Wrist Involvement in Rheumatoid Arthritis

The wrist is the most commonly involved joint in the upper extremity of patients with rheumatoid arthritis. Up to 75% of patients will develop wrist problems during the course of the disease. Cartilage degeneration and synovitis cause the typical skeletal erosions, ligamentous laxity, deformity, and tendon problems seen in the disease. Treatment involves a multidisciplinary approach with careful coordination of the primary care physician, rheumatologist, orthopaedic surgeon, and other members of the care team. As rheumatoid arthritis is a systemic, polyarticular disease, it is critical to consider the entire patient in any management decision. Initial management is usually non-operative and involves pharmacological treatment, activity modification, and possibly bracing. Operative treatments are geared to limit the negative effects of the disease, namely pain, loss of function, and deformity. Numerous procedures have been described. Common procedures from tenosynovectomy/synovectomy, distal radio-ulnar joint arthroplasty, arthrodesis, and total wrist arthroplasty are reviewed. Rheumatoid arthritis (RA) has a worldwide prevalence of approximately 1%. The disorder occurs three times as often in women and has a peak onset of between 40 to 60 years of age. The cause is unknown, but it is possible that genetic as well as environmental factors play a role. Synovial hyperplasia with extensive infiltration by inflammatory cells is the basic manifestation of the disease. Growth factors and cytokines such as tumor necrosis factor alpha and interleukin-1 are central to the initiation and progression of RA. A symmetric, systemic polyarthritis with significant ligament and tendon involvement is seen. The wrist is the most common joint involved in the upper extremity in RA. Approximately 75% of RA patients develop wrist symptoms. During the course of the disease, up to 95% of these patients will have bilateral involvement. The disability associated with progressive RA of the wrists is significant. Unfortunately, orthopaedic surgeons do not see many patients until the joint manifestations are advanced. Wrist Involvement in Rheumatoid Arthritis The wrist is a complex anatomic structure. It involves three joints [radiocarpal, midcarpal, and the distal radioulnar joint (DRUJ)] which have relatively low inherent bony stability. Much of the stability and balance of the wrist is due to the soft tissues including the radiocarpal ligaments, intercarpal ligaments, triangular fibrocartilage complex (TFCC), and crossing tendons. Since RA is a disease of the synovium, many of these stabilizing structures are affected. The ligaments are attenuated and become lax, the TFCC is progressively destroyed and the tendons are surrounded and infiltrated with hyperplastic synovium. In addition, inflammatory cytokines and proteolytic enzymes degenerate the cartilage and erode bone. Imbalance of the wrist then occurs causing deformity. The anatomic effects of RA on the wrist are generally predictable. Typical deformity includes shortening of the wrist, scapho-lunate dissociation, carpal supination, translocation of the carpus in a ulnar and volar direction, radial deviation of the carpus and dorsal subluxation of the ulna. The extensor carpi ulnaris (ECU) tendon often subluxes volarly, further contributing to the deforming forces. Tendons, which are already weakened by the disease process, now course over a deformed wrist with bony spicules and may rupture. The clinical result of these problems are pain, loss of function, Rheumatoid Arthritis of the Wrist Doron I. Ilan, M.D., and Michael E. Rettig, M.D. Doron I. Ilan, M.D., and Michael E. Rettig, M.D., are in the NYUHospital for Joint Diseases Department of Orthopaedic Surgery,