Chapter 38 - Rheumatoid Hand

Question 1

What are the primary goals in treating rheumatoid hand?

Answer 1

Pain relief
Restoration of function
Cosmetic improvement

Question 2

What are the three basic principles of rheumatoid hand surgery?

Answer 2

1. Synovectomy/soft tissue reconstruction done early in disease
2. Highly erosive disease (arthritis mutilans) treated early with fusion before bone loss
3. Correction of deformity that causes loss of motion and may severely compromise hand function

Question 3

What surgical sequence should be followed in the rheumatoid patient?

Answer 3

1. Lower extremity addressed first
2. Proximal joints before distal joints

Question 4

What is an essential part of preoperative evaluation in a rheumatoid patient?

Answer 4

Cervical spine evaluation. 25-50% of patients have atlantoaxial instability (plain cervical x-rays with flexion extension views)

Question 5

What is the pathogenesis in rheumatoid arthritis in the hand?

Answer 5

Autoimmune disorder resulting in erosive synovitis of the hand and wrist secondary to injury to synovial microvascular endothelial cells triggering a inflammatory reaction causing influx of PMN leukocytes, monocytes and macrophages

Question 6

Inflammatory cells/mediators produced by macrophages, monocytes, PMNs, stimulate which cell type in the rheumatoid hand?

Answer 6

Osteoclast. Responsible for subchondral osteopenia

Question 7

What are the four classes of drugs used to tread RA medically?

Answer 7

NSAIDs, corticosteroids, DMARDs (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, Azathioprine), biologics

Question 8

Which of the medication classes used in RA help to change the disease course?

Answer 8

DMARDs improve radiologic outcomes. They have anti-inflammatory and structural-modifying properties

Question 9

What are the two classes of biologic agents used to treat RA?

Answer 9

TNF inhibitors and IL-1 receptor antagonists. These agents act to neutralize cytokines that mediate the inflammatory pathogenesis in RA

Question 10

What are the extra-articular manifestations seen in RA?

Answer 10

Vasculitis, pericarditis, pulmonary nodules, episcleritis and subcutaneous nodules (MC, seen in 25%)

Question 11

Manifestation of accumulated inflammatory cells around capillaries of the synovium and tenosynovium is known as?

Answer 11

Synovitis and tenosynovitis

Question 12

What cellular processes are responsible for cartilage damage in RA?

Answer 12

Cytokine-activated neutrophils release lysosomal enzymes and free oxygen radicals which destroy cartilage in the affected joint.

Question 13

What is the pattern of joint involvement in RA?

Answer 13

MCPJ and PIPJ

Question 14

What is the pattern of joint involvement in OA?

Answer 14

DIPJ and Basilar joint of the thumb

Question 15

What are Bouchard nodes?

Answer 15

Enlargement of the PIPJ seen mainly in RA

Question 16

What are Heberden nodes?

Answer 16

DIP enlargement seen in OA

Question 17

What is the most commonly affected joint in RA?

Answer 17

wrist

Question 18

What is the most frequently affected area about the wrist in RA?

Answer 18

DRUJ

Question 19

Why is the DRUJ affected early in the course of RA?

Answer 19

Greater degree of vascularity at the prestyloid recess of the distal ulna, which allows for early synovial infiltration

Question 20

What are other commonly affected areas of the wrist in RA? (besides DRUJ)

Answer 20

Palmar side of the distal radius, waist of scaphoid, triquetrum

Question 21

What is the typical presentation of early RA?

Answer 21

Insidious onset of morning stiffness and polyarthropathy involving most commonly the hands and feet

Question 22

Decreased active digital flexion in a patient with RA is usually due to what?

Answer 22

Synovial nodules within flexor tendons. These nodules within the retinacular system reduce active flexion of the finger.

Question 23

What is the natural course of RA disease with articular involvement at the MCPJ?

Answer 23

Progressive joint erosion and collapse with palmar displacement

Question 24

How do tendon ruptures of the hand and wrist occur in patients with RA?

Answer 24

By attrition (abrasion over bony prominences), infiltration (synovitis), and ischemia (external pressure by compressive synovium)

Question 25

What is the most common direction of sagittal band rupture in RA?

Answer 25

Radial sagittal band, results in ulnar displacement of the extensor tendons

Question 26

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