Total wrist arthrodesis The ultimate salvage for any motion-preserving procedure is total arthrodesis (i.e., fusion). This procedure involves fusing all wrist bones, leaving the rotating joint between the radius and the ulna to preserve supination and pronation (Figure 24). Indications for total wrist fusion include a painful or unstable wrist due to col- lapse of the carpus, Kienbock’s disease, or SLAC wrist. According to Cannon (2020), to create total wrist fusion, the surgeon makes a dorsal incision extending along the third metacarpal to the dis- tal third of the radius. The dorsal wrist capsule is exposed and incised. The proximal row of carpal bones and distal radius are removed, and the dorsal surface of the third metacarpal is shaved to expose cancellous bone. A cancellous bone graft from the iliac or other viable donor site, including possible use of removed car- pal bone, is placed in the defect with a plate that extends to the radius along the third metacarpal (Shah & Stern, 2013). Figure 24: X-ray: Total Wrist Fusion
At four weeks postsurgery, the cast is removed and AROM wrist exercises can begin with the forearm in neutral (Cannon, 2020). By keeping the forearm in neutral or pronated, the distal end of the radius rests more proximally and puts less strain on the heal- ing wrist (Cannon, 2020). The thermoplastic wrist immobilization orthosis (Figure 23) is fabricated at this time (if the client was in the cast prior) or continued. Clients are instructed to wear it full time, removing it only for hygiene and exercises. This orthosis offers rest and protects the healing wrist. It enables the client to engage in ADL that are too forceful for an unprotected joint. For example, while wearing the orthosis, the client can complete dressing activ- ities and household tasks such as light meal preparation and light sweeping. The client should be educated on activities that are appropriate for this period and instructed to wait until additional healing occurs before attempting others. Scar-control techniques, including massage elastomer pressure inserts and silicone gel sheets, can be started as needed at four weeks, or sooner if the client was using the thermoplastic ortho- sis. If tendon gliding and excursion (i.e., the ability for tendons to travel freely through their sheaths) have been impacted by dorsal hand scarring and are causing difficulties with finger flexion and extension, the therapist can initiate neuromuscular electrical stim- ulation (NMES), an electrical modality that stimulates the muscle fibers to create a contraction, thereby assisting with application of internal force (i.e., pressure) to the scar adhesions surrounding the tendons. Light activities that target and encourage flexion and extension of the fingers should be suggested not only to encour- age movement of the hand but also to provide an opportunity for light protected strengthening and affirmation that the surgical intervention will lead to newfound, pain-free function. At five weeks postsurgery, active-assisted ROM can be initiated to the forearm and wrist as long as exercises remain pain-free. It is important to respect the client’s pain and never force recovery of motion (Cannon, 2020). Orthosis wear should be continued dur- ing resistive activity and sleeping but can be removed for light activities such as eating, reading, typing, writing, and watching television. At six weeks postsurgery, PROM geared toward increasing ROM can be initiated (Cannon, 2020). At eight weeks postsurgery, with wrist joint flexion limited to less than 30 degrees, a dynamic wrist flexion orthosis can be used. However, 30–35 degrees of wrist flexion is functional, and the wrist should not be pushed to gain more motion than that into flexion. The wrist immobilization orthosis can be mostly discontin- ued except for heavy activities that involve resistance or torque to the hand or wrist. Progressive strengthening can commence if the client has only low pain. Strengthening can be accomplished with therapy putty and wrist weights, beginning with the least resis- tive and lightest, and eventually working toward those with more resistance (Cannon, 2020). The client can also begin to use the hand in occupations that are mildly resistive and done in a con - trolled manner. For example, brushing teeth and using the hand for bathing, eating, and preparing light meals are appropriate. Working in the garden using tools or completing carpentry activi- ties is inappropriate at this time, but these activities are added to a client’s regimen within the next few weeks. No activity should be completed if it causes discomfort. Between 10 and 12 weeks postsurgery, the resting orthosis should be fully discontinued. Dynamic mobilization should be stopped at 12 weeks unless gains continue and more than 30 degrees of flexion is not being sought (Cannon, 2020). The client can be instructed to resume all normal activities. For those involved in heavy work, a workplace assessment will determine the amount of force that their job places on the wrist and whether a protec- tive circumferential wrist orthosis should be provided. This inter- vention significantly reduces the client’s pain and allows them more functional use despite an expected permanent decrease in strength and motion.
Note : “X-ray showing arthrodesis of right wrist” by TheFriendliest, used under Creative Commons license BY-SA 4.0 / Cropped from original. During fusion, the wrist is placed in 10 degrees of wrist extension to allow positioning of the hand needed for power gripping. Al- though the best wrist position for power gripping is 35 degrees of extension, that angle interferes with occupational engagement. A position of 5 to 10 degrees of ulnar deviation is also set (Shah & Stern, 2013). Following surgery, the client is placed in a postsurgi- cal cast and referred to therapy after approximately 10 days to 2 weeks. Therapeutic intervention following total wrist arthrodesis Following total wrist fusion, the client’s wrist is immobilized in a cast for as long as six weeks. During that time, the client is re- ferred to therapy for edema control and ROM of the noninvolved joints. Specific attention must be paid to the extensor indicis, the extensor digitorum, and the extensor pollicis longus tendons be- cause they can become adhered with a scar that develops from the long dorsal incision required to access the joint and apply the plate during the fusion. Gentle functional activities that encour- age excursion and gliding of these tendons should be initiated (Cannon, 2020). The therapist can use neuromuscular electrical stimulation if they are well versed in its application, indications, and contraindications. One-handed techniques and adaptive equipment ideas should be shared with the client to foster ADL function during this time of healing. Between six and ten weeks, when consolidation is progressing, the cast is removed and the therapist fits the client with a bivalve thermoplastic orthosis (Cannon, 2020). Scar massage can be started along with heat modalities to increase scar extensibility.
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