Arthritis

Arthritis

Rheumatoid arthritis Rheumatoid arthritis presents with classic symptoms: morning sti ff ness, symmetrical arthritis, hand deformities and rheuma - toid nodules. Diagnostic criteria include seropositive rheu - matoid factor and radiographic changes ( Table 38.1 ). The - inflamed rheumatoid synovium (pannus) destroys ligaments, tendons and joints, producing pain, deformity and loss of function. Typical rheumatoid defor mities in the hand include boutonnière ( Figure 38.46 ), swan neck ( Figure 38.47 ) and radial drift of the wrist (due to supination of the carpus), with compensatory ulnar deviation of the MCPJs ( Figure 38.48 ). Pannus can cause extensor tendon ruptures, classically starting with the little finger and progressing stepwise in a radial direc - tion (Vaughan-Jackson syndrome). With progressive deformity and instability of the wrist and hand, activities such as key - pinch and the opening of jars become impossible to perform. - The treatment should be dictated by the pa tient’s levels of pain and disability , not purely on the basis of deformity . -

TABLE 38.1 Radiographic differences between rheumatoid and osteoarthritis. Rheumatoid arthritis Osteoarthritis Periarticular osteoporosis/ Subchondral sclerosis and subchondral erosions cysts Periarticular soft-tissue swelling Less pronounced swelling Joint space narrowing Joint space narrowing Marginal erosions Marginal osteophytes Joint deformity/malalignment Less pronounced deformities Ankylosis Less common ankylosis

Summary box 38.13 Manifestations of rheumatoid arthritis in the hand /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The primary indications for surgery are: (i) pain relief; (ii) functional improvement; (iii) to prevent disease progres - sion; and (iv) cosmesis. Patients may require many surgical procedures over time and a helpful axiom is to start proximally and work distally , alternating between motion-sacrificing and motion-sparing procedures. T he various procedures that can be considered are: 1 Synovectomy: improves pain, increases function and pre - vents tendon rupture. 2 Trigger finger releases and nerve decompression surgery (carpal tunnel syndrome). 3 Distal ulna excision: reduces pain, prevents extensor ten - don rupture or protects repaired extensor tendons. Dis - tal ulna excision leads to instability and so, in the young patient, a constrained ulnar head arthroplasty is preferred. 4 Arthrodesis of the wrist, thumb and some of the smaller joints: gives good pain relief and creates a stable axis against which other parts can function. 5 MCPJ and IPJ replacements: provide pain relief and func - tional improvement. Total wrist arthroplasty will also pro - vide good pain relief and some motion ( Figure 38.49 ). 6 Tendon reconstructions: some ruptured tendons can cause significant morbidity ( Figure 38.50 ) and are often treated by either a tendon transfer or a local joint fusion. Osteoarthritis Wrist The radiocarpal joint can develop primary or secondary osteo - arthritis (after intra-articular trauma or infection). If conserva - tive measures have failed then operative management includes limited or total wrist arthrodesis and total wrist replacement.

Rupture Figure 38.46 Boutonnière deformity. Figure 38.47 Swan neck deformity. Figure 38.48 Rheumatoid hand showing ulnar drift at the metacarpo phalangeal joints, which is seen compensating for radial deviation at the wrist joint. Swan neck, boutonnière /f_i nger deformities Extensor tendon ruptures (Vaughan-Jackson syndrome) Flexor tendon synovitis or rupture MCPJs: /f_l exion, ulnar deviation, subluxation, dislocation Wrist: radial deviation, carpal supination, prominent ulnar head (caput ulnae), extensor tenosynovitis

Figure 38.49 Total wrist replacement.

Hand Females are more commonly a ff ected than males. The commonly a ff ected joints are the distal interphalangeal (Heberden’s nodes), proximal interphalangeal (PIP) (Bouchard’s nodes) and the thumb carpometacarpal joints ( Figure 38.51 ). Symptoms rarely correlate with the appear ance, either clinically or radiographically . Treatment includes splinting, physiotherapy and steroid injections. Surgical options include arthrodesis for distal interphalangeal (DIP) and PIP joints ( Figure 38.52 ), joint replacement (PIP and MCPJs) and excision arthroplasty (excision of the trapezium [trapeziectomy] for thumb carpometacarpal joint arthritis). Joint arthrodesis eliminates pain at the expense of motion, but function is often well preserved. Other forms of arthritis in the hand Psoriasis particularly a ff ects the IPJs, but is asymmetrical in nature and causes fusiform swelling of the digits along with nail changes. Gout causes pain, joint swelling and redness, as well as occasionally tophi (monosodium urate crystal deposits), and can be di ffi cult to di ff erentiate from septic arthritis. Serum urate is not always raised in acute attacks but finding negatively birefringent sodium urate crystals on microscopy of aspirated joint fluid is diagnostic.

Figure 38.50 Rupture of the extensor tendons to the little and ring /f_i ngers.

