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Education · wrist

Wrist Osteoarthritis Info In-depth Evidence

Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed

What you're feeling

Wrist arthritis often starts after an old injury. A broken wrist or a damaged ligament from years ago can set up wear-and-tear arthritis in the joint. The two most common patterns follow an injured scaphoid, one of the small bones on the thumb side of your wrist. Doctors call these SLAC and SNAC arthritis, short for scapholunate advanced collapse and scaphoid nonunion advanced collapse.

The pain is usually felt on the back of the wrist, and often worse on the thumb side. That side carries most of the load when you use your hand, so pushing up from a chair, wringing out a cloth or lifting a heavy pan can hurt. Sudden, heavy loading with the wrist bent back is especially uncomfortable. Rest and a splint tend to settle it. Some people notice the ache at night or first thing in the morning.

Daily tasks can become harder in ways you might not expect. You may find your grip is weak even though the wrist still moves well and does not hurt much. Heavy lifting can make you loosen your hold without meaning to, because the muscles working on a sore joint trigger pain. Opening jars, carrying shopping bags or leaning on the wrist to rise from a low seat can all feel unreliable.

Sometimes the wrist itself is not the complaint. A painful or unstable wrist can make the whole hand weaker and less nimble, because you cannot position it properly for gripping or fine work. Swelling or thickening around the wrist can also press on a nerve and cause carpal tunnel syndrome, with tingling or numbness in the fingers.

How much the wrist hurts does not always match what an X-ray shows. Some people with marked arthritis on a scan have little pain, and others with mild changes hurt a lot. What matters is what you can do, not what the image says.

What's actually happening

Your wrist is a cluster of eight small bones in two rows, working together so your hand can move in many directions. The row nearest your thumb includes the scaphoid, a small boat-shaped bone that acts like a keystone. It links the rows together and takes a large share of the load when you grip or push. When that link is damaged, the bones no longer move as one smooth team.

Think of the wrist as a set of scaffolding poles held by strong straps. The straps are ligaments, tough bands that hold bones in place. If a strap stretches or tears, often from an old sprain or fracture, the scaphoid can tip out of line. The joint surfaces then grind unevenly instead of gliding, and that grinding wears away the smooth cartilage that normally lets bone slide on bone. Over the years this wear becomes arthritis, and the wrist stiffens and aches.

The thumb side of the wrist is where most of this happens, because that side carries most of the force when you use your hand. It is also the part least built for sudden heavy loads, so it gives way first. That is why pushing up from a chair or lifting a heavy pan, the things you noticed in the section above, are the movements that hurt.

As the worn joint loses its smooth shape, the wrist can also lose some of its natural range. Grip weakness follows, because the muscles working over a sore, stiff joint cannot pull as hard. In some people the swelling and changed bone shape crowd the narrow channel at the front of the wrist where a nerve passes, which is why tingling or numb fingers can come along with the arthritis.

In short, an old injury has changed how the bones line up and move, and the joint has worn out as a result. The pain, stiffness and weakness you feel are the direct result of that wear.

What we can do about it

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess your history, examine your wrist and arrange imaging where it is needed to confirm the diagnosis.

Because this is a long-standing wear problem, we usually try non-operative care first. That means changing how you load the wrist, so heavy lifting and pushing up from chairs are done differently or shared out. A splint can rest the joint and settle the ache. Physiotherapy or hand therapy works on keeping the wrist moving, building grip strength and finding ways to do daily tasks with less strain on the sore side. We give this a fair trial before talking about anything further.

Pain medication can help you keep moving. Simple pain relievers settle the ache for many people, and anti-inflammatories reduce the swelling and irritation in the worn joint. These are used alongside, not instead of, the activity changes and splinting above.

If non-operative care has not given enough improvement, we consider surgery. The right operation depends on which part of the wrist is worn, how stable it is and how much movement you still have. For some people, cutting the small nerves that carry pain signals from the wrist settles the pain while keeping movement and strength. For others, fusing only the worn part of the wrist, or removing a damaged row of small bones, relieves pain while preserving some motion. When the whole joint is worn out, a full wrist fusion stops the pain by holding the wrist still, or a wrist replacement keeps some movement. We will talk through which option fits your wrist and what you need it to do, and decide together.

What to expect

Wrist arthritis from an old injury does not usually go away on its own. The wear in the joint is permanent, so the ache tends to come and go rather than settle for good. Splints, activity changes and pain relievers can keep it comfortable for a long time, but the underlying wear continues.

If non-operative care stops working, surgery aims to take the pain away. Fusing part or all of the wrist gives reliable pain relief, and most people who have a full fusion are satisfied with the result. You keep hold of your grip strength, and most people manage their daily activities with some adaptation. The trade-off is motion: a fused wrist no longer bends, and no operation can restore entirely full wrist function. A wrist replacement keeps some movement but carries a higher chance of complications and may eventually need redoing.

Recovery after surgery is gradual. Moving the wrist early, sometimes starting within 1 week, helps you regain movement in the wrist and forearm sooner and means fewer therapy visits. Stiffness is the main thing to work against in the early weeks. Over the following months, most people find they can accomplish most daily activities, though often with small changes to how they do them.

Complications can happen with any of these operations. Up to 23% of people having a wrist fusion have some other complication. The metalware used to hold the bones can cause discomfort or migrate, and removing pins, plates or screws is relatively common. Other problems include slow wound healing, nerve compression at the front of the wrist, and the fused bones not joining, which is usually painless if it happens.

Whichever path you and your surgeon choose, the goal is the same: a wrist that hurts less and lets you use your hand. Set your expectations on function rather than a perfect joint. With sensible planning and honest discussion about what you need your wrist to do, most people get back to the tasks that matter to them.

When to see someone

See your GP if wrist pain has lasted more than a few weeks, or if a splint, activity changes and simple pain relievers are no longer keeping it comfortable. Ask for a specialist review if you notice your grip weakening, your hand becoming less nimble, or tingling and numbness in your fingers, which can mean swelling is pressing on a nerve at the front of the wrist. Seek review sooner if the wrist is unstable, gives way when you load it, or if pain stops you sleeping or doing your job. Remember that how much your wrist hurts does not always match what an X-ray shows, so a scan that looks mild does not mean your symptoms are trivial. If you have already had surgery on your wrist and notice a wound that is slow to heal, new pins or plates causing discomfort, or increasing tingling and numbness in your fingers, contact your surgical team promptly.

In more depth

Advanced reading: the deeper science (optional)

This section goes further than you need for your own treatment decisions. Wrist osteoarthritis is worth the extra reading because it contains one of the clearest examples in hand surgery of a sensible-sounding idea that made outcomes worse, and because the choice between fusing and replacing the joint is closer than it is usually presented.

Cutting more nerves makes the result worse, not better

Wrist denervation treats pain without altering the joint. The nerve branches carrying pain sensation from the wrist capsule are divided, leaving the joint mechanically unchanged. It preserves movement and does not preclude anything later, which makes it an attractive option.

The commonest version divides the posterior interosseous nerve alone. Since the anterior interosseous nerve also supplies the capsule, dividing both should logically give more complete relief.

It does not. Across 325 patients, anterior plus posterior interosseous neurectomy does not offer greater advantages compared with isolated posterior neurectomy, and, more strikingly, the combined procedure seems to be associated with a paradoxical increase in the failure rate [1].

An intervention that does more and achieves less is worth pausing on. Whatever the mechanism, the finding is a caution against reasoning from anatomy to outcome, which is exactly the kind of reasoning that makes the combined operation sound better.

The broader evidence for denervation itself is encouraging but soft: a trend towards positive outcomes for pain relief, return to work and satisfaction, with heterogeneity across the literature and a call for standardised outcome reporting [2].

Fusion and replacement are closer than they sound

For advanced arthritis, the two definitive options are presented as opposites: fuse the wrist and lose all movement, or replace it and keep some. The evidence puts them nearer together than that framing suggests.

