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Rheumatoid Diseases of the Hand. R. Dale Reynolds, M.D. UT Houston Plastic and Reconstructive Surgery. Rheumatoid Arthritis. A 58 yo man requests definitive relief of severe wrist pain. A radiograph is shown. Which of the following is most appropriate: Arthroplasty with silicone implant

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rheumatoid diseases of the hand

Rheumatoid Diseases of the Hand

R. Dale Reynolds, M.D.

UT Houston

Plastic and Reconstructive Surgery

rheumatoid arthritis
Rheumatoid Arthritis
  • A 58 yo man requests definitive relief of severe wrist pain. A radiograph is shown. Which of the following is most appropriate:
    • Arthroplasty with silicone implant
    • Intercarpal arthrodesis
    • Proximal row carpectomy
    • Radial shortening
    • Total wrist arthrodesis
rheumatoid arthritis4
Rheumatoid Arthritis
  • 53 yr old woman with RA has Stage IV disease of the MCP. Which is the most characteristic posture of the patient’s MCP and PIP?
rheumatoid arthritis6
Rheumatoid Arthritis
  • 49 yr old woman with RA of wrists and hands has loss of active extension of the MCP of R middle and ring fingers for the past 6 months. PE shows full passive ROM of MCP; x-rays show no joint subluxation. When the digits are passively extended, she is able to maintain extension against resistance. Which is the most appropriate next step in management?
    • Observation
    • Arthroplasty of MCP of middle and ring
    • Repair of extensor tendon ruptures of middle and ring
    • Centralization of the extensor tendons of the middle and ring fingers at the MCP joints
    • Arthrodesis of MCP of middle and ring fingers
rheumatoid arthritis8
Rheumatoid Arthritis
  • The photograph shows a 60 year old man with advanced RA who has a boutonniere (type I) deformity of the thumb. Which of the following is the most likely cause of his findings?
    • Rupture of the EPL tendon
    • Rupture of the FPL tendon
    • Tenosynovial proliferation at the carpometacarpal joint of the thumb
    • Tenosynovial proliferation at the IP joint of the thumb
    • Tenosynovial proliferation at the MCP joint of the thumb
rheumatoid arthritis9
Rheumatoid Arthritis
  • 42 yr old woman with severe RA has advanced joint degeneration, pain, and decreased use of the right elbow, wrist and hand. On PE, the elbow is stiff and tender and the wrist and MCP joints are tender and subluxed. Radiographs confirm these findings. Which of the following staged sequences id the most appropriate?
    • Elbow arthroplasty, wrist arthrodesis, MCP joint arthroplasties
    • Elbow arthroplasty, MCP joint arthroplasties, wrist arthrodesis
    • MCP joint arthroplasties, elbow arthroplasty, wrist arthrodesis
    • MCP joint arthroplasties, wrist arthrodesis, elbow arthroplasty
rheumatoid arthritis10
Rheumatoid Arthritis
  • Changes in last 10 years
  • More aggressive treatment
  • Better drugs and medical management
  • Fewer isolated synovectomies
  • More severe deformities
  • Etanercept and Infliximab
  • Further radical change soon
rheumatoid arthritis11
Rheumatoid Arthritis
  • Diagnosis (4 of 7)
    • > 1 hr morning stiffness x 6 weeks (PA)
    • > 2 simultaneous PA regions x 6 weeks
    • Hand joint arthritis x 6 weeks
    • Symmetric arthritis x 6 weeks
    • RA nodules on extensor tendons (physician)
    • + Serum RF
    • Erosion or decalcification on x-rays (PA)
rheumatoid arthritis12
Rheumatoid Arthritis
  • May be initial presenting problem
  • Destructive synovitis
  • RA synovitis is associated with angiogenesis and a high lymphocyte content
  • Aggregates
  • Tendon sheath and synovial joints
  • Limited motion or rupture
  • Joint deformity
