Wrist arthritis is not one condition — it's a category. SLAC wrist, SNAC wrist, radiocarpal arthritis, rheumatoid arthritis, post-traumatic changes: each has a distinct pattern of joint involvement. Dr. R. David Graham at Jacksonville Orthopaedic Institute matches the surgical procedure precisely to which joints are arthritic — because the wrong fusion for the wrong pattern produces avoidable complications.
The question that determines the surgical procedure is simple: which joints are arthritic? The answer — established by X-ray, MRI, and clinical evaluation — determines everything else.
Understanding Wrist Arthritis
Wrist arthritis develops through several distinct pathways — each producing a characteristic pattern of joint destruction that guides the surgical plan.
Scapholunate Advanced Collapse — the most common form of wrist arthritis. An untreated or incompletely treated scapholunate ligament tear allows the scaphoid to rotate out of position, creating abnormal loading at the scaphoid fossa of the radius. Arthritis develops in a predictable progression: first at the radioscaphoid joint, then at the capitolunate joint. The lunate fossa typically spares until late stages.
Scaphoid Nonunion Advanced Collapse — the same arthritic cascade as SLAC, but driven by a scaphoid fracture that healed in the wrong position or never healed at all. The malunited or ununited scaphoid creates the same abnormal radioscaphoid loading pattern. The treatment framework — and Dr. Graham's preferred surgical approach — is identical to SLAC wrist.
Arthritis localized to the radiocarpal joint — the articulation between the radius and the proximal carpal row — from any cause. When limited to the scaphoid fossa, treatment mirrors SLAC/SNAC. When both the scaphoid fossa and lunate facet are involved, an RSL fusion that incorporates the lunate-radius articulation is required.
RA produces a diffuse synovial proliferation that destroys multiple joint surfaces simultaneously — typically affecting the radiocarpal joint, the DRUJ, and the midcarpal joints in combination. The destructive pattern is rarely limited enough for partial fusion to be effective. Total wrist fusion is the usual surgical approach; wrist arthroplasty is an option for appropriate candidates who want to preserve motion. Rheumatologist optimization is required before surgery.
Arthritis following wrist fractures — particularly distal radius fractures and scaphoid fractures — or from prior ligament injuries. The pattern of joint involvement depends on which injury occurred and how it healed. Post-traumatic arthritis may affect the radiocarpal joint, the DRUJ, or the midcarpal joint in varying combinations, and the surgical plan is determined by the specific pattern on imaging.
Kienböck's disease — avascular necrosis of the lunate — can progress to secondary wrist arthritis when untreated. The resulting arthritic pattern is addressed with the same framework as other wrist arthritis presentations, matched to which joints have been affected. For detail on Kienböck's disease itself, see the dedicated Kienböck's page. Other causes of wrist arthritis include calcium pyrophosphate deposition (CPPD), psoriatic arthritis, and gout.
The Key Clinical Question
This is the question that determines the surgical procedure. Dr. Graham establishes the answer through X-ray, MRI, and clinical evaluation — then matches the operation precisely to the arthritic pattern.
Radioscaphoid arthritis ± early capitolunate changes. Lunate fossa of the radius spared. Classic SLAC/SNAC progression.
The scaphoid is removed to eliminate the abnormal loading source. The capitate and lunate are fused together, creating a stable reduced-motion midcarpal joint that offloads the damaged scaphoid fossa while preserving some wrist flexion and extension. Dr. Graham does not perform four-corner fusion — capitolunate is his consistent approach.
Isolated scaphoid fossa involvement from any cause (post-traumatic, primary OA, partial SLAC). Lunate facet preserved.
Same procedure as SLAC/SNAC — eliminating the arthritic scaphoid-radius articulation while preserving the intact lunate facet for ongoing radiocarpal contribution to wrist motion.
Arthritis involving both the scaphoid fossa AND the lunate facet of the radius. The entire radiocarpal articulation is affected.
When the lunate facet is arthritic, a capitolunate fusion alone would leave the lunate-radius joint still loaded and painful. RSL fusion incorporates the radius, scaphoid, and lunate into a single fusion construct — eliminating both arthritic radiocarpal articulations. Some wrist motion is preserved through the midcarpal joint.
Diffuse synovial destruction affecting radiocarpal, midcarpal, and DRUJ simultaneously. Pan-carpal disease pattern typical.
The diffuse joint destruction of RA rarely leaves enough viable joint surface for a partial fusion to be effective. Total wrist fusion is Dr. Graham's preferred approach for RA. Wrist arthroplasty is offered to RA patients who want to preserve motion — and to selected patients who have failed partial fusion, failed a PRC, or who want to reserve motion before committing to total fusion.
