REHABILITATION OF THE

RHEUMATOID HAND

Peni Kusumastuti
Indonesia
The 3rd AOCPRM / XI Annual Scientific of Indonesian Association of PMR,
Bali , May 20-23 , 2012
 Objectives
• Clinical Diagnostic Criteria
• Pathophysiology
• Treatment Planning
• Splinting Fabrication
 Rheumatoid Arthritis

• Is a chronic systemic inflammatory condition

affecting synovial tissue
• Cause the joint destruction and deformities of
the hand
 Rheumatoid Arthritis
The Effect on :

Cartilage : mechanical destruction of the
cartilage

Ligament : ligament injury & joint instability

Bone : activated osteoclast & multinucleated
giant cells cause bone loss , destroy bone
and spontaneous fusion

Tendon : tendon weakness and rupture

Muscles : less common affected , can be
injured by perivascular inflammation
 Clinical Diagnostic Criteria for
Rheumatoid Arthritis
Diagnosis is defined by the presence of at least four
of seven criteria :
• Morning stiffness of 1 hour or more at lasting at
least 6 weeks
• Inflammatory arthritis with synovitis in more
three joints
• Inflammatory arthritis of the hand lasting at least
6 weeks w/ typical pattern including Wrist, MCP
or PIP joints
( The American Rheumatism Association 1987 revised criteria , Principles of
Hand Surgery and Therapy , 2nd Edition, Saunders Elsevier , 2010 )
 Clinical Diagnostic Criteria for
Rheumatoid Arthritis
• Any symmetric arthritis lasting longer than 6
weeks
• The presence of rheumatoid nodules
• Elevated rheumatoid factor titer
• Periarticular radiographic features, including
subchondral erosions and osteopenia of the
involved joints on radiographs

The American Rheumatism Association 1987 revised criteria ,

Principles of Hand Surgery and Therapy , 2nd Edition, Saunders Elsevier ,
2010
 PATHOPHYSIOLOGY
• The presence of synovial inflammation
• The synovial lining hypertrophies and spwans the
formation of macrophages and fibroblasts
 the results, called pannus , is aggressive and
destructive , able to stimulate the resorption
of underlying bone and cartilage
 along w/ articular destruction , the
attenuation and degradation of supporting
ligaments results in subluxation joints and
instability
The pathophysiologic processes are driven by specific
molecules, which include prostaglandins, tumor
necrosis factor-ᾶ ( TNF - ᾶ ) and interleukin - 1
 Tumor Necrosis Factor -ᾱ ( TNF- ᾱ ) and
Interleukin 1 ß ( IL-1 ß) act as a proinflammatory
cytokines in the rheumatoid joints.
Stages of Rheumatoid Arthritis
 End Stage Deformity of the Wrist
• Wrist dislocated volar ward
• With complete destruction or spontaneous
fusion of the carpal bone
• Complete dissociation of the radioulnar joint
Wrist become restricted and more restricted
by combination of subluxation, reactive
fibrosis and spontaneous fusion
 A B

Lateral wrist radiograph

A. Mild prominence of the distal
ulna
B. Progerssive involvement
Increase prominence and spur
C formation ; the carpus begin
subluxate
C. Advanced RA w/ very prominence
of distal ulna and complete volar sub
luxation
The caput ulna syndrome ( early ) synovitis and tenosynovitis
on the ulnar side of the wrist, the wrist subluxates volarward
and supinates
 Deformity of the MP joints

Volar subluxation of the the MP joints w/ volar subluxation

and ulnar deviation of the MP joints and radial deviation
of the Wrist and Metacarpal
 Swan-neck Deformity

PIP joint hyperextension and DIP joint flexion

As the result of muscle-tendon imbalance and/or
joint laxity
 Boutonniere Deformity

Results from rupture

of the central slip
and volar translation
of the lateral band

Represent an alteration of muscle and tendon

balance
Flexion of the PIP joint, Hyperextension of the
DIP joint and Hyperextension of the MP joint
 Boutonniere

Swan neck

Zig zag deformity

Wrist radial and Mp joint
ulnar deviation
Ligament laxity of the wrist
Volar subluxation of the carpus
on the radius
 Thumb Deformity

Swan neck Deformity

The boutonniere of
the thumb occurs Complete disruption of MCP joint ulnar collateral
w/ rupture of the ligament
EPB “ Gamekeeper’s thumb “
 Swan-neck Deformity

