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Diseases & Conditions

Arthritis of the Hand & Wrist

What is arthritis?

Arthritis is a disease of the various tissues inside joints. A joint is the point at which two or more bones meet. Arthritis can occur as a result of acute (short term) or chronic (ongoing) inflammation in a joint and its surrounding soft tissues. It can also occur after trauma to the joint (such as a broken finger) or possibly from genetic (heredity) and environmental causes.

With arthritis, joints continue to wear down as the cartilage wears down. Cartilage is the smooth ‘cushioning’ tissue that lines joints. This wear down of cartilage causes structural changes that can be seen on X-rays. The surrounding soft tissues may also deteriorate. Soft tissues are the tendons, ligaments, muscles, nerves, blood vessels, skin, fat, and synovial membranes that connect, support, or surround other structures and organs of the body.

Arthritis is frequently, but not always, painful and may result in a reduced range of motion in the joint, joint deformity, and loss of function. Although almost any joint in the body can be affected, the hand and wrist are common locations for many of the common types of arthritis.

What are the types and causes of arthritis?

Osteoarthritis (also known as degenerative arthritis) is the most common type of arthritis. It may affect one or more joints anywhere in the body. Osteoarthritis usually occurs later in life and commonly affects the hands and larger weight-bearing joints such as hips and knees. Osteoarthritis can cause pain, deformity, and limit the range of motion of the joint.

A number of factors are thought to be important in the development of this disease. Mechanical considerations (eg, joint stability and alignment) affect the distribution of forces across the joint and therefore impact the joint’s life span. Also, certain substances (ie, biochemical factors) in the cartilage itself are thought to play a role in the eventual abnormal changes of this tissue.

Risk factors for osteoarthritis include age, traumatic injuries (such as a broken wrist), joint infections, and possibly overuse. Some people inherit the tendency to develop osteoarthritis. How this happens is not well understood. Typically, these individuals are affected at an earlier age.

Arthritis may also result from inflammatory conditions that can occur anywhere in the body. The most common inflammatory condition is rheumatoid arthritis. Other inflammatory “arthropathies” include lupus, gout, pseudogout, ankylosing spondylitis, and the arthritis related to inflammatory bowel disease or psoriasis.

Rheumatoid arthritis is an inflammatory and presumed autoimmune disease that affects the entire body, especially the joints. (Autoimmune means the disease attacks its own tissue. Instead of protecting tissues of the body, the body’s natural defenses destroy the tissues.) With regards to the joints, rheumatoid arthritis targets the synovium. Synovium is a tissue that lines and nourishes joints and tendons throughout the body. As part of this condition, the synovium proliferates, causing local destruction of bones, joints, and soft tissues. Rheumatoid arthritis commonly begins in the hands, wrists, ankles and feet and often affects the same joints on each side of the body. Eventually many other joints are affected. The cause of rheumatoid arthritis is unknown, though genetic factors are thought to be critical.

Who is affected by arthritis?

Osteoarthritis affects virtually everyone, especially older people. Women are usually affected more than men and often at an earlier age. X-rays reveal joint destruction in approximately 60% of adults over age 60; and 80% to 90% of patients over age 75.

Rheumatoid arthritis affects about 1% of the adult population. Women are three times more likely than men to develop this disease. Though it may strike persons of any age, it typically begins between ages 20 and 40 years.

What are the symptoms?

Not all patients with osteoarthritis will complain of pain, loss of motion, or deformity. Symptom severity is only loosely linked with the severity of the arthritis as judged on X-rays.

Minor joint injuries may aggravate existing joint destruction, resulting in arthritic symptoms not previously experienced. These symptoms are more appropriately linked to the pre-existing arthritis, and not the recent, relatively minor traumatic injury.

Symptoms resulting from osteoarthritis and rheumatoid arthritis are in some ways the same. However, rheumatoid arthritis often will cause more long-lasting morning stiffness and lead to more swelling and redness of the joints. This inflammation of the soft tissues surrounding the joints can eventually result in severe deformities that limit patients’ ability to use their hands. In addition, patients in the early stage of rheumatoid arthritis may experience such symptoms as weakness/tiredness, general discomfort, and loss of appetite.

