Osteoartrite do punho Folheto In-depth

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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