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Ebopras > Rheumatoid Hand > Flashcards

Rheumatoid Hand Flashcards

1
Q

What are the three primary goals in treating the rheumatoid hand?

A

PRC:
1. Pain relief.
2. Restoration of function.
3. Cosmetic improvement of the hand.

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2
Q

What are the three basic principles in rheumatoid hand surgery?

A
  1. Synovectomy/soft tissue reconstruction done early in disease.
  2. Highly erosive disease (arthritis mutilans) treated early with fusion before bone loss.
  3. Correction of deformity that causes loss of motion and may severely compromise hand function.
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3
Q

What surgical sequence should be followed in a rheumatoid patient?

A
  1. Lower extremity addressed first.
  2. Proximal joints before distal joints (eg, elbow before wrist, wrist before metacarpophalangeal joint [MCPJ] and proximal interphalangeal joint [PIPJ]).
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4
Q

What is an essential part of the preoperative evaluation in a rheumatoid patient?

A

Cervical spine evaluation. Twenty-five percent to 50% of patients can have atlantoaxial instability (plain cervical
radiographs including flexion and extension views are standard).

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5
Q

❍ What is the pathogenesis in rheumatoid arthritis (RA) of the hand?

A

Autoimmune disorder resulting in erosive synovitis of the hand and wrist secondary to injury to synovial microvascular endothelial cells triggering an inflammatory reaction causing influx of polymorphonuclear leukocytes (PMNs), monocytes, and macrophages.

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6
Q

Inflammatory cells/mediators produced by macrophages, monocytes, PMNs stimulate which cell type in the rheumatoid hand?

A

Osteoclast. These are responsible for subchondral osteopenia.

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7
Q

What are the extra-articular manifestations seen in RA? Which one is most common?

A

Vasculitis, pericarditis, pulmonary nodules, episcleritis, and subcutaneous nodules. Subcutaneous nodules (25% of patients with RA).

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8
Q

Manifestation of accumulated inflammatory cells around capillaries of the synovium and tenosynovium is known as:

A

Synovitis and tenosynovitis.

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9
Q

Is pattern of joint involvement in RA different from osteoarthritis (OA) of the hand?

A

Yes. In RA, MCPJ and PIPJ are commonly involved. In OA, distal interphalangeal joint and basilar joint of thumb
are involved.

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10
Q

What are Bouchard’s nodes?

A

Enlargement of PIPJ seen mainly in RA. ∗∗Heberden’s nodes are seen in OA and refer to DIP enlargement.

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11
Q

What is the most frequently affected area about the wrist in RA patients?

A

Distal radioulnar joint (DRUJ).

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12
Q

Decreased active digital flexion in a patient with RA is usually caused by what?

A

Synovial nodules within flexor tendons. These nodules within retinacular system reduce active flexion of finger.

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13
Q

What is the natural course of rheumatoid disease with articular involvement at the MCPJ?

A

Progressive joint erosion and collapse with palmar displacement.

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14
Q

How do tendon ruptures of the hand and wrist occur in patient with RA?

A

By attrition (abrasion over bony prominences), infiltration (synovitis), and ischemia (external pressure by
compressive synovium).

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15
Q

How is the wrist affected in patients with RA?

A

Synovitis begins in ulnar aspect of the wrist with the DRUJ and radiocarpal joint first affected, usually sparing the midcarpal joint. Erosive changes seen at the prestyloid recess of the ulnar styloid, sigmoid notch of radius, insertion of radioscapholunate ligament, and the scaphoid waist. The carpus subluxes ulnarly and volarly with supination relative to radius. This carpal alignment leads to radial deviation of the metacarpals.

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16
Q

What is the natural course of wrist deformities with rheumatoid disease?

A

Supination, palmar dislocation, radial deviation, and volar–ulnar dislocation of the carpus on the radius

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17
Q

What are the treatment options available for the rheumatoid DRUJ/wrist?

