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Wrist Arthrodesis

Volkmann’s ischemic contracture is a complication of compartment syndrome of the forearm. Untreated compartment syndrome results in degeneration of the forearm muscles and nerves resulting in contractures.

It is classified by Holden into Type I and II. In Type the pathology is proximal to the forearm such as a vascular occlusion or injury.

Type I can be mild, moderate or severe.

In the mild type, there is involvement of the deep muscle compartment mainly FDPs to middle and ring fingers. There may be partial involvement of FPL and pronator teres muscles and median nerve.

The moderate type is called the classic type. In this there is involvement of the FDPs, FPL and pronator teres. Median nerve is involved and there may be partial involvement of the ulnar nerve. The hand is in an ‘intrinsic minus’ posture.

In the severe type all flexors and pronators are involved with partial or total involvement of the extensors and instrinsics. Median and ulnar nerves are involved. The hand is in an intrinsic minus posture. Median and ulnar nerves are involved. Soft tissue coverage may be tight.

In Type II the muscle injury is limited to the site of direct trauma. The extent of muscle injury is usually limited to the forearm compartment. There may be damage to the nerves and loss of soft tissue. The extent of the finger deformity is related to the degree of muscle injury.

Corrective surgery for Volkmann’s ischaemic contracture is dependent on the type of contracture and degree of involvement of various muscle compartments. The case discussed here is a Holden Type I severe type from a vascular occlusion in the upper arm. He presented with an acute compartment syndrome which was released but unfortunately it was delayed and there was already muscle necrosis.

He presented with a fixed flexion deformity of the wrist, hypertension at MCP joints of the fingers and flexion at interphalangeal joints. An MCP joint release using dorsal capsulotomy was done initially and a flexor muscle slide was attempted later. Unfortunately both these operations were unsuccessful.

This operation is aimed at correcting the wrist deformity through a total wrist fusion and a later tendon transfer to move the ECRL to FDPs of the fingers. He may also need a fusion of the thumb CMC joint in an anatomical position and a transfer of EIP to FPL.

The steps of a total wrist fusion is explained through this operation.

When performing a total wrist fusion, the radio-carpal joint, capito-lunate joint and third CMC joint are fused. In this case the joints between capitate and hamate and between triquetrum and hamate are also included in the fusion to increase the strength. The distal radio-ulnar joint is left intact which usefully preserves pronation & supination.

Author: Mr Rajive Jose FRCS

Institution : The Queen Elizabeth Hospital ,Birmingham ,UK.

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- Indications:
- painful or unstable wrist joint w/ advanced destruction due to OA, RA, post traumatic arthritis, SLAC wrist, spastic flexion
contracture, degenerative scaphoid non-union, unsuccessful wrist arthroplasty, and Keinbock's dz;
- this procedure is more beneficial for young, active pts or middle aged pts, but not for elderly pts;

- PreOp Considerations:
- in the rheumatoid wrist note that application of a dorsal plate increases the chances of dorsal wound dehiscence;
- ulnocarpal impaction
- if preoperative radiographs demonstrate abutment between between the distal ulna and the triquetrum in addition to loss of
supination, then consider the need for radial lengtening w/ bone graft;
- bone grafting:
- cancellous bone grafting (iliac or local) is sufficient when there is no significant loss of carpal bone stock nor cyst formation;
- cortico-cancellous bone grafting may be indicated w/ severe bone resorption or significant cyst formation
(however, complication rate is higher);
- ROM of other joints:
- remember that the elbow and shoulder joints will have to compensate for loss of wrist motion;