Results from laxity of

the volar plate, due to
inflammatory arthritis
and dorsal
subluxation of the
lateral bands.
Tightening of the
triangular ligament
and laxity of the
transverse retinacular
PIP joint hyperextension and DIP joint flexion
ligaments maintain
As the result of muscle-tendon imbalance
deformity
and/or joint laxity
 Thumb Deformity
A B

C D

A and B : early metacarpophalangeal joint flexion

C : radial abduction of the metacarpal and distal joint
hyperextension
D : the deformity is accentuated with pinch
Rheumatoid Thumb Deformities
 Evaluation of The Rheumatoid Hand

• Joint deformities • Range of Motion

• Nodules • Strength
• Crepitus • ADL
• Skin Condition • Pain
 Crepitus

• Crepitus may be
palpated or heard
during Active ROM
• Inspection the volar ,
palpate the A1 pulley
while flexes and
extends the digits
The Grind Test
Crepitous can be indicative
of damaged cartilage

The Grind Test at the carpal

metacarpal ( CMC ) joint:
compressing the joint while
gently rotating the head of
metacarpal on the
trapezium
 Skin Condition
Evaluation of skin condition should include :
 Color
 Temperature
 Areas of swelling
Range of Motion
 Goniometric measurement should
be done when possible
 Measurement of composite digit
flexion, active digit extension and
thumb opposition give more
functional information
 Loss of ROM can be caused by
tendon rupture ; EPL ,EDC , EDQ

The tendon may be weakened by the

inflammatory synovium , will fray and
eventually rupture . The extensors
tendon are more vulnerable to
rupture
 Strength

Grip Strength
JAMAR Hydraulic Pinch Strength
Dynamometer Pinch meter
Sphygmomanometer
 Pain
Pp

Pain Analog Scale can be used to determine the

effectiveness of treatment
 Treatment Planning

• Setting goals and treatment plan

• Goals are based on the individual needs and
set according to the stages of the disease
process
• Educating about the disease process at all
phases
The Treatment
 The Goals
Stage I
include reduction of pain and inflammation
Stage II
pain is less severe, maintaining or gently increasing
AROM , avoiding positions of potential deformity and
decreasing trauma to the joints
Stage III
joint deformities are evident, avoiding the position
that can aggravate the deformities
Stage IV
Deformities may affect ADL , the goals focus on
maintaining or increasing function
 Specific Treatment

• Medication
• Splinting
• Joint Protection Principles
• Exercise
 Specific Treatment : Splinting
In stage I – II
resting splints to rest the joints in position opposite of
potential deformity, to decrease muscle spasm, to
decrease inflammation and pain
Use at night or part time during the day
In Stage III
splinting and joint protection are applied to slow the
development of deformity , use as night splint or
functional day splints
In stage IV :
to ad joint stability during daily activities, increase
comfort and decrease pain. Splints likely cannot change
the deformity
 The Resting Splints
To prevent further
deviation of the wrist
provide wrist ulnar
alignment with
appropriate strapping
Swan Neck Splints

The Oval – 8 splint

Prevent PIP joint hyperextension , yet
allow flexion
Boutonniere Splint
 Splinting Volar Subluxation of the
Carpus to Radius
• The wrist is the key
joint to proper hand
function
• Instability at the wrist
will effect grip and
pinch activities
• The soft splints has
some flexibility which
facilitates grasping
objects
 Distal Ulna Dorsal Subluxation

• Provide stability to
the dorsaly
subluxed distal ulna
by put a gentle
ulnar-head
depression
• Can decrease pain
and increase
stability during
forearm rotation
activities
 MPJ Ulnar Deviation and Palmar
Subluxation
• Requires consideration of MP
subluxation and wrist radial
deviation deformities
• Can have effect on one another
• Splint simultaneously , should be
checked carefully
 avoid forcing the digits into
alignment in a splint that
aggravates the wrist
radial deviation deformity
 MPJ Palmar Subluxation
• In patient with MPJ palmar subluxation at the MP
joint , avoid proximal phalanx tilts , should be glide
into position. ( A & B ). This will increase pain and
absorption of the joint surface

• Provide gentle force at the base of the phalanx ( C )

to gently glide the joint into position ( D )
 MP joint Ulnar Deviation Splint
• At stage III – IV
• Functional splints to
give joint stability
during daily activities
• Soft material , not
bulky and
comfortable
Splinting for The Rheumatoid Thumb

The carpal metacarpal

( CMC ) joint is
stabilized.
Placing the metacarpal
in gentle palmar
abduction and
metacarpophalangeal
in slight fexion.
Thumb IP joint with Lateral Instability

