1. P Management of Hand
T
Def ormities in
R heumatoid Arthritis

2. Definition:
• Rheumatoid arthritis a chronic systemic disease
primarily of the joints, usually polyarticular, marked
by inflammatory changes in the synovial membranes
and articular structures and by atrophy and
rarefaction of the bones. In late stages, deformity
and ankylosis develop.

3. • Rheumatoid arthritis (RA) is a chronic autoimmune
disease that causes inflammation and deformity of
the joints. Other problems throughout the body
(systemic problems) may also develop, including
inflammation of blood vessels (vasculitis), the
development of bumps (called rheumatoid nodules)
in various parts of the body, lung disease, blood
disorders, and weakening of the bones
(osteoporosis). [1]
1. Rheumatoid arthritis; Dorland’s Medical Dictionary, 27th Edn

4. What are the Causes of RA?

5. • exact causes – unknown
• genetic susceptibility
• most likely triggered by a combination of
factors, including an abnormal autoimmune
response
• some environmental or biologic trigger, such
as a viral infection or hormonal changes

6. The Immune Response and
Inflammatory Process
• Two important components of the immune system -
B cells and T cells belong to lymphocytes.
• T cell- recognizes an antigen as "non-self,“ produces
chemicals (cytokines) -cause B cells to multiply and
release immune proteins (antibodies).
• antibodies recognize foreign particles and trigger
inflammation- rid the body of the invasion.
• For reasons still not completely understood, both
the T cells and the B cells become overactive in
patients with RA.

7. Genetic Factors
• Main genetic marker identified with
rheumatoid arthritis is HLA
• HLA-DRB1 and HLA-DR4 alleles are referred to
as the RA-shared epitope because of their
association with rheumatoid arthritis
• These genetic factors do not
cause RA, but they may make
the disease more severe once
it has developed.

8. Environmental Triggers
• Traces of E. coli have appeared in the synovial
fluid of people with RA.
• may stimulate the immune system to prolong
RA once the disease has started
• Other potential triggers include:
– Mycoplasma
– Parvovirus B19
– Retroviruses
– Mycobacteria, and
– Epstein-Barr virus.

9. • RA affects over 21 million
Who is Affected? people worldwide [2]
• There are about 3 million
people living with RA in
Europe [3]
• RA affects 3 times as many
women as men [4]
• It can affect people of all
ages but it is most common
in the 30-50 age range [5]
2. United Nations World Population Database, 2004 revision.
3. Weinblatt ME. Rheumatoid arthritis: treat now, not later. Ann Intern Med 1996;124:773-
774
4. Arthritis Research Campaign (http://www.arc.org.uk)

10. Disease Severity and Stages

11. Stage I
Early Acute Inflammatory
• Joint swelling
• Heat
• Redness
• Severe pain
• Radiological Changes: osteoporosis may be
present

12. Stage II
Moderate Subacute Proliferation
• Synovium begins to invade soft tissues,
leading to decreased mobility
• Tenosynovitis
• Less pain
• Radiological Changes: may show slight bone
and cartilage destruction

13. Stage III
Severe destructive, Chronic Active
• Joint deformity with soft tissue involvement
• Radiological Changes: bone, joint and cartilage
destruction with osteoporosis

14. Stage IV
Skeletal Collapse and Deformity
• Joint disorganization
• Severe deformity
• Muscle contracture
• Radiological Changes: severe bone, joint,
cartilage destruction with Joint instability,
dislocation and joint fusion.

15. ACR Criteria for Diagnosis
• Four or more of the following criteria must be
present:
– Morning stiffness > 1 hour
– Arthritis of > 3 joint areas
– Arthritis of hand joints (MCPs, PIPs, wrists)
– Symmetric swelling (arthritis)
– Serum rheumatoid factor
– Rheumatoid nodules
– Radiographic changes
• First four criteria must be present for 6 weeks or
more

17. Radiological Studies
• Plain Films
– Bilateral hands & feet
– Only 25% of lesions
– Less expensive
– Osteoporosis detection
– Deformities
• Color Doppler U/S & MRI
– Early signs of damage i.e. Erosions
– Bone Edema - even with normal findings on radiography

20. Hand Deformities in RA

21. Swan-neck Deformity
• Flexion of DIP joint, hyperextension of PIP
joint
• Flexor tendon synovitis- leads to use of
primarily the MP joint for digit flexion
• ‘Intrinsic plus type position’ during activities

23. Boutonniere Deformity
• PIP joint flexion and DIP joint hyperextension
• Synovitis causes central tendon to become
weakened, lengthened, disrupted from bony
capsular attachment, allowing PIP to rest in
flexion.

26. MP Joint Ulnar Deviation
• Ulnar deviation of MP joint- most common
• If restraining system of tendons, ligaments
and bones are affected by synovitis, the hand
collapses into deformity, as the MP joint has
more degree of mobility.
• Also called as Ulnar drift.

27. Volar subluxation of the Carpus on
the Radius
Ligament laxity due to chronic synovitis at the wrist
+
Natural volar tilt/displacement of distal articular
surface of the Radius
Lead to volar-subluxation of Carpus on the radius

28. Distal Ulna dorsal subluxation
• Normally, distal ulna is more prominent on
pronation and less prominent in supination.
Arthritic degeneration, leads to weakened
ligamentous structures.
Dorsal prominence of distal ulna, pain,
crepitations with pronation and supination

29. Carpal translocation and Wrist radial
deviation
• Ulnar displacement of the proximal carpal row
results in radial deviation of the hand
• Digits may be secondarily affected, and
deviated ulnarly.

