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The role of arthroscopy in the investigation of wrist disorders
THE ROLE OF ARTHROSCOPY IN THE INVESTIGATION OF WRIST DISORDERS W. A. JONES and M. E. LOVELL
From the Department of Orthopaedics, Broadgreen Hospital, Liverpool, UK The findings at arthroscopy of the wrist in 48 consecutive cases carried out over a 4.5 year period have been retrospectively reviewed. In correlating the clinical and arthroscopic findings in the 36 patients with wrist instability and triangular fihrocartilage injuries we found concurrence in 28 of the cases. In the six patients in whom we were unable to make any provisional clinical diagnosis we did not find arthroscopy helpful. Arthroscopy usefully influenced the management in two of the six patients in whom the articular surface was assessed. We feel that a careful clinical examination of the wrist is the mainstay of diagnosis in wrist disorders. Arthroscopy remains useful in selected cases but has a limited specialized role which should continue to be provided from specialist centres.
Journal of Hand Surgery (British and European Volume, 1996) 21B: 4." 442-445 The usefulness of arthroscopy in defining anatomically the patterns, combinations and extent of soft tissue injuries of the wrist have been confirmed by a number of authors (Adolfsson, 1992; 1994; Koman et al, 1990; North and Meyer, 1990). The role of arthroscopy as a dynamic investigation in visualizing abnormal mobility between the carpal bones has been emphasized by Dautel et al (1993). Kelly and Stanley (1990) found that their diagnostic rate improved from 40% to 95% after diagnostic arthroscopy, and Nagle and Benson (1992) were able to establish a diagnosis in 43 out of 43 patients with a previously unknown diagnosis. In addition to its role in establishing a diagnosis, arthroscopy has been recommended in the confirmation of a clinical diagnosis prior to operative treatment (Nagle and Benson, 1992) with the implication that findings may alter the subsequent management. Rettig and Amadio (1994) have challenged this indication on economic grounds. This study is a retrospective review of our first 48 consecutive diagnostic wrist arthroscopies. We have correlated the clinical and arthroscopic findings and, where possible, other special investigations with the arthroscopic findings. The aim has been to define more clearly the role of diagnostic wrist arthroscopy in the investigation of wrist disorders.
maintained overall control of their patient's management subsequently. All patients were clinically examined by the senior author and an attempt at a clinical diagnosis made. An assortment of other investigations had been done, including plain radiographs, bone scans, arthrograms, CT scans and MRI scans. Where possible the results of these investigations were correlated with the findings at arthroscopy. A standard arthroscopic technique was employed in all, as described by Kelly and Stanley (1990). All arthroscopies were performed as day case procedures under general anaesthesia; all were well tolerated with no complications. Indications for arthroscopy
In 27 of the cases, the senior author had sole responsibility for the management of the patients. In 20 of these cases, arthroscopy was performed to confirm the clinical diagnosis of a carpal or distal radioulnar joint (DRUJ) instability in patients who felt that their clinical symptoms were sufficiently severe to warrant further potential surgical treatment. In three cases arthroscopy was performed to assess the status of the articular surface of the wrist. In the remaining four cases arthroscopy was performed to establish a diagnosis. In 21 patients arthroscopy was performed as an investigation requested by another hand surgeon who was retaining overall responsibility for the management of the patient. In these cases, for whom a service commitment was being provided, the above criteria were less stringently adhered to although the indications were the same.
