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D. M. EVANS, B. M. ANSELL and M. A. HALL From the Departments of Plastic Surgery and Rheumatology,
Wexham Park Hospital, Slough
Patients with juvenile arthritis affecting the wrist have been reviewed six months or more after treatment, which has included steroid injection, synovectomy, arthroplasty, arthrodesis and distraction lengthening of the ulna. The pattern of wrist involvement is described, the general management reviewed, and the indications, techniques and results of these various procedures are presented. Journal of Hand Surgery (British Volume, 1991) 16B: 293-304
In juvenile arthritis, the wrist is the commonest joint in the hand to be involved (Chaplin et al., 1969) and, after the knee, the commonest joint in the body (Ansell and Kent, 1977). Wrist involvement (i.e. involvement of the radiocarpal, radio-ulnar and intercarpal joints) is detectable within one year of onset of juvenile arthritis in the majority of cases (Weinberger et al., 1982). Nalebuff, Yerid and Millender (1972) reported to the American Society for Surgery of the Hand on the incidence and severity of wrist involvement in arthritis of juvenile onset. In a group of 184 patients studied, 38% showed severe destructive changes. Those evaluated 20 years or more after onset showed an 80% incidence of severe wrist changes. There was a tendency in these patients for spontaneous fusion to occur. Ansell and Kent (1977) drew attention to the variation in severity in the different patterns ofjuvenile arthritis : pauciarticular (i.e. involvement of four joints or less), polyarticular (which may have progressed from pauciarticular) and systemic.
Fig. 1
Seropositive disease (referred to as juvenile rheumatoid arthritis) produces earlier and more severe destruction than seronegative disease (juvenile chronic arthritis) and bears a closer resemblance to adult rheumatoid arthritis. There is some confusion in terminology internationally. In the U.S.A. the term juvenile rheumatoid arthritis covers seropositive and seronegative disease, but in Britain only seropositive disease. The development of wrist deformity The first signs of wrist involvement are soft-tissue swelling and loss of full extension. Often the wrist is held in a few degrees of flexion. The first bony change on X-ray is premature appearance of the carpal bones, with narrowing of the intercarpal joint spaces, replacement of the immature pebble-shaped carpal bones by closer-fitting contours (Fig. 1) and early maturation or subsequent fusion of the ulnar epiphysis. Later, the carpus shows
(a) Normal left wrist and (b) affected right wrist of a nine-year-old girl showing pauciarticular juvenile chronic arthritis. Early maturity of the carpal bones can be seen, with a less rounded appearance and narrow joint spaces. The ulna is short and there is some ulnar translocation of the carpus.
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signs of ulnar translocation (Figs. 1, 4d and 9a) and the lunate moves away from its usual relationship with the radial articular surface and may lose contact with it altogether. The ulna becomes progressively shorter in relation to the radius and this has been documented by objective measurements (Hafner et al., 1989). We have also observed that the distance between the ulnar styloid process and the triquetral does not increase. In addition to the shortening, there is a change in shape of the distal end of the ulna; its ulnar side (the styloid process) becomes longer than the radial side, making the epiphyseal line oblique (Figs. 2 and 5a). In progressive cases, the lunate and the ulnar end of the radial epiphysis show signs of damage (Figs. 2, 3b, 4d and 9a), even to the point of fracture of the epiphysis. In addition to the above changes, erosions may be found in the bones forming the wrist-joint. It seems likely that the sequence of events is as follows. The growth of the ulna falls behind that of the radius, due to differential epiphyseal maturation, and this applies a traction force to the ulnar side of the carpus. In the untreated patient this leads to ulnar translocation of the carpus, with eventual dislocation leading to the bayonet deformity described by Chaplin et al. (1969). As will be described, the management of the early case is based on splintage to maintain alignment and, while this is vital to avoid the deformity that would otherwise develop, it is clear that a secondary effect of the splint may be to generate a compression force between the lunate and the distal radius on its ulnar side. This may be to some extent responsible for the observed damage to those two bones. This possibility and its consequences will be discussed further, under “Treatment”. In most children, the disease remits and some healing occurs, although there is usually residual damage; often spontaneous fusion between some or all of the carpal bones, including in some cases the radius. Since this process involves early epiphyseal closure, growth defects are common. Figure 2d shows typical fusion of carpal bones. Wrist deformity may be an important causative factor in the development of more distal deformities in the hand; Figure 3 shows the left wrist in a child who had not been splinted; there was a flexion deformity of the Vwrist and finger deformities which were to some extent related to the wrist position. Wrist flexion leads to hyperextension of the M.P. joints and flexion of the P.I.P. joint. Treatment is aimed at the prevention of deformity by general management of the disease, including drug therapy, and splintage. Some local preventive measures may be indicated, such as steroid injection and surgery which is limited to measures that will not affect epiphyseal plates during the growth period. When deformity or functional disturbance are established, corrective surgery may be necessary. The choice and timing of such surgery has to take account of future growth and likely further 294
progress of the disease. Usually these procedures are reserved for late adolescent and adult patients. This emphasizes the need for prolonged follow-up into adult life. Material and methods 33 procedures have been carried out over the past 12 years in 27 patients, and the results assessed after six months or more. Clearly long-term assessment is necessary in some of these cases, and further review will be undertaken. The procedures are listed in Table 1. Some have been carried out during childhood, and others after the affected children have grown up. Table l-Procedures
carried out in the wrist affected by juvenile arthritis
Long-acting steroid injection Synovectomy alone Silastic sheet interposition Excision of lower end of ulna Distraction lengthening of ulna Soft tissue release (no follow-up) Swanson wrist arthroplasty Arthrodesis
10 2 3 1 3 1 8 5
Total number of procedures
33
Characteristics ofpatients treated The disease types represented in the 27 patients are shown in Table 2. The majority suffered from pauciarticular-onset juvenile chronic arthritis, with or without progression to polyarticular disease. 11 of the patients have been on one or more disease-modifying drugs and six were on corticosteroids. 13 patients have undergone surgery to joints in other parts of the body. 15 patients were attending school or further education at the time of operation, ten were in work, one was retired because of her arthritis and one has been lost to follow-up. Table 2-Patterns
of disease
Juvenile chronic arthritis Pauciarticular Pauciarticular extending to polyarticular Systemic Juvenile rheumatoid arthritis (seropositive) Juvenile ankylosing spondylitis Psoriatic arthritis
23 9 12 2 2 1 1
Treatment and results All wrists with active disease were rested during the night on a paddle splint with the wrist held in a few degrees of extension. During the day, a light cock-up splint was worn to prevent flexion deformity and ulnar deviation; this was removed several times a day for active exercises (Ansell, 1980). Where established deTHE JOURNAL OF HAND SURGERY
Fig. 2
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Four X-rays of the right wrist of a boy at different ages. (a) At the age of nine, there is advanced maturity of the carpal bones. (b) By 12 they are fully mature, the ulna is short and there is a compression fracture of the radial epiphysis. (c) At 14, there is angulation of the ulnar epiphysis. (d) By 16 the wrist has undergone spontaneous inter-carpal and radio-carpal fusion in an acceptable position.
