The Rheumatoid Hand and Wrist

• Prevalence: RA affects approximately 0.5-1 percent of the global population
• Hand involvement: Up to 90 percent of RA patients develop hand/wrist manifestations
• Female-to-male ratio: 3:1
• Peak onset: 30-50 years, though all ages affected
• Bilateral and symmetrical: Characteristic distribution pattern

• Grip strength: Reduced by up to 70 percent in advanced disease
• Pinch weakness: Especially key pinch (thumb involvement)
• ADL limitation: Buttoning, writing, opening jars affected early
• Deformity progression: Predictable pattern from synovitis to ligament destruction to joint subluxation

• Disease duration and treatment: DMARDs, biologics, steroid history
• Hand function: Grip, pinch, ADLs (buttoning, key turning, writing)
• Deformity progression: Rate of change, which fingers affected first
• Pain: Localise to specific joints (wrist, MCP, PIP)
• Tendon function: Sudden loss of extension (rupture), triggering

• Inspect: Zig-zag deformity pattern, MCP ulnar drift, wrist supination, thumb posture
• Palpate: Synovitis (boggy swelling), caput ulnae, tendon fraying (crepitus)
• Active ROM: Finger extension (test each tendon individually), flexion cascade
• Tendon integrity: Test EDM independently (extend small finger while holding others flexed)
• Passive correctability: Can MCP joints be reduced? PIP deformity flexible or fixed?

• RA prevalence: 0.5-1 percent worldwide; higher in Northern European and North American populations
• Hand involvement: The most common site of RA manifestation across all ethnicities
• Declining surgery rates: Biologic DMARDs have dramatically reduced the need for reconstructive RA hand surgery in well-resourced settings
• Delayed presentation: In resource-limited settings, patients often present with established deformities

• High-resource: Early biologic therapy, hand therapy teams, silicone arthroplasty, total wrist arthroplasty as an option
• Limited-resource: Conventional DMARDs, arthrodesis preferred over arthroplasty (no implant costs, no need for long-term follow-up of implants)
• Universal principle: Tendon attrition must be addressed surgically regardless of resource setting - delay leads to further ruptures
• Surgical training: RA hand reconstruction is increasingly concentrated in specialist centres as caseloads decline

The Darrach procedure removes the attrition source but risks ulnar translocation of the carpus over time (10-25 percent). Sauve-Kapandji preserves the ulnar buttress but creates a pseudarthrosis that can be unstable. Choice depends on bone quality, DRUJ congruency, and surgeon preference. No high-quality RCTs compare the two.

Total wrist arthrodesis is reliable and durable but sacrifices all motion. Total wrist arthroplasty preserves some flexion-extension but has higher revision rates and is unsuitable for high-demand patients. In RA (low demand, bilateral disease), arthroplasty is increasingly considered for the non-dominant side while fusing the dominant wrist.

Silicone (Swanson) implants have long track records but fracture over time and may cause particulate synovitis. Pyrolytic carbon implants aim for more anatomical reconstruction but have limited long-term data in RA. Most surgeons still use silicone for RA MCP arthroplasty due to familiarity and published outcomes.

With effective biologic DMARDs, the need for RA hand surgery has declined markedly in well-resourced settings. This creates a training challenge: fewer cases mean fewer surgeons gaining expertise. The paradox is that when surgery is needed, it is often more complex (revision-type scenarios) and requires subspecialist skills.