Plastic Surgery Volume 6: Hand and Upper Extremity (4th Edition) – Peter C. Neligan

391
Clinical care in illness related to the workplace
worker, upon recovery, to return to the same regular duty
work that pre-dated the injury. If this is not possible, then a
modified job with the same employer may be possible. Failing
this, the worker may have to consider new work with a new
employer, or retirement. This can be a difficult decision that
requires coordination with a case manager or rehabilitation
counselor. There are some patients with conditions usually
well treated either non-surgically or surgically by the hand
surgeon, who do not seem to have the capacity to recover to
the extent that would let them return to their original job. This
group of people may be difficult to identify before treatment
begins but eventually they can be identified by a recovery that
falls below the threshold that allows them to return to their
pre-injury job. This group of patients is difficult for the hand
surgeon to manage, and care should be taken to avoid a
repetitious exposure to invasive treatments and repeated
surgeries that never quite reach the expected result.
In category three, the patients may have pain that is out of
proportion to their physical injury. They can be angry and
frustrated at the lack of improvement, despite adequate
medical care. Patients may have definite upper extremity
pathology but this is difficult to improve to a degree that will
be satisfactory to the patient. Surgeons will immediately rec­
ognize this group of patients, as features of the history and
physical examination will be identified as falling outside the
expected norms for the conditions being cared for. This embel­
lishment of symptoms and physical findings may represent
frustration on the part of the patient, an attempt to make the
surgeon realize the depth of their problem, or conscious
magnification of symptoms and findings. Unfortunately, this
is a group of patients that is difficult for the surgeon to
manage. An honest approach will result in anger on the part
of the patient, but management that deals with the upper
extremity problem as an isolated independent part of the
patient will not succeed.
In category four, the diagnosis of the upper extremity
problem is unclear. Many of these patients will have vague
diagnoses and may have had surgical procedures. They may
have previous experience with other workers’ compensation
injuries and may have seen other hand surgeons. For example
the patient may present with a problem whose existence
is controversial, its pathology unproven, its treatment ill-
defined, and its outcome uncertain. The patient may be in
conflict with their employer and may be terminated from
employment. When the worker has this type of an upper
extremity disorder, there may be conflict at every aspect of the
patient’s interaction with the surgeon and healthcare system.
The role of the hand surgeon is to take a careful history,
perform a physical examination, recommend the appropriate
diagnostic tests and provide honest recommendations for
further management. Going for a surgical “Hail Mary” will
be a disappointing misadventure.
At each step of care, the surgeon must be aware of the
play of internal and external forces that promote and limit
recovery. The structure of the workers’ compensation system
can create perverse incentives the surgeon must be perceptive
about and must guard against. The surgeon may have per­
ceived or real pressures to do things that are uncomfortable
from an ethical standpoint. For example the surgeon may be
pressured to return the injured worker back to the workplace
early after surgery on limited work such as “one-hand duty”.
Workers with pain in one extremity from a workplace injury
which includes the pathology located in the upper
extremity, how that is experienced by the patient, and
the external factors that can influence the management
and recovery.
2. It is important to the patient. In a work-related disorder
the financial benefits of the workers’ compensation
system may be the only source of financial security for
the patient.
3. An accurate and definitive decision about work
attribution may be the best way to avoid the negative
effects that accompany the workers’ compensation
system of insurance coverage. A rapid and accurate
decision either affirmative or negative will reduce the
potential for conflict and will be in the patient’s best
interest.
4. The surgeon is in the best position to gather and weigh
all the evidence that is available.
Clinical care in illness related to
the workplace
Injuries at the workplace can be broadly divided into acute
traumatic injuries and those without a single identifiable
traumatic incident.
When a worker suffers a verifiable traumatic injury at the
workplace that is directly observed and an injury is present
under any reproducible and acceptable method to define its
presence, the attribution to work is not an issue. Efforts are
provided at the best management and rehabilitation of the
injured worker.
Millender et al. has divided the more chronic occupational
injuries of the musculoskeletal system into four categories
that provide a useful framework for discussion (Table 18.1).3
In category one, most patients are highly motivated and
when the appropriate treatment is provided for the patient,
the upper extremity problem resolves. The patient can resume
work and there are no lingering effects. Happily in my experi­
ence this includes most injured workers.
In category two, some difficulties may arise as permanent
impairment is possible. When the patient is left with perma­
nent impairment the easiest resolution is for the injured
Table 18.1  Chronic occupational injuries of the musculoskeletal
system
Category 1
Diagnosis is easily established, good methods
are available for treating the condition, and
the prognosis for returning to work is good.
Category 2
Diagnosis is established, but neither non-
surgical nor surgical treatment is always
successful in returning the patient to the
original job.
Category 3
The condition combines definite physical
problems and additional non-medical
issues.
Category 4
Diagnosis is unclear
(Reproduced from Millender LH, Louis DS, Simmons BP (eds). Occupational
Disorders of the Upper Extremity. New York: Churchill Livingstone; 1992.)

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SECTION III
CHAPTER 18 • Occupational hand disorders
A cross-sectional study of 3710 workers in France revealed
that 90 (2.4%) had lateral epicondylitis. Age, BMI >25, and low
social support (for men) were significant risk factors. Hard
perceived physical exertion combined with elbow flexion/
extension (>2 hr/day) and wrist bending (>2 hr/day) was a
strong significant risk factor for elbow pain and epicondylitis.6
Interestingly, from 1994 to 2006 there was an increase in
ambulatory surgery rates for lateral epicondylitis from 7.29
to 10.44 per 100 000 persons.7
More recently, however, there is heightened interest is
non-surgical management of lateral epicondylitis as it has
become disseminated that this condition will resolve over
time. Treatment is therefore used to temporize symptoms.
Splinting,
counterforce
bracing,
non-steroidal
anti-
inflammatory drugs (NSAIDs), physical therapy, steroid
injection, or simple observation without intervention have all
shown to result in satisfactory results for a majority of patients.
In addition, new modalities are being evaluated continuously.
Surgical treatment is reserved for long time failures. Recently
studied predictors of failure of non-surgical treatment include
a workers’ compensation claim, prior injection, the presence
of radial tunnel syndrome, previous orthopedic surgery, and
duration of symptoms greater than 12 months.8
A variety of surgical techniques that typically include
debridement or tenotomy of the extensor carpi radialis brevis
origin are used with reported good success.
Tendinopathy at the wrist and hand
In a review of data collected in 1988, Tanaka et al.9 reported
that the period prevalence for tendinopathies, including ten­
donitis, synovitis, tenosynovitis, de Quervain’s, or epicondy­
litis, ganglion cyst, or trigger digit was 0.46% of the population
working within the previous year. Of these, 28% were thought
to be work-related. The authors found bending and twisting
of the wrist at work and female gender were associated with
reporting these disorders.
De Quervain’s tenosynovitis
Tenosynovitis of the first dorsal compartment is the signature
work-related tendinopathy (Fig. 18.1). Interestingly, this con­
dition is commonly seen in new mothers and in the worker.
Symptoms of de Quervain’s are typically well localized to
the radial side of the wrist. The Finkelstein’s test is a sensitive
or recent surgery may be required to go to the workplace
and answer the phone or even perform useless or demean­
ing tasks or simply sit in a room or lie on a stretcher. This
so-called presenteeism is a warping of societal norms that
has occurred to circumvent the negative impact of workers’
compensation protections. The physician wants to do the best
for the patient but feels those decisions are beyond the scope
of their influence. The presence of “one-hand work” creates
the aura of reasonableness creating a plausible justification for
the surgeon to agree to this. An alternative perspective to the
potential harm caused by early return to work is a belief that
the early return to the workplace is important in the recovery
of the injured worker. Although the literature is sparse in
this area there is a belief that returning an injured worker
to a routine including work will be beneficial and minimize
illness behavior.
If pushed back to work early, the patient may feel trapped
in a closed system. The patient can be suspicious of the com­
pensation system and lose the sense of control of their health­
care. Attempts to recover this control can be self-destructive
and misunderstood.
An awareness of these forces will help the surgeon provide
the best care for the patient and prevent a fatalistic approach
by both. A clear focus should be on providing the best possible
care for the upper extremity problem with perception of and
attention applied to the other concerns of the patient.
Tendinopathy
Medial and lateral epicondylitis
Van Rijn and associates have reviewed the literature evaluat­
ing the associations between lateral and medial epicondylitis
and work-related factors such as force, repetition, posture
and psychological issues.4 They report that handling tools of
weight >1 kg; repetitive movements >2 h/day; low job control,
and low social support, are associated with lateral epicondy­
litis. Handling tools >5 kg two times, at a minimum of 2 h/
day, or tools >20 kg at least 10 times per day; high-hand grip
forces for >1 h/day; repetitive movements for >2 h/day and
working with vibrating tools, are associated with medial
epicondylitis. The clinical management of these conditions
have recently been reviewed by Rineer and Ruch.5
Lateral epicondylitis
Lateral epicondylitis, tennis elbow, presents with well-
localized lateral elbow pain that is exacerbated by certain
activities such as gripping. The diagnosis is made by history
and physical examination. Physical examination will show
point tenderness directly over the lateral epicondyle. Pain will
be increased with resisted wrist extension, especially in elbow
extension.
Hints and tips
• Clinical problems associated with occupational disorders
have been observed to fall into specific patterns that can
lead to frustration and uncertainty.
• Early return to modified work is a “double-edged sword”
that requires further research evaluation.
Fig. 18.1  De Quervain’s tenosynovitis. Tendons of first dorsal compartment and
planned release on dorsal half of sheath.
Abductor pollicis longus
and accessory slip
1st dorsal compartment
Extensor pollicis brevis
Site of release

393
Clinical care in illness related to the workplace
Treatment for trigger digit includes rest, splinting, steroid
injection, and open or percutaneous surgery. Splinting can
be used at any joint and is primarily used at night. This is
particularly valuable if the finger is locked upon waking in
the morning as night-time splinting can prevent this problem.
Steroid injection is the mainstay of initial management for
trigger digit. A Cochrane review supports the use of steroid as
an efficacious treatment.15 Kerrigan and Stanwix used decision
analysis and showed that management with one or two injec­
tions prior to surgery minimizes the cost of management.16
To inject the A1 pulley, I have the patient’s hand resting
palm up on the examining table with the fingers pointed to
my left. This allows me to position my hand over the patient’s
wrist and angle the needle in a slight proximal to distal direc­
tion. I identify its position in the tendon by gentle passive
flexion and extension of the digit with my left hand. Using
gentle pressure on the syringe the needle is slowly withdrawn
until there is a drop in resistance to injection. The injection can
also be performed at the digital palmar flexion crease with the
needle tip angled in a proximal direction.
Surgical treatment is performed using local anesthetic. The
A1 pulley is released under direct vision and unrestricted
motion of the digit is demonstrated in the operating room.
Percutaneous release of trigger digit has been reported in the
literature and can be performed in the office with lower cost
than traditional surgery. One randomized trial found a high
success rate in both treatment groups without serious compli­
cations.17 Like many other surgical procedures, the choice of
procedure will depend on surgeon training and experience
and the wishes of the informed patient. The proximity of the
test for this problem and point tenderness is a specific test.
The diagnosis is made by history and physical examination.
Occasionally there will be a small ganglion overlying the first
compartment.
Non-surgical treatment, including oral non-steroidal anti-
inflammatory medication, steroid injections, splinting and
therapy are often used to treat de Quervain’s tenosynovitis. A
recent review by Ilyas, of non-surgical treatment, pointed out
the lack of randomized trials for this common condition.10
Nevertheless, one randomized trial of injection of triamcino­
lone versus placebo showed benefit from the active drug.11
The anatomy of the first dorsal compartment, specifically
the presence of a septum between the extensor pollicis brevis
and abductor pollicis longus is an interesting finding more
prevalent in de Quervain’s tenosynovitis requiring surgical
treatment than in cadaveric dissection. This anatomic feature
has direct surgical importance as each tendon must be identi­
fied and released during surgery (see Fig. 18.1).
Surgery is performed using local anesthesia. A longitudi­
nally oriented zigzag incision is made directly over the first
dorsal compartment. The subcutaneous tissue is gently spread
to avoid injury to small branches of the radial nerve and the
medial antebrachial cutaneous nerve of the forearm. The first
dorsal compartment is identified and opened dorsal to the
midline. After complete release, each tendon is identified
making sure the extensor pollicis brevis is released. If it is not
identified, it will lie in a separate tunnel on the dorsal margin
of the open first compartment. This is easily released from
within the first dorsal compartment. The tourniquet is released
before wound closure and a short thumb spica splint is worn
until suture removal about 10–14 days later.
Trigger finger
Trigger digit is one of the most common disorders of the hand.
A comprehensive review with extensive references has been
published by Moore.12 A case–control study found associa­
tions of trigger digit with female gender (OR 7.57, 95% CI
5.07–11.31); diabetes (OR 3.72, CI 2.43–5.70); obesity (OR 1.49,
CI 1.02–2.19); occupation as a homemaker (OR 2.44, 95% CI
1.62–3.69); seamstress (OR 4.8, CI 1.3–21.6); and secretary (OR
2.74, CI 1.38–5.52). It is not clear from the abstract if gender
was controlled for in these calculations although it would
seem to be difficult to accomplish.13 A study in a meat packing
plant found a person-year incidence rate of 12.4% for workers
using tools and 2.6% for those without tool use. The authors
believe high worker turnover may cause an underestimation
of the rate in the workplace.14
The diagnosis of trigger digit is relatively straightforward
and relies on history and physical examination. Triggering
will usually be demonstrable in the office. The patient who
presents with no active triggering and work attribution should
be managed without invasive intervention. These patients
may have triggering in the morning or heightened sensitivity
to symptoms. The author recommends initial management
with a night-time splint and re-evaluation of these patients.
Patients who present with triggering and the presence of
a flexion contracture of the proximal interphalangeal (PIP)
joint can present a challenge. The surgeon must point this
out before treatment starts and combine treatment of the
trigger digit with splinting and mobilization of the PIP joint
(Fig. 18.2).
Fig. 18.2  Trigger digit. Location of A1 pulley and planned incision on radial side
of the pulley.
Site of incision of pulley
A1 pulley

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SECTION III
CHAPTER 18 • Occupational hand disorders
possible and recommend a thorough course of non-surgical
treatment. Further detailed information on nerve compression
syndromes can be found in Chapter 24.
Vascular disorders
In some occupations, the heel of the hand is used as a hammer
to push objects into place. Some commonly recognized activi­
ties are “hammering” a board into place or putting on a hub
cap. The ulnar artery and ulnar nerve pass through Guyon’s
canal and are susceptible to injury in the hypothenar area.
Thrombosis, pseudoaneurysm formation, embolic phenom­
ena, and nerve symptoms are possible.
The history is usually highly suggestive of ulnar artery or
nerve problems. Examination of the fingers may show signs
of emboli and the Allen’s test may show occlusion of the
ulnar artery. The history will likely be specific if a pseudoan­
eurysm is present and it will usually be obvious on physical
examination.
Treatment of the so-called hypothenar hammer syndrome
is based on the presence of symptoms. The presence of an
ulnar artery occlusion on the Allen’s test without symptoms
or peripheral signs does not necessitate surgical intervention.
If there are compression symptoms and findings related to
the ulnar nerve in Guyon’s canal or evidence of ischemia
or emboli, then imaging is indicated. Magnetic resonance
imaging (MRI) will define localized vascular pathology as
well as masses within or deep to Guyon’s canal. Surgery will
usually be indicated in the presence of neurologic or vascular
symptoms.
Surgery for hypothenar hammer syndrome will start with
release of the ulnar artery and nerve from the wrist crease to
distal to Guyon’s canal. The motor branch of the ulnar nerve
should be identified and followed deep into the palm. For
ulnar arterial lesions, the area of obstruction is resected and
the flow in the hand is evaluated. Resection of the artery alone
has been reported to increase flow to the hand by way of a
regional sympathetic effect. Treatment of choice is to perform
an interposition vein graft with a short saphenous vein or a
forearm vein. Further detailed information on hand ischemia
syndromes can be found in Chapter 22.
Hand–arm vibration syndrome (HAVS)
The relationship of vibration to upper extremity pathology
has been the subject of extensive literature and regulatory
interest. For the upper extremity surgeon, there are criteria
that score the vascular and neurologic components of vibra­
tion injury.
The classification scheme that was produced at a workshop
in Stockholm bears its name as the Stockholm Workshop Scale
(Table 18.2) and is divided into neurologic symptoms and
vascular symptoms.28
Although there is clear experimental evidence that vibra­
tion can cause injury to tissues, many of the symptoms of
vibration-induced injury can be caused by other means. For
digital nerves to the A1 pulley in the index and the thumb
must be considered.
Nerve compression
The work attribution of nerve compression has a well-
documented history and is still the object of intense research
effort. As research designs are improved the relationship of
carpal tunnel syndrome to keyboard use, for example, has
become less certain. A recent review of the literature reveals
the association between keyboard use and CTS has been
based on epidemiologic studies with significant flaws.18 In
fact, Atroshi et al. recently reported a study where use of a
keyboard was found to be protective of CTS.19
Additional evidence exists confirming the relationship
between force and repetition and CTS20 and lack of an associa­
tion with computer use.
Subsequently a review of systematic reviews and meta-
analysis of current research concluded “there is high evidence
for an increased risk of CTS in activities requiring a high
degree of repetition and forceful exertion. The evidence for
vibration is moderate … There is no further evidence that CTS
is caused by working with a computer keyboard or mouse.”21
One other systematic review and meta-analysis has agreed
with this lack of association between computer use and carpal
tunnel syndrome22 while another suggests that “excessive
computer use, particularly mouse usage, might be a minor
occupational risk factor for CTS”.23
It is clear from the literature there is an inverse relationship
between the specificity of the diagnosis of a disorder and the
prevalence of the disorder. In other words, as the diagnostic
criteria become more specific, i.e., other non-carpal tunnel
syndrome causes of symptoms are ruled out, the prevalence
of CTS is reduced. The incidence rate of CTS when it is diag­
nosed with high specificity is quite low even in the population
of patients using a keyboard suggesting that this is unlikely
to be a major work-related condition in keyboard users.
A recent review of CTS and its epidemiologic associations
suggested occupational factors play a minor and debatable
role in the etiology of CTS. In spite of some objections to the
development of a scorecard based on the characteristics of an
association defined by Hill, this review is a comprehensive
and thought-provoking discussion of the potential causation
of work-attributed CTS.24
Even if work-attributed CTS is an upper extremity problem
defined administratively and not by causative mechanism or
pathology, it has been found the attribution to the workplace
results in inferior outcomes compared to non-work-related
surgical care for CTS.25 Manktelow and colleagues, in review­
ing a large population of CTS patients, found that residual
symptoms after release of the carpal tunnel are common.26
For CTS that has been attributed to the workplace, I recom­
mend the patient proceed with a course of non-operative
treatment before surgery is considered. Non-surgical treat­
ment is efficacious and the improvement after splinting and/
or injection is a good diagnostic test of the ability of the
patient to obtain improvement from further intervention. If
the diagnosis is correct, then any improvement following
efficacious non-surgical treatment will be a good indicator
that the patient has at least some potential for improvement.27
If absolutely no benefit is achieved from non-surgical care,
then the surgeon should confirm the diagnosis as much as
Hints and tips
• Evidence is accumulating to show the lack of association
between keyboard use and carpal tunnel syndrome.

