Osteoartrite do punho

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• Osteoarthritis of the hand and wrist requires an individualized approach to treatment strategies based on site-specific diagnoses and varying disease manifestations [1].
• Although the simultaneous occurrence of arthritis of the wrist and the base of the thumb is rare, it is imperative to carry out a preoperative clinical and radiological assessment of the wrist when managing trapeziometacarpal osteoarthritis [2].
• Posttraumatic arthritis occurs in patients following intra-articular fracture of the hand and wrist or destabilizing injuries of the carpus [12].
• The severity of the radiocarpal arthrosis following distal radius fracture seen on radiograph is not correlated with the presence of symptoms [12].
• Scapholunate interosseous ligament injury and extrinsic ligament complex attenuation lead to palmar flexion of the scaphoid and extension of the lunate (DISI—dorsal intercalated segment instability) [12].
• The radioscaphoid joint becomes incongruous, leading to alteration in the normal radioscaphoid contact forces and development of arthrosis [12].
• As the scaphoid flexes and the scapholunate diastasis increases, the capitate migrates proximally [12].
• The altered intercarpal contact forces result in arthrosis at the capitolunate joint [12].
• The styloscaphoid, radioscaphoid, and capitolunate joints are affected by SLAC wrist arthritic changes [12].
• The radiolunate joint is typically spared because of its spheroid shape [12].
• Symptoms of SLAC wrist include reduced grip and pinch strength [12].
• Symptoms of SLAC wrist include stiffness with extension and radial deviation [12].
• Symptoms of SLAC wrist include localized tenderness at the radioscaphoid articulation [12].
• Symptoms of SLAC wrist include decreased wrist motion on extension and radial deviation [12].
• A positive Watson shift test results when the scaphoid subluxates dorsally out of the scaphoid fossa and relocates when pressure is released [12].
• In SNAC wrist, the distal scaphoid articular surface with the radial styloid is affected first in stage I [12].
• In SNAC wrist, the proximal scaphoid pole and radioscaphoid fossa may be preserved [12].
• Ulnocarpal impingement is a degenerative condition resulting from a discrepancy in the relative length of the distal articular surfaces of the radius and ulna (positive ulnar variance) [12].
• Posttraumatic causes of ulnocarpal impingement include distal radius fracture with shortening, Galeazzi or Essex-Lopresti fracture (distal radioulnar joint [DRUJ] injury), and childhood epiphyseal plate injuries [12].
• Congenital causes of ulnocarpal impingement include dyschondroplasia (Madelung deformity) and naturally occurring positive ulnar variance [12].
• Symptoms of ulnocarpal impingement include pain on the dorsal side of the DRUJ and an intermittent clicking sensation [12].
• Symptoms of ulnocarpal impingement include pain exacerbated by forearm rotation and ulnar deviation [12].
• Symptoms of ulnocarpal impingement include pain with axial loading of the ulnar side of the wrist [12].
• Symptoms of ulnocarpal impingement include pain with dorsal and palmar displacement of the distal ulna, with the wrist in ulnar deviation (positive ballottement test) [12].
• Radiographs for ulnocarpal impingement reveal ulnar positive variance and cystic changes in the lunate [12].
• Arthrography for ulnocarpal impingement shows triangular fibrocartilage complex (TFCC) and lunotriquetral ligament tears [12].
• MRI for ulnocarpal impingement reveals changes on the ulnar border of the lunate indicating cystic change from impaction from the distal ulna [12].
• Treatment for ulnocarpal impingement includes open excision of the distal ulnar head (wafer resection) [12].
• Treatment for ulnocarpal impingement includes wrist arthroscopy and arthroscopic wafer resection (central TFCC tear is used for access) [12].
• Treatment for ulnocarpal impingement includes ulnar shortening osteotomy [12].
• When the primary etiology is distal radius malunion, corrective osteotomy of the distal radius may be indicated for ulnocarpal impingement [12].
• Symptoms of DRUJ arthrosis include pain on the dorsum of the wrist, with limitation of forearm pronation and supination [12].
• Symptoms of DRUJ arthrosis include snapping and crepitus at DRUJ [12].
• Clinical findings for DRUJ arthrosis include pain that increases with proximal rotation of the forearm and compression of the ulna against the radius [12].
• The diagnosis of DRUJ arthrosis is confirmed by improvement in rotation and grip strength with injection of a local anesthetic into the DRUJ [12].
• The differential diagnosis for DRUJ arthrosis includes instability, subluxation, and ulnocarpal impaction [12].
• Treatment for DRUJ arthrosis includes Darrach resection and/or DRUJ fusion (Sauve-Kapandji arthrodesis) [12].
• The most common complications of Darrach resection and/or DRUJ fusion are distal ulnar stump instability and radioulnar impingement [12].
• Treatment for DRUJ arthrosis includes distal ulnar hemiresection and tendon interposition (Bowers procedure), which preserves the TFCC insertion [12].
• Treatment for DRUJ arthrosis includes ulnar head or DRUJ arthroplasty [12].
• Good clinical results were maintained at 5 years after surgery for distal radius fractures, but progression of postoperative wrist osteoarthritis interfered with improvement of wrist flexion [3].
• At an average of 41 months’ follow-up, wrist denervation with a two-incision technique for post-traumatic osteoarthritis led to satisfactory results in 75% of cases with reduction of pain levels, preservation of range of motion and wrist strength [8].
• RCPI® is an interesting alternative and can be associated with proximal row carpectomy in advanced wrist osteoarthritis [10].
• PRC and 4CF are established motion-preserving procedures for wrist osteoarthritis, providing reliable pain relief and functional improvement, with current evidence favoring PRC in terms of range of motion and complication profile [11].
• Removal of the trapezium as treatment for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term [13].
• Indications for Amandys® implant must be limited to a well-aligned wrist with competent capsuloligamentous structure [17].
• While functional improvement was observed for arthroplasty patients, robust long-term follow-up data on wrist arthroplasty are not yet available [18].
• It is a reliable procedure in the long term with a low risk of complications for patients wishing to preserve the mobility of the wrist [20].
• Total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years after surgery [21].
• The technique could prove a reliable first line treatment for patients with debilitating wrist osteoarthritis confined to scaphoid/scapholunate articulation with radius as it preserves the ligamentous insertions and the bone stock [22].
• Good functional outcomes have been achieved after total wrist arthroplasty [25].
• Complete wrist denervation is an intervention with few complications indicated in chronic wrist pain of any aetiology [31].
• This method of wrist denervation was a viable salvage option for patients with symptomatic SLAC wrist osteoarthritis to preserve motion, decrease pain, and increase function with a low absolute failure rate at mid- to long-term follow-up [33].
• Arthroplasty should be used as an alternative to arthrodesis in the treatment of posttraumatic wrist arthritis, given the proper patient selection and indications [49].
• This prosthesis has broad indications such as radius fractures in osteoporotic elderly patients, sequelae of wrist trauma, and rheumatoid wrist [54].
• The surgical treatment of isolated scaphotrapeziotrapezoidal osteoarthritis resistant to medical treatment provides a significant functional improvement, particularly in terms of pain without altering the overall mobility of the wrist [55].
• While outcomes are generally favorable for therapeutic surgeries like arthrodesis and arthroplasty, further study is required to determine the best indications for ulnar head arthroplasty [62].
• Most wrists with advanced rheumatoid disease require definitive stabilization by total wrist fusion [63].
• A pain-free, stable wrist joint often outweighs the disadvantage of lacking/poor mobility [63].
• Patients prefer a mobile wrist, although patient satisfaction was high in both groups for wrist fusion versus wrist arthroplasty [63].
• Fusion seems to achieve better pain relief [63].
• Arthroplasty is associated with higher complication and revision rates, and only one-third of arthroplasty patients have a functional arc of motion [63].
• Wrist arthrodesis is a time-honored procedure by providing permanent relief [63].
• Patients need to understand that wrist fusion is typically irreversible [63].
• The achieved wrist stability enhances finger function and can correct the radial deviation of the metacarpals [63].
• Both radial deviation of the wrist joint and radial translocation of the metacarpals cause a compensatory ulnar deviation of the fingers [63].
• When this type of wrist deformity is coupled with unmanageable pain, total wrist fusion is indicated [63].
• Stable wrists with preserved bone stock are the best, if not the only, indication for wrist arthroplasty [63].
• Distal scaphoid excision should be preferred to improve functional results while decreasing scaphotrapeziotrapezoidal osteoarthritis and radiocarpal nonunion rates [69].
• The majority of patients (10 of 13) had a satisfactory clinical result after revision wrist arthroplasty with a biaxial design [152].
• In our department total wrist arthroplasty in rheumatoid patients is no longer the treatment of choice [154].
• The best indication for wrist arthroplasty is a stable, well-centered wrist with controlled disease activity [181].
• Patients should be informed of possible long-term complications and alternatives such as partial or total fusion [181].
• The goal of wrist arthroplasty is functional mobility with 30 degrees–0 degrees–30 degrees flexion/extension [181].
• Repetitive heavy loading should be avoided after wrist arthroplasty [181].
• The standard dorsal approach to the wrist is used for wrist arthroplasty [181].
• The DRUJ should be addressed if needed and depending on implant requirements during wrist arthroplasty [181].
• Implant choice for wrist arthroplasty is according to availability and experience [181].
• Resection guides should be used for precise implantation during wrist arthroplasty [181].
• Cementation should be avoided during wrist arthroplasty [181].
• Critical distal component fixation is required for wrist arthroplasty [181].
• The CMC fourth and fifth joints should not be crossed during distal component fixation for wrist arthroplasty [181].
• A stable distal bone block should be formed for implant fixation during wrist arthroplasty [181].
• The joint should not be overfilled, but also not too loose implantation to avoid dislocation during wrist arthroplasty [181].
• Mobility should be checked on the OR table for possible bone impingement during wrist arthroplasty [181].
• Postoperative care for wrist arthroplasty should be individualized depending on the bone quality, implant fixation, and intraoperative joint stability [181].
• Forearm splint protection for 6 weeks is recommended after wrist arthroplasty [181].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The wrist includes the distal radioulnar, radiocarpal, and ulnocarpal joints and the eight carpal bones and their proximal and distal articulations [82].
• The carpus comprises eight ossicles traditionally separated into a proximal row (scaphoid, lunate, triquetrum, pisiform) and a distal row (trapezium, trapezoid, capitate, hamate) [84].
• The distal radius articular surface has two concave facets for the scaphoid and lunate, separated by the scapholunate ridge [84].
• The sigmoid notch along the ulnar border of the distal radius is a shallow concavity for the articulating ulnar head at the distal radioulnar joint [84].
• The distal ulna is covered with hyaline cartilage on its dorsal, lateral, palmar, and distal surfaces [84].
• The ulnar styloid projects distally, and its base contains the fovea which serves as the insertion for the triangular fibrocartilage complex (TFCC) [84].
• The scaphoid's primary vascular supply is a branch of the radial artery at the dorsal ridge, with smaller vessels entering the palmar tubercle to supply the distal 30% [84].
• The lunate has a dorsal and palmar vascular supply in 80% of wrists, while only a palmar supply is found in 20% [84].
• The capitate head often relies on a retrograde vascular supply [84].
• The pisiform is a sesamoid bone within the flexor carpi ulnaris tendon and serves as the origin for the abductor digiti minimi [84].
• The distal radial articular surface has a double obliquity of 12–15 degrees in the lateral view and 15–20 degrees in the anteroposterior view [89].
• The carpal articular surface has a smaller diameter of curvature than the radius, making its stability in the medial and palmar aspects dependent on ligamentous and capsular resistance [89].
• The carpus is more stable in flexion than extension due to its anterior concavity [89].
• The scaphoid presents a long axis inclined by 45 degrees to the long axis of the radius [89].
• The lunate sits on the capitate and has anterior and posterior horns, with a line drawn between these horns lying perpendicular to the long axis of the wrist in neutral position [89].
• The ulnar head sits proximal to the distal radius and has only an indirect effect on stability of the wrist [89].

