1. DEFORMITIES OF THE HAND IN
RHEUMATOID ARTHRITIS

2. • Rheumatoid arthritis (RA) is the most common cause
of chronic inflammatory joint disease.
• Most typi- cal features are a symmetrical polyarthritis
and tenosynovitis, morning stiffness, elevation of the
ery- throcyte sedimentation rate (ESR) and the
appearance of autoantibodies that target
immunoglobulins (rheumatoid factors) in the serum

3. • Rheumatoid arthritis is a systemic disease but
the most characteristic lesions are seen in the
synovium or within rheumatoid nodules. The
synovium is engorged with new blood vessels
and packed full of inflammatory cells.

4. • Stage 1 – pre-clinical Well before RA becomes clini- cally
apparent the immune pathology is already begin- ning. Raised
ESR, C-reactive protein (CRP) and RF may be detectable years
before the first diagnosis.

5. • Stage 2 – synovitis Early changes are vascular
conges- tion with new blood vessel formation,
proliferation of synoviocytes and infiltration of
the subsynovial layers by polymorphs,
lymphocytes and plasma cells. There is thickening
of the capsular structures, villous forma- tion of
the synovium and a cell-rich effusion into the
joints and tendon sheaths. Although painful,
swollen and tender, these structures are still
intact and mobile, and the disorder is potentially
reversible

6. • Stage 3 – destruction Persistent inflammation causes
joint and tendon destruction. Articular cartilage is
eroded, partly by proteolytic enzymes, partly by
vascu- lar tissue in the folds of the synovial
reflections, and partly due to direct invasion of the
cartilage by a pan- nus of granulation tissue creeping
over the articular surface. At the margins of the joint,
bone is eroded by granulation tissue invasion and
osteoclastic resorption

7. • Stage 4 – deformity The combination of
articular destruction, capsular stretching and
tendon rupture leads to progressive instability
and deformity of the joints.

8. FINGER DEFORMITIES CAUSED BY
RHEUMATOID ARTHRITIS
• Deformities of the finger can be caused by
the normal forces applied to damaged joints
by the extrinsic flexors and extensors,
tightness of the intrinsic muscles,
displacement of the lateral bands of the
extensor hood, rupture of the central slip of
the hood, or rupture of the long extensor or
long flexor tendons.
• .

9. • Here abnormal forces also act on joints
already weakened by the disease.
• In addition, flexor tenosynovitis may produce
limitation of interphalangeal joint motion, so
the range of active flexion of these joints is
significantly less than passive flexion

10. 1.INTRINSIC PLUS DEFORMITY
2.SWAN NECK DEFORMITY
3.BUTTON HOLE DEFORMITY
4.ULNAR DEVIATION

11. 1.Intrinsic Plus Deformity
• The intrinsic plus deformity is caused by
tightness and contracture of the intrinsic
muscles.
• In hands with intrinsic plus deformity, the
proximal interphalangeal joint cannot be flexed
while the metacarpophalangeal joint is fully
extended.
• Often, the deformity develops in combination
with volar subluxation of the
metacarpophalangeal joints and ulnar deviation
of the fingers

12. Bunnell test for intrinsic tightness
Metacarpophalangeal joint is passively held in
extension, causing passive extension of the proximal
interphalangeal joint and preventing passive flexion of
the proximal interphalangeal joint (Fig. 70-11). When
the metacarpophalangeal joint is passively flexed, the
intrinsics are relaxed, and passive flexion of the
proximal interphalangeal joint is increased. With ulnar
drift of the fingers, this intrinsic tightness may be
present only on the ulnar side.

14. • To test this accurately, axial alignment of the finger
with the metacarpal should be maintained in
checking intrinsic tightness.
• Any ulnar deviation at the metacarpophalangeal
joint during the test slackens the intrinsics on the
ulnar side of the finger and confuses the findings.
• A tight first volar interosseous muscle pulls the
extended index finger ulnarward, but if the finger is
held in line with the second metacarpal during the
test, tightness of this muscle can be shown.

15. • The first volar interosseous is a flexor and an
adductor of the second metacarpophalangeal
joint, and usually the first dorsal interosseous
is an abductor only.

