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Surgery of the Hand and Wrist

by Nancy Callinan, MA, OTR, CHT

Now let’s take a closer look at some of the surgeries most commonly used in arthritis: arthroplasty and arthrodesis for osteoarthritis (OA) of the thumb, arthroplasty for fingers affected by RA, and excision and arthrodesis for the wrist.

OA of the thumb

Pain at the base of the thumb can signal destruction of the cartilage at the carpometacarpal (CMC) joint. The damage is most often found on the trapezium, the carpal (wrist) bone at the base of the thumb. If you have thumb OA, you may experience pain when pinching or grasping, collapse of the thumb at the base joint, and loss of the ability to make the thumb movements that let you grasp large objects. One arthroplasty option for OA in the CMC joint is called Ligament Reconstruction Tendon Interposition. When you have this surgery, the surgeon removes the trapezium and then takes a nonessential tendon from your forearm, hand, or wrist, coils part of it up, and places it in the space previously occupied by the trapezium. The other part of the tendon is used to reconstruct the ligament so as to reinforce the joint. The surgeon may insert a wire or pin into the joint for additional stability. This wire protrudes through the skin, and after three to four weeks it will be removed (without further surgery).

You will be given a splint or cast immediately after the surgery to immobilize the operated-on joint for three to four weeks. Once the initial cast or splint has been removed, you can begin moving the joint again. You will probably wear a lighter splint for several weeks to give the thumb additional support and protection. At about 6–8 weeks after surgery, you can use the hand for light activities, wearing the splint only for heavy activities or if pain persists. You can usually resume normal use of the hand after 12 weeks.

Most people have an excellent outcome after this surgery. They are pleased that they can resume activities with less pain. However, some pain is common. If it persists, you may continue to use your lighter splint, or another version of it, for some activities.

If you have severe arthritis and work in a job that demands heavy thumb use, the surgeon may suggest arthrodesis rather than arthroplasty. In this case, the doctor fuses the CMC joint, using a pin to provide stability. If you choose this option, you should realize that there will be a permanent loss of some thumb motion. However, the stability of the joint will be improved. Usually, the surgeon positions the joint in such a way that when it fuses, it will give you the best possible function for most activities. You will usually wear a splint or cast for several weeks after surgery to immobilize the thumb.

Often a surgeon will recommend surgery for OA in the CMC joint after conservative measures have failed to provide relief. Conservative treatments for the early stages of this condition include use of a thumb splint, thumb-strengthening exercises, joint protection, activity modification, and taking nonsteroidal anti-inflammatory drugs. Sometimes, people are given injections of corticosteroids into the thumb joint.

Fingers affected by RA

When RA affects the large knuckle (MCP) joints, causing pain and reducing stability, arthroplasty can help. Carbon, silicone, or plastic and metal joint replacements can be surgically inserted to replace the damaged joints. The middle (PIP) joints can also be replaced, although these surgeries are not as common. The tip (DIP) joints are not usually replaced, but they may be fused for more effective positioning.

When you have the large knuckles replaced, the surgeon makes an incision over the top of the knuckles on the back of the hand. Then the surgeon removes the damaged ends of the metacarpal bones and prepares the canals of the adjoining finger bones (the proximal phalanges) so the implants can be inserted into them. Next, the surgeon repositions the tendon over the top of each finger so that the fingers are aligned more effectively. MCP replacement surgery often involves synovectomy, in which the surgeon removes inflamed tissue from the joint.

After this surgery, the short-term goal is to achieve a balance between mobility and stability while the tissues around the implants heal. Immediately after surgery, you’ll be given a cast and a bulky gauze dressing. Within days you’ll be fitted with a splint for daytime use that allows some protected movement of the fingers and a splint to wear at night that rests the hand. Therapy usually begins within the first week and is an important part of after-surgery care. Your doctor may recommend hourly exercises. Splinting and therapy can continue for up to 12 weeks. Replacement of the MCP joints is often effective in reducing pain and in improving the position of the fingers, the hand’s appearance, and the hand’s ability to function. The outcomes are usually quite good. However, implants may fracture, dislocate, or wear out over time, meaning they’ll need to be replaced.

Last Reviewed on September 15, 2010

Nancy Callinan is Manager of Hand Therapy at TRIA Orthopaedic Center in Minneapolis, Minnesota.

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