Arthrodesjs

AN EVALUATION

of the Rheumatoid
OF SIXTY PATIENTS SURGICAL TECHNIQUE

Wrist

AND A DESCRIPTION

OF A DIFFERENT BY LEWIS H. MILLENDER, MD.*,

AND EDWARD A. NALEBUFF,

M.D.*,

BOSTON, MASSACHUSETTS

From the Department ofOrthopaedic Surgery, Robert Breck Brigha@n Hospital and Harvard Medical School, Boston
ABSTRACT: In a series of sixty patients (seventy arthrodeses) a technique was

developed in which freshened bone surfaces of the carpus and radius were coapted and immobilized by an iniramedullary pin, supplemented as needed by staples or a Kirschner wire. Fusion was successful in all but two patients and all patients benefited by increased strength and function in the hand. The advantages of the op eration are: short operating time, so that other procedures can be done concomitantly, and a short recuperation time, so that activity, such as walking with crutches, is not lost. It is generally accepted that involvement of the wrist in rheumatoid arthritis significantly affects function of the hand @ wrist not only is the key joint for 14 The positioning the hand , also is important in acts of strength and dexterity. Dam but age to the wrist joint is common in rheumatoid arthritis. In 2.7 per cent of a large group of patients with rheumatoid arthritis the initial involvement was in the wrist. In addition, 95 per cent of these patients eventually had bilateral wrist involve ment 15 No standard treatment for the pain, subluxation, and deformity present in wrists affected by rheumatoid arthritis has been established, and no general agree ment exists regarding the indications for wrist fusion in the rheumatoid patient. Whereas Carroll and Dick, Dupont and Vainio, Mannerfelt and Malmsten, and Clayton showed that it can give good results, Swanson, Straub and Ranawat, Albright and Chase, and Lipscomb recommended various types of arthroplasty to alleviate the pain without sacrificing motion. Very few reports are available regarding the functional results of wrist fusion in rheumatoid arthritis. This paper has three purposes: ( I ) to describe a modification of the surgical procedure for wrist fusion which Clayton and Mannerfelt and Malmsten described,
(2) to evaluate the effect of various degrees of involvement of the wrist on the func

tion of the hand, and (3) to report on the long-term follow-up of sixty patients who have undergone wrist fusion. Based on these findings, we will state our present mdi cations for wrist fusion in the patient with rheumatoid arthritis. Surgical Procedure
Technique

The operation is performed through a gently curving dorsal incision, which avoids the sensory branches of the radial and ulnar nerves. An S-shaped incision is contraindicated because of its tendency to produce necrosis of the skin. A dorsal tenosynovectomy is done and the retinaculum is prepared for relocation as described
* 209 Harvard Street, Brookline, Massachusetts 02146.

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by Clayton and Straub and Ranawat. The radiocarpal joint is then opened by a transverse incision and the capsule is preserved for later closure. The ulna is exposed subperiosteally and approximately two to three centimeters is removed @. is This done to avoid painful rotation and also to prevent impingement of the distal end of the ulna upon the carpus after the fusion is completed. The radio-ulnar capsule and periosteum are carefully preserved for later closure to prevent subluxation of the distal end of the ulna and the possibility of tendon rupture. With traction and mod erate fiexion the radiocarpal joint is exposed and the synovium and soft tissues are removed with a rongeur. The soft tissues are stripped extraperiosteally from the radial styloid process; the abductor pollicis longus and extensor pollicis brevis which are located in the first extensor compartment are retained intact. The styloid process may be excised in order to form a flat surface over the distal end of the radius so that there is a larger area of contact with the carpus. The cartilage and sclerotic bone are rongeured from the distal end of the radius and the proximal carpal row in such

a way as to ensure proper fit and alignment. The medullary canal of the radius is
entered with a pointed awl and the size ofthe cavity is gauged. The largest size Stein mann pin that the medullary canal will accommodate is then carefully drilled through the carpus to exit between the second and third or between the third and fourth metacarpals depending on the alignment needed between the freshened sur faces of the carpus and radius. The pin is then tapped into the radius and counter sunk into the intermetacarpal space. Carefully tapping, instead of drilling, the rod
into the radius will prevent perforation of the cortex of the radius by the rod. Bone

chips from the resectedsegmentof the ulna are packed into any gaps between the
@ bones and the capsule is closed. Recently one or two staples have been used to span the radiocarpal joint and to give additional internal fixation.
In a few wrists in which there was marked carpal destruction and loss of bone

we thought that the bone stock was inadequate to maintain firm internal fixation and we supplemented the Steinmann pin fixation with a medium-size Kirschner wire

which was driven into the radius and fixed into the fourth or fifth metacarpal (Fig.
I -B). This pin was buried subcutaneously and later was removed. In these cases the patient had to wear a short splint for approximately eight to ten weeks until there

was evidenceof fusion.