16. Test for tightness of oblique retinacular ligament. Proximal interphalangeal joint held in
maximal extension by examiner. Resistance to passive flexion of distal interphalangeal joint is
evaluated

17. CORRECTION
• Sx - release of intrinsic tightness +
synovectomy +/- arthroplasty/bone resection

18. 2.Swan-Neck Deformity
• Swan-neck deformity is described as a flexion
posture of the distal interphalangeal joint
and hyperextension posture of the proximal
interphalangeal joint, at times with flexion of
the metacarpophalangeal joint

19. • . It is caused by muscle imbalance and may be
passively correctable, depending on the
fixation of the original and secondary
deformities .
• Although usually associated with rheumatoid
arthritis, swan-neck deformity may occur in
patients with lax joints and in patients with
conditions such as Ehlers-Danlos syndrome.

20. Swan-neck deformity. A, Terminal tendon rupture may be associated with synovitis of distal interphalangeal joint, leading to distal
interphalangeal joint flexion and subsequent proximal interphalangeal joint hyperextension. Rupture of flexor digitorum superficialis
tendon can be caused by infiltrative synovitis, which can lead to decreased volar support of proximal interphalangeal joint and subsequent
hyperextension deformity. B, Lateral-band subluxation dorsal to axis of rotation of proximal interphalangeal joint. Contraction of
triangular ligament and attenuation of transverse retinacular ligament are depicted

21. Fixed rheumatoid swan-neck deformity, with proximal interphalangeal joint
hyperextension and distal interphalangeal joint flexion

22. • This deformity may begin as a mallet
deformity associated with a disruption of the
extensor tendon at the distal joint with
secondary overpull of the central tendon,
causing hyperextension of the lax proximal
interphalangeal joint. The proximal
interphalangeal joint may actively flex
normally.

23. • This deformity also may begin at the proximal
interphalangeal joint because synovitis causes
herniation of the capsule, tightening of the
lateral bands and central tendon, and
eventual adherence of the lateral bands in a
fixed dorsal position, so they can no longer
slide over the condyles when the proximal
interphalangeal joint is flexed

24. • This limits proximal interphalangeal flexion. The
dorsally and centrally displaced lateral bands
become relatively slack and may be ineffective
in extending the distal interphalangeal joint,
which may secondarily assume a mallet
deformity without actual rupture of the central
tendons. This mallet deformity usually is not as
severe, however, as that produced by a rupture
of the central tendons.
•

25. • A swan-neck deformity may require
synovectomy of the proximal interphalangeal
joint, mobilization of the lateral bands, and
release of the skin distal to the proximal
interphalangeal joint. Wrinkles and normal
laxity of the skin are lost at the level of the
proximal interphalangeal joint after several
weeks

26. • Nalebuff, Feldon, and Millender categorized
swan-neck deformities into four types and
recommended appropriate treatment plans
for each type

27. • Type I deformities are flexible and require
dermodesis, flexor tenodesis of the proximal
interphalangeal joint, fusion of the distal
interphalangeal joint, and reconstruction of
the retinacular ligament.
• Type II deformities are caused by intrinsic
muscle tightness and require intrinsic release
in addition to one or more of the
aforementioned procedures.

28. • Type III deformities are stiff and do not allow satisfactory
flexion, but do not have significant joint destruction
radiographically. These deformities require joint
manipulation, mobilization of the lateral bands, and dorsal
skin release.
• Type IV deformities have radiographic evidence of
destruction of the joint surface and stiff proximal
interphalangeal joints, which usually can be best treated
with arthrodesis of the proximal interphalangeal joint or, in
the ring and small fingers, with Swanson implant
arthroplasty of the proximal interphalangeal joint.