Ligaments & Soft Tissue¶

• The triangular fibrocartilage complex (TFCC) is formed by the central meniscus homolog, dorsal and volar radioulnar ligaments, the floor of the extensor carpi ulnaris tendon sheath, and volar ulnocarpal ligaments [84].
• The TFCC arises from the radial border of the distal radius and inserts into the base of the ulnar styloid and distal ulna through the ligamentum subcruentum [84].
• The dorsal and volar radioulnar ligaments are the primary stabilizers of the distal radioulnar joint [84].
• Only the peripheral 10% to 40% of the volar, ulnar, and dorsal TFCC has a vascular supply [84].
• The scapholunate interosseous ligament is C-shaped in the sagittal plane, with the dorsal third being the thickest and strongest portion [84].
• The volar portion of the lunotriquetral ligament is the thickest [84].
• The extrinsic wrist ligaments include the dorsal intercarpal ligament and the dorsal radiocarpal ligament [84].
• The intrinsic wrist ligaments include the scapholunate interosseous ligament and the lunotriquetral interosseous ligament [84].
• The terminal branches of the radial, ulnar, and anterior interosseous arteries provide extraosseous blood supply to the carpus through three dorsal and three palmar transverse arterial arches [86].
• The dorsal intercarpal arch is the largest of the dorsal arches and supplies the distal carpal row and, through anastomoses, the lunate and triquetrum [86].
• The deep palmar arch at the level of the metacarpal bases is consistent and communicates with the dorsal basal metacarpal arch and palmar metacarpal arteries [86].

Kinematics & Biomechanics¶

• The wrist functions as a two-joint system linking the hand to the forearm around the highly mobile bones of the proximal carpal row [85].
• The proximal carpal row has no muscular or tendinous attachments and is an intercalary segment [84].
• With ulnar deviation, the proximal row extends relative to the forearm/distal row, while with radial deviation, the proximal row flexes [84].
• With axial loading through the neutral wrist, approximately 80% of forces are transmitted through the distal radius (60% scaphoid facet, 40% lunate facet) and 20% through the distal ulna [84].
• With wrist flexion, 60% of the motion is midcarpal and 40% is radiocarpal [84].
• With wrist extension, 33% of the motion is midcarpal and 66% is radiocarpal [84].
• Relative contributions to wrist motion were measured as 63% radiocarpal and 36% midcarpal for flexion, and 53% radiocarpal and 46% midcarpal for extension [115].
• The joints within the proximal carpal row govern 35% of the wrist extension-flexion arc and 33% of the wrist radial-ulnar deviation arc [108].
• Wrist ligaments coordinate the positioning of the bones in the mid-range of carpal motions and restrict further motion in extreme positions [113].
• Traction (distraction) changes normal carpal kinematics, and motion combined with traction induces abnormal patterns of motion [87].
• The axis of rotation of the scaphoid/trapezoid motion during flexion-extension and radial-ulnar deviation runs through the radiopalmar aspect of the distal scaphoid and the waist of the capitate [120].
• A wrist joint is considered biomechanically unstable when it is not able to bear loads and does not exhibit normal kinematics throughout its arc of motion [41].

Pathophysiology of Degenerative & Posttraumatic Arthritis¶

• Primary osteoarthritis of the wrist is rare, with most cases of radiocarpal arthritis being secondary to structural changes often precipitated by trauma [188].
• Traumatic arthritis of the wrist is more common in men than in women and tends to affect younger persons than primary osteoarthritis [5].
• If a scaphoid fracture or scapholunate instability is left untreated, progressive degradation of articular cartilage and eventual arthritis will occur [5].
• Scaphoid injury or scapholunate ligament injury results in altered carpal kinetics and kinematics, increasing load on the distal scaphoid and scaphoid fossa [5].
• Increased load also occurs across the midcarpal articulation between the capitate and lunate, resulting in arthritis [5].
• The severity of radiocarpal arthrosis following distal radius fracture seen on radiograph is not correlated with the presence of symptoms [12].
• Distal radial fractures that result in a loss of normal palmar tilt lead to progressive load on the ulnocarpal and radioscaphoid articulations [123].
• Five degrees of scaphoid rotatory subluxation reduces the contact area of the proximal pole by 44%, with a shift to the dorsal lip of the radius [128].
• At 20° of scaphoid rotatory subluxation, the contact area is reduced by 77%, with a shift radially to the dorsal lip of the radial styloid [128].
• Scapholunate advanced collapse (SLAC) wrist pathophysiology involves scapholunate interosseous ligament injury leading to palmar flexion of the scaphoid and extension of the lunate (DISI) [12].
• In SLAC wrist, the radioscaphoid joint becomes incongruous, leading to altered contact forces and development of arthrosis [12].
• As the scaphoid flexes and scapholunate diastasis increases in SLAC wrist, the capitate migrates proximally [12].
• Altered intercarpal contact forces in SLAC wrist result in arthrosis at the capitolunate joint [12].
• The radiolunate joint is typically spared in SLAC wrist because of its spheroid shape [12].
• SNAC wrists differ from SLAC wrists in exhibiting a decreased sagittal lunotriquetral angle, indicating a distinct pathomechanism of carpal instability [127].
• Posttraumatic causes of ulnocarpal impingement include distal radius fracture with shortening, Galeazzi or Essex-Lopresti fracture, and childhood epiphyseal plate injuries [12].
• The experimental kinetic behavior of the chronic SLAC wrist is similar to that of a recent scapholunate dissociation without carpal collapse [114].
• Significant changes in radiocarpal loading occur after proximal row carpectomy [135].
• The kinematic consequences of resecting the distal scaphoid include diminished flexion-extension motion of the proximal row during deviations at the expense of increased radioulnar translational motion [95].

Pathophysiology of Inflammatory Arthritis¶

• The classic pattern of rheumatoid arthritis (RA) deformity involves the radiocarpal and radioulnar joints with destabilization of the carpus caused by attenuation of extrinsic wrist ligaments [155].
• The result of RA ligament attenuation is ulnar-palmar translocation and wrist supination [155].
• Three main pathophysiological factors play the greatest role in RA wrist deformation: cartilage destruction, synovial expansion, and ligamentous laxity [155].
• Bony erosion in RA arises due to synovial expansion, particularly at the site of vascular penetration into the bone such as the radial origin of the Testut ligament [155].
• The scapholunate interval starts to dissociate in RA, continuing to disintegrate the internal carpal architecture [155].
• The force vector across the RA wrist predominately acts in a palmar-ulnar direction [155].
• Flexion of the scaphoid through weakening of the SL ligament with subsequent collapse of the radial column is described in RA [155].
• Stretching of the wrist ulnar collateral ligament attenuates ulnar column support, leading to a typical carpal supination pattern in RA [155].
• Carpal supination in RA contributes to radial deviation of the metacarpals and accentuates ulnar deforming forces on the fingers at the MCP joints [155].
• Volar flexion of the lunate relative to the scaphoid in early-to-midstage RA wrists is caused by intrinsic ligament laxity, mainly of the SL ligament [155].
• In later RA stages, the capitate tends to flex dorsally due to midcarpal instability as a result of extrinsic ligament weakening [155].
• In juvenile arthritis, uncontrolled joint synovitis stretches essential ligaments and eventually erodes cartilage and bone [34].
• Uncontrolled synovitis in juvenile arthritis results in a progressive shift of the carpus ulnarward and volarward [34].
• This movement leaves the ulna dorsally dislocated and creates a dorsal wrist step-off because of the subluxed carpus [34].
• Destruction of joint mechanics in juvenile arthritis is accompanied by loss of active and passive wrist extension and weakness of grip [34].
• If the disease spreads to the distal radioulnar joint in juvenile arthritis, forearm rotation becomes limited [34].
• Type I and III rheumatoid wrists had radiographic progression and ultimately underwent deformation [28].