Across 961 patients, both wrist arthrodesis and wrist arthroplasty were effective at alleviating pain and improving grip strength, with comparable complication rates of 17% and 19%, functional improvement was observed after arthroplasty, but robust long-term follow-up data for replacement were lacking [3]. A network meta-analysis of 359 patients found replacement significantly improved DASH, pain and PRWE scores against pre-operative values in both inflammatory and non-inflammatory arthritis [4].

So both work, and both carry roughly a one-in-five complication rate. The real difference lies in what each leaves you with and how it fails. A fusion is durable and predictable, and its failure mode is nonunion, a defined problem with a defined solution. A replacement preserves motion, and its failure mode is loosening over years, in a joint at the end of a long lever with limited bone stock for revision.

The long-term data gap is the honest limitation, and it is the reason age and demand weigh so heavily: a wrist replacement needs to outlive the person's need for it.

Union rates after fusion are reliable

Where fusion is chosen, the technical variations do not appear to matter much. Across 3,517 patients, there was no difference in union or complication prevalence between total wrist arthrodesis techniques, or between different treatments of the carpometacarpal joint, though the authors note the included studies were of low quality with high heterogeneity, limiting confidence [5].

Reviewed by Dr Kieran Hirpara · 10 June 2026.

Talk to your treating clinician for advice specific to you.

References for the advanced reading
  1. Fidanza A, Necozione S, Garagnani L. Does anterior plus posterior interosseus neurectomy lead to better outcomes than isolated posterior interosseus neurectomy? A systematic review and meta-analysis. EFORT Open Rev. 2023;8(3):110-6.
  2. Chin KWTK, Engelsman AF, van Gulik TM, Strackee SD. Selective denervation of the wrist for chronic pain: a systematic literature review. J Hand Surg Eur Vol. 2019;45(3):265-72.
  3. Zhu XM, Perera E, Gohal C, Dennis B, Khan M, Alolabi B. A systematic review of outcomes of wrist arthrodesis and wrist arthroplasty in patients with wrist arthritis. J Hand Surg Eur Vol. 2020;46(3):297-303.
  4. Chong HH, Zabaglo M, Asif A, Boksh K, Kulkarni K. A systematic review and network meta-analysis of outcomes after total wrist arthroplasty. J Hand Surg Eur Vol. 2023;49(1):17-24.
  5. Owen DH, Booth JW, Agius PA, Perriman DM, Smith PN, Roberts CJ. Union and complication rates after total wrist arthrodesis: a systematic review and meta-analysis. J Hand Surg Am. 2025;50(4):508.e1-508.e12.
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Osteoarthritis of the hand and wrist requires an individualized approach to treatment strategies based on site-specific diagnoses and varying disease manifestations [1].
  • Removal of the trapezium as treatment for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term [2].
  • Posttraumatic arthritis occurs in patients following intra-articular fracture of the hand and wrist or destabilizing injuries of the carpus [7].
  • The severity of the radiocarpal arthrosis following distal radius fracture seen on radiograph is not correlated with the presence of symptoms [7].
  • Scapholunate interosseous ligament injury and extrinsic ligament complex attenuation lead to palmar flexion of the scaphoid and extension of the lunate [7].
  • The radioscaphoid joint becomes incongruous, leading to alteration in the normal radioscaphoid contact forces and development of arthrosis [7].
  • As the scaphoid flexes and the scapholunate diastasis increases, the capitate migrates proximally [7].
  • The altered intercarpal contact forces result in arthrosis at the capitolunate joint [7].
  • The styloscaphoid, radioscaphoid, and capitolunate joints are affected by SLAC wrist arthritic changes [7].
  • The radiolunate joint is typically spared because of its spheroid shape [7].
  • Symptoms of SLAC wrist include reduced grip and pinch strength [7].
  • Symptoms of SLAC wrist include stiffness with extension and radial deviation [7].
  • Symptoms of SLAC wrist include localized tenderness at the radioscaphoid articulation [7].
  • Symptoms of SLAC wrist include decreased wrist motion on extension and radial deviation [7].
  • A positive Watson shift test results when the scaphoid subluxates dorsally out of the scaphoid fossa and relocates when pressure is released [7].
  • In SNAC wrist, the distal scaphoid articular surface with the radial styloid is affected first in stage I [7].
  • In SNAC wrist, the proximal scaphoid pole and radioscaphoid fossa may be preserved [7].
  • Ulnocarpal impingement is a degenerative condition resulting from a discrepancy in the relative length of the distal articular surfaces of the radius and ulna [7].
  • Posttraumatic causes of ulnocarpal impingement include distal radius fracture with shortening, Galeazzi or Essex-Lopresti fracture, and childhood epiphyseal plate injuries [7].
  • Congenital causes of ulnocarpal impingement include dyschondroplasia (Madelung deformity) and naturally occurring positive ulnar variance [7].
  • Symptoms of ulnocarpal impingement include pain on the dorsal side of the DRUJ and an intermittent clicking sensation [7].
  • Symptoms of ulnocarpal impingement include pain exacerbated by forearm rotation and ulnar deviation [7].
  • Symptoms of ulnocarpal impingement include pain with axial loading of the ulnar side of the wrist [7].
  • Symptoms of ulnocarpal impingement include pain with dorsal and palmar displacement of the distal ulna, with the wrist in ulnar deviation [7].
  • Radiographs for ulnocarpal impingement reveal ulnar positive variance and cystic changes in the lunate [7].
  • Arthrography for ulnocarpal impingement shows triangular fibrocartilage complex (TFCC) and lunotriquetral ligament tears [7].
  • MRI for ulnocarpal impingement reveals changes on the ulnar border of the lunate indicating cystic change from impaction from the distal ulna [7].
  • Treatment for ulnocarpal impingement includes open excision of the distal ulnar head (wafer resection) [7].
  • Treatment for ulnocarpal impingement includes wrist arthroscopy and arthroscopic wafer resection [7].
  • Treatment for ulnocarpal impingement includes ulnar shortening osteotomy [7].
  • When the primary etiology of ulnocarpal impingement is distal radius malunion, corrective osteotomy of the distal radius may be indicated [7].
  • Symptoms of DRUJ arthrosis include pain on the dorsum of the wrist, with limitation of forearm pronation and supination [7].
  • Symptoms of DRUJ arthrosis include snapping and crepitus at DRUJ [7].
  • Clinical findings for DRUJ arthrosis include pain that increases with proximal rotation of the forearm and compression of the ulna against the radius [7].
  • The diagnosis of DRUJ arthrosis is confirmed by improvement in rotation and grip strength with injection of a local anesthetic into the DRUJ [7].
  • Treatment for DRUJ arthrosis includes Darrach resection and/or DRUJ fusion (Sauve-Kapandji arthrodesis) [7].
  • The most common complications of Darrach resection and/or DRUJ fusion are distal ulnar stump instability and radioulnar impingement [7].
  • Treatment for DRUJ arthrosis includes distal ulnar hemiresection and tendon interposition (Bowers procedure), which preserves the TFCC insertion [7].
  • Treatment for DRUJ arthrosis includes ulnar head or DRUJ arthroplasty [7].
  • The closing wedge radial osteotomy technique could prove a reliable first line treatment for patients with debilitating wrist osteoarthritis confined to scaphoid/scapholunate articulation with radius [6].
  • The closing wedge radial osteotomy technique preserves the ligamentous insertions and the bone stock [6].
  • While functional improvement was observed for arthroplasty patients, robust long-term follow-up data on wrist arthroplasty are not yet available [9].
  • Total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years after surgery [11].
  • Wrist denervation was a viable salvage option for patients with symptomatic SLAC wrist osteoarthritis to preserve motion, decrease pain, and increase function [18].
  • Wrist denervation has a low absolute failure rate at mid- to long-term follow-up [18].
  • Arthroplasty should be used as an alternative to arthrodesis in the treatment of posttraumatic wrist arthritis, given the proper patient selection and indications [26].
  • While outcomes are generally favorable for therapeutic surgeries like arthrodesis and arthroplasty, further study is required to determine the best indications for ulnar head arthroplasty [28].
  • Most wrists with advanced rheumatoid disease require definitive stabilization by total wrist fusion [30].
  • A pain-free, stable wrist joint often outweighs the disadvantage of lacking/poor mobility [30].
  • Patients prefer a mobile wrist, although patient satisfaction was high in both groups for fusion versus arthroplasty [30].
  • Fusion seems to achieve better pain relief [30].
  • Arthroplasty is associated with higher complication and revision rates [30].
  • Only one-third of arthroplasty patients have a functional arc of motion [30].
  • Wrist arthrodesis is a time-honored procedure by providing permanent relief [30].
  • Wrist fusion is typically irreversible [30].
  • The achieved wrist stability enhances finger function and can correct the radial deviation of the metacarpals [30].
  • Radial deviation of the wrist joint and radial translocation of the metacarpals cause a compensatory ulnar deviation of the fingers [30].
  • Total wrist fusion is indicated when wrist deformity is coupled with unmanageable pain [30].
  • Stable wrists with preserved bone stock are the best, if not the only, indication for wrist arthroplasty [30].
  • Distal scaphoid excision should be preferred to improve functional results while decreasing scaphotrapeziotrapezoidal osteoarthritis and radiocarpal nonunion rates [34].
  • Minimal arthroplasty may provide a temporary solution for active patients with symptomatic early wrist arthritis who are not candidates for salvage wrist surgery [38].
  • Clear information must be given about the high rate of complications connected with revision arthroplasty and the risk of further revision, eventually leading to total wrist fusion [85].
  • The best indication for wrist arthroplasty is a stable, well-centered wrist with controlled disease activity [95].
  • Patients should be informed of possible long-term complications and alternatives such as partial or total fusion [95].
  • The goal of wrist arthroplasty is functional mobility with 30 degrees–0 degrees–30 degrees flexion/extension [95].
  • Repetitive heavy loading should be avoided after wrist arthroplasty [95].
  • The standard dorsal approach to the wrist is used for wrist arthroplasty [95].
  • The DRUJ should be addressed if needed and depending on implant requirements during wrist arthroplasty [95].
  • Implant choice for wrist arthroplasty is according to availability and experience [95].
  • Resection guides should be used for precise implantation during wrist arthroplasty [95].
  • Cementation should be avoided during wrist arthroplasty [95].
  • Critical distal component fixation is required during wrist arthroplasty [95].
  • The CMC fourth and fifth joints should not be crossed during distal component fixation for wrist arthroplasty [95].
  • A stable distal bone block should be formed for implant fixation during wrist arthroplasty [95].
  • The joint should not be overfilled, but also not too loose implantation to avoid dislocation during wrist arthroplasty [95].
  • Mobility should be checked on the OR table for possible bone impingement during wrist arthroplasty [95].
  • Postoperative care for wrist arthroplasty is individualized depending on the bone quality, implant fixation, and intraoperative joint stability [95].
  • Forearm splint protection is required for 6 weeks after wrist arthroplasty [95].

