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© 1996 The Journal of Bone and Joint Surgery, Inc. Comparison of the Findings of Triple-Injection Cinearthrography of the Wrist with Those of Arthroscopy*  , PROVIDENCE, RHODE ISLANDInvestigation performed at the Departments of Orthopaedics and Diagnostic Imaging, Brown University, Rhode Island Hospital, Providence
Fifty consecutive patients who had a history and clinical findings consistent with internal derangement of the wrist were prospectively entered into a study to compare the findings of triple-injection arthrography with those of arthroscopy of the wrist with use of three portals. Twenty-six patients were men, and twenty-four were women. They had an average age of thirty-six years (range, eighteen to seventy years). The average duration of symptoms in the wrist was eight months (range, one to twenty-four months). The arthrograms of the wrist, which included cineradiographs, were all made and evaluated by the same radiologist. The arthroscopic evaluation of the wrists was performed by two hand surgeons who had previous knowledge of the arthrographic findings. The abnormal findings included in this study were limited to those that should be detectable with both arthrography and arthroscopy. These were full-thickness tears of the scapholunate ligament, the lunotriquetral ligament, and the triangular fibrocartilage. The findings of arthrography were normal in eighteen wrists, demonstrated a single lesion in twenty-one, and demonstrated multiple lesions in eleven. Twelve wrists were noted to have a tear of the scapholunate ligament; fifteen, a tear of the lunotriquetral ligament; and eighteen, a tear of the triangular fibrocartilage. The arthroscopic findings were normal in six wrists, demonstrated a single lesion in twenty-five, and demonstrated multiple lesions in nineteen. Twenty-two wrists were noted to have a tear of the scapholunate ligament; fifteen, a tear of the lunotriquetral ligament; and thirty, a tear of the triangular fibrocartilage. When compared with arthroscopy of the wrist, the sensitivity, specificity, and accuracy of triple-injection cinearthrography in detecting tears of the scapholunate ligament, lunotriquetral ligament, and triangular fibrocartilage, as a group, were 56, 83, and 60 per cent. Although arthrography of the wrist is a well accepted diagnostic modality in the evaluation of pain in the wrist, this study suggests that normal arthrographic findings do not necessarily rule out the possibility of internal derangement of the wrist.
Arthrography is a well established technique in the diagnostic evaluation of pain in the wrist2,6-10,12,14,15,17,18,21, and it has been suggested1,2,7,13,15,21 that advances in this modality, including the use of three separate sites for the injection of contrast medium in combination with cinefluorography, have resulted in an even greater degree of accuracy. Recently, improvement in instrumentation has allowed the techniques of diagnostic arthroscopy to be extended to the wrist joint. The purpose of the present study was to evaluate the sensitivity, specificity, and accuracy of triple-injection cinearthrography of the wrist in the identification of full-thickness tears of the scapholunate ligament, lunotriquetral ligament, and triangular fibrocartilage when compared with findings noted at subsequent arthroscopy of the wrist with use of the three-portal technique.
A prospective study was established to compare the findings of arthrography of the wrist with those of arthroscopy of the wrist for patients who had been seen by two hand surgeons (A.-P. C. W. and E. A.) for pain in the wrist and who had clinical evidence suggestive of internal derangement. Criteria for inclusion in this study were a history of pain in the wrist; failure of a conservative trial of full-time immobilization of the wrist in a splint and use of non-steroidal anti-inflammatory drugs for at least one month; and diagnostic findings on physical examination consistent with internal derangement, which included a positive scaphoid-shift test19, a positive lunotriquetral shear or compression test16, or direct tenderness over the region of the triangular fibrocartilage5. Two patients (Cases 12 and 16) had exquisite tenderness over the dorsal scapholunate interval and were included, as the findings were consistent with internal derangement. Patients who had had a previous operation in the region of the wrist and those who had rheumatoid arthritis were excluded from this study. Fifty patients met the criteria for inclusion during a period of eighteen months, and they formed the basis of this study. One patient met the inclusion criteria but declined to participate. Twenty-six patients were men, and twenty-four were women. They had an average age of thirty-six years (range, eighteen to seventy years). The average duration of symptoms in the wrist before the evaluation was eight months (range, one to twenty-four months). Pain was categorized as sharp and of sudden onset in thirty-seven patients and as aching and prolonged in thirteen. All fifty patients had pain in the wrist with activities during