By Christopher Maender, M.D.
Board Certified Orthopedic Surgeon
Orthopedic Center of Illinois
The wrist is an amazing joint. It is made up of the radius, ulna and 8 little wrist bones. All of these bones must work together for our wrists to work normally. They are held together tightly by many ligaments. A ligament holds two bones together. There is a great deal of motion through the wrist. This motion is possible because of the complex interaction between all of these bones. This motion positions our fingers to do our daily activities like open a jar, throw a ball, play darts, swim, brush your teeth, swing a hammer, among many other activities. Unfortunately, the wrist (like all joints) can wear out. This “wearing out” is called arthritis. As the joint wears out, the motion becomes limited, it gets inflamed and many times it hurts.
What is Arthritis?
Simply defined, arthritis is inflammation of one or more joints. “Arthro-“ means joint and “-itis” means inflammation. A joint is where two or more bones join together. At the ends of these bones there is a smooth cap covering over them. This cap is made up of cartilage. The cartilage of our joints is more smooth and more friction free than any substance we can manufacture. It’s pretty amazing! It’s like a thin coating of non-stick teflon that moves against another thin coating of non-stick teflon on the other side of the joint. Our joints are used everyday and see a lot of wear and tear through the years. Falls, sprains and direct blows to the wrist can cause damage to the joint as well. Unfortunately, our body is not able to repair this cartilage after we damage it. After injuries, this protective coating gets damaged and is no longer smooth and pristine. Just like our non-stick pans, when the coating gets scratched things start to stick and it doesn’t work like it once did. This damage leads to wearing down of the cartilage and inflammation of the joint, i.e. arthritis.
Even though there are hundreds of causes of arthritis, almost all arthritis of the wrist is only caused by three types: osteoarthritis, traumatic arthritis and rheumatoid arthritis. Osteoarthritis is wear and tear arthritis where the cartilage wears down with time. Traumatic arthritis is caused by injuries in the past where the joint was damaged. Rheumatoid arthritis is an autoimmune disease where your body sees the joint lining as foreign and tries to remove the joint similar to your body’s reaction to an infection.
Arthritis of the wrist causes swelling, pain, limited motion and weakness. It is worsened by lifting, gripping and twisting activities.
Initial treatment begins with non-surgical care. Modifying your activities is the first step in relieving symptoms. Braces for a short period of time can be very helpful at relieving symptoms and can delay and even eliminate the need for surgery. There are many braces available from rigid to soft with varying amounts of support. The more rigid the splint, obviously the more support it gives the joint, but a more rigid splint can be more difficult to wear and use throughout the day. Each patient will have to find how much support they require for pain relief. Anti-inflammatory medicines can also be very helpful at controlling symptoms. They will not reverse the arthritis, but it will decrease the inflammation and pain, hence their name. After these measures fail, an intra-articular cortisone injection is frequently tried and can help alleviate an acute exacerbation of pain. Cortisone is a powerful anti-inflammatory medicine.
Patients who fail these conservative measures are candidates for surgical reconstruction. The goal of surgery is to provide a pain-free, stable and functional wrist. Most options will sacrifice motion for pain relief. Nobody wants to give up motion, but in the wrist it is often necessary to obtain pain relief. This is usually well tolerated but does take time to adjust. Surgical options include: removing the arthritic bones, fusions, and joint replacements.
Remember the wrist is a complex joint made up of the radius, ulna and 8 wrist bones that all have to work together. If there is arthritis between only a few of them, then it can be an option to remove those bones. In this procedure, three of the bones are removed which eliminates the worn out portion. As a trade off, this will limit your motion. Studies have shown typical results of 80% of strength and 50% of motion compared to the opposite side.
Another option is partial fusions. A fusion is where two or more bones are made to fuse together and become one larger bone. This eliminates the worn out portions of the wrist, but again will limit motion. In order to fuse bones together, they have to be prepared and then held together with pins, screws or plates until it heals. This means that you will need a cast and then a brace to protect the wrist until it fully heals. Studies have shown typical results, similar to the removal of bones, with 80% strength and 50% motion. In this procedure the bones need to heal together and there is a 10% chance that they do not heal together and the surgery needs to be redone.
If the arthritis is more severe and involves more of the bones, then a complete wrist fusion is necessary. This involves removing all of the motion at the wrist for pain relief. All up and down and side to side motion will be eliminated, but forearm rotation will be preserved. Grip strength is expected to be 70% of normal. It typically takes 6 months to adjust to the wrist fusion.
A final option is wrist joint replacement. This involves removing the damaged joint and replacing it with an artificial device. This has had several variations through the years and is still being perfected. You could expect 40-50% motion and good pain relief. The downside of the wrist replacement is that it can loosen and wear out with time. It is placed into the small wrist bones and does not have the support like a knee or hip replacement. The typical replacement will last for 10 years.
The biggest limitation is with lifting or weight bearing and it is not recommended to lift more than 10-20 pounds with the arm. Too much activity or lifting will lead to loosening and breakage of the implant.
The wrist is a complex joint and the most common reason it wears out is a prior injury. When the wrist is arthritic and painful, try non-surgical treatments first: activity modification, a wrist brace, anti-inflammatories, and steroid injections. When those fail, then surgical options are very successful at alleviating the pain.