Complete Wrist Arthrodesis



Complete Wrist Arthrodesis


John C. Elfar

Andrew D. Markiewitz





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.




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

Jul 22, 2016 | Posted by in ORTHOPEDIC | Comments Off on Complete Wrist Arthrodesis

Full access? Get Clinical Tree

Get Clinical Tree app for offline access