Rheumatoid hands

Published on 02/04/2015 by admin

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127 Rheumatoid hands

Instruction

Examine this patient’s hands.

Salient features

History

• Painful swollen joints

• Morning stiffness.

Examination

• Ask the patient for permission to examine her hands and then ask whether the hands are sore.

Proceed as follows:

• Comment on deformities (Fig. 127.1) such as the following:

• Subluxation at the metacarpophalangeal joint

• Swan-neck deformity

• Boutonnière deformity (hyperextension at the terminal interphalangeal joint and flexion at the proximal interphalangeal joint)

• Z deformity of the thumb

• Dorsal subluxation of the ulna at the carpal joint.

• Comment on the following signs:

• Nailfold infarcts and vasculitic skin lesions

• Palmar erythema

• Wasting of the first dorsal interossei and other small muscles of the hand.

• Test grip and pincer movements. Quickly test for abductor pollicis brevis and interossei, and pinprick sensation over index and little fingers. The median nerve may be involved if there is associated carpal tunnel syndrome.

• Examine the elbow for rheumatoid nodules.

• Ask the patient to perform simple tasks involving hand function, such as unbuttoning clothes or writing.

• Tell the examiner that you would like to examine other joints.

• Highlight the following points:

• Whether terminal interphalangeal joints are spared or affected

• Whether the arthritis is active (if the joints are inflamed) or inactive

• Be prepared to discuss the radiological features.

Fig. 127.1 Deformities of the hands in rheumatoid arthritis.

Diagnosis

This patient has swan-neck deformity of the fingers (lesions) caused by rheumatoid arthritis (aetiology) with marked active arthritis of the interphalangeal joints, and is unable to button her clothes (functional status).

Questions

What is the significance of nodules in rheumatoid arthritis?

The presence of nodules indicates seropositive and more aggressive arthritis (Fig. 127.2).

Fig. 127.2 Hand in seropositive rheumatoid arthritis, showing fixed deformities and gross rheumatoid nodules.

(With permission from Canoso JJ 1997.)

Where are nodules found?

Flexor and extensor tendons of the hand, sacrum, Achilles tendon, sclera, lungs and myocardium.

What are the skin lesions in rheumatoid arthritis?

Vasculitis, nailfold infarcts.

What are the causes of anaemia in rheumatoid arthritis?

• Anaemia of chronic disease

• Megaloblastic anaemia from folate deficiency or associated pernicious anaemia

• Felty syndrome

• Drugs: NSAIDs causing iron-deficiency anaemia, gold causing bone marrow suppression.

What factors have been implicated in anaemia of chronic disease?

• Decreased production of red blood cells:

• Inadequate iron: impaired absorption and transport, failure to release iron stores

• Decreased concentration or marrow resistance to erythropoietin.

• Ineffective erythropoiesis

• Abnormal development of erythroid progenitor cells

• Increased destruction of red cells.

What is Felty syndrome?

It is seen in some patients with severe rheumatoid arthritis and consists of splenomegaly, anaemia, leucopenia, thrombocytopenia (hypersplenism) and leg ulcers. Splenectomy ameliorates hypersplenism. Felty syndrome is associated with positive rheumatoid factor.

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