This method of fusion of the wrist dictated that the radiocarpal joint be fused in a neutral position in regard to flexion and extension. However, by adjustment of

the osteotomy planes and the direction of the Steinmann pin, one can vary the de
gree of flexion or extension of the wrist by approximately matoid patients.
Adjutant Operations

5 or I0 degrees. However,

the neutral position has been found to be quite satisfactory for function in the rheu

After the fusion is completed, any ruptures of extensor tendons should be re paired. In our sixty patients there were fourteen with ruptures of tendons. Four of them had marked carpal destruction with dislocation of the wrist and multiple rup tures of finger and wrist extensor tendons. Complete wrist dislocation (Fig. I -A) is

commonly associatedwith multiple wrist and extensor tendon ruptures. Three of the
remaining ten patients had triple ruptures ofdigital extensor tendons and seven had either single or double ruptures of those tendons. In the seven patients repair was carried out either by a side-to-side anastomosis or by extensor indicis proprius transfer. The results from these procedures were quite good and the patient's range of motion in the affected finger or fingers postoperatively was comparable with that in patients without wrist fusion who had the same procedure. In two of the three patients with triple ruptures, transfer of the flexor digitorum superficialis was done
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with the flexor digitorum superficialis rerouted subcutaneously around the radial border of the forearm and sutured to the ruptured tendon at the level of the wrist joint. In both of these patients adhesions at the anastornosis site plus the lack of tenodesisbecauseof the fusion prevented a good range of metacarpophalangealjoint motion. When a transfer of the flexor digitoruni superficialis is needed in association
with the fusion, we now do it in two stages. Approximately eight to ten weeks after

the wrist fusion, the transfer is done. The tendon is sectioned in the digit, rerouted subcutaneously around the forearni bones, and sutured to the extensor Illechanisni at the level of the nietacarpophalangeal joint. This enables one to avoid operating in the scarred area of the fused wrist.

FIG. I-A

FIG. I-B extensor tendon ruptures. Kirschner wire fixed into

Fig. I-A: Dislocated wrist associated with multiple wrist and digital Fig. I-B: Postoperative roentgenogram shows use of supplemental radius and metacarpal in cases of marked carpal destruction.

Two patients with multiple ruptures also had dislocated irietacarpophalangeal joints. In these patients the wrist fusion was done as the first stage of a two-stage procedure. The second stage consisted of arthroplasty of the nietacarpophalangeal joints and, simultaneously, transfer of the tendons of the flexor digitorum super ficialis from the long and ring fingers to the extensor mechanism at the level of the metacarpophalangealjoint. This combined procedure in these difficult casesresulted
in approximately 40 degrees of motion of the metacarpophalangeal joint. The func

tional result was good because the motion was associated with a stable wrist and pai n-free, well aligned metacarpophalangeal joints. In three patients the goals of surgery were limited because of severe deforniities
of the hand with dislocated wrists and multiple ruptures of extensor tendons as

sociated with destruction and dislocation of the metacarpophalangeal joints (Fig. I -A). Fusion of the wrist was carried out and the one remaining extensor tendon of
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the wrist was transferred to the digital extensors. In these severely deformed hands, the alignment of the wrist and digits allowed the patients to use the hand for simple tasks. After Care After the tendon transfers were carried out, the dorsal retinaculum was su tured a 16 underneath the extensor tendons. We then released the tourniquet to con trol bleeding and reinflated it for closure. A Penrose drain was then brought through a stab wound proximally. Postoperatively a bulky dressing and volar splint were applied and the arm was elevated. Early finger motion was encouraged and, for the occasional patient who had difficulty regaining active finger extension, a dynamic splint was applied. If tendon transfers were done at the time of wrist fusion, the digits had to be immobilized for approximately three and a half weeks. After the sutures were removed, the patient wore a short volar splint which could be removed for bathing. The splint was discarded in approximately four weeks. Patients who could use platform crutches did so one week postoperatively. The Steinmann pins were not removed routinely, but if they caused discomfort, they could be removed four months after the procedure was done or at the time of any additional procedure such as nietacarpophalangeal joint arthroplasty. Indications and Contraindications One of the important advantages of this method of wrist fusion is its simplicity and speed, which allow additional surgical procedures to be done at the same opera tive session. The operative time for the wrist fusion in our hands has been less than one hour, and the sixty patients evaluated, twenty-four had additional, con
comitant procedures carried out on the same extremity. These included: fusion of the

