Rheumatoid Arthritis Of The Hand

DEFINITION

Rheumatoid arthritis (RA) is a systemic inflammatory disease that results in cartilage and bone destruction.

 RA is characterized by a typical pattern and distribution of synovial joint involvement. 

Disorganization of the joint leads to deformities and loss of function.

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SYNONYMS

• Rheumatic disease

• Rheumatism

ETIOLOGY

• Currently, the cause of RA is unknown, although there are several theories. Evidence points to a combination of environmental and genetic factors.

• RA progresses in four stages.Joints most commonly affected are those with the highest ratio of synovium to articular cartilage.

 The first stage is the swelling of the synovial lining, causing pain, warmth, stiffness,redness,and swelling around the joint.This stage is the most painful and usually causes patients to seek medical care.

  The second stage is characterized by the rapid division and growth of cells, or pannus, which causes the synovium to thicken. In this stage the pannus extends beyond the cartilage to adjacent ligaments and tendons.Pain decreases during this stage, and the joints do not yet exhibit deformities.

 The third stage is known asthe chronic active phase.The inflamed cells release enzymes that may digest bone and cartilage, often causing the involved joint to lose its shape, alignment, and ROM. Joint deformities become significant and irreversible in the phase.

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 The fourth stage is the chronic inactive phase. Skeletal collapse occurs with the presence of dislocation and spontaneous fusions.

• About 10% to 20% of RA patients have a sudden onset of the disease, followed by many years with no symptoms.This is considered a prolonged remission.

• Some RA patients experience periods of few or no symptoms between flare ups that can last for months.This is referred to as intermittent symptoms of RA.

• The majority of RA patients have the chronic, progressive type of RA that requires long-term medical management.

EPIDEMIOLOGY AND 

DEMOGRAPHICS

• Approximately 1.3 million people in the US have RA.

• All races and ethnicities are affected by RA.

• Onset usually occurs between 30 and 50 years of age. Earlier onset is associated with a more severe disease process.

• Women are two to three times more likely to be diagnosed with RA than men; however, men are more severely affected.

MECHANISM OF INJURY

RA commonly begins in the smaller joints of the fingers, hands, and wrists.

COMMON SIGNS AND 

SYMPTOMS

• Sausage-shaped (fusiform) swelling of the finger.

• A soft lump over the back of the hand that moves with the extensor tendons.

• Crepitus with movement.

• Shifting of the fingers as they drift away from the thumb (ulnar drift).

• Swelling and inflammation of the flexor tendons resulting in clicking or triggering of the fingers.

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• Tendon ruptures eliminating the ability to flex or extend the fingers or the thumb.

• Unstable joints in the wrist, fingers, and thumb.

• Boutonnière and swan-neck deformities.

AGGRAVATING ACTIVITIES

• Gripping activities

• Brushing hair

• Opening a door

EASING ACTIVITIES

• Rest

• Supportive splinting

• Medications

24-HOUR SYMPTOM PATTERN

• The patient may experience stiffness in the morning lasting more than 1 hour.

• Patient may require frequent breaks to complete tasks caused by fatigue and weakness.

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PAST HISTORY FOR THE REGION

• Symmetrical, multijoint pain

• Stiffness in the morning lasting more than 45 minutes

• Pain in your hands, wrists, and/or feet

• Feelings of weakness or fatigue.

PHYSICAL EXAMINATION

• The most common deformity is ulnar deviation of the MP joint. To examine the true amount of deviation the hand should be unsupported.

• Other common deformities include the following:

 Thumb deformities

 Distal ulna dorsal subluxation

 Volar subluxation of the carpal bones on radius.

 Ulnar displacement of the proximal carpal row causing radial deviation of the wrist.

• Skin changes present warm and red in the acute stage, but chronically the skin thins.

and easily bruises as a result of steroid use.

• Nodules with or without pain occur at joints or along tendons and most often the largest is at the elbow.

• Synovitis around the joint capsule.Chronicity thickens the synovitis and leads to instability, misalignments, restricted ROM, and eventual deformities.

• Loss of ROM is caused by tendon rupture; tendons weaken from inflamed synovium and rupture from gliding over rough bony areas.

• Boutonnière and swan-neck deformities in the fingers and thumbs.

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IMPORTANT OBJECTIVE TESTS

• Diagnosing RA is a process. There no one specific test that will positively diagnosis, physician relies on a number of tools to determine the best treatment for the symptoms of the patient.

• Possible laboratory tests include the following:

 Complete blood count (CBC)

 Erythrocyte sedimentation rate (ESR, or sed rate)

 C-reactive protein (CRP)

 Rheumatoid factor

 Antinuclear antibodies (ANA)

 Imaging studies, such as radiographs and MRI, may also be indicated.

