Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Posttraumatic Radiocarpal Arthritis


Key Points

  • Before embarking for salvage procedures, conservative treatment and corrective osteotomy should have been considered.

  • If these measures are inapplicable or fail, partial or extensive wrist denervation should be considered.

  • Partial or total wrist (TW) arthrodesis or arthroplasty are the next options to be considered, arthroplasties being more suited for the low-demand/elderly patients.

  • If the midcarpal joint is intact, a radioscapholunate (RSL) arthrodesis is another option. In low-demand patients, hemi-arthroplasty might be an alternative.

  • In patients who request a final procedure, or in the case of panarthritis, TW arthrodesis (or as an alternative in the elderly/low-demand patient: TW arthroplasty) is preferred.

Panel 1: Case Scenario

A 26-year-old construction worker sustained an intraarticular distal radial fracture (DRF) in his dominant right hand side. The fracture was conservatively treated and healed with a step-off in the radial joint surface. Some pain remained but this was tolerable and he returned to his previous employment.

Thirteen years later, he complained of increasing wrist pain and episodes of numbness in his radial sided fingers. After carpal tunnel decompression and resection of the terminal posterior interosseous nerve, the symptoms radiating to the fingers disappeared. However, his wrist pain persisted despite a change of profession, use of splints, analgesics, and intraarticular steroid injections. Radiographs revealed moderate osteoarthritis in the radiocarpal joint including the lunate fossa ( Fig. 1 ). How would you counsel him?

Fig. 1, Radiocarpal osteoarthritis 13 years after a distal radial fracture. Preserved midcarpal joint.

Importance of the Problem

Wrist degeneration after intraarticular DRFs is caused either by a direct blow to the cartilage, or joint surface disruption with step-offs and gaps. Joint degeneration can also develop as a result of extra-articular malunited fractures with altered angulations. Concurrent ligament injuries, if present, contribute to carpal incongruence and altered pressure areas.

In younger, nonosteoporotic patients, the prevalence of OA following DRFs has been reported as high as 32%–50% and frequently causes impairment. Ultimately the condition may end in a partial or TW arthrodesis and sometimes in inability for the patient to return to his or her habitual occupation. In elderly, low-demand patients posttraumatic wrist arthritis is better tolerated.

Main Question

Which procedures can we offer to a patient with a painful osteoarthritic wrist after a DRF and which outcomes can we expect?

Current Opinion

Conservative treatment is the first action to be taken in order to relieve the symptoms of painful posttraumatic OA. This includes nonsteroid antiinflammatory drugs, analgesics, cortisone injections, and splinting. There is time to carefully choose the right surgical option since spontaneous improvement of symptoms may occur as time goes by and the wrist stiffens. Some ligament injuries can also stabilize by time and, furthermore, proprioceptive training may reduce symptoms. However, even though splints and orthoses usually work well, they cannot always be used during work and are seldom a long-term solution. If severe symptoms persist, surgical treatment is indicated.

Wrist denervation could be the first surgical move before embarking for salvage procedures. RSL arthrodesis is an option if the midcarpal joint is preserved ( Fig. 2 ). TW arthrodesis is indicated in young patients who want a final solution, or as a salvage procedure in case of RSL failure ( Fig. 3 ). Prosthetic TW replacement is an alternative to TW arthrodesis especially in elderly, low-demand patients ( Fig. 4 ). In recent years, hemi-arthroplasty and interpositional pyrocarbon arthroplasty have been proposed as alternatives. Other salvage procedures for the wrist, including four corner arthrodesis and proximal row carpectomy, are less common options after DRF since a prerequisite for these procedures is an intact lunate facet of the radius. However, these procedures might be advised if the lunate facet is intact, or has been properly restored, while a concurrent scapholunate injury has caused a carpal collapse and subsequent OA.

Fig. 2, Radioscapholunate arthrodesis. In this case, plates and screws were used for fixation and no distal scaphoidectomy was performed.

Fig. 3, Total wrist arthrodesis

Fig. 4, Total wrist arthroplasty.

Prosthetic replacement of the wrist may offer reduction of pain, preserved range of motion, and improved function but the long-term durability in different subgroups of patients is not well established. Although by many considered a panacea, TW arthrodesis is not a guarantee for freedom of pain and return to work.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts