoscopes: optical and design considerations. British Medical Bulletin, 42: 3: 226-229. TAKAGI, K. (1982). The Classic Arthroscope. Clinical Orthopaedics and Related Research. 167: 6-8; Translated from Journal of the Japanese Orthopaedic Association. (1939) 14: 359. TALEISNIK, J. The Wrist. NewYork,Churchill Livingstone, 1985: 31. WATSON, H. K. (1989). Dynamic Instability of the Scaphoid. Paper given to Institut Francais De La Main, Paris in April, 1989. WHIPPLE, T. L., MAROTTA, J. J. and POWELL, J. H. (1986). Techniques of wrist arthroscopy. Arthroscopy, 2: 4: 244-252. YUNG-CHENG CHEN (1979). Arthroscopy of the Wrist and Finger Joints. Orthopedic Clinics of North America, 10: 3: 723-733. Mr. J. K. Stanley, Wigan, Lam. 0
F.R.C.S.,
1990 The British Society
Hand
for Surgery
Surgery
Unit,
Wrightington
Hospital,
Appley
Bridge,
of the Hand
02667681/90/00154236/%10.00
THE JOURNAL
OF HAND SURGERY
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WRIST
E. P. KELLYandJ. K. STANLEY From the Wrightington Hospital, Wigan
Endoscopy has developed steadily since its inception in the early part of the 19th century. In 1939, Dr Kenji Takagi of Tokyo University was the first to look inside a body cavity which had no natural portal, in that case the knee (Takagi, 1939). Nowadays arthroscopy of the knee has become accepted as a routine orthopaedic procedure for investigative and perathroscopic surgery. Arthroscopy of other joints has been slower to develop, hindered in part by instrument-makers’ concentration on arthroscopy of the knee but also by lack of knowledge of the precise anatomy of other joints and under-realisation of the potential of arthroscopy of those joints by orthopaedic surgeons in general. Arthroscopy of the wrist was described by YungCheng Chen (1979), Johnson (1981) and Whipple (1986) but it was not until recently, as the appreciation of carpal mechanics grew, that its relevance in the investigation of the painful wrist gained a new momentum. The ability to observe the inter-carpal movements and inspect the ligaments and joints directly, in the current awareness of their function, should give arthroscopy a definite place in the clinical investigation of the painful wrist. Material and method Arthroscopy of the wrist has been performed at Wrightington Hospital since 1984. Up to January, 1989, 120 arthroscopies had been carried out. The records of 98 of these were available at time of review. The referrals came from three sources : general practitioners in the locality: 27 cases (27.6%); other consultants both within and outside the region: 66 cases (67.3%); and other hand surgeons : five cases (5.1%) as tertiary referrals. 64 patients were male and 34 were female. Their ages ranged from 11 to 64 years, with a mean of 31.4 years, but two-thirds of the patients were aged between 20 and 40 years (Fig. 1).
Because there were so many secondary and tertiary referrals (72.4%), and because many of the referrals from general practitioners had been seen elsewhere in the past, the duration of symptoms was excessive in some cases (Fig. 2). It ranged from 1 to 360 months, with a mean of 30.27 months. 53 patients presented within a year of injury or onset of symptoms, but seven patients had had their symptoms for over ten years. 85 patients had a history of injury. Preliminary
assessment
The patients were first assessed in the out-patient department, where a record of their history and symptoms was made. Clinical examination endeavoured to identify the symptomatic area by ballottement of the inter-carpal joints. Another test which we found useful in the latter part of the series is the pseudo-stability test. This depends on a comparison of the injured wrist with the normal wrist. In the normal wrist, it is possible to elicit an anterior and posterior drawer sign as the radio-carpal joint is stressed (Fig. 3). On the abnormal side, antero-posterior stressing may demonstrate a similar picture to the normal wrist, increased laxity suggesting instability (Fisk 1984) or less laxity than the other wrist. In this last category, subluxation is not possible as these movements are resisted involuntarily by muscular spasm. Therefore a patient who has less laxity in the injured wrist is said to exhibit pseudo-stability. Many of the patients had been investigated elsewhere and brought with them special investigations such as scaphoid X-rays, technetium bone scans and arthrograms. Where instability was suspected, a further series ofX-ray films was taken which we call a “six-shot series”: P.A.in neutral position, P.A. with radial deviation, P.A. with ulnar deviation, clenched fist P.A. with radial
AGE OF PATIENTS
40.
DURATION OF SYMPTCHS
-
30.0
zi 30. 24.0 1
E 2 20.
