Hand Rheumatology

Question 1

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 1

A) Extensor digitorum communis

Question 2

Mechanisms for tendon rupture in rheumatoid arthritis

Answer 2

1. Constant wear over a bony prominence leading to attrition, direct invasion of the tendon
2. Synovitis and ischemic necrosis of the tendon secondary to proliferative synovitis.

Question 3

Clinical presentation after tendon rupture in rheumatoid arthritis

Answer 3

When tendon rupture occurs, it is usually painlessand results only after trivial use of the tendon. In some patients, the functional deficit is not noticeable immediately, leading to a delay in diagnosis.

Question 4

Tendons most commonly involved in rheumatoid arthritis tendon rupture

Answer 4

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.

Question 5

Complications that can be confused with extensor tendon rupture in rheumatoid arthritis

Answer 5

These include metacarpophalangeal joint dislocation, extensor tendon displacement between the metacarpal heads, and paralysis of the common extensor muscle

Question 6

1st and 2nd most common tendon rupture of the hand in rheumatoid arthritis

Answer 6

1st: Extensor tendons on the ulnar aspect of the hand
2nd: Extensor pollicis longus

Question 7

Clinical presentation of extensor policies longs rupture in rheumatoid arthritis

Answer 7

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.

Question 8

Treatment of tendon ruptures in rheumatoid arthritis

Answer 8

Treatment of tendon ruptures involves tendon grafts and transfers, as well as removal of bony prominences when appropriate.

Question 9

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?
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 9

E) Synovectomy and debridement of the flexor tendons

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.

Question 10

Trigger fingers in rheumatoid arthritis

Answer 10

Trigger fingers are common in patients with rheumatoid arthritis and are related to intratendinous nodules, as well as synovial inflammation common with rheumatoid arthritis.

Question 11

Initial management of trigger finger in rheumatoid arthritis

Answer 11

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.

Question 12

Surgical management for trigger finger in rheumatoid arthritis

Answer 12

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.

Normally, division of the A1 pulley results in excellent success, but the A1 pulley should never be divided in a rheumatoid patient.

Question 13

When is surgical treatment indicated for trigger finger?

Answer 13

When patients have failed conservative treatment with steroid injection, surgery is indicated.

Question 14

A1 pulley in rheumatoid arthritis patients

Answer 14

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.

Question 15

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 15

B ) Dorsal apparatus lateral band

The patient described has a classic case of ulnar nerve palsy. If MCP hyperextension is passively prevented by dorsalpressure, 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.

Question 16

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 16

E ) Pronator teres to extensor carpi radialis tendon transfer

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 alongwith 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.

Question 17

Restoration of wrist extension in isolated radial nerve palsy

Answer 17

Pronator teres to extensor carpi radialis brevis (ECRB) transfer is well described for restoration of wrist extension in isolated radial nerve injury or palsy.

Question 18

Procedure for Pronator teres to extensor carpi radialis brevis transfer?

Answer 18

The pronator teres is harvested from its insertion on the radius alongwith 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.

Question 19

Why is radius periosteum essential for pronator teres to extensor carpi radialis brevis transfer?

Answer 19

Necessary to have sufficient length for the transfer

Question 20

Innervation of the brachioradialis muscle

Answer 20

Radial nerve

Question 21

Axillary-radial nerve coaptation

Answer 21

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.

Question 22

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 pronator
B ) Extensor carpi radialis longus tendon
C ) Flexor carpi ulnaris fascicle nerve
D ) Flexor digitorum superficialis tendon
E ) Medial antebrachial cutaneous nerve

Answer 22

A ) Anterior interosseous nerve branch to the pronator

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.

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.

Question 23

Oberlin nerve transfer

Answer 23

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.

Question 24

Classical nerve transfer for a high ulnar nerve palsy, to restore hand intrinsic motor function

Answer 24

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 25

A proximal ulnar nerve lesion with a segmental nerve loss in an adult: potential advantage of a nerve transfer over a tendon transfer

Answer 25

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.

Question 26

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 26

B ) Transfer of the extensor indicis proprius

Transfer of either the FDS of the ring finger or the extensor indicis proprius (EIP) is appropriate.

