Wrist Arthrodesis: Limited and Complete

Nicole S. Schroeder, MD

Karen Pitbladdo, MS, OTR/L, CHT

Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Pitbladdo and Dr. Schroeder.

Introduction

Untreated carpal malalignment can result in abnormal stresses across the radiocarpal joint and eventually produce arthritis in the wrist. Limited and complete wrist arthrodeses are regarded as final salvage procedures for symptomatic posttraumatic, degenerative, postinfectious or inflammatory arthritis of the wrist. The goal of any type of wrist arthrodesis is to provide a functionally stable wrist that allows painless performance of activities of daily living (ADLs). Although fusion reduces pain at the expense of diminished range of motion (ROM), the goal of postoperative rehabilitation is to maximize allowable motion, limit pain, and ultimately restore and preserve hand function.

Several authors have demonstrated that normal wrist motion far exceeds what is needed to perform ADLs. Palmer and colleagues showed that only 5° of flexion, 30° of extension, 10° of radial deviation, and 15° of ulnar deviation are required to perform most standard tasks. Therefore, while arthodeses may restrict some motion, the elimination of pain and preservation of some motion that the procedures provide may not be detrimental to daily tasks.

This chapter reviews the surgical procedure and postoperative rehabilitation protocols for the following types of arthrodesis: scaphotrapezial-trapezoidal (STT), intercarpal fusion (ICF), four-corner fusion (FCF), and total wrist (Figure 34.1). In addition, the indications and surgical techniques for proximal row carpectomy (PRC) will be discussed. The choice of treatment depends on the findings of a complete evaluation of the patient, including an assessment of the patient’s functional needs and goals. Given that arthritic findings on plain radiographs do not always correlate with clinical symptoms, it is critical to use the clinical examination to identify the precise location that generates pain. In the setting of diffuse arthritis, isolated scaphotrapezial trapezoid or radiocarpal injections with lidocaine 1% can help to localize the pain as well as give a patient an idea of the degree of pain relief to expect after surgery. While there are general principles of postoperative rehabilitation, there are some aspects that relate to the specific surgical procedures.

Rehabilitation

Postoperative care varies depending on the exact procedure, but all protocols share three common phases: (1) protection, (2) ROM, and (3) strengthening. Progression from one phase to the next depends on radiographic evidence of fusion as well as surgeon’s preference. A clear understanding of the physician’s postoperative goals and expectations should be discussed at the initiation of any therapy. Most limited wrist arthrodeses are expected to reduce the preoperative wrist arc of motion by 40%.

Phase 1: Protection Phase (0–6 Weeks)

A postoperative splint is applied following the surgical procedure.
Splint (operative dressing) is removed at 2 weeks and a short arm or thumb spica cast is applied.
Casting should allow full finger motion through the metacarpophalangeal joints.
Immediate active finger ROM immediately with tendon gliding (Figure 34.2).
Arm elevation to minimize swelling and edema
Patients demonstrating substantial edema or those unable to comply with postoperative digital motion should be referred to hand rehabilitation early.
Shoulder and elbow ROM.

Phase 2: Range of Motion Phase (6–10 Weeks)

Postoperative goal is pain-free, functional arc of wrist motion.

ROM phase typically begins when the physician notes a solid fusion mass on radiographs.
Avoid maximizing ROM at the expense of stability and/or pain.
Cast is removed. Continue with edema management.
Custom-made or prefabricated splint is used and is selected based on comfort, fit, and extent of support needed.
Begin scar desensitization. Silicone gel sheets and scar massage are the cornerstones of desensitization (Figure 34.3, A and B).
Active ROM exercises should focus on synergistic motion of finger flexion with wrist extension
Passive stretching toward terminal degrees assisted in part by the surgeon’s expectation for maximal motion recovery
Patients are encouraged to use their hand in light bilateral activity and basic hygiene to allow incorporation of the operated hand in ADLs.

Figure 34.1 Illustration of scaphotrapezial-trapezoidal (STT), four-corner fusion (FCF), and total wrist arthrodesis.

Figure 34.2 Illustration of active tendon gliding exercises.

Figure 34.3 A, Silicone scar pad applied directly over the healing surgical scar. B, Desensitization of the scar and surrounding soft tissues using an abrasive surface.

Phase 3: Strengthening Phase (10+ Weeks)

At 10 to 12 weeks, patients begin to gradually increase the load across the joint with a combination of grasping activity and isometric, concentric, and eccentric wrist exercises.
Continue to address limitations in ROM while transitioning to strengthening.
Dart thrower’s motion (DTM) allows a patient to perform exercises in radial deviation/extension and ulnar deviation/flexion patterns that best duplicate many ADLs (Figure 34.4, A and B).
With evidence of complete fusion (typically around 12 weeks), grip strengthening and job simulation is initiated.
Strengthening can be done with the use of therapy putty or the incorporation of light free weights in ROM exercises.

Figure 34.4 Active exercising of the wrist in the dart thrower’s path from radial extension to ulnar flexion. A, With flexion and ulnar deviation. B, With extension and radial deviation.

Surgical Procedures

Scaphotrapezial Trapezoidal (STT) Arthrodesis

Indications

STT arthrodesis is indicated for the treatment of symptomatic osteoarthritis of the STT joint. It can also be used in select cases of midcarpal instability, static or dynamic rotatory subluxation of the scaphoid, chronic scapholunate dissociation, and avascular necrosis of the lunate. It has been shown to preserve pinch-and-grip strength without compromising functional ROM.

Contraindications

STT arthrodesis is contraindicated in pancarpal arthritis or associated radioscaphoid arthritis. While it has been advocated as a treatment of chronic scapholunate instability, there is a significant complication rate and it is rarely performed for isolated scapholunate ligament incompetence.

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