Arthritis

Rheumatoid arthritis Rheumatoid arthritis presents with classic symptoms: morning sti ff ness, symmetrical arthritis, hand deformities and rheuma - toid nodules. Diagnostic criteria include seropositive rheu - matoid factor and radiographic changes ( Table 38.1 ). The - inflamed rheumatoid synovium (pannus) destroys ligaments, tendons and joints, producing pain, deformity and loss of function. Typical rheumatoid defor mities in the hand include boutonnière ( Figure 38.46 ), swan neck ( Figure 38.47 ) and radial drift of the wrist (due to supination of the carpus), with compensatory ulnar deviation of the MCPJs ( Figure 38.48 ). Pannus can cause extensor tendon ruptures, classically starting with the little finger and progressing stepwise in a radial direc - tion (Vaughan-Jackson syndrome). With progressive deformity and instability of the wrist and hand, activities such as key - pinch and the opening of jars become impossible to perform. - The treatment should be dictated by the pa tient’s levels of pain and disability , not purely on the basis of deformity . -

TABLE 38.1 Radiographic differences between rheumatoid and osteoarthritis. Rheumatoid arthritis Osteoarthritis Periarticular osteoporosis/ Subchondral sclerosis and subchondral erosions cysts Periarticular soft-tissue swelling Less pronounced swelling Joint space narrowing Joint space narrowing Marginal erosions Marginal osteophytes Joint deformity/malalignment Less pronounced deformities Ankylosis Less common ankylosis

Summary box 38.13 Manifestations of rheumatoid arthritis in the hand /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The primary indications for surgery are: (i) pain relief; (ii) functional improvement; (iii) to prevent disease progres - sion; and (iv) cosmesis. Patients may require many surgical procedures over time and a helpful axiom is to start proximally and work distally , alternating between motion-sacrificing and motion-sparing procedures. T he various procedures that can be considered are: 1 Synovectomy: improves pain, increases function and pre - vents tendon rupture. 2 Trigger finger releases and nerve decompression surgery (carpal tunnel syndrome). 3 Distal ulna excision: reduces pain, prevents extensor ten - don rupture or protects repaired extensor tendons. Dis - tal ulna excision leads to instability and so, in the young patient, a constrained ulnar head arthroplasty is preferred. 4 Arthrodesis of the wrist, thumb and some of the smaller joints: gives good pain relief and creates a stable axis against which other parts can function. 5 MCPJ and IPJ replacements: provide pain relief and func - tional improvement. Total wrist arthroplasty will also pro - vide good pain relief and some motion ( Figure 38.49 ). 6 Tendon reconstructions: some ruptured tendons can cause significant morbidity ( Figure 38.50 ) and are often treated by either a tendon transfer or a local joint fusion. Osteoarthritis Wrist The radiocarpal joint can develop primary or secondary osteo - arthritis (after intra-articular trauma or infection). If conserva - tive measures have failed then operative management includes limited or total wrist arthrodesis and total wrist replacement.

Rupture Figure 38.46 Boutonnière deformity. Figure 38.47 Swan neck deformity. Figure 38.48 Rheumatoid hand showing ulnar drift at the metacarpo phalangeal joints, which is seen compensating for radial deviation at the wrist joint. Swan neck, boutonnière /f_i nger deformities Extensor tendon ruptures (Vaughan-Jackson syndrome) Flexor tendon synovitis or rupture MCPJs: /f_l exion, ulnar deviation, subluxation, dislocation Wrist: radial deviation, carpal supination, prominent ulnar head (caput ulnae), extensor tenosynovitis

Figure 38.49 Total wrist replacement.

Hand Females are more commonly a ff ected than males. The commonly a ff ected joints are the distal interphalangeal (Heberden’s nodes), proximal interphalangeal (PIP) (Bouchard’s nodes) and the thumb carpometacarpal joints ( Figure 38.51 ). Symptoms rarely correlate with the appear ance, either clinically or radiographically . Treatment includes splinting, physiotherapy and steroid injections. Surgical options include arthrodesis for distal interphalangeal (DIP) and PIP joints ( Figure 38.52 ), joint replacement (PIP and MCPJs) and excision arthroplasty (excision of the trapezium [trapeziectomy] for thumb carpometacarpal joint arthritis). Joint arthrodesis eliminates pain at the expense of motion, but function is often well preserved. Other forms of arthritis in the hand Psoriasis particularly a ff ects the IPJs, but is asymmetrical in nature and causes fusiform swelling of the digits along with nail changes. Gout causes pain, joint swelling and redness, as well as occasionally tophi (monosodium urate crystal deposits), and can be di ffi cult to di ff erentiate from septic arthritis. Serum urate is not always raised in acute attacks but finding negatively birefringent sodium urate crystals on microscopy of aspirated joint fluid is diagnostic.

Figure 38.50 Rupture of the extensor tendons to the little and ring /f_i ngers.

