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Biomechanics of the Rheumatoid Wrist Deformity

  • Gregory Ian BainEmail author
  • Thomas Clifton
  • John J. Costi
  • Jeganath Krishnan
Chapter

Abstract

The multiple ring concept helps to understand how the normal wrist maintains stability throughout the range of motion. Disruption of the individual rings leads to characteristic patterns of instability. Rheumatoid arthritis is a systemic inflammatory condition that commonly affects the wrist, causing pain, chronic inflammation, joint deformity, and destruction. Loss of articular cartilage height will produce a “pseudo-laxity” of ligaments, whereas the expanding pannus causes attenuation of the ligamentous attachments. Loss of these ligament supports creates instability within the “rings of the wrist” and is the main cause of the abnormal loading of the wrist joint. This results in a relatively predictable pattern of deformity, including collapse of the radial column and carpal translocation in a volar, ulnar, proximal, and supination direction. The distal radioulnar joint (DRUJ) is commonly affected, often with abutment of the ulna onto the carpus causing relative dorsal displacement of the ulna head or, more precisely, volar subluxation of the radius, as the ulna is the stable component of the forearm. As the forearm rotates, the ulnar head may be sculptured on the eburnated sigmoid notch like a “chisel shaping wood in a lathe.” This sharpens the ulnar head, which then can breach the joint capsule and subsequently abrade the extensor tendons. The goals of surgical intervention are to halt the progression of the disease, stabilize the joint, and minimize pain, while maintaining a functional motion. Targeted operative interventions depend upon the level of disease:
  1. 1.

    Minimal destruction—synovectomy

     
  2. 2.

    Localized destruction—reconstruction with radioscapholunate (RSL) fusion and/or matched hemi-resection of the distal ulna

     
  3. 3.

    Generalized destruction—salvage with full wrist fusion or arthroplasty

     

Videos are included in this chapter and can be accessed online.

Keywords

Rheumatoid arthritis Wrist Multiple ring theory Chisel and lathe Biomechanics Pseudo-laxity Radiocarpal Radiolunate Radioscapholunate DRUJ Hemi-resection 

Supplementary material

Video 8.1

Three days’ CT scan of the wrist demonstrating the severe deformity. The radius has dislocated from the distal ulna. The volar radius is fragmented, and the carpus has dislocated in a volar and ulnar direction. All videos published with kind permission of © Dr. Gregory Bain 2015. All Rights Reserved (MOV 20708 kb)

Video 8.2

Three days’ CT scan of the distal radius and ulna. Note the gauging of the distal radius articular surface from the lunate, which has occurred as the carpus slides down the slope of the distal radius. The instability of the distal ulna and deformity of the sigmoid notch are also well visualized. All videos published with kind permission of © Dr. Gregory Bain 2015. All Rights Reserved (MOV 14456 kb)

Video 8.3

There is considerable wrist deformity, with the carpus dislocated in a proximal, volar, ulnar, and supination direction. There is loss of active finger extension and restricted wrist extension. Same patient as Videos 8.1 and 8.2. All videos published with kind permission of © Dr. Gregory Bain 2015. All Rights Reserved (MOV 39939 kb)

Video 8.4

The active forearm rotation can be performed despite the severe deformity and the DRUJ dislocation. All videos published with kind permission of © Dr. Gregory Bain 2015. All Rights Reserved (MOV 13951 kb)

Video 8.5

This video demonstrates that despite such a marked deformity, it can be corrected passively. The radiocarpal, DRUJ, and fingers can all be reduced. All videos published with kind permission of © Dr. Gregory Bain 2015. All Rights Reserved (MOV 54638 kb)

Video 8.6

The soft tissue is retracted to expose the eroded distal radius, which no longer contains the carpus. All videos published with kind permission of © Dr. Gregory Bain 2015. All Rights Reserved (MOV 67644 kb)

Video 8.7

Intraoperative video. The extensor retinaculum is retracted to expose the attenuation rupture of the finger extensors. Note the shredded tendon adjacent to the sharp edge of the ulnar head. Same patient as Videos 8.1 and 8.2. All videos published with kind permission of © Dr. Gregory Bain 2015. All Rights Reserved (MOV 40261 kb)

Video 8.8

Intraoperative video. Eburnation of the sigmoid notch, which is shaping the distal ulna, like a chisel sharpening a piece of timber on a lathe. This sharp edge of the ulna then cuts through the dorsal DRUJ capsule and then threatens the extensor tendons. As the extensor tendons move with the fingers, they are progressively abraded by the sharp edge of the ulna. All videos published with kind permission of © Dr. Gregory Bain 2015. All Rights Reserved (MOV 16008 kb)

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Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Gregory Ian Bain
    • 1
    Email author
  • Thomas Clifton
    • 2
  • John J. Costi
    • 3
    • 4
  • Jeganath Krishnan
    • 1
  1. 1.Department of Orthopaedic SurgeryFlinders UniversityAdelaideAustralia
  2. 2.OrthopaedicsRoyal Adelaide HospitalAdelaideAustralia
  3. 3.Biomechanics and Implants Research GroupThe Medical Device Research InstituteAdelaideAustralia
  4. 4.School of Computer Science, Engineering and MathematicsFlinders UniversityAdelaideAustralia

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