Advances in Hand and Wrist Arthritis Surgery.

Edited By: Magee E. Saewert, MS, PA-C, Thomas Trumble, M.D.
Last updated Tuesday, March 28, 2006

Figure 5 - a characteristic deformity is the lunar drift of the fingers, which drift toward the small finger side of the hand at the metacarpophalangeal joint.

Figure 6 - The extensor tendons are the ones that are the most vulnerable.

Figure 7 - X-rays demonstrate scalped or punched out lesions of bone destruction adjacent to the joint.

Figure 8 - the carpometacarpal joint of the thumb is the next most commonly involved joint.

Figure 9 - the wrist joint, also referred to as the radiocarpal joint, is the next most commonly involved joint after the the carpometacarpal joint.

Figure 10 - adapted devices will also decrease the stress in the joints and improve the life span of joints afflicted with arthritis.

Figure 11 - a brace that helps to support the wrist in a comfortable position is quite useful.

Figure 12 - Example of gentle stretching exercises known as the ?Six-Pack? exercises.

Figure 13 - shows an application of Parafin C.

Review of the condition

What are some general characteristics of hand and wrist arthritis? What are its usual manifestations?

Hand and wrist arthritis is best considered in the two major classifications that we discussed above: Inflammatory arthritis and the common wear and tear arthritis referred to osteoarthritis. In inflammatory arthritis, such as rheumatoid arthritis, the patient so affected often has marked stiffness in the morning lasting an hour or more, swelling of the joints of the hands as well as the wrists, and if untreated medically, may develop permanent damage to the bone and cartilage and loss of the ability of the supporting structures such as the tendons to maintain the normal alignment of the joints of the hands and wrists. As noted in rheumatoid arthritis, a characteristic deformity is the lunar drift of the fingers, which drift toward the small finger side of the hand at the metacarpophalangeal joint. (Figure 5) Inflammation can also erode tendons, which rarely happens in osteoarthritis. Once the tendons are eroded, the digits can droop, which is known as an extensor lag. The extensor tendons are the ones that are the most vulnerable (Figure 6), Nodules can also occur about the hand and wrist as well as elsewhere in the body. These tend to occur over joint surfaces on the extensor portion of the hand prime area is the posterior region of the elbow called the olecranon, but these are also noted in the small joints in the hand

The treatment of inflammatory arthritis has been revolutionized by the recent introduction of new medications that are directed against the immune processes that cause the major damage. Etanercept, Infliximab, and Adalumumab are three new “biologic” agents that are now approved to treat rheumatoid arthritis and have had a huge impact in just a few years. The can effectively suppress inflammation and prevent damage to the joints. Older drugs such as methotrexate are still widely used and are often combined with the newer agents with excellent effect.

What are the different types of hand and wrist arthritis?

As discussed above, the two main categories include the arthritis associated with inflammatory disease such as rheumatoid arthritis and with the frequently strong genetic history and the more much more common but less world defined osteoarthritis. Osteoarthritis rarely affects the soft tissues such as the tendons although joint ligaments can be damaged as the joints become deformed. In rheumatoid arthritis, soft tissue damage is one of the hallmarks and frequently there is tendon rupture causing a loss of hand.

What else might be confused with or similar to hand and wrist arthritis? How can these be distinguished from the condition?

How common is hand and wrist arthritis (statistics, demographics, risk factors)?

How is hand and wrist arthritis diagnosed? What tests or exams may be used?

Arthritis is diagnosed by the patient’s history, physical examination, as well has x-rays showing ‘punched out lesions’ and laboratory studies. Swelling and tenderness around the joints with limitations of motion is one of the hallmark signs of arthritis. Instability and deformity of the joint occurs later in the course of the disease. The following clinical features correlate with certain types of arthritis.

1. Rheumatoid arthritis: The ulna deviation of the deformity of the hand at the level of the metacarpophalangeal joint (See Figure 5). Nodules can occur, particularly on the extensor surfaces and it is frequently warm when the swelling occurs.

2. Laboratory tests: Rheumatoid factor is positive in approximately 80% of patients and a newer test the anti-cyclic citrullinated peptide is even more specific for rheumatoid arthritis. The erythrocyte sedimentation is often elevated as well. This is a general sign of inflammation that can correlate with infection or arthritis. It is not a specific test, but helps to monitor the course of the disease. X-rays demonstrate scalped or punched out lesions of bone destruction adjacent to the joint. (Figure 7) The joint surfaces are referred to as the articular surfaces, and therefore the fact that these lesions occur adjacent to these lesions adjacent to the joint surface or on the perimeter of the joint surface has resulted in the term, ‘periarticular erosions.’

3. Lupus: This is also much more common in women, and is diagnosed by an elevated antinuclear antibody (ANA). There may be joint deformity with x-rays demonstrating far less destructive changes than occurs with rheumatoid arthritis. Redness around the face occurs around the eyes and cheeks in a hallmark fashion that is referred to a butterfly rash and occurs in a majority of patients at some point of their condition.

4. Psoriatic arthritis: In the majority of these patients, the rheumatoid factor and antinuclear antibodies are negative, but erythrocyte sedimentation rate can be elevated. The patients demonstrate joint swelling that that can affect an entire finger or toe and is referred to as a sausage digit. Psoriatic arthritis can damage the bone and cartilage just as rheumatoid arthritis. Patients usually demonstrate a scaly psoriatic rash along the scalp, trunk, or arms or legs in the course of the disease.

