Wrist osteoarthritis

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Wrist osteoarthritis
Other namesOsteoarthritis of the wrist
Osteo of the hand.jpg
Specialty Orthopedic

Wrist osteoarthritis is gradual loss of articular cartilage and hypertrophic bone changes (osteophytes). While in many joints this is part of normal aging (senescence), in the wrist osteoarthritis usually occurs over years to decades after scapholunate interosseous ligament rupture or an unhealed fracture of the scaphoid. Characteristic symptoms including pain, deformity and stiffness. Pain intensity and incapability (limited function) are notably variable and do not correspond with arthritis severity on radiographs.

Contents

Osteoarthritis of the wrist can be idiopathic, but it is mostly seen as a post-traumatic condition. [1] [2] There are different types of post-traumatic osteoarthritis. Scapholunate advanced collapse (SLAC) is the most common form, followed by scaphoid non-union advanced collapse (SNAC). [3] Other post-traumatic causes such as intra-articular fractures of the distal radius or ulna can also lead to wrist osteoarthritis, but are less common.

Types

Scapholunate advanced collapse SLAC.jpg
Scapholunate advanced collapse

SLAC and SNAC are two patterns of wrist osteoarthritis, following predictable patterns depending on the type of underlying injury. SLAC is caused by scapholunate ligament rupture, and SNAC is caused by a scaphoid fracture which does not heal non-union.

SLAC is more common than SNAC; 55% of the patients with wrist osteoarthritis have a SLAC wrist. [3]

SLAC

Scapholunate advanced collapse (SLAC) is a predictable pattern of wrist osteoarthritis that results from untreated long-standing scapholunate ligament rupture and the associated carpal malalignment. [4] The misalignment is described as dorsal intercalated segment instability (DISI) which is where the lunate angulates towards the dorsal side of the hand. [2] [5]

SNAC

Scaphoid nonunion advanced collapse SNAC.jpg
Scaphoid nonunion advanced collapse

Scaphoid fracture non-union changes the shape of the scaphoid bone and results in DISI malalignment. [2] [5] Scaphoid Non-union Advanced collapse (SNAC) is the pattern of osteoarthritis that develops in relation to the malalignment.

Stages

Post-traumatic osteoarthritis can be classified into four stages. [1] [6] These stages are similar between SLAC and SNAC wrists. Each stage has a different treatment.

Signs and symptoms

The most common initial presenting symptom of wrist osteoarthritis is joint pain. [7] [8] Other signs and symptoms, as with any joint affected by osteoarthritis, include:

These symptoms can lead to loss of function and less daily activity. [7]

Mechanism

Hand carpal bones.jpg
Anatomy wrist Hand normaal.jpg
Anatomy wrist

In order to understand the cause of post-traumatic wrist osteoarthritis it is important to know and understand the anatomy of the wrist. The hand is subdivided into three parts:[ citation needed ]

The wrist consists of eight small carpal bones. Each of these carpal bones has a different size and shape. They contribute towards the stability of the wrist and are ranked in two rows, each consisting of four bones.[ citation needed ]

Proximal row

From lateral to medial and when viewed from anterior, the proximal row is formed by the:[ citation needed ]

Distal row

From lateral to medial and when viewed from anterior, the distal row is formed by the:

Diagnosis

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. [2]

Medical history

The person may or may not recall an old wrist injury. [7]

Physical examination

Examination may identify limited passive wrist motion, pain at the extremes of wrist motion, tenderness at the radioscaphoid joint, and dorsal radial prominence. [2] Activities that use forceful wrist extension such as rising from a chair or push-ups may be painful.
In the absence of gout, chondrocalcinosis, rheumatoid arthritis, or prior distal radius fracture, a person with gradual onset limited motion and pain in the wrist likely has wrist osteoarthritis.[ citation needed ]

X-rays

Radiographs can confirm the diagnosis of wrist osteoarthritis. The earliest sign is narrowing of the joint space between the radius and the scaphoid and an osteophyte off the tip of the radial styloid. [9]

