Rheumatoid arthritis (RA) is a systemic disease (ie. it affects much 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 this disease damages, to treat destroyed and painful joints, and to return function. In addition, cosmesis 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.
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, surgical excision should be performed if the tenosynovitis is present for over 3-6 months despite being on anti-rheumatoid medication. If tendon rupture occurrs, 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 then 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 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, joint fusion (removing the joint), or joint replacement. This often reduces pain and deformity, improves cosmesis, and improves 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 is essentially ‘falling off’ of the wrist. This worsens any hand deformities, and usually needs to be corrected prior to, or simultaneously with, any hand reconstruction. As with the joints in the hand, the wrist can either be reconstructed, fused (stiffened) 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. It is difficult to effectively use the hand if the elbow and shoulder are painful and stiff. In younger patients, excision of the rheumatoid disease from the elbow and/or shoulder may help decrease symptoms. In many young patients, elbow arthritis can be treated by fascial interposition arthroplasty: please see the ‘elbow arthritis’ section for more details regarding this. In the shoulder, treating any rotator cuff disease also helps decrease pain. In older patients, or in those with advanced disease, elbow or shoulder replacement can be an effective option.
