HAND MANIFESTATIONS

IN
RHEUMATOID
ARTHRITIS
DEFORMITIES

• SWAN- NECK DEFORMITY

• BOUTONNIERE DEFORMITY
• INTRINSIC PLUS DEFORMITY
• Z- DEFORMITY OF HAND
• DEFORMITIES OF WRIST
• THUMB DEFORMITY
SWAN-NECK DEFORMITY
• Active synovitis at PIP joint
• PIP hyper extension – relaxes lateral tension band
• Central and dorsal displacement of band
• Inability to extend DIP
• PIP hyper extension pulls FDP- prominent flexion of DIP
CLASSIFICATION
4 main types by NALEBUFF

• TYPE 1- PIP flexible in all directions

• TYPE 2- PIP flexion limited in certain position
• TYPE 3- PIP flexion limited in all directions
due to contracture of extensor mechanism
• TYPE 4- PIP joint stiff with radiographic destruction
BOUTONNIERE DEFORMITY
• Synovial proliferation in PIP stretches and weakens extensor
mechanism
• Displaces lateral bands volarly
• SPIRAL OBLIQUE RETINACULAR LIGAMENTS gets shortened
• Causes DIP hyper extension
CLASSIFICATION
• MILD – slight extensor lag at PIP
slight hyper extension at DIP

• MODERATE- flexion deformity at PIP(30-40*)

MCP begins to hyper extend

• SEVERE- no passive extension of PIP

INTRINSIC PLUS DEFORMITY
• Caused by tightness and contracture of intrinsic muscles

• PIP cannot be flexed while MCP joint is fully extended

• May be associated with volar subluxation of MCP and ulnar deviation

of fingers

• BUNNELL TEST done for assesing intrinsic tightness

Z – DEFORMITY OF HAND
• Ulnar deviation of fingers at MCP , while radial deviation at wrist

• Proximal phalanges sublux or dislocate palmarly, lying beneath MC

head

• Occurs due to articular and soft tissue changes

STIRRAT’S MODIFICATION OF
NALEBUFF’S CLASSIFICATION
• EARLY- synovitis of MCP with no extension lag or ulnar deviation

• MODERATE- early erosions of MC head

extensor tendon displacement / ulnar deviation of
fingers or extensor lag seen
• LATE- destruction of articular cartilage causing joint subluxation
prominent ulnar deviation
extension lag prominent but passively correctable

• ADVANCED- deformities prominent with fixed ulnar deviation

ulnar and palmar displacement of extensor tendons
DEFORMITIES OF WRIST
• Ulnar side – most commonly affected

• Produces DRUJ disruption and caput ulna syndrome

• Earliest sign- dorsal swelling of wrist within the tendon sheaths of

extensor tendon
• ulnar caput syndrome results from synovitis stretching ulnar carpal
ligaments;

• there is dorsal dislocation of distal ulna, supination of carpus on hand,

volar subluxation of the ECU
THUMB DEFORMITIES
• Classified into 6 types

• Type 1 – BOUTONNIERE DEFORMITY (MC)

IP joint- HYPER EXTENDED
MCP – FLEXED
CMC – not involved
• TYPE 2 – uncommon
IP – HYPER EXTENDED
MCP- FLEXED
CMC – FLEXED AND ADDUCTED

TYPE 3- SWAN NECK DEFORMITY(2nd MC)

progression of type 2 with CMC subluxation
• TYPE 4- GAME KEEPERS THUMB
radial deviation of MCP
unstable ulnar collateral ligament
IP and CMC joints not involved