Wrist Arthritis

 

Wrist Arthritis


Osteoarthritis (OA) is a degenerative condition in which the surface linings of the bones that form joints deteriorate. OA of the wrist is not an uncommon condition.


Wrist arthritis is also common in patients with rheumatoid arthritis (RA), and Gout


Arthritis of the wrist results in pain and loss of motion. 1 person in 7 has wrist arthritis.


Primary OA occurs because of the degeneration of the articular cartilage through factors heavily affected age and genetics.


Secondary arthritis of the wrist joint is common Secondary OA follows trauma such as intra-articular distal radius fractures, scaphoid fractures, scapho-lunate dissociation, lunate dislocations, wrist instability, intercarpal intercalated instability, and other carpal bone fractures. Kienböck’s disease (avascular necrosis of the lunate) can also result in wrist arthritis.


Secondary OA resulting from previous trauma results from abnormal joint reaction forces with each movement of the wrist  producing degeneration of the lining of the joints, resulting in a range of patterns of arthritis.


for example, scaphoid fractures in particular can result in OA by 3 different mechanisms.


    Non-union


    Mal-union


    Avascular necrosis of the proximal pole


Inflammatory arthritis of the wrist may be caused by RA, psoriasis, or crystal-induced arthritis, which includes gout and pseudogout.


Gout affects the wrist in 1:300 of the population.


Patients with Rheumatoid Arthritis have wrist involvement in 75% cases have wrist involvement usually bilateral.


Rheumatoid Arthritis is a progressive inflammatory disease characterised by synovitis and joint destruction


In gouty arthritis, although elevated blood urate levels are a risk factor for the development of gout, the exact relationship between hyperuricemia and acute gout is unclear. Acute gouty arthritis can occur in the presence of normal serum uric acid concentrations. Conversely, many patients with hyperuricemia may never develop gouty arthritis.


Clinical


Wrist arthritis occurs commonly in persons older than 50 years. Inflammatory arthritis presents earlier. Secondary OA can appear at a young age depending on when and what type of trauma occurred


The dominant symptom of OA is pain that is aggravated during the extremes of movement in the early stages, gradually involving any available motion. The range of motion may also gradually deteriorate even such that the wrist has no movement, resulting in stiffness.


Deformity is another feature commonly in Rheumatoid Arthritis along with swelling of the wrist because of synovial thickening.


The wrist stabilises the hand for functioning, and as such pain and deformity may result in the loss of such function with weakness of the hand grip, impairing dexterity.


Rupture of the tendons may occur such as the thumb flexor tendon rupturing over the distal pole of the scaphoid; this is called a Mannerfelt lesion.


Likewise, the little and ring finger extensor tendons are prone to attrition ruptures.


Arthritis at the distal radio-ulnar joint may result in rupture of the extensor tendons and poor forearm rotation and deformity



INDICATIONS



Surgery is indicated for wrist arthritis when pain, loss of function in the hand result with no further response to medical therapy.


Deformity may be an indication for surgical intervention in selected patients.


ANATOMY


The wrist is a complex hinge joint that involves the distal radius, distal ulna, 8 carpal bones and the base of 5 metacarpal bones.






















The wrist joint can be divided into different joints called as radio-carpal, mid-carpal, and inter-carpal joints. The movements available in the joint are flexion, extension, radial and ulnar deviation, and a combination of these movements.


The carpal bones movements result from intricate carpal bone shapes and the ligament linkages, and muscle acting across them (but not attaching directly to them). I liken them to a Rubik’s cube that can move in defined ways and not others, but if a link is deformed or a linkage damaged the twisting doesn’t occur smoothly.



























In assessing the wrist there may be a role for blood tests and imaging studies which may be simple ‘X-rays’ or complex scans such as MRI and CT scans.


Some tests may be invasive requiring therapeutic or diagnostic injections.



TREATMENT


Non-operative measures


Rest, in the form of splinting

Overuse of splints may result in wrist stiffness and weakness produced by immobilisation.


Non-steroidal anti-inflammatory drugs are useful in controlling inflammation


Disease modifying anti rheumatoid medications with systemic steroids, methotrexate, and anti–TNF are useful in patients with RA.


Allopurinol may be useful in patients with gout.


Steroid injections with or without local anaesthetic into the joint may be performed and may be combined with local anaesthetic.


SURGERY


Surgery for wrist arthritis depends on the severity and the extent of arthritis in the wrist.


