Arthritis of Wrist PowerPoint Presentation

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Arthritis of the Wrist

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Goals To understand types of wrist arthritis and both surgical and non-surgical treatments

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Wrist Arthritis Radiocarpal – Intercarpal arthritis Sequela of trauma Distal radius fractures Scaphoid fractures Intercarpal – radiocarpal dislocation Scapholunate advanced collapse (SLAC) wrist Scaphoid – Trapezium – Trapezoid arthritis Primary osteoarthritis uncommon

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Scapholunate Advanced Collapse (SLAC) Wrist

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Scapholunate Advanced Collapse (SLAC) Wrist Progressive condition Begins with incompetence of the scapholunate interosseous ligament Follows a predictable radiographic pattern Radioscaphoid arthritis followed by capitolunate arthritis

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Scapholunate Advanced Collapse (SLAC) Wrist SLAC wrist with scapholunate widening and radioscaphoid arthritis Courtesy of Donald H. Lee, MD

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Scapholunate Advanced Collapse (SLAC) Wrist Symptoms Activity related pain Loss of motion Dorsoradial wrist pain Clinical findings Dorsoradial tenderness Scaphoid shift test

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Scapholunate Advanced Collapse (SLAC) Wrist Non-operative treatment Wrist splints NSAIDs Activity modification Injections

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Scapholunate Advanced Collapse (SLAC) Wrist Surgical indications Pain refractory to non-operative treatment Advanced arthritis

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Scapholunate Advanced Collapse (SLAC) Wrist Surgical options SLAC wrist reconstruction Scaphoid excision with capitate-lunate-hamate-triquetrum fusion (4 corner fusion) Proximal row carpectomy Wrist arthrodesis Wrist arthroplasty

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SLAC Wrist Reconstruction Scaphoid excision with fusion of capitate-lunate-hamate-triquetrum Courtesy of Donald H. Lee, MD

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SLAC Wrist Reconstruction Post-operative radiographs Courtesy of Donald H. Lee, MD

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Proximal Row Carpectomy Indications Radiocarpal arthrosis Arthrosis with deformity or malalignment of proximal carpus Kienböck’s disease Chronic scapholunate dissociation Failed silicone implants Scaphoid nonunion Requirements Normal articular surface of proximal pole of capitate and lunate fossa of the distal radius Preservation of radioscaphocapitate ligament

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Proximal Row Carpectomy Patient with Kienböck’s disease Courtesy of Donald H. Lee, MD

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Proximal Row Carpectomy Excision of scaphoid, lunate, and triquetrum with preservation of the radioscaphocapitate ligament (arrow) Courtesy of Donald H. Lee, MD

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Wrist Arthrodesis Indications Post-traumatic arthrosis Failed previous limited wrist fusion Failed arthroplasty Paralysis Reconstruction Tumor Infection Spastic hemiplegia Rheumatoid arthritis

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Wrist Arthrodesis Approaches Dorsal Radial Ulnar Joints to included in arthrodesis Radioscaphoid Radiolunate Capitolunate Ulnocarpal? Long finger CMC?

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Wrist Arthrodesis Types of Bone Graft Iliac crest Cancellous Local graft Allograft Synthetic bone graft substitutes Position of Fusion Extension Ulnar deviation

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Wrist Arthrodesis Types of Stabilization Corticocancellous graft K wires Plate fixation

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Wrist Arthrodesis Specialized plate used for wrist arthrodesis Courtesy of Donald H. Lee, MD

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Scaphoid Nonunion with Wrist Arthritis Pre-operative radiographs of patient with scaphoid nonunion Courtesy of Donald H. Lee, MD

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Wrist Arthrodesis Intraoperative view Wrist fusion with dorsal plate Courtesy of Donald H. Lee, MD

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Wrist Arthrodesis Post-operative radiographs Courtesy of Donald H. Lee, MD

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Scaphoid – Trapezium – Trapezoid Arthritis

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Scaphoid – Trapezium – Trapezoid Arthritis Clinical findings Radial sided wrist / hand pain Activity related Non-operative treatment Wrist splints NSAIDs Activity modification Injections Courtesy of Donald H. Lee, MD

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Scaphoid – Trapezium – Trapezoid Arthritis Surgical indications Pain refractory to non-operative treatment Advanced arthritis Surgical options Scaphotrapeziotrapezoid (STT) arthrodesis Trapezium excision, interposition arthroplasty Courtesy of Donald H. Lee, MD

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Rheumatoid Arthritis

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Rheumatoid Arthritis Systemic autoimmune disorder Chronic systemic erosive synovitis Deformities secondary to synovial hypertrophy and inflammation Prevalence increases with age Women:men ratio – 2.5:1 Metacarpophalangeal joint most commonly involved Wrist and other upper extremity joints Rheumatoid Nodules Courtesy of Donald H. Lee, MD

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Rheumatoid Arthritis Synovitis / Arthritis Metacarpophalangeal joint Wrist Shoulder / elbow Clinical findings Morning stiffness Digital and wrist synovitis Ulnar drift of fingers Radial deviation of wrist Regional Review Course 1998

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Rheumatoid Arthritis Deformities seen Tenosynovitis Tendon ruptures EPL (Lister’s tubercle) Extensor tendons (distal ulna) FPL (scaphoid) Joint Synovitis Joint Arthritis Hand deformities Extensor tenosynovitis Regional Review Course 1998

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Rheumatoid Arthritis Stages of Rheumatoid Joint Involvement Stage I - synovitis without deformity Stage II - synovitis with passively correctable deformity Stage III - fixed deformity without joint changes Stage IV - Articular destruction

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Rheumatoid Arthritis Non-operative treatment Medical management NSAIDs Disease remitting agents Rest Controlled exercises Splints Finger Resting hand splints Steroid injections Patient education Resting hand splint Regional Review Course 1998

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Rheumatoid Arthritis Surgical Indications Pain relief Restoration/improvement of function Prevention of deformities Improvement of appearance

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Rheumatoid Arthritis Surgical options Synovectomy Tendons Joint Tendon reconstruction Repair Adjacent suture Intercalated graft Tendon transfer Wrist Arthroplasty Arthrodesis Distal ulna resection Distal radioulnar joint fusion (Suave-Kapanji procedure) Wrist extensor tenosynovitis Regional Review Course 1998

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Rheumatoid Arthritis Patient with dorsal wrist tenosynovitis and prominent distal ulna Courtesy of Donald H. Lee, MD

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Rheumatoid Arthritis Extensor tenosynovectomy and distal ulna resection Courtesy of Donald H. Lee, MD

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Rheumatoid Arthritis Patient with wrist arthritis and extensor tenosynovitis Courtesy of Donald H. Lee, MD

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Rheumatoid Arthritis Extensor tenosynovectomy, silicone implant arthroplasty, extensor retinaculum reconstruction Courtesy of Donald H. Lee, MD

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Rheumatoid Arthritis Silicone wrist implant with metal grommets Courtesy of Donald H. Lee, MD

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Rheumatoid Arthritis Wrist deformity treated with wrist arthrodesis Regional Review Course 1998

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Rheumatoid Arthritis Resection of distal ulnar head Suave-Kapandji procedure Regional Review Course 1998

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Summary Rheumatoid arthritis commonly involves the metacarpophalangeal, wrist and other joints of the upper extremity Non-operative treatment includes the use of antinflammatory medications, splints and therapeutic modalities Surgical treatment includes soft tissue reconstruction, arthroplasty and arthrodesis