The Rheumatoid Hand and Wrist

Rheumatoid arthritis involves the hand and wrist in up to 90% of patients, more than any other region, and the hand deformities are the visible hallmark of the disease. The pattern is bilateral and symmetrical, with MCP and PIP synovitis and progressive deformity, in contrast to the DIP-predominant pattern of osteoarthritis.

Who. RA affects approximately 0.5-1% of the global population, women three times as often as men (3:1). Onset peaks at 30-50 years, though all ages are affected.

What it costs the hand. Grip strength is reduced by up to 70% in advanced disease, and pinch weakens, key pinch especially once the thumb is involved. Buttoning, writing and opening jars are affected early. Deformity then progresses in a predictable pattern, from synovitis to ligament destruction to joint subluxation.

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Synovitis drives everything. Dorsal synovitis starts at the wrist and MCP joints, and produces hypertrophied pannus that invades and destroys periarticular structures through enzymatic digestion and mechanical pressure. Pannus erodes articular cartilage and bone, and the destruction of stabilising ligaments and tendons leaves an imbalance between flexors and extensors that produces the classic zig-zag deformities. Medical control of synovitis is therefore the foundation of management. In the hand and wrist the process targets:

• Joint capsules and ligaments - instability, subluxation and ulnar drift
• Extensor tendons - attrition rupture over the caput ulnae
• Flexor tendons - FPL especially, in the carpal tunnel over the scaphoid (the Mannerfelt lesion)
• Articular cartilage and bone - marginal erosions, cartilage loss, osteopenia
• Intrinsic muscles - fibrosis and contracture drive swan-neck deformity and contribute to MCP subluxation

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Zig-zag collapse. When the carpus supinates and deviates radially as RA destroys it, the metacarpals point more ulnarly, so radial deviation of the wrist drives ulnar deviation at the MCP joints. Wrist position governs MCP alignment, and correcting the wrist is critical before or during MCP surgery.

Why the ulnar side fails first. The DRUJ and the ulnar-sided wrist structures are the first to be affected in RA:

• The ulnar styloid and head have thin overlying soft tissue
• The ECU tendon sheath is a common site of early synovitis
• The TFCC is vulnerable to pannus invasion
• The extensor tendons lie directly over the subluxing ulnar head, EDM especially, as the most ulnar tendon at the DRUJ

The rheumatoid thumb. The Nalebuff classification is the most commonly examined system for RA thumb deformity. The thumb is classified by the joint that is the primary site of destruction, which then dictates the surgical plan. There are six types, and Type I, the boutonniere, is by far the most common.

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History. The questions that shape the plan:

• Disease duration and treatment - DMARDs, biologics, steroid history
• Hand function - grip, pinch and ADLs such as buttoning, key turning and writing
• Deformity progression - the rate of change, and which fingers were affected first
• Pain - localised to specific joints (wrist, MCP, PIP)
• Tendon function - sudden loss of extension (rupture), triggering

Examination. Inspect for the zig-zag deformity pattern, MCP ulnar drift, wrist supination and thumb posture, and palpate for boggy synovitis, the caput ulnae and the crepitus of tendon fraying. Test active finger extension tendon by tendon and look at the flexion cascade. Then test passive correctability: can the MCP joints be reduced, and is the PIP deformity flexible or fixed?

The caput ulnae. A dorsally subluxed ulnar head at the DRUJ. The caput ulnae sign is the prominent ulnar head, visible and palpable dorsally, especially with the forearm pronated. The piano key test demonstrates the subluxation: press the ulnar head and it depresses like a piano key, rebounding when released. The sharp bony prominence it creates attritions the extensor tendons, EDM and the EDC to the small and ring fingers especially.

Testing the tendons. Test each finger's active extension independently. Test EDM by asking the patient to extend the small finger while the others are held flexed: inability is the Vaughan-Jackson rupture, and extension is then lost progressively from ulnar to radial digits. For FPL, test thumb IP flexion against resistance.

