Arthritis of the wrist
What is it?
Arthritis is wear and tear of the joint. There are two main types of arthritis: 'Osteoarthritis' (Degeneration) and 'Inflammatory arthritis' (Rheumatoid arthritis).
Osteoarthritis is a slow process that develops over many years. In this type of arthritis the joint cartilage gradually roughens and becomes thin. Small bits of loose cartilage may float around the joint. The bone underneath thickens and the bone at the edge grows outwards causing bony spurs (osteophytes). The joint may swell as the body makes extra fluid to lubricate the joint. The joint may become deformed and there will be gradual loss of movement. In the wrist, the swelling and deformity may cause compression of the median nerve (see information on carpal tunnel syndrome).
Inflammatory arthritis includes conditions like rheumatoid disease.
What is its cause?
The wrist is a complex joint with many bones and ligaments. The wrist joint is made up by the two forearm bones -the radius on the thumb side and the ulna on the little finger side. These articulate with eight small bones called the carpal bones. A complicated network of ligaments holds these bones together forming joints within the wrist joint. The movement when we bend or extend the wrist occurs in the joint between the forearm bones and the carpal bones. The movement when we turn our hand (giving/ or taking change) occurs in the joint between the radius and ulna.
In rheumatoid arthritis the arthritis spreads throughout the body. In this condition the patients’ own immune system mistakenly attacks the joints causing damage to many joints in the body.
The most common cause of osteoarthritis in the body is wear and tear of the joint due to ageing. This is called ‘primary osteoarthritis’. Fractures of wrist bones or injuries to the wrist ligaments can lead to osteoarthritis in later life. This is termed as ‘secondary osteoarthritis’.
Osteoarthritis of the wrist essentially involves four patterns and the treatment varies according to the pattern of arthritis.
- STT joint arthritis: Arthritis develops in the joint at the base of the thumb between the three bones – scaphoid, trapezoid and trapezium (see picture above).
- SLAC pattern of arthritis: There is a strong ligament between the two wrist bones - scaphoid and lunate. An injury to this ligament can cause instability in the wrist and many years later causing this pattern of wrist arthritis. (Scapho-Lunate Advanced Collapse) (see under ligament injuries to the wrist)
- SNAC pattern of arthritis: A fracture of the scaphoid bone may not heal altering the biomechanics of the wrist joint. This non union will cause ‘Scaphoid Non Union Advanced Collapse’ (see under fractures and non union of the scaphoid)
- Pan-carpal arthritis: Arthritis involving most of the wrist joint.
What are the symptoms and how is the condition diagnosed?
The symptoms are of gradually increasing pain and stiffness. Initially there is pain followed by increasing loss of movement. If the joint between the radius and ulna is involved, turning the hand / wrist will become difficult. With time the symptoms will increase and cause significant functional disability. Other associated symptoms could be pins and needles in the hand (irritation of the median nerve), grinding or crunching within the wrist, and deformity.
The wrist can be damaged by rheumatoid arthritis at any age (picture above). Patients with rheumatoid disease may have other associated problems like tendon ruptures and involvement of the other joints in the hand.
Will further tests or investigations be needed?
An x-ray of the wrist is needed. It will confirm the extent and type of arthritis. Electrical tests (nerve conduction studies) may be advised if the patient has pins / needles in the hand.
What is the treatment?
- Initial management consists of painkillers, anti-inflammatory medication and activity modification. It is aimed at easing the pain and regaining motion.
- If the above measures fail, surgery is considered. The type of surgery that will be recommended will depend on the nature and longevity of the symptoms, type and extent of arthritis, age and functional demands of the patient.
There are various operations that can be recommended as below, but you should discuss what is required for you specifically with your Hand Specialist.
Surgery for STT arthritis
Excision of distal scaphoid with or without replacement: This operation is indicated for isolated STT arthritis. The far end (about 1/3rd) of the scaphoid bone is excised. The gap that is left after excision of the bone may be filled by a tendon or interposed by using a pyrocarbon replacement.
Fusion of STT joint: In the young, fusion or arthrodesis of the joint can be considered. Fusion will provide a stable thumb for high power manual work.
Surgery for SLAC or SNAC pattern of arthritis
Arthroscopic (keyhole) surgery: A relatively small operation during which a telescope is passed into the wrist through one small incision (½ cm). Another 1-2 small stab incisions are used to pass instruments, to allow for removal of loose bodies, inflammatory tissue and debride any loose cartilage
Radial styloidectomy: In early stages of this pattern of arthritis, excision of the tip of the radius bone (styloid) is recommended.
