Osteoarthritis

Osteoarthritis (OA) is a progressive condition that destroys the smooth articular cartilage covering the ends of bones. Healthy joints move easily because of articular cartilage. Osteoarthritis causes this cartilage to wear away. When the bare bones rub against each other, it results in pain, stiffness, and weakness.

(Left) Articular cartilage protects the ends of bones where joints meet. (Right) In this x-ray of a wrist with osteoarthritis, the cartilage is destroyed and the healthy space between bones is narrowed (arrow).

(Left) Reproduced from J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003. (Right) Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic disease that attacks multiple joints throughout the body. Rheumatoid arthritis often starts in smaller joints, like those found in the hand and wrist. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.

Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In RA, the defenses that protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and soften bone.

RA often affects the joint between the two bones of the forearm, the radius and ulna. It can soften and erode the ulna which can cause tearing of the tendons that straighten your fingers. This can result in joint deformity, such as bent wrists and gnarled fingers.

In this x-ray of rheumatoid arthritis the carpal bones have collapsed into the radius and ulna.

Nonsurgical Treatment

In general, early treatment is nonsurgical and designed to help relieve pain and swelling.

Several therapies can be used to treat arthritis, including:

• Modifying your activities. Limiting or stopping the activities that make the pain worse is the first step in relieving symptoms.
• Immobilization. Keeping the wrist still and protected for a short time in a splint can help relieve symptoms.
• Medication. Taking non-steroidal anti-inflammatory medications, such as aspirin or ibuprofen, can reduce both pain and swelling.
• Exercise. Following a prescribed exercise program. Specific exercises can improve the range of motion in your wrist.
• Steroid injection. Cortisone is a powerful anti-inflammatory medicine that can be injected into the wrist joint.

When rheumatoid arthritis symptoms are not adequately controlled by the above therapies, additional medications with varying risks and benefits may be prescribed by your doctor. Specific medicines called disease-modifying anti-rheumatic drugs are designed to stop the immune system from destroying the joints. The appropriate use of these medications is directed by a rheumatologist.

Surgical Treatment

When nonsurgical treatments are no longer effective, resulting in progressive loss of hand and wrist function, surgery is an option. The goal of surgery is to relieve pain and to preserve or improve hand function.

Surgical options include:

• Removing the arthritic bones. In this procedure, three carpal bones are removed. This procedure, called a proximal row carpectomy, will relieve pain while maintaining partial wrist motion.
• Fusion. When motion is the source of pain, carpal bones can be fused together to make one, solid bone. A fusion can be partial, in which just some of the carpal bones are fused together. This eliminates pain and retains some wrist motion. When the arthritis is extensive, a complete fusion may be necessary. In this procedure, all of the carpal bones are fused together, as well as the radius. This completely eliminates wrist motion, but does not affect forearm rotation.
• Joint replacement. This surgery removes the damaged joint and replaces it with an artificial device (prosthesis). This surgery may help retain or recover wrist movement.

(Left) In a fusion, the bones are held together with a combination of a plates, screws, and pins. (Right) In a joint replacement, the worn-out bones have been replaced with an artificial implant.

You and your physician should discuss the surgical options and select the one that is best for you.