Hand and Wrist Surgery for Arthritis
An Information Booklet
Introduction
Our hands play a very important part in everyday activities. They allow us to make fine, pinching, movements (e.g. when writing or threading a needle) and also to grip powerfully (e.g. when sawing or opening a jar). If we are to lead an active, independent life the joints in our hands need to work properly. The hands also provide the main sensory organ of touch: it is possible to recognize the value of coins just with touch, as people who are blind do all the time. We also care about how our hands look because they are constantly on view and we use them to help us communicate when we meet and talk to people.
For most people with musculoskeletal and arthritis-related problems in their hands or wrists surgery is unnecessary. The decision whether to operate depends on a number of factors: the severity of the symptoms (pain or loss of hand function), the patient's wishes, and the response to other treatments, including drugs. Surgery is rarely carried out to improve the look of the hands, although an improvement in their appearance may be a welcome additional benefit. Your GP or rheumatology consultant can provide help and advice, and will refer you to a specialist hand surgeon if necessary.
This booklet describes how the hand and wrist work, the common musculoskeletal and arthritis-related problems that occur, the type of surgery carried out to treat these conditions, and what you should expect if you require an operation.
How the hand and wrist work
The normal structure of the hand and wrist is shown in Figure 1.
Figure 1. The normal structure of the hand and wrist showing the position of the nerves, arteries and tendons
The motor, or power, activities are controlled by muscles and tendons in the hand and forearm. The flexor group on the inside or front of the arm control grip; these pass over the front of the wrist and are held in place by a strong fibrous band called the flexor retinaculum or carpal tunnel ligament. The extensors on the outside or back of the forearm allow the hand to open up. There are also small muscles in the hand itself (the lumbricals) which allow fine movement. The tendons in the hand are covered by a layer of synovium, the same tissue that lines the joints. The tendon and synovium are covered by a tendon sheath, which is rather like the protective covering on electric cables.
The sense of touch in the hand is supplied by two main nerves, the median or carpal tunnel nerve and the ulnar or 'funny bone' nerve. The median nerve passes under the carpal tunnel ligament and supplies sensation to the majority of the hand (from the thumb to half of the ring finger) and power to muscles at the base of the thumb. The ulnar nerve supplies sensation to the little finger and half the ring finger and power to all the small muscles in the hand.
There are also two arteries (radial and ulnar) which supply blood to the hand. They can both be felt on the front of the wrist. The radial artery (nearer the thumb) is often felt 'to take your pulse'. The ulnar artery on the opposite side of the wrist is much more difficult to feel.
Carpal tunnel syndrome
This condition occurs when there is pressure on the median nerve as it passes through the wrist under the carpal tunnel ligament (see Figure 1). Although often no obvious cause for the condition can be found, anything which may cause swelling in the wrist will cause pressure on the median nerve. This includes rheumatoid arthritis, diabetes and fractures at the wrist, e.g. Colles' fracture. An electrical test (called nerve conduction studies) confirms the diagnosis of carpal tunnel syndrome. The early symptoms are 'pins and needles' in the hand, especially at night. If they only last a few minutes do not worry about them – just move your hand around. If they last for more than about 10 minutes and if they begin to occur during the day – for instance when you are holding the phone, drying your hair, or driving – then more should be done. Often all that is needed is to put your hand and wrist in a splint overnight. These can be obtained from chemists or the appliance department of your local hospital. Sometimes a steroid injection around the nerve at wrist level can relieve the symptoms (see arc leaflet 'Local Steroid Injections'). If the benefit lasts for at least 4 months then the injection may be repeated. However, if the symptoms keep returning, or there is no benefit from the approaches described above, surgery may be needed. Surgical treatment can reduce the pressure on the nerve and lessen the pain, particularly at night.
In the operation, the surgeon is able to relieve the pressure by dividing the carpal tunnel ligament. This is often done under local anaesthetic with no need to stay in hospital overnight. Following the operation there will be a bulky bandage on your wrist and hand for a day or two. When this bandage is removed a small dressing will be placed over the stitches for 10–14 days. During this time you will have full use of your fingers and thumb for daily activities, although heavy tasks should be avoided. It is important that you move your fingers to prevent the nerve and tendons becoming caught up in the scar tissue which may form after the operation. People who have this operation will normally recover from the effects of surgery in less than 1 month. In a small number of people, the scar may ache and be sensitive for some months, though this usually settles without further treatment. (See arc booklet 'Carpal Tunnel Syndrome'.)