rheumatoid arthritis13
Rheumatoid Arthritis
  • Wrist, MCP, PIP
  • RA nodules
  • Carpal tunnel syndrome
  • Digital vasculitis
    • Ischemic neuropathy
    • Muscle wasting
    • Raynaud’s phenomenon
rheumatoid arthritis14
Rheumatoid Arthritis
  • Autoimmune process
  • 50-80% + RF (IgM) against IgG
  • 15% normal population + RF
  • Seronegativity (Rheumatoid variants) questionable surgical prognosis
rheumatoid arthritis15
Rheumatoid Arthritis
  • High ESR in active phase
  • Plain x-rays (PA swelling, erosions)
  • U/S more sensitive for PA swelling (80%)
  • Synovial fluid (differential, crystals)
    • Gout, calcium pyrophosphate disease
  • Synovium in all joints and portions of flexor and extensor tendons (beneath pulleys)
rheumatoid arthritis16
Rheumatoid Arthritis
  • Stages
    • Proliferative: Swelling, pain with motion, limited movement, nerve compression
    • Destructive: Synovial erosion causes irreversible changes (tendon rupture, capsular weakness and disruption, bone erosion, joint subluxation and deformity)
    • Reparative:Fibrosis replaces inflammation (adhesions, ankylosis, fixed deformity)
rheumatoid arthritis17
Rheumatoid Arthritis
  • History
    • Monocyclic (10%) – One attack
    • Polycyclic (45%) – Variable duration, severity and intervals
    • Progressive (45%) - Unremitting
rheumatoid arthritis18
Rheumatoid Arthritis
  • History
    • Ask which aspects give them the most trouble
    • Often very functional although deformed
    • Functional grading
      • No incapacity
      • Manages all but the heaviest tasks
      • Only lightest duties
      • Chair or bed bound
rheumatoid arthritis19
Rheumatoid Arthritis
  • History
    • Pain
      • Recent increase in pain may indicate a “flare-up”
      • Not usually present at rest (only exacerbations)
      • Demonstration of painful movement can help localize most active joints
    • Stiffness
      • How long does it take to loosen up in the morning (limber up time =LUT)
rheumatoid arthritis20
Rheumatoid Arthritis
  • History
    • Numbness and paraesthesias
      • Compression: Median nerve more common than in general population due to increase synovial volume
      • Generalized neuropathy: Common in the lower limb
    • Weakness
      • From pain, joint collapse, synovitis
    • Appearance
      • Can be main complaint
rheumatoid arthritis21
Rheumatoid Arthritis
  • History
    • Medications
      • Steroids – wound healing, stress dose
      • Synovectomy during proliferative phase should wait until 3-6 month medical trial
rheumatoid arthritis22
Rheumatoid Arthritis
  • Non-articular effects
    • Iritis or uveitis - 3-5%
    • Scleromalacia perforans - globe rupture due to nodule necrosis
    • Anemia – 25% (normocytic, normochromic)
    • Polyneuropathy – lower limbs
    • Cardiac – pericarditis, myocarditis, valvular
    • Arteritis - uncommon
rheumatoid arthritis23
Rheumatoid Arthritis
  • Non-articular effects
    • Lung changes
      • Rheumatoid lung: Honeycombed appearance on CXR due to multiple nodules
      • Caplan’s syndrome: Found with pneumoconiosis massive pulmonary fibrosis
      • Idiopathic pulmonary fibrosis
rheumatoid arthritis24
Rheumatoid Arthritis
  • Rheumatoid syndromes
    • Felty’s syndrome: RA + LAD + splenomegaly  granulocytopenia / anemia
      • Splenectomy has no effect on arthritis
    • Sjogren’s syndrome (2 of 3): RA + keratoconjunctivitis sicca, xerostomia
rheumatoid arthritis25
Rheumatoid Arthritis
  • Examination
    • Neck, shoulder, elbow, radius, ulna, wrist extensors, thumb, MCP, PIP, DIP, nerve compression
    • Usually symmetrical joint involvement
    • Dominant hand often more advanced
rheumatoid arthritis26
Examination

