Hand - Arthritis

Question 1

Which of the following is the most likely cause of swan-neck deformities in patients with advanced rheumatoid arthritis?

(A) Hyperextension injuries of the proximal interphalangealjoints

(B) Ruptures of the extensor digitorumcommunistendons

(C) Ruptures of the flexor digitorumsuperficialistendons

(D) Tightness of the extrinsic tendons

(E) Tightness of the intrinsic tendons

Answer 1

The correct response is E

Patients with advanced rheumatoid arthritis have profound tenosynovialhypertrophy of the metacarpophalangeal(MP) joints, resulting in subluxation of the joints. They also exhibit ulnar drift of all fingers and swan-neck deformities of the ulnarmostthree fingers. The swan-neck deformity is characterized by flexion contractures of the MP joints and hyperextension deformities of the proximal interphalangeal(PIP) joints. This hand posture results from tightness of

the intrinsic tendons, which is caused by both intrinsic rheumatoid myositis and increased tension within the intrinsic system of the hand resulting from the aforementioned joint subluxation.

Recommended procedures for correction of swan-neck deformities include arthroplastiesof the MP joints of the fingers, comprehensive soft-tissue and intrinsic releases, centralization of the extrinsic extensor tendons over the MP joints, and spiral oblique retinacularligament or Zancolli-flexor digitorumsuperficialislasso reconstruction of the ulnarmostthree digits.

Hyperextension or volar plate injuries of the PIP joints can result in swan-neck deformities, but are unlikely to occur in patients with advanced rheumatoid arthritis.

Although ruptures of the extensor digitorumcommunis(EDC) tendons are common in patients with rheumatoid arthritis of the hand, they do not cause swan-neck deformities. Ruptures of the EDC tendons generally occur at the level of the distal ulna, impairing extension of the MP joints. These ruptures must be differentiated from subluxations of the EDC tendons at the level of the MP joints before surgery is performed. Rupture is characterized by a lack of continuity of the extensor tendons. In patients with subluxation, the tendons fall between the MP joints.

Ruptures of the flexor digitorumsuperficialistendons can result in swan-neck deformities in patients with rheumatoid arthritis, but occur less frequently than ruptures of the EDC and profundusflexor tendons and thus are much less common than intrinsic tendon tightness.

Tightness of the extrinsic tendons may contribute to a swan-neck deformity but is not the sole cause in the absence of other deforming conditions. Extrinsic tendon tightness usually results from scarring and adhesions of the extensor tendons over the metacarpals. Neuromuscular and central hand disorders can also cause extrinsic tightness. Affected patients are unable to flex the PIP joints when the MP joints are flexed fully.

Question 2

A 60-year-old woman with advanced rheumatoid arthritis presents with an inability to actively extend the ring and small fingers of her left hand for the past three months. The fingers can be passively extended, but the patient cannot maintain extension on her own. A photograph is referenced for examination.

Which of the following procedures is the most appropriate management for this condition?

(A) Arthroplasties of the metacarpophalangeal joints
(B) Centralization of the extensor tendons
(C) Excision of the distal ulna
(D) Release of the radial tunnel
(E) Synovectomy of the radiohumeral joint

Answer 2

Correct Answer: (C) Excision of the distal ulna

In this patient with rheumatoid arthritis involving the ulnocarpal joint, the carpus is supinated relative to the distal forearm. This leads to dorsal subluxation and prominence of the distal ulna (caput ulna). Progressive rheumatoid synovitis causes attritional ruptures of the common extensor tendons, typically starting with the ulnar digits and extending radially (known as the Vaughn-Jackson progression). If untreated, the patient is at risk of further extensor tendon ruptures, beginning with the small finger and progressing to the ring finger.

Management:

Excision of the distal ulna, also called the Darrach procedure, is performed to:
• Reduce prominence of the distal ulna.
• Correct supination of the carpus by tightening the ulnar carpal ligaments.
• Improve forearm mobility, including supination and pronation.

Dynamic stabilization of the distal ulna can be achieved using various techniques. Ruptured extensor tendons can be repaired directly, through grafting, or more commonly transferred to intact radial extensors. Additional procedures, such as complete synovectomy and extensor tendon retinaculum transposition, can help prevent future attritional ruptures.

Question 3

A 57-year-old woman with rheumatoid arthritis who has taken anti-inflammatory medication for the past six months has pain and catching of the ring finger; she has occasional locking when she attempts to flex the finger. On examination, the finger locks as she attempts to make a fist; a nodule is palpable in the palm.

Which of the following is the most appropriate operative procedure?

(A) Release of the A1 pulley only

(B) Release of the A1 pulley and excision of the flexor tendon nodule

(C) Release of the A1 pulley and tenosynovectomy

(D) Tenosynovectomyonly

(E) Tenosynovectomyand excision of the flexor tendon nodule

Answer 3

The correct response is E

The most appropriate management of this patient’s condition is flexor tenosynovectomyand excision of the flexor tendon nodule. This patient has developed trigger finger secondary to rheumatoid arthritis. The table below describes the four clinical types of trigger finger that may develop in patients with this condition.

Type I - There is a small localized area of disease with catching of the tendon with flexion
Type II - There is digital tenosynovitis; flexor tendon nodules in the palm cause the finger to lock during flexion
Type III - There is a nodule in the flexor digitorumprofundustendon in the region of the A2 pulley that causes the finger to lock in extension
Type IV - There is generalized tenosynovitis and limited motion

Flexor tenosynovectomyand excision of the flexor tendon nodules are indicated in the treatment of all types of tenosynovitis and triggering seen in patients with rheumatoid arthritis. The annular pulleys should be preserved to prevent the development of bowstringing. In addition, excision of the nodule at this time will prevent disease progression and potential tendon rupture.

In a patient with rheumatoid arthritis, release of the A1 pulley may further exacerbate ulnar drift.

Question 4

In patients with rheumatoid arthritis, attritional rupture of which of the following tendons is most likely?

(A) Flexor digitorum profundus of the index finger

(B) Flexor digitorum profundus of the small finger

(C) Flexor digitorum superficialis of the index finger

(D) Flexor digitorum superficialis of the small finger

(E) Flexor pollicis longus

Answer 4

The correct response is E

Patients with rheumatoid arthritis often experience attritional ruptures of the extensor and flexor tendons. Dorsal subluxation of the distal ulna typically results in ruptures of the extensor tendons in an ulnar-to-radial pattern. Ruptures of the flexor tendons occur most commonly in the carpal canal. Spurs have been shown to develop over a portion of the distal pole of the scaphoid, and the tendons often rupture over this region.

Ruptures of the flexor pollicis longus are most common, followed by the flexor digitorum profundus of the index finger. The flexor digitorum superficialis of the index finger and flexor digitorum profundus of the long finger are also frequently ruptured.

Question 5

A 7-year-old boy who has cerebral palsy is brought to the office because he has a thumb-in-palm deformity of the left hand. Physical examination shows contractures of the first web space and spasticity of the adductor pollicis brevis, flexor pollicis brevis, first dorsal interosseous, and flexor pollicis longus muscles. Hyperextension of the metacarpophalangeal joint of the thumb and weakness of the abductor pollicis longus, extensor pollicis longus, and extensor pollicis brevis muscles is also noted. A photograph of the hand is shown. Which of the following is the most appropriate management?

(A) Capsulotomy of the metacarpophalangeal joint
(B) Injection of botulinum toxin into the abductor pollicis brevis muscle
(C) Release of the adductor pollicis muscle
(D) Shortening of the tendon of the first dorsal interosseous muscle
(E) Transfer of the extensor pollicis longus tendon to the ulnar aspect of the thumb

Answer 5

The correct response is C

Of the management options listed, only release of the adductor pollicis muscle addresses a cause of the thumb-in-palm deformity associated with cerebral palsy. This deformity results from an imbalance caused by variable degrees of spasticity of adductors and flexors, contracture of the first web space, weakness of extensors and abductors, and laxity of the metacarpophalangeal (MCP) joint (see photographs below).

Spasticity of the flexor pollicis brevis, adductor pollicis brevis (APB), and first dorsal interosseous muscles causes flexion and adduction deformities and can be treated with release or repositioning of the muscles. The flexor pollicis longus tendon can be lengthened or used for an abductorplasty when spastic. Contracture of the skin and fascia of the first web space also resists abduction. This can be addressed at the time of muscle release through the use of local flaps and Z-plasty techniques.

Weakness of the extensor pollicis longus (EPL), extensor pollicis brevis (EPB), and abductor pollicis longus (APL) muscles prevents active extension and abduction. These deficits can be addressed with tendon transfers and tendon rerouting. The EPL can be rerouted or divided and redirected radially to provide thumb abduction. A number of muscles, including the palmaris longus, brachioradialis, flexor carpi radialis and ulnaris, extensor carpi radialis brevis and longus, and flexor digitorum superficialis, have been used as donors for tendon transfers to the APB and EPL to improve abduction and extension of the thumb. The APL and EPB tendons can be imbricated if lax.

Laxity of the MCP joint contributes to hyperextension and instability. Arthrodesis or capsulodesis can be performed to improve joint stability. Depending upon the functional status of the thumb, arthrodesis of the interphalangeal or carpometacarpal joints may be performed as alternatives to MCP arthrodesis.

Question 6

A 55-year-old woman is evaluated for continued weakness and deformity of the right thumb 6 months after a ligamentous reconstruction, tendon interposition arthroplasty for carpometacarpal degenerative disease. Which of the following is the most likely reason for her continued symptoms after arthroplasty?

A) Lack of a bone tunnel for the ligamentous reconstruction
B) Metacarpophalangeal hyperextension
C) Not pinning the metacarpal to maintain the joint space
D) Removal of the entire trapezium
E) Use of only half of the flexor carpi radialis for the ligamentous reconstruction

Answer 6

The correct response is Option B.

Hyperextension of the metacarpophalangeal (MCP) joint is part of the progression of the degeneration that affects the thumb basal joint. The hyperextension compensates for the adduction of the thumb base so that the thumb tip can be placed where it is most functional for pinch and grasp. Failure to address hyperextension greater than 30 degrees in MCP joints associated with basal joint arthritis has been shown to lead to weakness and poor hand function.

Multiple procedures have been proposed for treatment of basal joint arthritis. These include metacarpal osteotomy for early-stage conditions, trapeziectomy with or without tendon reconstruction, and interposition and trapeziometacarpal arthrodesis. Little difference in outcomes has been shown when comparing the different procedures that include trapeziectomy and the simple removal of the trapezium as the most critical portion of the procedure.

