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Loose body in the wrist: diagnosis and treatment
Loose Body in the Wrist: Diagnosis and Treatment Shukuki Koh, M.D., Ryogo Nakamura, M.D., Emiko Horii, M.D., Etsuhiro Nakao, M.D., Kaori Shionoya, M.D., and Hiroki Yajima, M.D.
Purpose: The purpose of this study was to report on 10 cases of symptomatic loose bodies in the wrist joints diagnosed using arthroscopy. Type of Study: Retrospective review. Methods: From1986 to 2000, we performed wrist arthroscopy for 707 patients, 10 of whom had loose bodies in the wrist joints. The clinical records were reviewed retrospectively. The patients included 8 men and 2 women, and the average age was 28 years (range, 16 to 67 years). The chief complaint was wrist pain in all patients, but locking was uncommon. Preoperative diagnosis was difficult in all but 3 cases; in those cases, an osseous component was found within the loose bodies. The remaining cases were diagnosed by wrist arthroscopy. Results: The loose bodies existed in the radiocarpal joint in 5 cases, and all could be removed arthroscopically. In the other 5 cases, the loose bodies were in the distal radioulnar joint, and arthrotomy was needed to remove them. After removal of the loose bodies, the pain was relieved in all cases without any surgical complications. Conclusions: Loose bodies in the wrist joint should be included in the differential diagnosis for chronic wrist pain. Wrist arthroscopy is of value because the preoperative diagnosis is usually difficult. Key Words: Wrist—Arthroscopy—Loose body—Radiocarpal joint—Distal radioulnar joint.
L
oose bodies in the joints are usually caused by osteochondral fracture, osteochondritis dissecans, degenerative arthrosis, or synovial osteochondromatosis and are quite common in the large joints. Kelly et al.1 reported an incidence of loose bodies of 24% in their retrospective review of 473 elbow arthroscopies, and other authors reported incidences of 4% in the knee2 and 3% in the shoulder joint.3 Loose bodies are rare, however, in wrist joints, except for the pisotriquetral joint. Only 5 cases have been reported.4-7 This article describes our experience with 10 patients with loose bodies in the wrist, with an emphasis on diagnosis and treatment. METHODS From 1986 to December 2000, we examined 707 patients with wrist disorders using wrist arthroscopy.
From the Department of Hand Surgery, Nagoya University School of Medicine, Nagoya, Japan. Address correspondence and reprint requests to Shukuki Koh, M.D., 65 Tsurumai, Showa, Nagoya 466-8560, Japan. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 0749-8063/03/1908-3395$30.00/0 doi:10.1053/S04790-8063(03)00738-2
820
All the records were retrospectively reviewed, and 10 cases were identified in which loose bodies were found in either the radiocarpal joint (RCJ) or the distal radioulnar joint (DRUJ). Wrist arthroscopy was performed for all 10 patients. The 3-4 or 4-5 portal was used to inspect the RCJ, and the midcarpal radial portal was used to inspect the midcarpal joint (MCJ). The DRUJ was examined if possible. In addition to removal of the loose bodies, ulnar shortening osteotomy was performed simultaneously for 3 patients who had ulnocarpal abutment syndrome or DRUJ instability, and one patient who had osteochondritis dissecans of the radial styloid underwent radial styloidectomy. The loose bodies were arthroscopically excised if possible, but in the cases of DRUJ loose bodies, arthrotomy was necessary. A longitudinal skin incision about 3 cm was made on the dorsal aspect of the wrist, and the joint was explored between the extensor digiti minimi and extensor carpi ulnaris. The joint capsule was also incised longitudinally. Postoperative management depended on the procedure performed. Arthroscopic excision and radial styloidectomy required 1 week of compressive dressing. Ulnar shortening osteotomy required 6 to 8 weeks of cast immobilization.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 8 (October), 2003: pp 820-824
LOOSE BODY IN THE WRIST
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TABLE 1. Individual Patient Data
Case No.
Age & Sex
Predisposing Factor
Preoperative Diagnosis
Locking
Click
Plain Diagnostic X-ray?
