ORTHOPAEDICS, Rheumatoi Hand, Hand deformity, Swan neck deformity, Bouttrine Deformity, Z - Deformity, Ulnar Deviation

2.  Rheumatoid arthritis is a chronic inflammatory disease of young or
middle aged adults characterized by destructive and proliferative
changes in synovial membrane, periarticular structures, skeletal
muscle, perineural sheaths

3.  In hand primarily affects the synovial linings of Wrist joint and
Metacarpophalangeal joint (MCP) [Early] and proximal interphalangeal
joint (PIP) [Late] and tendon sheath
 DIP spared
 Females

4. Pathology
 Involvement of synovial sheath of tendon
 Trigger finger may be the earliest evidence occurs due to diffuse synovitis
and constriction of the flexor tendon sheath and thickening of the flexor
digitorum superficialis
 Tendon become frayed, fragile, attenuated and may rupture where bony
compression and friction occur
 Extensor pollicis longus at lister’s tubercle (Mc)
 Extensor tendon of fingers in dorsal dislocation of ulnar styloid
 Flexor pollicis longus (Mc flexor)
 Compression of median nerve- synovial thickening within the unyielding
volar carpal ligament

5.  Synovial disease process attenuates and destroys the supportive ligaments,
capsule, and Joint.
 Stage of joint involvement
I. Synovitis without deformity
II. Synovitis with passively correctable deformity
III. Fixed deformity without joint changes
IV. Articular destruction

6. Revised criteria (ACR & EULAR)
 Joint involvement
 Involvement of 1 large joint – 0 points
 Involvement of 2-10 large joints- 1 points
 Involvement of 1-3 small joints- 2 points
 Involvement of 4-10 small joints- 3 points
 Involvement of >10 joints (Involvement of at least 1 small joint)- 5 points
 Serological (RF & ACPA)
 Negative RF & Negative ACPA- 0 points
 Low positive RF or low positive ACPA- 2 points
 High positive RF or High positive ACPA- 3 points
 Acute phase reactants: 1 point elevated ESR or CRP
 Duration: 1 point for symptoms lasting 6 weeks or longer
Total point 6 or >6 classified as RA

7. Deformity
 Finger deformity
 Deformity of thumb
 Rupture of tendons
 Deformity of wrist

8. Finger deformity
 Normal force applied to damaged joints by the extrinsic flexors and
extensors
 Tightness of the intrinsic muscles
 Displacement of lateral band of extensor hood
 Central slip rupture
 Rupture of long flexor or long extensor

9. Finger deformity
 Intrinsic plus deformity
 Swan neck deformity
 Button hole deformity (Boutonniere)
 Ulnar deviation

10. Intrinsic plus deformity
 Caused by intrinsic muscle tightness
 Deformity
 PIP: Extension
 MCP: Flexion
 Volar subluxation of MCP joint & ulnar
deviation of fingers
 Bunnell test

11. Swan neck deformity
 Deformity
 DIP: Flexion
 PIP: Hyperextension
 MCP: Flexion
 Caused by muscle imbalance and may be
passively correctable
 Also seen in
 Volar plate laxity
 Ehler danlos syndrome

12.  Begin as mallet deformity associated with extensor tendon
disruption at DIP with secondary overpull of central slip
cause hyperextension at PIP
 Begin at PIP because synovitis causes capsular disruption
,tightening of lateral band & central tendon, adherence of
lateral band in fixed dorsal position
 Flexor tenosynovitis- ineffective support by flexor
digitorum sublimis

13.  Types of swan neck (Nalebuff, Feldon, Millender)
I. Full ROM, no intrinsic tightness, no functional limitation
○ Flexor tenodesis PIP, fusion of DIP, Reconstruction of retinacular ligament
II. Intrinsic muscle tightness, limited PIP motion
○ Intrinsic release
III. Stiff PIP in all positions, no joint destruction
○ Mobilization of lateral bands, joint manipulation
IV. Severe Arthritic changes
○ Arthrodesis of PIP

