four-corner fusion of the wrist (avascular necrosis of the scaphoid)

[lerrymoe]

Hello, I have developed somehow an avascular necrosis of the scaphoid. The condition happens when the the scaphoid is broken and one of the parts is not supplied with blood and dies. The only good news is that it was not on my right hand, since I'm right handed. The doc wants now to do a partial fusion of the wrist, with excision of the scaphoid and fusing the other 4 bones on the top of the wrist to provide stability. The excision of the scaphoid is said to be the only solution with partial fution of the wrist since I have alredy developed arthritis on the concerned wrist.  

My current situation is the following: almost no extention or flexion on the wrist; all other movements intact. If I keep the hand continuously in a splint i'll have no pain, but if i take it out i'll have pain in a very short time, doing even minor tasks.

Since I am quite young (29yrs) I am wondering what should I do. I dont want to live in pain, but I also know that this surgery will probably not be the end of this story. I know about this since the beginning of the year, and since then I've also done almost no sports. Before that I did sports almost every day.

My question is: has anyone here experience with partial fusion of the wrist? (four-corner fusion). Would you recommend it? What was the outcome?

Thanks a lot in advance,

Lerry  

[Dr Vinod]

For avascular necrosis you cannot revive the bone so the movements at your wrist are restricted now.
So the solution as your orthopaedician has suggested in bone fusion to help you out with proper movements.

You would need physiotherapy after the fusion and you will slowly get some movements but the range of movements will never be similar to as before.

Discuss all the pros and cons and do's and dont's with your operating surgeon and we advice you to choose a person who is adept in this and has expirience. Take care!

[lerrymoe]

Hello Dr Vinod,

Thank you for your reply.

I am well aware of the fact that the wrist will never be as before, and I have at this point quite a lot of information about the 4-corner procedure. The thing that I fear the most are >> the complications from this surgery <<. Since I am 29 and I plan to live a long, healthy life, I'd like to avoid problems down the line.

Nowadays I have almost no extention or flexion movements. If I wear a wrist split and do no sports besides jogging (before did sports almost every day), I'll have no pain. But I also would not like to be wearing a wrist splint for the rest of my life. I also have to wear the splint while sleeping, so that I do not bend it accidentally.

I have read a lot of bad stuff on the internet about the spider plate too, so I wonder if it would be better to use K-Wires instead of the plate.

Given the X rays of my wrist I posted on my profile (one from Jan 2009, the other one from Aug 2009, so just from 15 days ago) and what I have described, what would you suggest, as a physician? Would you go for the surgery or continue wearing a splint? What is also your opinion about the spider plate? Is it reliable?

Thanks again in advance for your support,

- Lerry

[Dr Vinod]

We were trying to advice you that the procedure if done by experts is problem free and there is no need to wear a splint all your life.

It is your decision for going for the fusion surgery. If you go for it we can say that your quality of life will improve.

Some precautions should be taken, as you should not lift heavy weights, you cannot pull heavy weights but other activities are fine.

With Physiotherapy and over a period of time you will gain strength in your wrist but what we mentioned was it will never be same as before.

The plates and wires are all depending on case to case and surgery and leave it to the   expert. ( You can always suggest your operating surgeon about wires)

Take care!

[Phill614]

Hi lerry, first off i'm at a point of having my wrist fused. i'm in constant pain. the questions i have to ask myself is with a partical fusion will i have arthritis in a few years in the area not fused and will i have to go through this all again. i like you am extreemly active or at least was.  i am leaning to have a full wrist fusion.  i wouldn't listen to a thing that doctor responded to you.  look at his back ground he's a general practioner, he's not a orthpedic doctor. about a month has gone by since the post so i would be interested what you decided,  thanks   Phill

[kriyamon]

I too am faced with inevitable four corner fusion or proximal row carpectomy.  I broke my schaphoid 40 years ago and never knew it.  it's been painful for 30 years, and now necrotic and collapsed it is time.

I'm very glad to see this string as I have searched the internet for years for information and support with this problem.  I am an avid surfer, gardner, and guitar player and treasure the use of my hands.  

I want to talk to others who have been through this and can provide support and advice on procedures, doctors, etc. (I had my hip replace 2 years ago and there were numeroous web-based bulletin boards with tons of information and support.)  I have not found that for SNAC wrist problems.

Any suggestions?  If there is no group we should create one....there are others out there who need it too.

[kriyamon]

I too am faced with inevitable four corner fusion or proximal row carpectomy.  I broke my schaphoid 40 years ago and never knew it.  it's been painful for 30 years, and now necrotic and collapsed it is time.

