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Rheumatoid arthritis hand
1.
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
8.
9. One of the most painful arthritic conditions
Results in vulgar deformities of hand
withdrawal from society
Usually bilateral severe functional
limitation
10.
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
14.
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
17.
18.
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
20.
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
23.
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,
25.
26.
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.