Taking the whole flexor carpi radialis (FCR) for the suspension has shown a small difference in wrist kinematics. No studies have shown whether the whole or half of the FCR makes a difference in the success of the suspension.

Multiple successful procedures have been described that do not include a bone tunnel for anchoring the suspension to the base of the thumb metacarpal. Removal of the entire trapezium is the most important part of the operative procedure when treating basal joint arthritis surgically. Pin fixation of the metacarpal after trapeziectomy helps to prevent metacarpal subsidence and maintenance of thumb length but is not necessary with a ligamentous reconstruction as in this patient.

Question 7

A 36-year-old man comes to the office because of weakness in the right hand 4 months after sustaining a saw injury to the volar ulnar aspect of the proximal right forearm. At the time of injury, the wound was cleaned and sutured in the emergency department. Current physical examination shows finger clawing and ineffectual gripping of the right hand. An injury to the ulnar nerve is noted. Which of the following is the most effective transfer to restore function to the intrinsic hand muscles in this patient?

A ) Anterior interosseous nerve branch to the pronato

r B ) Extensor carpi radialis longus tendon

C ) Flexor carpi ulnaris fascicle nerve

D ) Flexor digitorum superficialis tendon

E ) Medial antebrachial cutaneous nerve

Answer 7

The correct response is Option A.

A proximal ulnar nerve lesion with a segmental nerve loss in an adult is unlikely to have intrinsic muscle function restored by nerve grafting, especially after some delay before treatment. Each tendon transfer may restore one aspect of the ulnar motor deficit. Both extensor carpi radialis longus transfer and the Zancolli flexor digitorum superficialis lasso procedure have been described for the ulnar claw posture of the fingers, but the potential advantage of a nerve transfer over a tendon transfer under these circumstances is the capacity for restoration of function of multiple muscle groups with a single nerve transfer.

A nerve transfer is an alternative to nerve grafting when time from injury to reconstruction is prolonged and when a proximal nerve injury requires a long distance for regeneration. The Oberlin nerve transfer was described for restoration of elbow flexion in patients with brachial plexus injury. This utilizes the flexor carpi ulnaris fascicle transfer to the musculocutaneous nerve. The classically described nerve transfer for a high ulnar nerve palsy to restore hand intrinsic motor function is to use the anterior interosseous branch to the pronator quadratus as a transfer into the ulnar motor nerve branch.

Question 8

A 76-year-old woman comes to the office because she has had progressive loss of extension of the nondominantlong, ring, and small fingers during the past two years. She has had intermittent pain and swelling of the dorsal aspect of the wrist. Examination shows full, painless range of motion of the wrist. Radiographs are shown. Which of the following is the most appropriate management?

(A) Direct repair

(B) Graft repair

(C) Injection of a corticosteroid

(D) Placement of the arm in a short cast

(E) Tendon transfer

Answer 8

The Correct Response is E

In the scenario described, the extensors to the small, ring, and long fingers have ruptured from an attritional inflammatory process, most likely rheumatoid arthritis (see the photograph below). Vaughn-Jackson reported this phenomenon of spontaneous extensor rupture in two cases in 1948. The rupture can result from inflammatory weakening of the tendons directly or secondary to attrition from underlying bony irregularity. The ruptures are typically painless and spontaneous. Operative findings will direct repair or reconstruction. Proximate tendon ends can be repaired; separated tendon ends with noncontractedmuscle can be grafted. Tendon transfers should be used in instances where contracted muscles do not relengthenon stretching. In the scenario described, with the extensor indicispropriusand extensor digitorumcommunis(EDC) of the index finger intact, the EDC of the long, ring, and small fingers can be transferred to the EDC of the index finger.

Injection of a corticosteroid can alleviate inflammation but will not correct ruptured extensors. Likewise, casting will not correct the ruptured extensors.

Question 9

A 35-year-old woman comes to the office for consultation because she has had rapidly progressive contractures of the thumb and index fingers of both hands and development of knuckle pads during the past nine months. She also has 1.5-cm painful nodules on the soles of both feet. Which of the following is the most likely cause of the patient’s disease?

A ) Decrease in apoptotic gene expression

B ) Decrease in ratio of type III to type I collagen

C ) Deposition of antigen-antibody complexes

D ) Inheritance of an autosomal recessive trait

E ) Proliferation of myofibroblasts

Answer 9

The correct response is E

The most likely causative event in the scenario described is proliferation of myofibroblasts. The patient described presents with Dupuytrendiathesis, a phenomenon of rapidly progressing contractures in a young person. A diathesis can be recognized when there is a strong family history in a patient who is young at the time of onset and presents with bilateral disease, especially with radial-sided disease or diffuse dermal involvement. There does not seem to be a correlation between Dupuytrendiathesis and patient gender. An association of ectopic disease is common. Ectopic deposits have been described on the soles of the feet (Lederhosedisease), over the dorsum of the proximal interphalangealjoints (Garrodknuckle pads), and on the penis (Peyroniedisease).

The three pathophysiologic phases of Dupuytrendisease are the proliferative, involutional, and residual stages. The proliferative stage is characterized by an intense proliferation of myofibroblasts. The involutionalstage is characterized by the alignment of the myofibroblastsalong lines of tension. During the residual stage, the tissue becomes mostly acellularand devoid of myofibroblasts, and only thick bands of collagen remain. Many studies confirm an increase in the ratio of type II to type I collagen in Dupuytrendisease. It is thought to be inherited as an autosomal dominant condition with incomplete penetrance.

A decrease in apoptotic gene expression is seen at the healing borders of keloids but has not been found in Dupuytrendisease. The pathophysiology causing autoimmune diseases such as lupuserythematosus, scleroderma, and rheumatoid arthritis is the deposition of antigen-antibody complexes.

Question 10

A 23-year-old man has decreased grip strength in the right hand 4 years after sustaining a volar forearm laceration. A photograph of the hand posture is shown. No nerve repair was performed at the time of injury. During testing with the metacarpophalangeal (MCP) joints blocked, the patient attempts to extend the interphalangeal (IP) joints (Bouvier maneuver) but is unable to do so. Passively, the IP joints can be extended. Tendon transfer to improve grip strength is planned. During this procedure, the tendon is best inserted distally at which of the following locations?

A ) A2 pulley

B ) Dorsal apparatus lateral band

C ) MCP joint volar plate

D ) Palmar fascia

E ) Proximal phalanx

Answer 10

The correct response is Option B. The patient described has a classic case of ulnar nerve palsy. If MCP hyperextension is passively prevented by dorsal pressure, the extensor digitorum communis may be able to extend the middle and distal phalanges (Bouvier maneuver). If this cannot be done, then the tendon transfer insertion is into the dorsal apparatus. Tendon transfer insertion into the A2 pulley and proximal phalanx will result in MCP joint flexion, but will have no effect on IP joint extension. Tendon transfer insertion into the MCP joint volar plate and palmar fascia are not appropriate locations.

Question 11

A 60-year-old woman comes to the office because of a 15-year history of rheumatoid arthritis affecting both hands. She has intractable pain, wrist collapse with carpal supination, a severe ulnar deviation with volar subluxation deformity of the metacarpophalangeal (MCP) joints, and distal interphalangeal (DIP) joint flexion deformities. She says these conditions are greatly decreasing her strength when she attempts to grasp objects. Which of the following findings is a contraindication to immediate MCP joint arthroplasty in this patient?

A) DIP joint flexion deformities
B) Grasp weakness
C) MCP joint subluxation
D) Severe pain
E) Wrist collapse

Answer 11

The correct response is Option E.

Patients with rheumatoid arthritis can have progressive deformity of their metacarpophalangeal (MCP) joints, ultimately resulting in loss of function. Classically, these patients present with ulnar drift and volar dislocation of these joints. When the pain in the MCP joint is severe along with weak grasp and poor appearance, implant arthroplasty may be performed to improve the functional range of motion, stability, and resistance to lateral and rotational forces.

These patients can also present with concurrent deformity of the wrist and joints distal to the MCP joint. Reconstruction of the rheumatoid hand must proceed from proximal to distal joints. If there is significant deformity of the wrist that is not addressed, the patient may get recurrent ulnar deviation of the fingers after arthroplasty. In addition, preoperative wrist pain may limit hand function, even after successful treatment of the MCP joint with arthroplasty. Thus, the wrist should be addressed first prior to MCP joint arthroplasty.

Question 12

A 56-year-old man comes to the office because of a 1-year history of deformity, pain, and decreasing range of motion in the proximal interphalangeal (PIP) joint of the right ring finger. History includes a crush injury to the right ring finger 3 years ago treated with splinting and therapy. Active range of motion of the PIP joint is 20 to 40 degrees. X-ray studies show severe joint space narrowing and osteophyte formation. Implant arthroplasty is discussed. Regardless of the type of implant chosen, which of the following is the most likely expected long-term outcome for this patient?

Range of Motion | Pain

A)Increased | no change

B)Increased | improved

C)Decreased | no change

D)Decreased | improved

E)No change | no change

F)No changeimproved

Answer 12

The correct response is Option F.

Several prospective and retrospective studies have shown that proximal interphalangeal (PIP) joint implant arthroplasty provides significant pain relief with no marked change in preoperative range of motion. This finding has been consistent for both silicone, pyrocarbon, and titanium-polyethylene.

Silicone PIP implants have been in use since the late 1960s. The silicone implant acts as a simple spacer following joint resection to allow for the formation of a fibrous capsule of scar tissue that functions as the new joint. The implants can be placed via volar or dorsal approach. PIP arthroplasty is indicated for osteoarthritis, post-traumatic arthritis, rheumatoid arthritis, and other inflammatory arthritic conditions. Complications for silicone arthroplasty are related to implant fracture or degradation; however, this does not guarantee the need for revision surgery. Revision rates for PIP silicone arthroplasty are between 11 to 13%. One long-term study showed greater than 50% of implants were fractured at 16 years. Studies all show significant pain reduction, improvement in functional scores, and good to high patient satisfaction.

Surface replacement PIP implants have been used since the late 1990s. These implants depend on either cementing or osseointegration for stability. Pyrocarbon has an elastic modulus similar to cancellous bone. Short-term studies have shown an increase in joint range of motion that is not maintained in longer-term follow-up studies. In addition, many longer-term outcome studies have shown a significantly higher complication rate with surface replacement implants mostly related to loosening, subsidence, fracture, squeaking, and contracture formation. Reoperation rates for surface replacement implants are as high as 39%. However, studies do show a reduction in pain with good patient satisfaction for these implants as well.