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Fig. 3 The left hand of a 13-year-old boy who had not been treated with splintage. (a) The wrist is in a fixed flexion position with a consequent tendency to M.P. hyperextension and P.I.P. flexion. (b) X-ray shows a growth defect in the ulna, loss of joint spaces which may lead to fusion, and damage to the ulnar half of the radial articular surface.
formity was present, this was corrected by serial splintage: a complete P.O.P. cast was applied in maximum extension after gentle manipulation with analgesia and a hot pack; 48 hours later it was removed and the process repeated up to three times. Intra-articular steroid injection for unilateral wrist involvement Ten wrists in ten patients with unilateral involvement were injected with Triamcinolone. The children, four of whom were boys, ranged in age from 5-12 years (average 7.4 years). Nine patients had pauciarticular juvenile chronic arthritis and in one it was originally pauciarticular but extended to polyarticular disease. The average 296
duration of disease was 3.7 years and duration of wrist involvement 1.6 years. The indications were persistent soft-tissue swelling, pain, loss of movement and difficulty in maintaining satisfactory wrist alignment despite the above splintage regime. All patients had radiological changes, with accelerated epiphyseal appearance and crowding of the carpal bones. In four children, the affected hand was smaller than the unaffected one. The treatment was combined with a continued programme of splintage and exercise. 20-30 mg. of Triamcinolone were injected under general anaesthetic, placing a fine needle directly into the radio-carpal joint from the dorsum. Firm pressure was applied to the injection site for five minutes after THE JOURNAL
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injection to prevent backflow of steroid into the subcutaneous fat and minimise the risk of localised fat atrophy (Fig. 4~). All patients have been followed up 12 months or more after injection (range one to eight years). All had softtissue swelling before injection. At follow-up, the softtissue swelling had resolved in eight wrists and was much reduced in the other two. Two patients who had pain prior to the injection were now pain-free. All patients had limited movement before injection and in seven wrists the movement had improved at follow-up. Catchup growth in the involved hand was observed in two children followed up for longer than three years (Fig. 4). Two patients developed skin atrophy at the injection site (Fig. 4c), but this resolved completely in one patient over three years. Figure 4 shows the effect of steroid injection combined with splintage over a six-month period, both on the position of the wrist and on the X-ray appearance.
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been improved and well-maintained improved range of movement.
(Fig. 6), with an
Excision ofthe lower end of the ulna This has only been necessary in one patient, a man aged 28 with extended pauciarticular disease, who had extensor tendon ruptures in the right hand. The distal ulna was resected and the tendons repaired. No ulnar head prosthesis was used. Six years later, function was satisfactory, but the carpus had subluxed ulnarwards shortly after the operation and had remained stable since. This was at first attributed to the ulnar head resection, but an identical deformity has since developed in the un-operated wrist and has been treated by arthrodesis. Distraction lengthening of the ulna
Synovectomy We have experience in only one patient with pauciarticular arthritis of juvenile onset who underwent synovectomy alone of both wrists on separate occasions. The right wrist was operated on at the age of 21, the left at 23. The radio-carpal joint was approached through a transverse incision and limited capsular incisions used to gain access to this joint and also the inter-carpal joints. The operation was successful in relieving-pain, removing swelling and improving the range of movement on both sides. The right side was operated on first and during the next two years there was some healing of the erosions in the bones in the operated side on X-rays taken at the time of the second operation (Fig. 5).
Silastic sheet interposition Silastic interposition arthroplasty of the wrist was described by Jackson and Simpson in 1979. We have used this procedure in three patients : once in a ten-yearold boy (Fig. 6) with extended pauciarticular disease who also had a proximal row carpectomy on the same wrist and twice in adults (aged 26 and 32, both female) one of whom had extended pauciarticular and the other juvenile rheumatoid arthritis). The indication for proximal row carpectomy was inability to correct a flexion deformity by conservative means. The triquetral, lunate and half the scaphoid were removed (Fig. 6b). In this patient, there was striking regeneration of the radial epiphysis. One of the adult patients also underwent a trapeziectomy on the same side. These patients have been followed up after six years in the case of the child and one year in the adults. All three were classed as successful : the alignment of the wrist has VOL. 16B No. 3 AUGUST
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In the preceding account of the development of deformity, it was suggested that the growth deficit of the ulna led to a tendency to ulnar translocation of the carpus and the corrective splintage which this required might be responsible for secondary changes in the lunate and distal radius due to compression. To alleviate this problem and facilitate realignment by splintage, we have employed distraction lengthening of the ulna in three wrists. Although ulnar lengthening has been used as a method of treatment for ulnar-minus variance in Kienbock’s disease (Armistead et al., 1982), its use has not been reported previously in juvenile arthritis. To avoid excessive dissection and mobilization around the distal ulna, we elected to carry out an osteotomy in its distal quarter and open a gap with a mini-Hoffman external fixation device (Fig. 7) which was widened daily for three weeks. A gap of about 1.5 cm. was created; then the osteotomy site was filled with a cortical bone graft from the proximal ulna, a plate inserted and the external fixator removed because of the restricted pronation and supination imposed by the percutaneous pins in the ulna. The procedure has been performed on both wrists of one boy with extended pauciarticular disease (Fig. 8). He was 14 when the right ulna was lengthened and the left was treated a year later. Following bone grafting, each wrist was placed in a hinged splint which allowed flexion and extension but prevented lateral movement. The left wrist has been similarly treated in a second case, a girl aged 12 with pauciarticular juvenile chronic arthritis. There was some loosening of the plate in this case after bone grafting, but union nevertheless proeeeded well, as it did in the first patient. A four-hole plate was used, as shown in Figure 8, to limit the exposure required but, despite the small size of the bones involved and the inevitable muscular weakness, a larger six-hole plate is now recommended. In all three wrists the developing 291
Fig. 4
(a) The right hand of a five-year-old girl with pauciarticular juvenile chronic arthritis, showing ulnar angulation. She was treated with intraarticular triamcinolone and splintage. (b) The splint used after injection. (c) Six months after treatment, the posture was improved. Mild fat atrophy is visible over the injection site but this improved subsequently. (d) X-ray before treatment shows the characteristic changes in the carpal bones and wrist, which can be compared with the normal left side. (e) After treatment, X-ray shows improved posture of the wrist and a slight improvement in the state of the radiocarpal joint to the ulnar side. (f) Eight years later; good alignment has been maintained during growth without further treatment.
