Complete Wrist Arthrodesis
John C. Elfar
Andrew D. Markiewitz
DEFINITION
Wrist arthritis occurs when the codependent joints of the wrist lose the ability to rotate normally around one another, thereby impairing wrist kinematics.
Wrist arthritis can originate from many causes including osteoarthritis, degenerative arthritis, and inflammatory arthritis.
Although sacrificing motion at the wrist, arthrodesis has been shown to reliably relieve pain.
ANATOMY
The wrist is perhaps the most complex set of joints in the body.
The eight bones of the wrist work together to provide motion in multiple planes, governed by the complex array of soft tissue ligaments that unite them.
Single ligament disruptions can cause degenerative change in nonadjacent bones and at times unlikely sites.
Untreated fractures can lead to malunions or nonunions that can disrupt the delicate balance of the wrist.
In broad terms, the wrist is divided into two distinct rows of bones.
The distal row, including the trapezium, trapezoid, capitate, and hamate, is united to the hand and shows little gross motion relative to the metacarpals.
As such, the most significant articulations in the wrist occur in the proximal row bones, which are the scaphoid, lunate, and triquetrum. These proximal row bones allow the wrist to flex, extend, deviate both radially and ulnarly, and pronosupinate.
PATHOGENESIS
Because of the many possible routes to the eventual destruction of the wrist joint, it is difficult to describe a single chain of events that leads to end-stage arthritis, most suitably treated by complete wrist fusion.
NATURAL HISTORY
Causes of wrist degeneration and the often-predictable pattern and pace of wear are detailed in other chapters.
PATIENT HISTORY AND PHYSICAL FINDINGS
Patients describe pain and stiffness as their major reasons for presentation. Pain limits their function and their strength.
Most patients are less concerned with motion loss if their dominant extremity is not involved. Wrist flexion and extension is typically more involved than supination and pronation.
If their dominant wrist is involved, patients prefer to preserve some motion even if faced with low-grade persistent pain after treatment. In this clinical setting, complete wrist fusions are less often performed as the index operation.
Physical examination findings may include deformity, tenderness, soft tissue swelling, loss of motion, instability, and pain with motion. Pinch and grip strength are reduced compared with age-matched peers and the uninvolved contralateral extremity.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Wrist arthritis is best studied with standard posteroanterior and lateral radiographs of the wrist.
These images often reveal the cause of the degeneration together with its pattern and progression.
Special attention is paid to the alignment of the wrist and the bone stock available for fusion and fixation.
Computed tomography helps plan limited fusions or salvage procedures when arthritis may have spared areas of the midcarpal or proximal carpal rows.
DIFFERENTIAL DIAGNOSIS
Limited wrist arthritis
Extrinsic joint contracture (including calcific tendinitis)
Inflammatory arthritis and synovitis (ie, rheumatoid, gout, or pseudogout)
Infection
Posttraumatic changes
Connective tissue diseases
NONOPERATIVE MANAGEMENT
In most every case, the first form of treatment for wrist arthritis is nonoperative:
Nonsteroidal anti-inflammatory medications (NSAIDs)
Disease-modifying medications (if the cause of the degenerative process can be identified and is appropriate)
Splinting
A custom-made thumb spica splint allows interphalangeal motion of the thumb but limits painful wrist motion.
A padded glove (similar to weight lifting or cycling glove) helps decrease the load across the wrist and the motion necessary for a satisfactory grip.
Narcotics should be avoided as addiction, dependency, and diversion may occur.
Local steroid injections placed in the wrist
These should be placed with a sterile technique and can be repeated as needed if the joint is destroyed and limited salvage options are available.
SURGICAL MANAGEMENT
Alternative motion-sparing procedures, including partial wrist fusions and proximal row carpectomy, should be considered before performing a complete wrist fusion, especially in patients who have at least 60 degrees of wrist flexion-extension and have isolated articular degeneration.
Wrist arthroplasty remains in its infancy and is associated with high revision rates and frequent implant design changes.
Wrist arthrodesis after arthroplasty is more difficult due to bone stock loss.
Wrist arthrodesis is the final treatment method for end-stage wrist degeneration due to multiple causes or as a salvage procedure in patients who have failed the more limited procedures mentioned earlier.
In patients who have undergone lower extremity joint replacements and therefore require support for ambulation, fusion of the wrist is generally regarded as a reliable procedure.
The two most popular methods used to fuse a wrist are plate osteosynthesis and rod osteosynthesis.2,8,15 A new locked intramedullary rod has been proposed to limit dorsal plate prominence.10
The chief considerations when choosing between these two options are the desired position of fusion, the quality of the bone and available soft tissue coverage, and the possibility of future infection.
The strongest grip is achieved when the wrist is fused in 20 to 30 degrees of extension. Advocates of fusion in this position favor the use of a plate and screw construct that is fabricated to reproduce this position.2,4,16 Straight wrist fusion plates are also available, and all these devices include screws and plates that match the size of the radius and the metacarpal.
A neutral wrist position obtained with rod osteosynthesis may be more favorable for activities of daily living, including perineal care.2,3,5,13
Plate and screw constructs rely on solid screw purchase and stable soft tissue coverage. If good-quality bone and viable soft tissues are not present, as might be the case in a patient with severe rheumatoid disease, intramedullary rod fixation may be a more effective means of fixation.Related posts:
Anatomy and Surgical Approaches of the Forearm, Wrist, and Hand
Arthroscopic Treatment of Chondral Injuries and Osteochondritis Dissecans
Fragment-Specific Fixation of Distal Radius Fractures
Arthroscopic and Open Triangular Fibrocartilage Complex Repair
Carpal Tunnel Release: Endoscopic, Open, and Revision
Surgical Treatment of Septic Arthritis in the Hand and Wrist
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