import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Rheumatoid Hands Examination The rheumatoid hand examination tests your ability to recognize classic deformities, assess tendon integrity, and understand the pathomechanics. Examiners expect you to describe findings systematically, understand the functional implications, and know the surgical options for each deformity pattern. ## Quick Reference One-Pager ## Introduction and Approach **Patient Positioning:** Seated facing you, hands resting on pillow **Exposure:** Both hands and forearms to elbows, remove rings and watch **Consent Script:** "I'd like to examine your hands. Please tell me if anything is painful." **Key Principle:** The rheumatoid hand examination is a classic orthopaedic examination that demonstrates your understanding of pathomechanics and surgical indications. ## Look (Inspection) **Skin:** - Thinning (steroid effect) - Rheumatoid nodules - Scars from previous surgery - Nail fold vasculitis (infarcts) **Joints:** - MCPJ synovitis (soft swelling) - Ulnar drift at MCPJs - PIPJ deformity (swan neck vs boutonniere) - DIPJ sparing (usually) **Tendons:** - Extensor tenosynovitis (swelling over dorsum) - Tendon ruptures (dropped fingers) - Caput ulnae (dorsal prominence of ulnar head) **Skin:** - Thenar wasting (median nerve) - Hypothenar wasting (ulnar nerve) - Palmar erythema - Dupuytren's (may coexist) **Tendons:** - Flexor tenosynovitis (volar wrist swelling) - Trigger fingers - Tendon nodules **Deformities:** - Radial deviation of carpus - Ulnar translocation - Caput ulnae (prominent ulnar head) - DRUJ subluxation **Swelling:** - Extensor tenosynovitis (6th compartment) - Flexor tenosynovitis (carpal tunnel) - Synovitis (radiocarpal, midcarpal) ## Classic Deformities **Swan Neck Deformity:** - PIPJ hyperextension, DIPJ flexion - Mechanism: FDS rupture or volar plate laxity - Lateral bands slip dorsal to axis - Test: Can PIPJ flex when MCP held extended? **Boutonniere Deformity:** - PIPJ flexion, DIPJ hyperextension - Mechanism: Central slip rupture - Lateral bands slip volar to axis - Elson test to assess central slip **Z-Thumb (Thumb Boutonniere):** - MCPJ flexion, IPJ hyperextension - Mechanism: EPB/EPL imbalance, MCP volar plate laxity - Severely impairs pinch **Ulnar Drift:** - MCPJ ulnar deviation - Mechanism: Radial sagittal band attenuation - Extensor tendons slip ulnar - Intrinsic tightness develops ## Tendon Assessment **Vaughan-Jackson Lesion:** Sequential EDC rupture starting at ulnar side (little finger first, then ring, middle). Caused by attritional rupture over rough caput ulnae. **Mannerfelt Lesion:** FPL rupture from attrition over scaphoid osteophyte (volar carpal boss). **Key Principle:** Test each tendon individually - don't rely on juncturae! ## Nalebuff Classification **Type I:** Flexible in all positions - Treatment: Flexor tenodesis, DIP fusion **Type II:** Limited PIPJ flexion with MCP extension - Intrinsic tightness - Treatment: Intrinsic release **Type III:** Limited PIPJ flexion in all MCP positions - Joint involvement - Treatment: Manipulation, soft tissue release **Type IV:** Fixed, stiff PIPJ with joint destruction - Treatment: Arthroplasty or fusion **Stage I:** Passively correctable, 10-15 degree extensor lag - Treatment: Splinting, extension exercises **Stage II:** Passively correctable, 30-40 degree lag - Treatment: Soft tissue reconstruction **Stage III:** Fixed flexion contracture - Treatment: Staged procedures, arthroplasty **Type I:** MCP flexion, IP hyperextension (boutonniere) - Most common in RA **Type II:** CMC subluxation, MCP hyperextension, IP flexion (swan neck) **Type III:** CMC subluxation, MCP and IP hyperextension - Combined pattern, severe instability ## Extra-Articular Manifestations **Rheumatoid Nodules:** - Location: Olecranon, finger extensor surfaces, flexor sheaths - Significance: Seropositive disease, methotrexate can increase **Vasculitis:** - Nail fold infarcts (splinter hemorrhages) - Digital gangrene (severe disease) - Skin ulceration **Nerve Compression:** - Carpal tunnel syndrome (flexor tenosynovitis) - Ulnar nerve at elbow - Posterior interosseous nerve (elbow synovitis) **Muscle Wasting:** - Thenar (median), hypothenar (ulnar) - Intrinsic wasting (T1/ulnar) - Forearm wasting (disuse, myopathy) **Complete the Systemic Screen:** - Elbows: Nodules, ulnar nerve - Eyes: Episcleritis, scleritis, dry eyes (Sjogren's) - Cervical spine: Atlantoaxial instability (before intubation!) - Chest: Interstitial lung disease - Skin: Vasculitic rash, leg ulcers ## Functional Assessment **Pinch Types:** - Key (lateral) pinch: Thumb to side of index - Tip pinch: Thumb to index fingertip - Tripod pinch: Thumb, index, middle **Grip:** - Power grip: Grasp cylinder - Hook grip: Carry bag **Fine Motor:** - Button/unbutton - Pick up coin - Write name - Turn key **ADLs:** - Feeding: Fork, knife, cup - Dressing: Buttons, zips - Hygiene: Toileting, washing **Priority Order for Reconstruction:** 1. Wrist stabilization first (provides stable platform) 2. MCPJ arthroplasty 3. Tendon reconstruction 4. PIPJ procedures last **Timing Considerations:** - Disease activity (wait for remission if possible) - Medication optimization - Cervical spine clearance - Cardiovascular assessment ## Wrist Examination **Caput Ulnae Syndrome:** - Prominent dorsal ulnar head - DRUJ instability (piano key sign) - Risk of EDC rupture - Treatment: Darrach, Sauve-Kapandji, or ulnar head replacement **Carpal Collapse:** - Radial deviation of carpus - Ulnar translocation - Supination deformity - Radiographs: Scalloped carpal bones **Flexor Tenosynovitis:** - Volar wrist swelling - Carpal tunnel symptoms - Trigger fingers - Treatment: Synovectomy, CTR ## Summary Presentation ## Examination Sequence 1. **Introduction**: Consent, positioning, exposure 2. **Look dorsal**: Skin, joints, tendons, wrist 3. **Look palmar**: Thenar/hypothenar, skin, tendons 4. **Specific deformities**: Name and classify each 5. **Tendon testing**: Each extensor individually, EPL, FPL 6. **Special tests**: Elson, piano key, Phalen's 7. **Sensory**: Median, ulnar nerve territories 8. **Functional**: Pinch, grip, fine motor 9. **Extra-articular**: Elbows, nodules, vasculitis 10. **Complete**: "I would examine cervical spine and take radiographs" ## Examiner Tips