SLAC

Because SLAC results from scapholunate ligament rupture, there is a larger space between the two bones, also known as the Terry Thomas sign. [10] Scaphoid instability due to the ligament rupture can be stactic or dynamic. [11] When the X-ray is diagnostic and there is a convincing Terry Thomas sign it is a static scaphoid instability. When the scaphoid is made unstable by either the patient or by manipulation by the examining physician it is a dynamic instability. [11]

SNAC

In order to diagnose a SNAC wrist you need a PA view X-ray and a lateral view X-ray. As in SLAC, the lateral view X-ray is performed to see if there is a DISI. [12] Computed tomography (CT) or Magnetic Resonance Imaging (MRI) are rarely used to diagnose SNAC or SLAC wrist osteoarthritis because there is no additional value. [7] Also, these techniques are much more expensive than a standard X-ray. CT or MRI may be used if there is a strong suspicion for another underlying pathology or disease. [7]

Treatment

Post-traumatic wrist osteoarthritis can be accommodated. A wrist splint, ice, acetaminophen, and NSAIDs may alleviate symptoms. Surgery to change the wrist anatomy to attempt to alleviate pain is an option. [1] [13] [2] [6]

Stage I

For stage I, normally, nonsurgical treatment is sufficient. Injections of corticosteroid may be considered. Keep in mind that corticosteroids provide, at best, temporary alleviation of discomfort. And corticosteroid injection harms cartilage. Since people with Stage 1 arthritis have good cartilage, one might be cautious with corticosteroid injection.

Surgical options for mild arthritis may include neurectomy of the anterior and posterior interosseous nerves, or radial styloidectomy, in which the radial styloid is surgically removed from the distal radius.

Stage II

The surgical options for stage II and III wrist osteoarthritis are excision of some of the bones with or without fusion (arthrodesis) of the others. The idea is to try to alleviate pain while maintaining some wrist motion.

One technique is to remove one row of carpal bones. The bones closer to the forearm (proximal) are removed: scaphoid, lunate, and triquetrum. [14] It is important that the radioscaphocapitate ligament is left intact, because if the ligament is not preserved the capitate bone will translate to the ulnar side of the wrist and move away from the distal radius. [1] [15]

The new articulation of the capitate with the lunate fossa of the distal radius is not as congruent as the former scaphoid-lunate-radius joint. [16] [17] This and other issues contribute to potential to develop arthritis over the years. In part based on these concerns, some surgeon prefer to maintain the lunate in patients younger than 40 years proximal row carpectomy. [6] [18]

A surgery called four-corner arthrodesis is an option. [6] The capitate, lunate, hamate and triquetrum are fused together in this procedure and the scaphoid is excised. [1] [14] Before the arthrodesis is executed, the lunate must be reduced out of DISI position. [14] Because the radiolunate joint is typically preserved in stage II SLAC and SNAC wrists, this joint can be the only remaining joint of the proximal wrist. Both procedures are often combined with wrist denervation, as described in the text of treatment stage I.[ citation needed ]

Stage III

In Stage III wrist osteoarthritis, some surgeons offer patients proximal row carpectomy and interpose some of the wrist capsule to account for the arthritis in the capitate. Four-corner arthrodesis, as described above in stage II, is also an option.

Stage IV

In this stage there are two surgical treatment options; total wrist arthroplasty and total wrist arthrodesis. Total wrist arthrodesis is 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. [14] This procedure eliminates all wrist motion, but heavy labor is still possible. [19]

An option for people who want to maintain some motion, and are willing to avoid using force with the hand, is total wrist arthroplasty. [20] There is some evidence that patients with a total wrist arthrodesis on one side and a total wrist arthroplasty on the other, prefer the total wrist arthroplasty. [21] The procedure exists of a couple of elements. 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. [14] Arthroplasty can have problems that may lead to another surgery.

Related Research Articles

<span class="mw-page-title-main">Carpal bones</span> Eight small bones that make up the wrist (or carpus) that connects the hand to the forearm

The carpal bones are the eight small bones that make up the wrist (carpus) that connects the hand to the forearm. The term "carpus" and "carpal" is derived from the Latin carpus and the Greek καρπός (karpós), meaning "wrist". In human anatomy, the main role of the carpal bones is to articulate with the radial and ulnar heads to form a highly mobile condyloid joint, to provide attachments for thenar and hypothenar muscles, and to form part of the rigid carpal tunnel which allows the median nerve and tendons of the anterior forearm muscles to be transmitted to the hand and fingers.

