Pathology
Joint arthritis occurs when the protective cartilage layer wears away. The joint then becomes more painful and loses motion. When all of the cartilage wears away, a grinding bone against bone feeling will be felt and can be demonstrated on exam. The four signs of arthritis on x-rays is the loss of joint cartilage resulting in joint space loss, increased density of the bone just inside the cartilage area called sub-chondral sclerosis, spur formation at the ends of the joint and cysts formation just under the sub-chondral sclerosis. The three most common causes of arthritis are: osteoarthritis, post-traumatic arthritis and inflammatory arthritis. Osteoarthritis is simply wear and tear as the body ages and primarily affects patients in their 60’s but the basilar thumb joint is an exception particularly in women. Post-traumatic arthritis is a consequence of a joint fracture or dislocation causing joint cartilage damage and loss of the cartilage cushioning effect. Inflammatory arthritis with rheumatoid arthritis being the most representative, can present in younger individuals including in early childhood and result in joint destruction with the associated deformities called mallet, Boutonniere and Swan neck deformities. The inflammatory arthritis conditions require special laboratory blood tests to make the correct diagnosis. The other two types of arthritis can be diagnosed by simple the history, physical examination and x-ray findings.
Treatment
In the early phases of a SLAC wrist when the deformity is still reduceable (passively correctable) and the damage to the cartilage is not significant, the treatment may consist on techniques attempting to recreate the ligament stabilizers and re-establish balance. When the collapse is more advanced with arthritis and a static unreducible deformity, an option may be a Proximal Row Carpectomy (PRC) that consists of removal of the bones from the proximal carpal row. A small resection of the radial styloid may be added to avoid the bones impinging on radial side of the wrist. Another option that preserves some wrist motion and provides good strength is a limited carpal fusion (arthrodesis). Patients can expect about 50 % of normal wrist motion as compared to opposite uninvolved wrist and over 70 % of normal grip strength. An example of a limited wrist fusion is a four corner fusion.
Total wrist fusion is a more definitive procedure that is offered when the wrist arthritis is extensive and involves all of the joints of the wrist and is considered a salvage procedure after other strategies have failed to relieve pain. It involves the fusion of both the radio carpal and mid-carpal joints. Other partial fusions and ligament reconstructive procedures have been described that can be discussed by your surgeon as deemed appropriate.
Rheumatoid arthritis is an inflammatory systemic condition of unknown cause that frequently affects the wrist and hand amongst other joints around the body. It is characterized by synovitis (inflammation of the synovial lining) of the wrist joint capsule and tendons around the wrist. Synovitis causes progressive destruction of the joint surfaces, bone stock, ligaments and results in joint instability. Rheumatoid arthritis should be treated according to the patient’s chief complaint and severity of the disease. The most important thing to keep in mind is that rheumatoid arthritis requires a comprehensive approach with a rheumatologist, surgeon and therapist for optimal results.
Nonoperative treatment can be initiated with hand therapy to learn ergonomics, protection from high risk activity and activity modification with the use of adaptive devices. The use of anti-inflammatory medication is at the discretion of the rheumatologist. Local steroid injections can also be used to relieve symptoms with the understanding that the improvement may be partial, temporary and only for symptom relief and not intended as a cure. Therapist participation for splinting and for ergonomic education, occupational therapy is useful. When non operative treatment has failed to relieved symptoms after six months of appropriate rheumatologic control, surgery is indicated.
Surgical treatment for rheumatoid patients may consist of synovectomy (cleaning of the joint from inflammed synovial tissue), tendon repairs or transfer to rebalance developing deformities, arthrodesis (joint fusion), arthroplasties (joint replacements) and other procedures to compensate for the established hand and wrist deformities.
Hand therapy is an integral part of the non-operative and surgical treatment and will be started early in the postoperative period. The focus of the program will center on pain and swelling control, early range of motion with modalities that depend on the presence of tendon repairs or reconstruction. The use of splints to assist function, protect the repairs or for resting positions during daytime and at night will also depend on the particular procedure and stage of the disease. Static progressive splinting may be required in stiff joints