Arthritis of the Wrist

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Arthritis of the Wrist
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Goals

• To understand types of wrist arthritis and both
  surgical and non-surgical treatments

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Wrist Arthritis

• Radiocarpal Intercarpal arthritis
• Sequela of trauma
• Distal radius fractures
• Scaphoid fractures
• Intercarpal radiocarpal dislocation
• Scapholunate advanced collapse (SLAC) wrist
• Scaphoid Trapezium Trapezoid arthritis
• Primary osteoarthritis
• uncommon

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Scapholunate Advanced Collapse (SLAC) Wrist
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Scapholunate Advanced Collapse (SLAC) Wrist

• Progressive condition
• Begins with incompetence of the scapholunate
  interosseous ligament
• Follows a predictable radiographic pattern
• Radioscaphoid arthritis followed by capitolunate
  arthritis

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Scapholunate Advanced Collapse (SLAC) Wrist
SLAC wrist with scapholunate widening and
radioscaphoid arthritis
Courtesy of Donald H. Lee, MD
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Scapholunate Advanced Collapse (SLAC) Wrist

• Symptoms
• Activity related pain
• Loss of motion
• Dorsoradial wrist pain
• Clinical findings
• Dorsoradial tenderness
• Scaphoid shift test

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Scapholunate Advanced Collapse (SLAC) Wrist

• Non-operative treatment
• Wrist splints
• NSAIDs
• Activity modification
• Injections

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Scapholunate Advanced Collapse (SLAC) Wrist

• Surgical indications
• Pain refractory to non-operative treatment
• Advanced arthritis

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Scapholunate Advanced Collapse (SLAC) Wrist

• Surgical options
• SLAC wrist reconstruction
• Scaphoid excision with capitate-lunate-hamate-triq
  uetrum fusion (4 corner fusion)
• Proximal row carpectomy
• Wrist arthrodesis
• Wrist arthroplasty

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SLAC Wrist Reconstruction
Scaphoid excision with fusion of
capitate-lunate-hamate-triquetrum
Courtesy of Donald H. Lee, MD
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SLAC Wrist Reconstruction
Post-operative radiographs
Courtesy of Donald H. Lee, MD
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Proximal Row Carpectomy

• Indications
• Radiocarpal arthrosis
• Arthrosis with deformity or malalignment of
• proximal carpus
• Kienböcks disease
• Chronic scapholunate dissociation
• Failed silicone implants
• Scaphoid nonunion
• Requirements
• Normal articular surface of proximal pole of
  capitate and lunate fossa of the distal radius
• Preservation of radioscaphocapitate ligament

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Proximal Row Carpectomy
Patient with Kienböcks disease
Courtesy of Donald H. Lee, MD
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Proximal Row Carpectomy
Excision of scaphoid, lunate, and triquetrum
with preservation of the radioscaphocapitate
ligament (arrow)
Courtesy of Donald H. Lee, MD
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Wrist Arthrodesis

• Indications
• Post-traumatic arthrosis
• Failed previous limited wrist fusion
• Failed arthroplasty
• Paralysis
• Reconstruction
• Tumor
• Infection
• Spastic hemiplegia
• Rheumatoid arthritis

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Wrist Arthrodesis

• Approaches
• Dorsal
• Radial
• Ulnar
• Joints to included in arthrodesis
• Radioscaphoid
• Radiolunate
• Capitolunate
• Ulnocarpal?
• Long finger CMC?

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Wrist Arthrodesis

• Types of Bone Graft
• Iliac crest
• Cancellous
• Local graft
• Allograft
• Synthetic bone graft substitutes
• Position of Fusion
• Extension
• Ulnar deviation

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Wrist Arthrodesis

• Types of Stabilization
• Corticocancellous graft
• K wires
• Plate fixation

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Wrist Arthrodesis
Specialized plate used for wrist arthrodesis
Courtesy of Donald H. Lee, MD
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Scaphoid Nonunion with Wrist Arthritis
Pre-operative radiographs of patient with
scaphoid nonunion
Courtesy of Donald H. Lee, MD
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Wrist Arthrodesis
Intraoperative view
Wrist fusion with dorsal plate
Courtesy of Donald H. Lee, MD
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Wrist Arthrodesis
Post-operative radiographs
Courtesy of Donald H. Lee, MD
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Scaphoid Trapezium Trapezoid Arthritis
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Scaphoid Trapezium Trapezoid Arthritis

