WRIST/ CARPAL ARTHRITIS

Question 1

Aetiology of wrist arthritis

Answer 1

4IT CASH or Traumatic vs. Atraumatic
Traumatic = more common
1. Fracture = DR/ carpal fracture
2. Ligament injury/ carpal instability = DISI/ VISI
3. Dislocation = perilunate/ lunate dislocation
Atraumatic
1. Idiopathic/ primary
2. Inflammatory = RA/ gout
3. Infective
4. AVN = Kienbock’s/ Preiser’s
5. Positive UV and ulnocarpal abutment = ulnocarpal arthrosis

Question 2

3 main nonoperative options for wrist arthritis

Answer 2

1. NSAIDs
2. Splints
3. Corticosteroid injections = diagnostic and therapeutic

Question 3

3 main groups of surgical options for wrist arthritis

Answer 3

1. Excision = PRC/ trapezectomy/ scaphoidectomy
2. Arthrodesis = 4CF/ limited or complete fusion
3. Arthroplasty

Question 4

Wrist denervation procedure:
Advantages
Disadvantages
Indications
Contraindications
Technique

Answer 4

1. Advantages
   - technically easy
   - fast recovery = no prolonged immobilisation
   - low complication rate
2. Disadvantages
   - low success rate in isolation
3. Indications
   - for pain relief in combination with other procedures
4. Contraindications
   - not recommended as isolated procedure
5. Technique
   - excision of terminal branches of the AIN and PIN
   - pain and proprioceptive fibres to wrist capsule
   - PIN = floor of 4th extensor compartment

Question 5

Proximal row carpectomy (PRC):
Advantages
Disadvantages
Indications
Contraindications
Technique

Answer 5

1. Advantages
   - technically easier
   - faster recovery = no prolonged immobilisation (2wks)
   - lower complication rate = no risk of nonunion
   - better ROM than 4CF = preserves 80% ROM and 60% grip
2. Disadvantages
   - loss of carpal length = weakness and decreased grip
   - risk of instability = ROC of capitate smaller than ROC of lunate resulting in mismatch
3. Indications
   - elderly low-demand patients
4. Contraindications
   - inflammatory arthritis (RA)
   - arthritis of capitate or lunate fossa
   - incompetence of radio-scapho-capitate (RSC) ligament = results in ulnar translocation
5. Technique
   - dorsal approach via 4th extensor compartment
   - radial transposition of EPL
   - excision of lunate then triquetrum then scaphoid (K-wire as joystick)
   - preservation of radiocarpal ligaments esp. RSC ligament

Question 6

Scaphoidectomy and 4 corner fusion:
Advantages
Disadvantages
Indications
Contraindications
Technique

Answer 6

1. Advantages
   - preservation of carpal length = better grip strength
   - lower risk of instability = ROC of lunate better match for lunate fossa
2. Disadvantages
   - more technically demanding
   - slower recovery = 6wks immobilisation
   - higher complication rate = 10% nonunion rate
   - ? less ROM than PRC = preserves 60% ROM and 80% grip
3. Indications
   - active high-demand patients
4. Contraindications
   - inflammatory arthritis (RA)
   - radiolunate arthritis
5. Technique
   - dorsal approach via 4th extensor compartment
   - radial transposition of EPL
   - preservation of dorsal radiocarpal ligament = Berger flap
   - scaphoid excision with K-wire as joystick while preserving volar RSC ligament
   - decortication and preparation of surfaces
   - circular plate fixation

Question 7

Wrist arthrodesis:
Advantages
Disadvantages
Indications
Contraindications
Technique

Answer 7

1. Advantages
   - most reliable procedure for pain relief
   - good grip strength
2. Disadvantages
   - technically demanding
   - slower recovery = 6-8wks immobilisation
   - higher complication rate = see complications
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
   RA wrist = transpose extensor tendons superficial to extensor retinaculum to avoid attrition
   Union rate with plate = 95%

Question 8

Position of wrist fusion

Answer 8

10deg extension and neutral radioulnar deviation
Bilateral wrist arthrodesis is controversial
If bilateral, dominant in 10deg flexion for perineal care and non-dominant in 10deg extension

Question 9

Complications of wrist arthrodesis

Answer 9

1. Approach
   - wound problems
   - infection
   - extensor tendon adhesions and synovitis
2. Arthrodesis
   - incorrect position
   - nonunion (especially 3rd CMC joint)
3. Other
   - CTS = 10% cases
   - adjacent joint disease = DRUJ problems

Question 10

Wrist arthroplasty:
Advantages
Disadvantages
Indications
Contraindications
Technique

Answer 10

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