Richard Berger, M.D., Ph.D., Orthopedics, Mayo Clinic: It was probably about eight or nine years ago that I finally pieced things together in terms of what the split tear is. I'd had a large number of patients that came in with pain in in in this region of their wrist and and we just couldn't find the solution to it. They were they were stable. They didn't have any sense of dislocation. They had typically pain that was mechanically related, in other words, they had to be doing something to to have the pain so I knew I knew it wasn't from a nerve or something else, but we would find normal x-rays. MRI studies were just becoming a little bit more popular in terms of evaluating the wrist and those were those were read as normal. We do arthrograms. Any number of imaging studies and they were all normal yet these patients continued to have have this pain. And I would even take them to the operating room and perform an arthroscopy, which was looking inside the wrist joint with a small telescope, and typically, I would see an area that was related to this region of the wrist geographically that was just sort of covered with with little projections of blood vessels. And it looks the best way to describe it is that it looks angry. It looks irritated and if you've ever seen any movies like Jacques Cousteau or something. It looks like a cluster of sea anenome, sort of drifting in the in the current. And so I'd say well you know maybe this is an area of irritation, so I would take a small shaver, which is a rotating tool much like a razor to a certain degree, and be able to go in and clean this area off and I would think well maybe that was that was all there was to it. And just in the hopes that this area of irritation was actually the cause of these patients pain. And sure enough for two months, three months maybe, after surgery, they'd feel a little bit better but then it would come back the same pain would come back and it was really quite frustrating.
I had a number of patients that came in after being treated by other surgeons under similar circumstances and they had had some relatively radical surgery done even removal of the end of the bone. We call that a Darrach resection and that's sort of a last resort type of an operation that we do for patients that have really bad arthritis or something but this was these these people had normal ulnar heads. They had good cartilage. They didn't have any evidence of arthritis but in an attempt to try and and treat this pain, their surgeon would actually remove the ulnar head. Well, now they had two problems. Now they had the original pain which didn't go away and they have an unstable forearm because they're missing part of their bone. And so it was clearly frustrating to everybody. This this was not negligent care. This wasn't bad judgment. It's just that we didn't have any alternatives because we didn't understand what was what was wrong with it.
And and so I had some grants through National Institutes of Health looking at different aspects of the mechanics of the distal radioulnar joint so, I was pretty up-to-date with with the anatomy, with mechanics of the joint and and I just I said I'm missing something here. I have to listen to what the patients are telling me that indeed they're telling me the truth. That it hurts right here and then I just started looking backwards saying well what's in there? We've got skin. There's a little bit of fat underneath the skin. There is a nerve that goes right through that area but again this was not nerve pain. And then there was the the socket, the ligament tissue that forms the socket of the joint, and that's what I was seeing on the inside with the arthroscope. And so I said there's nothing else. There's nothing else there. There must be something abnormal with that with that joint capsule. So the next several patients that I was looking at after shaving down the that irritated tissue, I started questioning what what is it that I'm actually looking at at this point? And I was assuming that I was looking at the surface of the ligament, but indeed it turns out that I was looking at the interior of the ligament because the ligament had split open and had had revealed itself much like you take a book and you open up a book. I was looking at the inside of the pages whereas before I was just assuming I was looking at the at the end of the book. I didn't realize that it had actually split open. It wasn't until I pulled the arthroscope back that I recognized the fact that this was this was a separate cavity. You almost need to have a sticker on the monitor when you're looking at an arthroscope. That's like on your rear view mirror, you know, that objects are smaller than what they appear to be because because you lose perspective sometimes about how how little things how big little things are with the arthroscope. And that was one of very few aha moments that I've had where I where I said "Oh, I get it now." That that I'm actually looking at the interior but it's still connecting one bone to another so the joint system is stable. It's just that this has been a a tearing down the length of the of the ligament and so I thought well, what can I do about this? And there's a technique that's been used and other joints to apply suture material across tissues using an arthroscope and so I just modified that for for this particular procedure, put a couple of stitches in, and and that was the second aha moment because once I got the stitches in and it closed this back up, that's the way it's supposed to look. That's the way it looks in everybody else. I just didn't recognize that and it turns out nobody else has recognized that either. And so, I routinely started doing this now on these patients and there are a lot of them. There there are a lot of patients that have this. That they're only about half of them report any any recollection of a specific injury so half of these guys are coming in with with a sort of chronic nagging pain and they and they don't understand it. They they can't find anything wrong. Their doctor doesn't doesn't necessarily believe in that they've got this kind of pain.