It may be possible to nearly restore normal anatomy to prevent degeneration of the wrist.


In the late stages of severe wrist arthritis stiffening affected joints (either a partial or total wrist arthrodesis), or replacement arthroplasty may be considered.


Options such as wrist arthroscopic assessment and/or debridement, and wrist denervation may be considered when the patient has a well-preserved range of motion but not established arthritis.


Wrist denervation


Wrist denervation can be performed by means of simple division of some small nerves near the wrist joint through a single incision on the back of the wrist.


Wrist denervation does not address the underlying wrist arthritis.



Synovectomy


Dorsal synovectomy is indicated to avoid tendon ruptures when the synovitis persists despite medical treatment, or performed after tendon ruptures have occurred to prevent further ruptures. This is often combined with ulnar head resection




Arthrodesis


Fusion of the wrist, can be limited or total. Limited fusion consists of fusion of only part of the carpal bones involved by arthritis aiming to preserve some motion in the remaining part of the carpus that is not affected by arthritis.


Bone grafting may be required from areas such as the iliac crest (Hip region).


Total wrist fusion


Total wrist fusion (TWF) is indicated in patients with whole wrist arthritis and is a successful option in patients with OA of the wrist from any cause and is reliable for pain control.


The disadvantage is loss of motion in any plane, which interferes with certain functions of the hand such as toilet activities and working in restricted spaces.


Wrist fusion usually improves grip strength, and the hand can be used for most functions without difficulty.



Bone grafts taken from either the distal radius or the iliac crest are used, with or without bone substitute to encourage fusion.


A titanium (or steel) plate is used such as the AO compression plate specially designed for it.


In those with Rheumatoid Arthritis, an intra-medullary pin arthrodesis can be used, but commonly the wrist will ‘autofuse’ without surgical intervention.



Four-corner fusion


Four-corner fusion is is used for scapholunate advanced collapse, also known as SLAC wrist. Fusing the capitate, lunate, hamate, and triquetrum.


It may be possible to regain 60% of normal motion in the wrist, depending on good articular surface congruity between the lunate and lunate fossa of the distal radius.


Tri-scaphe (STT) fusion


Tri-scaphe fusion involves fusion of the scaphoid, trapezium, and trapezoid bones when arthritis is confined to the scapho-trapezio-trapezoid joint. Fortunately this is rarely required since non-surgical treatment usually suffices.



Radio-scaphoid arthrodesis


Radio-scaphoid arthrodesis is rarely performed but can be considered when degenerative changes from wrist arthritis involve the entire radio-carpal joint with sparing of the mid-carpal joint, such as happens after distal radius fractures.


Approximately 1/3rd  of normal wrist motion can be regained because of the preserved mid-carpal joint. However, this may be improved to ½  by excising the distal pole of the scaphoid during the procedure.



Scapho-luno-capitate fusion


Scapho-luno-capitate fusion is indicated in patients with mid-carpal arthritis but without radio-carpal arthritis.


The range of normal wrist motion that may be possible after scapho-luno-capitate fusion is 33-50%.





Proximal-row carpectomy


The proximal-row carpectomy procedure is indicated for severe radio-carpal arthritis, when there is complete sparing of the radio-lunate joint and no degenerative changes over the head of the capitate.


The results are generally satisfactory but the wrist motion is only in the flexion and extension, and radial/ulnar deviation planes, and dart-throwing motion is lost (difficulty in bouncing a ball).


Point-loading forces may be present, and secondary OA may develop.



Total wrist Replacement


In patients with polyarthritis, as in Rheumatoid Arthritis, total wrist replacement may be preferred over wrist fusion for at least one wrist to enable activities of daily living. The results after total wrist replacement are improving.


NICE recommends that Total wrist replacement should only be used with special arrangements for clinical governance, consent and audit or research.


I can refer you to a colleague for this type of surgery in a centre of repute involved in the development of newer implants.



COMPLICATIONS


Wrist surgery can be complicated by infection, which may lead to implant removal and, in severe cases, may progress to amputation, though this is rare. Nerve or blood vessel injury, implant loosening, implant failure, and fractures are other complications.


The complications of wrist arthritis surgery are different for each type of operation.


Wrist fusion surgery can result in non-union or fibrous union with pain at the wrist on movement.


Replacement can be complicated by infection, joint instability or dislocation, wrist stiffness and decreased range of movement with pain at the wrist. The grip strength may be reduced, especially after replacement.