2 The Hand

10.1055/b-0038-160352

2 The Hand

S. Rehart, S. Sell, B. Kurosch, J. Richard

2.1 General

The assessment of treatment indications for the rheumatic hand is easily one of the most difficult topics in orthopaedic rheumatology.

Determining an optimal course of treatment for the patient requires simultaneous consideration of many factors. The hand’s current functional limitations need to be evaluated within the context of the underlying destruction and dysfunction of the hand structures, as well as the patient’s overall disease-related limitations. An in-depth knowledge of the different courses of specific rheumatic illness is essential for determining an indication for treatment. For example, does the patient have psoriatic arthritis that is more prone to ankyloses, or destabilizing arthritis that leads to instability?

The level of destruction plays only a limited role in determining the extent of surgical intervention. The best functional improvement is achieved by arthrodesis of the thumb carpometacarpal joint. Consequently, this type of intervention paves the way for and creates the necessary confidence in additional and potentially more major procedures. For it to be possible to give patients a timeline for surgical improvement of their hand, a therapeutic plan is often essential:

Stabilization of the wrist joint.
Swanson prosthesis of the metacarpophalangeal (MCP) joint.
Arthrodesis of the proximal interphalangeal (PIP) joint.

The importance of functional aftercare must be discussed with the patient from the outset because it is one of the keys to success.

It is relatively easy to determine indications for treatment of the hand in urgent or emergent situations. First and foremost among these are tendon ruptures. However, even these can be tolerated by some patients for months or years. The goal is to treat flexor or extensor tendon ruptures as quickly as possible. From both technical and functional standpoints, the more time that elapses after the initial event, the more difficult treatment of these ruptures becomes.

An end-to-end suture repair is only rarely feasible because the tissue is usually too damaged and the tendons have retracted too far. Side-to-side repair is possible for extensive ruptures, and a free transplant (for example, using the palmaris longus tendon) is an option for large defects. In these situations functional aftercare and, ultimately, outcomes are clearly more challenging.

A rupture of the tendon of the extensor pollicis longus (EPL) muscle, the most common tendon rupture of the hand, represents a special situation. It typically involves performing a surgical transposition of the tendon of the extensor indicis proprius muscle, although this requires lengthy follow-up treatment. Arthrodesis of the interphalangeal joint of the thumb presents an alternative and should be considered depending upon the amount of hand involvement and level of overall disease. Functionality should also be discussed with the patient.

The indications are much more obvious if there is medial nerve compression accompanied by significant inflammatory symptoms. Here patients usually seek medical care themselves due to pain. In addition to decompression of the median nerve, it is crucial to perform an extensive synovectomy of the flexor tendons.

Treatment indications for tenosynovitis, in contrast, are often more difficult to recognize and not as easy for patients to accept. Here the swelling in the hand is painless and, as long as tendon rupture has not occurred, does not impair the patient.

As a general rule for surgical correction of the hand: Start proximal, move distal!

For example, a soft tissue repair of an ulnar deviation of the MCP joint seems futile if the wrist has a severe axial deviation located more proximally. The repair inevitably results in recurrence.

According to the Schulthess classification of rheumatic wrist disease, there are three different progressive forms:

Arthritic.
Ankylosing.
Destabilizing.

The destabilizing progressive form, which leads to ulnar dislocation, usually originates from scapholunate (SL) ligament disruption. It must be recognized early in order to perform a radiolunate arthrodesis as this type of arthrodesis requires an intact distal wrist joint.

It is often difficult to determine indications for soft tissue repairs on MCP joints or swan neck/boutonnière deformities. There cannot be too much bone damage and the soft tissues must still be amenable to repair through a release. At the same time, there must still be sufficient long-term stability of the soft tissues after they are surgically repaired or transposed. Accurate assessment requires many years of experience treating rheumatic hands.

Clearly, it is much harder to determine the correct treatment indications than to perform the operative intervention itself.

2.2 The Wrist

2.2.1 Arthroscopic Synovectomy of the Wrist

Indication

Therapy resistant Larsen 0–II/III synovitis after optimization of medication therapy and cortisone injections.

Extensor tendon synovitis, which is frequently present, requires an open procedure.

Specific disclosures for patient consent

Recurrence. Infection. Radiosynoviorthesis or chemosynoviorthesis may be necessary 6 weeks postoperatively.

Instruments

Standard small joint arthroscope. Camera. Shaver system. Electrocautery.