Deformities on general inspection

Posterior subluxation of elbow

Palmar subluxation of wrist

Ulnar translocation of carpus

Radial deviation of the wrist

Ulnar drift of the fingers

Palmar subluxation of MCP

Swan neck or boutonniere deformity of fingers

Z- deformity of the thumb

Lateral dislocation of any of the IP joints

Misalignment of digits suggestive of tendon rupture

Rheumatoid Arthritis
rheumatoid arthritis27
Rheumatoid Arthritis
  • Z mechanism
    • Characteristic of many deformities of rheumatoid hand
    • Joint adopts an angulation in one direction, the joints on either side will tend to go in the opposite direction
    • Due to changes in mechanical advantage of tendons acting on a series of joints
rheumatoid arthritis28
Rheumatoid Arthritis
  • Gross Instability (Arthritis Mutilans, Opera- Glass Hands)
    • Results when bone ends are excessively eroded
    • Flail joints result
    • Grasp becomes impossible
    • Ankylosis of a joint may arrest its shortening and cause a disproportionately long digit
    • Arthrodesis of all affected IP joints early with bone grafting where appropriate
rheumatoid arthritis29
Rheumatoid Arthritis
  • Swellings
    • Rheumatoid nodules: Firm and rubbery (swollen olecranon bursa is fluctuant), most at ulnar border just distal to elbow but can be anywhere, poor prognosticator, painful, may ulcerate, should be excised
    • Benign pseudorheumatoid nodules: Histologic not clinically equivalent
rheumatoid arthritis30
Rheumatoid Arthritis
  • Swellings
    • Rheumatoid nodulosis: Seropositive adults, histologically rheumatoid, mild arthralgia, mild radiographic changes
    • Prominent ulnar head
    • Synovial swelling
rheumatoid arthritis31
Rheumatoid Arthritis
  • Skin
    • Thin, papery especially with steroids
    • Bruising, petechiae, fingertip hemorrhage, infarct
    • Psoriasis – elbow, fingernails, seronegativity
    • Palmar erythema – thenar and hypothenar
    • Intertrigo – accumulation of moisture most often b/w fingers and in the palm with MCP
rheumatoid arthritis32
Rheumatoid Arthritis
  • Muscle wasting
    • Excessive thenar wasting suggests possible median nerve compression
    • First dorsal interosseous suggested by deep concavity of dorsal aspect of the first web space
rheumatoid arthritis33
Rheumatoid Arthritis
  • Systemic regional assessment
    • Joint by joint, tendon by tendon, nerve by nerve
    • Pain
    • Synovial swelling
    • Tenderness
    • Range of motion (active, passive, associated pain)
    • Stability
    • Crepitus
    • Deformity (fixed, mobile)
rheumatoid arthritis34
Rheumatoid Arthritis
  • Neck (common)
    • Atlanto-axial subluxation
    • Superior migration of odontoid into foramen magnum
    • Subaxial subluxation of the vertebral bodies
    • Pain, instability, neurological disturbance
    • Full assessment before any general anesthetic (passive ROM, trigeminal nerve testing, lower limb reflexes)
rheumatoid arthritis35
Rheumatoid Arthritis
  • Neck
    • Neural deficit
      • I: Nil
      • II: Subjective weakness, hyperreflexia, dysaesthesia
      • IIIa: Objective long tract signs
      • IIIb: Quadriparesis
    • All should have AP and lateral in flexion and extension
    • Only 1 % need posterior fusion (II or III)
rheumatoid arthritis36
Rheumatoid Arthritis
  • Shoulder
    • Tested by touching interscapular region
    • Difficulty requires evaluation by orthopedic surgeon
rheumatoid arthritis37
Rheumatoid Arthritis
  • Elbow
    • Synovium – Active synovitis causes swelling
    • ROM – Normal 0-145o , synovitis causes pain at extremes, synovectomy help pain but not always ROM
    • Crepitus – Creaking or grinding with passive motion indicates marked synovitis or erosion
    • Stability – Dislocation uncommon, posterior, severe instability assessed by evaluation at 90o (Fig. 5.16)
rheumatoid arthritis38
Rheumatoid Arthritis
  • Radial head
  • Evaluate abducted at 90o supporting, pronating and supinating
    • Crepitus – Loss of articular cartilage in superior radioulnar joint, excision of the radial head is indicated and improves pain and ROM
    • ROM – Normal pronation 70o, supination 85o
    • Pain – Extreme supination often causes pain at ulnar head
rheumatoid arthritis39
Wrist

Synovitis

Extensor compartment:

Ulnar>radial

Hour glass constriction on exam from retinaculum

Joints of wrist:

Can be divided into three compartments each lined with synovium (radiocarpal, mid-carpal, radioulnar)

