Comprehensive examination of the rheumatoid hand including characteristic deformities, tendon rupture assessment, and functional evaluation.
Rheumatoid hand examination requires systematic identification of classic deformities and functional assessment. Examiners expect you to recognize the pattern of joint involvement, identify tendon ruptures, and understand the pathophysiology behind each deformity. Always assess function, not just appearance.
High-Yield Exam Summary
Characteristic Pattern (Bilateral Symmetric):
Spared Joints in RA:
Key Differentiator:
Pathophysiology of RA Hand:
Order of Tendon Ruptures (Vaughan-Jackson): Little → Ring → Middle → Index (EDC over ulnar head)
Look From Dorsal:
Look From Lateral:
Look From Palmar:
Caput Ulnae:
Swan Neck Deformity:
Causes in RA:
Classification (Nalebuff):
| Type | Description |
|---|---|
| I | Full PIP flexion in all MCP positions |
| II | PIP flexion limited by intrinsic tightness (MCP extension limits) |
| III | Limited PIP flexion in all MCP positions |
| IV | Stiff, arthritic PIP (fixed) |
Key Test: Intrinsic tightness test (Bunnell)
Vaughan-Jackson Syndrome:
EPL Rupture:
Testing Each Extensor:
Individual extensor tendon assessment
Inability to extend MCP against resistance
EDC rupture for that digit (note: test early as EDM and interossei can compensate)
Ability to detect true positives
Ability to exclude false positives
EPL tendon assessment
Inability to lift thumb off table or extend IP joint
EPL rupture - usually attritional at Lister's tubercle
Ability to detect true positives
Ability to exclude false positives
Mannerfelt Syndrome:
FDP Ruptures:
FDS Function:
Observe:
Palpate:
Move:
DRUJ Destruction:
Critical Functional Tests:
Document:
Skin:
Eyes:
Always Examine:
Ask About:
Cervical Spine in RA: ALWAYS ask about and assess cervical spine:
Pre-operative Cervical Spine X-rays: Essential before any surgery
| deformity | pip | dip | pathology | treatment |
|---|---|---|---|---|
| Swan Neck | Hyperextension | Flexion | Intrinsic tightness, VP laxity | FDS tenodesis, fusion |
| Boutonnière | Flexion | Hyperextension | Central slip attenuation | Soft tissue if early, fusion if late |
| Ulnar Drift | Variable | Variable | Radial sagittal band laxity | MCP arthroplasty |
| Z-Thumb | N/A (MCP flexion) | N/A (IP hyperextension) | EPB attenuation | Fusion or soft tissue rebalancing |
| Caput Ulnae | N/A | N/A | DRUJ destruction | Darrach or Sauvé-Kapandji |
"58-year-old woman with 15-year history of rheumatoid arthritis presents for hand assessment."
High-Yield Exam Summary