which they used the wrist or with generalized motion of the wrist, but nineteen patients also noted pain while at rest. Twelve patients had clicking or popping in the wrist during activities requiring a power grip accompanied by either flexion and extension of the wrist or pronation and supination of the forearm. Five patients had similar clicking or popping sensations in the wrist with activities involving motion alone. Two patients had clicking or popping of the wrist with both loaded and unloaded motion. At the initial evaluation, thirty-two patients were employed and eighteen had stopped working because of the symptoms in the wrist. Of the thirty-two patients who were employed, eighteen used some form of external support, most frequently a removable splint. The dominant hand was involved in thirty-three patients. Thirty-four patients had symptoms or injuries of the wrist that were related to activities of employment, and they were receiving Workers' Compensation. A physical examination of each wrist was performed to look for evidence of carpal instability or instability at the distal radio-ulnar joint. Twenty-seven wrists had a positive scaphoid-shift test19. In this examination, the examiner loads the distal pole of the scaphoid in a palmar-to-dorsal fashion with the wrist in full ulnar deviation. The wrist is then brought into radial deviation with the examiner maintaining pressure on the distal pole of the scaphoid. The scaphoid will attempt palmar flexion during the radial deviation maneuver and, if the scapholunate ligament is incompetent, the scaphoid may be felt to shift out of the distal radial fossa. The test is positive when either a palpable clunk or pain is noted during the maneuver. Twelve wrists were noted to have a positive lunotriquetral shear test16. In this test, the examiner stabilizes the lunate at the dorsal aspect of the wrist with use of the long finger of one hand while pushing the pisiform and triquetrum in a volar-to-dorsal direction with the other hand. In this manner, the triquetrum moves in a sagittal plane of motion adjacent to the stabilized lunate. The test is positive when pain or a palpable clunk is noted during the maneuver. Ten wrists had a positive lunotriquetral compression test16. In this test, the examiner uses one hand to stabilize the radial aspect of the wrist of the patient and employs the thumb of the other hand to push directly on the triquetrum toward the lunate in the coronal plane of motion. The test is positive when pain is noted at the lunotriquetral interval. Twenty-eight wrists had tenderness in the region of the triangular fibrocartilage5. In this examination, the radial aspect of the hand and wrist of the patient is supported while the thumb of the examiner presses into the soft area between the distal part of the ulna and the triquetrum in the coronal plane of motion. The test is positive when the patient notes pain in this region in association with the direct pressure applied to the triangular fibrocartilage. A protocol was designed to explain to all of the patients enrolled in this study the risks and benefits of triple-injection cinearthrography of the wrist and subsequent arthroscopy of the wrist. This protocol was reviewed by the Institutional Review Board at our hospital, and an informed-consent form was signed by all patients. When internal derangement of the wrist was suspected on the basis of the history and physical examination, each patient reviewed the protocol and agreed to have both triple-injection cinarthrography of the wrist and subsequent arthroscopy regardless of the outcome of the cinearthrography. Any wrist that demonstrated a tear of the scapholunate ligament, the lunotriquetral ligament, or the triangular fibrocartilage (or a combination of these) had arthroscopic débridement alone regardless of the magnitude of the lesion. When the arthrography was performed, the patients had augmentation analgesia by local injection of 1 per cent Xylocaine (lidocaine) at the sites of injection. When the arthroscopy was performed, the patients were offered either an axillary block or general anesthesia. Thirty-nine patients chose general anesthesia and eleven patients, regional anesthesia with an axillary block. All of the triple-injection cinearthrograms of the wrist were made by the same musculoskeletal radiologist (R. L.), who used a standard protocol and technique of pressurized injection of 60 per cent non-ionic contrast medium into the radiocarpal, mid-carpal, and distal radio-ulnar joints in a sequential fashion, followed by a period of exercise and then by standard radiographic and cinefluorographic examination. Before the injections were made, all patients had a static carpal series including anteroposterior and lateral radiographs, radiographs with the wrist in radial and ulnar deviation, and an anteroposterior radiograph with the hand held in a grip. Throughout the studies, dynamic carpal motion was evaluated under fluoroscopic observation with cine-recording for each patient. First, all patients had between 2.5 and 4.6 milliliters of contrast medium injected into the radiocarpal joint. Progressive