Rheumatoid arthritis (RA) and the hand

RA is a rare, but often, destructive disease of joints that frequently presents itself to the hand surgeon. It is a characterised by severe inflammation of the lining of the joints and tendon sheaths (synovium), and this can, if untreated lead to severe joint and tendon degeneration.

What hand problems can it cause?

It commonly affects the small joints of the hands, causing stiffness, pain, weakness and instability. It usually presents in a symmetrical fashion on both hands and wrists at the same time. The severity of the symptoms is dependent on the stage of the disease and the response to treatment. In severe, long standing cases the joints themselves can become severely arthritic. It can also present with pain and stiffness over the palmar surface of the fingers as a “tendinitis / tenosynovitis.” Rarely it can even present with rupture of the tendons themselves, with loss of movement of the affected finger.

The treatment of RA is complex, and should be overseen by an experienced rheumatologist (a physician specialising in joint diseases). Over the last 20 years there have been tremendous advances in the field of rheumatology with new classes of drugs to both inhibit the inflammation and reduce the risk of damage to bones, tendons and joints. For this reason, hand surgeons see less and less of end stage problems that RA can cause.

The specific surgical problems a hand surgeon would deal with would be:

End stage arthritis with severely painful joints – initially managed with splints, but often requiring joint replacement, or sometimes fusion

Acute severe synovitis (inflammation of tendon or joint lining) of the digits, that does not respond to drugs or steroid injection, requiring surgical excision of the inflamed tissues

Tendon ruptures – often requiring repair or reconstruction with a graft or tendon transfer (moving a well functioning strong tendon and muscle to restore the actions of a damaged one).

Carpal tunnel syndrome and tightness of finger flexion due to inflammation and synovitis of the tendons in the carpal tunnel. Generally treated with carpal tunnel decompression and removal of the synovial tissue.

RA and the wrist

Wrist degeneration is common with RA. It can present with differing patterns of arthritis with the wrist joint, as well as the distal radio ulnar joint (the articulation of the two forearm bones at the wrist) These problems sometimes require surgery for pain relief and restoration of function.