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The Rheumatoid Wrist
Abstract
Wrist involvement is common in patients with rheumatoid arthri-
tis. 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 ten-
dons may rupture because of synovial infiltration and bony irrita-
tion. 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. Be-
cause 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 stabil-
ity of the affected radiocarpal joint and maintaining motion at the
midcarpal joint. For pancarpal arthritis, total wrist fusion offers re-
liable pain relief at the cost of motion. Total wrist arthroplasty is
an alternative that preserves motion; however, the outcomes of to-
tal wrist replacement are still being evaluated.
R
heumatoid arthritis (RA) is a
chronic, systemic autoimmune
disease that causes chronic inflam-
matory synovitis. Once the diagno-
sis is made, early medical manage-
ment may slow natural disease
progression.
1

Despite aggressive
medical management, however,
many patients have persistent and
progressive disease. Wrist involve-
ment is exceedingly common, with
>66% of patients having at least
some wrist symptoms within the
first 2 years of diagnosis; this num-
ber increases to >90% by 10 years.
2
Surgical intervention markedly im-
proves hand and wrist function for
many rheumatoid patients. Careful
patient selection, preoperative plan-
ning, and selection of surgical tech-
nique are vital.
Natural History
RA is a progressive disease that af-
fects the wrist via three pathologic
processes: cartilage degradation, lig-
amentous laxity, and synovial ex-
pansion with erosion.
3
Cartilage is
destroyed by the chemical effects of
lysosomal enzymes and free oxygen
radicals released by cytokine-
activated neutrophils. Synovial tis-
sue hypertrophy is the sine qua non
of RA, invading areas of increased

vascularity first. Eventually, all
joints and tendon sheaths may be-
come diseased.
Steven R. Papp, MD, MSc,
FRCSC
George S. Athwal, MD, FRCSC
David R. Pichora, MD, FRCSC
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.
J Am Acad Orthop Surg 2006;14:

65-77
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
Volume 14, Number 2, February 2006 65
The prestyloid recess of the distal
ulna is an area of increased vascular-
ity and early synovial infiltration. As
RA progresses, the ulnar styloid un-
dergoes erosion and its associated
ligaments become attenuated, lead-
ing to dorsal prominence of the ulnar
head—the so-called caput ulnae syn-
drome.
4
Proliferative synovitis of the
distal radioulnar joint (DRUJ) causes
arthritis and also contributes to dis-
tal ulna instability. Tenosynovitis of
the extensor carpi ulnaris (ECU) ten-
don sheath is the third factor leading
to distal ulna instability.
Erosion of the palmar side of the
distal radius, the waist of the
scaphoid, and the triquetrum also
are common. Additionally, synovitis
affects many of the intrinsic and ex-
trinsic wrist ligaments, including
the palmar radiocarpal, scapholu-
nate, and lunotriquetral ligaments.
Dorsal intercalated segmental insta-

bility or palmar intercalated seg-
mental instability may develop with
collapse. Classically, the proximal
carpal row translates both palmarly
and ulnarly and supinates. Cartilage
degradation from lysosomal en-
zymes, coupled with the abnormal
wrist biomechanics caused by liga-
mentous attenuation, leads to arthri-
tis. Early disease involvement at the
DRUJ as well as at the radiolunate
and radioscaphoid joints is followed
by carpal collapse and, ultimately,
pancarpal arthritis.
5
Preoperative Evaluation
Patients should undergo a thorough
assessment, including a full history
of disease activity, the specific areas
of joint involvement (ie, distal radio-
ulnar versus radiocarpal), current
medication, and previous surgical
procedures. In particular, symptoms
of neck pain or neurologic deficits
suggest the possibility of cervical
spine instability, which require pre-
operative flexion/extension cervical
spine radiographs and further imag-
ing. Nutritional status also may be
compromised by disease and medi-

cation and should be optimized pre-
operatively. We prefer to continue
anti-rheumatic medications (eg,
methotrexate) perioperatively to
avoid flare-ups, which we believe is
reasonably safe to do.
6
However,
newer and more potent drugs, such
as anti–tumor necrosis factor-α
agents (eg, infliximab, etanercept),
are being used. It is important to
consult with the treating rheumatol-
ogist to weigh the risks and benefits
of continuing perioperative medica-
tions. Preoperative blood work and
other tests may be guided by the
medications the patient is using and
their potential side effects. Anes-
thetic consultation is often neces-
sary, especially in patients with cer-
vical spine instability.
A thorough physical examination
of the wrist and hand is important.
Routine radiographic assessment in-
cludes anteroposterior and lateral ra-
diographic views of the wrist. Radio-
graphic staging of each joint in the
wrist and hand may be performed
preoperatively, as described by Lar-

sen et al
7
(Table 1). The presence of
joint dislocations and bone loss
should be noted. Usually, neither
computed tomography nor magnetic
resonance imaging is helpful in pre-
operative planning. For patients
with neurologic signs or symptoms,
nerve conduction velocity studies
and electromyography are recom-
mended.
Surgical Timing and
Priorities
The timing of wrist surgery in pa-
tients with RA remains controver-
sial. Factors that may influence the
decision to operate include general
health, other musculoskeletal sys-
tem involvement (eg, hip or knee
disease, shoulder or elbow patholo-
gy), disease activity, patient needs,
patient compliance, and surgeon ex-
perience. In general, because of the
potential need for ambulatory aids,
it is preferable to manage lower ex-
tremity problems before wrist sur-
gery. Problems at the shoulder and
elbow also must be considered. A
hand that cannot be placed in a func-

