[Rheumatoid arthritis of the wrist with adult onset]

The author reviews the consequences of rheumatoid synovitis of tendons and joints at the wrist, consequences which are different on the volar and dorsal aspects of the wrist. He refers to a modified Larsen classification to describe the consequences of instability in the radiocarpal (RC), midcarpal (MC) and radioulnar (RU) joints, both in the coronal and sagittal planes. A. On the volar aspect, tenosynovitis of the flexor tendons is frequent but may be difficult to diagnose. Synovitis in the carpal tunnel, although frequent, rarely results in compression of the median nerve; persistence of synovitis despite medical treatment is an indication to synovectomy. The latter may have to be extended into the palm and over the proximal phalanges, using the appropriate approach in the individual cases. Flexor tendon ruptures may occur, mostly of the flexor pollicis longus (FPL) and the flexor tendons to the index finger. Rupture of the FPL may be treated by a tendon graft or by arthrodesis of the i.p. joint. Rupture of the deep flexor tendon to the index may be treated by anastomosis to that of the medius; rupture of the superficial flexor tendon to the index may be treated similarly; rupture of both flexor tendons requires a tendon graft. B. On the dorsal aspect, the indications vary according to the stage of the disease. In Larsen's stage IV or V (destruction of one or more of the radiocarpal and intracarpal joints with navicular dislocation), arthrodesis or arthroplasty is indicated; the latter is ruled out however if extensor tendons are ruptured or the bone stock is insufficient. An original or modified Mannerfelt technique is used for arthrodesis, with the wrist in neutral or slightly extended position. Several wrist prostheses are available. Swanson's silastic implant has been discontinued; the Meuli, CFV, Biax, Trispherical, ATW, and GUEPAR prostheses have all been used with varying degrees of success. The choice between arthrodesis and arthroplasty is based on the severity of articular and tendon pathology, on uni- or bilateral involvement and on the condition of other joints, particularly in the upper limb. In less advanced stages, the author advocates using a combined operation with synovectomy of the extensor tendons and of the RC, MC and RU joints, relaxation by tendon transfers and Sauvé-Kapandji's technique; he stresses important technical points. The specific indications for radiolunate arthrodesis are discussed.