THE WRIST IN JUVENILE ARTHRITIS
Fig. 5
(a) Both wrists of a 22-year-old woman before synovectomy. There is a large erosion in the triscaphe joint on each side. (b) Ten months after synovectomy on the right, there has been some healing of the erosion but on the left there is no change. Synovectomy of the left wrist was carried out later, also with good effect.
Fig. 6
(a) X-rays of a lo-year-old boy before left proximal row carpectomy. The right side is normal. (b) Six years later the X-ray shows good alignment of the wrist. The triquetral, lunate and proximal half of scaphoid have been removed. There has been striking regeneration of the radial epiphysis.
deformity has been well corrected and the need for splintage to maintain the position largely eliminated. In the bilateral case, the range of movement at follow-up after three and four years was 40” on the right and 30” on the left, with an equal range of extension and flexion on each side. VOL. 16B No. 3 AUGUST
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Soft tissue release
Soft-tissue release has been performed in one teenager with extended pauciarticular disease, whose flexion deformity of the wrist resisted conservative treatment and in whom the radio-carpal joint was well preserved. 299
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Fig. 7
Osteotomy of the ulna with’mini+Ioffitian distraction in place for ulnar lengthening in a 12-year-old girl.
device
The volar wrist joint capsule was divided beneath the flexor tendons, and the wrist flexors were lengthened. This gave a reasonable correction, but the patient was lost to follow-up. We feel that this procedure might be indicated in the occasional case. Swanson wrist arthroplasty The use of this procedure for juvenile arthritis has not been specifically reported in the literature. The general view appears to be that arthroplasty should be reserved for wrists with destruction of the joint surface but retained stability, which would preclude its use in juvenile patients. We have extended the indications to include patients with a subluxing wrist joint. Many of these patients have very poor hand function, with weak or compromised extensors of the fingers, and the maintenance of some stable wrist mobility can enhance function significantly by synergistic adjustment of wrist posture to improve the efficiency of long flexors and extensors. Patients with juvenile arthritis leading to severe destruction in the wrist invariably have gross changes in many other joints and, may also be stunted, which prevents them doing jobs in which force and strength are necessary. For the same reason, we are optimistic that our patients will be less likely to wear out their prostheses, so that the complication of particulate or silicone synovitis should not occur. Eight Swanson wrist arthroplasties have been performed in seven patients; four right and four left, all after growth in the wrist has ceased. The age range was 18 to 34. Two patients had systemic disease, two were pauciarticular extended to polyarticular, and there was one each with juvenile rheumatoid arthritis, juvenile 300
ankylosing spondylitis and psoriatic arthritis. We have taken as our indication severe symptomatic wrist destruction without ankylosis and have included several patients with some subluxation and extensor tendon ruptures, especially when arthrodesis has been thought to be undesirable for the reasons stated. All patients have been assessed after one year and most after three years. In six wrists the operation was considered to have been successful. Figure 9 shows a patient whose right wrist has been replaced, allowing comparison with the left side which was replaced subsequently and included in the series. Both sides were successful. In the successful cases, the range of movement was between 30” and 50”, the wrist alignment was improved and the patient had increased prehensile function. One patient in the successful group had presented with rupture of all digital extensor tendons as well as wrist-joint destruction; the tendons were reconstructed by tendon transfer using extensor carpi radialis longus at the same time as the wrist arthroplasty. The result was functionally good, but there is a tendency to wrist flexion and M.P. hyperextension which may need rebalancing in the future. One patient with a successful replacement also required tightening of all the digital extensors and reinsertion of the wrist extensors to correct a wrist flexion deformity and very poor grip. Two prostheses have been removed; one within two months of operation due to infection. This patient had extremely poor skin. One other patient showed carpal collapse around the prosthesis, which was removed and replaced with a peg of bone to form an arthrodesis (see below). Arthrodesis Because we have tried to preserve movement by arthroplasty in patients with uncorrectable ulnar translocation, we have only found it necessary to fuse five wrists in four patients. All were in their 30’s (range 3338). Two patients had pauciarticular juvenile chronic arthritis extended to polyarticular disease, and one each had juvenile rheumatoid arthritis and juvenile ankylosing spondylitis. The indications were uncorrectable ulnar translocation or radiocarpal subluxation and, in one patient, a failed Swanson arthroplasty. In four wrists, arthrodesis was achieved by a percutaneous Steinman pin passed down the third metacarpal. In two, this was an entirely closed procedure; in another it was combined with wrist arthrotomy and bone resection to achieve a straight position; in the fourth the pin became jammed in the narrow radial medullary canal. The few protruding millimetres were made to drop inside the metacarpal by inserting a bone graft in the wrist joint to maintain length. One year later the pin started to protrude again, and was removed after resection arthroplasty of the metacarpal head. In the patient with juvenile THE JOURNAL OF HAND SURGERY
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Fig. 8
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(a) X-rays of a boy aged 14 with polyarticular juvenile chronic arthritis. Both ulnae are short and there is ulnar translocation, with the lunate off the radius, (bayonet deformity). The radial articular surface is crushed on the ulnar side. It was felt that bilateral ulnar lengthening was needed to allow restoration of alignment. (b) The distraction device in place on the left and the osteotomy has been opened 1 mm. (c) The osteotomy has been opened 1 cm. over two weeks. (d) The fixator has been replaced with a plate and a small cortical bone graft taken from the proximal ulna to fill the gap. (e) The united osteotomy after a similar procedure on the right ulna. The wrist alignment is already corrected and could be maintained with the minimum of splintage, whereas previously continuous splinting was required. A similar result was obtained on the left.
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(a) Severe bilateral wrist subluxation in an 18-year-old boy. The lack of wrist control caused weakness and limited range in the long finger flexors and extensors. (b) X-ray following Swanson arthroplasty on the right. To avoid angulating the prosthesis, the proximal stem emerges through the cortex of the radius. The extensor carpi radialis tendons were reconstructed. (c and d) Photographs showing the right wrist after operation and the left before operation, demonstrating more effective flexion and extension of the fingers alforded by the stabilised wrist, reflected by functional improvement. The left was also effectively treated.
