Rheumatoid Hand
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- Wrist - caput ulna, RADIAL deviation
- Fingers - boutonniere, swan neck, ULNA deviation
- Thumb - Z shape (Boutonierres), gamekeeper, swan neck
- Tendon Ruptures - dropped fingers (Vaugh Jackson Syndrome), Mannerfelt syndrome (FPL)
- Acute inflammation - synovitis, swelling, erythema
- Nerve - Median nerve
- Check function
- Proximally - elbow rheumatoid nodules
- Complete - Lung for fibrosis, Eye for uveitis
- Ddx - plaques for psoriasis
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- "Bilateral symmetrical involvement"
- Erosions in MCP and PIPJ
- "periarticular osteopenia, Uniform joint space loss, bone erosions, soft tissue swelling, joint subluxation, subchondral cysts”
- Radial deviation of wrist, ulnar deviation of fingers at MCPJ
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- Principles will be big joint Lower limb replacement first
- This is to allow the use of walking aids without disrupting the UL recon
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- Proximal to distal
- Address caput ulna to prevent future tendon ruptures
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- This question is going specific into each hand deformity
- Deposition of Immune complex → panus → synovitis → joints and tendon ruptures
- [Ulnar Deviation] Disruption of RC ligaments → radial deviation of wrist → changes tendon pull on the digits ➔ ulnar deviation
- [Swan neck] Synovitis at MCPJ volar ➔ Volar subluxations of MCPJ ➔ extensors overpowered ➔ PIPJ Volar plate attenuation ➔ hyperextension of PIPJ
- [Boutonierre] Synovitis at central slip ➔ rupture of central slip at base of P2 ➔ Lateral slips sublux volarly
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- it is the volar subluxation of the carpus resulting in the prominent ulna head
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- 2 options of Bony procedures:
- Resection of distal ulna - Darrach's
- Arthrodesis of DRUJ with proximal pseudoarthrosis- Suave Kapanji technique
- Caput Ulnar.pdf
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- Resection Darrach's (+) Easy; (-) Progression of ulna translation of carpus with further sliding
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- Disruption of digital extensor tendons, beginning on the ulnar side with the EDM ➔ sequential rupturing of EDC ➔ EIP
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- Rupture of the FPL tendon caused by bony spur in carpal tunnel
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- Dependant on chronicity - if acute with fresh tendon edges - consider bridge graft e.g. Palmaris longus or FCR
- if chronic and require tendon transfer ➔ FDS tendon
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- Can be due to PIN palsy or tendon rupture or sagittal band rupture (in RA - due to volar subluxation of MCPJ also) . Do 2 tests -
- Check tenodesis test ➔ if positive = nerve problem or Sagittal band rupture
- Check if fingers can maintain extension ➔ if positive = sagittal band rupture
- Check for volar subluxation of MCPJ ➔ should be stiff and joints not reducible
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- Address primary pathophysiology of attrition. Darrach procedure to remove ulnar head (cause of ruptures)
- Options:
- 1. EIP to motor both EDM and ring finger
- 2. EIP to motor EDM, long finger EDC side to side to EDC ring finger
- 3. If insufficient tendons - PL and FDS tendons
Boutonnieres
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- Rupture of central slip that attaches to base of P2 resulting in flexion of PIPJ and Hyperextension of DIPJ
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- Inflammatory - RA, psoriatric arthropathy
- Traumatic - rupture of central slip
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- 1. Central slip rupture due to trauma or inflammation (RA) ➔
- 2. Attenuation of dorsal triangular ligaments holding the 2 lateral bands
- 3. Lateral bands migrate volar ➔ causing PIPJ flexion and DIPJ extension
- 4. Contracture of volar transverse retinacular ligaments and lumbricals on radial band ➔ fixed contracture
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- If loose, this means extension is by central slip
- If stiff, this means central slip ruptured, compensated by lateral bands that attach to DIPJ
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- If DIPJ is rigidly extended and unable to be flexed, this means central slip retracted with adjacent soft tissue contractures ➔ so the retracted central slip keeps pulling on the lateral bands to keep DIPJ extended.