Position

Supine. Tourniquet on the proximal upper arm. The arm is suspended using a wrist traction device with the elbow joint in 90° of flexion. The suspension device is draped in a sterile fashion (Fig. 2‑2). Weights (ca. 3 kg each) are hung on both sides.

Approach

See Fig. 2‑1.

Fig. 2.1 Anatomical view of the arthroscopic portals. 1, Abductor pollicis longus muscle. 2, Extensor pollicis brevis muscle. 3, EPL muscle. 4, Radial artery in the snuff box (tabatière). 5, Extensor carpi radialis longus muscle. 6, Extensor carpi radialis brevis muscle. 7, First dorsal interosseous muscle. 8, Extensor carpi ulnaris muscle. 9, Extensor digiti minimi muscle. 10, Extensor digitorum muscle. STT, os scaphoideum, trapezium, trapezoideum. DRU, distal radioulnar joint. From Kremer K, Lierse W, Platzer W, Schreiber HW, Weller S. Chirurgische Operationslehre Arthroskopie – obere und untere Extremität. Stuttgart: Thieme; 1997.

Fig. 2.2 The wrist traction device is draped in a sterile fashion.

Specifics

See Fig. 2‑3, Fig. 2‑4, Fig. 2‑5, Fig. 2‑6 . Prior to insertion of the trocar, the radiocarpal joint is insufflated through the 3/4 (radiocarpal) portal using a syringe. The probe and shaver are initially inserted through the 4/5 portal, and then later switched. Finally, the midcarpal joint is accessed via the midcarpal radial (MCR) and midcarpal ulnar (MCU) portals.

Fig. 2.3 The 3/4 and 4/5 radiocarpal and the midcarpal (MCR and MCU) portals are marked after palpation. The joint is punctured and insufflated with a syringe. Synovial fluid is withdrawn for analysis, if needed.

Fig. 2.4 A miniature camera is inserted into the radial 3/4 portal.

Fig. 2.5 View of an ulnar triangular fibrocartilage complex (TFCC) lesion with severe synovitis.

Fig. 2.6 A second portal (4/5) is placed under direct visualization and instruments are inserted (here a shaver).

Key steps

Arthroscopy should be performed carefully in the small spaces to avoid iatrogenic cartilage injuries.

Operative technique

See Fig. 2‑7, Fig. 2‑8.

Fig. 2.7 The frayed TFCC is shaved and a synovectomy is performed.

Fig. 2.8 Midcarpal synovitis is evident and is removed by a palmar synovectomy using the shaver (view of the joint between the hamate and capitate).

Specific complications

Recurrence. Progression of destruction. Development of a supination deformity.

2.2.2 Radiolunate Arthrodesis

Indication

Larsen III–IV destruction with significant clinical symptoms. Radiocarpal joint supination deformity with ulnar drift and palmar subluxation. Radiologically progressive destabilizing form. Impending extensor tendon rupture.

Note that there should be no more than moderate midcarpal destruction.

Consider performing a radioscapholunate arthrodesis if there is pronounced radioscaphoid joint destruction. A Mannerfelt arthrodesis or a prosthesis is indicated for midcarpal destruction.

Specific disclosures for patient consent

Loosening, breakage, or dislocation of staples. Tendon rupture (also secondary). Perioperative impact on flexor tendons and median nerve. Loss of wrist function. Pseudarthrosis. Bone fracture/perforation. Damage to sensory cutaneous nerve branches. Resection of the ipsilateral ulnar head is often necessary and cancellous bone is harvested to place into the radiolunate (RL) arthrodesis site.

Instruments

Stapler with 10 × 15-mm or 16 × 15-mm staples. Standard hand surgery set.

Position

Supine. Hand table. Arrange for perioperative mobile radiography.

Approach

See Fig. 2‑9.

Specifics

Preoperatively, fit a palmar plaster splint that is to be applied immediately postoperatively.

A residual midcarpal range of motion of 30–0–30° extension–flexion can be expected postoperatively.

Key steps

Precisely match the resection surfaces of the distal radius lunate fossa and the decorticated proximal lunate surfaces. Firmly reduce and hold the surfaces together during staple insertion. Resect the interosseous branch of the radial nerve on the floor of the fourth extensor tendon compartment.

Surgical technique

See Fig. 2‑10, Fig. 2‑11, Fig. 2‑12, Fig. 2‑13, Fig. 2‑14, Fig. 2‑15, Fig. 2‑16, Fig. 2‑17, Fig. 2‑18, Fig. 2‑19.