PATIENTS AND M E T H O D S There were 26 men and 22 women with a mean age of 32 years (range 13-62). A history of trauma was obtained in 43 patients and the mean duration of symptoms had been 19.5 mouths (range 3-72 months). Fourteen patients had come from our own hospital clinic. Thirty-four patients were tertiary referrals; of these 13 were referred from other specialists for an opinion and further treatment and 21 arose from other hand surgeons requesting wrist arthroscopy as part of their investigation protocol. The referring hand surgeon
RESULTS In considering the outcomes we think it best to consider the patients in groups according to the pre-arthroscopic clinical diagnosis (Table 1). 442
WRIST ARTHROSCOPY
443
Table 1 - - C l i n i c a l and arthroscopic diagnoses
Pre-operative clinical diagnosis
Clinical diagnoses confirmed arthroseopiealIy Concurrence
Scapholunate instability TFC or TFC plus injuries D R U J instability Triquetrolunate instability Ulnocarpal impingement Triquetolunate and scapholunate instability Articular surface assessment No clinical diagnosis
Scapholunate instability Three of these cases had complete dissociation of the scaphoid and lunate. Seven had torn radioscapholunate (RSL) ligaments, a partial tear of the palmar scapholunate (SL) interosseous ligament with abnormal movement between the scaphoid and lunate. The remaining four cases had a disruption of the RSL ligament with attenuation of the interosseous ligament and abnormal mobility. O f the complete dissociations only one was diagnosed on plain radiography, one had a hot bone scan and none had arthrograms. Of the seven partial tears, two had positive clenched fist radiographs and one bad a positive arthrogram. Two had negative bone scans and one a negative arthrogram. Of the four attenuated ligament injuries, one had an equivocal clenched fist radiograph, two had bone scans, one of which was hot, and there were two false negative arthrograms. In the whole group the clinical diagnosis was confirmed in all cases.
Triangular fibrocartilage (TFC) or TFC plus injuries Clinically, nine patients were thought to have a T F C injury alone or combined with some other ligamentous injury but without D R U J instability. Five patients were thought to have a T F C injury alone. This proved to be the case in only one with a tear of the radial attachment of the T F C in its central portion; the patient had an appropriately hot bone scan with a false negative arthrogram. Two had a tear of the radial attachment of the T F C in its central portion along with a triquetrolunate disruption in one and a partial scapholunate disruption in the other. The remaining two had a normal TFC; in one the arthroscopy was felt to be completely normal and the other had an isolated triquetrolunate instability. Three patients were thought to have a T F C injury combined with scapholunate instability. In only one was the clinical diagnosis confirmed at arthroscopy and an arthrogram in this patient also proved accurate. In the other two patients the clinical diagnosis was only
14 9 7 3 2
Partial concurrence clinically correct
14 2 ' 3 3
3 1
-
2
1
6 6
partially correct, there being a tear of the radial attachment of the T F C in its central portion in both combined with a perilunate injury. One patient was thought to have a combined TFC injury and triquetrolunate instability. At arthroscopy, triquetrolunate instability was confirmed but no T F C injury was found. Arthrography showed a T F C leak, which was later confirmed at surgery. Although a T F C injury was found in seven out of nine cases, the clinical diagnosis and arthroscopic diagnosis concurred in only two out of nine cases. Combinations of ligament injuries frequently occurred with T F C injuries and we feel that arthrography remains a useful adjunct to arthroscopy in the investigation of ulnarsided wrist pain.
Articular surface assessment An articular surface assessment was requested in one patient with a lunate cyst and another with known early Kienb6ck's disease. In both of these cases arthroscopies were considered entirely normal and it was doubtful if any useful additional information had been gleaned which affected further management. One case had arthroscopy for continued pain after scapholunate fusion; early degenerative changes were found in the radioscaphoid articulation. One case had arthroscopy for an assessment of the radiocarpal joint after a severe intraarticular fracture of the distal radius. This was the only case in which we failed to enter the radiocarpal joint; midcarpal arthroscopy confirmed a healthy joint and the patient did well following a radioscapholunate fusion. Two patients had an arthroscopy for continued discomfort after a scaphoid fracture. One had a known nonunion and the other an intact scaphoid but with avascular necrosis of the proximal pole. The arthroscopy provided information of questionable value which could have been obtained more cheaply by other investigations.
