Arthritis of the Hand

Dee Chapter 58

OKU Hand

Orthoteers

Rheumatoid arthritis of the hand

Diagnostic criteria

ARA Diagnostic criteria for RA (1997) / 7 criteria. Need 4 out of 7 to qualify
Clinical / Objective
1) Stiffness > 1 hour before maximal imp’ment x 6 weeks
2) Symmetric arthritis (Simultaneous involvement of same joint areas on both sides of body)
3) Arthritis of at least 1 hand joint (Wrist, MCP or PIP joint)
4) Arthritis (soft tissue swelling or fluid) of 3 or more joint areas (R or L PIP, MCP, wrist, elbow, knee, ankle, MTP) / 5) Serum rheumatoid factor (May be present in 5% of normal individuals and other chronic inflammatory conditions)
6) Rheumatoid nodules (S/C nodules over bony prominences or extensor surfaces or juxta-articular regions)
7) Radiologic changes on PA hand and wrist Xrays (Erosions or decalcification adjacent to involved joints)

Pathology

·  Synovial proliferation

o  Tenosynovitis about tendons and pannus in joints

·  Tendon erosion, attenuation or rupture

o  Direct synovial invasion

o  Ischaemic changes due to raised pressure within compartments

o  Erosion from bony spurs

·  Joint deformity

o  Joint erosion, periarticular osteoporosis, cysts, spurs, collapse, subluxation, dislocation, ankylosis

o  Increased joint pressure due to fluid production

o  Direct invasion by pannus

o  Loss of capsular and ligamentous support

Clinical assessment

HISTORY

1. Pain - due to synovitis or secondary OA

2. Loss of Function

Shortened ADL assesment:

1.  Using toothbrush, hairbrush, knife, fork

2.  Dressing - bra, pulling up trousers / stockings

3.  Operate remote control

4.  Hobbies

3. Cosmesis - may be extremely important to patient. A poor functional result of surgery may not be a poor result for the patient if cosmesis improved.

EXAMINATION

Expose above elbow

Quick elbow, shoulder & neck assessment

Look (most important):

1.  Exensor surface

2.  Flexor surface

·  swelling

·  wasting

·  zig-zag deformity - coronal / sagittal

·  MCPJs - dropped fingers, ulnar drift

·  finger deformities

·  Nodules

·  Features of SLE, Psoriasis, scleroderma (see below)

·  Note DRUJ when wrist supinated

Feel:

1.  Tender areas

2.  Passive correctability of deformed joints (correctable = soft tissue procedures indicated)

o  Must be tested with ligaments tight (i.e. MCPJs in flexion)

3.  Ulnar collat. lig of thumb

4.  Sensation

Move:

1.  Ask patient to extend & flex all joints fully, & oppose thumb.

o  Note extensor lag - tendon rupture or subluxation

2.  Intrinsic Tightness - Bunnell's Test in both deformed & corrected positions.

3.  Individual joint movements

General Medical Assesment:

1.  Cervical spine

2.  TMJ

3.  Pulmonary

4.  General

Investigations

1.  Xray changes

a.  Soft tissue swelling, periarticular erosions, periarticular osteoporosis, joint space narrowing, joint surface destruction, articular incongruity, loss of joint space, subluxations, dislocations.

b.  Partial or complete coalition in severe cases and JRA

2.  WBC (decr. in Felty's syndrome)

3.  platelet count (decr. with NSAIDs)

4.  Hb (anaemia of chronic disorders)

5.  LFT (methotrexate)

6.  ADL Assesment by Hand Therapist

o  Jebson test - writing, turning over cards, picking up small common objects, simulated feeding, stacking chequers, picking up large light & heavy objects.

o  Moberg's pick-up test - speed at picking up small common objects (coins, paper-clips)

Planning Treatment

Need to consider:

·  How the disease affects patient as a whole

·  Level of disability

Aims of Treatment:

·  Pain relief

·  Improve function

·  Prevent further damage

·  Cosmesis

Principles:

·  Operate on proximal joints then distal

·  Tendons before joints

·  Alternate fusions with motion-sparing procedures

·  Staged procedures

Deciding on Type of Surgery:

Souter staging :

Stage / Clinical / Treatment
1 / Acute synovitis / medical Mx & splinting
2 / Chronic synovitis / Synovectomy
3 / Specific deformation / Reconstructive
4 / Severe crippling / Salvage

Overview of clinical problems

Sensory and motor neurophathy

CTS

·  Vasculitis of vasa vasorum

·  Entrapment due to tenosynovitis of flexor tendons

Tendon problems – tenosynovitis, attenuation, ruptures

TENOSYNOVITIS

May affect flexor or extensor tendons

The most commonly affected leading to ruptures are the radial FDPs & FPL.

