Comprehensive examination of rheumatoid hands including characteristic deformities, tendon assessment, extra-articular manifestations, and functional assessment for surgical planning.
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.
High-Yield Exam Summary
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.
Skin:
Joints:
Tendons:
Swan Neck Deformity:
Boutonniere Deformity:
Z-Thumb (Thumb Boutonniere):
Ulnar Drift:
| deformity | pipj | dipj | mechanism | test |
|---|---|---|---|---|
| Swan Neck | Hyperextension | Flexion | FDS rupture, volar plate laxity | Flexibility with MCP extended |
| Boutonniere | Flexion | Hyperextension | Central slip rupture | Elson test |
| Z-Thumb | EPB/volar plate laxity | Pinch strength | ||
| Ulnar Drift | Radial sagittal band rupture | Passive correction |
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!
Identify tendon ruptures masked by juncturae
Cannot extend finger at MCP with adjacent fingers held flexed
EDC tendon rupture (Vaughan-Jackson if ulnar-sided)
Ability to detect true positives
Ability to exclude false positives
Assess extensor pollicis longus integrity
Cannot lift thumb off table
EPL rupture - common in RA (Lister's tubercle attrition)
Ability to detect true positives
Ability to exclude false positives
Assess flexor pollicis longus (Mannerfelt lesion)
Cannot flex thumb IPJ
FPL rupture - Mannerfelt syndrome (attrition over scaphoid)
Ability to detect true positives
Ability to exclude false positives
Assess central slip integrity (boutonniere)
DIPJ extends (goes rigid) while PIPJ remains weak
Central slip rupture - lateral bands subluxed volar, extending DIP
Ability to detect true positives
Ability to exclude false positives
Type I: Flexible in all positions
Type II: Limited PIPJ flexion with MCP extension
Type III: Limited PIPJ flexion in all MCP positions
Type IV: Fixed, stiff PIPJ with joint destruction
Rheumatoid Nodules:
Vasculitis:
Nerve Compression:
Muscle Wasting:
Complete the Systemic Screen:
Pinch Types:
Grip:
Fine Motor:
ADLs:
Priority Order for Reconstruction:
Timing Considerations:
Caput Ulnae Syndrome:
Carpal Collapse:
Flexor Tenosynovitis:
Assess DRUJ stability (caput ulnae)
Excessive dorsal-volar translation of ulnar head
DRUJ instability - caput ulnae syndrome
Ability to detect true positives
Ability to exclude false positives
"56-year-old woman with long-standing seropositive rheumatoid arthritis presents with progressive hand dysfunction."
High-Yield Exam Summary