ARTHRITIS OF WRIST
Primary
osteoarthritis of the wrist is exceedingly rare, and most often wrist arthritis
develops after trauma to the joint. Intra-articular malunion after radius
fracture, scapholunate interrosseous ligament disruption (SLAC), and scaphoid
nonunion (SNAC) all are common causes of articular destruction of the wrist.
SLAC and
SNAC wrist share a common pathophysiology of actual or relative flexion of the
scaphoid and altered loading of the radiocarpal and midcarpal articulations.
There is a defined sequence of arthritic progression first involving the
scaphoid and radial styloid (stage I), involvement of the entire radioscaphoid
joint (stage II), capitolunate degeneration (stage III), and pancarpal
arthritis (stage IV). The radiolunate joint is preserved except in the most
advanced stages of disease. Nonoperative treatment consists of activity modification,
nonsteroidal anti-inflammatory agents, splinting, and judicious use of
intra-articular corticosteroid injection. Operative treatment is reserved for
those who fail conservative treatment and have pain or deformity that limits
their daily activities. Surgical options can be grouped into motion-sparing
versus motion-eliminating procedures. Total wrist fusion is the best option for
the heavy laborer and/or patients with pancarpal degeneration. Patients with
sparing of the midcarpal joint are candidates for proximal row carpectomy,
which is the elimination of the scaphoid, lunate, and triquetrum. Stability is
maintained by the careful preservation of the volar radioscaphocapitate
ligament, and the wrist “runs”
on the newly created radiocapitate articulation. Proximal row carpectomy may
not be appropriate in the young/heavy laborer. When the radiolunate articulation
is preserved, some form of midcarpal fusion can provide excellent pain relief
and acceptable motion. Midcarpal fusion is always accompanied by scaphoid
excision and then is achieved via either capitolunate arthrodesis or four-bone
fusion. Total wrist arthroplasty is a motion-sparing procedure that can provide
excellent pain relief and preserve motion. Current designs are appropriate for the
patient with pancarpal degeneration with low demand for activities requiring
wrist motion.
Radiocarpal
destruction secondary to distal radius malunion can be managed with either
elimination of the radiocarpal joint via radioscapholunate fusion or total
wrist arthrodesis/arthroplasty. Again, the surgical decision is based on
patient factors as well as on direct intraoperative inspection of the
anticipated preserved articulations.