395
Return to work
Additional evaluations will often include electrodiagnostic
testing and non-invasive vascular testing. Angiograms are not
indicated unless there is evidence of a structural problem that
may require surgical planning.
Patients presenting with vascular or neurologic symptoms
should be advised to avoid exposure to vibration. This advice
does not implicate vibration as a cause of their symptoms but
seems prudent, given the experimental evidence of the poten­
tial for vibration to cause injury.
Management of the patient further depends on the accurate
diagnosis and management of other pathology such as CTS.
Return to work
Keeping the injured worker in the workplace or reintegration
of the injured worker into the workplace, is a vital outcome
of management of occupational illness of the upper extremity.
When an injury forces a patient to leave the workforce, even
temporarily, the surgeon should be aware of several possible
points of view: (1) The injury or illness may be more severe
causing symptoms that make work impossible. This can have
implications in the application of more invasive treatment at
an earlier stage of management. (2) The patient’s work activi­
ties may be more physical, requiring more intense use of the
upper extremities, something that will influence their poten­
tial for return. (3) The financial stakes for the employer become
higher, as salary replacement and a history of lost time injury
may be important. (4) When the injured worker is unable to
work, a set of emotional circumstances is potentially set into
play that can possibly make it difficult for the worker to return
to work.
In trying to return the patient to work, the first consideration
is whether the patient has the ability to work in any capacity.
The second consideration is whether the change in ability
to work is either permanent or temporary. For temporary
changes in the ability to work, restricted duty work is often
available if the employee has a work-related injury. This may
take the form of one-hand work if the injury is limited to
one extremity and the patient’s general condition allows safe
return. For a patient who has a temporary inability to work
in any capacity the surgeon will need to follow the patient
closely and communicate with the workplace about return
to work when the medical situation allows. If the patient has
an injury or illness that permanently prevents unrestricted
work, the surgeon will play an important role in returning the
patient to gainful employment. The first step is to determine
the permanent restrictions that will be recommended to the
patient to keep him/her safe in the workplace. For practical
purposes, this is done when the patient has reached their level
of maximum medical improvement. Further active medical
management would not be expected to increase the patient’s
status. At this time, the patient can have an impairment rating
example, the vascular symptoms of vibration injury can also
be caused by smoking, something that is highly prevalent in
some populations. The relationship of vibration to vascular
disorders is also potentially confounded not only by smoking
but also other problems such as peripheral vascular disease
of other etiologies. The neurologic symptoms of vibration
injury are typical of peripheral nerve compression so there is
often confusion between a diagnosis of CTS and vibration-
induced injury. The relationship between vibration injury and
nerve compression is not clearly elucidated. For patients with
nerve compression symptoms, however, it seems prudent to
limit exposure to future vibration.
Patient management
When a working patient has a vascular complaint or a history
of numbness or tingling, the surgeon should enquire about
vibration in the workplace as well as other potential causative
mechanisms for the symptoms including a cardiovascular
history, a smoking history, and a family history. Similarly, a
detailed history related to nerve symptoms may be helpful. If
the worker has been exposed to vibration, it is important to
create a temporal history of the time and degree of exposure
over their entire work history.
The physical examination will evaluate the upper extrem­
ity for evidence of vascular and neurologic findings. This will
include measuring the blood pressure in each arm, listening
to the heart and for bruits along the major vessels, palpating
pulses at various levels, performing an Allen’s test, and evalu­
ating the fingertips for color, trophic changes, and tempera­
ture. The examination of the peripheral nervous system
includes measuring sensory and motor function, and evalua­
tion for sites of nerve compression.
Table 18.2  Stockholm Workshop Scale
Neurologic symptoms
0 SN
Exposed to vibration but no symptoms
1 SN
Intermittent numbness, with or without tingling
2 SN
Intermittent or persistent numbness, reduced sensory
perception
3 SN
Intermittent or persistent numbness, reduced tactile
discrimination and/or manipulative dexterity
Vascular symptoms
0
−
No attacks
1
Mild
Occasional attacks affecting only the tips of
one or more fingers
2
Moderate
Occasional attacks affecting distal and
middle (rarely also proximal) phalanges
of one or more fingers
3
Severe
Frequent attacks affecting all phalanges of
most fingers
4
Very severe
As in stage 3, with trophic skin changes in
the fingertips
(Reproduced from McGeoch KL, Lawson IJ, Burke F, et al. Diagnostic criteria
and staging of hand-arm vibration syndrome in the United Kingdom. Ind Health.
2005;43:527–534.)
Hints and tips
• There continues to be a great deal of confusion
surrounding the relationship between HAVS and nerve
compression disorders.

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SECTION III
CHAPTER 18 • Occupational hand disorders
ally based, and internally consistent to the fullest extent
possible.”
“The vision … is articulated in terms of five specific new
axioms”:
1. The terminology and conceptual framework of the ICF
are adopted
2. Diagnosis and evidence-based where possible
3. Simplicity and ease of application
4. Functionally based
5. Conceptual and methodological congruity between and
within organ systems.
Measures of permanent impairment are primarily based on
diagnosis and then modified, based on several factors such as
severity and functional limitation. Whether these new guides
will supplant the 5th edition is not yet clear.
Use of the 5th or 6th edition of “The Guides” will bring
objectivity to the measurement of permanent impairment and
protects the surgeon from influence of the patient or the
employer and insurance carrier.
Summary
The care of the injured worker mirrors the care of all patients
with upper extremity injury and illness. The additional super­
imposition of the legal framework of workers’ compensation
adds an extra dimension to the care of the injured worker. The
upper extremity surgeon must be knowledgeable of the local
regulations and must be perceptive to their influence on the
patient, the workplace, and the surgeon, and maintain the
ability to take the best care possible of the patient.
Future directions
The increased use of valid clinical research methods by hand
surgeons continues to change our understanding of so-called
occupational upper extremity disorders. A clear example of
this is the elucidation of the relationship between keyboard
use and carpal tunnel syndrome. The application of valid
research methodology will continue to advance our under­
standing and care of the working patient. The concept of
presenteeism as it pertains to the injured worker and to the
aging worker is an area for fruitful research. Surgeons must
be cautious to insure their actions are in the best interest of
the patient, requiring perception of sometimes conflicting
interests of patients, employers, and insurance carriers.
calculated to facilitate compensation for the permanent effects
of the injury. The second step is to return the patient to the
workforce. Given a permanent impairment the first choice
of return to the workplace is the previous employer and
return to the pre-injury work. If this is not possible due to
the restrictions, then return to the previous employer in a
modified work capacity is often the easiest plan. This may
not be possible and the injured worker may be required to
search for a new job, limited by the restrictions that have
been imposed to ensure safety. It is obvious each step of the
process can have a big influence on the patient’s return to the
workplace and the ability to find future employment.
Measuring impairment
In measuring permanent impairment, the surgeon is provid­
ing a basis for financial compensation of the patient for the
permanent effects of an injury in the workplace. This mea­
surement is often performed by hand therapists. This mea­
surement is indicated at the time when no further diagnostic
testing or interventions are planned for the patient. It is meant
to be a tally of the permanent effects of an injury after all steps
have been taken to minimize them. Often, when the surgeon
perceives the patient has reached this stage of maximum
medical improvement, the evaluation of permanent impair­
ment and the decision about permanent work restrictions will
be accomplished simultaneously. If this is straightforward
and without conflict, this can be done by the surgeon at the
time of a final visit. If there is conflict, or if the return-to-work
restrictions are complicated, a hand therapist may be of
assistance.
In some situations of work-related upper extremity illness,
the patient may have prolonged symptoms and an inability
to work, despite maximum care, the determination that the
patient is at maximum medical improvement, the assignment
of permanent restrictions, and the determination of an impair­
ment rating can allow the patient to move on with their life
and provide a stopping point for further non-beneficial inter­
actions with the surgeon.
The most recent version of the Guides to the Evaluation of
Permanent Impairment, 6th edn, put forward by the American
Medical Association has a fundamental change in the evalu­
ation of permanent impairment, shifting to the ICF model, The
International Classification of Functioning, Disability and Health.29
This is outlined in the first chapter, “Conceptual Foundations
and Philosophy”.
“In this edition there is a paradigm shift, which adopts a
contemporary model of disablement: it is simplified, function­
2. Szabo RM, King KJ. Repetitive stress injury: diagnosis or self-
fulfilling prophecy? J Bone Joint Surg Am. 2000;82:1314–1322. This
current concepts review is a sobering review of the lack of science
surrounding the epidemic of repetitive motion injuries. Szabo logically in
a step-by-step fashion updates the literature on the perspective of a hand
surgeon regarding these diagnoses.
8. Knutsen EJ, Calfee RP, Chen RE, et al. Factors associated with
failure of nonoperative treatment in lateral epicondylitis. Am J
Sports Med. 2015;43:2133–2137. In this publication the authors point out
the risk factors for failure of non-operative treatment for lateral
epicondylitis.
9. Tanaka S, Peterson M, Cameron L. Prevalence and risk factors of
tendonitis and related disorders of the distal upper extremity among
US workers: comparison to carpal tunnel syndrome. Am J Ind Med.
2001;39:328–335. This study reviewed the results of a survey instrument
in a large population and found that 0.46% of those people who had worked
in the previous 12 months reported prolonged hand discomfort. 28% of
these problems were thought by a medical person to be work-related. The
authors estimate there were 520 000 patients with work-related
musculoskeletal disorders of the distal upper extremity in 1988.
21. Kozak A, Schedlbauer G, Wirth T, et al. Association between
work-related biomechanical risk factors and the occurrence of
Access the complete reference list online at

397
Future directions
carpal tunnel syndrome: an overview of systemic reviews and a
meta-analysis of current research. BMC Musculoskelet Disord.
2015;16:231. This study reviews the systematic reviews and meta-analysis
on the relationship between work and CTS. The study confirms the role of
biomechanical causality in CTS and essentially puts to bed the linkage
between CTS and the keyboard.
24. Lozano-Calderon S, Anthony S, Ring D. The quality and strength of
evidence for etiology: the example of carpal tunnel syndrome.
J Hand Surg Am. 2008;33A:525–538. The authors perform an exhaustive
evaluation of the literature on the relationship between activity and carpal
tunnel syndrome. Although it may not be prudent to use the guidelines of
Hill as criteria, the authors have an extensive reference list and
thoughtfully analyze the literature.
25. Harris I, Mulford J, Solomon M, et al. Association between
compensation status and outcome after surgery: a mea-analysis.
JAMA. 2005;293:1644–1652. An eye-opening article that documents what
surgeons have known for years. Patients whose medical problems are
attributed to the workplace have an inferior outcome. This manuscript
looks at carpal tunnel syndrome as one example. It cries out to researchers,
policy-makers, and society to try to understand and change this negative
influence.
26. Manktelow RT, Binhammer P, Tomat LR, et al. Carpal tunnel
syndrome: cross-sectional and outcome study in Ontario workers.
J Hand Surg Am. 2004;29A:307–317. This interesting study reports that
ongoing symptoms after carpal tunnel release in the working population
are common.
29. Rondinelli RD, ed. Guides to the Evaluation of Permanent Impairment.
6th ed. Chicago, IL: American Medical Association; 2008.

397.e1
References
References
1. Gerr F, Letz R, Landrigan PJ. Upper-extremity musculoskeletal
disorders of occupational origin. Annu Rev Public Health.
1991;12:543–566.
2. Szabo RM, King KJ. Repetitive stress injury: diagnosis or self-
fulfilling prophecy? J Bone Joint Surg Am. 2000;82:1314–1322. This
current concepts review is a sobering review of the lack of science
surrounding the epidemic of repetitive motion injuries. Szabo logically in
a step-by-step fashion updates the literature on the perspective of a hand
surgeon regarding these diagnoses.
3. Millender LH, Louis DS, Simmons BP, eds. Occupational disorders
of the upper extremity: orthopaedic, psychosocial, and legal
implications. In: Occupational Disorders of the Upper Extremity. New
York: Churchill Livingstone; 1992:1–14.
4. Van Rijn RM, Huisstede BM, Koes BW, et al. Associations between
work-related factors and specific disorders at the elbow: a
systematic literature review. Rheumatology. 2009;48:528–536.
5. Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures:
epicondylitis, biceps and triceps rupture. J Hand Surg Am.
2009;34A:566–576.
6. Herquelot E, Bodin J, Roquelaure Y, et al. Work-related risk factors
for lateral epicondylitis and other cause of elbow pain in the
working population. Am J Ind Med. 2013;56:400–409.
7. Best MJ, Buller LT, Nigen D, et al. US national practice patterns in
ambulatory operative management of lateral epicondylitis. Am J
Orthop. 2015;44:E508.
8. Knutsen EJ, Calfee RP, Chen RE, et al. Factors associated with
failure of nonoperative treatment in lateral epicondylitis. Am J
Sports Med. 2015;43:2133–2137. In this publication the authors point out
the risk factors for failure of non-operative treatment for lateral
epicondylitis.
9. Tanaka S, Peterson M, Cameron L. Prevalence and risk factors of
tendonitis and related disorders of the distal upper extremity
among US workers: comparison to carpal tunnel syndrome. Am J
Ind Med. 2001;39:328–335. This study reviewed the results of a survey
instrument in a large population and found that 0.46% of those people
who had worked in the previous 12 months reported prolonged hand
discomfort. 28% of these problems were thought by a medical person to be
work-related. The authors estimate there were 520 000 patients with
work-related musculoskeletal disorders of the distal upper extremity in
1988.
10. Ilyas AM. Nonsurgical treatment for de Quervain’s tenosynovitis.
J Hand Surg Am. 2009;34A:928–929.
11. Peters-Veluthamaningal C, Winters JC, Groenier KH, et al.
Randomized controlled trial of local corticosteroid injections for de
Quervain’s tenosynovitis in general practice. BMC Musculoskelet
Disord. 2009;10:131.
12. Moore JS. Flexor tendon entrapment of the digits (trigger finger and
trigger thumb). J Occup Environ Med. 2000;42:526–545.
13. De la Parra-Marquez ML, Tamez-Cavazos R, Zertuche-Cedillo L,
et al. Risk factors associated with trigger finger. Case–control
study]. Cir Cir. 2008;76:323–327.
14. Gorsche R, Wiley JP, Renger R, et al. Prevalence and incidence of
stenosing flexor tenosynovitis (trigger finger) in a meat-packing
plant. J Occup Environ Med. 1998;40:556–560.
15. Peters-Veluthamaningal C, van der Windt DAWM, Winters JC, et al.
Corticosteroid injection for trigger finger in adults. Cochrane
Database Syst Rev. 2009;(1):CD005617.
16. Kerrigan CL, Stanwix MG. Using evidence to minimize the cost of
trigger finger care. J Hand Surg Am. 2009;34A:997–1005.
17. Bamroongshawgasame T. A comparison of open and percutaneous
pulley release in trigger digits. J Med Assoc Thai. 2010;93:199–204.
18. Thomsen JF, Gerr F, Atroshi I. Carpal tunnel syndrome and the use
of computer mouse and keyboard: a systematic review. BMC
Musculoskelet Disord. 2008;9:134.
19. Atroshi I, Gummesson C, Ornstein E, et al. Carpal tunnel syndrome
and keyboard use at work. A population-based study. Arthritis
Rheum. 2007;56:3620–3625.
20. Fan ZJ, Harris-Adamson C, Gerr F, et al. Associations between
workplace factors and carpal tunnel syndrome: a multi-site cross
sectional study. Am J Ind Med. 2015;58:509–518.
21. Kozak A, Schedlbauer G, Wirth T, et al. Association between
work-related biomechanical risk factors and the occurrence of
carpal tunnel syndrome: an overview of systemic reviews and a
meta-analysis of current research. BMC Musculoskelet Disord.
2015;16:231. This study reviews the systematic reviews and meta-analysis
on the relationship between work and CTS. The study confirms the role of
biomechanical causality in CTS and essentially puts to bed the linkage
between CTS and the keyboard.
22. Mediouni Z, de Roquemaurel A, Dumontier C, et al. Is carpal
tunnel syndrome related to computer exposure at work? A review
and meta-analysis. J Occup Environ Med. 2014;56:204–208.
23. Shiri R, Falah-Hassani K. Computer use and carpal tunnel
syndrome: a meta-analysis. J Neurol Sci. 2015;15:15–19.
24. Lozano-Calderon S, Anthony S, Ring D. The quality and strength of
evidence for etiology: the example of carpal tunnel syndrome.
J Hand Surg Am. 2008;33A:525–538. The authors perform an exhaustive
evaluation of the literature on the relationship between activity and carpal
tunnel syndrome. Although it may not be prudent to use the guidelines of
Hill as criteria, the authors have an extensive reference list and
thoughtfully analyze the literature.
25. Harris I, Mulford J, Solomon M, et al. Association between
compensation status and outcome after surgery: a mea-analysis.
JAMA. 2005;293:1644–1652. An eye-opening article that documents what
surgeons have known for years. Patients whose medical problems are
attributed to the workplace have an inferior outcome. This manuscript
looks at carpal tunnel syndrome as one example. It cries out to researchers,
policy-makers, and society to try to understand and change this negative
influence.
26. Manktelow RT, Binhammer P, Tomat LR, et al. Carpal tunnel
syndrome: cross-sectional and outcome study in Ontario workers.
J Hand Surg Am. 2004;29A:307–317. This interesting study reports that
ongoing symptoms after carpal tunnel release in the working population
are common.
27. Edgell SE, McCabe SJ, Breidenbach WC, et al. Predicting the
outcome of carpal tunnel release. J Hand Surg Am.
2003;28A:255–261.
28. McGeoch KL, Lawson IJ, Burke F, et al. Diagnostic criteria and
staging of hand-arm vibration syndrome in the United Kingdom.
Ind Health. 2005;43:527–534.
29. Rondinelli RD, ed. Guides to the Evaluation of Permanent Impairment.
6th ed. Chicago, IL: American Medical Association; 2008.

