Rheumatoid Fingers

ConditionsBoutonniere Fingers

 

1.  PIPJ Synovitis

- synovectomy via dorsomedial approach

2.  Flexor tenosynovitis

- may cause trigger finger

- trial HCLA

- remove synovits but don't release A1 pulley

- will worsen ulna drift

3.  DIPJ

- rarely affects

- may get mallet

- arthrodesis

4.  Ankylosis

- arthrodesis / arthroplasty

5.  Unstable / flail

- arthrodesis usually best option

6.  Swan neck deformity

7.  Boutonnière deformity

 

Concepts

 

Boutonnière deformity

- usually good function

- often don't need surgical treatment

 

Hand Boutonniere Finger

 

Swan Neck

- much more debilitating

- usually need treatment

 

Swan Neck Deformity (Intrinsic Plus Deformity)

 

Deformity

 

Hyperextended PIPJ / MCPJ + DIPJ flexion

- Bunnell calls this "Intrinsic plus deformity"

 

Rheumatoid Boutonniere FingerRheumatoid Boutonniere Finger

 

Rheumatoid Finger Swan Neck XrayFinger Swan Neck

 

Cause

 

Primary process is usually synovitis

- starts at either MCPJ / PIPJ / DIPJ

 

DIPJ 

 

Dorsum

- terminal tendon ruptured or attenuated

 

Volar

- may also be due to stuck FDP

 

PIPJ 

 

Volar

- rupture of FDS due to synovitis

- volar capsule stretches due to synovitis 

 

Dorsum

- contracted central extensor slip

 

MCPJ 

 

Extrinsic

- relative shortening of long extensors

 

Intrinsic 

- relative intrinsic tightness

- also seen in CP / CVA

 

Articular 

- destruction or deformity

 

Rheumatoid Swan Neck secondary to MCPJ

 

Nalebuff Classification

 

Function depends upon PIPJ flexion

 

Bunnell Test

 

Assess Interossei Tightness

 

Positive test 

- PIPJ flexion less in MCPJ extension than with MCPJ flexion

- interossei are tighter in extension

- invalidated by MCPJ dislocation

 

Test

- hand dorsum up

- correct ulna deviation

- extend MCPJ & comment on active PIPJ range

- flex MCPJ & comment on active PIPJ range

 

Type I

- PIPJ passively correctable / regardless of MCPJ position

- Bunnell Test negative

 

Type II

- PIPJ flexion limited with extension of MCPJ

- Bunnell Test positive

- intrinsic tightness

 

Type III

- fixed PIPJ flexion regardless of MCPJ position 

- joint problem

- lateral bands dislocated dorsal to axis of rotation

 

Type IV

- joint destruction / X-ray arthritis

 

RA Swan Neck Fingers XrayRheumatoid PIPJ Destruction

 

Management

 

Aim is to create FFD

- many techniques described

 

Type 1

 

A.  Create FFD by FDS tenodesis

- use slip of FDS

- detach proximally

- pass through A2 pulley and attach to bone or on itself

- producing 20° FFD

 

+ DIPJ fusion

 

B.  Zancoli lateral band transfer

 

Lateral bands mobilised volar to axis of PIPJ

- raise flap of flexor retinaculum

- suture over lateral band to fix in place

- dorsal blocking splint / K wire

 

+ DIPJ fusion

 

Type II

 

Above +

 

Intrinsic release

- division of intrinsic oblique fibres

 

Anatomy

- oblique fibres which extend IPJ /  interossei

- transverse fibres flex the IPJ / lumbricals

 

Type III

 

PIPJ release first / Lateral band tenolysis / K wire

- release central slip / dorsal capsule / collateral ligs to allow flexion to >90o

- manipulate joint to flexed position

- fix with K-wire

- often stiff due to flexor synovitis

- often need flexor sheath synovectomy to get moving

 

Type IV

 

Arthroplasty RF / LF for grasp 

- arthroplasty has highest failure rate for Swan Neck 

- high recurrence and poor range

- 80% survival at 9 years

 

Fusion IF / MF for strength 

- angle of fusion a cascade 

- 20 30 40 50 (IF MF RF LF)

 

Rheumatoid Fusion PIPJ LF RF

 

Boutonniere's Deformity (Intrinsic Minus Deformity)

 

Boutonnierre Finger 1Boutonnierre Finger 2

 

Deformity

 

PIPJ flexed / DIPJ hyperextended /  MCPJ hyperextended

 

Often well tolerated & treatment not needed

 

Cause

 

1.  Central slip dysfunction

- always starts with PIPJ flexion 

 

2.  Lateral bands displace volar 

- secondary to triangular ligament stretching

 

3.  DIPJ hyperextends secondary to PIPJ flexion

- contracted oblique retinacular ligament

- becomes fixed

- examination finds limited DIPJ flexion with PIPJ in extended position

 

Nalebuff Classfication

 

Stage 1 

- mild extensor lag 10-15°

- passively correctable

 

Lateral band reconstruction

- reduce lateral bands dorsally

- suture together

 

Stage 2

- moderate 30-40° lag

- passively correctable

 

Lateral band reconstruction + Central slip shortening / reconstruction

 

Dorso-Medial Incision & Synovectomy

A. Reduce lateral bands dorsally & Suture together

B. Tenotomy Terminal slip

C. Central slip options

i)   Shorten 5 mm

ii)  Reconstruct with lateral bands (take inside half of each and suture together)

iii) Reconstruct with PL

iv) Matev central slip reconstruction

 

Matev Central Slip Reconstruction

- radial lateral band divided at level of P2 

- proximal stump rerouted through central slip 

- attached to base P2 at central slip insertion

- ulnar lateral band divided distally

- passed dorsally over P2 and attached to distal radial lateral band stump

 

Stage 3 

- severe 

- fixed with x-ray arthritic changes

 

Arthrodesis / arthroplasty

 

PIPJ replacement

 

Rheumatoid Arthritis PIPJ OA

 

Types

 

A. Pyrocarbon implants

- partially constrained press fit components

- relatively high failure rate

- can fracture when inserting and need cerclage wire

 

B.  Swanson spacer

 

Contra-Indications

 

Infection

Non reconstructable / irreparable

- extensor and flexor tendons

- collateral ligaments

 

Complications

 

Does not have same stability of MCPJ

- can dislocate

 

Technique

 

Dorsal incision

- straight or curved dorsomedially

- enter between central slip and lateral band

- can detach central slip proximally and reflect distally 

 

Release contractures

- balance soft tissues

- retain collaterals

 

Broach distally and proximally

- avoid extension at all times

 

Implant must achieve full extension

- no buckling, and no impingement

 

Repair central slip

 

Post op

- immobilise for 1 week

- dynamic extension splint 0 - 30o (Capner)

- active flexion

 

Arthrodesis PIPJ

 

Approach as above

- resect collaterals

- position as appropriate

- cross K wires / screw