Hand and Wrist Surgery
As many as seven out of ten people with rheumatoid arthritis (RA) develop problems with the joints, bones, and other structures in their hands or wrist at some point in the course of the disease. These problems can be painful and cause significant disability, often affecting the individual’s ability to function independently and productively. Because of the prominence and visibility of the hands, fingers, and wrists, such RA-related deformities can also be stigmatizing.1
How RA affects the hands & wrists
RA causes chronic inflammation in the joints, and the hands and wrists are commonly affected. The joints in the wrist may be one of the first symptoms of RA. About one-half of people with RA have wrist involvement when they are first diagnosed with the disease, and this increases to almost 90% of people with RA having wrist pain and loss of mobility within 10 years after diagnosis.2 The joints in the fingers are also commonly affected by RA, which can cause swelling or deformity in the fingers.3
Main types of hand & wrist surgery
In treatment of RA-related problems affecting the hands and wrists, the overriding goal is to control disease activity. Surgical interventions are only useful if systemic inflammation is controlled. Therefore, surgery must be seen as secondary to disease-modifying anti-rheumatic drugs (DMARD) and other treatments that aim to provide disease control. Two main categories of hand and wrist surgery in RA include prophylactic surgery, which is designed to slow or delay RA-related destructive processes and extend the functional lifespan of joints and tendons, and reconstructive surgery, which is designed to repair existing damage, relieve pain, and restore some level of function.1
Prophylactic (preventive) procedures
Prophylactic procedures include tendon rebalancing, joint synovectomy, and tenosynovectomy (removal of inflamed synovial tissue from the tendon sheath).
Tenosynovectomy is used to remove the inflamed synovial lining of the extensor tendons (the tendon that helps the fingers extend). Inflammation of the synovial lining results in swelling over the back of the hand and the wrist. If this inflammation and swelling continues, it can eventually lead to rupture of tendons.1
Synovectomy of the joints of the hand and wrist, as elsewhere in the body, is used to remove inflamed synovial tissue from the joint compartment to decrease swelling and associated pain. Synovitis affecting the wrist and finger joints can be painful and may limit motion of these joints.1
Swelling of joints can stretch support tendons and cause imbalances that lead to deformities of the fingers, hand, and wrist. Surgery to rebalance tendons can correct imbalances that limit the function of fingers and prevent further, more severe, tendon damage.1
Reconstructive procedures, which tend to be more complex than prophylactic ones, include arthrodesis, arthroplasty, and tendon transfer. Arthrodesis involves fusion of bones to immobilize a joint and arthroplasty involves joint reconstruction or replacement using some type of prosthetic joint. Tendon transfer is used in instances of tendon rupture and involves the use of tissue taken from another location in the body to repair the ruptured tendon.
Surgical approaches to common problems
Common RA-related problems affecting the hand and wrist include:
- Ulnar deviation of digits (fingers)
- Boutonniere (buttonhole) deformity
- Swan-neck deformity
- Mallet finger
- Collapse of the carpus
- Ulna head syndrome
- Tendon rupture
The wrist and hand are complex structures and the surgical approach to these various problems will vary depending on many different factors, including the extent of damage and your goals and preferences as a patient. If you have any of these RA-related problems, talk to your doctor or orthopedic surgeon about surgical options.
Tendons are contained in sheaths that are lined with synovial tissue like joints and filled with synovial fluid. In RA, these sheaths can become inflamed and swollen. This condition is called tenosynovitis, the symptoms of which include pain, swelling, and stiffness and difficulty of movement where the inflammation occurs. This condition can cause a finger to get stuck in a flexed (bent) position, a condition sometimes called “trigger finger”. Prophylactic surgery, such as tenosynovectomy, to manage tenosynovitis can prevent rupture of tendons and avoid the necessity of more involved reconstructive surgery.1
Ulnar deviation, also called ulnar drift, is a type of deformity affecting the hand in which swelling in the metacarpophalangeal (MCP) joints (the large knuckles at the base of the fingers) causes the fingers to become displaced toward the little finger or the side of the hand where the ulna bone connects at the wrist. The radius connects to the wrist on the thumb side of the hand and if the fingers shift toward the thumb-side of the hand it is called radial drift or deviation. Depending on the nature and extent of damage to MCP joints, surgical options include rebalancing of associated tendons, often performed along with synovectomy. If there is significant damage to MCP joints, arthroplasty may be performed.1
Boutonniere deformity, also called button-hole deformity, is a condition that affects the fingers (it can also affect the toes), in which the joint nearest the palm (or sole) (the proximal interphalangeal [PIP] joint) is bent toward the palm (PIP flexion) while the joint farthest from the palm and closest to the fingertip (the distal interphalangeal [DIP] joint) is bent back away from the palm (DIP hyperextension). Boutonniere results from rupture of the central extensor tendon over the PIP joint. This results in hyperextension of the MCP joint and flexion of the PIP joint. Boutonniere deformity is very difficult to treat. Importantly, surgery may result in a decrease in the flexion of the PIP joint with loss of grip strength, particular on ulnar-side fingers.