SECTION III • Acquired Non-traumatic Disorders
19 
Rheumatologic conditions of the hand
and wrist
Douglas M. Sammer and Kevin C. Chung
SYNOPSIS
■ Rheumatoid arthritis is a systemic autoimmune inflammatory disease
that affects the joints of the hand and wrist. Rheumatoid arthritis also
affects the soft tissues, and can cause disease processes such as
trigger finger and carpal tunnel syndrome.
■ The diagnosis of rheumatoid arthritis is primarily clinical, and is
supported by radiographic and laboratory studies. Although symptoms
can usually be managed effectively with newer biologic medications,
some patients require surgery to treat refractory pain or to improve
hand function.
■ Operations for rheumatoid arthritis can be broadly categorized into five
groups: synovectomy, tendon surgery, soft-tissue rebalancing,
arthrodesis, and arthroplasty. Specific techniques described include:
wrist synovectomy, tendon transfers for tendon rupture, soft-tissue
rebalancing, management of the distal ulna and distal radio-ulnar joint
(DRUJ), wrist arthrodesis and arthroplasty, small joint arthrodesis and
arthroplasty, and treatment of trigger fingers and carpal tunnel
syndrome.
Introduction
Rheumatoid arthritis (RA) is a systemic autoimmune disease
that affects 1% of adults (ranging from 0.33% to 6.8%,
depending upon the population).1 Although RA has many
diverse clinical manifestations, the single underlying patho­
logic process is synovial inflammation, which progressively
destroys joints and soft tissue leading to deformity and dis­
ability. Over the last 20 years, many advances in the medical
management of RA have been made. New medications have
improved the ability to control rheumatoid inflammation,
and can dramatically slow or prevent disease progression.2
In spite of these tremendous advances the hand surgeon
continues to play a crucial role in treating RA. Many patients
continue to suffer from recalcitrant pain or disability despite
maximal medical management, and may benefit from surgical
intervention.
In addition to RA, there are a number of diverse rheuma­
tologic disorders that commonly affect the hand and wrist.
These include systemic lupus erythematosus (SLE), sclero­
derma, gout, and others. These disorders frequently require
surgical intervention.
Basic science/disease process
Etiology
Though much is understood about the pathogenesis of RA,
the cause remains idiopathic. That being said, RA is known
to have a genetic component. This is demonstrated by the fact
that RA has a much higher concurrence rate in monozygotic
twins (15–20%) than in dizygotic twins (5%), with susceptibil­
ity transferred in an autosomal recessive mode.3–5 In addition,
there are certain ethnic groups such as the Pima Indians
that exhibit a greater incidence of RA than the rest of the
population, providing further evidence of a genetic compo­
nent to RA.6
Many studies suggest that a multitude of genes play a role
in contributing to susceptibility to RA. These include the class
II major histocompatibility complex (MHC) genes and many
others. The most well-understood genetic association is with
the class II MHC genes, which may contribute up to 40% of
the genetic component of RA.7 One class II MHC gene in
particular, human leukocyte antigen (HLA) DR4 is associated
not only with increased risk of disease, but also with increased
disease severity.4
In addition to genetics, gender influences the development
of RA. RA is more common in women than in men, with a
ratio of 2 : 1 to 3 : 1. Multiple laboratory and clinical studies
suggest that hormones, and estrogens in particular, affect the
development of RA. However, the exact role of estrogen in the
development of RA is not known.8
Although the mechanisms are not well understood, the
environment plays a role in the etiology of RA as well. Smoking
is a risk factor for the development of RA, particularly in
  Access video content for this chapter online at expertconsult.com

399
Basic science/disease process
initiated, this process becomes systemic and self-sustaining,
and does not require the prolonged presence of the trigger
antigen. The synovial pannus produces proteolytic enzymes
such as metalloproteinases, serine proteases, cathepsins, and
aggrecanases that erode cartilage, bone, and supporting soft-
tissue structures. Cytokines secreted by the pannus activate
osteoclasts in nearby bone, further contributing to bony ero­
sions and joint destruction.14–16
Medical management
The medications used to treat RA include non-steroidal anti-
inflammatory drugs (NSAIDs), corticosteroids, and disease-
modifying anti-rheumatic drugs (DMARDs). In general, a
combination of the above medications, with methotrexate as
the basis, is used to control symptoms and the underlying
disease. NSAIDs do little to affect the course of the disease,
and are rarely used in isolation. They are effective, however,
in treating symptoms such as joint pain, but must be used
judiciously due to their gastrointestinal and renal side
effects. Corticosteroids on the other hand are very effective
in treating both the symptoms of RA and the underlying
disease process. They can be administered systemically or
locally, in the form of a joint injection. However, long-term
systemic use is associated with substantial morbidity. Because
of this, a minimal clinically-effective dose is used. Often,
corticosteroids are used briefly to control acute symptoms or
flare-ups, and are then tapered as DMARDs begin to work.
DMARDs include a diverse array of medications that can be
divided into two groups: conventional DMARDs and biologic
DMARDs.
The conventional DMARDs include methotrexate, lefluno­
mide (Arava), azathioprine (Imuran), Plaquenil, and gold.17
Methotrexate is the most commonly administered DMARD
because of its effectiveness and favorable side-effect profile.
It is generally taken orally once a week, in combination
with folic acid in order to minimize side effects such as
susceptible men.9 Coffee intake and exposure to silica have
also been associated with RA.4 In addition, infectious diseases
likely act as a trigger in genetically susceptible individuals.
Possible triggering agents include mycoplasma, enteric
bacteria, Epstein–Barr virus, and other viral and bacterial
triggers.10–13 In summary, RA is an idiopathic disease, but
which is known to have both genetic and environmental
components. The genetic susceptibility and environmen­
tal triggers are complex and varied, and are not fully
understood.
Pathogenesis
The target tissue of RA is the synovium. The disease process
begins when an antigen, a trigger for RA, is presented to
T-cells within the synovium. A complex interaction between
macrophages, B-cells, T-cells, and synoviocytes ensues,
orchestrated by systemic inflammatory modulators and local
cytokines. The end result is the formation of proliferating
inflamed synovium, or pannus (Figs. 19.1 & 19.2). Once
Fig. 19.1  The erosive synovial pannus consists of
hypertrophic synovium and inflammatory cells.
Osteoclast
Joint capsule
Pannus
Joint space
Cartilage
Bone
Synoviocytes
Synovial
membrane
Fibroblast
Macrophage
Dendritic cell
T cell
Plasma cell
B cell
Neutrophil
Mast cell
Hyperplastic
synovial lining
Extensive
angiogenesis
Fig. 19.2  Gross appearance of synovial pannus.

400
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Diagnosis/presentation
The onset of RA is usually in the 3rd to 6th decade of life. The
incidence of RA in young men is one-third that of women, but
increases to be equal to that of women by the 6th or 7th
decades of life. From the onset, RA tends to affect the hands
and wrists. In fact, the metacarpophalangeal (MCP) joints,
proximal interphalangeal (PIP) joints, and the wrist are often
affected earlier and more frequently than other joints in the
body.2
Diagnostic criteria have been described, and are useful
in making the diagnosis of RA. They include: (1) morning
stiffness = 1 h; (2) soft tissue swelling of three or more joints;
(3) soft tissue swelling of hand joints (PIP, MCP, wrist); (4)
symmetrical soft tissue swelling; (5) subcutaneous nodules
(rheumatoid nodules); (6) seropositivity for rheumatoid factor
(RF); and (7) erosions or periarticular osteopenia in hand or
wrist joints. Four of the seven criteria should be present for
diagnosis, and criteria (1) through (4) must be present for 6
weeks or longer. Morning stiffness or stiffness after rest is
common, and may be present for a number of hours, improv­
ing with hand use. The most sensitive findings are symmetric
arthritis and arthritis of the hand joints. Classic radiographic
changes, and the presence of rheumatoid nodules are less
sensitive but very specific findings. RF is not only is a marker
for RA, but also correlates with disease severity.4 Although
not one of the classification criteria, anti-citrullinated protein
antibodies (ACPAs) are very specific for RA, and are useful
in confirming the diagnosis.4,25 Like RF, ACPA seropositiv­
ity also correlates with disease severity.26 In many cases,
seropositivity to RF and ACPA develops prior to the onset
of clinical disease. It should be noted, however, that some
patients with RA will convert to seropositivity after the onset
of disease, and some patients with RA will never become
seropositive.
RA usually develops in multiple joints slowly over a period
of months, although atypical presentations are not unusual.27
In some cases, symptoms can occur rapidly over a few days.
When symptoms develop rapidly, the diagnosis of RA is often
not considered, and septic arthritis or some other cause of
acute-onset joint inflammation is initially suspected. In other
hepatotoxicity and bone-marrow suppression. Leflunomide
(Arava) is a daily oral pyrimidine antagonist, with side effects
that include hepatotoxicity and marrow suppression. Plaque­
nil, an antimalarial drug that is effective in the treatment of
RA, is taken daily and has few serious side effects. Sulfasala­
zine is another common daily DMARD, and like many of the
other conventional DMARDs it can cause leukopenia. Gold is
rarely included in the anti-rheumatic regimen today due
to significant side effects and the need for intramuscular
injections.
Biologic DMARDs are those that target tumor necrosis
factor alpha (TNF-α) and interleukin 1 (IL-1), or the cellular
components of the immune system. Etanercept (Enbrel) is an
anti-TNF-α that requires once-weekly subcutaneous injec­
tions. Infliximab (Remicade) is a TNF-α blocker that is
administered every 1–2 months, intravenously. Adalimumab
(Humira) is a TNF-α blocker that is injected subcutaneously
every two weeks. All three are very effective in treating RA,
especially when combined with methotrexate.18,19 However,
the long-term toxicity of these new medications is unknown,
and all three result in an increased susceptibility to infec­
tions.20 Anakinra (Kineret) is a biologic DMARD that blocks
IL-1 receptors, and requires daily subcutaneous injections.
Like the anti-TNF-α biologics, it is associated with an increased
susceptibility to infections. Rituximab (Rituxan) is an intrave­
nously administered monoclonal antibody that targets certain
B-cells, and lasts from many months up to a year. Abatacept
(Orencia) is an antibody that targets T-cells, and requires a
monthly intravenous injection.
The surgeon must be aware of the potential toxicities and
side effects associated with these medications. The preopera­
tive evaluation of patients on DMARDs should include labo­
ratory panels to screen for hepatotoxicity and bone-marrow
suppression. In addition, the surgeon must weigh the risk of
increased susceptibility to infection with the benefits of
surgery.
The perioperative management of DMARDs and other
rheumatoid medications is somewhat controversial and
should be coordinated with the patient’s rheumatologist.
The perioperative cessation of DMARDs or corticosteroids
can result in an acute deterioration (rheumatoid flare-up)
that is poorly tolerated by the patient. In fact, the flare-up
may be so severe that it affects the patient’s ability to
participate in postoperative rehabilitation.21–23 In general,
methotrexate should be continued throughout the peri­
operative period at its normal dose. Methotrexate does
not appear to increase infection rates in patients with RA
undergoing elective surgery.21,22 Furthermore, corticoster­
oids, when used alone or in combination with methotrex­
ate, do not affect wound infection rates and should not be
stopped in the perioperative period.23 Data on the other
conventional DMARDs are more limited, and their peri­
operative dosing should be discussed with the patient’s
rheumatologist.
The appropriate perioperative management of biologic
DMARDs, particularly the TNF-α inhibitors, is less clear.
There are few data and no large studies to guide perioperative
dosing of the biologic DMARDs.22 Therefore, a conservative
approach is recommended at this time. In general, the TNF-α
inhibitors should be held 2–4 weeks before and after surgery.22
Similarly, few data exist regarding the other biologics, and a
similar approach is recommended.24
Hints and tips
Perioperative management of anti-rheumatic medications
Medication
Recommendation
Corticosteroids
Continue at normal preoperative dosage.
Provide stress-dose at time of surgery if
taking >5–10 mg/day, or if recently
stopped long-term corticosteroid use.
Methotrexate
Continue at normal preoperative dosage.
Other conventional
DMARDs
Discuss with rheumatologist, but in
general continue.
Biologic DMARDs
Discuss with rheumatologist, but in
general hold for 2–4 weeks before and
after surgery.

401
Diagnosis/presentation
Wrist involvement
Within the wrist and distal radioulnar joint (DRUJ), cartilage
is degraded and bony erosions develop. Bony erosions occur
first at sites of nutrient vessels and at the joint margins because
there is no protective cartilage at these locations, thereby
giving the invading pannus direct access to the bone.33 Radio­
graphic changes are first noted at the scaphoid waist, the
ulnar styloid and the distal radioulnar joint (DRUJ) (Fig.
19.3).34,35 As the arthritis progresses, the radiocarpal joint
becomes involved. Bony destruction tends to be more severe
at the radiocarpal joint than the mid-carpal joint, although
both joints are often involved.36 In late stages, the volar lip of
the distal radius becomes severely eroded, allowing proximal
migration, volar translation and volar angulation of the
lunate, with compensatory mid-carpal extension (Figs. 19.4 &
19.5).35,37
The ligaments of the wrist and DRUJ are affected as well.
As the pannus proliferates, it stretches and then directly
invades the intrinsic and extrinsic wrist ligaments. Synovitis
occurring at the scaphoid waist weakens the radioscaphocapi­
tate ligament, leading to ulnar translocation of the carpus
(Figs. 19.6 & 19.7).38 Destruction of the scapholunate ligament
leads to carpal instability, and further contributes to ulnar
translocation of the carpus. At the DRUJ, pannus invades the
triangular fibrocartilage complex (TFCC), including the dorsal
and palmar radioulnar ligaments, resulting in DRUJ instabil­
ity and eventually dorsal dislocation of the ulnar head. Pannus
also destroys the extensor carpi ulnaris (ECU) subsheath,
resulting in volar subluxation of the ECU.39,40 The ECU’s func­
tion as a wrist extensor and ulnar deviator is lost, contributing
to supination and radial deviation of the carpus. The combi­
nation of dorsal dislocation of the ulnar head, carpal supina­
tion and volar subluxation of the ECU is termed the “caput
ulnae” (Figs. 19.8 & 19.9).
cases, symptoms may involve one or two joints for some time
before becoming polyarticular, confounding the diagnosis.
Less commonly, some patients develop extra-articular disease
(rheumatoid nodules, vasculitis, pericarditis, pleural effusion
or interstitial disease, peripheral neuropathy, keratoconjunc­
tivitis sicca, and many others), before synovitis and arthritis
are evident.4 Palindromic rheumatism is a rare variant of RA,
in which symptoms begin in a single joint. Symptoms worsen
and spread to other joints for a few days, then disappear in
reverse order. Although the disease resolves in some patients,
about half eventually develop classic RA.28 Finally, it has been
noted that some patients tolerate RA quite well; a presentation
termed arthritis robustus. This tends to occur in athletes or
heavy laborers who have little pain or disability in spite of
severe radiographic changes.
Any joint in the body can be affected by RA, including the
articulations of the ossicles of the middle ear.29,4 However,
joint involvement tends to follow a predictable pattern. Symp­
toms often begin in the MCP, PIP and wrist joints first, in part
due to their high synovium to joint surface area ratio.30 Larger
joints like the knees, hips, shoulders and elbows are likely to
be affected later in the disease process due to their lower
synovium to joint surface area ratio.31 Within the hand, the
DIP joints are generally spared, possibly because of their rela­
tively small absolute amount of synovium. The synovial
lining of tendons is also affected by RA, and can result in a
multitude of symptoms, including carpal tunnel syndrome,
tendon rupture, tendonitis, and trigger digits.
It should be remembered that RA is a systemic disease with
multiple extra-articular manifestations. Rheumatoid nodules,
vasculitis, pericarditis, pleural effusion, interstitial pulmonary
disease, peripheral neuropathy, and keratoconjunctivitis sicca
are some of the more common extra-articular effects of RA.
Although rheumatoid nodules are present in only a minority
of patients with RA, they are a common reason for presenta­
tion to the hand surgeon. Rheumatoid nodules develop sec­
ondary to the same autoimmune process that occurs in the
joints. They occur most often on extensor surfaces or areas of
contact pressure such as the olecranon process. However, they
can appear anywhere, including within internal organs such
as the lungs, heart, or central nervous system.32
Hints and tips
Diagnostic criteria for rheumatoid arthritis
Criterion
Details
1. Morning stiffness
1 h
2. Soft-tissue swelling
3 or more joints
3. Soft-tissue swelling
Symmetric
4. Soft-tissue swelling of hand
MCP, PIP, wrist joints
5. Subcutaneous nodules
Rheumatoid nodules
6. Seropositivity
Rheumatoid factor (RF)
7. Typical radiographic findings
Periarticular erosions/
osteopenia, hand or wrist
Four of the seven criteria must be present, and criteria 1–4 must be present for at
least 6 weeks.
Fig. 19.3  PA radiograph of the left wrist, demonstrating early involvement of the
DRUJ, as well as scattered carpal erosions from invasive synovitis.

402
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
End-stage wrist arthritis falls into three different clinical
patterns, depending upon the degree of bony destruction and
ligamentous instability.41 These patterns are: (1) ankylosis; (2)
arthritic stable; and (3) arthritic unstable (subdivided into
ligamentous unstable and bony unstable). In the ankylosing
wrist, the carpus undergoes autofusion. Frequently, ankylosis
occurs with the wrist in acceptable alignment, although this
is not always the case. In the arthritic stable wrist, the arthritis
follows a pattern similar to that of osteoarthritis. Ligamentous
Fig. 19.4  PA radiograph of the right wrist, demonstrating severe involvement of the
wrist.
Fig. 19.5  Lateral radiograph of the right wrist, demonstrating destruction of the
volar lip of the radius, with volar subluxation of the carpus.
Fig. 19.6  PA radiograph of the left wrist, demonstrating ulnar translocation of the
carpus. Note that the lunate no longer sits in the lunate fossa.
Fig. 19.7  PA radiograph of the right wrist, demonstrating even more severe ulnar
translocation, and relative preservation of the mid-carpal joint as compared to the
radiocarpal joint.

403
Diagnosis/presentation
sharp bony edges at the ulna and DRUJ can lead to tendon
ruptures. The extensor tendons to the small finger are usually
affected first. Extensor tendon ruptures often progress
radially, eventually affecting all digits. This ulnar to radial
progression of extensor tendon ruptures is called the Vaughan-
Jackson syndrome (Fig. 19.11).42 Tendon ruptures are sudden,
and may not be painful. They can be difficult to identify in
patients with severe deformity, and must be differentiated
from volar subluxation of the MCP joint, radial nerve palsy,
and extensor tendon subluxation at the MCP joint. On the
volar aspect of the wrist, sharp erosions on the scaphoid can
result in attritional rupture of the flexor pollicis longus (FPL)
tendon, known as a Mannerfelt lesion (Fig. 19.12).43 Within the
carpal tunnel, synovial pannus and tenosynovitis proliferate,
creating a space-occupying lesion that results in carpal tunnel
syndrome (Fig. 19.13).
Finger and thumb involvement
In the fingers the MCP and PIP joints are primarily affected,
with relative sparing of the DIP joints. As cartilage is degraded,
destruction is limited, and the wrist remains stable over time.
In the unstable wrist, there is progressive malalignment. In
the ligamentous unstable wrist, bony destruction is minimal,
whereas in the bony unstable wrist, there is severe loss of bone
resulting in instability and eventually dislocation.
On the dorsal aspect of the wrist, synovitis develops within
the extensor tendon compartments (Fig. 19.10). Depending
upon the extent of the synovitis, there may be a bulge protrud­
ing beyond the distal and proximal margins of the extensor
retinaculum, creating an hourglass appearance. Direct inva­
sion of extensor tendons, combined with attritional wear over
Fig. 19.8  Caput ulnae, with dorsal dislocation of the ulnar head and carpal
supination.
Fig. 19.9  Lateral radiograph of the wrist, demonstrating a dorsally dislocated ulnar
head.
Fig. 19.10  Extensor tenosynovitis protruding from under the extensor retinaculum
distally.
Fig. 19.11  Patient with Vaughan-Jackson syndrome, demonstrating extensor
tendon ruptures associated with a caput ulnae.

