Rheumatoid Hand and Wrist for the FRCSOrth

Courtesy: Saurabh Aggarwal, Princess Royal University Hospital, London, UK

 

Definition

• Rheumatoid arthritis is a chronic systemic inflammatory disease characterized by symmetrical inflammatory polyarthritis.

• It predominantly affects the small joints of the hands, feet, and wrists.

• Symptoms persist for more than 6 weeks and are associated with characteristic laboratory abnormalities.

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Pathogenesis

• The disease begins with antigen-mediated activation of T lymphocytes.

• This initiates a cascade involving activation of endothelial cells and inflammatory mediators.

• Matrix metalloproteinases cause excessive collagen degradation and cartilage matrix destruction.

• The synovium transforms into an invasive pannus, composed of synoviocytes, T lymphocytes, and macrophages.

• Inflamed synovium with vascular proliferation invades adjacent cartilage and bone.

• This process leads to:

  • Progressive cartilage destruction

  • Activation of osteoclasts

  • Periarticular bony erosions

  • Juxta-articular osteopenia

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Clinical Features

• Insidious onset of symptoms.

• Joint pain, swelling, and stiffness, particularly morning stiffness lasting more than 1 hour.

• Symmetrical involvement is typical.

• Commonly affected joints include:

  • Metacarpophalangeal joints

  • Proximal interphalangeal joints

  • Interphalangeal joints of the thumb

  • Wrist joints

  • Metatarsophalangeal joints of the toes

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Physical Examination Findings

General Joint Findings

• Pain and localized tenderness

• Swelling and synovial thickening

• Restriction of joint movement

Hand Deformities

• Ulnar deviation (ulnar drift) of fingers

• Swan-neck deformity

• Boutonnière deformity

• Z-deformity of the thumb

• Bowstring sign

• Digital infarcts

• Rheumatoid nodules

Elbow

• Subcutaneous rheumatoid nodules

• Loss of extension

• Ulnar nerve compression neuropathy

Shoulder

• Adhesive capsulitis (frozen shoulder)

Foot and Ankle

• Synovitis of metatarsophalangeal joints

• Cock-up deformities of toes

• Flattening of foot arches

• Retrocalcaneal bursitis

• Tarsal tunnel syndrome

Knee

• Synovial thickening

• Joint effusion

• Restricted range of motion

• Ligamentous laxity leading to deformity

Axial Skeleton

• Cervical spine involvement

• Atlantoaxial subluxation

Other Joints

• Cricoarytenoid joint

• Temporomandibular joint

• Sternoclavicular joint

• Manubriosternal joint

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Radiographic Features

Early Changes

• Soft tissue swelling

• Juxta-articular osteopenia

Late Changes

• Joint space narrowing

• Marginal bony erosions

• Reduced intercarpal and radiocarpal joint spaces

• Carpal crowding and ankylosis

• Destruction of intercarpal articulations

• Marked subluxation of metacarpophalangeal joints

• Reduced joint space at carpometacarpal, metacarpophalangeal, and proximal interphalangeal joints

• Erosions of cartilage and bone are cardinal features of rheumatoid arthritis but are not diagnostic by themselves.

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Extra-Articular Manifestations

• Generalized osteopenia or osteoporosis

• Muscle wasting and weakness

• Rheumatoid nodules

• Skin ulcers

• Ocular involvement

• Pulmonary disease

• Cardiac involvement

• Renal disease

• Hematologic abnormalities

• Nervous system involvement

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Laboratory Findings

• Anemia of chronic inflammation

• Thrombocytosis

• Mild leukocytosis

• Positive rheumatoid factor

• Anti-citrullinated protein antibodies

• Elevated acute phase reactants:

  • Erythrocyte sedimentation rate

  • C-reactive protein

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Assessment of Disease Activity

• Disease Activity Score using 28 joints with erythrocyte sedimentation rate or C-reactive protein

• Simplified Disease Activity Index

• Clinical Disease Activity Index

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Poor Prognostic Factors

• Early functional impairment as assessed by validated scoring systems

• Presence of extra-articular disease

• High titers of rheumatoid factor or anti-citrullinated protein antibodies

• Elevated erythrocyte sedimentation rate at diagnosis

• Male gender

• Presence of rheumatoid nodules

• Radiographic evidence of bony erosions

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Pre-Treatment Evaluation

• Baseline investigations:

  • Complete blood count

  • Serum creatinine

  • Liver function tests

  • Erythrocyte sedimentation rate

  • C-reactive protein

• Screening for hepatitis B and C prior to initiating disease-modifying therapy

• Ophthalmologic examination before initiating hydroxychloroquine

• Screening for latent tuberculosis using Mantoux test or interferon-gamma release assay before starting biologic or Janus kinase inhibitor therapy

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Medical Management

• Nonsteroidal anti-inflammatory drugs for symptomatic relief

• Corticosteroids for short-term disease control

• Conventional synthetic disease-modifying antirheumatic drugs

• Biologic disease-modifying antirheumatic drugs

• Targeted synthetic disease-modifying antirheumatic drugs

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Surgical Management

Surgery is considered for pain relief, deformity correction, and functional restoration.

Common procedures include:

• Decompression of entrapped nerves

• Reconstructive joint procedures, including arthroplasty

• Corrective metatarsal arthrotomies

• Cervical spine stabilization

• Tendon release and tendon transfer procedures

• Arthrodesis, particularly of the ankle joint