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Hand

Rheumatoid Hand & Wrist

HandthinKbox SBA

Definition

  • An autoimmune systemic disease causing an inflammatory symmetric polyarthropathy primarily affecting synovial lined structures
  • In hand typically spares DIPJ

Classic X-Ray Features

  • Peri-articular erosions
  • Osteopenia
  • Joint subluxation and deformity

Medical Treatment

3 Groups of Drugs

  1. NSAIDS
  2. Corticosteroids
  3. Disease modifying drugs
    • Only DMARDs can prevent joint destructions

DMARDs

  • Split into Non-biologic and Biologic

Non-Biologic:

  • Methotrexate
    • Traditionally the only DMARD
    • Best used as an anchor drug in combination with biologic agent

Biologic DMARDs:

  • Further split into two categories:
    • TNF-alpha inhibitors
      • Etanercept
    • Interleukin-1 antagonists
      • Anakinara (shown to improve radiographic outcomes)

Classification of RA Joint Disease: Larsen Staging

  1. Normal joint
  2. Periarticular osteopenia, minimal narrowing
  3. Joint erosions, mild narrowing
  4. Moderate destructive narrowing
  5. End-stage joint destruction but preservation of joint surfaces
  6. Mutilating disease, complete articular destruction

Surgical Concepts

  • Many patients have adapted to severe deformities
  • Be specific in what the functional deficit you are trying to improve is
  • Not all deformities need correcting simultaneously
  • Patients often happy enough after one procedure

Wrist

Natural History

  • Soft tissue attenuation, synovitis, and rupture lead to bony deformities
  • Carpus:
    • Synovitis around wrist & extensor tendons
    • Scapholunate ligament degeneration
    • Extrinsic volar ligament attenuation and rupture
    • Scaphoid flexion
    • Radial column collapse
  • DRUJ:
    • Caput ulna syndrome
    • ECU subsheath rupture
    • Allows carpus to supinate
    • Stretches dorsal DRUJ restraints
    • Ulna head prominence – piano key sign
    • Eventually:
      • Midcarpal instability and collapse
      • Pan-carpal arthritis

Causes of DRUJ Instability

  • High vascularity in pre-styloid recess leads to rapid synovitis
  • Attenuates ulna-sided ligament supports – ECU subsheath
  • ECU tendon infiltration - instability
  • Arthritic destruction of DRUJ articular surfaces

Extensor Tendon Problems

  • Synovial infiltration of tendon sheaths – tenosynovitis
  • Tendon rupture – especially at wrist level
  • Tendon subluxation at MCP level

Wrist Synovitis

  • 'Hourglass swelling' on dorsum of wrist
  • Indicates impending tendon rupture
  • Synovium proximal and distal to extensor retinaculum

Tendon Rupture at Wrist

  • Infiltration of the tendons themselves
  • Attrition at bony prominences – DRUJ, Lister’s tubercle
    • DRUJ typical because of Caput Ulna prominence
  • Palmar subluxated carpus
  • Dorsal subluxated Ulna head
  • Rupture occurs sequentially from ulna to radial
    • EDM then EDC and so on

Vaughan Jackson Syndrome

  • EDM rupture due to caput ulna
  • Test by holding other fingers flexed-inability to extend little finger
    • Eliminates any juncturae or an EDC to little finger

MCPJ Tendon Problems

  • Loss of extension at MCPJ may be caused by:
    1. Subluxation
    2. Tendon rupture
    3. Joint dislocation
    4. PIN palsy
  • On examination they can be differentiated by:
    • Subluxation: tendon palpable and relocates with extension
    • Rupture: No palpable tendon or power in any position
    • Dislocation: XR and palpable + visible deformity
    • PIN Palsy: Other muscles affected - Tenodesis retained
      • (slight extension of fingers with maximal passive flexion at wrist)

Flexor Tendon Problems

Tenosynovitis

  • Painful thickened volar aspect fingers
  • Unable to pinch skin on examination
  • Crepitus and pain
  • Inject with steroid
  • Oral drugs
  • Splintage
  • Surgical synovectomy if no improvement to prevent rupture
  • Be fairly aggressive at preventing tendon rupture

Tendon Rupture

  • FDS, FDP, or both at any level
  • Primary repair or grafting has poor results
  • Consider DIPJ fusion if FDP alone
  • Buddy to adjacent flexor if at wrist level
  • Tendon grafting may be needed if both ruptured in finger – unpredictable
  • All tendon procedures should have a synovectomy concurrently

