RHEUMATOID WRIST
TENOSYNOVITIS
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RA is a disease of the synovium
Tendon sheaths as well as joint synovium are involved
tenosynovitis can cause pain and dysfunction of the tendons and ultimately tendon
rupture following invasion of the tendons
Three common sites of tendon sheath involvement
1. dorsal aspect of the wrist – under dorsal retinaculum
2. volar aspect of the wrist - under flexor retinaculum
3. volar aspect of the digits – digital flexor sheaths
Manage medically initially with rest, steroid injections, or DMARD medications
Tenosynovectomy is usually recommended if symptoms do not improve after 4-6
months of medical therapy.
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Goals of tenosynovectomy
1. to prevent tendon rupture (also need to remove bony spurs)
2. to relief pain
3. to relief compression/triggering
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After a tenosynovectomy, tendon rupture rarely occurs and complications are
infrequent
Postoperative adhesions may occur. Tendon adhesions result in an extensor lag of
metacarpophalangeal (MP) joints or decreased active finger flexion.
Easier to diagnose over dorsal wrist. May present as carpal tunnel syndrome in
flexor wrist tenosynovitis or triggering in the fingers. Rheumatoid nodules can
also develop within the tendons and within the subcutaneous tissue.
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DORSAL (EXTENSOR) TENOSYNOVITIS IN THE WRIST
Usually obvious and may the first sign in RA
Isolated dorsal tenosynovitis is painless and pts ignore until the tendons rupture
When pts complain of pain need to look at the wrist joint
Initially the synovium is thin, gradually thickens and may have small fibrinoid
"rice bodies" filling the tendon sheaths
The hypertrophic synovium erodes and weakens the tendons leading to he
eventual rupture
Management
Rest and or local steroid injection may result in remission
Dorsal tenosynovectomy is indicated if no improvement after 4-6 months
Technique
 Dorsal straight or curvilinear incision
 Incise through the 6th compartment
 Raise a radially based flap of extensor retinaculum
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Tenosynovectomy as required
Repair flayed tendons at risk of rupture
lay retinaculum 1/2 below the tendons and 1/2 above to prevent bowstringing
drain
Early mobilization with in 24-48 hrs with active flexion and ext exercises
Complications
 Skin necrosis and skin slough
 Delayed healing
 Adhesion formation – if not improved by 6mnths of therapy tenolysis
recommend
 Tendon rupture
FLEXOR TENOSYNOVITIS IN THE WRIST
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Less obvious as deep location but can cause symptoms by impingement on
structures ie median nerve , restricted motion of tendons
Need to release carpal tunnel and sometimes thenar branch
Early decompression and synovectomy recommended
Technique
 Incision needs to extend above the wrist
 Deep fascia at the level of the wrist divided to expose the median nerve
 Transverse carpal ligament incised
 Median nerve freed from the synovium and the motor branch traced to the
musculature
 Separate the superficial tendons and usually leave the deep tendons together
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Visualize the floor and smooth off any bony spicules and exposed bony
surface are covered by flap of local soft tissue
Look for smooth tendon gliding at the finish
FLEXOR TENOSYNOVITIS IN THE DIGITS
Four clinical patterns of rheumatoid trigger finger based on the size and nature of the
nodule
Type 1.small localized areas of disease at proximal end of A1 causing triggering
during flexion(as normal tenovaginitis)
Type 2.flexor tendons area present in the distal palm which causes the finger to trigger
as it is flexed
Type 3.nodule in FDP at the distal end of A2 pulley and finger locks in extension
Type 4.generalised tenosynovitis within the fibro-osseous canal with general
limitation of motion
Technique
 All treated with flexor tenosynovectomy and excision of the flexor nodules
 volar zig zag incision or transverse incision in palm for multiple fingers
 tenosynovium around the tendon is removed and the nodules are excised and
the pulleys are preserved if possible
 one slip of FDS excised if triggering still occurs despite synovectomy
 note triggering may occur between A2 and A4 (type 3)
 Preserve A1 to prevent ulnar drift of MCPJ
 Post op motion started early
TENDON RUPTURES
Due to
1. Attrition from bone roughened by tenosynovitis
2. tendon infiltration of proliferating synovium
3. ischemia of the tendon from pressure caused from proliferating synovium
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EPL rupture at Listers tubercle (Moore)
EDM/EDC at distal ulnar (Vaughn-Jackson syndrome)
FPL rupture from scaphoid spur (Mannerfelt)
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Treatment involves excision of spurs, tendon transfers and occasionally
arthrodesis
Difference between tendon transfers in rheumatoid arthritis
1. joints to be moved are stiff or unstable
2. bed scarred thus restricting excursion
3. tendons usually weakened by synovium
4. cannot rely on tenodesis effect as joints are stiff
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EXTENSOR TENDON RUPTURES
 Sudden loss of active extension
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EDM is usually the first dorsal tendon to be involved, then progress radially with
IF last as tendons move ulnarward to rub on the ulnar head
Test EDM by flexion all other fingers and attempting to extend LF
Differential Diagnosis
1. posterior interosseous nerve compression with elbow synovitis
 show radial deviation of the wrist with wrist extension
 tenodesis effect intact
2. ulnar subluxation of the extensor tendons at the MP joint.