A

Synovectomy of radiocarpal joint and DRUJ :Pain relief, done after 6 months of medical treatment and no radiographic changesPartial arthrodesis (radiolunate and scaphoradiolunate fusions):
Prevents progression of collapse
Radiolunate preserves function in patients with ulnocarpal translocation.
Resectionhemiarthroplasty of DRUj:
Preserves length of ulna and TFCC attachments. No DRUJ contact on pronation/supination—pain relief
Darrach procedure (resection of distal ulna)Easy. Can have radioulnar impingement/instability.Sauve ́–Kapandji(fusionofDRUJ,osteotomy of ulna at radial metaphyseal flare):LesscosmeticdefectthanDarrach.Canhaveradioulnar impingement. Good for younger patients.
Total wrist arthrodesis:
90%–95% good to excellent results (fused in 10◦–20◦ extension and neutral deviation)Wrist arthroplasty:Motion-preserving procedure (good bone stock, minimal deformity, intact extensors)

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18
Q

What is the total wrist arthroplasty experience in the United States?

A
  1. 1967: Swanson. Silicone hinge.
  2. 1972: Meuli. Ball and trunnion.
  3. 1973: Volz. Dorsopalmar tracking.
  4. 1977: Figgie and Ranawat. Trispherical (hinge). 5. 1982: Beckenbaugh. Biaxial (ellipsoidal).
  5. 1990: Mennon. Universal (anatomic).
  6. 2002: Adams. Universal 2 (uncemented).
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19
Q

❍ What are current accepted indications for total wrist arthroplasty?

A
  1. Painful pancarpal (diffuse) and advance arthritis.
  2. Progressive deformity with advanced arthritis.
  3. Patients who do not use walking aids with affected hand.
  4. Other joints of same extremity have significant limitations.
  5. Personal factors (low-demand activities that require wrist motion). 6. Contralateral wrist fused.
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20
Q

What are current accepted contraindications for total wrist arthroplasty?

A
  1. Previous sepsis.
  2. Rupture and not fully reconstructible wrist extensors.
  3. Resorption of distal carpal row.
  4. Previous wrist arthrodesis (autofusion not a contraindication)
  5. Previously failed silicone implant if fragmented and silicone synovitis. 6. Progressive deformity with advanced arthritis.
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21
Q

In the rheumatoid hand, are women affected more than men?

A

Yes. 2.5:1.

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22
Q

What is a painless dorsal wrist mass distal to the extensor retinaculum typically in RA patients?

A

Typical presentation of extensor tenosynovitis. Tenosynovectomy indicated after 4 to 6 months of medical
treatment to prevent rupture of extensor tendon.

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23
Q

What is the differential diagnosis of a patient with a rheumatoid hand and with inability to extend his fingers?

A
  1. Ulnar subluxation of the extensor tendon over MP joints second due to attritional lengthening of the radial sagittal band.
  2. Posterior interosseous nerve palsy (PIN) because of synovitis at the elbow.
  3. MP joint subluxation/dislocation.
  4. Extensor tendon attritional rupture.
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24
Q

When should PIN palsy at the elbow should be prime consideration in RA patients?

A

Inability to extend all four fingers and IP joint of thumb. Also, unable to deviate the wrist ulnarly secondary to extensor carpi ulnaris (ECU) paralysis.

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25
Q

Does a patient with an extensor tendon rupture have the ability to maintain digit extended if passively placed in that position?

A

No. They also lose the tenodesis effect of the hand (eg, finger extension with wrist flexion and vice versa).

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26
Q

In decreasing incidence, which extensor tendons are affected by RA?

A

Extensor digiti minimi (EDM), extensor digitorum communis (EDC) 5, EDC 4, EPL, EDC 3.

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27
Q

What anatomical landmark contributes to extensor pollicis longus rupture in patients with RA?

A

Lister’s tubercle. Contributes to attritional rupture while acting as a bone pulley.

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28
Q

What is Vaughn–Jackson syndrome?

A

Ischemic rupture of ulnar extensor tendons secondary to prominent irregular ulnar head. Most common cause of
tendon rupture in RA patients.

