Wrist Arthritis - An Overview

Introduction:

While the wrist is not a weight-bearing joint, it fulfills an essential function in daily tasks., making it prone to trauma and arthritis. Approximately 13.6 percent of people in this country suffer from wrist arthritis. Unfortunately, this condition is often overlooked or improperly managed. Enhancing the knowledge of interprofessional team members about wrist arthritis can lead to better patient management and outcomes. This article delves into causes and treatment options for wrist arthritis, emphasizing the importance of the interprofessional team in patient care.

What Is Wrist Arthritis?

Arthritis, characterized by joint inflammation, presents symptoms including pain, swelling, redness, stiffness, and limited joint motion. Wrist arthritis can significantly impact daily functioning, necessitating understanding its causes, seeking an accurate diagnosis, and finding effective long-term treatments to prevent disability.

Despite not being a weight-bearing joint, the wrist plays a crucial role in day-to-day activities, making it susceptible to trauma and arthritis. Approximately one in seven individuals (13.6 percent) suffer from wrist arthritis, which is often overlooked or mishandled. Enhancing the knowledge of interprofessional team members about this condition can lead to improved management and outcomes for affected patients.

Types of Wrist Arthritis:

According to the American Academy of Orthopedic Surgeons (AAOS), wrist arthritis manifests primarily in three types: osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.

• Osteoarthritis (OA): Common among the elderly but can affect any age group, with risk factors including aging, genetics, high BMI (body mass index), joint anatomy, and gender. In young adults, it often follows a joint injury.

• Rheumatoid Arthritis (RA): An inflammatory disorder affecting peripheral joints symmetrically, with a multifactorial etiology.

• Post-traumatic Arthritis: Develops following wrist injuries such as ligament damage or fractures, increasing arthritis risk over time despite treatment.

• Other causes include infection, crystal-induced arthritis (crystals, such as uric acid or calcium pyrophosphate in the joints), reactive arthritis (joint inflammation that develops in response to an infection), and systemic diseases like sarcoid arthropathy (joint inflammation associated with sarcoidosis, it is an inflammatory disease where granulomas, clusters of immune cells), myelodysplastic (blood disorders), and leukemic disorders (cancer that affects the blood and bone marrow).

How to Diagnose Wrist Arthritis?

The evaluation of wrist arthritis begins with a thorough history, including details about symptom onset, location, nature, duration, aggravating factors, and alleviating factors. For chronic pain, recent triggers for exacerbations should be explored. In addition to history, a comprehensive physical examination will aid the provider in ordering appropriate diagnostic tests.

• Imaging: Conventional radiography is the primary imaging modality to detect bone pathologies such as fractures, erosions, osteonecrosis, osteoarthritis, or juxta-articular bone tumors. Features of osteoarthritis seen on radiographs include marginal osteophytes, joint space narrowing, subchondral sclerosis (hardening of bone just below the cartilage surface in joints), and cysts (sac-like structures filled with fluid, semi-solid, or gaseous material). The presence of chondrocalcinosis suggests calcium pyrophosphate deposition disease (pseudogout).

While operator-dependent and limited in assessing bones or deep joint structures, ultrasonography can reveal osteoarthritis-associated changes, osteophytes, crystal deposition, synovial inflammation, joint effusion (abnormal accumulation of fluid in a joint), and erosions (loss of bone).

• Laboratory Tests: Leukocytosis (elevated white blood cell count) may indicate infection, necessitating cultures of blood, urine, or other potential primary sites of infection if septic arthritis is suspected. Elevated inflammatory markers like ESR (erythrocyte sedimentation rate) or CRP (C-reactive protein) suggest an infectious or inflammatory process. Rheumatoid factor and anti-CCP antibodies are ordered if rheumatoid arthritis is suspected. Serum uric acid levels may be checked for suspected gout. However, they can be unreliable during acute inflammatory conditions or gout attacks (episodes of severe joint pain, redness, swelling, and warmth generated by the accumulation of uric acid crystals within a joint).

• Synovial Fluid Analysis: Joint arthrocentesis and synovial fluid analysis are essential for suspected infection. Empiric antibiotic therapy should be initiated promptly after obtaining the synovial fluid sample. Synovial fluid analysis aids in diagnosing crystal-induced arthritis, with polarizing microscopy showing birefringent crystals in acute gout or pseudogout. The degree of synovial fluid white blood cell count elevation can help differentiate inflammatory from non-inflammatory causes of arthritis.