Anatomy & Pathophysiology

Bony Anatomy

  • The wrist includes the distal radioulnar, radiocarpal, and ulnocarpal joints and the eight carpal bones and their proximal and distal articulations and attached ligaments [43].
  • The carpus comprises eight ossicles traditionally separated into a proximal row (scaphoid, lunate, triquetrum, pisiform) and a distal row (trapezium, trapezoid, capitate, hamate) [43].
  • The distal radius articular surface has two concave facets, the scaphoid and lunate facets, separated by the scapholunate ridge [46].
  • The sigmoid notch along the ulnar border of the distal radius is a shallow concavity for the articulating ulnar head at the distal radioulnar joint [46].
  • The distal ulna is covered with hyaline cartilage on its dorsal, lateral, palmar, and distal surfaces [46].
  • The ulnar styloid projects distally, and at its base, the fovea is the insertion for the triangular fibrocartilaginous complex (TFCC) [46].
  • The scaphoid's primary vascular supply is a branch of the radial artery at the dorsal ridge, with smaller vessels entering the palmar tubercle to supply the distal 30% [46].
  • The lunate has a dorsal and palmar vascular supply in 80% of wrists, while only a palmar supply is found in 20% of wrists [46].
  • The capitate head often relies on a retrograde vascular supply [46].
  • The pisiform is a sesamoid bone within the flexor carpi ulnaris tendon and serves as the origin for the abductor digiti minimi [46].
  • The hamate consists of a body and a hook (hamulus) which serves as an attachment for the transverse carpal ligament and origins for the flexor digiti minimi and opponens digiti minimi [46].
  • The trapezium has a saddle-shaped articulation with the base of the thumb metacarpal and a palmar groove for the flexor carpi radialis [46].
  • The terminal branches of the radial, ulnar, and anterior interosseous arteries provide extraosseous blood supply to the carpus through three dorsal and three palmar transverse arterial arches with longitudinal connections [48].
  • The dorsal radiocarpal arch supplies the lunate and triquetrum [48].
  • The dorsal intercarpal arch is the largest and supplies the distal carpal row and, through anastomoses with the radiocarpal arch, the lunate and triquetrum [48].
  • The basal metacarpal arch is the most variable and supplies the distal carpal row [48].
  • The palmar intercarpal arch is the most variable and does not contribute to nutrient vessels in the carpus [48].

Ligaments and Soft Tissue

  • The extrinsic wrist ligaments include the dorsal intercarpal ligament and the dorsal radiocarpal ligament [46].
  • The intrinsic wrist ligaments include the scapholunate interosseous ligament and the lunotriquetral interosseous ligament [46].
  • The scapholunate interosseous ligament is C-shaped in the sagittal plane, with the dorsal third being the thickest and strongest portion [46].
  • The volar portion of the lunotriquetral ligament is the thickest [46].
  • The TFCC is formed by the central meniscus homolog, the dorsal and volar radioulnar ligaments, the floor of the extensor carpi ulnaris tendon sheath, and the volar ulnocarpal ligaments [46].
  • The TFCC arises from the radial border of the distal radius and inserts into the base of the ulnar styloid and distal ulna through the ligamentum subcruentum [46].
  • The dorsal and volar radioulnar ligaments are the primary stabilizers of the distal radioulnar joint [46].
  • Only the peripheral 10% to 40% of the volar, ulnar, and dorsal TFCC has a vascular supply [46].
  • The triangular fibrocartilage attaches to the base of the ulnar styloid and separates the hyaline cartilage-covered ulnar head from the styloid [43].
  • The chondroligamentous supports attaching the distal radius and ulnar side of the carpus to the distal ulna are designated as the triangular fibrocartilage complex [43].
  • The interosseous ligaments include the scapholunate and lunotriquetral interosseous ligaments connecting the proximal carpal row and ligaments connecting the trapezium to the trapezoid, trapezoid to the capitate, and capitate to the hamate in the distal carpal row [43].
  • The extrinsic or crossing ligaments include the radial collateral ligament from the radial styloid to the scaphoid waist, the ulnar collateral ligament from the base of the ulnar styloid attaching to the pisiform, and the transverse carpal ligament [43].
  • The volar extrinsic or crossing ligaments include the radioscapocapitate ligament, the radiolunotriquetral ligament, and the radioscapolunate ligament on the radial side and the ulnolunate and ulnotriquetral components of the TFCC on the ulnar side [43].
  • The dorsal radiocarpal ligament attaches along the dorsal radial articular margin of the lunate fossa, from the Lister tubercle to the lesser sigmoid notch, spans the lunotriquetral joint, and inserts on the dorsal surface of the triquetrum [43].
  • The dorsal intercarpal ligament is attached to the distal, dorsal surface of the triquetrum and passes across the midcarpal joint to attach to the dorsal surfaces of the scaphoid waist and the trapezoid [43].
  • The main cyst of a dorsal wrist ganglion is usually located directly over the scapholunate ligament [24].
  • A small, mucin-filled duct is invariably seen piercing the transverse fibers of the scapholunate ligament, connecting the underlying scapholunate joint with the main cyst [24].

