Rheumatology

Question 0

Describe the Nalebuff classification of swan neck deformities of the fingers in RA.

Answer 0

Type I Full AROM, no functional deficit, no intrinsic tightness.

Type II Intrinsic tightness only when MCPJ extended and radially deviated (corrected with ulnar deviation)

Type III PIPJ extension contracture and intrinsic tightness present regardless of ulnar deviation of extended MCPJ

Type IV X-rays show degenerative changes

Question 1

Should MTX be stopped perioperatively?

Answer 1

No difference in infection risk

Patient may suffer a flare of their connective tissue disorder

Question 2

Describe treatment for each joint deformity in a Nalebuff I rheumatoid swan deformity of the fingers.

Answer 2

MCP-not involved this early

PIPJ-silver ring splint, dermadesis (doesn’t work), FDS tenodesis, Littler ORL reconstruction

DIPJ-fusion

Question 3

Describe treatment for each joint deformity in a Nalebuff II rheumatoid swan deformity of the fingers.

Answer 3

MCPJ-intrinsic release

PIPJ-(same as for type I): silver ring splint, dermadesis (doesn’t work), FDS tenodesis, Littler’s ORL reconstruction

DIPJ-fusion

Question 4

Describe treatment for each joint deformity in a Nalebuff III rheumatoid swan deformity of the fingers.

Answer 4

MCPJ-intrinsic release, MCPJ reconstruction as needed

PIPJ-
For the Hyperextension: ring splint, dermadesis (doesn’t work), FDS tenodesis, Littler ORL reconstruction.

For the loss of PROM: MUA, dorsal skin release, lateral band mobilization, check for flexor adhesions.

DIPJ-fusion

Question 5

Describe treatment for each joint deformity in a Nalebuff IV rheumatoid swan deformity of the fingers.

Answer 5

MCPJ-intrinsic release, joint reconstruction as needed

PIPJ-fusion vs arthroplasty

DIPJ-fusion

Question 6

Describe the modified Nalebuff classification system for rheumatoid thumb deformities.

Answer 6

Type I (Most common) Boutonnière. CMC spared, MCP flexed, IP extended. Begins with mcpj synovitis.

Type II (rare) CMC subluxation, MCP hyper extension, IPJ hyper ext

Type III (second most common) Swan, treated just like in DJD, but lean toward fusion IPJ

Type IV (gamekeepers) (CMC not involved)-if early, reconstruct UCL. If late, fuse.

Type V MCP hyperextended secondary to volar plate stretch. IPJ hyper flexes due to increase tension on FPL. Simply stabilize MCP and the rest corrects.

Type VI Arthritis mutilans–usually fusions with structural bone grafts