Wrist denervation: surgical decision-making and technical considerations

Wrist pain, secondary to trauma or degeneration, impacts an increasing number of individuals, resulting in reduced function, psychosocial impact and an associated socioeconomic cost. Wrist denervation is a motion-preserving surgical option in the management of chronic wrist pain. It relies on an understanding of wrist anatomy to selectively disconnect distal radio-ulnar and carpal articular branches of the median, radial and, or without, ulnar nerves. Several surgical variations have been described and the reasons for our preferred method is outlined here. Surgical indications include following scaphoid trauma, Kienbock's disease, inflammatory arthritis, ulnocarpal abutment and occupation-associated vibration hand syndrome. Appropriate patient selection relies on a detailed history and evaluation. Preoperative local anaesthetic may be administered in clinic to simulate and predict surgical outcomes. Both partial and total denervation results in improvement of objectively measured grip strength and pain scales, and this is reflected by the high return to work rate postoperatively. The duration of relief is variable and the surgery does not influence disease progression, so patients should be counselled that further, function limiting surgeries may be required. Postoperative complications include recurrence, scar tenderness and rarely neuroma. Partial neurectomy can be performed alongside other motion-preserving surgical interventions and it may delay or obviate the need for function-reducing surgeries. As such it is a key tool in the wrist surgeon's armamentarium.