The wrist is a complex and remarkable joint that allows us to accomplish many of the hand and finger movements that we rely on for a range of daily tasks, from unscrewing the lid on a jar to brushing our hair. Normally, we take for granted the functionality of our wrists. However, when RA affects the wrist, it can make a range of common tasks and movements difficult or impossible, leading to pain and discomfort, as well as significant disability.
As is true with RA and joints throughout the body, the sooner diagnosis is made and treatment initiated, the greater the likelihood that joint damage can be minimized or prevented. The availability of disease-modifying anti-rheumatic drugs (DMARDs) including newer biologics that are effective at slowing or preventing structural damage to the joints, means that the wrist and other joints can often be preserved and function maintained.
Among joints in the arm, the wrist is the most commonly affected in patients with RA. In fact, the wrist can be one of the first joints affected by RA. Early and aggressive treatment with drugs to control inflammation and to slow or prevent joint damage is important. Chronic inflammation of the wrist (and other joints) can result in deformities and loss of function.
During early stages of the disease, a patient may find it difficult to bend his or her wrist backward. Other symptoms may include inflammation, swelling, pain, and weakness and will usually be accompanied by involvement in the joints of the fingers.1,2
Similar to the hands and other joints in RA, wrist involvement is usually symmetrical, affecting both wrists. A patient will typically experience stiffness that is worse in the morning.3
In later stages of RA, the wrist joint may become partially separated from the bones of the arm, allowing these to drift from their normal positions, with the head of the ulna (where it meets the styloid process) becoming increasingly prominent. Softening and erosion of the ulna can also result in rupture of the tendons that extend to the fingers. This can result in deformities, including a bent wrist and gnarled fingers.1,2,4
Management of symptoms affecting the wrist
Treatment of RA symptoms affecting the wrist depends on the severity of symptoms and the nature and extent of damage, as well as the patient’s goals and needs. Options include drug and non-drug treatments, and surgery.1
Drug treatments. The initial approach to treatment should involve medications to control inflammation and pain (including analgesics [NSAIDs], disease-modifying anti-rheumatic drugs [DMARDs], and glucocorticoid injection). Injection of glucocorticoid directly into the wrist may be useful in controlling acute inflammation.1
Non-drug management approaches. Rest and/or restricted activity and application of heat or cold may be useful in providing relief from acute pain. Splinting is commonly used to immobilize and support the wrist and relieve acute pain. However, use of splinting for too long a period of time may result in atrophy of the muscles that stabilize injured joints.1
Surgery. If joint symptoms do not respond to medication or other management approaches and there is progressive loss of function in the hand and wrist, surgical interventions may be used. The goal of wrist surgery is to improve or restore wrist and hand function and to provide pain relief.
Surgical options depend on the nature of damage to joints and other structures and may include removal of damaged bone, complete or partial fusion of carpal bones, or joint replacement.1
Surgical fusion of the wrist is used when motion causes pain. Depending on the extent of joint damage, some or all the carpal bones may be fused. Partial fusion may provide pain relief, while preserving some wrist motion. With extensive disease, complete fusion may be incorporated with all carpal bones fused together along with the radius. This procedure eliminates motion of the wrist, while preserving the ability of the forearm to rotate.1
In joint replacement surgery, the damaged joint is removed and replaced with an artificial or prosthetic joint. With this procedure, wrist movement may be preserved or recovered.1