Distal radioulnar joint instability Five patients were felt to have a dorsal instability of the DRUJ. One of these patients was known to have an
444
ulnar styloid non-union; arthroscopy was performed to assess the status of the T F C prior to styloid re-attachment. The T F C was normal; there was, however, a tear of the RSL ligament and palmar scapholunate interosseous ligament with abnormal scapholunate mobility, which was clinically asymptomatic. Two patients had a tear of the radial attachment of the palmar band of the T F C with a concomitant triquetrolunate instability in one. In the remaining two patients no T F C damage could be identified and arthrograms were normal in both. Two patients had palmar D R U J instability; in one, a tear of the dorsal band of the T F C from its radial attachment was found. In the other case, the arthroscopy was considered normal although an arthrogram had demonstrated a T F C leak at its radial attachment.
No clinical diagnosis Arthroscopy was performed to establish a diagnosis in six cases. In four, no pathology was found and in the other two there was a mild synovitis. Essentially, it was felt that little useful information was gleaned from arthroscopic examination.
Ulnocarpal impingement In both cases there was a history of a previous radial fracture with radial malunion and shortening. In one there was a central perforation of the T F C with concomitant perilunate ligament damage and abnormal scapholunate and triquetrolunate mobility. In the other the T F C was intact though abutment could be identified and no other pathology was found.
Triquetrolunate instability In all three, triquetrolunate disruption was identified with abnormal mobility and no associated injuries. One patient had a VISI collapse on plain radiographs, one patient had a normal arthrogram and dynamic cineradiography and one patient had a normal bone scan and M R I scan.
Combined scapholunate and triquetrolunate instability Arthroscopy revealed RSL and a palmar scapholunate interosseous tear with abnormal scapholunate mobility and synovitis but no evidence of triquetrolunate injury. DISCUSSION Wrist arthroscopy is undoubtedly a useful investigation in defining the patterns, combinations and extent of soft tissue injuries which frequently are more extensive than clinically suspected (Adolfsson, 1992; Kelly and Stanley, 1990; North and Meyer, 1990). Whether the improved
THE J O U R N A L OF H A N D SURGERY VOL. 21B No. 4 A U G U S T 1996
accuracy of diagnosis offered by arthroscopy provides actual benefit to the patient has to be critically analysed. There were six cases in our series in whom the indications for arthroscopy was an assessment of the articular surface. In only two of these cases did we feel that useful information influencing subsequent treatment was found. Both of these cases had post-traumatic arthritis, the extent and pattern of which affected further treatment. We did not find arthroscopy useful in the assessment of Kienb6ck's disease or scaphoid fractures. In most circumstances in these conditions information affecting treatment can be gleaned less expensively from plain radiographs, bone scans and CT or M R I scans. In 36 cases considered clinically to have either carpal instability or T F C pathology, the clinical and arthroscopic findings concurred in 22. The extent of soft tissue injury was clinically overdiagnosed in three cases and underdiagnosed in six cases. Of the remaining five cases, four had normal arthroscopies and one was a wrong diagnosis. Although the extent of soft tissue injury was clinically under- or overdiagnosed in nine cases, we feel we were correct in the diagnosis of the lesion causing the clinical problem in six of these cases, with an overall clinical accuracy of 28 out of 36 (Table 1). The extent to which arthroscopy is employed to establish a previously unknown diagnosis is extremely variable. Adolfsson (1992) established a diagnosis in 21 of 30 patients, Nagle and Benson (1992) in 43 out of 43 patients and Rettig and Amadio (1994) in 10 out of 27 patients. In our series there were six patients in whom no provisional diagnosis of any kind could be made to account for their wrist pain. In four of these cases arthroscopy was normal, a mild synovitis being present in the