404
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
One of two patterns of finger deformity can occur: the
swan-neck (Fig. 19.18) or boutonniere deformity (Fig. 19.19).
Although swan-neck deformity is more common, either
deformity can occur and both can occur in the same hand.
Swan-neck deformity can originate from pathology at the
MCP joint, the PIP joint, or the DIP joint (Fig. 19.20). At the
DIP joint the terminal tendon insertion attenuates or erodes,
resulting in a mallet finger. This causes an imbalance in the
extensor mechanism, with increased extension force at the PIP
joint. MCP flexion also contributes to increased pull of the
central slip at the PIP joint. When these increased extension
forces are combined with synovial disruption of the PIP volar
plate, PIP hyperextension occurs, resulting in swan-neck
deformity. Swan-neck deformity can originate at the PIP joint
joint space narrowing is seen. Pannus invades at the margins
of the joints, resulting in marginal bony erosions. The joint
capsule and collateral ligaments are initially stretched and
then directly invaded by the synovial pannus, resulting in
instability and deformity.
At the MCP joints, the typical pattern of instability is volar
subluxation and ulnar deviation, and is the result of multiple
forces.44,45 Synovitis at the MCP joint erodes the dorsoradial
portion of the joint capsule early in the disease process, creat­
ing an early tendency towards ulnar deviation (Fig. 19.14) and
volar subluxation (Fig. 19.15).46,47 Radial deviation at the wrist
creates an ulnar approach of the extensor tendons to the MCP
joints, which further contributes to ulnar deviation (Fig.
19.16).48 In addition, ulnar deviation forces during opposi­
tional and key pinch stretch the dorsoradial portion of the
capsule and the radial collateral ligament, particularly in the
index and long fingers.49 Finally, continued dorsoradial inva­
sion of the pannus weakens the radial sagittal bands, causing
ulnar subluxation of the extensor tendons between the meta­
carpal heads, which further increases ulnar deviation force on
the MCP joints, and weakens extension power at the MCP
joints (Fig. 19.17).35,50
Fig. 19.12  Axial cross-section of the radial side of the wrist, demonstrating the
Mannerfelt lesion. Note the proximity of the flexor pollicis longus tendon to the
sharp erosion on the volar aspect of the scaphoid.
Flexor carpi radialis
Flexor pollicis longus
Median nerve
Flexor digitorum superficialis
Flexor digitorum profundus
Scaphoid
Capitate
Trapezium
Fig. 19.13  Large proliferative flexor tendon tenosynovitis.
Fig. 19.14  Ulnar deviation at the MCP joints (ulnar drift).
Fig. 19.15  Radiograph of bilateral hands, demonstrating flexion and volar
subluxation of the MCP joints.

405
Diagnosis/presentation
the central slip insertion on the base of the middle phalanx.
Attenuation of the dorsal capsule, transverse retinacular liga­
ment and triangular ligament allows the lateral bands to
sublux volar to the joint axis of rotation, becoming PIP flexors.
The volar position of the lateral bands makes them even more
effective extensors of the DIP joint, resulting in secondary DIP
hyperextension.
as well. Pannus stretches and erodes the volar plate and
capsule, allowing hyperextension. Flexor tendon rupture may
also contribute to a loss of flexion force at the PIP joint. The
lateral bands slide dorsally, limiting PIP flexion. DIP joint
flexion is a secondary phenomenon in this scenario, and is due
to slack in the extensor mechanism combined with tightening
of the flexor digitorum profundus (FDP) from PIP hyperex­
tension. MCP pathology can initiate the development of
swan-neck deformity as well. Flexed MCP position results in
excessive pull through the extensor mechanism. The intrinsics
also tighten over time, thereby hyperextending the PIP joint
when MCP extension is attempted. The lateral bands also
migrate dorsally, contributing to the deformity. The most
debilitating result of swan-neck deformities is loss of flexion
at the PIP joints, resulting in an inability to flex the fingers for
pinching and grasping.
Boutonniere deformities are usually less debilitating than
swan-neck deformities, because pinch and grasp are usually
preserved. Unlike swan-neck deformities, boutonniere defor­
mities always begin with pathology at the PIP joint (Fig.
19.21). The initial insult is stretching, erosion, and rupture of
Fig. 19.16  Radial deviation and ulnar translocation at the wrist contribute to ulnar
deviation at the MCP joints.
Fig. 19.17  The extensor tendons displace ulnarly and volarly into the space
between the metacarpal heads, making them ineffective as MCP extensors, and
adding to ulnar deviation force.
Fig. 19.18  Classic swan-neck deformities of all fingers, with MCP flexion, PIP
hyperextension, and DIP flexion.

406
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Synovitis also develops within the flexor tendon sheath,
and can lead to triggering or rupture of the flexor tendons.
Trigger digits associated with RA are distinct in mechanism
and pathology from nonrheumatoid trigger digits, and occur
secondary to synovitis or small rheumatoid nodules in the
flexor tendon.51 The specific location of the synovitis or rheu­
matoid nodules determines the presentation of the rheumatoid
trigger finger. A nodule located proximal to the A1 pulley
may present like a typical nonrheumatoid trigger finger with
locking in flexion, or triggering during extension. A nodule
just distal to the A2 pulley can result in the finger locking in
extension, or triggering during flexion. Diffuse tenosynovitis
or multiple nodules can result in swelling and loss of flexion
and extension.52,53
The rheumatoid thumb deformity can be organized into
five categories. Type I, the most common, is a boutonniere
deformity with MCP flexion, IP hyperextension, and radial
abduction of the metacarpal (Fig. 19.22). Deformity begins
when synovial pannus at the MCP joint erodes dorsally,
attenuating and eventually rupturing the extensor pollicis
brevis (EPB) tendon insertion, and displacing the extensor
pollicis longus (EPL) ulnarly and volarly. Because of the loss
of dorsal capsule and the loss of the EPB, the MCP joint flexes
and subluxates volarly. Hyperextension at the IP joint occurs
secondarily, and can be exacerbated in patients with an FPL
rupture. Type III rheumatoid thumb deformity is a swan-neck
deformity, and is the second most common deformity, pre­
senting with MCP hyperextension, IP flexion, and metacarpal
adduction contracture. This deformity begins at the carpo­
metacarpal (CMC) joint, with attenuation of the volar beak
ligament. As the CMC joint subluxates or dislocates, metacar­
pal adduction occurs in a similar fashion to nonrheumatoid
CMC arthritis. MCP joint hyperextension occurs secondarily
as the thumb compensates for the adducted metacarpal, and
is exacerbated by volar plate attenuation or erosion from
pannus invasion.
Fig. 19.19  Boutonniere deformity of the right ring and small fingers, and left small
finger. Left ring finger demonstrates very early boutonniere deformity.
Fig. 19.20  (A) Swan-neck deformity originating from a
mallet finger, with subsequent increased extension force
at the PIP joint. (B) Swan-neck deformity originating at
the PIP joint, with volar plate attenuation and possible
FDS rupture due to PIP synovitis, and subsequent dorsal
subluxation of the lateral bands.
A
B
Dorsal subluxation of lateral band
PIP synovitis leading to attenuation of
volar plate and possible FDS rupture
Attenuated or ruptured terminal tendon (mallet finger)
Increased pull at PIP joint
Contracted triangular ligament

407
Patient selection
management.54 Atlantoaxial instability is another concern,
and is quite common in patients with RA. Flexion of the
neck during intubation in patients with significant instability
can cause spinal cord injury or death. Therefore, preopera­
tive cervical spine flexion–extension radiographs should be
obtained in all rheumatoid patients preoperatively. Fiberoptic
intubation with the patient in a cervical collar is recommended
in patients with atlantoaxial instability.55
Cardiac function can be affected as well. Pericardial effu­
sion, constrictive pericarditis, or conduction block can occur
secondary to RA. In addition, RA patients are at increased risk
for coronary artery disease. Pulmonary involvement may
include rheumatoid nodules, pleural effusion, and interstitial
disease. Patients with long-standing disease are at risk for
Felty’s syndrome, a combination of splenomegaly, neutrope­
nia, and secondary thrombocytopenia. For the above reasons,
RA patients undergoing surgery should have a thorough
preoperative anesthesia evaluation including an EKG, meta­
bolic panel, complete blood count and differential, chest X-ray,
and cervical spine radiographs.
Types II, IV, and V are less common, but do occur. Type II
rheumatoid thumb includes MCP flexion and IP extension,
but unlike a type I boutonniere deformity, there is dislocation
or subluxation at the CMC joint. Type IV is a gamekeeper’s
deformity secondary to synovial pannus destruction of the
ulnar collateral ligament. Type V is MCP hyperextension, and
compensatory flexion at the IP joint, similar to a swan-neck
deformity (type III) but without metacarpal adduction
contracture.
Patient selection
Perioperative considerations
Care must be taken during the preoperative workup of RA
patients, because many unique problems can impact the
safety and timing of surgery. Airway management can be
quite difficult. Temporomandibular joint arthritis can limit
oral opening, making intubation difficult. Glottic narrow­
ing can also occur due to inflammation or arthritis of the
cricoarytenoid joints, creating further difficulty with airway
Fig. 19.21  Boutonniere deformity secondary to synovitis at
the PIP joint, with attenuation of the central slip, and
subsequent volar subluxation of the lateral bands.
Volar subluxation of lateral band
PIP synovitis
Attenuated central slip
Contracted oblique retinacular
ligament
Fig. 19.22  Boutonniere deformity of the thumb.
Hints and tips
• Preoperative anesthesia clinic visit for all, regardless of
general medical condition
• C-spine radiographs, including lateral flexion and extension
views
• 12-lead EKG
• Chest X-rays
• Complete blood count (CBC) with differential
• Metabolic panel
Goals of surgery
The goals of surgery in RA patients are pain relief, improve­
ment of function, prevention of progression, and improve­
ment of appearance. In general, pain relief can be accomplished
reliably by arthrodesis or arthroplasty. Because of this, pain is
the primary indication for surgery in the rheumatoid patient.
Improvement of function is less reliably accomplished, and

408
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
After completing the extensor tenosynovectomy, a posterior
interosseous neurectomy may be performed to improve pain
relief. The posterior interosseous nerve is identified on the
floor of the fourth extensor compartment and a 2-cm segment
is excised, with cauterization of the proximal stump.
If painful wrist synovitis is present, a ligament-sparing
capsulotomy is made. Synovial pannus is identified at the
radiocarpal and mid-carpal joints. With the wrist flexed and
distracted, a synovial rongeur is used to remove all synovium
although important, is a secondary indication for surgery. It
is important to remember that deformity does not equal loss
of function. Many patients have little pain and are able to
function quite well in spite of severe deformity. These patients
may not benefit from surgery. Slowing the progression of
disease is a third priority, and is less often required in the era
of effective DMARDs. However, in some situations, surgery
is required to prevent progression of disease. For example, a
Darrach procedure (resection of the distal ulna) and dorsal
tenosynovectomy in the setting of an extensor tendon rupture
can prevent or delay additional extensor tendon ruptures.
Appearance is considered a last priority. However, aesthetic
considerations should not be discounted as these issues are
important to RA patients.
Sequence of surgery
In general, proximal problems within the upper extremity
should be corrected first, particularly if they affect more distal
problems. For example, wrist surgery should be performed
prior to finger surgery, because the deformity at the wrist
exacerbates the finger deformity. In practice however, the
sequence of surgery may be dictated by patient preference.
For example, a patient with severe swan-neck deformities and
a pain-free but ulnarly subluxated wrist may not accept the
idea of wrist surgery before correcting the finger deformity.
Another consideration is the mobility of the patient. Many RA
patients use crutches or canes for ambulation, or may even be
confined to a wheelchair, resulting in a loss of mobility during
the recovery period after hand surgery. The surgeon should
discuss these issues with the patient preoperatively so that
preparations can be made.
Treatment/surgical technique
Operations at the wrist
Wrist synovectomy/dorsal tenosynovectomy
A minority of patients will have persistent wrist synovitis or
dorsal tenosynovitis that is painful and unresponsive to at
least 6 months of maximal medical treatment. Wrist synovec­
tomy and/or dorsal tenosynovectomy may be effective in
improving pain in these patients.56,57 Whether this significantly
slows the progression of disease is unknown.
A midline longitudinal incision is made over the dorsal
wrist, and skin flaps are elevated at the level of the extensor
retinaculum, preserving the radial and ulnar sensory nerves
that lie within the subcutaneous tissue. If there is a large
amount of synovitis, it can be seen deep to the attenuated
extensor retinaculum (Fig. 19.23). The extensor retinaculum is
incised along the radial border of the first extensor compart­
ment, leaving enough substance intact for later closure. The
retinaculum is elevated in an ulnar direction to, but not
into the sixth extensor compartment, exposing the extensor
tendons. The extensor retinaculum is often very attenuated,
and care should be taken to preserve its integrity during eleva­
tion. Extensor tenosynovectomy is then performed. Working
systematically, each extensor tendon is retracted individually
and synovium is excised with curved tenotomy scissors (Fig.
19.24).
Fig. 19.23  Extensor tenosynovitis of the right wrist, with severely attenuated
extensor retinaculum.
Fig. 19.24  The extensor tenosynovitis has been partially removed. Note the
redundancy of the extensor tendons, which have been stretched by the long-
standing tenosynovitis.
Clinical tip
• Always be prepared to perform tendon transfers when you
are doing a tenosynovectomy.
• Ruptured tendons may be held together by thick pannus
and adhesions.
• Be sure to talk to tenosynovectomy patients about the
possibility of tendon transfer.

409
Treatment/surgical technique
Fig. 19.25  One retinacular flap (the distal half of the retinaculum) has been placed
deep to the extensor tendons to protect them from rough bony surfaces. The other
flap (the proximal half of the retinaculum) has been sutured dorsal to the extensor
tendons to prevent bow-stringing.
Clinical tips
• In some cases, the extensor retinaculum is attenuated and
cannot be used to pad rough surfaces.
• Be sure to have acellular dermal matrix (dermal allograft)
available for padding if needed.
Hints and tips
• Allow at least 6 months of maximized medical treatment
prior to considering surgery.
• Concomitant PIN neurectomy may improve pain relief.
• Ensure that all rough bony surfaces are smoothed and
covered with soft tissue.
Fig. 19.26  Chevron incision made directly over the ulnar head, with skin flaps
elevated and extensor retinaculum exposed.
within the radiocarpal and mid-carpal joints. Any sharp edges
are smoothed with a curette or rongeur. If DRUJ synovitis is
present, a longitudinal incision is made over the DRUJ, in the
floor of the fifth extensor compartment. This incision can be
extended 90° ulnarly just proximal to the TFCC if necessary
for additional exposure. Pronation also improves exposure of
the DRUJ. Synovial pannus is removed with a synovial
rongeur. Sharp bony edges are smoothed with a rongeur to
prevent tendon ruptures. The capsulotomy incisions are
closed with 3-0 absorbable suture.
If any rough bony surfaces remain exposed after closure of
the capsule, the retinaculum can be divided transversely,
creating two ulnarly based retinacular flaps. One flap is
sutured deep to the extensor tendons, covering the exposed
bony surfaces. The other retinacular flap is closed dorsal to
the extensor tendons, leaving the EPL transposed (Fig. 19.25).
Alternatively, if the ECU tendon is subluxated volarly, the
retinaculum can be used to stabilize it. The ECU tendon is
synovectomized and relocated to its normal position dorsal to
the ulna. Half of the retinacular flap is placed deep to the ECU
tendon, then wrapped back dorsally and radially and sutured
to itself at the border of the fifth extensor compartment, secur­
ing the ECU dorsal to the wrist axis of rotation.
Postoperative care
The wrist is immobilized for 2–3 weeks, followed by initiation
of motion. If the DRUJ was debrided a sugar-tong splint
should be used to prevent forearm rotation. If the wrist or
DRUJ is unstable prior to surgery, a longer period of mobiliza­
tion may be required.
Outcomes, prognosis, and complications
Synovectomy of the wrist or DRUJ usually relieves pain, but
recurrence of synovitis is the rule rather than the exception,
although the rate at which synovitis recurs is variable. Whether
wrist synovectomy significantly alters the course of the
disease is not known. Dorsal tenosynovectomy on the other
hand likely prevents or delays the occurrence of extensor
tendon ruptures.
Secondary procedures
If the patient develops recurrent painful synovitis after wrist
joint synovectomy, a definitive wrist procedure such as
arthrodesis may be indicated.
Distal ulna resection (Darrach procedure)
Distal ulna resection may be indicated for painful DRUJ
instability, painful destruction of the DRUJ, or caput ulna
syndrome with extensor tendon ruptures. It can be performed
in isolation, but is often combined with extensor tenosynovec­
tomy, extensor tendon repairs or tendon transfers, wrist
arthrodesis, or wrist arthroplasty.
If performed in isolation, a 3-cm longitudinally oriented
chevron incision is made over the dorsal aspect of the ulnar
head (Fig. 19.26). If combined with another wrist procedure,
skin flaps and retinacular flaps are elevated, and extensor
tenosynovectomies are performed as described above. A
longitudinal incision is made in the floor of the fifth extensor
compartment, with a 90° extension ulnarly just distal to the
head of the ulna, and just proximal to the TFCC. Although it

410
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Prior to closure, the ulnar stump should be stabilized and
the normal relationship between the ulna and the carpus
should be re-established or improved. The pronator quadratus
is elevated subperiosteally from the volar ulnar aspect of the
ulna, leaving its attachment to the radius intact. It is important
to keep the periosteum attached to the pronator quadratus. It
is then delivered through the interosseous space and draped
dorsally over the ulnar stump. The ulna is reduced volarly.
While maintaining the ulnar stump in reduction, the pronator
quadratus and its periosteum are sutured securely to the
dorsal aspect of the ulnar stump, using bone anchors if neces­
sary (Fig. 19.29). In this position, the pronator quadratus serves
as a buffer against impingement between the radius and ulna,
and also helps prevent dorsal subluxation of the ulna.
Alternatively, a distally based slip of the ECU is elevated.
The DRUJ capsule and periosteal flaps are closed with
Fig. 19.27  The DRUJ and ulnar head have been exposed through an incision in the
floor of the fifth extensor compartment.
is often destroyed, when the TFCC is present, it should be
preserved. The capsule is elevated off the ulnar head, and the
ulnar head and neck are dissected subperiosteally with a
15-blade and Freer elevator (Fig. 19.27). The ECU is usually
subluxed volarly, and is elevated off the ulna during subperi­
osteal dissection. Hohmann retractors are used to provide
exposure of the neck and head of the ulna. Once the ulnar
head and neck have been exposed circumferentially, a sagittal
saw is used to create a transverse osteotomy at the neck of the
ulna, at the level of the proximal margin of the sigmoid notch
of the radius. Any remaining soft-tissue attachments are
released, and the ulnar head is removed (Fig. 19.28). The
dorsal edge of the ulnar stump is then beveled with the sagit­
tal saw, and rasped smooth to prevent tendon abrasion and
rupture. Any remaining synovial pannus can now be easily
accessed, and is debrided with a synovial rongeur.
Fig. 19.28  The ulnar head has been removed. The distal end of the stump will be
beveled dorsally.
Fig. 19.29  The pronator quadratus is released from the volar aspect of the ulna, passed through the interosseous space, and sutured to the dorsal aspect of the ulna.
A
B
C
Pronator quadratus

411
Treatment/surgical technique
Outcomes, prognosis, and complications
One potential complication after distal ulna resection is exten­
sor tendon rupture due to attrition over the sharp dorsal edge
of the osteotomy. This is prevented by beveling and rasping
down the dorsal edge of the osteotomy, and by performing a
soft tissue stabilizing procedure at the time of the Darrach
procedure, in order to minimize dorsal subluxation of the
ulnar stump. Another potential complication is painful radio-
ulnar convergence and impingement, which tends to occur
during loading. Again, stabilization and/or padding of the
distal ulna at the time of Darrach procedure as described
above helps to minimize this.
Secondary procedures
Persistent painful instability or radio-ulnar impingement may
be treated with a soft-tissue stabilization procedure using the
ECU as described above. Alternatively, ulnar head implant
arthroplasty may be considered to salvage the failed Darrach
complicated by painful radio-ulnar impingement.
non-absorbable sutures, and are imbricated tightly with the
ulna reduced volarly. The slip of ECU is then woven through
the capsule at the distal end of the ulna, and is then sutured
to the dorsal ulnar aspect of the radius. This sling helps sta­
bilize the ulnar stump, and also reduces carpal supination
(Fig. 19.30). Pre- and postoperative radiographs are shown in
Fig. 19.31.
Postoperative care
The patient is placed in a sugar-tong splint in supination for
2–3 weeks prior to allowing wrist motion and forearm rota­
tion. If a tendon transfer is done, the patient should be splinted
for 4 weeks.
Fig. 19.30  Distally based slip of ECU is used to stabilize the ulnar stump.
A
B
Cut end of ulna
Extensor carpi ulnaris
Fig. 19.31  Pre- and postoperative radiographs demonstrating resection of the
ulnar head.
Hints and tips
• Create a dorsal bevel after making the transverse
osteotomy, and smooth with a rasp to prevent attrition
ruptures.
• Distal ulna resection should be performed at the time of
extensor tendon transfers if the distal ulna was the source
of extensor tendon rupture.
• A stabilizing procedure should be performed to decrease
recurrent dorsal subluxation, minimize radioulnar
convergence, and reduce carpal subluxation.