• Custom sized
• Can be worn full-time

SIRIS lateral-alignment
splint
Joint Protection Principles
Joint Protection Principles
Joint Protection Principles
Joint Protection Principles
Joint Protection to counteract MP Ulnar Deviation
Hand Joint
Protection
Techniques
 Modalities

Thermal agents : heat and cold
Paraffin, hot packs , MWD , electro therapy
etc

Exercise :
General principles are avoiding painful
active / passive ROM ( pain free ) to
prevent overstretching of joint structures
Hydrotherapy may beneficial
 Modalities

Strengthening Exercise
Should be used with caution to avoid
aggravation of deformities
Grip strengthening can place the digits in
increased ulnar deviation during flexion if
the position of the digits is unchecked

Therapy Exercise should never create

deforming forces or cause pain
Splinting
• DIP Immobilization Splints / Mallet’s splints
• PIP / Finger static splints
• Resting Wrist and Hand splints
• Thumb splints
LET’S PRACTICE
1
Make your Splint
In 30 minutes
 Distal Interphalangeal Splint / DIP
Immobilization Splint ( 1 )
• Common name :
• DIP extension splint
• DIP resting splint
• Static DIP extension splint
• Mallet finger splint

 To immobilize DIP joint to allow healing of

involved structure(s)
 To rest a painful and / or inflamed DIP joint
 Distal Interphalangeal Splint / DIP
Immobilization Splint ( 2 )
Pattern Creation
 Mark for proximal boarder distal to middle
digital crease
 Allow extra 1/4” to 1/2” of material around
borders, depending on digit circumference
 Distal Interphalangeal Splint / DIP
Immobilization Splint ( 3 )
Attention :
 Proximal border should allow nearly full PIP joint
motion
 Lateral borders should encompass two thirds of
circumference of digit to prevent undue compressive
stress from straps

Cut and Heat

 Position patient’s forearm supinated for volar design
and pronated for dorsal design
 If using dressing, apply to digit before heating splint
material
 Distal Interphalangeal Splint / DIP
Immobilization ( 4 )
Strapping :
 Use two ½” straps or one 1” strap to secure splint
 Place straps at proximal splint border and directly
over DIP joint
 Light padding under distal strap may reduce splint
migration and improve comfort
Finishing / Check Out :
 Smooth material borders and avoid rolling and
flaring, which may irritate adjacent soft tissues or
interfere w/ PIP joint movement
 Check for mobility of uninvolved joints
LET’S PRACTICE
2
Make your Splint
In 30 minutes
 PIP Immobilization Splint ( 1 )
Common Names :
• Finger splint
• PIP resting splint
• Static PIP extension splint
• Finger gutter splint

 To immobilize PIP joint to allow

healing of the involved structure(s)
 Rest a painful and/or inflamed
PIP joint
 Statically position PIPJ flexion contracture at maximum
extension to facilitate lengthening of tissue
 PIP Immobilization Splint ( 2 )
Pattern Creation
• Mark for proximal border at
proximal digital crease and
distal border at distal digital
crease
• Allow extra 1/4” to 1/2” of
material around borders,
depending on digit
circumference
Consider including DIP joint if
splinted digit is small ( children )
to secure desired PIP joint
position
 PIP Immobilization Splint ( 3 )
Attention :
 Proximal border should allow unrestricted MP
joint motion
 Distal border should allow unrestricted DIP joint
motion
 Lateral borders should encompass two thirds of
circumference of digit to prevent undue
compressive stress from straps
 Web space area should have adequate rooms to
allow unrestricted motion of adjacent digits
 PIP Immobilization Splint ( 3 )
Cut and Heat
• Position patient’s forearm supinated for volar design
and pronated for dorsal design
• Place material on volar aspect of digit, just clearing
DIP joint crease and slightly distal to MP joint crease
• Allow gravity to form lateral borders of splint. Avoid
grabbing or wrapping material around digit
• Carefully mold by gentle pressure through-out length
of splint in direction of extension ( if used to address
flexion contracture)
 PIP Immobilization Splint ( 4 )
Strapping
 Use two ½” straps or one 1” strap to secure
splint
 Place straps at proximal and middle phalanx
 Place one strap with piece of foam directly
over PIP joint , if maintaining PIP extension is
an issue
 Light padding under distal strap may reduce
splint migration and improve comfort
 PIP Immobilization Splint ( 4 )
Finishing / Check Out :
Smooth material borders and avoid rolling and
flaring, which may irritate adjacent soft tissues
and web spaces or may interfere w/ MP
and/or DIP joint movement
Check for mobility of uninvolved joints
Incorporation of DIP and PIP Splint
• The Dip joint can easily be incorporated into
either the dorsal or the volar splint
LET’S PRACTICE
3
Make your Splint
In 30 minutes
 Wrist Immobilization Splint
Dorsal / volar ( 1 )
Common Names :
 Wrist cock-up splint
 Wrist support
 Wrist extension splint
 Static wrist splint

