Rheumatoid Arthritis HAND

Rheumatoid Arthritis

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

Etiology

Exact cause at large Auto immunity suspected by

majority Recent advancement helped improve

our knowledge regarding pathogenesis helped improve management both Mx and Sx.

ARA classification of functional capacity of patients

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

Diagnosis

Primarily clinical Auto antibodies to Ig G – RA factors

in blood and joint fluids Revised ARA criteria – at least 4/7

features + for at least 6 weeks.

1987 Revised ARA Criteria for classification of RA

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 changesDemo in AP hand & wrist – erosions/bony

decalcification localized to or most marked close to the involved joints

RA - HandHypertrophic

synovitis

Cartilage of joints destroyed

Erodes and ruptures the tendons

Compresses adjacent nerves

Dislocates and erodes the joint itself

Disease burden

One of the most painful arthritic conditions

Results in vulgar deformities of hand withdrawal from society

Usually bilateral severe functional limitation

Finger deformities in RA

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.

Intrinsic Plus deformity

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

Swan neck deformity

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

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

Nalebuff, Feldon & Millender classification of Swan neck deformity

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

Button hole or Butonniere Deformity

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

Distal joint deformities

Main ones -- Mallet, Swan neck deformity

Usually treated by arthrodesis but not done in patients undergoing PIP arthrodesis.

Ulnar drift

Not unique to RA Pathogenesis not completely

understood Classified as mild, moderate and

severe type

Deformities of the thumbo 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,

Non operative methods

Anti inflammatory agents Local steroid + LA Inj:

Results less dramatic Helps delay surgery to some extend

Operative methods

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

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.