Wrist Arthrodesis Periprocedural Care

Updated: Mar 25, 2019
  • Author: John J Walsh, IV, MD; Chief Editor: Harris Gellman, MD  more...
  • Print
Periprocedural Care

Preprocedural Planning

History and physical examination

The history is simple and specific. The patient reports pain in one or both wrists. He or she may recall a history of trauma to the affected wrist or have a related diagnosis such as rheumatoid arthritis [35]  or gout. The patient's pain is usually progressive and, at the time of presentation to an orthopedic surgeon, has already been treated conservatively. The pain is usually exacerbated with use and relieved with rest and nonsteroidal anti-inflammatory drugs (NSAIDs). The patient may have swelling and stiffness associated with the wrist pain.

Preoperatively, patients should be assessed for the presence of carpal tunnel syndrome, distal radioulnar joint arthritis, or ulnocarpal impaction syndrome, which may become or remain symptomatic after arthrodesis.

On physical examination, painful range of motion of the wrist is present. Soft-tissue swelling or an effusion may be noted around the wrist. Provocative testing of the carpus may reveal instability or laxity of the intercarpal ligaments. The patient usually has decreased range of motion of the wrist due partly to a mechanical block and partly to pain.

Laboratory studies

Preoperative laboratory work should include studies that predict healing ability, such as prealbumin, albumin, and absolute lymphocyte count. Prealbumin results should be above 18 mg/dL for normal wound healing. The absolute lymphocyte count should be greater than 1500/μL for normal wound healing. Blood loss is not of great concern, and cross-matched blood is not generally required.

Imaging studies

Radiography

Preoperative radiography, including anteroposterior [AP], lateral, oblique, and clenched-fist views, should be obtained. (See the images below.) Radiographs of the wrist reveal changes consistent with arthropathy and arthritis. The standard three views of the wrist should identify the intracarpal and intercarpal joints with arthrosis. Radiographs should be examined for the following:

  • Loss of joint intervals
  • Subchondral reactive bone formation
  • Subchondral cysts
  • Osteophyte formation
Wrist arthrodesis. Posteroanterior wrist radiograp Wrist arthrodesis. Posteroanterior wrist radiograph demonstrating marked radiolunate degenerative joint disease. Either radioscapholunate fusion or total wrist fusion is appropriate treatment.
Wrist arthrodesis. Lateral wrist radiograph depict Wrist arthrodesis. Lateral wrist radiograph depicting marked wear in radiocarpal articulation.

Particular attention should be paid to joints that are not going to be fused, such as the distal radioulnar joint and the thumb, index, ring, and small finger carpal-metacarpal joints. Pain from arthropathy in these joints is not affected by fusion and can lead to suboptimal outcome. Contralateral wrist radiography can be used to assess ulnar variance of the pathologic side. Standard radiography with three views of the wrist (AP, lateral, oblique) is necessary to determine which of the carpal articulations is involved and the extent of any such involvement.

Scaphoid view radiography should be obtained to determine whether an occult nonunion of the scaphoid exists.

The clenched-fist view stresses the intercarpal ligaments and may reveal an incompetent scapholunate ligament. Failure to address this problem at operation results in the failure of a scaphotrapeziotrapezoidal (STT) fusion.

Computed tomography

On the rare occasions when plain radiography appears to be inadequate to identify all of the bony pathology accurately, computed tomography (CT) of the wrist can be helpful by exposing malalignment of bony columns and underlying arthropathy.

Next:

Patient Preparation

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.

Previous
Next:

Monitoring & 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; accordingly, 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.

Previous