other two. It is our view that the best way to diagnose the cause of wrist pain is a thorough clinical examination of the wrist. It is our experience that if no diagnosis can be made after a thorough clinical assessment, including appropriate imaging and haematological investigations, little further information is obtained from arthroscopy. We agree, however, with the view expressed by Kelly and Stanley (1990) that normal investigations can be of positive value, in that the reassurance that there is no serious intraarticular pathology is sufficient to allow the commencement of rehabilitation. Rettig and Amadio (1994) have been critical of arthroscopies carried out to confirm a clinical diagnosis if it does not also influence subsequent management. We agree with the views of these authors and clearly, as we become more confident in our clinical diagnosis, our diagnostic arthroscopy rate will fall from its current rate of 12 per annum. In this series bone scans had been carried out in 12 patients. There was one normal scan in a normal wrist. There were five further normal scans which were considered false negatives; two of these cases had triquetrolunate instability and three had scapholunate instability. There were six abnormal scans; three patients had
WRIST ARTHROSCOPY
scapholunate instability, one a TFC injury, one scaphoid non-union and one Kienb6ck's disease. The investigation is clearly non-specific and unreliable although positive scans may identify patients requiring further investigation. Arthrography of the wrist was performed in 14 patients. The findings were considered correct in eight cases. One was normal, two showed a synovitis and five had abnormal leaks. Four of the leaks were in the TFC, two of which were missed at arthroscopy. The arthrographic findings were incorrect in six. Two had TFC damage arthroscopically without arthrographic leaks, three had arthroscopic scapholunate instability and one a triquetrolunate instability. These latter cases had attenuation of the interosseous ligaments missed by arthrography, instability only being demonstrated by stressing the wrist at arthroscopy (Adolfsson, 1992; Dautel et al 1993). We would agree with Cooney (1993) that arthrography is most accurate in the diagnosis of TFC injuries and in this respect is a useful adjunct to arthroscopy in the investigation of ulnar-sided wrist pain. In conclusion, we feel that the best way to reach a diagnosis of the cause of chronic wrist pain is to perfect techniques of clinical examination of the wrist. Although arthroscopy has usefully demonstrated the anatomical extent and patterns of soft tissue injuries, these findings must be correlated with the clinical symptoms and signs.
445
This improved anatomical diagnosis has to be related to the ultimate benefit to the patient. That is to say, do the findings affect treatment decisions (Rettig and Amadio, 1994)? We believe that wrist arthroscopy still has a limited but specialized role in the investigation of wrist pain but even with the addition of arthroscopic treatment the technique is unlikely to become as universally widespread as knee arthroscopy. / References ADOLFSSON L (1992). Arthroscopy for the diagnosis of post-traumatic wrist pain. Journal of Hand Surgery, 17B: 46-50. ADOLFSSON L (1994). Arthroscopic diagnosis of ligament lesions of the wrist. Journal of Hand Surgery, 19B: 505-512. COONEY W P (1993). Evaluation of chronic wrist pain by arthrography, arthroscopy and arthrotomy. Journal of Hand Surgery, 18A: 815-822. DAUTEL G, GOUDOT B and MERLE M (1993). Arthroscopic diagnosis of scapho-lunate instability in the absence of X-ray abnormalities. Journal of Hand Surgery, 18B: 213-218. KELLY E P and STANLEY J K (1990). Arthroscopy of the wrist. Journal of Hand Surgery, 15B: 236-242. KOMAN L A, POEHLING G G, TOBY E B and KAMMIRE G (1990). Chronic wrist pain: indications for wrist arthroscopy. Arthroscopy, 6: 116-119. NAGLE D J and BENSON L S (1992). Wrist arthroscopy: indications and results. Arthroscopy, 8: 198-203. NORTH E R and MEYER S (1990). Wrist injuries: correlation of clinical and arthroscopic findings. Journal of Hand Surgery, 15A: 915-920. RETTIG M E and AMADIO P C (1994). Wrist arthroseopy: indications and clinical applications. Journal of Hand Surgery, 19B: 774-777.