Classification¶

• Degenerative disorders of the wrist are complex in their clinical and radiographic manifestations, with classification and understanding of pathomechanics important for treatment selection [4].
• The complex nature of the wrist has plagued clinicians and hampered the ability to formulate concise, yet thorough, algorithmic approaches to evaluation and treatment [7].
• The Watson and Ballet classification of SLAC wrist osteoarthritis is widely accepted, simple, and a well-recognized guide to treatment despite its significant limitations [143].
• Staging systems for SNAC wrist lack agreement [164].
• Radiographic classification of SLAC wrist has moderate reliability and reproducibility, whereas classification of SNAC wrist has limited reliability [174].
• Reviewing multiview radiographs more commonly yielded Vender stage 3 osteoarthritis classification for SNAC wrist [179].
• The Simmen classification of wrist destruction in rheumatoid arthritis is useful in early disease in about 50% of cases and provides reasonably reliable identification of wrists at significant risk of becoming severely unstable, though the false-negative rate is substantial [159].
• Type I and III wrists had radiographic progression and ultimately underwent deformation according to radiographic classification in patients with early rheumatoid arthritis [28].
• Advanced osteoarthritis of the midcarpal joint without radiocarpal involvement may be more common than previously thought, with isolated osteoarthritis of the scaphotrapeziotrapezoidal joint being the most prevalent pattern [9].
• Combining traditional qualitative evaluation and quantitative measurements may improve the classification of wrist osteoarthritis [109].
• Joint space height correlates with arthroscopic grading of wrist arthritis [67].

Clinical Presentation¶

General Presentation and Diagnosis¶

• Subtle differences in history, examination, laboratory values, and imaging, rather than one pathognomonic finding, can improve diagnostic acumen and expedite appropriate treatment options for monoarticular arthritis of the hand and wrist [15].
• The natural inclination to study radiographs or special imaging studies prior to a thorough history and physical examination should be avoided, as this introduces cognitive bias which can affect thinking and decision making [48].
• Physical examination always needs to be preceded by a thorough investigation of the patient’s medical history, with special emphasis on the mechanism of injury and acuity [48].
• Patients with wrist pain but without a diagnosis by standard evaluation methods often have persistent symptoms after nonsurgical treatment, but the symptoms are usually mild and improve [27].
• Painful wrist osteoarthritis can result in major functional impairment [98].
• Most cases of wrist osteoarthritis are related to posttraumatic sequel, metabolic arthropathies, or inflammatory joint disease, although wrist osteoarthritis occurs as an idiopathic condition in a small minority of cases [98].
• Crystal deposition diseases, especially chondrocalcinosis, are frequent in the wrist, with symptoms often being moderate or absent for long periods [58].
• Deceptive clinical manifestations of tuberculous carpal osteoarthritis, often presenting as chronic monoarthritis, lead to diagnostic and therapeutic delays responsible for irreversible functional lesions [131].
• The diagnosis of lunotriquetral dissociation is usually confounded by the many possible causes of ulnar-sided wrist pain and the frequently normal x-rays [51].
• A diagnostic test is required for dynamic ulnar impingement because the condition is so frequently missed and to assist in the differential diagnosis of distal forearm pain [53].
• The inconsequent use of available modern magnetic resonance imaging (MRI) techniques and the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain [59].
• Wrist arthroscopy can be a useful tool in the diagnosis and treatment of wrist pathology, providing views of and access to the intraarticular spaces of the wrist that are otherwise difficult to achieve without widely open approaches [52].
• Wrist arthroscopy is the best technique for early diagnosis of scapholunate instabilities and assures the best functional results [132].
• Patients without positive provocative sign on examination seldom yield positive findings at wrist arthroscopy [39].
• Arthroscopic findings need to correlate with clinical examination [39].
• There is much overlap in the clinical presentation of septic and non-septic causes of wrist joint inflammation [97].
• Physical examination, inflammatory markers, and imaging studies have not been shown to be useful in differentiating between septic and non-septic causes of wrist joint inflammation [97].
• Diagnosis of septic arthritis of the wrist is made based mainly on a thorough patient history, physical examination, and joint aspiration, as no serum laboratory values have been shown to consistently confirm wrist joint infection [105].

Examination Techniques¶

• Palpation for areas of maximal tenderness is one of the most useful tools in the diagnosis of wrist pathology, especially in patients with chronic dysfunctions [48].
• In acute dislocations, tenderness is seldom elicited at specific points but rather in a diffuse manner due to extensive soft tissue damage [48].
• The examination should begin in a nontender area and proceed rotationally around the carpus, ending at the most symptomatic area [48].
• A typical wrist examination begins at the radial column with an assessment of stress instability of the thumb basal joint, moving to Watson’s scaphoid shift test, Finkelstein and Eichhoff maneuvers, and manually resisted flexion/radial deviation [48].
• The examination proceeds to ballottement and shear tests for lunotriquetral instability, tendinopathy of the extensor carpi ulnaris (ECU), and assessment of the triangular fibrocartilage complex (TFCC) and distal radioulnar joint (DRUJ) [48].
• Ulnar impaction and ulnar styloid impingement must be assessed in pronation and supination, and osteoarthritis by compression testing [48].
• Resisted ulnar flexion can help rule out flexor carpi ulnaris tendinopathy and is accompanied by a pisotriquetral “shuck” test for synovitis or osteoarthritis [48].
• Nondissociative instability of the carpus is assessed with Lichtman’s midcarpal shift test and the associated “catch up clunk,” as well as Louis’ CLIP maneuver for midcarpal instability [48].
• Bilateral grip and pinch strength are useful to uncover underlying pathology in chronic cases [48].
• Strength may be diminished due to muscle atrophy, pain inhibition, or learned behaviors [48].
• A local injection of anesthetic to a painful joint or selected tendon sheath may help normalize dynamometer readings and narrow the diagnostic spectrum [48].
• Sensory testing should always accompany an examination of suspected nerve compression, using threshold or density testing [48].
• ROM is usually limited by pain in acute injuries, whereas it may be reduced or normal in more chronic cases [48].
• In chronic cases, passive assessment of mobility is valuable not only in determining the presence of abnormal motion or crepitus but also in reproducing the patient’s pain [48].
• The physician should record the motion in the contralateral, uninjured wrist for comparative purposes [48].
• A wrist joint should be considered biomechanically unstable when it is not able to bear loads and does not exhibit normal kinematics throughout its arc of motion [41].

Specific Clinical Patterns¶

Traumatic and Post-Traumatic Arthritis¶

• Traumatic arthritis of the wrist is more common in men than in women and tends to affect younger persons than does primary osteoarthritis [5].
• The reason for the higher incidence of traumatic arthritis in men may be, in part, trauma to the wrist that occurs during heavy labor jobs [5].
• The trauma causing traumatic arthritis may be a fracture (e.g., of the distal radius or scaphoid) or a ligamentous injury [5].
• The patient may not recall the original trauma or may believe that the injury was resolved without sequelae [5].
• Many wrist injuries that are diagnosed as “sprains" may be either unrecognized scaphoid fractures or subtle scapholunate ligament injuries [5].
• If a scaphoid fracture or scapholunate instability is left untreated, progressive degradation of the articular cartilage and, ultimately, arthritis will occur [5].
• The scaphoid injury or scapholunate ligament injury results in altered carpal kinetics and kinematics [5].
• Increased load is borne by the distal scaphoid and scaphoid fossa, which causes articular wear and eventual arthritis [5].
• Increased load also occurs across the midcarpal articulation between the capitate and lunate, with resultant arthritis [5].
• Although the range of movement may be limited with loss of grip, a painless wrist can be achieved through prompt recognition and early management of scaphoid fracture dislocation [142].

Scapholunate Advanced Collapse (SLAC) and Scaphoid Nonunion Advanced Collapse (SNAC)¶

• Arthritis due to scapholunate advanced collapse follows a predictable pattern in the wrist [24].
• The Watson shift test involves pressure directed over the palmar scaphoid tuberosity while the wrist is moved from ulnar to radial deviation [12].
• History, staging, and treatment for SNAC wrist are similar to that for SLAC wrist [12].
• In stage I SNAC wrist, the distal scaphoid articular surface with the radial styloid is affected first [12].
• In stage I SNAC wrist, the proximal scaphoid pole and radioscaphoid fossa may be preserved [12].
• Most patients were pleased postoperatively after four-corner fusion and scaphoid excision for SLAC and SNAC wrist deformities, with improvement in wrist pain being the most common finding [30].
• Seventeen patients (19 wrists) had no or mild pain after limited wrist arthrodesis for the salvage of SLAC wrist [29].
• One patient (one wrist) had moderate pain after limited wrist arthrodesis for SLAC and was subsequently diagnosed as having osteoarthritis of the distal radioulnar joint [29].
• Four patients had severe pain warranting ongoing surgical management after limited wrist arthrodesis for SLAC and were classed as failures [29].
• Moderate symptoms do persist after Blatt's dorsal capsulodesis for chronic scapholunate dissociation, becoming in some cases severe enough to necessitate wrist fusion [112].