I'm very glad to see this string as I have searched the internet for years for information and support with this problem.  I am an avid surfer, gardner, and guitar player and treasure the use of my hands.  

I want to talk to others who have been through this and can provide support and advice on procedures, doctors, etc. (I had my hip replace 2 years ago and there were numeroous web-based bulletin boards with tons of information and support.)  I have not found that for SNAC wrist problems.

Any suggestions?  If there is no group we should create one....there are others out there who need it too.

[lerrymoe]

I decided to have my four corner fusion; so lets see what will be the result. If I am mistaken; I will suffer with this decision the rest of my life. I got tired of listening to what people say; you will hear as many people saying you should do it as people saying you shouldnt. so it is about time to go by myself. will be 1 month in a cast, and hopefully all will be all right at the end

[lerrymoe]

Here is a video of a 4-corner fusion:

http://www.orthop.washington.edu/UserFiles/Media/faculty/Trumble/arthritissurgery/03/a/spider.mov

And here is some more information

http://www.orthop.washington.edu/UserFiles/Media/faculty/Trumble/arthritissurgery/03/a/spider.mov

[lerrymoe]

hi kriyamon, if you are leaving this long with a snac wrist you will probably need a total wrist fusion... a 4 corner fusion is called a partial arthrodesis of the wrist that can be performed given your other metacarpal bones did not go moved so that they occupy the space of the collapsed scaphoid... if this is the case (if the other bones already sunk on the space where the scaphoid was), only total wrist fusion can do it... this usually happens if you live a long time with this problem without doing much about it, and maybe this is your case.

[lerrymoe]

hi kriyamon, if you are living this long with a snac wrist you will probably need a total wrist fusion... a 4 corner fusion is called a partial arthrodesis of the wrist that can be performed given your other metacarpal bones did not go moved so that they occupy the space of the collapsed scaphoid... if this is the case (if the other bones already sunk on the space where the scaphoid was), only total wrist fusion can do it... this usually happens if you live a long time with this problem without doing much about it, and maybe this is your case.

[sozestail]

I also have avascular necrosis of the scaphoid and have been doing a lot of research on the internet.  I was curious if you finally got your partial fusion surgery and how it went.  I have been also reading about scaphoid replacement surgery, was that an option you considered?  I just found out a few days ago that the pain I have been experiencing for years may haunt me forever and I am really trying to find out the best options available to me.

[lerrymoe]

hi sozestail, i will get my surgery on monday, so in 3 days from today!!! f***, i am really nervous; cannot sleep and so on... thought about cancelling it, but that would be really bad for the docs, for the hospital and maybe for me, since i think the insurance would charge me for this last minute decision... anyways, now lets go for it. the thing that worries me the most is that i have not much pain, even though i have almost no flexion or extension on my hand now; my hand is at a point that it already does not move much up or down, so i have little pain. i cannot do any kinds of sports, though; only jogging is ok. so lets say, if you could imagine 3 stages: one where you are normal; one where your wrist if f*** up but you have no pain; and the last stage as the one with your wrist f*** up and you have pain; I am on the middle one. of course with this surgery i would like to improve as much as possible; but no doc would give me any guarantee; so at the end you are by yourself... it is a kind of a gamble with more chances of improvement than otherwise... will keep you posted...

[sozestail]

I hope your surgery went well :).  If you couldn't move your wrist well to begin with whats the harm in a little fusion surgery.  I think am in the third stage, constant pain, my scaphoid is almost completely collapsed.  I have been looking more into wrist replacement, but not too many doctor's do that.  I am trying electrotherapy now, we'll see how that goes, but it may be a little too late in the game.  I sure wish I would have taken care of this sooner, if only I had insurance when the injury occured.  Two years later and I have a permanently bum wrist at the ripe young age of 33.  :(

[kriyamon]

Best wishes to all with broken wrists.

Well, a good amount of traffic and potential for sharing here.  Lerrymoe how are you???????????   Sozestail, don't despair, you'll get by with a little help from your friends. So now for my story in short:

Note:  When I say "doc" below I'm eferring to several and many over the years.Orthopods mostly , but also rheumatologists, and alternative care practitioners.

