Management Summary

Rheumatoid Hands Xray

 

Rheumatoid Arthritis Diagnostic Criteria

 

1987 American College of Rheumatology 

 

Need 4/7 (MAX RANS)

1. Morning Stiffness

2. Arthritis of 3 areas > 6/52

3. Xray changes

4. Rh factor

5. Arthritis of Hand > 6/52

6. Nodules

7. Symmetric Arthritis > 6/52

 

Types of Surgery

 

5 basic Groups

 

1. Synovectomy / Capsulorrhaphy

2. Tenosynovectomy

3. Tendon surgery & soft tissue balancing

4. Arthroplasty

5. Arthrodesis

 

General Principles

 

Replace all MCPJs

Fuse IF/MF PIPJs

Replace RF/LF PIPJs

Fuse DIPJs

Correct wrist deformity at same time or risk recurrence

 

Caput Ulnae Syndrome 

 

Components

- volar subluxation of ulnar carpus 

- supination of carpus on wrist 

- apparent dorsal subluxation of distal ulna 

 

Nalebuff Classification MCPJ

 

Stage I - Synovitis

- medical Rx and splinting

- synovectomy

 

Stage II - Synovitis + Ulna deviation

- medical treatment and splinting

- synovectomy + soft tissue reconstruction

 

Stage III - Moderate joint destruction

- volar subluxation and ulnar drift

- soft tissue reconstruction possible

- arthroplasty gives more reliable results

 

Stage IV - Advanced joint destruction

- fixed joint deformities

- arthroplasty with soft tissue releases

 

Causes of MCPJ Deformity

 

Ulna Drift / Ulna Dislocation

 

1.  Physiological

- gravity

- lateral pinch pressure

 

2.  Anatomic

- shape of MC heads

- collateral ligament length & orientation

- intrinsics to LF asymmetric (hypothenars strong)

 

3.  Pathological

- joint / capsule instability due to bony erosions

- collateral ligament stretching due to synovitis

- ulna/volar dislocation flexor tendons due to stretching pulleys

- ulna dislocation extensor tendons due to stretching sagittal bands

- intrinsic contracture

- radial deviation of wrist (Landsmere) redirecting line of pull of tendons

- volar / ulna carpal subluxation

 

Nalebuff Classification Thumb

 

Note: Type II now removed as Nalebuff later said doesn't exist

 

Type I - Boutonniere

- the commonest

- MCPJ flexion, IPJ hyperextension

 

Type II - Boutonniere & Swan Neck

 

Type III - Swan Neck

- second most common

- deformity is at CMC / Dorsal & radial subluxation

- hyperextension MPJ / flexion IPJ

 

Type IV - Gamekeepers

 

Type V - Stretched Volar Plate MCPJ

 

Type VI - Arthritis Mutilans

 

Swan Neck

 

Causes

 

DIPJ 

- terminal extensor tendon rupture or attenuated

- entrapped FDP

 

PIPJ 

- volar capsule stretching / FDS rupture

- contracted central extenor slip

 

MCPJ 

- intrinsic tightness 

- extrinsic weakness / MCPJ subluxation and subluxation extensor apparatus

 

Management

 

Flexible

- FDS tenodesis / Lateral band transfer

- DIPJ arthrodesis (mallet)

 

Intrinsic tightness

- above +

- intrinsic release

 

Fixed deformity

- PIPJ dorsal release

- then above

 

Arthrosis 

- arthrodesis (20/30/40/50)

- arthroplasty (LF / RF)

 

Boutonniere Finger

 

Problem

- rupture of central slip

 

Solution

- flexible - Matev's central slips reconstruction

- radial lateral band to central slip

- ulna lateral band to radial lateral band insertion