Abstract
Rheumatoid arthritis is a systemic progressive inflammatory disease. It commonly affects the hand and wrist joints, causing joint damage, deformity, dysfunction, and disability. Common joint deformities of the hand include boutonnière deformities, swan neck deformities, and ulnar deviation of the fingers. Joint damage occurs early in the course of the disease. Radiologic evidence of joint damage (bony erosions) can be seen in 30% of patients at the time of diagnosis and in 60% of patients by 2 years. The goal of treatment is not only symptom relief but to prevent future structural damage, maintain function, and minimize disability. These goals are achieved through early diagnosis and early use of disease-modifying antirheumatic drugs. Diffuse periarticular osteopenia is the earliest radiographic sign of rheumatoid arthritis. Joint space narrowing and periarticular erosions are later radiographic findings. Rheumatoid deformities typically progress slowly, and patients often adapt well. Surgery is considered when correction of a deformity will improve function. In some cases, realignment or stabilization of one joint or finger will actually decrease function because it will interfere with an adaptive mechanism. For this reason, surgery for rheumatoid deformities must carefully match the functional goals of the patient with the risks and benefits of operative intervention. Rehabilitation of the rheumatoid hand involves adaptation and work simplification instructions, splinting regimens, heat modalities, and active range of motion and resistive exercises.
Keywords
Rheumatoid, arthritis, Hand, Swan neck deformity, Boutonnière deformity, Periarticular erosions
| Synonyms | |
| |
| ICD-10 Codes | |
| M05 | Rheumatoid arthritis with rheumatoid factor |
| M05.73 | Rheumatoid arthritis with rheumatoid factor of wrist without organ or systems involvement |
| M05.731 | Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems |
| M05.732 | Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems |
| M05.739 | Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement |
| M05.74 | Rheumatoid arthritis with rheumatoid factor of hand without organ or systems involvement |
| M05.741 | Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement |
| M05.742 | Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement |
| M05.749 | Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement |
| M06.0 | Rheumatoid arthritis without rheumatoid factor |
| M06.03 | Rheumatoid arthritis without rheumatoid factor, wrist |
| M06.031 | Rheumatoid arthritis without rheumatoid factor, right wrist |
| M06.032 | Rheumatoid arthritis without rheumatoid factor, left wrist |
| M06.039 | Rheumatoid arthritis without rheumatoid factor, unspecified wrist |
| M06.04 | Rheumatoid arthritis without rheumatoid factor, hand |
| M06.041 | Rheumatoid arthritis without rheumatoid factor, right hand |
| M06.042 | Rheumatoid arthritis without rheumatoid factor, left hand |
| M06.049 | Rheumatoid arthritis without rheumatoid factor, unspecified hand |
| M06.9 | Rheumatoid arthritis, unspecified |
Definition
Rheumatoid arthritis (RA) is a systemic progressive inflammatory disease causing joint damage, deformity, dysfunction, and disability. Hand and wrist joints are commonly involved in RA. Common joint deformities of the hand include boutonnière deformities, swan neck deformities, and ulnar deviation of the fingers. Joint damage occurs early in the course of the disease. Treatment for RA has significantly changed over the past 20 years. The presence of a joint erosion in a patient with joint swelling and no other obvious cause establishes the diagnosis of RA. The goals of treatment are not only symptom relief, but also to prevent structural damage, maintain function, and minimize disability. These goals are achieved through early diagnosis and early use of disease-modifying antirheumatic drugs (DMARDs). Methotrexate is the recommended first line treatment option for RA. The widespread early use of methotrexate has transformed RA into a much less devastating disease. The availability of targeted biologic therapies, such as the tumor necrosis factor (TNF) antagonists, has further improved the outcome of RA. Surgery has become much less common and more straightforward in patients with RA. For a discussion of RA, see Chapter 152 .
Symptoms
Presenting symptoms in the hand include joint pain in the fingers as well as stiffness and swelling, typically involving the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints but—in contrast to osteoarthritis—sparing the distal interphalangeal (DIP) joints. Stiffness usually is most pronounced in the morning.
Physical Examination
The evaluation of a hand affected by rheumatoid arthritis should include assessment of the following: joint pain and inflammation; joint stability; limitations in active and passive range of motion; grip and pinch strength deficits; limitations in hand dexterity; and degree of disability with respect to self-care, vocational activities, and recreational activities.
