FRCS Case Studies

Rheumatoid Hands

Candidate:

This is a clinical photo of the dorsal aspect of the hands showing a symmetrical, deforming, polyarthropathy consistent with rheumatoid arthritis. Notable features include bilateral Z-shaped thumbs, swan-necking of the right middle finger, and marked ulnar deviation of all fingers at the MCP joints.

Candidate:

The Eaton and Littler system can be used to stage this condition. Stage I is characterized by joint space widening with normal articular contours. Stage II involves up to one-third subluxation, with osteophytes less than 2 mm, and a normal scapho-trapezio-trapezoidal (STT) joint. In Stage III, we see marked narrowing of the joint space, more than one-third subluxation, and osteophytes greater than 2 mm. Finally, Stage IV is indicative of pan-trapezial arthritis.

Candidate:

Subluxation in this condition is due to degenerative attenuation and rupture of the palmar oblique ligament, also known as the ‘beak’ ligament. This strong ligament extends from the trapezium to the base of the first metacarpal, and its disruption results in dorsal subluxation of the first metacarpal.

Candidate:

Dorsal subluxation of the CMC joint leads to metacarpal adduction, a thumb in the palm deformity, and reduction in thumb span. This subsequently results in a secondary compensatory hyperextension at the MCP joint in an effort to increase the thumb span.

Candidate:

Non-operative management options include oral analgesia, activity modification, splints, physiotherapy, and intra-articular steroid injection. For operative options, we could consider excision of the trapezium, implant arthroplasty, CMC arthrodesis, or a first metacarpal-basal osteotomy. However, each option has its pros and cons and should be considered in the context of the patient’s overall health, lifestyle, and disease stage.

Candidate:

In this case, I would consider offering the patient excision of the trapezium and fusion of the MCP joint under general anesthetic or regional block. This could be performed as a day-case procedure.

Candidate:

Trapezium excision generally results in good pain relief and improved function. However, a potential downside is the slight shortening of the thumb which can lead to reduced power of pinch. Risks specific to the procedure include a painful scar, infection, nerve damage, specifically to the superficial branch of the radial nerve, blood vessel damage, particularly to the radial artery, incomplete relief of symptoms, especially if adjacent joints affected by osteoarthritis, a Relatively slow recovery of function and attainment of maximal pain relief, and instability of the carpus.

FRCS Case Studies

Curriculum

Rheumatoid Hands

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