43: Carpal Wedge Osteotomy for Congenital Wrist Flexion Contracture (Arthrogryposis)

Published on 18/04/2015 by admin

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Last modified 18/04/2015

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Procedure 43 Carpal Wedge Osteotomy for Congenital Wrist Flexion Contracture (Arthrogryposis)

Sandeep J. Sebastin, Kevin C. Chung

imageSee Video 35: Triceps Lengthening and Elbow Release in Arthrogryposis

Indications

image Wrist flexion contracture with fixed bony changes (carpal coalition) (Figs. 43-1 and 43-2)

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FIGURE 43-1

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FIGURE 43-2

Examination/Imaging

Clinical Examination

image The ability of the child to open and close the fingers should be determined. If the child does not have active finger extension, correction of the wrist flexion contracture will result in loss of ability to passively extend the finger by the tenodesis effect (Fig. 43-3).

image The function of the extensor carpi ulnaris (ECU) should be assessed. A transfer of the ECU to the radial wrist extensors may be required to improve wrist extension and diminish the ulnar deviation deformity.

image It is important to examine the child along with an occupational therapist to evaluate the functional status of the wrist. This will help to determine the optimal wrist position in children who need surgery and to avoid surgery in children who have adapted well to the wrist flexion contracture.

image These children frequently have lower limb anomalies that can be corrected simultaneously to reduce the overall number of procedures.

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FIGURE 43-3

Imaging

image Radiographs of the wrist can help in planning the location of the wedge resection.

Surgical Anatomy

image The extensor tendons are usually small. The radial wrist extensors (extensor carpi radialis longus and brevis) are usually adherent to the dorsal capsule, and the proximal musculature is absent. The ECU is often the largest extensor tendon.

Positioning

image The procedure is performed under tourniquet control with the patient in the supine position. The degree of elbow contracture may complicate arm position during surgery. The tourniquet should be placed as high as possible to increase the surgical field.

image Intraoperative fluoroscopy will be required to plan the wedge resection and to confirm position of the K-wires that will be used for fixation.

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