Rheumatoid arthritis is a chronic inflammatory disease affecting the synovium leading to joint damage and bone destruction. Within two years of diagnosis more than half of patients will have wrist pain and more than 90% will have wrist disease by 10 years. The surgical management of the advanced rheumatoid wrist is controversial. A Medline search was performed using the key words ‘rheumatoid arthritis and wrist arthroplasty’ ‘rheumatoid arthritis and wrist arthrodesis’ ‘rheumatoid arthritis and wrist fusion’. Total wrist arthroplasty is a motion preserving alternative which is slowly increasing in popularity. It is however a complex, technically demanding procedure with a high rate of complications. Wrist arthrodesis is currently the most widely used operative management for end stage rheumatoid arthritis. It provides pain relief and stability but there is a compromise of a loss of movement. We conclude that patients with end stage rheumatoid arthritis with good bone stock may have total wrist arthroplasty or wrist arthrodesis. Total wrist arthroplasty should be with the latest generation implants. Those patients with poor bone stock or soft tissues should have wrist arthrodesis.