The Mannerfelt lesion is easily missed. FPL rupture in RA is often painless and may present as an incidental finding, the patient simply unable to flex the thumb IP joint. Unlike the extensor ruptures it is a flexor-side attrition in the carpal tunnel, so always examine FPL function: loss of thumb IP flexion against resistance is diagnostic. Caught early, carpal tunnel release alone may prevent further ruptures.

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Radiographs first. PA, lateral and oblique views of both hands and wrists, bilateral for comparison and to document the symmetrical pattern typical of RA. Add the Norgard (ball-catcher) view, the most sensitive plain radiograph for early RA erosions in the hands: it profiles the MCP joints and wrist in slight oblique and ulnar-deviated position, revealing erosions that may be missed on a standard PA. The oblique projection exposes erosions and malalignment that can be underestimated on a single frontal view. Look for:

• Periarticular osteopenia
• Joint space narrowing and marginal erosions
• Carpal collapse, ulnar translocation and scapholunate dissociation
• MCP volar subluxation and ulnar drift

Larsen grading is a standardised scoring system for RA radiographic progression.

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Ultrasound or MRI if a rupture is suspected. Ultrasound gives a dynamic assessment of tendon integrity, synovitis (power Doppler) and tenosynovitis, and detects active disease before advanced radiographic destruction. MRI is the gold standard for early erosions, pannus and bone marrow oedema, and assesses tendon quality. The key findings are tendon discontinuity, surrounding synovitis and the bony spurs causing attrition.

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CT for planning (optional). CT assesses bone stock for arthroplasty or arthrodesis and the severity of carpal bone erosion. It helps plan wrist arthrodesis fixation and evaluate the architecture of the distal radius and ulnar head.

Medicine before surgery. Medical optimisation with DMARDs is the prerequisite to elective surgery, and the rheumatologist and hand surgeon must work as a team. Surgery on an actively inflamed joint has higher complication rates, so the general principle is to optimise medical management first, then operate on the structural consequences. Exceptions include acute tendon ruptures, which need urgent surgery to prevent further attrition, and severe nerve compression.

The surgical sequence. The rule is distal to proximal: DIP and PIP deformities first, then the MCP joints, then the wrist, with proximal procedures (elbow, shoulder) performed last. The wrist is the exception. Significant wrist disease drives MCP deformity, so the wrist is stabilised before or at the same time as MCP surgery, and procedures that use the same approach are combined when possible, such as a dorsal wrist operation with the extensor repair.

Medical ManagementTendon RupturesFingersMCP JointWristThumb

DMARD Therapy Timeline

DiagnosisImmediate

• Methotrexate, the first-line conventional synthetic DMARD (csDMARD)
• Adjuncts: hydroxychloroquine, sulfasalazine, leflunomide (combination therapy common)
• Bridging: short-term low-dose prednisone while awaiting DMARD effect (6-12 weeks)

3-6 MonthsIf Inadequate Response

• Biologic DMARDs (bDMARDs): TNF inhibitors (adalimumab, etanercept), IL-6 inhibitors (tocilizumab), B-cell therapy (rituximab)
• JAK inhibitors: tofacitinib, baricitinib, upadacitinib (targeted synthetic DMARDs)
• Treat-to-target: aim for remission or low disease activity

Surgical PlanningPre-operative

• Methotrexate: generally continue through surgery (evidence supports safety)
• Biologics: withhold 2-5 half-lives before surgery; restart once the wound has healed (usually 2 weeks)
• Prednisone: stress dose coverage if on chronic steroids
• Perioperative DMARD management is a joint decision with rheumatology

Treat the bone at the same operation. Transferring a tendon without removing the sharp bony edge guarantees re-rupture, so the bone causing the attrition must be addressed at the same operation. For the caput ulnae the two main options are the Darrach procedure (distal ulnar excision) and the Sauve-Kapandji (DRUJ arthrodesis with a proximal ulnar pseudarthrosis), compared under Wrist. The non-operative measures are DMARDs and a wrist splint to reduce attrition.

