1. Rheumatoid Wrist and Extensor Tendons Mr P R Stuart FRCS Freeman Hospital Newcastle upon Tyne HAND SURGERY REVISION COURSE - QMC Nottingham

2. Incidence 90% patients have wrist & digital disease Wrist ‘joint’ includes –radiocarpal –midcarpal –carpometacarpal –distal radioulnar –(forearm)

3. Chain of Articulations weakening of soft tissue support predictable collapse patterns painful & deformed wrist decreased hand function with or without digital disease

4. The ‘Classic’ Posture palmar & ulnar carpal subluxation supination of the carpus prominent distal ulnar radial deviation of the carpus ulnar deviation of the fingers

5. Functional Anatomy (radiocarpal) Capsular and ligamentous anatomy –dorsal thinner than volar intrinsic and extrinsic ligaments dynamic support from extrinsic tendons

6. Functional Anatomy (radiocarpal) Intercalated bone in a bimuscular, biarticular system control by –flexor tendons –extensor tendons –scaphoid zigzag collapse in three link system with only two controls

7. Functional Anatomy (DRUJ) ECU tendon and sheath important –active in flexion and extension –sheath attenuates –tendon subluxes destroyed from within by synovial tissue

8. Pathomechanics of Collapse Expanding synovium weakening and expansion of intrinsic and extrinsic ligament systems articular cartilage destruction weakening of carpal bones as carpal height reduces deformity is inevitable

9. Pathomechanics of Collapse Zigzag collapse in two planes –flexion / extension –radial / ulnar deviation VISI deformity concavity apparent on dorsum of wrist

10. Clinical Signs early loss of wrist extension synovitis palpable in snuffbox + DRUJ late progression to deformity

11. Radiological Signs Ulnar styloid and head

12. Radiological Signs notching of radial aspect of scaphoid scapholunate diastasis cyst or ‘geode’ formation

13. Radiological Signs

14. Grading / Classification (Larsen) Stage 0 = normal joint Stage 1 = soft tissue swelling and narrowing of some joint spaces Stage 2 = several small erosions and distinct narrowing of the joint spaces Stage 3 = multiple larger erosions with marked narrowing of the joint spaces Stage 4 = multiple severe erosions with severe destructive abnormality. Only minor parts of the articular surfaces remain. Stage 5 = complete destruction of the proximal and distal articulating joint surface area

15. Grading / Classification (Larsen)

16. Staging - The Schulthess Classification type I - ankylosis –‘stiffeners, spontaneous fusion, don’t collapse type II - secondary arthrosis –sclerosis, osteophyte formation, rarely collapse type III - joint disorganization –instability, subluxation, carpal collapse

17. Staging - The Schulthess Classification Type I - ankylosis stiffeners, spontaneous fusion, don’t collapse

18. Staging - The Schulthess Classification Type II secondary arthrosis –sclerosis, osteophyte formation, rarely collapse

19. Staging - The Schulthess Classification Type III - joint disorganization instability, subluxation, carpal collapse

20. Treatment Options splinting and joint protection –crutches –slight extension, neutral deviation –injections - symptomatic relief only

21. Treatment Options surgery –synovectomy –tendon transfers –arthroplasty –arthrodesis

22. Surgery - General Indications disabling pain non-responsive to medical management deformity or instability impairing function progressive deformity (prophylaxis) persistent active non-responsive synovitis

23. Synovectomy difficult to achieve clearance good short term pain relief some increased stability long term result depends on disease type and control with medication open / endoscopic

24. Tendon Transfer ERCL to ECU –joint subluxation with preserved articular surfaces dorsal wrist capsulodesis and / or synovectomy relieves deforming force, stabilises ECU

25. Arthrodesis gold standard’ operation only possible surgery in many cases partial vs. total pin vs. plate distal ulna

26. Arthrodesis Chamay & Della Santa 1983 - radio-lunate fusion poor long term results limited indications

27. Arthrodesis Total fusion –reliable, simple, fast –position (pin vs plate) –immobilisation –complications

28. Arthroplasty careful patient selection high failure / complication rates reported spacer vs. total joint aim for limited ROM dominant or non-dominant

29. Arthroplasty Biax total wrist arthroplasty

30. Arthroplasty Swanson interposition arthroplasty

31. Distal Radioulnar Joint Darrach Sauve-Kapandji HIT Bowers

32. Extensor Tendons anatomy pathology –tenosynovitis caput ulnae clinical presentation

33. Extensor Tendons synovectomy distal ulnar resection intra / extra tendon disease decompression ECU - relocation

34. Rupture differential diagnosis from ulnar side no set pattern for reconstruction ulnar & radial side –‘grip’ ‘manipulation’

35. Rupture repair - no grafting - seldom ‘buddying’ transfer –EIP –FDS III (through / round)

36. Rehabilitation tailor to patient depends on procedure early mobilisation ? Outriggers adjacent strapping care with walking aids mixed results

37. Further Reading Brian Adams, AAOS symposium 2002 www.aaos.org/wordhtml/anmt2002/sympos ia/symv.pdf This lecture (and some others from the course) www.stuart-orthopaedics.co.uk/Seminar % 20List.htm