Osteoarthritis and inflammatory disorders of hand and wrist Flashcards
What percentage of patients with radiographic osteoarthritis isolated to the 1st CMC joint become symptomatic?
28%. Although isolated radiographic osteoarthritis at the 1st CMC joint is common, only 28% of these patients report basal thumb pain.
What proportion of patients with combined radiographic osteoarthritis at both the 1st CMC and STT joints experience pain?
**55%. **Symptom prevalence significantly increases when osteoarthritis involves both the 1st CMC and STT joints.
Is there a correlation between the severity of radiographic osteoarthritis of the thumb CMC joint and the presence of symptoms?
**No. **
The severity of radiographic osteoarthritis does not correlate with symptomatic pain, emphasizing clinical rather than radiographic evaluation for treatment decisions.
Which surgical treatment has superior long-term outcomes for advanced thumb CMC osteoarthritis: simple trapeziectomy or trapeziectomy with ligament reconstruction?
Neither. Long-term clinical outcomes are equivalent for both simple trapeziectomy and trapeziectomy with ligament reconstruction or tendon interposition, based on systematic reviews.
What is a common complication following trapeziectomy with FCR ligament reconstruction for thumb base osteoarthritis?
A pulling sensation in the forearm, reported in up to 22% of patients due to harvesting and using the flexor carpi radialis tendon.
Who first described trapeziectomy, and when?
Harvey Gervis first described trapeziectomy in 1949 using a dorsal approach in a small clinical series.
Which procedure provides better wrist flexion-extension arc in younger patients with grade 2 SLAC wrist: Proximal Row Carpectomy (PRC) or Four Corner Fusion (4-CF)?
PRC provides a better mean flexion-extension arc of 73°, compared to 54° following 4-CF.
Between Proximal Row Carpectomy (PRC) and Four Corner Fusion (4-CF), which has a lower complication rate for grade 2 SLAC wrist in younger patients?
PRC has a lower complication rate compared to 4-CF, although pain relief is similar between the two procedures.
How does postoperative grip strength compare between Four Corner Fusion (4-CF) and Proximal Row Carpectomy (PRC)?
Grip strength following **4-CF is approximately 65% **of the contralateral side, slightly better than PRC, which provides approximately 54%.
Which surgical procedure for thumb CMC joint osteoarthritis results in the shortest duration of sick leave and quickest return to work?
Total joint arthroplasty. Prosthetic implant arthroplasty significantly shortens postoperative recovery and return-to-work time compared to soft tissue arthroplasty or trapeziectomy procedures.
Is patient age a significant factor in determining duration of postoperative sick leave after thumb CMC joint osteoarthritis surgery?
No. Patient age is not a significant factor influencing sick leave duration postoperatively.
Does patient gender significantly impact sick leave duration following surgery for thumb CMC joint osteoarthritis?
No. Patient gender does not significantly affect the length of postoperative sick leave.
Which condition is characterized radiographically by “hook-like” osteophytes on the radial aspects of MCP joint metacarpal heads?
**Haemochromatosis. **This radiographic appearance differentiates haemochromatosis from pseudogout and other arthropathies.
Which joint involvement typically excludes haemochromatosis arthropathy from the differential diagnosis?
Radiocarpal joint involvement. Haemochromatosis typically affects MCP joints and spares the radiocarpal joint.
Is calcification of the TFCC typical in haemochromatosis arthropathy?
No. Calcification of the TFCC is not typical for haemochromatosis and would prompt consideration of another diagnosis such as pseudogout.
What is the intermittent weight-bearing limit recommended after wrist arthroplasty to prevent implant failure?
5 kg intermittently, provided regular load remains below 1 kg.
Is previous wrist arthrodesis an absolute or relative contraindication for wrist arthroplasty?
An absolute contraindication. Prior wrist arthrodesis prevents successful wrist arthroplasty.
Is wrist arthroplasty suitable for high-demand patients requiring significant wrist loading?
No. Wrist arthroplasty is only suitable for low-demand patients due to load limitations preventing implant failure.