Single EDM rupture

Treatment of Bone

Darrach procedure or Sauve-Kapandji to remove attrition source

Tendon Reconstruction

EIP transfer to EDM stump (distal)

Post-op

Splint 4 weeks, then therapy

Multiple EDC ruptures

Treatment of Bone

Darrach or Sauve-Kapandji plus dorsal tenosynovectomy

Tendon Reconstruction

Side-to-side transfer from intact adjacent EDC; EIP to EDM

Post-op

Splint 4-6 weeks, controlled mobilisation

FPL rupture (Mannerfelt)

Treatment of Bone

Carpal tunnel release, remove scaphoid osteophyte

Tendon Reconstruction

FDS (ring finger) transfer to distal FPL; or intercalary graft

Post-op

Splint 4 weeks, then progressive flexion

Extensor rupture with poor remaining tendons

Treatment of Bone

Address underlying bone (ulnar head excision)

Tendon Reconstruction

Flexor-to-extensor transfer (FDS ring or middle through interosseous membrane)

Post-op

Prolonged rehabilitation 8-12 weeks

Surgical Options for Extensor Tendon Ruptures

Rupture Pattern	Treatment of Bone	Tendon Reconstruction	Post-op
Single EDM rupture	Darrach procedure or Sauve-Kapandji to remove attrition source	EIP transfer to EDM stump (distal)	Splint 4 weeks, then therapy
Multiple EDC ruptures	Darrach or Sauve-Kapandji plus dorsal tenosynovectomy	Side-to-side transfer from intact adjacent EDC; EIP to EDM	Splint 4-6 weeks, controlled mobilisation
FPL rupture (Mannerfelt)	Carpal tunnel release, remove scaphoid osteophyte	FDS (ring finger) transfer to distal FPL; or intercalary graft	Splint 4 weeks, then progressive flexion
Extensor rupture with poor remaining tendons	Address underlying bone (ulnar head excision)	Flexor-to-extensor transfer (FDS ring or middle through interosseous membrane)	Prolonged rehabilitation 8-12 weeks

An ECU rupture or subluxation is managed by ECU reconstruction or transfer, with stabilisation of the DRUJ.

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Swan-neck. Non-operative care is a PIP extension-block splint and exercise. The surgical options are FDS tenodesis, lateral band relocation and PIP arthrodesis.

Boutonniere. A PIP extension splint and DMARDs first; surgery is central slip reconstruction or PIP arthrodesis.

When to operate. Non-operative care is DMARDs, MCP splinting and intrinsic stretching. Surgery is indicated for pain, progressive deformity despite medical management, functional impairment, and loss of passive correctability.

Synovectomy

Indication

Persistent MCP synovitis despite 6 months DMARDs, passively correctable

Technique

Dorsal approach, remove hypertrophied synovium, preserve ligaments

Outcome

Temporary relief; often needs later arthroplasty

Crossed intrinsic transfer

Indication

Correctable ulnar drift with intact MCP joints

Technique

Release ulnar intrinsics, transfer radially to correct drift vector

Outcome

Good correction of drift, prevents recurrence

Silicone MCP arthroplasty

Indication

Fixed MCP subluxation, joint destruction, pain

Technique

Swanson or Sutter implant via dorsal approach; rebalance soft tissues

Outcome

Pain relief, improved alignment

MCP Surgical Options

Procedure	Indication	Technique	Outcome
Synovectomy	Persistent MCP synovitis despite 6 months DMARDs, passively correctable	Dorsal approach, remove hypertrophied synovium, preserve ligaments	Temporary relief; often needs later arthroplasty
Crossed intrinsic transfer	Correctable ulnar drift with intact MCP joints	Release ulnar intrinsics, transfer radially to correct drift vector	Good correction of drift, prevents recurrence
Silicone MCP arthroplasty	Fixed MCP subluxation, joint destruction, pain	Swanson or Sutter implant via dorsal approach; rebalance soft tissues	Pain relief, improved alignment