G 18.0 :: "c 2 12.0
h 9 10. ii?
a 9 8
0.0
l_m
g 0.0L 420
20-30
30-40
40-50
236
Graph
showing
the distribution
-36 -24 MONTHS
Fig. 2 of the patients
-
>50
YEARS Fig. 1
6.0
by age.
Graph showing whole group.
the length
THE
of duration
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Fig.
3
Demonstration of the examination of a wrist for pseudostability. This wrist had a positive test but the resistance has disappeared under anaesthetic.
deviation, P.A. with ulnar deviation, clenched fist P.A., standard lateral in neutral position and clenched fist lat,eral views. An image-intensifier was used to screen the wrists; on a few occasions, this was carried out under general anaesthetic. Arthrography, when indicated, was carried out using a triple-injection technique under anaesthetic and image intensification. Unlike Levinsohn (1987), we did not wait for the resorption of the dye between injections, but carried out the sequence of distal radio-ulnar, mid-carpal and radio-carpal injections in that order. Technique of arthroscopy
The patient is supine. General anaesthesia is not always necessary, as regional blocks and intravenous regional anaesthesia have been used and found to be adequate. In fact, as the examination is transmitted by camera to a television screen, it is possible and indeed may be useful, toa allow the patient to observe the procedure. We recommend the use of a video-camera. This allows the opportunity to teach, the participation in the procedure by an assistant and is more comfortable for the operator. In addition, there is some concern that the high energy light frequencies used may cause macular damage (Miller and Hollingsworth, 1986) during direct viewing. It is possible to install a video-recorder in the camera circuit and to record the arthroscopic examination; this allows the procedure to be re-appraised at leisure and with more discussion than is possible at arthroscopy. The hand is suspended using “Chinese finger traps” (Fig. 4) to maintain the hand and forearm vertical and the elbow at a right angle. The hand is best suspended from a device attached to the operating table (Fig. 5): a modified intravenous fluid stand leaves the limb too mobile and uncontrollable. In the method where the forearm is suspended from the theatre ceiling (Botte, VOL. 15B No. 2 MAY
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Cooney and Linscheid, 1989), it would appear necessary to use a hand clamp to steady the wrist. We have found that it is advantageous to be able to move the wrist around the arthroscope, rather than the reverse, at certain stages during the procedure. This is possible with our system, while still maintaining the required stability, due to the short lever arm in the suspension device. Counter traction (2 Kg) is applied through a sling applied to the upper arm beneath the sterile drapes. The bony landmarks used are the radial and ulnar styloids, the tubercle of Lister, the sulcus distal to the lunate and the third metacarpal. The soft-tissue landmarks in this area are the extensor retinaculum and its fibrous septa which form the six dorsal compartments (Taleisnik, 1985). The portals of entry to the wrist are named according to their relationship to these dorsal compartments: hence the 3/4 portal lies between the third and fourth compartments and the 6U portal lies to the ulnar side of extensor carpi ulnaris in the sixth compartment. Before insertion of the arthroscope, the radiocarpal joint is distended with approximately 5 ml of saline, usually through the 6U portal. The 3/4 portal has been found to be the most useful for comfortable access to the whole radio-carpal joint, although on occasions it is necessary to use the 6U portal. Access to the 3/4 portal is through a stab incision 1 cm distal to Lister’s tubercle. The capsular incision must be generous enough to prevent a traumatic procedure and render the use of the sharp trochar unnecessary. The arthroscope should be angled at approximately 20” in a proximal direction to allow for the volar angulation of the radio-carpal joint and to enable the tip of the arthroscope to be guided over the dorsal lip of the distal radius. Once in the joint, orientation is achieved by advancing the arthroscope to the anterior margin of the radius, where the fat pad in association with the radio-scapholunar ligament can be identified (Figs. 6 and 7). This is
Fig. 4
Steel mesh “Chinese
finger traps” are applied
to the fingers.