29. • Kiefhaber and Strickland found that
dorsoproximal interphalangeal capsulotomy
and lateral band mobilization improved
interphalangeal flexion by changing the arc of
motion of the proximal interphalangeal joint

30. NALEBUFF AND MILLENDER
TECHNIQUE
• FOR CORRECTION OF SWAN NECK
• DEFORMITY
• Begin a slightly curved dorsal incision at the
midportion of the proximal phalanx, continue
it distally from this point over the
dorsolateral aspect of the proximal
interphalangeal joint and over the middle of
the middle phalanx, and traverse obliquely
dorsally to form the tail of a J (Fig. 70-16A

31. Nalebuff and Millender technique for correction of swan-neck deformity. Skin incision is shown
curved to permit release of contracted skin. Incision should not be completely sutured. Lateral
tendons are mobilized by two longitudinal releasing incisions, and joint is flexed

32. • Elevate the skin carefully, taking with it the veins
• Make a longitudinal incision between each lateral
band and the central tendon, releasing them from
their fixed dorsal position
• Passively flex the proximal interphalangeal joint to
observe that the lateral bands now slip volarward,
sliding over the condyles of the joint
• A synovectomy can now be done, and good passive
motion usually is established unless there is a
bulging synovitis of the flexors

33. • Suture the skin incision proximally. Distally
suturing may not be possible; the distal
incision, being placed obliquely across the
middle phalanx, gapes open and
accomplishes a skin release. If the distal
portion of the skin incision is sutured
routinely, it might contribute again to
hyperextension of the joint. The open portion
of the incision usually heals without a graft in
about 2 weeks

34. • Ensure in the preoperative evaluation that active motion can
be established by evaluating active flexion of the joint by the
profundus and sublimis tendons. When active flexor
function is not confirmed, check the tendons by making an
incision in the palm and pulling on the tendons through the
palm to see that they are not stuck and are not held by
rheumatoid nodules.
• Pass a Kirschner wire across the proximal interphalangeal
joint to maintain this joint in flexion postoperatively for
approximately 3 weeks. During this time, the open portion
of the skin wound should close.

35. • Beckenbaugh observed that flexor tenosynovitis
results in ineffective support by the flexor
digitorum superficialis tendon and may be an
important factor in initiating the development
of swan-neck deformity in the rheumatoid hand.
• Every patient in his series had tenosynovitis
with adherence of the superficialis tendon,
preventing the tendon from stabilizing the
proximal interphalangeal joint against
hyperextension.
•

36. • The overpull of the central tendon, combined
with synovitis of the proximal interphalangeal
joint, stretches the surrounding tissue,
resulting in a swan-neck or hyperextended
position

37. • If there is marked hyperextension at the
proximal interphalangeal joint and a normal
radiographic appearance with maintenance
of a normal joint space, tenodesis with the
flexor sublimis tendon can be combined with
release of the lateral bands and the distal
skin

38. Beckenbaugh technique for correcting hyperextension
deformity of proximal interphalangeal joint

39. • If there is marked proximal interphalangeal
joint extension associated with joint
destruction on radiographs, arthrodesis may
be best if there is a near-normal
metacarpophalangeal joint, or if
metacarpophalangeal joint resection
arthroplasty is anticipated.

40. • Numerous fixation techniques have been
described to obtain successful proximal
interphalangeal joint arthrodesis in arthritic
joints, including a single Kirschner wire,
crossed Kirschner wires, intraosseous wiring,
bone pegs, polypropylene pegs, miniplates,
compression plates, tension bands, and
Herbert screws

41. 3.Buttonhole, or Boutonnière,
Deformity
• buttonhole deformity has a flexed proximal
interphalangeal joint, with a hyperextended
distal interphalangeal joint.
• It is commonly seen in patients with
rheumatoid arthritis, although this tendon
imbalance is not unique to rheumatoid disease.
In a patient with rheumatoid arthritis, it is
thought to be caused by synovitis of the
proximal interphalangeal joint with a stretching
out of the central slip, forcing the lateral bands
to begin subluxating volarward.

42. • As the deformity progresses, the lateral bands
are forced farther over the condyles of the
proximal interphalangeal joint and become
tightened by their new course and by pressure
from the underlying swollen joint

43. • They finally become fixed in a subluxated position
volar to the transverse axis of the joint and act as
flexors of the proximal interphalangeal joint. This
tightening causes a secondary hyperextension
deformity of the distal interphalangeal joint.
• The flexion deformity of the proximal
interphalangeal joint is compensated for by an
extension of the metacarpophalangeal joint .
• . The metacarpophalangeal joint deformity does not
become fixed, as do the distal two joints.