If this deformity is treated early, synovectomy may be used to prevent further damage and structural changes that occur over time. In the early stages, rebalancing of tendons may also be used to correct the deformity. If significant joint damage is present, arthrodesis or arthroplasty may be necessary.1
Patients can often compensate for the deformity, without resorting to surgery and losing grip strength, by the use of specially designed finger rings or splints (such as SIRIS™ Silver Ring Splints). An occupational therapist who specializes in hands can help fit you for such devices.
Swan neck deformity
Swan neck deformity is the opposite of boutonniere deformity. In swan neck deformity, the joint farthest from the palm (the distal interphalangeal [DIP] joint) is bent toward the palm (DIP hyperflexion) while the joint nearest the palm (the proximal interphalangeal [PIP] joint) is bent back away (PIP hyperextension). Causes of swan neck deformity include tightness and/or rupture of the various tendons and synovitis affecting the PIP joint. The surgical approach to this deformity will depend on the cause or causes and the extent of damage. Also, approaches will vary depending on whether the deformity occurs in the thumb or other fingers. Surgery focusing on tendon repair and reconstruction may be used to correct the deformity. In cases where damage is severe, procedures such as arthroplasty and arthrodesis may be used.1
In mallet finger, the joint farthest from the palm (the distal interphalangeal [DIP] joint) is bent toward the palm (DIP hyperflexion). This deformity is caused by rupture of the extensor tendon and may be repaired using tendon repair and reconstruction.1
The carpus is the assembly of bones (carpal bones) that connects the hand to the forearm (the Latin word carpus is derived from the Greek word meaning wrist). When these bones become misaligned and erode due to the RA disease process, the carpus can become unstable and collapse. Carpal collapse typically requires either arthrodesis or arthroplasty, depending on the extent of damage to joints and bones. The goal of surgery is to repair deformity, correct joint instability, and relieve associated pain.1
Ulna head syndrome
In ulna head syndrome, inflammation and destruction of the ligaments and other structures where the ulna joins the wrist (at the carpal structure) leads to dislocation of the joint. Swelling and inflammation (the ulna head is typically enlarged) can lead to rupture of the tendons on the back of the hand and loss of function of select fingers. The approach to ulna head syndrome will depend on the extent of damage to joints, bones, and other structures, and may include arthrodesis or arthroplasty, as well as reconstructive surgery for tendon repair.1
Tendon rupture can result from tenosynovitis that persists over time, destroying the tendon itself. If rupture occurs, surgical reconstruction and repair is necessary to correct deformities and loss of function that result from rupture. During surgery, infiltrating synovial tissue (the underlying cause of the rupture) and other affected bone and tissue should be removed. Ruptured tendons can be treated by repair of the rupture, transfer of tendon from some other location in the body, or by tendon grafting.1
Risks and goals of surgery
Surgery for hand and wrist problems associated with RA can deliver dramatic benefits. However, it is important to have realistic expectations and understand the risks and limitations associated with surgery. Although it can improve function, surgery to address RA-related hand and wrist problems can never fully restore function.1
Your surgeon will evaluate your condition before surgery to determine whether surgery will be beneficial and which type of intervention will be most useful. If you are a good candidate for surgery, your surgeon will recommend a procedure that will enhance and improve function and prevent the development of deformities in the future.1
If you require reconstructive surgery for your hands and wrists but also have other joints that need surgical treatment, your surgeon will determine the priority for such surgery. For instance, surgery on the lower extremities is often performed beforehand and wrist surgery in order to avoid stress on the hands and wrists from use of mobility aids (walkers or crutches).
Additionally, joints closer to the body (called proximal) are generally repaired before those further from the body (called distal). For instance, the elbow will be operated on before the wrist, and the wrist before the hand. This is because bones joined at the elbow influence the alignment of those of the wrist, and those of the wrist influence the alignment of the fingers.1