Rheumatoid arthritis is an autoimmune disease in which the lining of the joints and tendons becomes inflamed and, over time, damages what it surrounds. The hands and wrists are involved in most people who have it, usually on both sides. Treatment is medical and is led by your rheumatologist, and modern medication controls the disease well enough that severe deformity is now uncommon. Our role is for the problems medication does not fix: a ruptured tendon, a worn joint, a compressed nerve or a hand that no longer does what you need. Each has an operation, and most are day procedures.
What is rheumatoid arthritis?
The joints and tendons of the hand are lined by a thin membrane called synovium. In rheumatoid arthritis the immune system attacks that membrane. It thickens and releases enzymes that erode cartilage, bone, ligament and tendon. The joint swells, its ligaments stretch and the bones drift out of line. A tendon running through inflamed lining frays, and can rupture.
The knuckles (MCP joints), the middle joints of the fingers (PIP joints) and the wrist are the usual sites, the joints nearest the fingernails are mostly spared, and both sides are affected alike. Osteoarthritis, which is wear rather than inflammation, has almost the opposite pattern and is covered on the osteoarthritis page.
The deformities have names. Ulnar drift is the fingers leaning towards the little finger side as the knuckles give way. A swan neck finger bends backwards at the middle joint and down at the tip, and a boutonnière finger does the reverse. At the wrist the end of the ulna becomes prominent and can wear through the extensor tendons that run over it.
Symptoms
Most people describe:
- Swollen, warm, painful knuckles and wrists on both sides
- Morning stiffness that lasts an hour or more
- Soft swelling over the back of the wrist or along the tendons, rather than hard bony lumps
- Fingers drifting towards the little finger side, or developing a swan neck or boutonnière shape
- A finger that suddenly will not straighten or bend, which usually means a tendon has ruptured
- Numbness and tingling in the thumb, index and middle fingers, from swollen tendon lining pressing on the median nerve
A tendon rupture in rheumatoid arthritis is usually painless. The finger simply drops, often without any injury.
Causes and risk factors
Rheumatoid arthritis is an autoimmune disease and the trigger is not known. It is more common in women, usually starts between thirty and sixty, runs in some families and is more severe in smokers. The damage in the hand is proportional to how long the inflammation has run uncontrolled, which is why early rheumatology treatment matters more than anything a surgeon does later.
How it is diagnosed
The diagnosis of rheumatoid arthritis itself is made by a rheumatologist on the pattern of joint involvement, blood tests and imaging. If you come to us with swollen knuckles and wrists on both sides and no diagnosis yet, we arrange that referral.
Our assessment is of the hand. We examine each joint for inflammation, stability and alignment, each tendon for whether it is intact, and the nerves. An X-ray shows erosion and alignment. An ultrasound shows whether a tendon is intact and is arranged where the examination is unclear. We also ask what the hand can no longer do, because that, rather than the X-ray, decides whether surgery is worth it.
Non-surgical treatment
Your rheumatologist's medication is the treatment of the disease. Around it we offer:
Hand therapy and splinting
GRIP Hand Therapy is on site and no referral is needed. The therapists make resting splints for painful joints and night splints that slow ulnar drift, teach joint protection so that daily tasks load the joints less, and keep stiff fingers moving.
Corticosteroid injection
An injection into an inflamed joint or tendon sheath settles a flare and can be the whole treatment for a trigger finger. We arrange these under ultrasound guidance and would not repeat an injection more than twice at the same site.
When surgery is needed
Surgery is advised where a specific problem in the hand is no longer controlled by medication and is costing you function: persistent synovitis, a ruptured or rupturing tendon, a compressed nerve, or a joint that is painful, unstable or too deformed to use. We agree timing and medication with your rheumatologist. Methotrexate is usually continued, and biologic agents are usually withheld for one dosing interval before surgery.
The operation
Synovectomy removes the inflamed lining from a joint or from around the tendons. It reduces pain and swelling and, done early enough, protects the tendons. It is a day procedure under a general anaesthetic with a local anaesthetic for comfort afterwards, and takes 45 to 60 minutes. A prominent ulna that is wearing the extensor tendons is reshaped or removed at the same time.
Tendon repair and transfer. A ruptured tendon in rheumatoid arthritis cannot usually be sewn end to end, because the ends are damaged, so function is restored by joining it to a healthy neighbour or by transferring a tendon from elsewhere in the hand. The extensor tendons to the ring and little fingers are the usual ones. Carpal tunnel release and trigger finger release are done in the same way as in anyone else, and each has its own page.
