RA- WRIST

Question 1

4 main wrist deformities in RA

Answer 1

1. Radial deviation
2. Ulnar translocation
3. Volar subluxation
4. Intercarpal supination

Question 2

Pathoanatomy of radial deviation of wrist in RA

Answer 2

Attenuation of volar RCS and RL ligaments

Accentuates ulnar drift at MPJ via Z phenomenon

Question 3

Pathoanatomy of volar subluxation and carpal supination in RA

Answer 3

Attenuation of TFCC, ulnolunate and ulnotriquetral ligaments
Results in ulnar side of carpus falling off DR volarly
ECU tendon subluxes volarly contributing to volar subluxation and carpal supination

Question 4

Main surgical options for wrist pathology in RA

Answer 4

Salvage vs. sacrifice

1. ECRL to ECU transfer (Clayton procedure) = to address radial deviation and carpal supination
2. Radiolunate fusion (Chamay procedure) = to prevent ulnar translocation
3. Arthrodesis
4. Arthroplasty

Question 5

Wrist arthrodesis for RA wrist:
Advantages
Disadvantages
Indications
Contraindications
Technique

Answer 5

1. Advantages
   - most reliable procedure for pain relief
   - good grip strength
2. Disadvantages
   - technically demanding
   - slower recovery = 6-8wks immobilisation
   - higher complication rate = approach (wound, infection), arthrodesis (position, nonunion), other (tendon synovitis/ rupture, CTS)
3. Indications
   - end stage radiocarpal or intercarpal arthritis
   - deformity/ instability/ poor bone stock
4. Contraindications
   - active infection
   - poor soft-tissue envelope
5. Technique
   Preservation of dorsal radiocarpal ligaments = Berger
   5 arthrodesed joints:
   - radiocarpal (RS and RL) joints
   - SL joint
   - SC joint
   - CL joint
   +/- STT joints if symptomatic
   - 3rd CMCJ generally not fused = high nonunion rate
   Excision of Lister’s and dorsal surfaces of scaphoid/ lunate/ capitate to create flat surface for plate
   Precontoured wrist fusion locking plate
   Correct position of arthrodesis = 10deg extension and neutral radioulnar deviation
   RA wrist = transpose extensor tendons superficial to extensor retinaculum to avoid attrition
   Union rate with plate = 95%

Question 6

Wrist arthroplasty for RA wrist:
Advantages
Disadvantages
Indications
Contraindications
Technique

Answer 6

1. Advantages
   - preservation of ROM = function
2. Disadvantages
   - technically demanding
3. Indications = limited indications
   - elderly low-demand patients
   - inflammatory arthritis (RA)
   - good bone stock
4. Contraindications
   - active infection
   - poor soft-tissue envelope
   - deformity/ instability/ poor bone stock
5. Technique
   - lifetime 5kg lifting and loading limit