Kinematics and Biomechanics

  • The wrist can be considered a two-joint system linking the hand to the forearm around the highly mobile bones of the proximal carpal row [47].
  • The two principal articulations are the radiocarpal and midcarpal joints, situated proximal and distal to the mobile proximal carpal row [47].
  • The proximal carpal row has no muscular or tendinous attachments and is an intercalary segment [46].
  • With ulnar deviation, the proximal row extends relative to the forearm/distal row [46].
  • With radial deviation, the proximal row flexes relative to the forearm/distal row [46].
  • With axial loading through the neutral wrist, approximately 80% of forces are transmitted through the distal radius (60% scaphoid facet, 40% lunate facet) and 20% through the distal ulna [46].
  • With wrist flexion, 60% of the motion is midcarpal and 40% is radiocarpal [46].
  • With wrist extension, 33% of the motion is midcarpal and 66% is radiocarpal [46].
  • The normal inclination of the radiocarpal joint surface is an inherently unstable one consisting of ulnar deviation and volar flexion [21].
  • In a normal wrist, this unstable condition is neutralized by a strong and complex set of anterior wrist ligaments that resist supination of the carpal bones on the distal end of the forearm [21].
  • The primary function of the scapholunate interosseous ligament is to counteract the extension moment imparted by the lunotriquetral interosseous ligament by transferring the flexion moment from the scaphoid to the lunate [102].
  • The scapholunate interosseous ligament ensures that the lunate, capitate, and distal radius are collinear to efficiently transfer force from the hand to the forearm [102].
  • The scapholunate interosseous ligament is strongest dorsally, where it is supported by the dorsal intercarpal and dorsal radial carpal ligaments [102].
  • The volar scapholunate interosseous ligament is important as a secondary stabilizer and is supported by the volar wrist ligaments [102].
  • Wrist biomechanics were significantly altered following trapeziectomy, and of the reconstructions tested, ligament reconstruction tendon interposition most closely resembled the intact biomechanics in a cadaveric model [44].

Pathophysiology of Osteoarthritis

  • Primary osteoarthritis of the wrist is rare [42].
  • Most cases of radiocarpal arthritis are secondary to structural changes that are often precipitated by trauma [42].
  • The natural history of traumatic injuries to the wrist involves the development of arthritis at the radiocarpal, distal radioulnar joint, or intercarpal joint surfaces [42].
  • In the early stages of hand osteoarthritis, there is a functional deficit associated with a reduced muscle activity of the wrist muscles during manual activities [73].
  • No significant differences in myelinated fiber density, fascicular sectional area, or fiber diameter were found in the posterior interosseous nerve between controls and patients with wrist osteoarthritis [97].
  • No specific pattern of histopathology was observed in the posterior interosseous nerve among patients with wrist osteoarthritis [97].

Scapholunate Advanced Collapse (SLAC)

  • Scapholunate interosseous ligament injury and extrinsic ligament complex attenuation lead to palmar flexion of the scaphoid and extension of the lunate (dorsal intercalated segment instability) [7].
  • In stage I SLAC wrist, arthrosis is localized to the radial side of the scaphoid and the radial styloid, with sharpening of the radial styloid [7].
  • In stage II SLAC wrist, arthrosis involves the entire radioscaphoid joint, while the radiolunate joint is usually spared [7].
  • In stage III SLAC wrist, arthrosis progresses to the capitolunate joint due to proximal migration of the capitate [7].

Scaphoid Nonunion Advanced Collapse (SNAC)

  • The history, staging, and treatment of SNAC wrist are similar to that for SLAC wrist [7].
  • In stage I SNAC wrist, the distal scaphoid articular surface with the radial styloid is affected first [7].
  • The proximal scaphoid pole and radioscaphoid fossa may be preserved in stage I SNAC wrist [7].
  • SNAC wrists differ from SLAC wrists in exhibiting a decreased sagittal lunotriquetral angle, indicating a distinct pathomechanism of carpal instability [58].
  • Quantitative 3-D CT demonstrates distal row pronation and translation and radiolunate arthritis in the SNAC wrist [103].

Ulnocarpal Impingement

  • Ulnocarpal impingement is a degenerative condition resulting from a discrepancy in the relative length of the distal articular surfaces of the radius and ulna (positive ulnar variance) [7].
  • The load sharing across the wrist varies with the amount of ulnar variance [7].
  • Symptoms of ulnocarpal impingement include pain on the dorsal side of the distal radioulnar joint and an intermittent clicking sensation [7].
  • Symptoms of ulnocarpal impingement include pain with dorsal and palmar displacement of the distal ulna, with the wrist in ulnar deviation (positive ballottement test) [7].
  • Arthrography for ulnocarpal impingement shows triangular fibrocartilage complex and lunotriquetral ligament tears [7].

Distal Radioulnar Joint (DRUJ) Arthrosis

  • Symptoms of DRUJ arthrosis include snapping and crepitus at the DRUJ [7].
  • Clinical findings of DRUJ arthrosis include pain that increases with proximal rotation of the forearm and compression of the ulna against the radius [7].
  • The differential diagnosis for DRUJ arthrosis includes instability, subluxation, and ulnocarpal impaction [7].

Rheumatoid Arthritis Pathophysiology

  • The wrist is one of the main targets of rheumatoid arthritis that may deteriorate rapidly, despite current medical management strategies [77].
  • Cumulative incidences of wrist involvement in rheumatoid arthritis are over 70% and 95%, 3 and 11 years after the onset of the disease, respectively [77].
  • The classic pattern of deformity and destruction in rheumatoid arthritis involves the radiocarpal and radioulnar joints with destabilization of the carpus caused by attenuation of the extrinsic wrist ligaments [77].
  • The result of rheumatoid arthritis wrist destabilization is ulnar-palmar translocation and wrist supination [77].
  • Three main pathophysiological factors play the greatest role in the process of rheumatoid arthritis wrist deformation: cartilage destruction, synovial expansion, and ligamentous laxity [77].
  • Cartilage thinning in rheumatoid arthritis is caused by cytochemical effects with continuous degradation [77].
  • Bony erosion in rheumatoid arthritis arises due to synovial expansion, particularly at the site of vascular penetration into the bone such as the radial origin of the Testut ligament [77].
  • Bony erosion causes stretching of the retaining intrinsic and extrinsic wrist ligaments with deformation [77].
  • The scapholunate interval starts to dissociate and continues to disintegrate the internal carpal architecture in rheumatoid arthritis [77].
  • The force vector across the rheumatoid arthritis wrist predominately acts in a palmar-ulnar direction [77].
  • With ongoing destruction of the rheumatoid arthritis wrist, surrounding muscles lose their physiologic moment arms to produce deforming forces [77].
  • Flexion of the scaphoid through the weakening of the scapholunate ligament leads to collapse of the radial column in rheumatoid arthritis [77].
  • Stretching of the wrist ulnar collateral ligament attenuates the ulnar column support in rheumatoid arthritis [77].
  • Carpal supination in rheumatoid arthritis leads to collapse of the radial wrist, which contributes to radial deviation of the metacarpals and accentuates ulnar deforming forces on the fingers at the metacarpophalangeal joints [77].
  • A volar flexion of the lunate relative to the scaphoid was reported in 100 early-to-midstage rheumatoid arthritis wrists, caused by intrinsic ligament laxity, mainly of the scapholunate ligament [77].
  • This pattern in rheumatoid arthritis resembles the volar intercalated segment instability observed in trauma wrist injuries [77].
  • At later rheumat

Classification

  • Subtle differences in history, examination, laboratory values, and imaging, rather than one pathognomonic finding, can improve the diagnostic acumen and expedite appropriate treatment options for monoarticular arthritis of the hand and wrist [3].
  • Advanced osteoarthritis of the midcarpal joint without radiocarpal involvement may be more common than previously thought [4].
  • Isolated osteoarthritis of the scaphotrapeziotrapezoidal joint is the most prevalent pattern of wrist osteoarthritis [4].
  • Type I and III wrists had radiographic progression and ultimately underwent deformation [5].
  • Combining traditional qualitative evaluation and quantitative measurements may improve the classification of wrist osteoarthritis [14].
  • Reviewing multiview radiographs more commonly yielded Vender stage 3 osteoarthritis classification [40].
  • The Watson and Ballet classification of SLAC wrist osteoarthritis is widely accepted, simple, and a well-recognized guide to treatment [62].
  • The Watson and Ballet classification of SLAC wrist osteoarthritis has significant limitations [62].
  • The Simmen classification of wrist destruction in rheumatoid arthritis is useful in early disease in about 50% of cases [81].
  • The Simmen classification of wrist destruction in rheumatoid arthritis provides reasonably reliable identification of wrists at significant risk of becoming severely unstable [81].
  • The false-negative rate for the Simmen classification of wrist destruction in rheumatoid arthritis is substantial [81].
  • Staging systems for SNAC wrist lack agreement [84].
  • Radiographic classification of SLAC wrist has moderate reliability and reproducibility [89].
  • Radiographic classification of SNAC wrist has limited reliability [89].