tional position because of elbow dis-
ease will not be used, despite correc-
tive hand and wrist surgery. Some
authors advocate a proximal-to-
distal order; however, first managing
the most problematic joint is proba-
bly more sensible.
Patients with persistent synovi-
tis, despite a 6-month trial of
disease-modifying antirheumatic
drugs and anti-inflammatory medi-
cations supervised by a rheumatolo-
gist, may be considered for prophy-
lactic surgery. Options include
tenosynovectomy, wrist synovecto-
my, and DRUJ stabilization. Surgery
to prevent wrist deformity, such as
tendon transfer of the extensor carpi
radialis longus to the ECU, also
should be considered. This may be
especially important before or in
conjunction with metacarpopha-
langeal (MCP) joint arthroplasty. Re-
constructive surgery, such as tendon
transfer or grafting, DRUJ recon-
struction, partial or total wrist fu-
sion, or wrist arthroplasty, should be
considered in patients with persis-
tent symptoms and a more destruc-
tive clinical picture.

Table 1
Larsen Radiographic Staging of
Rheumatoid Arthritis
Larsen
Score Radiographic Status
0 No change, normal joint
1 Periarticular swelling,
osteoporosis, slight
narrowing
2 Erosion and mild joint
space narrowing
3 Moderate destructive
joint space narrowing
4 End-stage destruction,
preservation of articular
surface
5 Mutilating disease,
destruction of normal
articular surfaces
The Rheumatoid Wrist
66 Journal of the American Academy of Orthopaedic Surgeons
In general, it is best to accomplish
as much as possible at one surgical
setting. However, soft-tissue man-
agement, surgical time, tourniquet
time, postoperative rehabilitation,
and patient factors may dictate a
staged procedure.
Surgical Management
Extensor Tendons and the

Dorsum of the Wrist
At the wrist, the extensor tendons
are enclosed in a synovial sheath,
thus making them susceptible to
rheumatoid disease. The extensor
tenosynovium starts just proximal
to the extensor retinaculum and ex-
tends distal to it. Clinically , patients
present with painless swelling as
synovitis peers out from the proxi-
mal and distal edges of the extensor
retinaculum, giving the dorsal wrist
an hourglass appearance. The exten-
sor tendons are separated and con-
tained in one fibrous sheath and five
fibro-osseous sheaths. Tenosynovitis
may be limited to one compartment
or may be more generalized. Initial-
ly, there is fluid production and in-
flammation, but as the synovium
proliferates and invades the tendon,
adhesions form and may cause ten-
don rupture (Figure 1).
Bony deformity at the wrist also
may cause extensor tendon dysfunc-
tion. Rheumatoid disease of the ra-
diocarpal joint and DRUJ leads to
palmar subluxation and supination
of the carpus and a prominent ulnar
head—the caput ulnae syndrome.

Ryuetal
8
reported that risk factors
for tendon rupture include persistent
tenosynovitis, dorsal dislocation of
the ulna, and the so-called scallop
sign (ie, bony erosion over the ulnar
side of the distal radius). Patients
with two or three of these risk fac-
tors were given the option of prophy-
lactic surgery, which seemed to pre-
vent tendon rupture in most
patients.
Because of its anatomic position
in the fifth dorsal compartment over-
lying the ulnar head, the extensor
digiti quinti (EDQ) is at high risk of
attritional rupture (ie, Vaughan-
Jackson syndrome).
9
In most individ-
uals, an isolated EDQ rupture is clin-
ically silent because of the remaining
extensor digitorum communis (EDC)
and juncturae tendinae. Assessment
for EDQ rupture is done by attempt-
ing little finger extension while hold-
ing the other fingers flexed into the
palm. In one study, patients with
loss of EDQ function were offered

surgery; intraoperative findings
showed perforation of the DRUJ cap-
sule and direct bony contact between
the ulnar head and the ruptured ten-
don.
10
Early diagnosis of EDQ rup-
ture may be an important indicator
for preventing further extensor ten-
don rupture. Left untreated, the pa-
tient may experience further rupture
of the EDC tendon to the fifth finger
and, sequentially, to the radial-sided
tendons, leading to significant dis-
ability.
The rheumatoid patient present-
ing with an inability to extend the
MCP joints likely has an extensor
tendon injury.
4
This injury usually is
caused by tenosynovial invasion and
attrition of tendons over bony prom-
inences, such as the EDQ over a
prominent caput ulnae or extensor
pollicis longus over Lister’s tubercle.
Other causes must be considered,
however, including extensor tendon
subluxation, MCP joint dislocation,
and posterior interosseous nerve pal-