Cartilage degradation, synovial expansion, ligamentous laxity

Rheumatoid Arthritis
rheumatoid arthritis40
Rheumatoid Arthritis
  • Cartilage destruction
    • Chemical effects of intra articular lysosomes and free oxygen radicals
  • Synovial expansion
    • Essence of RA
    • Bony erosions  bony spicules / tendon rupture
    • Attempted grip increases pressure and pain
rheumatoid arthritis41
Rheumatoid Arthritis
  • Ligamentous laxity
    • Stretching from distended synovium
    • Carpal supination and ulnar translocation and associated with scapholunate dissociation
    • Muscle tendon units crossing deform  carpal collapse  palmar facing carpal row / carpal height / ROM / strength
    • Degenerative arthritis due to bony contact
    • Carpal supination and palmar subluxation of the distal radius and carpus  dorsal subluxation of the distal ulna in the region of the distal radioulnar joint
rheumatoid arthritis42
Rheumatoid Arthritis
  • Ligamentous laxity
    • All may be affected but ulnar carpal complex (UCC) is commonly first
    • Synovitis causes:
      • Scalloping laterally
      • Eventual rupture of the triangular fibrocartilaginous complex (TFCC) distally and can damage extensors 4 and 5 with ulnar head erosion
      • Threatens effectiveness of ECU medially
rheumatoid arthritis44
Rheumatoid Arthritis
  • Ligamentous laxity
    • Radioscaphocapitate (RSC) or sling ligament is second
    • Joined by incompetence of the radioscapholunate (RSL)  rotatory subluxation of the scaphoid / loss of radial carpal height
    • Joined by radiolunatriquetral (RLT) and wrist subluxes into anterior position
rheumatoid arthritis46
Rheumatoid Arthritis
  • Ligamentous laxity
    • Dorsal radiocarpal(DRC) ligament fails  ulnar translocation of carpus
    • If whole carpus moves then type I translocation
    • Mid-carpal joint is relatively spared usually
    • Triquetrohamitatocapitate (THC) can deteriorate  volar intercalated segment instability (VISI)
rheumatoid arthritis47
Rheumatoid Arthritis
  • Ligamentous laxity

UCC  prominent ulnar head

 supinated carpus

 ineffective ECU

RSC

+RSL  loss of radial height

+ RLT 

+ DRC  ulnar translocation

= radial carpal rotation anterior wrist subluxation

(Shapiro angle = 112o in normal, higher in RA)

[radial cortex index metacarpal to line from tip of radial styloid to the ulnar corner of the distal radius]

rheumatoid arthritis48
Rheumatoid Arthritis
  • Ligamentous laxity
    • Prominent ulnar head  extensor tendon rupture
    • Radial carpal rotation  changing alignment of the metacarpus and encouraging ulnar drift (Z)
    • Anterior wrist subluxation  reduced efficiency of the extrinsic tendons  weakens grasp / encourages swan neck deformity
rheumatoid arthritis49
Rheumatoid Arthritis
  • PE
    • Synovium
      • Three finger test for fluctuance over ulnar / dorsal
    • ROM
      • Normal: Flexion 75o, extension 70o, ulnar deviation 35o, radial deviation 20o
    • Pain
      • Synovitis  extremes of range
      • Articular cartilage loss  limited arcs
rheumatoid arthritis50
Rheumatoid Arthritis
  • Distal Radioulnar Joint (Ulnar Head)
    • Inherently unstable
    • Sigmoid notch never contacts more than 60% of the ulnar head
    • In some positions it is <10%
    • Stability largely from TFCC but ECU, pronator quadratus, the interosseous membrane, the dorsal carpal ligaments and FCU all contribute
rheumatoid arthritis51
Rheumatoid Arthritis
  • Distal Radioulnar Joint (Ulnar Head)
    • Extreme supination produces pain and is evidence of subluxation
    • Piano key sign: Depression of the ulnar head > 5mm and with release springs back into position
rheumatoid arthritis52
Rheumatoid Arthritis
  • Distal Radioulnar Joint (Ulnar Head)
    • Depression of ulnar head:
      • Pain
      • Synovial swelling of ulnar border
      • Recurrence of radial deviation
    • Extensor tendon ruptures called Vaughan-Jackson lesions imply impending rupture and are an indication for early surgery
    • Earliest erosions at distal scaphoid and ulnar styloid
    • Deep erosions then occur at the sigmoid notch producing the scallop sign this always indicates impending rupture
rheumatoid arthritis wrist
Rheumatoid Arthritis Wrist
  • Synovectomy
    • Used alone if present for 6 months with failed medical treatment
    • Used with more complex procedures usually due to effective medicine
    • Can improve wrist pain and improve motion
    • Does not effect progression
rheumatoid arthritis wrist54
Rheumatoid Arthritis Wrist
  • Ulnar head resection (Darrach procedure)
    • For subluxation of ulnar head causing extensor tendon rupture or painful pronation / supination
    • Customary to attempt reduction of the supinated carpus during same procedure by realigning the ECU using a radially based sling of extensor retinaculum
    • Can add transfer of ECR longus to ECU
rheumatoid arthritis wrist55
Rheumatoid Arthritis Wrist
  • Ulnar head resection (Darrach procedure)
    • Soft-tissue reconstruction is essential part an is aimed at treating:
      • Carpal supination
      • Distal ulnar shaft instability
      • ECU palmar migration
rheumatoid arthritis wrist56
Rheumatoid Arthritis Wrist
  • Ulnar head resection
    • Alternatives
      • Hemiresection-interposition arthroplasty
        • Retains ulnar styloid and the TFCC
        • Ulnar shortening followed by tendon interposition
      • ‘Matched’ distal ulnar resection
        • Removal of 4.5-6 cm long, lateral portion of the ulna
rheumatoid arthritis wrist57
Rheumatoid Arthritis Wrist
  • Arthroplasty
    • Older patients who do no heavy manual work and have intact wrist motors
    • Choices:
      • Soft-tissue arthroplasty
      • Fibrous ankylosis
      • Total wrist replacement
      • Silicone interposition arthroplasty
rheumatoid arthritis wrist58
Rheumatoid Arthritis Wrist
  • Interposition arthroplasty
    • Wrist is stable but painful due to cartilage loss
    • 3 mm sheet of silicone
    • No reported cases of silicone synovitis
rheumatoid arthritis wrist59
Rheumatoid Arthritis Wrist
  • Limited arthrodesis
    • Radiolunate arthrodesis
      • To correct and stabilize ulnar translocation
rheumatoid arthritis wrist60
Rheumatoid Arthritis Wrist
  • Total arthrodesis
    • Good bone stock allows standard procedure
    • Stabilize with pin if osteoprotic
rheumatoid arthritis wrist61
Rheumatoid Arthritis Wrist

