Description
The hand and wrist have multiple small joints that work together to produce motion. This gives you the fine motion needed to thread a needle or tie a shoelace. When the joints become affected with arthritis, activities of daily living can be difficult. Arthritis can occur in multiple areas of the hand and wrist. It can have multiple causes.

All arthritic joints lose cartilage, which works as nature’s “shock absorber.” Cartilage provides a smooth gliding surface for the joint. When the cartilage becomes worn or damaged, or is lost due to disease or trauma, the joint no longer has a painless, mobile area of motion.

The body attempts to make up for the lost cartilage. It produces fluid in the joint lining (synovium), which tries to act like a cushion, like water in a waterbed. But it also causes the joint to swell. This restricts motion. The swelling causes stretching of the joint covering (capsule), which causes pain.

Over time, if the arthritis is not treated, the bones that make up the joint can lose their normal shape. This causes more pain and further limits motion.

Risk Factors/Prevention
It is estimated that one out of every five people living in the United States has at least one joint with signs or symptoms of arthritis. About half of arthritis sufferers are under age 50. Arthritis is the leading cause of disability in the United States. It typically occurs from either disease or trauma. The exact number of people with arthritis in the hand and wrist is not known.

When arthritis occurs due to disease, the onset of symptoms is gradual and the cartilage decreases slowly. The two most common forms of arthritis from disease are osteoarthritis and rheumatoid arthritis. Osteoarthritis is much more common and generally affects older people.

It appears in a predictable pattern in certain joints. Rheumatoid arthritis has other system-wide symptoms and may be passed from parent to child (genetically).

When arthritis is due to trauma, the cartilage is damaged. People of any age can be affected. Fractures–particularly those that damage the joint surface–and dislocations are the most common injuries that lead to arthritis (see Figure 1). An injured joint is about seven times more likely to become arthritic, even if the injury is properly treated.

Arthritis does not have to result in a painful or sedentary life. It is important to seek help early so that treatment can begin and you can return to doing what matters most to you.

Diagnosis
A doctor can diagnose arthritis of the hand by examining you and taking X-rays. Specialized studies such as MRI (magnetic resonance imaging) scans are usually not needed. Sometimes a bone scan is helpful (see Figure 2).

A bone scan may help the doctor diagnose arthritis when it is in an early stage, even if X-rays look normal. Arthroscopy is another way to look at the joint by direct inspection. During an arthroscopic procedure, the surgeon inserts a small camera into the joint to look inside.

It provides the clearest picture of the joint without having to make a large incision. However, this is an invasive procedure and should not be used as a routine diagnostic tool (see Figure 3).

Symptoms
Early symptoms of arthritis of the hand include joint pain that may feel “dull,” or a “burning” sensation. The pain often occurs after periods of increased joint use, such as heavy gripping or grasping. The pain may not be present immediately, but may show up hours later or even the following day.

Morning pain and stiffness are typical. As the cartilage wears away and there is less material to provide shock absorption, the symptoms occur even with less use. In advanced disease, the joint pain may wake you up at night.

When the affected joint is subject to greater stress than it can bear, it may swell in an attempt prevent further joint use. Your pain might be made worse with use and relieved by rest. Many people with arthritis complain of increased joint pain with rainy weather. Activities that once were easy, such as opening a jar or starting the car, become difficult due to pain.

To prevent pain at the arthritic joint, you might adapt the way you use your hand. In patients with advanced thumb base arthritis, the neighboring joints may become more mobile than normal (see Figure 4).

The arthritic joint may feel warm to touch. This is due to the body’s inflammatory response. There may be a sensation of grating or grinding in the affected joint (crepitation). This is caused by damaged cartilage surfaces rubbing against one another. If arthritis is due to damaged ligaments, the support structures of the joint may be unstable or “loose.”

In advanced cases, the joint may appear larger than normal (hypertrophic). This is usually due to a combination of bone changes, loss of cartilage and joint swelling.

When arthritis affects the end joints of the fingers (DIP joints), small cysts (mucous cysts) may develop (see Figure 5). The cysts may then cause ridging or dents in the nail plate of the affected finger.

Treatment Options: Nonsurgical
Treatment options for arthritis of the hand and wrist include medication, splinting, injections and surgery. Treatment depends on many factors:

• How far the arthritis has progressed
• How many joints are involved
• Your age, activity level and other medical conditions
• If the dominant or non-dominant hand is affected

Your personal goals, home support structure, and ability to understand the treatment and comply with a therapy program

Medications: Medications treat symptoms but cannot restore joint cartilage or reverse joint damage. The most common medications for arthritis are anti-inflammatories, which stop the body from producing chemicals that cause joint swelling and pain.