sy. Both passive and active range of
motion (ROM) of the wrist and fin-
gers should be documented on phys-
Figure 1
A, Note the hourglass appearance as dorsal tenosynovitis peers out just distal to the extensor retinaculum (arrow). B, Dorsal
midline incision and reflection of the extensor retinaculum (white arrow). The infiltrative process of the tendons leads to a toffee-
like appearance (black arrow), softening, and, eventually, rupture.
Steven R. Papp, MD, MSc, FRCSC, et al
Volume 14, Number 2, February 2006 67
ical examination. Extensor tendon
continuity is determined by palpat-
ing the dorsal aspect of the wrist dur-
ing active contraction in various
wrist positions. On full passive wrist
flexion, the tenodesis effect of intact
extensor tendons normally causes
MCP joint extension. When the fin-
ger can actively be held in full exten-
sion once it has been passively posi-
tioned, then tendon subluxation
caused by sagittal band attenuation
is likely. Fixed contractures caused
by MCP joint dislocation or arthritis
also may prevent extension. Finally,
the inability to extend all of the fin-
gers and the thumb may be the re-
sult of posterior interosseous nerve
palsy at the elbow.
11
Indications for early surgical treat-

ment remain controversial.
12
The
goals of surgery are to decrease pain,
improve function, limit progression,
and prevent tendon rupture. Options
include extensor tenosynovectomy,
wrist joint synovectomy, and soft-
tissue balancing. DRUJ instability is
an important part of wrist and ten-
don dysfunction, and correction of
instability should be considered
when performing soft-tissue proce-
dures above the wrist. Once the ex-
tensor tendon ruptures, the deficits
are usually significant and surgery
becomes necessary.
Synovectomy is indicated for ac-
tive or recurrent extensor tenosyno-
vitis or for wrist synovitis that per-
sists despite 3 to 6 months of
medical management (including
corticosteroid injections). Tenosyn-
ovectomy is unlikely to be of value
when the associated joints are stiff
or ankylosed because of arthritis or
deformity. Early in the disease
course, dorsal tenosynovectomy and
wrist synovectomy may benefit pa-
tients with persistent disease. How-

ever, there are conflicting data on
the usefulness of these soft-tissue
procedures. Some studies suggest
short-term benefit without long-
term effects on the natural history o f
RA at the wrist.
13
Alternatively , oth-
er authors believe that decreased
pain, increased function, and de-
creased chance of tendon rupture
justify inter vening even if halting
the disease process is unproved.
14,15
Although open wrist synovectomy is
standard and allows inspection of all
compartments as well as of the ex-
tensor tendons, arthroscopic syn-
ovectomy has been used successful-
ly in select patients. Arthroscopic
synovectomy offers the potential ad-
vantage of less postoperative loss of
wrist motion than with open teno-
synovectomy.
16
Tenosynovectomy is performed
through a midline dorsal approach to
protect the radial sensory and dorsal
ulnar sensory nerves. The extensor
retinaculum is entered between the

fifth and sixth extensor compart-
ments, and a radially based flap of
retinaculum is raised to the first dor-
sal compar tment to allow excision
of the infiltrating synovium around
the extensor tendons (Figure 2). For
pain relief, partial wrist denervation
may be performed by resecting the
terminal branch of the posterior in-
terosseous nerve in the floor of the
fourth extensor compartment. We
prefer to enter the radiocarpal and
midcarpal joints with a straight lon-
gitudinal incision, although there
are alternatives, such as the
ligament-sparing arthrotomy de-
scribed by Berger and Bishop.
17
All
bony prominences that may cause
tendon abrasion must be removed.
Figure 2
Tenosynovectomy. A midline dorsal approach is made (double-headed arrow) to
avoid the superficial radial sensory and dorsal ulnar sensory nerves. This incision
offers an excellent view of the extensor compartments. A retinacular flap may be
raised and reflected from ulnar to radial. APL = abductor pollicis longus, ECRB =
extensor carpi radialis brevis, ECRL = extensor carpi radialis longus, EDC =
extensor digitorum communis, EPB = extensor pollicis brevis, EPL = extensor
pollicis longus. (Permission to reproduce this figure courtesy of the Indiana Hand
Center, Manus, and Gary Schultz.)

The Rheumatoid Wrist
68 Journal of the American Academy of Orthopaedic Surgeons
Lister’s tubercle and a prominent ul-
nar head are the most common
sources of tendon abrasion. For the
unstable distal ulna, a distal ulna re-
section (Darrach procedure) or a dis-
tal radioulnar joint fusion proximal
resection (Sauvé-Kapandji procedure)
is indicated to prevent further ten-
don abrasion.
Once the tenosynovectomy is
complete, some authors advocate
preserving or repairing the distal por-
tion of the retinaculum to minimize
the chance of extensor tendon bow-
stringing.
18
We routinely lay the ex-
tensor retinacular flap under the ex-
tensor tendons to further protect
them from abrasion. Postoperative-
ly, a splint is applied for comfort, and
early ROM of the fingers and wrist is
begun. After a Darrach or Sauvé-
Kapandji procedure, the wrist and
forearm are immobilized for approx-
imately 4 weeks, followed by part-
time splinting with ROM exercises.
Early in the disease process, ten-

