R. Vincent Davis, DC, PT, DNBPM
Involvement of the wrist joint components by chronic inflammatory reaction of the articular capsule and the tendons may be a clinicopathological state involving these specific joint components, or it may be related to a generalized disease process associated with rheumatoid arthritis.
In either situation, there is commonly inflammation and proliferation of the wrist joint synovium with capsular distention by effusion. This may progress to synovial hypertrophy and destruction of the capsuloligamentous structures due to invasion. In the case of rheumatoid arthritis, a pannus may form with progressive destruction of the articular cartilage and pericarpal capsule. With the progression of time, the presence of intra-articular edema leads to adhesion formation. In the event that this lesion is allowed to progress to chronicity, the tendon components may disintegrate and be replaced by detritus.
Clinically, the lesion may present with exacerbating episodes of edema, pain, redness, and heat; the cardinal signs of inflammation with reduced ROM to avoid pain on motion. As adhesion formation progresses, the tendon excursions of the wrist may gradually become increasingly limited as it becomes bound by adhesions.
Very gentle ROM exercises performed b.i.d., may prevent adhesion formation. These usually form respective to the presence of static edema. The application of heat prior to ROM exercises is advisable using paraffin bath or continuous medical ultrasound at a low wattage output (0.3 to 0.5 W/cm2) for three to five minutes under water. Of course, paraffin bath is preferred. If the edema seems intractable therapeutically, hydrocortisone acetate (one percent) phonophoresis, b.i.d., p.r.n., wrist edema using pulsed energy should be performed.
If the clinical and radiographic findings demonstrate a progression of the lesions toward intractable chronicity, the patient should be referred for synovectomy. A proliferative synovium must be removed prior to serious damage to ligaments, cartilage, and tendons.
The therapeutic history of these lesions, in chronic form, may provide for physician and patient frustration.
References
Davis, RV. Therapeutic Modalities for the Clinical Health Sciences, 2nd ed. Library of Congress Card #TXu-389-661, 1989.
Griffin and Karselis. Physical Agents for Physical Therapists, 2nd ed. Thomas Publishers, 1982.
Krupp and Chatton. Current Medical Diagnosis and Treatment. Lange Publications, 1980.
Turek. Orthopedics -- Principles and Their Application, 3rd. ed. J.B. Lippincott.
R. Vincent Davis, DC, PT, DNBPM
Independence, Missouri
