Osteoarthritis of the Wrist
This is the normal “wear and tear” arthritis that is usually seen as we get older, although some people never develop OA. The articular cartilage, which allows for smooth movement of the joints, begins to wear away, causing painful symptoms, and eventually leads to bone-on-bone changes. It is usually a result of genetics, meaning one or both of your parents had OA or perhaps you injured your wrist at some point, making it more susceptible to the development of OA.
OA symptoms usually develop over time, with stiffness, especially in the morning, swelling, weakness and pain. Range of motion is affected, but is limited to the wrist joint, and it may be more difficult to perform daily activities.
OA is usually diagnosed by physical examination, x-rays and taking a complete history of the patient’s symptoms. There is no blood test for OA. OA can affect one or both wrists at the same time.
Rheumatoid Arthritis
This chronic type of Arthritis is caused by inflammatory changes in the body where the body begins to attack its own joints, causing erosion of the cartilage. The exact cause is unknown, but it is suspected that a trigger of some nature starts the process in a patient. If left untreated, it can result in devastating deformity and pain for the patient, because it affects not only bone but soft tissue as well. It always affects both wrists at the same time.
The symptoms of RA are much like those of OA; however the knuckle joints of the hand will also be affected, not simply the wrist. Pain, swelling, stiffness and weakness are also common.
Diagnosing RA can be done with a blood test. Your physician will also take x-rays to ascertain the extent of the disease and complete a physical examination and history.
Psoriatic Arthritis
Another form of Arthritis afflicts patients who have the chronic skin disorder of psoriasis. PA or Psoriatic Arthritis is found in about 30% of the patients who have psoriasis. Like RA, it is caused by an auto-immune disorder which causes the body to attack its own joints. Unlike RA, PA can affect only one wrist at a time or both wrists. Like the other forms of arthritis, the symptoms are pain, swelling, stiffness and reduced range of motion. With PA, the joints may also feel warm to the touch.
PA is diagnosed much like the other forms of Arthritis, with a complete history and physical exam, x-rays and blood work. Your physician will look for the presence of psoriasis, although some patients who have PA will not exhibit skin symptoms of psoriasis. PA looks different on x-rays than RA, so your physician will study your imaging tests carefully.
Blood work will reveal that you do not have RA and will perhaps reveal a genetic marker HLA-B27. More than half of those with PA will carry this marker. You will also have high levels of inflammation in your body and this will be reflected in your labs.
Treatment of Wrist Arthritis
In the early stages, all forms of arthritis may be treated similarly.
• Anti-inflammatory medication – either OTC or prescription
• Activity modification
• Heat or Ice
• Physical Therapy
• Bracing
• Specific Exercise Program
• Steroid Injections into the Wrist Joint
In the later stages, OA is treated differently that RA and PA because it is caused by a different form of inflammatory response in the body. OA is progressive and can damage joints eventually. However, because RA and PA are chronic, aggressive and can permanently damage and deform joints quickly, a Rheumatologist will manage the care of those patients. Orthopaedists will be consulted for procedures and injections as necessary.
Treatment of Moderate to Severe RA or PA
Because of the potential for damage and deformity to your wrist and knuckles, your Rheumatologist will monitor you carefully to ascertain when stronger medications are needed. Thankfully, there are now drugs that have been shown to effectively arrest the damage caused by RA and PA. These drugs are called Biologics and work to suppress the immune system that is attacking the joints. These drugs are taken by IV, intramuscularly or one is now available orally. Although they can work miracles for RA or PA sufferers, they have many side-effects and patients must be closely monitored while on these drugs.
Drug Specifically for PA
An oral drug for PA was recently approved called Otezla. It works differently than the Biologic drugs by targeting specific molecules within the immune cells and inhibiting a specific enzyme. In doing so, Otezla decreases the inflammatory response of psoriasis and PA. Most patients see good results with Otezla; however, there are side-effects, so patients must be monitored by their Rheumatologist when taking this medication.
Surgical Treatments
For late stage OA, RA and PA with bone-on-bone changes, the most effective options for pain relief are surgical. There are three surgical options for a severely arthritic wrist:
• Joint replacement – the natural wrist is replaced with a prosthetic implant, allowing for wrist movement. Post-operatively, a cast will be worn for the first several weeks. Then, a removable protective splint will be worn for the next 6 to 8 weeks. Gradual exercise will be added and patients can expect to regain about 50% of normal range of motion. Currently, wrist prostheses last about 10-15 years, with careful use.
• Wrist Fusion – The arthritic bones of the wrist are fused together, preventing some or all movement and reducing pain. The fusion can be partial or total. Post-operatively, the wrist will be casted for six weeks to two months to allow for fusion. Then a removable splint will be applied that can be taken off for bathing and during stretching. As soon as your surgeon is sure that fusion has taken place by x-raying your wrist, you will begin rehabilitation and strengthening exercises.
• Carpectomy – the arthritic bones of the wrist are removed, allowing for partial wrist movement. Post-operatively, the wrist is splinted in a padded, solid cast for two weeks. After two weeks, sutures are removed, a removable splint is applied and the patient may begin rehabilitation.
All of these procedures are performed by an Orthopaedic surgeon who specializes in hand surgery and these may be done at an Outpatient Surgery Center.
Recovery and Rehabilitation
For each procedure, Physical Therapy with a Hand Specialist would be prescribed to help the patient regain the maximum use of their wrist and fingers. Therapy might continue for as long as several months, depending upon the progress of the patient.