 Rheuma in Greek – something that flows
 Chronic Systemic Inflammatory Disease
 Mostly involving the small joints of ha...
 Exact cause at large
 Auto immunity suspected by majority
 Recent advancement helped improve our
knowledge regarding p...
 Class I – patients can carry out all ususal activities
without handicap
 Class II – patients can perform normal activit...
 Primarily clinical
 Auto antibodies to Ig G – RA factors in blood
and joint fluids
 RevisedARA criteria – at least 4/7...
Criterion Definition
Morning stiffness In & around joints lasting ≥ 1 Hr before max improvement
Arthritis of 3 or more are...
Hypertrophic synovitis
Cartilage of joints
destroyed
Erodes and ruptures the
tendons
Compresses adjacent
nerves
Dislocates...
 One of the most painful arthritic conditions
 Results in vulgar deformities of hand 
withdrawal from society
 Usually...
 MP & wrist affected early; distal joints later
 MP joint involvement affects the finger
movement more
 Ulnar deviation...
 Caused by tightness of intrinsic muscles
 PIP cannot be flexed when MP is fully
extended
 Bunnel test
 Accurate asses...
 Flexion posture of DIP & hyperextension of
PIP +/- MP flexion
 Caused by muscle imbalance
 It may initially resemble a...
 Deformity may also begin at PIP as
hyperplastic synovitis  herniation of
capsule  tightening of the lateral bands 
ev...
 Type I  flexible; require dermodesis,
arthrodesis (DIP), flexor tenodesis, retinacular
ligament reconstruction.
 Type ...
 Commonly seen in RA, but not unique
 Caused by synovitis of PIP with stretching out
of the central slip, forcing latera...
 Main ones -- Mallet, Swan neck deformity
 Usually treated by arthrodesis but not done in
patients undergoing PIP arthro...
 Not unique to RA
 Pathogenesis not completely understood
 Classified as mild, moderate and severe type
o Complex – may involve joints individually or in
combbination.
 Nalebuff Classification
 Type I – Buttonhole deformity,...
 Anti inflammatory agents
 Local steroid + LA Inj:
 Results  less dramatic
 Helps delay surgery to some extend
 When considered – all aspects of
musculoskeletal involvement must be
assessed
 Better to start with a Sx that is likely...
 When multiple operations are indicated,
order of priority must be considered.
 For eg: wrist arthoplasty/desis done fir...
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
Rheumatoid arthritis   hand
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Rheumatoid arthritis hand

  1. 1.  Rheuma in Greek – something that flows  Chronic Systemic Inflammatory Disease  Mostly involving the small joints of hand and feet  Adult RA  usually polyarticular ; rarely systemic involevement in visceral organs or eyes
  2. 2.  Exact cause at large  Auto immunity suspected by majority  Recent advancement helped improve our knowledge regarding pathogenesis  helped improve management both Mx and Sx.
  3. 3.  Class I – patients can carry out all ususal activities without handicap  Class II – patients can perform normal activities despite the handicap of discomfort or limited motion at one or more joints  Class III – patients are limited to a few duties of their usual occupation or self care  Class IV – patients are largely or completely incapacitated, are bed ridden or confined to a wheel chair and are limited to little or no self care
  4. 4.  Primarily clinical  Auto antibodies to Ig G – RA factors in blood and joint fluids  RevisedARA criteria – at least 4/7 features + for at least 6 weeks.
  5. 5. Criterion Definition Morning stiffness In & around joints lasting ≥ 1 Hr before max improvement Arthritis of 3 or more areas ≥ 3 joints have had soft tissue swelling or fluid (not bony overgrowth alone) Arthritis of hand joints At least one area involved as mentioned above an a wrist, PIP, or MCP Symmetric arthritis Self expl: Rheumatoid nodules S/c nodules over bony prominences, extensor surface or juxta articular regions Serum RA factor Abnl amounts of RA factor has been demonstrated in < 5% of normal individuals X Ray changes Demo in AP hand & wrist – erosions/bony decalcification localized to or most marked close to the involved joints
  6. 6. Hypertrophic synovitis Cartilage of joints destroyed Erodes and ruptures the tendons Compresses adjacent nerves Dislocates and erodes the joint itself
  7. 7.  One of the most painful arthritic conditions  Results in vulgar deformities of hand  withdrawal from society  Usually bilateral  severe functional limitation
  8. 8.  MP & wrist affected early; distal joints later  MP joint involvement affects the finger movement more  Ulnar deviation, palmar sublux/dislocation typifies RA  Caused by tightness of intrinsic muscles, displacement of lateral band of extensor hood, rupture of central slip of hood or rupture of long extensor or flexor tendons  Flexor tenosynovitis  limitation of IP joint motion – worse than that assessed by passive examination.
  9. 9.  Caused by tightness of intrinsic muscles  PIP cannot be flexed when MP is fully extended  Bunnel test  Accurate assessment – MC must be in line with the Ph; ulnar deviations must be corrected at test.  Sx  release of intrinsic tightness + synovectomy +/- arthroplasty/bone resection
  10. 10.  Flexion posture of DIP & hyperextension of PIP +/- MP flexion  Caused by muscle imbalance  It may initially resemble a Mallet finger with disruption of extensor tendon with secondary over pull of central tendon  HyEx of PIP  PIP may flex normally
  11. 11.  Deformity may also begin at PIP as hyperplastic synovitis  herniation of capsule  tightening of the lateral bands  eventual adherence  prevention of lateral bands sliding over the condyles  DIP remains flexed  Sx  synovectomy of PIP, mobilization of lateral bands +/- release of skin distal to PIP
  12. 12.  Type I  flexible; require dermodesis, arthrodesis (DIP), flexor tenodesis, retinacular ligament reconstruction.  Type II  caused by intrinsic muscle tightness; require intrinsic release + one or more of above mentioned procedures.  Type III  stiff, no satisfactory flexion, but no significant joint destruction (X ray)  Type IV  joint destruction, stiff PIP; requires arthrodesis of PIP
  13. 13.  Commonly seen in RA, but not unique  Caused by synovitis of PIP with stretching out of the central slip, forcing lateral bands to subluxate volarward  Final result  flexion of PIP, hyperextension of DIP extension of MP  Nalebuff, Millender categorized as mild moderate and severe based on X ray appearences. Sx differs amongst the types
  14. 14.  Main ones -- Mallet, Swan neck deformity  Usually treated by arthrodesis but not done in patients undergoing PIP arthrodesis.
  15. 15.  Not unique to RA  Pathogenesis not completely understood  Classified as mild, moderate and severe type
  16. 16. o Complex – may involve joints individually or in combbination.  Nalebuff Classification  Type I – Buttonhole deformity, most common type  Type II – MP flexion, IP hyper extension, CMc sublux/dislocation, rare  Type III – swan neck deformity,  Type IV – game keeper’s thumb; abduction of Prox Ph + Mc adduction, seen in assoc with ulnar drift,
  17. 17.  Anti inflammatory agents  Local steroid + LA Inj:  Results  less dramatic  Helps delay surgery to some extend
  18. 18.  When considered – all aspects of musculoskeletal involvement must be assessed  Better to start with a Sx that is likely to succeed, beginning with the less involved hand  Correct deformities of larger joints like elbow and shoulder  Sx should be designed based on individual needs
  19. 19.  When multiple operations are indicated, order of priority must be considered.  For eg: wrist arthoplasty/desis done first.  Additional minor procedures like tendon release may be done concurrently but major procedures must be deterred.

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