I apparently cracke dmy scaphoid skateboarding when 18 but did not recieve medical treatment.  At 23 I went to the doc and he asked "when did you break your scaphoid?  At that point there was no procedure to repair (now there is grafting, replacement, etc), so I put up with pain.  About every 5 years I'd ask the doc what to do.  Surgery he said.I chose pills splints massage accupuncture and anything else that seemed to help.  At around 50 the pain started to become a problem (this is when it really inhibits your lifestyle) and I started getting carpal tunnel syndrome.  Now the doc said surgery or cortizone injections.  So I've had about 5 injections over the past 4 years.  They help each time for a good 6-8 weeks, but when they wear off I find I have used my wrist so much it is even worse.  I would ask the doc what would happen if I didn't get surgery.  He said it would just hurt more until surgery, but he wanted to keep an eye on one bone (can;t remember the name) to make sure it didn't get screwed up because that would make surgey not so good.  

Then 3 months ago out of the blue my thumb tendon broke while I was clipping my fingernails (yes, cliping fingernails).  I surf and and quite active an wish I had a better story, but I was cliping my nails.  It was painless, in fact, it reduced a little pain and carpal tunnel.  The doc said "you broke your thumb tendon"  I asked why and he said sometimes it happens with a collapsed scaphoid.  So he tranferred a tendon from my wring finger to my thumb and I'm still in recovery (although I'm doing very well).

I've found a PT who has helped several very active (surfing type) people through wrist fusion and that is a relief.  At least I have non-surgeon who knows surgey person on my side.  He is helping me a lot at this point and I intend to have some type of surgey in Jamuary.

If I create a wrist fusion bulletin board on another web site, how many takers are there out there????  When I had my hip replaced two years ago there were numerous sites I could go to for public information trade, right down to what doc and what hospital are the best.

[LLWB]

My ex husband, who was a roofer , installed wood cedar shake roofs with an electric nail gun. Not sure what it weighed, but not light. After many years doing this, he had a major amount of pain. Upon seeing an orthopedic dr, and having x-rays, it was found that the bones in his wrist died from the jarring impact of the nail gun. So, he had a partial wrist fusion. After 6 weeks in a plaster cast, then 2 months in the velcro dohickey cast, wrist brace, etc. he was back to square one. In extreme pain, and unable to use his wrist. So back to surgery for a total wrist fusion. He was very angry  for having the surgeon recommend the partial fusion first, then having to do a total fusion after all. We found out later most partial fusions don't work. Or didn't back then, in 1980. I hope the outcome have improved since then. It took him awhile to figure out how to use his right hand with it fused (he is right handed) but now does 99% of the things he wants to do.Even very fine art work. So even if you have a total fusion, just know that with time and working on it, you will be able to do almost anything you want. Good luck to all here.

[lerrymoe]

hi, just came back 2 hrs ago from the hospital... still kind of hard to type on the keyboard... had my for corner with scaphoid excision on monday.... after the op i had only one day with strong pain; thereafter only mild pain... they had to make a cut in my lower back to take red cells from my iliac creast to use on the wrist, and that is what hurted on the 1st day... now i have a cast on my hand and still it is quite swollen, but my fingers are moving just ok... i have to do as much exercise with my fingers now... will keep you guys posted on the progress.. cheers to all

[lerrymoe]

http://www.medhelp.org/user_groups/members/504

[sozestail]

Hope you are doing well post surgery.  Let us know how you progress.

[sozestail]

I have avascular necrosis of the scaphoid (of course on my dominant hand) and have a terrible doctor (stupid HMO).  Does anyone know if there are things I should or should not be doing?  I am in constant pain and I don't know if I should exercise the wrist and bear the pain or keep it as still as possible and avoid pain.  It just keeps getting worse and worse every day.  If I wear a wrist brace for too long I get a little sore, but if I don't wear one I end up bending or twisting it in a painful way.  Oh what to do.  I just called a specialist to see if I could just speak with him about my condition and with no insurance, it will cost me $230 for a conversation.  There has to be some other way to get advice.  

[shellygarza]

Hello.  I am a new member... and luckily found your discussion, which I am hoping will help me.  I was recently diagnosed with advanced Preiser's disease.  

I am a single mother of 5, so the term "soccer mom" doesn't come close!  I work, chase kids, cook and drive kids all over the place. And, feeling very overwhelmed and scared right now, since I am right handed, and of course it is my right hand that is affected.  

With gardening being my only hobby, since my time is consumed in work and children, I have accepted the fact that I will probably have to give up the digging, planting and mulching.... but it is the active mom role that I am worried about. (and the fact I can't lift a cookie sheet.... nor a pot off the stove)

I am in Houston, and have a great doctor, who has treated several of these cases (which I now know are pretty rare alltogether).  So, that is somewhat of a relief.  However, I would really like to hear of a happy ending.  So, Lerrymoe (or anyone else that has been through this sort of surgery), please pass on your outcome.  I would really appreciate any input, as I am scheduled for surgery on December 21st, My surgical plan is that my doctor planning to perform bone grafts and revascularization.  However, after he starts the procedure, if he feel the odds are not good (based on what he sees, he will then perform a 4 corner fusion.  He says it is 50/50.... so, I will not know the outcome until I wake up.