Fig. 2.10 View of the fourth extensor tendon compartment after dividing the extensor retinaculum (arrow).

Fig. 2.11 The ulnar head capsule is opened longitudinally. A synovectomy is performed in both pronated and supinated position. For ulnar head destruction, the ulnar head is sparingly resected using the oscillating saw (see alsoChapter 2.2.3).

Fig. 2.12 The wrist joint is opened with a V-shaped capsulotomy. The radiolunate joint is mobilized and inspected to evaluate the condition of the cartilage.

Fig. 2.13 The resection surfaces are debrided with a Luer and a Lexer chisel (with the aid of an awl or a K-wire). Articular surface with cartilage excised (arrow).

Fig. 2.14 The lunate bone is repositioned dorsally and radially over the radius. Temporary K-wire fixation is used if necessary.

Fig. 2.15 Cancellous bone (derived mainly from the resected ulnar head) is placed after the lunate bone has been reduced.

Fig. 2.16 The stapler is positioned on the lunate bone and distal radius and staples are inserted.

Fig. 2.17 Operative view after staple insertion.

Fig. 2.18 The joint capsule is closed meticulously. In a rheumatoid joint with a thinned capsule, the extensor retinaculum is horizontally split and one half is sutured to the capsule as reinforcement.

Fig. 2.19 The tendons are then repositioned and the extensor retinaculum is reconstructed.

Specific complications

Fracture and dislocation of staples. Pseudarthrosis (often asymptomatic).

Postoperative aftercare

Radiographic imaging at 2 and 6 weeks postoperatively.

Immobilization in the plaster splint (palmar plaster splint, with fingers freely mobile at the MCP joints) until stitches are removed 14 days postoperatively. Then an additional 2 to 4 weeks of immobilization in a forearm circular cast. Cast removal is dependent upon follow-up radiographic findings. See Fig. 2‑20 for an 8-year follow-up.

Fig. 2.20 **(a,b)** Eight-year follow-up after radiolunate arthrodesis. Wrist destabilization has not progressed.

2.2.3 Ulnar Head Resection

Indication

Larsen II–III destruction of the radioulnar joint with instability and pain that limits forearm rotational movement. Synovitis. (Pseudo-)Prominence of the ulnar head with skin breakdown imminent or impending rupture of the fourth or fifth digit extensor tendons.

Specific disclosures for patient consent

Wrist joint extension/flexion range of motion may be reduced by as much as 30%. Reduced distal radioulnar joint (DRUJ) range of motion for pronation and supination.

Instruments

Standard hand surgery set. Oscillating saw.

Position

Supine. Hand table.

Specifics

A tenosynovectomy of the entire wrist and extensor tendons is also typically performed. Ulnar head resection is frequently combined with a partial radiocarpal arthrodesis (radiolunate or radioscapholunate) due to anticipated instability. Alternatively, a split tendon transfer using the extensor carpi radialis brevis (ECRB) tendon or a Sauvé–Kapandji procedure (distal ulnar segment resection and radioulnar fusion) can be performed.

Approach

A dorsal longitudinal incision is made over the wrist and continued over the DRUJ. A lateral incision over the distal end of the ulna is used only for isolated ulnar head resection. See Fig. 2‑21, Fig. 2‑22, Fig. 2‑23.

Fig. 2.21 A dorsal longitudinal skin incision is made over the DRUJ and the extensor retinaculum is exposed.

Fig. 2.22 The proximal and distal ends of the extensor retinaculum are identified and it is incised longitudinally parallel to the extensor carpi ulnaris tendon.

Fig. 2.23 A meticulous tenosynovectomy and joint capsulotomy with extensive articulosynovectomy are performed.

Key steps

Meticulous joint tenosynovectomy, capsule reconstruction, and repositioning of the extensor carpi ulnaris muscle tendon over the ulnar head.

Surgical technique

See Fig. 2‑24, Fig. 2‑25, Fig. 2‑26, Fig. 2‑27, Fig. 2‑28.

Fig. 2.24 The capsule is opened longitudinally over the ulnar head and an extensive synovectomy is performed. Ulnar head destruction is demonstrated using two Hohmann elevators.

Fig. 2.25 Subcapital resection of the ulnar head is **done** using an oscillating saw. The synovectomy is then completed in the lower portion of the joint as well.

Fig. 2.26 The ulnar stump is repositioned with a tamper and the capsule is reconstructed.

Fig. 2.27 The palmarly subluxed extensor carpi ulnaris muscle tendon is repositioned.