412
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
mid-carpal motion. A transverse osteotomy is made at the
proximal margin of the distal pole of the scaphoid using a
reciprocating saw. The distal pole is then removed piece-meal
with a rongeur.
Autologous cancellous bone graft is packed into the fusion
site. This should be obtained from the iliac crest, or from the
resected distal pole of the scaphoid and from the distal ulna
if a Darrach procedure has been performed. Bone graft should
not be harvested from the distal radius, as this reduces the
stability of the radioscapholunate fixation. Fixation is achieved
with headless compression screws that are inserted into the
dorsal aspect of the distal radius, and driven distally and
volarly into the scaphoid and lunate. Three or four compres­
sion screws are used, with two passing from the radius into
the scaphoid, and one or two passing from the radius into the
lunate (Fig. 19.33). It is usually necessary to back out the
temporary fixation K-wires in order to achieve compression.
In addition, in order to achieve even compression when two
screws are placed across one articulation, the screws should
be simultaneously advanced. After screw placement, final
c-arm views are used to confirm carpal alignment and screw
position. The mid-carpal joint is directly examined to ensure
that there is no screw penetration. If there is any concern
about the stability of the fixation, supplemental K-wires can
be placed. If the bone quality is too poor to support compres­
sion screws, as it often is in patients with rheumatoid arthritis,
fixation can be performed with K-wires alone (Fig. 19.34).
Other alternatives for fixation include staples or a T-shaped
plate. The capsule is closed and the extensor retinaculum is
closed with the EPL transposed.
Partial wrist arthrodesis
(radioscapholunate arthrodesis)
In some rheumatoid wrists, the radiocarpal joint becomes
arthritic with relative preservation of the mid-carpal joint (Fig.
19.32). In these patients, radioscapholunate arthrodesis may
be indicated to treat refractory pain secondary to radiocarpal
arthritis. Patients should understand that they will lose
approximately 60% of wrist flexion–extension, depending
upon the quality of the mid-carpal joint. In addition, patients
should be consented for the possibility of complete wrist
arthrodesis if the mid-carpal joint is found to be substantially
arthritic at the time of surgery.
The skin and retinacular incisions are the same as described
above. Extensor tenosynovectomies are performed if required,
and a posterior interosseous neurectomy is performed. An
H-shaped capsulotomy is made, exposing the radiocarpal and
mid-carpal joints. Radiocarpal and mid-carpal synovectomies
are performed. The quality of the mid-carpal joint is assessed,
and the decision to proceed with radiocarpal fusion versus
complete wrist fusion is made. The radiocarpal joint is
assessed as well. In some cases, the radioscaphoid articulation
is preserved, allowing the surgeon to perform a radiolunate
fusion, although in most instances the entire radiocarpal joint
is arthritic. With the wrist flexed and distracted, a rongeur is
used to remove the remaining articular cartilage and subchon­
dral bone from the distal radius and the proximal articular
surfaces of the lunate and scaphoid. The articular surfaces are
prepared in this manner until bleeding cancellous bone is
encountered. During joint surface preparation, the matching
concave–convex surfaces of the radiocarpal joint should be
preserved. The carpus is then reduced by maneuvering the
lunate into neutral flexion–extension, correcting any scapholu­
nate gap, and correcting ulnar translocation if present. The
use of 0.062-inch K-wires as joysticks may be necessary for
reduction. The scaphoid and lunate are temporarily held in
reduction with 0.062-inch radiocarpal K-wires, and a mini
c-arm is used to confirm carpal alignment. Next, the distal
pole of the scaphoid is resected in order to improve
Fig. 19.32  Bilateral wrist radiographs demonstrating severe involvement of the
radio-carpal joint, and relative sparing of the mid-carpal joint.
Fig. 19.33  Radiocarpal arthrodesis, with compression screws. The distal pole of
the scaphoid is resected to preserve mid-carpal motion. Triquetrum excision is
optional.

413
Treatment/surgical technique
Fig. 19.35  Wrist arthrodesis with fusion plate. Use of a plate and screws is limited
to patients with good bone quality.
Fig. 19.36  Wrist arthrodesis with headless compression screws in a patient with
good bone quality.
Fig. 19.34  Radiocarpal arthrodesis with K-wires.
Postoperative care
The wrist is immobilized until bony union occurs. Active and
passive range of motion and strengthening exercises are initi­
ated after bony union occurs.
Complete wrist arthrodesis
Complete wrist arthrodesis is an effective treatment for the
painful and unstable wrist. However, the loss of wrist motion
after complete arthrodesis can cause significant functional
difficulty, particularly if the patient has a stiff contralateral
wrist. Because of this, it should be reserved for patients with
recalcitrant pain or debilitating instability or malalignment, in
spite of maximum medical management, steroid injections,
and wrist splinting.
In patients with high quality bone, a dorsal wrist fusion
plate or headless compression screws can be used (Figs. 19.35
& 19.36). However, if bone quality is poor, Steinmann pin fixa­
tion may be performed.58,59 The wrist is exposed as described
above for radioscapholunate fusion. If indicated, a Darrach
procedure is performed as described above. The radio carpal
and mid-carpal joints are exposed. With the wrist flexed and
distracted, a synovial rongeur is used to debride synovial
pannus, allowing access to the articular surfaces. A rongeur is
then used to remove articular cartilage and subchondral bone
from the opposing articular surfaces, until bleeding cancel­
lous bone is encountered (Fig. 19.37). A small Steinmann pin
is drilled retrograde into the radius in order to create a track
for the final Steinmann pin. The starting point on the radius
is chosen carefully, in order to allow the Steinmann pin to pass
directly into the isthmus of the medullary canal without any
angulation. The correct starting point is usually in the dorsal
half of the radius articular surface, and near the interval
between the scaphoid and lunate fossae. Fluoroscopy is used
to confirm the position of the Steinmann pin. The small Stein­
mann pin is removed and exchanged for the largest diameter
Steinmann pin that will fit into the medullary canal of the
radius. The large Steinmann pin is removed from the radius
and then it is drilled antegrade through the carpus, exiting the
carpus at the 2nd or 3rd intermetacarpal space, and exiting
the skin between the MCP joints. With the radius and carpus
reduced, the Steinmann pin is tapped retrograde back into the
radius, and through the isthmus of the medullary canal (Fig.
19.38). It is cut distally at the skin, and then tapped 2–3 cm
proximal to the level of the skin. If necessary, additional fixa­
tion with temporary K-wires can be used. Cancellous autograft
is packed into the radiocarpal and mid-carpal joints. The

414
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
capsule is closed with 3-0 absorbable sutures, and the reti­
naculum and skin are closed as described above. The wrist is
immobilized until union occurs.
An alternative is to use two smaller Steinmann pins. The
technique is similar to that described above, except that one
pin passes through the second intermetacarpal space, and one
passes through the third intermetacarpal space. An oblique
K-wire can be added to augment the fixation. The pins are cut
deep to the skin, and can be removed after bony union is
achieved (Figs. 19.39 &, 19.40). If future MCP arthroplasty is
planned, and there is no reason to preserve the articular
surface of the metacarpal head, one pin can be advanced
through the medullary canal of the long finger metacarpal,
exiting the metacarpal head distally, and then tapped proxi­
mally into the radius after reduction. If a Steinmann pin is
placed in the medullary canal of the long finger metacarpal,
it should be tapped proximally to allow enough room for
future MCP arthroplasty (Figs. 19.41 & 19.42). As noted above,
in patients with high quality bone, a dorsal wrist fusion plate
can be used. These plates allow compression across the wrist,
and result in very stable fixation.
Postoperative care
The wrist is immobilized until bony union occurs.
Outcomes, prognosis, and complications
Limited or complete wrist arthrodesis reliably treats pain in
RA when used for appropriate indications. Although the
complication rate is less than that for total wrist arthroplasty,
minor complications such as delayed skin healing, prominent
hardware, tendon irritation, neurapraxia, and pin-site issues
Fig. 19.37  Shaded areas represent the articulations that should be prepared for a
complete wrist arthrodesis.
Fig. 19.38  Wrist arthrodesis with a single Steinmann pin. The pin exits the carpus
in the second intermetacarpal space, and is cut just below the skin for later
removal. The oblique K-wire is optional.
Steinmann pin
Optional
additional
K-wire
are not uncommon. Potential major complications include
infection, loss of fixation, and nonunion. A deep infection
requires hardware removal, serial debridement, and intrave­
nous antibiotics. Nonunion, if it occurs, may or may not be
symptomatic.
Secondary procedures
In some cases prominent hardware requires removal. Unless
there is an indication for more urgent removal, this should be
delayed for a year after union is achieved. After hardware
removal, the wrist should be protected in a splint or cast for
a minimum of 6 weeks.

415
Treatment/surgical technique
Fig. 19.39  Wrist arthrodesis with two Steinmann pins. The pins exit the carpus in
the second and third intermetacarpal spaces, and are cut just below the skin for
later removal.
Steinmann pins
Fig. 19.40  Wrist arthrodesis with two longitudinal Steinmann pins, and a third
oblique pin for added fixation.
Fig. 19.41  Wrist arthrodesis with a single Steinmann pin placed in the medullary
canal of the long finger metacarpal. Note that the length of the Steinmann pin
should not prohibit future MCP arthroplasty.
Hints and tips
• Resection of all cartilage and subchondral bone, with
exposure of bleeding cancellous bone, is critical in order to
achieve union.
• Compression screw or plate and screw fixation should be
used only if bone quality is good, otherwise K-wires or
Steinmann pins may be used for fixation.
• Assessment of bony union may be difficult with plain
radiographs. In this situation, computed tomography (CT
scan) is ideal for confirming union.

416
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
The distal radius is then sequentially broached, keeping the
broach aligned with the medullary canal. After broaching, the
radial trial component is placed and impacted. If it is proud,
further broaching or burring of the radius may be required.
Next, the radial trial is removed, and the carpus is prepared.
This step varies depending upon the implant used. After
Total wrist arthroplasty
Total wrist arthroplasty is effective at relieving pain in patients
with rheumatoid wrist arthritis. However, in spite of recent
advances, wrist arthroplasty is associated with a high compli­
cation rate. In order to minimize complications such as loos­
ening, migration, and dislocation, wrist arthroplasty should
only be performed in patients who place low demands on
their wrists. In addition, arthroplasty is only indicated in
wrists with good bone stock that will support an implant.
Furthermore, the patient must have functioning wrist flexors
and extensors to benefit maximally from wrist arthroplasty. It
is important to discuss complications such as infection, loos­
ening, migration and dislocation with the patient, as well as
the postoperative rehabilitation and long-term limitations
that will be placed on wrist use. A number of implant designs
are available worldwide. The most commonly used implants
consist of cobalt chrome metal components, often with tita­
nium plasma spray on the stems to improve osseointegration,
and ultra-high molecular weight polyethylene on metal
articulations. Because wrist implants are continually modified
and refined, the details of the surgical technique change and
the implant manufacturer’s specific recommendations should
be followed. The general steps of the operation are described
below.
The dorsal wrist capsule is exposed as described above
(Fig. 19.43). A distally based U-shaped capsulotomy is created,
leaving a cuff of capsule on the radius for closure (Fig. 19.44).
Radiocarpal and mid-carpal synovectomies are performed. A
transverse carpal osteotomy is made, removing 2 mm of the
head of the capitate, the proximal pole of the hamate, the
proximal half of the scaphoid, and the entire triquetrum and
lunate. With the wrist flexed, the surface of the radius is
prepared using a guide and a burr or saw (Fig. 19.45). Next,
a guide-wire is drilled into the radius. It should be in line with
the medullary canal, with a starting point about 2–3 mm volar
to the dorsal lip of the radius and near the interfossal ridge.
Fig. 19.42  PA and lateral radiographs demonstrating wrist arthrodesis performed
with a single intramedullary pin. Note the large caliber of pin required to fill the
medullary canal of the radius.
Fig. 19.43  A radially based retinacular flap has been elevated, exposing the
extensor tendons. Synovectomy is being performed.
Fig. 19.44  A wrist capsulotomy has been made. The capsulotomy is U-shaped,
and is distally based, providing full exposure of the wrist joint.
Fig. 19.45  An osteotomy has been made at the distal end of the radius. Note the
saw-guide held in place with two K-wires.

417
Treatment/surgical technique
Outcomes, prognosis, and complications
Total wrist arthroplasty effectively relieves wrist pain.
However, the surgeon and patient are accepting a higher
complication rate in order to preserve wrist motion. Major
complications include implant instability or dislocation,
migration, infection, fracture, loss of alignment, and persistent
pain.
Secondary procedures
Although revision arthroplasty may be attempted, failed total
wrist arthroplasty is most reliably treated with complete wrist
arthrodesis. Wrist arthrodesis after failed total wrist arthro­
plasty is not straightforward, due to scarring and loss of bone
stock. Difficulty with fixation and delayed union are not
uncommon.
preparing the carpus, a trial reduction is performed with both
the radial and carpal trial components. Articulation and range
of motion are checked. Trials are removed, the wound is
copiously irrigated, fresh towels are placed, and gloves are
changed. The radial implant is placed first and impacted, and
its position checked with fluoroscopy. Next, the carpal
component(s) is placed and impacted, and the joint reduced
(Fig. 19.46). Hardware position and alignment are checked
with fluoroscopy (Fig. 19.47). Depending upon the implant
design, carpal screws may be placed. Joint stability and ROM
are checked, and final X-rays are taken. The tourniquet is let
down, hemostasis is achieved, and the retinaculum is closed
with the EPL transposed.
Postoperative care
The patient is splinted in 30° of extension for 2 weeks. ROM
begins at 2 weeks under the guidance of a therapist, and
protection of a removable splint for the next 6–8 weeks.
Strengthening begins at 4–6 weeks. Patients are given a 20-lb
lifting restriction, and sports and other heavy activities are
prohibited. It is crucial for the patient to take preoperative
antibiotics before dental, urologic, and gastrointestinal proce­
dures, etc.
Fig. 19.46  The radial and carpal components have been seated, and the joint
reduced. Final position of the implant.
Fig. 19.47  PA and lateral radiographs demonstrating good position and alignment
of the prosthesis.
Hints and tips
• Total wrist arthroplasty is a “high risk–high reward”
operation. The patient is accepting a relatively high
complication rate for the chance to preserve wrist motion.
• The patient must be aware of lifetime limitations on upper
extremity use.
• The patient must be instructed in taking antibiotics prior to
dental, urologic, GI, and other invasive procedures or
surgeries after total wrist arthroplasty.
Operations for the hand and fingers
MCP synovectomy and soft tissue reconstruction
Synovectomy and soft-tissue reconstruction of the MCP joints
is a temporizing operation, and synovitis and deformity
usually recur. It is only indicated in patients with persistent
synovitis that does not respond to at least 6 months of
maximum nonoperative management who have radiographi­
cally intact joints, correctable deformities, and substantial
dysfunction. Patients with adequate function should not
undergo MCP synovectomy and soft-tissue reconstruction,
regardless of the presence of synovitis or deformity.
A transverse incision is made over the dorsal aspect of the
MCP joints. Dissection is carried down to the extensor mecha­
nism over each joint, using longitudinal spreading to protect
the dorsal veins and sensory nerves. Often, the extensor
tendon has subluxated ulnarly, and there may be attenuation
or destruction of the radial sagittal band. The ulnar sagittal
band is incised longitudinally, adjacent to the extensor tendon.
A 15-blade is then used to separate the extensor mechanism
from the underlying joint capsule. The capsule, which is
usually very thin, is then incised transversely with a 15-blade,
exposing the MCP joint. Synovial pannus is removed with a
curette or small synovial rongeur. (It should be noted that PIP
synovectomy can be performed as well for painful synovitis
that is unresponsive to medical management, as demonstrated
in Figs. 19.48 and 19.49).
The finger is checked for intrinsic tightness. The PIP joint
is passively flexed while the MCP joint is alternately held in
flexion, and then hyperextension. Increased resistance to PIP
flexion when the MCP is held in hyperextension indicates

418
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
sagittal band reconstruction is not secure, the extensor tendon
should be sutured directly to the underlying joint capsule at
the base of the proximal phalanx.
Postoperative care
A splint is applied with the MCP joints extended and in
neutral radio-ulnar alignment. Active ROM in a dynamic
MCP extension splint is begun once pain and edema have
improved. A resting splint that holds the MCPs extended and
in neutral alignment should be worn at night and at other
times. Splinting can be weaned after 6–8 weeks, although
night-time splinting may be continued indefinitely.
Outcomes, prognosis, and complications
Recurrence of synovitis and deformity should be expected
over time. Fig. 19.51 demonstrates a patient before and 1.5
years after MCP synovectomy and cross-intrinsic transfer.
intrinsic tightness. In addition, ulnar sided intrinsic tightness
is evaluated by testing the PIP joint with the MCP ulnarly
versus radially deviated. If intrinsic tightness is present,
an ulnar intrinsic release and cross-intrinsic transfer are
performed.
On both sides of the finger, the soft tissue is elevated off
the lateral bands using tenotomy scissors. The ulnar lateral
band is divided distally and freed proximally to the muscu­
lotendinous junction. It is then transferred to the radial lateral
band of the adjacent finger and secured with a modified
Pulvertaft weave (Fig. 19.50). The cross-intrinsic transfer
should be tensioned with the finger in neutral alignment. In
the small finger the abductor digiti minimi is released with a
15-blade at its musculotendinous junction. Finally, the exten­
sor tendons are mobilized radially and relocated centrally
over the MCP joints. The radial sagittal band of each joint is
imbricated. The MCP joints are then passively ranged. If the
extensor mechanism tends to re-subluxate, or if the radial
Fig. 19.48  A slightly curved incision has been made over the dorsal aspect of the
PIP joint, and skin flaps have been elevated. The synovial pannus can be seen
protruding ulnar to the central slip.
Fig. 19.49  Excision of the synovial pannus, working in a proximal to distal
direction.
Fig. 19.50  The ulnar lateral bands of the index, long and ring fingers
are divided distally, and transferred to the radial lateral bands of the
adjacent long, ring, and small fingers. The abductor digiti minimi of
the small finger is divided.
Ulnar lateral band is released.
Ulnar lateral band is sutured to
extensor mechanism on
radial side or adjacent digit.