14. Littler (Intrinsic release)

15. Beckenbaugh

16. Nalebuff & Millender (Lateral band
mobilization)

17. IP Arthrodesis

18. Swanson PIP Arthroplasty

19. Boutonniere deformity (button hole)
 Deformity
 PIP: Flexion
 DIP: Hyperextension
 MCP: Hyperextension
 Caused by
 synovitis of PIP with stretching out of central
slip allowing latral bands to subluxating
volarward
 Shortening of the oblique retinacular
ligaments results in hyperextension at DIP
 Flexion deformity of PIP is compensated by
extension of MCP joint (Not fixed)

20. Nalebuff & Millender Grading
 Mild (Flexion 15 at PIP, decreased flexion at DIP)
 Satisfactory motion
 Radiograph normal
 Repositioning of lateral band, PIP synovectomy, extensor tenotomy
 Moderate (Flexion 40 at PIP, Hyperextension at DIP)
 Passively correctable PIP
 Normal flexor tendon function
 Joint space preserved
 Soft tissue procedure with central slip reconstruction
 Severe
 Stiff joint

21. PIP Arthroplasty

22. DIP joint deformity
 Mallet, hyperflexed DIP
 Due to the rupture of extensor
slip
 Arthrodesis

23. Ulnar deviation
 MCP joint synovitis weakens the dorsoradial capsular restraints
 Stretching of MCP joint collateral ligaments by volarly directed forces of
flexor tendons permitting volar displacement of proximal phalanges
 Stretching of the accessory collateral ligaments
 Stretching of flexor tunnels that permits even more ulnar displacement
 Interosseous muscle contracture
 Attenuated radial sagittal bands
 Long extensor tendon rupture at wrist level

25. Ulnar deviation grades
 Mild to Moderate
 Absence of severely diseased articular surfaces or dislocated joints
 Intrinsic release or transfer, extensor tendon realignment, MCP
synovectomy
 Severe
 One or more MCP joints have dislocated & severely diseased
articular surfaces
 Long flexor tendons are major deforming force that drifts
ulnarward either within or without their sheaths, exerting palmarly
directed force
 Arthroplasty

27. Deformities of thumb
 Nalebuff classification
I. Type (MC)
○ Boutonniere deformity
II. Type (Rare)
○ MCP Flexion, IP hyperextension, Trapeziometacarpal joint subluxation
or dislocation
III. Type (2 MC)
○ Swan neck deformity
IV. Type
○ Ulnar collateral ligament laxity
○ Abduction of proximal phalanx with MC adduction

28. Boutonniere deformity
 Synovitis beginning in the MCP joint & bulges
dorsally with attenuation of extensor pollicis brevis
insertion
 Proximal phalanx: Palmar subluxation
 MCP : Flexion
 IP: Hyperextension
 If deformity correctable MCP synovectomy &
Extensor reconstruction
 If MCP fixed & IP correctable but destruction of
joint Arthrodesis of MCP
 If MCP & IP fixed with satisfactory trapezio-
metacarpal joint then MCP Arthroplasty & IP
Arthrodesis

29. Swan neck deformity
 Synovitis begins in the Trapeziometacarpal joint
 Deformity
 Dorsal subluxation of metacarpal base
 Hyperextension of the metacarpophalangeal
joint
 Metacarpal adduction contracture
 Mild
 Pain persist trapeziometacarpal
hemiarthroplasty
 Advanced
 MCP joint fusion added

30. Game keeper’s thumb (Type IV)
 Synovitic destruction of the capsuloligamentous
supports on the ulnar side of the MCP joint
 Due to laxity of the ulnar collateral ligament of the
MCP joint
 Mild
 MCP synovectomy, Ligament reconstruction,
adductor release
 Advanced
 MCP Arthroplasty or Arthrodesis

31. Opera Glass Hand (La Main En
Lorgnette)
 Arthritis mutilans of hand
 Shortening of fingers due to destruction
of phalanges
 Excess skin gets folded transversely
resembling ‘Opera Glass’