Usually FDP to index finger (attrition on spike from scaphoid = Mannerfelt Syndrome)

Clinical:

·  puffy thick feeling palm

·  Pinch test - thickened tenosynovium bulges out thro defects in fibrous sheath creating bulges of tissue which can be 'pinched'

·  Test tendon function individually

·  Test function of FDP index & FPL by asking patient to pinch. Normal = tip-to-tip; AbN = pulp-to-pulp (also occurs with AIN palsy) [also called Pinch Test by some]

Management:

·  Acute synovitis = splinting & drugs (NSAIDs, steroids)

·  Chronic synovitis:

·  If conservative Rx has failed after 4 months should consider surgery.

·  Synovectomy:

·  Three sites-

1. Carpal tunnel

2. Palm at level of mouth of A1 pulley

3. Just distal to A2 pulley

TENDON RUPTURE

Tendon attenuation and ruptures - Due to attrition over bony spurs or direct invasion by diseased synovium. Examples include :

·  Vaughn-Jackson

o  4-5th extensor tendon

o  usually EDM first, then EDC to 5th and 4th

·  Caput ulnae

o  extensor digiti quinti over prominent distal ulna

o  usually after DRUJ synovitis and joint destruction with supination of carpus away from ulnar head

·  EPL over Listers

·  Mannerfelt

o  FPL over prominent trapezoidal ridge

o  Need to explore because can go on to rupture index finger flexor tendons

o  Remove bone spike and treat with FDS tendon transfer or interposition tendon graft

Treatment modalities :

1. Primary tendon repair - rarely done as poor tissue at tendon ends

2. Primary tendon graft - fraught with difficulties & poor results; only consider for young patient.

3. Tendon transfer - limited available on flexor side (palmaris longus, brachioradialis)

4. Side-to-side suture - good in older patients; wrist level.

5. Arthrodesis - DIPJ mainly.

Joint problems
All joints are linked

Collapse/deformity of 1 intercalated segment

·  results in opposite direction deformities (Z-deformities) at adjacent segments

·  1 level deformity may need to be addressed to avoid multi-level deformities later

Joint deformities, subluxations, dislocations

Partial or complete coalition in severe cases and JRA

Other findings

Weakness and muscle atrophy

Arthritis mutilans – Digital shortening and telescoping

Principles of management

Non surgical

Medicine

Splints and aids for ADLS

Hand OT

Surgical

Goals of surgery

·  Control medically resistant inflammatory process

·  Preserve function prior to onset of deformity – synovectomy, nerve decompression, trigger-finger release, intrinsic releases

·  Restore function and correct deformity – soft tissue reconstruction of joints and tendons, arthroplasty, arthrodesis

Problems that may benefit from surgery

·  Painful teneosynovitis

·  Tendon ruptures

·  Nerve entrapment

·  Joint deformities associated with compromised function

Multiple procedures may be combined at one operation

In general, surgery done before fixed joint contractures yields better results

Postop motion in MCPJ and PIPJs is dependant on tendon function

Operate LL before upper limb – demands on hands with walking aids

Operate proximal before distal

·  Shoulder before elbow

·  MCPJ before PIPJ

Specific clinical problems and their management

Wrist joint

Introduction

Wrist involvement usually follows hand involvement

May not be the cause of finger deformities, but

·  May contribute to development of finger deformities

·  Worsen preexisting deformity in fingers

·  Compromise surgical correction

In general recommended to treat wrist imbalance prior to or simultaneous with fingers

Development of deformity
Radial side

Attenuation of radioscaphocapitate ligament and radioscapholunate ligament

Resultant rotatory subluxation of scaphoid and SL dissociation

Radiocarpal shortening

Radial shift of metacarpals

Ulnar side

Triangular fibrocartilage extending from dorsal ulna to volar wrist capsule

Attrition of ulnolunate and ulnotriquetral ligaments

Palmar collapse of ulnar carpus

Relative supination of carpus and increased metacarpal descent

Results in prominent distal ulna dorsally

·  Combined with DRUJ synovitis and joint destruction

·  Results in true dorsal shift of ulna and caput ulnae syndrome

·  Also relative ulna plus position

Volar shift and supination of carpus

·  ECU moves forwards with the wrist to become volar to wrist axis

·  Contributes to further carpal displacement by unopposed wirst flexors

Tendon ruptures
Apparent ruptures and tendon dysfunction

Extensor tendons may be intact but subluxed from normal position

·  Instead of on top of MC heads, in the valleys g become flexors not extensors

·  Careful examination of tendon position

·  May see ulnar drift of digits or even MCPJ subluxation

·  May still have partial, weak extension due to juncturae connexions between tendons

Partial or complete PIN syndrome

·  Synovitis of elbow may compress PIN as it passes through supinator muscle at arcade of Frohse

·  Need EMG

Fixed joint deformities may limit tendon excursion

True extensor tendon ruptures

True EPL rupture may be masked by intrinsic extension of thumb

Test with wrist pronated on table and extend thumb, feeling for EPL tendon

Surgery
Indications

Chronic tenosynovitis unresolving with medical mx x 3-6 months

Actual or impending tendon rupture

·  Better do surgery early

·  Single tendon rupture get better results than if many ruptured with joint deformity

