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The Rheumatoid Wrist

Dr. Papp is Assistant Professor, University of Ottawa, Ottawa Civic Hospital, Ottawa, ON, Canada. Dr. Athwal is Assistant Professor, University of Western Ontario, Hand and Upper Limb Centre, St. Joseph’s Health Care, London, ON. Dr. Pichora is Chairman, Division of Orthopedic Surgery, and Hand Fellowship Director, Queen’s University, Kingston General Hospital, Kingston, ON.

None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Papp, Dr. Athwal, and Dr. Pichora.

Reprint requests: Dr. Papp, Ottawa Civic Hospital, Room 2-018, 1053 Carling Avenue, Ottawa, ON, Canada K1Y 4E9.

Wrist involvement is common in patients with rheumatoid arthritis. Individual patient assessment is important in determining functional deficits and treatment goals. Patients with persistent disease despite aggressive medical management are candidates for surgery. Soft-tissue procedures offer good symptomatic relief and functional improvement in the short term. Extensor and flexor tendons may rupture because of synovial infiltration and bony irritation. When rupture occurs, direct repair usually is not possible. However, when joints that are motored by the ruptured tendon are still functional, tendon transfer or grafting may be considered. Because of the progressive nature of the disease, dislocation and end-stage arthritis often require stabilization with bony procedures. The distal radioulnar joint is usually affected first and is commonly treated with either the Darrach or the Sauvé-Kapandji procedure. Partial wrist fusion offers a compromise between achieving stability of the affected radiocarpal joint and maintaining motion at the midcarpal joint. For pancarpal arthritis, total wrist fusion offers reliable pain relief at the cost of motion. Total wrist arthroplasty is an alternative that preserves motion; however, the outcomes of total wrist replacement are still being evaluated.

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