distal interphalangeal joints, three patients; arthroplasty of the metacarpophalangeal joints in two digits, one patient; fusion of the metacarpophalangeal joint thumb, six patients; fusion of the interphalangeal joint of the thumb, five patients; fusion of the proximal interphalangeal joint in one digit, one patient; arthroplasty of the carpometacarpal joint of the thumb, three patients; fusion of the carpometacarpal joint of the thumb, one patient; extensor tenotomy, one patient; and resection of the radial head and synovectomy of the elbow, three patients. Thus, most of the additional procedureswere fusionsofjoints of the thumb or fingers. The one patient who had arthroplasty of the metacarpophalangeal joints of two digits was unable to exercise adequately postoperatively because of pain on attempting to activate the extensor tendons. The result was stiffness and we now do not recommend that arthroplasties of the metacarpophalangeal joint be done at the same time as fusion of the wrist. With our Illethod of fusion of the wrist, both angular deviation and lateral shift of the carpus in relationship to the radius can be corrected. Radial deviation of the
wrist occurs secondary to collapse of the navicular, whereas both ulnar deviation

and lateral shift usually are secondary to subluxation of the distal end of the ulna because of disru ption of the distal radio-ulnarjoi nt and loss of ulnar stabilizing forces. Proper alignment of the wrist is important and if significant radial deviation exists, a reciprocal ulnar deviation of the metacarpophalangeal joints may de velop 13 the case of ulnar deviation of the fingers associated with radial shift of In the carpus, one must align and stabilize the wrist prior to arthroplasty of the meta carpophalangeal joints in order to prevent recurrent ulnar deviation of the meta carpophalangeal joint. Results The sixty patients on whom this report is based had seventy wrist fusions per

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L. H. MILLENDERANDE. A. NALEBUFF

formed between I 968 and 1972, thirteen by other methods than that described. An additional twenty-five patients have had the procedure described previously be tween January and June 1972. Their complications are included in this report but their results are not included in the long-term follow-up evaluation. Forty-seven patients were followed for more than two years. All twenty-five recent patients had the new procedure. All patients were examined by one of the authors to provide the follow-up data. The forty-five female and fifteen male patients with long-term follow-up av eraged forty-eight years in age and had had the disease for an average of I 0.4 years. Two young men, nineteen and twenty years old, had rheumatoid arthritis, one for two and the other for three years. The oldest patient was sixty-nine years old and the longest a patient had had rheumatoid arthritis at the time of fusion was thirty years. All of the patients, except the two youngest, had multiarticular disease, often with severe involvement of the joints. Sixteen patients had received treatment with gold salts and twenty-three of the patients had received steroids. Ten patients were on crutches or were bedridden. Twelve patients had undergone surgery to the hip and twelve to the knee. Fifteen patients had had previous surgery to the hand. As has been pointed out, twenty-four of the patients had additional procedures on the same extremity at the time the wrist was fused. In many patients the wrist fusion was the first of a staged series of operations.

Complications
The following complications occurred. One patient developed a deep wound infection which was cured by dbridement and antibiotics. The Steinmann pin was not removed and solid arthrodesis resulted. In two patients pseudarthrosis developed because of premature removal of the Steinmann pin. Both patients had a painless, stable wrist with approximately I0 to 15 degrees of motion. Twelve patients had distal migration of the pin associated with so much pain that the pin had to be re moved. In four of these the pin had to be removed before the fusion had con solidated and the wrist was then immobilized in a plaster cast. Two of these four pa tients were those in whom pseudarthrosis developed. These complications occurred
before we had begun to countersink the pin and to add the staples. Since these

modifications were devised, we have had no difficulty with pin migration. Slough of the skin occurred in three patients. in two there also was necrosis and slough of the extensor tendons, and impairment of finger function was the result.
Slough of the skin is always a hazard in the rheumatoid patient because he has thin

