Wrist Arthritis

Wrist arthritis is a condition that results in inflammation, pain, and stiffness in the wrist. This article explains what causes wrist arthritis and how it can be diagnosed.

Related Anatomy

The anatomy of the wrist joint is probably the most complex of all the joints in the body. The wrist is a collection of many bones and joints, which allow the use of our hands in many different ways. The wrist must be extremely mobile to give hands a full range of motion. At the same time, the wrist must provide the strength for gripping heavy objects.

Fifteen bones form connections from the end of the forearm to the hand. The wrist itself contains eight carpal bones. These bones are grouped in two rows across the wrist. Beginning with the thumb side of the wrist, the proximal row of carpal bones is made up of the scaphoid, lunate, and triquetrum. The distal row is made up of the trapezium, trapezoid, capitate, hamate, and pisiform bones.

One reason that the wrist is so complicated is because every small carpal bone forms a joint with the bone next to it. The wrist joint is composed of many small joints. In the wrist, articular cartilage covers the sides of all the carpals and the ends of the bones that connect from the forearm to the fingers. Matrix metalloproteinases and proinflammatory cytokines (e.g., interleukin-1) are important mediators of cartilage destruction in patients with primary osteoarthritis. Interleukin-1 increases the synthesis of matrix metalloproteinases and thereby plays an important role in osteoarthritis.

During the initial stages of osteoarthritis, the superficial layers of the articular cartilage fibrillate and crack. As degeneration progresses, deep layers become involved, resulting in erosions that produce bare subchondral bone.

Denatured type II collagen is found in abundance in osteoarthritic articular cartilage, with decreased water content and decreased ratio of chondroitin sulfate to keratan sulfate constituents.

In chronic injuries of the scapholunate ligament and in scaphoid nonunions, osteoarthritis starts in the radioscaphoid joint and progresses to the capitolunate joint. The radiolunate joint remains unaffected during the early stages.

See Also: Wrist Anatomy

Wrist Arthritis Types

Rheumatoid arthritis of the wrist is a progressive inflammatory disease characterized by synovitis and joint destruction. Synovial cell proliferation results in pannus formation and fibrosis, which cause erosion of cartilage and bone. Cytokines, prostanoids, and proteolytic enzymes mediate this process. A cell-mediated immune response to an unidentified antigen appears essential in the pathogenesis of rheumatoid arthritis. Proinflammatory cytokines, such as interleukin-1 and tumor necrosis factor , and T-cell initiation are the central mediators in rheumatoid arthritis.

In gouty arthritis, allantoin, the enzyme uricase that breaks down uric acid into a more soluble product, is deficient, resulting in tissue deposition of crystalline forms of uric acid. Although hyperuricemia is a risk factor for the development of gout, the exact relationship between hyperuricemia and acute gout is unclear. Acute gouty arthritis can occur in the presence of normal serum uric acid concentrations. Conversely, many patients with hyperuricemia may never develop gouty arthritis.

Secondary wrist osteoarthritis resulting from previous trauma to the carpal bones or ligaments results in abnormal joint reaction forces with each movement of the wrist, causing misdirected forces that lead to some combination of loading forces. This process produces degeneration of the articular cartilage, resulting in radiocarpal arthritis, selective intercarpal arthritis, or pancarpal arthritis, depending on the initial injury and subsequent healing.

Scaphoid fractures can result in osteoarthritis by three mechanisms:

1. If the fracture results in nonunion, abnormal movement occurs between the fragments, leading to an abnormal distribution of forces across the wrist and resulting in early degeneration of the radioscaphoid joint.
2. In a malunion, the height of the scaphoid may be reduced, and the range of motion in one or more planes may be restricted, resulting in increased strain and leading to osteoarthritic changes over time.
3. Scaphoid fractures resulting in avascular necrosis of the proximal pole can lead to collapse and degeneration of the radioscaphoid joint, which may involve the lunate and then the entire wrist.

Kienböck disease results in lunatomalacia. The weakened lunate is subjected to a nutcracker effect between the prominent radius and the capitate head, causing progressive collapse. In its final stages, Kienböck disease leads to osteoarthritis in the radiolunate joint.

See Also: SNAC and SLAC of the wrist

Wrist Arthritis Symptoms

Pain is the predominant symptom of osteoarthritis. Pain that is usually aggravated during the extremes of movement in the early stages gradually worsens to involve the full available range of motion.

The range of motion may gradually deteriorate, and the osteoarthritis progresses. In severe cases, the wrist has no movement, resulting in stiffness.

Deformity is another feature of wrist arthritis. This is common in rheumatoid arthritis wrist, in which deformity may be complicated by associated subluxation of the radiocarpal and inferior radioulnar joints.

Swelling of the wrist, one of the most common manifestations of rheumatoid arthritis, may occur because of synovial thickening.

Because the wrist stabilizes the hand for functioning, pain and deformity may result in weakness of the hand grip. Wrist deformity and instability reduce support for the hand to grasp, impairing dexterity, whereas stiffness and the inability to extend the wrist deprive the fingers of the tenodesis effect.

Classic rheumatoid wrist arthritis begins with radial deviation of the wrist, resulting in ulnar head prominence. This progresses to supination and ulnar translation of the carpus, leading to volar subluxation of the radiocarpal joint. Crepitus in the wrist becomes more apparent as joint disease progresses.

