Rheumatoid arthritis is a systemic disease involving synovial tissue, and all deformities, joint destruction, and pathologic anatomic changes that manifest are the result of disease-induced proliferation of synovial tissue, which alters the surrounding soft tissue environment. In rheumatoid arthritis, synovial tissue destroys articular cartilage through an unknown pattern of enzymatic reactions, invades the subchondral bone, alters the soft tissue conditions around the affected joint, and simultaneously encases and invades the flexor-extensor tendon apparatus, resulting in damage to the normal structures of the hand and wrist joints and loss of balance of the flexor-extensor tendons in the hand-wrist unit. Surgeries affecting rheumatoid arthritis of the external hand and wrist are broadly classified into the following five categories: synovectomy, tenosynovectomy, tendon surgery, joint replacement and joint fusion. The timing of surgery and the selection of a surgical plan require extensive clinical experience and should be individualized based on the patient’s hand function, the patient’s actual needs, and the surgeon’s clinical experience. The choice of surgical option depends on the severity and type of disease. Synovectomy may be an option for mild patients receiving drug therapy who present with persistent synovitis in one or two joints. The disease should also be closely monitored for progression so that surgical correction can be chosen as necessary before severe deformity develops. In patients with rapidly progressive disease, early synovectomy of the tendon sheath can prevent tendon rupture. With the use of anti-tumor necrosis factor (anti-TNF) in clinical practice, communication between rheumatologists and hand surgeons during treatment is even more important for patients with progressive disease. The decision to intervene surgically should be preceded by appropriate medical therapy. Surgical intervention before the appearance of severe fixed deformity or joint subluxation or dislocation can lead to a better outcome. After elongation of the joint capsule and joint ligament destruction, maintaining the force line and function of the joint becomes very difficult due to the lack of adequate soft tissue support. In patients with significant pain and loss of function despite multiple joint destruction, surgery can significantly reduce pain or improve function. Before surgery, there should be in-depth good communication between the surgeon and the patient so that the patient has a full understanding of the disease and his or her expectations should be consistent with the purpose of the surgery and the results that can be achieved. For patients with rheumatoid arthritis, functional reconstructive surgery of the hand has become an effective part of the overall treatment plan because it can relieve pain, prevent the appearance or correct severe deformities, and improve appearance and function. Of course, this requires that the hand surgeon should work collaboratively with the rheumatologist, orthopedic surgeon, internist, occupational physician and hand rehabilitator to better understand the overall treatment plan and thus provide the best treatment options for patients with rheumatoid arthritis.