don transfers have been advocated for
soft-tissue and wrist balancing. As
the rheumatoid wrist deteriorates,
the carpus translates ulnarly and pal-
marly. The classic zigzag deformity
of radial deviation at the wrist and ul-
nar deviation at the fingers may de-
velop. Although there are many con-
tributing factors to ulnar drift of the
fingers, the deformity is thought to
originate at the wrist.
19
The Darrach
procedure, which is commonly done
at the same time as wrist synovec-
tomy, is thought to be a risk factor
for ulnar carpal subluxation because
it further destabilizes the ulnar side
of the wrist.
17
Extensor carpi radialis
longus tendon transfer to the ECU
was first described as a means to pre-
vent this wrist deformity.
20
A recent
retrospective study concluded that
extensor carpi radialis longus tendon
transfer aids in wrist stabilization,
preventing ulnar carpal translation

and radial deviation. The authors also
noted decreased ulnar drift of the fin-
gers at a mean 8.8-year follow-up.
21
This procedure also may help prevent
caput ulnae syndrome by tethering
the ECU tendon dorsally over the ul-
nar head.
Tendon Transfer for
Extensor Tendon Rupture
The extensor tendons and soft-
tissue envelope are frequently com-
promised in RA. Although antirheu-
matic medications may adversely
affect healing, reasonable improve-
ments in hand function may be
achieved by tendon transfer in pa-
tients with functional limitations
caused by extensor tendon rupture.
For patients with tendon rupture
associated with RA, primary tendon
repair is rarely feasible (Figure 3).
The diffuse nature of the tendon
damage, combined with fibrosis, at-
rophy, and retraction of the muscle,
usually precludes repair. When rup-
ture is diagnosed early, tendon graft-
ing may be successful.
22
Some au-

thors think that tendon grafting
results are poor because of the long-
standing nature of the disease and
decreased musculotendinous unit
excursion, leading to loss of flexion
following grafting.
23
Tendon transfer is the most com-
mon surgical choice. The simplest is
side-to-side transfer, in which the
distal stump of the ruptured tendon
is sewn into one of the adjacent ex-
tensor tendons. With rupture of mul-
tiple extensor tendons, the recruit-
ment of distant motors is necessary.
Common options include the exten-
Figure 3
A, Patient demonstrating the classic findings at the wrist of persistent dorsal tenosynovitis (arrow) and a prominent ulnar head
(arrowhead). This patient also presented with a suspected extensor tendon rupture at the fifth extensor compartment.
B, Intraoperative photograph of the exposed tendons and raised retinacular flap of a similar patient demonstrating an obviously
arthritic and prominent ulnar head (arrow) and long-standing rupture of the extensor tendons to the ring and little fingers.
(Ruptured proximal tendon in forceps and ruptured distal tendons reflected over the skin.)
Steven R. Papp, MD, MSc, FRCSC, et al
Volume 14, Number 2, February 2006 69
sor indicis proprius tendon and one of
the flexor digitorum superficialis
(FDS) muscles. The most common
extensor tendon rupture involves the
little finger, with rupture of the EDQ
and/or the EDC to the fifth finger.

This injury may be treated by simple
side-to-side transfer into the intact
fourth EDC tendon. In the presence
of multiple tendon ruptures, recon-
struction becomes more complex;
fortunately, several tendon transfers
are available (Table 2) (Figure 4).
Flexor Tendons and Carpal
Tunnel Syndrome
The nine tendons and median
nerve that pass under the transverse
carpal ligament also may be affected
by RA. A swollen flexor tenosyn-
ovium may be obscured by thick
volar fascia and the transverse carpal
ligament and therefore may not be as
clinically apparent as dorsal wrist
synovitis.
24
Because of the fixed space
of the carpal tunnel, however, pa-
tients may present with symptoms of
carpal tunnel syndrome (CTS) or dif-
ficulty with finger flexion. Full pas-
sive finger flexion with compromised
active flexion, crepitus, and trigger-
ing are signs of flexor tendon prob-
lems.
CTS is common in patients with
RA. The patient may present with

the classic symptoms, including
numbness and paresthesias in the
median innervated fingers, with
worsening at night causing waking.
It is essential to assess the elbow,
shoulder, and neck because of the
possibility of nerve compression
from more proximal locations. Also,
the systemic nature of rheumatoid
disease may affect peripheral nerves
directly. Because of the possibility of
other diagnoses, confirmatory nerve
conduction velocity studies and
electromyography are often helpful.
Shinoda et al
25
recently reported im-
provement in 28 of 29 hands operat-
ed on for CTS in patients with RA.
Patients with loss of active flexion
at the MCP or interphalangeal joints
may have flexor tenosynovitis or
flexor tendon rupture. In a classic
study, Mannerfelt and Norman
26
doc-
umented tendon rupture in the rheu-
matoid hand. Extensor tendon rup-
ture was most common, seen in 41 of
66 patients (62%); however, flexor