Early in the disease course, involved joints are usually stiff, painful, and swollen as synovitis predominates. In some patients, the first sign of RA may be extensor tenosynovitis on the dorsum of the hand and wrist or de Quervain tenosynovitis (although this can also be an idiopathic condition). Chronic synovitis may destroy capsuloligamentous and tendinous structures, creating laxity and deformity. In RA, in contrast to the arthritis of systemic lupus erythematosus, this soft tissue damage is usually accompanied by destruction of bone with periarticular erosions evident on radiographs.
Typical hand deformities associated with advanced RA include subcutaneous rheumatoid nodules, radial deviation of the wrist, ulnar drift at the MCP joints, boutonnière deformities (flexion of the PIP joint and extension of the DIP joint), and swan neck deformities (hyperextension of the PIP joint with flexion of the DIP joint). It is not uncommon to see varying patterns on the fingers of one hand ( Fig. 34.1 ).
Inability to extend the index through small fingers may be due to the following: deformity and subluxation or dislocation of the index through small finger MCP joints; ulnar translocation of the extensor tendons due to laxity and destruction of the radial sagittal bands; extensor tendon ruptures due to a combination of dorsal tenosynovitis and distal radioulnar joint deformity or abrasions; or posterior interosseous nerve compression by elbow synovitis. Ulnar drift of the fingers usually accompanies each of these deformities.
Rupture of the extensor tendons usually proceeds in a sequence from ulnar to radial, referred to as the Vaughn-Jackson syndrome. Mannerfelt syndrome is the equivalent on the volar side, progressing from the thumb to the index and long fingers, producing flexor tendon ruptures as a result of bony spurs from erosion of the scaphoid bone and trapezium, most often the flexor pollicis longus tendon.
Synovitis in the wrist may result in volar and ulnar subluxation and supination of the hand in relation to the forearm (radial deviation at wrist). This wrist deformity can exacerbate the Vaughn-Jackson syndrome and ulnar drift (ulnar deviation at MCP joints).
Extensive synovitis or tenosynovitis may cause nerve compression, but, except for carpal tunnel syndrome, this is uncommon now that synovitis can be controlled by effective medications.
Functional Limitations
Chronic inflammation and disease progression causes hand pain and may cause ligament laxity, muscle and tendon weakness, ligament and tendon ruptures, and muscle and tendon contractures which result in significant functional limitations. Hand, wrist, and upper extremity fine motor skills and gross motor tasks can become impaired, impacting activities of daily living (ADLs), vocational and recreational activities, and quality of life. Rheumatoid deformities typically progress slowly, and patients often adapt well. In some cases, realignment or stabilization of one joint or finger will actually decrease function because it will interfere with an adaptive mechanism. For this reason, surgery for rheumatoid deformity must carefully match the functional desires and goals of the patient with the risks and benefits of operative intervention. Many severe deformities are left untreated when patients have adapted well.
Diagnostic Studies
The diagnosis of RA is based predominantly on its clinical presentation. Laboratory testing is used to monitor disease activity and toxicity of drug therapy. Acute phase reactants, such as C-reactive protein and erythrocyte sedimentation rate, may be elevated in the setting of active joint inflammation, but nearly 60% of patients with active rheumatoid arthritis have both normal C-reactive protein and erythrocyte sedimentation rate. Many patients with RA have circulating rheumatoid factor or anti-citrullinated protein antibodies. The presence of one of these serologic markers suggests a more aggressive and destructive disease course.
Diffuse periarticular osteopenia is the earliest radiographic sign of RA. Joint space narrowing and periarticular erosions may be observed in more than half of patients with RA during the first 2 years of disease. If left untreated, joints involved by RA may be destroyed by chronic synovitis ( Fig. 34.2 ).
Clinical examination and radiographs can lack sensitivity and accuracy to detect early signs of joint inflammation and structural damage. Ultrasound is more sensitive for detecting early and minimal synovitis even in clinically unaffected joints. Doppler and gray-scale ultrasound findings predict the appearance of later structural damage on conventional radiographs. Ultrasound can be used to differentiate between articular synovial inflammation and tenosynovitis, bursitis, or other soft tissue lesions as the cause of joint swelling. Magnetic resonance imaging of the hand may reveal synovitis and erosions early in the course of RA, before they are apparent on plain radiographs.
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