Fig. 2.28 The extensor retinaculum is closed and the incision is sutured in layers. 1, Repositioning the tendons. 2, Extensor retinaculum.

Specific complications

Progressive ulnar translocation of the carpus may occur if only an isolated ulnar head resection is performed without carpal fixation.

Postoperative aftercare

Postoperative radiography. Immobilize the joint in a palmar forearm plaster splint until wound healing is complete. Administer active and passive physical exercise therapy.

2.2.4 Wrist Prosthesis

Indication

Larsen III–V destruction with significant clinical symptoms. Absence of severe axial deformities. No wrist instability (function-sparing procedures such as radiolunate arthrodesis are no longer possible).

Specific disclosures for patient consent

Prosthesis loosening or dislocation. Tendon rupture (also secondary). Loss of wrist joint function. Bone fracture/perforation. Damage to sensory nerve branches.

Instruments

Prosthesis system from the manufacturer of choice. Standard hand surgery set.

Position

Supine. Hand table. The hand should be extended as far as possible onto the hand table. A radiograph may be needed.

Approach

See Fig. 2‑29, Fig. 2‑30.

Fig. 2.29 A longitudinal skin incision is made extending from the second or third interdigital space down the ulnar aspect of the wrist joint. A midline incision avoids the radial and ulnar sensory nerve branches.

Fig. 2.30 The extensor retinaculum is divided at the level of the fourth extensor tendon compartment. 1, Extensor digitorum muscle. 2, Extensor pollicis brevis muscle. 3, EPL muscle. 4, Extensor digiti minimi muscle. 5, Extensor retinaculum.

Wrist prosthesis system (Maestro, Biomet):

Carpal plates in eight sizes; capitate stems in three different lengths; carpal heads in three different heights to allow for wrist balancing.
Scaphoid augments in various sizes.
Anatomically contoured radial plates in two sizes with four different radial stem sizes.

Surgical technique

See Fig. 2‑29, Fig. 2‑30, Fig. 2‑31, Fig. 2‑32, Fig. 2‑33, Fig. 2‑34, Fig. 2‑35, Fig. 2‑36, Fig. 2‑37, Fig. 2‑38, Fig. 2‑39, Fig. 2‑40, Fig. 2‑41, Fig. 2‑42, Fig. 2‑43, Fig. 2‑44, Fig. 2‑45, Fig. 2‑46, Fig. 2‑47.

Fig. 2.31 The extensor retinaculum is exposed and the fourth extensor tendon compartment is dissected free. The sensory nerve branches are avoided (exposing the nerves is not essential).

Fig. 2.32 The extensor retinaculum is divided over the fourth extensor tendon compartment so that an ulnar strip remains. This can be used later if needed to reposition the extensor carpi ulnaris in the event of a subluxed tendon.

Fig. 2.33 Start of extensor tendon synovectomy. This is accomplished mainly with Luer and Stellbrink rongeurs. The remaining tendon compartments, I–III and V, are exposed. EPL on the dorsal tubercle of radius (Lister’s tubercle) (arrow).

Fig. 2.34 A glove finger and clamp are fastened around the extensor tendons so that they can be held to the side (restraint system). The interosseous nerve of the radial nerve is exposed (forceps). The wrist is denervated by excising ca. 1 cm of the nerve and coagulating the nerve stump.

Fig. 2.35 A T-shaped capsulotomy is performed and the capsule is detached from the radius. The capsule is released and the entire damaged wrist joint is revealed. Lister’s tubercle (arrow) is shaved flat. It frequently has very sharp edges and can lead to a rupture of the EPL.

Fig. 2.36 The carpal resection guide is positioned. It is oriented in a direction parallel to the long axis of the third metacarpal. A judicious resection is crucial. The ulnar wing of the guide is aligned with the triquetrum hamate joint and the radial wing bisects the distal third of the scaphoid.

Fig. 2.37 With the wrist in a neutral position, a saw is used to score the radial reference line. This serves as a marker for the resection level of the radius later in the procedure.

Fig. 2.38 Resection of the scaphoid and capitate head and along the triquetrum edge is accomplished using the carpal resection guide.

Fig. 2.39 The wrist is opened. The entry point is marked with a K-wire. If there is doubt, a fluoroscopy image is useful.

Fig. 2.40 The center opening is bored with a reamer placed over the K-wire. Arrow indicates the radius.

Fig. 2.41 The prosthesis components are trial fitted and the height of the scaphoid augment is determined.

