Hand Bone

Hand deformity and rheumatoid disease

Rheumatoid hand and wrist deformity, boutonniere and swan neck, soft tissue principles.

61 questions 8 source pages

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Q1Describe the X-ray in this RA patient on long-term steroids.▸

Fracture distal radius with comminution at the volar aspect, intra-articular
Joint volarly subluxed
Ulnar styloid fracture
Soft tissue at risk: SL ligament, TFCC

Q2Which soft tissue structures are at risk in this fracture, and what systemic factor affects management?▸

SL ligament and TFCC at risk (intra-articular fracture with volar subluxation)
Ulnar styloid fracture present
Systemic: manage osteoporosis (RA patient on long-term steroid)

Q3What classifications are used for distal radius fractures?▸

AO
Fernandez: bending/shearing/compression/avulsion/combined or explosion
Melone 4 components: undisplaced or die-punch/volar spike/separation or rotation/metaphyseal-diaphyseal comminution
Frykman

Q4What is the management including instability criteria?▸

Systemic: osteoporosis
Local: CR + slab
Lafontaine criteria 3/5 = unstable: ulnar, intra-articular, dorsal comminution, dorsal angulation >20 degrees, age >60
OT: volar plating, screen TFCC; if not stable splint in supination for 3 weeks

Q5Describe the Leddy and Packer classification of FDP avulsion.▸

Type 1: retracts to the palm, both vinculae disrupted, will not retract beyond the wrist due to the lumbrical
Type 2: retracts to the PIPJ, distal to A2 pulley, short vinculae disrupted
Type 3: minimal retraction, distal to A4 pulley
Type 4: double avulsion
Type 5: DP base comminution

Q6How is an acute FDP avulsion managed?▸

Large fragment: screw fixation
Small fragment: pull-out wire

Q7What factors decide one- versus two-stage reconstruction in chronic FDP avulsion?▸

Soft tissue envelope status
Joint contracture
Pulley status
Also guided by chronicity and Leddy and Packer stage

Q8Describe the two-stage reconstruction of FDP avulsion (Hunter and Salisbury).▸

Stage 1: silicon rod placed to create a favourable tendon bed, rod sutured to FDS/FDP as donor; physio for ROM
Stage 2 (3-4 months): rod retrieved, tendon graft passed through the mesothelium-lined psuedosheath
Suture to distal first with pull-out wire technique (allows excursion adjustment)
Suture to proximal at zone 5 with Pulvertaft technique (zone 3 if graft is soft)

Q9What are the options for pulley reconstruction?▸

Non-encircling: Kleinert ever-present rim, Karev belt-loop, Lister extensor retinaculum, Doyle and Blythe palmaris longus
Encircling: Bunnell single-loop, Okutsu triple-loop
Need at least 3 loops: one A2 loop and two A4 loops
A2 loops pass deep to the extensor mechanism; A4 loops (around the bone) pass superficial to the extensors

Q10Why is the ring finger most commonly affected in FDP avulsion?▸

The RF tip is 5mm more prominent in grip in 90% of patients, exposing it to greater forces
The ring finger cannot be fully extended when the middle and small finger MCPJ are flexed to 90deg, due to intertendinous connections

Q11What is the clinical presentation and X-ray finding in this FDP avulsion?▸

Clinical photo: DIPJ failed flexion, no open wound
XR: volar DP base fracture
Articular surface involvement, comminution, +/- DIPJ dislocation/subluxation

Q12What history is important in FDP avulsion?▸

Mechanism of injury
Chronicity
Function demands, occupation, smoking

Q13What examination findings are sought in FDP avulsion?▸

Scar
ROM, active and passive
Palpate the tendon along its sheath to the level of the palm

Q14What imaging is used in FDP avulsion?▸

USG

Q15What are the complications of FDP avulsion surgery?▸

Fracture
Stiffness
Persistent bowstring

Q16What is the salvage procedure for a failed FDP avulsion reconstruction?▸

DIPJ fusion

Q17When is a tension transfer performed in FDP avulsion?▸

If there is a non-functional motor unit

Q18Describe the Paneva Holovich two-stage reconstruction.▸

Stage 1: silicon rod in the flexor sheath, pulleys reconstructed; a loop between the proximal FDS and FDP stumps is created in the palm
Stage 2: rod retrieved; FDS is cut proximally and reflexed distally through the pseudosheath
FDS attached directly to FDP or secured with a button

