Indications
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Wrist salvage procedures provide options for patients with a history of long-standing wrist instability, degeneration, and/or pain that severely limit function. They are performed to decrease pain and to restore stability and strength to the wrist to allow for optimal hand function, not to maximize range of motion (ROM).
Preoperative Evaluation
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When considering a total wrist arthrodesis, a period of immobilization in a removable orthosis is recommended before surgery to determine the best individual wrist position and to allow the patient to become accustomed to an immobile wrist.
Pearls and Pitfalls
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The postoperative therapy goal is pain-free functional wrist motion. A stable wrist that has a pain-free arc of limited ROM is more functional than an unstable, painful wrist that has full ROM.
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A wrist salvage procedure will likely result in restricted wrist ROM, but these restrictions are not necessarily detrimental to daily function. Palmer and colleagues concluded that functional range of wrist motion was 5 degrees of flexion, 30 degrees of extension, 10 degrees of radial deviation, and 15 degrees of ulnar deviation.
Postoperative Care
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Protective Phase. Postoperative care after a wrist salvage procedure will vary depending on the procedure performed. The average time needed for healing to occur will vary with each method of fixation and will determine the length of the protective phase.
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ROM Phase. When radiographs indicate acceptable healing, the cast is removed, a removable orthosis is fabricated, and active ROM is initiated (unless a wrist fusion was performed).
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Strengthening Phase. This phase begins when the fusion is able to tolerate the increased forces associated with resistive activity. The patient may now be weaned from the orthosis. Gentle active assisted or passive ROM may be initiated, if needed, to increase ROM. Forceful manipulations and joint mobilizations are not appropriate. Treatment may be progressed to include isometric exercise, followed by gentle strengthening exercises such as progressive resistive exercise and graded grip strengthening. Heavier resistance, lifting simulations, and more strenuous activity are avoided until bony healing is confirmed on radiographs, which may vary from 8 to 16 weeks.
Return to Work
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Return to work for heavy laborers may take as long as 6 months, depending on the procedure performed.
The wrist is the link between the hand and the upper extremity. It must be mobile to allow positioning of the hand to perform activities of daily living (ADLs), work, and recreation. It must be stable to allow for force transfer for lifting, gripping, and carrying. This mobile yet stable joint is dependent on intact ligaments and proper bony alignment of articular surfaces to function properly. There are no muscle bellies crossing the wrist joint that can be strengthened to compensate for ligament insufficiencies.
The wrist joint, by its anatomic position, is subject to frequent use, high stress, and injury. Undiagnosed and untreated carpal fracture and/or ligament injury produces carpal malalignment. This malalignment, while allowing continued function, places abnormal stress on the articular surfaces of the wrist causing degeneration. Progressive degeneration of the wrist will result in pain, weakness, loss of wrist motion, and inability to use the hand for ADLs. Many patients first present for medical treatment when this degenerative arthritis has progressed to the point of functional limitation.
This chapter reviews salvage procedures for the degenerated wrist due to fracture, ligamentous instability, avascular necrosis (AVN), and arthritis. Intercarpal arthrodesis, replacement arthroplasty, proximal-row carpectomy (PRC), and total wrist arthrodesis procedures are also reviewed, discussing surgical indications, expected clinical results, postoperative therapeutic protocols, and outcomes data.
Functional Wrist Motion
A “normal” wrist has a greater ROM than that required for most ADLs. A wrist salvage procedure will likely result in restricted wrist ROM. Motion can be expended to achieve stability without compromising function. The amount of motion required to perform ADLs has been evaluated by several authors. Palmer and colleagues measured wrist motion in 10 normal subjects using a triaxial electrogoniometer. They evaluated 52 standardized tasks. The normal functional range of wrist motion in this study was 5 degrees of flexion, 30 degrees of extension, 10 degrees of radial deviation, and 15 degrees of ulnar deviation. Ryu and associates. studied 40 subjects using a biaxial wrist electrogoniometer. They evaluated 31 activities that reflected major functional wrist requirements, categorizing them as palm placement, personal care and hygiene, diet and food preparation, and work activities. The entire group of activities could be performed with a minimum of 60 degrees of extension, 54 degrees of flexion, 17 degrees of radial deviation, and 40 degrees of ulnar deviation. Most of the activities (except rising from a chair and perineal care) could be performed with 40 degrees of flexion and extension, 10 degrees of radial deviation, and 30 degrees of ulnar deviation. The authors concluded that this is the minimal ROM needed to perform a majority of ADLs. They also concluded that wrist ulnar deviation and extension are the most important positions for wrist activities. This position must be taken into consideration with orthotic fabrication and reconstructing the wrist.
De Smet studied 205 patients who had undergone a variety of reconstructive wrist procedures. He correlated wrist ROM with disability of the upper limb using the Disability of the Arm, Shoulder, and Hand (DASH) score, finding a significant but weak correlation. When wrist arthrodesis was included, a stronger correlation was found, illustrating the impact of complete loss of motion versus restricted motion. Reconstructive salvage procedures should strive to create a stable wrist and maintain functional ROM.