Examples of anti-inflammatory drugs include over-the-counter medications such as Tylenol® and Advil® and prescription drugs such as Celebrex®. Glucosamine and chondroitin are widely advertised “neutraceuticals.”

Neutraceuticals are not drugs. Rather, they are compounds that are the “building blocks” of cartilage. They were originally used by veterinarians to treat arthritic hips in dogs. However, neutraceuticals have not yet been studied as a treatment of hand and wrist arthritis.

Injections: When first-line treatment with anti-inflammatory medication is not appropriate, injections may be used. These typically contain a long-acting anesthetic, similar to novacaine but longer lasting, and a steroid that can provide pain relief for weeks to months.

The injections can be repeated, but only a limited number of times, due to possible side effects, such as lightening of the skin, weakening of the tendons and ligaments and infection.

Splinting: Injections are usually combined with splinting of the affected joint. The splint helps support the affected joint to ease the stress placed on it by activities. Splints are typically worn during periods when the joints hurt.

They should be small enough to allow functional use of the hand when they are worn. Wearing the splint for too long can lead to muscle wasting (atrophy). Muscles can assist in stabilizing injured joints, so atrophy should be prevented.

Treatment Options: Surgical
If non-operative treatment fails to give you relief, surgery is usually discussed. There are many surgical options. The option chosen should be one that has a reasonable chance of providing long-term pain relief and return to function. It should be tailored to your individual needs. It is important that the treating physician is well versed in current surgical techniques. If there is any way the joint can be preserved or reconstructed, this option is usually chosen.

When the damage has progressed to a point that the surfaces will no longer work, a joint replacement or fusion (arthrodesis) is performed (see Figure 6). Joint replacements attempt to provide pain relief and functional joint motion. Joint fusions provide pain relief but stop joint motion. The fused joint no longer moves; the damaged joint surfaces are gone, so they cannot cause symptoms.

As with hip and knee replacements, there have been significant improvements in joint replacements in the hand and wrist. The replacement joints are made of materials similar to those used in weight-bearing joints, such as ceramics or long wearing metal and plastic parts (see Figure 7). The goal is to improve the function and longevity of the replaced joint. Most of the major joints of the hand and wrist can be replaced.

A surgeon often needs additional training to perform the surgery. As with any evolving technology, the long-term results of the hand or wrist joint replacements are not yet known. Early results have been promising. Talk with your doctor to find out if these implants are right for you.

After any type of joint reconstruction surgery, there is a period of recovery. Often, you will be referred to a trained hand therapist, who can help you maximize your recovery. You may need to use a postoperative splint or cast for awhile after surgery. This helps protect the hand while it heals.

During this postoperative period, you may need to modify activities to let the joint reconstruction heal properly. Typically, pain medication you take by mouth is also used to reduce discomfort.

It is important to discuss your pain with your doctor so it can be adequately treated. Length of recovery time varies widely and depends on the extent of the surgery performed and multiple individual factors. However, people usually can return to most if not all of their desired activities in about three months after most major joint reconstructions.

Research on the Horizon/What’s New?
Increasingly, doctors are focusing on how to preserve the damaged joint. This includes getting an earlier diagnosis and repairing joint components before the entire surface becomes damaged. Arthroscopy of the small joints of the hand and wrist is now possible because the equipment has been downsized.

There have been encouraging results in cartilage repair and replacement in the larger joints such as the knee, and some of these techniques have been applied to the smaller joints of the hand and arm. In addition, stem cell research may be an option to regenerate damaged joint surfaces.

Both bursitis and tendinitis are forms of impingement syndrome. Bursitis occurs when the bursa (normally thin fluid filled sack that allows the rotator cuff to glide smoothly under the acromion) becomes swollen or inflamed.

Tendinitis occurs when the tendons of the rotator cuff or the long head of the biceps becomes swollen or inflamed (normally thin fluid filled sack that allows the rotator cuff to glide smoothly under the acromion) becomes swollen or inflamed.

Injury Mechanism: Bursitis and tendinitis are commonly seen in throwing athletes, those doing overhead lifting, or with repetitive motions and overuse of the shoulder. Often, one does not recall a specific injury, but awakens with pain.

Symptoms: When patients have bursitis, they describe pain over the lateral aspect of the shoulder with overhead reaching or laying on that shoulder at night. With tendinitis, pain occurs when using the rotator cuff or biceps in addition to the pain with overhead reaching or laying on that shoulder at night.