237
E. P. KELLY AND J. K. STANLEY
often found to be damaged in association with ruptures of the scapho-lunate ligament. Once the fat pad has been identified, withdrawal of the instrument will allow visualisation of the scapho-lunate joint. When this is done, then the sweep across the scaphoid fossa of the radius can begin. Radially one is limited by capsular attachments to the non-articular area of the scaphoid. Returning to the scapho-lunate joint, one can then move across to the triquetro-lunate joint. By rotation of the
arthroscope, the radial attachment of the triangular fibrocartilage complex can be seen as the arthroscope moves on into the ulnar compartment, the limit of which is the ulnar recess, lying anterior and distal to the ulnar styloid. During radio-carpal examination the condition of the intercarpal ligaments, the triangular fibrocartilage complex and the articular surfaces of the scaphoid and lunate fossae of the distal radius can be seen. Evidence of ligamentous injury, the presence or absence of synovitis and degenerative change can be recorded. Entry to the mid-carpal joint is through a stab incision in the sulcus just distal to the lunate in the line of the third metacarpal. This can best be identified by tracing the line of the third metacarpal vertically down through the carpus across the capitate. Again the arthroscope must be directed proximally. As in the radio-carpal examination, the capsular incision must be generous enough (approximately 5 mm) to allow easy insertion of the arthroscope sheath. Once in the joint, the superior surface of the scapho-lunate joint may be identified by the presence of an anterior triangle of fat which is a continuation of the anterior fat pad seen in the radiocarpal joint (Fig. 8). This finding is consistent. The midcarpal joint is a joint within a joint: it is a space within the wrist joint and is maintained by the intrinsic and extrinsic ligaments of the wrist joint as a whole. The intercarpal ligaments which bind the periphery of the carpal bones together are not now in evidence and the intercarpal movement can be observed and tested. The range of vision usually extends from inside the triscaphoid joint on the radial side of to the triquetrohamate joint on the ulnar side. The fact that the observer is looking down into a concavity (as compared with looking up at a convexity in the radio-carpal joint) allows
Fig. 6
Fig. 7
Fig. 5
238
The hand is suspended
from a device attached
Arthroscopic picture showing a normal with the fat pad below and anterior to it.
to the table.
scapho-lunate
joint
Arthroscopic picture showing a disrupted scaphohmate joint with an associated tear of the radio-scapho-lunate ligament. THE JOURNAL
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Table l-Showing the list of all diagnoses foond at arthroscopy. Scapholunate injury alone indicates those cases in which no other pathology could be identified Arthroscopic diagnosis Scapho-lunate injury Scapho-lunate injury alone Triangular fibrocartilage injury Synovitis Luno-triquetral injury Osteo-arthritis Peri-lunar injury Scaphoid fracture Loose body Hypermobile joint Ganglion Normal
Fig. 8
A midcarpal arthroscopic picture joint with the anterior fat pad.
showing
the scapholunate
the examiner an unimpeded view of the distal surfaces of the scaphoid, lunate, triquetrum and their intervening joints. Apart from assessing the condition of their articular surfaces and that of the opposing dome of the capitate, it is possible to ballotte the proximal row and make a qualitative assessment of the stability of the joints. (This does not apply to radio-carpal examination, except in cases of complete disruption of the carpal ligaments). Fractures of the scaphoid are more readily seen and assessed from the mid-carpal approach. No per-arthroscopic procedures, except for removal of loose bodies, have been attempted so far. However, the introduction of a fine blunt probe through the 6R portal, with simultaneous insertion of the arthroscope through the 3/4 portal, allows triangulation and assessment of the size and quality of the chondral surfaces. Results It is not entirely correct to use the term results in relation to the findings at arthroscopy. What we have endeavoured to do is to collate the findings in such a way that they may be of use to the prospective arthroscopist. Table 1 lists all the diagnoses made in order of frequency. It is obvious from the totals that there is considerable overlap and often several diagnoses were found at the same examination. The most frequent site VOL. 15B No. 2 MAY
1990
No. of cases 31 21 11 7 6 6 3 2 1 1 1 5