419
Treatment/surgical technique
(Fig. 19.54). A silicone implant acts as a spacer and internal
mold that becomes encapsulated, and thereby provides some
degree of alignment stability. A number of silicone MCP
implants are commercially available. Although there are some
minor differences in design, the surgical techniques are similar.
A transverse incision is made across the dorsal aspect of
the MCP joints. If only one joint is undergoing arthroplasty, a
longitudinal incision can be used. The extensor mechanism is
exposed as described above. Because of the alignment of the
fingers, arthroplasty is performed at the index finger and
Secondary procedures
Recurrent synovitis and deformity that are painful or adversely
affect hand use are indications for arthroplasty.
MCP arthroplasty (silicone)
MCP arthroplasty is indicated in patients who have pain or
substantial loss of function due to MCP deformity and arthritis
(Video 19.2
). If the patient has reasonable hand function
without pain, arthroplasty is not indicated regardless of the
degree of deformity. PyroCarbon implants or surface replace­
ment arthroplasty (SRA) implants can be used in rheumatoid
patients in certain situations (Figs. 19.52 & 19.53). However,
because of the soft-tissue laxity and joint instability associ­
ated with RA, silicone arthroplasty is generally preferred
Fig. 19.51  Preoperative (above) and postoperative (below) views of both hands
after cross-intrinsic transfers.
Fig. 19.52  Index and long MCP arthroplasties with PyroCarbon implants. The use
of PyroCarbon implants should be limited to patients without soft-tissue instability.
Fig. 19.53  MCP arthroplasty with surface replacement implant. The proximal
component is made of cobalt-chrome, and the distal radiolucent component is
made of ultra-high-molecular-weight polyethylene (UHMWPE).

420
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
just distal to the insertion of the collateral ligaments. The
proximal phalanx is then brought into extension, and a trans­
verse osteotomy is created at the proximal phalanx base,
resecting only articular cartilage and subchondral bone (Fig.
19.57). Conservative osteotomies should be made initially, as
more bone can be resected later if necessary. The medullary
canals of the metacarpal and proximal phalanx are broached
sequentially until an appropriately sized implant can be
placed (Fig. 19.58). Trials are used to select an implant that
matches the diameter of the medullary canals and covers the
entire exposed bony surface, but that does not overhang.
When broaching the medullary canals, the broach should be
oriented in such a way as to minimize the rheumatoid defor­
mity. For example, in the index finger, the rectangular broach
should be positioned high on the dorsal ulnar side of the base
of the proximal phalanx, and low on the radial palmar side.
This helps bring the finger into supination when the implant
is placed, and prevents pronation deformity. The small finger
broaching should be done in the opposite manner to prevent
supination deformity. After broaching is completed, a rasp is
used to smooth all cortical surfaces that may come in contact
with the implant. The trial is then placed and the joint is
reduced (Fig. 19.59). The transverse barrel should seat against
both osteotomy sites, but should not be compressed. The joint
is then passively ranged. If the implant is compressed during
extension, further bone resection is required. There should be
no bony impingement with flexion and extension. The trial is
removed, and the wound is copiously irrigated. Using fresh
powder-free gloves, the final silicone implant is placed. The
radial collateral ligament is imbricated using 3-0 Ethibond
sutures. If release of the radial collateral ligament was required,
it must be sutured back to the periosteum or to bone holes
created prior to implant placement. The capsule is closed, and
the radial sagittal band is imbricated, centralizing the extensor
tendon. A cross intrinsic transfer may be performed as
described above.
Of note, some patients with severe MCP disease are poor
candidates for implant arthroplasty. For example, longstand­
ing volar MCP subluxation or dislocation can result in erosion
and remodeling of the base of the proximal phalanx to the
extent that it cannot accommodate the stem of an implant. In
these patients, a volar plate interposition arthroplasty is a
reasonable alternative. The volar plate is released palmarly
from its origin on the metacarpal through a separate palmar
incision, while maintaining the attachment to the base of the
proximal phalanx. The metacarpal head is resected as for
implant arthroplasty through a dorsal approach. The joint is
reduced, and the proximal end of the volar plate is anchored
to the dorsal cortex of the metacarpal. The volar plate serves
two purposes, acting as interposed soft tissue, and also sus­
pending the base of the proximal phalanx to resist recurrent
palmar subluxation.
progresses ulnarly. A longitudinal incision is made in the
ulnar sagittal band adjacent to the extensor tendon. The exten­
sor mechanism is elevated off the joint capsule, and the
extensor tendon is retracted radially. If intrinsic tightness is
contributing to ulnar deviation, an ulnar intrinsic release can
be performed as described above. The capsule is incised
longitudinally with a 15-blade and synovectomy is performed.
The ulnar collateral ligament is released by separating its
proximal insertion from the lateral aspect of the metacarpal
head. If possible, the radial collateral ligament is preserved.
The MCP joint is then maximally flexed, exposing the meta­
carpal head. A starter awl is used to open the medullary
canals of the metacarpal and proximal phalanx, and fluoros­
copy is used to confirm appropriate alignment (Fig. 19.55). In
order to center the awl in the medullary canal, the entrance
point should be in the dorsal third of the articular surface (Fig.
19.56). A transverse osteotomy is made in the metacarpal head
Fig. 19.54  MCP arthroplasty with a silicone implant. The implant is relatively
radiolucent, but the broached regions of the metacarpal and proximal phalanx that
are occupied by the stems of the implant are visible on radiographs. The barrel of
the implant which serves as a spacer between the two bones can be seen.
Clinical tip
• When performing an MCP arthroplasty, if the dorsal base of
the proximal phalanx is too eroded to support an implant, a
volar plate arthroplasty should be performed. This will
interpose soft tissue into the arthroplasty space, and
suspend the proximal phalanx.

421
Treatment/surgical technique
collateral ligaments should be preserved if possible. If col­
lateral ligament recession is required for adequate exposure
of the joint, the collateral ligaments are repaired prior to skin
closure. A transverse osteotomy is made in the head of the
proximal phalanx just distal to the collateral ligament inser­
tion. An osteotomy is not required at the base of the middle
phalanx, but osteophytes should be removed and the articular
surface smoothed. Bony resection should be conservative, and
further resection can be performed later if required. A starter
awl is used to open the medullary canals, and fluoroscopy is
used to confirm correct alignment. Broaches are then used to
sequentially broach up the medullary canals of the proximal
and middle phalanges. Trials are used to select the appropri­
ate implant size as described above. The appropriately sized
trial is placed, the joint is reduced and ranged, and checked
for instability or impingement. If required, further bony resec­
tion and re-broaching is performed. The trial is removed and
bone edges are smoothed. The wound is copiously irrigated,
gloves are changed, and the final implants are inserted. If
required, the central slip and collateral ligaments are reat­
tached to bone using sutures passed through bone holes
drilled with a Kirschner wire. The bone holes should be
created and the sutures passed prior to placing the final
implant. The divided central slip is approximated with
absorbable sutures, and the skin is closed.
Postoperative care
Patients begin motion postoperatively, as soon as edema and
pain are improved. Splinting is continued for at least 6 weeks
postoperatively. The position and type of splinting required
vary substantially, depending upon the preoperative defor­
mity and patient’s postoperative progress.
Outcomes, prognosis, and complications
Although the outcomes reported in the literature are variable,
silicone MCP arthroplasty has been demonstrated in multiple
studies to effectively treat pain, correct ulnar drift, improve
Postoperative care
Postoperatively, the wrist is splinted in 20° of extension, and
the MCPs are splinted in extension and slight radial deviation.
The IP joints are left free. Once edema and pain have improved,
active motion with the guidance of a therapist is initiated. The
patient wears an MCP extension splint in between exercises,
and a dynamic MCP extension splint may be used for exercises
if needed. Modifications of splinting position are frequently
required, depending on the severity of the preoperative
deformity, and on patient progress after surgery. Splinting is
weaned at 6 weeks.
PIP arthroplasty
PIP arthroplasty can effectively relieve pain and improve
alignment, while preserving joint mobility in patients with
PIP arthritis. However, PIP arthroplasty is less reliable than
MCP arthroplasty in terms of stability and correction of
deformity. PIP arthroplasty should therefore be avoided in the
index finger, which must resist strong ulnar deviation forces
during pinch. It is most effective in patients with pain due to
arthritis, who have relatively good soft tissue.
The procedure is similar to that for MCP arthroplasty
described above. A dorsal longitudinal incision is made over
the PIP joint, and skin flaps are elevated at the level of the
extensor mechanism. The central slip is divided longitudinally
from the mid-portion of the proximal phalanx to the central
slip insertion, without disrupting the central slip insertion.
The joint is flexed and a transverse capsulotomy is made. The
Fig. 19.55  A starter awl is used to open the subchondral bone at
the head of the metacarpal and at the base of the proximal
phalanx, in order to gain access to the medullary canal.
Fig. 19.56  In order to be in line with axis of the medullary canal, the starting point
should be created at the junction of the middle and dorsal third of the articular
surface.
1/3

422
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
continues to function as a spacer, and the patient may not
notice a change in joint function. When revision arthroplasty
is performed, it is important to correct any issues that may
have contributed to implant failure, such as soft tissue deform­
ing forces, sharp bony edges, or inadequate bone resection.
MCP joint arc of motion, and improve appearance. These
effects are often maintained for years, although slow deterio­
ration usually occurs. At the PIP joint, arthroplasty typically
relieves pain, but is not as effective at correcting deformity or
improving motion. Potential complications include recurrence
of deformity, extension lag or loss of flexion, fracture of sili­
cone implant, dislocation of implant, silicone synovitis, and
infection. Recurrence may be due to soft tissue changes,
implant fracture, or inappropriate positioning of implant.
Secondary procedures
Revision arthroplasty after implant failure is possible, but
should be reserved for patients with loss of hand function that
is directly correlated to the failure of the implant. Often,
overall upper extremity function is decreased not because of
implant failure, but because of ongoing changes at the wrist,
elbow, or shoulder. Furthermore, a fractured implant often
Fig. 19.57  A sagittal saw is used to create osteotomies of the
metacarpal head and base of proximal phalanx. Conservative
osteotomies should be made at first, and revised if needed. The
collateral ligaments should be preserved if possible.
A
B
Hints and tips
• Pyrolytic carbon or other surface replacement arthroplasties
should be reserved for patients with stable joints and
normal ligaments and soft tissue.
• Most RA patients who require MCP or PIP arthroplasty
should have silicone rather than surface replacement
arthroplasty.
• The surgeon should start with conservative osteotomies and
broaching. More bone can always be resected if needed.

423
Treatment/surgical technique
Fig. 19.58  The medullary canals are sequentially broached.
Fig. 19.59  Final position of the implant.
MCP and IP arthrodesis
Arthrodesis of the MCP or IP joints is a reliable method for
treating refractory pain due to arthritis. Although motion is
sacrificed, the complication rate of arthrodesis is less than that
of arthroplasty, making it an attractive option in some clinical
situations. Arthrodesis is most commonly indicated at the
index or long finger PIP joint, where the ability to resist strong
ulnar deviation forces during pinch is crucial.
The joint is exposed as described above for arthroplasty.
The collateral ligaments can be divided in order to improve
joint exposure. With the joint flexed, a rongeur is used to
remove all articular cartilage and subchondral bone from the
opposing articular surfaces, creating flat opposing cancellous
surfaces. The flat cancellous surfaces must be created in such
a way that when they are apposed, there is full contact
between the two surfaces with the joint in the desired amount
of flexion, without radial or ulnar deviation. Next, two paral­
lel 0.035 or 0.045-inch K-wires are drilled across the joint,
entering the cortical bone dorsally at least 1 cm proximal to
the arthrodesis site, and angled volarly into the medullary
canal of the distal bone. The K-wires should be advanced until
they enter cortical or subchondral bone distal to the osteotomy
site. Next, a 0.045-inch K-wire is used to create a transverse
hole in the distal bone, 1 cm distal to the arthrodesis site. A
24-gauge stainless steel wire is passed through the transverse
hole in the distal bone. Both ends of the wire are then turned
proximally, crossed over the dorsal aspect of the arthrodesis
site and wrapped around the K-wires, creating a figure-of-
eight (Figs. 19.60 & 19.61). The free ends are twisted down

424
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Fig. 19.60  K-wire and stainless steel wire configuration for
tension band arthrodesis of the PIP joint.
A
B
Fig. 19.61  Lateral radiograph of a thumb MCP arthrodesis with tension band.
Fig. 19.62  PA views of DIP joint arthrodesis with headless compression screws.
with a needle driver until strong compression is achieved. The
excess wire is then cut and bent down against the bone. The
two K-wires are retracted 2 mm proximally, bent 90° and cut,
and then tapped back in to prevent a sharp protruding K-wire.
The extensor mechanism is repaired, and the skin is closed.
For the DIP joint, because fusion in a flexed position is not
necessary, a headless compression screw provides effective
fixation (Fig. 19.62).
Postoperative care
Light active finger motion is allowed immediately and a splint
is worn for comfort only. Heavy activity is allowed after union
is achieved.

425
Treatment/surgical technique
Outcomes, prognosis, and complications
MCP or PIP arthrodesis effectively relieves pain at the expense
of motion. Often, the severely arthritic and painful joint has
little motion prior to surgery, and in many cases hand function
is improved rather than worsened after arthrodesis. Although
the complication rate is lower than that of arthroplasty, com­
plications are not unusual, and may include delayed union or
nonunion, infection, skin flap compromise, and hardware-
related problems such as loss of fixation, palpability, and
tendon irritation.
Correction of swan-neck deformity
Swan-neck deformity is more debilitating than boutonniere
deformity because the fingers cannot be flexed into the palm
for grasping objects. Swan-neck deformity can be divided into
four types, based upon the degree joint mobility and arthritic
changes. In a finger with type I deformity, full active PIP
flexion is preserved, there is no intrinsic tightness, and patients
have little if any functional problems. In a finger with type II
deformity, intrinsic tightness is present. With the MCP in
ulnar deviation and flexion, PIP flexion is possible. However,
if the MCP deformity is corrected by placing it in extension
and correcting ulnar deviation, the ulnar intrinsics are tight­
ened, and PIP flexion becomes more difficult. Fingers with
type III deformity have more severe intrinsic tightness, and
PIP flexion is difficult or impossible regardless of MCP posi­
tion. In the type IV deformity substantial arthritic changes are
present.
In type I deformities, a silver ring splint that prevents PIP
hyperextension, while at the same time allowing PIP flexion,
is adequate treatment. For type II deformities an intrinsic
release and a PIP extension block are required. A Bruner inci­
sion is made over the PIP joint and the flexor tendon sheath
is exposed. The ulnar intrinsics are exposed through the volar
incision and are released as described above. A transverse
incision is then made in the midportion of the A2 pulley. One
slip of flexor digitorum superficialis (FDS) is transected with
tenotomy scissors as proximally as possible. The transected
end which remains attached distally at the FDS insertion is
passed through the slit in the A2 pulley, and turned distally.
It is then sutured to itself near the FDS insertion through a
small window in the flexor tendon sheath (Fig. 19.63). This is
tensioned so that the joint cannot be passively extended
beyond 20–30° of flexion. If the MCP joint is subluxated and
ulnarly deviated, MCP arthroplasty and soft-tissue recon­
struction should be performed as well. Persistent DIP flexion
is treated with arthrodesis if necessary.
In type III deformity, the PIP joint is stiff regardless of MCP
position. PIP flexion is limited not only by intrinsic tightness,
but also because the lateral bands are fixed in a dorsal posi­
tion. A dorsal skin contracture further complicates the defor­
mity. The first goal is to regain passive mobility in the PIP
joint. Serial casting or dynamic splinting should be used in an
attempt to restore passive mobility. If passive mobility is
restored, the type III swan-neck is converted to a type II swan-
neck, and is treated accordingly. However, if nonoperative
methods fail, passive motion must be restored surgically. A
longitudinal incision is made over the PIP joint, with an
oblique extension over the dorsal aspect of the middle phalanx.
Skin flaps are elevated. A longitudinal incision is made on
each side of the central slip, releasing the dorsally displaced
lateral bands (Fig. 19.64). The joint is passively flexed, and the
lateral bands should slide volarly. If the joint cannot be flexed,
a dorsal capsulotomy and collateral ligament recession may
be required. An intrinsic release is performed as described
above. The PIP joint is then pinned in flexion. The skin is
closed proximally, but the oblique distal portion of the inci­
sion is allowed to gap open and heal secondarily (Fig. 19.65).
This takes tension off the dorsal skin closure, and prevents
skin necrosis.
In type IV swan-neck deformity with articular destruction,
PIP arthrodesis is a reasonable option. In the ring and small
fingers, PIP arthroplasty combined with an FDS sling is an
alternative.
Postoperative care
The K-wire is removed and active and passive PIP motion
within a dorsal blocking splint is initiated, as soon as finger
edema is improved. After the finger has healed and passive
mobility is restored, the swan-neck deformity can be treated
with an FDS tenodesis. If present, MCP deformity should
be corrected as well. Persistent DIP flexion is treated with
arthrodesis.
Correction of boutonniere deformity
Boutonniere deformity is less functionally limiting than swan-
neck deformity because the patient retains the ability to flex
the finger for pinch and grasp. Furthermore, surgical treat­
ment of boutonniere deformity creates the risk of converting
a boutonniere deformity into a swan-neck deformity. Because
of this, surgery should only be considered for moderate or
severe boutonniere deformity that substantially affects hand
function.
Stage I boutonniere deformity is mild, with only a slight
extension lag at the PIP joint. The PIP joint is passively
correctable and the MCP joint is normal. There is little
functional limitation. However, if DIP joint hyperextension
is severe, it can be treated with an extensor tenotomy.60 A
longitudinal incision is made over the dorsal aspect of the
middle phalanx. Skin flaps are elevated and the extensor
mechanism is exposed. An oblique incision is made through
the entire extensor mechanism at the level of the middle of the
middle phalanx, allowing the DIP joint to flex. Care should
be taken not to injure the oblique retinacular ligament. If a
mallet deformity occurs, it is treated with a splint or with DIP
arthrodesis. Finger motion is allowed immediately postop­
eratively. A dynamic PIP extension splint is worn for 6 weeks
postoperatively.
Stage II boutonniere deformity involves a more severe PIP
flexion contracture of 30–40°. MCP hyperextension is present,
and DIP hyperextension is more severe. If the PIP joint is not
passively correctable serial casting should be attempted pre­
operatively. If serial casting fails to restore passive mobility,
surgery is required to restore passive motion. Once the joint
is supple, the boutonniere deformity can be corrected. A
longitudinal incision is made over the PIP joint, and extended
distally over the middle phalanx. An extensor tenotomy is
performed as described above to allow DIP flexion. At the PIP
joint, the goal is to shorten the central slip and correct the
volar subluxation of the lateral bands. The central slip is
transected 3 mm proximal to its insertion on the base of the
middle phalanx, leaving enough for a later repair. A 15-blade

426
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Fig. 19.63  Sublimis sling for correction of swan-neck deformity. A Bruner incision is made (A) exposing the FDS and FDP. One slip of FDS is isolated (B) and divided
proximally (C). The FDS slip is then passed through an incision in the A2 pulley (D, E) and then sutured back on itself (F), creating a block to hyperextension of the PIP
joint.
A
B
C
D
E
F
A2 pulley
Flexor digitorum
profundus
Flexor digitorum
superficialis

427
Treatment/surgical technique
is used to separate the central slip from the volarly subluxated
lateral bands. A longitudinal incision is then made in the
transverse retinacular ligament on each side of the finger, just
volar to the lateral band. The lateral bands are then mobilized
dorsally, and the PIP joint is brought into extension. The
central slip is advanced distally towards the distal remnant at
the central slip insertion. Excess central slip is excised, usually
measuring about 5 mm in length, and the central slip is
sutured to the remnant on the base of the middle phalanx
using nonabsorbable sutures. Next, the lateral bands are
sutured to the central slip using horizontal mattress sutures
(Fig. 19.66). It should be possible to passively flex the PIP joint
after tendon reconstruction.
In severe boutonniere deformity, the PIP joint is severely
flexed and cannot be passively extended. In many cases, the
PIP joint is arthritic or the joint surfaces have remodeled. PIP
arthroplasty combined with soft-tissue reconstruction can be
considered. However, in this situation PIP arthrodesis is prob­
ably the most reasonable option.
Postoperative care
The PIP joint is splinted in full extension for 4 weeks, and then
finger motion is begun with a wire-foam dynamic extension
splint during the day, and a volar PIP extension splint at night
for 6 weeks.
Outcomes, prognosis, and complications
Outcomes after correction of swan-neck and boutonniere
deformities are variable, and depend largely upon the sever­
ity of the original deformity. The most common complications
are stiffness, recurrence, and pain. It should be emphasized
that boutonniere deformity is in general a less debilitating
deformity than swan-neck deformity, and the surgeon should
be careful not to convert a boutonniere to a swan-neck by
overcorrection.
Fig. 19.64  An incision is made between the central slip and the lateral bands,
allowing the lateral bands to relocate volarly with PIP joint flexion.
A
B
C
Fig. 19.65  When there is an insufficiency of dorsal skin in cases of long-standing
swan-neck deformity, the distal portion of the incision is allowed to gap and heal
secondarily.
Hints and tips
• Swan-neck deformities can be more debilitating than
boutonniere deformities.
• The surgeon should be careful not to overcorrect a
boutonniere deformity, thereby creating a swan-neck
deformity.
Correction of thumb deformities
The most common thumb deformity is a boutonniere defor­
mity (type I thumb deformity), with MCP flexion, IP hyper­
extension, and CMC abduction (Fig. 19.67). Early in the
disease process the joints are passively correctable, and splint­
ing may be adequate treatment. If splinting fails to improve
function, reconstruction of the extensor mechanism can be
performed. A dorsal incision is made over the MCP joint, and
the extensor mechanism is exposed. An incision is made
between the EPB and EPL tendons, and tenosynovectomies of
the attenuated or ruptured EPB tendon and of the volarly
subluxated EPL are performed. A transverse capsulotomy is
made, leaving most of the capsule attached distally to the base
of the proximal phalanx. MCP joint synovectomy is performed.