skin and vasculitis. Slough of skin on the dorsum of the hand and wrist is potentially one of the most serious complications from surgery in those areas because of the pos sibility of involvement of the tendons. Gentle handling of the skin and thorough hemostasis with drainage tubes will reduce the incidence of slough; but if it does oc cur, dbridement, frequent dressing changes, secondary closure or split-thickness skin grafts may be necessary to protect the underlying tendons. We were unable to determine the minimum time necessary for fusion. In pa tients from whom the pin was removed and in thirteen patients who were treated without an intramedullary pin, the average time for fusion was three to four months. The patients with the intramedullary pin were immobilized with a removable splint for an average of six weeks, while the usual immobilization time for all other methods was four to five months in a long or short arm cast. Now that we routinely use the staple, the period of external immobilization has been decreased and presently, if we get firm fixation at the time of surgery, we generally have the patient wear the splint for only two to four weeks.

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Evaluation of the Effect of Involvement of the Wrist on Function of the Hand The indications for arthrodesis in rheumatoid arthritis are deformity, instability, or pain. Although most patients had more than one of these three indications for
fusion, the predominant indications for arthrodesis in the wrists of our patients were

as follows: deformity, ten; instability, twenty-one; and pain alone, thirty-nine. It is well known that deformity and instability of the wrist can affect function of the hand. A flexion contracture or lateral deviation can prevent proper positioning, and in stability, associated with carpal destruction or ruptures of tendons results in both weakness and loss of dexterity. In addition, a painful wrist even with full motion and stability can diminish both strength and dexterity. The effects of the pain on the function of the hand often are not fully appreciated. We have frequently seen pa tients with pain in the wrist who, therefore, were unable to carry out their daily tasks. Sometimes it became apparent that the pain alone even without deformity or instability impairs both the strength and dexterity not only of the wrist but also of the hand. This may be a subtle but important finding, not previously emphasized. We have now observed a number of patients whose only complaint has been weakness of grasp and who, on direct questioning, denied pain in the wrist. These patients demonstrate a good range of motion, absence of spasm, and no instability. On careful examination there may be tenderness to palpation over the radiocarpal joint, pain on wrist compression, and discomfort on stressing the wrist. Roentgenograms will show varying but minor degrees of arthritis of the wrist. When these patients attempt to lift heavy objects, the muscle contractions acting on an inflamed wrist joint elicit pain, and unconsciously the patient relaxes his grip. The patient may then perceive only weakness.

Follow-up
The factors which were considered in follow-up included pain, stability, strength, rotation, functional loss from arthrodesis, and over-all functional results. Because of the many variable and multiple deformities which the sixty patients pre sented, it was impossible to develop a system of evaluation, but nevertheless, a
realistic evaluation could be made by study ofeach patient.

Alleviation of pain was the most striking benefit from the operation. None of the patients had pain in the wrist, although a few complained of discomfort from dorsal subluxation of the ulna. Except for the two patients with pseudarthrosis, none of the patients had pain on stressing the wrist or applying pressure over the fusion site. Stability and strength were uniformly increased and the patients were able to carry heavier objects and lift more than they could preoperatively (Fig. 2). One patient, who was an industrial supply salesman, could lift supplies weighing forty-five to sixty-eight kilograms. A twenty-year-old college student who had a bilateral wrist fusion was able to box. After bilateral wrist fusion in one patient with severe involvement of the lower extremities, he was able to walk with crutches. Prior to wrist fusion this patient was unable to control the crutches because of pain and weakness. Some female patients said that the added strength increased their ability
to do housework. Preoperatively they would carry pots with two hands, while post

operatively they were able to lift them with one hand. In addition to strength and grasp, there was an increase in dexterity. One patient is now able to play a guitar. Another patient is a laboratory technician able to func tion with pipettes and test tubes and another is a dental technician. Several of the patients are now able to type. When the fusion is on the dominant side, some problems may be noted, for ex ample with handwriting or with handling eating utensils. A few patients who had the fusion on their dominant side were initally unhappy with the operation, because
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A, Painful unstable wrist; B, preoperative roentgenogram demonstrates radiocarpal destruc

lion and dislocation; C, postoperative appearance after wrist fusion and arthrodesis of multiple

digits; and D, postoperative roentgenogram mann pin for internal fixation.

