Elsevier

The Journal of Hand Surgery

Volume 42, Issue 12, December 2017, Pages 1034.e1-1034.e6
The Journal of Hand Surgery

Scientific article
Volar Capsular Release After Distal Radius Fractures

https://doi.org/10.1016/j.jhsa.2017.08.002Get rights and content

Purpose

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

Methods

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

Results

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

Conclusions

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

Type of study/level of evidence

Therapeutic IV.

Section snippets

Methods

After obtaining institutional review board approval, we completed a retrospective chart review of patients surgically treated, by a single surgeon (D.S.R.), for wrist extension loss after volar plating for a distal radius fracture. Because the clinical indication for this procedure was loss of functional wrist motion, the primary outcome measure was patient-reported disability using the DASH score. Secondary outcomes included degrees of improvement in wrist flexion, extension, pronation,

Results

We reviewed 14 charts and found 11 patients that met the inclusion criteria during the study period (Table 1). Average age was 45 years (range, 21–62 years). Mean follow up was 4.5 years and median follow up was 4.1 years (range, 1.8–8.2 years). There were no reports of a clunk, snap, or patient-reported instability.

Discussion

Postoperative wrist stiffness can occur after fixation of distal radius fractures. Although stiffness with loss of functional wrist extension is uncommon, there is limited literature to guide management of this complication. Verhellen and Bain30 previously reported arthroscopic release of the volar capsule in 2 patients. This study reported on the safety of this approach to neighboring structures, along with improved wrist ROM, grip strength, and pain at 6 months after surgery We report the

References (45)

  • W. Wang et al.

    Stability of severely stiff elbows after complete open release: treatment by ligament repair with suture anchors and hinged external fixator

    J Shoulder Elbow Surg

    (2014)
  • M.J. Rainbow et al.

    In vivo kinematics of the scaphoid, lunate, capitate, and third metacarpal in extreme wrist flexion and extension

    J Hand Surg Am

    (2013)
  • A.D. Blevens et al.

    Radiocarpal articular contact characteristics with scaphoid instability

    J Hand Surg Am

    (1989)
  • D.B. Siegel et al.

    Radial styloidectomy: an anatomical study with special reference to radiocarpal intracapsular ligamentous morphology

    J Hand Surg Am

    (1991)
  • R. Verhellen et al.

    Arthroscopic capsular release for contracture of the wrist: a new technique

    Arthroscopy

    (2000)
  • M.R. DiBenedetto et al.

    A standardized measurement of ulnar carpal translocation

    J Hand Surg Am

    (1990)
  • W.B. Kleinman et al.

    The distal radioulnar joint capsule: clinical anatomy and role in posttraumatic limitation of forearm rotation

    J Hand Surg Am

    (1998)
  • F.M.A.P. Claessen et al.

    Influence of priming on patient-reported outcome measures: a randomized controlled trial

    Psychosomatics

    (2016)
  • A.-M. Vranceanu et al.

    A preliminary RCT of a mind body skills based intervention addressing mood and coping strategies in patients with acute orthopaedic trauma

    Injury

    (2015)
  • R.A. Berger

    The ligaments of the wrist. A current overview of anatomy with considerations of their potential functions

    Hand Clin

    (1997)
  • R.A. Berger et al.

    The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints

    J Hand Surg Am

    (1990)
  • V. Feipel et al.

    A new method for measuring wrist-joint ligament length changes during sagittal and frontal motion

    Clin Biomech (Bristol Avon)

    (1998)
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      Clinically, the loss of wrist extension is a reported complication after operative fixation of DR fractures.20 Contracture management with plate removal and open volar capsular release has shown promising results without clinical evidence of carpal instability at follow-up.20 In our study, we expanded upon the findings of previous studies and evaluated a ligament-sparing approach for exposure and visualization of the radiocarpal joint, which may provide an opportunity for meaningful articular assessment during volar plate fixation of the DR. The biomechanical findings of the current study support the use of a volar radiocarpal arthrotomy with partial sectioning and subsequent repair of the LRL and SRL ligaments, with or without dorsal radiocarpal ligamentous disruption.

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