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rheumatoid arthritis the arthrodesis was a salvage procedure for a failed Swanson arthroplasty (see above) and was accomplished by replacing the Swanson prosthesis with a bone peg from the iliac crest. All cases were successful, including one whose Steinman pin was extruded after three years, leaving a stable ankylosis. Discussion
Chaplin et al. (1969) gave the first detailed account of the natural history of juvenile arthritis affecting the wrist. They found X-ray changes in the wrist(s) of 59% of the children with juvenile arthritis studied and attributed the deformities to an abnormality of growth : a combination of increased bone growth resulting from hyperaemia and decreased bone growth due to early epiphyseal closure. They observed shortening of the ulna, noted its significance and demonstrated by careful X-ray measurement that the final amount of ulnar shortening was greater when the disease had an early onset. They deduced that shortening of the ulna was associated with ulnar deviation “of the hand” (our’ quotation marks), by which we understand them to mean the wrist, and with ulnar translocation of the carpus (which they call “glissement carpien”). They also found that this deformity was associated with a shortening of the distance between the radial styloid process and the base of the first metacarpal. They reported untreated patients who developed the “bayonet deformity”, in which the carpus is completely dislocated in an ulnar direction and the axis of the hand is widely displaced from that of the forearm, like a fixed bayonet. Findley et al. (1983) emphasise the importance of volar subluxation of the carpus. Ulnar deviation of the wrist may be responsible for the radial deviation that is sometimes found in the metacarpo-phalangeal joints, in contrast to the more usual ulnar deviation found in adults with rheumatoid arthritis. The previous literature on surgical treatment of the wrist in juvenile arthritis is limited. Fink et al. (1969) described five wrists in which synovitis was eliminated by synovectomy, with an improved range of movement in three. They felt that there was a greater risk of a poor result if synovectomy was performed before the age of six, but they based this statement on the experience of only five cases. Kampner and Ferguson (1972) included two wrists in their series of synovectomies and found them to be ankylosed but free of disease. Granberry and Brewer (1974) and Granberry and Mangum (1980) reported their experience of synovectomy in three patients: two were found to have “dry” synovitis and surgery led to ankylosis, so they concluded that synovectomy was not advisable in the young. Jacobsen et al. (1985) include four wrists in their series, but did not analyse their wrists separately and had little enthusiasm for synovectomy generally. Arthrodesis has been menVOL.
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tioned as the treatment of choice for uncorrectable ulnar translocation (Harrison, 1978). Surgical intervention in the wrist is a rare event in an uncommon condition, and for that reason the numbers in this series are small. Decisions about indications and timing of surgical intervention are extremely difficult and require close co-operation between rheumatologist and surgeon. We have tried to clarify the indications that we have adopted and believe that careful analysis of the child’s or adult’s problems can lead to appropriate surgical decisions. Indications for prophylactic treatment during childhood are infrequent : there may be a need for steroid injection, synovectomy, ulnar lengthening, and possibly proximal row carpectomy or release of the volar capsule for resistant flexion contracture. The reduction in synovitis and improved range of movement seen after intra-articular steroid injection are encouraging and we believe that early injection may help to prevent the underdevelopment of the hand and forearm sometimes seen in patients with persistent synovitis in the wrist. Ulnar lengthening may prove to have considerable value in allowing restoration of wrist alignment without prolonged splintage and the consequent compression force generated across the radio-lunate joint. It can be combined with a wrist synovectomy, as was done on the first side of our first case. The more invasive reconstructive procedures may further inhibit growth and are therefore delayed until after the end of growth, bearing in mind that early epiphyseal fusion may bring that date forward. These procedures include Swanson arthroplasty and arthrodesis, but we try to maintain wrist movement by arthroplasty whenever possible. References ANSELL, B. M. Rheumatic Disorders in Childhood. London: Butterworths, 1980: 118. ANSELL, B. M. and KENT, P. A. (1977). Radiological Changes in Juvenile Chronic Arthritis. Skeletal Radiology, 1: 3: 129-144. ARMISTEAD, R. B., LINSCHEID, R. L., DOBYNS, .I. H. and BECKENBAUGH, R. D. (1982). Ulnar Lengthening in the Treatment of Kienbock’s Disease. Journal of Bone and Joint Surgery, 64A: 2: 170-178. CHAPLIN, D., PULKKI, T., SAARIMAA, A. and VAINIO, K. (1969). Wrist and finger deformities in juvenile rheumatoid arthritis. Acta Rheumatologica Scandinavica, 15 : 206223. FINDLEY, T. W., HALPERN, D. and EASTON, J. K. M. (1983). Wrist Subluxation in Juvenile Rheumatoid Arthritis: Pathophysiology and Management. Archives of Physical Medicine and Rehabilitation, 64: 2: 69-74. FINK, C. W., BAUM, J., PARADIES, L. H. and CARRELL, B. C. (1969). Synovectomy in Juvenile Rheumatoid Arthritis. Annals of The Rheumatic Diseases, 28: 612-616. GRANBERRY, W. M. and BREWER, E. J. (1974). Results of Synovectomy in Children with Rheumatoid Arthritis. Clinical Orthopaedics and Related Research, 101: 120-126. GRANBERRY, W. M. and MANGUM, G. L. (1980). The hand in the child with juvenile rheumatoid arthritis. Journal of Hand Surgery, 5: 2: 105-l 13. HAFNER, R., POZNANSKI, A. K. and DONOVAN, J. M. (1989). Ulnar varianceinchildren-standardmeasurementsforevaluatingulnarshortening in juvenile rheumatoid arthritis, hereditary multiple exostosis and other bone or joint disorders in childhood. Skeletal Radiology, 18: 7: 513-516. HARRISON. S. H. Wrist and Hand Problems and their Management. In: Arden. G. P. aid Ansell, B. M. (Ed%) Surgical A4amzgement if Juvenile Chronic Arthritis. London, Academic Press, 1978: 161-183.
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JACOBSEN, S. T., LEVINSON, J. E. and CRAWFORD, A. H. (1985). Late Results of Synovectomy in Juvenile Rheumatoid Arthritis. Journal of Bone and Joint Surgery, 67A: 1: 8-15. KAMPNER, S. L. and FERGUSON, A. B. (1972). Efficacy of Synovectomy in Juvenile Rheumatoid Arthritis. Clinical Orthopaedics and Related Research, 88: 94109. NALEBUFF, E. A., YERID, G. and MILLENDER, L. (1972). The Incidence and Severitv of Wrist Involvement in Juvenile Rheumatoid Arthritis. Journal of Bone ani Joint Surgery, 54A: 4: 905.
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WEINBERGER, A.,ANSELL, B. M. and EVANS,D. (1982). Wrist involvement in juvenile chronic arthritis five years after onset of the disease. Israel Journal of Medical Sciences, 18: 653-654.