Articular wear? No Synovectomy

Yes

Joint subluxed? No Interposition Arthroplasty

Yes

Fixed Deformity? No Stabilization

Yes

Wrist extensors gone? No Arthroplasty

Yes

Osteoporosis? No Formal arthrodesis

Yes

Rod stabilization

rheumatoid arthritis62
Rheumatoid Arthritis
  • Extensor tendons
    • Synovium
      • Well-demarcated swelling extending to dorsum of hand, thumb and forearm
      • Significant synovitis requires synovectomy before it leads to tendon rupture
rheumatoid arthritis63
Rheumatoid Arthritis
  • Extensor tendons
    • Tendon rupture
      • Tendon involvement in 50%
      • Dorsal
      • Not first (APL and EPB)
      • Second (ECRL and ECRB) uncommon
      • Third (EPL) very common
      • Fourth (EIP and EDC) late and uncommon
      • Fifth (EDM) early
      • Sixth (ECU)
rheumatoid arthritis64
Rheumatoid Arthritis
  • Extensor tendons
    • Tendon rupture
      • Only occur where it lies in tendon sheath
      • Most occur at bony prominences
        • EPL on radial tubercle
        • EDM and EDC of ring and small fingers on subluxed ulnar head
    • In addition to rupture, sudden inability to extend fingers
      • Ulnar subluxation at MCP
      • Dislocation of MCP
      • Posterior interosseous nerve compression
rheumatoid arthritis65
Rheumatoid Arthritis
  • Extensor tendons
    • Tendon rupture
      • EPL
        • Posture: flexion of both MCP and IP thumb
        • Active test: resisted thumb extension
      • EDM / EDC
        • Posture: drooping of affected fingers at MCP joint
        • Active test: resisted extension of the MCP joint
rheumatoid arthritis66
Rheumatoid Arthritis
  • Extensor tendons
    • Tendon rupture
      • Indications
        • MCP and wrist joints assessed first
        • Repair joints at same time or first
        • Tendon transfer or tendon graft
        • End to end repair is not possible
rheumatoid arthritis68
Rheumatoid Arthritis
  • Thumb
    • Trapeziometacarpal
      • With subluxation the base of the first MCP moves radially and anterior to the trapezium
    • MCP and IP
      • Each collateral ligament
    • Crepitus
      • Evidence of loss of articular cartilage
rheumatoid arthritis69
Rheumatoid Arthritis
  • Thumb
    • Stability (skeletal collapse)
      • Type I (=Boutonniere)
        • Commences at MCP
        • Attrition of EPB and ulnar displacement of EPL
        • Becomes intrinsic minus and MCP flexion results
        • Distal and palmar displacement of APB and AP
      • Synovectomy + insertion of EPL into base of proximal phalynx
rheumatoid arthritis71
Rheumatoid Arthritis
  • Thumb
    • Stability (skeletal collapse)
      • Type I (=Boutonniere)
        • Synovectomy + insertion of EPL into base of proximal phalynx
          • Joints can be reduced passively
          • Joints are stable laterally in the reduced position
          • Articular surfaces are adequate on x-ray
        • If any of the above are not present then stabilize MCP by arthrodesis or peg
rheumatoid arthritis72
Rheumatoid Arthritis
  • Thumb
    • Stability (skeletal collapse)
      • Type II (=adducted boutonniere)
        • Identical to I but is consequent upon disease in the trapeziometacarpal joint with adduction of the first metacarpal
rheumatoid arthritis73
Rheumatoid Arthritis
  • Thumb
    • Stability (skeletal collapse)
      • Type III (adducted Swan Neck)
        • Commences at the trapeziometacapral joint with synovitis  articular erosions with dorsoradial subluxation at the metacarpal base  adduction and flexion of first metacarpal
