Rheumatoid arthritis (RA) is a chronic inflammatory disease that primarily involves the small joints of the hands and feet. The exact cause is unknown but autoimmunity is suspected. RA results in painful and deforming changes to the joints. It is classified based on the patient's functional ability. Hand deformities are common in RA and include swan neck, boutonniere, and Z-thumb deformities. Surgical treatment depends on the type and severity of deformity and aims to relieve pain and improve function.

2.  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

3.  Exact cause at large
 Auto immunity suspected by majority
 Recent advancement helped improve our
knowledge regarding pathogenesis  helped
improve management both Mx and Sx.

4.  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

5.  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.

6. 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

7. Hypertrophic synovitis
Cartilage of joints
destroyed
Erodes and ruptures the
tendons
Compresses adjacent
nerves
Dislocates and erodes
the joint itself

9.  One of the most painful arthritic conditions
 Results in vulgar deformities of hand 
withdrawal from society
 Usually bilateral  severe functional
limitation

11.  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.

12.  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

13.  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

15.  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

16.  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

19.  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

21.  Main ones -- Mallet, Swan neck deformity
 Usually treated by arthrodesis but not done in
patients undergoing PIP arthrodesis.

22.  Not unique to RA
 Pathogenesis not completely understood
 Classified as mild, moderate and severe type

24. 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,

27.  Anti inflammatory agents
 Local steroid + LA Inj:
 Results  less dramatic
 Helps delay surgery to some extend

28.  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

29.  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.