Accepted: 31 July 1990 D. M. Evans, F.R.C.S., Wexham
Park Hospital,
Slough,
SL2 4HL
0 1991 The British Society for Surgery of the Hand
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D. M. EVANS, B. M. ANSELL and M. A. HALL From the Departments of Plastic Surgery and Rheumatology,
Wexham Park Hospital, Slough
Patients with juvenile arthritis affecting the wrist have been reviewed six months or more after treatment, which has included steroid injection, synovectomy, arthroplasty, arthrodesis and distraction lengthening of the ulna. The pattern of wrist involvement is described, the general management reviewed, and the indications, techniques and results of these various procedures are presented. Journal of Hand Surgery (British Volume, 1991) 16B: 293-304
In juvenile arthritis, the wrist is the commonest joint in the hand to be involved (Chaplin et al., 1969) and, after the knee, the commonest joint in the body (Ansell and Kent, 1977). Wrist involvement (i.e. involvement of the radiocarpal, radio-ulnar and intercarpal joints) is detectable within one year of onset of juvenile arthritis in the majority of cases (Weinberger et al., 1982). Nalebuff, Yerid and Millender (1972) reported to the American Society for Surgery of the Hand on the incidence and severity of wrist involvement in arthritis of juvenile onset. In a group of 184 patients studied, 38% showed severe destructive changes. Those evaluated 20 years or more after onset showed an 80% incidence of severe wrist changes. There was a tendency in these patients for spontaneous fusion to occur. Ansell and Kent (1977) drew attention to the variation in severity in the different patterns ofjuvenile arthritis : pauciarticular (i.e. involvement of four joints or less), polyarticular (which may have progressed from pauciarticular) and systemic.
Fig. 1
Seropositive disease (referred to as juvenile rheumatoid arthritis) produces earlier and more severe destruction than seronegative disease (juvenile chronic arthritis) and bears a closer resemblance to adult rheumatoid arthritis. There is some confusion in terminology internationally. In the U.S.A. the term juvenile rheumatoid arthritis covers seropositive and seronegative disease, but in Britain only seropositive disease. The development of wrist deformity The first signs of wrist involvement are soft-tissue swelling and loss of full extension. Often the wrist is held in a few degrees of flexion. The first bony change on X-ray is premature appearance of the carpal bones, with narrowing of the intercarpal joint spaces, replacement of the immature pebble-shaped carpal bones by closer-fitting contours (Fig. 1) and early maturation or subsequent fusion of the ulnar epiphysis. Later, the carpus shows
(a) Normal left wrist and (b) affected right wrist of a nine-year-old girl showing pauciarticular juvenile chronic arthritis. Early maturity of the carpal bones can be seen, with a less rounded appearance and narrow joint spaces. The ulna is short and there is some ulnar translocation of the carpus.
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signs of ulnar translocation (Figs. 1, 4d and 9a) and the lunate moves away from its usual relationship with the radial articular surface and may lose contact with it altogether. The ulna becomes progressively shorter in relation to the radius and this has been documented by objective measurements (Hafner et al., 1989). We have also observed that the distance between the ulnar styloid process and the triquetral does not increase. In addition to the shortening, there is a change in shape of the distal end of the ulna; its ulnar side (the styloid process) becomes longer than the radial side, making the epiphyseal line oblique (Figs. 2 and 5a). In progressive cases, the lunate and the ulnar end of the radial epiphysis show signs of damage (Figs. 2, 3b, 4d and 9a), even to the point of fracture of the epiphysis. In addition to the above changes, erosions may be found in the bones forming the wrist-joint. It seems likely that the sequence of events is as follows. The growth of the ulna falls behind that of the radius, due to differential epiphyseal maturation, and this applies a traction force to the ulnar side of the carpus. In the untreated patient this leads to ulnar translocation of the carpus, with eventual dislocation leading to the bayonet deformity described by Chaplin et al. (1969). As will be described, the management of the early case is based on splintage to maintain alignment and, while this is vital to avoid the deformity that would otherwise develop, it is clear that a secondary effect of the splint may be to generate a compression force between the lunate and the distal radius on its ulnar side. This may be to some extent responsible for the observed damage to those two bones. This possibility and its consequences will be discussed further, under “Treatment”. In most children, the disease remits and some healing occurs, although there is usually residual damage; often spontaneous fusion between some or all of the carpal bones, including in some cases the radius. Since this process involves early epiphyseal closure, growth defects are common. Figure 2d shows typical fusion of carpal bones. Wrist deformity may be an important causative factor in the development of more distal deformities in the hand; Figure 3 shows the left wrist in a child who had not been splinted; there was a flexion deformity of the Vwrist and finger deformities which were to some extent related to the wrist position. Wrist flexion leads to hyperextension of the M.P. joints and flexion of the P.I.P. joint. Treatment is aimed at the prevention of deformity by general management of the disease, including drug therapy, and splintage. Some local preventive measures may be indicated, such as steroid injection and surgery which is limited to measures that will not affect epiphyseal plates during the growth period. When deformity or functional disturbance are established, corrective surgery may be necessary. The choice and timing of such surgery has to take account of future growth and likely further 294
progress of the disease. Usually these procedures are reserved for late adolescent and adult patients. This emphasizes the need for prolonged follow-up into adult life. Material and methods 33 procedures have been carried out over the past 12 years in 27 patients, and the results assessed after six months or more. Clearly long-term assessment is necessary in some of these cases, and further review will be undertaken. The procedures are listed in Table 1. Some have been carried out during childhood, and others after the affected children have grown up. Table l-Procedures
carried out in the wrist affected by juvenile arthritis
Long-acting steroid injection Synovectomy alone Silastic sheet interposition Excision of lower end of ulna Distraction lengthening of ulna Soft tissue release (no follow-up) Swanson wrist arthroplasty Arthrodesis
10 2 3 1 3 1 8 5
Total number of procedures
33
Characteristics ofpatients treated The disease types represented in the 27 patients are shown in Table 2. The majority suffered from pauciarticular-onset juvenile chronic arthritis, with or without progression to polyarticular disease. 11 of the patients have been on one or more disease-modifying drugs and six were on corticosteroids. 13 patients have undergone surgery to joints in other parts of the body. 15 patients were attending school or further education at the time of operation, ten were in work, one was retired because of her arthritis and one has been lost to follow-up. Table 2-Patterns
of disease
Juvenile chronic arthritis Pauciarticular Pauciarticular extending to polyarticular Systemic Juvenile rheumatoid arthritis (seropositive) Juvenile ankylosing spondylitis Psoriatic arthritis
23 9 12 2 2 1 1
Treatment and results All wrists with active disease were rested during the night on a paddle splint with the wrist held in a few degrees of extension. During the day, a light cock-up splint was worn to prevent flexion deformity and ulnar deviation; this was removed several times a day for active exercises (Ansell, 1980). Where established deTHE JOURNAL OF HAND SURGERY
Fig. 2
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Four X-rays of the right wrist of a boy at different ages. (a) At the age of nine, there is advanced maturity of the carpal bones. (b) By 12 they are fully mature, the ulna is short and there is a compression fracture of the radial epiphysis. (c) At 14, there is angulation of the ulnar epiphysis. (d) By 16 the wrist has undergone spontaneous inter-carpal and radio-carpal fusion in an acceptable position.
