2. Why Rheumatoid Arthritis is Important ?
Rheumatoid arthritis-
systemic autoimmune disorder with chronic systemic erosive synovitis.
deformities secondary to hypertrophied synovial tissue.
common cause of inflammatory joint disease most often involving the
small joints of the hand & feet, although any synovial joint can be
affected.
Peak during 4th and 5th decades.
Women affected 3-4 times than men.
3. Pathogenesis
Inflammatory pathways that lead to proliferation
of synovial cells in joints.
Pannus formation leads to underlying cartilage
destruction and bony erosions.
Overproduction of pro inflammatory cytokines
(TNF, IL-6).
6. Rheumatoid Hand (Developement)
Early stage >
Synovitis of the joint and tendon sheaths.
As disease progresses >
Joint and tendon erosions > Mechanical dearrangement.
Late Stage >
Joint destruction,attenuation of the ligaments and tendon
ruptures > instability and progressive deformity.
7. Clinical Presentation(Early)
Pain and morning stiffness.
MCP & wrist affected early but IP
joints are lately.
Hot swollen tender joints(synovitis)
Flexor tenosynovitis.
Swelling due to synovitis or subtle
synovial thickening may be palpable.
Skin atrophy and nodules
8. Diagnostic test
RF, anti-CCP, or both
CRP and ESR
CBC
X-ray - hands
-evaluate for periarticular
erosive changes
9. Rheumatoid hand deformities(late)
Ulnar drift of fingers & Radial
deviation of wrist
Intrinsic plus deformity
Swan neck deformity
Boutonniere deformity
Mallet finger
Trigger finger
Drop finger
11. Management of MCP joint deformity
Splintage
Synovectomy
Reefing of radial sagittal bands
Tightening of radial collateral ligament
Intrinsic muscle release and transfer
Arthroplasty
12. Intrinsic plus deformity
Caused by tightness and contracture of
the intrinsic muscles.
PIP joint extension> MCP joint extention
>Thumb adduction.
Volar sublaxation of MCP joints and ulnar
deviation of the fingers.
13. Swan neck deformity
PIP joint is hyperextension and the
DIP joint flexion,at times flexion of
the metacarpo phalangeal joints.
It is caused by muscle imbalance &
may be passively correctable,
depending on the fixation of the
original & secondary deformities.
15. Management
Figure of eight ring splint
FDS tenodesis
Lateral band mobilization
Arthrodesis / arthroplasty
16. Boutonniere deformity(Buttonhole)
Fixed flexion of the proximal & hyperextension
of the DIP joint
Due to interruption or stretching of the central
slip of the extensor tendon,forcing the lateral
Bands to begin subluxating volarward
17. Management
Non operative
Splint PIP in full extension for 6 weeks.
Operative
Repair central slip + K wire fixation for 3 weeks
Division of extensor tendon just proximal to
its insertion.
PIP arthrodesis.
18. Continue…
Mallet finger
caused by disruption of the terminal extensor
tendon distal to DIP joint
Trigger finger
Thickening of flexor tendon sheath > “snap” felt
forced extension lead to secondary nodule
development over tendon
19. Drop finger
Sudden loss of extension at MCP joint due to
tendon rupture at wrist
The thumb and distal radioulnar joint
are also invoved
20. Surgical indications
Pain relief.
Restoration/improvement of function.
Prevention of deformities.
Improvement of appearance.
21. Treatment
Synovitis
splint and medical treatment
Joint space narrowing,bone erosions and osteopenia
Synovectomy
Contracture releases
Joint distruction,fixed deformity,loss of hand function
Surgery based on condition