Additional Surgery USO USO — Radial styloidectomy — USO —
1 2 3 4
21 16 17 20
M M M F
Volleyball Baseball Baseball Gymnastics
UCA UCA TFC injury OCD
No No No No
No No Yes No
5 6
32 M 23 M
Bowling Motorcycle accident
No No
No Yes
7
30 M
Manual work
Yes
No
Yes
8
19 M
Using crutch
9 10
67 F 35 M
None Wrist contusion
TFC injury DRUJ instability with TFCC injury DRUJ loose body DRUJ loose body DRUJ OA DRUJ loose body
No No No Yes (retrospectively) No No
Site of Loose Body
Number
Size (mm)
Arthroscopic Excision?
RCJ RCJ RCJ RCJ
2 3 2 1
5, 3 10, 4, 3 5, 3 4
Yes Yes Yes Yes
RCJ DRUJ
1 1
3 6
Yes No
DRUJ
1
6
No
No
No
Yes
—
DRUJ
1
5
No
No No
Yes No
No Yes
— —
DRUJ DRUJ
1 3
5 3, 3, 3
No No
Abbreviations: UCA, ulnocarpal abutment syndrome; USO, ulnar shortening osteotomy; OCD, osteochondritis dissecans.
RESULTS Eight of these patients were men, and 2 were women. The ages ranged from 16 to 67 years (average 28 years), and the time interval from onset of symptoms to surgery averaged 21.3 months (range, 4 to 84 months). All patients complained of wrist pain. Four patients had ulnar side wrist pain, and 4 patients had DRUJ discomfort. Only 1 patient described “locking,” and 3 had crepitation with motion. Five patients experienced wrist injury before the onset of symptoms, although the severity ranged from minor contusion to a motor vehicle accident. Four of the other patients experienced repetitive minor trauma to the wrist from either sports activity or manual labor. One patient had no predisposing factor. The ulnocarpal abutment sign was positive in 2 cases. Range of motion was minimally affected, and the grip strength averaged 90% of the contralateral side. The preoperative diagnosis varied, and only 3 patients were diagnosed to have loose bodies in the wrist joint based on a plain radiograph. In one case, a loose body with osseous component could be identified in the retrospective review. Magnetic resonance imaging was performed for 4 patients but was not effective in visualizing the loose bodies in any of these cases. The loose bodies existed in the RCJ in 5 cases and in the DRUJ in 5 cases. Loose bodies in the RCJ could be removed arthroscopically, whereas loose bodies in the DRUJ required arthrotomy. The number of loose bodies varied from 1 to 3. Two cases were associated with ulnocarpal abutment syndrome, and one case was osteochondritis dissecanse of the radial styloid. In
other cases, the source of the loose bodies was uncertain. The sizes of the loose bodies varied from 3 to 10 mm. The loose bodies consisted of cartilaginous tissue with or without an osseous core in nine cases. In the remaining case, the loose body was a nodular synovium. Individual patient data are summarized in Table 1. After removal of the loose bodies, the pain was relieved in all cases without any surgical complication. Case Reports Case 2: A 16-year-old boy was referred to us with a 7-month history of left wrist pain. The pain was induced by grinding the wrist with ulnar flexion. The patient began to feel the pain after he joined a baseball club. Range of motion was full, and grip strength was 94% of the unaffected wrist. The preoperative diagnosis was ulnocarpal abutment syndrome (Fig 1A). Wrist arthroscopy was performed before ulnar shortening osteotomy, and it revealed 3 large chondral fragments in the RCJ (Fig 1B). The sizes of the fragments were 10, 4, and 3 mm, respectively. The joint surface of the ulnar aspect of the lunate and the surface of the triangular fibrocartilage (TFC) were fibrillated, thus suggesting that ulnar abutment syndrome coexisted with or may cause the loose bodies. Because one of the loose bodies was in the radial side of the joint and moderate synovitis was present, we judged that not only ulnar abutment but also the loose bodies caused the wrist pain. They were arthroscopically extracted using a small rongeur. Bone union was achieved after 6 weeks of immobilization, and the pain was resolved.