These studies provide a measure of functional wrist motion. Wrist extension and ulnar deviation are the most important positions for wrist activities. When a functional ROM cannot be maintained as a result of a salvage procedure, extension and ulnar deviation must be maintained with arthrodesis.
Therapy Implications
Wrist salvage procedures provide options for patients with a history of long-standing wrist instability, degeneration, and/or pain that severely limit function. They are performed to decrease pain and to restore stability and strength to the wrist to allow optimal hand function, not to maximize ROM. For this reason, the postoperative therapy goal is pain-free functional wrist motion. A stable wrist that has a pain-free arc of limited ROM is more functional than an unstable, painful wrist that has full ROM. Functional and pain-free wrist motion is a sum of all the movements of this complicated articular complex and dependent on equilibrium of the dynamic system. These complicated surgical procedures require skilled hand therapy to achieve optimal function, maximize surgical efforts and goals, and avoid unnecessary complications.
Intercarpal Arthrodesis
The goal of intercarpal arthrodesis is to provide the patient with a painless wrist that remains durable under prolonged stress, maintains functional mobility, and is not subject to overload and subsequent degenerative joint disease elsewhere in the wrist. The primary pathology and its secondary pattern of degeneration will determine which carpal bones should be fused. Common diagnoses that can be treated by intercarpal arthrodesis include chronic scapholunate instability, lunate AVN, and degenerative and post-traumatic arthritis.
The following is a general postoperative therapy guideline. Treatment is based on the procedure performed, fixation used, and bone healing.
Postoperative Management
Weeks 0 to 4
A cast is applied and worn for 4 weeks after surgery. Delayed union requires a longer period of immobilization. The home exercise program should include edema control and active ROM (AROM) of the joints proximal and distal to those immobilized in the cast.
Weeks 4 to 6
At week 4, a custom thermoplastic wrist orthosis is fabricated. If there is scaphoid involvement, a forearm-based thumb spica orthosis is required. The thumb is placed in a position opposing the index finger. The orthosis is worn full time except for hygiene. Edema control and AROM of the uninvolved joints continue. Scar management techniques may be initiated.
Weeks 6 to 8
Gentle wrist AROM can be initiated at 6 weeks. Generally, by 8 weeks, one can expect to see a 60- to 80-degree flexion–extension arc of motion. As ROM improves and symptoms resolve, gentle isometric exercises for grip, wrist, and forearm may be performed with care to avoid increasing painful symptoms. Treatment may be progressed to include strengthening exercises and passive range of motion (PROM) when radiographs confirm bony healing.
Weeks 8 to 12
Adaptive equipment, ergonomic adjustments, and task modifications should be addressed. Wrist wraps and gloves may be used as needed for comfort and pain relief. Heavy activity should be avoided for 3 months postoperatively. Expect the arthrodesis to be secure by 10 to 12 weeks; full symptom resolution and strength recovery may ultimately require 6 to 12 months.
Outcomes Data
Minami and colleagues reported on 12 of 15 wrists (4 radiocarpal/11 intercarpal) that showed an average of 32 degrees of flexion and 33 degrees of extension at both 22 and 89 months postoperatively. Grip strength was nearly identical at both visits. These results suggest that the clinical and radiographic results were maintained at the final follow-up visit and that the effect of limited wrist fusion does not deteriorate.
Scaphotrapezial Trapezoidal Arthrodesis
Fusion of the scaphotrapezial trapezoidal (STT) joint is indicated in the treatment of degenerative arthritis of the STT joint ( Fig. 76-1 ). STT fusion offers good pain relief in patients with STT arthrosis. It maintains grip and pinch strength without sacrificing functional motion. STT arthrodesis is also indicated in the treatment of AVN of the lunate. The STT fusion has been shown to be effective in unloading the lunate at the expense of increased radioscaphoid contact. This load transfer may eventually lead to degenerative arthritis of the radioscaphoid joint. , STT fusion has also been advocated for scapholunate instability. Long-term studies have demonstrated significant problems with the procedure, with a 50% complication rate. For this reason, it is important that postoperative therapy include education regarding long-term joint protection techniques.
The surgical technique involves fusion of the distal pole of the scaphoid to the trapezium and trapezoid via a dorsal approach. Internal fixation is used to maintain the scaphoid in an extended position to maintain proper carpal alignment ( Fig. 76-2 ). Distal radial bone grafting is used. The procedure prevents scaphoid flexion and extension and will alter carpal motion.
Postoperative Management
Weeks 0 to 4
Immediately after STT arthrodesis, a short-arm thumb spica cast is applied. During this time, AROM may be performed proximally at the shoulder and elbow as well as at those remaining joints of the hand not included in the cast.
At 4 weeks, the cast is usually removed. The duration of this protective phase may vary depending on the type of fixation used and the status of healing. Smokers may require a longer period of immobilization.