Clinical Presentation

General Assessment and Diagnostic Approach

  • The natural inclination to study radiographs or special imaging studies and reports prior to a thorough history and physical examination should be avoided, as this introduces cognitive bias which can affect thinking and decision making [74].
  • Physical examination always needs to be preceded by a thorough investigation of the patient’s medical history, with special emphasis on the mechanism of injury and acuity [74].
  • The patient should be asked details about the location, duration, and characteristics of any pain, including aggravating and relieving factors and previous treatments [74].
  • With chronic problems, it is important to inquire about the patient’s jobs and hobbies, and whether there has been exposure to repetitive stress, vibrating tools, or potentially dangerous instruments [74].
  • Elucidating a history of ligamentous laxity or multiple joint instabilities, especially in younger patients presenting with chronic wrist pain, is important [74].
  • Palpation for areas of maximal tenderness is one of the most useful tools in the diagnosis of wrist pathology, especially in patients with chronic dysfunctions [74].
  • In acute dislocations, tenderness is seldom elicited at specific points but rather in a diffuse manner due to extensive soft tissue damage [74].
  • A careful assessment of neural and vascular status is imperative, with particular attention being paid to the median and ulnar nerves [74].
  • Bilateral grip and pinch strength are useful to uncover underlying pathology in chronic cases [74].
  • Strength may be diminished due to muscle atrophy, pain inhibition, or learned behaviors [74].
  • A local injection of anesthetic to a painful joint or selected tendon sheath may help normalize the dynamometer readings and narrow the diagnostic spectrum [74].
  • Sensory testing should always accompany an examination of suspected nerve compression, using threshold or density testing [74].
  • Patients with wrist arthritis who undergo surgery face higher risks of carpal tunnel syndrome and subsequent carpal tunnel release than those managed conservatively [12].

Specific Clinical Findings by Pathology

  • In SLAC wrist, symptoms include reduced grip and pinch strength [7].
  • In SLAC wrist, symptoms include stiffness with extension and radial deviation [7].
  • In SLAC wrist, symptoms include localized tenderness at the radioscaphoid articulation [7].
  • In SLAC wrist, symptoms include decreased wrist motion on extension and radial deviation [7].
  • In ulnocarpal impingement, symptoms include pain on the dorsal side of the distal radioulnar joint and an intermittent clicking sensation [7].
  • In ulnocarpal impingement, pain is exacerbated by forearm rotation and ulnar deviation [7].
  • In ulnocarpal impingement, pain occurs with axial loading of the ulnar side of the wrist [7].
  • In ulnocarpal impingement, pain occurs with dorsal and palmar displacement of the distal ulna, with the wrist in ulnar deviation (positive ballottement test) [7].
  • In distal radioulnar joint arthrosis, symptoms include pain on the dorsum of the wrist with limitation of forearm pronation and supination [7].
  • In distal radioulnar joint arthrosis, symptoms include snapping and crepitus at the distal radioulnar joint [7].
  • In distal radioulnar joint arthrosis, clinical findings include pain that increases with proximal rotation of the forearm and compression of the ulna against the radius [7].
  • The diagnosis of distal radioulnar joint arthrosis is confirmed by improvement in rotation and grip strength with injection of a local anesthetic into the distal radioulnar joint [7].
  • In juvenile arthritis, early wrist joint synovitis is manifested clinically as a relatively subtle fusiform swelling that does not move with finger flexion and extension [21].
  • In juvenile arthritis, uncontrolled joint synovitis results in a progressive shift of the carpus ulnarward and volarward [21].
  • In juvenile arthritis, this process leaves the ulna dorsally dislocated and creates a dorsal wrist step-off because of the subluxed carpus [21].
  • In juvenile arthritis, destruction of joint mechanics is accompanied by loss of active and passive wrist extension and weakness of grip [21].
  • If juvenile arthritis disease spreads to the distal radioulnar joint, forearm rotation becomes limited [21].
  • In patients with continued pain over the radial side of the carpus, attention should be given to the other carpal bones and the distal radius and not just the scaphoid [65].
  • Os styloideum must be suspected in patients with persistent pain in the dorsal aspect of the hand or wrist [60].
  • In patients with bilateral Kienböck disease, routine screening of the contralateral wrist is unjustified if the patient is asymptomatic [15].

Imaging and Diagnostic Modalities

  • Radiographs revealing ulnar positive variance and cystic changes in the lunate are used in the imaging of ulnocarpal impingement [7].
  • Arthrography shows triangular fibrocartilage complex and lunotriquetral ligament tears in ulnocarpal impingement [7].
  • MRI reveals changes on the ulnar border of the lunate indicating cystic change from impaction from the distal ulna in ulnocarpal impingement [7].
  • Ultrasound may help to detect subclinical hand involvement in juvenile rheumatoid arthritis [59].
  • MRI studies revealed signs of subclinical inflammation, especially synovitis, tenosynovitis, and bone marrow lesions in carpal and metacarpal joints, in 63% of patients with juvenile rheumatoid arthritis in clinical remission for more than 6 months [59].
  • Plain radiography remains the most common imaging technique for documentation of bone and joint involvement in juvenile rheumatoid arthritis [59].
  • Diagnosis of septic arthritis of the wrist is made based mainly on a thorough patient history, physical examination, and joint aspiration, as no serum laboratory values have been shown to consistently confirm wrist joint infection [56].
  • Physical examination, inflammatory markers, and imaging studies have not been shown to be useful in differentiating between septic and non-septic causes of wrist joint inflammation [53].
  • The definitive diagnosis of septic arthritis often rests on a positive bacterial isolate from wrist joint fluid, bacteremia, or visualization of pus in the wrist joint intra-operatively [53].
  • To be successful with wrist arthroscopy and mitigate iatrogenic injury, a clear understanding of the topographical and 3-dimensional spatial anatomic relationships in the wrist as well as a patient’s unique anatomic variances is critical [10].
  • Patients without positive provocative sign on examination seldom yield positive findings at wrist arthroscopy [90].
  • Arthroscopic findings need to correlate with clinical examination [90].

Investigations

Radiography

  • Advanced osteoarthritis of the midcarpal joint without radiocarpal involvement may be more common than previously thought, with isolated osteoarthritis of the scaphotrapeziotrapezoidal joint being the most prevalent pattern [4].
  • The occurrence of osteoarthritis of the scaphotrapeziotrapezoid and distal radioulnar joints was affected by the presence of osteoarthritis of the adjacent joint [19].
  • 10° of supination can drastically alter the developed radiograph, highlighting the significant effect of rotation on radiographic landmarks at the wrist [25].
  • Routine radiographic series for evaluating a painful wrist consist of four views: posteroanterior, lateral, oblique, and ulnar-deviated posteroanterior scaphoid view [55].
  • Spot views of the carpal bones for detail (carpal tunnel view) are a useful radiographic technique for evaluating a painful wrist [55].
  • Fluoroscopic spot views of the wrist are a useful radiographic technique for evaluating a painful wrist [55].
  • A series of views for instability includes anteroposterior clenched fist, posteroanterior in neutral, radial, and ulnar deviation, lateral in neutral and full flexion and extension, semipronated oblique 30 degrees from the posteroanterior, and semisupinated oblique 30 degrees from the lateral [55].
  • Cine or video fluoroscopy is a radiographic technique useful in evaluating a painful wrist [55].
  • Bone scanning is a radiographic technique useful in evaluating a painful wrist [55].
  • Arthrography of the wrist, including triple injection when indicated, is a radiographic technique useful in evaluating a painful wrist [55].
  • CT is a radiographic technique useful in evaluating a painful wrist [55].

