The Rheumatoid Hand Deformities & Management. Dr. Anirudh Sharma Resident Department of Orthopedics

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1 + The Rheumatoid Hand Deformities & Management Dr. Anirudh Sharma Resident Department of Orthopedics

2 + Why is Rheumatoid Arthritis important?

3 + RA is a very debilitating disease median life expectancy decreases by 10 years for women & by 4 years for men 1/3 patients stop work within 5 years of diagnosis, 1/2 within 10 years

4 + Introduction systemic autoimmune disorder with chronic systemic erosive synovitis deformities secondary to hypertrophied synovial tissue most common cause of inflammatory joint disease

5 + Introduction 1-3% prevalence peak during fourth and fifth decade women affected 3 4 times more than men

6 + Pathophysiology inflammatory pathways that lead to proliferation of synovial cells in joints pannus formation leads to underlying cartilage destruction and bony erosions overproduction of proinflammatory cytokines (TNF, IL-6)

7 + Pathophysiology

8 + What is Rheumatoid Factor? n B-cell activation leads to the production of anti-igg autoantibodies n these are detected in the blood as rheumatoid factor (RF)

9 + Presentation Early: pain and morning stiffness > 30 minutes involving PIP and MCP joints fatigue, weight loss and low-grade fever swelling due to synovitis or subtle synovial thickening may be palpable

10 + Presentation Late: joint deformities instability destruction

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13 + Diagnostic Test RF, anti-ccp, or both CRP and ESR used to follow disease activity and response to medication CBC Xray - hands evaluate for periarticular erosive changes

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16 + Treatment n Methotrexate: first-line treatment in patients with active RA n Leflunomide used as an alternative to methotrexate n Sulfasalazine or hydroxychloroquine is recommended as monotherapy in patients with low disease activity

17 + n Combination therapy more effective than monotherapy n If RA is not well controlled, a biologic DMARD should be initiated n TNF inhibitors are first-line biologic therapy n If TNF inhibitors ineffective, additional biologic therapies can be considered

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20 + Rheumatoid Deformities Hand

21 + Hand Deformities n Ulnar drift of fingers & Radial deviation of wrist n Swan neck deformity n Boutonniere deformity n Mallet finger n Trigger finger n Drop finger

22 + Metacarpo-phalangeal deformities carpal row slides ulnarwards è metacarpals deviate radialwards è reciprocal ulnar deviation of mcp joint (zig-zag mechanism)

23 + Management of MCP joint deformity n Splintage n Synovectomy n Reefing of radial sagittal bands n Tightening of radial collateral ligament n Intrinsic muscle release and transfer n Arthroplasty

24 + MCP Joint Arthroplasty n Indications n Pain with arthritis n Severe ulnar drift with loss of function n Marked flexion contractures n Decreased arc of motion (< 40 deg.) n Contraindications n Poor bone stock n Poor skin condition

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26 + Swan Neck Deformity PIP joint is hyperextended and the DIP joint flexed Occurs due to: 1. If PIP extensors overact 2. If PIP flexors are inadequate 3. If Palmar Plate fails

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28 + Management of Swan-Neck Deformity n Figure of eight ring splint n FDS tenodesis n Lateral band mobilization n Arthrodesis / arthroplasty

29 + Boutonniere Deformity n fixed flexion of the proximal and hyperextension of the DIP joint n due to interruption or stretching of the central slip of the extensor tendon

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31 + Management of Boutonniere deformity n Post-traumatic (early) n Splint PIP in full extension for 6 weeks n Open injuries n Repair central slip + K wire fixation for 3 weeks n Division of extensor tendon just proximal to its insertion

32 + Mallet Finger n injury to the extensor tendon of the terminal phalanx n terminal joint held flexed, but passive movement is normal n X-rays are taken to show or exclude a fracture.

33 + Management of Mallet Finger deformity n With bony injury: n Minimal subluxation splintage in extension for 6 weeks n Large fragment with subluxation operative (complications high) n Without bony injury: n Splint DIP joint in extension 8 weeks è 4 weeks night splintage n Fusion for arthritic joints

34 + Trigger Finger n Thickening of flexor tendon sheath è snap felt with forced extension n lead to secondary nodule development over tendon

35 + Management of Trigger finger n injection of corticosteroid at the mouth of the tendon sheath n Operative: incise A1 section of the fibrous until tendon moves freely

36 + Dropped Finger n sudden loss of extension at MCP joint n due to tendon rupture at wrist

37 + Surgical Indications n Pain relief n Restoration/improvement of function n Prevention of deformities n Improvement of appearance

38 + Surgical options n Synovectomy n Tendons n Joint n Contracture releases

39 + Surgical options n Tendon reconstruction n Repair n Adjacent tendon suture n Intercalated graft n Tendon transfer n Arthroplasty n Arthrodesis

40 + Thank You