eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Wrist Arthrodesis: Treatment

Author: John J Walsh IV, MD, Associate Professor, Department of Orthopedic Surgery, University of South Carolina School of Medicine
Coauthor(s): Mark Harper, MD, Staff Physician, Department of Orthopedic Surgery, Palmetto Richland Memorial Hospital
Contributor Information and Disclosures

Updated: Jun 25, 2008

Treatment

Medical Therapy

Unfortunately, by the time the patient presents to an orthopedic surgeon, most conservative medical therapies have been attempted.

The mainstay of medical treatment is nonsteroidal anti-inflammatory drugs (NSAIDs). Combined with physical and occupational therapy and activity modification, NSAID therapy can provide a lasting level of pain relief and should be attempted prior to any consideration of arthrodesis.

Mechanical bracing also has efficacy by reducing the amount of movement through the wrist. Specific treatments aimed at disease modification may be indicated for diseases such as rheumatoid arthritis and gout.

Combination intra-articular injection of corticosteroids and local anesthetic can alleviate pain, but the pain almost always recurs. Caution must be observed if corticosteroid treatment is to be used in the rheumatoid joint. The added attritional effects of the corticosteroids combined with weakness of tendons due to inflammation and mechanical stress establish the potential for rupture.

Surgical Therapy

One surgical treatment not involving arthrodesis is particularly useful in the SLAC wrist. The treatment involves partial denervation of the wrist through division of the anterior and posterior interosseous nerves at the level of the wrist through a small dorsal incision, as described by Berger.¹¹ This does not affect the articular changes directly but can reduce symptoms to allow arthrodesis to be postponed or avoided.

The surgical technique depends mainly on the quality of bone substance and degree of joint degeneration. Differences between fusion types include the type of bone graft and osteosynthesis being used. The aim is to create a stable joint in an acceptable functional position. The position of arthrodesis depends on the patient's needs. A neutral position is generally accepted in patients with rheumatoid arthritis, whereas slight wrist extension and ulnar deviation are preferred in patients with degenerative joint disease.^12,13 A stable osteosynthesis with plate fixation is reliable and allows early rehabilitation.

The use of internal fixation has decreased the need for prolonged immobilization in a cast postoperatively and has improved outcomes. Historically, single or multiple screws have been used to hold a cortical bone graft in place in the dorsal aspect of the wrist. The use of a single K-wire to supplement immobilization in a cast has also been described. A technique described for use in patients with rheumatoid arthritis uses a single permanent Steinmann pin advanced retrograde from the third metacarpal into the medullary canal of the radius.

A later modification of this method was the addition of a Rush rod with supplementary staple fixation, eliminating the need for postoperative immobilization in a cast. In fact, the results of a modification of this technique reported by Millender and Nalebuff support the finding that immobilization in a plaster cast is not imperative after wrist arthrodesis in patients with rheumatoid arthritis when internal fixation isused.¹⁴ This technique has also been used for arthrodesis of wrists in individuals with posttraumatic disorders.

Other methods of internal fixation included the use of multiple staples without an intramedullary pin and the technique of placing a pin from the thenar eminence into the medullary canal of the radius without exposing the wrist. The use of dorsal placement of a 9-hole plate from the second metacarpal to the radius with an additional corticocancellous autogenous iliac crest bone graft was first described in 1972. Later, Larsson described a similar technique that used a 6-hole self-compressing plate.¹⁵ By the early 1980s, a larger 8-hole 3.5 mm dynamic compression plate was advocated to provide more appropriate rigid fixation.

Currently, a specifically designed wrist arthrodesis plate is available, which combines a 3.5 mm dynamic compression plate proximally and 2.7 mm dynamic compression plate distally (see Images 5-6). This combination AO-ASIF (Arbeitsgemeinschaft fur Osteosynthesefragen, Association for the Study of Internal Fixation) wrist arthrodesis plate allows for improved and stable fixation by using larger screws in the distal radius and provides reduced risk of metacarpal fracture and fragmentation by using smaller 2.7-mm screws into the metacarpal (see Images 7-8).

Use of this wrist fusion plate yields a high rate of fusion when bone graft is used and, in comparison to other wrist arthrodesis techniques, yields a more predictable rate of fusion.¹⁶ Three versions of the AO wrist fusion plate are available: short carpal bend, long carpal bend, and straight plate. All versions use three 2.7-mm metacarpal screws; one 2.7-mm capitate screw, and four 3.5-mm radius screws.

The use of corticocancellous bone graft from the iliac crest is still advocated to augment the site of the arthrodesis for appropriate osseous consolidation. Slot grafts and onlay grafts create the added physical integrity of corticocancellous grafts. However, data have been reported showing that cancellous bone alone is sufficient for fusion when used with fixation. This has facilitated harvesting cancellous bone from the distal radius, eliminating the need for iliac crest bone graft harvest when limited amounts of graft are needed.