Question 13

An otherwise healthy 50-year-old surgeon has the sudden, rapid onset of severe swelling in the fingers as well as pain, stiffness, and swelling of the distal interphalangealjoints. On examination, the fingernails are pitted and cracked. These findings are most consistent with

(A) gout

(B) HIV infection

(C) rheumatoid arthritis

(D) systemic lupus erythematosus

Answer 13

The correct response is B

A diagnosis of HIV infection should be considered in patients who have the rapid or explosive onset of psoriatic arthritis or Reiter’s syndrome. Arthritic HLA B27-associated conditions are frequently seen in conjunction with HIV infection and are often more aggressive and resistant to treatment. Psoriasis either develops or worsens with the onset of HIV infection; in contrast, Reiter’s syndrome, which in most patients is a triad of arthritis, conjunctivitis, and uveitis, is more likely to have only polyarthriticinvolvement. However, awareness of the coexistence of HIV infection in this patient is important because immunosuppressive therapy, which is often prescribed for management of arthritis, can have devastating effects in patients with HIV infection. The findings in this patient can also be mistaken for onychomycosisor herpetic whitlow.

Gout is a crystalline arthropathy, while rheumatoid arthritis and systemic lupus erythematosusare inflammatory systemic autoimmune diseases. None of these conditions would present with the above findings, although some symptoms of HIV infection can mimic systemic lupus erythematosus.

Question 14

In patients with rheumatoid arthritis, the inciting event in development of a boutonniere deformity is which of the following?

A) Central slip attenuation
B) Intrinsic tightness
C) Lateral band volar subluxation
D) Oblique retinacular ligament contracture
E) Proximal interphalangeal (PIP) joint synovitis

Answer 14

The correct response is Option E.

Rheumatoid arthritis is a chronic autoimmune disease characterized by inflammation and deterioration of the joints. Synovial proliferation is the hallmark of rheumatoid arthritis and is often seen early in the course of the disease. There is a progression to synovial pannus formation, periarticular bone demineralization, cartilage destruction, and subchondral osseous erosions. This process is mediated by synovial infiltration of activated T lymphocytes, which promote chronic synovial inflammation.

The boutonniere deformity is extremely common in patients with rheumatoid arthritis. It is characterized by flexion of the proximal interphalangeal (PIP) joint with hyperextension of the distal interphalangeal (DIP) joint.

The causative event of boutonniere deformity in rheumatoid arthritis is synovitis and synovial pannus formation within the PIP joint. This causes the joint capsule to distend, resulting in attenuation of the central slip. Central slip insufficiency results in loss of PIP joint extension and subsequent volar translocation of the lateral bands, which further accentuates the deformity by providing a flexion force across the PIP joint. Extension forces are transferred to the DIP joint. Contraction of the oblique retinacular ligament is associated with a fixed deformity.

Intrinsic tightness would cause the PIP joint to be unable to be flexed when the MP is in extension.

Question 15

In patients with rheumatoid arthritis, which of the following tendons is ruptured most commonly?

(A) Extensor indicisproprius

(B) Extensor pollicislongus

(C) Flexor carpi ulnaris

(D) Flexor digitorumprofundusto the small finger

(E) Flexor pollicislongus

Answer 15

The correct response is B

Tendon ruptures are a common complication of rheumatoid arthritis because the environment, structure, and vascularity of the tendon are affected abnormally by this condition. Tendon ruptures often occur as the tendon glides over a roughened area of bone, joint, retinaculum, or synovium. In addition, hypertrophic tenosynoviummay displace a tendon from its normal position. Tendon ruptures typically manifest as sudden onset of sharp pain or a snapping sensation. However, associated findings may be more subtle in patients who have severe deformities resulting from rheumatoid arthritis.

The extensor tendons are ruptured most commonly, with the extensor pollicislongus(EPL) and extensor digitiquinti(EDQ) tendons being affected most frequently. While rupture of the EPL tendon may manifest as sudden inability

to extend the thumb, it also may be more subtle, because the intrinsic tendons of the thumb may act to extend the thumb. However, if this were to occur, thumb extension would be weak when compared with the contralateral extremity. Options for repair include direct surgical coaptationof the tendon (if the ends have not retracted) or transfer of the extensor pollicisor extensor carpi radialislongustendon.

Other extensor tendon ruptures typically occur on the ulnar side of the wrist as the tendons glide over the damaged radioulnarjoint. These ruptures generally occur in a pattern beginning at the ulnarmostdigits and extending to the radial digits (ie, Vaughn-Jackson progression). In this pattern, the EDQ tendon ruptures first, followed by the extensor digitorumcommunistendon to the small, the ring, and then the long fingers.

Flexor tendon ruptures are far less frequent and usually involve the radial digits. Rupture of the flexor pollicislongustendon by a scaphoid spur is typically referred to as a Mannerfeltlesion.

Question 16

A 56-year-old woman is evaluated for the sudden, painless inability to flex the interphalangeal joint of the right thumb. Medical history includes rheumatoid arthritis. There is no history of antecedent trauma to the hand. Physical examination shows that flexor pollicis longus tenodesis is absent. X-ray studies show an osteophyte along the volar aspect of the scaphoid. Which of the following is the most appropriate next step in management?

A) Anterior interosseous nerve decompression
B) Extensor indicis proprius (EIP) tendon transfer
C) Palmaris longus tendon grafting with osteophyte resection
D) Primary tendon repair
E) Observation

Answer 16

The correct response is Option C.

This patient has an atretic flexor pollicis longus (FPL) tendon rupture due to a scaphoid osteophyte. This is termed a Mannerfelt lesion. FPL ruptures are the most common flexor tendon ruptures in patients with rheumatoid arthritis. The underlying pathophysiology is secondary to osteophyte formation along the volar aspect of the scaphoid. Surgical treatment can include tendon transfer, tendon grafting, or interphalangeal joint fusion to correct the deformity. Treatment should include exploration of the carpal tunnel with resection of the underlying osteophyte to avoid additional attritional tendon ruptures. Due to the fraying of the tendon caused by the osteophyte, primary repair of the FPL tendon is not typically feasible. Treatment options include FDS tendon transfer and palmaris longus tendon graft. EIP tendon transfer is typically employed for extensor tendon ruptures in rheumatoid patients.

An incomplete anterior interosseous nerve (AIN) palsy can mimic FPL rupture. Physical examination allows differentiation between AIN palsy and FPL rupture. In the setting of AIN palsy, tenodesis of the IP joint will still be present with MCP hyperextension of the thumb. Initial management of AIN neuropathy consists of observation and splinting. Nerve conduction studies can be of diagnostic as well as prognostic value. Surgical exploration and decompression of the anterior interosseous nerve is a consideration after failure of nonoperative management of a compression neuropathy.

Question 17

In a patient with rheumatoid arthritis with painful, debilitating deformity of the left wrist and hand, which of the following is the most appropriate first step in reconstruction?

A) Intercarpal fusion with ulnar head arthroplasty
B) Proximal interphalangeal joint arthrodesis with terminal extensor tendon release
C) Silicone metacarpophalangeal joint arthroplasty with sagittal band reconstruction
D) Soft-tissue reconstruction of the extensor tendon rupture with tendon transfer
E) Total wrist arthrodesis with ulnar head excision

Answer 17

The correct response is Option E.

Rheumatoid arthritis is a complex disease, and the treatment for rheumatoid hand deformities remains controversial. Over 70% of rheumatoid patients report hand and wrist dysfunction. In addition, patient concerns over the aesthetic appearance of the hand and wrist can have a significant influence on patient satisfaction following rheumatoid hand surgery. When planning surgery, one must take into account the patient’s symptoms; clinical appearance, including the amount of synovitis; function; and x-ray studies.

Rheumatoid arthritis is a polyarticular disease and deformities of the proximal joints will affect the position of more distal joints. This makes timing and sequence of surgical reconstruction critical. The wrist is the most common joint affected by rheumatoid disease. The accepted strategy is to reconstruct more proximal joints first. This may provide enough stability and motion so that distal surgery is not needed. Surgical treatment of the rheumatoid wrist is usually performed to alleviate wrist pain or to treat deformities that contribute to finger deformities distally. A stable wrist is critical to a successfully reconstructed rheumatoid hand.

Synovitis is the principal pathologic feature of rheumatoid arthritis. Synovitis of the ulnar side of the wrist tends to appear first, resulting in attenuation and rupture of the extensor carpi ulnaris sheath and ligamentous stabilizers of the distal radioulnar joint (DRUJ). This leads to dorsal dislocation of the ulnar head and caput ulna syndrome. Synovitis of the volar and intercarpal ligaments leads to volar and ulnar subluxation of the carpus with supination. The intact radial wrist extensors then contribute to the radial deviation of the metacarpals at the carpometacarpal joint and compensatory ulnar drift at the metacarpophalangeal joint.

Treatment of rheumatoid wrist deformities involves stabilization of the carpus. In this patient, x-ray studies show pancarpal arthritis. This leaves total wrist arthrodesis as the only option presented here. If the mid-carpal joint is unaffected by disease, a limited wrist fusion may be performed such as a radiolunate arthrodesis. Treatment of the DRUJ and ulnar head is accomplished with ulnar head excision when the wrist is stabilized with a fusion. In cases of isolated DRUJ disease, the Sauvé-Kapandji procedure is recommended to prevent further ulnar subluxation of the carpus.

The other answers address pathology distal to the wrist and should not be considered primarily in patients with this degree of wrist pathology.

Question 18

A 75-year-old woman with a medical history significant for rheumatoid arthritis presents with painless loss of extension of the thumb and all digits of the left hand. When she attempts wrist extension, the wrist deviates radially while actively extending. When the examiner passively flexes the wrist, the thumb and fingers extend. Which of the following best describes the likely cause of this patient’s functional deficit?

A) Dorsal ulna prominence; rupture of multiple extensor tendons
B) Ligamentous laxity; subluxation of multiple metacarpophalangeal joints
C) Proliferative synovitis of the radiocapitellar joint; compression of posterior interosseus nerve
D) Scaphoid bone osteophyte; rupture of flexor pollicis longus muscle
E) Weakening of extensor hood; dislocation of extensor tendon

Answer 18

The correct response is Option C.

This patient demonstrates posterior interosseus nerve (PIN) syndrome. She has loss of active thumb and finger extension while maintaining active wrist extension with radial deviation. Proliferative synovitis secondary to rheumatoid arthritis of the radiocapitellar joint or within the radial tunnel is traditionally the culprit at the proximal forearm. Rheumatoid arthritis is characterized by cartilage degradation, synovial expansion, ligamentous laxity, and bony erosion. All joints and tendon sheaths can be involved.

