Chapter Seventeen: Orthoses for the arthritic hand and wrist

Question 1

Osteoarthritis usually affects what joints in the hand?

Answer 1

DIP
PIP
CMC

Question 2

What are the common symptoms of ostearthritis?

Answer 2

Joint tenderness sometimes accompanied by crepitus pain and pain progression at night

Question 3

What is the longitudinal arch?

Answer 3

It extends from wrist to the tip of the third digit, and is deepened by the flexion of the digit.

Question 4

What is the distal transverse arch?

Answer 4

It is the metacarpal joint.
It is deepened by the mobility of the first, fourth, and fifth metacarpals around the stability of the second and third metacarpals.

Question 5

What is the proximal transverse arch?

Answer 5

The arch at the radiocarpal/ulnarcarpal joint or the arch at the wrist.

Question 6

What joint does Rheumatoid arthritis usually affect?

Answer 6

Wrist joint

Question 7

What are the three pathological processes that can alter the carpus directly and produce deformity in Rheumatoid arthritis?

Answer 7

Cartilage degradation
Synovial expansion with erosion
Ligamentous laxity

Question 8

When is cartilage degradation usually seen in rheumatoid arthritis?

Answer 8

Early

Question 9

What can synovial expansion and erosion lead to in rheumatoid arthritis?

Answer 9

Ruptured tendons, especially the extensor tendons of the ulnar fingers or the flexor pollicis longus.
It may also lead to volar subluxation of the proximal carpal row.

Question 10

What can ligament laxity in rheumatoid arthritis cause?

Answer 10

wrist instability and further carpal derangement, which in turn can lead to a radial shift of the carpus on the radius.

Question 11

What joint is often involved in rheumatoid arthritis?

Answer 11

Radial ulnar joint.

Question 12

Radial ulnar joint involvement in rheumatoid arthritis does what?

Answer 12

Prevents supination and pronation and prevents the forearm from full rotation.

Question 13

Destructive synovitis in Rheumatoid arthritis produces what, which can cause what?

Answer 13

Distal radial ulnar joint instability with dorsal subluxation of the ulna on the radius and plamar subluxation of the extensor carpi ulnaris tendon resulting in pain, weakness, and decreased ROM.

Question 14

Extension of the wrist does what?

Answer 14

Relaxes the extensors and increases the mechanical advantages of the flexor muscles.

Question 15

Which orthosis is the most common orthosis for rheumatoid arthritis?

Answer 15

Cockup wrist splint.

Question 16

What position does the cockup wrist splint place the hand?

Answer 16

10-30 degrees of extension at the wrist to allow max function.

Question 17

What is the goal of the cockup wrist splint?

Answer 17

Immobilize the radiocarpal joint, providing rest and stability and allowing reduction of inflammation and pain.
It also protects the extensor tendons which may be at risk of rupture in rheumatoid arthritis.

Question 18

When is a resting hand orthosis used ?

Answer 18

In acute rheumatoid arthritis to decrease pain and the align the joint sin a normal anatomic position to avoid the zigzagging pattern.

Question 19

What position is the resting hand orthosis usually in?

Answer 19

10-20 degrees of wrist extension
20-30 degrees metacarpophalngeal joint flexion,
0-20 degrees of PIP flexion
slight flexion of DIP
Thumb CMC in slight extension and abduction
MP and IP of the thumb in slight flexion.

Question 20

What percent of patients with rheumatoid arthritis experience the ulnar drift deformity of the MP joints.

Answer 20

45% of patients whose disease has persisted longer than 5 years

Question 21

What is the ulnar drift deformity?

Answer 21

Deviation of the phalanx from the Metacarpal head and lateral shift of the phalanx upon the metacarpal.

Question 22

What are contributors to the ulnar drift deformity in Rheumatoid arthritis?

Answer 22

Synovitis within the MP join alters the supportin gstructures. The radial collateral ligaments, which are weaker than the ulnar counterparts stretch.
Extensor tendons migrate toward the ulnar side
As the fingers flex, the flexors pull the digit ulnarly
Contracture of the intrinsic muscles caused by a reflex protective muscle spasm secondary to the synovitis contribute an MP volar displacing force
MP joint cartilage loss and bony erosion lead to volar subluxation
Flexor tenosynovitis can lead to volar subluxation at the MP joint

Question 23

Which orthosis can be used to help or prevent ulnar drift of the MP joints in rheumatoid arthritis?

Answer 23

Ulnar deviation orthosis.

Question 24

When is a thumb spica indicated?

Answer 24

Acute rheumatoid arthiritis
Osteoarthritis
To decrease pain and provide stability

Question 25

What are the two most common thumb deformities?

Answer 25

Boutonniere deformity

Swan neck deformity

Question 26

What is the boutonniere deformity?

Answer 26

MCP joint flexion and IP joint hyperextension

Question 27

What is the swan neck deformity?

Answer 27

MCP joint hyperextension and adduction

IP joint flexion

Question 28

What causes boutonniere deformity?

Answer 28

Synovitis at the CMC joint

Question 29

What causes swan neck deformity?

Answer 29

Synovitis at the CMC joint followed by stretching of the joint capsule and radialward subluxation of the base of the metacarpal.

Question 30

What are the stages of a boutonniere deformity?

Answer 30

Stage I exhibits slight extensor lag and light loss of DIP flexion
Stage II A 40 degree PIP flexion deformity
Stage III: The PIP joint has a fixed flexion deformity

Question 31

For swan neck and boutonniere deformities in the fingers, what orthosis is commonly used?

Answer 31

A figure-of-eight ring orthosis or tripoint finger splint