428
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Fig. 19.66  Correction of boutonniere deformity. Excess central slip
is excised and closed, and the volarly subluxated lateral bands are
mobilized dorsally and sutured to the central slip. Care must be taken
not to create a swan-neck deformity.
A
B
C
Lateral band
Fig. 19.67  Boutonniere deformity of the thumb. Synovitis at the
MCP joint results in attenuation or rupture of the EPB near its
insertion. The EPL is volarly subluxated.
Extensor pollicis brevis
Volarly subluxated
extensor pollicis longus
Abductor pollicis longus
Flexor pollicis longus

429
Treatment/surgical technique
The EPL tendon is divided between the MCP and IP joints,
and is mobilized proximally. This allows the IP joint to move
into flexion. A small transverse incision is made in the distal
aspect of the MCP joint capsule, just distal to the MCP joint.
The MCP joint is then positioned in full extension, and the
proximal EPL tendon is passed through the incision in the
capsule. It is then turned proximally and sutured to itself
under tension. The EPB is advanced and sutured to the base
of the proximal phalanx and to the adjacent EPL tendon. The
MCP joint is pinned in extension for 6 weeks. Motion at the
IP joint is initiated immediately after surgery, but the IP joint
is splinted in extension between exercises to prevent develop­
ment of an extension lag. The MCP K-wire is removed in 6
weeks, splinting is discontinued, and motion is initiated.
In more severe boutonniere deformities, the MCP and IP
joints can become fixed or arthritic. Treatment depends upon
the status of these two joints. If the IP joint is fixed in extension
but the articular surfaces remain intact, joint release with EPL
release is performed. If the IP joint is arthritic, arthrodesis is
performed. The fixed or arthritic MCP joint is treated with
arthrodesis if motion can be preserved at the IP joint. If IP joint
arthrodesis is required, the MCP joint should be treated with
silicone arthroplasty and extensor tendon reconstruction.
Swan-neck deformity (type III thumb deformity) is the
second most common thumb deformity. Dorsoradial CMC
subluxation occurs, and metacarpal adduction contracture
develops, followed by MCP hyperextension and IP flexion
(Fig. 19.68). Early disease is treated with ligament reconstruc­
tion and tendon interposition (LRTI). More advanced disease
is also treated with LRTI, but may also require a webspace
release and adductor pollicis release. After trapezial resection,
a four-flap Z-plasty is designed in the first webspace. The skin
is incised and skin flaps are elevated. If the skin release alone
is not sufficient to allow contracture release, dissection is
carried down to the adductor pollicis and first dorsal interos­
seous. The contracted fascial bands of the adductor pollicis
and first dorsal interosseous are released. If necessary, the
adductor pollicis is released from its origin on the third meta­
Fig. 19.68  Swan-neck deformity of the thumb. Synovitis and
subluxation at the CMC joint results in metacarpal adduction
contracture and compensatory hyperextension at the MCP joint.
Compensation MCP hyperextension
Adduction contracture of metacarpal
carpal. The LRTI is then completed. Significant MCP hyper­
extension is treated with MCP arthrodesis.
Treatment for type II and type V thumb deformities is
individualized, and depends upon the specific deformity at
each joint. Type IV deformity, or gamekeeper’s thumb, is
treated with MCP arthrodesis.
Postoperative care
A thumb spica splint is used to immobilize the thumb for 4–6
weeks postoperatively. After 4–6 weeks, splinting is weaned
and active motion is initiated. Motion is advanced, light activ­
ity is allowed, and gentle strengthening is initiated gradually,
as tolerated.
Outcomes, prognosis, and complications
As with finger deformities, outcomes are related largely to the
severity of the deformity and the degree of arthritis present
before surgery.
Tendon surgery and carpal tunnel syndrome
Carpal tunnel syndrome
Carpal tunnel syndrome is common in RA patients and is
secondary to the mass-effect of proliferative flexor tenosyno­
vitis within the carpal tunnel. Very mild and intermittent
carpal tunnel syndrome can be treated with medical manage­
ment of the RA, splinting, and steroid injections. However,
significant, constant, or progressive symptoms should be
treated surgically. Standard carpal tunnel release is generally
inadequate. An extended carpal tunnel release with flexor
tenosynovectomy is usually required.
A standard carpal tunnel release is performed, and the
carpal canal is examined for the presence of synovitis. If
synovitis is present, the incision is extended distally to the
distal palmar crease in a zig-zag fashion, and proximally
across the wrist crease in a zig-zag fashion, continuing at least

430
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Postoperative care
A volar forearm based wrist splint is applied for 2 weeks.
Finger motion is initiated immediately. Full activity without
restrictions may resume 5 weeks after surgery.
Outcomes, prognosis, and complications
Carpal tunnel release with flexor tenosynovectomy is effective
at relieving carpal tunnel symptoms, particularly in patients
who experience symptoms only intermittently, or who have
had symptoms for a short period of time. Patients who have
constant numbness, particularly if associated with two-point
discrimination changes or thenar atrophy, will have slow or
even incomplete relief of symptoms. Complications will be
more common with carpal tunnel release in this population,
due to the presence of adhesions and synovitis within the
carpal canal.
Secondary procedures
Recurrence of carpal tunnel symptoms is minimized by effec­
tive medical control of the RA. However, if tenosynovitis
recurs and leads to recurrent carpal tunnel symptoms, repeat
carpal tunnel release and tenosynovectomy is indicated in
order to relieve pressure on the median nerve. Secondary
surgery is tedious, and great care must be taken to avoid
injury to the median nerve. The incision and initial dissection
should begin a few centimeters proximal to the original inci­
sion, so that the median nerve can be identified in a tissue
plane that has not been previously operated on. Dissection is
then carried distally, protecting the median nerve while
completing the flexor tenosynovectomy through the distal
forearm and carpal tunnel.
5 cm proximally in the forearm. Care is taken to keep the
incision ulnar to the palmar cutaneous branch of the median
nerve. Distal to the transverse carpal ligament, dissection is
performed with tenotomy scissors, elevating skin flaps, while
preserving the superficial palmar arch and the branches of the
median nerve. Proximally, scissors are used to dissect down
to the antebrachial fascia which is divided longitudinally,
ulnar to the palmaris longus, exposing the full extent of the
tenosynovitis (Fig. 19.69). Next the median nerve is identified
proximally, where there is less synovitis, and a vessel loop is
passed around it. Next, flexor tenosynovectomies are per­
formed, beginning with the FDS tendons and progressing to
the FPL and FDP tendons (Fig. 19.70). Each tendon should be
addressed individually, working sequentially, and removing
all hypertrophic synovium (Fig. 19.71). The fingers should be
flexed by retracting on the flexor tendons, one by one, to
ensure that excursion is not limited. The median nerve is
examined. Hypertrophic synovium is carefully removed from
the nerve with tenotomy scissors, preserving the deep motor
branch distally, and the palmar cutaneous branch proximally.
Finally, the floor of the carpal tunnel is examined. Sharp bony
erosions or osteophytes should be removed using a rongeur,
and soft tissue or capsule sutured over the smoothed area. The
skin is closed with horizontal mattress sutures.
Fig. 19.69  Carpal tunnel release in patients with rheumatoid arthritis usually
requires an extensive flexor tenosynovectomy using an extensile exposure.
Fig. 19.70  Tenosynovectomy is performed one tendon at a time, while protecting
the median nerve.
Fig. 19.71  The carpal tunnel is decompressed after tenosynovectomy.
Hints and tips
• Carpal tunnel syndrome may be the initial presenting
complaint in RA.
• RA patients typically require an extensile incision, with flexor
tenosynovectomy.
• A standard or limited-incision carpal tunnel release is
generally not indicated, and will not treat the underlying
pathology.

431
Treatment/surgical technique
Flexor tendon ruptures
Flexor tendon ruptures present with an acute loss of finger
flexion. However, in a rheumatoid patient with limited motion
due to flexor tenosynovitis or joint destruction, a flexor tendon
rupture may go unnoticed. A difference between the active
and passive finger ROM is suggestive of rupture, but can also
be due to flexor tenosynovitis or a rheumatoid trigger finger.
Fig. 19.72  Mannerfelt lesion. The osteophyte on the volar aspect of the scaphoid is identified and removed. Next, a flap of volar capsule is elevated and rotated to cover
the rough bony surface.
A
B
C
D
Scaphoid
Flexor pollicis longus
Sharp bony surface
Capsular flap
Sharp bone debrided
Lunate
Capitate
FPL rupture is common, and is due to a sharp bony edge
on the volar aspect of the scaphoid (Mannerfelt lesion). The
incision for flexor tenolysis is made as described above.
Flexor tenolysis is performed. The osteophyte is removed
with a rongeur, and the capsule closed over the area to
provide a smooth gliding surface (Fig. 19.72). If both ends
of the ruptured tendon can be identified within the wrist
and palm incision, a small bridge graft of palmaris longus

432
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Postoperative care
If tendon transfers are performed, the hand and fingers are
immobilized in such a way as to take tension off of the transfer.
The transfer is immobilized for 3–4 weeks, after which motion
and retraining are begun under the guidance of a therapist. It
should be noted that there is an increasing interest in early
movement protocols following tendon transfer surgery, and
this may result in improved outcomes or earlier recovery.
Outcomes, prognosis, and complications
Patients have the potential to maintain good finger function
after isolated rupture of the FDS or FDP, if their pre-rupture
finger function was good and if they receive appropriate treat­
ment in a timely fashion. However, if pre-rupture finger
function was limited, outcomes will be poor even if the
rupture is treated appropriately. Outcomes after rupture of
both the FDS and FDP are poor, regardless of pre-rupture
finger function or the method of treatment.
Trigger fingers
Triggering can occur due to the presence of rheumatoid
nodules or because of hypertrophic synovium. A very small
nodule or synovitis can significantly affect tendon excursion
and finger function. Furthermore, the location of the pathol­
ogy is variable. Although the source of triggering can often be
located preoperatively, the surgeon should plan for the pos­
sibility of an extensile incision.
The operation is performed under sedation and with local
anesthetic, so that the patient can actively flex the finger after
tenosynovectomy. A Bruner incision is made over the finger.
Initially, the incision is limited to the suspected area of pathol­
ogy, and can be extended later if necessary. Skin flaps are
elevated and the flexor tendon sheath is exposed, preserving
the neurovascular bundles. A window is made within the
flexor tendon sheath at the level of the cruciate pulley, or at
the A1 or A3 pulley nearest the pathology. The flexor tendons
are retracted out of the flexor tendon sheath individually
through the window using a Ragnell retractor. Synovium is
removed from the flexor tendons using tenotomy scissors or
a synovial rongeur, taking care to preserve the vincula (Figs.
19.73 & 19.74). If a rheumatoid nodule is encountered, it is
excised. If pathology is more extensive, more windows are
created within the sheath at the cruciate, A1 or A3 pulleys,
allowing full access to the tendons. Rarely, it is necessary to
excise the FDS tendon in order to allow FDP excursion. Com­
plete release of the A1 pulley is avoided to lessen the chance
of abnormal pull of the flexor tendon that would contribute
to ulnar deviation. The patient is awakened and asked to
actively flex the finger. If active motion is less than passive
motion, or if triggering has not resolved, the surgeon must
search for further pathology.
Postoperative care
A light dressing is placed and active and passive motion is
begun immediately postoperatively, including tendon gliding
exercises.
Outcomes, prognosis, and complications
A good outcome is dependent upon identification and treat­
ment of the cause of the triggering. In order to prevent
or a strip of the FCR is used. It is weaved proximally and
distally into the FPL using a Pulvertaft weave and 3-0 hori­
zontal mattress sutures to secure the weave. It is important
to resect frayed and damaged tendon edges, and graft into
healthy tendon. If grafting within the palm is not possible,
tendon transfer is required. A Bruner incision is made on the
long finger over the proximal phalanx. The FDS is divided
1.5 cm proximal to its insertion and retracted into the palmar
wound. Another Bruner incision is made over the thumb IP
joint. Dissection is carried down to the flexor tendon sheath,
and the FPL insertion. The sheath is opened near the FPL
insertion, and the FPL is retracted and delivered into the
distal thumb incision. The FPL is divided transversely with
scissors, leaving a 1-cm stump attached to the insertion.
The FPL stump is then divided longitudinally in its midline
along its entire remaining 1 cm length, along its insertion.
A small amount of elevation of the central portion of the
insertion is performed, but care is taken to keep most of the
insertion intact. The volar aspect of the base of the distal
phalanx is roughened with a small rongeur to provide a
surface for tendon healing. The FDS is delivered through the
fibro-osseous canal of the thumb using a pediatric feeding
tube. Two suture anchors with 3-0 Ethibond are placed in the
base of the distal phalanx, between the split halves of the FPL
stump. The FDS is then laid down between the split halves
of the FPL and secured to the bone by tying it down to the
suture anchors. Next, the two halves of the FPL stump are
brought around and volar to the FDS tendon, and sutured to
the FDS tendon with horizontal mattress sutures, reinforcing
the insertion. Tension should be set so that IP extension occurs
with wrist flexion, and full flexion into the palm occurs with
wrist extension.
An isolated FDS rupture does not necessarily result in
significant functional loss. An end-to-side suture to an adja­
cent FDS is performed if the rupture occurs within the palm
or carpal tunnel, using a Pulvertaft weave. Flexor tenosyno­
vectomy and treatment of any sharp bone edges should be
performed. If the FDS rupture occurs within the finger, a
tenosynovectomy with resection of the FDS should be
performed.
FDP rupture may also not result in severe functional loss,
if isolated. Flexor tenolysis, and treatment of any sharp bony
edges should be performed. If the rupture occurs within
the palm or wrist, an end-to-side suture to an adjacent
FDP is performed. If FDP rupture occurs within the finger
and the FDS is functional, the FDP is resected. If the DIP
joint hyperextends during pinch or grip, DIP arthrodesis is
performed.
Rupture of both the FDS and FDP results in significant
functional loss. If the ruptures are within the palm or carpal
tunnel, end-to-side suturing of the FDP to an adjacent tendon
is performed. Alternatively, a bridge graft can be used as
described above for the FPL, with the FDS serving as a
donor graft. If both tendons have ruptured within the flexor
tendon sheath, a staged reconstruction can be considered.
However, the outcome of staged flexor tendon reconstruc­
tion in patients with RA is often disappointing, and patients
should be counseled that recovery of motion will be limited.
In patients with arthritis of the IP joints, the best option is
arthrodesis of the PIP and DIP joints in a functional posi­
tion, with preservation of some finger motion at the MCP via
the intrinsics.

433
Treatment/surgical technique
of healthy tendon. The cause of the rupture should be sought,
and is usually related to a sharp edge of bone. Care should be
taken to smooth down all bony surfaces. In many cases a
Darrach procedure is indicated, and can be performed at this
time as described above. Next, a retinacular strip is transferred
volar to the extensor tendons to cover any remaining exposed
areas of bone. Next, the tendon reconstruction is performed.
Rarely, the tendon ends can be repaired primarily. In most
cases, there is a substantial zone of injury that precludes direct
repair.
The reconstruction depends upon the number of tendons
ruptured. If the tendon(s) to a single finger is (are) ruptured,
the distal stump(s) should be sutured to an adjacent tendon
using an end-to-side Pulvertaft weave (Figs. 19.75 & 19.76).
Alternatively, the extensor indicis proprius (EIP) can be trans­
ferred in an end-to-end fashion to the ruptured tendon (Fig.
19.77). For the EIP transfer, a longitudinal incision is made
over the index MCP joint, extending distally to the middle of
the proximal phalanx. Skin flaps are elevated, exposing the
extensor mechanism. The interval between the ulnarly located
EIP and the radially located extensor digitorum communis
(EDC) is identified and incised longitudinally, separating the
two tendons. The sagittal band is carefully elevated off the
EIP with a 15-blade, for later repair. The EIP is divided as far
distally as possible, and retracted into the dorsal wrist inci­
sion. The distal stump of the EIP is sutured to the adjacent
EDC, the sagittal band is repaired and the skin is closed. The
EIP is then Pulvertaft weaved into the EDC and extensor digiti
quinti (EDQ) of the small finger. It is important to tension the
transfer correctly, creating a natural cascade of the fingers. The
wrist is passively flexed and extended, checking the tenodesis
effect. With the wrist flexed, the MCP joint should easily come
the complication of persistent postoperative triggering, the
surgeon must make sure that he or she has located and
addressed all potential sources of triggering by having the
patient actively range the finger prior to incision closure.
Extensor tendon ruptures
Extensor tendon ruptures most commonly occur at the wrist
(Video 19.1
). They are due to a combination of erosive
tenosynovitis and attritional wear over a sharp spicule of
bone at the ulnar side of the wrist, often arising from the ulnar
head or DRUJ. Rupture of the EPL is common as well. In
addition to treating the rupture, it is critical to address the
underlying cause in order to prevent subsequent ruptures.
A dorsal wrist incision is made, skin flaps are elevated, and
the retinaculum is incised as described above. A dorsal teno­
synovectomy is performed as described above. The ruptured
tendon is identified, and soft friable ends are resected with
tenotomy scissors until the proximal and distal stumps consist
Fig. 19.73  Proliferative synovitis can be seen protruding through rents in the flexor
tendon sheath.
Fig. 19.74  A large piece of synovitis is being removed through a small opening in
the flexor tendon sheath just distal to the A2 pulley.
Fig. 19.75  The small finger extensors (EDC and EDQ) have ruptured at the level of
the wrist, and their distal ends can be seen just distal to the extensor retinaculum.