Accepted after revision: 5 February 1996 W. A. Jones, FRCS, Department of Orthopaedics, Broadgreen Hospital, Thomas Drive, Liverpool L14 3LB, UK. © 1996 The British Society for Surgery of the Hand
From the Department of Orthopaedics, Broadgreen Hospital, Liverpool, UK The findings at arthroscopy of the wrist in 48 consecutive cases carried out over a 4.5 year period have been retrospectively reviewed. In correlating the clinical and arthroscopic findings in the 36 patients with wrist instability and triangular fihrocartilage injuries we found concurrence in 28 of the cases. In the six patients in whom we were unable to make any provisional clinical diagnosis we did not find arthroscopy helpful. Arthroscopy usefully influenced the management in two of the six patients in whom the articular surface was assessed. We feel that a careful clinical examination of the wrist is the mainstay of diagnosis in wrist disorders. Arthroscopy remains useful in selected cases but has a limited specialized role which should continue to be provided from specialist centres.
Journal of Hand Surgery (British and European Volume, 1996) 21B: 4." 442-445 The usefulness of arthroscopy in defining anatomically the patterns, combinations and extent of soft tissue injuries of the wrist have been confirmed by a number of authors (Adolfsson, 1992; 1994; Koman et al, 1990; North and Meyer, 1990). The role of arthroscopy as a dynamic investigation in visualizing abnormal mobility between the carpal bones has been emphasized by Dautel et al (1993). Kelly and Stanley (1990) found that their diagnostic rate improved from 40% to 95% after diagnostic arthroscopy, and Nagle and Benson (1992) were able to establish a diagnosis in 43 out of 43 patients with a previously unknown diagnosis. In addition to its role in establishing a diagnosis, arthroscopy has been recommended in the confirmation of a clinical diagnosis prior to operative treatment (Nagle and Benson, 1992) with the implication that findings may alter the subsequent management. Rettig and Amadio (1994) have challenged this indication on economic grounds. This study is a retrospective review of our first 48 consecutive diagnostic wrist arthroscopies. We have correlated the clinical and arthroscopic findings and, where possible, other special investigations with the arthroscopic findings. The aim has been to define more clearly the role of diagnostic wrist arthroscopy in the investigation of wrist disorders.
maintained overall control of their patient's management subsequently. All patients were clinically examined by the senior author and an attempt at a clinical diagnosis made. An assortment of other investigations had been done, including plain radiographs, bone scans, arthrograms, CT scans and MRI scans. Where possible the results of these investigations were correlated with the findings at arthroscopy. A standard arthroscopic technique was employed in all, as described by Kelly and Stanley (1990). All arthroscopies were performed as day case procedures under general anaesthesia; all were well tolerated with no complications. Indications for arthroscopy
In 27 of the cases, the senior author had sole responsibility for the management of the patients. In 20 of these cases, arthroscopy was performed to confirm the clinical diagnosis of a carpal or distal radioulnar joint (DRUJ) instability in patients who felt that their clinical symptoms were sufficiently severe to warrant further potential surgical treatment. In three cases arthroscopy was performed to assess the status of the articular surface of the wrist. In the remaining four cases arthroscopy was performed to establish a diagnosis. In 21 patients arthroscopy was performed as an investigation requested by another hand surgeon who was retaining overall responsibility for the management of the patient. In these cases, for whom a service commitment was being provided, the above criteria were less stringently adhered to although the indications were the same.
