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Stiff and swollen wrist
Mr Carlos Cobiella offers advice on analysing such a presentation
such a presentation
A 22-year-old woman presents with the acute onset of a red and swollen left wrist. She is also complaining of daily spiking fevers and chills. Upon further questioning, she reports a 30-pound unintentional weight loss over the last three months.
She says she has had previous episodes of pain and swelling of her left wrist, and sometimes both her knees, that had responded to NSAIDs. On one occasion she was admitted to hospital and required steroid treatment to control the symptoms. No definite diagnosis was made and she was lost to follow-up. There is no history of joint disease in her family.
On examination she had a temperature of 36°C; minimal boutonnière deformities; no active synovitis; normal range of motion of all joints both actively and passively. Laboratory investigations revealed a WBC of 36.9 and an ESR of 140.
The wrist joint is composed of the distal radius and ulna with the triangular fibrocartilage complex on one side and the carpal bones on the other. To add complexity to the matter the eight carpal bones have well-defined joints with each other and also with the metacarpals. It is for this reason that conditions producing swelling and stiffness of the wrist cannot be assesses without considering conditions that affect the hand and fingers.
In broad terms, it can be said these conditions can be due to trauma, infection or inflammatory/ degenerative causes.
Trauma to the soft tissues of the wrist, with or without associated fracture/bony injury, is common. Symptoms can persist for several weeks, or even months, depending on the severity of the injury. There is generally a good history of injury to the wrist. The examination will reveal not only swelling but commonly bruising around the wrist. As part of the investigation, a plain radiograph of the wrist should be requested to explore the possibility of a fracture of the distal radius, the scaphoid or other carpal bones and joints.
Complications of trauma, such as scaphoid non-union, carpal instability or joint involvement, can eventually produce degenerative changes.
Also, as a consequence of injury, patients can develop type II complex regional pain syndrome (Sudeck's atrophy). As well as swelling and stiffness of the wrist and finger joints there is associated pain, which is neuropathic in nature and does not respond well to regular analgesia. On the radiograph there is characteristic decalcification of involved bones.
One of the more controversial issues affecting the wrist is that of repetitive strain injury. There is little agreement about this condition which is difficult to treat and often has a complex psychosocial, as well as occupational, aetiology and management.
Infections of the wrist are uncommon. These are usually pyogenic and present not only with swelling and stiffness but also with severe pain and with signs and symptoms of generalised sepsis. Septic arthritis of the wrist is often seen in intravenous drug abusers. In areas of high prevalence, tuberculosis can also affect the wrist, ultimately causing muscle wasting and bony erosions and so blood investigations (white cell count, ESR, CRP) should be carried out.
Degenerative changes of the wrist joint usually appear in the context of osteoarthritis. This can rarely be primary, usually in the context of multiple joint involvement, but more frequently is secondary to trauma. Treatment is conservative when possible, with exercise and splints.
Operative management consists mainly of fusion of the joints, which can be limited to a few of the carpal bones or complete arthrodesis of the wrist. Replacements of the wrist joint are available, but the jury is still out with regards to longevity and function.
Inflammatory forms of arthritis, such as rheumatoid arthritis, are more frequent around the wrist. Involvement of the synovium of the joint and tendon sheaths produces marked swelling, stiffness, heat and pain. Treatment is usually of the underlying condition, but when the deformities are severe and degenerative changes are present, treatment options are identical to the above.
Other causes of swelling and stiffness of the wrist include De Quervain's disease (stenosing tenosynitis), Charcot neuropathy, carpal tunnel syndrome and Kienbock's disease (avascular necrosis of the lunate).
A radiograph of this woman's left wrist revealed diffuse radiocarpal and intercarpal joint space narrowing with small bony erosions involving the ulnar styloid. She was given the diagnosis of adult onset Still's disease.
This is a rare condition that accounts for 6 per cent of prolonged (over six months) pyrexia cases of undetermined origin. Diagnosis of Still's is made after exclusion of infections and malignancies.
There are no diagnostic physical signs or tests, so the following set of criteria have been devised.
Diagnosis of Still's disease requires the presence of all criteria in A and any two from B:
Arthralgia or arthritis
WCC> or = =15 x 109/l
Pleuritis or pericarditis
Hepatomegaly or splenomegaly or generalised lymphadenopathy.
The typical Still's rash is an evanescent, salmon pink macular or maculopapular rash, seen along with the spike of fever on the trunk and proximal extremities.
She was prescribed low-dose prednisolone and celecoxib upon discharge from the hospital.
These effectively controlled her fever and other symptoms and the disease eventually settled. Long-term management of the condition is still required such as disease-modifying drugs.
Unfortunately, once the damage is done to the joints they do not return to normal. The aim is to prevent the damage by controlling the flare-ups.
Carlos Cobiella is consultant orthopaedic surgeon at the Whittington Hospital, London