Deformity of hands in Rheumatoid Arthritis











 Identify the problem 

    


Symmetrical Deformity Polyarthropathy 

Thumbs - Z shaped deformity

 Fingers - Swan neck deformity

 All fingers- ulnar deviation at MCP joints 

Findings are consistent with Rheumatoid Arthritis involving Hands.


Grading of thumb conditions radiographically 

    stage I - Joint space narrowing,normal articular contours 

    stage II- up to 1/3rd subluxation (on stress radiographs)

                  osteophytes less than 2 mm 

                  Scaphotrapezoidal (STT) joints normal

    stage III- > 1/3rd subluxation 

                    osteophytes > 2 mm

                    joint space markedly narrowed

       stage IV- Pantrapezial arthritis  



How does subluxation occur ? 

   Palmar ligament (Beak Ligament ) ,very strong ligament.

            Degeneration, attenuation and rupture of this ligament leading to dorsal subluxation of Ist MC.

                    


How to explain hyperextension deformity of MCP joints ? 

   Dorsal subluxation at CMC Joint leads to metacarpal adduction leading to thumb in palm deformity and reduction in thumb span.

  Secondary compensatory hyperextension at MCP joint leads to increased thumb span. 


Management Options 

   Non operative - Activity modification, Splints, PT, Intrarticular                                     steroids (outpatient clinic under fluoroscopic                                     guidance )

   Medicines 

   Operative         - 1.Excision of trapezium - pain relief but weakens                                     pinch grip 

                                2. Suspension Procedure and tendon                                                        interposition arthroplasty 

                                3. Implant Arthroplasty - no good long term                                            results

                                4. CMC arthrodesis - good for laborers

                                    provides stable thumb and good pinch.

                                 5. First MC basal osteotomy

 


Trapezium Excision 

    advantages - good pain relief 

                         improves function

                         thumb shortening 

                         reduces power of pinch

        disadvantages 

                          painful scar

                          infection

                           nerve damage (superficial radial nerve )

                           blood vessel damage (radial artery )

                           incomplete relief of symptoms

                           slow recovery of functions 

                           attainment of maximal pain relief

                           instability of carpus


While taking the quick review of symptoms for a long case , bear following in mind if the patient has such symptoms .



Diagnostic Criteria of American College of Rheumatology and Management part not discussed here. 

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