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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.