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    Rheumatoid Hand

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    Emmanuel Koma
    The management of the rheumatoid hand

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    © All Rights Reserved
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    Rheumatoid Hand

    Uploaded by

    Emmanuel Koma
    4 views5 pages
    The management of the rheumatoid hand

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    © © All Rights Reserved

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    The management of the rheumatoid hand

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    4 views5 pages

    Rheumatoid Hand

    Uploaded by

    Emmanuel Koma
    The management of the rheumatoid hand

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Rheumatoid Hand

    Epidemiology

    -Rheumatoid Arthritis affects 1% of the US population. RA is more common in


    women.

    -Etiology of RA is unknown, but it is thought to be multifactorial with both


    genetic (particularly HLA DR4) and environmental factors playing a role.

    Pathophysiology

    -RA is a common inflammatory arthritis resulting from a T-cell driven


    autoimmune process, this results in an inflammatory response within
    synovium with upregulation of TNF-a and IL-1, causes synovial hypertrophy
    (pannus) that erodes cartilage, bone, and soft tissue.

    Diagnosis

    – 4 of 7:

    1. morning joint stiffness

    2. soft tissue swelling of 3+ joints

    3. symmetrical joint involvement

    4. involvement of MP, PIP, or wrist joints

    5. rheumatoid nodules

    6. seropositive RF

    7. radiographic findings

    Labs

    – RF positive in 70-80%
    – Anticitrullinated peptide antibody (anti CCP) has high specificity for RA

    Medical Management: This is managed by rheumatologists.

    – Medical management has improved significantly in recent years with


    advent of biologics, may see LESS rheumatoid hand in your clinic but
    the cases you do see are likely to be more severe
    – Treatment aims for the containment of chronic inflammation as well as
    structural protection for the joints.

    There are 3 general classes of medications.


    NSAIDS: treatment only and does not alter course of disease or prevent joint
    destruction. (ex: ibuprofen)

    Corticosteroids: prednisone and methylprednisone used to reduce


    inflammation and regulate immune system activity when NSAIDS are no
    longer able to control symptoms or during flares.

    DMARDS (disease modifying antirheumatic drugs): used after a


    diagnosis of RA to reduce structural damage early on. These drugs have anti-
    inflammatory effects along with structurally modifying properties. This is
    used for long lasting control of RA and have two types: nonbiologic (IE
    methotrexate) and biologic.

    Holding medications for surgery:

    – Methotrexate and other DMARDS – typically are continued, but should


    be discussed with rheumatology
    – Steroids – continued at normal preoperative dosage, and may require a
    stress dose at time of surgery if taking 5-10mg/day or more
    – Biologics – May need to be held for 2-4wks before and after surgery

    Imaging- typically radiographic examination. This will exhibit:

    – Joint space narrowing


    – Marginal erosions
    – Characteristic deformities- ulnar translocation of carpus, ulnar
    deviation of fingers.

    Surgical Intervention:

    – Surgery recommended after failure of conservative management with


    6-12 months of medical management

    Principles:

    – Principal indication for surgery is PAIN, and function is secondary. Many


    patients have compensated for these deformities and minimal
    functional complaints
    – Start with PROXIMAL procedures before distal – for example you would
    address a wrist deformity prior to the digits as the wrist deformity likely
    exacerbates the digital deformity
    – Presenting Hand Deformities: Wrist deformities, metacarpal phalangeal
    joint deformities, Tendon Involvement, and Finger Deformities.
    Remember, a stable wrist sets the foundation for future reconstruction
    of the hand!
    Wrist: The wrist is the most commonly affected joint in RA.

    – Synovitis of the wrist joint weakens bot the intrinsic and extrinsic wrist
    ligaments which leads to deformities such as ulnar translocation of the
    carpus, DRUJ disruption and ulnar dislocation, ECU tendon attenuation
    – This results in the “Caput ulnae” deformity (*ulnar head dislocates
    dorsally) results in DRUJ incongruity and impaction of the distal ulna on
    the carpus which can lead to arthric changes and PAIN

    Surgical Correction: This can be considered prophylactic or corrective.

    Prophylactic: RL (radiolunate) arthrodesis procedure (only if midcarpal joint


    is free from disease)- stabilizes wrist and allows better motion through the
    midcarpal joint

    (Corrective) DRUJ: Darrach and Sauve-Kapandji.

    – The Darrach procedure involves resection of distal ulna. This provides


    pain relief from DRUJ and distal ulna impingement on the carpus.
    – SK: Ostectomy of the proximal ulna with FUSION of the DRUJ, fuses
    distal radioulnar joint in combination with proximal ulna ostectomy to
    provide stable rotary function. This preserved ulnar head gives support
    to the carpus and prevents ulnar translocation.
    – Finally debilitating pain can be corrected with wrist arthrodesis vs
    arthroplasty.

