A cause of painful clicking wrist: A case report In a patient with symptomatic unilateral clicking of the wrist, a partial tear of the scapholunate ligament with subsequent scarring of the proximal third of the dorsal portion of the ligament had occurred. At operation the dorsomedial edge of the proximal pole of the scaphoid had snapped over the dorsal edge of the lunate as the palmar-flexed wrist was being returned to a neutral position. Release of the scarred portion of the scapholunate ligament was associated with widening of the scapholunate joint space to normal dimensions and cessation of the clicking phenomenon. Fourteen months after operation there was complete relief of symptoms, a full range of wrist motion and no radiographic evidence of widening of the scapholunate space, ligamentous instability, or rotatory subllO:ation of the scaphoid.
Paul M. Weeks, M.D., Vernon L. Young, M.D., and Louis A. Gilula, M.D.,
St. Louis, Mo.
Clicking of the wrist is not uncommon, but painful clicking is unusual. The cause and treatment of one example of painful clicking in the wrist is recorded.
Case report A 21-year-old woman fell while skiing, sustaining an injury to her left wrist. She did not remember how or the position of her hand when she fell. She developed moderate dorsal wrist swelling associated with minimal discomfort. Treatment was not sought, and the swelling subsided rapidly, allowing her to continue her vacation. Approximately 2 weeks later she noted a slight click as she gradually extended her wrist from the position of full palmar flexion. During the ensuing II months, the click became more pronounced and uncomfortable, until she was unable to perform her duties as a keypunch operator. At our initial examination, a loud click was audible and its vibration palpable at 30° of palmar flexion as the wrist was extended from full palmar flexion. When the wrist was held in radial deviation and extended from the fully flexed position, clicking occurred. Holding the wrist in maximum ulnar deviation minimized but did not eliminate the clicking. The clicking never occurred during flexion from the fully extended position to full palmar flexion of the wrist. Actively and passively holding the fingers and/or thumb in flexion or extension had no effect on the clicking. The application of digital pressure over the extensor carpi radialis brevis tendon at the level of the lunate prevented clicking. There was no swelling, point tenderness, or joint crepitus. She had a normal From the Division of Plastic Surgery, Washington University School of Medicine, and the Department of Radiology (L.A. G.), Mallinckrodt Institute of Radiology, St. Louis, Mo. Received for publication Feb. 27, 1979. Reprint requests: Paul M. Weeks, M.D., Division of Plastic Surgery, 4960 Audubon Ave., St. Louis, MO 63110.
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THE JOURNAL OF HAND SURGERY
Fig. 1. Arthrogram: of the left wrist: contrast is in the radiocarpal joint (arrows) without contrast in the scapholunate (arrowheads) or the mid-carpal joints. Contrast overlying the scaphoid, radius, triquetrum, and pisiform is in capsular recesses. range of wrist motion, including dorsiflexion, palmar flexion, radial and ulnar deviation, and pronation-supination of the forearm. Her grip strength was normal. Three weeks prior, at an outside hospital, she had a normal wrist arthrogram (Fig. I). On our initial examination, routine roentgenograms and fluoroscopic examination for carpal bone motion were normal when compared to those from the opposite wrist (Fig. 2).1 Specificially the scapholunate joint did not widen, despite views in posteroanterior and anteroposterior
0363-5023/79/060522+04$00.40/0 © 1979 American Society for Surgery of the Hand
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Fig. 2. A. Posteroanterior roentgenogram of the left wrist: the scapholunate space is not widened. B, Lateral wrist: scapholunate and capitolunate angles are normal. 2 The scaphoid is not palmar flexed. (C, capitate; L, lunate; S. scaphoid axes.)
