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

Published on 18/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1896 times

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)

image

FIGURE 43-1

image

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.

image

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.

Exposures

image A single 4-cm longitudinal incision centered over the dorsum of the wrist is made. The extensor retinaculum is identified, and skin flaps are raised on both sides superficial to the retinaculum.

image The third compartment is identified by its location ulnar to Lister tubercle and opened. The extensor pollicis longus (EPL) tendon is brought out of the third compartment.

image The wrist capsule is opened in the floor of the third compartment. The second and fourth compartments are elevated extraperiosteally off the distal radius and the carpus to expose the carpus.

Pearls

The sensory branches of the radial and ulnar nerve are elevated along with the skin flaps.

The entire midcarpal joint must be visualized and the extensor compartments mobilized sufficiently for full exposure.

Pitfalls

The EPL is small and must be handled carefully. The radial extensor tendons are atrophic and usually attached to the dorsal capsule.

Procedure

Step 1

image A wedge of bone is removed from the midcarpal joint using an osteotomy. The amount of bone removed depends on the preoperative flexion and ulnar deviation deformity. The proximal cut is made perpendicular to the long axis of the radius, and the distal cut is made perpendicular to the metacarpals. This results in a wedge because of the flexion deformity. The wedge should be made wider on the radial side if correction of an ulnar deviation deformity is also required (Fig. 43-4).

image

FIGURE 43-4

Step 1 Pearls

Intraoperative fluoroscopy can be used to confirm the position of the osteotomy in the older child. In the younger child whose carpus has not yet ossified, the position should be confirmed visually.

A scalpel blade can be used in the younger child because the carpus is relatively soft. An osteotome will be required in the older child. Using a saw is not necessary because there is less control of the cut and the bone is soft.

Step 1 Pitfalls

Ensure that the wedge resection is over the midcarpal joint and not the radiocarpal joint.

Prevent injury to the volar wrist capsule.

Step 2

image The aim of the wedge osteotomy is to get the wrist into a posture of slight extension (Fig. 43-5). If the wrist cannot be brought into this position, tendons on the volar side need to be released. A 4-cm volar longitudinal incision is made proximal to the wrist crease and ulnar to the palmaris longus.

image A tight palmaris longus tendon can be divided. Up to 2 cm of lengthening can be obtained by dividing the tendinous portions at the musculotendinous junction.

image

FIGURE 43-5

Step 3

image Two 0.062-inch K-wires are passed to maintain the corrected position of the wrist after wedge excision of the carpus and release of any volar restricting structures (Fig. 43-6).

image

FIGURE 43-6

Step 3 Pearls

It is easy to pass the K-wires in an antegrade fashion through the osteotomy site to exit at the skin distally between the metacarpals. Then the osteotomy is closed, and the K-wires are passed retrograde across the osteotomy and the radiocarpal joint into the distal radius.

Step 3 Pitfalls

The position of the K-wires should be confirmed by intraoperative fluoroscopy. The wires should pass through both midcarpal and radiocarpal joints to ensure a stable fixation.

Step 4

image The dorsal capsule is repaired using 3-0 Vicryl sutures.

Step 5

image If a good-quality ECU tendon is present, it can be divided distally and transferred subcutaneously to reach the radial wrist extensors to provide some radial wrist extension.

image The skin and subcutaneous tissue are closed with absorbable sutures.

Postoperative Care and Expected Outcomes

image The limb is immobilized in an above-elbow fiberglass cast. The cast will be maintained for 6 weeks to allow the osteotomy site to heal. The K-wires are removed at 6 weeks, and the osteotomy site is protected with use of an intermittent splint for 3 months. Finger motion is permitted within the cast.

image Formal therapy is usually not required in younger children who adjust to the repositioned wrist. Surgery reliably repositions the wrist, which improves grasp (Fig. 43-7). Improvements in activities of daily living are dependent on degree of limb involvement and overall status of the child.

image

FIGURE 43-7

Evidence

Bennett JB, Hansen PE, Granberry WM, Cain TE. Surgical management of arthrogryposis of the upper extremity. J Pediatr Orthop. 1985;5:281-286.

Case series of 25 patients who underwent 56 operative procedures to correct upper extremity deformities due to arthrogryposis. Functional improvement was observed clinically and reported subjectively by the patients or their parents in 75% of the cases. (Level IV evidence)

Related posts:

81: Ulnar Shortening Osteotomy 61: Trapeziometacarpal Ligament Reconstruction 21: Steindler Flexorplasty 50: Open Reduction and Internal Fixation of Phalangeal Shaft Comminuted Fractures 21: Steindler Flexorplasty 37: Duplicated Thumb Reconstruction