Hand - Arthritis Flashcards
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
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.
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
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.
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
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.
In patients with rheumatoid arthritis, attritional rupture of which of the following tendons is most likely?
(A) Flexor digitorumprofundusof the index finger
(B) Flexor digitorumprofundusof the small finger
(C) Flexor digitorumsuperficialisof the index finger
(D) Flexor digitorumsuperficialisof the small finger
(E) Flexor pollicislongus
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 pollicislongusare most common, followed by the flexor digitorumprofundusof the index finger. The flexor digitorumsuperficialisof the index finger and flexor digitorumprofundusof the long finger are also frequently ruptured.
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 pollicisbrevis, flexor pollicisbrevis, first dorsal interosseous, and flexor pollicislongusmuscles. Hyperextension of the metacarpophalangealjoint of the thumb and weakness of the abductor pollicislongus, extensor pollicislongus, and extensor pollicisbrevismuscles is also noted. A photograph of the hand is shown. Which of the following is the most appropriate management?
(A) Capsulotomyof the metacarpophalangealjoint
(B) Injection of botulinumtoxin into the abductor pollicisbrevismuscle
(C) Release of the adductor pollicismuscle
(D) Shortening of the tendon of the first dorsal interosseousmuscle
(E) Transfer of the extensor pollicislongustendon to the ulnar aspect of the thumb
The correct response is C
Of the management options listed, only release of the adductor pollicismuscle 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 pollicisbrevis, adductor pollicisbrevis(APB), and first dorsal interosseousmuscles causes flexion and adduction deformities and can be treated with release or repositioning of the muscles. The flexor pollicislongustendon can be lengthened or used for an abductorplastywhen 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-plastytechniques.
Weakness of the extensor pollicislongus(EPL), extensor pollicisbrevis(EPB), and abductor pollicislongus(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 palmarislongus, brachioradialis, flexor carpi radialisand ulnaris, extensor carpi radialisbrevisand longus, and flexor digitorumsuperficialis, 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 capsulodesiscan be performed to improve joint stability. Depending upon the functional status of the thumb, arthrodesis of the interphalangealor carpometacarpal joints may be performed as alternatives to MCP arthrodesis.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
The correct response is D
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.
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
The correct response is E
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.
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
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.
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
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.
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
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.
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?
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
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.