positions with neutral, radial, and ulnar deviation and with or without fist compression. Carpal bone alignment was normal without evidence of ligamentous instability. 2. 3 Treatment included application of a volar splint to support the wrist in extension for 2 weeks . When the splint was removed, clicking still was present and thereafter became worse. The left wrist was then explored through a dorsal transverse skin incision. The distal I cm of the sheath of extensor carpi radialis brevis tendon was opened and was normal. The extensor tendons were retracted ulnarward, and the wrist joint was opened by detachment of the radiocarpal ligament complex from the base of the metacarpals and the distal row of carpal bones . The dorsal capsule was reflected proximally; exposing the radiocarpal and intercarpal joints . There was no evidence of active synovitis. As the wrist was palmarly flexed, the dorsomedial edge of the proximal pole of the scaphoid was noted to rise dorsally I to 2 mm above and to overlap the adjacent edge of the lunate. As the wrist was extended from the fully flexed position, the dorsomedial edge of the scaphoid snapped over the adjacent edge of the lunate, producing the clicking phenomenon. This occurred as the wrist approached 30° of palmar flexion. As wrist extension continued. the dorsomediallip of the scaphoid moved farther ventrally from the dorsal edge of the lunate. When flexion was begun from the position of full dorsiflexion, the dorsomedial edge of the proximal pole of the scaphoid moved dorsally to the dorsal edge of the lunate without producing the clicking phenomenon. At least 40° of palmar flexion was required to allow the dorsomedial lip of
the proximal pole of the scaphoid to rise dorsally to the edge of the lunate and "load" the clicking mechanism. Since before operation we had observed that digital pressure on the extensor carpi radialis brevis tendon at the level of the lunate prevented clicking , this maneuver was reproduced at the operating table. Clicking did not occur because the pressure was transmitted to the proximal pole of the scaphoid and prevented its dorsomedial edge from rising dorsal to the edge of the lunate, thereby precluding loading of the clicking mechanism. Examination of the dorsal portion of scapholunate intercarpal ligament revealed the proximal half to be replaced by scar. Thus we reasoned that the dorsal portion of the proximal half of the scapholunate ligament had been torn at the original injury, and the resulting scar had narrowed the scapholunate space, producing an abnormal approximation of the bony edges and thereby predisposing to the development of the clicking phenomenon. If this reasoning was correct, division of the scarred dorsal portion of the scapholunate ligament should have resulted in widening of the scapholunate space and cessation of clicking . The proximal third of the dorsal portion of the scarred ligament was incised . This resulted in an immediate increase in the scapholunate space of about I mm to a total of 2 mm. Full flexion and extension of the wrist did not reproduce clicking, even though the dorsomedial edge of the proximal pole of the scaphoid still moved dorsal to the edge of the lunate in full palmar flexion and moved volar to the edge of the lunate during full dorsiflexion of the wrist. Since this maneuver completely relieved the clicking, we excised the edges of the incised ligament to minimize
524
The Journal of HAND SURGERY
Weeks, Young, Gilu/a
Fig. 3. Roentgenograms of the left wrist 14 months after operation show normal carpal bone excursion with normal scapholunate joint width. A, Posteroanterior positions with radial and , B. ulnar deviation . C , Anterior position with radial deviation. subsequent scarring. The remainder of the scapholunate ligament was left intact. The reflected dorsal ligament complex was repaired with No. 2-0 Dexon suture. A subcutaneous drain was inserted and the skin edges were closed. A volar plaster splint was used to stabilize the wrist. Repair of the dorsal wrist ligaments precluded early full motion but allowed restricted motion . The splint was discarded at 3 weeks . She has regained a full range of asymptomatic wrist motion without recurrence of clicking. Radiographs 14 months after operation showed no evidence of scapholunate joint widening, ligamentous instabi lity. or rotatory subluxation of the scaphoid (Fig. 3).
Discussion There are many reports of clicking wrist; however, only two of painful clicking wrist. 4, 5 Sutro 4 reported two patients with bilateral clicking without antecedent trauma. In one wrist clicking was due to anterior subluxation of the capitate. Conservative treatment was ineffective . Arthrodesis between the capitate, the scaphoid, and the lunate relieved the symptoms. The opposite wrist was not symptomatic enough to warrant surgical treatment. In a second patient, roentgenograms showed "bilateral anterior partial subluxation of the distal row of the carpal and contiguous bones." No treatment was given because the patient was lost to follow-up. Sacks 5 reported one patient who complained of occasional painful clicking in both wrists, particularly when performing rotatory movements of the wrist against resistance. There was no history of injury . Roentgenograms showed an unusually large gap between the scaphoid and the capitate. He assumed that this gap was due to the presence of an os centrale which was not ossified. No treatment or follow-up was reported.
Trigger wrist has been reported, occurring in patients with rheumatoid arthritis where triggering was associated with the development of nodules and reactive synovium about the flexor tendons. 6 The volar retinacular ligament acted as the triggering point. Triggering was produced only by finger flexion and extension and was unrelated to wrist motion . This should not be a problem in differential diagnosis or management of the painful clicking wrist. Other causes of clicking of the wrist which should be considered are (I) ununited scaphoid fracture, (2) bipartite scaphoid, (3) loose joint bodies, (4) osteochondritis dissecans, and (5) osteoarthritis. These can be detected by roentgenographic examination. The pertinent findings in our patient were ( I) a previous history of trauma, (2) no point tenderness, swelling, or joint crepitus, (3) a normal range of wrist movement without pain except when the click occurred, (4) the click always occurring at the same position, 30° of palmar flexion, (5) the clicking occurring only after the wrist had been palmarJy flexed beyond 40° and then extended, (6) the greatest vibration associated with the clicking phenomenon being palpable over the scapholunate area, (7) digital pressure dorsally over the proximal pole of the scaphoid preventing the clicking phenomenon, (8) ulnar deviation of the hand minimizing the clicking phenomenon, (9) radial deviation of the hand having no effect on clicking, (10) roentgenograms and radiographic motion studies being normal, (11) the clicking not being bilateral, and (12) the patient being in excellent health .
