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Osteoarthritis

Osteoarthritis can develop due to normal wear-and-tear in the wrist, particularly in older people and those who have a family history of arthritis. It is a common problem for many people after they reach middle age, though it may occur in younger people, too.

In osteoarthritis, the smooth and slick articular cartilage that covers the ends of the bones gradually wears away over time. Because the cartilage surface has little to no blood supply, it is unable to heal or regenerate when it becomes injured or worn down.

As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone and lead to pain and stiffness in the joint.

(Left) This X-ray of a healthy wrist shows normal joint space. (Right) In this wrist with osteoarthritis, the cartilage is worn and the healthy space between bones is narrowed.

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

Osteoarthritis in the wrist can also develop from Kienböck's disease. In Kienböck's disease, the blood supply to one of the carpal bones — the lunate — is disrupted, causing the bone to die and slowly collapse. Over time, this collapse can lead to changes and arthritis in the joints around the lunate.

Posttraumatic Arthritis

Posttraumatic arthritis can develop after an injury, such as a broken wrist bone (scaphoid fracture or distal radius fracture) or a torn ligament. This trauma can cause a direct injury to the cartilage or a delayed wearing of the cartilage due to a change in the way the bones move together — such as after a ligament tear.

Posttraumatic arthritis can develop over many years from the initial injury. Even with proper treatment, an injured joint is more likely to become arthritic over time.

Inflammatory (or Rheumatoid) Arthritis

Rheumatoid arthritis is a chronic disease that can affect multiple joints throughout the body. The condition often starts in smaller joints, such as those found in the hand and wrist. It is symmetrical, meaning it usually affects the same joint on both sides of the body.

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

Inflammatory arthritis often affects the joint between the two bones of the forearm, the radius and ulna. This can cause the ulna to become prominent, leading to wear and possible rupture of the tendons that straighten your fingers. This, in turn, can cause more deformity and loss of function in your hand.

The exact cause of inflammatory arthritis is not known — there are no clear genetic or environmental factors. However, although it is not directly inherited, researchers believe some people have genes that could make them more likely to have the disease.

Surgical photo of the lunate bone in a patient with Kienböck's disease. The cartilage in the center of the joint surface has worn down, exposing the bone underneath (red arrow). The black arrows indicate an area of healthy cartilage.

Physical Examination

Your doctor will talk with you about your overall health and medical history and ask you to describe your symptoms. They will perform a careful examination of your hand and wrist, looking for:

• Reduced range of motion
• Any areas of pain or tenderness
• Joint instability
• Swelling or other changes in appearance

During the examination, your doctor will measure the range of motion in your wrist.

During the examination, your doctor may also evaluate:

• Finger and thumb mobility — to determine how well your tendons and joints are functioning
• Nerve function — to determine whether you have another condition that may be affecting your wrist, such as carpal tunnel syndrome (nerve compression)

Tests

X-rays. X-rays provide detailed images of dense structures, such as bone. X-rays of your wrist will help your doctor learn more about the exact location and severity of your arthritis. They can also help your doctor distinguish between various types of arthritis.

Blood tests. Your doctor may recommend blood tests to determine which type of arthritis you have. With rheumatoid and other types of inflammatory arthritis, blood tests are important for an accurate diagnosis. Osteoarthritis is not associated with blood test abnormalities.

Nonsurgical Treatment

In general, initial treatment for arthritis is nonsurgical in nature and designed to help minimize your symptoms.

Nonsurgical treatment options may include:

• Activity modification. Limiting or stopping the activities that make your pain worse is the first step in relieving symptoms.
• Immobilization. Wearing a wrist splint for a short time will help support the joint and ease the stress placed on it by frequent use and activities.
• Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, naproxen, and ibuprofen can help reduce both pain and swelling. Topical NSAIDs can be applied directly to the skin around the joint.
• Exercise. Specific exercises will help improve range of motion and function in your wrist. Your doctor or a physical therapist can help develop an exercise program that meets your specific needs.
• Steroid injection. Cortisone is a powerful anti-inflammatory agent that can be injected into an arthritic joint. Although an injection of cortisone can provide relief and reduce inflammation, the effects may be temporary.
• Other therapies. This may include using "contrast soaks" — alternating soaking your wrist in warm and cold water — to help reduce swelling.

If your symptoms of inflammatory arthritis are not adequately controlled by the above therapies, your doctor may prescribe additional medications. These medications — called disease-modifying anti-rheumatic drugs (DMARDs) — are designed to stop the immune system from attacking the joints.

Like all medications, DMARDs have both risks and benefits. Your use of DMARDs will be directed by a rheumatologist.

Surgical Treatment

If nonsurgical treatment does not relieve your pain and your quality of life has been significantly affected by arthritis, your doctor may recommend surgery.

The goal of surgery is to relieve pain while preserving or improving hand function. Typically, this is done by minimizing or eliminating bone-on-bone contact. There are a number of procedures for arthritis of the wrist. Your doctor will talk with you about which procedure will work best in your case.

Proximal row carpectomy. In this procedure, your doctor removes three carpal bones in the row of bones closest to the forearm. The procedure is designed to reduce your pain while maintaining some wrist motion.

(Left) The three wrist bones that are removed in a proximal row carpectomy. (Right) X-ray image of a wrist after the procedure.

Fusion. If motion is the source of your pain, your doctor may recommend fusion. Fusion is essentially a welding process in which the bones are fused together so they heal into a single, solid bone. The theory behind fusion is that if the painful bones do not move against each other, they should not hurt.

During the procedure, your doctor removes the damaged cartilage and then uses pins, plates, or screws to hold the joint in a permanent position. Over time, the bones fuse, or grow together— similar to the way the fractured ends of a bone heal together.

In some cases, your doctor can perform a partial fusion in which just some of the carpal bones are fused together. This addresses the damaged joint surfaces but leaves the healthy joints intact to preserve some wrist motion.

In this partial wrist fusion, the scaphoid bone has been removed and screws have been used to hold four carpal bones in place.

If your arthritis is extensive, however, a complete wrist fusion may be necessary. In this procedure, all of the carpal bones are fused together, along with the radius (one of the bones in the forearm). Although all wrist motion is eliminated in a complete fusion, forearm rotation and finger/thumb motion are generally preserved.

In this complete wrist fusion, the bones are held together with a combination of plates, screws, and pins.

Total wrist replacement (arthroplasty). In total wrist replacement, your doctor removes the damaged cartilage and bone in your wrist and then puts in new metal or plastic joint surfaces to restore the function of the joint. Replacing the wrist joint relieves the pain of arthritis while allowing more wrist movement than fusion.

Like all joint replacements, total wrist replacements do not last forever and may need to be revised (done again) in the future.

In this total wrist replacement (arthroplasty), the worn-out bones have been replaced with an implant made of metal and plastic.