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 27

Low median nerve palsy

Answer 27

Loss of thumb opposition only

Question 28

High median nerve palsy

Answer 28

Loss of all FDS function, loss of FDP function of the index and long fingers, loss of flexor palmaris longus function

Question 29

Tendon transfer options for opponensplasty

Answer 29

Transfer of either the FDS of the ring finger or the extensor indices proprius is appropriate

Question 30

Procedure for FDS of the ring finger transfer for opponensplasty

Answer 30

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

Question 31

Procedure for EIP transfer for for opponensplasty

Answer 31

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.

Question 32

Opponensplasty: Transfer of the EIP versus FDS of the ring finger

Answer 32

EIP is nsidered by many authors to be superior to the FDS transfer because possible adhesion formation to a constructed pulley is avoided.

Question 33

Using the palmaris longus tendon after carpal tunnel release

Answer 33

Transfer of the palmaris longus is often performed during a carpal tunnel release following long-standing median nerve compression to augment weakened thenar muscles

Question 34

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 34

D ) Range of motion

Fusion provides stability and allows pain-free function. It can restore anatomical alignment, and grip strengthcan be quite good. Arthroplasty also provides pain relief and corrects alignment. Generally speaking, arthroplasty does 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.

Question 35

Choosing between arthroplasty and arthrodesis for a painful joint

Answer 35

Fusion provides stability and allows pain-free function. It can restore anatomical alignment, and grip strengthcan be quite good.

Arthroplasty also provides pain relief and corrects alignment, but does 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.

Question 36

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 ) Tenolysis of superficialis and profundus tendons
E ) Tenosynovectomy and resection of slip of the superficialis tendon

Answer 36

E ) Tenosynovectomy and resection of slip of the superficialis tendon

In patients with rheumatoid arthritis, the A1 pulley should be preserved and a flexor tenosynovectomy of the fingers should be performed as well as, if necessary, a resection of one slip of the superficialis tendon.

Question 37

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 nondominant left 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 tenodesis effect 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 interosseous nerve
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 lumbrical muscles

Answer 37

B ) Compression of the posterior interosseous nerve

Posterior interosseous nerve (PIN) compression is a complication of rheumatoid arthritis which, together with extensor tendon rupture and metacarpophalangeal joint 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.

Question 38

Differential in a patient with posterior interosseous syndrome who is unable to extend the fingers

Answer 38

Posterior interosseous nerve (PIN) compression, extensor tendon rupture and metacarpophalangeal joint dislocation, should be considered in the differential diagnosis of inability to extend the fingers in a patient with rheumatoid arthritis

Question 39

Differentiating posterior interosseous syndrome from other causes of inability to extend the fingers in a patient with rheumatoid arthritis

Answer 39

The inability to extend the thumb in PIN entrapment can be a useful distinguishing clue on physical examination.

Question 40

Cause of posterior interosseous syndrome in patients with rheumatoid arthritis

Answer 40

Elbow joint swelling and compression of the PIN at the arcade of Frohse are the main reasons for PIN entrapment in rheumatoid arthritis.

Question 41

Treatment for symptoms of posterior interosseous syndrome in patients with rheumatoid arthritis

Answer 41

Elbow joint swelling and compression of the PIN at the arcade of Frohse are the main reasons for PIN entrapment in rheumatoid arthritis.

Intraarticular corticosteroid injections and surgical intervention resolve symptoms of PIN entrapment in rheumatoid arthritis.

Question 42

Caput-ulnae syndrome

Answer 42

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

Question 43

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 43

E ) Proliferation of myofibroblasts

The most likely causative event in the scenario described is proliferation of myofibroblasts. The patient described presents with Dupuytren diathesis, a phenomenon of rapidly progressing contractures in a young person.

Question 44

Phases of Dupuytren disease

Answer 44

The three pathophysiologic phases of Dupuytren disease are the proliferative, involutional, and residual stages.

Question 45

Proliferative stage of Dupuytren disease

Answer 45

he proliferative stage is characterized by an intense proliferation of myofibroblasts.