Summary A patient with symptomatic unilateral clicking of the wrist is thought to have had a partial tear of the
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Fig. 3, cont'd. D, Anteroposterior position with ulnar deviation . E, Lateral roentgenogram with the left wrist in neutral position: scapholunate and capitolunate angles are normal. The slight change in angle sizes from Fig. 2, B , is consistent with variations in drawing axes and slight change in wrist position. (C, capitate; L, lunate; S, scaphoid axes.) F, lateral extension and, G, lateral palmar flexion roentgenograms demonstrate normal carpal bone motion at the radiocarpal and mid-carpal joints.
scapholunate ligament, with subsequent scarring of the proximal third of the dorsal portion of the ligament. At operation the dorsomedial edge of the proximal pole of the scaphoid was snapping over the dorsal edge of the lunate as the pal marly flexed wrist was being returned to a neutral position . Release of the scarred portion of the scapholunate ligament was associated with widening of the scapholunate joint space to normal dimensions and cessation of the clicking phenomenon. Fourteen months after operation there was complete relief of symptoms, a full range of wrist motion, no radiographic evidence of widening of the scapholunate space, no ligamentous instability, and no rotatory subluxation of the scaphoid.
REFERENCES 1. Arkless R: Cine radiography in nomlal and abnomlal wrists. Am J Radiol 96:837-44. 1966 2. Dobyns JH , Linscheid RL. Chao EYS, Weber ER, Swan son GE: Traumatic instability of the wrist. AAOS Instructional Course Lectures . St. Louis , 1975 , The C V Mosby Co, pp . 182-9 3. Gilula LA, Weeks PM: Post-traumatic ligamentous instabilities of the wrist. Radiology 129:64I-S 1, 1978 4. Sutro C: Bilateral recurrent intercarpal subluxation. Am J Surg 72: 110-3 , 1946 S. Sacks S: Painful clicking wrists. S Afr Med J 23:766-7, 1949 6. Davalbhakta VV, Bailey RN: Trigger wrist: Report of two cases. Br J Plast Surg 2S:376-9. 1972
Paul M. Weeks, M.D., Vernon L. Young, M.D., and Louis A. Gilula, M.D.,
St. Louis, Mo.
Clicking of the wrist is not uncommon, but painful clicking is unusual. The cause and treatment of one example of painful clicking in the wrist is recorded.
Case report A 21-year-old woman fell while skiing, sustaining an injury to her left wrist. She did not remember how or the position of her hand when she fell. She developed moderate dorsal wrist swelling associated with minimal discomfort. Treatment was not sought, and the swelling subsided rapidly, allowing her to continue her vacation. Approximately 2 weeks later she noted a slight click as she gradually extended her wrist from the position of full palmar flexion. During the ensuing II months, the click became more pronounced and uncomfortable, until she was unable to perform her duties as a keypunch operator. At our initial examination, a loud click was audible and its vibration palpable at 30° of palmar flexion as the wrist was extended from full palmar flexion. When the wrist was held in radial deviation and extended from the fully flexed position, clicking occurred. Holding the wrist in maximum ulnar deviation minimized but did not eliminate the clicking. The clicking never occurred during flexion from the fully extended position to full palmar flexion of the wrist. Actively and passively holding the fingers and/or thumb in flexion or extension had no effect on the clicking. The application of digital pressure over the extensor carpi radialis brevis tendon at the level of the lunate prevented clicking. There was no swelling, point tenderness, or joint crepitus. She had a normal From the Division of Plastic Surgery, Washington University School of Medicine, and the Department of Radiology (L.A. G.), Mallinckrodt Institute of Radiology, St. Louis, Mo. Received for publication Feb. 27, 1979. Reprint requests: Paul M. Weeks, M.D., Division of Plastic Surgery, 4960 Audubon Ave., St. Louis, MO 63110.