Arthritis

Rheumatoid arthritis Rheumatoid arthritis presents with classic symptoms: morning sti ff ness, symmetrical arthritis, hand deformities and rheuma - toid nodules. Diagnostic criteria include seropositive rheu - matoid factor and radiographic changes ( Table 38.1 ). The - inflamed rheumatoid synovium (pannus) destroys ligaments, tendons and joints, producing pain, deformity and loss of function. Typical rheumatoid defor mities in the hand include boutonnière ( Figure 38.46 ), swan neck ( Figure 38.47 ) and radial drift of the wrist (due to supination of the carpus), with compensatory ulnar deviation of the MCPJs ( Figure 38.48 ). Pannus can cause extensor tendon ruptures, classically starting with the little finger and progressing stepwise in a radial direc - tion (Vaughan-Jackson syndrome). With progressive deformity and instability of the wrist and hand, activities such as key - pinch and the opening of jars become impossible to perform. - The treatment should be dictated by the pa tient’s levels of pain and disability , not purely on the basis of deformity . -

TABLE 38.1 Radiographic differences between rheumatoid and osteoarthritis. Rheumatoid arthritis Osteoarthritis Periarticular osteoporosis/ Subchondral sclerosis and subchondral erosions cysts Periarticular soft-tissue swelling Less pronounced swelling Joint space narrowing Joint space narrowing Marginal erosions Marginal osteophytes Joint deformity/malalignment Less pronounced deformities Ankylosis Less common ankylosis

Summary box 38.13 Manifestations of rheumatoid arthritis in the hand /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The primary indications for surgery are: (i) pain relief; (ii) functional improvement; (iii) to prevent disease progres - sion; and (iv) cosmesis. Patients may require many surgical procedures over time and a helpful axiom is to start proximally and work distally , alternating between motion-sacrificing and motion-sparing procedures. T he various procedures that can be considered are: 1 Synovectomy: improves pain, increases function and pre - vents tendon rupture. 2 Trigger finger releases and nerve decompression surgery (carpal tunnel syndrome). 3 Distal ulna excision: reduces pain, prevents extensor ten - don rupture or protects repaired extensor tendons. Dis - tal ulna excision leads to instability and so, in the young patient, a constrained ulnar head arthroplasty is preferred. 4 Arthrodesis of the wrist, thumb and some of the smaller joints: gives good pain relief and creates a stable axis against which other parts can function. 5 MCPJ and IPJ replacements: provide pain relief and func - tional improvement. Total wrist arthroplasty will also pro - vide good pain relief and some motion ( Figure 38.49 ). 6 Tendon reconstructions: some ruptured tendons can cause significant morbidity ( Figure 38.50 ) and are often treated by either a tendon transfer or a local joint fusion. Osteoarthritis Wrist The radiocarpal joint can develop primary or secondary osteo - arthritis (after intra-articular trauma or infection). If conserva - tive measures have failed then operative management includes limited or total wrist arthrodesis and total wrist replacement.

Rupture Figure 38.46 Boutonnière deformity. Figure 38.47 Swan neck deformity. Figure 38.48 Rheumatoid hand showing ulnar drift at the metacarpo phalangeal joints, which is seen compensating for radial deviation at the wrist joint. Swan neck, boutonnière /f_i nger deformities Extensor tendon ruptures (Vaughan-Jackson syndrome) Flexor tendon synovitis or rupture MCPJs: /f_l exion, ulnar deviation, subluxation, dislocation Wrist: radial deviation, carpal supination, prominent ulnar head (caput ulnae), extensor tenosynovitis

Figure 38.49 Total wrist replacement.

Hand Females are more commonly a ff ected than males. The commonly a ff ected joints are the distal interphalangeal (Heberden’s nodes), proximal interphalangeal (PIP) (Bouchard’s nodes) and the thumb carpometacarpal joints ( Figure 38.51 ). Symptoms rarely correlate with the appear ance, either clinically or radiographically . Treatment includes splinting, physiotherapy and steroid injections. Surgical options include arthrodesis for distal interphalangeal (DIP) and PIP joints ( Figure 38.52 ), joint replacement (PIP and MCPJs) and excision arthroplasty (excision of the trapezium [trapeziectomy] for thumb carpometacarpal joint arthritis). Joint arthrodesis eliminates pain at the expense of motion, but function is often well preserved. Other forms of arthritis in the hand Psoriasis particularly a ff ects the IPJs, but is asymmetrical in nature and causes fusiform swelling of the digits along with nail changes. Gout causes pain, joint swelling and redness, as well as occasionally tophi (monosodium urate crystal deposits), and can be di ffi cult to di ff erentiate from septic arthritis. Serum urate is not always raised in acute attacks but finding negatively birefringent sodium urate crystals on microscopy of aspirated joint fluid is diagnostic.

Figure 38.50 Rupture of the extensor tendons to the little and ring /f_i ngers.