CTS

Joint subluxation, dislocation, painful arthritis

Wrist surgery prior to onset of deformity / After deformity or late disease /
Synovectomy of flexor or extensor tendons
Synovectomy dorsal or volar carpus
CTS release
Restoration of ruptured tendons
1.  tendon transfer
2.  end to side repair and free tendon graft
Wrist rebalancing
1.  tendon transfer
2.  dorsal stabilisation techniques / Darrach excision of distal ulna
Hemiresection arthroplasty of DRUJ
Sauve-Kapandji ulnar pseudarthrosis operation
Total wrist arthroplasty
Wrist arthrodesis
·  steinman pins ± bone graft
·  compression plate with local ±ICBG

MCPJ

Deformities

Keystone for both longitudinal and transverse skeletal arches

Usually site of intense RA inflammation

Progression of deformity

·  Ulnar deviation of digits

o  Caused by:

1. Radial deviation of wrist

2. Stretching of the extensor mechanism by synovitis (on radial side)

3. Loss of volar plate & collat. lig. stabilisation of the flexor sheath & A2 pulley, causing ulnar displacement of the flexor tendon pull.

4. Erosion of metacarpal heads.

5. This all causes shortening & scarring of the ulnar collat. lig. & interosseous muscle on the ulnar side. At this stage passive correction is not possible.

·  Volar subluxation of proximal phalanx

·  Dislocation of MCPJ

·  Reciprocal distal joint collapse

Clinical features

·  Main problem is inability to extend the MCPJs enough to hold large objects. (opp. to IPJ disease)

·  Deformity - always progressive

·  Pain

·  Examine:

o  Passively correct ulnar drift (soft tissue procedures are worthwhile)

o  Ability to reduce volar subluxation

o  Intrinsic tightness (Bunnell test)

o  Integrity of flexor & extensor tendons (treat first)

o  Carpal tunnel syndrome

Causes for MCPJ deformities

Mainly 3 big groups

  1. forces normally acting on hand that promote ulnar devision of digits
  2. normal anatomy contributing to ulnar finger deviation
  3. rheumatoid involvement leading to ulnar deviation and volar subluxation
Surgery for MCPJ
Prior to deformity

Synovectomy

·  some have rapid recurrence

·  some may have satisfactory result

Soft tissue procedures

·  intrinsic transfer

·  extensor tendon realignment

Late stages with deformity

Resection-interposition arthroplasty

·  soft tissue

·  silicone spacers are gold standard

o  predictable pain relief, motion and stability

o  cysts and lysis may occur due to silicone, but this is more commonly seen in wrist implants

o  complications include infection, implant failure, i ROM

Rebalancing procedures

·  extensor relocation

·  intrinsic release or transfer

Arthrodesis

PIPJ
Swan neck deformity

Hyperextension deformity of PIPJ

·  concommitant extensor lag of DIPJ

·  some degree of MCPJ flexion

occuring in 30% of patients

many factors contribute to swan neck, main finding is tight intrinsics

4 types depending on flexbility of PIPJ and degree of intrinsic tightness, as well as radiographic changes

- surgical treatment dependent on stage (Nalebuff and Millender)

Swan neck / PIPJ flexibility
Type I / Flexible in all positions / Flexor tenosynovectomy
Type II / PIPJ mobility limited when MCPJ extended
(Intrinsic tightness) / Flexor tenosynovectomy
Type III / PIPJ mobility limited in all positions of MCPJ
(Due to articular and paraarticular problems) / Arthroplasty
Flexible implant
Arthrodesis
Type IV / PIPJ stiff with advanced radiographic changes / Resection arthroplasty
Flexible implant
Arthrodesis
Boutonniere deformity

Flexion at PIPJ

·  hyperextension at DIPJ

·  some degree of MCPJ hyperextension

Chronic dorsal synovitis and capsular swelling

·  gradual attenuation of central extensor tendon

·  flexion of PIPJ

·  gradual inability to extend

·  lateral bands eventually sublux forward and start to act as PIPJ flexors instead of extensors

·  Distally

o  lateral bands gradually tighten in subluxed position, resulting in DIPJ hyperextension

o  oblique retinacular ligaments also shorten limiting their active flexion of DPIJ

·  Proximally

o  Extensor tendons unable to extend PIPJ, so end up extending MCPJ

Many patients do not need operation

Can be considered in severe cases

Classification system helps to guide treatment – Nalebuff and Millender

Boutonniere / Joints
Type I / Mild deformity
PIPJ lag < 15°
± DIPJ hyperextension with intrinsic-intrinsic tightness (passive loss of joint flexion) / Extensor tenotomy over middle phalanx
Type II / Moderate deformity
PIPJ lag 30-40°
DPIJ hyperextended with intrinsic-intrinsic tightness / Central slip shortening
Mobilisation of lateral bands and tenotomy
PIPJ fusion
Type III / Fixed PIPJ deformity with hyperextended DIPJ / PIPJ fusion

DIPJ

Must not confuse with OA

Less frequently directly involved

Usually minor problems

Can get mallet from extensor rupture or hyperextension from volar plate or FDL rupture