29
Q

What is caput ulnae syndrome?

A

Failure of the ulnar aspect of the wrist and DRUJ secondary to RA resulting in: 1. dorsal dislocation of distal ulna
2. supination of carpus on the radius
3. volar subluxation of ECU

30
Q

What is the “piano keyboard sign”? What does it signify?

A

Elicited when the prominent ulnar head is volarly depressed and rebounds as pressure is released. DRUJ instability,
seen in a third of patients with RA.

31
Q

What is the scallop sign in patients with RA?

A

Erosion of the radial sigmoid notch with formation of a sclerotic border. It is an ominous sign of impending
extensor tendon ruptures.

32
Q

When is extensor tendon surgery indicated in patients with RA?

A
  1. refractory to medical treatment
  2. dorsal dislocation of the ulnar head
  3. a positive scallop sign
  4. recurrent dorsal tenosynovitis
33
Q

Is surgery needed after an extensor tendon rupture in RA patients to prevent damage to intact tendons?

A

Yes. Unchecked tenosynovitis damages outer surfaces of underlying tendons, leads to tendon adhesions and eventual attritional rupture.

34
Q

What is referred to as a pseudotendon in patients with RA?

A

A thin strand of opaque tissue situated between healthy appearing tendinous material proximally and distally.

35
Q

Attritional rupture of flexor pollicis longus (FPL) is known as?

A

Mannerfelt–Norman syndrome. Most common flexor tendon rupture in RA.

36
Q

Where is the most common location for rupture of FPL?

A

Scaphoid. Secondary to a spur at the level of STT joint. ∗If spur not excised, it will lead to tendon ruptures of the
FDP tendons in a radial to ulnar progression.∗

37
Q

What is the most common location of flexor tenosynovitis?

A

The palm. Seen as pain, triggering, and tendon rupture with passive finger flexion that is greater than active flexion.

38
Q

Should the A1 pulley be preserved in rheumatoid patients?

A

Yes. Avoids increasing the lever arm of the tendon and thus potentiating flexion deformity at the MP joints.

39
Q

Triggering secondary to digital flexor tenosynovitis usually locks the digit in flexion. What is happening if locked in extension?

A

Profundus tendon nodule distally at the A2 pulley is the cause of locking.

40
Q

What is referred to as a pseudotendon in patients with RA?

A

A thin strand of opaque tissue situated between healthy appearing tendinous material proximally and distally

41
Q

Attritional rupture of flexor pollicis longus (FPL) is known as?

A

Mannerfelt–Norman syndrome. Most common flexor tendon rupture in RA.

42
Q

Where is the most common location for rupture of FPL?

A

Scaphoid. Secondary to a spur at the level of STT joint. ∗If spur not excised, it will lead to tendon ruptures of the
FDP tendons in a radial to ulnar progression.∗

43
Q

What is the most common location of flexor tenosynovitis?

A

The palm. Seen as pain, triggering, and tendon rupture with passive finger flexion that is greater than active flexion.

44
Q

Should the A1 pulley be preserved in rheumatoid patients?

A

Yes. Avoids increasing the lever arm of the tendon and thus potentiating flexion deformity at the MP joints.

45
Q

Triggering secondary to digital flexor tenosynovitis usually locks the digit in flexion. What is happening if locked in extension?

A

Profundus tendon nodule distally at the A2 pulley is the cause of locking.

46
Q

Ruptured Tendon,Transfer Recommended

A

EPL. –>EIP to EPL or EPB to EPL at metacarpal level
EDM and EDC5, or EDM alone –>EIP to EDC5 or EDM, side to side to EDC4
EDM, EDC5, EDC4 –>EDC4 side to side to EDC3, EIP to EDM or EDC5, tendon grafts
EDC5/EDM, EDC4, EDC3 –>FDS (long) to EDC4 and EDC5, EDC3 side to side to EDC2/EIPEDC5/EDM, EDC4, EDC3, EDC2 –>FDS (long) to EDC2 and EDC3, FDS (ring) to EDC4 and EDC5

47
Q

How is tension adjusted in extensor tendon reconstruction/transfer in patients with RA?