Dupuytren's contracture
This is a painless condition. The cause of the condition is unknown and it is not usually associated with arthritis. Scar tissue forms in the palm of the hand and the fingers. It may cause only skin nodules, but it can also form bands of scar that make the fingers curl down into the palm of the hand. Injections do not help this condition. Often the curling of the finger does not progress, but if the finger does continue to curl into the palm surgery may be needed. This will need 1–4 days in hospital depending on the severity. It will take 2–3 weeks for the skin to heal. It usually takes 6–12 weeks for the effects of the surgery to pass and for full use to return. A night splint will be used for some weeks in order to keep the fingers straight while the internal scars heal. Hand physiotherapy may form part of the treatment plan. During the day it is essential to try to use the hand normally and to keep it supple.
The problem sometimes comes back, and full correction of the finger deformity is not always possible.
Trigger finger
In this condition the tendon which allows the finger to bend becomes a little thickened so that it becomes stuck in the sheath which surrounds the tendon. The tendon thickening is usually very localized, and once it has been pulled into the sheath the tendon moves freely. Occasionally the opening to the sheath becomes narrowed, trapping the tendon. Again this is not commonly associated with arthritis, and if you have trigger finger it does not mean you will go on to develop arthritis.
Typically in this condition it is possible to make a fist but when the affected finger is opened up it becomes trapped in a curled position. With an effort or help from the other hand, the finger will trigger straight; hence the name. Pulling the finger out straight is often painful. A local injection helps in most cases. If this fails, a minor day-case operation (with no overnight stay in hospital) may be needed to release the tendon. Recovery within 1–2 weeks is usual.
Tendon rupture
As mentioned above, there are two main groups of tendons controlling the hand and wrist: the flexor tendons, which enable you to grip and to curl the fingers into a fist, and the extensor tendons, which open the fingers up. Tendon rupture in the hand and wrist is not common and when it occurs it is usually as a result of rheumatoid and other types of inflammatory arthritis (see arc booklet 'Introducing Arthritis').
- Flexor tendons When a flexor tendon snaps, or ruptures, the finger it controls cannot be bent properly. Flexor tendons are at risk of rupturing as a result of inflammation of the synovium which surrounds the tendon within the tendon sheath. Early treatment is required if surgery is to be successful and other tendons protected from rupture. Often undamaged flexor tendons from other fingers are used to repair the ruptured tendon.
- Extensor tendons Rupture of the extensor tendon occurs either because of inflammation or by rubbing of the tendon against a piece of rough bone in the wrist. It results in a sudden inability to lift the fingers up. This may happen in any finger, but it is most common in the little and ring fingers and the thumbs (see Figure 2). As with repair of the flexor tendons, early treatment is necessary if surgery is to be successful and other tendons are to be protected from rupture. Usually the surgeon will use undamaged tendons from other fingers to repair the ruptured tendon. If the tendon has ruptured because it has rubbed against rough bone in the wrist, then the bone will have to be smoothed or removed to prevent the repaired tendons from rupturing again.
Figure 2. The effect of tendon rupture in the hand (ring finger and little finger extensor tendons are affected)
Repaired tendons need at least 6 weeks to heal. During this time you will not be able to use your hand at all and must only do the exercises shown to you by the therapist. You will have to wear a splint on your hand day and night to protect the healing tendons from damage. It is important that the splint and the movement in your fingers are checked regularly. Usually this means seeing a therapist frequently and it will be around 2–3 months before recovery is complete.
Ganglions
Joints and tendons are lubricated by a thick fluid called synovial fluid. If some of this fluid leaks out of the joint or tendon sheath, the fluid concentrates and becomes very thick and sticky and may form cysts, known as ganglions. These ganglions feel firm or hard when pressed. They are commonly found on the back of the wrist, but can occur elsewhere. They may get better on their own but sometimes they are uncomfortable and unsightly; in this case a needle can be put into them to allow withdrawal of the fluid. Rarely minor surgery is needed to remove them, although even then they may recur. They are not usually associated with arthritis.