Magnetic Resonance Imaging (MRI)

  • MRI should be added for evaluation of the triangular fibrocartilage, the distal radioulnar joint, and vascularity of the various carpal bones, extrinsic ligaments, joint surfaces, and surrounding soft tissues to confirm clinical suspicion and correlate with physical examination findings [55].
  • A high rate of false-positive findings on MR images of normal subjects has been reported [55].
  • A dedicated wrist coil provides enhanced resolution of wrist structures [55].
  • Successful MRI study of the wrist requires high-resolution images that are best obtained with surface coil technique and high field system [51].
  • With CT as the reference method, MRI showed moderate sensitivity and good specificity and accuracy for detection of erosions in rheumatoid arthritis and healthy wrist bones, while radiography showed very low sensitivity [96].
  • MRI provides earlier detection of synovitis and erosive bone changes associated with rheumatoid arthritis than do radiographs [51].
  • MRI is useful in detecting additional marrow abnormalities in osteonecrosis, as seen in the lunate in Kienböck disease or in the scaphoid after fracture [51].
  • Asymmetry of marrow signal in proximal and distal fragments of a fractured scaphoid is suggestive of proximal pole ischemia [51].
  • MRI currently has a limited role in the evaluation of carpal tunnel syndrome, although axial imaging with T2 weighting can clearly display masses within the confines of the carpal tunnel, as well as edema and swelling of the median nerve [51].
  • MRI has an expanding role in the evaluation of inflammatory arthritis [51].

Arthroscopy

  • Arthroscopic assessment of intercarpal ligament injuries and instability is considered by many the “gold standard” for evaluation of these conditions, as well as for examination of patients who have wrist pain of unknown origin [52].
  • Indications for wrist arthroscopy include the evaluation of ligamentous injuries, examination of joint articular surfaces, removal of loose bodies, biopsy of synovium, irrigation and debridement of joints, and confirmation and supplementation of wrist arthrography [52].
  • Arthroscopy has been found to be more accurate than arthrography in identifying the location and size of triangular fibrocartilage and interosseous ligament injuries [52].
  • Arthroscopy is more accurate than triple-injection cinearthrography in detecting tears of the dorsal sensory branch of the ulnar nerve during arthroscopic repair of the triangular fibrocartilage [52].
  • Joint space height correlates with arthroscopic grading of wrist arthritis [33].

Other Imaging and Diagnostic Modalities

  • Diagnostic ultrasound is a radiographic technique useful in evaluating a painful wrist [55].
  • Fifteen minutes bone scintigraphy is useful as a second line investigation for continuing wrist pain following trauma in the presence of normal radiography [98].
  • Surgeons should maintain a high index of suspicion for bilateral Kienböck disease in patients with specific comorbidities, but routine screening of the contralateral wrist is unjustified if the patient is asymptomatic [15].

Treatment

Non-Operative Management

  • Initial treatment for hand manifestations of osteoarthritis is medical, with many patients doing well with splinting and hand therapy [8].
  • A neuromuscular exercise therapy program showed no clinically meaningful differences compared to range-of-motion training in the treatment of wrist osteoarthritis at 6 and 12 months [72].

Arthroscopic Procedures

  • Arthroscopic distal scaphoidectomy is indicated for symptom control in selected cases of SNAC wrist and in the treatment of STT joint osteoarthritis [75].
  • In SNAC wrist, arthroscopic distal scaphoidectomy can be regarded as a “buying time” procedure that removes the primary source of mechanical symptoms without involving implant fixation or more involved partial fusion or carpectomy surgeries [75].
  • Arthroscopic distal scaphoidectomy enables early rehabilitation without the need for prolonged immobilization and does not preclude subsequent scaphoidectomy and four-corner fusion if required [75].
  • A significant dorsal lunate tilt deformity (DISI) is considered a relative contraindication to arthroscopic distal scaphoidectomy [75].
  • Marked arthritis at the lunocapitate joint constitutes a relative contraindication to arthroscopic distal scaphoidectomy [75].
  • An intact scapholunate ligament and radioscaphocapitate ligament are considered prerequisites for arthroscopic distal scaphoidectomy to minimize progressive midcarpal collapse and DISI [75].
  • Arthroscopic wafer resection is a treatment option for ulnocarpal impingement, utilizing a central TFCC tear for access [7].
  • Arthroscopic partial wrist fusion is a surgical technique described for the management of wrist arthritis [70].

Osteotomy and Resection

  • Closing wedge radial osteotomy could prove a reliable first-line treatment for patients with debilitating wrist osteoarthritis confined to the scaphoid/scapholunate articulation with radius, as it preserves ligamentous insertions and bone stock [6].
  • Radial styloidectomy plus scapholunate reduction and stabilization is the treatment for Stage I SLAC wrist, characterized by arthrosis localized to the radial side of the scaphoid and the radial styloid [7].
  • Open excision of the distal ulnar head (wafer resection) is a treatment option for ulnocarpal impingement [7].
  • Ulnar shortening osteotomy is a treatment option for ulnocarpal impingement [7].
  • Corrective osteotomy of the distal radius may be indicated when the primary etiology of ulnocarpal impingement is distal radius malunion [7].

Arthrodesis

  • Elimination of the radioscaphoid joint by proximal row carpectomy (PRC) is a treatment option for Stage II SLAC wrist, with disadvantages including reduction of wrist motion and grip strength [7].
  • Four-corner fusion (SLAC procedure) is a treatment option for Stage II SLAC wrist that retains 60% of wrist motion and 80% of grip strength [7].
  • Radioscapholunate fusion is a treatment option for Stage II SLAC wrist [7].
  • Total wrist arthrodesis is a treatment option for Stage II SLAC wrist [7].
  • Distal scaphoid excision should be preferred over other methods to improve functional results while decreasing scaphotrapeziotrapezoidal osteoarthritis and radiocarpal nonunion rates in radioscapholunate fusion [34].
  • Patients tolerate the restrictions caused by a stiff wrist provided it is painless [66].
  • Wrist arthrodesis is a time-honored procedure providing permanent relief for patients with intractable pain and dislocation of the wrist joint [30].
  • Wrist arthrodesis is typically irreversible [30].
  • Achieved wrist stability from fusion enhances finger function and can correct the radial deviation of the metacarpals [30].
  • Total wrist fusion is indicated for wrists with advanced rheumatoid disease requiring definitive stabilization, where a pain-free, stable joint often outweighs the disadvantage of lacking mobility [30].
  • Fusion seems to achieve better pain relief than arthroplasty [30].
  • Most patients undergoing four-corner fusion and scaphoid excision for SLAC and SNAC wrist deformities were pleased postoperatively, with improvement in wrist pain being the most common finding [13].
  • Postoperative care for wrist arthrodesis involves immobilizing the hand and wrist in a bulky dressing and splint for 10 to 14 days, followed by a short-arm cast for 2 to 4 more weeks [23].
  • Patients undergoing wrist arthrodesis are given a 1-kg weight limit for the first 8 weeks postoperatively [23].
  • Strengthening begins at 8 to 10 weeks post-wrist arthrodesis, with full use allowed at 10 to 12 weeks [23].

