The Injury

Wrist Arthritis (Osteoarthritis) is not one of the most common conditions of the hand and wrist – Rheumatoid Arthritis is much more likely to affect the wrist. Typical signs and symptoms of Wrist Osteoarthritis include wrist pain, wrist stiffness and a loss of wrist range of movement. Because of the importance of wrist movement to hand function, Wrist Arthritis can have a serious effect on everyday activities. Wrist Arthritis occurs most commonly in people aged over 45, but can occur earlier in those people who have sustained a broken wrist or a sprained wrist that causes wrist joint instability.

To fully understand Wrist Arthritis it's helpful to have a basic introduction to the anatomy of the wrist. The wrist is made up of a complex series of joints that are responsible for rotational, forward and back, and side to side movements of the wrist and hand.

Anatomy of Wrist Arthritis

In the forearm, the joint between the Radius and Ulna bones is known as the Radio-Ulna joint. The joint between the forearm and small bones of the wrist is known as the Radio-Carpal joint and the joints between the small bones of the wrist are known as the Carpal joints. Rotation of the wrist largely takes place at the forearm when the Radius rotates around the Ulna. Forward and back and side to side movements of the wrist largely take place at the Radio-Carpal and Carpal joints, although there is a combination of joint movements with all wrist motion.

Wrist Arthritis most often occurs following a broken wrist – either the Scaphoid bone (Scaphoid Fracture) or the Radius bone (Colles Fracture). Typically the Scaphoid fails to heal due to its poor blood supply and a condition known as 'Avascular Necrosis' (breakdown of the bone due to a disruption of the blood supply to the broken Scaphoid). This breakdown of the Scaphoid causes changes in the mechanics of the wrist (this can be compared to taking an important brick out of a wall) that lead to 'Scaphoid Non-Union Advanced Collapse' (SNAC), where first the Styloid Tip of the Radius, then the joint between the Radius and the Scaphoid come into abnormal contact and become arthritic.

Wrist Arthritis may also occur subsequent to a wrist ligament injury. Following a Sprained Wrist, damage to the ligaments (most commonly the Scapho-Lunate ligament between the Scaphoid and Lunate bones) can cause wrist instability that leads to Wrist Arthritis via 'Scapho Lunate Advanced Collapse' (SLAC) – this causes total destruction of the joint surfaces of the Scapho-Lunate joint.

In both SNAC and SLAC type degeneration of the wrist, arthritis progressively affects:

  1. The Radial Styloid-Scaphoid junction,
  2. the Radio-Scaphoid joint.
  3. the joint between the Capitate and the Lunate, then
  4. all the joints between the bones of the wrist.

The initial trauma changes the mechanics of the wrist joints and sets off a process of progressive degeneration.

Like all joints, the ends of the bones of the wrist joints are covered in Hyaline cartilage. The Hyaline cartilage is ultra smooth to allow friction free movement. However, early damage to the superficial layers produces a frayed appearance. In time, with more stress, this frayed surface evolves into cracks or 'fissures' in the articular cartilage, which can leave the underlying bone exposed to the point that there is bone on bone contact. This causes inflammation of the wrist joint that is characterised by pain and swelling. Fragments of bone can become loose in the wrist causing locking or a restriction of wrist movement.

Non traumatic conditions, such as Kienböck's disease or Madelung's deformity, can also lead to Wrist Arthritis. In Kienböck's disease the Lunate bone 'dies' due to a lack of blood supply. The exact cause of Kienböck's is unknown, but may be due to repetitive stress across the wrist during work activities.

In other cases congenital disorders of the wrist, such as Madelung's deformity can lead to Wrist Arthritis. Madelung's deformity is a developmental problem that affects the Radius bone and causes abnormal wrist growth. Madelung's deformity is most often seen in teenage girls. The changes caused by Kienböck's disease or Madelung's deformity affect the mechanics of the wrist joints and lead to early degeneration and arthritis of the wrist joints.

Signs & Symptoms

Wrist pain is the most common symptom of Wrist Arthritis. Activities such as turning a door handle, removing the lid from a jar or gripping sports such as golf or tennis tend to be the things which aggravate Wrist Arthritis most – the first sign tends to be pain on these types of activities. As Wrist Arthritis progresses, loose pieces of cartilage or bone may cause a restriction of wrist movement. The inflammation that accompanies the breakdown of the joint surfaces can lead to painful swelling of the wrist. The diagnosis of Wrist Arthritis is confirmed with an x-ray which is characterised by a loss of joint space between the bones.

People with Wrist Arthritis typically 'overdo it', either in sport or during work activities, and they will experience a flare up from the affected joints. This flare up may last for 48 hours and usually consists of stiffness (particularly in the morning) and pain in the affected joint. Flare ups will settle with rest and the use of Non Steroidal Anti Inflammatory Drugs (NSAIDs) prescribed by a doctor. Ice therapy can also be helpful. Ice Packs can be applied to the wrist for periods of twenty minutes every couple of hours (never apply ice directly to the skin as it can cause an ice burn). The Aircast Hand and Wrist CryoCuff is an excellent method of providing ice and compression to the wrist joint. It can provide up to six hours of continuous cold therapy to relieve pain and reduce inflammation within the tissue.

