1. Hand Deformity in RheumatoidArthritisDr Sushil SharmaFirst Year Orthopedic Resident

2. Introduction Rheumatoid arthritis (RA) is the most common causeof chronic inflammatory joint disease. Most typical features are a symmetrical polyarthritis tenosynovitis morning stiffness, elevation of the erythrocytesedimentation rate (ESR) autoantibodies that target immunoglobulins (rheumatoidfactors) in the serum 3. Stages of RA1. Pre Clinical2. Synovitis3. Destruction4. Deformity 4. Development of Deformity As the disease progresses, the persistentinflammation causes joint & tendondestruction. Erosion of the articular cartilage, tenosynovitis& eventually rupture of tendon occurs. Combination of articular destruction, capsularstretching and tendon rupture leads toprogressive 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 fingersare typical deformities. 7. FINGER DEFORMITIES CAUSED BYRHEUMATOID ARTHRITIS Normal forces applied to damaged joints bythe extrinsic flexors and extensors Tightness of the intrinsic muscles Displacement of the lateral bands of theextensor hood Rupture of the central slip of the hood Rupture of the long extensor or long flexortendons. 8. Deformity of Fingers1.INTRINSIC PLUS DEFORMITY2.SWAN NECK DEFORMITY3.BUTTON HOLE DEFORMITY4.ULNAR DEVIATION 9. Intrinsic plus deformity Caused by intrinsic muscletightness and contracture. Deformity PIP joint : Extension MCP joint : Flexion Thumb : Adduction Volar subluxation of MCPjoint & ulnar deviation offingers Bunnell test 10. Swan neck deformity Deformity DIP joint : Flexion PIP joint : Hyperextension MCP joint : Flexion Caused by muscleimbalance & may bepassively correctable. Also seen in Volar plate laxity Ehler Danlos Syndrome 11. Causes: Mallet deformity associated with extensortendon disruption at the DIP Capsular disruption, tightening of the lateralbands and central tendon, and adherence of thelateral bands at PIP Flexor tenosynovitis 12. BOUTONNIRE 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 thecentral slip, forcing the lateral bands to begin subluxatevolarward Shortening of the oblique retinacular ligaments resultsin hyperextension and limited active flexion of the DIPjoint. The flexion deformity of the PIP joint is compensatedby extension of the MCP joint. MCP joint deformity not fixed as the distal two joints. 14. Nalebuff and Millender GradingGrade Deformity PIP joint DIP Joint RadiographMild Passivelycorrectable(Lateral bandsubluxated volarlybut not adherent)Flexiondeformity(15)DecreasedflexionNormalModerate Not correctablepassivelyNormal flexortendon functionFlexor contracture(40)Hyperextension Joint spacepreservedSevere Fixed flexiondeformity (90)AnkylosisHyperextension Jointdestruction 15. DIP Joint Deformity mallet, hyperflexeddistal interphalangealjoint Due to the rupture ofextensor slip 16. Ulnar drift of fingers Due to1. metacarpophalangeal joint synovitis thatweakens the dorsoradial capsular restraints2. Loosening of the metacarpophalangeal jointcollateral ligaments results in decreased stability3. stretching of the flexor tunnels that permits evenmore ulnar displacement of the long flexortendon 17. 4. interosseous muscle contracture that causesulnar deviation and proximal interphalangealjoint hyperextension as well asmetacarpophalangeal joint flexion andeventually subluxation;5. long extensor tendon rupture at the wristlevel that increases the possibility ofmetacarpophalangeal joint dislocations. 18. Ulnar Drift - Grades Mild to moderate ulnar drift absence of severely diseased articular surfaces ordislocated joints Severe ulnar drift one or more metacarpophalangeal joints havedislocated & severely diseased articular surface. 19. Thumb Deformity - Nalebuff Classification 20. Boutonniere deformity Synovitis beginning in themetacarpophalangeal jointfrequently leads to aboutonnire deformity ofthe thumb. proximal phalanx :subluxation metacarpophalangeal joint: flexion interphalangeal joint :hyperextension 21. Swan Neck Deformity Synovitis begins in thecarpometacarpal joint Deformity: Dorsal subluxation ofthe metacarpal base hyperextension of themetacarpophalangealjoint (swan-neckdeformity). 22. Game Keepers Thumb Synovitic destruction of thecapsuloligamentoussupports on the ulnar sideof the metacarpophalangealjoint Due to laxity of the ulnarcollateral ligament of themetacarpophalangeal joint 23. Opera Glass Hand(La Main En Lorgnette) Arthritis Mutilans ofHand Shortening of fingersdue to destruction ofphalanges. Excess skin gets foldedtransversely resemblingopera glass 24. Wrist Deformity Rheumatoid synovitis in wrist affects Ulnar styloid Ulnar head Mid portion of scaphoid Synovitis stretches ulnar carpal ligamentouscomplex & 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 volarradiocarpal ligament & intercarpal ligament whichresults in volar subluxation of scaphoid. combination of rotatory subluxation of the scaphoid volar subluxation of the ulnar carpus dorsal subluxation of the distal ulnarelative supination ofthe wrist 26. Wrist collapse leads to imbalance of the extensortendons radial shift of the metacarpals ulnar deviation of the fingers untreated, end-stage rheumatoidwrist is Dislocated volarward Complete destruction of thecarpal bones Complete dissociation of theradioulnar joint. 27. Tenosynovitis Rheumatoid arthritis is a disease of the synovium. Tendon sheath involvement is common and may occurmonths before the symptoms of intra-articular diseaseare 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 extensortenosynovitis causes painlessswelling. If painful look for involvement ofradioulnar & radiocarpal joint. May be the first sign of RA D/D : ganglion cyst, dorsalcapsular synovitis Extensor nodule may impingeon distal extensor retinaculumcausing 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 Listers tubercle (pulley for EPL gliding) 30. The small finger usually is involved first andsubsequently the ring (Vaughn-Jacksonsyndrome) and then sequentially more radialdigital extensors. The long extensor tendon of the thumb,because of its tortuous course, frequentlyruptures at the Lister tubercle, where it anglesthrough an enclosed tunnel or pulley. 31. Flexor tenosynovitis volar surface of the wrist andfingers. Fusiform swelling of one ormore flexor tendon sheathsextending from the middle ofthe palm to the distalinterphalangeal joint. The swelling is typically painfuland causes a gradual decrease infinger flexion. synovium is thickened andnodules can be felt along thetendon sheath with tendonexcursion; crepitus and gratingusually 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 ligamentsover radial osteophytes contribute to flexorpollicis longus rupture in the carpal tunnel(Mannerfelt lesion). 33. Flexor tendon rupture Not as common as extensor tendon rupturebut is much more difficult to treat surgically. Sites: Digit (infiltrative tenosynovitis) Wrist (FPL tendon : Most common tendon torupture) Infiltration, weakening, and eventual ruptureof the profundus tendons may likewise occurand are more obvious and disabling clinically. 34. Thank You