Scaphotrapeziotrapezoid (STT) and First Carpometacarpal (CMC) Arthritis¶

• The clinical picture in STT OA is associated with ‘‘radial wrist’’ pain [118].
• STT OA is characterized by insidious pain, which increases progressively at the base of the thumb, which it shares with basal joint arthritis [118].
• Pinch strength is reduced in STT OA, and the patient has discomfort when unscrewing a cap [118].
• Pain in STT OA is worse when participating in racket sports or golf [118].
• An anterior synovial cyst, swelling over the joint, tendinitis of the flexor carpi radialis (FCR) or carpal tunnel syndrome may lead to the discovery of STT OA [118].
• In STT OA, the pain is more proximal than in basal joint arthritis and is volar [118].
• Pain in STT OA is reproduced during resisted wrist extension [118].
• Pain in STT OA is provoked by palpation of the STT joint line [118].
• The landmarks for the STT joint line are the wrist’s distal flexion crease in front, the bottom of the anatomical snuffbox laterally and between the 2nd and 3rd extensor compartments in back [118].
• Pain provoked by radial deviation of the wrist is pathognomonic for STT OA [118].
• A standard differential diagnosis for STT OA is De Quervain’s tenosynovitis [118].
• Risk factors for STT OA include genetics, female gender (with more severe forms) and age (>40 years) [118].
• The presence of 2 locations of arthritis may explain persistent hand and wrist pain in this population despite CMC arthroplasty [16].
• Subjective complaints for CMC arthritis include difficulty opening a jar and buttoning [5].
• Objective findings for CMC arthritis include CMC subluxation and CMC grind [5].
• X-ray findings for CMC arthritis include MP hyperextension, CMC subluxation, CMC osteophyte, and STT narrowing [5].
• Subjective complaints for STT arthritis include limited forceful radial deviation and heavy use [5].
• Objective findings for STT arthritis include STT tenderness and decreased radial deviation [5].
• X-ray findings for STT arthritis include pain with scaphoid shift test, STT joint narrowing, and no CMC changes [5].
• Rupture of the flexor carpi radialis tendon associated with scapho-trapezial osteoarthritis presents with pain and swelling rather than the loss of function characteristic of other tendon ruptures [111].

Ulnar-Sided and DRUJ Pathology¶

• Pain in ulnocarpal impingement is exacerbated by forearm rotation and ulnar deviation [12].
• Pain in ulnocarpal impingement occurs with axial loading of the ulnar side of the wrist [12].
• Pain in ulnocarpal impingement occurs with dorsal and palmar displacement of the distal ulna, with the wrist in ulnar deviation (positive ballottement test) [12].
• Piso-triguetral osteoarthritis is an infrequent cause of ulnar wrist compartment pain, and specific clinical manoeuvres may help for diagnosis [107].
• Full return to normal function is the rule for piso-triguetral osteoarthritis if the problem is not associated with other wrist pathology [121].

Other Specific Conditions¶

• Patients with symptoms of extensor tendon rupture should undergo imaging of the wrist joints to ascertain concomitant Kienböck’s disease [47].
• Os Styloideum is an infrequent pathology and must be suspected in patients with persistent pain in the dorsal aspect of the hand or wrist [139].
• Carpal coalitions are asymptomatic and result in no wrist dysfunction [57].
• In the right wrist, all the clinical and radiological signs suggested a bipartite scaphoid, but in the left wrist the presence of pain and pan-radial osteoarthritis rather suggested a pseudarthrosis of the scaphoid [50].
• Surgeons should maintain a high index of suspicion for bilateral Kienböck disease in patients with specific comorbidities, but routine screening of the contralateral wrist is unjustified if the patient is asymptomatic [117].
• The hand manifestations of osteoarthritis can be debilitating, with initial treatment being medical and many patients doing well with splinting and hand therapy [14].
• In early stages, wrist joint synovitis in juvenile arthritis is manifested clinically as a relatively subtle fusiform swelling that does not move with finger flexion and extension [34].
• This swelling is in contradistinction to tenosynovitis of the extensor tendons, in which the swelling is much more obvious and moves to and fro with finger motion [34].
• In the inflamed wrist of a patient with juvenile arthritis, uncontrolled joint synovitis stretches essential ligaments and eventually erodes cartilage and bone [34].
• When uncontrolled, this process results in a progressive shift of the carpus ulnarward and vol

Investigations¶

Clinical Assessment¶

• Physical examination must be preceded by a thorough investigation of the patient’s medical history, with special emphasis on the mechanism of injury and acuity [48].
• For chronic wrist problems, it is important to inquire about the patient’s jobs and hobbies, and whether there has been exposure to repetitive stress, vibrating tools, or potentially dangerous instruments [48].
• Elucidating a history of ligamentous laxity or multiple joint instabilities is important in younger patients presenting with chronic wrist pain [48].
• A careful assessment of neural and vascular status is imperative, with particular attention being paid to the median and ulnar nerves [48].
• A thorough set of provocative maneuvers should be performed to rule out alternative or even concurrent diagnoses [48].
• Subtle differences in history, examination, laboratory values, and imaging can improve the diagnostic acumen and expedite appropriate treatment options for monoarticular arthritis of the hand and wrist [15].
• The complex nature of the wrist has hampered the ability to formulate concise, yet thorough, algorithmic approaches to evaluation and treatment [7].

Radiographic Evaluation¶

• After the history and physical examination, radiographic evaluation is helpful in determining the diagnosis, prognosis, and management of wrist problems [99].
• Routine radiographic series for evaluating a painful wrist consist of four views: posteroanterior, lateral, oblique, and ulnar-deviated posteroanterior scaphoid view [99].
• Spot views of the carpal bones for detail (carpal tunnel view) are a useful radiographic technique [99].
• Fluoroscopic spot views of the wrist are a useful radiographic technique [99].
• A series of views for instability includes anteroposterior clenched fist, posteroanterior in neutral, radial, and ulnar deviation, lateral in neutral and full flexion and extension, semipronated oblique 30 degrees from the posteroanterior, and semisupinated oblique 30 degrees from the lateral [99].
• Measurements of carpal bone angles on lateral wrist radiographs can be of assistance in the diagnostic evaluation of wrist malalignment [202].
• The prevalence of radiographic osteoarthritis was highest in the distal radioulnar joint, followed by the scaphotrapeziotrapezoid joint, and lowest in the radiocarpal joint [78].
• The presence of arthritis in two locations may explain persistent hand and wrist pain in patients with CMC arthritis despite CMC arthroplasty [16].
• In cases of radio-scapho-lunate osteoarthritis without degenerative change in the midcarpal joint, radio-scapho-lunate fusion is a possible solution [197].
• Progressive radiographic changes were obvious in each case of Swanson interpositional wrist arthroplasty, with cystic changes noted in a significant proportion of wrists [23].
• There has been no long term deterioration of wrist function following costo-osteochondral grafts in the wrist [6].
• Late radiographic findings do not support concerns that radioscaphoid arthritis becomes a significant complication of scaphocapitate arthrodesis, as DASH scores were statistically equivalent to those patients without such radiographic changes [65].
• Radiographic disease progression occurred only in 2 wrists, rated stage IIIB, at 8 and 10 years follow-up for Kienböck disease treated with capitate shortening osteotomy, without a bad clinical outcome [77].
• There is a large difference in reported rates of radiographic arthritis following acute perilunate injuries, although this finding does not appear to correlate with postoperative pain or disability [200].
• At the final examination, none of the patients treated for trans-scaphoid perilunate dislocations had radiographic evidence of arthritis [199].
• Type I and III wrists in early rheumatoid arthritis had radiographic progression and ultimately underwent deformation [28].
• A diagnostic test is required for dynamic ulnar impingement because the condition is so frequently missed and also to assist in the differential diagnosis of distal forearm pain [53].
• Patients with wrist pain but without a diagnosis by evaluation methods often have persistent symptoms after nonsurgical treatment, but the symptoms are usually mild and improve [27].
• Patients with symptoms suggestive of Kienböck’s disease should undergo imaging of the wrist joints to ascertain concomitant Kienböck’s disease [47].

Advanced Imaging (MRI, CT, Ultrasound)¶

• MRI should be added for evaluation of the triangular fibrocartilage, the distal radioulnar joint, and vascularity of the various carpal bones, extrinsic ligaments, joint surfaces, and surrounding soft tissues to confirm clinical suspicion and correlate with physical examination findings [99].
• A high rate of false-positive findings on MR images of normal subjects has been reported [99].
• A dedicated wrist coil provides enhanced resolution of wrist structures [99].
• MRI has an expanding role in the evaluation of pathologic conditions of the elbow and wrist, requiring high-resolution images best obtained with surface coil technique and high field system [94].
• With proper technique, injuries to the triangular fibrocartilage complex can be demonstrated with MRI [94].
• The triangular fibrocartilage complex is composed of signal-poor fibrocartilage, and perforations appear as linear defects or gaps filled with hyperintense fluid on coronal gradient-echo or T2-weighted pulse sequences [94].
• Evaluation of the scapholunate and lunotriquetral ligaments is more challenging, but with optimal technique and equipment the integrity of these structures can be consistently assessed [94].
• The addition of arthrographic contrast improves the visualization of scapholunate and lunotriquetral ligaments on MR images [94].
• MRI has gained a greater role in the evaluation of acute wrist trauma, where bone marrow edema may reveal fractures of the carpal bones or distal radius that are radiographically occult [94].
• MRI is useful in detecting additional marrow abnormalities in osteonecrosis, as seen in the lunate in Kienböck disease or in the scaphoid after fracture [94].
• Asymmetry of marrow signal in proximal and distal fragments of a fractured scaphoid is suggestive of proximal pole ischemia [94].
• MRI currently has a limited role in the evaluation of carpal tunnel syndrome, although axial imaging with T2 weighting can clearly display masses within the confines of the carpal tunnel, as well as edema and swelling of the median nerve [94].
• MRI provides earlier detection of synovitis and erosive bone changes associated with rheumatoid arthritis than do radiographs [94].
• With CT as the reference method, MRI showed moderate sensitivity and good specificity and accuracy for detection of erosions in rheumatoid arthritis and healthy wrist bones, while radiography showed very low sensitivity [192].
• The inconsequent use of available modern magnetic resonance imaging techniques and the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain [59].
• MRI is controversial for TFCC tears, but newer innovations suggest value in detection and localization of TFCC pathology [102].
• A 15-minute bone scintigraphy is useful as a second line investigation for continuing wrist pain following trauma in the presence of normal radiography [194].
• Diagnostic ultrasound is listed as a radiographic technique useful in evaluating a painful wrist [99].
• Cine or video fluoroscopy is listed as a radiographic technique useful in evaluating a painful wrist [99].
• Bone scanning is listed as a radiographic technique useful in evaluating a painful wrist [99].
• CT is listed as a radiographic technique useful in evaluating a painful wrist [99].