The PIN branch of the radial nerve is a motor nerve. It provides innervation to the extensor carpi radialis brevis (although this can be innervated by the radial nerve proper), supinator, extensor carpi ulnaris, extensor digitorum communis, extensor pollicis longus and brevis, abductor pollicis longus, extensor indicis proprius, and extensor digiti minimi muscles. In compression or entrapment of the PIN nerve, the extensor carpi radialis longus is traditionally spared, as it is innervated by the radial nerve proper, proximal to the level of compression. Thus, active wrist extension with radial deviation is maintained.

Dorsal subluxation of the ulna is secondary to attenuation of surrounding capsular ligaments, and erosion of the distal radioulnar joint leads to dorsal subluxation of the ulna. The dorsally placed ulna can result in attritional rupture of extensors, traditionally affecting the ulnar-most digital extensors first. Multiple extensor ruptures at the level of the wrist would not demonstrate intact extension on tenodesis examination. Attenuation of extrinsic and intrinsic wrist ligaments in rheumatoid arthritis leads to carpal volar subluxation, supination, and ulnar translocation. Wrist collapse leads to metacarpal radial deviation and eventual ulnar drift of the fingers. Further volar and ulnar subluxation of the fingers at the metacarpophalangeal joints (MCPJs) is a result of asymmetry of the metacarpal heads, flexor-extensor-intrinsic imbalance, attenuation of the extensor hood, and attenuation of collateral ligaments. MCPJ subluxation would not result in an intact examination with tenodesis and would not affect wrist extension with radial deviation posture. Weakening of the extensor hood would result in extensor tendon subluxation ulnarly. Classically in the situation of extensor tendon subluxation at the level of the MCPJ, if the joints are not fixed and the examiner passively reduces the joints, the patient is able to maintain active MCPJ extension. Wrist extension should not be impacted.

Scaphoid osteophytes in rheumatoid arthritis can result in attritional rupture of the flexor pollicis longus (FPL), termed the Mannerfelt lesion. FPL rupture should impact the thumb interphalangeal joint with loss of active flexion.

Question 19

A 34-year-old man is brought to the emergency department with marked pain and swelling on the radial side of the right hand after falling on his outstretched hand. Radiographs are shown above. Which of the following is the most appropriate next step in management?

(A) Closed reduction of a complex dislocation of the metacarpophalangealjoint of the thumb

(B) Closed reduction of a dislocation of the carpometacarpal joint of the thumb

(C) Closed reduction of a displaced scaphoid fracture

(D) Closed reduction of a transradialstyloidperilunatefracture-dislocation

(E) Closed reduction of a trapezoid fracture-dislocation

Answer 19

The correct response is B

Based on the above radiographs, this patient has a dislocation of the carpometacarpal (CMC) joint of the thumb, a rare injury. The metacarpophalangealjoint is not involved. Dislocations of the CMC joint at the base of the small finger are more common. Closed reduction of the dislocated joint should be performed as soon as possible; this can be accomplished by applying axial traction and pronation combined with manual pressure over the metacarpal base. Because CMC joint dislocations in the thumb are frequently accompanied by complete tears of the palmar oblique ligament (volar beak ligament), further management should include Kirschnerwire stabilization and casting if the dislocation is unstable. Patients with stable dislocations may require casting only. Immobilization and stabilization of the ligament tear will protect the ligament during healing. There is no associated fracture in this patient.

Open reduction and internal fixation are recommended for management of displaced scaphoid fractures. Perilunatedislocation would be demonstrated by incongruity of Gilula’sarcs on posteroanteriorradiographs and by subluxation of the capitatefrom its articulation with the lunate. Trapezoid fractures can be subtle on standard radiographs of the wrist; fluoroscopic imaging or CT scans may be beneficial. Because trapezoid fractures are typically stable and nondisplaced, cast immobilization alone is indicated.

Question 20

A 42-year-old woman with severe rheumatoid arthritis has advanced joint degeneration, pain, and decreased use of the right elbow, wrist, and hand. On examination, the elbow is stiff and tender and the wrist and metacarpophalangealjoints are tender and subluxed. Radiographs confirm these findings.

Which of the following staged sequences is most appropriate?

(A) Elbow arthroplasty, wrist arthrodesis, MP joint arthroplasties

(B) Elbow arthroplasty, MP joint arthroplasties, wrist arthrodesis

(C) MP joint arthroplasties, elbow arthroplasty, wrist arthrodesis

(D) MP joint arthroplasties, wrist arthrodesis, elbow arthroplasty

Answer 20

The correct response is A

This patient with severe rheumatoid arthritis should first undergo total elbow arthroplastyfollowed by wrist arthrodesis and then by MP joint arthroplasties. This proximal-to-distal sequence of procedures is advocated for most patients who have diffuse rheumatoid arthritis of the upper extremity. Performing the elbow arthroplastyfirst will facilitate the subsequent surgical procedures and postoperative recovery and rehabilitation by stabilizing the arm, increasing elbow mobility, and decreasing pain. Postoperative self-care following subsequent surgeries will be easier for the patient. In addition, patients with rheumatoid arthritis have joint and tendon imbalance and resultant Òzig-zagÓdeformities; the ulnar deviation and volar subluxation of the MP joints is further aggravated by the radial deviation and supination of the wrist. Therefore, wrist arthrodesis should precede MP joint arthroplasties.

Question 21

A 60-year-old man comes to the office because of a 20-year history of rheumatoid arthritis. Which of the following is the most likely thumb deformity in this patient?

A) Boutonnière
B) Clinodactyly
C) Gamekeeper’s thumb
D) Swan-neck
E) Thumb-in-palm

Answer 21

The correct response is Option A.

Boutonnière deformity is the most common deformity in rheumatoid arthritis thumbs. Swan-neck deformity is the second most common deformity. The pathophysiology begins with metacarpophalangeal (MCP) joint synovitis which stretches the dorsal joint structures. The extensor pollicis brevis (EPB) tendon insertion is disrupted leading to a flexion deformity. Next, the extensor pollicis longus (EPL) tendon subluxes volar early causing flexion of the proximal phalanx. Early treatment includes synovectomy and extensor reconstruction and late treatment the MCP joint arthrodesis. Swan-neck deformity begins with carpometacarpal (CMC) joint synovitis causing bony erosion of the joint. The CMC joint will dorsiflex and radially subluxate causing an adduction contracture of the first metacarpal leading to hyperextension of the MCP joint. Gamekeeper’s thumb occurs from ulnar collateral ligament weakness. Thumb-in-palm deformity is seen in patients with cerebral palsy. Thumb clinodactyly is a congenital disorder.

Question 22

A 65-year-old woman with a 30-year history of rheumatoid arthritis comes for evaluation of a deformity of the right hand. Physical examination shows severe ulnar drift and pain on passive flexion. She is unable to extend her fingers. X-ray study (shown) demonstrates subluxation of the metacarpophalangeal (MCP) joint of all four fingers. Which of the following is the most appropriate treatment?

A ) Centralize the extensor tendons with lumbrical transfers
B ) Crossed intrinsic transfer
C ) Release the A1 pulley for all four fingers
D ) Silicone prosthesis arthroplasty of the MCP joints
E ) Synovectomy of the fourth through sixth compartments of the wrist

Answer 22

The correct response is Option D.

Silicone prosthesis arthroplasty for the MCP joint has been performed for over 40 years. Only recently have prospective studies attempted to quantify the improvement that the surgery provides.

Some short-term follow-up studies have demonstrated improved range of motion following surgery. The improvement in range of motion returns is not maintained at long-term follow-up, although the arc of motion of the MCP joint is in a more extended position (23 to 59 degrees) than compared with preoperative (57 to 87 degrees) reports, according to one large series. This is better for hand function. Pain control and function related to activities of daily living have been shown to improve after surgery when measured on validated outcome questionnaires such as the Michigan Hand Outcomes Questionnaire (MHQ) and the Arthritis Impact Measurement Scale (AIMS).

Ulnar dislocation of the extensor tendon is part of the deformity present in this patient. However, correction of extensor tendon position without also addressing the joint will not improve mobility or function.

Crossed intrinsic transfer would be inappropriate because it does not address the joint destruction.

A1 pulley release could be used to treat loss of extension because of trigger digit, but is not appropriate for this patient.

Synovectomy of the extensor compartments of the wrist removes inflammatory tissue from this area. It is designed to prevent tendon rupture at the wrist level.

Question 23

A 55-year-old woman comes to the office with progressive swelling around the wrist. Tendon rupture is suspected. Which of the following tendons is most likely to rupture in a patient with rheumatoid arthritis?

A) Extensor digitorum communis
B) Extensor digitorum manus
C) Extensor pollicis longus
D) Flexor digitorum profundus
E) Flexor pollicis longus

Answer 23

The correct response is Option A.

Tendon rupture in patients with rheumatoid arthritis is caused by either constant wear over a bony prominence leading to attrition, direct invasion of the tendon, or synovitis and ischemic necrosis of the tendon secondary to proliferative synovitis. When tendon rupture occurs, it is usually painless and results only after trivial use of the tendon. In some patients, the functional deficit is not noticeable immediately, leading to a delay in diagnosis.

The tendons involved most commonly are the extensor tendons on the ulnar aspect of the hand. Once the ulnar extensors rupture, the progression will advance radially to the remaining extensors. Other complications of rheumatoid arthritis can be confused with extensor tendon rupture and should be ruled out. These include metacarpophalangeal joint dislocation, extensor tendon displacement between the metacarpal heads, and paralysis of the common extensor muscle.

Extensor pollicis longus rupture is the second most common rupture found in rheumatoid disease of the hand, and it is diagnosed by an inability to extend the interphalangeal joint of the thumb. The flexor pollicis longus will rupture more commonly than any of the other flexor tendons of the remaining fingers. Differential diagnosis includes the presence of rheumatoid nodules in the tendon preventing movement of the tendon through the finger. Treatment of tendon ruptures involves tendon grafts and transfers, as well as removal of bony prominences when appropriate.

Question 24

A 65-year-old woman with long-standing rheumatoid arthritis comes to the office because she has been unable to extend the thumb and fingers of her nondominantleft hand for the past eight weeks. Examination shows moderate rheumatoid arthritis with caput-ulnae syndrome, zigzag deformity of the left hand, and a boggy fullness over the extensor tendons at the wrist and around the elbow. Testing for tenodesiseffect shows extension of the digits on passive flexion of the wrist. Which of the following is the most likely cause of the disability in this patient?