Proximal row carpectomy: This surgery is advised in certain patterns of wrist arthritis. Three carpal bones – scaphoid, lunate and triquetrum are exised and a new joint is created between the capitate and radius. The advantage of this procedure is that some movement of the wrist is maintained.
Scaphoid excision and four-corner fusion (picture below): This surgery is advised for either the SLAC or SNAC pattern of arthritis. The scaphoid is excised and the joints between the lunate, triquetrum, capitate and hamate are fused. This is a technically demanding procedure but about 50-60% of motion will be preserved.
Surgery for pan-carpal arthritis
Total wrist fusion: This is a standard operation for pan-carpal wrist arthritis. The pictures below show x-rays after fusion of the wrist. The procedure is practiced in relatively young patients who have arthritis in one wrist and high physical demands on the wrist. The operation will lead to good pain relief. The disadvantage is that the patient will lose movement of the wrist.
Total wrist replacement: Joint replacement of the wrist is a relatively modern technique. The pictures and x-rays below are of a patient who had a replacement 5 years earlier. The procedure is practiced in patients who have arthritis in both wrists, with relatively low manual demands on the wrist. The operation will lead to good pain relief and a functional range of movement.
Wrist denervation: In this procedure, nerve branches that take sensations from the wrist to your brain are cut.This will reduce pain perception and will improve symptoms temporarily. This operation will not stop further progress of arthritis but may delay the immediate need for extensive surgery.
What happens if it is not treated?
In some cases, over time, pain may lessen and a functional range of motion may be maintained. The symptoms may resolve to such an extent that the patient may be able to cope with the residual lack of movement. However most patients will find that their symptoms will increase with time and they will need further treatment.
What is the success of surgical treatment?
Each of the surgical treatments is successful if they have been advised at an appropriate stage of the disease. More than 90% patients will achieve a better range of movement and significant improvement in their pain after these procedures. Success rates will vary on individual situations and this will need to be discussed with your Hand Specialist.
What are the complications of surgical treatment?
- The surgical scar may be tender for a few weeks but that will nearly always settle. There is a small possibility that the scar may remain unattractive. An area of numbness can occur around the scar but this does not cause any problems.
- A degree of aching may persist in the wrist after certain procedures. This will depend on the extent of arthritis that was present at the time of surgery.
- Infection of the wound is possible but usually can be successfully treated with antibiotics. Very rarely infection may spread into the joint replacement.
- Injury to the nerve (superficial radial and cutaneous branch of ulnar nerve) can occur. This may lead to altered sensations, painful spot (neuroma) and tingling. It is important that the nerves are cared for at the time of surgery.
- In the long term, the wrist joint replacement may fail. If that does occur the replacement will need to be revised or converted to a wrist fusion. It is expected that nearly 80% of the wrist replacements will still be successful after 10 years in low demand patients.
- Problems related to implants used to achieve fusion of the wrist may cause problems. They may have to be removed at a later stage.
- The bones may fail to fuse and further surgery may be needed to address this problem.
- Severe complex regional pain syndrome (CRPS) is a rare but serious complication after hand surgery. Unfortunately it is not possible to predict this problem but CRPS needs to be monitored and treated (usually with just physiotherapy) if it develops.
- Any surgical intervention has the risk of developing complications / setbacks which are unpredicted. These complications may have the potential to leave the patient worse than before surgery.
Is there anything I can do to improve the outcome?
- Keep the wounds dry and clean until they have healed.
- After the operation the therapist will see you and start movements of the wrist. It is important to do the prescribed exercises regularly both during the physiotherapy sessions and at home. It will help to keep the pain levels down with analgesics so as to keep your wrist and fingers moving.
- It is advised against wearing rings on the operated side for 4-6 weeks after surgery.
When can I do various activities?
Return to work depends on many factors including the nature of the job and hand dominance. Following most procedures you will be able to return to a desk job within 4-6 weeks of the operation, and perform reasonable tasks with the limb by that time.
- Manual work after surgery should be avoided for 8-12 weeks.
- Manual work is not recommended after a wrist replacement.
- Driving should be possible within 1-2 weeks of keyhole surgery. It may take 4-6 weeks after the other operations. Before driving do check that you can manage all controls and start with short journeys