Rheumatoid hand published by Dr.Sk Golam Mahbub

1. RHEUMATOID HAND
Dr. Sheikh Golam Mahbub
D-Ortho Student
BSMMU

2. Why Rheumatoid Arthritis is Important ?
 Rheumatoid arthritis-
systemic autoimmune disorder with chronic systemic erosive synovitis.
deformities secondary to hypertrophied synovial tissue.
common cause of inflammatory joint disease most often involving the
small joints of the hand & feet, although any synovial joint can be
affected.
Peak during 4th and 5th decades.
Women affected 3-4 times than men.

3. Pathogenesis
 Inflammatory pathways that lead to proliferation
of synovial cells in joints.
 Pannus formation leads to underlying cartilage
destruction and bony erosions.
 Overproduction of pro inflammatory cytokines
(TNF, IL-6).

5. Continue….
 Rheumatoid arthritis is typically polyarticular, bilateral,symmetrical and most
commonly affects the hands & feet.

6. Rheumatoid Hand (Developement)
 Early stage >
Synovitis of the joint and tendon sheaths.
 As disease progresses >
Joint and tendon erosions > Mechanical dearrangement.
 Late Stage >
Joint destruction,attenuation of the ligaments and tendon
ruptures > instability and progressive deformity.

7. Clinical Presentation(Early)
 Pain and morning stiffness.
 MCP & wrist affected early but IP
joints are lately.
 Hot swollen tender joints(synovitis)
 Flexor tenosynovitis.
 Swelling due to synovitis or subtle
synovial thickening may be palpable.
 Skin atrophy and nodules

8. Diagnostic test
 RF, anti-CCP, or both
 CRP and ESR
 CBC
 X-ray - hands
-evaluate for periarticular
erosive changes

9. Rheumatoid hand deformities(late)
 Ulnar drift of fingers & Radial
deviation of wrist
 Intrinsic plus deformity
 Swan neck deformity
 Boutonniere deformity
 Mallet finger
 Trigger finger
 Drop finger

10. Metacarpo-phalangeal deformities
 Carpal row slides ulnarwards > metacarpals deviate radialwards
> reciprocal ulnar deviation of MCP joint (zig-zag mechanism)

11. Management of MCP joint deformity
 Splintage
 Synovectomy
 Reefing of radial sagittal bands
 Tightening of radial collateral ligament
 Intrinsic muscle release and transfer
 Arthroplasty

12. Intrinsic plus deformity
 Caused by tightness and contracture of
the intrinsic muscles.
 PIP joint extension> MCP joint extention
>Thumb adduction.
 Volar sublaxation of MCP joints and ulnar
deviation of the fingers.

13. Swan neck deformity
 PIP joint is hyperextension and the
DIP joint flexion,at times flexion of
the metacarpo phalangeal joints.
 It is caused by muscle imbalance &
may be passively correctable,
depending on the fixation of the
original & secondary deformities.

14. Continue…

15. Management
 Figure of eight ring splint
 FDS tenodesis
 Lateral band mobilization
 Arthrodesis / arthroplasty

16. Boutonniere deformity(Buttonhole)
 Fixed flexion of the proximal & hyperextension
of the DIP joint
 Due to interruption or stretching of the central
slip of the extensor tendon,forcing the lateral
Bands to begin subluxating volarward

17. Management
 Non operative
 Splint PIP in full extension for 6 weeks.
 Operative
 Repair central slip + K wire fixation for 3 weeks
 Division of extensor tendon just proximal to
its insertion.
 PIP arthrodesis.

18. Continue…
 Mallet finger
caused by disruption of the terminal extensor
tendon distal to DIP joint
 Trigger finger
Thickening of flexor tendon sheath > “snap” felt
forced extension lead to secondary nodule
development over tendon

19.  Drop finger
Sudden loss of extension at MCP joint due to
tendon rupture at wrist
 The thumb and distal radioulnar joint
are also invoved

20. Surgical indications
 Pain relief.
 Restoration/improvement of function.
 Prevention of deformities.
 Improvement of appearance.

21. Treatment
 Synovitis
splint and medical treatment
 Joint space narrowing,bone erosions and osteopenia
Synovectomy
Contracture releases
 Joint distruction,fixed deformity,loss of hand function
Surgery based on condition

22. Surgical options
 Tendon reconstruction
 Repair
Adjacent tendon suture
Intercalated graft
Tendon transfer
 Arthroplasty
 Arthrodesis