A ) Attritional rupture of the extensor tendons

B ) Compression of the posterior interosseousnerve

C ) Contracture of the ulnar-sided collateral ligaments of the metacarpophalangeal(MCP) joints

D ) Subluxation of the extensor tendons into the gutter between the MCP joints

E ) Tightness of the intrinsic lumbricalmuscles

Answer 24

The correct response is B

Posterior interosseousnerve (PIN) compression is a complication of rheumatoid arthritis which, together with extensor tendon rupture and metacarpophalangealjoint dislocation, should be considered in the differential diagnosis of inability to extend the fingers. The inability to extend the thumb in PIN entrapment can be a useful distinguishing clue on physical examination. Elbow joint swelling and compression of the PIN at the arcade of Frohseare the main reasons for PIN entrapment in rheumatoid arthritis. Intraarticularcorticosteroid injections and surgical intervention resolve symptoms of PIN entrapment in rheumatoid arthritis.

Caput-ulnae syndrome is a dorsal dislocation of the distal ulna resulting from synovitis, ligament laxity, and extensor carpi ulnaristendon translocation. Erosions in the prominent ulna put the extensor tendons at risk of attritional rupture.

The tenodesiseffect is intact, so none of the other options is appropriate.

Question 25

In patients with rheumatoid arthritis, the inciting event in the development of a boutonniere deformity of the thumb is which of the following? A) Adductor contracture B) Attenuation of the extensor pollicis brevis C) Carpometacarpal joint synovitis D) Extensor pollicis longus subluxation E) Metacarpophalangeal joint synovitis

Answer 25

The correct response is Option E. The boutonniere deformity is the most common deformity of the thumb in rheumatoid arthritis (RA). The pathology originates at the metacarpophalangeal (MCP) joint, at which synovitis results in dorsal hood disruption and attenuation of the extensor pollicis brevis with loss of MCP joint extension and volar subluxation of the proximal phalanx. This is accompanied by secondary subluxation of the extensor pollicis longus (EPL) tendon ulnarly. This results in increased tension on the extensor mechanism with resultant distal phalanx extension and concomitant proximal phalanx dorsal subluxation. Treatment is predicated on status of joint deformity. If the deformity is able to be reduced passively with adequate joint stability and absent radiographic evidence of joint destruction, then reconstruction is achieved by synovectomy and insertion of the EPL tendon into the base of the proximal phalanx. If the contractures are fixed, then MCP arthrodesis is indicated for treatment of symptomatic deformity. The Nalebuff classification of thumb deformity in RA identifies six types of deformities: Type 1: Boutonniere Type 2: Boutonniere with carpometacarpal subluxation Type 3: Swan-neck deformity Type 4: Gamekeeper deformity Type 5: Swan-neck with MCP volar plate laxity Type 6: Arthritis mutilans RA is a chronic autoimmune disease characterized by inflammation and deterioration of the joints. Synovial proliferation is the hallmark of RA and is often seen early in the course of the disease. There is a progression to synovial pannus formation, periarticular bone demineralization, cartilage destruction, and subchondral osseous erosions. This process is mediated by synovial infiltration of activated T lymphocytes, which promote chronic synovial inflammation.

Question 26

A 29-year-old woman is referred to the office because she has flu-like symptoms as well as pain and stiffness in the joints of the hands. The pain keeps her awake at night and the stiffness occurs in the morning and lasts approximately two hours. The patient was evaluated for these symptoms in the emergency department two weeks ago. Analysis of aspirate from the affected joints was negative for white blood cells and organisms. A one-week course of cephalexin was initiated at that time. Current temperature is 38.1EC (100.6EF). Examination of the hands shows inflammation, swelling, and tenderness of the proximal interphalangealjoints of the index and long fingers. Which of the following is the most likely diagnosis? (A) Gout (B) Osteoarthritis (C) Pseudogout (D) Rheumatoid arthritis (E) Septic arthritis

Answer 26

The correct response is D The patient described has the hallmarks of rheumatoid arthritis, the diagnosis of which is made on clinical grounds. The criteria for diagnosis were published in 1988; these criteria are the gold standard for diagnosis. Patients with the following symptoms for six or more weeks are suspected to have rheumatoid arthritis: morning stiffness; soft tissue swelling; swelling of the proximal interphalangeal, metacarpophalangeal, and/or wrist joints; and symmetric arthritis. They may also have subcutaneous nodules, a positive rheumatoid factor, and positive findings on plain radiographs. Although the other diagnoses (gout, osteoarthritis, pseudogout, and septic arthritis) should not be ruled out, the clinical findings described make rheumatoid arthritis the most likely diagnosis. A complete blood count, erythrocyte sedimentation rate, serum rheumatoid factor, and antinuclear antibodies, although not adequate for making a conclusive diagnosis, will make diagnosis more conclusive when combined with plain radiographs and clinical findings. Gout would be indicated by an elevated serum uric acid level or uric acid crystals in the joint aspirate. Calcium pyrophosphate crystals would be found in the joint aspirate in pseudogout. Leukocytes and pathogens would be noted in the aspirate in septic arthritis.

Question 27

A 43-year-old man with rapidly progressive scleroderma comes to the office for follow-up examination because of skin atrophy, sclerosis, and telangiectasesresulting from his disease condition. On physical examination, multiple contractures and skin lesions are noted. The largest lesion is located on the dorsum of the metacarpophalangealjoint of the index finger of the right hand, with exposure of the dorsal joint capsule and dorsal bone surfaces. Which of the following is the most appropriate surgical procedure for correction of this deformity? (A) Coverage with a local flap (B) Cross-finger flap (C) Full-thickness skin grafting (D) Reconstruction with bilaminateneodermis (E) Split-thickness skin grafting

Answer 27

The correct response is D ## Footnote In the scenario described, because one of the fingers is not contracted and still functional, salvage is important for rudimentary activities. This view, in surgery, shows the open metacarpophalangealjoint and degenerated bone at the base of the phalanx. These open structures required suitable coverage. Histology showed stenoticfibrotic arteries typical of immunopathicangiopathy, and impaired circulation made any surgery risky. Conventional options for closure, including topical care and skin grafts, are likely to fail. Sclerotic skin renders local flaps a technical impossibility, and amputation of the index finger is a more destructive option. The Integra healed the open bones and joint and preserved a functioning finger, shown below at six months. The material is compliant enough to allow full flexion. Threats to the finger are gone, and daily function is possible.

Question 28

A 45 year old woman comes to the office for consultation because she has a two-month history of stiffness of the wrists and fourth and fifth metacarpophalangealjoints bilaterally when she awakens in the morning. The stiffness lasts approximately two hours. Physical examination shows warm, edematous, and tender joints. Radiographs of both hands show narrowed joint spaces and bony erosions. Which of the following is the most appropriate next step to confirm the suspected diagnosis? (A) Arthritis Impact Measurement Scale score (B) Examination of joint aspirate (C) Intra-articular injection of triamcinolone (D) Radiographs of the cervical spine (E) Serum rheumatoid factor assay

Answer 28

The correct response is E The most appropriate next step in establishing the diagnosis in the scenario described is obtaining a complete blood count, rheumatoid factor (RF), and erythrocyte sedimentation rate. Rheumatoid arthritis (RA) has a prevalence of approximately 1% in the United States. Female-to-male ratio is approximately 3:1, and the age of onset is usually between 25 and 50 years. The diagnosis is typically made when four of seven qualifying criteria established by the American Rheumatism Association are met: Morning stiffness lasting longer than one hour before improvement Arthritis involving three or more joints Arthritis of the hand, particularly involvement of the proximal interphalangeal, metacarpophalangeal, or wrist joints Bilateral involvement of joint areas Positive serum RF Rheumatoid nodules Radiographic evidence of RA A rheumatologist should be consulted soon after the diagnosis is made. The diagnosis must be established before documentation of the baseline disease or initiation of a rheumatoid work-up or any therapy. A complete blood count indicates the presence of anemia in approximately 80% of patients with RA. Erythrocyte sedimentation rate is elevated in approximately 90% of patients with RA. A serum RF result is positive in approximately 70% of patients with RA. The Arthritis Impact Measurement Scale aids in documenting baseline disease activity and damage but is not used for establishing the diagnosis. Joint fluid analysis of the inflamed joint usually shows a leukocyte count of 2000 to 5000/mm3 without crystals or bacteria. Gout is diagnosed by evidence ofuratecrystals in the synovial fluid and usually has a monoarthriticpresentation. More than 75% of acute gout attacks affect the lower extremity. The clinical presentation of the patient described is most likely RA, and joint fluid analysis is not part of the initial steps in establishing the diagnosis. Injection of triamcinolone is often used to treat flexor tenovaginitis(trigger finger) or aid in the diagnosis of carpal tunnel syndrome. Clinicians will sometimes inject triamcinolone into osteoarthritic joints for temporary pain relief. Many patients with RA are on a medical regimen including an oral corticosteroid. Injection of triamcinolone is not performed to aid in the diagnosis of RA. Rheumatoid arthritis can affect the cervical spine with inflammation and destruction of cartilage, bone, and ligaments, most commonly in the upper cervical spine. Laxity and destruction of ligaments can lead to significant instability with frank subluxation and cord damage. Once the diagnosis of RA is established, severity of the disease can be evaluated, which is especially important if a surgical procedure is planned. Cervical spine evaluation is not part of the initial steps in establishing the diagnosis.