• Clinical findings
• Radial sided wrist / hand pain
• Activity related
• Non-operative treatment
• Wrist splints
• NSAIDs
• Activity modification
• Injections

Courtesy of Donald H. Lee, MD
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Scaphoid Trapezium Trapezoid Arthritis

• Surgical indications
• Pain refractory to non-operative treatment
• Advanced arthritis
• Surgical options
• Scaphotrapeziotrapezoid (STT) arthrodesis
• Trapezium excision, interposition arthroplasty

Courtesy of Donald H. Lee, MD
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Rheumatoid Arthritis
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Rheumatoid Arthritis

• Systemic autoimmune disorder
• Chronic systemic erosive
  
  synovitis
• Deformities secondary to synovial hypertrophy and
  inflammation
• Prevalence increases with age
• Womenmen ratio 2.51
• Metacarpophalangeal joint most commonly involved
• Wrist and other upper extremity joints

Rheumatoid Nodules
Courtesy of Donald H. Lee, MD
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Rheumatoid Arthritis

• Synovitis / Arthritis
• Metacarpophalangeal joint
• Wrist
• Shoulder / elbow
• Clinical findings
• Morning stiffness
• Digital and wrist synovitis
• Ulnar drift of fingers
• Radial deviation of wrist

Regional Review Course 1998
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Rheumatoid Arthritis

• Deformities seen
• Tenosynovitis
• Tendon ruptures
• EPL (Listers tubercle)
• Extensor tendons (distal ulna)
• FPL (scaphoid)
• Joint Synovitis
• Joint Arthritis
• Hand deformities

Extensor tenosynovitis
Regional Review Course 1998
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Rheumatoid Arthritis

• Stages of Rheumatoid Joint Involvement
• Stage I - synovitis without deformity
• Stage II - synovitis with passively
  correctable deformity
• Stage III - fixed deformity without joint
  changes
• Stage IV - Articular destruction

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Rheumatoid Arthritis

• Non-operative treatment
• Medical management
• NSAIDs
• Disease remitting agents
• Rest
• Controlled exercises
• Splints
• Finger
• Resting hand splints
• Steroid injections
• Patient education

Resting hand splint
Regional Review Course 1998
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Rheumatoid Arthritis

• Surgical Indications
• Pain relief
• Restoration/improvement of function
• Prevention of deformities
• Improvement of appearance

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Rheumatoid Arthritis

• Surgical options
• Synovectomy
• Tendons
• Joint
• Tendon reconstruction
• Repair
• Adjacent suture
• Intercalated graft
• Tendon transfer
• Wrist
• Arthroplasty
• Arthrodesis
• Distal ulna resection
• Distal radioulnar joint fusion (Suave-Kapanji
  procedure)

Wrist extensor tenosynovitis
Regional Review Course 1998
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Rheumatoid Arthritis
Patient with dorsal wrist tenosynovitis and
prominent distal ulna
Courtesy of Donald H. Lee, MD
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Rheumatoid Arthritis
Extensor tenosynovectomy and distal ulna resection
Courtesy of Donald H. Lee, MD
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Rheumatoid Arthritis
Patient with wrist arthritis and extensor
tenosynovitis
Courtesy of Donald H. Lee, MD
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Rheumatoid Arthritis
Extensor tenosynovectomy, silicone implant
arthroplasty, extensor retinaculum reconstruction
Courtesy of Donald H. Lee, MD
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Rheumatoid Arthritis
Silicone wrist implant with metal grommets
Courtesy of Donald H. Lee, MD
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Rheumatoid Arthritis
Wrist deformity treated with wrist arthrodesis
Regional Review Course 1998
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Rheumatoid Arthritis
Suave-Kapandji procedure
Resection of distal ulnar head
Regional Review Course 1998
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Summary

• Rheumatoid arthritis commonly involves the
  metacarpophalangeal, wrist and other joints of
  the upper extremity
• Non-operative treatment includes the use of
  antinflammatory medications, splints and
  therapeutic modalities
• Surgical treatment includes soft tissue
  reconstruction, arthroplasty and arthrodesis