pain in the wrist or leakage of contrast medium into the dorsal tendon sheath was used as a pressure end point for injection into the joint. Motion was evaluated with cinefluorography both before and after at least two minutes of exercise of the wrist. After the period of exercise, a second complete series of five radiographs of the wrist was made. After an appropriate delay to allow the contrast medium that had been injected into the radiocarpal joint to disperse, two to four milliliters of contrast medium was injected into the mid-carpal joint and one to two milliliters of contrast medium was injected into the distal radio-ulnar joint. Each injection was also followed by cinefluorographic evaluation as well as by static anteroposterior and lateral radiographic examination. Digital subtraction was not used in this study as it excludes motion studies involving the injection of contrast medium. Interosseous ligaments were graded as intact when typical pooling or so-called clubbing of the contrast medium was seen on the mid-carpal side of the ligament border. This finding is noted on anteroposterior cinearthrograms of the wrist as a slight widening of the profile of the contrast medium just distal to the ligament itself. If this pooling was not seen, repeat fluoroscopy was performed until the pooling of the contrast medium was sufficiently demonstrated, thereby allowing a ligament to be graded as intact. The results of the cinearthrography and any internal derangement noted by the radiologist were communicated to the two operating surgeons. This requirement was defined by the Institutional Review Board as a condition for approval of this protocol. The cost of both the triple-injection cinearthrography of the wrist and the arthroscopy was determined by combining all of the charges for procedural fees, anesthesia (if applicable), and use of the operating or radiology suite. At our institution, the summarized charge for triple-injection cinearthrography of the wrist is $1395, that for arthroscopy of the wrist with arthroscopic débridement is $2498, and that for a diagnostic arthroscopic examination only is $2194. For purposes of comparison, the cost of a single non-cinefluorographic arthrogram at our institution is $720 and that for a magnetic resonance imaging scan of the wrist is $935. All of the patients had subsequent arthroscopy of the wrist with use of multiple standard portals by one of the two hand surgeons (A.-P. C. W. or E. A.) (Fig. 1). After the administration of either general or regional anesthesia, traction to the wrist is provided by longitudinal pull to the index and long fingers through fingertraps attached to a 4.5-kilogram (ten-pound) weight by means of a pulley. With the elbow flexed 90 degrees, countertraction is provided to the distal part of the humerus by a soft cuff attached, by means of a second pulley, to another 4.5-kilogram weight. The arm is positioned horizontally on a hand-table extension. Inflow irrigation to the wrist joint is provided by a 14-gauge barbed plastic catheter placed in the 6U portal (just volar to the extensor carpi ulnaris tendon and distal to the distal part of the ulna). A 2.7-millimeter arthroscope with a 25-degree visual offset is introduced into the 3/4 portal (between the third and fourth dorsal compartments just distal to the Lister tubercle of the distal part of the radius) through a sheathed trocar. A probe is placed in the 4/5 portal (between the fourth and fifth dorsal compartments just distal to the distal part of the radius), and the radiocarpal joint is examined20.
A tear of an interosseous ligament that was noted on arthroscopic examination and probing was defined as complete or limited. Both types of tears consisted of a full-thickness rent, with the differentiation involving the magnitude of the tear. A complete tear was defined as the absence of bridging ligament tissue between the adjacent carpal bones. The tear was considered limited when any bridging intercarpal ligament tissue was seen arthroscopically, even though a portion of the same ligament was disrupted. Examination of the mid-carpal joint is made through the mid-carpal-radial and ulnar portals (at the mid-carpal joint radial and ulnar to the fourth compartment). All lesions noted at arthroscopy were treated, according to the protocol, by débridement of the torn area alone with use of an oscillating cutter blade or a suction punch placed through the 4/5 portal. The results of triple-injection cinearthrography of the wrist, as compared with those of arthroscopy of the wrist, were categorized as true-positive (TP), false-positive (FP), true-negative (TN), or false-negative (FN) with the following formulae. Sensitivity (per cent) = (TP/[FN + TP]) x 100; specificity (per cent) = (TN/[FP + TN]) x 100; and accuracy (per cent) = ([TP + TN]/ [TP + TN + FP + FN]) x 100. The sensitivity, specificity, and accuracy of triple-injection cinearthrography for the detection of lesions was calculated on the basis of whether or not all of the lesions, as a group, that were seen on arthroscopy had also been detected with use of triple-injection cinearthrography.