Question 29

A 64-year-old woman with rheumatoid arthritis is evaluated for abrupt onset of inability to extend the ring and little fingers of the left hand. Surgical exploration confirms attritional tendon rupture and caput ulnae syndrome. In addition to tendon reconstruction, which of the following interventions is most likely to prevent recurrence of this condition? ## Footnote A) Distal ulna resection B) Proximal row carpectomy C) Radiocarpal arthrodesis D) Scaphoid excision and four-corner fusion E) Trapeziectomy and ligament reconstruction

Answer 29

The correct response is Option A. **Darrach procedure, or distal ulna resection,** is a well-established procedure to treat distal radioulnar joint (DRUJ) arthritis and distal ulnar instability such as in caput ulnae syndrome. A dorsal approach is used to gain access to the DRUJ via dorsal fifth extensor compartment approach. The triangular fibrocartilage complex (TFCC) and extensor carpi ulnaris (ECU) sheath are preserved. Excision of the distal ulnar head is performed proximal to the radial sigmoid notch. DRUJ arthritis and instability may result in attritional rupture of the extensor tendons due to tendons abrading against the dislocated, eroded ulna head as well as restriction of forearm rotation. Thus, the aims of treatment for DRUJ arthritis are pain relief, prevention of attritional tendon rupture if the patient presents prior to tendon rupture, and improvement of forearm rotation. These aims are commonly achieved using a Darrach procedure or Sauvé-Kapandji procedure and less commonly by ulnar head replacement arthroplasty. The Sauvé-Kapandji procedure was introduced amid concerns over ulnar translocation of the carpus following resection of the distal ulnar head as done in the Darrach procedure, yet both procedures have shown good outcomes in the treatment of DRUJ arthritis. In fact, a recent systematic review found no significant difference in outcomes between the two procedures in rheumatoid arthritis patients. Proximal row carpectomy and scaphoid resection and four-corner fusion are both used to treat wrist arthritis, but are usually for osteoarthritis such as with SLAC and scaphoid nonunion advanced collapse (SNAC) wrist, and are not generally used in rheumatoid arthritis patients. Trapeziectomy and ligament reconstruction are procedures used to treat acarpal arthritis of the thumb, not DRUJ arthritis. Radiocarpal arthrodesis is a treatment for radiocarpal arthritis, and not DRUJ arthritis with caput ulnae.

Question 30

A 63-year-old right-hand-dominant woman with rheumatoid arthritis comes to the office because of a progressive deformity of the long finger of the left hand characterized by proximal interphalangeal (PIP) joint hyperextension and distal interphalangeal (DIP) joint flexion. Examination shows limited PIP joint flexion in all metacarpophalangeal (MCP) joint positions. Which of the following is the most appropriate management? ## Footnote A) DIP joint arthrodesis with a small-caliber cannulated screw B) Figure-of-eight splinting for 6 to 8 weeks C) PIP joint arthrodesis and MCP joint intrinsic release D) Transection of the terminal tendon E) Translocation of the lateral bands and dorsal PIP joint capsulectomy

Answer 30

The correct response is Option E. Rheumatoid arthritis is a chronic, systemic inflammatory disorder that principally affects synovial joints. Finger deformities resulting from rheumatoid arthritis are often disabling and aesthetically unsatisfactory. The swan-neck deformity consists of PIP joint hyperextension and DIP joint flexion. Classification of swan-neck deformities is based on PIP joint mobility and radiographic changes. Nalebuff described four types: Type I: Flexible PIP joint deformity, regardless of MCP joint position Type II: Limited PIP joint flexion with the MCP extended because of intrinsic tightness Type III: Limited PIP joint flexion in all MCP joint positions because of a fixed dorsal position of the lateral bands Type IV: PIP joint destruction Management depends on the extent of the PIP joint deformity. Type I swan-neck deformities generally respond to figure-of-eight splinting. DIP arthrodesis can be considered for swan-neck deformity resulting from a mallet. Type II swan-neck deformities may be managed by a figure-of-eight splint or by an intrinsic release if the intrinsics are tight without MCP joint subluxation or degeneration. Type III swan-neck deformities are treated with translocation of the lateral bands, PIP joint capsulectomy and collateral ligament release. Type IV swan-neck deformities are treated with PIP joint arthrodesis or PIP joint silicone arthroplasty.

Question 31

A 54-year-old violinist has severe posttraumatic osteoarthritis of the metacarpophalangeal(MP) joint of the nondominantleft long finger. She has severe pain and limited finger use despite administration of nonsteroidalanti-inflammatory drugs and protection of the joint. Radiographs show fracture union, adequate metacarpal and phalangeal bone stock, and severe degenerative arthritis of the MP joint. Which of the following is the most appropriate management of the MP joint? (A) Perichondrialautograftarthroplasty (B) Silicone implant arthroplasty (C) MP joint arthrodesis (D) Nonvascularizedtoe joint arthroplasty (E) Free vascularized toe joint arthroplasty

Answer 31

The correct response is B This 54-year-old violinist with posttraumatic arthritis of the MP joint of the long finger requires motion. Therefore, the most appropriate management is silicone implant arthroplastyof the MP joint. This procedure will alleviate pain and yield good range of motion of the joint. Arthroplastyand arthrodesis are typically performed for operative management of posttraumatic joint arthritis. Although both procedures generally alleviate pain, only the arthroplastyprocedure permits joint motion. Joint arthrodesis diminishes pain but results in a stable, rigid joint, which would not be appropriate in a violinist who requires motion. Perichondrialautograftsare unpredictable, especially when used in complete joint resurfacing.Nonvascularizedtoe joint transfers provide only a limited range of joint motion, and degeneration of donor cartilage occurs. Free vascularized toe joint transfers allow growth in young patients, and offer composite tissue (joint, extensor mechanism, and bone stock). However, range of motion following any type of toe joint transfer is less than with silicone implant arthroplasty.

Question 32

A 63-year-old man with a five-year history of rheumatoid arthritis comes to the office because he has had recurrent painful triggering of the ring and small fingers of the right hand for the past four months. He has not had numbness or tingling of the fingers. The ring and small fingers trigger and lock. A radiograph is shown. Which of the following is the most appropriate management? A ) A1 pulley release B ) Centralization of extensor mechanism and repair of the sagittal bands C ) Replacement of the metacarpophalangeal(MCP) joint D ) Tenolysisof superficialisand profundustendons E ) Tenosynovectomyand resection of slip of the superficialistendo

Answer 32

The correct response is E ## Footnote The patient described has mild rheumatoid arthritis. Ulnar drift in the rheumatoid hand can be exacerbated by resection of the A1 pulley. In patients with rheumatoid arthritis, the A1 pulley should be preserved and a flexor tenosynovectomyof the fingers should be performed as well as, if necessary, a resection of one slip of the superficialistendon. Very mild cases may also respond to corticosteroid injection. In patients with rheumatoid arthritis who have flexor tenosynovitis, the surgeon should always be cognizant of concomitant carpal tunnel syndrome, and a carpal tunnel release should also be performed if carpal tunnel symptoms are present, which is not the case in the patient described. Surgical procedures to replace the MCP joint should only be performed in cases with radiographic evidence of arthritis and pain at the MCP joints. Extensor tendon centralization and sagittal band repair are considered in cases where the subluxation of the extensor tendons results in inability to fully extend the MCP joints. Tenolysisis used to treat flexor tendon adhesions. Flexor tendon adhesions can be suspected when passive proximal interphalangealand distal interphalangealjoint motion is greater than active joint motion.

Question 33

A 30-year-old man is referred for poor thumb opposition following an injury to the median nerve at the level of the wrist of the dominant right hand sustained 18 months ago. Physical examination shows strong function of the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) of the little, ring, long, and index fingers. Extension of the wrist, fingers, and thumb is also strong. Which of the following tendon transfers into the abductor pollicis brevis insertion is most appropriate for correction of the deficit in this patient? A ) Transfer of the extensor carpi radialis brevis B ) Transfer of the extensor indicis proprius C ) Transfer of the FDP of the ring finger D ) Transfer of the flexor carpi ulnaris E ) Transfer of the flexor palmaris longus

Answer 33

The correct response is Option B. The patient described most likely has a low median nerve palsy marked only by loss of opposition. The FDS of all the fingers and the FDP of the index and long fingers are functional. High median nerve palsy would result in loss of all FDS function, loss of FDP function of the index and long fingers, and loss of flexor palmaris longus function. Therefore, a tendon transfer that specifically addresses opposition is necessary. Transfer of either the FDS of the ring finger or the extensor indicis proprius (EIP) is appropriate. FDS transfer requires formation of a pulley at approximately the level of the pisiform. This is most easily created using the ulnar half of the flexor carpi ulnaris tendon. The EIP tendon is long and can be easily routed around the ulnar aspect of the forearm and still reach the thumb proximal phalanx, obviating the need for a pulley. This tendon transfer is considered by many authors to be superior to the FDS transfer because possible adhesion formation to a constructed pulley is avoided. Transfer of the extensor carpi radialis brevis directly to the thumb proximal phalanx is not a described opponensplasty and would disrupt the most centralized wrist extender. Transfer of the FDP of the ring finger is inappropriate because distal interphalangeal flexion of the ring finger would be lost. Transfer of the palmaris longus is often performed during a carpal tunnel release following long-standing median nerve compression to augment weakened thenar muscles, but this tendon transfer does not provide as much opposition strength as the EIP and FDS transfers in lower median nerve palsy. This is especially true for reconstruction of the dominant hand.

Question 34

A 63-year-old woman comes to the office because she has sharp pain in the thumb of the dominant right hand at the level of the basilar joint that has been increasing for the past two years. A radiograph of the right hand is shown. In the natural progression of this disease, which of the following pathologic processes is most likely to appear first? (A) Decreased vascularity from the recurrent branch of the radial artery to the scaphoid (B) Disruption of the abductor pollicislongustendon (C) Formation of osteophytes in the first metacarpophalangealjoint (D) Laxity of the volar anterior oblique (beak) ligament (E) Synovitisof the abductor pollicislongusand extensor pollicisbrevistendons

Answer 34

The correct response is D The clinical history and radiograph show classic arthritis of the basilar joint of the thumb. The basilar joint of the thumb is the second most common joint affected by arthritis. One third of postmenopausal women have radiographic evidence of arthritis. The basilar joint of the thumb, the second most common site of arthritis, comprises four articulations among the trapezium, scaphoid, trapezoid, and thumb metacarpal. The anterior oblique (beak) ligament is the primary stabilizer of the trapeziometacarpaljoint of the thumb. Laxity of this ligament is generally the first sign in basilar joint arthritis. This laxity is generally followed by articular damage in the palmar articular surface of the scaphoid, which can progress to osteophyte formation and complete loss of the scaphoid articular surface. The radiograph shows a normal sesamoidbone at the first metacarpophalangealjoint. Vascularity of the scaphoid is supplied by a recurrent branch of the radial artery. Trauma to the radial aspect of the wrist can cause fractures of the scaphoid, which may have delayed healing because of disruption of blood supply. Preiserdisease, or avascular necrosis, is not shown on the radiograph. When evaluating patients with pain at the base of the thumb, consideration of the scaphoid and scaphoid nonunion should always be taken into account. De Quervaindisease is irritation of the abductor pollicislongusand extensor pollicisbrevistendons as they go through the first dorsal compartment of the wrist. The clinical scenario described does not support this diagnosis.

