Hand Deformity in Rheumatoid

Arthritis
Dr Sushil Sharma
First Year Orthopedic Resident
 Introduction
Rheumatoid arthritis (RA) is the most common cause
of chronic inammatory 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
 Stages of RA
1. Pre Clinical
2. Synovitis
3. Destruction
4. Deformity
 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.
 Deformities of hand
Def. of fingers
Def of thumb
Def. Of wrist
Rupture of tendons
 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.
 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.
 Deformity of Fingers
1.INTRINSIC PLUS DEFORMITY
2.SWAN NECK DEFORMITY
3.BUTTON HOLE DEFORMITY
4.ULNAR DEVIATION
 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
 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
 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
 BOUTONNIRE DEFORMITY
(Button hole)
Deformity
PIP joint : Flexion
DIP joint : Hyperextension
MP joint : Hyperextension
 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.
 Nalebuff and Millender Grading
Grade Deformity PIP joint DIP Joint Radiograph

Mild Passively Flexion Decreased Normal

correctable deformity(15) flexion
(Lateral band
subluxated volarly
but not adherent)

Moderate Not correctable Flexor contracture Hyperextension Joint space

passively (40) preserved
Normal flexor
tendon function

Severe Fixed flexion Hyperextension Joint

deformity (90) destruction
Ankylosis
 DIP Joint Deformity
mallet, hyperflexed
distal interphalangeal
joint
Due to the rupture of
extensor slip
 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
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.
 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.
Thumb Deformity - Nalebuff Classification
 Boutonniere deformity
Synovitis beginning in the
metacarpophalangeal joint
frequently leads to a
boutonnire deformity of
the thumb.
proximal phalanx :
subluxation
metacarpophalangeal joint
: flexion
interphalangeal joint :
hyperextension
 Swan Neck Deformity
Synovitis begins in the
carpometacarpal joint
Deformity:
Dorsal subluxation of
the metacarpal base
hyperextension of the
metacarpophalangeal
joint (swan-neck
deformity).
 Game Keepers 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
 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
 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
 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
relative supination of
volar subluxation of the ulnar carpus the wrist

dorsal subluxation of the distal ulna

 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.
 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
 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.
 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)
 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.
 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.
 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).
 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.
Thank You