Knuckle (MCP joint) arthritis
Rheumatoid arthritis of the knuckles (metacarpophalangeal or MCP joints) may cause damage and deformity with the result that the fingers 'drift' sideways away from the thumb (see Figures 3 and 4). This may be very painful and significantly reduce hand function and affect everyday tasks. If the use of the hand is badly affected then surgery can be carried out to replace the knuckles with small artificial joints that act as flexible hinges. This operation reduces any pain and also corrects the deformity of the fingers, so the hand will look better. Most importantly, it puts the fingers in a better position so that the hand can be used more normally.
Figure 3. Hand deformities caused by severe rheumatoid arthritis which could be helped by joint surgery
Figure 4. The hand before and after surgery to replace the knuckles (MCP joints) with artificial joints
This type of surgery usually requires several days in hospital and several months of outpatient treatment. Immediately after the operation the hospital staff will ensure your hand is rested for a few days before the process of rehabilitation is started. Before discharge from hospital the occupational therapist or physiotherapist will teach you exercises that will help you to move your fingers. These exercises are essential for your recovery and should be practised at home for several months. For 6–8 weeks after the operation you will need a splint when not doing the exercises. It will be several months before the hand is strong enough to work properly. The occupational therapist will advise on adaptations around the home which will help in the recovery period.
Your new joints will never be as hard-wearing as natural joints, so some care will always be needed using the hand. The occupational therapist or physiotherapist will advise you on how to take care of your hand to give the artificial joints a long life.
The MCP joint of the thumb is often affected by rheumatoid arthritis, but it is unusual to replace it with an artificial one. Instead, a surgeon may deliberately stiffen the joint, allowing the joints next to it to make up for its loss of movement. This operation is usually effective at relieving pain and helping the hand to pinch.
Osteoarthritis of the thumb
Arthritis in the joint at the base of the thumb may cause pain and interfere with simple tasks such as opening jars, sewing, knitting, writing and taking the handbrake off the car. This condition is most common in women in their 50s and 60s, but it can also affect men. It is not necessarily the beginning of a more general arthritis but it is often associated with bony lumps on the joints at the tip and middle joints of the fingers. (An arc booklet on osteoarthritis of the hand is in preparation.) In most people the pain will go through good and bad phases and the condition will often become painless if given enough time. A special splint which supports the joint at the base of the thumb (sometimes known as a thumb spica) is available and can normally be obtained from your local appliance, physiotherapy or occupational therapy department. This splint is often best used when you are doing active work, including household tasks, and may help to control pain. (See arc leaflet 'Splints for Arthritis of the Wrist and Hand'.) If the joint is inflamed and going through a bad phase, an injection of steroid into the joint will often reduce the pain.
For some people the pain persists and an operation is needed. The operation involves the removal of the joint and affected bone. Sometimes the space this leaves is filled with a silicone rubber spacer or a metal and plastic joint. More recently, surgeons have been using natural body materials from the surrounding tendons to fill the space. After the operation the base of the thumb is put in a splint for 6 weeks. You will be given exercises to do at home to help you regain the movement in the thumb and increase its strength. It will be several months before the thumb feels comfortable, but this operation usually relieves pain and improves the function of the joint. Only occasional visits to the hospital are needed so that your progress can be checked.
Wrist joint arthritis
Arthritis in the wrist joint is common in people with rheumatoid arthritis. For many, wearing wrist splints relieves the pain and improves the strength in the wrist. However, some people may need an operation if the joint is very painful and not responding to other treatment such as steroid injections. Often, if the wrist is badly affected, not only will moving the hand up, down and sideways be very painful but also it will be very difficult to twist the forearm to place the palm of the hand upwards (this is called supination). Often coins will slip out of your hand as the forearm is twisted.
The type of operation will depend on your individual needs and circumstances. There are two options: firstly stiffening, or fusion, of the wrist, and secondly wrist joint replacement.