What proportion of patients experience symptomatic improvement for at least 3 months following steroid injection for thumb trapeziometacarpal osteoarthritis?
**50%. Half of patients have symptomatic relief lasting about 3 months, **independent of osteoarthritis severity.
Does increased severity of thumb trapeziometacarpal osteoarthritis reduce the effectiveness of steroid injections?
**No. **Severity does not correlate with reduced injection efficacy; severe cases may have comparable or slightly better outcomes.
Is the duration of symptomatic relief typically longer after a first steroid injection compared to subsequent injections for thumb trapeziometacarpal osteoarthritis?
Yes. The first steroid injection typically provides longer symptomatic relief than subsequent injections.
Which condition has the poorest clinical outcomes following wrist denervation surgery?
Intra-articular distal radius fractures, due to complex joint pathology and persistent symptoms.
Among scaphoid non-union, Kienböck’s disease, and primary wrist osteoarthritis, which have better outcomes following wrist denervation?
All typically yield better outcomes compared to intra-articular distal radius fractures.
Who originally described wrist denervation surgery, and when was it first described?
Camitz first described denervation surgery principles in 1933, and
Wilhelm specifically applied it to wrist surgery in 1966.
What radiographic finding represents the most significant risk factor for lunate collapse in Kienböck’s disease?
Decreased radial inclination significantly increases load on the lunate, predisposing it to collapse.
Is ulnar negative variance strongly supported as a risk factor for lunate collapse in Kienböck’s disease by current literature?
No. Despite common clinical assumptions, meta-analyses show insufficient evidence supporting ulnar negative variance as a significant risk factor.
Which anatomical type of lunate bone is most susceptible to collapse in Kienböck’s disease?
Type 1 lunate (trapezoidal), due to weaker trabecular structure predisposing to fragmentation and collapse.
What is the Masada shelf arthroplasty procedure in rheumatoid wrist surgery a variation of?
The Sauve-Kapandji procedure, involving a 90° rotated ulnar head to improve DRUJ stability and wrist function.
Which joint in the hand is most commonly affected by rheumatoid arthritis?
The wrist joint is the most commonly affected joint, with over 70% of rheumatoid patients reporting dysfunction.
Are pyrocarbon MCP joint replacements suitable for rheumatoid arthritis patients? Why or why not?
Generally no, due to high complication rates (32%) and re-operation rates (29%), largely related to ligamentous laxity and joint deformity characteristic of rheumatoid arthritis.
What radiographic feature is pathognomonic for SCAC (scaphoid chondrocalcinosis advanced collapse) wrist?
Erosion of the proximal scaphoid into the radius. SCAC wrist characteristically presents with calcification of soft tissues (chondrocalcinosis), widened scapho-lunate interval, and scaphoid erosion into the radius.
How does SCAC wrist typically differ symptomatically from SLAC wrist?
SCAC wrist is rarely persistently symptomatic and usually responds well to non-operative management, unlike SLAC wrist, which often requires intervention.
Which crystals are involved in chondrocalcinosis seen in SCAC wrist?
Calcium pyrophosphate dihydrate (CPPD) crystals, leading to ligament attenuation and mid-carpal joint degeneration.
How does forearm pronation affect the length of the radius relative to the ulna?
Forearm pronation results in a relative shortening of the radius by approximately 1.95 cm, potentially causing dynamic ulnocarpal impaction.
When less than 4 mm of ulnar shortening is required, does arthroscopic wafer resection offer superior outcomes compared to ulnar shortening osteotomy?
No. Both procedures offer similar outcomes when shortening less than 4 mm, but arthroscopic wafer resection has a lower risk of secondary surgery.
What investigation is most accurate for diagnosing dynamic ulnocarpal impaction?
MRI, especially when performed with the wrist in pronation or clenched fist, is more accurate than radiographs for diagnosing dynamic ulnocarpal impaction.
In which condition was the Vaughan-Jackson lesion originally described?
Osteoarthritis. The original description by Vaughan-Jackson in 1948 involved extensor tendon ruptures secondary to osteoarthritic changes at the distal radio-ulnar joint.