    Limited arthrodesis can slow progression of deformities.

    Total wrist fusion can achieve stable wrist and decrease pain. This is used
    with a combination of pins or plates.

    – If bilateral wrists are involved- it is recommended for arthroplasty of


    dominant wrist and arthrodesis of nondominant wrist in neutral to 15
    degrees extension.

    MCP Joints: typical deformity in RA is volar subluxation of proximal


    phalanges and ulnar deviation of the fingers and this is secondary to attrition
    of the RADIAL SAGGITAL BAND

    Classic finding – these patients will not be able to actively extend digits at
    MCP on their own but if you passively extend them they are able to hold
    MCPS in extension. This limitation is due to this radial saggital band rupture
    and subluxation of the extensor mechanism. When they are passively
    corrected this centralizes the extensor mechanism and they are then able to
    hold in extension. — ASKED PREVIOUSLY on exam
    Treatment: arthrodesis vs arthroplasty. Arthrodesis rarely performed
    because of arc of motion of the fingers is initiated at the MCP joint

    One way to address this MCP deformity with a “cross intrinsic transfer”
    where the ulnar lateral band to a digit is divided and transferred to adjacent
    digit radial saggital band, alternatively could preform only a “intrinsic
    release”

    Another common finding in RA is Tendon Rupture:

    2 reasons for tendon rupture

    1) abrasion of the tendon over bony prominences (eroded distal ulna or distal
    pole of scaphoid)

    2) weakening of the tendon by synovial invasion.

    Tendon problems include: Trigger finger due to focal tenosynovitis or


    rheumatoid nodule within sheath/tendon;

    Don’t perform A1 pulley release, surgically debride tenosynovitis and nodules

    Flexor Tendon Ruptures -FPL rupture is the most common, secondary to


    wear against volar scaphoid osteophyte, called Mannerfelt lesion;

    Surgery includes removing osteophyte at level of scaphoid and index FDS


    transfer to FPL or arthrodesis of thumb IP joint

    Extensor tendon ruptures- due to extensor tenosynovitis, attrition over


    sharp edges caused by DRUJ and radiocarpal arthritis

    – Extensor tendon involvement typically progress from ulnar to radial.


    Small finger followed by ring, long, index extensors (Vaughn-Jackson
    syndrome)
    – Diagnosis of small finger EDQ rupture comes from testing EDQ
    independent of EDC (extend small finger while other fingers flexed).
    – Definitive operative management includes Darrach and excision of
    synovial tissue over extensor tendon.
    – Additionally, EPL rupture can occur- typically reconstructed with EIP
    – Other extensor deficits:

    If patient is unable to actively extend the digits, but extensor tenodesis is


    intact, an additional cause may be PIN Syndrome due to compression of this
    nerve around the elbow at the radiocapitellar joint

    RA Finger Deformities: Boutonniere versus Swan-Neck


    – Boutonniere deformity: PIP flexion, DIP hyperextension, pathology
    always originates at PIP joint patients present mainly an aesthetic
    concern. Typically starts as elongation of the central slip. The lateral
    bands sublux below the axis of rotation, resulting in shortening of the
    retinacular ligaments. This causes flexion of the PIP and extension of
    the DIP (from tightening of the lateral bands).
    – Two different deformities (flexible or fixed). For flexible deformities may
    use soft tissue reconstruction including joint synovectomy, tightening
    of the stretched central tendon, and dorsal fixation of the lateral
    bands.

    Arthrodesis is typically favored in fixed boutonniere given that arthroplasty


    requires excision and removal of collateral ligaments thus destabilizing the
    joint.

    – Swan neck deformity: PIP hyperextension, DIP flexion

    Pathology can originate at several different levels

    DIP: erosion of terminal tendon (mallet type finger)

    PIP: stretching of volar plate or rupture of FDS insertion resulting in PIP


    hyperextension

    MCP: subluxation of the joint and extensor tendon mechanism can result in
    ulnar intrinsic tendon tightness

    – Surgical correction of swan neck depends on its origin and if it is


    flexible or fixed.
    – Flexible PIP joint can be treated with splinting
    – Limited PIP joint flexion with MCP extended (intrinsic tightness) – Tx
    with splint +/- intrinsic release
    – If joint is fixed then options include arthroplasty or arthrodesis

    Thumb Deformities:

    – Most common deformity is boutonniere (MCP flexed IP extended) or


    more rare swan neck deformity

    Treatments:

    Boutonniere- MCP fusion

    Swann- Neck CMC arthroplasty or arthrodesis

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