DIFFERENTIAL 

DIAGNOSIS

• Connective tissue diseases such as scleroderma and systemic lupus erythematosus (SLE)

• Fibromyalgia

• Hemochromatosis

• Infectious endocarditis

• Polyarticular gout

• Polymyalgia rheumatica

• Sarcoidosis

• Thyroid disease

• Viral arthritis

CONTRIBUTING FACTORS

• Female gender

• Family history

• Older age

• Silicate exposure

• Smoking

TREATMENT

SURGICAL INDICATORS

Debilitating pain and loss of functional use of the hand

SURGICAL OPTIONS

• Synovectomy reduces the amount of inflammatory tissue by removing the diseased synovium or lining of the joint. It may result in less swelling and pain. This surgery may also slow or prevent further joint damage.

• Arthroscopic surgery can be used as a treatment or diagnostic tool. Tissue samples can be obtained, loose cartilage removed, tears in the soft tissue repaired, joint surfaces smoothed, and diseased synovial tissue removed.

• Osteotomy cuts the bone to increase stability by redistributing the weight on the joint. Osteotomy is not often used with rheumatoid patients because there are many other options available.

• Joint replacement surgery or arthroplasty involves the removal of the joint, resurfacing and relining of the ends of bones, and replacement with a man-made component. This procedure is usually recommended for people over 50 years of age or those who have severe disease progression. Typically, a new joint will last between 20 and 30 years.

• Arthrodesis or fusion fuses two bones together. Although it limits movement, it also decreases pain and increases stability of the joints.

• Tendon ruptures occur frequently in the rheumatoid hand, and multiple surgical procedures are used to restore finger flexion, extension, and thumb ROM. Choice of procedure depends on how many tendons have ruptured and current status of the remaining tendons available for transfer.

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SURGICAL OUTCOMES

Unfortunately, there is no cure for RA. However, surgical procedures can often help correct deformities,relieve pain, and improve function.

REHABILITATION

• Treatment must be tailored to the individual, taking into account the severity of the arthritis, individual lifestyle, and co-morbidities.

• Current treatment methods focus on relieving pain, reducing,inflammation, stopping or slowing joint damage, and improving overall function and sense of well-being.

• Joint deformities should be palpated to determine if they are rigid or flexible. The clinician should not attempt to correct a rigid deformity; instead, the joint should be protected from further deformity progression.

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• Because of the chronic nature of RA,the patient should be educated on healthy lifestyle choices that may decrease the severity and progression of the disease.

These changes include the following:

 Staying healthy and fit with regular exercise 

 Activity and rest 

 Managing stress, depression, and fatigue 

 Avoiding joint pain and injury

 Using preventive medications

• Equipment: Today, many devices are available to help decrease pain and increase functional use of the hand. Electric knives,scissors, and jar openers are simple devices that can reduce hand damage. Ergonomic door handles and writing devices are examples of utensils that can preserve the joints of the hand.

• Splinting: Custom splints allow painful joints to rest while a person is sleeping.

 Splints are worn during the day to increase function and limit pain.

 Splints should only be used to support the hand and prevent further pain and deformity. Research has demonstrated that corrective splinting is unsuccessful.

 During stage one, resting splints should be used to reduce pain.These can be worn selectively during the day or night.

 During stage two,night splints should be used to prevent future deformity and reduce pain.

 During stage three, the patient will need splints during the day to increase functional use of the hand. Night splinting may also prevent further deformity.

 During stage four, splinting increases joint stability and function during the day.Night splinting provides comfort.

• Therapeutic exercise should avoid all painful ROMs and overstretching the already unstable joints.Gentle wrist and finger flexion and extension and thumb opposition AROM can be used to maintain function.

 Strengthening should be used with extreme caution because it may increase deformities of the hand. Strengthening activities should not be painful.

PROGNOSIS

• There is no known cure for RA.

• Factors influencing the prognosis for RA include the following:

 Lower education level and socioeconomic status.

 Early involvement of multiple joints.

  Markersfor inflammation are elevated on laboratory tests (elevated CRP and ESR).

  Significant joint damage already evident on radiographs at diagnosis.

 Testing positive for rheumatoid factor or anti-cyclic citrullinated peptide antibody (anti-CCP).

SIGNS AND SYMPTOMS 

INDICATING REFERRAL 

TO PHYSICIAN

Joint destruction begins within a few weeks of symptom onset. Early treatment decreases the rate of disease progression.

If RA is suspected, refer the patient to a rheumatologist.

SUGGESTED READINGS

1- Biese J.Therapist’s evaluation and conservative management of rheumatoid arthritis in the hand and wrist.

 2- Mackin EJ, Callahan AD, Osterman AL, Skirven TM, Schneider LH, and Hunter JM. Hunter, Mackin & Callahan's  Rehabilitation of the Hand and Upper  Extremity. 5th ed. vol. 2. St. Louis, Missouri: Mosby; 2002:1569–1582.

3- Rindfleisch JA, Muller D. Diagnosis and management of rheumatoid arthritis. Am Fam Physician. 2005;72:1037–1047.