Which direction does tendon rupture progression typically occur in Vaughan-Jackson lesions?
Tendon ruptures progress from the ulnar side (small finger) towards the radial side due to progressive attrition.
Which structure causes extensor tendon attrition in a Vaughan-Jackson lesion associated with osteoarthritis?
A bone spur on the dorsum of the distal ulna perforates the joint capsule and progressively causes attrition and rupture of the overlying extensor tendons.
Which fixation method for PIP joint arthrodesis has the lowest reported non-union rate?
Headless compression screw, with the lowest non-union rate (3.9%) compared to other fixation methods.
What fixation method has the highest non-union rate in PIP joint arthrodesis?
K-wire fixation, which carries the highest non-union rate (8.7%).
In addition to headless compression screws, which fixation method shows relatively low non-union rates for PIP joint arthrodesis?
Tension band wiring, with a non-union rate of approximately 4.1%.
What is the main consequence of scapho-lunate ligament disruption in SLAC wrist?
Rotational subluxation of the scaphoid due to loss of ligament continuity, causing eccentric loading and degenerative changes.
Is SLAC wrist typically caused by a single acute traumatic ligament injury?
No. SLAC wrist is typically degenerative and results from progressive attrition rather than acute ligamentous disruption.
Is proximal row carpectomy indicated for treatment of SLAC wrist grade 3?
No. Proximal row carpectomy is contraindicated in SLAC wrist grade 3 due to degenerative changes on the capitate head.
What radiographic feature is most characteristic of gouty arthritis in hand joints?
Peri-articular erosions with sclerotic margins, indicative of localized inflammation due to monosodium urate crystal deposition.
Are peri-articular calcifications typical for gouty arthritis?
No. Calcifications are characteristic of pseudogout (calcium pyrophosphate deposition) rather than gout (monosodium urate deposition).
Is loss of joint space a specific radiological sign of gouty arthritis?
No. Loss of joint space can occur secondarily but is not specific to gout; peri-articular erosions with sclerotic margins are more diagnostic.
What percentage of patients with Kienböck’s disease experience persistent functional limitation due to pain?
Approximately 25% of patients experience functional limitation and persistent pain.
Do clinical symptoms correlate well with the degree of carpal collapse in Kienböck’s disease?
No. Clinical symptoms often do not correlate well with radiographic progression or severity of carpal collapse.
Do coronal split fractures of the lunate associated with Kienböck’s disease typically heal spontaneously?
No. Coronal split fractures associated with lunate collapse in Kienböck’s disease have poor prognoses and typically do not unite spontaneously.
Are severe joint deformities in SLE arthritis typically accompanied by erosive cartilage damage?
No. Severe joint deformities in SLE occur without erosive cartilage damage or significant degenerative changes.
In Systemic Lupus Erythematosus (SLE), which carpal bone is most commonly subluxed or dislocated?
The lunate, typically affected due to ligamentous laxity without structural changes to the bones themselves.
Does Systemic Lupus Erythematosus (SLE) arthritis predominantly affect males or females?
Females. SLE is significantly more common in females, with a ratio of approximately 9:1 compared to males.
What is the most appropriate surgical treatment for a Nalebuff type 1 rheumatoid thumb deformity (boutonniere deformity)?
MCP joint synovectomy with extensor pollicis longus (EPL) tendon re-routing, correcting the boutonniere deformity caused by MCP synovitis and EPL tendon subluxation.
What deformity characterizes a Nalebuff type 1 rheumatoid thumb?
A boutonniere deformity, featuring MCP joint flexion with IP joint hyperextension, resulting from EPL subluxation due to synovitis.
In Nalebuff rheumatoid thumb classification, which type involves a deformity originating from the thumb MCP joint rather than the CMC joint?
Type 1 (boutonniere deformity). It originates primarily from synovitis at the MCP joint rather than degenerative CMC changes.
What is the most common cause of persistent pain following STT joint arthrodesis?
Radial styloid impingement, caused by failure to perform concomitant radial styloidectomy.
Is complex regional pain syndrome (CRPS) a common cause of persistent pain after STT joint arthrodesis?