Question 35

A 65-year-old woman presents with severe osteoarthritis of the proximal interphalangeal (PIP) joint of the nondominant left middle finger. Medical history includes chronic pain and an angular deformity of the joint. Range of motion of the PIP joint is 30 to 60 degrees. Silicone implant arthroplasty is planned. Which of the following is the principle benefit of this procedure? A) Correction of angular deformity B) Improved cosmesis C) Improved range of motion D) Increased grip strength E) Pain relief

Answer 35

The correct response is Option E. Expected outcomes for small joint implant arthroplasty are pain relief with similar range of motion to preoperative values. The procedure involves excision of the arthritic proximal phalanx head and middle phalanx base and replacement with a silicone stemmed implant. The implant acts as a spacer for development of a scar capsule. Although angular deformity is corrected with this procedure, and many patients report satisfaction with the improved appearance of the alignment of the finger, the primary goal of the procedure is pain relief from underlying arthritis. Outcome studies have not demonstrated improved grip strength or range of motion. Long-term outcome studies show 90% implant survival at 10 years, high patient satisfaction, and a low revision rate despite a relatively high incidence of implant fracture or deformity over time.

Question 36

A 57-year-old right-hand–dominant woman with rheumatoid arthritis presents with 10/10 pain of the right thumb that is preventing her from painting, her primary activity. X-ray study shows rheumatoid changes in multiple joints; right thumb carpometacarpal (CMC) joint is consistent with Eaton stage 3-4 disease. On physical examination, the right thumb metacarpal base is prominent. Grind test result is positive. Which of the following is the most appropriate management to help this patient resume her normal activities? ## Footnote A) Arthrodesis of the thumb CMC joint B) Pyrocarbon implant arthroplasty of the thumb CMC joint C) Referral to a rheumatologist for infliximab D) Regimen of splinting, rest, and ibuprofen 800 mg 3 times daily E) Trapeziectomy with ligament reconstruction and tendon interposition

Answer 36

The correct response is Option E. The patient described has a severe case of thumb carpometacarpal (CMC) joint arthritis keeping her from doing her activities of daily living. Given the severity of her disease, splinting, rest, and anti-inflammatory medications may temporize the problem, but will likely not provide her the degree of symptomatic improvement to allow her to return to her desired activities. Trapeziectomy with ligament reconstruction and tendon interposition is a good option for this patient, since she clearly has advanced CMC disease and seeks function requiring minimal strength with preservation of mobility postoperatively. If she were a laborer or needed significant grip strength, this option would be less acceptable. Infliximab (Remicade) is a reasonable option when multiple joints are significantly involved. Because this patient primarily has single joint disease, the systemic side effects of infliximab, most commonly infections and rarely malignancy, do not justify its use in this patient. Arthrodesis would eliminate this patient’s pain, but it would also limit thumb mobility, potentially negatively affecting her fine-motor work. Fusion of that joint would make opposition difficult and may alter the way she holds her paintbrush. Although FDA approved, thumb CMC silicone implants are inferior to trapeziectomy with ligament reconstruction and tendon interposition. Pyrocarbon implant arthroplasty is intended for patients with osteoarthritis but does not provide the soft-tissue stability required in this patient.

Question 37

A 56-year-old man with a 10-year history of pain in the wrist caused by rheumatoid arthritis comes to the office for consultation regarding surgical treatment options. Total joint replacement (arthroplasty) is a more appropriate choice than joint fusion (arthrodesis) if this patient indicates that his primary goal is which of the following? A ) Grip strength B ) Pain relief C ) Proper alignment D ) Range of motion E ) Stability

Answer 37

The correct response is D ## Footnote Whenever a patient has a painful joint condition, various options are available for treatment. Fusion provides stability and allows pain-free function. It can restore anatomical alignment, and grip strength can be quite good. Arthroplastyalso provides pain relief and corrects alignment. Generally speaking, arthroplastydoes not provide the stability or strength of arthrodesis. The decision to pursue arthroplasty over arthrodesis is usually made because of the patient's desire or necessity to preserve as much range of motion as possible. The decision of performing fusion versus arthroplastyoccurs in various joints in the hand, including the basal joint, wrist joint, metacarpophalangeal, and proximal interphalangeal.

Question 38

A 65-year-old woman comes to the office because she is unable to actively extend the left ring and small fingers. Medical history includes rheumatoid arthritis and no marked trauma. On physical examination, the ring and small fingers are held in 45 degrees of flexion with ulnar deviation at the metacarpophalangeal (MCP) joints. Mild swelling around the MCP joints of all fingers and a prominent ulnar head are noted. The patient is able to maintain extension when her fingers are passively extended. X-ray studies show moderate to severe wrist arthritis but minimal arthritic changes of the finger joints. Which of the following best explains the physical examination findings in this patient? A) Extensor tendon rupture of the ring and small fingers at the ulnar head B) Incomplete radial nerve palsy C) Severe ulnar neuropathy at the elbow D) Ulnar subluxation of the extensor mechanism at the MCP joint E) Volar subluxation of the MCP joint

Answer 38

The correct response is Option D. Rheumatoid arthritis (RA) is an autoimmune inflammatory polyarthritis. Immune complex deposition results in inflammation and synovial hypertrophy, joint destruction, and weakening of the ligamentous support structures. This results in a predictable pattern of deformities seen in the hand and wrist related to the inflammatory synovitis. The wrist is the most commonly affected joint in the upper extremity in RA. Collapse of the carpal height on the radial aspect of the wrist from attenuation of the scapholunate ligament results in weakening of the ulnar collateral ligaments of the wrist, ulnar subluxation and supination of the carpus, and radial deviation of the metacarpals. Along with synovitis of the metacarpophalangeal (MCP) joints, this contributes to the characteristic ulnar drift of the fingers seen in RA. The loss of active finger extension in rheumatoid patients is because of one of three causes. Attenuation of the radial sagittal band of the MCP joint from inflammation and ulnarly directed forces from pinch and grip may result in ulnar subluxation of the extensor mechanism. The extensor tendons will slide into the valley between the metacarpal heads and the extensor tendon will place a flexion force on the MCP joint. In this case, passive extension of the fingers will centralize the extensor and the patient will be able to maintain the fingers actively in an extended position. This is the critical physical exam maneuver to diagnose this issue and the key to the patient in this question. Patients with synovitis of the distal radioulnar joint and dorsal subluxation of the ulnar head (caput ulna) may present with spontaneous rupture of the extensor tendons. This occurs in a predictable sequence beginning with the extensor digiti quinti and progressing radially across the hand. Intact junctura may make this difficult to diagnose initially, but these patients will not be able to extend the small finger with the adjacent digits flexed. These patients will not be able to actively maintain finger extension even if the fingers are passively extended. Finally, volar subluxation or dislocation of the MCP joints from synovitis can be a cause of ulnar drift and loss of digit extension. This may or may not be passively correctable. This can be distinguished easily from extensor tendon subluxation by x-ray evaluation of the hand. Joint malalignment is easily seen on standard x-rays but is not present in this patient. It is important to understand the cause of the deformity because the treatment for each is different. Radial neuropathy in RA is very rare and would not likely be isolated to extension of the ring and small fingers only. One would expect more global posterior interosseous nerve (PIN) palsy, which is not present in this case. Severe ulnar neuropathy would result in intrinsic weakness and possibly clawing of the ulnar digits. This would present with hyperextension of the MCP joints and flexion of the interphalangeal joints.

Question 39

A 60-year-old woman with rheumatoid arthritis (RA) comes to the office because of the sudden inability to extend the right thumb. The patient reports no pain or swelling before the loss of extension. She notes her RA symptoms have been well controlled for over 10 years with low-dose prednisone and methotrexate. Physical examination shows strong flexion of the right thumb at the interphalangeal joint. The patient is unable to extend the thumb interphalangeal joint against resistance and is unable to lift the thumb off the tabletop when the palm is held flat. Full passive mobility of the thumb is noted. Rupture of which of the following tendons is most likely upon surgical exploration? A) Abductor pollicis brevis at the metacarpophalangeal joint B) Abductor pollicis longus at the carpometacarpal joint C) Extensor pollicis brevis at the metacarpophalangeal joint D) Extensor pollicis longus at the wrist E) Flexor pollicis longus near the scaphoid

Answer 39

The correct response is Option D. One of the more common tendon ruptures in rheumatoid arthritis (RA) is the extensor pollicis longus (EPL) at the level of the wrist. Although spontaneous ruptures with no other known pathology occur, the most common etiologies for rupture center around mechanical or vascular changes in the EPL within the third extensor compartment as the tendon bends around Lister's tubercle. This appears to be related in part to the proximity of the tendon to an injury (in distal radius fractures) and to the "watershed" zone of perfusion of the EPL at Lister tubercle. In this patient with RA, the rupture is likely a combination of ischemia and direct inflammatory synovial infiltration of the tendon within the third compartment. Other tendon ruptures may occur in the setting of RA, the common ruptures being the extensor digitorum communis and extensor digiti minimi on the dorsal wrist and the flexor pollicis longus (Mannerfelt lesion) on the volar wrist. The presence of strong flexion of the thumb at the interphalangeal joint rules out flexor pollicis longus (FPL) rupture. Rupture of the extensor pollicis brevis (EPB) would not result in obvious loss of function as the motion would be compensated for by an intact EPL. Neither abductor rupture would result in loss of interphalangeal joint extension or retropulsion (lifting the thumb off the table with the palm held flat on the surface).

Question 40

A 30-year-old man sustains a laceration to the radial nerve at the mid-humerus level. Physical examination shows wristdrop. A photograph is shown. Which of the following transfers is most appropriate to restore wrist extension in this patient? A ) Axillary to radial nerve transfer B ) Biceps to triceps muscle transfer C ) Brachioradialis to extensor carpi ulnaris tendon transfer D ) Phrenic nerve to posterior cord transfer E ) Pronator teres to extensor carpi radialis tendon transfer

Answer 40

The correct response is Option E. Pronator teres to extensor carpi radialis brevis (ECRB) transfer is well described for restoration of wrist extension in isolated radial nerve injury or palsy. The pronator teres is harvested from its insertion on the radius along with an extension of radius periosteum (necessary to have sufficient length for the transfer) and is woven either end-to-end into the ECRB or end-to-side into the ECRB if the surgeon feels the ECRB may recover some function. Some authors also advocate weaving a portion of tendon graft harvested from the extensor carpi radialis longus (ECRL) to increase the strength of the repair. The image shown demonstrates the transfer. The pronator teres is raised with an extension of radius periosteum and woven into the ECRB tendon. Tendon grafting from ECRL reinforces the repair. Axillary-radial nerve coaptation is performed in the proximal upper arm and uses the radial nerve as a donor to provide axons to the axillary nerve and deltoid muscle. Transfer of median nerve axons to the nerve to the ECRB may be used to provide wrist extension. Biceps to triceps transfer has been described to restore a component of radial nerve dysfunction in tetraplegia, but this transfer would provide elbow extension, not wrist extension. The brachioradialis muscle is innervated by the radial nerve. If the nerve were lacerated at the mid-humerus level, the brachioradialis would not be functional. The phrenic nerve could provide donor axons to the posterior cord, which would eventually become the radial nerve; however, axons transferred at this level would face the problem of interruption at the mid-humerus level within the radial nerve.

