(iv) The management of the rheumatoid wrist

Abstract

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.