In the evaluation of wrist pain, clinicians should also consider the following differentials:

• Peri-Articular conditions: Tenosynovitis, including De Quervain tenosynovitis, pigmented villonodular tenosynovitis, and acute calcific periarthritis.

• Bone Lesions: Fractures, neoplasms, infection, and osteonecrosis conditions like Kienbock disease (the lunate bone's avascular necrosis) and Preiser disease (avascular necrosis of scaphoid bone).

• Neurological Conditions: Nerve entrapment syndromes, notably carpal tunnel syndrome and ulnar nerve entrapment within the Guyon (ulnar canal).

• Vascular Conditions: Scleroderma (chronic autoimmune disease) and occupational vibration syndromes.

• Referred Pain: Cervical spine disorders and reflex sympathetic osteodystrophy (bone disorders marked by abnormal development or remodeling).

How to Treat Wrist Arthritis?

The treatment for wrist arthritis varies depending on the type of arthritis involved.

Osteoarthritis: Non-surgical management options include:

• Acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), and other analgesic medications.

• Avoiding activities that worsen the pain.

• Immobilizing joints with wrist splints, especially during daytime and activities.

• Physical therapy.

• Local corticosteroid injections.

• Systemic steroids should be avoided, and pills containing hyaluronic acid and glucosamine are ineffective.

Rheumatoid Arthritis (RA): The cornerstone of RA management is disease-modifying antirheumatic drug (DMARD) therapy. Additional treatments include:

• Anti-inflammatory therapies such as systemic and intraarticular glucocorticoids and NSAIDs.

• Traditional DMARDs like Methotrexate, Hydroxychloroquine, Sulfasalazine, and Leflunomide.

• Biologic agents include anti-TNF or tumor necrosis factor-alpha agents, IL or interleukin-6 inhibitors, JAK (Janus kinase) inhibitors, and anti-CD-20 monoclonal antibodies.

• Surgical treatment may be necessary if disabling pain persists despite conservative measures. Surgical options include proximal row carpectomy (removal of the proximal row of wrist bones to alleviate pain and improve wrist motion), wrist fusion (surgical fusion of wrist bones to stabilize the joint and alleviate pain), partial wrist fusion (fusing only some wrist bones to retain partial motion while stabilizing the joint and reducing pain), and total wrist replacement (replacement of the entire wrist joint with artificial components).

Surgical Options:

• Proximal Row Carpectomy: Remove three carpal bones near the forearm to relieve pain and maintain wrist motion.

• Wrist Fusion (Arthrodesis): Welding process to eliminate damaged cartilage and fuse wrist bones, reducing pain at the expense of range of motion.

• Total Wrist Replacement: Replacement of damaged wrist cartilage and bones with plastic or metal joints to restore function and reduce pain, although results may not be as satisfying as knee or hip replacement.

What Is the Prognosis and Associated Complications?

• Prognosis: The prognosis of wrist arthritis depends on its cause. Osteoarthritis or repetitive use injury arthritis may respond well to conservative or surgical treatment. Autoimmune causes may have a poorer prognosis based on disease severity and the effectiveness of disease-modifying agents in controlling inflammation. Inadequate pain control can lead to progressive debility and morbidity in the elderly, resulting in reduced functional status.

• Complications: Complications of wrist arthritis treatment mainly arise from surgical interventions. Fusion surgeries may lead to continued wrist pain due to nonunion or fibrous union. Risks associated with orthopedic procedures include prosthetic infection, neurovascular injury, and implant failure or loosening.

Conclusion:

Diagnosing and managing wrist arthritis can pose challenges due to its impact on essential hand motions. Providers must meticulously address wrist arthritis promptly to prevent disability, considering an interprofessional approach involving rheumatologists, orthopedic surgeons, physical therapists, and occupational therapists as needed. While initial assessment may occur with the primary care provider or nurse, timely referral to a rheumatologist or orthopedic surgeon is crucial for confirming the diagnosis and initiating treatment promptly, leading to improved outcomes. Pharmacists play a crucial role in educating patients about medication adherence and monitoring for drug interactions. Efficient communication among team members is essential for coordinating treatment procedures.