Arthroscopy and Arthrography¶

• Wrist arthroscopy has developed into an effective therapeutic tool, useful for the treatment of a variety of wrist disorders from arthritis to acute fractures [96].
• Arthroscopic assessment of intercarpal ligament injuries and instability is considered by many the “gold standard” for evaluation of these conditions, as well as for examination of patients who have wrist pain of unknown origin [96].
• Indications for wrist arthroscopy include the evaluation of ligamentous injuries, examination of joint articular surfaces, removal of loose bodies, biopsy of synovium, irrigation and debridement of joints, and confirmation and supplementation of wrist arthrography [96].
• Arthroscopy has been found to be more accurate than arthrography in identifying the location and size of triangular fibrocartilage and interosseous ligament injuries [96].
• Arthroscopy is more accurate than triple-injection cinearthrography in detecting tears of the dorsal sensory branch of the ulnar nerve during arthroscopic repair of the triangular fibrocartilage [96].
• Arthroscopy is the gold standard for detection of TFCC tears [102].
• The arthroscopic trampoline test is performed to assess TFCC resiliency by balloting central portion with small probe [102].
• The arthroscopic hook test can be used to demonstrate peripheral detachment of the TFCC [102].
• The arthroscopic suction test can show laxity of the TFCC when peripherally scarred in or foveal detachment when the DRUJ is clinically unstable [102].
• Arthrography of the wrist (triple injection when indicated) is a radiographic technique useful in evaluating a painful wrist [99].

Treatment¶

General Principles and Non-Operative Management¶

• A randomized controlled trial found no clinically meaningful differences between a neuromuscular exercise therapy program and range-of-motion training in the treatment of wrist osteoarthritis at 6 and 12 months [151].
• Patients with wrist arthritis who undergo surgery face higher risks of carpal tunnel syndrome and subsequent carpal tunnel release than those managed conservatively [156].

Arthroscopic Procedures¶

• Arthroscopic distal scaphoidectomy is indicated for symptom control in selected cases of SNAC wrist, as well as in the treatment of STT joint osteoarthritis [153].
• In SNAC wrist, arthroscopic distal scaphoidectomy can be regarded as a “buying time” procedure in removing the primary source of mechanical symptoms in painful scaphoid nonunion [153].
• The best indication for distal scaphoidectomy in SNAC wrist is when cartilage degeneration, osteophyte formation, and deformity are confined mainly to the distal scaphoid articular surface on both radiocarpal and midcarpal joint surfaces [153].
• Marked arthritis at the lunocapitate joint constitutes a relative contraindication of arthroscopic distal scaphoidectomy [153].
• A significant dorsal lunate tilt deformity (DISI) is considered a relative contraindication to arthroscopic distal scaphoid excision [153].
• Arthroscopic partial wrist fusion is indicated for chronic wrist pain of uncertain etiology and failed conservative treatment for over 3 months [39].
• Arthroscopic partial wrist fusion is indicated for the assessment of Kienböck disease and posttraumatic arthritis [39].
• Arthroscopic proximal row carpectomy is a therapeutic option for Kienböck disease when the proximal lunate articular surface is non-functional [61].
• Arthroscopic wafer resection is a treatment option for ulnocarpal impingement [12].
• Arthroscopic synovectomy is a therapeutic arthroscopic procedure for inflammatory arthritis, septic arthritis, gouty arthritis, and posttraumatic synovitis [147].

Motion-Preserving Salvage Procedures¶

• Proximal row carpectomy (PRC) and four-corner fusion (4CF) are established motion-preserving procedures for wrist osteoarthritis, providing reliable pain relief and functional improvement [11].
• Current evidence favors proximal row carpectomy over four-corner fusion in terms of range of motion and complication profile [11].
• Four-corner arthrodesis retains 60% of wrist motion and 80% of grip strength [12].
• Proximal row carpectomy is associated with a reduction of wrist motion and grip strength [12].
• Proximal row carpectomy should be avoided if there are capitate head degenerative changes [12].
• The addition of soft tissue interposition allograft (STIA) into PRC for patients with capitate and/or lunate fossa cartilage degeneration yielded outcomes akin to traditional PRC, improving wrist function, pain, and grip strength [161].
• Short- to mid-term outcomes in patients with end-stage wrist arthritis affecting the capitate who undergo PRC and meniscus interposition arthroplasty are comparable with those receiving PRC alone [32].
• Capitolunate arthrodesis is a satisfactory therapeutic alternative to four corners fusion for chronic instability of the wrist with osteoarthritis [150].
• Radioscapholunate fusion is a treatment option for stage II SLAC wrist [12].
• Distal scaphoid excision should be preferred to improve functional results while decreasing scaphotrapeziotrapezoidal osteoarthritis and radiocarpal nonunion rates in radioscapholunate fusion [69].
• Clinically, distal scaphoid excision after radioscaphoid arthrodesis should provide an effective alternative in the treatment of isolated radiocarpal arthritis with an intact midcarpal joint [157].
• A closing wedge radial osteotomy could prove a reliable first line treatment for patients with debilitating wrist osteoarthritis confined to scaphoid/scapholunate articulation with radius as it preserves the ligamentous insertions and the bone stock [22].
• Good clinical results were maintained at 5 years after volar locking plate fixation of distal radius fractures, but progression of postoperative wrist osteoarthritis interfered with improvement of wrist flexion [3].

Wrist Denervation¶

• Wrist denervation with a two-incision technique for post-traumatic osteoarthritis led to satisfactory results in 75% of cases with reduction of pain levels, preservation of range of motion and wrist strength at an average of 41 months’ follow-up [8].
• Wrist denervation was a viable salvage option for patients with symptomatic SLAC wrist osteoarthritis to preserve motion, decrease pain, and increase function with a low absolute failure rate at mid- to long-term follow-up [33].

Total Wrist Arthrodesis¶

• Total wrist arthrodesis is indicated for pan-carpal arthrosis of the radiocarpal and midcarpal joints [19].
• Total wrist arthrodesis is indicated for failed past limited arthrodesis [19].
• Total wrist arthrodesis is indicated for failed total joint or previous arthroplasty [19].
• Total wrist arthrodesis is indicated for paralysis of the wrist or hand with the potential for using functioning tendons for transfer [19].
• Total wrist arthrodesis is indicated for reconstruction after segmental tumor resection, infection, or traumatic segmental bone loss of the distal radius and carpus [19].
• Total wrist arthrodesis is indicated for inflammatory arthritis with good bone stock [19].
• Total wrist arthrodesis is indicated for significant bone loss of the distal radius and carpus [171].
• Total wrist arthrodesis is indicated for other inflammatory arthritis or deformity [171].
• Fusion seems to achieve better pain relief than arthroplasty [63].
• Patients tolerate the restrictions caused by a stiff wrist provided it is painless [145].
• The achieved wrist stability from fusion enhances finger function and can correct the radial deviation of the metacarpals [63].
• Total wrist arthrodesis yields significant pain relief, stability, and power grasp [146].
• Immobility of the wrist after arthrodesis requires compensatory motion of the elbow and shoulder to accurately place the hand in space [146].
• Loss of wrist motion can give rise to significant dysfunction in occupational, self-care, and recreational activities [146].
• Patients who have undergone wrist arthrodesis on one side and wrist replacement on the other prefer the wrist replacement to the wrist fusion and state that they find preservation of some motion of considerable importance [146].
• Wrist arthrodesis is typically irreversible [63].
• Carefully assess preoperative carpal tunnel symptoms and perform a concomitant release, even for mild symptoms, during wrist arthrodesis [171].
• Decorticate the dorsal 80% of the third CMC joint during wrist arthrodesis [19].
• Remove the dorsal distal radius and provide a dorsal slot for improved plate fit during wrist arthrodesis [19].
• Harvest a distal radius metaphyseal bone graft and apply to the fusion site during wrist arthrodesis [19].
• In a patient with rheumatoid arthritis and ulnar translation, remove part of the radial styloid to facilitate realignment of the wrist during arthrodesis [19].
• Fluoroscopy is helpful in ensuring that the plate position, wrist alignment, compression at the fusion mass, and screw lengths are appropriate during arthrodesis [19].
• Transpose the EPL during wrist arthrodesis [19].
• Fix the plate to the metacarpal first during wrist arthrodesis [19].
• Reduce the wrist and fix the plate to the radius in compression mode during wrist arthrodesis [19].
• In patients with poorer bone stock, locking screws will help strengthen the construct during wrist arthrodesis [19].
• Add additional graft from the dorsal distal aspect of the radius and excised carpal bones to the fusion area during wrist arthrodesis [19].
• The triquetrum can be removed if ulnocarpal impingement is of concern during wrist arthrodesis [19].
• The drill hole through the metacarpal portion of the plate must be in the sagittal plane to avoid rotational deformity of the third metacarpal during arthrodesis [19].
• If the capitate does not contact the undersurface of the plate and is lagged up to the plate, the screw may end up being too long and protrude into the carpal canal during arthrodesis [19].
• If non-self-tapping screws are used, be careful to avoid excessive penetration of the tip through the metacarpal, which may injure the deep motor branch of the ulnar nerve during arthrodesis [19].
• Failure to reduce the lunate to the lunate fossa may invite ulnocarpal impingement if the ulna and/or triquetrum is not resected during arthrodesis [19].
• Immobilize the hand and wrist in a bulky dressing and splint for 10 to 14 days postoperatively after plate fixation wrist arthrodesis [19].
• Apply a short-arm cast for 2 to 4 more weeks postoperatively after plate fixation wrist arthrodesis [19].
• At 4 to 6 weeks, graduate to a removable splint after plate fixation wrist arthrodesis [19].
• Patients are given a 1-kg weight limit for the first 8 weeks after plate fixation wrist arthrodesis [19].
• At 8 to 10 weeks, begin strengthening after plate fixation wrist arthrodesis [19].
• Allow full use at 10 to 12 weeks after plate fixation wrist arthrodesis [19].
• Full use is allowed after 10 weeks as symptoms and radiographs permit for athletic participation after plate fixation wrist arthrodesis [19].
• Immobilize the hand and wrist in a bulky dressing and splint for 10 days postoperatively after intramedullary pin wrist arthrodesis [171].
• Protect against excessive use with a removable short-arm cast until 6 weeks postoperatively after intramedullary pin wrist arthrodesis [171].
• At 6 weeks, discontinue the cast after intramedullary pin wrist arthrodesis [171].
• At 8 weeks, begin strengthening after intramedullary pin wrist arthrodesis [171].
• Remove the ulnar head in one piece if indicated for additional source of graft during intramedullary pin wrist arthrodesis [171].
• Morselize the entire articulating surfaces of the scaphoid, lunate, capitate, and radius during intramedullary pin wrist arthrodesis [171].
• Remove the anterior lunate fossa shelf if present during intramedullary pin wrist arthrodesis [171].
• Insufficient removal of the anterior shelf is a pitfall in intramedullary pin wrist arthrodesis [171].
• Acute carpal tunnel syndrome is a pitfall in intramedullary pin wrist arthrodesis [171].
• Pain from incomplete fusion of the third CMC joint is a pitfall in intramedullary pin wrist arthrodesis [171].
• Insufficient countersinking of the pin past the isthmus of the third metacarpal is a pitfall in intramedullary pin wrist arthrodesis [171].

