Treatment Options for Failed Wrist Fusion with Broken Plate in 89-Year-Old
In an 89-year-old with a broken wrist fusion plate causing extensor tendon irritation and intermittent swelling, the primary treatment should be plate removal with or without revision fusion, prioritizing quality of life and symptom relief over achieving solid fusion in this elderly patient.
Clinical Assessment and Diagnosis
The broken plate is likely causing mechanical irritation of the extensor tendons, particularly affecting the fourth dorsal compartment (extensor digitorum communis to the middle finger). The intermittent swelling suggests ongoing inflammation from hardware irritation 1, 2.
Initial Imaging Workup
Obtain 3-view wrist radiographs (PA, lateral, oblique) to assess:
- Plate position and fracture pattern
- Degree of fusion achieved
- Bone quality and stock
- Carpal alignment 3
Consider CT without IV contrast if radiographs are equivocal regarding:
- Extent of bony union
- Precise location of plate failure
- Preoperative planning for hardware removal 3
MRI without IV contrast or ultrasound if extensor tendon pathology needs confirmation:
Treatment Algorithm
Primary Recommendation: Hardware Removal
Remove the broken plate to eliminate the mechanical source of tendon irritation and swelling. This addresses the immediate quality-of-life issue in this elderly patient 1, 2.
Intraoperative assessment is critical:
- Inspect extensor tendons for attrition or partial tears
- If tendon damage is present, perform debridement and repair as needed
- Consider extensor retinaculum plasty (Kapandji technique) if fourth compartment stenosis is identified - this enlarges the compartment while preserving pulley function 1
Decision Point: Revision Fusion vs. Conservative Management
If wrist is stable and minimally symptomatic after plate removal:
- Accept fibrous union or partial fusion
- Immobilize in short-arm cast for 4-6 weeks
- Begin active finger motion exercises immediately to prevent stiffness 5
- Home exercise program is sufficient for this age group 5
If wrist remains unstable and painful:
- Consider revision fusion with alternative fixation (intramedullary rod or different plate configuration)
- However, at age 89, prioritize pain relief and function over achieving solid fusion 6, 7
- Rod fixation may be preferable to plate in elderly patients with poor bone quality 6
Specific Management Considerations
Extensor Tendon Management
If middle finger extension deficit persists after hardware removal:
- Synovectomy of fourth compartment
- Tendon debridement or repair if attritional damage present
- Z-plasty of extensor retinaculum to prevent recurrent stenosis 1, 2
Postoperative Protocol
- Immediate active finger motion - critical to prevent stiffness, which is more disabling than wrist stiffness in elderly patients 5
- Short-arm splint for comfort, removable for exercises
- No routine early wrist motion needed if stable 5
- Home exercise program adequate; supervised therapy only if complications develop 5
Common Pitfalls to Avoid
Do not leave symptomatic broken hardware in place - it will continue causing tendon irritation and potential rupture 1, 2
Do not pursue aggressive revision fusion in this age group unless absolutely necessary - the morbidity of prolonged immobilization and surgical complications outweighs benefits 6, 7
Do not neglect finger motion - hand stiffness is more functionally disabling than wrist stiffness and extremely difficult to treat after it develops 5
Assess for carpal tunnel syndrome preoperatively - may become symptomatic or remain problematic after revision surgery 6
Expected Outcomes
With hardware removal and appropriate tendon management:
- Pain relief is predictable 6, 7
- Wrist extension typically improves 20-30° if tendon decompression performed 1
- Grip strength modestly improves 1
- Patient satisfaction is high when pain is relieved, even without perfect fusion 6, 7
The goal in this 89-year-old is pain-free function for activities of daily living, not anatomic perfection 6, 7.