Q19What are the advantages and disadvantages of the Paneva Holovich technique?▸

Advantage: FDS graft size known at stage 1, so the correct rod size is chosen
Advantage: FDS is intrasynovial, so fewer adhesions
Advantage: relies on one tenorrhaphy site
Disadvantage: problems with tension at the distal tenorrhaphy site

Q20What is the pathophysiology of rheumatoid hand involvement?▸

RA is a progressive, systemic, cell-mediated (T-cell, MHC class II) autoimmune condition affecting the synovial lining of joints and tendon sheaths
Rheumatoid factor = IgM autoantibodies directed against the Fc portion of IgG, forming immune complexes
Pannus causes destruction of the articular surface through release of activated neutrophils and microvascular ischemia
Stages: Stage 1: synovitis, Stage 2: destruction, Stage 3: deformity; synovial fluid becomes a Newtonian fluid (loss of shear thinning), altering tribology
Genetics: associated with HLA DW4, DR4

Q21What happens in the hand in rheumatoid arthritis?▸

UC ligament synovitis causes dorsal subluxation of the ulnar head (caput ulnare)
RC ligament synovitis + ECU subluxation causes ulnar translocation of the carpus
Caput ulnare + ECU subluxation = Vaughan Jackson syndrome, with attrition rupture of extensor tendons (EDM, then EDC, then EI)
MCs deviate radially; flexors and extensors sublux ulnar and volar
Leads to MCPJ ulnar drift with ulnar intrinsic and collateral contracture

Q22What intrinsic factors in the hand cause MCPJ ulnar drift in RA?▸

Lateral pinch and power grip exert an ulnar directed force
Small sloping ulnar condyle
Gravity
Attenuation of sagittal band and radial joint capsule

Q23What are the classic deformities seen in the rheumatoid hand?▸

Swan neck deformity
Boutonniere deformity
Z thumb
Vaughan Jackson syndrome with ulnar caput
Mannerfelt syndrome
Ulnar drift

Q24What are the aims of treatment in the rheumatoid hand?▸

MDT and maximise medical treatment
Treat according to function: painless, good hand function with good ROM, adequate power
Prevent deformity and complication

Q25What are the urgent indications in the rheumatoid hand?▸

Acute carpal tunnel syndrome
Locked trigger finger
Impending tendon rupture

Q26What is the priority in managing the rheumatoid hand?▸

Aim: MDT, maximise medical treatment, treat according to function (painless, good ROM, adequate power); prevent deformity and complication
Urgent: acute CTS, locked trigger finger, impending tendon rupture
Reconstruction follows Souter's order of predictability: extensor tenosynovectomy + wrist stabilisation + ulnar head resection, then flexor tenosynovectomy, thumb, DIPJ, MCPJ

Q27What are the ACR/EULAR 2010 diagnostic criteria for RA?▸

Synovitis in >=1 joint plus no alternative diagnosis
>=6/10 across 4 domains
Joints involved 0-5; RF/anti-CCP 0-3; inflammatory marker 0-1; duration >6 weeks 0-1

Q28What thumb and finger deformities accompany the MCPJ ulnar drift in this patient?▸

Boutonniere deformities of both thumbs
Swan neck deformity in multiple other digits
Prominent knuckles with radial deviation of the MCs; no scars and no active joint swelling
Overall picture: symmetrical polyarthropathy with typical deformities of RA

Q29What are the intrinsic causes of MCPJ dislocation in RA?▸

Anatomical: ulnar condyle smaller and ulnar sloping condyles of IF and MF; radial collaterals weaker; EI and EDM on ulnar side
Biomechanical: grip exerts ulnar directed force from the thumb
Gravity causes ulnar subluxation

Q30What are the extrinsic causes of MCPJ dislocation in RA?▸

Carpal ulnar translocation causes radial deviation of MCs; extensor vector pulls MCPJ into ulnar drift
MCPJ synovitis -> sagittal band erosion + volar plate stretching -> extensor tendon ulnar subluxation -> ulnar intrinsic contracture -> PP ulnar deviation
Flexors also ulnar sublux, causing further ulnar drift

Q31How do you treat MCPJ dislocation in RA?▸

Splinting and activity modification (eg how to hold a mug)
Supple: extensor tenosynovectomy, extensor realignment (radial sagittal band imbrication, RCL reefing, cross intrinsic transfer, volar plate release + collateral recon)
Rigid: fusion or arthroplasty; advocate arthroplasty as MCPJ is >60% of hand function
Arthroplasty: silicone/pyrocarbon; correct wrist radial deviation + collateral recon same OT
Complications: infection, loosening, recurrence