Figure 4
The extensor indicis proprius (EIP) tendon is transferred to the ruptured extensor
tendons of the ring and little fingers. The distal stump of the extensor EIP is sewn to
the extensor digiti communis (EDC) tendon. EDQ = extensor digiti quinti.
(Reproduced with permission from Ferlic D: Repair of ruptured finger extensors in
rheumatoid arthritis, in Strickland JW [ed]: Master Techniques in Orthopaedic
Surgery: The Hand. Philadelphia, PA: Lippincott-Raven, 19 98, p 417.)
Table 2
Treatment Options for Extensor Tendon Transfers
Ruptured Tendon Transfer Alternative
EDM/EDC5 EDC5 side-to-side
EDC4
—
EDM/EDC5/EDC4 EDC4/5 side-to-side
EDC3
EIP to EDC4/5
EDM/EDC5/EDC4/EDC3 EDC3 side-to-side
EDC2
EIP to EDC4/5
FDS D4
to EDC4/D5
EDM/EDC2-5/EIP FDS D3 and D4 to
EDC2-5
—
D2, 3, 4, 5 = index, middle, ring, little fingers, respectively; EDC = extensor digitorum
communis; EDM = extensor digiti minimi; EIP = extensor indicis proprius; FDS =
flexor digitorum superficialis
The Rheumatoid Wrist
70 Journal of the American Academy of Orthopaedic Surgeons
tendon rupture also was common

(25/66 [38%]). Of the flexor tendon
ruptures, flexor pollicis longus (FPL)
rupture was the most common
(14/25 [56%]). In fact, 23 of 25 pa-
tients had either FPL or index flexor
digitorum profundus (FDP) tendon
rupture. The authors attributed these
ruptures to a combination of infiltra-
tive rheumatoid disease with soften-
ing of the tendons and attrition re-
sulting from bony prominences.
The Mannerfelt lesion occurs
when the distal pole of the scaphoid
and trapezium pierce the volar wrist
capsule, causing FPL tendon rup-
ture.
26
Ertel et al
27
described a simi-
lar pattern of distinct ulnarward pro-
gression of tendon ruptures, first at
the FPL, followed by the index FDP
and then the index FDS or middle
FDP. This is in contrast to the ulnar-
to-radial direction of extensor tendon
ruptures on the dorsum of the wrist.
Many cases of CTS or flexor teno-
synovitis are minimally symptomat-
ic, and function may not be compro-

mised. Even rupture of the FPL or
index FDP may go unnoticed by the
patient (Figure 5, A). FDS ruptures
are commonly missed on clinical ex-
amination in the presence of intact
FDP function. Even with minimal
symptoms, surgery should be con-
sidered to help prevent further loss
of function. Patients with overt car-
pal tunnel symptoms and weakness
of grip and pinch usually benefit
from surgery.
Generally, we perform open car-
pal tunnel release and flexor teno-
synovectomy (Figure 5, B). Endo-
scopic carpal tunnel release has been
successful in the rheumatoid pa-
tient;
28
however, it is offered only to
patients with no sign of tenosynovi-
tis. During open surgery, the flexor
tendons are examined for attrition or
rupture. When the FDP tendons re-
main scarred together but intact, it
is probably best to leave the mass
alone. The floor of the carpal tunnel
is explored. When there is a defect in
the volar capsule with prominent
bony spicules (most commonly

scaphoid tubercle), then a bony dé-
bridement is done. Volar capsular ro-
tation flap to provide soft-tissue cov-
erage of resected bony areas is
illustrated in Figure 6. In patients
with severe palmar subluxation of
the carpus, partial or total wrist fu-
sion should be considered to prevent
further tendon damage.
FPL tendon rupture may be man-
aged in several ways. Primary tendon
repair is rarely possible. Because rup-
ture commonly occurs within the car-
pal tunnel and not in the fibro-
osseous canal, a short tendon graft
using the palmaris longus may be pos-
sible. The results of grafting are de-
pendent on supple joints and a com-
pliant, functional musculotendinous
unit. Tendon transfer using FDS ten-
don from the ring finger is an option
if preserving thumb motion is impor-
tant, such as in a young, active pa-
tient with well-controlled disease.
Thumb interphalangeal fusion is the
simplest and most reliable solution.
In patients with rupture of the FDP
to the index finger, distal interpha-
langeal joint fusion or side-to-side
FDP transfer are reasonable options.

With rupture of both the FDP and the
FDS to the index finger, tendon trans-
fer using the FDS of the middle or ring
finger may be perfor med. For any
other flexor-sided tendon rupture, op-
tions include fusion, side-to-side re-
pair, tendon transfer, and tendon
grafting. Taking into consideration
the patient’s compromised function
and disease severity usually leads to
Figure 5
A, Clinical examination demonstrating fullness in the carpal tunnel as well as functional loss of the flexor pollicis longus tendon
of the thumb and of both the flexor digitorum superficialis and the flexor digitorum profundus to the index finger. B, Intraoperative
photograph demonstrating the palmar aspect of the wrist with severe flexor tenosynovitis and multiple flexor tendon ruptures in
a 60-year-old man with rheumatoid arthritis.
Steven R. Papp, MD, MSc, FRCSC, et al
Volume 14, Number 2, February 2006 71
considering the simplest solution first
(Table 3).
Distal Radioulnar Joint
In rheumatoid disease, the DRUJ
is often affected early. It is important
to have a comprehensive under-
standing of the anatomy of the area
of the wrist involving the DRUJ, tri-
angular fibrocartilage, and ulnar-
sided ligaments.
29
Patients may present with a con-
stellation of symptoms. In many cas-

