Before embarking for salvage procedures, conservative treatment and corrective osteotomy should have been considered.
If these measures are inapplicable or fail, partial or extensive wrist denervation should be considered.
Partial or total wrist (TW) arthrodesis or arthroplasty are the next options to be considered, arthroplasties being more suited for the low-demand/elderly patients.
If the midcarpal joint is intact, a radioscapholunate (RSL) arthrodesis is another option. In low-demand patients, hemi-arthroplasty might be an alternative.
In patients who request a final procedure, or in the case of panarthritis, TW arthrodesis (or as an alternative in the elderly/low-demand patient: TW arthroplasty) is preferred.
A 26-year-old construction worker sustained an intraarticular distal radial fracture (DRF) in his dominant right hand side. The fracture was conservatively treated and healed with a step-off in the radial joint surface. Some pain remained but this was tolerable and he returned to his previous employment.
Thirteen years later, he complained of increasing wrist pain and episodes of numbness in his radial sided fingers. After carpal tunnel decompression and resection of the terminal posterior interosseous nerve, the symptoms radiating to the fingers disappeared. However, his wrist pain persisted despite a change of profession, use of splints, analgesics, and intraarticular steroid injections. Radiographs revealed moderate osteoarthritis in the radiocarpal joint including the lunate fossa ( Fig. 1 ). How would you counsel him?
Importance of the Problem
Wrist degeneration after intraarticular DRFs is caused either by a direct blow to the cartilage, or joint surface disruption with step-offs and gaps. Joint degeneration can also develop as a result of extra-articular malunited fractures with altered angulations. Concurrent ligament injuries, if present, contribute to carpal incongruence and altered pressure areas.
In younger, nonosteoporotic patients, the prevalence of OA following DRFs has been reported as high as 32%–50% and frequently causes impairment. Ultimately the condition may end in a partial or TW arthrodesis and sometimes in inability for the patient to return to his or her habitual occupation. In elderly, low-demand patients posttraumatic wrist arthritis is better tolerated.
Which procedures can we offer to a patient with a painful osteoarthritic wrist after a DRF and which outcomes can we expect?
Conservative treatment is the first action to be taken in order to relieve the symptoms of painful posttraumatic OA. This includes nonsteroid antiinflammatory drugs, analgesics, cortisone injections, and splinting. There is time to carefully choose the right surgical option since spontaneous improvement of symptoms may occur as time goes by and the wrist stiffens. Some ligament injuries can also stabilize by time and, furthermore, proprioceptive training may reduce symptoms. However, even though splints and orthoses usually work well, they cannot always be used during work and are seldom a long-term solution. If severe symptoms persist, surgical treatment is indicated.
Wrist denervation could be the first surgical move before embarking for salvage procedures. RSL arthrodesis is an option if the midcarpal joint is preserved ( Fig. 2 ). TW arthrodesis is indicated in young patients who want a final solution, or as a salvage procedure in case of RSL failure ( Fig. 3 ). Prosthetic TW replacement is an alternative to TW arthrodesis especially in elderly, low-demand patients ( Fig. 4 ). In recent years, hemi-arthroplasty and interpositional pyrocarbon arthroplasty have been proposed as alternatives. Other salvage procedures for the wrist, including four corner arthrodesis and proximal row carpectomy, are less common options after DRF since a prerequisite for these procedures is an intact lunate facet of the radius. However, these procedures might be advised if the lunate facet is intact, or has been properly restored, while a concurrent scapholunate injury has caused a carpal collapse and subsequent OA.
Prosthetic replacement of the wrist may offer reduction of pain, preserved range of motion, and improved function but the long-term durability in different subgroups of patients is not well established. Although by many considered a panacea, TW arthrodesis is not a guarantee for freedom of pain and return to work.
Finding the Evidence
Articles were selected through searches made in Cochrane, Embase, and Medline databases ( Fig. 5 ). The searches were based on the following terms: wrist, radiocarpal joint, osteoarthritis, arthroplasty, hemi-arthroplasty, replacement, implant, denervation, styloidectomy, carpectomy, fusion, arthrodesis, salvage. Only articles written in English, German, or French were considered. Anatomical and cadaver studies were excluded as well as articles published before the year of 2000 in order to avoid obsolete methods and implants. Cohorts with less than 10 cases and (review) articles without original data were excluded. Series that also included rheumatoid arthritis or Kienböck’s disease were also excluded if the DRFs could not be assessed separately. A total of 2831 articles were identified (Cochrane n = 120, Embase n = 1370, and Medline n = 1858). After deleting duplicates ( n = 973), 1858 articles were accepted for further review by using Rayyan® online software. The articles were reviewed independently and blindly by three reviewers. Two hundred and nine abstracts rendered interest by at least one of the three reviewers. After joined discussion, 37 abstracts were accepted for full-text review. A considerable amount of articles were excluded because of mixed patient cohorts, without specification of the data for DRFs. Finally, only four articles were found to meet inclusion and exclusion criteria. One more article dealt specifically with wrist arthritis after DRF. It was a review article without original data but made reference to a previous publication with relevant data. We decided to include that publication instead. By further reducing the restrictions and accepting articles that included posttraumatic OA in general and not solely on the basis of DRF, eight additional articles were selected.
