89: Total Wrist Fusion

Procedure 89 Total Wrist Fusion



Jeffrey A. Greenberg


imageSee Video 67: Total Wrist Fusion


We would like to acknowledge Kevin C. Chung, MD, for providing the clinical pictures for this chapter.



Indications




image Painful wrist with limited range of motion (ROM)


image Osteoarthritis, inflammatory arthritis, and posttraumatic arthritis


image Multijoint involvement, radiocarpal and midcarpal


image Failed limited wrist fusions


image Failed soft tissue reconstructions


image Carpal instability patterns


image Patient’s desire for definitive, one-stage treatment


image Contraindications for joint arthroplasty


image Failed arthroplasty



Examination/Imaging



Clinical Examination




image Painful ROM


image Limited ROM


image Decreased grip strength


image May have hypertrophic synovitis


image Visible deformity


image Pain, instability, and crepitus with load


image Associated carpal tunnel syndrome



Imaging




image Plain films are usually sufficient to diagnose degenerative changes at the radiocarpal and midcarpal articulations. Fig. 89-1 shows a patient with scaphoid nonunion advanced collapse.


image

FIGURE 89-1



Surgical Anatomy




image Deformity is frequently encountered.


image Alignment must be corrected, and the wrist must be positioned appropriately.


image Hypertrophic synovitis may obscure bony anatomy.



Positioning




image The patient is placed in a supine position with the affected extremity on a table designed for hand surgery.


image Operative procedures are more easily performed with the surgeon at the head as opposed to being seated at the axilla.



Exposures




image A dorsal midline incision is used, centered at the radiocarpal joint and extending past the midpoint of the long finger metacarpal and proximally, about 5 cm proximal to the Lister tubercle (Fig. 89-2).


image Flaps are elevated, keeping cutaneous nerves in the flaps (Fig. 89-3).


image Incise third dorsal compartment and retract the extensor pollicis longus (EPL) tendon (Fig. 89-4).


image Raise retinacular flaps, exposing the second to fifth extensor compartments.


image The posterior interosseous nerve (PIN) is located on the floor of the fourth extensor compartment. A PIN excision is performed after retracting the extensor tendons.


image A radially based capsular flap is formed by incising the dorsal intercarpal and dorsal radiocarpal ligaments and elevating them off the dorsal triquetrum (Fig. 89-5).


image Subperiosteal dissection is used to expose the dorsal radius, the carpus, and the long finger metacarpal (Fig. 89-6).


image

FIGURE 89-2


image

FIGURE 89-3


image

FIGURE 89-4


image

FIGURE 89-5


image

FIGURE 89-6



Pearls

Related posts:

28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 32: Crossed Intrinsic Tendon Transfer 26: Reconstruction of Key Pinch in Tetraplegia Patients 33: Correction of Swan-Neck Deformity in the Rheumatoid Hand 30: Synovectomy

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 89: Total Wrist Fusion

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