Mannerfelt Syndrome

  • Isolated rupture of FPL or sometimes index FDP
  • Attrition on volar STT joint osteophyte
  • May be confused with AIN palsy
  • Treat with thumb IPJ fusion
    • FDS transfer or tendon grafting has poor results

Triggering

  • Usually due to tenosynovitis rather than A1 pulley thickening
  • Preserve pulleys if possible (maintain stability of tendon)
  • Excise synovitis

Carpal Tunnel Syndrome

  • Either concurrent or due to synovitis in tunnel
  • Explore carpal tunnel fully if RA present
  • Excise synovitis and decompress nerve

Surgery for Wrist RA

Goals:

  • Prophylactic or corrective
  • Pain relief
  • Prevention of tendon rupture
  • Correct deformities contributing to functional impairment
  • Restore function

DRUJ Procedures

  • Darrach’s: Distal ulna resection - often leave styloid tip

    • Possible in older low demand patients
    • Comparable pain relief but grip strength poor
    • Complications:
      • Ulna translation of the carpus into defect
      • Can do concurrent RL fusion to prevent

  • Suave Kapanji: DRUJ fusion with Ulna osteotomy to maintain rotation

    • Main complication: Stump pain - abutment against radius
    • Lower complication rate than Darrach
    • Better for younger patients

  • DRUJ Arthroplasty:

    • No long-term results and loosening/pain are problems

Radiocarpal Arthritis

Fusion or Arthroplasty

Fusions: Limited or Total

Radiocarpal Fusion (Chamay) (Radius to Lunate and Scaphoid)

  • Prophylactic to prevent ulna subluxation of carpus
  • Halts natural progression outlined above
  • Contraindicated in presence of midcarpal OA

Total Wrist Fusion

  • Predictably good results with dorsal fusion plates/pins
  • Some prefer not using dorsal plates because of poor bone
  • AO locking wrist fusion plate is better though
  • Pain relief good and function satisfactory
  • Complication rate is low
  • Pseudoarthroses tend to be pain free

Surgical Steps

  • Longitudinal dorsal approach
  • Dorsal half carpal bones and distal radius fragmented and used as graft
  • IM pins, Steiman pins, or AO fusion plate
  • For bilateral cases try and avoid bilateral fusion
  • Consider arthroplasty of one wrist

Wrist Arthroplasty

  • Better results but still evolving
  • Rheumatoid arthritis is a possible indication
  • Improved results with the Universal 2 wrist replacement
    • Should have:
      • Minimal deformity
      • Good bone stock
      • Intact extensors

MCP Joints

Typical Deformities

  • Volar joint subluxation due to synovitis
  • Ulna drift caused by tendon subluxation

Functional Problems

  • Difficult to pinch if index drifted ulnar ward
  • Difficulty cupping objects
  • Aesthetically displeasing

Surgical Options

Soft Tissue or Bony Procedures

Synovectomy & Cross Intrinsic Transfer of Lateral Bands

  • Early disease only
  • Prevents subluxation

Relocation of Tendon

  • Tightening of radial and release of ulna soft tissues
  • Contraindicated if joint affected

Fusion

  • Not usually good option as finger motion is initiated at MCPJ
  • Fusion is functionally poor at MCPJ
  • Last resort

Arthroplasty

  • Usually the best solution
  • Shortens digit > reduces soft tissue tension and deforming forces
  • Must be combined with tendon relocation and soft tissue balance
  • Concurrent wrist re-alignment to prevent chronic instability
  • Better deformity correction in radial joints
  • Silicone spacers most common
    • Traditionally the Swanson
    • Currently Neuflex is most common
    • Scar tissue formed stabilises joints despite loosening
  • Pyrocarbon unconstrained joints not good for RA but good in OA

Surgical Principles

  • Correct proximal wrist deformities and tendons first
  • Multiple or single transverse or longitudinal incisions
  • Release capsule and intrinsics
  • Excise MCPJ head distal to collaterals
  • Imbricate lax radial capsule and sagittal band in closure

Volar Plate Arthroplasty

  • Interposition of volar plate in joint - pain relieving
  • Unreliable correction of deformity
  • Best reserved if bone too small for arthroplasty

Tendon Rupture

  • Sequentially occurs from EDM then each EDC
  • All procedures should address the tendon deficiency and the cause