        • Hyperextension of the joint and hyperflexion of the interphalangeal joint
rheumatoid arthritis74
Rheumatoid Arthritis
  • Thumb
    • Stability (skeletal collapse)
      • Type III (adducted Swan Neck)
        • (1)Correct adduction of first metacarpal by release of AP or first interosseous or overlying fascia or all three
        • (2)Maintain correction by attending to trapeziometacarpal disease (maintain motion)
        • If: Articular surfaces adequate on x-ray and no evidence of disease in other trapezial joints
        • Then: Synovectomy + ligament reconstruction with FCR or ECRL
rheumatoid arthritis75
Rheumatoid Arthritis
  • Thumb
    • Stability (skeletal collapse)
      • Type III (adducted Swan Neck)
        • If: Articular surfaces not adequate
        • Then: basal joint arthroplasty
        • (3) Once adduction contracture overcome then MCP and IP joint deformities can be corrected
          • If: (a) joints reducible passively (b) joints stable laterally in the reduced position © articular surfaces adequate on x-ray
          • Then: synovectomy + capsulodesis or tenodesis
          • If: (a), (b) or © not present then stabilization
rheumatoid arthritis76
Rheumatoid Arthritis
  • Thumb
    • Stability (skeletal collapse)
        • Type IV (Gamekeeper’s thumb
          • Commences at MCP  ulnar collateral ligament laxity  radial deviation at MCP or IP
          • (1) Correct adduction and release the adductor and first interosseous +/- z-plasty to skin
        • For MCP or IP joints:
          • If articular surfaces adequate on x-ray  synovectomy + collateral ligament recon.
          • If articular surfaces poor (common)  stabilize MCP +/ IP
rheumatoid arthritis78
Rheumatoid Arthritis
  • Thumb
    • Stability (skeletal collapse)
      • Type V (Isolated Swan Neck)
        • Chronic synovitis  MCP palmar plate instability  MCP hyperextension and IP joint flexion
        • Treatment involves stabilizing the MCP in the flexed position with:
          • Capsulodesis, sesamoidesis, fusion of MCP
rheumatoid arthritis79
Rheumatoid Arthritis
  • Thumb
    • Stability (skeletal collapse)
      • Type VI (Arthritis Mutilans)
        • Marked skeletal collapse due to bone loss
        • Usually all digits involved with psoriatic arthritis
        • Treatment: Multiple fusions, bone grafting
rheumatoid arthritis80
Rheumatoid Arthritis
  • MCP
    • Synovitis leads to:
      • Palmar subluxation or
      • Ulnar drift
    • Harrison’s Grading (often determines tx)
      • I: Dislocation of the extensor tendon, no medial shift
      • II: Ulnar drift + medial shift
      • III: Subluxation of MCP + II
      • IV: Limited passive extension + III
rheumatoid arthritis81
Rheumatoid Arthritis
  • MCP
    • Synovectomy of MCP in grade I:
      • Failure of medical treatment (painful swelling)
      • Early erosions on x-ray
      • Synovitis + displacement of extensor tendons
    • All should be warned of possibilty of jt replacement
rheumatoid arthritis82
Rheumatoid Arthritis
  • MCP
    • Instability
      • Weakness of first dorsal interosseous
      • Disruption of collateral ligaments (usually from erosion)
    • When these are present, normal forces cause palmar subluxation and ulnar drift
rheumatoid arthritis83
MCP

Ulnar deviation (seen in normal hand)

Thumb pressure in all pinch grips

Ulnar inclination of metacarpal head

Action of AbDM (strong ulnar deviatorof camll finger proximal phalynx)

Ulnar drift (pathologic)