Diagnosis: The physician’s work-up will start with a careful history and exam. With tendinitis, the physician can isolate the tendons involved by eliciting pain with use of those tendons plus the impingement test is positive. With bursitis, pain cannot be elicited with use of specific tendons, but the impingement test is still positive.

X-rays are often normal with bursitis or tendinitis, but occasionally a spur is identified on a special “outlet view” that can be obtained in the physician’s office. An MRI scan is sometimes obtained to confirm that the rotator cuff is not torn, especially when patients do not respond to initial treatment.

Treatment: The mainstay of treatment for bursitis and tendinitis is non-surgical. Most patients respond to a short course of anti-inflammatories, stretching, and gentle strengthening of the external rotators of the shoulder. This can be accomplished at home with rubber tubing. If symptoms persist, one can inject the bursa with cortisone to cause the swollen tissues to shrink so they will no longer rub, or impinge.

If the symptoms respond temporarily to the injections, but keep recurring, one can consider surgery to shave down the undersurface of the acromion (acromioplasty) to make more clearance for the rotator cuff and bursa to slide underneath without rubbing. This type of surgery is performed through the arthroscope, using 2 or 3 small incisions, and looking inside the shoulder with a small lens and camera.”

What to expect after surgery: Most shoulder surgery is now performed as an outpatient procedure. In the rare event that an acromioplasty is needed to stop the impingement process, most patients find that they do best by resting their shoulder in a sling for 3 or 4 days following surgery.

They are then encouraged to come out of the sling for gentle stretching exercises. Once comfortable (usually 1 or 2 weeks following surgery), gentle strengthening is initiated with rubber tubing. Once the patient is off of his/her medication, they can resume driving and returning to office work. Most patients can return to full activities in 6 to 8 weeks.

Dr. Peterson and Dr. Shapiro have been performing a relatively new procedure called reverse total shoulder replacement for the last several years.

This particular procedure is designed for people who have rotator cuff arthropathy or a large, irreparable rotator cuff tear. The rotator cuff is a group of muscles and tendons that surround the shoulder joint and allow you to lift your arm over your head. When this structure is severely torn, shoulder arthritis can set in and mobility is limited.

During this procedure, the surgeon removes damaged bone joint tissue.  A smooth,  polished, spherical alloy metal “glenosphere” is then fixed to the old bony “cup” of the shoulder, and a stemmed alloy and polymer cup to the shaft of the upper-arm bone.

Why is Reverse Total Shoulder Replacement Done?

This surgery was developed because traditional shoulder surgeries do not work well when patients also have a severe rotator cuff tear with arthritis. With reverse total shoulder replacement, the deltoid muscle powers the new prosthesis, allowing pain free motion overhead in many patients.

Who is a Candidate for Surgery?

Reverse total shoulder replacement may be recommended if you have:

• A completely torn rotator cuff that cannot be repaired.
• Cuff tear arthropathy (arthritis with a severe cuff tear).
• A previous should replacement that was unsuccessful.
• Severe shoulder pain and difficulty lifting your arm.
• Tried other treatments that have not relieved your shoulder pain.

Reverse shoulder replacement may not be recommended for people who have:

• Poor general health and may not tolerate anesthesia and surgery well.
• An active infection or are at risk for infection.
• Severe weakness of or damage to the deltoid muscle of the shoulder.
• A shoulder problem deemed appropriate for more traditional replacement procedures.

How do I Prepare for this Procedure?

Anesthesia – This procedure can be performed under general or regional anesthesia, depending on what your orthopedic surgeon prefers.

Antibiotics – You will probably be prescribed antibiotics to take before and after the surgery to prevent infection.

Medications – Be sure you tell your orthopedic specialists about all the medications you are taking. He may advise you to stop certain medications before the procedure.

Home Planning – There are some things you should be aware of that will make your recovery period much easier. First of all, you will need to take several weeks off from work following the surgery. When you come home, you will need help for a few weeks with dressing, bathing, and simple household chores. Also, you may not be permitted to drive following the surgery and for a few weeks.

What Happens During the Surgery?

A reverse total shoulder replacement usually takes about 1.5 hours. The surgeon will make an incision at the top or front of your shoulder and remove the damaged bone. Then he will position the new components to restore function to your shoulder joint. The incision will then be closed with sutures.What Should I Expect After the Procedure?

After your procedure, the healthcare professionals will give you pain medication to keep you comfortable and several doses of antibiotics. Most patients are allowed to eat solid food and get out of bed the day after the surgery. You will go home on the first or second day following your procedure.