 May fall volar to become weak extensors
 differentiated by ability to maintain extension when the fingers are
brought into extension or tenodesis effect intact
3. volar subluxation of the MCPJ
 test passive extension of MCPJ
Treatment Summary (Green)
Treatment summary (Lister)
EPL
- EI or
- EPB (useful if EI is needed elsewhere)
- EDM
Single digit
- link to adjacent digit or EI to EDM
2 digits (usuallyRF/LF)
- EI to LF + adjacent digit link RF to MF
3 digits or more
- MF to IF(if intact) and EI to RF/LF
- FDS around radial border with FDS MF to IF/MF and
FDS RF to RF/LF
- avoid wrist motors (ECU or FCU)– poor excursion
- brachioradialis to ERCL but more common to
Wrist extensors
arthrodese
 Aim to also correct ulnar drift at wrist with the transfer
 Early intervention may allow for reconstruction using an intercalated tendon graft.
EPL Rupture
 Note IP extension to neutral may be maintained by thumb intrinsic function(hyper
ext lost)
 Options are end to end repair, tendon graft and tendon transfer
 Transfer usually required
Method
 Usually EI or ECRL or EDB
 Judge tension in repair the thumb must be in full ext with flexion of the
wrist and in ext of the wrist the thumb should passively touch pulp of little
finger
 Immobilized for 4-5 weeks
 Excise spurs if indicated
Single tendon rupture
 Small finger rupture most common
 EI to EDM sometimes used
Method
 Tendon stump sutured to an adjacent extensor
 End to end repair if possible (rare) Do if possible as the results are said to be
better. In this technique the MPJ need to be hyper ext and the fingers are out
of sequence when the repair is completed. This posture improves over 10 days
as the tendon stretches
Two tendon rupture
 Usually ring and small finger
 Consider adjacent tendon suturing
 May need EI for LF extensor in if distal stump is too short or cannot reach the RF
tendon without significant abduction of the small finger
Rupture of more than 3 extensor tendons
 For 3 tendons, may use EI or FDS
 For 4 tendons, best to use 2 FDS
Method
 FDS passed through a large window in the interosseous membrane
 Window needs to be large enough for the tendon and the muscle belly to pass
through
 If excessive scarring in the region of the wrist then use MF tendon and reroute
around the radial border of the wrist, deep to radial nerve (Nalebuff prefers this)
 FDS to RF/LF and MF link to IF
 If 4 tendon rupture then use 2 FDS (MF and RF) one flexor joined to two ext
 May need to use bridge grafts (PL)
Tendon transfers with fused wrists
 Can use wrist motors as tendon transfers
 Useful in this case as no need to down grade the flexor function with FDS transfer
 Wrist extensors usually do not need bridge grafts however the wrist flexors do
Tendon transfers with MPJ disease
 If MPJ can not be moved passively, then tendon transfer will not work and will
get stuck
 Thus important to do arthroplasty first with dynamic splinting followed by
staged tendon transfer
FLEXOR TENDON RUPTURES
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Less common than extensor rupture
FPL most common tendon to rupture usually due to a volar osteophyte on the
scaphoid -Mannerfelt lesion
This spicule must be explored as even if thumb is fused, it will cause rupture of
the FDP IF
FPL Rupture
 Need to treat the boney spicule tp prevent other ruptures
 volar aspect of palm and the wrist explored through a thenar crease incision
extended onto the wrist in zig zag fashion
 the volar ulna spicule on the scaphoid is removed and soft tissue mobilized to
cover the bone
 Options
1. bridge graft (PL, half FCR or slip of APL) between the two ruptured ends
2. tendon transfer with the FDS MF/RF
 middle finger preferred as tendon is long and does not interfere with
grip
 Usually detached in the distal palm and attached to the distal phalanx
with a pull out suture
3. IPJ arthrodesis
 Indicated if there is instability of the IPJ or articular destruction
 CTR and tenosynovectomy at the same time
Rupture of the FDP
 Level of rupture in the most important point
 At palm and wrist level suture to the other intact tendons
 If in the fibro-osseous tunnel and intact FDS
 perform tenosynovectomy for FDS and treat conservatively as usually
stable, otherwise consider fusion of DIPJ
 Results with staged tendon reconstruction, especially with an intact FDS is
not good
Rupture of FDS
 Nil obvious functional loss
 Consider tenosynovectomy only an
 Direct to suture to adjacent tendon if ruptured at wrist level
Rupture of FDS and FDP
 Obvious functional loss – “finger gets in the way
 At the wrist, bridge graft prox and distal to the carpal region for FDP or suture