Arthrographic examination demonstrated twelve tears of the scapholunate ligament, all of which were noted at arthroscopy (six were seen to be complete and six, limited). Of the thirty-eight patients who had a negative arthrogram for a tear of the scapholunate ligament, ten were found to have a tear of that ligament at arthroscopy (six were complete and four, limited). Arthrographic examination demonstrated fifteen tears of the lunotriquetral ligament, fourteen of which were noted at arthroscopy (five were complete and nine, limited). Of the thirty-five patients who had a negative arthrogram for a tear of the lunotriquetral ligament, one was found to have a limited tear of the ligament at arthroscopy. Examination of the triangular fibrocartilage by arthrography demonstrated eighteen full-thickness tears, all noted at subsequent arthroscopy. Of the thirty-two patients who had a negative arthrogram for a tear of the triangular fibrocartilage, twelve were found to have a full-thickness tear on arthroscopy. Cinefluorography demonstrated abnormal motion at the scapholunate interval (a sudden gapping with motion in the coronal plane) in two wrists. One wrist had a positive arthrogram for a tear of the scapholunate ligament confirmed by arthroscopy. In the other wrist, no ligament defect was seen on either arthrography or arthroscopy. Of the fifty arthrograms, thirty-two demonstrated one or more of the three defined lesions, all but one of which were confirmed by arthroscopy. Of the remaining eighteen wrists that had a negative arthrogram, twelve were found to have at least one of the three defined lesions at subsequent arthroscopy (Table I).
The sensitivity, specificity, and accuracy of triple-injection cinearthrography in detecting full-thickness tears of the scapholunate ligament, lunotriquetral ligament, and triangular fibrocartilage, as a group, were 56, 83, and 60 per cent. The sensitivity, specificity, and accuracy of the arthrograms in determining each of the three lesions were also calculated. The sensitivity was 60 per cent for both tears of the scapholunate ligament and those of the triangular fibrocartilage, and the specificity was 100 per cent for both. The sensitivity and specificity for evaluating tears of the lunotriquetral ligament were 93 and 97 per cent, respectively. The accuracy of the arthrograms was 84 per cent for tears of the scapholunate ligament, 76 per cent for those of the triangular fibrocartilage, and 96 per cent for those of the lunotriquetral ligament (Table II).
Of the twenty-two patients who had a complete or limited tear of the scapholunate ligament, seventeen (77 per cent) had a positive scaphoid-shift test. Seventeen (63 per cent) of the twenty-seven patients who had a positive scaphoid-shift test had a tear of the scapholunate ligament identified on arthroscopy. Of the fifteen patients who had a complete or limited tear of the lunotriquetral ligament, twelve had a positive lunotriquetral shear or compression test, or both. Of the eighteen patients who had a positive lunotriquetral shear or compression test, or both, twelve were seen to have a tear of the lunotriquetral ligament on arthroscopy. Thirty patients had a tear of the triangular fibrocartilage at arthroscopy, with twenty-five (83 per cent) of them having had tenderness in the region of the triangular fibrocartilage on physical examination. Of the twenty-eight patients who had tenderness in the region of the triangular fibrocartilage, twenty-five (89 per cent) were noted to have a tear of the triangular fibrocartilage on arthroscopy. Three patients reported substantial discomfort in the wrist after arthrography, but this problem resolved after no more than three days. After arthroscopy, five patients reported substantial discomfort in the wrist. It was controlled by elevation of the wrist and orally administered analgesics; three of these patients had the soft bulky postoperative dressing changed. Neither study was associated with complications related to the extensor tendon or with neurapraxia. The patients were evaluated for symptoms of the wrist at an average of fifteen months (range, eleven to twenty-seven months) after the arthroscopic débridement. Thirty-five patients (70 per cent) had no pain in the wrist. Seven patients (14 per cent) had mild pain in the wrist (especially after activity), and two of them had a subsequent procedure for shortening of the ulna. Eight patients (16 per cent) had substantial pain with motion of the wrist, necessitating a secondary operative procedure: four had reconstruction of the scapholunate ligament; three, a partial arthrodesis of the wrist; and one, a Darrach procedure. These secondary procedures were performed only if symptoms had persisted for four months after the arthroscopy.