What silicone arthroplasty buys. It improves hand appearance and corrects deformity, and soft tissue rebalancing (intrinsic release, extensor relocation) matters as much as the implant itself. The honest framing is a soft-tissue rebalancing operation around a flexible spacer, which buys posture, extension and appearance, all of which decay over a decade (roughly two-thirds of the drift correction is lost), and which does not restore grip strength.

Be careful calling the pain relief reliable. In the longest series, 208 implants at a mean of 14 years, only 27% of hands were pain-free and patients were satisfied with the function of only 38%. The implants fail as well, and a broken implant is not benign (see Complications).

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Dorsal tenosynovectomy

Indication

Persistent dorsal tenosynovitis, early tendon fraying

Key Steps

Dorsal approach, excise hypertrophied tenosynovium, inspect tendons

Expected Outcome

Prevents tendon ruptures; may need concurrent ulnar head procedure

Darrach procedure

Indication

Caput ulnae with extensor tendon attrition

Key Steps

Distal ulnar excision through dorsal approach, stabilise ECU

Expected Outcome

Eliminates attrition source; risk of ulnar translocation over time

Sauve-Kapandji

Indication

Caput ulnae with preserved DRUJ congruency

Key Steps

DRUJ arthrodesis with screw + proximal ulnar osteotomy for forearm rotation

Expected Outcome

Maintains ulnar buttress (prevents translocation), allows pronosupination

Total wrist arthrodesis

Indication

End-stage RA wrist, carpal collapse, severe pain

Key Steps

Dorsal approach, carpal denuding, dorsal plate fixation (commonly an AO wrist fusion plate)

Expected Outcome

Reliable pain relief, stable platform for MCP reconstruction

Total wrist arthroplasty

Indication

Low-demand patient with bilateral disease, reasonable bone stock

Key Steps

Fourth-generation implants (e.g., Motec, Remotion)

Expected Outcome

Preserves some motion; higher revision rate than arthrodesis

Wrist Surgical Options

Procedure	Indication	Key Steps	Expected Outcome
Dorsal tenosynovectomy	Persistent dorsal tenosynovitis, early tendon fraying	Dorsal approach, excise hypertrophied tenosynovium, inspect tendons	Prevents tendon ruptures; may need concurrent ulnar head procedure
Darrach procedure	Caput ulnae with extensor tendon attrition	Distal ulnar excision through dorsal approach, stabilise ECU	Eliminates attrition source; risk of ulnar translocation over time
Sauve-Kapandji	Caput ulnae with preserved DRUJ congruency	DRUJ arthrodesis with screw + proximal ulnar osteotomy for forearm rotation	Maintains ulnar buttress (prevents translocation), allows pronosupination
Total wrist arthrodesis	End-stage RA wrist, carpal collapse, severe pain	Dorsal approach, carpal denuding, dorsal plate fixation (commonly an AO wrist fusion plate)	Reliable pain relief, stable platform for MCP reconstruction
Total wrist arthroplasty	Low-demand patient with bilateral disease, reasonable bone stock	Fourth-generation implants (e.g., Motec, Remotion)	Preserves some motion; higher revision rate than arthrodesis

Arthrodesis is the usual endpoint. Total wrist arthrodesis is the most commonly performed wrist procedure in end-stage RA, and in practice most advanced RA wrists are treated this way. The stable, pain-free platform it provides is what lets distal hand reconstruction (tendon transfers, MCP arthroplasty) function optimally. Postoperative AP and lateral views confirm neutral alignment, carpal compression, plate position and screw length, and finger and forearm motion must be preserved.

Position of Wrist Fusion

Fuse the wrist in slight extension (10-20 degrees) with neutral deviation: this optimises grip and key pinch.