A

Wrist in 40◦ extension the MCP joints are capable of 15◦ of flexion and wrist in full extension complete MCP
flexion should be possible.

48
Q

What is associated with extension loss for all four fingers with absence of all digital extensor and proprius tendon function at surgery?

A

Palmar dislocation of the carpus on the radius rather than extensor tenosynovitis.

49
Q

What is a contraindication in using the superficialis flexor tendon for extensor tendon transfer in RA?

A

Presence of swan neck deformity and significant flexor tenosynovitis.

50
Q

What is the recommended treatment for loss of wrist extensors in RA?

A

Arthrodesis of the wrist.

51
Q

What is Clayton procedure in the rheumatoid hand? Prevents what?

A

Transfer of the ECRL to ECU. Redistributes wrist forces diminishing radial rotation and volar subluxation of
carpus at the wrist.

52
Q

What are the eight steps leading to MCPJ ulnar drift?

A
  1. Synovitis leading to stretching of radial sagittal bands.
  2. Extrinsic extensors subluxate into intermetacarpal sulcus, become ulnar deviators.
  3. Lax MP collateral ligaments from joint synovitis allow ulnar deviation.
  4. Synovitis causing further damage to cartilage and bone—destabilizes MCPJ.
  5. Ulnar intrinsics contract and become ulnar and volar deforming forces.
  6. Radial deviation of wrist alters vector pull on the extrinsic extensors toward ulnar direction. 7. Flexor sheath synovitis distends retinaculum allowing the flexors to shift in an ulnar direction. 8. Resultant forces during pinch are in volar and ulnar directions.
53
Q

What is the Nalebuff classification of MCPJ in a rheumatoid hand?

A

Stage I: only synovial proliferation.
Stage II: recurrent synovitis without deformity.
Stage III: moderate articular degeneration, ulnar and palmar drift of digits that is passively correctable. Stage IV: severe joint destruction with fixed deformities.

54
Q

What is the treatment recommendation based on the Nalebuff classification of MCPJ?

A

Stage I: medical management and splinting.
Stage II: synovectomy (after 6 months of medical treatment).
Stage III: synovectomy plus extensor tendon relocation, intrinsic releases, crossed intrinsic transfers, and radial
collateral ligament imbrication.
Stage IV: silicone spacer combined with relocation of extensors and radial collateral ligament imbrication. ∗∗Surgical intervention reserved for patients with pain and functional disability.

55
Q

If you have MCPJ disease and tendon rupture, which do you treat first?

A

MCPJ. Multiple authors recommend treating both at same time.

56
Q

What is the reported arc of motion usually achieved after silicone interposition arthroplasty for MCPJ in patients with RA?

A

40◦ to 60◦. Regression of digits ulnarly commonly seen, typically < 10◦.

57
Q

What is a swan neck deformity? Causes?

A

PIP hyperextension and DIP flexion. DIP mallet, synovitis attenuating volar plate, FDS rupture, and intrinsic tightness from MCPJ disease.

58
Q

What is the recommended treatment and classification for rheumatoid swan neck deformity?

A

∗∗Classification based on severity of PIP deformity, stiffness, and arthritis (radiographic findings).
type 1:PIP flexible in all MCPJ positionsProximal Fowler tenotomy, flexor PIP tenodesis, SORL reconstruction
type 2:PIP joint flexion position dependent on MCPJ
Intrinsic release and/or realignment or arthroplasty MCPJ
type 3 PIP flexion limited in all MCPJ positions Open capsular release, dorsal skin releases, closed manipulation with/without pinning, lateral band mobilization
type 4:Radiographic joint destruction with minimal PIP joint motion Arthrodesis and arthroplasty

59
Q

What is a boutonnie`re deformity? Causes?

A

Hyperflexion of PIP joint and hyperextension DIP joint. Synovitis leading to attenuated central slip, volar
subluxation of lateral bands, tight transverse retinacular ligament, and volar plate contracture.