demonstrates

arthrodesis

and alignment

using Stein

they felt more clumsy. However, after three to four months they became accustomed
to the fusion and adjusted to the lack of flexion and extension. They then were sat is

fled with the operation. In trying to determine the functional loss we were impressed with the substitu tion patterns which developed. The elbow was used in activities such as combing the hair or dealing cards. Some women had to fasten their bras from the front and some had to alter their way ofwiping the floor or washing windows becauseof lack of dorsiflexion. One woman said that she was now unable to place objects on the top shelf of her closet because she could not flex her wrist. None of the patients thought that the functional impairments were significant. They thought that the increased function due to alleviation of pain and increased strength outweighed any impair ment which resulted from loss of flexion and extension of the wrist. Our method of fusion dictates that the wrist be fused in a neutral or slightly flexed position. All of the patients thought that neutral was a satisfactory position. In a few of the patients treated by other methods, wrists were fused in 10 to 15 de grees of dorsiflexion. We saw no functional difference. Two patients thought their
function would flexion. have been better if their wrists had been placed in slight volar

We carefully questioned the ten patients with bilateral fusions regarding their personal hygiene. One woman with severely involved hands and stiffness in the
proximal interphalangeal joints did have difficulty attending to her personal hygiene

after the fusion. In a patient with marked digital deformity, bilateral wrist fusion may be contraindicated and arthroplasty in one of the wrists might be preferable.
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Discussion The benefits from our modification of the methods of Clayton and Mannerfelt and Malmsten, with stable intramedullary rod fixation, have overcome many tech nical problems. Older techniques of wrist fusion which depend on autogenous iliac-bone grafts and use of an arm cast for long periods postoperatively substantially increase the morbidity, particularly in elderly patients, and prevent patients who need
crutches from walking until the cast is removed. Our method relies on a large Stein

mann pin and staple and the internal fixation is sufficiently firm so that only a re movable volar splint is needed. Crutch patients may walk with platform crutches one week after the procedure. The average operative time is less than one hour. Our
pseudarthrosis rate has not been affected by this method and our two non-unions

can be attributed to premature removal of the Steinmann pin. Clayton introduced the concept of using the Steinmann pin for internal fixation and also advocated either an autogenous iliac bone graft or a sliding bone graft from the radius into the third metacarpal. This large a bone graft apparently is unneces sary. Small grafts of bone from the distal end of the ulna are sufficient to accomplish fusion in the rheumatoid patient as our series has shown.
In the technique of Mannerfelt and Malmsten a Rush rod is introduced into the

shaft of the third metacarpal and is driven into the medullary canal of the radius. This fixation is reinforced by a staple similar to the one we use. The size of the Rush rod is dictated by the diameter of the metacarpal. In female patients or in children the diameter of the metacarpal may be small, and while the rod might fit snugly
within the metacarpal, it tends to be loose in the radius. Moreover, this technique

requires a longer skin incision than ours, with bigger flaps for exposure of the
metacarpal shaft, and is more difficult and more time-consuming than our technique.

There are two advantages to the technique of Mannerfelt and Malmsten. In casesof severe carpal destruction with lossof bone stock, purchaseof the rod in the metacarpal bone will be more firm. However, when firmer fixation is needed in our method, a Kirschner wire may be used, as previously described. A virtue of Manner felt and Malmsten's method is that, because of the flexibility of the Rush rod, it can be bent and the wrist can be fused in different degrees of flexion or extension, if needed. Our use of a rigid Steinmann pin results in fusion of the wrist in a neutral position and we agree with Flatt and Linscheid that this position is preferable to the one of slight dorsiflexion, the position hitherto deemed ideal . Actually most activi ties are carried out with the wrist in neutral. The position of powerslight dorsi flexionis not the usual functional position. Certainly in bilateral cases the neutral position is preferable. Another purpose ofthis paper was to evaluate what disability would result from loss of flexion and extension of the wrist. One would hesitate to advise fusion in pa tients with rheumatoid arthritis in whom there is severe damage to the joint, if there were significant loss of function after the operation. Each of our patients was care fully questioned regarding possible disabilities resulting from our procedure. The patients uniformly described patterns of substitution, and used the elbow and the shoulder in these patterns. The increased strength and the loss of pain and deformity outweighed what slight disability resulted from the loss of motion. Even the patients in whom pain was the only indication for operation, who had good preoperative motion and good stability, thought that their hand function was improved with the painless but fused wrist as compared with a painful wrist with normal motion. Our indications for wrist fusion have broadened since we began this study. Initially we were carrying out fusions mainly in wrists in which there was a gross instability, deformity, and destruction. However, because of this study we now con sider rheumatoid wrist problems in three categories. For the patient with persistent
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L.H.MILLENDER AND E.A.NALEBUFF