Arthroplasty and Interposition

  • Functional improvement was observed for arthroplasty patients, but robust long-term follow-up data on wrist arthroplasty are not yet available [9].
  • Arthroplasty is associated with higher complication and revision rates than arthrodesis [30].
  • Low-demand patients with special needs or a desire for wrist motion are the best candidates for wrist arthroplasty [69].
  • Short- to mid-term outcomes in patients with end-stage wrist arthritis affecting the capitate who undergo PRC and meniscus interposition arthroplasty are comparable with those receiving PRC alone [16].
  • The addition of soft tissue interposition (STIA) into PRC for patients with capitate and/or lunate fossa cartilage degeneration yielded outcomes akin to traditional PRC, improving wrist function, pain, and grip strength [83].
  • Total wrist arthroplasty has gained popularity as a motion-preserving option for treating wrist pain caused by arthritis but still lags behind arthrodesis as a first-line treatment [91].
  • Older patients with rheumatoid arthritis have been the most common recipients of total wrist arthroplasty, accounting for 51%–71% of all patients undergoing the procedure [91].
  • After total wrist arthroplasty, patients are allowed to temporarily remove the splint to perform active mobilization and gentle stretching exercises in the absence of pain [94].
  • Patients undergoing total wrist arthroplasty must wear a splint during the night for 4 weeks postoperatively [94].
  • The splint is removed 8 weeks after total wrist arthroplasty, allowing patients to return to daily activities within 12 weeks while avoiding weights over 3 kg permanently [94].

Salvage and Other Procedures

  • Wrist denervation was a viable salvage option for patients with symptomatic SLAC wrist osteoarthritis to preserve motion, decrease pain, and increase function with a low absolute failure rate at mid- to long-term follow-up [18].
  • Darrach resection and/or DRUJ fusion (Sauve-Kapandji arthrodesis) are treatments for DRUJ arthrosis [7].
  • Distal ulnar hemiresection and tendon interposition (Bowers procedure) is a treatment for DRUJ arthrosis that preserves the TFCC insertion [7].
  • Ulnar head or DRUJ arthroplasty is a treatment option for DRUJ arthrosis [7].
  • A staged approach is commonly recommended for the treatment of the SLAC wrist [39].
  • Stage I SLAC wrist often can be managed with splints and nonsteroidal anti-inflammatory medications [39].
  • Preservation of movement is beneficial to function, and a preferable compromise may be selective excision and partial fusion of the wrist using knowledge of the aetiology and pattern of degenerative change [37].

Preoperative Considerations

  • Prompt diagnosis and treatment of scaphoid non-union is vital, whether symptomatic or not, to prevent osteoarthritis developing in the future [20].
  • Patient age and delay from acute scaphoid fracture to non-union surgery do not influence the outcome of bone grafting surgery provided that there is no secondary wrist osteoarthritis [22].

Complications

Wrist Arthroplasty and Hemiarthroplasty

  • Robust long-term follow-up data on wrist arthroplasty are not yet available [9].
  • Distal component loosening is a primary concern regarding total wrist arthroplasty [80].
  • Radial hemiarthroplasty using the Universal II implant has been associated with a 30% osteolysis rate, significant incidence of wrist contracture/stiffness, and diminished grip strength postoperatively [80].
  • Polyethylene erosion on capitate cartilage was a problem in Maestro radial hemiarthroplasty cases [80].
  • In a series of 52 radial and 6 carpal hemiarthroplasties, the most common complications were contracture, followed by component failure [80].
  • In a study of 11 patients who underwent carpal hemiarthroplasty for SLAC/SNAC wrist arthritis, nearly half required revision to wrist replacement or arthrodesis secondary to pain [80].
  • In a longer-term assessment of 20 patients with radial hemiarthroplasty, three required manipulation under anesthesia to improve motion and three were revised (two to total wrist arthroplasty and one to arthrodesis) [80].

Wrist Arthrodesis

  • The most common complications of Darrach resection and/or DRUJ fusion (Sauve-Kapandji arthrodesis) are distal ulnar stump instability and radioulnar impingement [7].
  • In wrist arthrodesis, if the capitate does not contact the undersurface of the plate and is lagged up to the plate, the screw may end up being too long and protrude into the carpal canal [23].
  • In wrist arthrodesis, failure to reduce the lunate to the lunate fossa may invite ulnocarpal impingement if the ulna and/or triquetrum is not resected [23].
  • In wrist arthrodesis, if non-self-tapping screws are used, excessive penetration of the tip through the metacarpal may injure the deep motor branch of the ulnar nerve as it crosses radially [23].
  • In wrist arthrodesis, if the drill hole through the metacarpal portion of the plate is not in the sagittal plane, subsequent radius fixation will cause rotational deformity of the third metacarpal [23].
  • Functional results of 4-corner fusion for SLAC and SNAC wrist were good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients [17].

Rheumatoid Arthritis and Inflammatory Conditions

  • Continued carpal collapse was reported following the surgical resection of the ulnar head together with a synovectomy of the wrist extensor tendons (Backdahl procedure) [92].
  • Significant long-term acceleration of ulnar translation was observed in wrists treated with distal ulna resection and wrist extensor synovectomy compared with untreated wrists [92].
  • Carpal collapse and translocation could not be predicted by preoperative x-rays and the progression of carpal dislocation continued in a linear fashion throughout the follow-up period after dorsal wrist synovectomy and distal ulna resection [92].
  • The two main concerns associated with the rheumatoid wrist are tendon ruptures and irreversible joint damage [92].

Nerve Injury and Carpal Tunnel Syndrome

  • Delayed-onset ulnar neuropathy at the wrist can occur 12 to 30 years after conservatively treated distal radius fractures with malunion and distal radioulnar joint arthritis [99].

Other Surgical Complications

  • An approximate 10% risk of secondary wrist arthrodesis exists in patients with persistent or progressive ulnar wrist pain following partial wrist denervation for inflammatory arthritis [41].

Recovery

  • Postoperative recovery of the wrist was rapid following treatment for an unusual carpometacrometacarpal fracture-dislocation [88].
  • Finger extension remained poor for over 3 months postoperatively following treatment for an unusual carpometacrometacarpal fracture-dislocation [88].

