The management of the rheumatoid wrist

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MINI-SYMPOSIUM: SURGICAL RHEUMATOLOGY

(iv) The management of the rheumatoid wrist

Current Orthopaedics

Volume 21, Issue 5, October 2007, Pages 344-357

http://www.sciencedirect.com/

B.R. Simmena, C. Kolling, a, and D.B. Herrena

aSchulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland

Summary

The wrist joint is often involved early in Rheumatoid arthritis (RA) and is

regarded as one of the main targets of the disease. As the wrist plays a key

role in the chain of the articulations in the upper extremity, treatment of

this joint preserves the patient's ability to work and to remain

independent.

When surgical therapy is considered, evaluation of the stage of the disease

is as important as the type of rheumatoid involvement. This can be achieved

by an extensive clinical and functional assessment of the whole extremity.

Moreover, adequate understanding of the radiological findings helps to

recognize the type of rheumatoid destruction, possible further development

of the disease and its direct consequences on surgical decisions. Several

classifications exist that describe the rheumatoid wrist involvement and

present possible treatment algorithms.

The success of surgical management depends on a well-considered strategy in

timing the different procedures. Prophylactic surgery may prevent further

destruction and deformation. This includes synovectomy of the tendons in

order to prevent attrition rupture, to avoid challenging tendon

reconstruction. Together with synovectomy of the wrist, including the distal

radio-ulnar joint, long-lasting pain relief can be observed. In later stages

of the disease, it is the extent of destruction at the radiocarpal level

which has great implications in reconstructive surgery. Possible options are

partial joint fusion, combined with an ulnar head resection, total wrist

fusion or wrist arthroplasty. In cases of severe destruction, however,

definitive stabilization by total wrist fusion is indicated.

A pain-free, stable wrist joint often outweighs the disadvantage of the lack

of mobility.

Keywords: Rheumatoid Disease; Synovitis; Arthrodesis; Arthroplasty;

Inflammatory wrist arthropathy; Surgical management; Classification systems

Corresponding author. Tel.: +41 44 385 75 83; fax: +41 44 385 75 90.