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Total wrist fusion This is an end stage procedure for wrist problems. Most commonly for forms of wrist arthritis or rheumatoid arthritis of the wrist which is a result of a totally destroyed wrist joint. It can also be used in Keinbock's disease (ref). Essentially total wrist fusion will stop the movement of the wrist in extension (bending the wrist backwards) and flexion (bending of the wrist towards the palm). Rotation of the forearm (rotating the palm upwards and downwards) is not affected by this operation. It is used to help significant pain in the wrist as it stops the wrist moving it tends to cure wrist pain. It is a very drastic operation and is not used as a first line of treatment. ANAESTHETIC General or regional anaesthetic. OPERATIVE PROCEDURE A longitudinal 10cm incision over the back of the wrist. The tendons on the back of the wrist identified and avoided. There is commonly a nerve that lies directly over the back of the wrist called the posterior interosseous nerve which is dissectioned which helps wrist pain. The wrist joint is then exposed from the level of the radius to the carpus and the base of the middle finger metacarpal. Articular surfaces of the wrist joint are then burred with a dental burr (horrible drill used by dentists!) and this takes off any remaining cartilage or gristle on the back of the bones so that one can obtain bone to bone contact. It is very common that a bone graft is used which is often taken from the hip (not from hip joint itself, but from the pelvis where you hang your trousers). This bone graft is placed in between the burred bony surfaces and a plate applied that is essentially an internal splint that attaches to the base of the middle finger metacarpal and 3 screws are placed in that bone and 3 screws are placed in the radius to allow rigid internal fixation. The plate allows and incorporates fixed position of 10 - 15° if dorsi flexion of the wrist joint (this means that the wrist is bent back by 10 - 15°). The wrist wound is closed in layers and the tendons are placed in their original position. A layer of tissue and sutures over the back of the tendons and then the skin is repaired. POST OPERATIVELY A Plaster of Paris splint is applied incorporating half of the wrist as this operation can involve a lot of post operative swelling so to in case the whole wrist would be dangerous. ½ wrist splint to be maintained for two weeks with the hand elevated in a high arm sling. Patient reviewed at two weeks. Sutures removed and wounds checked. Splint replaced with a full forearm case below the elbow for a period of 4 weeks. Total plaster time of 6 weeks. Physiotherapists get the fingers moving within the cast. COMPLICATIONS
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