Q32What are the outcomes of MCPJ arthroplasty in RA?▸

70% satisfaction at 1 year, 69% survivorship at 20 years
Silicone implant 63% fracture in 17 years
Decreases ulnar deviation and extension lag

Q33Why is arthroplasty advocated over fusion at the MCPJ in RA?▸

MCPJ provides >60% of hand function
Correct wrist radial deviation and collateral recon in the same OT
Implant options: silicone or pyrocarbon

Q34What are the operative options for a supple versus a rigid MCPJ in RA?▸

Supple: extensor tenosynovectomy and extensor realignment (radial sagittal band imbrication, RCL reefing, cross intrinsic transfer, volar plate release + collateral recon)
Rigid: fusion or arthroplasty

Q35What is the Souter principle / priority in RA hand surgery?▸

Urgent: C spine, acute carpal tunnel, impending tendon rupture
LL first: foot, hip, knee, ankle
UL: proximal --> distal

Q36What are the 3 aetiologies of swan neck deformity?▸

MCPJ: joint volar subluxation, dorsal subluxation of lateral band
PIPJ: volar plate attenuation / FDS rupture
DIPJ: mallet finger (terminal extensor tendon rupture)

Q37What perpetuates a swan neck deformity and what are the complications?▸

Attenuation of transverse retinaculum; tightening of triangular ligament and intrinsics -> further dorsal dislocation of lateral band
Hyperextension of PIPJ functionally lengthens extensor mechanism -> DIPJ in flexion
Complication: intrinsic tightness (Bunnell test) + fixed deformity

Q38What is the Nalebuff classification of swan neck deformity?▸

1: flexible and full ROM
2: intrinsic tightness
3: stiff PIPJ
4: arthritis

Q39How do you detect intrinsic tightness and why does it matter?▸

Use the Bunnell test
It determines the choice between FDS tenodesis (no tightness) and SORL reconstruction + intrinsic release (intrinsic tightness)

Q40How is swan neck deformity treated?▸

Determine if there is intrinsic tightness
Conservative if no complication: double ring splint at PIPJ (Murphy ring)
No intrinsic tightness: FDS tenodesis (ulnar FDS slip cut, loop around A2 and suture back proximally with PIPJ in 40deg flexion)
Intrinsic tightness: SORL reconstruction + intrinsic release
DIPJ/PIPJ arthrosis: fusion

Q41How do you choose between FDS tenodesis and SORL reconstruction?▸

Check if DIPJ flexion deformity corrects upon PIPJ flexion; if not corrected, do SORL reconstruction
PL vs lateral band as SORL graft: PL more bulky
Lateral band may not be present when the underlying cause was terminal slip rupture

Q42What is a boutonniere deformity?▸

Button hole: the lateral band is the hole and the PIPJ passes through the hole

Q43What is the pathophysiology of a boutonniere deformity?▸

Central slip rupture (traumatic/inflammatory) -> failed extension at PIPJ; central slip transmits extension force to DIPJ via the intact lateral band connection
With time bilateral lateral band volar subluxation with contracted transverse retinacular ligament and ORL
Triangular ligament attenuated; subluxed lateral band becomes a flexor to PIPJ instead of extensor, exacerbating deformity
Does not happen in acute central slip rupture as lateral bands are not yet subluxed

Q44How is an acute boutonniere deformity managed?▸

Conservative first +/- central slip repair

Q45How is a chronic boutonniere deformity managed according to extension lag?▸

Mostly conservative as less disabling than swan neck deformity
<15 degrees (flexible/grade I): Capener splint to prevent ORL contracture; Fowler tenotomy (cut lateral band just proximal to DIPJ to let ORL flex the DIPJ)
30-40 degrees (rigid, grades II/III) with TRL/SORL contracture: TRL release + extensor recon (Matev)
Arthritis: fusion

Q46Summarise the Matev reconstruction for chronic boutonniere deformity.▸

Cut ulnar slip of lateral band at DIPJ and radial slip at MP
Connect ulnar proximal stump to radial distal to lengthen the terminal extensor
Radial proximal loops around the central slip remnant as reconstruction for the central slip
Put simply: ulnar LB to radial LB to lengthen extensor, radial LB recon CS

Q47What is the Burton classification of boutonniere deformity?▸

Stage 1: supple
Stage 2: fixed contracture of lateral band
Stage 3: joint involvement with fibrosis + volar plate
Stage 4: arthritis

