Hand deformity in rheumatoid arthritis

Hand deformity in rheumatoid arthritis

1. Hand Deformity in Rheumatoid Arthritis Dr Sushil Sharma First Year Orthopedic Resident

2. Introduction Rheumatoid arthritis (RA) is the most common cause of chronic inflammatory joint disease. Most typical features are a symmetrical polyarthritis tenosynovitis morning stiffness, elevation of the erythrocyte sedimentation rate (ESR) autoantibodies that target immunoglobulins (rheumatoid factors) in the serum

3. Stages of RA Pre Clinical Synovitis Destruction Deformity

4. Development of Deformity As the disease progresses, the persistent inflammation causes joint & tendon destruction. Erosion of the articular cartilage, tenosynovitis & eventually rupture of tendon occurs. Combination of articular destruction, capsular stretching and tendon rupture leads to progressive instabilty & deformity of joints.

5. Deformities of hand Def. of fingers Def of thumb Def. Of wrist Rupture of tendons

6. Deformity In RA MCP & Wrist affected early IP jts are affected late, typically. MCP- most important jt affecting function in RA. Ulnar deviation & volar subluxation of fingers are typical deformities.

7. FINGER DEFORMITIES CAUSED BY RHEUMATOID ARTHRITIS Normal forces applied to damaged joints by the extrinsic flexors and extensors Tightness of the intrinsic muscles Displacement of the lateral bands of the extensor hood Rupture of the central slip of the hood Rupture of the long extensor or long flexor tendons .

8. Deformity of Fingers 1.INTRINSIC PLUS DEFORMITY 2.SWAN NECK DEFORMITY 3.BUTTON HOLE DEFORMITY 4.ULNAR DEVIATION

9. Intrinsic plus deformity Caused by intrinsic muscle tightness and contracture. Deformity PIP joint : Extension MCP joint : Flexion Thumb : Adduction Volar subluxation of MCP joint & ulnar deviation of fingers Bunnell test

10. Swan neck deformity Deformity DIP joint : Flexion PIP joint : Hyperextension MCP joint : Flexion Caused by muscle imbalance & may be passively correctable. Also seen in Volar plate laxity Ehler Danlos Syndrome

11. Causes: Mallet deformity associated with extensor tendon disruption at the DIP Capsular disruption, tightening of the lateral bands and central tendon, and adherence of the lateral bands at PIP Flexor tenosynovitis

12. BOUTONNIÈRE DEFORMITY (Button hole) Deformity PIP joint : Flexion DIP joint : Hyperextension MP joint : Hyperextension

13. Patho Anatomy Synovitis of the PIP joint with a stretching out of the central slip, forcing the lateral bands to begin subluxate volarward Shortening of the oblique retinacular ligaments results in hyperextension and limited active flexion of the DIP joint. The flexion deformity of the PIP joint is compensated by extension of the MCP joint. MCP joint deformity not fixed as the distal two joints.

14. Nalebuff and Millender Grading Grade Deformity PIP joint DIP Joint Radiograph Mild Passively correctable (Lateral band subluxated volarly but not adherent) Flexion deformity (15) Decreased flexion Normal Moderate Not correctable passively Normal flexor tendon function Flexor contracture (40) Hyperextension Joint space preserved Severe Fixed flexion deformity (90) Ankylosis Hyperextension Joint destruction

15. DIP Joint Deformity mallet, hyperflexed distal interphalangeal joint Due to the rupture of extensor slip

16. Ulnar drift of fingers Due to metacarpophalangeal joint synovitis that weakens the dorsoradial capsular restraints Loosening of the metacarpophalangeal joint collateral ligaments results in decreased stability stretching of the flexor tunnels that permits even more ulnar displacement of the long flexor tendon

17. interosseous muscle contracture that causes ulnar deviation and proximal interphalangeal joint hyperextension as well as metacarpophalangeal joint flexion and eventually subluxation ; long extensor tendon rupture at the wrist level that increases the possibility of metacarpophalangeal joint dislocations.

18. Ulnar Drift - Grades Mild to moderate ulnar drift absence of severely diseased articular surfaces or dislocated joints Severe ulnar drift one or more metacarpophalangeal joints have dislocated & severely diseased articular surface.