Initially, arthrography of the wrist involved use of only a single radiocarpal injection to determine whether a disruption of an intercarpal ligament or a tear of the triangular fibrocartilage was present. The use of a triple-injection technique, with pressurized radiopaque contrast medium placed sequentially in the radiocarpal, mid-carpal, and distal radio-ulnar joints, has been advocated in later studies to diagnose lesions that might not be visualized with the single-injection technique7,13,15,21. It has been theorized that the triple-injection technique eliminates the possibility that a so-called one-way flap valve will result in a false-negative examination when a disruption of either an intercarpal ligament or the triangular fibrocartilage is present. Triple-injection techniques with digital subtraction have improved the speed of this method, although some authors have believed that the inability to move the wrist reduces the accuracy7,8,15,18. Other authors have reported that they believe that single-injection techniques have the potential to be just as accurate as triple-injection techniques if the radiopaque contrast medium is injected with the appropriate pressure and if a period of exercise is performed before the radiographic determination of whether there has been any leakage of contrast medium9,10. Studies performed with use of this modified single-injection technique have demonstrated a high sensitivity and specificity when compared with studies done with the triple-injection technique in the same patients. The use of a cineradiographic technique for the evaluation of movement of the contrast medium is advantageous because it not only detects subtle shifts of the contrast medium but also provides valuable information on any abnormal changes in the three-dimensional movement of the carpal bones during motion of the wrist1,2. Nevertheless, in previous studies3,5,7, triple-injection arthrography has always been used as the most comprehensive technique against which other methods of arthrography have been evaluated. Although arthrography is a well accepted diagnostic modality for the evaluation of pain in the wrist, it has been criticized because the results depend on the interpretation of an individual radiologist, and its over-all accuracy has been questioned6,7,14. On the basis of our expanded experience in diagnostic arthroscopy of the wrist, we believe that this investigative technique can be used to define the accuracy, specificity, and sensitivity of arthrography of the wrist more precisely. In our opinion, arthroscopic evaluation of the wrist joint is an extremely accurate method of determining intercarpal lesions by direct evaluation. A comparison of these two techniques is worthwhile because not only can it help physicians to determine the most appropriate evaluation for a particular patient who has substantial pain in the wrist but it also provides information on how confident physicians should be regarding arthrographic data. We chose to use a triple-injection technique for cinearthrography of the wrist, as this study provides more information than any other arthrographic method and, therefore, is arguably the most likely to detect a lesion if it is present. The ability of triple-injection cinearthrography to detect all of the lesions, as a group, in a specific patient and its ability to detect each lesion individually were carefully assessed by a comparison with the results of multiportal arthroscopy of the wrist. It was important to determine in this study how frequently these specific lesions might be present because a high prevalence might induce some surgeons to forego arthrography in favor of arthroscopy. Our study indicates that a negative finding on a triple-injection cinearthrogram does not rule out the possibility of internal derangement of the wrist involving a tear of the scapholunate ligament, the lunotriquetral ligament, or the triangular fibrocartilage. These findings are in general agreement with those of a study in which the results of arthrography of the wrist were compared with those of arthroscopy of the wrist in twenty consecutive patients3. In addition, and not surprisingly, the ability of arthrography to detect the presence or absence of all of the lesions correctly, as a group, in a particular wrist is less than its ability to detect a single lesion. It is of interest that triple-injection cinearthrography of the wrist is most accurate for the evaluation of the integrity of the lunotriquetral ligament, which is certainly the most difficult region of the radiocarpal joint to visualize arthroscopically. This finding might be explained by the anatomy of the lunotriquetral ligament or by an artificially low rate of detection of injury of the lunotriquetral ligament due to the difficulty with visualization of this area. Redundancy of the torn scapholunate ligament was frequently seen during arthroscopic evaluation, but redundancy of the lunotriquetral ligament was rarely seen. This finding may be one explanation for the relatively increased frequency of false-negative arthroscopic studies involving tears of the scapholunate ligament because a large redundant ligament, by effect of its mass, could block the free flow of contrast medium despite the presence of a full-thickness fenestration in the ligament. Because this type of redundancy was never found in the lunotriquetral ligament, it may be argued that this area has a lower propensity for false-negative findings, as there is no so-called bunching-up of the ligament, which can prevent the free flow of contrast medium. Although visualization of the lunotriquetral ligament is more difficult than that of the scapholunate ligament, this area can be seen adequately by placing the arthroscope in the 4/5 or 6R portal. A positive finding on a triple-injection cinearthrogram is, nevertheless, very accurate in the definition of a lesion that is actually present; only one false-positive finding was noted in our series. However, well performed arthrography that reveals a negative finding does not eliminate the possibility of an injury of an interosseous ligament (Fig. 2). In fact, several patients were noted to have a complete, massive disruption of the scapholunate ligament at arthroscopy despite a negative arthrographic evaluation (Figs. 3-A, 3-B, and 3-C).
