(i) The principles of surgery in the rheumatoid hand and wrist

The indications for surgery to the rheumatoid hand and wrist are relief of pain, improvement or preservation of function, correction of deformity, and cosmesis. The systemic, progressive and multi-articular nature of the disease gives decision-making a greater degree of complexity than is found in other areas of hand surgery. There are strong arguments for making decisions about surgery in a combined medical/surgical clinic at which all those responsible for the patient’s management contribute. Operative procedures include nerve decompression, synovectomy, tenosynovectomy, tendon surgery, arthroplasty and arthrodesis. Severe nerve compression and impending tendon rupture are indications for urgent operation. Stable internal fixation with buried implants is the preferred method for arthrodesis in the arthritic hand. The results of arthroplasty depend on appropriate function and balance in the soft tissues, which may be sub-optimal in rheumatoid disease.