PATIENTS AND M E T H O D S There were 26 men and 22 women with a mean age of 32 years (range 13-62). A history of trauma was obtained in 43 patients and the mean duration of symptoms had been 19.5 mouths (range 3-72 months). Fourteen patients had come from our own hospital clinic. Thirty-four patients were tertiary referrals; of these 13 were referred from other specialists for an opinion and further treatment and 21 arose from other hand surgeons requesting wrist arthroscopy as part of their investigation protocol. The referring hand surgeon
RESULTS In considering the outcomes we think it best to consider the patients in groups according to the pre-arthroscopic clinical diagnosis (Table 1). 442
WRIST ARTHROSCOPY
443
Table 1 - - C l i n i c a l and arthroscopic diagnoses
Pre-operative clinical diagnosis
Clinical diagnoses confirmed arthroseopiealIy Concurrence
Scapholunate instability TFC or TFC plus injuries D R U J instability Triquetrolunate instability Ulnocarpal impingement Triquetolunate and scapholunate instability Articular surface assessment No clinical diagnosis
Scapholunate instability Three of these cases had complete dissociation of the scaphoid and lunate. Seven had torn radioscapholunate (RSL) ligaments, a partial tear of the palmar scapholunate (SL) interosseous ligament with abnormal movement between the scaphoid and lunate. The remaining four cases had a disruption of the RSL ligament with attenuation of the interosseous ligament and abnormal mobility. O f the complete dissociations only one was diagnosed on plain radiography, one had a hot bone scan and none had arthrograms. Of the seven partial tears, two had positive clenched fist radiographs and one bad a positive arthrogram. Two had negative bone scans and one a negative arthrogram. Of the four attenuated ligament injuries, one had an equivocal clenched fist radiograph, two had bone scans, one of which was hot, and there were two false negative arthrograms. In the whole group the clinical diagnosis was confirmed in all cases.
Triangular fibrocartilage (TFC) or TFC plus injuries Clinically, nine patients were thought to have a T F C injury alone or combined with some other ligamentous injury but without D R U J instability. Five patients were thought to have a T F C injury alone. This proved to be the case in only one with a tear of the radial attachment of the T F C in its central portion; the patient had an appropriately hot bone scan with a false negative arthrogram. Two had a tear of the radial attachment of the T F C in its central portion along with a triquetrolunate disruption in one and a partial scapholunate disruption in the other. The remaining two had a normal TFC; in one the arthroscopy was felt to be completely normal and the other had an isolated triquetrolunate instability. Three patients were thought to have a T F C injury combined with scapholunate instability. In only one was the clinical diagnosis confirmed at arthroscopy and an arthrogram in this patient also proved accurate. In the other two patients the clinical diagnosis was only
14 9 7 3 2
Partial concurrence clinically correct
14 2 ' 3 3
3 1
-
2
1
6 6
partially correct, there being a tear of the radial attachment of the T F C in its central portion in both combined with a perilunate injury. One patient was thought to have a combined TFC injury and triquetrolunate instability. At arthroscopy, triquetrolunate instability was confirmed but no T F C injury was found. Arthrography showed a T F C leak, which was later confirmed at surgery. Although a T F C injury was found in seven out of nine cases, the clinical diagnosis and arthroscopic diagnosis concurred in only two out of nine cases. Combinations of ligament injuries frequently occurred with T F C injuries and we feel that arthrography remains a useful adjunct to arthroscopy in the investigation of ulnarsided wrist pain.
Articular surface assessment An articular surface assessment was requested in one patient with a lunate cyst and another with known early Kienb6ck's disease. In both of these cases arthroscopies were considered entirely normal and it was doubtful if any useful additional information had been gleaned which affected further management. One case had arthroscopy for continued pain after scapholunate fusion; early degenerative changes were found in the radioscaphoid articulation. One case had arthroscopy for an assessment of the radiocarpal joint after a severe intraarticular fracture of the distal radius. This was the only case in which we failed to enter the radiocarpal joint; midcarpal arthroscopy confirmed a healthy joint and the patient did well following a radioscapholunate fusion. Two patients had an arthroscopy for continued discomfort after a scaphoid fracture. One had a known nonunion and the other an intact scaphoid but with avascular necrosis of the proximal pole. The arthroscopy provided information of questionable value which could have been obtained more cheaply by other investigations.