es, the disease first affects the stabi-
lizing ligaments. A patient with a
prominent ulnar head may present
with minimal symptomatology. Ul-
nar head prominence may present
with mild to moderate synovitis of
the extensor tendons or synovitis of
the radiocarpal joint (Figure 7). In
other patients, the instability alone
or, more commonly, arthritic chang-
es in the DRUJ, cause pain and crep-
itus during forear m rotation. Pa-
tients also may present with
extensor tendon rupture.
On examination, the so-called pi-
ano key sign is present. With this
test, downward pressure is applied to
the dislocated ulnar head, which
temporarily relocates, only to redis-
locate dorsally when pressure is
removed. ROM in the flexion/
extension and supination/pronation
arcs should be noted. Proximally, an
arthritic radioulnar joint may be a
source of limited rotation; therefore,
the elbow should be examined.
Plain radiographs are necessary,
including anteroposterior and later-
al views with the forearm in neutral
position. Although rarely required,

computed tomography may be the
most accurate technique for detect-
ing subtle DRUJ subluxation.
30
Ear-
ly findings may include soft-tissue
swelling, diffuse osteopenia, and
marginal erosion in the area of the
ulnar styloid. Later, more obvious
arthritic changes and dislocations
may present. To plan the surgical
procedure, radiographs should be
studied for radioulnar joint sublux-
ation, ulnar variance, bone loss, and
Figure 6
A, Carpal tunnel release and capsular exposure. B, The scaphoid tubercle may
pierce the volar capsule, leading to FPL attrition. C, Primary closure of the volar
capsule may be possible after scaphoid débridement. D, When direct closure is not
possible, volar capsule rotation may be performed. Dashed line indicates the
planned volar capsule rotation flap. E, Complete volar capsular rotation flap. C =
capitate, FCR = flexor carpi radialis, FDP = flexor digitorum profundus, FDS = flexor
digitorum superficialis, FPL = flexor pollicis longus, L = lunate, S = scaphoid, T =
trapezium. (Reproduced with permission from Feldon et al: Rheumatoid arthritis and
other connective tissue diseases, in Green DP, Hotchkiss RN, Pederson WC [eds]:
Green’s Operative Hand Surgery. Philadelphia, PA: Churchill Livingstone, 1999,
vol 2, p 1669.)
Table 3
Treatment Options for Flexor Tendon Rupture
Ruptured Tendon Treatment Alternative
FPL IP fusion or PL graft FDS to FPL

FDP D2 DIP fusion Side-to-side repair, FDS
D4 to FDP
FDS + FDP D2 FDS D3/4 to FDP PIP/DIP fusion
D2, 3, 4 = index, long, ring fingers, respectively; DIP = distal interphalangeal; FDP =
flexor digitorum profundus; FDS = flexor digitorum superficialis; FPL = flexor pollicis
longus; IP = interphalangeal; PIP = proximal interphalangeal; PL = palmaris longus
The Rheumatoid Wrist
72 Journal of the American Academy of Orthopaedic Surgeons
ulnocarpal translation and carpal su-
pination deformity.
In the rare situation of persistent
DRUJ synovitis with no evidence of
arthritis or instability, synovectomy
may be considered. Because the
DRUJ is so often involved early in
the disease course, more definitive
distal ulnar procedures may eventu-
ally be required. Although good out-
comes have been reported with liga-
mentous reconstruction in the
posttraumatic group,
31
the natural
history of ligamentous laxity in pa-
tients with RA has led most sur-
geons away from using these types of
procedures. More commonly, bony
procedures, such as the Darrach or
Sauvé-Kapandji procedure, are per-
formed.

Distal Ulna Resection: The
Darrach Procedure
Although the Darrach procedure
has a long, favorable clinical history,
it also has the most described com-
plications.
32,33
Nevertheless, when
done correctly, this procedure re-
mains a reliable surgical option for
most patients with RA.
The Darrach procedure may be
performed through the same skin in-
cision as that used for an extensor
tenosynovectomy or wrist fusion.
The ulnar head is resected just prox-
imal to the point of contact between
its articular surface and the sigmoid
fossa of the distal radius. The radial
side of the distal ulnar stump may be
rounded to minimize impingement
as well as to increase the surface area
of any potential contact between the
radius and ulna (Figure 8). A distally
based flap of volar capsule is sewn to
the dorsal ulnar stump to control
distal ulnar instability. The ECU
tendon is relocated back to its dorsal
position using a radially based flap of
extensor retinaculum. Currently , we

favor the Darrach procedure as a re-
liable treatment option in older or
less active RA patients, or in pa-
tients with severe erosion of the dis-
tal ulnar head.
34
Failure after the Darrach proce-
dure commonly occurs as the result
of recurrent instability or pain
caused by radioulnar impingement.
In fact, dynamic convergence is
common but not always symptom-
atic.
35
These complications may be
minimized with good surgical tech-
nique to preserve and repair soft-
tissue constraints.
36
Some authors
advocate an ECU tenodesis as an im-
portant part of the initial procedure
to minimize the risk of instability.
37
Occasionally, an unstable or painful
distal ulnar stump after the Darrach
procedure requires revision. Several
revision procedures have been de-
scribed, including a combined ECU
and flexor carpi ulnaris tenode-