- Dorsal Approach to the Wrist:
- w/ severe deformity, consider wider exposure to the first dorsal compartment inorder to allow excision of the radial styloid;
- individual carpal bones and distal radius are exposed w/ wrist hyperflexion;
- articular cartilage is removed w/ rongeur;
- proximal row carpectomy:
- consider performing a proximal row carpectomy procedure so that the proximal capitate and hamate are fused into the distal
radial surface;
- the proximal row carpectomy is especially indicated for patients with ulnar positive varience, because it eliminates
common occurence of ulnotriquetral impingement following arthrodesis;
- after proximal carpal row is excised, the carpi can be used as bone graft;
- the standard fusion technique then procedes on, using the standard fusion plate;
- references:
- Capitate-radius arthrodesis: an alternative method of radiocarpal arthrodesis.
- Wrist arthrodesis in post traumatic arthritis: a comparison of two methods.
- fusion:
- most surgeons prefer not to fuse the index CMC joint;
- whether to fuse the long CMC joint remains controversial (sparing the joint allows it to participate in power grip);
- ref: AO-wrist arthrodesis: with and without arthrodesis of the third carpometacarpal joint.
- intrinsic compartment release:
- it has been observed that intrinsic tightness in the of the index and long digits is a frequent complication of wrist fusion,
and may be related to occult compartment syndrome;
- to manage this potential problem, consider releasing the dorsal fascial compartments;
- ulnar head:
- in RA consider resection of the ulnar head, and then using it for bone graft;

- Position of Arthrodesis:
- w/ non RA wrist, 10 deg of dorsiflexion is ideal because its allows position for power gripping;
- maximum grip is generated in 35 deg of dorsiflexion but this interferes with ADL's;
- in pts w/ RA (see RA wrist), neutral or flexed position is more desirable;
- position of 5-10 deg of ulnar deviation is perferred in order to counter balance zig zag collapse and ulnar drift;
- note that despite the usual recommendations, some patients will prefer slightly more flexion or extension in the wrist;
- if possible, consider casting the wrist before surgery in extension and the neurtral position to determine which position is
more comfortable for the patient;
- reference:
- The relationship between wrist position, grasp size, and grip strength.

- Methods of Fixation:
- pin Fixation:
- in the report by Rehak DC, et al (2000), the authors compared use of pin fixation vs 3.5 mm reconstruction plate;
- wrists showed a tendency for migration into volar flexion (3-6 deg) from the initial intra-operative position;
- 3.5 mm reconstruction plate:
- in the report by Rehak DC, et al (2000), the authors compared use of pin fixation vs 3.5 mm reconstruction plate;
- technique involved placement of the extensor retinaculum beneath the extensor tendons;
- 3-4 screws are placed in the distal radius and two screws are placed in metacarpal, and if possible one screw in capitate;
- wrists had an average 5 deg of extension and 5 deg of ulnar deviation;
- A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist.
- synthes plate:
- 8 hole titanium, w/ 2.7 mm screws inserted into the distal 4 holes, and 3.5 mm holes in the proximal 4 holes;
- in order to have the wrist in 10 deg of dorsiflexion, a contoured plate is necessary;
- often the dorsal articular lip will have to be sculpted and Lister's tubercle will have to be removed in order to achieve a flat
bed for the plate;
- most often the plate is applied to the long metacarpal so that 3 cortical screws can be inserted into the metacarpal and 4
screws in the radius (often a screw will also be inserted into the capitate)
- in some cases, the plate will be attached to the index metacarpal, if this optimizes the wrist position (for ulnar deviation)
or if it optimizes plate fit;
- in some cases, the plate must be placed obliquely across the dorsal radial surface inorder to get the optimal amount of
ulnar deviation;

- Wound Closure:
- consider detaching the ECRB insertion and then moblizing it over the plate and incorporating it into the capsular closure (this may
help prevent wound dehicience;

- Post Op:
- Volar splint for 2 weeks;
- unionn is usually achieved by 3 months;
- plate is not removed unless it causes symptoms;

- Case Example:

- Complications:
- extensor tenosynovitis most common complication and is related to prominent plate and screws;
- intrinsic contracture;
- carpal tunnel syndrome;
- non union of the CMC joint;
- RU joint instability:
- ulno-carpal abutment:
- reference:
- Ulnocarpal abutment after wrist arthrodesis.

High re-operation and complication rates 11 years after arthrodesis of the wrist for non-inflammatory arthritis

Wrist arthrodesis in paralyzed arms of children.

Wrist arthrodesis in rheumatoid arthritis. A comparison of two methods of fusion.

An in vitro analysis of wrist motion: the effect of limited intercarpal arthrodesis and the contributions of the radiocarpal and midcarpal joints.

Arthrodesis of the Wrist for Post Traumatic Disorders.

Complications following AO/ASIF wrist arthrodesis.

Long-Term Follow-Up Study of Radiocarpal Arthrodesis for the Rheumatoid Wrist.