522
THE JOURNAL OF HAND SURGERY
Fig. 1. Arthrogram: of the left wrist: contrast is in the radiocarpal joint (arrows) without contrast in the scapholunate (arrowheads) or the mid-carpal joints. Contrast overlying the scaphoid, radius, triquetrum, and pisiform is in capsular recesses. range of wrist motion, including dorsiflexion, palmar flexion, radial and ulnar deviation, and pronation-supination of the forearm. Her grip strength was normal. Three weeks prior, at an outside hospital, she had a normal wrist arthrogram (Fig. I). On our initial examination, routine roentgenograms and fluoroscopic examination for carpal bone motion were normal when compared to those from the opposite wrist (Fig. 2).1 Specificially the scapholunate joint did not widen, despite views in posteroanterior and anteroposterior
0363-5023/79/060522+04$00.40/0 © 1979 American Society for Surgery of the Hand
Vol. 4. No.6 November, 1979
Painful clicking wrist
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Fig. 2. A. Posteroanterior roentgenogram of the left wrist: the scapholunate space is not widened. B, Lateral wrist: scapholunate and capitolunate angles are normal. 2 The scaphoid is not palmar flexed. (C, capitate; L, lunate; S. scaphoid axes.)
positions with neutral, radial, and ulnar deviation and with or without fist compression. Carpal bone alignment was normal without evidence of ligamentous instability. 2. 3 Treatment included application of a volar splint to support the wrist in extension for 2 weeks . When the splint was removed, clicking still was present and thereafter became worse. The left wrist was then explored through a dorsal transverse skin incision. The distal I cm of the sheath of extensor carpi radialis brevis tendon was opened and was normal. The extensor tendons were retracted ulnarward, and the wrist joint was opened by detachment of the radiocarpal ligament complex from the base of the metacarpals and the distal row of carpal bones . The dorsal capsule was reflected proximally; exposing the radiocarpal and intercarpal joints . There was no evidence of active synovitis. As the wrist was palmarly flexed, the dorsomedial edge of the proximal pole of the scaphoid was noted to rise dorsally I to 2 mm above and to overlap the adjacent edge of the lunate. As the wrist was extended from the fully flexed position, the dorsomedial edge of the scaphoid snapped over the adjacent edge of the lunate, producing the clicking phenomenon. This occurred as the wrist approached 30° of palmar flexion. As wrist extension continued. the dorsomediallip of the scaphoid moved farther ventrally from the dorsal edge of the lunate. When flexion was begun from the position of full dorsiflexion, the dorsomedial edge of the proximal pole of the scaphoid moved dorsally to the dorsal edge of the lunate without producing the clicking phenomenon. At least 40° of palmar flexion was required to allow the dorsomedial lip of
the proximal pole of the scaphoid to rise dorsally to the edge of the lunate and "load" the clicking mechanism. Since before operation we had observed that digital pressure on the extensor carpi radialis brevis tendon at the level of the lunate prevented clicking , this maneuver was reproduced at the operating table. Clicking did not occur because the pressure was transmitted to the proximal pole of the scaphoid and prevented its dorsomedial edge from rising dorsal to the edge of the lunate, thereby precluding loading of the clicking mechanism. Examination of the dorsal portion of scapholunate intercarpal ligament revealed the proximal half to be replaced by scar. Thus we reasoned that the dorsal portion of the proximal half of the scapholunate ligament had been torn at the original injury, and the resulting scar had narrowed the scapholunate space, producing an abnormal approximation of the bony edges and thereby predisposing to the development of the clicking phenomenon. If this reasoning was correct, division of the scarred dorsal portion of the scapholunate ligament should have resulted in widening of the scapholunate space and cessation of clicking . The proximal third of the dorsal portion of the scarred ligament was incised . This resulted in an immediate increase in the scapholunate space of about I mm to a total of 2 mm. Full flexion and extension of the wrist did not reproduce clicking, even though the dorsomedial edge of the proximal pole of the scaphoid still moved dorsal to the edge of the lunate in full palmar flexion and moved volar to the edge of the lunate during full dorsiflexion of the wrist. Since this maneuver completely relieved the clicking, we excised the edges of the incised ligament to minimize
524
The Journal of HAND SURGERY
Weeks, Young, Gilu/a
Fig. 3. Roentgenograms of the left wrist 14 months after operation show normal carpal bone excursion with normal scapholunate joint width. A, Posteroanterior positions with radial and , B. ulnar deviation . C , Anterior position with radial deviation. subsequent scarring. The remainder of the scapholunate ligament was left intact. The reflected dorsal ligament complex was repaired with No. 2-0 Dexon suture. A subcutaneous drain was inserted and the skin edges were closed. A volar plaster splint was used to stabilize the wrist. Repair of the dorsal wrist ligaments precluded early full motion but allowed restricted motion . The splint was discarded at 3 weeks . She has regained a full range of asymptomatic wrist motion without recurrence of clicking. Radiographs 14 months after operation showed no evidence of scapholunate joint widening, ligamentous instabi lity. or rotatory subluxation of the scaphoid (Fig. 3).
