RHEUMATOID HAND

Rheumatoid arthritis

The commonest inflammatory disease affecting the hand

Principally affects synovial linings of joints and tendon sheaths

Destroys ligaments and tendons subluxation of Jts.

Compress the adj nerveMajor deformities develop often in women

No fixed pattern of deformity

Usually B/L symmetricalDuring the early inflammatory stage, intr. Muscles are in spasm.

Later int. contracture develops

MCP & Wrist affected earlyIP jts are affected late, typically.MCP- most important jt affecting function in

RA.Ulnar deviation & volar subluxation of fingers

are typical deformities.

Pathology

Proliferation of synovium is the basic pathology destruction of cartilage & SC bone.

Stretching of Jt C. & Jt L.Produces damage through two ways

Mechanical Chemical

Deformities of hand

Def. of fingersDef of thumbDef. Of wristRupture of tendons

Deformities in fingers

Intrinsic plus deformitySwan neck def.Boutonneires def.Def. of distal jointsUlnar drift

Intrinsic plus deformity

Caused by tightness of intrinsic muscles

PIP joints cannot be flexed while MCP is fully extended.

Often assoc. with volar subluxation & Ulnar deviation fingers

Swan neck deformity

Flex. at the DIP joint and hyper extension at PIP. Jt

May begin as Mallet deformity

Either caused by muscle imbalance or by disruption of ext. tendon

Nalebuff et al Classification

Based on PIP Jt mobility & X ray evidence of destruction.

Type I deformities are flexible in all positions and require dermodesis, flexor tenodesis of the PIP JT, fusion of DIP JT, and reconstruction of the retinacular ligament.

Type II deformities are caused by intrinsic muscle tightness and require intrinsic release.

Type III deformities are stiff and do not allow satisfactory flexion but do not have significant joint destruction . These deformities require joint manipulation, mobilization of the lateral bands, and dorsal skin release.

Type IV deformities have X ray evidence of destruction of the joint surface and stiff PIP jt, which usually can be best treated with arthrodesis of the PIP jt or, in the ring and small fingers, with Swanson implant arthroplasty of the PIP Jt.

Boutonniere’s Deformity

Caused by synovitis of the PIP jt. With stretching out of the central slip

This forces lateral bands of the ext. tendon to subluxate volar wards

Grading of Boutenniere Def. (Nalebuff & Millender)

MildModerateSevere

Mild

Satisfactory motionX ray normal Repositioning of the lateral band portion of

the extensor mechanism, proximal interphalangeal joint synovectomy, and extensor tenotomy over the middle phalanx (Dolphin-Fowler procedure)

Moderate

Passively correctable PIP jt.Normal flex. Tendon functionSatisfactory preservation of jt. Space in X ray

soft tissue procedure with central slip reconstruction using the lateral band or a tendon graft is an option

Severe

Joints stiffSevere destruction of the joint in X ray

For long, ring, and little fingers can be treated with extensor reconstruction and silastic implant arthroplasty; in the index finger arthrodesis of the proximal interphalangeal joint may suffice.

Def. Of distal joints

Mallet fingerHyper extensible DIP jtAttenuation of capsulo-ligamentous structures

Rupture of flex. Tendons.

Ulnar drift

Characterestic deformity in which the fingers displace ulnarwards at the MCP jts.

S.P volar plate & C.L attachments lose competence

Cartilage & bone destruction Radial deviation of wrist & ass. M.C alters coronal plane balance of finger deviators

Attenuation of radial sagittal bands extensor tendons shifting ulnarwards.

Ulnar intrinsics may gradually tightens, maintaining the deformity.

Components of ulnar drift

Ulnar deviation of fingersVolar subluxation of prox. Phalanges

Dislocation of Ext. tendon to the ulnar side of their respective MC heads.

Components of ulnar drift (contd.)

Hyperextn of the middle finger joints

Flexion of the distal jointsBasically, this is an intrinsic plus deformity

Deformities in thumb

May involve the joints individually or in combination

Classification (Nalebuff) Type I Type II Type III Type IV

Type I

Most common Boutenniere def.

Type II

RareMCP jt flexion flexion, IP jt hyperextension.CarpoMCP jt subluxation / dislocation

Type III

2nd most commonSwan neck def.

Type IV

UnusualResults from Ulnar collateral lig. Laxity

Includes ABD. of the proximal Phalanx & ADD. of the MC

Rupture of tendons

Ext. tendon ruptureFlex tend. Rupture Rheumatoid tenosynovitis is the basic cause.,

Extensor tendon rupture

Long ext. tendons of middle, ring and little finger may rupture as a group

Dorsal subluxation of distal ulna contributes

Long ext. tendon of thumb at the level of Listers tubercle.

Flexor tendon rupture

Not so common Difficult to treat surgicallyMay rupture within the digit ( due to ITS) or at the level of wrist.

Rupture of one sublimus slip may cause trigger finger

VAUGHN JACKSON SYND

Rupture of EDC ring & small fingers.Attrition rupture of due to dorsally displaced

ulnar head.

MANNERFELT SYNDROME

FPL tendon ruptureMost common flexor tendon ruptureDue to carpal irregularities, such as spurring

of volar surface of scaphoid.

Deformities of wrist

Dorsum of wrist is usually the location of first painful swelling in Rh. Arthritis

Tenosynovial Swelling may contribute to De Quervains disease, Trigger finger or CTS

Hourglass swelling due to constriction of middle part by dorsal carpal lig.

Destruction of joints may contribute to...

Subluxation of distal ulnaUlnar shifting of carpal bonesRadial angulation of MC & ulnar shifting of carpals.

Volar subluxation of wrist

CAPUT ULNA SYNDROME

End stage of destruction of DRUJ Ulnar sided wrist pain, weakness, decreased

forearm rotation, dorsal ulnar prominence.Piano key sign.Preventive treatment splinting, local steroid

inj, synovectomy.

Darrach procedureSauve Kapandji procedure.Resection hemiarthroplasty of DRUJ.

Z- Deformity

Due to DRUJ & radiocarpal Jt pathology.Carpus supinates & slides ulnarly on the

radius with resultant radial deviation of metacarpals

Ulnar drift & Volar subluxation of MCP Jt.

Main en lorgnette

Opera glass handSevere form of deformities of fingers &

thumb by an erosive rheumatoid disease.

Rheumatoid nodules

Subcutaneous masses with collagenous matrix over bony prominence

Commonly over dorsum of fingersUnsightly and tenderImpinge digital nerves & alter finger movt.Erode draining sinusNodule excision.

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