Arthritis of wrist
What is Arthritis of the wrist?
Wrist is one of the most complex joint in our body made of multiple small bones and joints. Arthritis of wrist involves one or more joints of the wrist. It can be caused by degenerative wear and tear due to ageing (osteoarthritis), rheumatoid arthritis and after an injury (posttraumatic) like a broken wrist or a torn ligament. Osteoarthritis mostly affects adults above 60 years. Rheumatoid arthritis commonly affects women in the age between 20-40 years. Arthritis of wrist can also be caused by congenital causes such as Madelung’s deformity or by secondary causes such as Kienbock’s or Preiser’s disease.
Research studies show that 60 % of adults develop arthritis above 60 years of age and 80% adults above 75 years of age. Rheumatoid arthritis influence only 1 % of the adult population.
What are the symptoms of Arthritis of the wrist?
Most patients with wrist arthritis presents with pain, swelling, stiffness and deformity. The symptoms could be variable and is usually depends on severity of arthritis and level of activity of the affected person. Persistent stiffness could lead to weakness and in advanced stages the joint could sublux leading to the deformity. A grinding, cracking or clicking sound is also audible with the movement of the wrist and in some patients the pain could wake them up from sleep.
How is it diagnosed?
Your orthopaedic surgeon will investigate your symptoms, your medical history and family history. He will perform a physical exam of your wrist and will ask you for tests such as X-rays, scans (CT, MRI) and blood tests. X-rays are helpful to get detailed images of the wrist joints to know the exact location of arthritis. Blood tests detect the inflammatory condition like rheumatoid arthritis, etc.
What happens if nothing is done?
If the arthritis of wrist is left untreated, it may damage bones, ligaments and joints permanently. In advanced cases the bones could fuse together leading to painful, deformed and weak hand and wrist.
How is it treated?
Arthritis is not curable. However, its symptoms can be reduced by a number of treatments. It can be managed surgically and non-surgically. Non-surgical treatment options involve activity modification, splinting, painkillers, anti-inflammatory medicines, warm or cold therapy, steroid injection and hand therapy.
Surgery is indicated in-
- Failure of conservative treatment
- Advanced arthritis
- Severe pain
- Unstable joint
- Joint subluxation/dislocation with reduced hand span
- Patient preference
What are the non-operative treatments?
Non-operative treatments involve the following
- Activity modification- you should limit all the activities that can provoke pain. Repeated use of the affected wrist should be avoided.
- Immobilization- your surgeon can give you a splint to wear to protect the wrist from injury. It supports the joint and relieves the stress on the joint. However regular use may make your wrist more stiff and weak.
- Cold application- Application of ice packs helps to reduce pain and swelling of the wrist.
- Medicines- Painkillers like paracetamol or codeine are given to relieve pain. Topical painkillers are given in the form of gel or cream that can stimulate nerve endings and reduce pain by blocking their supply to the brain.
Anti-inflammatory medicines such as aspirin or ibuprofen are prescribed to control swelling and pain. It is advisable to take these medicines for a short term with food as they can damage your stomach and kidneys.
- Steroid injection– steroid injection (cortisone) in the affected joint relieves pain. However, it usually provides temporary relief of pain and inflammation of the wrist.
- Cold or warm therapy- application of ‘’contrast soaks’’ of cold or warm water directly to the affected area can reduce swelling.
- DMARDs- in case of rheumatoid arthritis, DMARDs or disease modifying anti-rheumatic drugs are prescribed to control the exaggerated immune system. It should be taken only under the advice of your surgeon.
- Hand therapy-Hand therapy is recommended to the patient to restore normal function and strength of the wrist. The affected joint is treated with heat application, splinting and the patient is encouraged to do regular exercises. The exercises can improve the strength and can help in regain the good range of movements.
What does the operation involve?
The surgical operation is aimed at the improvement of the function of the wrist, quality of life and relief of pain.
- You are admitted to the hospital and the operation is usually performed as a day case.
- The operation is performed under general anaesthesia or local anaesthesia (Block). In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation but he cannot feel whatever is happening in the surgical area. Your anaesthetist can select a combination of both local and general anaesthetic.
- Positioning- the patient is positioned in the supine position and hand is centred on the hand table.
- A tourniquet is tied around your upper arm to reduce blood loss during surgery.
- Procedure– once anaesthesia is given to the patient, antibiotics are also given to him to prevent any infection during and after the operation
Wrist arthrits could be treated by following procedures-
- Proximal row carpectomy- in this procedure, three carpal bones near the forearm are removed to reduce pain during wrist movement.
- Fusion- This could be limited (few bones) or entire wrist joint. In this procedure, bones are fused together into one solid bone and are joined with pins, screws or plates to keep the bones in a fixed position during the healing process. This procedure predictably releives pain and restore strength back. However you wont be able to bend the fused joint. In some patients to help with bone healing/fusion, bone grafts are taken from the iliac crest (pelvis).
- Total wrist replacement (arthroplasty)- the damaged cartilage and bone of the wrist is removed, new metal or plastic joint surfaces are placed in its position to allow free movement of the wrist. Though the early outcomes are encouraging, there are no long-term results similar to hip and knee replacements in the literature. Even if the arthroplasty fails, there is still the option of wrist fusion.
- The Skin is closed using absorbable sutures. The operation takes usually 1-2 hours and the majority of the patients are discharged on the same day.
What happens after surgery?
- The local anaesthetic wears off in 4 to 12 hours after surgery. Patients are given painkillers before the pain starts i.e. on return to home. It is continued for at least 48 hours after the first dose. Thus, most of our patients report little pain.
- Your wrist is rested in a half cast for 2 weeks to protect it from injury and allow proper healing. You have to keep your hand and wrist elevated (above the level of your heart) and keep moving your fingers, elbow and shoulder to maintain the flexibility and stiffness of its joints.
- The patient is reviewed in clinic around 2 weeks following the operation for wound check and hand therapy. Usually the half cast is removed and splint applied for next 4-8 weeks and the exercises for thumb is started.
- The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness) and helps scar to mature.
- Physical therapy of hand is essential to restore the range of motion, normal function and strength of the hand.
Are there any risks?
- Damage to nerves, vessels and tendons
- Hardware problems
- Persistence of symptoms
- Need for revision surgery
- CRPS (Complex Regional Pain Syndrome)
What are the results of the operation?
Most patients report great relief of pain and restoration of good function of the wrist after surgery.
When can I return to driving and work?
Immobilisation/restrictions in movements usually ends in 6- 8 weeks after the surgery, after this, you can get back to your normal activities like driving. However, it may take another 6-12 months to achieve full recovery. Your surgeon can give you the correct estimation.
- 88 year old gentleman presented to us with severe wrist arthritis, night pain, weak grip strength and struggling with activities of daily living. B. Wrist fusion releived the pain and restored the function back to his wrist.
- 40 year old lady with juvenile rheumatoid arthritis affecting wrist joint. B. Total wrist replacement releived the pain, restored function and movement.