Question 41

In children with juvenile rheumatoid arthritis, which of the following hand deformities is most common? (A) Loss of flexion of the interphalangealjoint (B) Radial deviation of the carpus (C) Rupture of the extensor tendons (D) Supination of the carpus (E) Ulnar deviation of the metacarpophalangealjoints

Answer 41

The correct response is A Hand deformities associated with juvenile rheumatoid arthritis typically differ from those seen in adult patients with rheumatoid arthritis. Affected pediatric patients have wrist flexion with loss of wrist extension. The carpus and metacarpals are deviated ulnarly, and loss of flexion and radial deviation of the metacarpophalangealjoints is characteristic. In addition, there is a loss of flexion of the interphalangealjoints. Swan-neck and boutonniere deformities and spontaneous tendon ruptures are rare. In contrast, adults with rheumatoid arthritis exhibit radial deviation and supination of the carpus. The metacarpophalangealjoints are subluxedpalmarlyand deviated ulnarly. Swan-neck deformities, boutonniere deformities, and spontaneous tendon ruptures occur in significant numbers.

Question 42

A 35-year old woman with a 10-year history of systemic sclerosis is referred to the office for consultation regarding severe flexion contractures of the proximal interphalangeal(PIP) joints of the small and ring fingers of both hands. For the past five months, she has had increasing difficulty performing activities of daily living. Hand therapy has not been effective in alleviating the contractures. Physical examination shows shallow, clean ulcers over the dorsal PIP joints of the small and ring fingers bilaterally. Which of the following is the most appropriate management? (A) Amputation of the affected digits (B) Arthrodesis of the PIP joints (C) Capsulotomyof the involved joints (D) Split thickness skin grafting of the ulcers (E) Ulnar sympathectomy

Answer 42

The correct response is B ## Footnote Systemic sclerosis (scleroderma) is a systemic autoimmune disease. Affected patients may suffer from calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia. Patients may develop flexion contractures, most commonly of the PIP joints. The skin over the PIP joint becomes stretched and thinned, leading to local ischemia and ulceration. Surgery should be reserved for severe cases where patients have severe disability or digital ulceration. Arthrodesis of the affected joints in moderate flexion coupled with bone shortening will allow ulcer closure and address the underlying contracture. In cases where there has been compensatory metacarpophalangeal(MCP) hyperextension and loss of mobility at the MCP joint, it may be necessary to perform MCP capsulotomyprior to proceeding with PIP joint arthrodesis. Amputation of the affected digits will reduce hand function (grip strength) and risks poor healing and infection. Capsulotomyof the PIP joints is not appropriate because it does not address the underlying flexion contracture and deformity will persist. Split-thickness skin grafting of the ulcers does not address the underlying pathophysiology, and the ulcers will recur. Ulnar sympathectomyis a treatment for Raynaud phenomenon and does not address the issue of interphalangealjoint flexion contracture.

Question 43

A 57-year old woman who has rheumatoid arthritis comes to the office for consultation because she has had increased pain and swelling of the dominant right hand for the past six months. The pain interferes with activities of daily living, and she is unhappy about the appearance of the hand. A photograph of the hand is shown. Current medications include naproxen, infliximab, and methotrexate. Physical examination shows metacarpophalangeal(MCP) synovitis. The ulnar drift can be corrected passively. Radiographs show marked narrowing of MCP joint spaces. In addition to extensor tendon rebalancing, intrinsic release, and synovectomy, which of the following is the most appropriate management? (A) A1 pulley release (B) Extensor digitorumcommunistendon transfer (C) Intra-articular injection of triamcinolone (D) Silicone MCP joint arthroplasty (E) Wrist arthrodesis

Answer 43

The correct response is D In addition to extensor tendon rebalancing, intrinsic release, and synovectomy, the most appropriate management is silicone MCP joint arthroplasty. Alleviation of joint pain, improvement of function and appearance, and retardation or correction of deformity are the surgical indications for rheumatoid arthritis (RA). Surgery will neither restore normal function nor improve grip strength or dexterity. The patient described has persistent pain caused by articular destruction of her MCP joint. The photograph shows MCP synovitis, extensor digitorumcommunisulnar sublimation, and MCP ulnar drift. Tendon rebalancing will improve finger alignment and extensor lag. Intrinsic release will help balance the forces causing ulnar drift. Synovectomywill retard tendon rupture and misalignment. Silicone MCP joint arthroplasty will alleviate the painful bone-on-bone contact. PyrocarbonMCP joint arthroplastycan be considered in young or high-demand RA patients who have less than 60 degrees of extension lag, less than 45 degrees of ulnar deviation, and no severe dislocation or shortening. A1 pulley release is contraindicated in RA patients because the pulleys help maintain alignment of the digits; tenosynovectomyis preferred. Extensor tendon transfers are indicated after extensor tendon ruptures caused by inflammation. They are not indicated for the correction of ulnar drift. Oral corticosteroids are often included in the medical regimen of an RA patient. Injections of corticosteroids may be used to temporarily alleviate the inflammation associated with osteoarthritis, but they will not correct articular destruction. Joint fusion (arthrodesis) is indicated in RA patients for stabilization of joints that must sustain high load forces or in patients with arthritis mutilans. Thumb MCP joint arthroplastyis not recommended; fusion is the treatment of choice. Partial or complete wrist and distal interphalangealjoint fusions are often indicated with malalignment. However, MCP joint fusion would cause unnecessary and severe functional limitations in the low-demand patient described.

Question 44

A 60-year-old woman with a history of rheumatoid arthritis presents with a boutonnière deformity of the long finger. Which of the following is the most likely cause of the deformity? ## Footnote A) Destruction of the cartilage of the proximal interphalangeal joint B) Dorsal subluxation of the lateral bands at the proximal interphalangeal joint C) Metacarpophalangeal joint subluxation D) Rupture of the distal extensor tendon E) Synovitis at the proximal interphalangeal joint

Answer 44

The correct response is Option E. The posture of a boutonnière is flexion of the proximal interphalangeal (PIP) joint and hyperextension of the distal interphalangeal joint. The common injury for non-rheumatoid patients that suffer traumatic injuries that lead to the deformity is a rupture of the central slip that means no active extension at the PIP joint. Over time, the lateral bands slip volarly and cause hyperextension of the distal joint. Synovitis of the PIP joint leads to subsequent attenuation of the central slip, which leads to the same deformity.

Question 45

A 76-year-old woman with rheumatoid arthritis comes to the office because of a 2-month history of difficulty flexing the index finger of the left hand. She says that when she flexes the finger, a painful snapping sensation occurs. Physical examination shows fullness of the flexor tendon at the level of the A1 pulley. Which of the following is the most appropriate surgical treatment? ## Footnote A) Release of the A1 pulley alone B) Release of the A1 pulley and stair-step expansion repair of the pulley C) Removal of the entire flexor digitorum superficialis tendon D) Routing of the A1 pulley under the flexor tendons E) Synovectomy and debridement of the flexor tendons

Answer 45

The correct response is Option E. This examination and history of the patient described are consistent with a diagnosis of trigger finger. Trigger fingers are common in patients with rheumatoid arthritis and are related to intratendinous nodules, as well as synovial inflammation common with rheumatoid arthritis. Typical management of trigger fingers consists of conservative treatment with steroid injection as the initial course of action. This is true in patients with rheumatoid arthritis as well. When patients have failed conservative treatment with steroid injection, surgery is indicated. Normally, division of the A1 pulley results in excellent success. However, in the case of a rheumatoid patient, the A1 pulley is often the only remaining structure preventing ulnar drift of the tendons and joints. As a result, the A1 pulley should never be divided in a rheumatoid patient. The most appropriate surgical treatment is flexor tenosynovectomy and removal of intratendinous nodules. If this is unsuccessful, removal of a slip of the superficialis tendon is appropriate. Stair-step expansion and rerouting the tendon are not appropriate treatments.

Question 46

A 45-year-old woman who has a 15-year history of rheumatoid arthritis comes for evaluation because of the inability to actively extend the metacarpophalangeal (MCP) joints of the right small and ring fingers. On examination today, she has near full passive motion of all fingers and is able to actively extend the thumb, index, and long fingers. Photographs are shown. She is unable to hold the ring and small fingers in extension when they are passively extended. X-ray studies show severe destructive arthropathy of the wrist, MCP, and proximal interphalangeal joints. There is ulnar drift and subtle volar subluxation of the MCP joint in all fingers; the ulnar head is prominent dorsally and is unstable. Which of the following is the most likely cause of her inability to actively extend the MCP joints of the ring and small fingers? ## Footnote A) MCP joint contracture B) Posterior interosseous nerve palsy associated with elbow synovitis C) Rupture of the extensor tendons in zone VII D) Rupture of the sagittal bands E) Volar subluxation of the MCP joints

Answer 46

The correct response is Option C. Extensor lag of the fingers is a common problem in patients with rheumatoid arthritis and severe wrist and finger arthropathy. Persistent synovial inflammation results in periarticular osseous destruction and weakening of the stabilizing ligaments. Any of the choices can potentially cause a restriction of finger extension at the metacarpophalangeal (MCP) joints, but only rupture of the extensor tendons would result in the constellation of findings observed here. This patient has severe wrist arthritis and dorsal prominence of the ulnar head (unstable). This can result in attritional ruptures of the extensor digiti minimi and ulnar-sided extensor digitorum communis tendons; treatment is resection of the ulnar head and tendon transfer to restore extensor function. Posterior interosseous nerve palsy resulting from synovitis about the radiocapitellar joint is well described in patients with rheumatoid arthritis, but would affect extension of all fingers and the thumb. Rupture and subluxation of sagittal bands would lead to inability to actively extend the MCP but, in contrast to extensor tendon ruptures, full extension can be maintained after the fingers are passively extended. MCP joint contracture would limit active and passive finger motion.