eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Wrist Arthritis

Author: Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS (Tr & Orth), Specialist Registrar, Department of Trauma and Orthopedics, Wansbeck General Hospital, UK
Coauthor(s): Lester Sher, MBBCh, FRCS, Honorary Clinical Lecturer, Department of Orthopedics, Wansbeck Hospital, UK
Contributor Information and Disclosures

Updated: Jan 23, 2008

Introduction

Osteoarthritis (OA) is a degenerative condition in which the articular cartilage on the surfaces of the bones that form joints progressively deteriorates. The terms osteoarthrosis and OA are often used interchangeably. Although inflammation is generally absent in this degenerative condition, most physicians commonly refer to it as OA. Hence, this is the term in daily use.¹

OA is common in weight-bearing joints. Although the wrist is not a weight-bearing joint, OA of the wrist is not an uncommon condition that orthopedic surgeons encounter in day-to-day practice. The images below depict severe wrist arthritis.

Wrist arthritis is also common in patients with rheumatoid arthritis (RA), which is a systemic autoimmune inflammatory disorder that affects the joints; in the upper limb, the wrist is most frequently affected. RA invariably results in functional difficulty over time.² The image below depicts RA of the wrist.

History of the Procedure

For many decades, synovectomy of the wrist alone was used in patients with inflamed joints. This procedure is usually of the most benefit when there is considerable synovitis present, as in RA or psoriatic arthritis rather than OA.

Arthrodesis of the wrist has been used as a treatment for more than a century. Because many bones participate in the wrist joint, either a limited (partial) or a total arthrodesis of the wrist is possible.^3,4

The initial procedure of wrist stabilization was performed for poliomyelitis reconstruction and spastic hemiparesis as early as 1918. In 1920, the procedure was adopted for tuberculous arthritis.

Different techniques for wrist arthrodesis with different methods of bone grafting and fixation have been described in the literature. The AO (Arbeitsgemeinschaft für Osteosynthesefragen, or Association for the Study of Osteosynthesis) technique of compression arthrodesis of the wrist has yielded good results.

Arthroplasty of the wrist has been in use for the last few decades. Initial devices were metal and plastic wrist prostheses with cement fixation that had 2 stems for distal fixation. As the wrist progressed to ulnar deviation, the procedure was changed to a single distal stem into the third metacarpal alone. Ball-and-socket design implants were associated with significant component loosening; hence, a transversely oriented, semiconstrained, ellipsoid design implant was developed. Later, semihinged implants were developed. However, the implants have not yielded the same satisfactory results seen with total hip or knee arthroplasty.

Problem

Arthritis of the wrist results in both severe pain and restriction of movement. Early in the disease, patients may have well-preserved, useful range of motion but severe pain.

Wrist arthritis is a common feature in patients with RA, who are usually treated by rheumatologists and general practitioners. In RA patients who have upper limb involvement, surgical timing is critical because procedures for treating wrist arthritis are usually successful in these patients and can influence the management of other joints of the hand and upper limb.

Frequency

The wrist joint is not commonly affected by primary OA because it is not weight bearing. However, secondary arthritis of the wrist joint is common because of the complex anatomy and kinematics involved. Approximately 1 person in 7 (13.6%) of the US population has wrist arthritis. Gout affects the wrist in 0.28% of the population. RA affects the wrist in 2.5 million people in the United States, and the general prevalence of wrist arthritis is 75%. One wrist joint is affected in 30% of patients, but it then progresses to become bilateral in 95%. The distal radioulnar joint is affected in approximately 50% of patients with rheumatoid wrist arthritis.

Etiology

Primary OA occurs because of the degeneration of the articular cartilage. Various reasons have been postulated for this occurrence, including the important roles age and genetics play. Secondary OA following trauma can result in intra-articular distal radius fractures, scaphoid fractures, scapholunate dissociation, lunate dislocations, wrist instability, intercarpal intercalated instability, and other carpal bone fractures. Kienböck disease (avascular necrosis of the lunate) can also result in wrist arthritis. Inflammatory arthritis of the wrist may be caused by RA, psoriasis, or crystal-induced arthritis, which includes gout and pseudogout.

Pathophysiology

Matrix metalloproteinases and proinflammatory cytokines (interleukin-1 [IL–1]) appear to be important mediators of cartilage destruction in patients with primary OA. IL-1 increases the synthesis of matrix metalloproteinases and, hence, plays an important role in OA.

During the initial stages of OA, fibrillation and cracking of the superficial layers of the articular cartilage occur. As the degeneration progresses, deep layers become involved, finally resulting in erosions that produce bare subchondral bone. Denatured type II collagen is found in abundance in OA articular cartilage, with a decrease in the water content and in the ratio of chondroitin-sulfate to keratan-sulfate constituents. In chronic injuries of the scapholunate ligament and in scaphoid nonunions, osteoarthritis starts in the radioscaphoid joint and progresses to the capitolunate joint. The radiolunate joint remains unaffected during the early stages.

RA, on the contrary, is a progressive inflammatory disease characterized by synovitis and joint destruction. Synovial cell proliferation results in pannus formation and fibrosis, which, in turn, result in erosion of cartilage and bone. Cytokines, prostanoids, and proteolytic enzymes mediate this process. A cell-mediated immune response to an unidentified antigen seems to be the important pathogenesis of RA. Proinflammatory cytokines, such as IL-1 and tumor necrosis factor-alpha (TNF-α), are the central mediators in RA with T-cell initiation.

