One of the many options for the treatment of chronic wrist
pain is wrist denervation. (Michael W. Grafe,
MD, Paul D. Kim, MD, Melvin P. Rosenwasser, MD, Robert J. Strauch, MD, New
York, NY, Wrist Denervation and the Anterior Interosseous Nerve: Anatomic
Considerations, J Hand Surg 2005;30A:1221–1225.)
wrist denervation resulted in improvement in two thirds of chronic wrist pain
in patients with degenerative arthritis. (Long-Term
Follow-Up Evaluation of Denervation of the Wrist Andreas Schweizer et al,J Hand
Surg 2006;31A:559–564. )
In 2002 Weinstein and Berger8 reported
encouraging results with partial denervation of the wrist via a single dorsal
incision by resection of the distal PIN and AIN.( Weinstein LP, Berger RA. Analgesic benefit, functional outcome,
and patient satisfaction after partial wrist denervation. J Hand Surg
number of studies have shown that partial neurectomies are inconsistent in
their effectiveness in relieving chronic wrist pain compared to total wrist
denervation. (Dellon AL. Partial dorsal wrist
denervation: resection of the distal posterior interosseous nerve. J Hand Surg
Partial neuroctomy may
be an effective alternative to wrist salvage. (Anterior and Posterior Interosseous Neurectomy for
the Treatment of Chronic Dynamic Instability of the Wrist Eric P. Hofmeister et
al, Hand. 2006 Dec; 1(2): 63–70.)
In 1998, Berger described a single dorsal
incision to perform a denervation of the anterior and posterior interosseous
nerves. Berger reported that 76% of chronic wrist pain patients with
degenerative arthritis improved their pain rating, and grip strength. )Berger RA. Partial denervation of the wrist: a new approach. Tech Hand
Up Extrem Surg 1998;2:25–35.(
Aim of this study was to determine the results of posterior
interosseous neurectomy, with four corner fusion, in patients with chronic
wrist pain secondary to SNAC wrist.
Patients and Methods
2014 and January 2017, all patients at Alzhraa university hospital with SNAC
wrist were enrolled into a prospective study, and had undergone the PIN
search on 30 patients 22 men (22 wrists) and 8 women (8 wrists). The dominant
hand was involved in 25 patients (25 Right handed), nondominant in 5, and
bilateral in two. The gender breakdown was 26 males and 4 females. The average
age at the time of the surgery was 35 years (range; 18–50 y), the average
follow-up period was 18monthes (range; 12m –30m).
average duration of wrist pain prior to our evaluation was 3.5 years (range: 6
months–10 years). The location of the pain was central in 20 wrists and radial
in 10 wrists. The mechanism of injury was reported all patients had wrist
injuries resulting after a fall on the outstretched hand, 22 patients diagnosed
as a fracture scaphoid and casting for long time, and 8 cases were missed. All
patients underwent trials of nonsteroidal anti-inflammatory medications and/or
splints to alleviate their pain.
diagnosis for the surgery was degenerative changes caused by scaphoid nonunion
advanced collapse wrist in 20 patients, and 10 cases with scaphoid nonunion. 22
patients had occupations requiring heavy use of their hands (manual workers),
while the remaining had minimal activities.
patients with SNAC wrist underwent a detailed history, a systematic physical
examination of bilateral wrists, and radiographs. All patients with SNAC wrist
underwent a scaphoid excision, four corner fusion and PIN neurectomy through
dorsal approach. Patients with scaphoid nonunion underwent open reduction and
iliac one graft. Preoperatively, all patients completed the Disabilities of the
Arm, Shoulder and Hand outcomes questionnaire (DASH).
cases managed by scaphoid excision and four corner fusion and fixation were
done by K. wires. The PIN was exposed on
the floor of the fourth compartment (fig 1). A 1-cm portion of the PIN was removed.
The skin was closed with sutures, and a hand dressing with a short arm cast was
applied for 6-8 weeks, and sutures were removed after 15 days. In cases with
scaphoid nonunion managed through volar approach to scaphoid, open reduction,
iliac one grafting and fixation by Herbert screw, and separate dorsal approach
for posterior interosseous neurectomy (fig 2). At the end of 6 weeks of
immobilization, a ROM protocol and strengthening program was initiated. (Wilhelm A. Zur Innervation der Gelenke der oberen
Extremität.Z Anat Entwicklungsgesch 1958; 120:331–371.
A. Denervation of the wrist. Hefte Unfallheilkd1965; 81:109 –114.
Buck-Gramcko D. Denervation of the wrist joint. J Hand Surg 1977; 2A:254–261.)
Fig 1: The
PIN was exposed on the floor of the fourth compartment
Fig 2: separate
dorsal approach for posterior interosseous neurectomy
were examined for grip strength, ROM, and Each patient rated his pain relief on
a 100-point scale and completed a DASH outcomes questionnaire. All patients
asked if they satisfied by the procedure.
examination of bilateral wrists, and radiographs were done at each follow-up.
The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire (Arabic forum) fill out by the patient, restriction of occupational and daily activities. Patients were asked about the postoperative improvement of pain during follow-up evaluation, the pain relief were little or worse. They asked if they were able to return to their occupations or had to change their occupations.
were analyzed to find any correlation between preoperative and postoperative
follow-up. Preoperative and postoperative motions, grip strengths, and DASH
scores were compared.
30 patients enrolled into this study the
chronic wrist pain registry during the follow-up period, 30 patients with 30 involved
wrists underwent a PIN neurectomy for relief of pain.
neurectomies were performed concurrently with the wrist main surgery. There
were no perioperative complications related to PIN neurectomy.
ROM and grip strength at an average of 18 months (range: 12–30 months)
follow-up. Differences in ROM from preoperative measures were not statistically
significant (p = 0.413). (Table 1)
Table 1: Pre and postoperative wrist range of motion and