Carpal Ligament Surgery: Before Arthritis
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Osteoarthritis of the wrist is predominantly a clinical diagnosis, and thus is primarily based on the patients medical history, physical examination and wrist X-rays.
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Medical history of the patient should include age, hand dominance, occupation and most important an evaluation of recent hand traumas. Examination will often show tenderness at the radioscaphoid joint when palpated or while moving the radioscaphoid joint , dorsal radial swelling and instability of the wrist joint. Younger people may complain about not being able to do push-ups anymore because of a painful hand. Osteoarthritis between the radius bone and the carpals is indicated by a radiocarpal joint space of less than 2mm.
Because SLAC results from scapholunate ligament rupture , there is a larger space between the two bones, also known as the Terry Thomas sign. When the scaphoid is made unstable by either the patient or by manipulation by the examining physician it is a dynamic instability. CT or MRI may be used if there is a strong suspicion for another underlying pathology or disease.
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Post-traumatic wrist osteoarthritis can be treated conservatively or with a surgical intervention. In many patients, a conservative non-surgical approach is sufficient. Because osteoarthritis is progressive and symptoms may get worse, surgical treatment is advised in any stage.
For stage I, normally, nonsurgical treatment is sufficient. This type of therapy includes the use of splint or cast immobilization, injections of corticosteroid in the pain causing joints and the use of a systemic non-steroidal anti-inflammatory drug to reduce pain and improve the functional use of the affected joint.
However, the amount of pain that can be suppressed by nonsurgical therapy is limited and with the progression of the wrist osteoarthritis surgical treatment is inevitable. In stage I surgical treatment often consists of neurectomy of the posterior interosseous nerve and is often combined with other procedures.
In the case of a SLAC, the scapholunate ligament can be reconstructed in combination with a radial styloidectomy, in which the radial styloid is surgically removed from the distal radius. In the case of a SNAC, the scaphoid can be reconstructed by fixating the scaphoid with a screw or by placing a bone graft Matti-Russe procedure to increase the stability of the scaphoid. In the treatment of stage II wrist osteoarthritis, there are two treatment options that have proved to be most successful. The first treatment option is proximal row carpectomy. During this surgical intervention the proximal row of the carpal bones is removed scaphoid, lunate, triquetrum, pisiform.
Patients younger than 40 years have a big chance to develop osteoarthritis in the radiocapitate joint. These patients have longer to live, therefore the incongruence of the joint will exist for a longer time. Thus, in this patient population four-corner arthrodesis is the treatment of first choice. Both procedures are often combined with wrist denervation, as described in the text of treatment stage I. The only treatment option for stage III wrist osteoarthritis is four-corner arthrodesis, as described above in stage II.
Proximal row carpectomy is not an option, because in stage III patients the capitate is already affected by the osteoarthritis. So, this procedure would merely lead to a new painful joint. In this stage there are two surgical treatment options; total wrist arthroplasty and total wrist arthrodesis.
Total wrist arthrodesis has become the standard surgical treatment for patients with stage IV wrist osteoarthritis. During this procedure the carpal bones are all fused together and are then fastened to the distal radius.
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However, the arc of motion is extremely diminished by this type of surgery. The best option for those who wish for a motion-sparing procedure is total wrist arthroplasty.
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However, impact loading should be avoided, an object heavier than 4. Nevertheless, patients with a total wrist arthrodesis on one side and a total wrist arthroplasty on the other, prefer the total wrist arthroplasty. First, the proximal row is removed and the distal row is fastened to the metacarpals. Then, one side of the arthroplasty is placed upon the distal row and the other side on the distal radius.
Additionally, the head of the ulna is removed. From Wikipedia, the free encyclopedia. Wrist osteoarthritis Other names Osteoarthritis of the wrist Specialty Orthopedic Wrist osteoarthritis is a group of mechanical abnormalities resulting in joint destruction, which can occur in the wrist. Further information: Scapholunate ligament. The Journal of Hand Surgery. Scand J Surg. It seeks to analyze, understand, explain and make comprehensible, if not obvious, the reflections that each practitioner should employ during the diagnosis and treatment of carpal ligamentary lesions.
The focus is consciously not on degenerative carpal pathology, which usually enjoys more visibility. We hope that readers will benefit from the fact that fragmented pieces of knowledge are gathered in a single work, that they will find in this initial synthesis an inspiration to rethink a difficult and sometimes thankless surgery and to further the surgical advances of the 21st century. It has by now been established that carpal ligamentary lesions may lead to instability and ultimately to carpal arthritis. Drs Camus and Overstraten have jointly organized the "Wrist Franco-Belgian congress about ligamentary lesions of the wrist before degenerative arthritis", held in April in Tournai Belgium.
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