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FIGURE 1. (A) Preoperative plain radiograph of the wrist. (B) Loose bodies in the radiocarpal joint. (Asterisks indicate a loose body; R, radius; S, scaphoid; L, lunate.)
Case 5: A 32-year-old man had experienced right wrist pain since he sprained his right wrist while bowling 3 years earlier. The pain worsened when he tightened bolts or turned the accelerator on his motorcycle. Preoperative radiographs and magnetic resonance imaging showed no definite diagnosis (Fig 2). A tentative diagnosis was made of triangular fibrocartilage complex (TFCC) injury, which was proven to be intact by wrist arthroscopy. The only finding was a round cartilaginous fragment of 3 mm in diameter in the RCJ (Fig 2C). The patient has been asymptomatic since removal of this fragment. DISCUSSION Loose bodies in the wrist are rare, with only 15 cases reported previously. In 10 of these cases, the loose bodies were in the pisotriquetral joint. For the wrist joint in a narrow sense, the number of reported cases falls to 5.4-7 The RCJ was involved in 3 cases, and the MCJ and DRUJ were involved in 1 case each. However, our experience shows that loose bodies in the wrist joint are not extremely rare. They accounted for 1.4% of the cause of chronic wrist pain. We did not
find any loose bodies from the pisotriquetral joint, although that was the most common site in previous reports. We did not examine this joint with arthroscopy routinely, and we have not experienced a case to suspect the existence of the loose bodies in this joint. Preoperative diagnosis is difficult when the loose bodies are composed of nonosseous tissue. Four of the previously reported cases had osseous components within the loose bodies and were diagnosed from plain radiographs.4-6 Only 3 of the cases in the present study, however, were diagnosed using plain roentgenograms preoperatively; the remaining 7 were diagnosed by arthroscopy by chance. Magnetic resonance imaging failed to reveal the loose bodies in this series. Wrist arthroscopy is important to diagnose the exact cause of chronic wrist pain because the joint is too small for nonosseous components to be seen in detail using other methods. This is also true in the diagnosis of loose bodies because more than half of cases are radiolucent. Steinmann and Linscheid8 stated that trispiral tomography delineated all loose bodies in pisotriquetral joints, even when routine radiography failed to show them. Tehranzadeh and Gabriele9 recommended computed tomography after double-con-
LOOSE BODY IN THE WRIST
823
FIGURE 2. (A) Preoperative plain radiograph of the wrist. (B) Preoperative T1-weighted magnetic resonance image of the wrist. (C) A loose body existed in the radiocarpal joint. (Asterisk indicates the loose body; R, radius; L, lunate.)
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trast arthrography. If the physician is trying to rule out loose bodies, these are effective, reasonable options for examination; however, if the tentative diagnosis was some other entity, they would not be the options selected. Locking is thought to be a characteristic symptom of loose bodies, and this is true in the previous reports. In this series, however, only one patient experienced locking, while 3 other patients felt clicking in the wrist. The explanation for this discrepancy is that the size of the loose body was relatively small compared with the joint capacity in our series. Loose bodies in RCJs are usually too small to cause locking, but still they induce pain severe enough to disturb activities of daily living or sports activities. The one patient in the present study who experienced locking had an osteochondral loose body in the DRUJ. If loose bodies are large enough, they could cause locking more often. In the previous reports, the causes of loose bodies are osteochondral fracture in one case6 and synovial osteochondromatosis in 3 cases.4,5 Zachee et al.7 reported the case of a cartilaginous loose body diagnosed only by arthroscopy, in which the cause or origin was unclear. In the present series, the majority of the loose bodies seemed to be caused by traumatic events. However, we could not always find the “origin” of the osteochondral fragment while inspecting the joint surface by arthroscopy. This series included 3 cases in which ulnar shortening osteotomy was performed other than by loose body excision. In 1 case, it was performed to tighten a loose TFCC and to stabilize the unstable and crepitating DRUJ. After the shortening osteotomy, we explored the DRUJ because the crepitation still existed and arthroscopy of RCJ revealed only loosening of
