RHEUMATOID ARTHRITIS OF WRIST
Rheumatoid arthritis is a chronic inflammatory condition involving the synovium of joints and tendons. The hand and wrist are commonly affected by this condition. The radiocarpal joint initially demonstrates painful synovitis that progresses to cartilage degeneration, ligamentous laxity, and osseous destruction. The common deformities at the wrist consist of carpal supination, volar subluxation, and ulnar translocation. The DRUJ is also frequently involved with synovitis, instability, and eventual dorsal subluxation/dislocation of the distal ulna. Extensor tenosynovitis is another common presentation and often seen in conjunction with joint involvement. These deformities can also have significant impact on the joints proximal and distal to the wrist.
Clinical examination of the wrist reveals diffuse thickening, prominence of the ulnar head, extensor tenosynovitis, and possible extensor tendon lag. Extensor tenosynovitis can often be differentiated from radiocarpal synovitis by movement of the swelling with digital motion, palpation of the boundaries of the swelling, and a “dumbbell” shape to the swelling as the tenosynovium travels beneath the extensor retinaculm with swelling both proximal and distal.
Nonoperative treatment consists of medical management by the rheumatologist and selective use of splints to control symptoms. Hand therapy is critical and involves a systematic approach including education, activity modification, gentle exercise, and splinting for comfort. Failure of nonoperative treatment is often defined as failure of at least 6 months of appropriate medical management and/or progression of disease with impending or actual tendon rupture.
Surgical intervention is based on the stage and severity of the disease. Realistic goals and expectations must be discussed, with the primary goals always being to relieve pain, restore function, and halt the progress of further destruction. Patients with extensor tenosynovitis and/or radiocarpal/distal radioulnar synovitis can be considered for synovectomy. These patients must be free of articular and bony destruction and should have failed at least 6 months of medical management. Synovectomy can greatly diminish the risk of extensor tendon rupture and can slow the process of articular/ bony destruction. Patients presenting with caput ulna (dorsal subluxation of the ulnar head) and/or pending/ actual extensor tendon rupture are managed with extensor tenosynovectomy, distal ulna excision, and tendon reconstruction (single or multiple tendon transfers). Articular destruction requires either limited versus total wrist arthrodesis or arthroplasty.