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The Rheumatoid Hand Deformities & Management

Dr. Anirudh Sharma Resident

Department of Orthopedics

+Why is Rheumatoid Arthritis important?

+RA is a very debilitating disease

¤ median life expectancy decreases by 10 years for women & by 4 years for men

¤ 1/3 patients stop work within 5 years of diagnosis, 1/2 within 10 years

+Introduction

�  systemic autoimmune disorder with chronic systemic erosive synovitis

�  deformities secondary to hypertrophied synovial tissue

�  most common cause of inflammatory joint disease

+Introduction

�  1 - 3% prevalence

�  peak during fourth and fifth decade

�  women affected 3 – 4 times more than men

+Pathophysiology

�  inflammatory pathways that lead to proliferation of synovial cells in joints

�  pannus formation leads to underlying cartilage destruction and bony erosions

�  overproduction of proinflammatory cytokines (TNF, IL-6)

+Pathophysiology

+What is Rheumatoid Factor?

n  B-cell activation leads to the production of anti-IgG autoantibodies

n  these are detected in the blood as ‘rheumatoid factor’ (RF)

+Presentation

�  Early: �  pain and morning stiffness > 30 minutes �  involving PIP and MCP joints �  fatigue, weight loss and low-grade fever �  swelling due to synovitis or subtle synovial

thickening may be palpable

+Presentation

�  Late: �  joint deformities �  instability �  destruction

+Diagnostic Test

�  RF, anti-CCP, or both

�  CRP and ESR �  used to follow disease activity and response to medication

�  CBC

�  Xray - hands �  evaluate for periarticular erosive changes

+Treatment

n  Methotrexate: first-line treatment in patients with active RA

n  Leflunomide used as an alternative to methotrexate

n  Sulfasalazine or hydroxychloroquine is recommended as monotherapy in patients with low disease activity

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n  Combination therapy more effective than monotherapy

n  If RA is not well controlled, a biologic DMARD should be initiated

n  TNF inhibitors are first-line biologic therapy

n  If TNF inhibitors ineffective, additional biologic therapies can be considered

+Rheumatoid Deformities Hand

+Hand Deformities

n Ulnar drift of fingers & Radial deviation of wrist

n Swan neck deformity

n Boutonniere deformity

n Mallet finger

n Trigger finger

n Drop finger

+Metacarpo-phalangeal deformities

carpal row slides ulnarwards è metacarpals deviate radialwards è reciprocal ulnar deviation of mcp joint (zig-zag mechanism)

+Management of MCP joint deformity

n Splintage

n Synovectomy

n Reefing of radial sagittal bands

n Tightening of radial collateral ligament

n Intrinsic muscle release and transfer

n Arthroplasty

+MCP Joint Arthroplasty

n Indications n Pain with arthritis n Severe ulnar drift with loss of function n Marked flexion contractures n Decreased arc of motion (< 40 deg.)

n Contraindications n Poor bone stock n Poor skin condition

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+Swan Neck Deformity

PIP joint is hyperextended and the DIP joint flexed

Occurs due to:

1.  If PIP extensors overact

2.  If PIP flexors are inadequate

3.  If Palmar Plate fails

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+Management of Swan-Neck Deformity

n  Figure of eight ring splint

n  FDS tenodesis

n  Lateral band mobilization

n  Arthrodesis / arthroplasty

+Boutonniere Deformity

n fixed flexion of the proximal and hyperextension of the DIP joint

n due to interruption or stretching of the central slip of the extensor tendon

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+Management of Boutonniere deformity

n Post-traumatic (early) n Splint PIP in full extension for 6 weeks

n Open injuries n Repair central slip + K wire fixation for 3 weeks

n Division of extensor tendon just proximal to its insertion

+Mallet Finger

n injury to the extensor tendon of the terminal phalanx

n terminal joint held flexed, but passive movement is normal

n X-rays are taken to show or exclude a fracture.

+Management of Mallet Finger deformity

n With bony injury: n Minimal subluxation – splintage in extension for

6 weeks n Large fragment with subluxation – operative

(complications high)

n Without bony injury: n Splint DIP joint in extension 8 weeks è4 weeks

night splintage n Fusion for arthritic joints

+Trigger Finger

n Thickening of flexor tendon sheath è “snap” felt with forced extension

n lead to secondary nodule development over tendon

+Management of Trigger finger

n injection of corticosteroid at the mouth of the tendon sheath

n Operative: incise A1 section of the fibrous until tendon moves freely

+Dropped Finger

n sudden loss of extension at MCP joint

n due to tendon rupture at wrist

+Surgical Indications

n  Pain relief

n  Restoration/improvement of function

n  Prevention of deformities

n  Improvement of appearance

+Surgical options

n Synovectomy n Tendons n Joint

n  Contracture releases

+Surgical options

n  Tendon reconstruction n Repair n Adjacent tendon suture n Intercalated graft n Tendon transfer

n  Arthroplasty

n  Arthrodesis

+Thank You