Key Evidence

  • [L5] Osteoarthritis of the hand and wrist requires an individualized approach to treatment strategies based on site-specific diagnoses and varying disease manifestations. [1] (10.1016/j.jht.2022.01.001)
  • [L3] Removal of the trapezium as treatment for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term. [2] (10.1186/s13018-021-02856-x)
  • [L5] Subtle differences in history, examination, laboratory values, and imaging, rather than one pathognomonic finding, can improve the diagnostic acumen and expedite appropriate treatment options for monoarticular arthritis of the hand and wrist. [3] (10.1016/j.jhsa.2012.04.010)
  • [L4] Advanced osteoarthritis of the midcarpal joint without radiocarpal involvement may be more common than previously thought, with isolated osteoarthritis of the scaphotrapeziotrapezoidal joint being the most prevalent pattern. [4] (10.1177/17531934241275450)
  • [L2] Type I and III wrists had radiographic progression and ultimately underwent deformation. [5] (10.1016/j.jhsa.2009.01.016)
  • [L4] The technique could prove a reliable first line treatment for patients with debilitating wrist osteoarthritis confined to scaphoid/scapholunate articulation with radius as it preserves the ligamentous insertions and the bone stock. [6] (10.1016/j.jisako.2025.100448)
  • [L5] The hand manifestations of osteoarthritis can be debilitating, with initial treatment being medical and many patients doing well with splinting and hand therapy. [8] (10.1016/j.hcl.2010.09.003)
  • [L2] While functional improvement was observed for arthroplasty patients, robust long-term follow-up data on wrist arthroplasty are not yet available. [9] (10.1177/1753193420953683)
  • [L5] To be successful with wrist arthroscopy and mitigate iatrogenic injury, a clear understanding of the topographical and 3-dimensional spatial anatomic relationships in the wrist as well as a patient’s unique anatomic variances is critical. [10] (10.1016/j.eats.2024.103223)
  • [L4] Total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years after surgery. [11] (10.1016/j.jhsa.2024.03.002)
  • [L2] Patients with wrist arthritis who undergo surgery face higher risks of CTS and subsequent CTR than those managed conservatively. [12] (10.1016/j.jhsa.2026.01.013)
  • [L4] Most patients were pleased postoperatively, with improvement in wrist pain being the most common finding. [13] (10.1097/bth.0b013e3181f60fec)
  • [L4] Combining traditional qualitative evaluation and quantitative measurements may improve the classification of wrist osteoarthritis. [14] (10.1177/1753193416669261)
  • [Paper] Surgeons should maintain a high index of suspicion for bilateral disease in patients with these comorbidities, but routine screening of the contralateral wrist is unjustified if the patient is asymptomatic. [15] (10.1177/15589447251350174)
  • [L3] Our short- to mid-term outcomes in patients with end-stage wrist arthritis affecting the capitate who undergo PRC and meniscus interposition arthroplasty are comparable with those receiving PRC alone. [16] (10.1177/15589447241262052)
  • [L4] Functional results were good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients. [17] (10.1177/1558944716681949)
  • [L4] This method of wrist denervation was a viable salvage option for patients with symptomatic SLAC wrist osteoarthritis to preserve motion, decrease pain, and increase function with a low absolute failure rate at mid- to long-term follow-up. [18] (10.1016/j.jhsa.2021.02.023)
  • [L4] The occurrence of osteoarthritis of the scaphotrapeziotrapezoid and distal radioulnar joints was affected by the presence of osteoarthritis of the adjacent joint. [19] (10.1016/j.jhsa.2023.05.009)
  • [L4] Prompt diagnosis and treatment of scaphoid non-union is vital, whether symptomatic or not, to prevent osteoarthritis developing in the future. [20] (10.1016/s0020-1383(02)00162-6)
  • [L4] The results of this study suggest that patient age and delay from acute scaphoid fracture to non-union surgery do not influence the outcome of this surgery, provided that there is no secondary wrist osteoarthritis. [22] (10.1016/s0020-1383(00)00059-0)
  • [Paper] Our results highlight the significant effect of rotation on radiographic landmarks at the wrist, indicating that 10° of supination can drastically alter the developed radiograph. [25] (10.1177/15589447241255705)
  • [L3] Arthroplasty should be used as an alternative to arthrodesis in the treatment of posttraumatic wrist arthritis, given the proper patient selection and indications. [26] (10.1016/j.jhsa.2013.02.013)
  • [L5] While outcomes are generally favorable for therapeutic surgeries like arthrodesis and arthroplasty, further study is required to determine the best indications for ulnar head arthroplasty. [28] (10.1016/j.jht.2013.12.002)
  • [L3] [33] (10.1007/s11552-013-9522-9)
  • [L4] Distal scaphoid excision should be preferred to improve functional results while decreasing scaphotrapeziotrapezoidal osteoarthritis and radiocarpal nonunion rates. [34] (10.1055/s-0039-1688939)
  • [L5] Preservation of movement is beneficial to function, and a preferable compromise may be selective excision and partial fusion of the wrist using knowledge of the aetiology and pattern of degenerative change. [37] (10.1302/0301-620x.97b10.35717)
  • [L4] Minimal arthroplasty as described may provide a temporary solution for active patients with symptomatic early wrist arthritis who are not candidates for salvage wrist surgery. [38] (10.1055/s-0033-1338255)
  • [L4] [39] (10.5435/00124635-200307000-00007)
  • [L4] Reviewing multiview radiographs more commonly yielded Vender stage 3 osteoarthritis classification. [40] (10.1177/1558944720937359)
  • [L4] Our findings suggest an approximate 10% risk of secondary wrist arthrodesis in patients with persistent or progressive ulnar wrist pain. [41] (10.1007/s10067-019-04645-8)
  • [L4] [42] (10.1016/j.csm.2004.08.011)
  • [L5] Wrist biomechanics were significantly altered following trapeziectomy, and of the reconstructions tested, LRTI most closely resembled the intact biomechanics in this cadaveric model. [44] (10.1016/j.jhsa.2019.10.003)
  • [L4] [53] (10.1177/1753193417738166)
  • [L5] Diagnosis is made based mainly on a thorough patient history, physical examination, and joint aspiration, as no serum laboratory values have been shown to consistently confirm wrist joint infection. [56] (10.5435/jaaos-d-16-00414)
  • [L4] SNAC wrists differ from SLAC wrists in exhibiting a decreased sagittal lunotriquetral angle, indicating a distinct pathomechanism of carpal instability. [58] (10.1186/s12891-025-08652-6)
  • [L5] [59] (10.1016/j.jhsa.2015.06.111)
  • [L4] Os Styloideum is an infrequent pathology and must be suspected in patients with persistent pain in the dorsal aspect of the hand or wrist. [60] (10.1177/15589447251317232)
  • [L5] Despite its significant limitations, the Watson and Ballet classification of SLAC wrist osteoarthritis is widely accepted, simple, and a well-recognized guide to treatment. [62] (10.1097/corr.0000000000000451)
  • [L4] In patients with continued pain over the radial side of the carpus, attention should be given to the other carpal bones and the distal radius and not just the scaphoid. [65] (10.1016/0020-1383(95)00081-j)
  • [L4] Patients tolerate the restrictions caused by a stiff wrist provided it is painless. [66] (10.1054/jhsb.2002.0806)
  • [L1] We found no clinically meaningful differences between the neuromuscular exercise therapy program and range-of-motion training in the treatment of wrist osteoarthritis at 6 and 12 months. [72] (10.1186/s12891-025-09463-5)
  • [L3] In the early stages of HOA, there is a functional deficit associated with a reduced muscle activity of the wrist muscles during manual activities. [73] (10.1016/j.jht.2019.12.010)
  • [L3] The Simmen classification of wrist destruction in rheumatoid arthritis is useful in early disease in about 50% of cases and provides reasonably reliable identification of wrists at significant risk of becoming severely unstable, though the false-negative rate is substantial. [81] (10.1054/jhsb.1999.0196)
  • [L4] The addition of STIA into PRC for patients with capitate and/or lunate fossa cartilage degeneration yielded outcomes akin to traditional PRC, improving wrist function, pain, and grip strength in a safe and straightforward manner. [83] (10.1177/15589447231221245)
  • [Paper] Staging systems for SNAC wrist lack agreement. [84] (10.1007/s12593-012-0062-2)
  • [L4] When advising the patient, clear information must be given about the high rate of complications connected with revision arthroplasty and the risk of further revision, eventually leading to total wrist fusion. [85] (10.5435/jaaosglobal-d-21-00035)
  • [L5] Postoperatively recovery of the wrist was rapid, though extension of the fingers remained poor for over 3 months. [88] (10.1016/0020-1383(94)90161-9)
  • [L4] Radiographic classification of SLAC wrist has moderate reliability and reproducibility, whereas classification of SNAC wrist has limited reliability. [89] (10.1177/1753193413484629)
  • [L1] [91] (10.1177/17531934231199317)
  • [L4] [94] (10.1055/s-0037-1598637)
  • [L4] With CT as the reference method, MRI showed moderate sensitivity and good specificity and accuracy for detection of erosions in rheumatoid arthritis and healthy wrist bones, while radiography showed very low sensitivity. [96] (10.1186/ar2378)
  • [L2] [97] (10.1055/s-0040-1713655)
  • [L4] We find this rapid version of the bone scan useful as a second line investigation for continuing wrist pain following trauma in the presence of normal radiography. [98] (10.1016/s0020-1383(99)00280-6)
  • [L4] Delayed-onset ulnar neuropathy at the wrist can occur 12 to 30 years after conservatively treated distal radius fractures with malunion and DRUJ arthritis. [99] (10.1016/j.jhsa.2009.11.005)
  • [L5] [102] (10.1016/j.eats.2025.103820)
  • [L3] [103] (10.2106/jbjs.22.01350)

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