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Quick Test posted on 1.26.10:
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Acquired Hand Dysfunction
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Arthritis of the hand is divided into two categories. Degenerative changes are usually due to some trauma resulting in damage to the bone or cartilage or to the supporting ligamentous structures. The increased wear to the joint results in inflammation and damage to the cartilage or underlying bone followed by reactive new bone formation (spurs). The wrists, hips, and knees are most commonly affected. Rheumatoid arthritis is a systemic disease characterized by synovial inflammation. The diseased synovium destroys adjacent tendons and joints in a specific way, leading to characteristic deformities in the hand.
Patients with degenerative arthritis complain of pain, aching, and stiffness in the area of the affected joint. Progression of the problem leads to immobility of the joint that affects the entire hand. Radiographic studies demonstrate joint narrowing and periosteal thickening early in the problem, progressing to bone spurs, loss of the articular surface, and bone destruction later. Patients with rheumatoid arthritis often present with very severe deformities without pain. Nodules around the olecranon and dorsum of the hand are often found. Both flexor and extensor tendons at the wrist can be inflamed, limiting tendon movement and resulting in rupture of the tendon. Involvement of the tendons and ligaments at the digits and MCP joints results in ulnar deviation of the digits, MCP joint destruction and dislocation, and swan-neck and boutonni�re deformities. Destruction of the wrist joint is also common.
Arthritis is common among older patients and usually treated by primary care physicians and rheumatologists with anti-inflammatory medications and modification of the patient's activities. In most cases, it is only when symptoms greatly hinder the patient's lifestyle that they are referred to a hand surgeon. Physical therapy, splints, and medications are often no longer effective for these patients.
Surgical treatment of painful joints includes replacement with a prosthetic joint and partial or full fusion. Prosthetic joints of metal or Silastic permit near-normal movement but can become unstable and dislocate or degenerate over time. For a durable solution to the problem, fusion of the joint is recommended. Motion is severely limited, but pain relief is complete. There are more therapeutic options for the wrist, such as replacement, local fusion of only the affected carpal bone, or complete excision of the proximal row of carpal bones, leaving motion and stability to the distal carpal bones and ligaments.
Therapy for synovial inflammation in rheumatoid disease includes excision of the synovium to increase tendon excursion and prevent rupture, repair of ruptured tendons, and excision of painful nodules. Tendon-balancing procedures can help ulnar deviation of the MCP joints and improve joint movement. The most important concept of treating patients with rheumatoid hand disease is that often the patients have adapted well to their functional deficits. Correcting a physical deformity in a well-compensated patient may actually result in more problems for that patient.
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| Fig. 44-18. Arthritis of the hand and wrist. A. This patient injured her scapholunate ligament years before presentation. The scapholunate interval is widened (double arrow), and the radioscaphoid joint is degenerated (solid oval), but the radiolunate and lunocapitate joint spaces are well preserved (dashed ovals). B. This patient has had rheumatoid arthritis for decades. The classic volar subluxation of the metacarpophalangeal joints of the fingers (dashed oval) and radial deviation of the fingers are apparent. |
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Quick Test Questions QUESTION 1: Which of the following is NOT part of the
triad seen with Felty's syndrome?
QUESTION 2: Which of the following is NOT a treatment
option for a radial ganglion?
QUESTION 3: A 19-year-old college student serves
as a pallbearer at the funeral of a friend who was killed in a motor
vehicle accident. Shortly after the funeral he develops numbness
in his fingers of the right hand. That night he has difficulty sleeping
because of discomfort in the entire right upper extremity and worsening
paresthesias of all of his fingers. He comes to the ER 6 days later
because of weakness in his right hand and aching of the upper extremity.
Paresthesias waken him at night and are accentuated by driving a
car and holding up a book. He frequently shakes his hand for relief. The most likely diagnosis is
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