The hand and wrist have a very complex anatomy. The wrist is composed of eight irregularly-shaped bones. Each bone is connected to its neighbor by tough soft tissue ligaments that stabilize the bones and guide their movement. The wrist is designed to be stable and to allow a large amount of motion. The wrist is so versatile that it can support body weight, as well as exactly position the hand to thread a needle.
The hand is another precision instrument. The capabilities of the hand are one of the features that distinguish humans from apes. Because of our wrist, hand and thumb, we can manipulate, make tools and position objects around us to our advantage.
A joint occurs when one bone moves against another. In order for the motion to be smooth and require less energy, the surface of the bone is covered with cartilage within the joint. Cartilage is a specialized material that allows the bones to move easily. It can be compared to the Teflon in the frying pain. When the Teflon is present the eggs don’t stick but when it is scraped or chipped the eggs turn out to be a mess.
Arthritis occurs when cartilage is damaged or worn. When this happens the joint becomes painful and mobility decreases. In an attempt to counteract this, the lining of the joint, or the synovium, produces more fluid to lubricate the joint. In many cases this causes swelling, pain and further decrease of motion.
Arthritis can be the result of trauma, wear and tear, or a specific disease process. Any injury that damages the cartilage, or fracture that enters the joint, can result in traumatic arthritis. Our ability to make new cartilage mostly stops at the end of our growth. When cartilage is damaged or destroyed by trauma, our ability to restore normal cartilage is limited. This results in the onset of traumatic arthritis.
Osteoarthritis is a much more common condition and occurs as people age. The cartilage gradually wears away. Osteoarthritis of the hand and wrist usually occurs in the last joints of the finger and at the base of the thumb.
Rheumatoid arthritis and other associated conditions also affect the joints of the hand. Chemicals are produced by the body, which weaken and destroy the joint and the joint surface. This results in swelling, inflammation and deformity.
In order to make a diagnosis of arthritis in the hand, the physician takes a history to find out the duration of the symptoms, if there has been any trauma and any family history. A physical examination will note loss of motion in the joint, deformities and if the joint is unstable. Some degenerated joints develop spurs or nodes that can be felt. X-rays are usually obtained to quantify the location of the arthritis and the severity. A normal x-ray shows a darkened space between the ends of the bones, which represents the thickness of the cartilage. As arthritis progresses the space narrows, thus implying the degree of arthritis.
MRI imaging is sometimes done to more accurately evaluate the cartilage. It is also especially useful to determine if there is damage to the multitude of ligaments about the wrist.
Arthroscopy is both an alternative, as well as an adjunct, to x-ray and MRI. Arthroscopy of the wrist and hand is an outpatient surgical procedure where the surgeon inserts a fiberoptic cord connected to a camera into the joint by way of small incisions. The condition of the joint, stability of the ligaments and cartilage can be directly evaluated. In some cases surgical procedures can be done through the arthroscope to correct various conditions.
The symptoms of early arthritis are usually intermittent pain with use and stiffness after rest. As the cartilage deteriorates, there may be swelling, permanent loss of motion and pain at rest. As the cartilage continues to thin, grating sensations may occur or the joint may appear loose. In some cases cysts or spurs develop.
Treatment of the arthritic hand and wrist is dependent upon the severity of the arthritis. In addition to age, activity level and goals of the patient must be considered. In the early stages, over-the-counter anti-inflammatory medications have been found to be very successful. Naproxen and ibuprofen are two of the most common drugs. Prescription anti-inflammatory medications are also an alternative. They counteract the inflammation and swelling caused by an arthritic joint. In some cases the physician may prescribe splinting or rest to quiet and inflamed joint. When specific joints become greatly inflamed, steroid injections may be an option. These can be repeated but multiple injections may lead to unwanted side effects.
When nonoperative treatment has failed, surgery is an option. When a joint in the wrist or hand has been destroyed it can either be replaced or fused. A joint fusion connects the two bones of the joint together. This usually decreases pain but eliminates motion. Especially in the wrist, with multiple joints, excision of specific arthritic bones in the wrist, with fusion of other small bones, is an option. In other situations, resection of the joint and insertion of the patient’s own tissue may resolve the pain and maintain motion.
Joint replacement tries to eliminate pain and provide motion to the joint. Although not as common as hip and knee replacement, there have been great improvements in the past several years in regard to wrist and finger joint replacement. The wrist can be replaced with metal and plastic components, similar to hip replacements. Finger joints can also be replaced with either plastic, modified carbon implants or a combination of metal and plastic components. While joint replacement in the hand and wrist does not restore normal motion and function, it strives to eliminate pain and restore some motion to allow the majority of daily activities.
Arthritis of the hand and wrist is relatively common. Treatment is determined by the extent of the damage. In the majority of patients, nonoperative and conservative care greatly eliminate the symptoms. In more severe cases, fusion, partial fusion and tissue or total joint replacement is an option. Complete replacement of the joint is becoming more common because of advances in technique, a well as the increasing age of our population.