TFCC. In cases 1 and 2, the osteotomy was performed to prevent further abutment of the ulna to carpal bones, which we believed was the etiology of the loose bodies. In these cases, both ulnocarpal abutment and loose bodies seemed to cause wrist pain. Arthroscopic excision was a successful treatment when the loose bodies were in the RCJ. If the loose bodies were in the DRUJ, conversely, arthrotomy was needed in all cases. This is because the joint capacity is too small for the surgeon to use both the arthroscope and the instruments. Loose bodies in the wrist joint should be included in the differential diagnosis for chronic wrist pain that cannot be diagnosed using physical signs and imaging techniques. REFERENCES 1. Kelly EW, Morrey BF, O’Driscoll SW. Complication of elbow arthroscopy. J Bone Joint Surg Am 2001;83:25-34. 2. Buckley SL, Alexander A, Jones M, et al. Arthroscopic surgery of the knee: Its role in the support of U.S. troops during Operation Desert Shield of USNS Mercy. Arthroscopy 1992;8: 359-362. 3. G¨achter A, Seelig W. Arthroscopy of the shoulder joint. Arthroscopy 1992;8:89-97. 4. DeSmet L, Van Wetter P. Synovial chondromatosis of the distal radio-ulnar joint. Acta Orthop Belgica 1987;53:106-108. 5. Ono H, Yajima H, Fukui A, Tamai S. Locking wrist with synovial chondromatosis. J Hand Surg [Am] 1994;19:797-799. 6. Tehranzadeh J, Labosky DA. Detection of intraarticular loose osteochondral fragments by double-contrast wrist arthrography. Am J Sports Med 1984;12:77-79. 7. Zachee B, DeSmet L, Fabry G. A snapping wrist due to a loose body: Arthroscopic diagnosis and treatment. Arthroscopy 1993; 9:117-118. 8. Steinmann SP, Linscheid RL. Pisotriquetral loose bodies. J Hand Surg [Am] 1997;22:918-921. 9. Tehranzadeh J, Gabriele OF. Intra-articular calcified bodies: Detection by computed arthrotomography. South Med J 1984; 77:703-710.
Purpose: The purpose of this study was to report on 10 cases of symptomatic loose bodies in the wrist joints diagnosed using arthroscopy. Type of Study: Retrospective review. Methods: From1986 to 2000, we performed wrist arthroscopy for 707 patients, 10 of whom had loose bodies in the wrist joints. The clinical records were reviewed retrospectively. The patients included 8 men and 2 women, and the average age was 28 years (range, 16 to 67 years). The chief complaint was wrist pain in all patients, but locking was uncommon. Preoperative diagnosis was difficult in all but 3 cases; in those cases, an osseous component was found within the loose bodies. The remaining cases were diagnosed by wrist arthroscopy. Results: The loose bodies existed in the radiocarpal joint in 5 cases, and all could be removed arthroscopically. In the other 5 cases, the loose bodies were in the distal radioulnar joint, and arthrotomy was needed to remove them. After removal of the loose bodies, the pain was relieved in all cases without any surgical complications. Conclusions: Loose bodies in the wrist joint should be included in the differential diagnosis for chronic wrist pain. Wrist arthroscopy is of value because the preoperative diagnosis is usually difficult. Key Words: Wrist—Arthroscopy—Loose body—Radiocarpal joint—Distal radioulnar joint.
L
oose bodies in the joints are usually caused by osteochondral fracture, osteochondritis dissecans, degenerative arthrosis, or synovial osteochondromatosis and are quite common in the large joints. Kelly et al.1 reported an incidence of loose bodies of 24% in their retrospective review of 473 elbow arthroscopies, and other authors reported incidences of 4% in the knee2 and 3% in the shoulder joint.3 Loose bodies are rare, however, in wrist joints, except for the pisotriquetral joint. Only 5 cases have been reported.4-7 This article describes our experience with 10 patients with loose bodies in the wrist, with an emphasis on diagnosis and treatment. METHODS From 1986 to December 2000, we examined 707 patients with wrist disorders using wrist arthroscopy.
