Thumb deformity

rheumatoid thumb

1. Thumb Deformity in Rheumatoid Arthritis Ashraf Abdelaziz MD Lecturer of orthopedic surgery Hand and reconstructive surgery Alzhraa University Hospital Al- Azhar university 2016

2. Introduction Rheumatoid arthritis (RA) is the most common cause of chronic inflammatory joint disease. Most typical features are a S ymmetrical polyarthritis T enosynovitis M orning stiffness, Elevation of the erythrocyte sedimentation rate (ESR) A utoantibodies that target immunoglobulins (rheumatoid factors) in the serum

3. Stages of RA Pre Clinical Synovitis Destruction Deformity

4. Development of Deformity The persistent inflammation causes; Erosion of the articular cartilage, tenosynovitis & eventually rupture of the tendons occurs. Progressive process leads to joint instabilty & deformity.

5. Stretch the supporting structures of a joint, causing a flexion, extension, or lateral deformity Disruption of the normal thumb biomechanics leads to significant loss of ability to carry out daily living activities

6. Thumb Deformity ( Nalebuff ) Classification

7. Boutonniere deformity The most common type Synovitis beginning in the MP joint frequently leads to a boutonnière deformity of the thumb. Proximal phalanx : subluxation MP joint : flexion IP joint hyperextension

8. EPB tendon insertion become attenuated EPL tendon displaces ulnarly The patient loses the ability to actively extend the MP joint Articular erosion and ligament laxity occur to varying degrees.

9. Treatment Options Mild stage ; both MP and IP joints are correctable passively Synovectomy of the MP joint and reconstruction of the extensor mechanism Nalebuff procedure EPL-rerouting procedure through the dorsal capsule of the joint to provide additional extensor force

10. Moderate stage ; a fixed MP joint is present with or without intra- articular joint destruction Most patients are seen at this stage. Arthrodesis is recommended for the MP joint, if adjacent joints minimally affected(15 degrees flexion, abd , and pronation ) Arthroplasty if the a adjacent joints affected

11. Sever stage ; Both a fixed MP joint flexion deformity and a fixed IP joint hyperextension deformity. Surgery depends on the severity of the deformity, the status of the articular surfaces. Synovectomy, Arthrodesis, or Arthroplasty.

12. Treatment Options for ( Boutonniýre Deformity) Stage MP IP Mild Synovectomy Synovectomy EPL rerouting Restore FPL function Flexor tenodesis Moderate Fusion Joint release Arthroplasty Sever Arthroplasty Fusion Joint release

13. Swan Neck Deformity The second most common thumb deformity Synovitis begins in the CMC joint Deformity: Dorsal subluxation of the metacarpal base Hyperextension of the metacarpophalangeal joint (swan-neck deformity ). Metacarpal adduction

14. Operative Treatment Mild stage , a painful CMC joint, weak pinch Conservative therapy (splinting or injection) Resection arthroplasty and tendon interposition Moderate stage show varying degrees of CMC joint deformity and passively correctable MP joint hyperextension Resection arthroplasty + MP joint fusion

15. Sever stage ; complete CMC j dislocation, fixed adduction and fixed hyperextension of the MP joint CMC resection arthroplasty with ligament reconstruction and MP joint fusion

16. Game Keeper’s Thumb Type IV deformity Destruction of the capsuloligamentous supports on the ulnar side of MP joint Laxity of the ulnar collateral ligament of the MP joint

17. Operative Treatment MP joint synovectomy and collateral ligament reconstruction are performed. In advanced cases, MP joint arthrodesis is done. Adductor fascia release

18. Arthritis Mutilans ( Opera Glass Hand) Arthritis Mutilans of Hand Shortening of fingers due to destruction of phalanges and joints. Excess skin gets folded transversely resembling ‘opera glass’

19. Operative Treatment Arthrodesis is the procedure of choice Bone grafts will be required to restore length and to allow fusion to occur

20. Tenosynovitis RA is a disease of the synovium and Tendon sheath. Presentation : Pain Tendon dysfunction (e.g. trigger finger) Tendon rupture

21. Rupture of the Extensor Pollicis Longus Tenosynovitis leads to tendon rupture Frequently ruptures at the Lister tubercle, where it enclosed in tunnel. Incomplete extension of the IP joint The intrinsics alone can extend IP to neutral Rupture of EPL loses extension of the MP joint because the EPB is not strong enough to extend this joint

22. If the tendon is ruptured and the functional loss is significant, EPL function should be restored. Tendon transfer ; The two most commonly used are EIP or ECRL

23. The most common flexor tendon rupture in RA patients. Erosion of the capsule and ligaments over radial osteophytes contribute to flexor pollicis longus rupture in the carpal tunnel ( Mannerfelt lesion). Rupture of the Flexor Pollicis Longus

24. Surgical options Tendon graft, Tendon transfer; FDS of Middle finger is usually used for transfer.

25. Take a home massage RA is the most common cause of chronic inflammatory joint disease. Don’t forget to mange the disease Boutonniere deformity and Swan Neck Deformity the common types of thumb deformity Concern to any joint affected and deformity to plane for the treatment Physiotherapy and splinting prevent progress of the deformity

26. Thank You