Rheumatoid arthritisThe commonest inflammatory disease affecting the hand
Principally affects synovial linings of joints and tendon sheathsDestroys ligaments and tendons subluxation of Jts.Compress the adj nerveMajor deformities develop often in womenNo 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.
PathologyProliferation 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 handDef. of fingersDef of thumbDef. Of wristRupture of tendons
Deformities in fingersIntrinsic plus deformitySwan neck def.Boutonneires def.Def. of distal jointsUlnar drift
deformityCaused by tightness of intrinsic musclesPIP joints cannot be flexed while MCP is fully extended.Often assoc. with volar subluxation & Ulnar deviation fingers
Swan neck deformityFlex. at the DIP joint and hyper extension at PIP. Jt May begin as Mallet deformityEither caused by muscle imbalance or by disruption of ext. tendon
Nalebuff et al ClassificationBased 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.
DeformityCaused by synovitis of the PIP jt. With stretching out of the central slipThis forces lateral bands of the ext. tendon to subluxate volar wards
Grading of Boutenniere Def. (Nalebuff & Millender)MildModerateSevere
MildSatisfactory motionX ray normalRepositioning of the lateral band portion of the extensor mechanism, proximal interphalangeal joint synovectomy, and extensor tenotomy over the middle phalanx (Dolphin-Fowler procedure)
ModeratePassively correctable PIP jt.Normal flex. Tendon functionSatisfactory preservation of jt. Space in X raysoft tissue procedure with central slip reconstruction using the lateral band or a tendon graft is an option
SevereJoints stiffSevere destruction of the joint in X rayFor 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 jointsMallet fingerHyper extensible DIP jtAttenuation of capsulo-ligamentous structures Rupture of flex. Tendons.
Ulnar driftCharacterestic deformity in which the fingers displace ulnarwards at the MCP jts.S.P volar plate & C.L attachments lose competenceCartilage & bone destructionRadial 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 driftUlnar deviation of fingersVolar subluxation of prox. PhalangesDislocation of Ext. tendon to the ulnar side of their respective MC heads.
Components of ulnar drift (contd.)Hyperextn of the middle finger jointsFlexion of the distal jointsBasically, this is an intrinsic plus deformity
Deformities in thumbMay involve the joints individually or in combinationClassification (Nalebuff) Type I Type II Type III Type IV
Type IVUnusualResults from Ulnar collateral lig. LaxityIncludes ABD. of the proximal Phalanx & ADD. of the MC
Rupture of tendonsExt. tendon ruptureFlex tend. Rupture Rheumatoid tenosynovitis is the basic cause.,
ruptureLong ext. tendons of middle, ring and little finger may rupture as a groupDorsal subluxation of distal ulna contributesLong ext. tendon of thumb at the level of Listers tubercle.
Flexor tendon ruptureNot 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 SYNDRupture of EDC ring & small fingers.Attrition rupture of due to dorsally displaced ulnar head.
MANNERFELT SYNDROMEFPL tendon ruptureMost common flexor tendon ruptureDue to carpal irregularities, such as spurring of volar surface of scaphoid.
Deformities of wristDorsum of wrist is usually the location of first painful swelling in Rh. ArthritisTenosynovial Swelling may contribute to De Quervains disease, Trigger finger or CTSHourglass 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 SYNDROMEEnd stage of destruction of DRUJUlnar 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- DeformityDue to DRUJ & radiocarpal Jt pathology.Carpus supinates & slides ulnarly on the radius with resultant radial deviation of metacarpalsUlnar drift & Volar subluxation of MCP Jt.
Main en lorgnetteOpera glass handSevere form of deformities of fingers & thumb by an erosive rheumatoid disease.
Rheumatoid nodulesSubcutaneous masses with collagenous matrix over bony prominenceCommonly over dorsum of fingersUnsightly and tenderImpinge digital nerves & alter finger movt.Erode draining sinusNodule excision.