In-Service Exam
Hand - Rheumatoid - 2002





In children with juvenile rheumatoid arthritis, which of the following hand deformities is most common?

(A) Loss of flexion of the interphalangeal joint
(B) Radial deviation of the carpus
(C) Rupture of the extensor tendons
(D) Supination of the carpus
(E) Ulnar deviation of the metacarpophalangeal joints

The correct response is Option A.

Hand deformities associated with juvenile rheumatoid arthritis typically differ from those seen in adult patients with rheumatoid arthritis. Affected pediatric patients have wrist flexion with loss of wrist extension. The carpus and metacarpals are deviated ulnarly, and loss of flexion and radial deviation of the metacarpophalangeal joints is characteristic. In addition, there is a loss of flexion of the interphalangeal joints. Swan-neck and boutonnire deformities and spontaneous tendon ruptures are rare.

In contrast, adults with rheumatoid arthritis exhibit radial deviation and supination of the carpus. The metacarpophalangeal joints are subluxed palmarly and deviated ulnarly. Swan-neck deformities, boutonnire deformities, and spontaneous tendon ruptures occur in significant numbers.

References
1. Chaplin D, Pulkki T, Saarimaa A, et al. Wrist and finger deformities in juvenile rheumatoid arthritis. Acta Rheumatol Scand. 1969;15:206-223.
2. Rao SB, Crawford AH. Traumatic and acquired wrist disorders in children. In: Lichtman DM, Alexander AH, eds. The Wrist and its Disorders. Philadelphia, Pa: WB Saunders Co; 1997:540.
3. Simmons BP, Nutting JT. Juvenile rheumatoid arthritis. Hand Clin. 1989;5:157-168.

PHOTO

A 34-year-old man is brought to the emergency department with marked pain and swelling on the radial side of the right hand after falling on his outstretched hand. Radiographs are shown above. Which of the following is the most appropriate next step in management?

(A) Closed reduction of a complex dislocation of the metacarpophalangeal joint of the thumb
(B) Closed reduction of a dislocation of the carpometacarpal joint of the thumb
(C) Closed reduction of a displaced scaphoid fracture
(D) Closed reduction of a transradial styloid perilunate fracture-dislocation
(E) Closed reduction of a trapezoid fracture-dislocation

The correct response is Option B.

Based on the above radiographs, this patient has a dislocation of the carpometacarpal (CMC) joint of the thumb, a rare injury. The metacarpophalangeal joint is not involved. Dislocations of the CMC joint at the base of the small finger are more common. Closed reduction of the dislocated joint should be performed as soon as possible; this can be accomplished by applying axial traction and pronation combined with manual pressure over the metacarpal base. Because CMC joint dislocations in the thumb are frequently accompanied by complete tears of the palmar oblique ligament (volar beak ligament), further management should include Kirschner wire stabilization and casting if the dislocation is unstable. Patients with stable dislocations may require casting only. Immobilization and stabilization of the ligament tear will protect the ligament during healing. There is no associated fracture in this patient.

Open reduction and internal fixation are recommended for management of displaced scaphoid fractures. Perilunate dislocation would be demonstrated by incongruity of Gilula's arcs on posteroanterior radiographs and by subluxation of the capitate from its articulation with the lunate. Trapezoid fractures can be subtle on standard radiographs of the wrist; fluoroscopic imaging or CT scans may be beneficial. Because trapezoid fractures are typically stable and nondisplaced, cast immobilization alone is indicated.

References
1. Dray GJ, Eaton RG. Dislocations and ligament injuries in the digits. In: Green DP, ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone, Inc; 1993;1:767.
2. Wolfe SW, Elliott AJ. Metacarpal and carpometacarpal trauma. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;1:883.

A 54-year-old violinist has severe posttraumatic osteoarthritis of the metacarpophalangeal (MP) joint of the nondominant left long finger. She has severe pain and limited finger use despite administration of nonsteroidal anti-inflammatory drugs and protection of the joint. Radiographs show fracture union, adequate metacarpal and phalangeal bone stock, and severe degenerative arthritis of the MP joint.

Which of the following is the most appropriate management of the MP joint?

(A) Perichondrial autograft arthroplasty
(B) Silicone implant arthroplasty
(C) MP joint arthrodesis
(D) Nonvascularized toe joint arthroplasty
(E) Free vascularized toe joint arthroplasty

The correct response is Option B.

This 54-year-old violinist with posttraumatic arthritis of the MP joint of the long finger requires motion. Therefore, the most appropriate management is silicone implant arthroplasty of the MP joint. This procedure will alleviate pain and yield good range of motion of the joint.

Arthroplasty and arthrodesis are typically performed for operative management of posttraumatic joint arthritis. Although both procedures generally alleviate pain, only the arthroplasty procedure permits joint motion. Joint arthrodesis diminishes pain but results in a stable, rigid joint, which would not be appropriate in a violinist who requires motion. Perichondrial autografts are unpredictable, especially when used in complete joint resurfacing. Nonvascularized toe joint transfers provide only a limited range of joint motion, and degeneration of donor cartilage occurs. Free vascularized toe joint transfers allow growth in young patients, and offer composite tissue (joint, extensor mechanism, and bone stock). However, range of motion following any type of toe joint transfer is less than with silicone implant arthroplasty.

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. Foucher G. Vascularized joint transfers. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1251-1270.