Quality of Evidence
All selected articles had methodical flaws, including low number of patients and low quality of evidence ( Tables 1–4 ). Generally, preoperative patient-reported outcome measures (PROMs) were missing. Reported postoperative PROMs were not easily comparable between studies.
|Publication||Study Design||Number of Cases||Technique||Follow-Up||Pain||PROM|
|Schweizer et al. (2006)||Retrospective||71 (11 DRF, no RA)||Extensive (complete)||9.6 (1–23) years||35 None or little |
15 Considerable or severe
|DASH-score 33 for DRF|
|Radu et al. (2010)||Retrospective||70 (43 to f.u., 30 hereof PT)||29 Extensive, 14 partial||51 (18–97) months||63%–64% PT had pain reduction. |
Better in extensive denervation
|DASH-score 38–46 for PT|
|Publication||Study Design||Number of Cases||Technique||Follow-Up||Union||Wrist Motion |
|Pain||OA at FU||Outcome|
|Beyermann and Prommersberger (2000)||Retro||18 DRF||No DS. |
|19 (6–66) months||1 Required reoperation||F: 23 (5–40) a |
E: 24 (10–40) a
R: 9 (0–20)
U: 16 (10–25)
|VAS score in activity: 3.6 (0–9) |
VAS score at rest: 0.6 (0–20)
|No MC-joint OA||DASH score 26 (3–55)|
|Degeorge et al. (2019)||Retro||85 PT, 75 at FU||Locking T-plate/screws/staplers/K-wires |
25 with DS, 50 without DS
|9 (1–21) years||24% nonunion (less after DS)||45% had functional mobility b||33% had no or slight pain||MC OA in 44% (independent of DS)||QDASH score 31–40 |
Good in 80% with DS, 40% without DF b
|Garcia-Elias et al. (2005)||Retro (comparing with literature)||16 (13 DRF)||K-wires. All with DS in own series, no DS in selected literature||34 (12–70) months||All united||F: 36 (16–52) |
E: 36 (25–50)
R: 16 (10–28)
U: 29 (5–32)
(F better than in literature)
|13/16 no or slight pain. 3 occasional pain (better than in literature)||No MC OA after DRF. |
(1/3 in literature had MC OA)
|Muhldorfer-Fodor et al. (2012)||Retro||61, 35 for f.u. (hereof 32 DRF)||K-wires |
20 DS, 15 no DS
|23–28 (10–47) months||3 nonunions (all without DS)||F with DS: 25 (25–50) |
F without DS: 20 (0–45)
E with DS: 28 (0–50)
E without DS: 28 (0–40)
R with DS: 12 (0–25)
R without DS: 7 (0–15)
U with DS: 17 (5–35)
U without DS: 16 (0–30)
|VAS score with DS: 4.5 (0–8.5) |
VAS score without DS: 3.6 (0–8)
|6 MC OA with DS |
6 MC OA without DS
14 of the initial 61 patients had a TW arthrodesis
|DASH score with DS: 43 (12–83) |
DASH score without DS: 44 (9–81)
|Nagy and Büchler (1997)||Retro||15 DRF||Plates and screws, no DS||8 (7–12) years||4 nonunions (2 converted to TW arthrodesis, 1 re-RSL)||F: 18 (6–356) |
E: 32 (20–55)
R: 3 (− 25 to 10)
U: 25 (5–45)
|11 no pain |
1 occasional pain
3 considerable pain
|3 progressive OA |
5 nonprogressive OA
|Quadlbauer et al. (2017)||Retro||11 DRF||Locking frame plate. DS in all||63 (30–97) |
|No nonunions||F: 63 (30–97) c |
E: 42 (20–60) c
R: 10 (0–20)
U: 25 (20–30)
|VAS score 2 (0–5)||No MC OA||DASH score 24 (4–68)|