No. CRPS incidence is relatively low (around 2%); radial styloid impingement is more frequent.
What adjunctive procedure is routinely performed during STT arthrodesis to prevent radial-sided wrist pain?
Radial styloidectomy, which alleviates impingement and reduces the incidence of postoperative persistent pain.
What is the most common cause of PIP joint swan neck deformity in rheumatoid arthritis?
Metacarpophalangeal (MCP) joint subluxation. Swan neck deformities in RA commonly result from intrinsic muscle tightness caused by MCP joint subluxation, as it leads to relative lengthening of extrinsic flexors and extensors.
What characteristic finger posture defines a swan neck deformity?
Hyperextension of the PIP joint and flexion at the DIP joint, resulting from dorsal migration of lateral bands and increased tension in the FDP tendon, impairing DIP joint extension.
What pathologies can lead to swan neck deformities in the hand?
Swan neck deformities can result from issues at the DIP, PIP, MCP joints, or carpus—including rupture of the terminal extensor, rupture of FDS tendon, volar plate laxity, intrinsic tightness, or MCP joint subluxation.
Which surgical procedure for Lichtman grade 3a Kienböck’s disease has the highest patient satisfaction rate?
Distal radius core decompression, with a satisfaction rate of 92%, popularized by Illarramendi due to observed resolution of Kienböck’s disease post-distal radius fractures.
Why is four corner fusion generally not recommended for Lichtman grade 3a Kienböck’s disease?
Due to impaired lunate vascularity and chondral degeneration, fusion is unreliable, and ongoing degeneration at radiolunate articulation can lead to persistent symptoms.
Is proximal row carpectomy indicated for Lichtman grade 3a Kienböck’s disease?
No, proximal row carpectomy is a salvage procedure, typically reserved for Lichtman grade 3b disease or worse, not indicated for the sclerosis and limited collapse characteristic of grade 3a.
How many points does a high positive rheumatoid factor or anti-CCP antibody test contribute to rheumatoid arthritis diagnosis based on ACR/EULAR 2010 criteria?
A high positive rheumatoid factor or anti-CCP antibody test scores 3 points, significantly contributing to a diagnosis of rheumatoid arthritis.
What total score is required for definitive rheumatoid arthritis diagnosis using ACR/EULAR 2010 criteria?
A summation score of 6 or greater across clinical and laboratory criteria is required to definitively diagnose rheumatoid arthritis.
How is joint involvement scored in the ACR/EULAR 2010 criteria for rheumatoid arthritis?
Joint involvement scores range from 1 point for 1 large joint involvement, up to a maximum of 5 points for involvement of more than 10 joints (small joint involvement is scored more heavily).
What percentage of patients undergoing thumb CMC joint denervation require further surgery for persistent pain?
Approximately 6%. A systematic review found a 6% revision rate due to persistent symptoms following thumb carpometacarpal joint denervation.
What is the overall complication rate of thumb denervation procedures reported in the literature?
The overall complication rate reported is approximately 11.4%, including minor complications.
What types of surgeries typically follow unsuccessful thumb denervation?
The most common subsequent surgery is trapeziectomy, following unsuccessful thumb carpometacarpal joint denervation.
What anatomical structures cause boutonniere deformity in rheumatoid arthritis?
Boutonniere deformity results from rupture of the central slip at the PIP joint due to synovitis, shifting extensor forces volarly via lateral bands, causing flexion of the PIP and hyperextension at the DIP.
Is boutonniere deformity typically a functional or aesthetic concern in rheumatoid arthritis patients?
Primarily an aesthetic problem rather than functional, unless flexion exceeds 70°, which interferes with grip function.
What surgical option reliably corrects a fixed boutonniere deformity?
Arthrodesis (joint fusion) is the only reliable surgical correction for a fixed boutonniere deformity in rheumatoid arthritis patients, given the difficulty correcting deformities through arthroplasty.
What is the optimal surgical procedure for treating Grade 1 osteoarthritis of the 1st CMC joint?
Eaton-Littler procedure. This involves reconstructing the volar oblique (beak) ligament using half of the FCR tendon, effectively stabilizing the joint and reducing synovitis and degenerative progression.