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Fig. 3 The left hand of a 13-year-old boy who had not been treated with splintage. (a) The wrist is in a fixed flexion position with a consequent tendency to M.P. hyperextension and P.I.P. flexion. (b) X-ray shows a growth defect in the ulna, loss of joint spaces which may lead to fusion, and damage to the ulnar half of the radial articular surface.
formity was present, this was corrected by serial splintage: a complete P.O.P. cast was applied in maximum extension after gentle manipulation with analgesia and a hot pack; 48 hours later it was removed and the process repeated up to three times. Intra-articular steroid injection for unilateral wrist involvement Ten wrists in ten patients with unilateral involvement were injected with Triamcinolone. The children, four of whom were boys, ranged in age from 5-12 years (average 7.4 years). Nine patients had pauciarticular juvenile chronic arthritis and in one it was originally pauciarticular but extended to polyarticular disease. The average 296
duration of disease was 3.7 years and duration of wrist involvement 1.6 years. The indications were persistent soft-tissue swelling, pain, loss of movement and difficulty in maintaining satisfactory wrist alignment despite the above splintage regime. All patients had radiological changes, with accelerated epiphyseal appearance and crowding of the carpal bones. In four children, the affected hand was smaller than the unaffected one. The treatment was combined with a continued programme of splintage and exercise. 20-30 mg. of Triamcinolone were injected under general anaesthetic, placing a fine needle directly into the radio-carpal joint from the dorsum. Firm pressure was applied to the injection site for five minutes after THE JOURNAL
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injection to prevent backflow of steroid into the subcutaneous fat and minimise the risk of localised fat atrophy (Fig. 4~). All patients have been followed up 12 months or more after injection (range one to eight years). All had softtissue swelling before injection. At follow-up, the softtissue swelling had resolved in eight wrists and was much reduced in the other two. Two patients who had pain prior to the injection were now pain-free. All patients had limited movement before injection and in seven wrists the movement had improved at follow-up. Catchup growth in the involved hand was observed in two children followed up for longer than three years (Fig. 4). Two patients developed skin atrophy at the injection site (Fig. 4c), but this resolved completely in one patient over three years. Figure 4 shows the effect of steroid injection combined with splintage over a six-month period, both on the position of the wrist and on the X-ray appearance.
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been improved and well-maintained improved range of movement.
(Fig. 6), with an
Excision ofthe lower end of the ulna This has only been necessary in one patient, a man aged 28 with extended pauciarticular disease, who had extensor tendon ruptures in the right hand. The distal ulna was resected and the tendons repaired. No ulnar head prosthesis was used. Six years later, function was satisfactory, but the carpus had subluxed ulnarwards shortly after the operation and had remained stable since. This was at first attributed to the ulnar head resection, but an identical deformity has since developed in the un-operated wrist and has been treated by arthrodesis. Distraction lengthening of the ulna
Synovectomy We have experience in only one patient with pauciarticular arthritis of juvenile onset who underwent synovectomy alone of both wrists on separate occasions. The right wrist was operated on at the age of 21, the left at 23. The radio-carpal joint was approached through a transverse incision and limited capsular incisions used to gain access to this joint and also the inter-carpal joints. The operation was successful in relieving-pain, removing swelling and improving the range of movement on both sides. The right side was operated on first and during the next two years there was some healing of the erosions in the bones in the operated side on X-rays taken at the time of the second operation (Fig. 5).
Silastic sheet interposition Silastic interposition arthroplasty of the wrist was described by Jackson and Simpson in 1979. We have used this procedure in three patients : once in a ten-yearold boy (Fig. 6) with extended pauciarticular disease who also had a proximal row carpectomy on the same wrist and twice in adults (aged 26 and 32, both female) one of whom had extended pauciarticular and the other juvenile rheumatoid arthritis). The indication for proximal row carpectomy was inability to correct a flexion deformity by conservative means. The triquetral, lunate and half the scaphoid were removed (Fig. 6b). In this patient, there was striking regeneration of the radial epiphysis. One of the adult patients also underwent a trapeziectomy on the same side. These patients have been followed up after six years in the case of the child and one year in the adults. All three were classed as successful : the alignment of the wrist has VOL. 16B No. 3 AUGUST
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In the preceding account of the development of deformity, it was suggested that the growth deficit of the ulna led to a tendency to ulnar translocation of the carpus and the corrective splintage which this required might be responsible for secondary changes in the lunate and distal radius due to compression. To alleviate this problem and facilitate realignment by splintage, we have employed distraction lengthening of the ulna in three wrists. Although ulnar lengthening has been used as a method of treatment for ulnar-minus variance in Kienbock’s disease (Armistead et al., 1982), its use has not been reported previously in juvenile arthritis. To avoid excessive dissection and mobilization around the distal ulna, we elected to carry out an osteotomy in its distal quarter and open a gap with a mini-Hoffman external fixation device (Fig. 7) which was widened daily for three weeks. A gap of about 1.5 cm. was created; then the osteotomy site was filled with a cortical bone graft from the proximal ulna, a plate inserted and the external fixator removed because of the restricted pronation and supination imposed by the percutaneous pins in the ulna. The procedure has been performed on both wrists of one boy with extended pauciarticular disease (Fig. 8). He was 14 when the right ulna was lengthened and the left was treated a year later. Following bone grafting, each wrist was placed in a hinged splint which allowed flexion and extension but prevented lateral movement. The left wrist has been similarly treated in a second case, a girl aged 12 with pauciarticular juvenile chronic arthritis. There was some loosening of the plate in this case after bone grafting, but union nevertheless proeeeded well, as it did in the first patient. A four-hole plate was used, as shown in Figure 8, to limit the exposure required but, despite the small size of the bones involved and the inevitable muscular weakness, a larger six-hole plate is now recommended. In all three wrists the developing 291
Fig. 4
(a) The right hand of a five-year-old girl with pauciarticular juvenile chronic arthritis, showing ulnar angulation. She was treated with intraarticular triamcinolone and splintage. (b) The splint used after injection. (c) Six months after treatment, the posture was improved. Mild fat atrophy is visible over the injection site but this improved subsequently. (d) X-ray before treatment shows the characteristic changes in the carpal bones and wrist, which can be compared with the normal left side. (e) After treatment, X-ray shows improved posture of the wrist and a slight improvement in the state of the radiocarpal joint to the ulnar side. (f) Eight years later; good alignment has been maintained during growth without further treatment.