Distal radioulnar joint instability Five patients were felt to have a dorsal instability of the DRUJ. One of these patients was known to have an
444
ulnar styloid non-union; arthroscopy was performed to assess the status of the T F C prior to styloid re-attachment. The T F C was normal; there was, however, a tear of the RSL ligament and palmar scapholunate interosseous ligament with abnormal scapholunate mobility, which was clinically asymptomatic. Two patients had a tear of the radial attachment of the palmar band of the T F C with a concomitant triquetrolunate instability in one. In the remaining two patients no T F C damage could be identified and arthrograms were normal in both. Two patients had palmar D R U J instability; in one, a tear of the dorsal band of the T F C from its radial attachment was found. In the other case, the arthroscopy was considered normal although an arthrogram had demonstrated a T F C leak at its radial attachment.
No clinical diagnosis Arthroscopy was performed to establish a diagnosis in six cases. In four, no pathology was found and in the other two there was a mild synovitis. Essentially, it was felt that little useful information was gleaned from arthroscopic examination.
Ulnocarpal impingement In both cases there was a history of a previous radial fracture with radial malunion and shortening. In one there was a central perforation of the T F C with concomitant perilunate ligament damage and abnormal scapholunate and triquetrolunate mobility. In the other the T F C was intact though abutment could be identified and no other pathology was found.
Triquetrolunate instability In all three, triquetrolunate disruption was identified with abnormal mobility and no associated injuries. One patient had a VISI collapse on plain radiographs, one patient had a normal arthrogram and dynamic cineradiography and one patient had a normal bone scan and M R I scan.
Combined scapholunate and triquetrolunate instability Arthroscopy revealed RSL and a palmar scapholunate interosseous tear with abnormal scapholunate mobility and synovitis but no evidence of triquetrolunate injury. DISCUSSION Wrist arthroscopy is undoubtedly a useful investigation in defining the patterns, combinations and extent of soft tissue injuries which frequently are more extensive than clinically suspected (Adolfsson, 1992; Kelly and Stanley, 1990; North and Meyer, 1990). Whether the improved
THE J O U R N A L OF H A N D SURGERY VOL. 21B No. 4 A U G U S T 1996
accuracy of diagnosis offered by arthroscopy provides actual benefit to the patient has to be critically analysed. There were six cases in our series in whom the indications for arthroscopy was an assessment of the articular surface. In only two of these cases did we feel that useful information influencing subsequent treatment was found. Both of these cases had post-traumatic arthritis, the extent and pattern of which affected further treatment. We did not find arthroscopy useful in the assessment of Kienb6ck's disease or scaphoid fractures. In most circumstances in these conditions information affecting treatment can be gleaned less expensively from plain radiographs, bone scans and CT or M R I scans. In 36 cases considered clinically to have either carpal instability or T F C pathology, the clinical and arthroscopic findings concurred in 22. The extent of soft tissue injury was clinically overdiagnosed in three cases and underdiagnosed in six cases. Of the remaining five cases, four had normal arthroscopies and one was a wrong diagnosis. Although the extent of soft tissue injury was clinically under- or overdiagnosed in nine cases, we feel we were correct in the diagnosis of the lesion causing the clinical problem in six of these cases, with an overall clinical accuracy of 28 out of 36 (Table 1). The extent to which arthroscopy is employed to establish a previously unknown diagnosis is extremely variable. Adolfsson (1992) established a diagnosis in 21 of 30 patients, Nagle and Benson (1992) in 43 out of 43 patients and Rettig and Amadio (1994) in 10 out of 27 patients. In our series there were six patients in whom no provisional diagnosis of any kind could be made to account for their wrist pain. In four of these cases arthroscopy was normal, a mild synovitis being present in the other two. It is our view that the best way to diagnose the cause of wrist pain is a thorough clinical