What procedure is indicated for Lichtman Grade 4 Kienböck’s disease?
Total wrist arthrodesis, as the lunate’s vascularity and cartilage are irreversibly compromised, making partial arthrodesis unreliable.
In rheumatoid arthritis affecting the MCP joints, when the medullary canal is too narrow for implants, what surgical option is recommended?
Tupper volar plate arthroplasty, preserving motion by resecting and reshaping the volar plate as a soft tissue interposition.
What procedure is appropriate for treating Vaughan-Jackson syndrome?
Watson’s matched distal ulnar resection, contouring the distal ulna to reduce impingement and attritional rupture of extensor tendons.
Which procedure is suitable for distal radio-ulnar joint instability with irreparable TFCC damage?
Adams procedure, reconstructing radioulnar ligaments using a tendon graft tunneled through the distal radius and ulna.
Which surgical approach and implant combination yields the lowest revision rate in PIP joint arthroplasty?
Volar approach with silicone implant, offering the lowest revision rate (6%).
Which method of PIP joint arthroplasty provides the greatest postoperative range of motion?
Volar approach silicone arthroplasty, averaging a 17° improvement in range of motion.
What type of PIP joint arthroplasty carries the greatest risk of postoperative swan neck deformity?
Surface replacement (Metal-Polyethylene) implants due to dorsal approach disruption and extensor tendon shortening.
Which surgical approach for PIP arthroplasty spares venous drainage and potentially reduces postoperative swelling?
Volar approach, preserving venous drainage and facilitating early rehabilitation.
Which type of PIP joint implant is associated with the highest prevalence of peri-prosthetic fractures?
Pyrocarbon implants, with the highest fracture rate (2%), typically occurring intraoperatively.
Which fixation method has the highest union rate in DIP joint arthrodesis?
Headless compression screw, achieving the highest union rate (96.1%).
Which fixation technique for DIP joint arthrodesis is associated with the highest infection rate?
Cerclage wire, having the highest infection rate (4.2%).
What fixation method uniquely risks nail abnormalities in DIP joint arthrodesis?
Headless compression screw fixation, uniquely associated with nail deformities.
What is the union rate for percutaneous DIP arthrodesis using a headless compression screw?
59% union rate, as this technique provides limited joint preparation and alignment correction.
What is the complication risk for DIP joint arthrodesis in patients with psoriatic arthropathy?
Up to 44%, significantly higher due to poor bone stock rather than fixation method.
Telangiectasia is a characteristic finding in which rheumatological condition affecting the hand?
Scleroderma, specifically CREST syndrome.
Which rheumatological disease causes characteristic “opera glass” digit deformities?
Psoriatic arthropathy, due to severe erosive arthritis and telescoping digit collapse.
Mannerfelt-Norman syndrome is associated with what rheumatologic condition?
Rheumatoid arthritis, characterized by volar bone spurs causing flexor tendon rupture, especially the FPL tendon.
Raynaud’s phenomenon is prominently associated with which rheumatological disorder?
Scleroderma, specifically the CREST subtype.
Which condition commonly causes nail pitting in conjunction with arthritis of distal joints?
Psoriatic arthropathy, affecting up to 41% of patients.
Which wrist arthroscopy portal provides the best visualization of dorsal carpal ligaments?
Volar ulnar portal, ideal for clear dorsal ligament visualization.
During wrist arthroscopy, establishing which portal places the radial artery at greatest risk?
The 1,2 portal, with the radial artery located approximately 3mm radial to it.
For accurate assessment of the scapholunate ligament during wrist arthroscopy, which portal is optimal?
Midcarpal radial (MCR) portal, allowing direct probe assessment.
Which wrist arthroscopy portal poses the greatest risk to the dorsal sensory branch of the ulnar nerve?
The 6R portal, with the nerve within 2.5mm proximity.
The wrist arthroscopy 3,4 portal is established between which anatomical structures?
Between the radioscapholunate ligament and the long radiolunate ligament, passing between EPL and EDC tendons.