Tendon Transfer Options

  • Only EDM ruptured
    • End-to-side transfer (stitch end of EDM to EDC of ring finger)
  • If ulna 2 tendons ruptured
    • EIP transfer to power ring & little or,
    • EIP to EDM and buddy ring to middle EDC
  • If ulna 3 tendons ruptured
    • EIP to ring and little
    • Middle finger end to side with Ext Indicis Communis
    • Weak extension as all fingers powered by index extensors
    • Alternative is to combine FDS into transfer
  • If all 4 tendons gone:
    • FDS tendons transferred through interosseous membrane
    • FDS is not synergistic > function difficult to get used to
    • FDS has excellent excursion so is very useful

Boutonniere Deformity

Primary Cause

  • Synovitis, attenuation, and rupture of central slip
  • Volar subluxation of lateral bands and hyperextension of DIPJ
  • Often not functionally too limiting but,
    • Patients don't like appearance
  • Correction to an extended position of PIPJ can actually impair function
    • Therefore avoid for aesthetics

Classification (Nalebuff)

  • Mild: Mobile PIPJ, PIPJ extensor lag <15 degrees
  • Moderate: Mobile PIPJ, PIPJ extensor lag 15-40 degrees
  • Severe: Fixed PIPJ with loss of extension and arthritis

Management

Flexible Deformity:

  • If acute: Capener splint – allows active DIPJ motion
  • If chronic:
    • Extensor tendon tenotomy – at distal phalanx
    • Leaves ORL intact so no mallet finger develops
    • Tendon reconstruction
    • Passive motion must be restored
    • Re-location of lateral bands or,
    • Transfer of ulna lateral band to central slip

Fixed Deformity:

  • Arthrodesis
    • Gold standard – reliable and durable
  • Arthroplasty
    • Described but deformity often recurs – more difficult to salvage

Swan Neck Deformity

  • More functionally limiting than Boutonniere
  • Patient unable to flex finger and grip properly

Causes

  • DIPJ: Mallet finger caused by DIPJ disease or trauma
  • PIPJ:
    • Synovitis causes volar plate attenuation or FDS rupture
    • Dorsal subluxation of lateral bands
    • Transverse and oblique ligaments incompetent
  • MCPJ: Joint or tendon subluxation causes intrinsic tightness

Classification (Nalebuff)

  • Type 1: Fully flexible PIPJ with mild hyperextension
  • Type 2: Intrinsic tightness, PIPJ tight with MCPJ extension only
  • Type 3: PIPJ tight regardless of MCPJ position, No arthritis
  • Type 4: Stiff, arthritic PIPJ

Management

  • Treatment based on cause of deformity and functional deficit
  • REMEMBER: Doing nothing may be the best option
  • Optimization of medical treatment prior to surgery

Stage-wise Treatment

  • Stage 1:
    • Extension restricting splint if PIPJ is problem
    • DIPJ fusion if DIPJ problem
  • Stage 2:
    • Intrinsic release
    • FDS tenodesis or volar plate advancement to prevent hyperextension
  • Stage 3:
    • Arthrodesis of PIPJ + intrinsic release
    • Can MUA PIPJ to restore motion then do as for stage 2
  • Stage 4: Arthrodesis
  • Arthroplasty: PIPJ results are poor in RA

Thumb Deformities

  • Thumb Boutonniere (MCPJ problem)
  • Thumb Swan Neck (CMCJ problem)
  • Mainstay are fusion procedures to provide a strong post for grip
    • Instability rather than loss of motion causes the most symptoms
    • Fuse the appropriate joint
    • If both CMCJ and MCPJ unstable can fuse both but limits function badly
    • Consider CMCJ arthroplasty and MCPJ fusion or just fuse MCPJ

Classification of Rheumatoid Thumb (Nalebuff)

  1. Type 1: Boutonniere (MCPJ flexion) – most common
  2. Type 2: Boutonniere with CMCJ dislocation or arthritis (rare)
  3. Type 3: Swan Neck (CMCJ adduction and flexion)
  4. Type 4: Ulna collateral ligament laxity
  5. Type 5: Swan Neck with no adduction of metacarpal (rare)
  6. Type 6: Mutilating disease – gross joint destruction

Related FRCS revision notes

Kienbock's DiseaseBiomechanics handHandWrist biomechanicsBrachial Plexus ExaminationUlnar Nerve Compression

Linked from

← Hand← Biomechanics hand← Dupuytren’s Contracture← Rheumatoid Hand← Rheumatoid hand

Written/reviewed by Kishore Puthezhath

Professor of Orthopaedics and Consultant Paediatric Orthopaedic Surgeon

FRCS (Tr & Orth) revision resource

Reviewed: September 2026

Core revision references: Miller's Review of Orthopaedics; Campbell's Operative Orthopaedics; Orthobullets. Current specialty guidelines are linked within individual notes where applicable.