Question 46

Involutional stage of Dupuytren disease

Answer 46

The involutional stage is characterized by the alignment of the myofibroblasts along lines of tension.

Question 47

Residual stage of Dupuytren disease

Answer 47

During the residual stage, the tissue becomes mostly acellular and devoid of myofibroblasts, and only thick bands of collagen remain.

Question 48

Dupuytren diathesis and patient gender

Answer 48

There does not seem to be a correlation between Dupuytren diathesis and patient gender.

Question 49

Dupuytren diathesis

Answer 49

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.

Question 50

Dupuytren disease and ectopic manifestation

Answer 50

Ectopic deposits have been described on the soles of the feet (Lederhose disease), over the dorsum of the proximal interphalangeal joints (Garrod knuckle pads), and on the penis (Peyronie disease)

Question 51

Peyronie disease

Answer 51

Dupuytren disease on the penis

Question 52

Garrod disease

Answer 52

Dupuytren disease on the dorm of the PIPJ’s

Question 53

Lederhose disease

Answer 53

Dupuytren disease on the soles of the feet

Question 54

Collagen in Dupuytren disease

Answer 54

Many studies confirm an increase in the ratio of type II to type I collagen in Dupuytren disease.

Question 55

Heredity of Dupuytren disease

Answer 55

It is thought to be inherited as an autosomal dominant condition with incomplete penetrance.

Question 56

A 76-year-old woman comes to the office because she has had progressive loss of extension of the nondominant long, 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 56

(E)Tendon transfer

In the scenario described, the extensors to the small, ring, and long fingers have ruptured from an attritional inflammatory process, most likely rheumatoid arthritis.

Tendon transfers should be used in instances where contracted muscles do not relengthen on stretching. In the scenario described, with the extensor indicis proprius and extensor digitorum communis (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.

Question 57

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 metacarpophalangeal joints 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 57

(E)Serum rheumatoid factor assay

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.

Question 58

Rheumatoid arthritis (RA) has a prevalence of approximately __% in the United States.

Answer 58

Rheumatoid arthritis (RA) has a prevalence of approximately 1% in the United States.

Question 59

Female-to-male ratio for rheumatoid arthritis is approximately:

Answer 59

Female-to-male ratio for rheumatoid arthritis is approximately 3:1

Question 60

Age of onset for rheumatoid arthritis is usually:

Answer 60

Between 25 and 50 years

Question 61

Diagnosis of Rheumatoid Arthritis

Answer 61

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

Question 62

CBC in patients with Rheumatoid arthritis

Answer 62

80% of patients with RA have anemia

Question 63

ESR in patients with Rheumatoid arthritis

Answer 63

Elevated in 90% of patients with RA

Question 64

RF is (+) in __% of patients with Rheumatod arthritis

Answer 64

70%

Question 65

___% of acute gout attacks affect the lower extremity.

Answer 65

75% of acute gout attacks affect the lower extremity.

Question 66

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 (MCP synovitis, extensor digitorum communis ulnar sublimation, and MCP ulnar drift.) 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 digitorum communis tendon transfer
(C)Intra-articular injection of triamcinolone
(D)Silicone MCP joint arthroplasty
(E)Wrist arthrodesis

Answer 66

(D)Silicone MCP joint arthroplasty

The patient described has persistent pain caused by articular destruction of her MCP joint.
In addition to extensor tendon rebalancing, intrinsic release, and synovectomy, the most appropriate management is silicone MCP joint arthroplasty.

Question 67

Indictions for surgery in rheumatoid arthritis

Answer 67

Alleviation of joint pain, improvement of function and appearance, and retardation or correction of deformity are the surgical indications for rheumatoid arthritis (RA).

Question 68

Reason for tendon rebalancing in patients with rheumatoid arthritis

Answer 68

Tendon rebalancing will improve finger alignment and extensor lag. Intrinsic release will help balance the forces causing ulnar drift.

Question 69

Reason for synovectomy in patients with rheumatoid arthritis

Answer 69

Synovectomy will retard tendon rupture and misalignment.

Question 70

Reason for silicone MCP joint arthroplasty in patients with rheumatoid arthritis

Answer 70

Silicone MCP joint arthroplasty will alleviate the painful bone-on-bone contact.