Fig. 2.42 With the wrist in flexion, the radial entry point is created with a K-wire near the center in close proximity to Lister’s tubercle. Fluoroscopy helps confirm position. The opening is widened by drilling over the K-wire and then using a radius reamer.

Fig. 2.43 With the reamer kept in place, the resection guide is inserted over the boom.

Fig. 2.44 A broach is used as the final step in preparing the radius canal entrance.

Fig. 2.45 Trial implantation. First the standard size carpal head is inserted. The stability is evaluated and, if necessary, a larger +2 or +4 carpal head is inserted. Intraoperative fluoroscopy with an image intensifier is used. If the soft tissues are under too much tension, the radius is further resected.

Fig. 2.46 The permanent implant anchoring screw is drilled.

Fig. 2.47 Implanted prosthesis. Cancellous bone is obtained from the resected segments and applied to the eroded bone using compression.

Postoperative aftercare

See Fig. 2‑48, Fig. 2‑49 . Immediate full range of motion mobilization (caveat: no shoulder immobilization!). Early finger exercises. Palmar splint for 1 to 3 weeks.

Fig. 2.49 An alternative to joint replacement and a potential possibility for revision surgery: Swanson prosthesis.

2.2.5 Mannerfelt Wrist Arthrodesis

Indication

Advanced Larsen IV–V radiocarpal and midcarpal destruction. Simmen type III advanced instability with ulnar drift and palmar subluxation. This is particularly appropriate for fixing the dominant hand in 10 to 20° extension. If needed, the contralateral hand can then be fixed in a neutral position or fitted for a prosthesis.

Specific disclosures for patient consent

Postoperative wrist joint function. Delayed or failed bone healing. Hardware dislocation or breakage. Fracture. Damage to sensory nerve branches. Tendon rupture (also secondary).

Instruments

Standard hand surgery set; intramedullary hook-end nail (Rush pin). Alternative: plate fixation arthrodesis. Fluoroscopy equipment.

Position

Supine. Hand table. The hand should be extended as far as possible onto the hand table. A radiograph may be needed.

Specifics

The bones are frequently very osteoporotic.

Approach

A dorsal longitudinal incision is made starting over the third metacarpal and extending to the wrist along the ulnar axis.

Key steps

Reposition the wrist joint. Completely decorticate the joint surfaces. Prebend the hook-end nail to ca. 50° at the level of the wrist (clinically there will still be 20° of extension left postoperatively). Insert the nail on the ulnar side of the base of the third metacarpal via a bone window.

Surgical technique

See Fig. 2‑50, Fig. 2‑51, Fig. 2‑52, Fig. 2‑53, Fig. 2‑54, Fig. 2‑55, Fig. 2‑56, Fig. 2‑57, Fig. 2‑58, Fig. 2‑59, Fig. 2‑60, Fig. 2‑61.

Fig. 2.50 After identifying the distal and proximal ends, the extensor retinaculum is divided longitudinally overlying the fourth extensor tendon compartment, taking care to protect the sensory nerves.

Fig. 2.51 The DRUJ capsule is opened with a longitudinal incision and a synovectomy is performed.

Fig. 2.53 The wrist joint capsule is opened via a flap incision followed by synovectomy and complete decortication of the joint surfaces. Longitudinal traction of the wrist joint and, if needed, palmar flexion facilitate exposure of the joint surfaces. The interosseous (radial) nerve is denervated (see also Chapter 2.2.4).

Fig. 2.54 An awl is used to preform the passage before the nail is inserted into the radius.

Fig. 2.55 The appropriate length and diameter of the nail are determined.

Fig. 2.56 The third metacarpal is exposed (arrow) by placing two Hohmann elevators behind it. A windowlike opening is made in the distal third quarter for insertion of the nail.

Fig. 2.57 An awl is used to continue preparing the third metacarpal for the Rush pin.

Fig. 2.58 The nail is inserted distally after prebending it to conform to the desired wrist position.

Fig. 2.59 Cancellous bone, obtained from the resected ulnar head, is placed into the wrist joint.

Fig. 2.60 The nail is driven in completely. If necessary, staples can be inserted for additional (rotational) stabilization.

Fig. 2.61 The wrist capsule is sutured and the wound is closed in layers.

Postoperative aftercare

Postoperative radiography. A palmar forearm plaster splint should be applied until wound healing is complete, then circular forearm cast for an additional 4 weeks.

Alternative

Plate fixation arthrodesis (Fig. 2‑62, Fig. 2‑63 ).