Total Wrist Arthroplasty¶

• Total wrist arthroplasty cannot duplicate the intricate system of normal wrist motion but can potentially produce a stable, pain-free joint with a functional range of motion [146].
• Achieving a functional and durable outcome in total wrist arthroplasty requires appropriate patient selection, preoperative planning, and accurate surgery [146].
• Because arthroplasty poses greater risks than arthrodesis does, low-demand patients with special needs or desire for wrist motion are the best candidates [146].
• Caution is advised when advising patients with high demands and perhaps unrealistic expectations for total wrist arthroplasty [146].
• Arthroplasty is associated with higher complication and revision rates than fusion [63].
• Only one-third of arthroplasty patients have a functional arc of motion [63].
• Indications for pyrocarbon wrist arthroplasty must be limited to a well-aligned wrist with competent capsuloligamentous structure [17].
• Pain relief has been excellent after total wrist arthroplasty, and after surgical revisions the clinical results were satisfactory in most wrists [149].
• Wrist arthroplasty has broad indications such as radius fractures in osteoporotic elderly patients, sequelae of wrist trauma, and rheumatoid wrist [54].
• Minimal arthroplasty may provide a temporary solution for active patients with symptomatic early wrist arthritis who are not candidates for salvage wrist surgery [180].
• Total wrist arthroplasty has gained popularity as a motion-preserving option for treating wrist pain caused by arthritis [177].
• Unlike the hip or knee, total wrist arthroplasty still lags behind arthrodesis as a first-line treatment [177].
• Classically, the most appropriate candidates for wrist arthroplasty have been those with lower functional demands [177].
• Older patients with rheumatoid arthritis have been the most common recipients of total wrist arthroplasty, accounting for 51%–71% of all patients undergoing TWA [177].
• The indications for total wrist arthroplasty have broadened to include primary and post-traumatic arthritis, where bone stock and soft tissue preservation are often better [177].
• The age of patients undergoing total wrist arthroplasty for primary and post-traumatic arthritis may be lower and their functional demands higher, which raises questions about the survivorship of these implants [177].

Distal Radioulnar Joint (DRUJ) and Ulnocarpal Impingement¶

• Open excision of the distal ulnar head (wafer resection) is a treatment for ulnocarpal impingement [12].
• Ulnar shortening osteotomy is a treatment for ulnocarpal impingement [12].
• When the primary etiology of ulnocarpal impingement is distal radius malunion, corrective osteotomy of the distal radius may be indicated [12].
• Darrach resection and/or DRUJ fusion (Sauvé-Kapandji arthrodesis) are treatments for DRUJ arthrosis [12].
• Distal ulnar hemiresection and tendon interposition (Bowers procedure) is a treatment for DRUJ arthrosis which preserves the TFCC insertion [12].
• Ulnar head or DRUJ arthroplasty is a treatment for DRUJ arthrosis [12].
• The minimal resection Darrach procedure is indicated for use in patients who have distal radial-ulnar arthritis, and a normal-to-decreased radial inclination angle [126].
• Surgery does not appear to improve mobility of the wrist in Madelung's deformity of dyschondrosteosis [186].

Other Specific Procedures¶

• Radial styloidectomy plus scapholunate reduction and stabilization is the treatment for stage I SLAC wrist [12].
• Elimination of the radioscaphoid joint by PRC, four corner fusion, radioscapholunate fusion, total wrist arthrodes

Complications¶

Post-traumatic and Degenerative Progression¶

• Progression of postoperative wrist osteoarthritis after volar locking plate fixation of distal radius fractures interfered with improvement of wrist flexion [3].
• The scaphoid injury or scapholunate ligament injury results in altered carpal kinetics and kinematics, causing increased load on the distal scaphoid and scaphoid fossa which leads to articular wear and eventual arthritis [5].
• Prompt diagnosis and treatment of scaphoid non-union is vital, whether symptomatic or not, to prevent osteoarthritis developing in the future [71].

Arthrodesis Complications¶

• The most common complications of Darrach resection and/or DRUJ fusion (Sauve-Kapandji arthrodesis) are distal ulnar stump instability and radioulnar impingement [12].
• In wrist arthrodesis, if the drill hole through the metacarpal portion of the plate is not in the sagittal plane, the plate will lie rotated on the metacarpal, causing rotational deformity of the third metacarpal upon subsequent radius fixation [19].
• In wrist arthrodesis, if the capitate does not contact the undersurface of the plate and is lagged up to the plate, the screw may end up being too long and protrude into the carpal canal [19].
• In wrist arthrodesis, if non-self-tapping screws are used, excessive penetration of the tip through the metacarpal may injure the deep motor branch of the ulnar nerve as it crosses radially [19].
• Failure to reduce the lunate to the lunate fossa in wrist arthrodesis may invite ulnocarpal impingement if the ulna and/or triquetrum is not resected [19].
• Four patients had severe pain warranting ongoing surgical management after limited wrist arthrodesis for SLAC wrist, which were classed as failures [29].
• One patient (one wrist) had moderate pain after limited wrist arthrodesis for SLAC wrist and was subsequently diagnosed as having osteoarthritis of the distal radioulnar joint [29].

Arthroplasty Complications¶

• One of the primary concerns regarding total wrist arthroplasty is distal component loosening [158].
• In a study of 10 patients undergoing radial hemiarthroplasty, there was a 30% osteolysis rate, a significant incidence of wrist contracture/stiffness, and diminished grip strength postoperatively [158].
• In the 8 Maestro cases of radial hemiarthroplasty, polyethylene erosion on capitate cartilage was a problem [158].
• In a study of 52 radial and 6 carpal hemiarthroplasties, the most common complication was contracture, followed by component failure [158].
• In a study of 11 patients who underwent carpal hemiarthroplasty for SLAC/SNAC wrist arthritis, nearly half had to be revised to wrist replacement or arthrodesis secondary to pain [158].
• In a longer-term assessment of 20 patients with radial hemiarthroplasty, three required manipulation under anesthesia to improve motion and three were revised: two to total wrist arthroplasty and one to arthrodesis [158].
• A higher percentage of failures in Swanson silicone rubber interpositional wrist arthroplasty came from the group of patients carrying the preoperative diagnosis of posttraumatic arthritis or osteoarthritis of the wrist [182].
• In patients with rheumatoid arthritis who had poor results after Swanson silicone rubber interpositional wrist arthroplasty, active synovitis in many joints, including the postoperative wrist, was the norm [182].

Denervation Complications¶

• Total wrist denervation offers better long-term outcomes in terms of pain relief, with fewer subsequent procedures being needed compared to partial denervation, and with a low complication rate [148].
• Findings suggest an approximate 10% risk of secondary wrist arthrodesis in patients with persistent or progressive ulnar wrist pain following partial wrist denervation in inflammatory arthritis [79].

Other Surgical Complications¶

• Continued carpal collapse was reported following the Backdahl procedure (resection of the ulnar head together with a synovectomy of the wrist extensor tendons) [40].
• Carpal collapse and translocation could not be predicted by preoperative x-rays and the progression of carpal dislocation continued in a linear fashion throughout the follow-up period after dorsal wrist synovectomy and distal ulna resection [40].
• Significant long-term acceleration of ulnar translation was observed in wrists treated with distal ulna resection and wrist extensor synovectomy compared with the untreated opposite wrist [40].

Recovery¶

• The study found an overall survival probability above 50% at 5 years after partial wrist denervation in painful wrist OA [66].
• Findings suggest an approximate 10% risk of secondary wrist arthrodesis in patients with persistent or progressive ulnar wrist pain following partial wrist denervation for inflammatory arthritis [79].
• Elbow, wrist and hand surgery provided long-lasting benefits in rheumatoid arthritis patients according to patient-reported outcome assessment [64].
• Functional results were good at long-term follow-up for 4-corner fusion for SLAC and SNAC wrist despite radiographic changes in the radiolunate joint in 73% of patients [138].
• The evaluation of matched distal ulnar resection in 44 wrists, with an average follow-up of 6.5 years, has shown satisfactory results [36].
• Radiographic disease progression occurred only in 2 wrists, rated stage IIIB, at 8 and 10 years follow-up without a bad clinical outcome for capitatum shortening osteotomy [77].
• Three joints loosened over a period of observation that ranged from 1 to 7 years for total joint replacement at the base of the thumb [203].
• Postoperatively recovery of the wrist was rapid, though extension of the fingers remained poor for over 3 months following carpometacarpal fracture-dislocation surgery [173].
• When last seen at 9 months after surgery for sarcoid flexor tenosynovitis of the wrist, the patient was asymptomatic and enjoyed excellent wrist function [73].

