Rheumatoid Wrist

EpidemiologyRheumatoid Wrist

 

Extremely common

- 90% by 10 years have wrist problems

 

Principles

 

Landsmeer 1961

- treat wrist at same time as treat fingers or will recur

 

Frequently combine procedures

- synovectomy

- tendon transfer

- ulna procedure

 

Treatment Priorities

 

1. Pain Control

2. Slow progression

3. Restore /  Function

4. Cosmetic Improvement

 

Pathology

 

1. Synovitis

 

Starts

- ulna styloid

- ulna head

- scaphoid midportion

 

Radial side 

- synovitis scaphoid midportion

- RCL & RSCL become attenuated 

- subluxation of scaphoid & scapholunate dissociation

- radiocarpal shortening

 

Ulnar side 

- synovitis begins ulna styloid

- TFCC, ULL & UTL attenuated 

- DRUJ stretches

- volar subluxation of ulnar carpus & supination

- develop caput ulna

- ulnar becomes prominent because carpus is falling away from it

- carpus volar translated & supinated

 

Wrist RA

 

2.  Loss of ECU mechanical advantage 

- secondary to supinated carpus & carpal collapse 

- ECU subluxes volar to flexion / extension axis

- increases mechanical advantage of radial wrist extensors 

- radial deviation of carpus 

 

3.  Carpal Collapse

- decreases mechanical advantage of long finger flexors / extensors

- leads to intrinsic plus deformity

 

Rheumatoid WristRheumatoid Wrist Carpal Collapse

 

Failure to address wrist deformity will lead to failure of MP or IP reconstruction

 

Operative Management

 

Indications

 

Failure of optimal rheumatology supervised medical management for 6 months

 

Options

 

Preventative

- synovectomy

- tendon transfers

- CTD

- tendon repairs

 

Salvage

- DRUJ excision

- arthrodesis

- arthroplasty

 

1.  Synovectomy

 

Indications

 

Persistent painful wrist synovitis not settling with medical management

-  > 6/12 

- minimal X-ray changes

 

Advantages

 

1.  Relieves pain

- no evidence synovectomy alone will halt progression of wrist deformity

 

2.  Prevents subsequent tendon rupture

- recurrent tenosynovitis rare

- once one tendon ruptures often followed by multiple ruptures 

- tendon rupture can occur by direct invasion

- seen in up to 50% at time of tenosynovectomy

 

Operations

 

A.  Flexor tenosynovectomy 

 

Often difficult to diagnose

- not as easily seen as dorsally

- patients present with limited active finger flexion / CTS

 

Technique

- through incision of CTD

 

B.  Dorsal Tenosynovectomy + Carpal Synovectomy

 

Clinically

- dumbbell shape under extensor retinaculum dorsally

 

Midline dorsal incision

- divide extensor retinaculum between 5th and 6th extensor compartments (EDM & ECU)

- elevate radially based flap to 1st compartment

- perform partial wrist denervation (PIN in floor of 4th)

 

RCJ & Intercarpal joints exposed 

- use ligament sparing arthrotomy (between DRC and DIC ligaments)

- synovectomy

 

DRUJ exposed through longitudinal incision

- debride

- stabilise if unstable

 

Repair extensor retinaculum underneath tendons to protect bed

 

2.  Tendon Transfer

 

ECRL to ECU insertion 

 

Timing

- at time of synovectomy 

 

Advantages

A.  Corrects a correctable radial deviation deformity

B.  Holds ECU over ulna head

- prevents ulna subluxation

 

3.  CTD

 

Cause

 

Secondary to synovitis

 

Management

- good results with decompression

- usually perform flexor tenosynovectomy at same time

- may wish to examine floor to ensure no bone protruding which may rupture tendons

 

4.  Tendon rupture

 

A.  Extensor tendon rupture

 

Dropped FingersDropped Fingers 1Dropped Fingers 2

 

Sequence

- EDQ > LF > RF > MF > IF > EI

- goes ulna to radial 

- opposite to flexor tendons

 

Cause of rupture

- tenosynovitis

- caput ulna (EDQ)

- EPL over Lister's tubercle

 

Extensor Digiti Quinti / Vaughan-Jackson Syndrome

 

5th dorsal compartment

- can be clinically silent

- EDC and juncturae tendinae compensate

 

