Overview
Definitions of Hand Function
In the poorly functioning hand, House functional level 0,
"does not use," or 1, "poor active assist,"
wrist fusion is appropriate in selected individuals to improve
appearance, to facilitate hygiene, and/or to enhance position in
space (House 1981).
Severe wrist deformity can occur in functional hands that
demonstrate good to excellent voluntary grasp and release in the
flexed or extended positions. In the case of a functional hand,
avoid arthrodesis, if possible, because tenodesis from wrist motion
may aid both grasp and release. If passive placement of the wrist
in neutral positions allows digital function, fusion can be
performed in isolation. However, such function is rare, so a
combination of fusion, wrist shortening, and tendon balance may be
necessary to maintain function.
Technique: Wrist fusion in the immature
child (Figure 22)
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Longitudinal S or straight incision over 3rd or 4th
dorsal compartment |
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Elevate periosteum of distal radius |
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Elevate 4th compartment intact |
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Incise wrist capsule
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If excessive tension, excise proximal row lunate, 1/2
scaphoid and triquetrum |
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Decorticate remaining carpal bones and the 2nd
and 3rd carpometacarpal joints (Figure 22A) |
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Decorticate distal radius without crossing radial physis
(Figure 22B) |
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Fix position with 2 or more smooth Steinman pins or Kirschner
wires; crossing physis with smooth pins only; pins may be
longitudinal or crossed |
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Pack with autologous bone graft or with osteoinductive
or osteoconductive allograft (autograft) |
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Close capsule with absorbable suture |
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Test digit tension, if necessary.
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Augment extensor tendons with transfer |
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Fractionally lengthen or z-lengthen long finger flexors
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Transfer to augment finger flexors |
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Cast for 6 weeks or until radiographic healing is evident |
Technique: Wrist fusion in the skeletally mature
individual (Figure 23)
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Make longitudinal S or straight incision over 3rd
or 4th dorsal compartment |
|
Elevate periosteum of distal radius either through 3rd
compartment or in between 3rd and 4th
compartment
|
Elevate 4th compartment intact |
|
|
Incise wrist capsule |
|
If excessive tension, excise proximal row (lunate, 1/2
scaphoid and triquetrum) |
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Decorticate remaining carpal bones and 2nd and 3rd
carpometacarpal joint |
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Decorticate distal radius |
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Osteotomize dorsal 1/3 of carpal bones and expose 2nd
and 3rd carpometacarpal joints |
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Bone graft
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Remote-site autologous bone graft (e.g., iliac crest) |
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Create local autologous distal radius graft by outlining
3-cm x 7-cm dorsal graft with drill holes and elevating a
6- to 8-mm-deep block with an osteotome |
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Autologous bone chips may be used |
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Allograft may be utilized |
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Slide graft to cross wrist (Figure 23__) |
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Complete fixation with
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Smooth or threaded wires |
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Dorsal plates and screws (Figure ___) |
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Custom wrist fusion plates are available. These have
2.7-mm distal or 3.5-mm proximal screw holes with preset
wrist positions
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Position wrist in neutral to 5° to 10° of
extension |
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Plate may bridge wrist from distal radius to 2nd
or 3rd metacarpal (Figure 23 C, D) |
|
|
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Close capsule with absorbable suture |
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Test tension in each digit
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Augment extensor tendons with transfer if needed for
strength (Figure 23E, 23F) |
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Fractionally lengthen or z-lengthen long finger flexors
|
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Postoperative Care
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Cast for 6 weeks or until radiographic healing is evident |
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Begin active and passive range of motion therapy as
indicated |
Wrist Flexion
and Contraction |
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