Post on 05-Aug-2020
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The Rheumatoid Hand Deformities & Management
Dr. Anirudh Sharma Resident
Department of Orthopedics
+Why is Rheumatoid Arthritis important?
+RA is a very debilitating disease
¤ median life expectancy decreases by 10 years for women & by 4 years for men
¤ 1/3 patients stop work within 5 years of diagnosis, 1/2 within 10 years
+Introduction
� systemic autoimmune disorder with chronic systemic erosive synovitis
� deformities secondary to hypertrophied synovial tissue
� most common cause of inflammatory joint disease
+Introduction
� 1 - 3% prevalence
� peak during fourth and fifth decade
� women affected 3 – 4 times more than men
+Pathophysiology
� inflammatory pathways that lead to proliferation of synovial cells in joints
� pannus formation leads to underlying cartilage destruction and bony erosions
� overproduction of proinflammatory cytokines (TNF, IL-6)
+Pathophysiology
+What is Rheumatoid Factor?
n B-cell activation leads to the production of anti-IgG autoantibodies
n these are detected in the blood as ‘rheumatoid factor’ (RF)
+Presentation
� Early: � pain and morning stiffness > 30 minutes � involving PIP and MCP joints � fatigue, weight loss and low-grade fever � swelling due to synovitis or subtle synovial
thickening may be palpable
+Presentation
� Late: � joint deformities � instability � destruction
+Diagnostic Test
� RF, anti-CCP, or both
� CRP and ESR � used to follow disease activity and response to medication
� CBC
� Xray - hands � evaluate for periarticular erosive changes
+Treatment
n Methotrexate: first-line treatment in patients with active RA
n Leflunomide used as an alternative to methotrexate
n Sulfasalazine or hydroxychloroquine is recommended as monotherapy in patients with low disease activity
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n Combination therapy more effective than monotherapy
n If RA is not well controlled, a biologic DMARD should be initiated
n TNF inhibitors are first-line biologic therapy
n If TNF inhibitors ineffective, additional biologic therapies can be considered
+Rheumatoid Deformities Hand
+Hand Deformities
n Ulnar drift of fingers & Radial deviation of wrist
n Swan neck deformity
n Boutonniere deformity
n Mallet finger
n Trigger finger
n Drop finger
+Metacarpo-phalangeal deformities
carpal row slides ulnarwards è metacarpals deviate radialwards è reciprocal ulnar deviation of mcp joint (zig-zag mechanism)
+Management of MCP joint deformity
n Splintage
n Synovectomy
n Reefing of radial sagittal bands
n Tightening of radial collateral ligament
n Intrinsic muscle release and transfer
n Arthroplasty
+MCP Joint Arthroplasty
n Indications n Pain with arthritis n Severe ulnar drift with loss of function n Marked flexion contractures n Decreased arc of motion (< 40 deg.)
n Contraindications n Poor bone stock n Poor skin condition
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+Swan Neck Deformity
PIP joint is hyperextended and the DIP joint flexed
Occurs due to:
1. If PIP extensors overact
2. If PIP flexors are inadequate
3. If Palmar Plate fails
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+Management of Swan-Neck Deformity
n Figure of eight ring splint
n FDS tenodesis
n Lateral band mobilization
n Arthrodesis / arthroplasty
+Boutonniere Deformity
n fixed flexion of the proximal and hyperextension of the DIP joint
n due to interruption or stretching of the central slip of the extensor tendon
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+Management of Boutonniere deformity
n Post-traumatic (early) n Splint PIP in full extension for 6 weeks
n Open injuries n Repair central slip + K wire fixation for 3 weeks
n Division of extensor tendon just proximal to its insertion
+Mallet Finger
n injury to the extensor tendon of the terminal phalanx
n terminal joint held flexed, but passive movement is normal
n X-rays are taken to show or exclude a fracture.
+Management of Mallet Finger deformity
n With bony injury: n Minimal subluxation – splintage in extension for
6 weeks n Large fragment with subluxation – operative
(complications high)
n Without bony injury: n Splint DIP joint in extension 8 weeks è4 weeks
night splintage n Fusion for arthritic joints
+Trigger Finger
n Thickening of flexor tendon sheath è “snap” felt with forced extension
n lead to secondary nodule development over tendon
+Management of Trigger finger
n injection of corticosteroid at the mouth of the tendon sheath
n Operative: incise A1 section of the fibrous until tendon moves freely
+Dropped Finger
n sudden loss of extension at MCP joint
n due to tendon rupture at wrist
+Surgical Indications
n Pain relief
n Restoration/improvement of function
n Prevention of deformities
n Improvement of appearance
+Surgical options
n Synovectomy n Tendons n Joint
n Contracture releases
+Surgical options
n Tendon reconstruction n Repair n Adjacent tendon suture n Intercalated graft n Tendon transfer
n Arthroplasty
n Arthrodesis
+Thank You