sis
38,39
and pronator quadratus inter-
position.
40
Distal ulnar prosthetic replace-
ments, such as the uHead prosthesis
(SBI, New York, NY), are another op-
tion. There are concerns related to
the ability of the prosthesis to offer
long-term stability, considering the
poor soft-tissue envelope. To help
stabilize the ulnar head, this pros-
thesis has an area for reattachment
of the ECU subsheath and triangular
fibrocartilage. Scheker et al
41
de-
signed a semiconstrained total DRUJ
prosthesis to address persistent in-
stability. The long-term durability of
these prostheses under physiologic
Figure 7
A, Clinical photograph of a patient with rheumatoid arthritis of the right hand who presented with a painful and clinically
dislocated distal radioulnar joint. B, Lateral radiograph confirming the dislocated distal radioulnar joint.
Figure 8
Same patient as in Figure 7.
Anteroposterior radiograph after the
Darrach procedure was performed. The
slope of the distal ulnar resection is

parallel to the slope of the distal radius
to minimize impingement symptoms.
Steven R. Papp, MD, MSc, FRCSC, et al
Volume 14, Number 2, February 2006 73
load is unproved. Nonetheless, early
results are very promising,
41
and res-
toration of the normal anatomy may
better restore function on a long-
term basis.
Sauvé-Kapandji Fusion
The Sauvé-Kapandji procedure of-
fers another treatment alternative
for DRUJ disease in the rheumatoid
wrist. Some authors have noted fur-
ther destabilization of the carpus
with the Darrach procedure, leading
to ulnar translation.
42,43
The Sauvé-
Kapandji procedure offers the advan-
tage of preserving the ulnar support
structures of the wrist via retention
of the ulnar head and fusion of the
DRUJ. Resection of 10 to 15 mm of
the distal ulna is planned just prox-
imal to the DRUJ, and the perios-
teum is removed to diminish chanc-
es of regrowth. The DRUJ is entered,

and the remaining cartilage from
both the ulna and radius is denuded.
The distal ulnar stump is translated
slightly proximally to prevent any
ulnocarpal abutment and to reten-
sion the ulnocarpal ligaments. The
distal fragment is then temporarily
pinned. Proper positioning is con-
firmed with fluoroscopy. Kirschner
wire (K-wire) fixation is acceptable;
however, we prefer to exchange the
K-wires for one or two small-
diameter interfragmentary screws.
Once stabilized, gentle forearm
rotation should demonstrate move-
ment through the resection site with
no impingement. The remaining lo-
cal soft tissues, including the prona-
tor quadratus, may be sewn into the
resection gap. Four weeks of long
arm casting in the neutral position is
followed by a physiotherapy proto-
col supervised by a hand therapist.
Vincent et al
44
reported excellent
pain relief in 17 rheumatoid patients
using this technique and favor it be-
cause of their “dissatisfaction with
clinical results of the Darrach proce-

dure.” W e currently favor this proce-
dure in most active patients with RA
and have found it to be reliable, with
a low complication rate. Distal ulnar
stump instability, impingement, and
extensor tendon rupture may occur
after this procedure, but they are not
as commonly reported as they are
with the Darrach procedure.
45
Partial Wrist Fusion
Radiolunate and radioscapholu-
nate ar throdesis offer consistent
pain relief, wrist stabilization, and
preservation of some wrist mo-
tion.
46,47
Indications for limited ra-
diocarpal fusion include advanced
radiocarpal arthritis and radiocarpal
instability with sparing of the mid-
carpal joint.
The standard dorsal approach to
the wrist is performed. If necessary,
an extensor retinacular flap is raised
and the extensor tendons are
débrided. The radiocarpal and mid-
carpal joints are explored and corre-
lated with preoperative expectations.
Wrist joint synovectomy is per-

formed. The radiolunate joint is de-
nuded of any remaining cartilage, and
the lunate is positioned against the
lunate fossa of the distal radius for fu-
sion. Bone graft (most commonly dis-
tal radius or the resected distal ulna
bone) may be used to improve con-
solidation. When the radioscaphoid
joint is severely affected, a radio-
scapholunate fusion may be pre-
ferred, whereby the lunate is gently
reduced and held in a neutral posi-
tion for fusion, correcting any carpal
malalignment and ulnocarpal trans-
lation. If the lunate is left in exces-
sive extension, wrist flexion may be
limited. Importantly, complete resto-
ration of carpal height and carpal
translation in patients with long-
standing fixed defor mity may be
harmful, causing midcarpal sublux-
ation or rotation and precipitating ac-
celerated secondary arthrosis.
48
Fu-
sion rates are high, and fixation may
be accomplished using K-wires, sta-
ples, screws, or mini-condylar plates.
In the presence of mild to moder-
ate arthritic changes in the midcar-

pal joint, partial wrist fusion com-
bined with wrist denervation still
seems to offer reliable pain relief. Al-
though the midcarpal joint may en-
counter more stresses following a
partial wrist fusion, there is little ev-
idence of rapid deterioration com-
pared with nonoperated wrists.
47
Total Wrist Fusion Versus
Arthroplasty
For the patient with advanced ar-
thritic changes, either wrist fusion
or arthroplasty may be considered
(Figure 9). Long-term studies on
wrist fusion have reported it to be
safe and reliable.
49,50
Techniques for
total wrist fusion include intramed-
ullary rods or plates.
51
The AO (Syn-
thes, Paoli, PA) low-profile wrist fu-
sion plate has become a popular
choice for this procedure. Its design
allows the wrist to be fused in ap-
proximately 10° of extension with a
low-profile contour over the third
metacarpal. In a recent study on to-