Limited intercarpal arthrodesis can be achieved by either onlay corticocancellous grafts or interpositional cancellous grafts performed through a dorsal exposure. In an attempt to preserve motion, various limited arthrodeses of the carpus have been described. Although these procedures are technically demanding, successful results may be expected, especially in conditions of carpal instability.

The decision as to which carpal bones are to be fused depends on the location and type of pathology. Kienböck disease (avascular necrosis of the lunate) can be treated by fusing the radial aspect of the carpus. An STT arthrodesis stabilizes the carpus and unloads the central column of the wrist.¹⁷ Scapholunate dissociation resulting from rupture of the scapholunate ligament can also be treated with STT fusion. If degenerative changes are evident in the radioscaphoid articulation, then a scaphoid excision and 4-corner (ie, lunate-triquetrum-capitate-hamate) arthrodesis is necessary.^18,19

Preoperative Details

Preoperative radiography, including AP, lateral, oblique, and clenched-fist views, should be obtained. Preoperative laboratory work should include studies that predict healing ability, such as prealbumin, albumin, and absolute lymphocyte count. Blood loss is not of great concern, and cross-matched blood is not generally required. Smoking cessation prior to surgery is critical and should be addressed early in the preoperative planning. The operative extremity should be confirmed with the patient and marked in the holding area by the operating surgeon.

Intraoperative Details

The condition of the articular surfaces and interarticular ligaments should be inspected closely during the operation. Preoperative radiographs and clinical examination may not accurately identify all of the intercarpal joints with significant arthroplasty and/or laxity. Significant pathology in adjacent joints may lead to subtotal arthrodesis to total arthrodesis. Carpal instability in joints not fused must be addressed adequately. In addition, inspection of the extensor tendons may reveal tenosynovitis and possibly impending rupture. Performing an arthrodesis and ignoring tendinopathy is a mistake. The use of the Synthes compression plate can lead to shortening of the carpus and result in ulnar impingement, which should be addressed at the time of fusion. Arthritis of the distal radioulnar joint must also be recognized, and it can be managed surgically by resection of the distal ulna and extensor carpi ulnaris tenodesis stabilization of the distal ulna site.

Postoperative Details

In total wrist arthrodesis, the use of the Synthes 3.5 fusion plate has all but obviated the need for significant postoperative immobilization. A bulky hand dressing is applied with an incorporated volar plaster slab. Subtotal arthrodesis or total arthrodesis using methods other than the Synthes plate require significant postoperative immobilization. Most limited arthrodeses can be immobilized in a short arm cast; however, an STT fusion should be treated with a short-arm thumb spica cast.

As with any hand operation, the central postoperative management necessity is elevation of the extremity and local modalities to prevent postoperative edema.

Follow-up

The dressing is removed 10-14 days postoperatively, and the sutures are removed if the surgical site is healed. Although some authors have questioned the need for postoperative immobilization of the wrist after using a compression fusion plate, most postoperative courses include either a removable plastic wrist splint or short-arm cast for at least 6 weeks postoperatively.

Loss of mobility is of great concern, so occupational hand therapy is started for range of motion of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints as soon as the dressing is removed. However, weightbearing is restricted until radiographic and clinical evidence of fusion is noted. An Isotoner glove can be used to control edema in the hand. Radiographs of the wrist generally are obtained at 3 and 6 weeks, and then every 3 weeks until fusion is obtained.

The internal stabilization in subtotal wrist arthrodesis and in older methods of total wrist arthrodesis generally does not provide the rigid mechanical integrity provided by the Synthes plate. Therefore, postoperative immobilization with a well-constructed splint and later a short-arm cast is required. Care should be taken to allow for motion at the MCP, PIP, and DIP joints. Postoperative care in these situations is similar to that with the Synthes plate, except that the wrist is kept strictly immobilized in a cast until fusion. After fusion, physical therapy is continued to regain partial motion in the wrist.

For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center and Arthritis Center. Also, see eMedicine's patient education article Rheumatoid Arthritis.

Complications

Complications of total wrist arthrodesis are relatively common and range from minor transient problems to major problems, such as wound dehiscence, infection, extensor tendon adhesions, and plate tenderness, which may require implant removal.²⁰ Major complications include pseudarthrosis, deep wound infection, neuroma, and fracture of healed fusion. Minor complications are similar to other operations of the hand and include transient nerve palsy and superficial skin necrosis.²¹

A complication related to plate use is fracture at the ends of the fusion plate; therefore, some authors recommend removal of the plate after solid healing.²² A recognized potential complication of using compression plating is the possibility of impingement between the ulnar head and the carpus. This occurs secondary to the relative shortening across the radiocarpal joint after decorticating bone and obtaining joint surface apposition. Carefully check for impingement intraoperatively and, if present, treat by some form of ulnar shortening (distal or diaphyseal).

Specific wrist fusion complications include the following:

• Nonunion
• Plate tenderness
• Extensor/flexor tendon adhesions requiring tenolysis
• Carpal tunnel syndrome
• Iliac crest donor complications
• Distal radioulnar joint pain or dysfunction
• Reflex sympathetic dystrophy
• Wound-healing problems
• Persistent unexplained pain

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