[joyster]

i have had ma scaphiod broken since 2008 in iraq i was told it was a sprain however in feb 2009 got it xrayed and it was broken i have had a bone graft which unfortuanatly did not work. i have spoke to my orthopedic and i have decided to go for fusion.reasons been its over a yr now i have been lifting doing pressups and weights on the bone and its nae good. with me being in the forces and having to go abroad all the time i have decided to get it done i have been told that some people get all movement and strngh back however some arnt i suppose it all depends on your body how well it heals.the way i look at it there is to options. leave it and live in pain and run the risk of losing all movment or get it done and lose 20 percent i chose 20 percent is better than none  as for the arthritis your going to get it at some point some quicker than others but at the end of the day it doesnt stiop you from getting on woth what you do im going to remain in the forces and progress regardless im nae having a dig at anyone ma heart goes out to you all honestly. But it doesnt matter what people say. if they aint had it done them selves they wont know so go with your instinct then it cant be the wrong decision thats my advice good luck to all

[lerrymoe]

hi joyster, you should definitely stop doing weight lifting and press ups... the more you f'' your wrist up, the worst will be for you, and i assume you need your wrist a lot since your are in the military. My case is that i have a "normal" day job, and therefore this is not such a great deal for me.

here is my experience:

I had the surgery done. The docs convinced me at the end to use the spider plate... anyhow, after almost 1/2 year after the surgery, I must say that I am quite satisfied with the result... definitely I am much better now than before... I have no pain, and my hand is getting stronger by the day. Of course it is not as before, but surely enough to carry on with a normal life. The only things I had to change was mostly regarding sports... I dont do sports anylonger that require a lot of my wrist (eg climbing, rowing, etc), i also wear a splint while doing other kinds of sports... I dont do any sports that press my wrist; I have noticed that this is no good. But I allow myself to do, very carefully and in a very limited manner (only certain movements; very limited weight) some weight lifting. I decided to do that since my arm with my problem wrist was getting too thin, and I was getting a bit asymmetric... Anyhow, the summary is that things are good; hopefully they stay that way or get better...

cheers and I hope you get better!

[Quasarlis]

Hello Lerry. I have had 4 corner fusion surgery in 2007 following a mis-diagnosed displaced Scaphoid fracture as a 15yr old school boy in 1985, it was only brought to light after a mild accident on the same wrist when I was 20, the x-rays found I had 2 old fracture sites,  healed fusion lines on my Trapezium but my Scaphoid was basically in half still with a cist inbetween the 2 halves, the side seperated from the blood supply had died (necrosis). I had 3 attempts made to fix this using bone grafts from my hip and Herbert screw to compress the union site of the fracture .. they thought the 3rd attempt had worked .. but un-knowing to me it didnt, I thought the pain, stiffness I was suffering was a result of the surgery and my trade as a plasterer and hobby as a drummer. It was in 2004 when plastering a ceiling my wrist colapsed in, my Scaphiod basically crumbled, the pin was loose in my wrist cavity .. so on and so fourth. I had to have a 4 corner fusion done which is a Scaphoid removal and the fusion of bones in the wrist to compensate, also a lot of nerve work and ligament repair .... what basically happens is that they cause fractures across the 4 top bones in the wrist and fuse them together with pins and a spider wheel .. I'm not sure if you will need ligament and nerve work done but be prepared, I was in plaster for 10 weeks not six and my arm was black from my elbow down to my finger tips I kid you not!! Its one thing breaking a bone but its a totally different ball game when a surgeon has taken a drill, screw driver, screws and saw to them. The pain management was good though, a nerve block in your arm pit lasts for about 3 days but the paracetamol they give you is useless .. to be honest I would say put up with it how it is as mine is now weak and painful. I have lost about 40% of its movement, my right hand is noticabley smaller than my Ieft and the motor funtions of my fingers say during writing causes me severe pain ... I regulary have to take full strength C-codamol 500mg Paracetamol-30mg Codiene Phosphate to eleviate the pain.

I wish you the best of luck Lerry.

[mnechy]

At the end of this month I will be getting the 4 corner fusion and scaphoid excision due to an injury from Iraq back in 2005.  I'll be getting the k-wires instead of the spider plate though.  Now that it's been at least 6 months from your surgery, how is your wrist holding up?  Still happy?