<span class="mw-page-title-main">Wrist</span> Part of the arm between the lower arm and the hand

In human anatomy, the wrist is variously defined as (1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand; (2) the wrist joint or radiocarpal joint, the joint between the radius and the carpus and; (3) the anatomical region surrounding the carpus including the distal parts of the bones of the forearm and the proximal parts of the metacarpus or five metacarpal bones and the series of joints between these bones, thus referred to as wrist joints. This region also includes the carpal tunnel, the anatomical snuff box, bracelet lines, the flexor retinaculum, and the extensor retinaculum.

<span class="mw-page-title-main">Trapezoid bone</span> Carpal (wrist) bone

The trapezoid bone is a carpal bone in tetrapods, including humans. It is the smallest bone in the distal row of carpal bones that give structure to the palm of the hand. It may be known by its wedge-shaped form, the broad end of the wedge constituting the dorsal, the narrow end the palmar surface; and by its having four articular facets touching each other, and separated by sharp edges. It is homologous with the "second distal carpal" of reptiles and amphibians.

<span class="mw-page-title-main">Scaphoid bone</span> Bone of the carpus

The scaphoid bone is one of the carpal bones of the wrist. It is situated between the hand and forearm on the thumb side of the wrist. It forms the radial border of the carpal tunnel. The scaphoid bone is the largest bone of the proximal row of wrist bones, its long axis being from above downward, lateralward, and forward. It is approximately the size and shape of a medium cashew nut.

<span class="mw-page-title-main">Capitate bone</span> Carpal bone in the wrist

The capitate bone is a bone in the human wrist found in the center of the carpal bone region, located at the distal end of the radius and ulna bones. It articulates with the third metacarpal bone and forms the third carpometacarpal joint. The capitate bone is the largest of the carpal bones in the human hand. It presents, above, a rounded portion or head, which is received into the concavity formed by the scaphoid and lunate bones; a constricted portion or neck; and below this, the body. The bone is also found in many other mammals, and is homologous with the "third distal carpal" of reptiles and amphibians.

<span class="mw-page-title-main">Hamate bone</span> Carpal bone in the wrist

The hamate bone, or unciform bone, Latin os hamatum and occasionally abbreviated as just hamatum, is a bone in the human wrist readily distinguishable by its wedge shape and a hook-like process ("hamulus") projecting from its palmar surface.

<span class="mw-page-title-main">Lunate bone</span> Carpal bone in the human hand

The lunate bone is a carpal bone in the human hand. It is distinguished by its deep concavity and crescentic outline. It is situated in the center of the proximal row carpal bones, which lie between the ulna and radius and the hand. The lunate carpal bone is situated between the lateral scaphoid bone and medial triquetral bone.

<span class="mw-page-title-main">Distal radius fracture</span> Fracture of the radius bone near the wrist

A distal radius fracture, also known as wrist fracture, is a break of the part of the radius bone which is close to the wrist. Symptoms include pain, bruising, and rapid-onset swelling. The ulna bone may also be broken.

<span class="mw-page-title-main">Kienböck's disease</span> Medical condition

Kienböck's disease is a disorder of the wrist. It is named for Dr. Robert Kienböck, a radiologist in Vienna, Austria who described osteomalacia of the lunate in 1910.

<span class="mw-page-title-main">Carpometacarpal joint</span>

The carpometacarpal (CMC) joints are five joints in the wrist that articulate the distal row of carpal bones and the proximal bases of the five metacarpal bones.

<span class="mw-page-title-main">Madelung's deformity</span> Medical condition

Madelung's deformity is usually characterized by malformed wrists and wrist bones and is often associated with Léri-Weill dyschondrosteosis. It can be bilateral or just in the one wrist. It has only been recognized within the past hundred years. Named after Otto Wilhelm Madelung (1846–1926), a German surgeon, who described it in detail, it was noted by others. Guillaume Dupuytren mentioned it in 1834, Auguste Nélaton in 1847, and Joseph-François Malgaigne in 1855.