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Stability for pinch. For the thumb in RA, arthrodesis is generally preferred over arthroplasty at the MCP and IP joints because it provides stability for pinch. The CMC joint is the exception, where arthroplasty (ligament reconstruction and tendon interposition, or hemiarthroplasty) is favoured to preserve first web mobility.

Type I (MCP boutonniere)

Primary Procedure

MCP arthrodesis (most reliable)

Adjunct Procedures

EPL re-routing

Goal

Stable MCP position, restore thumb-length pinch

Type II (MCP + CMC)

Primary Procedure

CMC arthroplasty + MCP arthrodesis

Adjunct Procedures

Soft tissue rebalancing at both joints

Goal

Pain-free stable thumb column

Type III (CMC swan-neck)

Primary Procedure

CMC arthroplasty or arthrodesis

Adjunct Procedures

MCP flexion release; MCP volar capsulodesis or flexor pollicis brevis advancement

Goal

Prevent MCP hyperextension, restore first web space

Type V (MCP volar plate laxity)

Primary Procedure

MCP volar plate capsulodesis or sesamoid arthrodesis

Adjunct Procedures

MCP arthrodesis if the joint is destroyed

Goal

Restore the volar checkrein at the MCP rather than addressing the CMC

Type VI (arthritis mutilans)

Primary Procedure

Bony reconstruction with bone graft and arthrodesis (usually needed)

Adjunct Procedures

-

Goal

Restore length and a stable post for pinch

Nalebuff-Type Surgical Approach

Type	Primary Procedure	Adjunct Procedures	Goal
Type I (MCP boutonniere)	MCP arthrodesis (most reliable)	EPL re-routing	Stable MCP position, restore thumb-length pinch
Type II (MCP + CMC)	CMC arthroplasty + MCP arthrodesis	Soft tissue rebalancing at both joints	Pain-free stable thumb column
Type III (CMC swan-neck)	CMC arthroplasty or arthrodesis	MCP flexion release; MCP volar capsulodesis or flexor pollicis brevis advancement	Prevent MCP hyperextension, restore first web space
Type V (MCP volar plate laxity)	MCP volar plate capsulodesis or sesamoid arthrodesis	MCP arthrodesis if the joint is destroyed	Restore the volar checkrein at the MCP rather than addressing the CMC
Type VI (arthritis mutilans)	Bony reconstruction with bone graft and arthrodesis (usually needed)	-	Restore length and a stable post for pinch

Type I. MCP arthrodesis is the most reliable procedure; MCP synovectomy with extensor reconstruction is the soft-tissue alternative, but read it against Terrono's recurrence figures after EPL rerouting in the Evidence section. Fuse the MCP and leave the IP alone: an IP release combined with MCP fusion recurs frequently and is not recommended.

The isolated IP joint. IP joint destruction from synovitis is a rare isolated pattern, often ending in fibrous or bony ankylosis. It is treated by IP arthrodesis, addressing any concurrent MCP or CMC disease, for a stable pain-free IP joint.

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Prevention. Control synovitis before elective surgery, and coordinate perioperative DMARD management with rheumatology to balance infection risk against flare. Handle the soft tissues meticulously, because RA tissues are fragile and prone to failure, and remove the bony attrition sources and diseased tenosynovium at the index operation.

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Read the silicone row alongside the 14-year series under MCP Joint before quoting it to a patient.

What predicts the result. The best outcomes come with well-controlled disease on DMARDs, intervention before deformity becomes fixed, good bone stock, compliance with therapy and not smoking. Active synovitis at the time of surgery, steroid dependence, multiple previous surgeries, poor bone quality and vasculitis predict poor ones.

Setting expectations. RA hand surgery is reconstructive, not curative. It improves function and reduces pain but rarely restores normal hand mechanics, and its goals are pain relief, improved function and prevention of further deformity; patients who understand this have better satisfaction.

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