- Wrist fusion Your surgeon may suggest this operation if the wrist is very painful and badly damaged. The operation usually eliminates the pain and increases the strength, but prevents movement in the wrist. However, the twisting or supination of the hand is usually improved as well. Having no wrist movement is not as bad as it sounds. Following the operation, the movement which remains difficult is undertaking personal hygiene, e.g. wiping your bottom. The occupational therapist will help you overcome this problem. The hospital stay is for a few days only. After the operation, it is necessary to keep the wrist still for 6–8 weeks in a lightweight cast, but your fingers will be free for eating or writing. Few exercises are needed after this operation as the aim is to eliminate wrist movement.
- Wrist joint replacement This is not yet a common operation but the aim is to keep some wrist movement and eliminate pain. You will be in hospital for a few days but it will be several months before recovery is complete. After the operation the wrist is kept still for 2–6 weeks before you start rehabilitation, which is aimed at improving the movement in the wrist and function in your hand. The therapist will discuss with you what you should and should not do with the replacement joint to keep it in good condition.
What will happen if an operation is necessary?
Before the operation
Waiting times vary across the country and depend on the type of anaesthetic and the type of operation. Surgery can be performed using either a local or general anaesthetic, and your surgeon will discuss with you the best option. If a local anaesthetic is chosen you will be fully awake during the operation, but you will not experience any pain or discomfort. If the operation needs a general anaesthetic you will usually be in hospital for a little longer. This will depend on the type of operation and your own health, as well as home or other circumstances that might affect your recovery. You should talk to the doctor if you have any worries.
Before the operation you will be asked to sign a consent form, so that the surgeon has permission to carry out the necessary treatment. It is important to ask any questions you may still have at this stage. Ask the doctor, nurse or therapist to explain anything you don't understand. A doctor or nurse will check your general health to ensure there will be no problems with a general anaesthetic, if this is being used. After the operation it is customary for people to be checked over in a recovery room for a short period before they return to the ward.
Very often after operations on the hand and wrist it is necessary to wear splints to protect the healing tissues and bone, which will make everyday tasks difficult. In particular, you may have difficulty cooking, cleaning, driving the car, or getting dressed. To minimize these difficulties it is a good idea to make preparations before the operation. Simple things like choosing clothes with wide arms, stocking up the freezer, or arranging to have some help in the home will all make it easier to manage one-handed. It is also sensible to arrange help with transport, as it is nearly always necessary to attend the hospital regularly to see the doctor or therapist. If you are concerned that you will have difficulties following your operation, arrange to speak to a therapist at the hospital before you are admitted to find out exactly what is involved and how best to manage.
After the operation
Different surgeons have different ideas about the treatment required after an operation. This is affected by the type of operation and your own physical health. Support will be given by the nurse or therapist. After you have been discharged from hospital an appointment will be made for you to come in as an outpatient so that your progress can be checked. Sometimes a local GP will help with this aftercare. A district nurse may be asked to remove stitches and change dressings.
Complications
For people who are generally healthy the risk of a serious complication from an operation is very small. Every possible care is taken to prevent complications but in a few cases these do happen. For example some people may develop an infection, but this can be treated with antibiotics. Some people may develop swelling and stiffness, but physiotherapists and occupational therapists can help with exercises and other advice.
Please remember
Surgery is not necessary for most people who have arthritis in their hands. For those who do need surgery, it is usually very helpful in reducing pain and improving hand function.
Useful addresses
Arthritis Research Campaign (arc)
PO Box 177
Chesterfield
Derbyshire S41 7TQ
Phone: 0870 850 5000
www.arc.org.uk
As well as funding research, we produce a range of free information booklets and leaflets. Please contact the address above for a list of titles or, on this website, see Publications for People with Arthritis.
Arthritis Care
18 Stephenson Way
London NW1 2HD
Phone: 020 7380 6500
Helpline (freephone): 0808 800 4050
www.arthritiscare.org.uk
Offers self-help support, a helpline service, and a range of leaflets on arthritis.
nras (National Rheumatoid Arthritis Society)
Unit B4 Westacott Business Centre
Westacott Way, Littlewick Green
Maidenhead SL6 3RT
Phone: 0845 458 3969
Helpline: 0800 298 7650
www.rheumatoid.org.uk
A national charity which focuses specifically on rheumatoid arthritis.
Information on drugs
Separate arc leaflets are available on many of the drugs used for arthritis and related conditions. We would recommend that you read the relevant leaflets for more detailed information about your medication.