<span class="mw-page-title-main">Intercarpal joints</span> Joints of the carpal bones of the wrist

The intercarpal joints can be subdivided into three sets of joints : Those of the proximal row of carpal bones, those of the distal row of carpal bones, and those of the two rows with each other.

<span class="mw-page-title-main">Triangular fibrocartilage</span> Anatomical feature in the wrist

The triangular fibrocartilage complex (TFCC) is formed by the triangular fibrocartilage discus (TFC), the radioulnar ligaments (RULs) and the ulnocarpal ligaments (UCLs).

<span class="mw-page-title-main">Midcarpal joint</span>

The midcarpal joint is formed by the scaphoid, lunate, and triquetral bones in the proximal row, and the trapezium, trapezoid, capitate, and hamate bones in the distal row. The distal pole of the scaphoid articulates with two trapezial bones as a gliding type of joint. The proximal end of the scaphoid combines with the lunate and triquetrum to form a deep concavity that articulates with the convexity of the combined capitate and hamate in a form of diarthrodial, almost condyloid joint.

<span class="mw-page-title-main">Scaphoid fracture</span> Fracture of the scaphoid bone in the wrist

A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally includes pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include nonunion of the fracture, avascular necrosis of the proximal part of the bone, and arthritis.

<span class="mw-page-title-main">Carpal tunnel</span> Structure of human wrist

In the human body, the carpal tunnel or carpal canal is the passageway on the palmar side of the wrist that connects the forearm to the hand.

<span class="mw-page-title-main">Scapholunate ligament</span>

The scapholunate ligament is a ligament of the wrist.

Watson's test, also known as the scaphoid shift test, is a diagnostic test for instability between the scaphoid and lunate bones of the wrist.

<span class="mw-page-title-main">Trapeziometacarpal osteoarthritis</span> Medical condition

Trapeziometacarpal osteoarthritis (TMC OA) is, also known as osteoarthritis at the base of the thumb, thumb carpometacarpal osteoarthritis, basilar (or basal) joint arthritis, or as rhizarthrosis. This joint is formed by the trapezium bone of the wrist and the metacarpal bone of the thumb. This is one of the joints where most humans develop osteoarthritis with age. Osteoarthritis is age-related loss of the smooth surface of the bone where it moves against another bone (cartilage of the joint). In reaction to the loss of cartilage, the bones thicken at the joint surface, resulting in subchondral sclerosis. Also, bony outgrowths, called osteophytes (also known as “bone spurs”), are formed at the joint margins.

<span class="mw-page-title-main">Dorsal intercalated segment instability</span>

Dorsal intercalated segment instability (DISI) is a deformity of the wrist where the lunate bone angulates to the dorsal side of the hand.

