Wrist osteoarthritis
Osteoartritis causes changes in the cartilage between the wrist bones

Definition

Osteoarthritis of the wrist is a degenerative condition resulting in progressive wear of the wrist joints. It is also called arthrosis as opposed to arthritis, which implies the involvement of an inflammatory process.

Left, normal hand & wrist, right osteoarthritis showing altered joints

Pathology

Osteoarthritis of the wrist is a complex pathology. It can affect numerous joints of the hand and forearm, which connect the radius and ulna with metacarpal bones and more distally to the phalanges, or finger bones. In osteoarthritis, the articular cartilage covering the bone extremities becomes damaged mostly due to ageing, overuse and trauma. The cartilage is a specialised connective tissue that facilitates the movement between bones by reducing friction. The cartilage also absorbs shock and traumatic impacts to the joints.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Osteoarthritis of the wrist after complex distal radius fracture. Note the holes in the radius from previous osteosynthesis

Causes

Osteoarthritis of the wrist most often is caused by ageing and traumatic injury. It can also result from medical conditions such as chronic autoimmune inflammation (rheumatoid arthritis) or from the reduction of blood flow through the lunate carpal bone (Kienböck’s disease). Generally, the ageing process affects all joints due to wear and tear and osteoarthritis is more frequent in those patients with a family history of the disease.

Wrist osteoarthritis can result from a previous injury following the repair of a fracture or as a consequence of small changes in the anatomy of the wrist bones that increase pressure on the joint cartilage, which gradually degenerates. The pathology can also arise from traumatic damage to the cartilage itself, leading to a rigid scar formation that impairs a smooth joint movement. This is named post-traumatic osteoarthritis.

Top, elderly woman with moderate hand/wrist osteoarthritis, low, psoriatic arthritis of hands and wrist

Risk factors

There are a various risk factors leading to wrist osteoarthritis, the main ones being:

Aging

Overuse

Mechanical injury

Familiar predisposition

Additional medical factors:

Chronic inflammatory and autoimmune diseases (Rheumatoid arthritis, psoriasis, gout (accumulation of uric acid in the joint))

Kienböck’s disease

Septic arthritis (infection of the wrist joint)

Poor muscle training

Postmenopausal hormonal reduction

Diabetes

Pain to the wrist is the most frequent symptom of wrist osteoarthritis

Symptoms

The main symptoms of wrist osteoarthritis are:

Swelling of the wrist

Fluid accumulation in the joint

Early stage: pain with movement that eases off with activity

Advanced stage: chronic pain without movement

Noise when moving the wrist (crepitus)

Stiffness of the joint

Reduced range of motion

Wrist weakness

Poor sleep quality due to pain

Widespread joint pathology (e.g. rheumatoid arthritis)

Examination of the wrist's range of movement

Diagnosis

The diagnosis of wrist osteoarthritis begins with a medical history. The examiner will discuss the occurrence of past injuries and familiar predisposition to autoimmune diseases and arthritis. During the physical examination the specialist will assess the condition of the wrist and other joints. Other aspects of the diagnosis include:

Definition of pain characteristics

Passive and active exercises to assess changes in the range of movement

Comparison of both wrists' anatomy and function

X-rays to visualise changes in bones and cartilage

Blood test to exclude other medical conditions (rheumatoid arthritis)

Treatment

Immobilisation with a wrist band protects the wrist and reduces pain

Nonoperative treatment

In most cases wrist osteoarthritis is treated conservatively unless the pathology has severely compromised the anatomy of the joint or the pain has become unsustainable.

Antiinflammatory therapy with NSAIDs to reduce swelling, pain and permit the wrist movement

Local steroid injection in more severe symptoms

Painkillers

Heat to provide comfort and reduce inflammation

Temporary immobilisation with a brace to reduce acute symptoms

Physical and occupational therapy to modify activities

Exercise to strengthen the wrist muscles and increase range of movement

X-ray following wrist fusion (arthrodesis) which blocks movements of the wrist

Surgical treatment 

In case of severe pain or advanced degeneration of the wrist joint affecting function and quality of life surgery is necessary. Numerous methods are available depending on aetiology causing osteoarthritis.

Wrist arthroscopy is an exploratory minimally invasive surgery to assess in situ the damage of bones, cartilage and ligaments. It can be used to repair small tears of soft tissue or to remove cartilage fragments following an injury.

Resection of arthritic bones mostly of the carpal bones reduces pain and maintains partial wrist function.

Arthrodesis consists in wrist joint fusion of the radius with the carpal bone by placing a plate along the wrist. The bones will grow together and flexion/extension of the wrist will no longer be possible. This surgery will resolve pain but is significantly debilitating.

Wrist arthroplasty or joint replacement prosthesis is recommended in case of chronic rheumatoid arthritis where both sides are compromised and fusion is not an option.

Wearing a wrist brace is recommended initially after surgery

Rehabilitation 

After surgery initial rehabilitative care includes:

Arm elevation

Immobilisation with a cast or splint for 10-14 days or longer for 4-6 weeks

Ice pads

Antiinflammatory therapy with NSAIDs

Painkillers

Gentle physiotherapy can begin at a suitable time as directed by the surgeon depending on the type of surgery or following conservative treatment with a cast or splint. A number of exercises guided by a physiotherapist or hand-therapist will aim to acquire flexibility, function and strength of the wrist such as:

Gentle hand exercises within a bowl of warm wax

Use of ice packs to the joints before and after motion

Massage

Joint mobilisation

Stretches

Electrotherapy

Taping / bracing

Return to activity plan

Stretching and strengthening exercises help only partially to prevent wrist osteoarthritis

Prevention

To prevent severe damage of the arthritic wrist the patient is advised to avoid stress on the joint by modifying daily activities such as:

Gentle movements when twisting, pulling or pushing

Avoid carrying weights and bags

Exercise the muscles of the forearm and wrist to alleviate pressure on the wrist

Frequent motion of the wrist to reduce stiffness

Stretching exercises

Wear a wrist support when working with computers or returning to sport