to the adjacent tendons
 Use the ruptured FDS as a tendon graft as no need to reconstruct the FDS
 In the palm then direct suture to adjacent tendons
 In fibro-osseous canal then staged tendon repair using silicone rubber tubing,
probably best in young patients with minimal joint disease (poor results)
 Fusion in the functional position is another option
WRIST
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Is the keystone of the hand and painful unstable deformed wrist impairs
hand function regardless of the status of the fingers
Major cause of finger deformity
Pathophysiology
 Synovitis occurs in 2 regions of the wrist
1. dorsal compartment of wrist (more on ulnar aspect)
2. wrist joints – 3 compartments
a)
radio-carpal
b)
mid-carpal
c)
radio-ulnar
 Three pathological processes
a)
Cartilage destruction
b)
Synovial expansion
 Causes bony erosions especially in areas of vascular penetration of
bone (ie ligament of Testut, waist of scaphoid)
c)
Ligamentous laxity
 Synovitis follows a predictable pattern in the wrist with ulnar sided structures
being the earliest to be involved
 Carpal changes occur following involvement of radiocarpal ligaments
Ulnar carpal involvement
 Synovitis with attrition and rupture of the TFCC results in:
a)
scalloping of the radius at the DRUJ
 synovitis at the sigmoid notch
b)
supination of the carpus on the hand
c)
ulnar translocation of carpus
 increase in Shapiro angle (angle between radial cortex of IF
metacarpus and line from radial styloid to ulnar border of
radius on AP)
d)
volar subluxation of distal radius and carpus leads to
 dorsal dislocation of distal ulnar at the DRUJ
 volar subluxation of ECU – becomes a weak flexor
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Patients with caput ulnar usually complain of pain in the wrist on rotation
Radiocarpal involvement
 Synovitis destruction of radioscaphocapitate ligament followed by
incompetence of the radioscapholunate ligament (of Testut)
o results in rotatory instability(subluxation) of scaphoid
o leads to volar flexed scaphoid and loss of radial carpal height
 next ligament to fail is the radiolunatotriquetral (long radiolunate)
o results in anterior subluxation of carpus
 together with failure of dorsal radiocarpal ligament
o ulnar translocation
Summary
Ulnacarpal
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prominent ulnar head
RSC
+ RLT
+ DRC
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Supinated carpus
Ineffective ECU
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loss of radial carpal height
ulnar translocation
this leads to radial deviation of the wrist and metacarpals and a Z-collapse of the
MP joints into ulnar deviation
carpal collapse – reduction in wrist ROM and grip strength
Thus the 3 visible wrist deformities (caput ulnar syndrome) are
1. prominent ulnar head
2. radial carpal rotation
3. anterior wrist subluxation
Management
Non-Surgical
 Patient education
 Splinting and steroid injection
 Hand therapy with modifications of wrist use
Surgical
 Either preventative or reconstructive
Preventive
1. DRUJ and RC joint synovectomies
2. Wrist extensor balancing procedure
3. Tenosynovectomies
Reconstructive
1. Distal ulna excision
2. Reconstruction of the DRUJ (not generally recommended in presence of arthritis)
3. Radiocarpal arthroplasty
4. Partial wrist fusion
5. Complete wrist fusion
Choice of procedures
1. Ulnar excision alone
a. indicated in patients whose symptoms are limited to the DRUJ
b. has a stable and functional radiocarpal joint even when the radiocarpal
joint shows evidence of significant destruction on xray
2. Wrist arthroplasty
a. Limited indications
3. Partial wrist fusion
a. early collapse pattern and those with destruction limited to the
radiocarpal joint
4. Total wrist fusion
a. Those with high demand on wrist (younger patients)
b. those with advanced wrist disease, instability, poor extensor function
or poor bone stock
Synovectomy
Aim:
1. Alleviate pain
2. Retard disease progression
3. maintain motion
 Indicated in isolation in pts with significant pain and only minimal xray changes
at the wrist
 Dorsal approach for synovectomy
 Straight longitudinal incision ad the sixth compartment is entered and the ext
retinaculum raised as a radially based flap
 The PI nerve can be sectioned in as it lies deep to the 4th comp tendons as
mode of pain relief
 A transverse or U shaped incision in the wrist capsule can be raised as a
distally based flap to expose wrist and the intercarpal joints
 This distal flap allows wrist capsule to be reefed easily to stabilize wrist joint
by limiting flexion.