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Fig. 5
(a) Both wrists of a 22-year-old woman before synovectomy. There is a large erosion in the triscaphe joint on each side. (b) Ten months after synovectomy on the right, there has been some healing of the erosion but on the left there is no change. Synovectomy of the left wrist was carried out later, also with good effect.
Fig. 6
(a) X-rays of a lo-year-old boy before left proximal row carpectomy. The right side is normal. (b) Six years later the X-ray shows good alignment of the wrist. The triquetral, lunate and proximal half of scaphoid have been removed. There has been striking regeneration of the radial epiphysis.
deformity has been well corrected and the need for splintage to maintain the position largely eliminated. In the bilateral case, the range of movement at follow-up after three and four years was 40” on the right and 30” on the left, with an equal range of extension and flexion on each side. VOL. 16B No. 3 AUGUST
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Soft-tissue release has been performed in one teenager with extended pauciarticular disease, whose flexion deformity of the wrist resisted conservative treatment and in whom the radio-carpal joint was well preserved. 299
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Fig. 7
Osteotomy of the ulna with’mini+Ioffitian distraction in place for ulnar lengthening in a 12-year-old girl.
device
The volar wrist joint capsule was divided beneath the flexor tendons, and the wrist flexors were lengthened. This gave a reasonable correction, but the patient was lost to follow-up. We feel that this procedure might be indicated in the occasional case. Swanson wrist arthroplasty The use of this procedure for juvenile arthritis has not been specifically reported in the literature. The general view appears to be that arthroplasty should be reserved for wrists with destruction of the joint surface but retained stability, which would preclude its use in juvenile patients. We have extended the indications to include patients with a subluxing wrist joint. Many of these patients have very poor hand function, with weak or compromised extensors of the fingers, and the maintenance of some stable wrist mobility can enhance function significantly by synergistic adjustment of wrist posture to improve the efficiency of long flexors and extensors. Patients with juvenile arthritis leading to severe destruction in the wrist invariably have gross changes in many other joints and, may also be stunted, which prevents them doing jobs in which force and strength are necessary. For the same reason, we are optimistic that our patients will be less likely to wear out their prostheses, so that the complication of particulate or silicone synovitis should not occur. Eight Swanson wrist arthroplasties have been performed in seven patients; four right and four left, all after growth in the wrist has ceased. The age range was 18 to 34. Two patients had systemic disease, two were pauciarticular extended to polyarticular, and there was one each with juvenile rheumatoid arthritis, juvenile 300
ankylosing spondylitis and psoriatic arthritis. We have taken as our indication severe symptomatic wrist destruction without ankylosis and have included several patients with some subluxation and extensor tendon ruptures, especially when arthrodesis has been thought to be undesirable for the reasons stated. All patients have been assessed after one year and most after three years. In six wrists the operation was considered to have been successful. Figure 9 shows a patient whose right wrist has been replaced, allowing comparison with the left side which was replaced subsequently and included in the series. Both sides were successful. In the successful cases, the range of movement was between 30” and 50”, the wrist alignment was improved and the patient had increased prehensile function. One patient in the successful group had presented with rupture of all digital extensor tendons as well as wrist-joint destruction; the tendons were reconstructed by tendon transfer using extensor carpi radialis longus at the same time as the wrist arthroplasty. The result was functionally good, but there is a tendency to wrist flexion and M.P. hyperextension which may need rebalancing in the future. One patient with a successful replacement also required tightening of all the digital extensors and reinsertion of the wrist extensors to correct a wrist flexion deformity and very poor grip. Two prostheses have been removed; one within two months of operation due to infection. This patient had extremely poor skin. One other patient showed carpal collapse around the prosthesis, which was removed and replaced with a peg of bone to form an arthrodesis (see below). Arthrodesis Because we have tried to preserve movement by arthroplasty in patients with uncorrectable ulnar translocation, we have only found it necessary to fuse five wrists in four patients. All were in their 30’s (range 3338). Two patients had pauciarticular juvenile chronic arthritis extended to polyarticular disease, and one each had juvenile rheumatoid arthritis and juvenile ankylosing spondylitis. The indications were uncorrectable ulnar translocation or radiocarpal subluxation and, in one patient, a failed Swanson arthroplasty. In four wrists, arthrodesis was achieved by a percutaneous Steinman pin passed down the third metacarpal. In two, this was an entirely closed procedure; in another it was combined with wrist arthrotomy and bone resection to achieve a straight position; in the fourth the pin became jammed in the narrow radial medullary canal. The few protruding millimetres were made to drop inside the metacarpal by inserting a bone graft in the wrist joint to maintain length. One year later the pin started to protrude again, and was removed after resection arthroplasty of the metacarpal head. In the patient with juvenile THE JOURNAL OF HAND SURGERY
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Fig. 8
ARTHRITIS
(a) X-rays of a boy aged 14 with polyarticular juvenile chronic arthritis. Both ulnae are short and there is ulnar translocation, with the lunate off the radius, (bayonet deformity). The radial articular surface is crushed on the ulnar side. It was felt that bilateral ulnar lengthening was needed to allow restoration of alignment. (b) The distraction device in place on the left and the osteotomy has been opened 1 mm. (c) The osteotomy has been opened 1 cm. over two weeks. (d) The fixator has been replaced with a plate and a small cortical bone graft taken from the proximal ulna to fill the gap. (e) The united osteotomy after a similar procedure on the right ulna. The wrist alignment is already corrected and could be maintained with the minimum of splintage, whereas previously continuous splinting was required. A similar result was obtained on the left.
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(a) Severe bilateral wrist subluxation in an 18-year-old boy. The lack of wrist control caused weakness and limited range in the long finger flexors and extensors. (b) X-ray following Swanson arthroplasty on the right. To avoid angulating the prosthesis, the proximal stem emerges through the cortex of the radius. The extensor carpi radialis tendons were reconstructed. (c and d) Photographs showing the right wrist after operation and the left before operation, demonstrating more effective flexion and extension of the fingers alforded by the stabilised wrist, reflected by functional improvement. The left was also effectively treated.
