Characteristics of arthritis of the hand

True arthritis in the hand manifests as swelling over the wrist and the metacarpal phalangeal joint (the knuckles of the hand) with deformity of the fingers as they drift away from the thumb.

Types

Similar conditions

Incidence and risk factors

The hand is one of the most likely areas for rheumatoid arthritis to cause symptoms.

Diagnosis

Clinical examination and X-rays provide most of the useful information regarding the diagnosis and treatment for rheumatoid arthritis of the hand.

Medications

Medications have made a major impact in the severity of the symptoms of rheumatoid arthritis. The use of methrotrexate has dramatically slowed the rate of deformity in the hand.

Exercises

Exercises can help maintain the strength and dexterity of the hand. Night splints can be helpful to decrease the progression of deformity of the hand.

Possible benefits of hand surgery

Surgery can be extremely helpful in decreasing the rate of tendon ruptures, particularly when swelling has developed in the wrist. When pain and deformity develop in the fingers, surgery can be helpful in relieving pain and correcting the deformity.

Who should consider hand surgery?

Patients who have had persistent swelling over the wrist despite medical treatment should consider having a removal of the diseased tissue. Patients with progressive deformity or increasing symptoms of pain involving the fingers or wrist also should consider surgery if the symptoms have progressed despite appropriate medical treatment.

What happens without surgery?

Once the deformity in the fingers become so severe it becomes very difficult to restore function with joint replacements. Patients with persistent swelling due to their synovitis will have tendon ruptures. Tendon ruptures result in loss of hand function, particularly in loss of the ability to extend the fingers.

Surgical options

Synovectomy with removal of the diseased tissue from the wrist joint region can be very helpful in preventing tendon ruptures. When tendons have ruptured, tendon transfers can be done to balance the hand and restore function. When there are painful joints involving either the wrist or fingers, joint replacement can help relieve pain and restore function.

Effectiveness

The surgeries can permanently improve function of the hand and prevent significant complications such as tendon ruptures.

Urgency

The most urgently needed procedures occur in patients with persistent swelling about the wrist and imminent tendon rupture. Patients with rapidly progressing deformity also should be considered for urgent surgery.

Risks

Complications are rate but can include wound infections, particularly in patients on high doses of steroids and delayed healing. When fusions are performed to stabilize joints, delayed healing can occur especially with patients with marked bone loss due to steroid use or serious bone destruction from the disease.

Managing risk

Treatment of wound infections with intravenous antibiotics can resolve most problems, and careful therapy programs can help to protect the joints and prevent excessive stress on the sites of the surgical incisions.

Costs

Our patient care coordinators can provide rough estimates of the surgical costs. More exact estimates are performed by matching the patient's diagnosis and surgical procedure with that of a patient with a similar diagnosis and surgical procedures to more carefully estimate the total cost of anesthetic, hospital care, therapy, etc.

Surgical team

The procedure should be performed by a board certified hand surgeon in a setting of a medical facility that has trained staff who regularly deal with patients who have rheumatoid arthritis to manage the special needs in terms of anesthetics, medications, and medical consultations.

Finding an experienced surgeon

The faculty page on this web site has information on the board certified hand surgeons affiliated with the University of Washington. In addition, the American Society for Surgery of the Hand maintains a directory of hand surgeons with the certification nationwide.

Facilities

The procedure is usually performed in operating rooms in a medical center that has the ability to have both inpatient and outpatient procedures to help accommodate for patients who may have special medical needs.

Technical details

Three major classifications that are performed and these can be performed in different sites.

1. Synovectomy is removal of the diseased tissue. This is most commonly done at the level of the wrist and sometimes is accompanied by the removal of portions of bones that have been destroyed by the disease. Occasionally these surgeries to remove the diseased tissue are combined with surgeries to transfer tendons if tendons have already ruptured. A tendon that duplicates another tendon function is removed and physically moved to attach to the end of the tendon that has ruptured. The ruptures cannot be repaired in an end-to-end fashion because the disease destroys a segment of the tendon.
2. Replacements are done by removal of the disease joint surfaces that are producing the pain and interposing an artificial joint that is usually made of a soft synthetic material. These joints typically have a stem on either end with a spacer in the middle. The stems are placed in the ends of the bone on either side of the joint that has been removed.
3. Joint fusions mean removing the joint and stimulating the bones to grow across the site of the joint surface to create a solid segment of bone. This is usually done by adding bone graft material with bone from another site of the body such as the pelvis or wrist and using metal plates or pins to stabilize the bones while the fusion takes place.

Anesthetic

Patients can either have a regional anesthetic where the arm is blocked or made numb by the use of a local anesthetic injected near the shoulder or a general anesthetic can be used.

Length of hand surgery

The time length can vary from one to two hours depending on the number of separate procedures that have to be done to address the individual patient's needs.

Physical therapy

Most patients will require therapy at least once or twice a week for a period of four to six weeks. Therapy begins one to two weeks after the surgery once the swelling has subsided and there is sufficient healing to allow early motion.

Rehabilitation options

The rehabilitation program should be under the care of a therapist who is skilled in hand therapy. Most therapists have a special certification in hand therapy. Typically we maintain a list of skilled therapists throughout the five-state region to manage the needs of patients regardless of where they live. The therapy needs to be done close to their home where it is convenient.

Although it is important to continue the exercise program at home, we recommend that the patients have a program supervised by a skilled therapist with their visit adjusted according to their needs.

The program varies somewhat depending on what types of surgery where performed as different combinations result in the patient's individual program. We recommend that the patients have access to therapy for at least four to six weeks from their surgery.

Returning to ordinary daily activities

We encourage patients to use their hands, although this is sometimes has to be done while the patient is wearing a splint to do some of their simplest activities such as dressing and eating. Most patients are free from splints and casts within six weeks from time of surgery and can perform most of their daily functions. It generally requires two to three months from time of surgery before patients regain the type of strength that they need to perform all of their pre-surgery activities.

Long-term patient limitations

In general, we try to minimize the restrictions on the patients. In many cases, the patient's surgery has been tapered to their expected activity level. For example, joint replacement surgeries cannot withstand heavy lifting and we do not recommend these in patients who can otherwise pursue heavy physical activities. Overall, the goal of the surgery is to enhance the patient's life style and increase the number of activities that they can perform. Patients can generally use their own judgement as to which activities they feel comfortable pursuing.