pain, whose roentgenograms show minimum cartilage loss and bone destruc

tion, and who does not respond to splinting and occasional cortisone injections, wrist synovectomy without fusion has been helpful. For patients with more advanced, roentgenographic changes, who also may have early subluxation, but who have only minimum pain, splinting and steroid injections are used. However, we now think that early wrist fusion is indicated in patients showing persistent pain in the wrist who derive no relief from splinting, occasional cortisone injection, and physical therapy and whose roentgenograms show loss ofjoint cartilage and early destruction. References
1. ALBRIGHT, J. A.. and CHASE, R. A.: Palmar-Shelf Arthroplasty of the Wrist in Rheumatoid

2. CARROLL, E., and DIcK, H. M.: Arthrodesis of the Wrist for Rheumatoid Arthritis. J. R. Bone and Joint Surg., 53-A: 1365-1369, Oct. 1971.
3. CLAYTON, M. L.: Surgical 4. CRAccHI0L0, Treatment at the Wrist in Rheumatoid Arthritis. A Review Ulna of

Arthritis. A Report of Nine Cases.J. Bone and Joint Surg., 52-A: 896-906, July 1970.

Thirty-Seven Patients. J. Bone and Joint Surg., 47-Al 741-750, June 1965.
ANDREA, III, and MARMOR, LEONARD: Resection of the Wrist of the Distal in Rheumatoid A Surgical in Rheu A J.

matoid Arthritis. Arth. and Rheum., 12: 415-422, 1969.

5. DUPONT, MICHEL, and VAINI0, KAUKO: Arthrodesis 7. HADDAD, R. J., JR., and RI0siAN, D. C.: Arthrodesis Arthritis. Technique.

6. FLATT, . E.: The Care ofthe Rheumatoid Hand. St. Louis, The C. V. Mosby Co., 1963. A Bone and Joint Surg., 49-A: 950-954, July 1967. 8. KESSLER,SIDOR, VAINIO, AUKO: osterior (Dorsal) Synovectomy for Rheumatoid In I and K P
of the Wrist.

Study of 140 Cases. Ann. Chir. et Gynec. Fenn., 57: 513-5 19, 1968.

Jointurg., S 48-A: 1085-1094, 1966. Sept. 9. LINSCHEID, L.: Surgery for Rheumatoid ArthritisTiming and Techniques: The Upper R.
Extremity. J. Bone and Joint Surg, 50-A: 605-613, Apr. 1968. of the Wrist in Rheumatoid Arthritis.

volvement of the Hand and Wrist. A Follow-up Study of Sixty-six Procedures. J. Bone and

10. LIPSCOMB, R: Surgery for Rheumatoid ArthritisTiming and Techniques: Summary. P. J. Bone and Joint Surg., 50-A: 614-617, Apr. 1968.
1 1. MANNERFELT, L., and MALMSTEN, M.: Arthrodesis 1971.

A Technique without External Fixation. ScandinavianJ. Plast. Reconstr. Surg., 5: 124-130, 12. MARTEL, WILLIAM; HAYES, T.; and DUFF, I. F.: The Pattern of Bone Erosion in the Hand J. and Wrist in Rheumatoid Arthritis. Radiology, 84: 204-214, 1965. 664-676, Nov. 1969. 14. RANAWAT, S.; FREIBERGER, H.; JORDAN, R.; and STRAUB, R.: Arthrography in C. R. L. L. the Rheumatoid Wrist Joint. A Preliminary Report. J. Bone and Joint Surg., 51-A: 12691281,ct. O 1969.
I 5. SHORT, C. L.; BAUER, WALTER; and REYNOLDS, W. E.: Rheumatoid 13. PAHLE, J. A., and RAUNIO, PAuLI: The Influence of Wrist Position on Finger Deviation in the Rheumatoid Hand. A Clinical and Radiological Study. J. Bone and Joint Surg., 51-B:

of the Disease and Clinical Description Based on a Numerical Study of 293 Patients and Controls. Cambridge, Harvard University Press, 1957. 16. STRAUB, R., and RANAWAT, S.: The Wrist in Rheumatoid Arthritis. Surgical Treatment L. C. and Results. J. Bone and Joint Surg., 51-A: 1-20,Jan. 1969.
17. SWANSON, W: Personal communication. A.

Arthritis.

A Definition

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