From the Department of Hand Surgery, Nagoya University School of Medicine, Nagoya, Japan. Address correspondence and reprint requests to Shukuki Koh, M.D., 65 Tsurumai, Showa, Nagoya 466-8560, Japan. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 0749-8063/03/1908-3395$30.00/0 doi:10.1053/S04790-8063(03)00738-2
820
All the records were retrospectively reviewed, and 10 cases were identified in which loose bodies were found in either the radiocarpal joint (RCJ) or the distal radioulnar joint (DRUJ). Wrist arthroscopy was performed for all 10 patients. The 3-4 or 4-5 portal was used to inspect the RCJ, and the midcarpal radial portal was used to inspect the midcarpal joint (MCJ). The DRUJ was examined if possible. In addition to removal of the loose bodies, ulnar shortening osteotomy was performed simultaneously for 3 patients who had ulnocarpal abutment syndrome or DRUJ instability, and one patient who had osteochondritis dissecans of the radial styloid underwent radial styloidectomy. The loose bodies were arthroscopically excised if possible, but in the cases of DRUJ loose bodies, arthrotomy was necessary. A longitudinal skin incision about 3 cm was made on the dorsal aspect of the wrist, and the joint was explored between the extensor digiti minimi and extensor carpi ulnaris. The joint capsule was also incised longitudinally. Postoperative management depended on the procedure performed. Arthroscopic excision and radial styloidectomy required 1 week of compressive dressing. Ulnar shortening osteotomy required 6 to 8 weeks of cast immobilization.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 8 (October), 2003: pp 820-824
LOOSE BODY IN THE WRIST
821
TABLE 1. Individual Patient Data
Case No.
Age & Sex
Predisposing Factor
Preoperative Diagnosis
Locking
Click
Plain Diagnostic X-ray?
Additional Surgery USO USO — Radial styloidectomy — USO —
1 2 3 4
21 16 17 20
M M M F
Volleyball Baseball Baseball Gymnastics
UCA UCA TFC injury OCD
No No No No
No No Yes No
5 6
32 M 23 M
Bowling Motorcycle accident
No No
No Yes
7
30 M
Manual work
Yes
No
Yes
8
19 M
Using crutch
9 10
67 F 35 M
None Wrist contusion
TFC injury DRUJ instability with TFCC injury DRUJ loose body DRUJ loose body DRUJ OA DRUJ loose body
No No No Yes (retrospectively) No No
Site of Loose Body
Number
Size (mm)
Arthroscopic Excision?
RCJ RCJ RCJ RCJ
2 3 2 1
5, 3 10, 4, 3 5, 3 4
Yes Yes Yes Yes
RCJ DRUJ
1 1
3 6
Yes No
DRUJ
1
6
No
No
No
Yes
—
DRUJ
1
5
No
No No
Yes No
No Yes
— —
DRUJ DRUJ
1 3
5 3, 3, 3
No No
Abbreviations: UCA, ulnocarpal abutment syndrome; USO, ulnar shortening osteotomy; OCD, osteochondritis dissecans.