44. Boutonnière deformity. A, Primary synovitis of proximal interphalangeal (PIP) joint can lead to attenuation of
overlying central slip and dorsal capsule and increased flexion at PIP joint. Lateral band subluxation volar to
axis of rotation of PIP joint can lead in time to hyperextension. Contraction of oblique retinacular ligament,
which originates from flexor sheath and inserts into dorsal base of distal phalanx, can lead to extension
contracture of distal interphalangeal joint. B, Clinical photograph illustrates flexion posture of PIP joint and
hyperextension posture of distal interphalangeal joint in boutonnière deformity.

45. Nalebuff and Millender categorized buttonhole deformities on the basis of the radiographic
appearance of the joint surface and the amount of active and passive motion
Mild buttonhole deformities
• there is a flexion deformity at the proximal
interphalangeal joint with lessened ability to flex the
distal joint fully, but the joint is not fixed in
hyperextension.
• The flexion deformity at the proximal interphalangeal
joint is passively correctable from a position of
approximately 15 degrees of flexion.
• In these deformities, treatment may consist of
releasing the lateral tendons near their insertion into
the distal phalanx

46. • Moderate buttonhole deformity
• has an approximately 40-degree flexion
contracture of the proximal interphalangeal
joint, most of which is passively correctable. The
distal joint is hyperextended, and usually the
metacarpophalangeal joint is correctable to full
flexion passively. The lateral bands are fixed in
their subluxated position volarward by virtue of
the contracted transverse retinacular ligament.

47. • To correct this deformity, there must be
functional restoration of the central slip and
correction of the subluxation of the lateral bands.
Radiographs of these joints should show no
severe joint destruction.
• If the metacarpophalangeal joint is destroyed
and fixed, but the interphalangeal joint is
preserved, this deformity can be treated with
metacarpophalangeal joint arthroplasty or fusion

48. Severe or fixed buttonhole deformity
• usually has joint changes on radiographs and a
passively uncorrectable flexion contracture of the
proximal interphalangeal joint.
• Combined procedures on both joints, usually
metacarpophalangeal joint arthroplasty or fusion
with interphalangeal joint release or fusion, are
necessary.
• Kiefhaber and Strickland found central extensor
tendon reconstruction for rheumatoid boutonnière
deformities unpredictable and recommended
arthrodesis for severe boutonnière deformities

49. • The mildest deformities, with satisfactory motion and
normal-appearing radiographs, can be treated with
repositioning of the lateral band portion of the
extensor mechanism, proximal interphalangeal joint
synovectomy, and extensor tenotomy over the middle
phalanx (Dolphin-Fowler procedure).
• For moderate deformities with a passively correctable
proximal interphalangeal joint, normal flexor tendon
function, and satisfactory preservation of joint space
radiographically, a soft-tissue procedure with central
slip reconstruction using the lateral band or a tendon
graft is an option.

50. For severe deformities with
stiff joints, the long, ring, and
little fingers can be treated
with extensor reconstruction
and Silastic implant
arthroplasty; in the index
finger, arthrodesis of the
proximal interphalangeal joint
may suffice

51. • Arthroplasty of the proximal interphalangeal joints of the
ring and little fingers may be done when there are near-
normal metacarpophalangeal joints proximally
• Swanson advised proximal interphalangeal joint resection
arthroplasty and implant for the index finger when the
deformity is singular and severe. If the proximal
interphalangeal joints of the index and middle fingers are
involved, arthrodesis of the joint of the index finger and
resection arthroplasty of the joint of the middle finger may
be indicated.