Question 71

When is pyrocarbon MCP joint arthroplasty indicated in rheumatoid arthritis?

Answer 71

Pyrocarbon MCP joint arthroplasty can 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.

Question 72

Arthroplasty of the thumb MCP

Answer 72

Thumb MCP joint arthroplasty is not recommended; fusion is the treatment of choice.

Question 73

Arthrodesis

Answer 73

Joint fusion

Question 74

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 74

(C)Release of the adductor pollicis muscle

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.

Question 75

What hand deformity is associated with cerebral palsy?

Answer 75

Thumb in palm deformity

Question 76

What does thumb in palm deformity result from in cerebral palsy?

Answer 76

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
• Laxity of the metacarpophalangeal (MCP) joint

Question 77

Treatment of thumb in palm deformity in cerebral palsy

Answer 77

Release of the adductor pollicis muscle

Question 78

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)Capsulotomy of the involved joints
(D)Split-thickness skin grafting of the ulcers
(E)Ulnar sympathectomy

Answer 78

(B)Arthrodesis of the PIP joints

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 capsulotomy prior to proceeding withPIP joint arthrodesis.

Question 79

Systemic sclerosis and symptoms

Answer 79

Systemic sclerosis (scleroderma) is a systemic autoimmune disease. Affected patients may suffer from calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia.

Question 80

Hand manifestations of systemic sclerosis

Answer 80

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.

Question 81

Treatment of PIPJ flexion contractors in systemic sclerosis

Answer 81

Surgery should be reserved for severe cases where patients have severe disability or digital ulceration:

PIP Joints in moderate flexion: Arthrodesis coupled with bone shortening will allow ulcer closure and address the underlying contracture.

When there has been compensatory MCPJ hyperextension and loss of mobility at the MCPJ, it may be necessary to perform MCP capsulotomy prior to proceeding with PIP joint arthrodesis.

Question 82

Surgical treatment for Raynaud phenomenon

Answer 82

Ulnar sympathectomy is a treatment for Raynaud phenomenon.

Question 83

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 pollicis longus tendon
(C)Formation of osteophytes in the first metacarpophalangeal joint
(D)Laxity of the volar anterior oblique (beak) ligament
(E)Synovitis of the abductor pollicis longus and extensor pollicis brevis tendons

Answer 83

(D)Laxity of the volar anterior oblique (beak) ligament

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.

Question 84

Basilar joint of the thumb: clinical relevance

Answer 84

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.

Question 85

Basilar joint of the thumb: articulations

Answer 85

The basilar joint of the thumb, the second most common site of arthritis, comprises four articulations among the trapezium, scaphoid, trapezoid, and thumb metacarpal.

Question 86

Beak ligament

Answer 86

The anterior oblique (beak) ligament is the primary stabilizer of the trapeziometacarpal joint of the thumb. Laxity of this ligament is generally the first sign in basilar joint arthritis.

Question 87

Progression of arthritis of the basilar joint of the thumb

Answer 87

Laxity in the anterior oblique (beak) ligament is generally the first sign.
Followed by articular damage in the palmar articular surface of the scaphoid
Can progress to osteophyte formation and complete loss of the scaphoid articular surface.

Question 88

De Quervain disease

Answer 88

De Quervain disease is irritation of the abductor pollicis longus and extensor pollicis brevis tendons as they go through the first dorsal compartment of the wrist.

Question 89

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 interphalangeal joints 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 89

(D)Rheumatoid arthritis

The patient described has the hallmarks of rheumatoid arthritis, the diagnosis of which is made on clinical grounds.

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.

Question 90

Joint aspirate with gout

Answer 90

Gout would be indicated by an elevated serum uric acid level or uric acid crystals in the joint aspirate.

Question 91

Joint aspirate with pseudogout

Answer 91

Calcium pyrophosphate crystals would be found in the joint aspirate in pseudogout.