60
Q

What is the recommended treatment and classification for rheumatoid boutonnie`re deformity?

A

∗∗Classification based on PIP motion and severity of arthritis.
type 1:Mild loss of PIP active extension, full passive PIP extension
Synovectomy, inject PIP and splints, lateral band, or distal Fowler’s tenotomy
type 2: Moderate loss of PIP extension, full passive PIP extension
Synovectomy, central slip reconstruction, lateral band reconstruction, or distal Fowler’s tenotomy
type 3:PIP not passively correctable, no arthritic changes
PIP injection, serial extension casting, consider type II treatment if motion restored
type 4:Fixed PIP contracture, arthritic changesObjective is to reduce PIP, PIP fusion or arthroplasty

61
Q

What is the most common rheumatoid thumb deformity?

A

Boutonnie`re deformity (MP joint flexion and IP joint hyperextension).

62
Q

What is the Nalebuff classification of rheumatoid thumb?

A

Type I: Boutonniere deformity. Type II: Boutonniere deformity with CMC involvement
Type III: Swan neck deformity (stage 1: CMC synovitis, stage 2: CMC joint synovitis, MP joint extension
deformity correctable, stage 3: CMC joint destruction, MP joint extension deformity fixed) Type IV: Gamekeeper deformity
Type V: Swan neck deformity with MP joint and CMC unaffected
Type VI: Arthritis mutilans

63
Q

What is the recommended treatment for the first four stages of the rheumatoid thumb?

A

Early Disease /Moderate Disease /Advanced Disease
type 1:MP synovectomy and EPL rerouting
MP fusion or arthroplasty
IP fusion and MP arthroplasty
type 2:MP synovectomy and EPL rerouting
MP joint fusion and CMC hemiarthroplastyMP joint fusion and CMC hemiarthroplasty
type 3:
CMC partial trapezial/ metacarpal base resection CMC implant arthroplastyMP fusion
CMC partial trapezial/ metacarpal base resection
MP fusion
CMC partial trapezial/metacarpal base resection
CMC implant arthroplasty Release first web space contracture
type 4:MP synovectomy, UCL reconstructionMP fusion
MP fusion
Release first web space contracture

64
Q

What is the recommended treatment for the stages V and VI of the rheumatoid thumb?

A

Stage V:
a. No articular degeneration of MCPJ—volar capsulodesis. b. Articular degeneration—MCPJ fusion.
Stage VI: Fusion and soft tissue balancing when possible.

65
Q

What are the three major types of juvenile rheumatoid arthritis (JRA)?

A

(∗∗Based on presentation at onset of diagnosis and during first 6 months of disease.) 1. systemic onset (25%)
2. polyarticular onset (30%)
3. pauciarticular onset (45%)

66
Q

What are the characteristics of pauciarticular onset JRA?

A
  1. Involvement of fewer than five joints in an asymmetric pattern.
  2. Involvement of large joints.
  3. Male
    Onset 10 years old
    ANA and RF negative HLA–B27 association
    Lower extremity involvement Risk for sacroiliitis
    Female
    Onset < 6 years old
    ANA and RF positive Predominance of iridocyclitis
67
Q

Name five clinical differences found in JRA not found in the rheumatoid hand?

A
  1. Ulnar deviation of wrist and metacarpals.
  2. Radial deviation of MCP J.
  3. Abnormal ring and small finger metacarpals secondary to long bone epiphyseal accelerated maturation. 4. Shortened ulna.
  4. Narrow small tubular bones of the hand (hand size is small).
68
Q

What is Still disease?

A

It is the systemic onset of 20% JRA cases. Clinical findings consist of: 1. intermittent high fevers
2. transient arthritis with associated fevers
3. hepatosplenomegaly, lymphadenitis, uveitis
4. leukocytosis and anemia
5. rheumatoid factor not present
6. severe, chronic arthritis in only 25% of patients

Ebopras (32 decks)

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