52. • This procedure gives a more stable index
finger for pinch and permits flexion of the
middle finger for grasp. Resection arthroplasty
for the ring and little fingers also can be done
when indicated. If the joint contracture is so
tight that extensive bone resection is required
for satisfactory placement of the implant,
arthrodesis should be considered

53. Deformities of the Distal Joint
• The rheumatoid deformities at the distal joint
include a mallet, hyperflexed distal
interphalangeal joint (Fig. 70-22), which may
occur in conjunction with a swan-neck deformity
or as a result of attenuation of the terminal
central slip of the extensor tendon, and a
hyperextensible distal interphalangeal joint,
which also may be related to attenuation of
capsuloligamentous structures or to flexor
tendon rupture.

54. • Usually either of these deformities can be
treated with distal interphalangeal joint
arthrodesis. In a patient who has had a
proximal interphalangeal joint arthrodesis, the
distal interphalangeal joint mallet deformity
might be left untreated because the small
amount of mobility remaining in the distal
interphalangeal joint can contribute
significantly to fingertip function

55. mallet finger in long finger

56. 4.Ulnar Drift or Deviation of the Fingers
• The deformity of ulnar drift or deviation of the fingers (Fig. 70-23)
is found in conditions other than rheumatoid arthritis.
• In the normal hand, factors are
• (1) the ulnar deviation of the phalanges at the
metacarpophalangeal joints, especially of the index finger;
• (2) the small and sloping ulnar condyle of asymmetrical
metacarpal heads, especially those of the index and middle
fingers;
• (3) the approach from the ulnar direction of the long flexor and
extensor tendons to the metacarpophalangeal joints;
• (4) the greater ulnar deviation than radial deviation of the digits
permitted by the radial collateral ligaments when the
metacarpophalangeal joints are flexed; and
• (5) the greater strength of the abductor digiti quinti and flexor
digiti quinti than of the third volar interosseous

57. • Factors found in the rheumatoid hand are
• (1) stretching of the collateral ligaments of the
metacarpophalangeal joints by the volarly directed forces of the
flexor tendons, permitting volar displacement of the proximal
phalanges;
• (2) stretching of the accessory collateral ligaments that permits
ulnar displacement of the flexor tendons within their tunnels;
• (3) stretching of the flexor tunnels that permits even more ulnar
displacement of the long flexor tendons;
• (4) ulnar displacement of the long flexor tendons caused by
surgical release of their sheaths for multiple trigger fingers or for
improving strength of grasp by changing their angle of approach
to the fingers;

58. • 5) contracture of the interosseous muscles that causes (in
addition to ulnar deviation of the digits) hyperextension
of the proximal interphalangeal joints, flexion, and
eventually subluxation of the metacarpophalangeal joints
and eventually subluxation of these latter joints;
• (6) attenuated radial sagittal bands that allow ulnar
displacement of the long extensor tendons, further
increasing their deforming influence (this displacement is
caused by ineffective radial sagittal bands);
• (7) rupture of long extensor tendons at the distal edge of
the dorsal carpal ligament that increases the possibility of
dislocation of the metacarpophalangeal joints.

59. Ulnar deviation of fingers in rhuematoid
arthritis

60. Subluxation of metacarpophalangeal joints of fingers in severe rheumatoid arthritis. B,
Subluxations have been treated by resecting metacarpal heads. Because at surgery articular
cartilage of joints was eroded, intrinsic release would have been insufficient treatment

61. Severe Ulnar Drift and
Metacarpophalangeal Dislocation
• In severe ulnar drift, often one or more
metacarpophalangeal joints have dislocated (Fig.
70-27); consequently, this type of drift and
dislocation of these joints are discussed
together.
• Here the dislocation of the
metacarpophalangeal joint in effect has released
the soft-tissue structures that cross the joint and
by decreasing tension has protected, at least
partially, the proximal interphalangeal joint
• .

