Arthritis
Rheumatoid
arthritis
Rheumatoid arthritis is a disease which affects many systems and many
joints. It can devastate the wrist and hand. The synovitis destroys
ligaments, tendons and joints, producing pain, deformity and loss of function. Zig-zag
collapse is typical of rheumatoid arthritis — as one joint deforms in
one direction, the next deforms in the opposite (e.g. boutonniere, swan neck,
ulnar drift of metacarpophalangeal joints with radial drift of wrist). As the
joints deform, the tendons overlying them gain a greater mechanical advantage,
leading to greater deformity. Simple activities of daily living, such as
thumb pinch and opening jars, stress the weakened ligaments and produce
worsening deformity (particularly ulnar drift at the metacarpophalangeal
joints).
Assessment
For the hand to function well, it must be placed accurately and
firmly in place — the elbow, shoulder and wrist must be carefully assessed as
well.
History.
What are the patient’s social circumstance, mobility, occupation and general
health? These all influence the treatment that is offered. Which particular
joints concern the patient? What is the patient’s problem with these joints
—pain, instability, weakness, stiffness, appearance? Are there symptoms
elsewhere, particularly the shoulder and elbow? What specific functional
problems are there?
Examination.
Does the patient have a typical pattern of deformity? Are the joints stable or
unstable? Is there synovitis in the joints or tendons? What is the active and
passive range
Deformities
in rheumatoid arthritis
Wrist:
• Radial deviation
• Carpal supination
• Prominent, unstable ulnar head
• Extensor tenosynovitis
Metacarpophalangeal
joints:
• Flexion
• Ulnar deviation
• Subluxation, dislocation
• Swan neck
• Boutonniere
• Extensor tendon rupture
• Flexor tendon rupture
• Flexor synovitis
•Congenital deformities
Type
Example
Failure of formation
Longitudinal absence-radial
(radial club hand), longitudinal
absence-ulnar (ulnar club
hand), longitudinal absence-
central (lobster claw hand)
Failure of differentiation
Syndactyly (fingers joined by
skin and sometimes bone)
Duplication
Thumb duplication
Overgrowth
Macrodactyly
Undergrowth
Thumb hypoplasia
Constriction ring syndrome
Simple rings
Generalised skeletal abnormalities
Marfan’s, Turner’s, Down’s, etc.
Nonoperative
treatment
Rheumatoid arthritis is best managed with a team comprising the
patient, physician, physiotherapist, occupational therapist, social worker and
surgeon. Drugs can reduce symptoms and slow progression. Resting
splints are helpful during flare-ups. Appliances can help with tasks
such as turning on taps or opening jars, which would otherwise strain and damage
the lax ligaments. Static splints stabilise and protect lax joints and
improve function.
Surgery
The hand can never be made normal but many patients benefit from
carefully planned surgery. Surgery must be tailored for each patient. In
general, the shoulders, elbow and wrist should be treated before the hand, and
reliable operations (e.g. thumb or wrist fusion) should be undertaken before
more uncertain operations (e.g. soft-tissue reconstruction).
• pain;
• prevention of progression;
• improving function;
• improving appearance.
Synovectomy
of the wrist joint,
metacarpophalangeal joints and interphalangeal joints should be considered if
medical treatment has failed to control pain, with minimal joint damage on
radiographs. Synovectomy of the flexor tendons may be needed if the patient
has flexor tendon rupture, poor active finger flexion, trigger finger or carpal
tunnel syndrome. Synovectomy of the extensor tendons (often with excision of the
distal ulna) removes unsightly swelling and reduces the risk of rupture.
Excision
of the distal end of the ulna, often
with reconstruction of the associated extensor tendon ruptures, reliably
improves pain and function, and prevents extensor tendon rupture.
Replacement
of the wrist with silicone or
metal—polyethylene implants carries a high risk of failure. Replacement of
the metacarpophalangeal joints helps pain and appearance, and the implants can
last for a considerable time; the extensor tendons, collateral ligaments and
intrinsic tendons all need careful reconstruction to overcome ulnar deviation.
Replacement of the proximal interphalangeal joint can maintain some movement
but there is an appreciable failure rate.
Fusion
of the radiocarpal joint gives a
pain-free, stable platform for the hand. An intramedullary pin with bone graft
usually suffices. Fusion of the thumb metacarpophalangeal joint and the finger
distal interphalangeal joints can considerably improve function by providing
stability and removing pain.
Tendon
reconstruction is sometimes necessary.
A ruptured extensor pollicis longus is treated effectively with an extensor
indicis transfer. A ruptured flexor pollicis longus is most reliably treated, if
the patient’s symptoms need it by thumb interphalangeal joint fusion.
Multiple tendon ruptures on the dorsum of the wrist are managed with
side-to-side suture to intact tendons, tendon transfer or a tendon graft.
Swan
neck deformity (Fig. 30.15) is caused by imbalance of the flexor and extensor tendons
over the finger, subluxation of the metacarpophalangeal joint, tightness of the
intrinsic
Osteoarthritis
Wrist
The radiocarpal joint may develop osteoarthritis after an intra-articular
fracture or infection; it can develop without an obvious cause. If
splintage, analgesics and modification of activity fail, then fusion of the
wrist at about 20degree extension with a dorsal plate and bone graft will give a stable,
pain-free wrist. Arthritis may develop around the scaphoid after a
scaphoid fracture or a scapholunate ligament rupture. If simple measures fail,
then bone excision, a limited fusion or total wrist fusion may be needed. The pisotriquetral
joint can develop osteoarthritis. There is focal tenderness over the joint
and 30degree supination radiographs show the pathology (Fig.
30.16). If rest,
splintage and a steroid injection fail, pisiform excision is helpful.
Hand
Osteoarthritis of the hand is most commonly part of a predisposition
to generalised osteoarthritis, particularly in late middle-aged females.
Infrequently it follows joint injury or infection. The proximal interphalangeal
joints may be involved (Bouchard’s nodes), the distal interphalangeal joints
(Heberden’s
nodes) or the carpometacarpal joint of the thumb. The metacarpophalangeal joints
and finger carpometacarpal joints are rarely involved. The symptoms do not
correlate well with the radiographs. Occasionally surgery is needed. Fusion of
the distal interphalangeal joint removes pain and gives good function. The
proximal interphalangeal joint can be fused, but the loss of flexion is a
significant hindrance; the alternative of replacement with silastic is
unreliable. The basal joint of the thumb usually responds to analgesics, steroid
injections and
Other
forms of arthritis
Gout
can easily be mistaken for a septic
arthritis in the wrist or finger joints. The diagnosis is confirmed by measuring
the serum urate and examining the joint aspirate under a microscope. In more
chronic forms, tophi are seen beneath the skin and bone can be eroded. Gout can
also cause tenosynovitis leading to trigger finger or carpal tunnel syndrome. Psoriasis
often involves the joints of the hand and wrist. The nails are pitted and
bone may resorb.