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Total wrist fusion for Volkmann’s ischaemic contracture (Using Synthes fusion plate)

    Overview

    Learn the Total wrist fusion for Volkmann’s ischaemic contracture (Using Synthes fusion plate) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Total wrist fusion for Volkmann’s ischaemic contracture (Using Synthes fusion plate) surgical procedure.
    Volkmann’s ischemic contracture is a complication of compartment syndrome of the forearm. Untreated compartment syndrome results in degeneration of the forearm muscles and nerves resulting in contractures.
    It is classified by Holden into Type I and II. In Type the pathology is proximal to the forearm such as a vascular occlusion or injury.
    Type I can be mild, moderate or severe.
    In the mild type, there is involvement of the deep muscle compartment mainly FDPs to middle and ring fingers. There may be partial involvement of FPL and pronator teres muscles and median nerve.
    The moderate type is called the classic type. In this there is involvement of the FDPs, FPL and pronator teres. Median nerve is involved and there may be partial involvement of the ulnar nerve. The hand is in an ‘intrinsic minus’ posture.
    In the severe type all flexors and pronators are involved with partial or total involvement of the extensors and instrinsics. Median and ulnar nerves are involved. The hand is in an intrinsic minus posture. Median and ulnar nerves are involved. Soft tissue coverage may be tight.
    In Type II the muscle injury is limited to the site of direct trauma. The extent of muscle injury is usually limited to the forearm compartment. There may be damage to the nerves and loss of soft tissue. The extent of the finger deformity is related to the degree of muscle injury.
    Corrective surgery for Volkmann’s ischaemic contracture is dependent on the type of contracture and degree of involvement of various muscle compartments. The case discussed here is a Holden Type I severe type from a vascular occlusion in the upper arm. He presented with an acute compartment syndrome which was released but unfortunately it was delayed and there was already muscle necrosis.
    He presented with a fixed flexion deformity of the wrist, hypertension at MCP joints of the fingers and flexion at interphalangeal joints. An MCP joint release using dorsal capsulotomy was done initially and a flexor muscle slide was attempted later. Unfortunately both these operations were unsuccessful.
    This operation is aimed at correcting the wrist deformity through a total wrist fusion and a later tendon transfer to move the ECRL to FDPs of the fingers. He may also need a fusion of the thumb CMC joint in an anatomical position and a transfer of EIP to FPL.
    The steps of a total wrist fusion is explained through this operation.
    When performing a total wrist fusion, the radio-carpal joint, capito-lunate joint and third CMC joint are fused. In this case the joints between capitate and hamate and between triquetrum and hamate are also included in the fusion to increase the strength. The distal radio-ulnar joint is left intact which usefully preserves pronation & supination.

    Indications

    INDICATIONS:
    Wrist fusion is an operation performed for several indications including bony and soft tissue problems.
    It is commonly performed for advanced arthritis involving the radiocarpal and mid-carpal joints. Alternatively for isolated radiocarpal joint arthritis, a radio-scapholunate fusion can be performed and likewise for arthritis between the carpal bones, limited wrist fusions can be performed.
    It is also performed as a salvage operation after a failed limited fusion such as a four-corner fusion or failed wrist arthroplasty.
    It can be an option for patients with brachial plexus or high peripheral nerve injury where there are no tendons working to move the wrist or to use the wrist tendons for providing finger movements after fusing the wrist.
    The indication to fuse the wrist in a Volkmann’s ischaemic contracture is when there are no suitable soft tissue operations to improve the wrist position.
    SYMPTOMS & EXAMINATION:
    Patients for wrist fusion are usually those with pain and limited movements from arthritis.
    In this case, the patient has a fixed flexion deformity of the wrist, hyperextension of the MCP joints and flexion deformity of the IP joints. He has imparied sensations of the median and ulnar nerves. His problems are related to soft tissues and the bony anatomy is normal.
    IMAGING :
    While assessing for wrist fusion in case of bony problems imaging is indicated pre-operatively. In most cases plain X-Rays in AP and Lateral views are sufficient. However if the joint surfaces cannot be assessed accurately in less severe arthritis, CT scan is useful. MRI scans are usually not needed.
    X-Rays were performed in this case and were normal.
    ALTERNATIVE OPERATIVE TREATMENT:
    There are several techniques for wrist fusion and some techniques are preferred depending on the indications and surgeon’s preference. The common methods are using plate and screws, Steinmann pin inserted through the head of the third metacarpal head or cross K-wires. The latter two are preferred in Rheumatoid arthritis patients where the bone stock is poor. In this case we opted to use a plate and screw fixation as he is a young fit individual with good bone stock and we can position the wrist in slight extension which will help to relax the extensor tendons of his fingers thereby improving the finger flexion.
    In general the alternatives to a total wrist fusion, where it is performed for arthritis are wrist replacement or denervation procedures. Replacement of the wrist joint is being increasingly performed. Wrist denervation involves dividing the anterior and posterior interosseous nerves as well as any other smaller nerve branches supplying the joint.
    The alternative procedure in this case would be a proximal row carpectomy but with the attenuation of the wrist extensor tendons this would provide a less reliable functional outcome.
    NON-OPERATIVE MANAGEMENT: For patients with arthritis, there is an option of conservative treatment using splints, analgesics or steroid injections. This patient has significant functional impairment due to the poor position of his wrist and therefore conservative options do not exist.
    CONTRAINDICATIONS: Active infection in the skin or soft tissues is an absolute contra-indication for wrist fusion. Relative contra-indications include poor bone stock and a non-compliant patient.