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rheumatoid arthritis the arthrodesis was a salvage procedure for a failed Swanson arthroplasty (see above) and was accomplished by replacing the Swanson prosthesis with a bone peg from the iliac crest. All cases were successful, including one whose Steinman pin was extruded after three years, leaving a stable ankylosis. Discussion
Chaplin et al. (1969) gave the first detailed account of the natural history of juvenile arthritis affecting the wrist. They found X-ray changes in the wrist(s) of 59% of the children with juvenile arthritis studied and attributed the deformities to an abnormality of growth : a combination of increased bone growth resulting from hyperaemia and decreased bone growth due to early epiphyseal closure. They observed shortening of the ulna, noted its significance and demonstrated by careful X-ray measurement that the final amount of ulnar shortening was greater when the disease had an early onset. They deduced that shortening of the ulna was associated with ulnar deviation “of the hand” (our’ quotation marks), by which we understand them to mean the wrist, and with ulnar translocation of the carpus (which they call “glissement carpien”). They also found that this deformity was associated with a shortening of the distance between the radial styloid process and the base of the first metacarpal. They reported untreated patients who developed the “bayonet deformity”, in which the carpus is completely dislocated in an ulnar direction and the axis of the hand is widely displaced from that of the forearm, like a fixed bayonet. Findley et al. (1983) emphasise the importance of volar subluxation of the carpus. Ulnar deviation of the wrist may be responsible for the radial deviation that is sometimes found in the metacarpo-phalangeal joints, in contrast to the more usual ulnar deviation found in adults with rheumatoid arthritis. The previous literature on surgical treatment of the wrist in juvenile arthritis is limited. Fink et al. (1969) described five wrists in which synovitis was eliminated by synovectomy, with an improved range of movement in three. They felt that there was a greater risk of a poor result if synovectomy was performed before the age of six, but they based this statement on the experience of only five cases. Kampner and Ferguson (1972) included two wrists in their series of synovectomies and found them to be ankylosed but free of disease. Granberry and Brewer (1974) and Granberry and Mangum (1980) reported their experience of synovectomy in three patients: two were found to have “dry” synovitis and surgery led to ankylosis, so they concluded that synovectomy was not advisable in the young. Jacobsen et al. (1985) include four wrists in their series, but did not analyse their wrists separately and had little enthusiasm for synovectomy generally. Arthrodesis has been menVOL.
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tioned as the treatment of choice for uncorrectable ulnar translocation (Harrison, 1978). Surgical intervention in the wrist is a rare event in an uncommon condition, and for that reason the numbers in this series are small. Decisions about indications and timing of surgical intervention are extremely difficult and require close co-operation between rheumatologist and surgeon. We have tried to clarify the indications that we have adopted and believe that careful analysis of the child’s or adult’s problems can lead to appropriate surgical decisions. Indications for prophylactic treatment during childhood are infrequent : there may be a need for steroid injection, synovectomy, ulnar lengthening, and possibly proximal row carpectomy or release of the volar capsule for resistant flexion contracture. The reduction in synovitis and improved range of movement seen after intra-articular steroid injection are encouraging and we believe that early injection may help to prevent the underdevelopment of the hand and forearm sometimes seen in patients with persistent synovitis in the wrist. Ulnar lengthening may prove to have considerable value in allowing restoration of wrist alignment without prolonged splintage and the consequent compression force generated across the radio-lunate joint. It can be combined with a wrist synovectomy, as was done on the first side of our first case. The more invasive reconstructive procedures may further inhibit growth and are therefore delayed until after the end of growth, bearing in mind that early epiphyseal fusion may bring that date forward. These procedures include Swanson arthroplasty and arthrodesis, but we try to maintain wrist movement by arthroplasty whenever possible. References ANSELL, B. M. Rheumatic Disorders in Childhood. London: Butterworths, 1980: 118. ANSELL, B. M. and KENT, P. A. (1977). Radiological Changes in Juvenile Chronic Arthritis. Skeletal Radiology, 1: 3: 129-144. ARMISTEAD, R. B., LINSCHEID, R. L., DOBYNS, .I. H. and BECKENBAUGH, R. D. (1982). Ulnar Lengthening in the Treatment of Kienbock’s Disease. Journal of Bone and Joint Surgery, 64A: 2: 170-178. CHAPLIN, D., PULKKI, T., SAARIMAA, A. and VAINIO, K. (1969). Wrist and finger deformities in juvenile rheumatoid arthritis. Acta Rheumatologica Scandinavica, 15 : 206223. FINDLEY, T. W., HALPERN, D. and EASTON, J. K. M. (1983). Wrist Subluxation in Juvenile Rheumatoid Arthritis: Pathophysiology and Management. Archives of Physical Medicine and Rehabilitation, 64: 2: 69-74. FINK, C. W., BAUM, J., PARADIES, L. H. and CARRELL, B. C. (1969). Synovectomy in Juvenile Rheumatoid Arthritis. Annals of The Rheumatic Diseases, 28: 612-616. GRANBERRY, W. M. and BREWER, E. J. (1974). Results of Synovectomy in Children with Rheumatoid Arthritis. Clinical Orthopaedics and Related Research, 101: 120-126. GRANBERRY, W. M. and MANGUM, G. L. (1980). The hand in the child with juvenile rheumatoid arthritis. Journal of Hand Surgery, 5: 2: 105-l 13. HAFNER, R., POZNANSKI, A. K. and DONOVAN, J. M. (1989). Ulnar varianceinchildren-standardmeasurementsforevaluatingulnarshortening in juvenile rheumatoid arthritis, hereditary multiple exostosis and other bone or joint disorders in childhood. Skeletal Radiology, 18: 7: 513-516. HARRISON. S. H. Wrist and Hand Problems and their Management. In: Arden. G. P. aid Ansell, B. M. (Ed%) Surgical A4amzgement if Juvenile Chronic Arthritis. London, Academic Press, 1978: 161-183.
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JACOBSEN, S. T., LEVINSON, J. E. and CRAWFORD, A. H. (1985). Late Results of Synovectomy in Juvenile Rheumatoid Arthritis. Journal of Bone and Joint Surgery, 67A: 1: 8-15. KAMPNER, S. L. and FERGUSON, A. B. (1972). Efficacy of Synovectomy in Juvenile Rheumatoid Arthritis. Clinical Orthopaedics and Related Research, 88: 94109. NALEBUFF, E. A., YERID, G. and MILLENDER, L. (1972). The Incidence and Severitv of Wrist Involvement in Juvenile Rheumatoid Arthritis. Journal of Bone ani Joint Surgery, 54A: 4: 905.
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WEINBERGER, A.,ANSELL, B. M. and EVANS,D. (1982). Wrist involvement in juvenile chronic arthritis five years after onset of the disease. Israel Journal of Medical Sciences, 18: 653-654.
Accepted: 31 July 1990 D. M. Evans, F.R.C.S., Wexham
Park Hospital,
Slough,
SL2 4HL
0 1991 The British Society for Surgery of the Hand
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