32. Thumb MCP joint
Reconstruction

33. Wrist Deformity
 Rheumatoid synovitis in wrist affects
 Ulnar styloid
 Ulnar head
 Mid portion of scaphoid
 Synovitis stretches ulnar carpal ligamentous complex & causes ‘Caput ulna
syndrome’
 Dorsal prominence of distal ulna
 Supination of carpus
 Volar subluxation of ECU
 Radial deviation of wrist

34.  Dorsal synovectomy
 Synovitis is moderate and no change in bone but pain present
 Persistent swelling at dorsum of wrist for 6 weeks despite medical
treatment
 Synovitis begins in the region of deep volar radiocarpal ligament & intercarpal
ligament which results in volar subluxation of scaphoid
 Combination of
 Rotatory subluxation of the scaphoid
 Volar subluxation of the ulnar carpus Relative supination of wrist
 Dorsal subluxation of distal ulna

35.  Wrist collapse leads to
 Imbalance of the extensor tendon
 Radial shift of the metacarpal
 Ulnar deviation of the fingers
 Untreated, end-stage rheumatoid wrist is
 Dislocated volarward
 Complete destruction of carpal bones
 Complete dissociation of the radioulnar
joint

36. Tenosynovitis
 Rheumatoid arthritis is a disease of the synovium
 Tendon sheath involvement is common and may occur months before the
symptoms of intra-articular disease noted
 Common sites
 Dorsal aspect of wrist
 Volar aspect of wrist
 Volar aspect of digits
 Presentation
 Pain
 Tendon dysfunction
 Tendon rupture

37. Extensor tenosynovitis
 Wrist & digital extensor tenosynovitis causes
painless swelling
 May be the first sign of RA
 D/D: ganglion cyst, dorsal capsular synovitis
 Extensor nodule may impinge on distal
extensor retinaculum causing discomfort in
wrist & finger extension
 Splinting & medical treatment if no
improvement extensor tenosynovectomy

38. Extensor tendon rupture
 Rheumatoid tenosynovitis is common cause of tendon rupture and a major
cause of deformity and disability
 Rupture occurs at
 Distal end ulna (ulnar subluxation)
 Lister’s tubercle
 The small finger usually involved first and subsequently the ring (Vaughn-
Jackson syndrome) and then sequentially more radial digital extensors
 The long extensor tendon of thumb, because of its tortuous course,
frequently ruptures at lister tubercle where it angles through an enclosed
tunnel or pulley

40.  A ruptured extensor tendon can be repaired by direct suture if found within a few
days and if the remaining tendon is adequate
 If ruptured tendon is diagnosed after several weeks, a segmental tendon graft or
tendon transfer to adjoining intact tendon may be satisfactory
 Extensor indicis proprius might be transferred for use as a motor to the little
finger

41. Flexor tenosynovitis
 Volar surface of the wrist and fingers
 Fusiform swelling of one or more flexor tendon
sheaths extending from middle of palm to distal
IP joint
 Swelling is typically painful and causes a
gradual decrease in finger flexion
 Synovium is thickened and nodules can be felt
along the tendon sheath with tendon excursion;
crepitus and grafting usually are present

42.  Presentation
 Interferes with finger motion
 Compresses median nerve in carpal tunnel
 Trigger finger
 Tendon rupture
 Erosion of the volar capsule & ligaments over radial osteophytes contribute to
flexor pollicis longus rupture in the carpal tunnel (Mannerfelt lesion)
 Tenosynovectomies & flexor sublimis ulnar slip removal reduce recurrence

43. Flexor tendon rupture
 Not as common as extensor tendon rupture but is much more difficult to
treat surgically
 Sites:
 Digit (infiltrative tenosynovitis)
 Wrist (FPL tendon: MC tendon to rupture)
 Infiltration, weakening, and eventual rupture of the profundus tendon may
likewise occur and are more obvious and disabling clinically
 Grafting of flexor tendons always fails exception is at the wrist, where a
segmental graft occasionally can be used as treatment for a ruptured flexor
pollicis longus tendon
 If the flexor profundus & superficialis are ruptured in the digit, proximal &
distal IP joint stabilization by arthrodesis

44. Thank
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