In gouty arthritis, allantoin, the enzyme uricase that breaks down uric acid into a more soluble product, is deficient, resulting in tissue deposition of crystalline forms of uric acid. Although hyperuricemia is 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.

Secondary OA resulting from previous trauma to the carpal bones or ligaments results in abnormal joint reaction forces with each movement of the wrist, causing misdirected forces that lead to some combination of loading forces. This process produces degeneration of the articular cartilage, resulting in radiocarpal arthritis, selective intercarpal arthritis, or pancarpal arthritis, depending on the initial injury and subsequent healing.

Scaphoid fractures in particular can result in OA by 3 different mechanisms.

• If the fracture results in nonunion, abnormal movement occurs between the fragments, leading to an abnormal distribution of forces across the wrist and resulting in early degeneration of the radioscaphoid joint.
• In malunion, the height of the scaphoid may be reduced. Furthermore, the range of motion in 1 or more planes may be restricted, resulting in increased strain and leading to OA changes over time.
• Scaphoid fractures resulting in avascular necrosis of the proximal pole can lead to collapse and, thus, degeneration of the radioscaphoid joint, which may then involve the lunate and, subsequently, the entire wrist.

Kienböck disease results in lunatomalacia; the weakened lunate is subjected to a nutcracker effect between the prominent radius and the capitate head, causing progressive collapse. In its final stages, Kienböck disease leads to the beginning of OA in the radiolunate joint.

Presentation

Wrist arthritis occurs commonly in persons older than 50 years. However, RA and its variants may manifest earlier. Likewise, in patients with previous trauma, secondary OA can appear at a young age.

The predominant symptom of OA is pain. Pain that is usually aggravated during the extremes of movement in the early stages gradually worsens to involve the full, available range of motion. The range of motion may also gradually deteriorate, and the OA progresses to such an extent that, in severe cases, the wrist has no movement, resulting in stiffness. However, in rare cases in which the patient has inherent hyperelasticity, as in those with Ehlers-Danlos syndrome or Marfan syndrome, the wrist may have good range of motion despite severe degenerative changes. The images below depict a patient with normal range of motion.

Deformity is another feature of wrist arthritis. This is common in RA, in which deformity may be complicated by association with subluxation of the radiocarpal and inferior radioulnar joints. Swelling of the wrist is one of the most common manifestations of RA and may occur because of synovial thickening.

Because the wrist stabilizes the hand for functioning, pain and deformity may result in the loss of such function with weakness of the hand grip. Wrist deformity and instability reduce support for the hand to grasp, impairing dexterity, whereas stiffness and the inability to extend the wrist deprive the fingers of the tenodesis effect.

Attrition rupture of the tendons may occur, specifically when they glide over the rough osteophytes, resulting in loss of function in the fingers. The flexor pollicis longus tendon is prone to such ruptures over the distal pole of the scaphoid; this is called a Mannerfelt lesion. Cases have been described in the literature in which the flexor pollicis longus, flexor digitorum superficialis, and flexor digitorum profundus tendons to the index finger all are ruptured, with osteophytes at the distal pole of the scaphoid. Likewise, the small and ring finger extensor digitorum communis tendons are prone to attrition ruptures.

Persistent synovitis at the distal radioulnar joint may result in dorsal subluxation of the distal ulna, crepitus during forearm pronation and supination, deformity of the carpus, and rupture of the extensor digitorum communis tendons—this is called caput ulna syndrome. Because the tendons in the flexor and extensor compartments of the wrist have a synovial lining, synovitis of the wrist results in tenosynovitis in most cases, and it may lead to tendon subluxation, tendon adhesion, and, finally, tendon rupture. See image below.

Indications

Surgery is indicated for wrist arthritis when disabling pain emerges despite nonoperative treatment. Because the wrist is the stabilizer for effective functioning of the hand, the loss of function in the hand is also an indication for intervention. In its early stages, synovitis must be actively treated with medical means. If there is no response to medical therapy, synovitis should be treated surgically to prevent tendon ruptures. Deformity may be an indication for surgical intervention in selected patients, because a motion-preserving procedure may be possible when performed early, whereas neglecting such patients in the early stages may relegate them to later treatment with fusion only.^3,5

Relevant Anatomy

The wrist extends from the distal border of the pronator quadratus up to the carpometacarpal joints of the fingers. It is a complex hinge joint that involves the distal radius, distal ulna, 7 carpal bones (among which the pisiform acts mainly as a sesamoid), and the base of 5 metacarpal bones. The wrist joint can be divided into radiocarpal, midcarpal, and intercarpal joints. The movements available in the joint are dorsiflexion, palmar flexion, radial deviation, ulnar deviation, and a combination of 2 or more of these movements.

The wrist functions by positioning the hand in relation to the forearm, providing a mechanical advantage, and also acts as a stabilizer for effective functioning of the hand. The motor fiber units that produce wrist motion arise proximally in the forearm, cross the wrist, and then are inserted distally to the wrist without any attachment to the carpal complex.

The unique kinetics of the carpal bones depend on the intricate carpal geometry (and arrangement), ligament function, and muscle activity. Carpal bones are arranged in 2 rows. From radial to ulnar, the proximal row consists of the scaphoid, lunate, triquetrum, and pisiform, whereas the distal row has the trapezium, trapezoid, capitate, and hamate. Accessory carpal bones are present in 1.6% of the population, one of which is the os centrale carpi, which sits between the scaphoid, capitate, and trapezoid and may be responsible for the condition "clicky wrist."

Contraindications

Infection at the wrist is an absolute contraindication for wrist arthroplasty. Surgery may also be contraindicated in patients with poor medical status.

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