Question 92

A 43-year-old man with rapidly progressive scleroderma comes to the office for follow-up examination because of skin atrophy, sclerosis, and telangiectases resulting from his disease condition. On physical examination, multiple contractures and skin lesions are noted. The largest lesion is located on the dorsum of the metacarpophalangeal joint 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 bilaminate neodermis
(E)Split-thickness skin grafting

Answer 92

(D)Reconstruction with bilaminate neodermis

In the scenario described, because one of the fingers is not contracted and still functional, salvage is important for rudimentary activities.

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 93

Local flaps in scleroderma

Answer 93

Sclerotic skin renders local flaps a technical impossibility

Question 94

Coverage of an open defect for a patient with Scleroderma where the finger is functional

Answer 94

Integra; compliant enough to allow full flexion.

Question 95

In patients with rheumatoid arthritis, which of the following tendons is ruptured most commonly?
(A) Extensor indicis proprius
(B) Extensor pollicis longus
(C) Flexor carpi ulnaris
(D) Flexor digitorum profundus to the small finger
(E) Flexor pollicis longus

Answer 95

(B) Extensor pollicis longus

The extensor tendons are ruptured most commonly, with the extensor pollicis longus (EPL) and extensor digiti quinti (EDQ) tendons being affected most frequently

Options for repair include direct surgical coaptation of the tendon (if the ends have not retracted) or transfer of the extensor pollicis or extensor carpi radialis longus tendon.

Question 96

Most common tendon ruptures in rheumatoid arthritis

Answer 96

The extensor tendons are ruptured most commonly, with the extensor pollicis longus (EPL) and extensor digiti quinti (EDQ) tendons being affected most frequently.

Question 97

Mannerfelt lesion.

Answer 97

Rupture of the flexor pollicislongus tendon by a scaphoid spur is typically referred to as a Mannerfelt lesion.

Question 98

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 interphalangeal joints
(B) Ruptures of the extensor digitorum communis tendons
(C) Ruptures of the flexor digitorum superficialis tendons
(D) Tightness of the extrinsic tendons
(E) Tightness of the intrinsic tendons

Answer 98

(E) Tightness of the intrinsic tendons

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.

Question 99

Rheumatoid arthritis: Which fingers demonstrate swan neck deformity?

Answer 99

The ulnarmost three fingers.

Question 100

Swan neck deformity

Answer 100

Flexion contractures of the MP joints and hyperextension deformities of the proximal interphalangeal (PIP) joints.

Question 101

In RA, what does swan neck deformity result from?

Answer 101

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.

Question 102

Correction of swan neck deformities in RA

Answer 102

• Arthroplasties of the MP joints of the fingers
• Comprehensive soft-tissue and intrinsic releases
• Centralization of the extrinsic extensor tendons over the MP joints,
• Spiral oblique retinacular ligament
• Zancolli-flexor digitorum superficialis lasso reconstruction of the ulnarmost three digits.

Question 103

A 60-year-old woman with advanced rheumatoid arthritis has been unable to extend the ring and small fingers of the left hand for the past three months. The fingers can be passively extended, but the patient cannot maintain extension. Appropriate management of this patient would include which of the following procedures?
(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 103

(C) Excision of the distal ulna

Question 104

Vaughn-Jackson progression

Answer 104

In Rheumatoid arthritis, Extensor tendon ruptures generally occur in a pattern beginning at the ulnarmost digits and extending to the radial digits.

Question 105

Darrach procedure

Answer 105

Excision of the distal ulna, also known as the Darrach procedure, can be used to decrease the prominence of the distal ulna and to correct the supination of the carpus through reefing of the ulnar carpal ligaments.

Question 106

Most common treatment of ruptured extensor tendons in Rheumatoid arthritis

Answer 106

Although the ruptured extensor tendons can be repaired directly or through grafting, they are more commonly transferred to the intact radial extensors.

Question 107

Management of subluxation of the extensor tendons at the MP joints in RA

Answer 107

Centralization of the extensor tendons is appropriate management of subluxation of the extensor tendons at the MP joints. Patients with this condition are able to maintain the digits in an extended position after they are passively placed in extension

Question 108

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 108

(E) Flexor pollicis longus

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 109

What typically results in ruptures of the extensor tendons in an ulnar to radial pattern?