Central slip rupture.pdf427.5KB
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- Nalebuff - principle is fixed vs flexed
- 1 = 15 deg extensor lag
- 2 = 30-40 lag
- 3 = fixed contracture with OA changes
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- 1 (Flexible) = Capner splint that keeps PIPJ extended
- 2 (Flexible)
- Tenotomy of lateral bands and central tendon
- Lateral band relocation and Triangular ligament reconstruction
- Tendon reconstruction e.g. Matev procedure, FDS Slip transfer
- 3 (Rigid) = PIPJ Arthrodesis (Presence of OA changes)
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- One lateral band divided and sutured to remaining central slip
- THe other lateral band crossed and suruted to opposite lateral band
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- The FDS tendon is transferred from volar to dorsal through the lumbrical canal and sutured into the dorsally mobilized lateral bands
FDS transfer to lateral bands.pdf1909.1KB
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- Non op = capner splint
- Op if acutely displaced avulsion fracture, open wounds
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- 4 diagnostic features of this lesion (McCue et al. 1970)https://journals.sagepub.com/doi/abs/10.1016/0072-968X_75_90013-3?journalCode=jhsa
- It is a flexion contracture of the PIPJ
- Slight hyperextension of the DIPJ
- Radiological evidence of calcification at proximal attachment of volar plate of PIPJ
- History of hyperextension injury at PIPJ
- Also used to describe the Duputryen's disease flexion deformity at the PIPJ
- "Prolonged flexion contracture of the PIP joint can lead to central slip attenuation, incompetence of the distal interphalangeal (DIP) joint volar plate, and volar subluxation of the lateral bands"
- FDS transfer to lateral bands.pdf
Swan neck deformity
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- Hyperextension at PIPJ, flexion at DIPJ
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- Primary Lesion: Volar plate laxity at PIPJ ➔ hyperextension of PIPJ by central slip ➔ FDP pulls DIPJ flexed ➔ Attenuation of the transverse retinacular ligament on volar side ➔ Lateral bands sublux dorsally and worsen hyperextension
- Secondary Lesion leads to imbalance of forces on PIPJ with PIPJ extension forces greater than PIPJ forces
- [MCPJ] volar subluxation in RA due to synovitis
- [PIPJ] FDS rupture ➔ unopposed PIPJ extension with subsequent attenuation of transverse retinacular ligaments
- [DIPJ] Mallet injury ➔ due to attrition of terminal tendon, extension forces now go thru central slip that attaches to base of middle phalanx, leading to hyperextension at PIPJ
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- Inflammatory - RA, psoriatric arthropathy
- Traumatic - mallet finger
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- Nalebuff [essential principle is fixed vs flexible]
- 1 = FROM, no intrinsic tightness
- intrinsic tightness
- 3 = cannot be corrected
- 4 = Severe OA
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- Bunnell test - to assess for joint stiffness
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What are the 3 special hand tests?
Bunnell/ Swan neck/ intrinsic tightness /Passive/ flex MCPJ/ check PIPJ ROM
If better = positive = intrinsic tightness
If not = negative = capsular tightness; will not benefit from balancing procedures
Boyes/ Boutonierre/ Passive/ Extend PIPJ/ check DIPJ ROM
If better = flexible = can do balancing procedures
If not = capsular tightness
Bouvier/ Claw/ Passive/ Flex MCPJ/ See if claw straightens out
if straightens = Zancolli capsulodesis
if not but flexible = need Zancolli lasso
if rigid and fixed = joint tightness
- Bunnell´s test is a passive test, that evaluates the presence of intrinsic muscle tightness by comparing the range of motion and force needed to passively flex the proximal interphalangeal joints while the MCP joints are passively extended and flexed. It also helps determine if tightness is secondary to extrinsic muscle contracture or interphalangeal capsule adhesions.
- If MCPJ flexed and PIPJ cannot flex better = due to capsule adhesions and soft tissue procedures will not work.
- If MCPJ flexed and PIPJ can flex better = intrinsic tightness with no capsule adhesions
- https://www.statpearls.com/ArticleLibrary/viewarticle/23735
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- Spiral Oblique Retinacular Ligament Reconstruction – "using small tendon graft in spiral fashion to act as dynamic tenodesis to restore DIPJ extension and restrain PIPJ hyperextension"
- Advancement of Volar plate
- Central slip tenotomy = Fowler Tenotomy
- 3 = Articular tightness = Manipulation under GA (Bunnell +)
- 4 = Arthritis = Fusion
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- Can lead to secondary Boutonniere's
RA Thumb
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- Nalebuff classification
- Type 1 = Boutonniere (central slip that attaches to P1 ruptures) = Z Thumb
- 2 = boutonniere + CMCJ Synovitis
- 3 = Swan neck MCPJ volar plate attenuation
- 4 = gamekeeper’s thumb (UCL attenuation)
- 5 = MCPJ volar plate laxity with swan neck
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- Recontruction
- vs Fusion
RA HAND - OTHERS
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- Nail = Mannerfelt fusion vs plate fusion
