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
1. Pre Clinical
2. Synovitis
3. Destruction
4. 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

13. BOUTONNIÈRE DEFORMITY
(Button hole)
• Deformity
– PIP joint : Flexion
– DIP joint : Hyperextension
– MP joint : Hyperextension

14. 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.

16. 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

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

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

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

21. 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.

22. Thumb Deformity - Nalebuff Classification

23. 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

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

25. 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

26. 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’

27. 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

28. • 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

29. • 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.

30. 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

31. 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.

32. 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)

33. • 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.

35. 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.

36. 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).

37. 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.

38. Thank You