When you leave the surgical center, your arm will be in a sling to provide support. Your orthopedic specialist will instruct you on exercises to increase your mobility and endurance and plan a physical therapy program to strengthen your shoulder and improve your flexibility. Full recovery from this surgery usually occurs in 4-6 months.

Arthritis is a condition that irritates or destroys a joint. Although there are several types of arthritis, the one that most often affects the joint at the base of the thumb (the basal joint) is osteoarthritis (degenerative or “wear-and-tear” arthritis).

Osteoarthritis occurs when the smooth cartilage that covers the ends of the bones begins to wear away. Cartilage enables the bones to glide easily in the joint; without it, bones rub against each other, causing friction and damage to the bones and the joint.

The joint at the base of the thumb, near the wrist and at the fleshy part of the thumb, enables the thumb to swivel, pivot, and pinch so that you can grip things in your hand. Arthritis of the base of the thumb is more common in women than in men, and usually occurs after age 40.

Prior fractures or other injuries to the joint may increase the likelihood of developing this condition.

Symptoms

• Pain with activities that involve gripping or pinching, such as turning a key, opening a door, or snapping your fingers.
• Swelling and tenderness at the base of the thumb.
• An aching discomfort after prolonged use.
• Loss of strength in gripping or pinching activities.
• An enlarged, “out-of-joint” appearance.
• Development of a bony prominence or bump over the joint.
• Limited motion.

Diagnosis
Your physician will ask you about your symptoms, any prior injury, pain patterns, or activities that aggravate the condition. The physical examination may show tenderness or swelling at the base of the thumb.

One of the tests used during the examination involves holding the joint firmly while moving the thumb. If pain or a gritty feeling results, or if a grinding sound (crepitus) can be heard, the bones are rubbing directly against each other.

An X-ray may show deterioration of the joint as well as any bone spurs or calcium deposits that have developed.
Many people with arthritis at the base of the thumb also have symptoms of carpal tunnel syndrome, so your physician may check for that as well.

Treatment
In its early stages, arthritis at the base of the thumb will respond to nonsurgical treatment.

• Ice the joint for five to fifteen minutes several times a day.
• Take an anti-inflammatory medication such as aspirin or ibuprofen to help reduce inflammation and swelling
• Wear a supportive splint to limit the movement of the thumb, and allow the joint to rest and heal. The splint may protect both the wrist and the thumb.
• It may be worn overnight or intermittently during the day.

Because arthritis is a progressive, degenerative disease, the condition may worsen over time. The next phase in treatment involves a steroid solution injection into the joint. This will usually provide relief for several months. However, these injections cannot be repeated indefinitely.

Surgical Options
When conservative treatment is no longer effective, surgery is an option. The operation can be performed on an outpatient basis, and several different procedures can be used. One option involves fusing the bones of the joint together.

This, however, will limit movement. Another option is to remove part of the joint and reconstruct it using either a tendon graft or an artificial substance. You and your physician will discuss the options and select the one that is best for you.

After surgery, you will have to wear a cast for several weeks. A rehabilitation program, often involving a physical therapist, helps you regain movement and strength in the hand. You may feel some discomfort during the initial stages of the rehabilitation program, but this will diminish over time.

Full recovery from surgery takes several months. Most patients are able to resume normal activities and are quite satisfied with the results.

The knee joint is one of the largest joints in the body. It is a complex joint with four bones: the femur (thigh bone), the tibia (main lower leg bone), the fibula (smaller lower leg bone), and the patella (kneecap). The bones are connected with four main ligaments: ACL (anterior cruciate ligament), PCL (posterior cruciate ligament), MCL (medial collateral ligament), and the LCL (lateral collateral ligament).

The ACL and PCL control the forward/backwards movement of the knee joint and prevent pivoting of the knee. The MCL and LCL prevent giving away on either side of the knee. The quadriceps is a group of 4 muscles that converge on the front of the thigh and together allow one to straighten their knee by pulling through the kneecap and patellar tendon, which attaches to the front of the lower leg bone (tibia).

The hamstrings are the muscles on the back of the thigh that help bending the knee by crossing the joint in the back of the knee and attaching to the lower leg bones. Between the femur and tibia, sitting centrally in the knee joint, are two C-shaped pads (the medial and lateral menisci) that act as cushions or shock absorbers between the two bones. The meniscal pads are made of cartilage.

There is also about a quarter of an inch of cartilage on the distal end of the thighbone and on the proximal end of the lower leg bone. Arthritis occurs when that joint cartilage becomes damaged or thin.