Diagnosis

- attempt to hold LF extended whilst other fingers flexed

- indicates that progressive tendon rupture likely and intervention required

 

DDx dropped finger

- extensor tendon subluxation

- MCPJ dislocation

- dislocated extensor tendons

- PIN palsy (can't extend wrist or thumb)

- locked trigger

 

Extensor Tendon transfers

 

LF rupture

- side to side RF

 

LF / RF

- side to side MF

 

LF / RF / MF

- LF / RF to EI

- MF to IF

- or RF FDS to LF / RF

 

LF / RF / MF / EI / IF

- RF & MF FDS

 

B.  Flexor tendon rupture

 

Mannerfelt lesion

- distal pole of scaphoid and trapezium erode through volar capsule

- FPL most common

- FPL / FDP IF / FDS IF / MF

- opposite direction to extensors

 

Management

 

In severe deformity, may wish to fuse wrist to prevent further ruptures

 

Approach

- bed of FCR

- carpal tunnel incision

 

Debride bony prominences

- rotated capsule to cover floor

 

FPL rupture

- fuse IPJ

- young patient transfer FDS IF / RF +/- PL graft

 

IF FDP

- fuse DIPJ

 

IF FDP / FDS

- fuse DIPJ

- MF FDS transfer

 

5.  DRUJ

 

RA Wrist Caput UlnaRA Wrist Caput Ulna 2

 

Clinically

 

Frequently subluxes dorsally

- ECU may also be ruptured

 

Patient presents with pain with rotation

- may have extensor tendon rupture

 

Piano Key sign

- reduce the ulna, it simply redislocates

 

Options

 

A.  Darrach's 

 

Darrach's

 

Principle

- excision arthroplasty

 

Indications

- older patient

 

Technique

- same dorsal approach as for synovectomy

- radial based ER flap

- excise distal ulna

- proximal limit is articulation with sigmoid notch

- usually 1.5 cm

- round off radial side

- stabilise with volar capsule + ECU tenodesis

- can stabilise with Pronator Quadratus

 

Complications

- can be unstable

- even with ECU tenodesis

- revise by ECU / FCU tenodesis + pronator quadratus interposition

- or by further shortening!!!

 

B.  Suave - Kapandji

 

Principle

- fusion DRUJ & ulna pseudoarthrosis

 

Indication

- younger patient

 

Technique

- resection of 10 - 15 mm long segment of ulna proximal to DRUJ

- resect proximal periosteum +/- interposition of pronator quadratus to prevent regrowth

- DRUJ denuded of cartilage

- distal fragment brought slightly proximally to prevent ulno-carpal abutment  

- fuse to distal radius with screws or K wires

- 4 weeks in LA POP in neutral

 

Results

- may have better result than Darrach's in RA

- less instability

 

C.  Hemi-resection arthroplasty 

 

Not usually done in RA

- TFCC and DRUJ soft tissues very poor

- indicated for DRUJ arthritis with good soft tissue stability

 

D.  Arthroplasty

 

6.  Wrist Fusion

 

A.  Partial Wrist Fusion

 

Options

- Radiolunate / Radioscapholunate fusion 

 

Indications

- isolated arthritis

- midcarpal joint spared

 

Results

- usually have to do wrist fusion later

- may maintain some movement for 5 years or so 

 

B.  Total Wrist Fusion

 

Wrist Fusion APWrist Fusion Lateral

 

Advantage

- predictable

- stable and pain free wrist

 

Indications for Arthrodesis

- poor bone stock

- stiff wrist

- loss of wrist extensors

- painful erosive RA

- high demand

 

Techniques

 

A.  Steinmann pin in third MC / Mannerfelt Fusion

 

B.  Plate fixation 

 

RA Wrist Fusion Darrachs APRA Wrist Fusion and Darrachs Lateral

 

Gold standard

- Synthes low profile contoured plate

- 10o degrees extension

- fused to MF metacarpal

- avoid radial deviation

- ulna deviation OK 

 

Bilateral one up one down

 

Complications

- functional difficulties

- i.e. opening jar

 

7.  Arthroplasty

 

Indications

- low demand patient that requires ROM

- intact wrist extensors

- good bone stock

 

Results

 

Millander 1986

- 25% revision rate at 5 years