Radial deviation of the wrist

Ulnar shift of extensor tendons

Ulnar applied fore of the flexor tendons

Intrinsic tightness

Rheumatoid Arthritis
rheumatoid arthritis85
Rheumatoid Arthritis
  • MCP
    • Palmar subluxation (Harrison’s III or IV)
      • Only occurs with displacement of collateral ligaments
      • Intrinsic tightness
      • Extrinsic flexor tendons
      • Often evident by inspection
      • Non reducible = Grade IV
rheumatoid arthritis87
Rheumatoid Arthritis
  • MCP
    • Crossed intrinsic transfer
      • Beneficial and longlasting
    • Implant resection arthroplasty
      • Mainstay of treatment
    • Possible complications
      • Ulnar drift recurrence
      • Implant fracture
      • Surface wear  silicone synovitis
rheumatoid arthritis88
Rheumatoid Arthritis
  • Intrinsics
    • Tightness is caused by inflamed MCP joints and fibrosis
    • Tightness causes:
      • Weakness of power grasp
      • Ulnar drift
      • Palmar subluxation
      • Swan neck deformity of fingers
rheumatoid arthritis89
Rheumatoid Arthritis
  • Intrinsics
    • Tightness test
      • Hold the MCP in full passive extension
      • Gently flex the PIP with other hand
        • Normal hand: Full proximal IP joint flexion is possible
        • Abnormal: Firm, resilient resistance in seen
      • MCP allowed to fall progressively into flexion while keeping pressure applied to middle phalynx, the proximal IP will flex further as the MCP is lowered in extension
rheumatoid arthritis90
Rheumatoid Arthritis
  • Intrinsics
    • Tightness test
      • Pure intrinsic tightness  PIP will flex fully once the MCP has been allowed to pass into flexion, the extent by which it fails to achieve full flexion is a measure of IP joint disease of the extrinsic tendon adhesion
      • Repeat test while deviating ulnarward and radially
        • Ulnar intrinsic problem: More tightness radially
        • Radial intrinsic problem: More tightness in ulnar deviation
rheumatoid arthritis95
Rheumatoid Arthritis
  • Intrinsics
    • Release
      • One of the swiftest and most effective procedures in surgery
      • Complete excision of the wing tendon should be employed
        • Removes lateral band tightness (grasp weakness and swan neck)
rheumatoid arthritis96
Rheumatoid Arthritis
  • PIP
    • One of earliest and most commonly affected
    • Destructive forces can cause:
      • Boutonniere deformity (most common)
      • Swan neck deformity
        • Usually from superficialis synovitis or MCP joint sublux
      • Joint destruction
      • Lateral instability
rheumatoid arthritis98
Rheumatoid Arthritis
  • PIP
    • Boutonniere deformity
      • Stage I: Slight extensor lag at the PIP which is passively correctable. Loss of DIP flexion. Tx is night splintage and possible steroid injections, extensor tenotomy over the middle phalynx
rheumatoid arthritis99
Rheumatoid Arthritis
  • PIP
    • Boutonniere deformity
      • Stage II: 40o flexion deformity which is passively correctable. In time, fibrosis will produce inability to extend joint passively. Tx: freeing lateral bands by division of the palmar portion of the transverse retinacular ligament, mobilizing the lateral bands dorsally and reefing the dorsal apparatus of the central slip. K-wire for 3 wks then ROM in Carpenter splint
rheumatoid arthritis100
Rheumatoid Arthritis
  • PIP
    • Boutonniere deformity
      • Stage III: Fixed flexion deformity +/- intra-articular damage. Tx: Arthrodesis. Disadvantage is flexion being limited to DIP and resulting MCP dominance. Second line choice is arthroplasty (best for little > ring finger) requires adequate soft tissues and immediate ROM with night extension splints
rheumatoid arthritis101
Rheumatoid Arthritis
  • PIP
    • Swan Neck Deformity
      • Usually secondary to problems elsewhere (MCP)
      • Basis is weakening of periarticular structures of PIP by active synovitis
      • Abnormal force applied to joints is intrinsic tightness
      • Some think it is only from synovitis of FDS
      • Z-mechanism causes flexion in DIP and MCP
rheumatoid arthritis103
Rheumatoid Arthritis
  • PIP
    • Swan Neck Deformity
      • Type I: Difficult initiation but full flexion of the PIP possible.Tx: Silver ring splints. Surgical treatment centers around eliminating the flexion deformity at the DIP or preventing PIP hyperextension. Arthrodesis of the DIP. Flexor tenodesis using the superficialis tendon.
rheumatoid arthritis104
Rheumatoid Arthritis
  • PIP
    • Swan Neck Deformity