RESULTS Eight of these patients were men, and 2 were women. The ages ranged from 16 to 67 years (average 28 years), and the time interval from onset of symptoms to surgery averaged 21.3 months (range, 4 to 84 months). All patients complained of wrist pain. Four patients had ulnar side wrist pain, and 4 patients had DRUJ discomfort. Only 1 patient described “locking,” and 3 had crepitation with motion. Five patients experienced wrist injury before the onset of symptoms, although the severity ranged from minor contusion to a motor vehicle accident. Four of the other patients experienced repetitive minor trauma to the wrist from either sports activity or manual labor. One patient had no predisposing factor. The ulnocarpal abutment sign was positive in 2 cases. Range of motion was minimally affected, and the grip strength averaged 90% of the contralateral side. The preoperative diagnosis varied, and only 3 patients were diagnosed to have loose bodies in the wrist joint based on a plain radiograph. In one case, a loose body with osseous component could be identified in the retrospective review. Magnetic resonance imaging was performed for 4 patients but was not effective in visualizing the loose bodies in any of these cases. The loose bodies existed in the RCJ in 5 cases and in the DRUJ in 5 cases. Loose bodies in the RCJ could be removed arthroscopically, whereas loose bodies in the DRUJ required arthrotomy. The number of loose bodies varied from 1 to 3. Two cases were associated with ulnocarpal abutment syndrome, and one case was osteochondritis dissecanse of the radial styloid. In
other cases, the source of the loose bodies was uncertain. The sizes of the loose bodies varied from 3 to 10 mm. The loose bodies consisted of cartilaginous tissue with or without an osseous core in nine cases. In the remaining case, the loose body was a nodular synovium. Individual patient data are summarized in Table 1. After removal of the loose bodies, the pain was relieved in all cases without any surgical complication. Case Reports Case 2: A 16-year-old boy was referred to us with a 7-month history of left wrist pain. The pain was induced by grinding the wrist with ulnar flexion. The patient began to feel the pain after he joined a baseball club. Range of motion was full, and grip strength was 94% of the unaffected wrist. The preoperative diagnosis was ulnocarpal abutment syndrome (Fig 1A). Wrist arthroscopy was performed before ulnar shortening osteotomy, and it revealed 3 large chondral fragments in the RCJ (Fig 1B). The sizes of the fragments were 10, 4, and 3 mm, respectively. The joint surface of the ulnar aspect of the lunate and the surface of the triangular fibrocartilage (TFC) were fibrillated, thus suggesting that ulnar abutment syndrome coexisted with or may cause the loose bodies. Because one of the loose bodies was in the radial side of the joint and moderate synovitis was present, we judged that not only ulnar abutment but also the loose bodies caused the wrist pain. They were arthroscopically extracted using a small rongeur. Bone union was achieved after 6 weeks of immobilization, and the pain was resolved.
822
S. KOH ET AL.
FIGURE 1. (A) Preoperative plain radiograph of the wrist. (B) Loose bodies in the radiocarpal joint. (Asterisks indicate a loose body; R, radius; S, scaphoid; L, lunate.)
Case 5: A 32-year-old man had experienced right wrist pain since he sprained his right wrist while bowling 3 years earlier. The pain worsened when he tightened bolts or turned the accelerator on his motorcycle. Preoperative radiographs and magnetic resonance imaging showed no definite diagnosis (Fig 2). A tentative diagnosis was made of triangular fibrocartilage complex (TFCC) injury, which was proven to be intact by wrist arthroscopy. The only finding was a round cartilaginous fragment of 3 mm in diameter in the RCJ (Fig 2C). The patient has been asymptomatic since removal of this fragment. DISCUSSION Loose bodies in the wrist are rare, with only 15 cases reported previously. In 10 of these cases, the loose bodies were in the pisotriquetral joint. For the wrist joint in a narrow sense, the number of reported cases falls to 5.4-7 The RCJ was involved in 3 cases, and the MCJ and DRUJ were involved in 1 case each. However, our experience shows that loose bodies in the wrist joint are not extremely rare. They accounted for 1.4% of the cause of chronic wrist pain. We did not
find any loose bodies from the pisotriquetral joint, although that was the most common site in previous reports. We did not examine this joint with arthroscopy routinely, and we have not experienced a case to suspect the existence of the loose bodies in this joint. Preoperative diagnosis is difficult when the loose bodies are composed of nonosseous tissue. Four of the previously reported cases had osseous components within the loose bodies and were diagnosed from plain radiographs.4-6 Only 3 of the cases in the present study, however, were diagnosed using plain roentgenograms preoperatively; the remaining 7 were diagnosed by arthroscopy by chance. Magnetic resonance imaging failed to reveal the loose bodies in this series. Wrist arthroscopy is important to diagnose the exact cause of chronic wrist pain because the joint is too small for nonosseous components to be seen in detail using other methods. This is also true in the diagnosis of loose bodies because more than half of cases are radiolucent. Steinmann and Linscheid8 stated that trispiral tomography delineated all loose bodies in pisotriquetral joints, even when routine radiography failed to show them. Tehranzadeh and Gabriele9 recommended computed tomography after double-con-
LOOSE BODY IN THE WRIST
823
FIGURE 2. (A) Preoperative plain radiograph of the wrist. (B) Preoperative T1-weighted magnetic resonance image of the wrist. (C) A loose body existed in the radiocarpal joint. (Asterisk indicates the loose body; R, radius; L, lunate.)