    Setup

    The surgery is being performed under a brachial block with an upper arm tourniquet. A single dose of 1gm Flucloxacillin has been administered intravenously. The hand is positioned on the hand table and prepped and draped. The typical deformities of Volkmann’s ischemic contracture can be seen with the wrist flexion and clawing of fingers.

    Operation – 1

    The photograph shows the deformities which are typical of a Volkmann’s ischaemic contracture. As seen from the photograph there is a flexion deformity of the wrist and hyperextension of the MCP joints. The thumb is adducted. Though previous MCP joint released have been attempted they have relapsed into hyperextension due to the wrist flexion deformity which tightens the extensor tendons which cross the joint. The primary pathology has been ischaemia to the forearm muscles with resulting muscle necrosis and fibrosis. The shortening of the flexor muscles bring the wrist into flexion and the pull of the extensors on the MCP joints bring them into hyperextension.

    The view from the dorsum shows the hyperextension of the MCP joints and flexion of the interphalangeal joints.

    The view of the wrist on the volar side shows a healed stretched scar from the previous operations. The flexor tendons can be seen tight under the skin.

    A dorsal incision is made centred on the Lister’s tubercle. The distal end of the incision is up to the neck of the third metacarpal and the proximal end is about five cm proximal to Lister’s tubercle.

    The skin incision is made taking care to protect the dorsal sensory nerve branches of superficial radial nerves. These nerve branches lie in the subcutaneous plane alongside the superficial veins. Blunt dissection using a tenotomy scissors help to spread the tissues and move the nerve branches out of the field.

    Extensor retinaculum is opened over the Extensor pollicis longus tendon and it is mobilised radially. A self retaining retractor is useful to improve the exposure

    At this point, one can either open the fourth extensor compartment(compartment containing extensor digitorum tendons and extensor indices proprius tendon) and go through the floor to access the wrist joint. A more elegant method which I prefer is to lift the fourth compartment and access the joint capsule and ligaments underneath it. This step requires sharp dissection using a No.15 scalpel lifting the floor of the fourth extensor compartment off the dorsal wrist ligaments. As one dissects, the transverse fibres of the extrinsic dorsal wrist ligaments come into view.

    At this point, Lister’s tubercle is osteotomised and removed. A sharp osteotome is used to do the osteotomy as shown. The aim is to get a uniformly flat surface of the distal radius where the plate can be kept without being prominent.

    The radiocarpal joint is exposed through a longitudinal incision on the dorsum of the joint. This incision goes through the transversely oriented extrinsic ligaments and joint capsule. As the wrist is being fused one does not need to worry about preserving the extrinsic wrist ligaments.
    If a partial fusion such as a four corner fusion is being performed, the wrist ligaments can be preserved by using what is knows as Berger’s incision. This is a transversely oriented ‘v’ incision with the apex of the ‘v’ over triquetrum.
    As the radiocarpal joint is exposed, one can appreciate the proximal surfaces of the scaphoid and lunate held together by the scapholunate ligament.

    The exposed radiocarpal joint can be well seen here.

    The joint is further exposed by flexing the wrist. This allows visualisation of the proximal parts of scaphoid and lunate as well as the whole of the articular surface of the radius.
    Here it is being lavaged as part of the preparation.

    At this point the joint is prepared. This involves removing the articular cartilage from the distal radius, proximal carpal row and between the carpal bones. The cartilage from the proximal pole of scaphoid, proximal and distal part of lunate and proximal part of capitate have to be nibbled. The cartilage between triquetrum and hamate can be preserved but removing it gives a larger area of bone contact for a more solid fusion.

    Cartilage can be removed using a combination of osteotomes and bone nibblers. A power saw or burr are alternatives. The aim is to denude the cartilage till punctate bleeding from subchondral bone can be seen.

    The prepared joint can be seen. The cartilage from the articular surface has been removed.
    Bone graft is not necessary for fusions when it is done as a primary procedure and when the bone stock is good. In this case, part of the proximal scaphoid and lunate has been removed to shorten the wrist allowing the flexor tendons to loosen up. When bone graft is needed usually it is taken from the iliac crest. Bone graft from distal radius is not sufficient.