References

  1. 1 2 3 4 5 Weiss, KE; Rodner, CM (May–June 2007). "Osteoarthritis of the Wrist, Review article". The Journal of Hand Surgery. 32A (5): 725–46. doi:10.1016/j.jhsa.2007.02.003. PMID   17482013. S2CID   5821652.
  2. 1 2 3 4 5 6 Shah, CM; Stern PJ (2013). "Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist arthritis". Curr Rev Musculoskelet Med. 6 (1): 9–17. doi:10.1007/s12178-012-9149-4. PMC   3702758 . PMID   23325545.
  3. 1 2 Bisneto EN, Freitas MC, Paula EJ, Mattar R, Zumiotti AV (2011). "Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study". Clinics (Sao Paulo). 66 (1): 51–5. doi:10.1590/s1807-59322011000100010. PMC   3044580 . PMID   21437436.
  4. ↑ Tischler, Brian T.; Diaz, Luis E.; Murakami, Akira M.; Roemer, Frank W.; Goud, Ajay R.; Arndt, William F.; Guermazi, Ali (2014). "Scapholunate advanced collapse: a pictorial review". Insights into Imaging. 5 (4): 407–417. doi:10.1007/s13244-014-0337-1. ISSN   1869-4101. PMC   4141341 . PMID   24891066.
  5. 1 2 Omori, S; Moritomo, H; Omokawa, S; Murase, T; Sugamoto, K; Yoshikawa, H (July 2013). "In vivo 3-dimensional analysis of dorsal intercalated segment instability deformity secondary to scapholunate dissociation: a preliminary report". The Journal of Hand Surgery. 38 (7): 1346–55. doi:10.1016/j.jhsa.2013.04.004. PMID   23790423.
  6. 1 2 3 4 Strauch, RJ (Apr 2011). "Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis--update on evaluation and treatment". The Journal of Hand Surgery. 36 (4): 729–735. doi:10.1016/j.jhsa.2011.01.018. PMID   21463735.
  7. 1 2 3 4 5 Sinusas, K (2012). "Osteoarthritis: diagnosis and treatment". Am Fam Physician. 85 (1): 49–56. PMID   22230308.
  8. 1 2 Manek, NJ; Lane NE (2000). "Osteoarthritis: current concepts in diagnosis and management". Am Fam Physician. 61 (6): 1795–804. PMID   10750883.
  9. ↑ "Radiocarpal joint space". radref.org. Retrieved 2017-01-18.
  10. ↑ Wolfe, SW; Hotchkiss, RN (2011). Green's Operative Hand Surgery, 6th Edition (6th ed.). Churchill Livingstone. ISBN   978-1-4160-5279-1.
  11. 1 2 Jupiter, JB; Edwards, JE (1991). Flynn's hand surgery, fourth edition; chapter 10 dislocations and fracture dislocations of the carpus (4th ed.). Baltimore: Williams&Wilkins. pp. 198–199. ISBN   978-0-683-04490-4.
  12. ↑ Novelline, RA (2004). Squire's fundamentals of radiology, 6th Edition (6th ed.). United States of America: President and fellows of Harvard college. ISBN   978-0-674-01279-0.
  13. ↑ Talwalkar, SC; Hayton MC; Stanley JK (2008). "Wrist osteoarthritis". Scand J Surg. 97 (4): 305–9. doi: 10.1177/145749690809700406 . PMID   19211384. S2CID   43701956.
  14. 1 2 3 4 5 Berger, RA; Weiss, APC (2004). Hand surgery, first edition; Principles of Limited Wrist Arthrodesis (1st ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 1290–1295, 1320–1329, 1352–1373. ISBN   978-0-7817-2874-4.
  15. ↑ Berger, RA; Landsmeer, JM (1990). "The palmar radiocarpal ligaments: a study of adult and fetal hunman wrist joints". The Journal of Hand Surgery. 15 (6): 847–854. doi:10.1016/0363-5023(90)90002-9. PMC   2328843 . PMID   2269772.
  16. ↑ Inglis, AE; Jones, EC (1977). "Proximal row carpectomy for diseases of the proximal row". The Journal of Hand Surgery. 59A (4): 460–463. PMID   863938.
  17. ↑ Imrbiglia, JE; Broudy, AS; Hagberg, WC (1990). "Proximal row carpectomy: clinical evaluation". The Journal of Hand Surgery. 15 (3): 426–430. doi:10.1016/0363-5023(90)90054-U. PMID   2348060.
  18. ↑ Wall, LB; DiDonna, ML (Aug 2013). "Proximal row carpectomy: minimum 20-year follow-up". The Journal of Hand Surgery. 38 (8): 1498–1504. doi:10.1016/j.jhsa.2013.04.028. PMID   23809467.
  19. ↑ Weiss, APC; Hastings, H (Jan 1995). "Wrist arthrodesis for traumatic conditions: a study of plate and local bone graft application". The Journal of Hand Surgery. 20A (5): 50–56. doi:10.1016/S0363-5023(05)80058-9. PMID   7722266.
  20. ↑ Anderson, MC; Adams, BD (2005). "Total wrist arthroplasty". Hand Clinics. 21 (4): 621–630. doi:10.1016/j.hcl.2005.08.014. PMID   16274871.
  21. ↑ Vicar, AJ; Burton, RI (1988). "Surgical management of the rheumatoid wrist-fusion or arthroplasty". The Journal of Hand Surgery. 11A (6): 790–797. doi: 10.1016/s0363-5023(86)80224-6 . PMID   3794231.
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