 Traction applied to the wrist and rongeur used to debride the synovium
 DRUJ is exposed through an incision proximal to the TFC
 Capsule is closed in supination to tighten up the capsule
 Closed over a drain and wrist splinted in neutral for three weeks
 If post op laxity then put back into a splint for a further 4-6 weeks
 Volar wrist synovectomy
 Done when flexor synovectomy is also indicated to prevent destruction of the
deep volar ligamentous and rotatory subluxation of the scaphoid
 Same approach for tenosynovectomy
 Transverse incision into the joint, traction and then synovectomy with rongeur
 Capsule closed and splint as above
DRUJ Instability
Darrach procedure
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distal ulnar excision performed in conjunction with DRUJ synovectomy
Indicated for DRUJ instability with arthritis
Principles
1. Correction of carpal supination -suture the TFCC to dorsoulnar corner of the
radius
2. Stabilise distal ulna
3. Relocation ECU tendon from volar to dorsal
Operative technique
 Dorsal approach
 Extensor retinaculum opened
 ECU identified and brought dorsally and can be secured in the dorsal position
with a sling of ext retinaculum
 Longitudinal capsular incision over the distal ulnar and the capsule and the TFCC
are reflected from the ulnar and preserved
 Periosteum of the ulnar elevated
 No more than 2 cm of bone is resected to prevent instability
 Complete synovectomy performed whilst protecting the TFCC
 The ulnar is then stabilized using
1. distally based volar capsule flap brought dorsally and fixed to the ulna
2. strip of ECU and passed through the ulna and sutured to its self
3. FCU strip
4. FCU-ECU tenodesis (Breen and Jupiter)
5. Reinserting pronator quadratus insertion on dorsal aspect of ulnar
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The wrist splinted in supination for a period of 2-3 weeks
Ulnar head stabilization with distally based volar capsule
ECU strip
FCU Strip
Combined ECU/FCU tenodesis (Breen and Jupiter)
 dorsal and palmar approach
 extensor retinaculum is divided longitudinally, mobilized, and constructed into a
circular pulley for dorsal ECU stabilization.
 subperiosteal dissection of the most distal one inch of ulna is done between the
FCU and ECU interval.
 distal ulna is resected extraperiosteally just proximal to the sigmoid notch
 9-10 cm proximal based half slip of ECU tendon is created
 8-10 cm distally based slip of FCU tendon (still attached to the pisiform) is
constructed
 Communicating hole made in ulnar to medullary canal
 tenodesis weave is then created by passing both the ECU and FCU tendon slips
through these drill holes and suturing them to one another
 ECU is dorsally stabilized with the circular pulley constructed from the extensor
retinaculum
Complications
1. painful forearm rotation
o importance of stabilizing procedure to prevent this
2. persistent instability
3. impingement against radius during rotation and gripping
4. extensor tendon rupture over the sharp ulna end
o bevel edge of dorsum of distal ulna
Sauve-Kapandji procedure (1936)
Principle
 fusion of the DRUJ and the creation of an ulna pseudoarthrosis proximal to this
fusion
Operative technique
 dorsal longitudinal incision followed by a dorsal tenosynovectomy of the DRUJ
and dorsal tendon compartments
 Subperiosteal dissection of the distal ulna followed by stabilization of the distal
ulna with a Kwire
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Osteotomy of the ulnar proximal to the ulnar head flare (taking 10—20 mm)
a rongeur is used to remove articular surfaces from both the ulnar head and
sigmoid notch.