    Once the joint is prepared once can use a trial plate to see how the wrist is positioned. There are two main positions for fusions. One is in neutral and the other with slight extension. In this instance we felt that slight extension will be beneficial and a plate with a short bend was chosen. As one can see from the patient’s pre-operative photographs he has wrist flexion and hyperextension of the MCP joints. Bringing the wrist into slight extension will automatically correct the MCP joint hyperextension by relaxing the extensor tendons.
    The plating system used here is the Synthese one. There are alternative plating systems available. We prefer this plate as it gives the option of fusing in slight extension which in this case is an advantage.
    The Synthes plate used here is a short bend plate with distal 2.7mm screws and proximal 3.5mm screws. It is a non-locking plate and allows compression of the bones if the hole is placed eccentrically.
    One ideally needs six cortical screws in total on either side of the radiocarpal joint. These will be two on the third metacarpal, one on the capitate and three on the distal radius. Additional screws are useful in giving more stability to the fixation.

    This photograph shows the distal fixation on the third metacarpal. It is practical to do the metacarpal fixation first as there is more flexibility with the positioning of the plate on the distal radius. The drill used is a 2mm drill. A drill guide is used to place the drill accurately without soft tissue interposition. The hole is drilled in the middle as it is a non-compressing screw.

    After drilling both cortices the depth is measured using a depth gauge.

    A tap is used to cut the grooves in the bone for the screws.

    The first screw is inserted. A second screw is inserted into the metacarpal using the same technique. This is also a non-compressing screw.

    The plate is now positioned on the distal radius and fixed. A 2.5mm drill is used and after measuring the depth a tap is used. The first hole on the distal radius is drilled eccentrically to allow compression of the plate.

    After this a check X-Ray is done to assess the position of the plate. If it is satisfactory further screws are inserted in the sequence given below. These are all non-compressing screws.
    Two more screws on the distal radius
    Single screw on the capitate.
    An additional screw on the third metacarpal if possible.

    A final check X-Ray is done. AP and Lateral views are needed to assess the position of the plate and screws. The AP view shows the plate positioned correctly over the third metacarpal and distal radius across the centre of the joint.

    The lateral view is helpful in assessing the lengths of the screws. The screws should purchase on both cortices without penetrating beyond the far cortex.

    The wound is closed in layers. The joint capsule is closed with 4-0 Maxon.

    Extensor retinaculum is closed with the same suture exteriorising the EPL tendon. Doing this protects the EPL from rubbing against the plate.

    Operation – 2

    The rest of the wound is closed using 3-0 Monocryl.

    The closed wound can be seen.

    The wound is dressed with jelonet, gauze, velband, POP backslab and bandage. The POP backslab extends from the mid-forearm to the MCP joints.

    Post Operative

    Patients is kept overnight for hand elevation and analgesia.
    After discharge, patient is reviewed in the dressing clinic in one week.
    Dressing are removed and a simple Mepore dressing applied.
    A below elbow POP is applied upto the MCP joints. Hand therapy is started to mobilise the Thumb and fingers actively and passively. This is kept for another 5 weeks and a check X-Ray is performed. If it is satisfactory POP is discontinued and hand therapy continued.
    Patients are advised that they can start light activities after coming out of the POP in six weeks. If there is satisfactory bony union on X-Rays, they can start strengthening exercises as six weeks and by three months can do moderate physical activity. By six months, the fusion is usually strong enough for all physical activities.
    After a total wrist fusion patients can perform most day today activities including driving. Patients learn to adapt for loss of wrist movements for most activities. However sports activities such as racquet sports and swimming are difficulty due to limitation of wrist movements.

    Recommended Reading

    1.Houshian S, Schrøder HA. Wrist arthrodesis with the AO titanium wrist fusion plate: a consecutive series of 42 cases. J Hand Surg Br. 2001 Aug;26(4):355-9.
    The authors have looked at 42 cases of total wrist fusions. The indications were post-traumatic arthritis in 29 wrists, Kienböck’s disease in eight, rheumatoid arthritis in three, mono-arthritis in one and Volkmann’s contracture in one. They concluded that AO/ASIF Titanium wrist fusion plate is an excellent option for treatment
    2.Richterman I, Weiss AP. Wrist fusion. Hand Clin. 1997 Nov;13(4):681-7.
    This is a review article looking at indications and techniques of wrist fusion. They concluded that It provides predictable pain relief, enhanced hand function, and a high degree of patient satisfaction. The AO/ASIF wrist fusion plate allows rigid internal fixation and optimizes wrist position for maximum hand function. In comparison to other wrist arthrodesis techniques, the wrist fusion plate produces a high rate of fusion.
    3.Jebson PJ, Adams BD. Wrist arthrodesis: review of current techniques. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):53-60.
    This article looked at various methods for wrist fusion. They concluded that although a variety of techniques for achieving a solid fusion have been described, the combination of rigid stabilization with a dorsal plate and autogenous cancellous bone grafting results in a high fusion rate.

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