Q48What is the differential diagnosis of multiple boutonniere deformities?▸

RA
Psoriasis

Q49What is the Nalebuff classification of RA thumb deformity?▸

I: boutonniere of thumb (MCPJ disease)
II: boutonniere + CMCJ involvement
III: swan neck of thumb
IV: gamekeeper thumb
V: swan neck without IPJ involvement + MCPJ disease (MCPJ volar plate stretched)
VI: arthritis mutilans

Q50Describe Nalebuff type I RA thumb deformity and its treatment.▸

Boutonniere of thumb: primary MCPJ disease with extensor hood synovitis; EPB attenuated, EPL subluxes ulnar and becomes a flexor of MCPJ
Supple: synovectomy + EPL to EPB rerouting + IPJ fusion
MCPJ rigid, IPJ supple: MCPJ fusion + EPL reroute
MCPJ and IPJ rigid: IPJ fusion + MCPJ fusion (if CMCJ normal) or MCPJ arthroplasty (if CMCJ arthritis)

Q51Describe Nalebuff type II RA thumb deformity and its treatment.▸

Boutonniere + CMCJ involvement; primary pathology is CMCJ arthritis
Tx: CMCJ fusion / trapeziectomy + soft tissue interposition

Q52Describe Nalebuff type III RA thumb deformity and its treatment.▸

Swan neck of thumb: CMCJ arthritis with subluxation, 1st webspace contracture, recruitment of EDB to hyperextend MCPJ to get the thumb out of the palm
Supple: volar plate capsulodesis + FPL tenodesis
Rigid: MCPJ arthrodesis +/- webspace release

Q53Describe Nalebuff type IV RA thumb deformity and its treatment.▸

Gamekeeper thumb: attenuation of UCL of MCPJ + contracture of 1st webspace
Supple: UCL reconstruction + webspace release
Rigid: fusion

Q54Describe Nalebuff types V and VI RA thumb deformity.▸

V: swan neck without IPJ involvement + MCPJ disease (MCPJ volar plate stretched)
VI: arthritis mutilans - treatment is fusion

Q55What features of RA wrist involvement should you look for in this patient?▸

Prominent ulnar styloid with finger drop of MF to LF
+/- prominent knuckles +/- ulnar deviation of MCPJ
Skin thin with loss of cutaneous fat; no scars or other joint swelling/deformity
Assess the DRUJ for instability and check for radiocarpal joint involvement

Q56What is the differential diagnosis of finger drop in RA and how do you differentiate?▸

Tendon rupture - test tenodesis
PIN palsy - test EPL and EI function; radial deviation of wrist (intact ECRL)
MCPJ subluxation - try to reduce MCPJ - unable
Sagittal band rupture - reduce MCPJ, able to maintain extension
Intrinsic contracture - Bunnell test

Q57What is the pathophysiology of caput ulnare and Vaughan-Jackson syndrome?▸

RA involvement of DRUJ and UC ligament -> ulnar head dorsal subluxation
ECU sheath synovitis -> ECU volar subluxation; with RC ligament erosion the carpus subluxes volarly, translocates ulnarly and supinates
This places the carpal further away from the ulnar head and increase pressure over the extensor compartment -> progressive attrition rupture starting EDM, then EDC, then EI

Q58What are the priorities in managing RA?▸

Systemic: medical treatment; locally in the hand follow Souter's principle of predictable success
Systemically: life threatening, patient preference, most symptomatic, sure win
LL first, then UL; UL proximal first, then distal

Q59How do you treat Vaughan-Jackson syndrome?▸

First prevent further tendon rupture - give a splint
Treat caput ulnare: Sauve-Kapandji (preferred in RA with ulnar translocation) or Darrach (not in unstable carpus; can do if wrist already fused)
Darrach problems: ulnar impingement on radius (prevent by soft tissue interposition with PQ reattached dorsally), ulnar dorsal/volar instability (prevent by ECU tenodesis), decreased grip strength
Bower not a good option as it requires intact TFCC
Ruptured tendon: graft if good muscle quality with excursion >2cm (likely 2-stage, 2 anastomoses) vs transfer (side to side, EI or R/F FDS)

Q60When do you use a tendon graft versus a tendon transfer for ruptured extensor tendons in RA?▸

Tendon graft if good muscle quality with excursion >2cm, but likely needs 2 stages and has 2 anastomosis sites
Tendon transfer (side to side, EI or R/F FDS) has one healing site but the donor unit downgrades one motor power grade

Q61How do you prevent further attritional extensor rupture in RA?▸

Extensor retinacular reconstruction
Re-routing of the extensor retinaculum
Tenosynovectomy

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Hand deformity and rheumatoid disease