PMC7519977_01
XR of the right hand post open synovectomy and biopsy: AP (a) and lateral (b) views. Erosive arthropathy at the intercarpal joints and carpometacarpal joints, with joint space narrowing within the radiocarpal articulation. Cortical erosion and reduced trabecular markings within the base of the 5th metacarpal and ulnar styloid.
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Follow-up X-ray and MRI of the right hand in April 2018 showed changes favouring acute or chronic rheumatoid arthritis, without joint effusion or drainable collections, while the patient continued to have pain and swelling over the dorsal and increasingly over the volar wrist with associated reduced range of motion (Figure 1).
Clinical photograph of the right hand in between serial surgical debridement and washout. Note the extensive soft tissue damage with exposed extensor tendons.
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The skin overlying the wrist had necrotic, sloughed edges that required progressive debridement, resulting in a large dorsal wrist wound with exposed, residual extensor tendons (Figure 2).
XR of the right hand with voriconazole-impregnated Palacos beads in situ: AP (a) and lateral (b) views. Note the evidence of proximal carpectomy and distal ulnar excision.
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Seven Palacos (nonbiodegradable) cement beads impregnated with 600 mg of voriconazole were inserted in December 2018 during proximal row carpectomy, washout, and debridement (Figure 3).
Clinical photograph of the right hand with external fixation devices in situ.
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External fixation was applied to the now flail right wrist in January 2019 to achieve skeletal stability, and the patient was discharged on oral voriconazole and Terbinafine (Figures 4 and 5).
XR of the right hand with the external fixation device in situ: AP (a) and lateral (b) views. Proximal screws in the midright radius, distal screws in the second metacarpal.
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External fixation was applied to the now flail right wrist in January 2019 to achieve skeletal stability, and the patient was discharged on oral voriconazole and Terbinafine (Figures 4 and 5).
Clinical photograph of the right hand, post wrist fusion.
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At four months post right wrist fusion, the patient remained clinically well and pain-free and had regained some function in relation to the use of the right hand (Figure 6).