Discussion There are many reports of clicking wrist; however, only two of painful clicking wrist. 4, 5 Sutro 4 reported two patients with bilateral clicking without antecedent trauma. In one wrist clicking was due to anterior subluxation of the capitate. Conservative treatment was ineffective . Arthrodesis between the capitate, the scaphoid, and the lunate relieved the symptoms. The opposite wrist was not symptomatic enough to warrant surgical treatment. In a second patient, roentgenograms showed "bilateral anterior partial subluxation of the distal row of the carpal and contiguous bones." No treatment was given because the patient was lost to follow-up. Sacks 5 reported one patient who complained of occasional painful clicking in both wrists, particularly when performing rotatory movements of the wrist against resistance. There was no history of injury . Roentgenograms showed an unusually large gap between the scaphoid and the capitate. He assumed that this gap was due to the presence of an os centrale which was not ossified. No treatment or follow-up was reported.
Trigger wrist has been reported, occurring in patients with rheumatoid arthritis where triggering was associated with the development of nodules and reactive synovium about the flexor tendons. 6 The volar retinacular ligament acted as the triggering point. Triggering was produced only by finger flexion and extension and was unrelated to wrist motion . This should not be a problem in differential diagnosis or management of the painful clicking wrist. Other causes of clicking of the wrist which should be considered are (I) ununited scaphoid fracture, (2) bipartite scaphoid, (3) loose joint bodies, (4) osteochondritis dissecans, and (5) osteoarthritis. These can be detected by roentgenographic examination. The pertinent findings in our patient were ( I) a previous history of trauma, (2) no point tenderness, swelling, or joint crepitus, (3) a normal range of wrist movement without pain except when the click occurred, (4) the click always occurring at the same position, 30° of palmar flexion, (5) the clicking occurring only after the wrist had been palmarJy flexed beyond 40° and then extended, (6) the greatest vibration associated with the clicking phenomenon being palpable over the scapholunate area, (7) digital pressure dorsally over the proximal pole of the scaphoid preventing the clicking phenomenon, (8) ulnar deviation of the hand minimizing the clicking phenomenon, (9) radial deviation of the hand having no effect on clicking, (10) roentgenograms and radiographic motion studies being normal, (11) the clicking not being bilateral, and (12) the patient being in excellent health .
Summary A patient with symptomatic unilateral clicking of the wrist is thought to have had a partial tear of the
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Painful clicking wrist
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Fig. 3, cont'd. D, Anteroposterior position with ulnar deviation . E, Lateral roentgenogram with the left wrist in neutral position: scapholunate and capitolunate angles are normal. The slight change in angle sizes from Fig. 2, B , is consistent with variations in drawing axes and slight change in wrist position. (C, capitate; L, lunate; S, scaphoid axes.) F, lateral extension and, G, lateral palmar flexion roentgenograms demonstrate normal carpal bone motion at the radiocarpal and mid-carpal joints.
scapholunate ligament, with subsequent scarring of the proximal third of the dorsal portion of the ligament. At operation the dorsomedial edge of the proximal pole of the scaphoid was snapping over the dorsal edge of the lunate as the pal marly flexed wrist was being returned to a neutral position . Release of the scarred portion of the scapholunate ligament was associated with widening of the scapholunate joint space to normal dimensions and cessation of the clicking phenomenon. Fourteen months after operation there was complete relief of symptoms, a full range of wrist motion, no radiographic evidence of widening of the scapholunate space, no ligamentous instability, and no rotatory subluxation of the scaphoid.
REFERENCES 1. Arkless R: Cine radiography in nomlal and abnomlal wrists. Am J Radiol 96:837-44. 1966 2. Dobyns JH , Linscheid RL. Chao EYS, Weber ER, Swan son GE: Traumatic instability of the wrist. AAOS Instructional Course Lectures . St. Louis , 1975 , The C V Mosby Co, pp . 182-9 3. Gilula LA, Weeks PM: Post-traumatic ligamentous instabilities of the wrist. Radiology 129:64I-S 1, 1978 4. Sutro C: Bilateral recurrent intercarpal subluxation. Am J Surg 72: 110-3 , 1946 S. Sacks S: Painful clicking wrists. S Afr Med J 23:766-7, 1949 6. Davalbhakta VV, Bailey RN: Trigger wrist: Report of two cases. Br J Plast Surg 2S:376-9. 1972
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