62. • . Conversely, if the proximal interphalangeal joint
dislocates first, the metacarpophalangeal joint is
partially protected. Because of the deforming
forces mentioned earlier in this section, the
metacarpophalangeal joints would have deviated
ulnarward more and more
• For this type of ulnar drift, surgery is done mainly
on the metacarpal head and its surrounding
ligaments and tendons

63. Metacarpophalangeal dislocation in rheumatoid
arthritis

64. Extensor Tenosynovitis
• Although it usually is relatively painless, tenosynovitis of
the extensors of the digits and wrist causes visible
swelling over the dorsum of the wrist with an area of
constriction at the extensor retinaculum. One or all
extensor tendons may be affected by rheumatoid
tenosynovitis, which weakens the tendon and may lead to
tendon rupture.
• Nonoperative treatment with medication and
corticosteroid injections may lead to resolution of the
tenosynovitis. Because of the possibility of extensor
tendon rupture, extensor tenosynovectomy usually is
recommended if there has been no improvement in the
tenosynovitis with 6 months of nonoperative treatment.

65. RHEUMATOID DEFORMITIES OF THE
WRIST
Synovitis of the Wrist
• Often, the dorsum of the wrist is the location of
the first painful swelling in rheumatoid arthritis.
The tenosynovial swelling may contribute to de
Quervain disease, trigger finger, or carpal tunnel
syndrome, whereas rheumatoid arthritis as the
underlying cause may not be suspected.
• The swelling may begin as a small soft mass at
the distal end of the ulna; radiographs may
reveal a small pit at the base of the ulnar styloid
as the first radiographic evidence of the disease.

66. • The synovitis can spread and cause massive
swelling in the shape of an hourglass, its
middle being constricted by the dorsal carpal
ligament. Eventually, destruction of joints may
contribute to dorsal subluxation of the distal
ulna, ulnar shifting of the carpal bones, radial
angulation of the metacarpals, and ulnar
deviation of the fingers. Finally, the wrist may
subluxate volarly. Tendons, especially those of
the three ulnar finger extensors, may rupture

68. • If the synovitis is only moderate, and if changes in the
bones are absent, but pain is significant, dorsal
synovectomy of the wrist seems to be of lasting benefit.
• Persistent swelling at the dorsum of the wrist that
continues for 6 weeks or longer despite adequate
medical treatment may be an indication for a dorsal
synovectomy.
• This may be considered a prophylactic measure to
avoid rupture of the extensor tendons. Rupture of these
tendons is quite disabling, and function can never be
restored completely

69. • Any tendons ruptured at the level of the wrist can
be repaired at the time of synovectomy.
• Options include side-to-side anastomosis, free
tendon graft, and tendon transfers to bridge a
defect in a tendon.
• If synovitis involves the wrist and the
metacarpophalangeal joints, synovectomy often can
be done at both levels through carefully planned
incisions during the same operation, usually only on
one limb at a time

70. • On the volar aspect of the wrist, even slight hypertrophy of the
synovium undetectable clinically can cause compression of the
median nerve and symptoms of carpal tunnel syndrome.
• . Synovitis is considered one of the most frequent causes of the
syndrome.
• Compression of the nerve in rheumatoid arthritis should be
relieved surgically if conservative treatment with splinting and
steroid injections has been unsuccessful.
• If hypertrophy of the tenosynovium on the volar aspect of the
wrist is obvious clinically, with or without symptoms of
compression of the median nerve, a palmar (flexor)
tenosynovectomy may be useful in relieving pain and in
preventing rupture of tendons

71. Reconstructive procedures
available for an arthritic wrist joint include
arthrodesis and arthroplasty

72. Flexor surface, left hand and wrist with rheumatoid tenosynovium bulging to palmar
and ulnar (medial) side of distal forearm. B, At flexor tenosynovectomy. Note
extension of incision distally into palm and proximally into forearm. Excised
tenosynovial mass lies to medial side of hand

73. Radiograph of wrist affected by severe rheumatoid arthritis
with carpal collapse and radiocarpal disease. B, Film
obtained after replacement of wrist joint with Swanson
silicone implant and titanium grommets

74. Correctly implanted Meuli III wrist prosthesis in 55-year-old woman with rheumatoid
arthritis. A, Radiographs before surgery. B, Radiographs 4.5 years after surgery. Note
reconstruction of carpal height and axial alignment. Prosthesis is firmly fixed in
carpal bone stock with no palmar protrusion

75. Long-standing rheumatoid disease and symptomatic wrist
arthritis. C and D, Two years after total wrist arthroplasty

76. THANK YOU