Posttraumatic arthritis of the radiocarpal and midcarpal joints is the most common indication for wrist arthrodesis. For example, a chronically nonunited scaphoid fracture or scapholunate dissociation with advanced carpal collapse and secondary degenerative arthritis can be treated effectively by wrist arthrodesis. When posttraumatic arthritis involves only the radiocarpal joint or midcarpal joint, wrist arthrodesis is an alternative to limited arthrodesis. Wrist arthrodesis often is required to salvage a failed previous, more limited arthrodesis or wrist arthroplasty (1,2). It is unlikely that any wrist reconstruction will improve motion. For this reason, wrist arthrodesis is recommended as the preferred initial treatment in cases of limited disease when wrist dorsiflexion and palmar flexion are less than 30 degrees (Algorithm 1).

Less frequent indications for wrist arthrodesis include diseases that cause significant instability, such as rheumatoid arthritis or infection. Cavaliere and Chung (3) found outcomes to be comparable and possibly better for wrist arthrodesis, in comparison to wrist arthroplasty, for patients with rheumatoid arthritis. Segmental bone loss involving the distal radius and carpus resulting from severe crush is another indication, as well as mutilating open injuries inflicted by gunshot blasts, saws, press injuries, or other industrial trauma (Fig. 27-1). Paralytic disorders can cause a wrist deformity interfering with hand function that is corrected most effectively by wrist arthrodesis in a position of stable alignment. At times, hand reconstruction for combined nerve palsy requires the use of a single residual functioning wrist motor, which is possible only by stabilization of the wrist. Addosooki et al. (4) reported on the use of wrist arthrodesis in conjunction with free muscle transfer for reconstruction following total brachial plexus palsy. Wrist arthrodesis can be indicated as a method of reconstruction following tumor resection (5). Freeland et al. (6) discussed performing the procedure for irreparable intra-articular distal radial fractures.

The primary contraindication to wrist arthrodesis is the rare situation in which motion is essential to perform a highly important or dependent activity. For example, a tetraplegic patient must have wrist dorsiflexion preserved to be capable of body transfer. A second contraindication is the necessity for wrist motion to provide for, or to augment, digital motion by tenodesis effect. De Smet (7) studied the correlation of wrist motion and disability in 205 patients who had had a variety of wrist operations. A correlation was seen between wrist motion and the Disabilities of the Arm, Shoulder and Hand (DASH) score, although the correlation was weak.

Most patients considered for wrist arthrodesis have pain with use, limited wrist motion, and weakness. Physical findings vary with the location and extent of arthritis. It is important to note the presence and location of swelling, crepitus, and tenderness. It is desirable to record preoperative grip and range-of-motion measurements accurately. Examine the distal radioulnar joint to detect potential
problems such as pain, instability, or restriction of forearm rotation that may require surgical treatment in addition to wrist arthrodesis.

Many patients with long-standing arthritis or wrist deformity also have symptoms of carpal tunnel syndrome. Even if the symptoms initially are mild, they can become clinically significant following surgery. Examine all patients scheduled to undergo wrist arthrodesis for the presence of carpal tunnel syndrome by Phalen’s test (8) and sensory testing. The symptoms of carpal tunnel syndrome can increase following wrist arthrodesis owing to perioperative edema formation. Carpal tunnel release should be considered before, or concomitant with, wrist arthrodesis when clinical evaluation is positive and the presence of a compressive neuropathy affecting the median nerve is confirmed by electrodiagnostic testing.

Appropriate radiographic evaluation includes an anteroposterior (AP) and lateral view as well as two oblique views. The oblique view best shows the extent of arthritic involvement. Carefully evaluate the ulnar midcarpal joint (triquetral-hamate and capitohamate) to determine if it is free of clinical and radiographic deformity or if it is arthritic and therefore requires inclusion within the fusion. The lateral view is helpful in evaluating the capitolunate and distal radioulnar joints.

Additional studies may be indicated based on the findings of the routine radiographs. An ulnar-deviated posteroanterior (PA) view often is needed to evaluate the scaphotrapeziotrapezoid joint for
arthritic deformity. A computed tomographic scan provides the best assessment for the capitolunate joint, which may be difficult to evaluate for arthritic deformity using routine radiographs. Surgery can be performed under axillary block or general anesthesia. A general anesthetic is required if an iliac crest bone graft is to be used. The involved extremity and the opposite iliac crest are prepared and draped if an iliac crest bone graft is to be performed.