tal wrist fusion using this plate,
Meads et al
52
reported excellent rates
of fusion and low rates of soft-tissue
complication, with only a 15% rate
of hardware removal. Although ex-
cellent rates of fusion with in-
tramedullary fixation have been re-
ported,
53
the plate technique allows
for more rigid fixation and earlier
mobilization, which are crucial in
patients with RA. Compared with
intramedullary fixation, plate fixa-
tion offers more reliable mainte-
nance of wrist position.
51
Although wrist arthrodesis offers
reasonable functional results and is
an excellent treatment option for pa-
tients with RA, patients report diffi-
culties with certain activities of dai-
ly living, such as opening a jar,
writing, and personal hygiene. These
problems may be magnified in pa-
tients with shoulder, elbow, finger,
and bilateral wrist involvement. Ul-
timately, wrist fusion remains a reli-

able treatment option at the expense
of motion. Wrist arthroplasty offers
improvement in pain and deformity,
with the advantage of preserved or
improved motion. Vicar and Bur-
ton
54
reported on patients treated
with wrist arthrodesis on one side
The Rheumatoid Wrist
74 Journal of the American Academy of Orthopaedic Surgeons
and arthroplasty on the contralater-
al side; patients preferred the latter.
Murphy et al
55
reported that patients
with RA perform certain functions
(eg, hygiene, button fastening) better
when treated with arthroplasty rath-
er than with arthrodesis. We prefer
wrist fusion because of its reliability
and low complication rate; however,
improvements in arthroplasty tech-
nique, soft-tissue balancing, and im-
plant design are offering improved
outcomes.
Several types of wrist implants
have been developed over the years,
including silicone implants, metal/
polyethylene implants (uncon-

strained and semiconstrained), and
cemented and cementless prosthe-
ses.
56,57
With the older designs, ten-
don rupture, soft-tissue imbalance,
dislocation, prosthetic loosening,
and implant fracture occurred at un-
reasonably high rates. Newer pros-
thetic designs and better under-
standing of surgical indications and
techniques have led to improved
outcomes.
58
Aseptic loosening of wrist im-
plants is usually at the metacarpal
side of the prosthesis.
56
Newer im-
plants have been designed to address
the higher rates of metacarpal loos-
ening and to increase stability .
57
The
Universal Total Wrist Replacement
system (KMI, San Diego, CA) and
the Avanta Resurfacing Total Wrist
(SBI) are designed to have a more sta-
ble articulation and better distal
component fixation. The distal por-

tion of the implant involves less
bony resection with partial sparing
of the proximal carpal row. The fix-
ation into the third metacarpal is
augmented with two screws on the
radial and ulnar sides, and the inter-
carpal joints are denuded to facilitate
a distal row fusion. The Universal
prosthesis has shown reasonable re-
sults with less loosening on the
metacarpal side; however, there is a
reported 14% dislocation rate.
58
Al-
though wrist arthrodesis after failed
wrist arthroplasty is possible, it car-
ries a higher complication rate.
59
To-
tal wrist arthroplasty likely will be-
come more popular as designs
improve and surgeons become more
experienced with the procedure.
Summary
The wrist and hand are commonly
involved in RA. As the disease man-
ifests, deformity and arthritis follow
a fairly typical pattern of progres-
sion. Synovitis develops first at the
tendon sheaths, then at the DRUJ

and the radiocarpal joint. When dis-
ease activity persists despite ade-
quate medical management, select-
ed patients benefit from early
Figure 9
Anteroposterior (A) and lateral (B) radiographs of a patient with rheumatoid arthritis with a destructive clinical picture, including
end-stage arthritis and carpal dislocation. C, Anteroposterior radiograph after total wrist fusion using a wrist fusion plate.
Steven R. Papp, MD, MSc, FRCSC, et al
Volume 14, Number 2, February 2006 75
surgery. Extensor tenosynovectomy
and dorsal wrist synovectomy may
be necessary, often in conjunction
with DRUJ stabilization. Flexor
tenosynovectomy and carpal tunnel
release are effective. Flexor and ex-
tensor tendon rupture may occur.
Direct repair is rarely possible, but
treatment options include tendon
transfer, grafting, and joint fusion.
The Darrach and the Sauvé-
Kapandji procedures are the most
common treatment methods for a
dislocated or arthritic DRUJ. Partial
wrist fusion is well tolerated and
may be considered when radiocarpal
arthritis is predominant. For patients
with pancarpal arthritis, total wrist
fusion compromises motion for sta-
bility; however, total fusion offers re-
liable pain relief and reasonable func-

tional outcomes. The advantage of
preserved motion through total wrist
arthroplasty is attractive in patients
with other affected upper extremity
joints. Rheumatoid patients with
hand and wrist involvement warrant
orthopaedic consultation for assess-
ment of baseline status and possible
prophylactic surgery.
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