      • Type II: Display intrinsic tightness but are still fully passively correctable. PIP motion is dependent on MCP. In MCP extension PIP is limited but MCP has full flexion. Usually secondary to MCP subluxation. Tx: Intrinsic release and MCP arthroplasty.
rheumatoid arthritis105
Rheumatoid Arthritis
  • PIP
    • Swan Neck Deformity
      • Type III: Fixed hyperextension of PIP. Tx: Joint manipulation, if this fails then lateral band mobilization with release of the contracted dorsal transverse retinacular ligament. Flexor synovectomy may also be necessary.
rheumatoid arthritis106
Rheumatoid Arthritis
  • PIP
    • Swan Neck Deformity
      • Type IV: Radiologic evidence of joint destruction + type III. Tx: Arthroplasty in ring and little fingers unless MCP requires arthroplasty. Fusion for index and middle fingers.
rheumatoid arthritis107
Rheumatoid Arthritis
  • PIP
    • Surgical Treatment for Swan Neck Deformity
      • Early (before irreversible changes):
        • Intrinsic release to eliminate deforming force
        • Flexor synovectomy when flexor synovitis is present
        • Correction of hyperextension with capsulodesis or tenodesis
    • Surgical treatment for boutonniere deformity
      • Early
        • Synovectomy and reconstruction of extensor apparatus
rheumatoid arthritis108
Rheumatoid Arthritis
  • PIP
    • Advanced PIP deformities are very difficult to correct
    • Synovectomy and intrinsic release are performed early (improves 60% at 5 yrs)
      • Failure of medical treatment (painful swelling)
      • Early erosions on x-ray
      • Incipient boutonniere deformity as evidenced by synovitis associated with some laf to PIP extension
rheumatoid arthritis109
Rheumatoid Arthritis
  • PIP
    • Advanced disease with articular changes, lateral instability or joint destruction precludes soft-tissue reconstruction
    • Choices:
      • Stabilization
        • Arthrodesis
        • Peg stabilization
      • Replacement arthroplasty
rheumatoid arthritis110
Rheumatoid Arthritis
  • PIP
    • Choice is made according to:
      • Extent of disease in other parts of the hand
      • Age and occupation
      • Digit requiring treatment
        • Index: Stabilization (for pinch maneuvers)
        • Ulnar: Replacement arthroplasty (ROM important for power grasp)
rheumatoid arthritis111
Rheumatoid Arthritis
  • DIP
    • Uncommonly affected unless secondary
    • Think of psoriasis
    • Arthrodesis or peg stabilization is treatment
      • Angle at which fusion is performed increases form radial to ulnar
rheumatoid arthritis112
Rheumatoid Arthritis
  • Flexor Tendons
    • Morning stiffness or severe pain in the presence of good joints can mean synovitis
    • ‘Slow finger’ flexes out of phase with others due to synovitis, can even appear to be trigger
    • Carpal tunnel syndrome can occur due to compression of median nerve from increased volume of the synovium
rheumatoid arthritis113
Rheumatoid Arthritis
  • Flexor Tendon Rupture
    • Contributing factors:
      • Attrition against roughened bone
      • Ischemic degeneration
      • Invasive synovitis intratendinous granuloma
    • Surgeon undertaking flexor synovectomy must prepare patient for possible tendon graft and possible DIP fusion
    • FPL>FDP little> index>FDS ring>middle
rheumatoid arthritis114
Rheumatoid Arthritis
  • Flexor Tendon
    • Surgical indications
      • Carpal tunnel release with flexor synovectomy is indicated with median nerve compression
      • Trigger fingers: Synovectomy with attention paid to intratendinous nodules which may be the primary cause
    • Flexor tenosynovectomy improved PIP motion in 40o – 84o
rheumatoid arthritis115
Rheumatoid Arthritis
  • Flexor Tendon Rupture
    • Synovectomy indicated when significant bulk of synovium is detected around the flexor tendons
    • Difficult to determine degree of erosion so early tx:
      • If there is a mass of partially ruptured profundi these should be left alone as they tend to heal by fibrosis
      • FPL - grafting or fusion of the IP if there is destruction or instability. A ring finger FDS transfer may be used if the IP is normal
      • FDP - fuse DIP
      • Both superficialis and profundus – a superficialis transfer from the adjacent finger to the profundus or bridge grafting
rheumatoid variants
Rheumatoid Variants
  • Juvenile RA
  • SLE
  • Systemis Sclerosis
  • Ankylosing Spondolytis
  • Mixed Connective Tissue Disease
  • Psoriatic Arthritis
  • IBD
  • Reiter’s Syndrome
  • Behcet’s Syndrome
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