See Also: Grip Strength Test

Radiology

The radiographic evaluation system used for wrist arthritis is the Outerbridge classification of cartilage defects.

1. Grade 0 signifies normal cartilage.
2. Grade I chondral lesions are characterized by softening and swelling, which often require tactile feedback with a probe or other instrument to assess. A Grade II lesion describes a partial-thickness defect with fissures that do not exceed 0.5 inches in diameter or reach subchondral bone.
3. Grade III is fissuring of the cartilage with a diameter > 0.5 inches with an area reaching subchondral bone.
4. Grade IV includes erosion of the articular cartilage that exposes subchondral bone 

Haims and colleagues think that magnetic resonance imaging (MRI) of the wrist (41 indirect MR arthrograms and 45 unenhanced [nonarthrographic] MR images) was not adequately sensitive or accurate for diagnosing cartilage defects in the distal radius, scaphoid, lunate, or triquetrum, as demonstrated by correlating MRI with arthroscopic findings.

In cases of synovitis and ulnar-sided pathology, MRI results are a strong indicator of which areas need to be addressed with the arthroscope. Cartilage defects are often confirmed after diagnostic arthroscopy is completed. Arthroscopic abrasion arthroplasty, subchondral drilling, and microfracture can be performed for focal chondral defects in patients with moderate degenerative wrist arthritis or when plain radiographs indicate vascular necrosis. MRI is a sensitive method for excluding the diagnosis of avascular necrosis and for evaluating the extent to which fibrocartilaginous repair tissue has formed postoperatively.

Wrist Arthritis Treatment

Nonoperative Wrist Arthritis Treatment are primarily aimed at relieving pain in the wrist. These Include:

1. Rest in the form of splinting with removable thermoplastic splints may be useful during exacerbations. The wrist is usually maintained in neutral or slight dorsiflexion, which is the functional position for the wrist.
2. Nonsteroidal anti-inflammatory drugs can control inflammation, thereby reducing synovitis and swelling. They are most useful in inflammatory arthritis.
3. Anti-rheumatism medications, including systemic steroids, methotrexate, and anti–tumor necrosis factor, help patients with rheumatoid arthritis.
4. Allopurinol may be useful in patients with gouty arthritis of the wrist.
5. Steroid injections, with or without local anesthetic into the joint, may be performed, but the results are equivocal.
6. Methylprednisolone acetate injection into the wrist may play a role in treating a degenerate triangular fibrocartilage.

Surgery for wrist arthritis depends on the severity and the extent of arthritis in the wrist:

1. In the earliest stages, when the problems are mainly caused by carpal instability (i.e., prearthritic stage), the aim of the surgery is to rectify the anatomic position and to correct the carpal instability to prevent degeneration of the wrist.
2. In the late stages of severe wrist arthritis, a partial or total wrist arthrodesis or an arthroplasty may be contemplated.
3. In the intermediate stages, when the patient has well-established arthritis but a well-preserved range of motion, no standard treatment has been established.

The available options are wrist arthroscopic débridement and wrist denervation.

Wrist Arthroscopic synovectomy has become a well-described procedure:

• Aggressive arthroscopic débridement, including radial styloidectomy and partial resection of the scaphoid, has been reported.
• Resection of the lunate in patients with Kienböck disease may be performed arthroscopically.
• In the distal radioulnar joint, arthroscopy can be used for débridement of the TFCC and for a modified Darrach procedure that involves distal ulna resection.
• Arthroscopic reconstructive procedures have been described for repair of the lunate-triquetrum ligament and ulnocarpal ligament complex and for capsular placation.

References

1. Haims AH, Moore AE, Schweitzer ME , et al . MRI in the diagnosis of cartilage injury in the wrist . AJR Am J Roentgenol. 2004 ; 182 : 1267 – 1270.
2. Slattery C, Kweon CY. Classifications in Brief: Outerbridge Classification of Chondral Lesions. Clin Orthop Relat Res. 2018 Oct;476(10):2101-2104. doi: 10.1007/s11999.0000000000000255. PMID: 29533246; PMCID: PMC6259817.
3. Amrami KK, Askari KS, Pagnano MW, Sundaram M . Radiologic case study. Abrasion chondroplasty mimicking avascular necrosis . Orthopedics. 2002 ; 25 :1018, 1107- 1108 .
4. Larsen A, Dale K, Eek M . Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn (Stockh). 1977 ; 18 : 481 – 491 .
5. Yao J, Osterman AL . Arthroscopic techniques for wrist arthritis (radial styloidectomy and proximal pole hamate excisions). Hand Clin. 2005 ; 21: 519 – 526.
6. Dautel G, Merle M . Chondral lesions of the midcarpal joint . Arthroscopy. 1997 ; 13 : 97 – 102 .
7. Viegas SF, Wagner K, Patterson R, Peterson P. Medial (hamate) facet of the lunate . J Hand Surg Am. 1990 ; 15 : 564 – 571 .
8. Viegas SF . The lunatohamate articulation of the midcarpal joint . Arthroscopy. 1990 ; 6 : 5 – 10 .
9. Yao J, Osterman AL . Arthroscopic techniques for wrist arthritis (radial styloidectomy and proximal pole hamate excisions) . Hand Clin. 2005 ; 21 : 519 – 526 .
10. Weinstein LP, Berger RA . Analgesic benefi t, functional outcome, and patient satisfaction after partial wrist denervation . J Hand Surg Am. 2002; 27 : 833 – 839