Long-standing rheumatoid arthritis can result in spontaneous tendon rupture and causes functional deficient. Ruptures of the ulnar-side extensor tendons, flexor pollicis longus, and the flexor digitorum profundus can be seen. Known as the Vaughn-Jackson syndrome, the classic presentation of DRUJ disruption along with rupture of the EDM and EDC to ring and small finger resulting in small finger and ring finger metacarpophalangeal joint extension lag, was first described in 1948. Flexor tendon ruptures caused by either attrition on bone spurs or by direct invasion of the tendon by hypertrophic synovium can also be observed in rheumatoid arthritis. Attrition ruptures of flexor tendon occur within the carpal tunnel and represent the most common cause of flexor tendon rupture.
Instability of the DRUJ in patients with RA may leads to disruption of the dorsal capsule and protrusion of the bony edge of ulnar head thus causing attritional rupture of the extensor tendons of the wrist. Many wrist procedures were referred to address the underlying cause of extensor tendon rupture. Darrach procedure is indicated in patients who are low demand and elderly. The Sauve-Kapandji procedure involves arthrodesis of the DRUJ while enabling forearm rotation by the creation of a pseudoarthrosis. Outcomes of the Sauve-Kapandji procedure has been documented as consistently better than those of the Darrach. Besides these two major procedures, hemiresection interposition arthroplasty, originally reported by Bowers, for patient with RA, and matched distal ulnar resection described by Watson and Gabuzda , a similar technique of resection of the radial portion of the ulnar head, have been reported with good results. However, neither are currently considered first-line surgical solutions for patients with painful, disrupted DRUJs from RA. Debates exist.
Reconstruction of extensor tendon ruptures in patients with rheumatoid arthritis can be performed either by interposition tendon graft mostly using palmaris longus, or tendon transfer techniques using adjacent extensor tendons as donor motors. A biomechanical model suggests that tendon repair using an interposition graft, retains the anatomical axis of tendon function, and achieves greater forces during active finger extension. However, there were no significant differences in clinical outcomes between tendon transfer and tendon grafts. The results of extensor tendon reconstruction are satisfactory with little exception, even though notable post-operation extension lag of MP joint presented in reported case series. Challenging issues still exist in situations when all the fingers joints were severely destructed, tendons were disrupted and dislocated, and the soft tissue was dystrophic from steroid treatment.
The future will likely lead clinicians away from surgical reconstruction of the wrist as RA is diagnosed earlier and medical management becomes more effective at controlling the disease.

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