Proximal Row Carpectomy

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What’s the Problem?

If a scaphoid fracture is managed without surgery, it can lead to the development of advanced whole wrist osteoarthritis. If it is identified early enough, treatment can include fixing and bone grafting the scaphoid, but if there is too much degeneration, one treatment option is a proximal row carpectomy

How can you treat it?

In some instances, non-surgical treatment is appropriate. This includes:

• Taking pain relief
• A steroid injection
• A splint around the wrist to help immobilise it
• Physio or Hand Therapy to mobilise the wrist and surrounding muscles/tendons

Ultimately, surgery is only reserved for patients whose pain and dysfunction is severe enough that they cannot tolerate it in most aspects of their life.

The Operation

A Proximal Row Carpectomy involves removing the three bones that make up half of the wrist joint – the scaphoid, lunate and triquetrum. Generally, these bones will be highly arthritic, and therefore removing them allows a smooth joint to be re-created by the large bone from the next row – the capitate. The nerve that controls pain sensation (the posterior interosseous nerve) can also be removed in the same operation to prevent recurring pain.

The Anaesthetic

You will be asleep for the duration of the operation (ie a general anaesthetic). The anaesthetist may talk to you about a nerve block before the operation, which helps with pain relief and generally lasts 24-48 hours. Alternatively, Mr Lau can put local anaesthetic into the wound whilst you are asleep, which can also help reduce pain.

What are the Risks of this Operation?

• Infection:
  Usually only a superficial wound infection to the top-most layer of the skin. In rarer cases a deep infection can develop and this is a serious complication that may require further surgery. Rare but serious, <1%.
• Damage to the nerves and blood vessels around the wrist.
  Rare but serious, <1%
• Reduced Grip Strength and Range of Motion:
  Because removing the proximal row of the carpus shortens the overall length of the hand, this can result in the loss of some grip strength. Generally patients retain 70% of their pre-existing grip strength, and 60% of their range of motion
• Progressive Arthritis:
  Sometimes, while removing the proximal row works well in eliminating pain, it also allows additional forces to pass through those bones and onto the joints beyond. In that case, progressive degeneration and arthritis of other joints like the bases of fingers can occur. If symptoms are severe enough, the fusion can be extended surgically to involve the entire wrist – approximately 4%.
• Complex Regional Pain Syndrome (CRPS):
  This is a chronic pain response that develops after an insult (like trauma or surgery) which we don’t have a full understanding of. It usually presents as ongoing burning or stinging to the hand, with change in sensation as well. Some factors increase the risk of developing this such as injury to the hands or feet, middle age and female gender. Mr Lau routinely prescribes Vitamin C post operatively, which has been shown in some studies to reduce the development of CRPS, but if it does develop, then a prolonged rehabilitation with hand therapy may be required.

Benefits

If Mr Lau recommends a proximal row carpectomy, it is because he feels you will have a better outcome with surgery. In particular, your wrist will maintain some grip strength and retain better range of motion than some of the other surgical options that could be considered (a 4 corner fusion). The main focus of surgery is the reduction of pain in your wrist, and this is usually achievable.

What can I expect?

You will wake up with your arm in a sling after your surgery and in a half-plaster. If you have had a nerve block, you shouldn’t feel any pain till the next day. The nurses will provide you pain relief and the next morning a physio or hand therapist will see you to go through some exercises you can do to mobilise the fingers and elbow to prevent excessive stiffness in these joints. These exercises will change over the next few weeks to months but you should try to do them regularly to maximise your rehabilitation.

Most patients spend 1 day in hospital after surgery, before going home. A number of allied health staff (physios, occupational therapists) will make sure you have adequate support at home before discharge. An appointment will be made for you for a wound check at 2 weeks. At this time, the plaster will be removed and a plastic removable splint made for you. This splint is removable and allows for washing, whilst also keeping your wrist immobilised. Another appointment with Mr Lau will be at 6 weeks with repeat XRs.

What should I avoid doing?

• In the first 2 weeks:
  Keep your plaster/wound dry. Try to mobilise your fingers and elbow as much as possible
• Between 2 and 6 weeks:
  You will be placed into a moulded thermoplastic splint which allows for washing of the hand/wrist. Ongoing exercises to the fingers, wrist and elbow can continue when you take your arm out of the splint. You can pick up lighter objects such as a phone or cup with the affected side. You will have physio or hand therapy to help you with rehabilitation
• Between 6 and 12 weeks:
  Full mobilisation of the wrist, fingers and elbow. The only restriction is no heavy lifting (weights, heavy pots/pans etc) till after 12 weeks.

Return to…?

• Work
  Depends what you do. Desk based work can be done from 2 weeks post operatively, if you can do these tasks single handedly. Otherwise generally 6 weeks before you can use both hands freely whilst seated.
  For manual work, it depends on what kind of lifting/pushing you do, but generally not before 3 months
• Drive
  In Australia, you can’t drive unless you are in full control of both your arms. Therefore, whilst you’re in a sling, you cannot drive. Generally 6 weeks post operatively.
• Sports/Hobbies:
• Gentle swimming: after 6 weeks
• Gardening (light tasks only): 8-12 weeks
• Bowls: after 3 months
• Golf, tennis, badminton, squash: after 4-6 months
• Weights: commence after 3 months

Concerns or questions?

If you have any concerns post operatively, or you would like further information, please contact Mr Lau through the VBJS on 03 5752 5020 or via email at admin@vbjs.com.au

If you need urgent medical help, call 000 or go to your nearest emergency department.

Rehabilitation protocol

• Proximal Row Carpectomy

These notes have been prepared by Mr Simon Lau. They are general overviews and information aimed for use by his patients. They reflect Mr Lau’s views, opinions and recommendations. They do not constitute medical advice. The contents are provided for information and education purposes only. Please seek Mr Lau’s specific advice with any questions regarding medical conditions and treatment.