In-Service Exam
Hand - Rheumatoid - 2001





A 42-year-old woman with severe rheumatoid arthritis has advanced joint degeneration, pain, and decreased use of the right elbow, wrist, and hand. On examination, the elbow is stiff and tender and the wrist and metacarpophalangeal joints are tender and subluxed. Radiographs confirm these findings.

Which of the following staged sequences is most appropriate?

(A) Elbow arthroplasty, wrist arthrodesis, MP joint arthroplasties
(B) Elbow arthroplasty, MP joint arthroplasties, wrist arthrodesis
(C) MP joint arthroplasties, elbow arthroplasty, wrist arthrodesis
(D) MP joint arthroplasties, wrist arthrodesis, elbow arthroplasty

The correct response is Option A.

This patient with severe rheumatoid arthritis should first undergo total elbow arthroplasty followed by wrist arthrodesis and then by MP joint arthroplasties. This proximal-to-distal sequence of procedures is advocated for most patients who have diffuse rheumatoid arthritis of the upper extremity. Performing the elbow arthroplasty first will facilitate the subsequent surgical procedures and postoperative recovery and rehabilitation by stabilizing the arm, increasing elbow mobility, and decreasing pain. Postoperative self-care following subsequent surgeries will be easier for the patient. In addition, patients with rheumatoid arthritis have joint and tendon imbalance and resultant Òzig-zagÓ deformities; the ulnar deviation and volar subluxation of the MP joints is further aggravated by the radial deviation and supination of the wrist. Therefore, wrist arthrodesis should precede MP joint arthroplasties.

References
1. Berger RA, Beckenbaugh RD, Linscheid RL. Arthroplasty in the hand and wrist. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:147-191.
2. Flatt AE. The Care of the Arthritic Hand. Saint Louis, Mo: Quality Medical Publishing, Inc; 1995.
3. Gould J. Arthroplasty of the metacarpophalangeal and interphalangeal joints of the digits and thumb. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;2:1677-1689.

An otherwise healthy 50-year-old surgeon has the sudden, rapid onset of severe swelling in the fingers as well as pain, stiffness, and swelling of the distal interphalangeal joints. On examination, the fingernails are pitted and cracked. These findings are most consistent with

(A) gout
(B) HIV infection
(C) rheumatoid arthritis
(D) systemic lupus erythematosus

The correct response is Option B.

A diagnosis of HIV infection should be considered in patients who have the rapid or explosive onset of psoriatic arthritis or Reiter's syndrome. Arthritic HLA B27-associated conditions are frequently seen in conjunction with HIV infection and are often more aggressive and resistant to treatment. Psoriasis either develops or worsens with the onset of HIV infection; in contrast, Reiter's syndrome, which in most patients is a triad of arthritis, conjunctivitis, and uveitis, is more likely to have only polyarthritic involvement. However, awareness of the coexistence of HIV infection in this patient is important because immunosuppressive therapy, which is often prescribed for management of arthritis, can have devastating effects in patients with HIV infection. The findings in this patient can also be mistaken for onychomycosis or herpetic whitlow.

Gout is a crystalline arthropathy, while rheumatoid arthritis and systemic lupus erythematosus are inflammatory systemic autoimmune diseases. None of these conditions would present with the above findings, although some symptoms of HIV infection can mimic systemic lupus erythematosus.

References
1. Hewitt RG. Manifestations of human immunodeficiency virus infection in the upper extremity. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;2:1787-1796.
2. Matteucci BM, Schumacher HR. Systemic arthritic conditions of the upper extremities - inflammatory. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;2:1617-1631.

A 57-year-old woman with rheumatoid arthritis who has taken anti-inflammatory medication for the past six months has pain and catching of the ring finger; she has occasional locking when she attempts to flex the finger. On examination, the finger locks as she attempts to make a fist; a nodule is palpable in the palm.

Which of the following is the most appropriate operative procedure?

(A) Release of the A1 pulley only
(B) Release of the A1 pulley and excision of the flexor tendon nodule
(C) Release of the A1 pulley and tenosynovectomy
(D) Tenosynovectomy only
(E) Tenosynovectomy and excision of the flexor tendon nodule

The correct response is Option E.

The most appropriate management of this patient's condition is flexor tenosynovectomy and excision of the flexor tendon nodule. This patient has developed trigger finger secondary to rheumatoid arthritis. The table below describes the four clinical types of trigger finger that may develop in patients with this condition.

Type I - There is a small localized area of disease with catching of the tendon with flexion
Type II - There is digital tenosynovitis; flexor tendon nodules in the palm cause the finger to lock during flexion
Type III - There is a nodule in the flexor digitorum profundus tendon in the region of the A2 pulley that causes the finger to lock in extension
Type IV - There is generalized tenosynovitis and limited motion

Flexor tenosynovectomy and excision of the flexor tendon nodules are indicated in the treatment of all types of tenosynovitis and triggering seen in patients with rheumatoid arthritis. The annular pulleys should be preserved to prevent the development of bowstringing. In addition, excision of the nodule at this time will prevent disease progression and potential tendon rupture.

In a patient with rheumatoid arthritis, release of the A1 pulley may further exacerbate ulnar drift.

References
1. Feldon P, Terrono AL, Nalebuff EA, et al. Rheumatoid arthritis and other connective tissue disorders. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1651-1739.
2. Ferlic DC. Rheumatoid flexor tenosynovitis and rupture. Hand Clin. 1996;12:561-572.