434
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
incision. The transfer is completed and tensioned as described
above.
into full extension or slight hyperextension. With the wrist
extended, it should be possible to passively flex the MCP joint.
It is preferable to slightly over-tighten the transfer, as there
will be some loosening with time.
If both the small and ring finger extensor tendons are
ruptured, the ring finger EDC is transferred to the long finger
EDC in an end-to-side fashion. The small finger extensors,
however, will not reach the long finger EDC, and end-to-side
transfer usually cannot be performed. Therefore, the EIP
tendon is transferred end-to-end to the small finger extensors
(Fig. 19.78). The EIP is transferred to both the EDC and EDQ
of the small finger, using a Pulvertaft weave. Again, setting
tension properly is critical. The natural cascade of the fingers
and the tenodesis effect are used as a guide to set the tension.
If three or four of the extensor tendons are ruptured, an
FDS transfer is often performed. With three ruptures, the long
finger EDC is sutured to the adjacent intact index EDC, and
the ring FDS or EIP is used to restore extension of the small
and ring fingers (Fig. 19.79). With four ruptures, two FDS
transfers are required. The long FDS is used to restore index
and long finger extension, and the ring FDS is used to restore
ring and small finger extension (Fig. 19.80). For FDS harvest,
a Bruner incision is made over the proximal phalanx of the
appropriate finger. Skin flaps are elevated, and the flexor
tendon sheath exposed. A small opening is made in the flexor
tendon sheath, and the FDS is divided 1.5 cm proximal to its
insertion. A longitudinal volar incision is made in the distal
forearm proximal to the wrist flexion crease, and ulnar to the
palmaris longus. Dissection is carried down to the FDS
tendons, and the divided FDS is retracted into the wrist inci­
sion. The FDS is passed around the radial subcutaneous
border of the wrist and delivered into the dorsal wrist
Fig. 19.76  The small finger extensors (EDC and EDQ) have been transferred
end-to-side to the ring finger EDC.
Fig. 19.77  Rupture of the EDC and EDQ to the small finger. The EIP is transferred
to the small finger extensors.
Extensor
digitorum
communis
Extensor indicis
proprius
One finger
Clinical tip
• The FDS tendons may be routed through an opening in the
interosseous membrane for a straighter line of pull.
• It is critical to make a wide interosseous tunnel, both in
transverse and in longitudinal dimensions so that the FDS
tendons have a straight line of pull, and do not become
entrapped.
EPL rupture is not always symptomatic, and may not require
treatment. IP extension is usually preserved through the
intrinsics, and MCP extension may or may not be lost. If MCP
extension is lost and thumb function is affected, the EPL
rupture is treated with an EIP to EPL transfer. The EIP is
harvested as described above, and is retracted into the wrist
incision. It is then passed distally to the dorsal aspect of the
thumb, and transferred to the EPL with a Pulvertaft weave at
the level of the metacarpal. It should be tensioned so that the
MCP joint fully extends with the wrist flexed. With the wrist
extended, it should be possible to passively flex the MCP joint.

435
Treatment/surgical technique
Other rheumatologic disorders of the hand
and wrist
Seronegative spondyloarthropathies
Seronegative spondyloarthropathies include Reiter’s syn­
drome, psoriatic arthritis, ankylosing spondylitis, and inflam­
matory bowel disease-associated arthritis. The most common
seronegative spondyloarthropathy to affect the hands is pso­
riatic arthritis. Patients are usually RF negative, have an
inflammatory arthritis, and have psoriasis (Table 19.1). Psoria­
sis affects 2% of the population and onset usually occurs in
the 2nd decade of life.61 Among patients with psoriasis, the
prevalence of psoriatic arthritis is unknown, but ranges from
approximately 5% to 40%.
Radiographic findings are diverse, and may include ero­
sions and resorption, osteolysis, periostitis, ankylosis (often at
the PIP joint), or juxta-articular bone formation. Radiographs
may reveal a “pencil-in-cup” deformity at the DIP joint, which
is the result of new marginal bone formation at the base of the
distal phalanx, combined with osteolysis of the head of the
middle phalanx.
Joint involvement can be symmetric or asymmetric, and
may be oligoarticular or polyarticular. The small joints of the
hands and feet are most commonly affected, and DIP involve­
ment is often a prominent feature of psoriatic arthritis.
Although tenosynovitis and tendon ruptures are rare, inflam­
mation at tendon insertions may occur. Another occasional
finding is dactylitis, which involves swelling and inflamma­
tion of an entire digit. The nails also develop abnormalities.
Pitting is the classic finding, although onycholysis, nail dys­
trophy, leukonychia, and hyperkeratosis can occur as well.
The most common finger deformity is a PIP flexion contrac­
ture, with compensatory MCP hyperextension. This is not a
true boutonniere deformity. Swan-neck deformities can occur
secondary to a mallet finger. In the thumb, a boutonniere
deformity can occur, and the CMC joint can become arthritic
as well. Wrist arthritis and DRUJ arthritis can occur as well.
Rarely, severe osteolysis, or arthritis mutilans, results in col­
lapse of the fingers known as the “opera glass hand”.
Swan-neck deformity is treated in a similar fashion to
swan-neck deformity associated with RA. Severe fixed PIP
flexion contractures are treated with arthrodesis. MCP exten­
sion contractures with associated joint destruction are treated
with silicone arthroplasty. Arthritis mutilans is treated with
arthrodesis, often requiring bone graft. Wrist involvement is
Postoperative care
For finger extensor tendon transfers, the wrist and MCP joints
are splinted in extension for 4 weeks. Active motion and
retraining is begun under the supervision of a hand therapist
after 4 weeks. Gentle passive flexion can be started at 6 weeks,
and strengthening at 8 weeks. Full activity and discontinua­
tion of extension splinting occurs at 12 weeks. The thumb is
protected in a thumb spica splint with the MCP and IP joints
extended for 4 weeks, after which motion is initiated.
Outcomes, prognosis, and complications
Restoration of MCP extension can be reliably achieved with
tendon transfers in patients who have preserved MCP joints.
In patients with volarly subluxed and arthritic MCP joints, it
is preferable to restore joint alignment and passive mobility
by arthroplasty and soft-tissue reconstruction prior to per­
forming tendon transfers. Any attempt to restore extension
without first addressing MCP deformity or arthritis will result
in suboptimal outcomes. Recurrent rupture can occur, and is
minimized by correcting the underlying causes, including
extensor tenosynovitis, rough bony surfaces, and the caput
ulna.
Fig. 19.78  Rupture of the small and ring finger extensors. The ring finger EDC is
transferred end-to-side to the long finger EDC. The EIP is transferred end-to-end to
the small finger extensors.
Extensor
digitorum
communis
Extensor digitorum communis
Two fingers
Extensor
digitorum
quinti
Extensor indicis
proprius
Hints and tips
• Once an extensor tendon rupture occurs, subsequent
ruptures can occur in rapid sequence.
• Although not an emergency, there is some urgency to
treating the underlying cause.
• The surgeon should be careful to treat the underlying cause
of the rupture when performing tendon transfers for
extensor tendon rupture.
• The surgeon should have a low threshold for performing a
distal ulna resection if there is concern that distal ulna or
DRUJ pathology caused the ruptures.

Fig. 19.79  Rupture of the long, ring, and small finger extensors. The EDC of the long finger is transferred end-to-side to the EDC of the index finger. The EIP (A) or the
FDS (B) can be transferred to the small and ring finger extensors.
A
B
Extensor digitorum
communis/quinti
Extensor digitorum
communis
Extensor digitorum communis
Radial nerve
Three fingers
Extensor indicis
proprius
Flexor digitorum
superficialis
Table 19.1  Characteristics of other rheumatologic conditions of the hand
Serology
Radiographs
Examination
Psoriatic arthritis
Negative
Erosions
Resorption
Osteolysis
Periostitis
Ankylosis (PIP)
Juxta-articular bone formation
Pencil-in-cup (DIP)
Psoriasis
Nail abnormalities
Dactylitis
PIP flexion contracture
Opera glass hand swan-neck deformity
SLE
ANA
Anti-DNA
Antiphospholipid antibody
Leucopenia
Hemolytic anemia
Thrombocytopenia
Preservation of joints
Secondary OA
Deformity similar to that seen in RA
Malar rash
Discoid rash
Serositis
Other
Scleroderma
ANA
Anti-centromere
Anti-topoisomerase I
Anti-RNA polymerase
Tuft resorption
Secondary OA
Cutaneous telangiectasia
Raynaud’s
Cutaneous sclerosis Ischemic ulceration
Joint contracture due to skin contracture
Gout
Hyperuricemia
Negatively birefringent crystals
(synovial analysis)
Sclerotic joint margins
Overhanging edges
Erosion from tophi (late)
Joint destruction (late)
Red, hot, swollen joint
MTP of great toe involvement
Tophi
Pseudogout
(CPPD)
Negative
Chondrocalcinosis of TFCC
Scapholunate widening
Scapholunate advanced
collapse pattern arthritis
Presentation may be similar to osteoarthritis
May be chronic inflammatory arthritis (mono-, oligo-,
or polyarticular)
May present as acute pseudogout attack (red, hot,
swollen joint)

437
Treatment/surgical technique
anemia, thrombocytopenia, and many others. Seropositivity
for antinuclear antibody (ANA) is very sensitive (95%),
although there are cases of ANA-negative lupus. However,
specificity is low and ANA may be positive in multiple rheu­
matologic diseases. Other supportive laboratory findings
include anti-DNA, anti-Sm nuclear antigen, and antiphospho­
lipid antibodies.
The IP joints, MCP joints, and wrist are commonly involved,
and may be the initial presenting symptoms of the disease.
Patients experience swelling, pain, effusion and morning stiff­
ness. The arthritis associated with SLE is not erosive, and may
not be deforming. If finger deformities do occur, they are very
similar to those seen in rheumatoid arthritis. Volar subluxation
and ulnar deviation occurs at the MCP joints, and swan-neck
or boutonniere deformities may occur, but with an absence of
destructive joint changes. In addition, tenosynovitis may
occur, and may result in tendon ruptures. Synovitis within the
carpal tunnel may lead to carpal tunnel syndrome. In addi­
tion, patients may develop subcutaneous nodules along the
flexor tendons, histologically similar to those that develop in
rheumatoid arthritis.
In many cases, the finger and wrist deformities that occur
with SLE are passively correctable. In these cases splinting can
be quite helpful. Intrinsic stretching can also be helpful to
decrease MCP flexion and ulnar deviation. Because of poor
soft-tissue quality, soft-tissue procedures alone are rarely
successful, and the mainstays of surgery in the fingers are
arthrodesis and arthroplasty, which can be combined with
soft-tissue procedures. Partial wrist arthrodesis or total wrist
arthrodesis may be beneficial, depending upon the deformity
and instability pattern. The Darrach procedure is often indi­
cated for dorsal subluxation of the ulna, which can often
cause attrition ruptures. Because of the many organ systems
involved, patients must have a thorough medical workup and
preoperative clearance.
Scleroderma
Scleroderma, or systemic sclerosis (see Table 19.1), is a disease
of the connective tissue and small blood vessels that affects
multiple tissues. It is rarer than either rheumatoid arthritis or
SLE, with a prevalence of <300 per 1 million in the United
States. Like most rheumatologic disorders it is more common
in women than men, and onset typically occurs in the 3rd or
4th decade of life. The disease is idiopathic, but there is a
genetic component and an environmental trigger is likely
required to initiate the disease. Systemic sclerosis can present
as limited cutaneous disease (often involving the fingers or
hands), diffuse cutaneous disease, or CREST syndrome (cal­
cinosis, Raynaud’s phenomenon, esophageal involvement,
sclerodactyly, and telangiectasias). Systemic sclerosis can
affect the lungs, resulting in interstitial disease and pulmonary
fibrosis. Cardiac, vascular, renal, gastrointestinal and other
organ systems are also commonly involved. The diagnosis is
clinical, and is supported by antibody testing. Nail fold capil­
lary microscopy is also helpful. ANA, anti-centromere, anti-
topoisomerase I, anti-RNA polymerase antibodies are all
associated with systemic sclerosis.
Raynaud’s phenomenon affects almost all patients, and is
present in limited cutaneous, diffuse cutaneous, and CREST
forms of the disease. Critical ischemia, however, occurs due
to vascular disease related to the systemic sclerosis, and is not
Fig. 19.80  Rupture of the extensor tendons to all four fingers. The long finger FDS
is transferred to the index and long finger extensors, and the ring finger FDS is
transferred to the ring and small finger extensors.
Extensor digitorum
communis
Extensor
digitorum
communis
Flexor digitorum
superficialis
(ring)
Flexor digitorum
superficialis
(long)
Radial nerve
Four fingers
treated with limited intercarpal fusions or complete wrist
arthrodesis, depending upon the pattern of joint involvement.
A Darrach procedure may be indicated for DRUJ arthritis.
Systemic lupus erythematosus
Systemic lupus erythematosus (SLE) is a systemic autoimmune
disease (see Table 19.1), in which tissue damage is caused by
autoantibodies and immune complexes. It affects five in 10 000
people in the United States, and women are affected much
more frequently than men (9 : 1). African Americans and
Latinos are affected more often than Caucasians, and tend to
have a more severe disease process. Susceptibility is related
to multiple genes. Many potential environmental triggers
have been implicated, including Epstein–Barr virus (EBV)
infection, multiple medications, dietary factors and bacteria.
The diagnosis of SLE is primarily clinical, and is supported
by positive laboratory findings. Extra-articular manifestations
are diverse and may include malar rash, discoid rash, photo­
sensitivity, cardiovascular disease, oral ulcers, arthritis, sero­
sitis, proteinuria, seizures, psychosis, leukopenia, hemolytic

438
SECTION III
CHAPTER 19 • Rheumatologic conditions of the hand and wrist
Crystalline arthropathy (gout)
Gout is characterized by recurrent bouts of acute arthritis,
eventually progressing to chronic arthritis (see Table 19.1). It
affects approximately 1% of the population, and is more
common in men. Risk factors include obesity, alcohol use,
hypertension, renal disease, and certain medications. Triggers
for an acute gout attack include physiologic stress, fever,
surgery, dehydration, and alcohol use. In addition, foods that
are high in purine increase the risk of a gout attack, including
oatmeal, mushrooms, lentils and spinach.
Initially gout attacks are monoarticular, and involvement
of the MTP joint of the great toe is classic. The joint becomes
swollen, red, and exquisitely painful. Initially radiographs
may be negative. The acute attack may last from hours to
many days. As gout progresses, it can become polyarticular,
and systemic symptoms such as fever, chills, or sweats may
be present. Hand and wrist involvement is common. Eventu­
ally chronic arthritis and tophi develop, with continued epi­
sodic acute attacks. In chronic gout radiographic findings
include erosions with sclerotic margins, and overhanging
edges of bone (Fig. 19.81). Definitive diagnosis is made by
arthrocentesis and identification of crystals with negative
birefringence under polarized light microscopy. For an acute
attack, colchicine, indomethacin, or corticosteroids are often
used. An intra-articular steroid injection is quite effective.
Prophylaxis is provided by daily low-dose colchicine or
indomethacin. In addition, xanthine oxidase inhibitors such
as allopurinol, or uricosuric agents such as probenecid can be
used to reduce serum uric acid levels. Chronic gouty arthritis
is treated with selective arthrodesis of joints that are painful,
or that have deformity that is affecting function. Large painful
tophi, or tophi that are interfering with function can be
excised.
due to Raynaud’s phenomenon. Occlusive vascular changes
affect the medium-sized vessels, and the ulnar artery in par­
ticular. Ischemic ulceration may occur in the fingertips, on the
extensor surface over flexed joints, and in areas of calcinosis.
Ischemia-related resorption of the tufts can occur, and is
termed acro-osteolysis. Cutaneous telangiectasia may be seen
on the palm. Treatment of the vascular manifestations of the
disease is outside the scope of this chapter.
Finger deformities are related to skin contracture, and to
fibrosis and contracture of joint ligaments and capsule. Arthri­
tis and joint destruction do not occur directly. If joint changes
or arthritis are seen, they are usually osteoarthritic changes
that occur secondary to prolonged deformity and abnormal
motion. The most common deformity in the hand is PIP
flexion contracture. These contractures can be severe, and
dorsal skin ulceration can occur with tendon or joint exposure.
MCP hyperextension occurs secondarily, and can become
fixed as well. In addition, the first webspace contracture is
common. Soft-tissue loss over joints should be treated conser­
vatively, with Silvadene dressing changes and minimal
debridement. Ultimately, bony debridement or amputation
may be required. At times, skin breakdown occurs over an
area of calcinosis. Removal with a curette and irrigation with
saline is performed. For severe PIP contractures with intact
overlying skin, arthrodesis may be indicated. Care should be
taken when managing the skin, and minimal skin flap eleva­
tion should be performed. In addition, significant bony resec­
tion should be performed, in order to take tension off the
overlying skin. A compression screw or removable K-wires
should be used in order to avoid subcutaneous hardware.
Dressings should be light, and noncompressive. Patients
should be cautioned about the possibility of wound healing
problems, potentially resulting in the need for amputation. At
the MCP joint resection arthroplasty is indicated for severe
fixed extension contracture. A volar longitudinal incision is
made directly over the metacarpal head. Dissection is carried
down to the flexor tendon sheath, retracting the neurovascular
bundles radially and ulnarly. The A1 pulley is incised, and the
flexor tendons retracted. A 15-blade is used to create a volar
arthrotomy through the volar plate and joint capsule. Subperi­
osteal dissection is then performed, exposing the head and
neck of the metacarpal. A sagittal saw is then used to resect
the metacarpal head. Bony resection is performed until MCP
flexion is possible. The skin is closed and the patient is splinted
with the MCPs flexed. Motion is allowed as soon as skin
healing has occurred. First webspace contracture is difficult
to treat. Because of the stiff nature of the skin, Z-plasties are
rarely successful, and the contracture must be treated more
like a severe burn contracture. A long transverse incision is
made in the first webspace. Dissection is carried down to the
adductor pollicis and first dorsal interosseous. Tight fascial
bands are released with tenotomy scissors until the thumb can
be abducted. If thumb CMC arthritis or CMC subluxation
contributes to the adduction deformity, trapeziectomy can be
performed through a separate incision. A full-thickness skin
graft is used to close the defect, and should be harvested from
an area with minimal skin involvement.
Postoperative care
The thumb should be pinned in abduction for 6 weeks, fol­
lowed by motion and intermittent splinting.
Fig. 19.81  PA radiograph of the hand demonstrating large gouty tophi of the PIP
joints, and overhanging erosions.