Symptoms of arthritis from any cause can include:

  • Pain limited to the joint itself. This is the main symptom. Initially, pain will come and go and made worse when in use (such as when gripping heavy objects). However, pain is relieved with rest. There may be days or weeks without pain, but also periods of constant discomfort. As the disease advances, the pain becomes more constant, even occurring at rest. The pain changes from a dull ache to a sharp pain, which sometimes extends beyond the joint area.
  • Loss of motion in the joint as arthritis progresses. However, sometimes as motion is lost, pain is lessened.
  • Joint motion that is accompanied by grinding, clicking, or cracking as the cartilage continues to wear down.
  • Joints that swell and often become red and tender to the touch. This is a sign of damage to the tissues surrounding the joint and the bony response to the constant irritation. Deformity occurs as these stabilizing soft tissues are worn away.
  • Weakness that results from joint pain, loss of motion, and joint deformity.

How is arthritis diagnosed?

A combination of patient history, physical examination, X-ray results and other findings are used to diagnose arthritis. In the case of rheumatoid arthritis, blood tests are frequently helpful.

What are the non-surgical treatments for arthritis?

First-line treatments for osteoarthritis include:

  • cutting back, stopping or adapting the activities that are causing pain
  • splinting the affected joint for short periods of time. Splinting keeps the joint still, which helps reduce pain.
  • applying heat/ice to reduce pain and swelling
  • taking acetaminophen (Tylenol®) and anti-inflammatory medicines (such as ibuprofen (Advil®/Motrin®) to reduce pain and swelling. The prescription drug celecoxib (Celebrex®) is approved for the relief of the signs and symptoms of osteoarthritis and rheumatoid arthritis.
  • Injecting joints with a cortisone preparation to relieve symptoms for a period of time. In many cases, these injections may be repeated every few months.
  • exercising the joints – gently -- through the full range of motion on a daily basis

Unfortunately, there are no known medications or other treatments that can slow down the loss of cartilage or make new cartilage.

Rheumatoid arthritis. Treatment for rheumatoid arthritis includes many of the same treatments used for osteoarthritis; however, these measures alone are not enough. It is now well understood that the treatment must also include medications that can not only help symptoms, but also slow the progression of disease. These drugs include disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate (Trexall®) and leflunomide (Arava®) and biologic agents such as etanercept (Enbrel®), infliximab (Remicade®) and rituximab (Rituxan®). Oral glucocorticoids, such as prednisone, can be used to help reduce symptoms, but they do not appear to be disease modifying. Also, their risks tend to outweigh their benefits.

What are the surgical treatment options for arthritis?

Surgery is considered when treatments, such as those mentioned above, no longer relieve the pain, or when deformity prevents functional use of the hand. Surgery is also recommended in some patients with inflammatory arthritis. In these patients, the surgery stabilizes joints and prevents tendon damage. Deformity, loss of motion and pain that is not adequately controlled are the main reasons for surgery.

Surgical options include a variety of reconstructive procedures as well as joint fusion.

Reconstructive surgery for osteoarthritis involving the base of the thumb is commonly performed and highly effective. The procedure involves removing one of the arthritic bones and replacing it with a piece of rolled-up tendon from the forearm (the part of the arm between the wrist and elbow) of the same arm. This procedure provides excellent pain relief, allows good range of motion, and restores function to the thumb.

Joint fusion (also called arthrodesis) is used to treat arthritis in many hand and wrist joints. As an example, the joint at the tip of the finger is frequently affected by osteoarthritis. Fusing this joint with the joint below it stabilizes and straightens the joint, which eliminates pain. However, the joint is no longer able to be bent.

Joint replacement is recommended for ‘low-demand’ patients, especially those with rheumatoid arthritis involving the joints at the base of the fingers. In these individuals, joint replacements may improve the range of motion, making the fingers more useful. Pain is improved, as is use of the hand. However, these artificial hand joints do not provide the same stability as joint fusion and will, in time, wear down.

While arthritis in the hands and wrists is common and can be a painful and a functionally limiting disorder, many treatments are available to reduce symptoms and help patients. Newer medications available for the treatment of the rheumatoid arthritis have led to a significant reduction in the severe hand deformities that these diseases, when untreated, can cause. Surgical treatments for osteoarthritis and rheumatoid arthritis can provide pain relief and allow patients to return to many of the activities they enjoy.

References

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 10/10/2013...index#7082