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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