Rheumatoid Wrist

- See:
        - Caput Ulnae Syndrome
        - Rheumatoid Hand
        - Wrist Arthrodesis

- Discussion:
    - wrist involvement w/ RA is common;
    - findings inlude peri-articular osteoporosis, destructive osteolysis, arthritis of distal RU joint, and carpal arthrosis;
    - final pattern is one of volar & ulnar carpal subluxation, radial deviation of the hand, and intercarpal supination;
    - flexor tendon rupture:
    - extensor tendon rupture:
           - rupture or attenuation of radial wrist extensors;
           - concomitant dorsal tenosynovitis is differentiated from inflammed carpal synovium by noting whether the inflammatory tissue moves as the fingers are flexed and extended;
           - may be due to dislocation of RU joint;
    - radial side:
         - attenuation of radioscapholunate & radiocapitate ligament;
         - joint erosion & progressive capsular stretching results in ulnar displacement of proximal carpal bones w/ secondary radial deviation of hand;
         - radiocarpal joint:
                   - scaphoid & lunate slip into palmar position on radius;
                   - rotation (supination) of carpus on radius
                   - radial metacarpal shift
                   - volar dislocation of carpus beneath radius;
                   - bony erosion of volar carpus
                   - in some cases radius & lunate become spontaneously fused;
                   - rotatory displacement of scapoid and SLD;
                   - DISI deformity may occur because of disruption of scapholunate ligament;
    - ulnar side:
         - attenuation of ulno-carpal ligaments
         - volar displacement of ECU (becomes flexor rather than extensor)
         - volarflexion intercalary segment instability (VISI) pattern may be present because of destruction of ulno-carpal ligament;
         - ulnar translocation:
         - radio-ulnar joint: (see anatomy)
                 - ulnar translocation of carpus
                 - caput ulnae syndrome (dorsal prominence of ulna);
                 - dislocation of RU joint;
                       - results from destructive synovitis involving TFCC;
                       - pain and limitation of motion;
                       - may cause extensor tendon rupture;
    - MP joints

- PreOp Considerations:
    - begin w/ proximal joints first: shoulder > elbow > wrist > hand;
    - begin with predicatabler procedures;
           - carpal tunnel release
           - tenosynovectomy
           - wrist stabilization
           - distal ulnar resection;
    - then begin with less predictable and more complicated surgery;
           - thumb surgery
           - DIP fusion
           - MP arthroplasty
           - PIP arthroplasty etc.

- Treatment Methods:
    - teno-synovectomy:
    - ECRL to ECU transfer:
           - indicated for correctable radial deviation deformity (or wrist supination deformities), especially if there is a loss of active wrist ulnar deviation; (deformity must be passively correctable);
           - frequently MP-ulnar deviation will be present, which may require additional surgery;
           - technique:
                  - standard longitudinal approach to the wrist;
                  - enter dorsal retinaculum thru the ECU tendon sheath;
                  - elevate the retinaculum radially to the second extensor compartment;
                  - isolated the ECRL to the musculotendinous junction, and distal end is freed;
                  - the extensor retinaculum is split and the distal half is passed deep to the tendons and the proximal half is place superficial to the extensor tendons;
                  - ECRL is woven into the ECU (superficial to the extensor tendons and retinaculum);
                  - tension is adjusted until the wrist maintains a neutral position;
           - tendon is passed superficial to the other wrist extensors and is anchored to the ECU with the wrist in a neutral position;
           - references:
                  Tendon transfer for radial rotation of the wrist in rheumatoid arthritis.
                  Radiologic evaluation of the rheumatoid hand after synovectomy and extensor carpi radialis longus transfer to extensor carpi ulnaris.


    - dislocation of RU joint:
           - often due to destructive synovitis of TFFC;
           - may lead to extensor tendon rupture and painful limited motion;
           - treatment options:          
                 - Darrah's procedure with reconstruction of the TFFC and the joint capsule;
                 - Sauve Kapandji
                 - Hemi-resection Arthroplasty of RU Joint

    - radiocarpal arthrodesis:
           - indicated for early radiocarpal volar subluxation (if there is no mid-carpal deformity);

    - wrist arthrodesis:
           - indicated for significant deformity of radiocarpal joint;
           - consider concomitant RU joint arthroplasty;
           - w/ severe deformity, consider wider exposure to the first dorsal compartment in order to allow excision of the radial styloid;
           - carpometacarpal joints are usually not included in the fusion;
           - wrist position:
                  - unlike conventional wrist fusion (performed for traumatic DJD), the rheumatoid wrist should be fused in slight flexion;
                  - remember that the rheumatoid patient will often have difficult with MP extension (not flexion), and therefore, the wrist should be fused in slight flexion to promote extensor tenodesis effect;
           - internal fixation:
                  - dorsal plate may cause wound slough;
                  - consider fixation w/ Steinman pin directed between the index and long web space, through the carpi, and then into the distal radius;
                  - a second pin can be directed from the third web space into the radius;


    - Considerations for Wrist Prosthesis:
           - balance of extensor tendons is of primary importance, esp ECRB;
           - if this tendon is ruptured, there is no effective wrist extension;
           - one should not confuse ECRL or EDC when evaluating for f(x) of ECRB;
           - if active wrist extension does not go beyond neutral, or if there is significant palmar carpal subluxation, integrity of ECRB should be questioned;
           - when ECRB tendon is not intact, wrist arthrodesis is indicated


Long-term results of Swanson silastic arthroplasty in the rheumatoid wrist.

Swanson silicone arthroplasty of the wrist in rheumatoid arthritis: a long-term follow-up.

Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure.

Limited arthrodesis for the rheumatoid wrist.

Results of extensor carpi ulnaris tenodesis in the rheumatoid wrist undergoing a distal ulnar excision

Palmar shelf arthroplasty. A follow-up note.

Palmar shelf arthroplasty in the rheumatoid wrist. Results of long-term follow-up

Extensor digiti minimi tendon transfer to prevent recurrent ulnar drift.

Comparison of arthroplasty and arthrodesis for the rheumatoid wrist.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, September 20, 2012 1:34 pm