Joint replacement. Worn and drifting MCP joints are replaced with silicone implants, which realign the fingers and restore a useful arc of movement. It takes about 45 minutes per joint as a day procedure under a general anaesthetic, and is described on the finger joint replacement page.
Joint fusion. Where a joint is too unstable or too eroded to replace, or where stability matters more than movement, it is fused. The thumb joints, the wrist and the index finger PIP joint are the usual ones. A fused wrist gives a strong, pain free platform for the fingers and still rotates.
A rheumatoid hand often needs more than one of these, and the order matters: tendons and nerves first, joints afterwards.
Recovery, week by week
Indicative. A synovectomy recovers in weeks, a tendon transfer or joint replacement in months.
Day of surgery. Home the same day. Fingers may feel numb for one to three days from the local anaesthetic.
Days 1 to 7. Keep the dressing clean, dry and elevated. The hand therapist fits a custom made removable splint.
Two weeks. Review and suture removal. After a synovectomy, movement starts now. After a joint replacement, guided movement out of the splint begins.
Four to six weeks. Tendon transfers come out of the splint and begin active movement at 4 weeks. Joint replacements are weaned from the splint, with buddy taping from four weeks.
Six to twelve weeks. Splinting stops and strengthening begins. A fusion is checked on X-ray at 8 to 12 weeks. A transferred tendon takes months to learn its new job.
Driving and work. After a synovectomy, driving and office work at one to two weeks. After a tendon transfer or joint replacement, once out of the splint at 4 to 6 weeks. Heavy work at 3 months.
Risks and complications
These operations are routine and complications are uncommon. They can include:
- Wound healing problems or infection. Skin in rheumatoid arthritis is often thin and long term steroids slow healing, so wounds are watched closely.
- Nerve injury. Numbness in a patch of skin near the scar, which often recovers.
- Stiffness. The main risk after joint and tendon surgery, and why therapy starts early.
- Recurrence. Synovitis can return if the disease is not controlled, and a repaired or transferred tendon can rupture again.
- Implant problems. Silicone implants can fracture or loosen over years and may need revision.
- Nonunion. A fusion that does not knit, more likely in smokers.
- Bruising, ongoing tenderness, swelling or slower than expected recovery.
When to be seen sooner
Contact us, or see your GP or rheumatologist, if you have:
- A finger that has suddenly dropped, which may be a tendon rupture and is easier to treat early
- Numbness and tingling in the thumb, index and middle fingers that wakes you at night
- A hot, red, swollen joint with fever, which can be infection rather than a flare, and the same after an injection or an operation
If you have had surgery with us and have questions or concerns afterwards, phone the rooms during office hours on (08) 7127 0365.
Frequently asked questions
Do I need a hand surgeon if I already see a rheumatologist?
Most people with rheumatoid arthritis never do. Your rheumatologist treats the disease. We are involved when a mechanical problem in the hand, such as a ruptured tendon, a compressed nerve or a worn joint, needs an operation, and we keep your rheumatologist informed.
Can surgery cure rheumatoid arthritis?
No. Surgery treats the damage the disease has done in one place. It does not change the disease, so medication continues.
Will I have to stop my medication for surgery?
Not all of it. Methotrexate is usually continued. Biologic agents are usually withheld for one dosing interval before the operation and restarted once the wound has healed. We agree the plan with your rheumatologist before the date is set.
My finger suddenly dropped. Is that urgent?
It should be seen within days rather than weeks. A dropped finger usually means an extensor tendon has ruptured, and the neighbouring tendons are at risk of the same thing. Early surgery protects them.
Will my fingers be straight again after a joint replacement?
Straighter, and in a position the hand can use. A replaced knuckle does not move as far as a normal one and some drift can return over years. The aim is a hand that grips and pinches comfortably rather than one that looks the way it did.
What does the surgery cost?
You will receive written informed financial consent setting out the surgeon, anaesthetist and hospital fees, your Medicare rebate and your health fund's contribution before anything is booked. Phone the rooms on (08) 7127 0365 for an estimate.
Do I need a referral?
A referral from your GP or rheumatologist means you can claim a Medicare rebate on the consultation with a surgeon. We can see you without one, but the rebate will not apply. No referral is needed for GRIP Hand Therapy.
Written and clinically reviewed by Dr Paul van Minnen, MD, PhD, EBOPRAS, FRACS (Plast)
Last reviewed 8 November 2026