A substantial time period may pass before there is another flare up of Wrist Arthritis, but typically each flare up will get progressively worse. The time interval between flare ups will decrease to the point where, eventually, the person will have pain even at rest. As the disease progresses the symptoms that start off being triggered by over activity become triggered by immobility. Whereas, in the early stages, rest is essential during a flare up period, disuse in the later stages will exacerbate the problem.

Treatment

 

The key to treatment of Wrist Arthritis is a thorough assessment by an orthopaedic doctor who specialises in hand and wrist injuries. This specialist doctor will order appropriate investigations such as x-rays and MRI scans and identify the specific area of the wrist that is causing the problem. Once the exact diagnosis is made and the specific wrist joints with arthritis are identified, then appropriate treatment can be initiated.

Patient education is one of the most effective treatment strategies for Wrist Arthritis. By understanding the nature of Osteoarthritis the patient can make adjustments to their lifestyle that will make the problem more manageable. Practical adjustments such as larger size grips on cutlery, tools and sporting equipment like golf clubs and rackets, can significantly reduce strain on the wrist joints.

Conservative treatment, such as physiotherapy can play an important role in preventing further wrist degeneration and maintaining wrist and hand function. Splinting using a Wrist Brace can be extremely effective as it removes stresses from the wrist that would otherwise cause further degeneration. Wrist Supports and Wrist Braces can be very effective at removing stresses from the wrist region and can help to prevent flare ups of Wrist Arthritis.

Flare ups of Wrist Arthritis can be treated with Non Steroidal Anti Inflammatory Drugs (NSAIDs) prescribed by a doctor to provide pain relief. Anti Inflammatory Gel can also help and doesn't have the side effects associated with Anti Inflammatory tablets. An Ice Pack may be used to relieve a hot painful wrist joint. Ice Packs can be applied for periods of twenty minutes every couple of hours (never apply ice directly to the skin as it can cause an ice burn). The Aircast Hand and Wrist CryoCuff can be used to provide continuous ice and compression to the wrist joint. It can relieve pain and reduce inflammation within the tissue. If chronic pain becomes the main problem then a TENS Machine may be helpful to relieve symptoms.

In the later stages, if there is pain at rest and during the night, and Wrist Arthritis is affecting activities of daily life such as washing, dressing and cooking, then more invasive treatment options may be appropriate. Injections of corticosteroid can decrease pain and help to improve wrist and hand function. However, as Wrist Arthritis progresses corticosteroid injections become less effective and wrist surgery should be considered.

The exact type of wrist surgery will depend on the circumstances of the patient and the exact joints in the wrist that are affected. Generally speaking there is a choice for the surgeon of Wrist Arthrodesis (wrist fusion) or Wrist Arthroplasty (wrist replacement). Wrist Fusion surgery is more suitable for people who have physically demanding jobs that involve heavy use of the wrist. This is because heavy manual work is still possible despite the restricted movement caused by the fusion. Following surgery the Aircast Hand and Wrist CryoCuff can provide continuous ice and compression to the wrist joint. It can relieve pain and reduce inflammation within the tissue. Following wrist fusion a wrist brace should be worn for around 6 weeks and a return to full activity is possible after around 3 months of physiotherapy treatment.

In people who don't need to use the wrist for heavy labour then a wrist replacement is a more appropriate procedure. Wrist joint replacements provide pain relief and allow wrist movement that allows the patient to do activities such as writing, but heavy lifting is not allowed following a wrist replacement. Following wrist replacement surgery the wrist is immobilised for up to six weeks to prevent loosening of the new metal components of the replacement wrist. Another six weeks of physiotherapy is usually required to restore wrist range of motion and strength.

Wrist arthroscopy (keyhole surgery) is constantly developing and is more appropriate if the specialist has identified early damage to specific bones and joints of the wrist. This technique allows loose fragments of bone and cartilage to be removed in order to restore normal wrist function. Wrist arthroscopy is much less invasive than conventional wrist joint surgery and has been demonstrated to decrease pain and improve range of motion.

Prevention

Each individual case is different and a full assessment by a Chartered Physiotherapist will identify factors that may exacerbate the problem. Where the wrist joint is affected maintenance of full range of motion is encouraged to reduce stiffness. Wrist movement can be lost if the person doesn't use the full range of motion because of pain. A physiotherapist can use manual techniques to help maintain the range of movement. Massage can help to relieve wrist pain and restore function.

Repetitive wrist movements and prolonged work with tools should be avoided. Frequent breaks should be taken to stretch and take the wrist joint through its full range of motion, as the Hyaline cartilage draws most of its nourishment from the Synovial Fluid within the joint, and this has the effect of providing nutrients to the joint surfaces.

Pain in the wrist joint can lead to weakness in the hand and finger muscles. This can lead to a loss of grip strength. Exercises to maintain hand and finger muscle strength are encouraged to help maintain hand function. This strengthening should be done under the supervision of a physiotherapist. Grip Strengtheners, Therapeutic Putty and Hand Therapy Balls can all be used to maintain grip strength and dexterity.




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