5. Gout: Men more commonly develop gout than women. It usually occurs n the third and fourth decades of life. In addition to the hands, the big toe is commonly affected and titled Podagra for its presentation. The joints are hot and swollen when the gout is active. The majority of patients have elevated uric acid levels that are tested on blood tests and when the joint tapped and fluid is drawn from the joints, the sharp edge to gouty crystals are frequently seen in the joint fluid. Gout responds well to medications that diminish inflammation such as indomethacin or even prednisone. Allopurinol can be an excellent way to treat the patient on a long-term basis. The destructive or punched out lesions are present around the joints similar to rheumatoid arthritis, but when the crystal deposits become large enough, they form masses called tophi that can also be seen as a hazy, mass on x-ray.

6. Osteoarthritis: This condition is the most common and has the least characteristic signs. Radiographs are often quite classic with patients with development of changes in bone spurs with new bone formation outside the normal confines of the skeleton. The laboratory tests are generally negative. When fluid is dropped from the joint, there is noted to be an increased level of numbers of white blood cells, but far less than that occurs the types of inflammatory arthritis or gouty/crystal and arthritis described above. In osteoarthritis, the PIP joints are frequently affected. The distal phalangeal (DIP) joints are frequently affected. (Figure 3B). In addition, the carpometacarpal joint of the thumb is the next most commonly involved joint (Figure 8) followed by the wrist joint also referred to as the radiocarpal joint (Figure 9)

Can medications help hand and wrist arthritis?

Although nonsteroidal inflammatory drugs (NSAIDS) like ibuprofen and naproxen as well as newer drugs rofecoxib and celecoxib can help to relieve symptoms in the majority of patients with arthritis. Braces that help to alleviate stress in the joints can be uniformly helpful. In addition, adapted devices that help to improve the leverage that the patient can apply to opening jars, cutting food, etc. will also decrease the stress in the joints and improve the life span of joints afflicted with arthritis. (Figure 10) When the thumb is involved, a special splint called opponents splint can be extremely helpful. (Figure 4B) When the wrist is involved, a brace that helps to support the wrist in a comfortable position is quite useful. (Figure 11).

Specific Drug Treatment by Diagnosis:

1. In order of increasing immunosuppressant power, available drugs include Hydroxychloroquine, Sulfasalazine, Azathioprine, and Methotrexate. Steroid medication has a rapid effect, but can cause a significant side effects such as osteoporosis. The disease modifying Antirheumatic drugs are referred to DMARDs.

2. Systemic lupus erythematosus: Treatment depends on disease severity. Steroids are the mainstay with Hydroxychloroquine, Methotrexate, Azathioprine, and Cyclophosphamide used as needed.

3. Rheumatoid arthritis: Hydroxychloroquine, Sulfasalazine, Methotrexate, Leflunomide, Etanercept, Infliximab, Adalumumab are medications that can be used in this disease.

4. Scleroderma (CREST Disorder): The acronym CREST stands for: C – calcinosiscutis R – raynaud’s syndrome E – esophageal motility disorders S – sclerodactyly, thickening of the skin of the fingers T – telangiectasia Medical therapy can include calcium channel blocking drugs, nitrogen paste, and infusion of prostaglandin analogs.

5. Psoriatic Arthritis: For the medical management of psoriatic rheumatoid arthritis, high-dose steroids should be avoided.

6. Crystalline arthropathies:

Gout The acute attacks respond well to high-dose non-steroidal anti-inflammatory drugs (NSAIDS), Colchicine can be used to prevent attacks. Oral and injectable steroids can also be effective. Allopurinol blocks the breakdown pathway of purines and was thought to be effective in preventing attacks of gout, but more recent evidence questions the efficacy of the drug.

Chondrocalcinosis (Pseudogout) Steroid injections into the inflamed joint and NSAIDS can be a very effective treatments.

Can exercises help hand and wrist arthritis?

Specifically, how is hand and wrist arthritis improved by hand and wrist arthritis surgery?

Prior to surgery for the hand and wrist can be extremely helpful when other modalities such as drug therapy and splints no longer provide the patients with sufficient pain relief or improvement of function. When patients have difficulty performing even simply household tasks despite braces and therapy, surgery can be extremely helpful.

Reconstructive Hand and Wrist Arthritis Surgery includes one of four types of treatments:

1. Joint replacement surgery: This surgery corrects the deformed and arthritic joints to prevent the bone on bone contact that produces the severe grinding pain. It is particularly important where motion is a high priority, including the CMC joint at the base of the thumb, the PIP joint in the middle of the digits, and the MCP joints at the base of the digits as well as in the wrist.

2. Joint fusion or arthrodesis or fusion of the joint: Fusion eliminates the motion in the joint that produces pain by fusing the two bone surfaces together. Patients obtain relief of pain and stability, but they lose the joint motion. This is most successful in the small Dip joints, but can also be used in the wrist for a partial fusion or complete fusion.

3. Synovectomy to remove the inflamed joint or tendon lining: There is strong clinical evidence to suggest that the persistence of the swelling around tendons or joints referred as synovitis can produce severe destructive changes if careful medical management cannot eliminate the synovitis within a six month period of time. The synovectomy can relieve pain and prevent tendon rupture that causes severe loss of hand and wrist function.

4. Tendon repair and reconstructive surgery: In severe cases, once the arthritis has caused erosion of tendons with rupture, tendon reconstruction with transfers or grafting can restore function to the patient’s hand.

Surgery for Hand and Wrist Arthritis at the University of Washington

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