of pathology is in relation to the lunate and/or the scapholunate joint. With the experience we now have, we feel that these findings can perhaps be interpreted as various stages of the peri-lunate injury described by Mayfield (1984). Post-traumatic synovitis was the only diagnosis in two cases. Similarly, triangular fibrocartilage complex injuries were found in isolation in only three cases. Some degree of triquetro-lunate injury (attenuation and partial rupture) was seen in association with scapho-lunate ligament ruptures in two cases, but these were not considered to be complete peri-lunate injuries which have been recorded separately. In reviewing these cases, we became aware that there were two groups of patients, differentiated by their relative indications for arthroscopy. Group I : ‘investigative
group”
In these patients, arthroscopy was carried out to assist in making a diagnosis. There were 64 cases : 37 male and 27 female. The age range was from 11 to 64 years, with an average of 3 1.7 years. The range of duration of symptoms was from 1 to 360 months, with a mean of 26.6 months. The source of referral for this group was : Primary-16 cases, Secondary-46 cases, Tertiary-2 cases, Clearly the lack of diagnosis was the main problem, as 75% of these were consultant referrals. Of the 64 in this group, 60 gave a history of trauma. 18 were off work because of their wrist pain. Although this group were considered to be undiagnosed before arthroscopy, some form of provisional diagnosis had been recorded. This was shown to be incorrect in 29 patients: approximately 40% of the total in the group, though this improved as the series continued. 239
E. P. KELLY
AND
The largest group of patients in whom a provisional diagnosis was made fell under the umbrella term “nonspecific carpal instability”. The patients in this group gave a history of an injury which had failed to resolve fully, with symptoms of pain and loss of grip. In all, 52 patients had been diagnosed as having non-specific carpal instability. 38 patients were considered to have normal x-rays in their pre-arthroscopic assessment. The decision to proceed to arthroscopy was made on persisting symptoms of pain and weakness of grasp. Table 2 lists the final diagnoses in the patients in the investigative group, while Table 3 shows the final diagnoses in those patients within that group who were considered to have a normal radiological examination. Group 2: “Assessment group”
These patients had already been diagosed and were undergoing arthroscopy to assess the condition of the wrist joint. There were 34 patients : 27 male and 7 female. The age range was from 18 to 58 years, with a mean of 3 1.7 years. 11 patients were referred primarily from general practitioners in the area, while 21 were secondary referrals from other consultants. The vast majority of referring consultants were orthopaedic surgeons, but a small number were rheumatologists. 26 gave a history of trauma (76%). The duration of symptoms ranged from 3 to 360 months, with a mean of 38.97 months. Seven patients were off work because of the pain in the wrist. Table 2-Showing
the artbroscopic diagnoses in group 1 or investigative
J. K. STANLEY
Table 4 gives the diagnoses made at arthroscopy this assessment group.
in
Treatment groups The results of the arthroscopic diagnosis have been recorded not only in respect of the pathological abnormality found, but also with regard to the planning of further treatment following the arthroscopic examination and diagnosis. Accordingly the patients can be categorised into three treatment groups (Table 5). Treatment group A Those
recommends arthroscopy.
patients for whom one surgery as a result of the findings at
Treatment group B Those patients for whom surgery can be recommended should persisting symptoms warrant further surgical intervention. Treatment group C Those patients for whom conservative treatment is recommended.
Previously negative investigations
There is one group which merits further scrutiny. There is nothing more frustrating for a clinician than to be faced with a patient who continues to complain despite a series of normal investigations. In addition, this is the sort of patient who might eventually be considered a little less than reliable subjectively. There were 38 patients who, in the face of persisting symptoms and previously normal investigation, were arthroscoped because of a high index of suspicion of the presence of pathology in the wrist joint. Many of these had had arthrography, six-
group Arthroscopic diagnosis Scapho-lunate injury Triangular fibrocartilage Triquetro-lunate injury Synovitis Peri-lunate injury Hypermobile Ganglion Normal
Table 3-The investigations
No. of cases 26 9 5 3 2 1 1 5
injury
Table &The
diagnosis io the assessment group Arthroscopic diagnosis
Scaphoid non-union Healed scaphoid fracture due to deformity Kienbock’s disease Scapho-lunate dissociation degeneration Loose body O.A. secondary to fracture Ganglion
14 with
instability 2 9
with
secondary 6 1 1 1
diagnosis in those patients who had normal radiological Table 5-Distribution Arthroscopic diagnosis
Scapho-lunate injury Scapho-lunate injury alone Triangular cartilage injury Ganglion Hypermobile Normal
240
No. of cases
of patients in the treatment groups (see text)
No. of cases 21 16 8 1 1 5
Treatment Grp.
