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.