Despite the excellent specificity of triple-injection cinearthrography in defining injuries of the wrist, the fact that this particular procedure is not very sensitive is a concern if its use is exclusionary in nature. It may be argued that, for patients who have an appropriate clinical history and persistent pain in the wrist, primary arthroscopy of the wrist is more appropriate for evaluation of intercarpal injury and arthrography should not be performed, in order to avoid the additional cost and possible morbidity. Nevertheless, we continue to use arthrography in selected patients to evaluate painful wrists, but we now maintain a healthy vigilance in the face of a negative test and clinical findings consistent with an intercarpal lesion. Another advantage of an arthroscopic evaluation of any lesion that is detected by arthrography is that the extent of the lesion can be determined. A positive arthrogram only establishes that a defect exists; it does not allow quantitative evaluation of that particular defect. It can certainly be argued that all tears of the scapholunate or lunotriquetral ligament or of the triangular fibrocartilage are not equal. Some may be relatively minor, imparting no substantial intercarpal instability to the wrist and yet providing enough of a portal for radiopaque contrast medium to leak into the mid-carpal or distal radio-ulnar joint. With use of the appropriate techniques for visualization and a probe during arthroscopy, the exact magnitude of any tear in either an intercarpal ligament or the triangular fibrocartilage can be evaluated and the appropriate treatment can be determined. A small tear may need only simple local débridement under arthroscopic guidance, with secondary formation of postoperative scar tissue or decompression alone eliminating the symptoms. Because most patients in the present study had a long-standing condition with refractory pain, the preliminary results of arthroscopic débridement alone for relief of pain appear promising on the basis of our most recent follow-up examinations. Whether these results will deteriorate with time or whether secondary conditions will arise because of the rather limited treatment remain to be discovered with longer-term studies. This study had several drawbacks, including the possibility of inherent bias in the design of the protocol because the two surgeons knew the arthrographic results. In addition, the follow-up evaluation of the patients was performed by the same operating surgeons, which might have introduced additional bias in the reporting of the results. The Institutional Review Board at our hospital did not consider it appropriate to blind the surgeons with regard to the arthrographic findings. Therefore, this requirement could not be eliminated from the protocol. Despite these limitations, we consider the results of the study to be valid and reproducible, as the definitions for the preoperative and postoperative evaluation of symptoms were quite strict. In addition, only full-thickness tears of the scapholunate or lunotriquetral ligament or the triangular fibrocartilage that were noted arthroscopically were considered positive lesions. It would be difficult to over-identify these types of lesions because little interpretation is necessary. Less well defined lesions, the identification of which requires substantial experience and some degree of interpretation by the observer, were not included in the determination of the sensitivity, specificity, or accuracy of arthrography. These less well defined lesions include partial-thickness tears of the triangular fibrocartilage, chondro-osseous defects, and attenuated but intact ligaments, among others11. The decision-making process with regard to diagnostic and therapeutic intervention for patients who have chronic pain in the wrist will come under increased economic pressure. Arthrography appears to remain a valid technique, although it should not be used to exclude the possibility of lesions. Other, newer imaging modalities, such as magnetic resonance imaging, should become increasingly cost-effective. Evidence appears to support the use of magnetic resonance imaging of the wrist for defining tears of the triangular fibrocartilage. However, its use for visualizing tears of an intercarpal ligament remains to be established4. Ideally, a single intervention should be all-encompassing in its evaluation of a painful wrist. Arthroscopy of the wrist certainly allows the unique possibility of both diagnostic and therapeutic intervention. To determine whether it should be used as the primary procedure, experience with the cost-effectiveness of the technique, the reproducibility of the diagnosis, and the long-term efficacy of any treatments performed will need to be documented. To a lesser extent, the ability of arthroscopy to quantitate the magnitude of a lesion and thereby define an algorithm for secondary treatment may be extremely important even if primary treatment during diagnostic arthroscopy does not stand the test of time. Arthroscopy of the wrist represents a valuable, although incompletely defined, diagnostic and treatment tool for surgeons. Patients with persistent pain in the wrist who have an appropriate objective examination and yet have had a negative arthrogram should be evaluated with arthroscopy of the wrist. Patients who have chronic pain in the wrist but have not had diagnostic imaging may benefit from primary arthroscopic evaluation, although the efficacy of this protocol remains to be established.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
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Abstract
Introduction
,Z. D.: Age changes in the triangular fibrocartilage of the wrist joint. J. Anat., 126: 367-384, 1978.
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