Rheumatoid arthritis (RA) is a systemic disease (i.e. it affects multiple systems of the body). The primary treatment for RA is medical, and there are many new excellent drugs that can decrease pain and greatly slow the progression of RA. Surgery is used mainly to prevent and correct deformities, to protect and repair the finger tendons that RA damages, to treat destroyed and painful joints, and to return function. In addition, the appearance of the hand is usually improved by surgery.
The hands, wrists, elbows and/or shoulders can all be involved, leading to pain, weakness, and disability. In addition, tendons can rupture, leading to loss of finger motion and hand function.
Tenosynovitis (inflammation of the tendon lining) is one of the biggest problems in RA. Tenosynovitis often appears as a swelling on the back of the hand, and occasionally on the palmar side of the wrist. This tenosynovitis can lead to tendon rupture, stiffness and “triggering” of the digits, and carpal tunnel syndrome (because it takes up space and compresses the median nerve). Even though it doesn’t hurt, to prevent tendon rupture, which is harder to treat than to prevent, surgical excision should be performed if the tenosynovitis is present for 3-6 months while on appropriate medication. If tendon rupture occurs, surgery should be performed urgently, before the next tendon ruptures. Once tendon rupture has occurred, it becomes much more difficult to restore hand function. The easiest way to check for tendon rupture is to make the “Texas Longhorns sign”: You should be able to extend your small finger with the middle and ring finger flexed. If not, you should see a hand surgeon very soon. Remember: treating problems early is a lot easier for all involved then is treating them later.
RA can lead to pain, deformity and destruction of the hand. Pain can often be decreased by splinting, steroid injections, physical therapy, and occasionally by surgery. The fingers may drift / angle away from the thumb, making pinch and grasp difficult. The thumb may become deformed, further impairing function. These deformities may be treated by reconstructing the tendons and ligaments of the digits, fusing the joint (making it stiff, strong and pain-free), or joint replacement. These surgeries often reduce pain and deformity, and improve hand appearance and hand function.
The rheumatoid wrist is also a frequent source of problems. RA attacks the ligaments that support the wrist, leading to instability, deformity, pain, stiffness and weakness. In some cases the hand essentially “falls off” of the wrist. This wrist deformity exacerbates the hand deformities. The wrist problem usually needs to be corrected prior to, or simultaneously with, any hand reconstruction. The wrist may need to be partially or totally fused or, in suitable candidates, replaced. This usually greatly improves hand function.
If there are significant problems with the elbow or shoulder, they should probably be addressed first, before the hand or wrist. This is because it is difficult to effectively use the hand if the elbow and shoulder are painful and stiff. In younger patients, excision of the rheumatoid inflammation from the elbow and/or shoulder may help decrease symptoms. In many young patients, elbow arthritis can be treated by “Fascial Interposition Arthroplasty” (see the elbow arthritis section for more details). In the shoulder, fixing any rotator cuff tears helps decrease pain and improves function. In older patients, or in those with advanced disease, elbow or shoulder replacement may be appropriate.