The wrist joint is often involved in the early stages of the rheumatoid arthritis (RA) and is regarded as a main target of the disease. Since the wrist plays a key role in the articulations of the upper extremities, appropriate treatment of this joint will preserve the patient's work ability and independence. When surgical intervention is considered, determining the disease extent is as important as the type of rheumatoid involvement. This can be achieved by performing an extensive clinical and functional assessment of the extremities. In addition, understanding radiological findings also helps to determine the type of rheumatoid destruction, and the subsequent treatment algorithms. Success of surgical management depends on a well-considered strategy in the timing of different procedures. Prophylactic surgery, such as a synovectomy of the joint or tendon could be performed in the early stages to prevent further destruction and deformation. As destruction at the radiocarpal level progresses in the later stages of the disease, reconstructive surgery such as partial joint fusion combined with ulnar head resection, total wrist fusion or wrist arthroplasty could be considered. In the event of severe destruction, definitive stabilization by total wrist fusion is indicated. A pain-free, stable wrist joint often outweighs immobility.