Answer 109

Dorsal subluxation of the distal ulna typically results in ruptures of the extensor tendons in an ulnar-to-radial pattern.

Question 110

In RA, where do ruptures of the flexor tendons most commonly occur?

Answer 110

Ruptures of the flexor tendons occur most commonly in the carpal canal

Question 111

Most common flexor tendon ruptures in RA

Answer 111

Most common: Flexor pollicis longus
Second most: 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 112

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

Answer 112

(A) Loss of flexion of the interphalangeal joint

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 metacarpophalangeal joints is characteristic. In addition, there is a loss of flexion of the interphalangeal joints.

Hand deformities associated with juvenile rheumatoid arthritis typically differ from those seen in adult patients with rheumatoid arthritis. Swan-neck and boutonnire deformities and spontaneous tendon ruptures are rare.

Question 113

Hand deformities in juvenile rheumatoid arthritis

Answer 113

Wrist flexion with loss of wrist extension
Ulnar deviation of the carpus and metacarpals
Loss of flexion and radial deviation of the metacarpophalangeal joints Loss of flexion of the interphalangeal joints.

Swan-neck and boutonniere deformities and spontaneous tendon ruptures are rare.

Question 114

Hand deformities in adults with rheumatoid arthritis

Answer 114

Radial deviation and supination of the carpus.
MCPJ’s are subluxed palmarly and deviated ulnarly.
Swan-neck deformities
Boutonnire deformities
Spontaneous tendon ruptures

Question 115

A 54-year-old violinist has severe posttraumatic osteoarthritis of the metacarpophalangeal (MP) joint of the nondominant left long finger. She has severe pain and limited finger use despite administration of nonsteroidal anti-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) Perichondrial autograft arthroplasty
(B) Silicone implant arthroplasty
(C) MP jointarthrodesis
(D) Nonvascularized toe joint arthroplasty
(E) Free vascularized toe joint arthroplasty

Answer 115

(B) Silicone implant arthroplasty

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 arthroplasty of the MP joint. This procedure will alleviate pain and yield good range of motion of the joint.

Nonvascularized toe 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 116

Arthroplasty vs arthrodesis

Answer 116

Although both procedures generally alleviate pain, only the arthroplasty procedure permits joint motion. Joint arthrodesis diminishes pain but results in a stable, rigid joint

Question 117

Perichondrial autografts for complete joint resurfacing

Answer 117

Perichondrial autografts are unpredictable, especially when used in complete joint resurfacing.

Question 118

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 metacarpophalangeal joints 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 118

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

This patient with severe rheumatoid arthritis should first undergo total elbow arthroplasty followed 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.

Question 119

Diffuse rheumatoid arthritis in the upper extremity: order of procedures

Answer 119

Proximal-to-distal sequence of procedures is advocated for most patients who have diffuse rheumatoid arthritis of the upper extremity.

Question 120

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 interphalangeal joints. 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 120

(B) HIV infection

A diagnosis of HIV infection should be considered in patients who have the rapid or explosive onset of psoriatic arthritis or Reiter’s syndrome.

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.

Question 121

What should be considered in patients who have the rapid or explosive onset of psoriatic arthritis or Reiter’s syndrome.

Answer 121

A diagnosis of HIV infection should be considered in patients who have the rapid or explosive onset of psoriatic arthritis or Reiter’s syndrome.

Awareness of the coexistence of HIV infection is important because immunosuppressive therapy, which is often prescribed for management of arthritis, can have devastating effects in patients with HIV infection.

Question 122

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) Tenosynovectomy only
(E) Tenosynovectomy and excision of the flexor tendon nodule

Answer 122

(E) Tenosynovectomy and excision of the flexor tendon nodule

Question 123

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?
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 123

E) Translocation of the lateral bands and dorsal PIP joint capsulectomy

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 124

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 124

E) Wrist collapse

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 125

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 125

D ) Silicone prosthesis arthroplasty of the MCP joints

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 126

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?
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 126

E) Trapeziectomy with ligament reconstruction and tendon interposition

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 127

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 127

E) Total wrist arthrodesis with ulnar head excision

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 128

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 change	improved

Answer 128

F) No change improved

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.