30. Thumb deformities [6]
• Type I (Boutonniere deformity)
• Type II (uncommon)
• Type III (Swan neck)
• Type IV (Gamekeepers)
• Type V
• Type VI (Arthritis mutilans)
6. Nalebuff, Philips: The rheumatoid Thumb. In Hunter JM, Rehabilitation of the
Hand: surgery and therapy. Ed 3, Philadelphia, 1990, Mosby.

31. Type CMC Joint MP Joint IP Joint
Type I Not involved Flexed Hyper ext en
(bout onnier e ded
)
Type I I CMC f lexed, Flexed Hyper ext en
(uncommon) adduct ed ded
Type I I I CMC Hyper ext en Flexed
(Swan neck) subluxed, ded
f lexed,
adduct ed
Type I V CMC f lexed, MP Not involved
(Gamekeeper adduct ed hyper ext end
’s) ed
Unst able
ulnar

32. Swan-neck Thumb

33. Gamekeeper’s thumb

34. Other Features:

35. Synovitis
• Stage I; Redness and heat at the joints may be
apparent, with swelling and tenderness at the
joints
• Later stages: less or no synovitis, more of
structural changes
• On Observation: location of swelling and
presence of deformities, helpful to determine
stage of the disease

36. Nodules
• Rheumatoid nodules develop in 50% of RA
patients.
• Nodules-made up of granulomatous and
fibrous tissue, may or may not be painful.
• Should not be confused with ‘nodes’
(DIP- Heberden’s, PIP- Bouchard’s)

37. Crepitus
• Grating/Crepitus- a crunching or popping
sound on performing AROM.
• Can be indicative of a damaged cartilage.
• Grind test- compression of joint, while gently
rotating Metacarpal over the Carpal.
• Positive sign- pain and/or crepitus

38. Skin Condition
• Evaluate- color, temperature and noted areas
of swelling
• Initial stage- skin is red and warm
• Later stages- skin may be very thin and bruise
easily.

39. Range of Motion
• Increased stiffness, often noted early in the
morning.
• Loss of AROM can be caused by tendon
rupture.
• EPL and ED tendons are particularly
vulnerable.

40. Strength
• Joint instability- rather than weakness, usually
is more of a problem during ADL.
• Even with a good muscle strength, patients
will be unable to maintain a grip on an object
if their joints collapse into deformities.

41. Pain
• Pain caused by acute inflammation in the
early stages of the disease is usually greater
than in the end stages.
• Rheumatoid nodules can be painful when
palpated- important to evaluate and note.
May affect splint design or strap placement

42. Management of Hand deformities
1. Protection principles:

43. Respect pain:
1. Stop activities before the point of discomfort
2. Decrease activities that cause pain that lasts
for more than 2 hours.
3. Avoid activities that put strain on painful or
stiff joints.

44. Balance rest and activity:
1. Rest before exhaustion.
2. Take frequent short breaks
3. Avoid staying in one position for a long time.
4. Avoid rushing- plan ahead
5. Alternate heavy and light activities.

45. Exercise in pain-free range:
1. Initiate warm-water pool exercises.
2. Exercise should be specific to each deformity.

46. Avoid position of deformity:
1. Avoid bent elbows, knees, hips, and back
while sleeping.
2. Splinting

47. Use the larger joints
1. Use palms rather than fingers to lift or push.
2. Carry a backpack instead of a hand-held
purse.
3. Push swinging doors open with side of body
instead of hands.

48. Use adaptive aids
• Use jar openers, button hooks, etc., that are
specific to each patient’s needs.

49. Management of Hand deformities
2. Splinting

50. Splinting for MP Ulnar Drift and
Palmar subluxation
• Resting Splint.
• Hand-based hinged MCP joint splint

51. Splinting for Swan-neck deformity:
• Prevent PIP joint hyperextension, yet alow for
flexion
• Example:
• High-temperature plastic custom splint
• Oval 8 splint
• Silver-ring splint.

52. High-temperature plastic custom splint

53. Oval 8 splint

54. Silver-ring splint

55. Splinting for Boutonniere
deformity:
• PIP joint in extension, DIP joint extension
block.
• Many patients reject this splint during daily
activities as it limits the ability to flex the PIP
joint.
• Examples:
– Silver-ring splint (reverse).

57. Splint for Volar subluxation of
Carpus on the Radius:
• Soft, fabric splint with a volar rigid bar is used.

58. Splint for distal Ulna Dorsal
subluxation:
• Provide gentle ulnar-head depression, often
can decrease pain and increase stability.

59. Splinting the Rheumatoid Thumb:

60. Management of Hand deformities
3. Modalities

61. • Reduce pain, encourage relaxation:
– Superficial heating modalities.
• Paraffin
• Hot packs
• Hydrotherapy
• Electric mitts.
• Acute inflammation: cryotherapy

62. Management of Hand deformities
4. Exercises:

63. A.ROM
• To work within the comfortable ROM.
• Wrist AROM
• Gentle digit flexion and extension
• Thumb opposition
• Shoulder and Elbow ROM in supine
• Pool exercises- to reduce strain on weight
bearing joints and also for conditioning.

64. Strengtheninig
• Strenthening should be done with caution- to
avoid aggravation of deformity

65. Management of Hand deformities
5. Remedies

66. • Nutritional supplements
• Diet plan
• Topical medication
• Patient education on disease progression and
deformities.

67. THANK YOU