Arthritis of the Wrist and Hand
What is arthritis?
Arthritis is a disease of the various tissues inside the joints. A joint is a point at which two or more bones meet. Arthritis can occur as a result of acute (short-term) or chronic (long-term) inflammation (irritation and swelling) 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 (inherited) and environmental causes.
With arthritis, joints continue to worsen as the cartilage wears down. (Cartilage is the smooth “cushioning” tissue that lines joints.) This wear-down of cartilage causes changes in the structure that can be seen on X-rays. The surrounding soft tissues may also get weaker. (Soft tissues are the tendons, ligaments, muscles, and synovial membranes that connect, support, or surround the joint.)
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.
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 damage in approximately 60% of adults over age 60, and in 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 the ages of 20 and 40.
Symptoms and Causes
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 and deformity and can limit the range of motion of the joint.
A number of factors are thought to be important in the development of osteoarthritis. Mechanical considerations (for example, joint stability and alignment, or arrangement) affect how forces are distributed across the joint, and therefore have an impact on how long the joint will last. Also, certain substances (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. These people are usually 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 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 body’s immune system attacks its own tissue.) With regard 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 grows, causing local damage to 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.
What are the symptoms of arthritis?
Not all patients with arthritis will complain of pain, loss of motion, or deformity. The severity of the symptoms is only loosely linked with the severity of arthritis as seen on X-rays.
Minor joint injuries may aggravate existing joint damage, resulting in arthritic symptoms that the patient has not had before. These symptoms are more likely to be caused by the pre-existing arthritis, and not by the recent, relatively minor traumatic injury.
Symptoms of 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 deformities that limit patients’ ability to use their hands. In addition, patients in the early stage of rheumatoid arthritis may have such symptoms as weakness/tiredness, general discomfort, and loss of appetite.
Symptoms of arthritis from any cause can include:
- Pain that is limited to the joint itself. This is the main symptom. At first, the pain will come and go and is 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 joints 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 body’s response to the constant irritation. The deformity occurs as these stabilizing soft tissues are worn away.
- Weakness that results from joint pain, loss of motion, and joint deformity.
Diagnosis and Tests
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.
Management and Treatment
What are the non-surgical treatments for arthritis?
Osteoarthritis: 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.
- Injecting joints with a cortisone preparation to relieve symptoms for a period of time. In some cases, these injections may be repeated.
- Exercising the joints – gently – through the full range of motion on a daily basis. You may need to see a hand therapist.
Unfortunately, there are no known medications or other treatments that can slow 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 understood that the treatment must also include medications that can not only help symptoms but also slow the progression (advance) of disease. These drugs include disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate and newer biologic agents. Oral glucocorticoids, such as prednisone, can be used to help reduce symptoms, but they do not appear to be disease-modifying. Also, the risks of glucocorticoids tend to outweigh the benefits.
What are the surgical treatment options for arthritis of the wrist and hand?
Surgery is considered when treatments, such as those mentioned above, no longer relieve the pain, or when deformity keeps the patient from being able to use his or her hand. 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 in 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 a 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. For 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 in the hand is recommended for “low-demand” patients, especially those with rheumatoid arthritis involving the joints at the base of the fingers. In these patients, 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 functionally limiting disorder, many treatments are available to reduce symptoms and help patients. Newer medications for the treatment of rheumatoid arthritis have led to a major 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.