Investigative
Assessment
A B C
25 20 19
19 11 4
Total
64
34
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shot series of wrist X-rays and/or stress X-rays. Some were referred from other centres because their investigations to date had failed to show any abnormality. There were 22 males and 16 females with an average age of 27.3 years. 36 gave a history of injury and the average length of duration of symptoms was 15.7 months. As regards the decisions taken following arthroscopy, it was again possible to allocate them to the three treatment groups. Treatment group A. 12 patients, Triscaphoid fusion was recommended in eight cases. A luno-triquetral fusion was recommended in one patient and the operative procedure was not specified in three cases. Treatment group B. 13 patients, Triscaphoid fusion was suggested for four patients. The procedure was not specified in nine cases. Treatment group C. 13 Patients were treated conservatively. Of these, five had a normal arthroscopic examination, and eight patients had some form of identifiable pathology at arthroscopy. Of the latter, four had scapholunate injuries: two were in isolation, one in association with a triangular fibrocartilage tear and one associated with a marked synovitis. There was one patient with an isolated triangular fibrocartilage tear and one with evidence of a triquetro-lunate injury for which surgery was not recommended. A further patient had a marked post-traumatic synovitis but no other pathology. Pseudo-stability Pseudo-stability was recorded in 36 patients. Of these patients, 27 (75%) were found at arthroscopy to have a scapho-lunate dissociation. Only two cases in whom pseudo-stability was found at the clinical examination had normal arthroscopic findings and in these two only radiocarpal arthroscopy was performed, not mid-carpal arthroscopy which is more sensitive to instability patterns. Of the patients who exhibited pseudo-stability and were found to have a scapholunate dissociation, 15 (55.6%) had a normal radiological examination. Discussion As long as arthroscopy of the wrist is performed in special centres and as long as we are on the early, steep and upward swing of the learning curve, we must look critically at its value and constantly re-appraise its relevance to the patient. It is obvious from our experience and that of other centres that there are pitfalls in the investigation of chronic wrist pain. Wrist pain has been described as the “low back pain of hand surgery” (Brown and Lichtman, 1984): there is therefore a natural desire to develop a VOL. 15B No. 2 MAY
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technique which will allow the clinician the best possible chance of making a precise diagnosis. In our series of 98, only five patients had a normal arthroscopic appearance, yet 64 (the “Investigative group”) had complained for a long time, without a firm diagnosis being made. Although these patients were seldom off work, pain, interference with leisure activities and being labelled as undiagnosed chronic wrist pain were problems. Even the few normal examinations were of some value. It is important, as Dandy (1986) pointed out, to take complaints seriously and to the limit of reasonable investigation, particularly when dealing with the often highly-charged situation of a young person and his or her parents. The reassurance that there is no major or sinister pathology inside the joint is sometimes enough to make the situation acceptable to the patient and to allow the commencement of rehabilitation. However, we must admit that this is not always the case. By far the most common diagnosis made at arthroscopy was an injury involving the scapho-lunate joint, though frequently it was found in association with other pathology. As pointed out previously, these injuries may, in the future, be demonstrated to be all part of a spectrum of injury which is proportional to the severity of the trauma involved (Mayfield, 1984). Triangular fibrocartilage lesions were rarely found alone. They provide a particular problem, because it is not clear whether the discontinuity is due to an injury or is an incidental finding which may be within normal limits. Of the seven young adults with triangular fibrocartilage tears, only three complained of pain on the ulnar side of the wrist. There is a preponderance of males in our series, as in others, and it has been suggested that this is due to the type of activities commonly associated with wrist injuries : football and motor-cycling accidents. Although women rarely present with painful non-union of the scaphoid, we suggest that it may occur but that their subsequent activities are not sufficient to render it painful. There are two interesting features about the categorisation of the patients in this series. The first is the division according to indication for arthroscopy. The 64 patients who had “done the rounds” and had not yet arrived at a diagnosis, seemed on occasions to be driven as much by dissatisfaction as by symptoms. Clinically they clearly present a problem, but it is our impression that as experience grows so does one’s clinical sensitivity to the location of the problem. It is possible to ballotte the intercarpal joints individually and become more precise in one’s diagnosis. The non-specific diagnoses were more common in the early part of the series and we hope to show in later publication that accuracy improves with experience. However, this clinical development runs parallel to the ability to make confirmatory accurate arthroscopic diagnoses. Although we have not, as yet, undertaken any 241
E. P. KELLY AND J. K. STANLEY