Key Evidence¶

• [L5] Osteoarthritis of the hand and wrist requires an individualized approach to treatment strategies based on site-specific diagnoses and varying disease manifestations. [1] (10.1016/j.jht.2022.01.001)
• [L5] Although the simultaneous occurrence of arthritis of the wrist and the base of the thumb is rare, it is nonetheless imperative to carry out a preoperative clinical and radiological assessment of the wrist when managing trapeziometacarpal osteoarthritis. [2] (10.1016/j.hansur.2020.08.013)
• [L4] Good clinical results were maintained at 5 years after surgery, but progression of postoperative wrist osteoarthritis interfered with improvement of wrist flexion. [3] (10.1142/s2424835519500061)
• [Paper] Degenerative disorders of the wrist are complex in their clinical and radiographic manifestations, with classification and understanding of pathomechanics important for treatment selection. [4] (10.1016/s0363-5023(85)80025-3)
• [L5] [5] (10.1016/s0894-1130(00)80036-8)
• [L4] There has been no long term deterioration of wrist function. [6] (10.1097/00130911-200109000-00008)
• [Paper] The complex nature of the wrist has plagued us clinically and hampered our ability to formulate concise, yet thorough, algorithmic approaches to evaluation and treatment. [7] (10.1016/s0894-1130(96)80065-2)
• [L4] At an average of 41 months’ follow-up, wrist denervation with a two-incision technique for post-traumatic osteoarthritis led to satisfactory results in 75% of cases with reduction of pain levels, preservation of range of motion and wrist strength. [8] (10.1016/j.hansur.2017.04.003)
• [L4] Advanced osteoarthritis of the midcarpal joint without radiocarpal involvement may be more common than previously thought, with isolated osteoarthritis of the scaphotrapeziotrapezoidal joint being the most prevalent pattern. [9] (10.1177/17531934241275450)
• [L4] RCPI® is an interesting alternative and can be associated with proximal row carpectomy in advanced wrist osteoarthritis. [10] (10.1016/j.otsr.2023.103783)
• [L1] PRC and 4CF are established motion-preserving procedures for wrist osteoarthritis, providing reliable pain relief and functional improvement, with current evidence favoring PRC in terms of range of motion and complication profile. [11] (10.1007/s00402-026-06423-z)
• [L3] Removal of the trapezium as treatment for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term. [13] (10.1186/s13018-021-02856-x)
• [L5] The hand manifestations of osteoarthritis can be debilitating, with initial treatment being medical and many patients doing well with splinting and hand therapy. [14] (10.1016/j.hcl.2010.09.003)
• [L5] Subtle differences in history, examination, laboratory values, and imaging, rather than one pathognomonic finding, can improve the diagnostic acumen and expedite appropriate treatment options for monoarticular arthritis of the hand and wrist. [15] (10.1016/j.jhsa.2012.04.010)
• [L4] The presence of 2 locations of arthritis may explain persistent hand and wrist pain in this population despite CMC arthroplasty. [16] (10.1177/1558944716660555hw)
• [L3] Indications must be limited to a well-aligned wrist with competent capsuloligamentous structure. [17] (10.1016/j.main.2012.07.013)
• [L2] While functional improvement was observed for arthroplasty patients, robust long-term follow-up data on wrist arthroplasty are not yet available. [18] (10.1177/1753193420953683)
• [L4] It is a reliable procedure in the long term with a low risk of complications for patients wishing to preserve the mobility of the wrist. [20] (10.1016/j.hansur.2016.10.058)
• [L4] Total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years after surgery. [21] (10.1016/j.jhsa.2024.03.002)
• [L4] The technique could prove a reliable first line treatment for patients with debilitating wrist osteoarthritis confined to scaphoid/scapholunate articulation with radius as it preserves the ligamentous insertions and the bone stock. [22] (10.1016/j.jisako.2025.100448)
• [L4] Progressive radiographic changes were obvious in each case, with cystic changes noted in a significant proportion of wrists. [23] (10.1016/0363-5023(91)90009-z)
• [L5] Arthritis due to scapholunate advanced collapse follows a predictable pattern in the wrist. [24] (10.1097/00130911-199712000-00003)
• [L5] Good functional outcomes have been achieved after total wrist arthroplasty. [25] (10.1097/01.bth.0000137214.52093.a7)
• [L4] Patients with wrist pain but without a diagnosis by these evaluation methods often have persistent symptoms after nonsurgical treatment, but the symptoms are usually mild and improve. [27] (10.1053/jhsu.2002.30079)
• [L2] Type I and III wrists had radiographic progression and ultimately underwent deformation. [28] (10.1016/j.jhsa.2009.01.016)
• [L4] [29] (10.1016/s0266-7681(97)80267-7)
• [L4] Most patients were pleased postoperatively, with improvement in wrist pain being the most common finding. [30] (10.1097/bth.0b013e3181f60fec)
• [L4] Complete wrist denervation is an intervention with few complications indicated in chronic wrist pain of any aetiology. [31] (10.1016/j.main.2012.07.005)
• [L3] Our short- to mid-term outcomes in patients with end-stage wrist arthritis affecting the capitate who undergo PRC and meniscus interposition arthroplasty are comparable with those receiving PRC alone. [32] (10.1177/15589447241262052)
• [L4] This method of wrist denervation was a viable salvage option for patients with symptomatic SLAC wrist osteoarthritis to preserve motion, decrease pain, and increase function with a low absolute failure rate at mid- to long-term follow-up. [33] (10.1016/j.jhsa.2021.02.023)
• [L4] The evaluation of the procedure in 44 wrists, with an average follow-up of 6.5 years, has shown satisfactory results. [36] (10.1016/s0363-5023(86)80228-3)
• [L5] A wrist joint should be considered biomechanically unstable when it is not able to bear loads and does not exhibit normal kinematics throughout its arc of motion. [41] (10.1053/jhsu.1999.0866)
• [L5] Patients with these symptoms should undergo imaging of the wrist joints to ascertain concomitant Kienböck’s disease. [47] (10.1142/s2424835520720042)
• [L3] Arthroplasty should be used as an alternative to arthrodesis in the treatment of posttraumatic wrist arthritis, given the proper patient selection and indications. [49] (10.1016/j.jhsa.2013.02.013)
• [L5] In the right wrist, all the clinical and radiological signs suggested a bipartite scaphoid, but in the left wrist the presence of pain and pan-radial osteoarthritis rather suggested a pseudarthrosis of the scaphoid. [50] (10.1016/j.main.2007.11.001)
• [L5] The diagnosis is usually confounded by the many possible causes of ulnar-sided wrist pain and the frequently normal x-rays. [51] (10.1097/00130911-199803000-00002)
• [L5] Wrist arthroscopy can be a useful tool in one’s armamentarium in the diagnosis and treatment of wrist pathology, providing views of and access to the intraarticular spaces of the wrist that are otherwise difficult to achieve without widely open approaches. [52] (10.1016/j.eats.2024.103223)
• [L4] A diagnostic test is required because the condition is so frequently missed and also to assist in the differential diagnosis of distal forearm pain in this particular clinical context. [53] (10.1016/s0266-7681(97)80264-1)
• [L4] This prosthesis has broad indications such as radius fractures in osteoporotic elderly patients, sequelae of wrist trauma, and rheumatoid wrist. [54] (10.1016/j.main.2015.10.049)
• [L4] The surgical treatment of isolated scaphotrapeziotrapezoidal osteoarthritis resistant to medical treatment provides a significant functional improvement, particularly in terms of pain without altering the overall mobility of the wrist. [55] (10.1016/j.hansur.2019.10.003)
• [L4] Carpal coalitions are asymptomatic and result in no wrist dysfunction. [57] (10.1016/0363-5023(92)90108-2)
• [L5] Crystal deposition diseases, especially chondrocalcinosis, are frequent in the wrist, with symptoms often being moderate or absent for long periods. [58] (10.1016/j.main.2003.09.012)
• [L4] The inconsequent use of available modern magnetic resonance imaging (MRI) techniques and the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain. [59] (10.1177/1558944716660555hs)
• [L4] [61] (10.1097/00130911-200603000-00003)
• [L5] While outcomes are generally favorable for therapeutic surgeries like arthrodesis and arthroplasty, further study is required to determine the best indications for ulnar head arthroplasty. [62] (10.1016/j.jht.2013.12.002)
• [L4] Our original patient-reported outcome assessment tool revealed that elbow, wrist and hand surgery provided long-lasting benefits in RA patients. [64] (10.1111/1756-185x.13340)
• [Paper] Late radiographic findings do not support concerns that radioscaphoid arthritis becomes a significant complication, as DASH scores were statistically equivalent to those patients without such radiographic changes. [65] (10.1097/00130911-200206000-00003)
• [L3] The study found an overall survival probability above 50% at 5 years after partial wrist denervation in painful wrist OA. [66] (10.1177/17531934261425490)
• [L3] [67] (10.1007/s11552-013-9522-9)
• [L4] Distal scaphoid excision should be preferred to improve functional results while decreasing scaphotrapeziotrapezoidal osteoarthritis and radiocarpal nonunion rates. [69] (10.1055/s-0039-1688939)
• [L4] Prompt diagnosis and treatment of scaphoid non-union is vital, whether symptomatic or not, to prevent osteoarthritis developing in the future. [71] (10.1016/s0020-1383(02)00162-6)
• [L5] When last seen at 9 months after surgery, the patient was asymptomatic and enjoyed excellent wrist function. [73] (10.1016/s0363-5023(97)80173-6)
