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  • 1. RHEUMATOID HAND
  • 2. Rheumatoid arthritisThe commonest inflammatory disease affecting the hand
  • 3. Principally affects synovial linings of joints and tendon sheathsDestroys ligaments and tendons subluxation of Jts.Compress the adj nerveMajor deformities develop often in womenNo fixed pattern of deformity
  • 4. Usually B/L symmetricalDuring the early inflammatory stage, intr. Muscles are in spasm.Later int. contracture develops
  • 5. MCP & Wrist affected earlyIP jts are affected late, typically.MCP- most important jt affecting function in RA.Ulnar deviation & volar subluxation of fingers are typical deformities.
  • 6. 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
  • 7. Deformities of handDef. of fingersDef of thumbDef. Of wristRupture of tendons
  • 8. Deformities in fingersIntrinsic plus deformitySwan neck def.Boutonneires def.Def. of distal jointsUlnar drift
  • 9. 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
  • 10. 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
  • 11. 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.
  • 12. 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.
  • 13. 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.
  • 14. 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
  • 15. Grading of Boutenniere Def. (Nalebuff & Millender)MildModerateSevere
  • 16. MildSatisfactory motionX 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)
  • 17. ModeratePassively correctable PIP jt.Normal flex. Tendon functionSatisfactory 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
  • 18. SevereJoints stiffSevere 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.
  • 19. Def. Of distal jointsMallet fingerHyper extensible DIP jtAttenuation of capsulo-ligamentous structures Rupture of flex. Tendons.
  • 20. 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
  • 21. Attenuation of radial sagittal bands  extensor tendons shifting ulnarwards.Ulnar intrinsics may gradually tightens, maintaining the deformity.
  • 22. Components of ulnar driftUlnar deviation of fingersVolar subluxation of prox. PhalangesDislocation of Ext. tendon to the ulnar side of their respective MC heads.
  • 23. Components of ulnar drift (contd.)Hyperextn of the middle finger jointsFlexion of the distal jointsBasically, this is an intrinsic plus deformity
  • 24. Deformities in thumbMay involve the joints individually or in combinationClassification (Nalebuff) Type I Type II Type III Type IV
  • 25. Type IMost common Boutenniere def.
  • 26. Type IIRareMCP jt flexion flexion,IP jt hyperextension.CarpoMCP jt subluxation / dislocation
  • 27. Type III2nd most commonSwan neck def.
  • 28. Type IVUnusualResults from Ulnar collateral lig. LaxityIncludes ABD. of the proximal Phalanx & ADD. of the MC
  • 29. Rupture of tendonsExt. tendon ruptureFlex tend. Rupture Rheumatoid tenosynovitis is the basic cause.,
  • 30. 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.
  • 31. Flexor tendon ruptureNot so common Difficult to treat surgicallyMay rupture within the digit ( due to ITS) or at the level of wrist.Rupture of one sublimus slip may cause trigger finger
  • 32. VAUGHN JACKSON SYNDRupture of EDC ring & small fingers.Attrition rupture of due to dorsally displaced ulnar head.
  • 33. MANNERFELT SYNDROMEFPL tendon ruptureMost common flexor tendon ruptureDue to carpal irregularities, such as spurring of volar surface of scaphoid.
  • 34. 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.
  • 35. Destruction of joints may contribute to...Subluxation of distal ulnaUlnar shifting of carpal bonesRadial angulation of MC & ulnar shifting of carpals.Volar subluxation of wrist
  • 36. 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.
  • 37. Darrach procedureSauve Kapandji procedure.Resection hemiarthroplasty of DRUJ.
  • 38. 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.
  • 39. Main en lorgnetteOpera glass handSevere form of deformities of fingers & thumb by an erosive rheumatoid disease.
  • 40. Rheumatoid nodulesSubcutaneous masses with collagenous matrix over bony prominenceCommonly over dorsum of fingersUnsightly and tenderImpinge digital nerves & alter finger movt.Erode  draining sinusNodule excision.
  • 41. THANK YOU

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