Non-Surgical Management
Dr. Graham performs corticosteroid injections before considering surgery for wrist arthritis. Many patients manage effectively with periodic injections for months or years. PRP is always an option alongside cortisone.
A targeted cortisone injection into the affected wrist compartment — radiocarpal, midcarpal, or DRUJ depending on where arthritis is causing symptoms — significantly reduces inflammatory pain and swelling. Injections are performed before any surgical discussion to establish whether adequate relief is achievable non-operatively, and to confirm the joint responsible for the patient's primary pain complaint.
Some patients achieve months of relief from a single injection and return on their own schedule as needed. Others find that the relief window narrows over time — which becomes a meaningful part of the surgical timing conversation. Either way, Dr. Graham does not proceed to surgery without first giving injection management a genuine trial.
Platelet-Rich Plasma is available for wrist arthritis patients who want a biologically targeted approach alongside or instead of cortisone. PRP delivers concentrated growth factors into the arthritic joint, targeting the inflammatory and degenerative processes rather than simply suppressing them. It is relevant for early-to-moderate arthritis where meaningful cartilage remains, and as an adjunct to maintain functional joint quality in patients managing their arthritis non-operatively.
PRP does not reverse established joint destruction — but for patients on the earlier end of the arthritic spectrum, it can meaningfully extend the non-operative window. Dr. Graham discusses PRP candidacy at every wrist arthritis evaluation. PRP is cash-pay and not covered by insurance.
Regenerative Option
Wrist arthritis — regardless of its cause — involves progressive cartilage loss driven by an inflammatory environment that accelerates joint destruction. Standard cortisone injections are effective at interrupting that inflammatory cycle but don't address the underlying biology of the arthritic joint. PRP delivers a different biological signal — concentrated platelets and growth factors that modulate the joint environment more directly.
For wrist arthritis, PRP is most relevant in the earlier stages — SLAC Stage I or II, early radiocarpal arthritis, or RA patients with active inflammation alongside structural change — where meaningful cartilage surface remains and the biological environment is still responsive. In advanced end-stage arthritis where the joint surfaces are entirely gone, PRP has less to offer.
In Dr. Graham's practice, PRP is always discussed as an option and offered to any wrist arthritis patient who wants to explore it. It fits naturally into the management sequence — either as a complement to periodic cortisone or as the primary injection approach for patients who want to minimize steroid exposure. The candidacy conversation happens at your appointment, where the specific pattern and severity of arthritis can be assessed.
Surgical Treatment
Each procedure below corresponds to a specific arthritic pattern. Getting that match right is the difference between a wrist that works better and one that doesn't improve.
Dr. Graham's preferred partial wrist fusion. The scaphoid — the bone that initiates the arthritic cascade in both SLAC and SNAC wrist — is removed. The capitate and lunate are then fused together, redirecting wrist loading through the intact lunate fossa of the radius. This eliminates the arthritic radioscaphoid joint, preserves the healthy radiolunate articulation, and maintains a functional — though reduced — arc of wrist motion. He does not add the triquetrum and hamate to make a four-corner fusion; capitolunate fusion is his consistent approach.
Performed at Baptist Beaches Hospital or Horizon Surgery Center as a same-day outpatient procedure under regional block ± general anesthesia. Tourniquet applied. Operative time approximately 90 to 120 minutes.
A longitudinal dorsal incision exposes the carpus through the extensor retinaculum. The articular surfaces of the affected joints are inspected directly to confirm the arthritic pattern matches the preoperative imaging — and specifically to confirm that the lunate fossa of the radius is preserved and suitable for continued radiocarpal articulation.
The scaphoid is excised in its entirety, removing the arthritic bone and eliminating its abnormal loading contribution to the radioscaphoid joint. Care is taken to preserve the surrounding soft tissue envelope and to protect the radial artery and its branches during the excision.
The cartilage surfaces of the capitate and lunate are denuded down to cancellous bone, and the bones are positioned in their optimal alignment. Bone graft — typically from the excised scaphoid itself — is packed into the fusion site. Internal fixation (headless compression screws or staples) holds the construct while bone consolidation occurs over 8 to 12 weeks.
The wound is closed in layers and a short-arm splint is applied. The patient goes home the same day. Formal hand therapy begins after the fusion heals — typically 8 to 12 weeks post-operatively — with progressive wrist motion and strengthening exercises.