19. Thumb Deformity - Nalebuff Classification

20. Boutonniere deformity Synovitis beginning in the metacarpophalangeal joint frequently leads to a boutonnière deformity of the thumb. proximal phalanx : subluxation metacarpophalangeal joint : flexion interphalangeal joint : hyperextension

21. Swan Neck Deformity Synovitis begins in the carpometacarpal joint Deformity: Dorsal subluxation of the metacarpal base hyperextension of the metacarpophalangeal joint (swan-neck deformity).

22. Game Keeper’s Thumb Synovitic destruction of the capsuloligamentous supports on the ulnar side of the metacarpophalangeal joint Due to laxity of the ulnar collateral ligament of the metacarpophalangeal joint

23. Opera Glass Hand (La Main En Lorgnette) Arthritis Mutilans of Hand Shortening of fingers due to destruction of phalanges. Excess skin gets folded transversely resembling ‘opera glass’

24. Wrist Deformity Rheumatoid synovitis in wrist affects Ulnar styloid Ulnar head Mid portion of scaphoid Synovitis stretches ulnar carpal ligamentous complex & causes ‘caput ulna syndrome’ Dorsal prominence of distal ulna Supination of carpus Volar subluxation of ECU Radial deviation of wrist

25. Synovitis begins in the region of deep volar radiocarpal ligament & intercarpal ligament which results in volar subluxation of scaphoid . combination of rotatory subluxation of the scaphoid volar subluxation of the ulnar carpus dorsal subluxation of the distal ulna relative supination of the wrist

26. Wrist collapse leads to imbalance of the extensor tendons radial shift of the metacarpals ulnar deviation of the fingers untreated, end-stage rheumatoid wrist is Dislocated volarward Complete destruction of the carpal bones Complete dissociation of the radioulnar joint.

27. Tenosynovitis Rheumatoid arthritis is a disease of the synovium . Tendon sheath involvement is common and may occur months before the symptoms of intra- articular disease are noted. Common sites Dorsal aspect of wrist Volar aspect of wrist Volar aspect of digits Presentation : Pain Tendon dysfunction Tendon rupture

28. Extensor tenosynovitis Wrist & digital extensor tenosynovitis causes painless swelling. If painful look for involvement of radioulnar & radiocarpal joint. May be the first sign of RA D/D : ganglion cyst, dorsal capsular synovitis Extensor nodule may impinge on distal extensor retinaculum causing discomfort in wrist & finger extension.

29. Extensor tendon rupture Eventually tenosynovitis leads to tendon rupture Major cause of deformity and disability. Causes Attrition rupture Infiltration of synovium Ischemic rupture Attrition rupture occurs at Distal end of the ulna Lister’s tubercle (pulley for EPL gliding)

30. The small finger usually is involved first and subsequently the ring ( Vaughn-Jackson syndrome ) and then sequentially more radial digital extensors. The long extensor tendon of the thumb, because of its tortuous course, frequently ruptures at the Lister tubercle, where it angles through an enclosed tunnel or pulley.

31. Flexor tenosynovitis volar surface of the wrist and fingers. Fusiform swelling of one or more flexor tendon sheaths extending from the middle of the palm to the distal interphalangeal joint. The swelling is typically painful and causes a gradual decrease in finger flexion. synovium is thickened and nodules can be felt along the tendon sheath with tendon excursion; crepitus and grating usually are present.

32. Flexor tenosynovitis Presentation interferes with finger motion Compresses the median nerve in the carpal tunnel Trigger finger Tendon rupture. Erosion of the volar capsule and ligaments over radial osteophytes contribute to flexor pollicis longus rupture in the carpal tunnel ( Mannerfelt lesion).

33. Flexor tendon rupture Not as common as extensor tendon rupture but is much more difficult to treat surgically. Sites: Digit (infiltrative tenosynovitis ) Wrist (FPL tendon : Most common tendon to rupture) Infiltration, weakening, and eventual rupture of the profundus tendons may likewise occur and are more obvious and disabling clinically.

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