 To immobilize wrist joint to allow

healing, rest, or protection the
involved structure (s )
 Substitute for weak or absent wrist extensor muscle function
 Improve functional grasp and pinch by positioning wrist in
extension
 Wrist Immobilization Splint
Dorsal / volar ( 2 )
Pattern Creation

• Mark proximal boarder two thirds

length of fore arm
• Mark distal boarder just proximal MP
joints
• Distal radial tab should be long
enough ( 3“ ) to traverse through
dorsum and secure on distal border
• Mark thumb clearance by making arc
from thumb MP to base of first CMC
joint
• Encompass half to two thirds
circumference of forearm
 Wrist Immobilization Splint
Dorsal / volar ( 3 )
Attention :
• Proximal boarder should
allow full elbow motion
• Distal boarder should allow
unimpeded motion of
digital MP and thumb joint
 Wrist Immobilization Splint
Dorsal / volar ( 4 )
Cut and Heat
• Position patient w/ elbow resting on table and forearm
supinated
• Prepad ulnar styloid w/ putty, cotton ball or silicone gel etc
• Position material on volar hand and wrist just proximal to MP
joint
• Place radial bar through thumb web and guide to proximal MP
joints dorsally and securing on distal ulnar border
• Incorporate arches of hand by gently molding
• Make sure desired wrist position is maintained

• Attention : patients tend to flex and deviate wrist while splint

is being formed
• Do not grab the splint while molding
 Wrist Immobilization Splint
Dorsal / volar ( 5 )
Strapping
• Distal strap : 1”
connecting radial bar to
distal ulnar border
• Middle strap : 2” strap just
proximal to dorsal wrist
crease
• Proximal strap : 2” strap
just at the proximal of the
splint
 Wrist Immobilization Splint
Dorsal / volar ( 6 )
Finishing / Check Out :
• Smooth and slightly flare borders
• Gently around dorsal thumb
region
• Check clearance of elbow, radial
and ulnar stylod processes, thumb
and MP joints
• Attention to index metacarpal
which frequently abuts radial
portion of splint
• Check for compression over radial
and ulnar sensory nerve branches
LET’S PRACTICE
4
Make your Splint
In 30 minutes
 Thumb MP immobilization Splint ( 1 )

Common Names
• MP Slint
• Short Opponen Splint
• Basal Joint splint
• Gamekeeper’s thumb splint

 Immobilize MP joint to allow for

healing
 Rest painful and / or inflamed
joint
 Promote gliding FPL tendon
during thumb flexion exercise
 Thumb MP immobilization Splint ( 2 )

Pattern Creation
• Mark for proximal border
just distal to wrist crease ;
should allow full wrist
motion
• Mark ulnar border at third
Immobilize MP Joint
metacarpal ; should allow
full mobility of distal arch
• Radial portion of splint
should enough to be pulled
through first web space and
adequately cover dorsum of
web space
Immobilize CMC Joint
Thumb MP immobilization Splint ( 2 )
Cut and Heat
Position patient’s forearm in slight supination
• Place thumb in palmar abduction and MP joint in
appropriate flexion
• Proximally, place and mold material across thenar
eminence to thenar crease
• Distally , wrap material through first web space
from dorsal to volar
• Mold though web space and overlap aterial onto
itself by approx. 1”
• Be sure to maintain desired thumb CMC and MP
joints position
 Fit While Molding
• Proximally, place and mold material across thenar
eminence to thenar crease
• Distally , wrap material through first web space from
dorsal to volar
• Mold though web space and overlap material onto
itself by approx. 1”
• Be sure to maintain desired thumb CMC and MP js
position
• Avoid direct pressure over dorsum MPJ
• Clear IPJ flexion crease , avoid rolling material
• 1” strap around wrist
 Thumb MP Immobilization Splint ( 3 )

Attention
• Avoid direct pressure over dorsum MPJ
• Clear IPJ flexion crease , avoid rolling material
• 1” strap around wrist
 Thumb MP Immobilization Splint ( 4 )

Finishing and Check Out

• Smooth distal and proximal borders
• Gently flare proximal to thumb IP Joint
• Check clearance of wrist , thumb IP and index finger
MP Joints , make sure no abutment with splint
material
Thank You