When arthritis has extended to involve the lunate facet of the radius — not just the scaphoid fossa — a capitolunate fusion alone would leave the damaged radiolunate articulation still loaded and painful. RSL fusion addresses this by incorporating the radius, scaphoid, and lunate into a single fusion construct, eliminating both arthritic radiocarpal articulations simultaneously. Some wrist motion is preserved through the midcarpal joint (capitate-lunate and capitate-hamate articulations), which remains free.
RSL fusion is indicated specifically when imaging confirms arthritis of the lunate facet, not just the scaphoid fossa. Dr. Graham confirms this on preoperative CT or MRI and verifies under direct visualization intraoperatively before committing to the larger fusion construct.
The radius, scaphoid, and lunate are all incorporated into the fusion. Their cartilage surfaces are denuded and bone-grafted. Internal fixation spans the radiocarpal joint, locking all three bones into a solid construct. The midcarpal joint is left completely free, allowing residual wrist motion through that level.
RSL fusion eliminates all radiocarpal motion but preserves midcarpal motion — typically producing 30–50% of normal wrist flexion-extension through the free midcarpal joint. This is less motion than after a capitolunate fusion, but significantly better than a total wrist fusion, and is adequate for most daily activities.
Total wrist fusion fuses the radius, all carpal bones, and typically the third metacarpal into a single rigid construct. No wrist motion remains. In exchange, the patient gets a permanently stable, pain-free wrist that can bear load without restriction. This is Dr. Graham's preferred approach for rheumatoid arthritis, where the diffuse joint destruction pattern leaves insufficient viable joint surface for partial fusion. Forearm rotation (pronation and supination) is preserved because the DRUJ is not included in the fusion.
Before surgery in any patient with rheumatoid or other inflammatory arthritis, Dr. Graham requires coordination with the patient's rheumatologist. Disease-modifying medications — particularly biologics like TNF inhibitors — may need to be held perioperatively to reduce the risk of wound healing complications and infection. The rheumatologist manages the timing of medication holds and restarts.
Systemic disease activity, bone quality, and nutritional status must all be optimized before wrist reconstruction in RA patients. Operating on an RA patient with poorly controlled disease or on active biologic therapy without appropriate perioperative management significantly increases surgical risk. Dr. Graham coordinates closely with the referring rheumatologist throughout.
When fusion is not the right answer — or not yet — wrist arthroplasty replaces the arthritic joint surfaces with a prosthetic implant, preserving wrist motion while eliminating pain. Dr. Graham considers arthroplasty for four groups of patients: those with rheumatoid arthritis who want to preserve motion; patients who have failed a prior proximal row carpectomy (PRC); patients who want a motion-preserving option before committing to total wrist fusion; and patients who have failed a prior partial wrist fusion.
Full procedure detail, implant options, and recovery on the dedicated page.
Surgical technique, candidacy in depth, what to expect postoperatively, and Dr. Graham's experience with revision arthroplasty — all covered in full.
Recovery
Recovery varies significantly by procedure. All wrist arthritis operations are outpatient — patients go home the same day — but fusion healing requires patience, and formal hand therapy is essential for arthroplasty outcomes.
Short-arm splint or cast protecting the fusion while bone consolidation occurs. Finger motion encouraged throughout to prevent stiffness. No wrist motion yet.
CT scan confirms bone healing across the fusion site. Once solid fusion is confirmed, immobilization is discontinued and therapy begins to restore wrist motion and grip strength.
Wrist motion and grip strength recover progressively over 3 to 6 months through hand therapy. Final motion — typically 50–70% of normal for capitolunate fusion — is established by 6 months.
In Dr. Graham's experience, most patients return to full work and activity — including manual labor — by 6 months after partial wrist fusion, with a wrist that is durable and pain-free indefinitely.
A longer immobilization period than partial fusion due to the larger construct and the need to include the metacarpal base in the fusion. Fingers are kept mobile throughout.
After confirmed fusion healing, grip strengthening and forearm rotation restoration through therapy. Wrist motion is permanently eliminated; compensation through shoulder and elbow begins to feel natural.
Most patients with total wrist fusion are fully functional — including lifting, carrying, and manual work — by 6 months. The fused wrist is their strongest wrist in years: stable, pain-free, and load-bearing.
"Dr. Graham explained exactly which part of my wrist was arthritic and why that determined the specific procedure he recommended. I walked out of that appointment understanding my wrist better than I ever had — and trusting completely that we had the right plan."
Pamela Schauben · Wrist Surgery · Verified Google Review ★ 5/5
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