Correct ulnar variance
ulnar fragment fixed to the radius with a 4.0mm cancellous screw or k wire
Fascia of the pronator quadratus is brought through the osteotomy site and sutured
into the fascia over the proximal ulnar shaft. This interposition minimizes the risk
of regrowth and fusion at the pseudoarthrosis.
the dorsal capsule then repaired or recon with extensor tendons
Benefits
o IOM and TFCC are not disturbed
o radio-ulnar joint surface is maintained, and permits physiologic force
transmission from the hand to the forearm
Post op splint for 10 days followed by 3 week long arm splint
Best reserved for younger more active patients with localized DRUJ pain and
dysfunction.
Does not prevent ulnar carpal translocation
Watson’s matched distal ulnar resection (1986)
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maintains an intact TFCC and eliminates DRUJ articulation
Rongeurs are used to resect 6 cm of the distal ulna border of the ulna, while
maintaining a cuff of periosteum and ligamentous structures attached to the distal
ulna.
The ulna is shaped into a long, sloping convex curve to match the opposing
concave radius.
The technique requires an intact or reconstructible TFCC
Bowers procedure/Hemiresection Interposition Arthroplasty (1984)
 maintains an intact TFCC and reconstructs an incongruent DRUJ with autogenous
tissue (interpositional arthroplasty)
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autogenous tissue (muscle, tendon, or capsule) is placed between the radius and
ulna, and this in turn functions to prevent impingement
advantage of this technique is a shorter recovery period as no bony union can
occur and prolonged immobilization is not needed.
The technique requires an intact or reconstructible TFCC
Tendon balancing
 With caput ulna syndrome there is volar subluxation of the ECU
 Leads to unopposed radial deviation of the wrist which is exacerbated by
concomitant intercarpal dissociation with collapse deformity of the scaphoid
 Rebalance with
1. reposition ECU
2. ECRL to ECU
o Only if the radial deviation is passively correctable
o Usually in combination with other procedures
o ECRL divided at insertion and rerouted dorsal to extensors tensioned
to maintain wrist at neutral
Wrist arthroplasty
 Limited role
 Silicon rubber arthroplasty by Swanson was used but long term results showed
failure rate of 25% with recurrent deformity or fracture
 Limited to patients who will have low demand function on the wrist post op
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Bilateral wrist arthroplasties contraindicated
Prerequisites
1. functional wrist ROM
2. wrist extensors in good condition
3. minimal wrist deformity
4. good bone stock
Wrist arthrodesis
 partial or total
 plays a significant role
Partial wrist fusion
 Dorsal approach
 synovectomy and the articular cartilage removed exposing cancellous bone
underneath
 resect ulnar head
 remove articular cartilage from selected joints for fusion
 Bone graft from ulnar if head has been resected, or radius or iliac crest
 For radius take off Listers tubercle or window in the dorsal cortex
 Usually fuse radius, scaphoid and lunate
 Important to preserve overall dimensions of the carpus with bone grafting
 if midcarpal fusion as well then fuse all joints around the capitate
 cannulated screws for radiocarpal joints and k wire for midcarpus
Total wrist fusion
 Dorsal approach, longitudinal incision
 Synovectomy
 Expose the distal ulnar and radius
 Resect ulnar
 Remove cartilage and sclerotic bone from radiocarpal and proximal carpal row
 Bone graft fusion sites
 Medullary canal of radius perforated with awl to provide channel for Steinman pin
 Exit in between 3rd and 4th MC or 2nd and 3rd MC through the carpus and under
direct vision into the radius
 more recently use of wrist fusion plate placed from the radius to the 3rd
metacarpal
 long arm cast initially then after dressing change to a short arm cast
 the pins may be removed at 4-6-months but no problems leaving them in
 may be combined with MPJ arthroplasties as a single stage – contraindicated if
patient has severely deformed/dislocated wrist requiring extensive radiocarpal
exposure
Complications
1. pseudoarthrosis - usually does not require further surgery
2. deep wound infection
3. median and radial nerve compression
4. skin necrosis
5. fracture though the fusion site
6. pin migration