examination of the wrist. It is our experience that if no diagnosis can be made after a thorough clinical assessment, including appropriate imaging and haematological investigations, little further information is obtained from arthroscopy. We agree, however, with the view expressed by Kelly and Stanley (1990) that normal investigations can be of positive value, in that the reassurance that there is no serious intraarticular pathology is sufficient to allow the commencement of rehabilitation. Rettig and Amadio (1994) have been critical of arthroscopies carried out to confirm a clinical diagnosis if it does not also influence subsequent management. We agree with the views of these authors and clearly, as we become more confident in our clinical diagnosis, our diagnostic arthroscopy rate will fall from its current rate of 12 per annum. In this series bone scans had been carried out in 12 patients. There was one normal scan in a normal wrist. There were five further normal scans which were considered false negatives; two of these cases had triquetrolunate instability and three had scapholunate instability. There were six abnormal scans; three patients had
WRIST ARTHROSCOPY
scapholunate instability, one a TFC injury, one scaphoid non-union and one Kienb6ck's disease. The investigation is clearly non-specific and unreliable although positive scans may identify patients requiring further investigation. Arthrography of the wrist was performed in 14 patients. The findings were considered correct in eight cases. One was normal, two showed a synovitis and five had abnormal leaks. Four of the leaks were in the TFC, two of which were missed at arthroscopy. The arthrographic findings were incorrect in six. Two had TFC damage arthroscopically without arthrographic leaks, three had arthroscopic scapholunate instability and one a triquetrolunate instability. These latter cases had attenuation of the interosseous ligaments missed by arthrography, instability only being demonstrated by stressing the wrist at arthroscopy (Adolfsson, 1992; Dautel et al 1993). We would agree with Cooney (1993) that arthrography is most accurate in the diagnosis of TFC injuries and in this respect is a useful adjunct to arthroscopy in the investigation of ulnar-sided wrist pain. In conclusion, we feel that the best way to reach a diagnosis of the cause of chronic wrist pain is to perfect techniques of clinical examination of the wrist. Although arthroscopy has usefully demonstrated the anatomical extent and patterns of soft tissue injuries, these findings must be correlated with the clinical symptoms and signs.
445
This improved anatomical diagnosis has to be related to the ultimate benefit to the patient. That is to say, do the findings affect treatment decisions (Rettig and Amadio, 1994)? We believe that wrist arthroscopy still has a limited but specialized role in the investigation of wrist pain but even with the addition of arthroscopic treatment the technique is unlikely to become as universally widespread as knee arthroscopy. / References ADOLFSSON L (1992). Arthroscopy for the diagnosis of post-traumatic wrist pain. Journal of Hand Surgery, 17B: 46-50. ADOLFSSON L (1994). Arthroscopic diagnosis of ligament lesions of the wrist. Journal of Hand Surgery, 19B: 505-512. COONEY W P (1993). Evaluation of chronic wrist pain by arthrography, arthroscopy and arthrotomy. Journal of Hand Surgery, 18A: 815-822. DAUTEL G, GOUDOT B and MERLE M (1993). Arthroscopic diagnosis of scapho-lunate instability in the absence of X-ray abnormalities. Journal of Hand Surgery, 18B: 213-218. KELLY E P and STANLEY J K (1990). Arthroscopy of the wrist. Journal of Hand Surgery, 15B: 236-242. KOMAN L A, POEHLING G G, TOBY E B and KAMMIRE G (1990). Chronic wrist pain: indications for wrist arthroscopy. Arthroscopy, 6: 116-119. NAGLE D J and BENSON L S (1992). Wrist arthroscopy: indications and results. Arthroscopy, 8: 198-203. NORTH E R and MEYER S (1990). Wrist injuries: correlation of clinical and arthroscopic findings. Journal of Hand Surgery, 15A: 915-920. RETTIG M E and AMADIO P C (1994). Wrist arthroseopy: indications and clinical applications. Journal of Hand Surgery, 19B: 774-777.
Accepted after revision: 5 February 1996 W. A. Jones, FRCS, Department of Orthopaedics, Broadgreen Hospital, Thomas Drive, Liverpool L14 3LB, UK. © 1996 The British Society for Surgery of the Hand