• [L4] Radiographic disease progression occurred only in 2 wrist, rated stage IIIB, at 8 and 10 years follow-up without a bad clinical outcome. [77] (10.1016/j.main.2014.10.086)
• [L4] The prevalence of radiographic osteoarthritis was highest in the distal radioulnar joint, followed by the scaphotrapeziotrapezoid joint, and lowest in the radiocarpal joint. [78] (10.1016/j.jhsa.2023.05.009)
• [L4] Our findings suggest an approximate 10% risk of secondary wrist arthrodesis in patients with persistent or progressive ulnar wrist pain. [79] (10.1007/s10067-019-04645-8)
• [L5] Traction (distraction) changes normal carpal kinematics and motion of the wrist combined with traction induces abnormal patterns of motion. [87] (10.1053/jhsu.1999.jhsu24a0113)
• [L4] The kinematic consequences of resecting the distal scaphoid are different: the flexion-extension motion of the proximal row during deviations is diminished at the expense of increased radioulnar translational motion. [95] (10.1097/00130911-199909000-00004)
• [L4] [97] (10.1177/1753193417738166)
• [L4] [98] (10.1016/j.otsr.2014.06.025)
• [L5] Diagnosis is made based mainly on a thorough patient history, physical examination, and joint aspiration, as no serum laboratory values have been shown to consistently confirm wrist joint infection. [105] (10.5435/jaaos-d-16-00414)
• [L4] Piso-triguetral osteoarthritis is an infrequent cause of ulnar wrist compartment pain, and specific clinical manoeuvres may help for diagnosis. [107] (10.1016/s1297-3203(02)00114-2)
• [L5] The joints within the proximal carpal row govern 35% of the wrist extension-flexion arc and 33% of the wrist radial-ulnar deviation arc. [108] (10.1016/0363-5023(90)90101-v)
• [L4] Combining traditional qualitative evaluation and quantitative measurements may improve the classification of wrist osteoarthritis. [109] (10.1177/1753193416669261)
• [L5] Rupture of the flexor carpi radialis tendon associated with scapho-trapezial osteoarthritis presents with pain and swelling rather than the loss of function characteristic of other tendon ruptures. [111] (10.1016/0266-7681(92)90126-m)
• [L4] Moderate symptoms do persist, becoming in some cases severe enough to necessitate wrist fusion. [112] (10.1016/s0363-5023(03)80342-8)
• [L5] Wrist ligaments co-ordinate the positioning of the bones in the mid-range of carpal motions, and restrict further motion in extreme positions of the wrist joint. [113] (10.1016/0266-7681(93)90015-8)
• [L5] The experimental kinetic behavior of the chronic SLAC wrist is similar to the one with a recent scapholunate dissociation without carpal collapse associated. [114] (10.1177/1558944716660555w)
• [L5] Relative contributions to wrist motion were: wrist flexion: RC joint 63%, MC joint 36%; wrist extension: RC joint 53%, MC joint 46%. [115] (10.1016/s0363-5023(88)80013-3)
• [Paper] Surgeons should maintain a high index of suspicion for bilateral disease in patients with these comorbidities, but routine screening of the contralateral wrist is unjustified if the patient is asymptomatic. [117] (10.1177/15589447251350174)
• [Paper] [118] (10.1016/j.hansur.2020.12.007)
• [L5] The axis of rotation of the scaphoid/trapezoid motion during both FEM and RUD wrist motions was essentially the same and runs through the radiopalmar aspect of the distal scaphoid and the waist of the capitate. [120] (10.1053/jhsu.2000.8637)
• [L4] Full return to normal function is the rule if the problem is not associated with other wrist pathology. [121] (10.1016/0266-7681(92)90072-a)
• [L5] Distal radial fractures that result in a loss of normal palmar tilt lead to progressive load on the ulnocarpal and radioscaphoid articulations. [123] (10.1016/s0363-5023(87)80202-2)
• [L4] It is indicated for use in patients who have distal radial-ulnar arthritis, and a normal-to-decreased radial inclination angle. [126] (10.1016/0363-5023(91)90011-y)
• [L4] SNAC wrists differ from SLAC wrists in exhibiting a decreased sagittal lunotriquetral angle, indicating a distinct pathomechanism of carpal instability. [127] (10.1186/s12891-025-08652-6)
• [L5] [128] (10.1016/s0363-5023(87)80066-7)
• [L5] Deceptive clinical manifestations, often presenting as chronic monoarthritis, lead to diagnostic and therapeutic delays responsible for irreversible functional lesions. [131] (10.1016/j.main.2009.04.006)
• [L5] Wrist arthroscopy is the best technique for early diagnosis, and assures the best functional results. [132] (10.1016/j.main.2006.07.027)
• [L5] Significant changes in radiocarpal loading occur after proximal row carpectomy. [135] (10.1016/j.jhsa.2004.07.006)
• [L4] Functional results were good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients. [138] (10.1177/1558944716681949)
• [L4] Os Styloideum is an infrequent pathology and must be suspected in patients with persistent pain in the dorsal aspect of the hand or wrist. [139] (10.1177/15589447251317232)
• [L5] Although the range of movement may be limited, with loss of grip, a painless wrist can be achieved through prompt recognition and early management. [142] (10.1016/s0020-1383(97)00020-x)
• [L5] Despite its significant limitations, the Watson and Ballet classification of SLAC wrist osteoarthritis is widely accepted, simple, and a well-recognized guide to treatment. [143] (10.1097/corr.0000000000000451)
• [L4] Patients tolerate the restrictions caused by a stiff wrist provided it is painless. [145] (10.1054/jhsb.2002.0806)
• [L3] Total wrist denervation offers better long-term outcomes in term of pain relief, with fewer subsequent procedures being needed compared to partial denervation, and with a low complication rate. [148] (10.1016/j.hansur.2020.05.010)
• [L4] Pain relief has been excellent, and after surgical revisions the clinical results were satisfactory in most wrists. [149] (10.1016/s0363-5023(77)80043-9)
• [L4] It is a satisfactory therapeutic alternative to four corners fusion for chronic instability of the wrist with osteoarthritis. [150] (10.1016/j.main.2013.07.002)
• [L1] We found no clinically meaningful differences between the neuromuscular exercise therapy program and range-of-motion training in the treatment of wrist osteoarthritis at 6 and 12 months. [151] (10.1186/s12891-025-09463-5)
• [L4] The majority of patients (10 of 13) had a satisfactory clinical result after revision wrist arthroplasty with a biaxial design. [152] (10.1016/0363-5023(93)90045-5)
• [L4] In our department total wrist arthroplasty in rheumatoid patients is no longer the treatment of choice. [154] (10.1016/j.main.2015.10.065)
• [L2] Patients with wrist arthritis who undergo surgery face higher risks of CTS and subsequent CTR than those managed conservatively. [156] (10.1016/j.jhsa.2026.01.013)
• [L5] Clinically, this procedure should provide an effective alternative in the treatment of isolated radiocarpal arthritis with an intact midcarpal joint. [157] (10.1053/jhsu.2001.27762)
• [L3] The Simmen classification of wrist destruction in rheumatoid arthritis is useful in early disease in about 50% of cases and provides reasonably reliable identification of wrists at significant risk of becoming severely unstable, though the false-negative rate is substantial. [159] (10.1054/jhsb.1999.0196)
• [L4] The addition of STIA into PRC for patients with capitate and/or lunate fossa cartilage degeneration yielded outcomes akin to traditional PRC, improving wrist function, pain, and grip strength in a safe and straightforward manner. [161] (10.1177/15589447231221245)
• [Paper] Staging systems for SNAC wrist lack agreement. [164] (10.1007/s12593-012-0062-2)
• [L5] Postoperatively recovery of the wrist was rapid, though extension of the fingers remained poor for over 3 months. [173] (10.1016/0020-1383(94)90161-9)
• [L4] Radiographic classification of SLAC wrist has moderate reliability and reproducibility, whereas classification of SNAC wrist has limited reliability. [174] (10.1177/1753193413484629)
• [L1] [177] (10.1177/17531934231199317)
• [L4] Reviewing multiview radiographs more commonly yielded Vender stage 3 osteoarthritis classification. [179] (10.1177/1558944720937359)
• [L4] Minimal arthroplasty as described may provide a temporary solution for active patients with symptomatic early wrist arthritis who are not candidates for salvage wrist surgery. [180] (10.1055/s-0033-1338255)
• [L4] [182] (10.1016/s0363-5023(86)80046-6)
• [L4] Surgery does not appear to improve mobility of the wrist. [186] (10.1016/0266-7681(88)90042-3)
• [L4] [188] (10.1016/j.csm.2004.08.011)
• [L4] With CT as the reference method, MRI showed moderate sensitivity and good specificity and accuracy for detection of erosions in rheumatoid arthritis and healthy wrist bones, while radiography showed very low sensitivity. [192] (10.1186/ar2378)
• [L4] We find this rapid version of the bone scan useful as a second line investigation for continuing wrist pain following trauma in the presence of normal radiography. [194] (10.1016/s0020-1383(99)00280-6)
• [L4] In cases of radio-scapho-lunate osteoarthritis without degenerative change in the midcarpal joint, radio-scapho-lunate fusion is a possible solution. [197] (10.1016/j.main.2008.08.014)
• [L4] At the final examination none of the patients had radiographic evidence of arthritis. [199] (10.1016/s0020-1383(11)70073-0)
• [L1] There is a large difference in reported rates of radiographic arthritis, although this finding does not appear to correlate with postoperative pain or disability. [200] (10.1177/15589447241231291)
• [L4] Measurements of carpal bone angles on lateral wrist radiographs can be of assistance in the diagnostic evaluation of wrist malalignment. [202] (10.1016/s0363-5023(10)80156-x)
• [L4] Three joints loosened over a period of observation that ranged from 1 to 7 years. [203] (10.1016/s0363-5023(82)80174-3)

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