Arthritis of the Hand and Wrist
What is arthritis?
Arthritis is a disease of the cartilage in joints. It can occur as a result of acute or chronic inflammation of a joint and its surrounding soft tissues, following trauma to the joint, or from so far poorly defined genetic and environmental causes. It is characterized by progressive joint deterioration with loss of the smooth "cushioning" cartilage that lines joints. This wear causes structural changes visible on X-rays. The stabilizing soft tissues may also deteriorate. Arthritis is frequently, but not always, painful and may result in limitation of motion, joint deformity, and loss of function.
What are the types and causes of arthritis?
The most common form of arthritis, degenerative arthritis or osteoarthritis, may affect one or more joints anywhere in the body. Degenerative arthritis occurs later in life and mainly affects the hands and large, weight-bearing joints. Degenerative arthritis can cause pain, deformity, and limitation of motion.
A number of factors are thought to be important in the development of this disease. Mechanical considerations (e.g., joint stability and alignment) affect the distribution of forces across the joint and therefore impact the joint's longevity. Risk factors include traumatic injuries, joint infections, and possibly heavy use. Some people inherit the tendency to develop degenerative arthritis, though this genetic predisposition is not well understood. Typically, these individuals are affected at an earlier age.
Arthritis may also result from a systemic inflammatory condition, the most common of which 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 a disease of the synovium, a tissue which 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. Commonly, the disease begins in peripheral joints (hands and feet) and is often symmetrical, eventually involving multiple joints. Its cause is also unknown, though genetic factors are thought to be critical. Rheumatoid arthritis is an inflammatory disease that affects the entire body, especially joints.
Who is affected by arthritis?
Degenerative arthritis affects virtually everyone, especially older patients. Females are usually more commonly affected than males and often at an earlier age. X-rays reveal joint degeneration in approximately 60 percent of adults over age 60 and 80 percent to 90 percent of patients over age 75.
Inflammatory arthritis, specifically rheumatoid arthritis, affects about 2.5 percent of the adult population. Women are three times more likely than men to develop this disease. Though it may strike persons of any age, the peak age of onset is between ages 20 and 40 years.
What are the symptoms?
Not all patients with degenerative arthritis will complain of pain, loss of motion, or deformity. Symptom severity is only loosely correlated with the severity of the arthritis as judged on the X-rays.
Minor joint injuries may aggravate underlying joint degeneration resulting in arthritic symptoms not previously experienced. These symptoms are most appropriately linked to the pre-existing arthritis not the recent, relatively minor traumatic injury.
Symptoms resulting from degenerative arthritis and rheumatoid arthritis are in many ways the same. However, rheumatoid arthritis more often affects multiple joints and is characterized by episodic flares associated with severe soft tissue manifestations such as swollen, red, hot, and tender joints. This inflammation of the soft tissues surrounding the joints can eventually result in severe deformities that limit the patient's ability to use their hands. In addition, especially early in rheumatoid arthritis, these patients may experience a variety of systemic symptoms like fatigue, malaise, and loss of appetite.
Symptoms of arthritis from any cause can include:
- Localized joint pain as the predominant symptom. Initially, the pain will be intermittent and aggravated by activity but relieved by rest. There may be days or weeks without pain alternating with periods of constant discomfort. As the disease progresses, the pain becomes more constant, even occurring at rest. The character of the pain changes from a dull ache to sharp, sometimes radiating pain. Generally, the pain is worse when the barometric pressure falls.
- Joint mobility will diminish as the arthritis progresses. Sometimes, as motion is lost, pain is lessened.
- Joint motion will be accompanied by grinding, clicking, or cracking as the cartilage progressively deteriorates.
- Joints will swell and often become red and tender to the touch. This signifies damage to the tissues around the joint and the bony response to the constant irritation. Deformity occurs as these stabilizing soft tissues are lost.
- Weakness results from pain, loss of motion, and deformity.
How is arthritis diagnosed?
Findings that include a combination of patient history, physical examination, and X-ray results are used to diagnose arthritis. In the case of rheumatoid arthritis, blood tests are frequently helpful.
What is the treatment for arthritis?
First line treatment for early arthritis involves a host of conservative measures including activity modification, splinting, heat /ice, acetaminophen, and anti-inflammatory medicines. Joint injection with a cortisone preparation can provide improvement in symptoms for a varying length of time. In many cases these injections may be repeated at several month intervals. It is important to gently exercise the joints through the full range of motion daily.
Is surgical treatment for arthritis available?
When conservative measures no longer relieve the pain, or when deformity prevents functional use of the hand, surgery is offered. Surgery is also recommended in some patients with inflammatory arthritis to stabilize joints and prevent tendon damage. Pain that is not adequately controlled is the main reason for surgery. As a general rule, joint motion is not improved following surgery and, in many cases, is lessened in the pursuit of pain relief. Strength, also, does not reliably improve, except that activities that require strength become much less painful.
Surgical options include a variety of reconstructive procedures, as well as joint fusion (also called arthrodesis), which makes a joint solid and eliminates motion.
Reconstructive surgery for degenerative arthritis 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 of the same arm. This procedure provides excellent pain relief, allows good range of motion, and restores function to the thumb.
Joint fusion is utilized for the treatment of arthritis in many hand and wrist joints. The distal interphalangeal joint at the tip of the finger is frequently affected by degenerative arthritis. Fusion stabilizes and straightens the joint, eliminating pain. Joint replacement is indicated for low-demand patients, particularly those with rheumatoid arthritis involving the metacarpophalangeal joints at the base of the fingers. In these individuals joint replacements may improve the functional arc of motion, making the fingers more useful. Pain is improved, as is use of the hand. However, these artificial joints do not provide the same stability afforded by a 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 minimize the symptoms and help patients. Newer medications available for the treatment of the inflammatory arthropathies have led to a significant reduction in the severe hand deformities that these diseases, when untreated, can cause. Surgical interventions for both types of arthritis can provide great pain relief and allow patients to return to many of the activities they enjoy.