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This picture of the hands shows the typical features of rheumatoid arthritis with subluxation of the metacarpophalangeal (MCP) joints, radial deviation of the wrist joint and ulnar deviation of the fingers.

The hand more than any other part of the body is affected by this systemic inflammatory disease process.  In the early stages of the disease, synovitis of the MCP and proximal interphalangeal (PIP) joints is often the main manifestation.  Both hands are affected usually in a more or less symmetrical pattern.  The tendon sheaths may also be inflamed.  This early stage often progresses to joint and tendon erosions which prepare the ground for later mechanical derangement. Finally, joint instability and tendon rupture results in progressive deformity and functional loss.  Clinically, this pathological continuum has been artificially divided into three stages.  In Stage 1 disease joint pain, stiffness and swelling are the common clinical features.  This may be associated with the development of a carpal tunnel syndrome.  Examination shows swelling of the MCP and PIP joints.  Joint tenderness and tendon sheath crepitus may be apparent.  In Stage 2 disease radial deviation of the wrist and ulnar deviation of the fingers starts to develop.  Swan neck and boutonniere deformity of the fingers may be seen.  Deformity is progressive and usually increasingly difficult to correct. Mallet fingers are a recognised complication.  Stage 3 disease is characterised by established deformities.  The carpus has a radial tilt with volar subluxation. There is often a severe functional loss.  Radiological changes usually parallel this clinical progression.  In Stage 1 disease soft tissue swelling and periarticular osteoporosis are often seen.  In Stage 2 disease joint narrowing and periarticular erosions, particularly of the MCP joints and ulna styloid are identified.  In Stage 3 disease severe articular disruption throughout the carpus is often apparent.

Management of the rheumatoid hand is often difficult.  In early disease, treatment is aimed at controlling systemic disease and local synovitis.  Mechanical splints to rest the joints may be useful.  Steroid and local anaesthetic injections may also be beneficial.  Flexor tendonitis may require a synovectomy.  One of the main aims of early treatment is to prevent the development of deformity.  This requires a multidisciplinary approach with physiotherapy often being useful.  Occasionally soft tissue reconstruction and tendon transfers for tendon ruptures are required.  In late disease, surgery aimed at the soft tissues is often inadequate.  Joint replacement surgery with silastic spacers has been shown to be of benefit.  Arthrodesis may be required to reduce joint pain, improve carpal stability and improve hand function.

Recent papers

O'Brien B T.  Surgical principles and planning for the rheumatoid hand and wrist.  Clin Plast Surg 1996;  23:  407-420.

Stanley J K.  Soft tissue surgery in rheumatoid arthritis of the hand.  Clin Orthop 1999;  Sep:  78-90.

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