824
S. KOH ET AL.
trast arthrography. If the physician is trying to rule out loose bodies, these are effective, reasonable options for examination; however, if the tentative diagnosis was some other entity, they would not be the options selected. Locking is thought to be a characteristic symptom of loose bodies, and this is true in the previous reports. In this series, however, only one patient experienced locking, while 3 other patients felt clicking in the wrist. The explanation for this discrepancy is that the size of the loose body was relatively small compared with the joint capacity in our series. Loose bodies in RCJs are usually too small to cause locking, but still they induce pain severe enough to disturb activities of daily living or sports activities. The one patient in the present study who experienced locking had an osteochondral loose body in the DRUJ. If loose bodies are large enough, they could cause locking more often. In the previous reports, the causes of loose bodies are osteochondral fracture in one case6 and synovial osteochondromatosis in 3 cases.4,5 Zachee et al.7 reported the case of a cartilaginous loose body diagnosed only by arthroscopy, in which the cause or origin was unclear. In the present series, the majority of the loose bodies seemed to be caused by traumatic events. However, we could not always find the “origin” of the osteochondral fragment while inspecting the joint surface by arthroscopy. This series included 3 cases in which ulnar shortening osteotomy was performed other than by loose body excision. In 1 case, it was performed to tighten a loose TFCC and to stabilize the unstable and crepitating DRUJ. After the shortening osteotomy, we explored the DRUJ because the crepitation still existed and arthroscopy of RCJ revealed only loosening of
TFCC. In cases 1 and 2, the osteotomy was performed to prevent further abutment of the ulna to carpal bones, which we believed was the etiology of the loose bodies. In these cases, both ulnocarpal abutment and loose bodies seemed to cause wrist pain. Arthroscopic excision was a successful treatment when the loose bodies were in the RCJ. If the loose bodies were in the DRUJ, conversely, arthrotomy was needed in all cases. This is because the joint capacity is too small for the surgeon to use both the arthroscope and the instruments. Loose bodies in the wrist joint should be included in the differential diagnosis for chronic wrist pain that cannot be diagnosed using physical signs and imaging techniques. REFERENCES 1. Kelly EW, Morrey BF, O’Driscoll SW. Complication of elbow arthroscopy. J Bone Joint Surg Am 2001;83:25-34. 2. Buckley SL, Alexander A, Jones M, et al. Arthroscopic surgery of the knee: Its role in the support of U.S. troops during Operation Desert Shield of USNS Mercy. Arthroscopy 1992;8: 359-362. 3. G¨achter A, Seelig W. Arthroscopy of the shoulder joint. Arthroscopy 1992;8:89-97. 4. DeSmet L, Van Wetter P. Synovial chondromatosis of the distal radio-ulnar joint. Acta Orthop Belgica 1987;53:106-108. 5. Ono H, Yajima H, Fukui A, Tamai S. Locking wrist with synovial chondromatosis. J Hand Surg [Am] 1994;19:797-799. 6. Tehranzadeh J, Labosky DA. Detection of intraarticular loose osteochondral fragments by double-contrast wrist arthrography. Am J Sports Med 1984;12:77-79. 7. Zachee B, DeSmet L, Fabry G. A snapping wrist due to a loose body: Arthroscopic diagnosis and treatment. Arthroscopy 1993; 9:117-118. 8. Steinmann SP, Linscheid RL. Pisotriquetral loose bodies. J Hand Surg [Am] 1997;22:918-921. 9. Tehranzadeh J, Gabriele OF. Intra-articular calcified bodies: Detection by computed arthrotomography. South Med J 1984; 77:703-710.