arthroscopic surgery of the wrist, we still see two clear roles for arthroscopy of the wrist. In the investigative group, 38 of 64 patients had normal X-rays; others had varying degrees of abnormality in their pre-arthroscopic assessment and therefore required arthroscopy to make or complete the diagnosis. We have used other parameters of assessment, such as single-phase radio-carpal arthrography, progressing to three-phase arthrography (Levinsohn, 1987) in the latter part of the series. In addition, the patients have been subjected to the “six-shot” radiological series of X-rays, plus stress testing with and without anaesthesia. This still leaves a significant number of patients without a proper diagnosis. Arthroscopy therefore gives one the opportunity to make a more precise diagnosis. The “assessment” group of patients are those in whom one can add to the pool of clinical information for a particular complaint. At the time when a silastic replacement was considered a suitable treatment for Kienbock’s disease, it was possible first to assess the lunate fossa with the arthroscope. Similarly in non-union of the scaphoid the condition of the radio-carpal joint can be assessed. The fracture can be identified directly through the mid-carpal joint and even be entered on occasions: the whole length of the scaphoid, except the tubercle, can be visualised. In patients with established abnormality and some degenerative change, it is possible to examine the wrist joint before deciding whether to carry out a limited wrist fusion. The decision made after arthroscopy seems to depend as much on the patient as on the pathology. The disorder is not life-threatening, so it is interference with work, hobbies and leisure activities will determine both the surgeon’s and patient’s willingness to proceed to further surgery. As the commonest presentation is in young males, it follows that the young adult group had the highest number of patients recommended primarily for a surgical procedure. Treatment group B (those patients for whom surgery could be deferred) contains a spectrum of patients including those who had sought a diagnosis but were not sure that their symptoms required surgical intervention. It also includes those patients who were sure that they did not wish for further surgery, but because of our findings, it was felt that they would require some intervention in the future. This is reflected in the rather large numbers of patients for whom no operative procedure was specified. Young patients who have been treated for an injury to the wrist and fail to get better, even when the fractured
242
scaphoid has united (but flexed and shortened), cause a considerable diagnostic problem. Physiotherapy usually makes them worse. All investigations may be normal, Arthroscopy would appear to have a considerable advantage. It can be carried out as a day case, general anaesthesia is not always necessary and the morbidity is low. These patients fall into the classification recently put forward by Watson (1989) which he described as “the dynamic instabilities”. His first type includes patients who have no abnormality radiologically. The second consists of patients who demonstrate abnormality in some special X-rays e.g. arthrography. The third is those patients who have identifiable instability patterns on plain X-rays (“static instability”). In our hands, arthroscopy of the wrist has proved to be a safe, and reliable investigative tool. It has allowed us to make a diagnosis in approximately 95% of patients. It is well-tolerated by the patients, even under local anaesthesia. Increased familiarity with the injury patterns of the wrist will help us achieve a more complete understanding of the functional anatomy of the wrist.
References BOTTE, M. J., COONEY, W. P. and LINSCHEID, R. L. (1989). Arthroscopy of the wrist: Anatomy and technique. Journal of Hand Surgery, 14A: Z(1): 313-316. BROWN, D. E. and LICHTMAN, D. M. (1984). The Evaluation of Chronic Wrist Pain. Orthopedic Clinics of North America, 15: 2: 183-192. DANDY, D. J. (1986). Arthroscopy in the Treatment of Young Patients with Anterior Knee Pain. Orthopedic Clinics of North America, 17: 2: 221-229. FISK, G. R. (1984). The Wrist. Journal of Bone and Joint Surgery, 66B: 3: 396 407. JOHNSON, L. L. Diagnostic and Surgical Arthroscopy, 2nd edn. St. Louis, C. V. Mosby, 1981: 400. LEVINSOHN, E. M., PALMER, A. K., COREN, A. B. and ZINBERG, E. M. (1987). Wrist Arthrography: the value of the three compartment injection technique. Skeletal Radiology, 16: 539-544. MAYFIELD, J. K. (1984). Wrist Ligamentous Anatomy and Pathogenesis of Carpal Instability. Orthopedic Clinics of North America, 15: 2: 209-216. MILLER, R. A. and HOLLINGSWORTH, T. R. (1986). Rigid Endoscopes: optical and design considerations. British Medical Bulletin, 42: 3: 226-229. TAKAGI, K. (1982). The Classic Arthroscope. Clinical Orthopaedics and Related Research. 167: 6-8; Translated from Journal of the Japanese Orthopaedic Association. (1939) 14: 359. TALEISNIK, J. The Wrist. NewYork,Churchill Livingstone, 1985: 31. WATSON, H. K. (1989). Dynamic Instability of the Scaphoid. Paper given to Institut Francais De La Main, Paris in April, 1989. WHIPPLE, T. L., MAROTTA, J. J. and POWELL, J. H. (1986). Techniques of wrist arthroscopy. Arthroscopy, 2: 4: 244-252. YUNG-CHENG CHEN (1979). Arthroscopy of the Wrist and Finger Joints. Orthopedic Clinics of North America, 10: 3: 723-733. Mr. J. K. Stanley, Wigan, Lam. 0
F.R.C.S.,
1990 The British Society
Hand
for Surgery
Surgery
Unit,
Wrightington
Hospital,
Appley
Bridge,
of the Hand
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