Weeks 4 to 6
At about 4 weeks, a full wrist-thumb spica orthosis is fabricated. During fabrication, care must be taken to ensure that the thumb is positioned in palmar abduction. In some cases, the surgeon may choose to place the patient in a long-arm thumb spica or Munster ( Fig. 76-3 , online) cast for optimum control of forearm rotation, thereby ensuring immobilization at the fusion site. Generally, gentle AROM of the wrist may begin at 4 weeks. Edema control and scar management are performed as indicated.
A review of the literature reveals that after STT fusion, one can expect to see an average arc of wrist flexion–extension ranging from 67 to 115 degrees and an average arc of radioulnar deviation ranging from 31 to 56 degrees.
Weeks 6 to 8
At 6 weeks, gentle assisted AROM (AAROM) and later PROM may be initiated in wrists that are stiff and have limited motion. Forceful, painful manipulations are to be avoided. Isometric exercises may be initiated at 6 weeks, and gentle strengthening exercises may begin at 8 weeks when approved by the surgeon based on healing of the fusion. This may include graded grip strengthening, isotonic exercises, and light work simulations. A review of the literature indicates that after STT arthrodesis, one can expect to achieve grip strength ranging from 65% to 83% of that of the uninvolved extremity.
When there is evidence of solid healing, heavier resistance and job simulations may be added to the program, usually by week 12. Watson and colleagues, in a series of 800 STT fusions, reported that 88% of the patients and 80% of the heavy laborers returned to preoperative employment. Similar findings are reported by Sauerbier and colleagues and Kleinman and colleagues, with 80% and 92%, respectively, of their patients returning to their original occupations.
Outcomes Data
Several authors reported the use of the DASH as an outcome measure after STT fusion. This questionnaire, which has been found to be a valid, reliable, and responsive tool, evaluates symptoms and physical function. A higher score reflects greater disability. Following STT fusion, DASH scores ranging from 24.8 to 29 have been reported, indicating less pain and disability.
Four-Bone Arthrodesis
Watson and Ballet described the scapholunate advanced collapse (SLAC) deformity arising from chronic scapholunate instability. The scaphoid rotates, the capitate pushes in between the scaphoid and lunate, and degeneration occurs first at the scaphoid radial styloid joint ( Fig. 76-4A ) and then at the capitate lunate joint (see Fig. 76-4B ). The radiolunate joint is spared and maintains good articular cartilage in most patients. Pain occurs from degenerative arthritis at the radial scaphoid and capitate lunate joints. For surgical treatment to succeed, this pathology must be addressed. The four-bone arthrodesis procedure removes the scaphoid to eliminate this focus of degeneration and fuses the lunate, capitate, hamate, and triquetrum to stabilize the wrist ( Fig. 76-5B , online). This choice of intercarpal fusion prevents further capitate migration. It eliminates the midcarpal degeneration between the capitate and lunate and maintains carpal height. This fusion is also indicated in patients with radiocarpal arthritis from scaphoid nonunion and scaphoid AVN.
Four-bone intercarpal fusion maintains 50% to 60% of normal wrist motion and 80% of the grip strength on the contralateral side. Long-term studies demonstrate no secondary radiolunate degeneration. ,
The most common complication after this procedure is dorsal radiocarpal impingement in wrist extension. , This occurs when the lunate is fused in an extended position. The capitate impinges on the dorsal rim of the radius with wrist extension ( Fig. 76-6 , online). Cohen and Kozin proposed fusing the lunate in slight flexion relative to the capitate to avoid this complication and, as a result, provide greater wrist extension.
Postoperative Management
Protective Phase
Postoperative care will vary depending on the type of fixation used at the time of surgery. A variety of methods used to secure the arthrodesis are described in the literature, such as K-wires, , Spider plates, and staples and screws. The average time needed to achieve fusion will vary with each method of fixation. El-Mowafi and colleagues estimate that for K-wires (which provide minimal stability and no compression ), approximately 8 to 10 weeks is needed to achieve fusion. Krakauer and colleagues indicate that this period of immobilization may be shortened if fusion was accomplished with compression screws (which provide increased stability and allow for early mobilization). Therefore, the chosen method of fixation will determine the postoperative course of therapy. During this phase of treatment, while the patient is in a protective cast, therapy focuses on edema control and AROM of the uninvolved joints.
ROM Phase
When radiographs indicate sufficient healing, a thermoplastic thumb spica orthosis is fabricated ( Fig. 76-7 , online). In some cases, the surgeon may choose to place the patient in a long-arm thumb spica or Munster orthosis for optimum control of forearm rotation, thereby ensuring immobilization at the fusion site. It is worn fulltime with removal for hygiene and exercise for the next 4 weeks. Gentle AROM may now be initiated at the wrist. During this phase, undue stress at the repair site such as grip-strengthening exercises and testing that significantly load the carpus should be avoided. Edema control continues as indicated. The patient is instructed in scar management. Modalities such as moist heat may be initiated to enhance ROM and tendon-gliding exercises.
