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Flashcards in Rheumatoid arthritis Deck (34)
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1

What is rheumatoid arthritis

  • Deformity of joint and periarticular tissue secondary to autoimmune disease causing synovitis. 
  • Charcaterized by
    • pannus formation
    • synovitis (hypertrophy of vili, edema of joint)
    • T cell infiltration into synovium
  • Cellular and humoral activity
  • onset 35-65yo, F>M
  • thought do be environmentla stimulus in genetically susceptible individual (having HLA-DR4 antigen + smoking/parvo/EBV,rubella viral infx)

2

What cytokines are active in RA and targets for DMARDs

IL-1,6, TNFalpha

3

What is the diagnostic criteria for RA

Score >6/10 in pt with joint synovitis and no clear other explanation

Socring based on 

  • Joint involvement (more pts for more/smaller jts)
  • Serology (RF, ACPA)
  • Acute phase reactants (ESR, CRP)
  • Duration of symptoms (>6wks)

4

What is your management work-up for pt with RA

Hx

  • symptoms progression
  • joint involved, function
  • previous Tx (medical, splints)

PE

  • examine neck, all UE
  • Joint: effusions, deformities, crepitus, stiffness, stability
  • Skin: nodules
  • tendon: AROM/PROM, rupture, triggering, subluxation
  • Nerve: compression testing
  • Cosmesis: deformity
  • Objectiv etetsing: goniometer, grip and pinch strength

Investigation

  • B/W: ESR/CRP, RF, ACPA
  • synovial fluid: WBC 500-25 000
  • Xray

5

What are findings on xray suggestive of RA

 

EARLY

  • JOINT SPACE WIDENING (EFFUSION)
  • osteopenia

LATE

  • Joint space narrow (articular loss)
  • Irregular cortical erosions (rat-bite)
  • subluxation (ligamentous laxity)

6

How do you classify RA

  • By mode of onset
    • Systemic (fever, HSM, rash, no jt involved)
    • Pauciarticular (usually knee)
    • Polyarticular  (synovitis of more than 4jts)
  • By Nalebuff 
    • stage 1 - tenosynovitis/synovitis <6mths
      • Tx: non surgical
    • stage 2- tenosynovitis >6mths
      • Tx: tenosynovectomy
    • stage 3 - rheumatoid specific hand defority
      • Tx: reconstructive sx
    • stage 4- crippled hand
      • Tx: salvage surgery
  • By course of disease
    • Remitting
      • Male, acute asymmetric jt, no nodules, neg RF/ANA, no HLA marker, no bone/cartilage erosion
    • Unremitting
      • female >40, gradual symmetric jts, nodules, +R/ANA, + HLA, joint destruction

7

What are goals and principles of treatment for RA

GOALS

  • Pain control
  • Funciton improvement
  • Control local disease
  • Cosmesis

 

PRINCIPLES

  • Non-operative Tx first - multidisciplinary
    • Medical - DMARDs, steroid injection
    • OT/PT - splints, hand therapy
  • Optimize medically before surgery
  • Optimize aenesthetic issues pre-op
  • Operative Treatment
    • Preventative (destruction/deformity
      • synectomy/tenosynovectomy
    • Corrective
      • nerve decompression
      • soft tissue recon
      • tenosynovectomy 
      • synovectomy (preserve pulleys)
      • tendon transfer
    • Reconstructive/Salvage
      • arthroplasty
      • arthrodesis
  • ORDER of operative treatments - Priorities - 
    • proximal >distal
    • painful >painless
    • flexor before extensor
    • flexor recon before MCP arthroplasty>extensor recon
    • reliable procedures - tenosynovectomy, wrist fusion, distal ulna rsx

8

What are perioperative considerations for RA pts

  • Cervical instability (atlanto-axial subluxation)
  • TMJ ankylosis
  • cricoarytenoid arthristis
  • Pulmonary fibrosis,s mall airway disease
  • CV disease
  • Steroids - wound healing, stress dosing (if >5mg/day)
  • Infection & wound healing with DMARDS 

9

What is your management of RA skin nodules

  • nodulosis in areas of increased pressure (olecranon,extensors)
  • negative prognostic indicator
  • Tx if painful, infected, ulcarated - resection or steroid inj

10

What is your management of RA nerve injuries

  • trasnsient paresthesia - due to vascular insufficiency, self resolving
  • Polyneuritis - due to vasculitis, Tx steroids
  • Compression neuropathy
    • Median - CTS common. Tx synovectomy +CTR
    • Ulnar - rare - due to ulnohumeral synovitis - Tx - synovectomy + cubital tunnel release
    • Radial - rare - Tx - PIN decopmression

11

What is your management of RA EXTENSOR Tenosynovitis

TENOSYNOVITIS - EXTENSOR

  • MECHANICAL OBSTRUCTION IN SHEATH =>TRIGGERING, AROM
  • Tenosynovectomy at wrist if present for >6mths despite medical Tx

Extensor tenosynovectomy

  • skin incision dorsal longitudinal
  • watch DRSN, DSUN
  • open extensor retinaculum b/w 3rd and 4th compartment in stairstep fashion w large radially- and ulnarly-based flaps
  • resect all inflammed synovium, PIN at base of 4th
  • if tenodn ruptured/frayed, tenodese to adjacent
  • CLosure: pass radially based flap UNDer tendons and ulnarly based flap OVER tendons to improve glinding. Can capture ECU to prevent volar subluxation
  • Post- op- splint in neutral, mobilize in 2days

 

12

What is your management of RA EXTENSOR Tendon rupture

  • Etiology
    • caput ulnae ->EDM, EDC
    • synovium invasion of 4th ->EDC, EIP
    • listers tubercle->EPL
  • ruptures ulanr to radial
  • DDX for loss of digit extension
    • MCP volar dislocation - loss of passive ROM
    • tendon volar subluxation - can be actively held once passively extended
    • PIN compression - all extensors, tenodesis normal

TREATMENT of extensor rupture

* all graft donors include PL, strip of ECRB/L, 4th toe extensor. Graft is always option for all ruptures

Rupture EPL => transfer EIP/EPB

" EDM => Tenodese EDM/EDC4/5, transfer EIP

" EDM, EDC5 => Tenodese EDC4 to EDM/5 OR transfer EIP to EDM/5

" EDM, EDC 4/5 =>Tenodeses EDC3 to 4, transfer EIP to 5/EDM

"EDM, EDC 3/4/5 =>Tenodeses EDC2 to 3, trasnfer EIP to 4/EDM

" EDM, EDC 2/3/4/5 =>Tenodese EIP to EDC3, trasnfer FDS4 to EDC 4/EDM

'All fingers => Trasnfer FDS3 to EIP/EDC2/3 and FDS4 to EDC4/EDM

Thumb + all fingers => FDS3 to EPL/EIP, FDS4 to EDC3/4/5

13

What is your management of RA FLEXOR TENOSYNOVITIS

  • may present as triggering and locked in flexion or extension
  • tenosynovectomy if no improvement >6mths despite optimial medical Tx

FLEXOR TENOSYNOVECTOMY @ wrist

  • palmar longitudinal incision slightly more ulnar than CTR, zigzag at wrist
  • perform CTR
  • excise synovium and nodules on tendon until full PROM

FLEXOR TENOSYNOVECTOMY @ digits (trigger)

  • Bruner incision
  • synovectomy long flexor tendon +/- nodule rsx +/- repair any flexor deficit +/- excise FDS slip
  • DO NOT Release A1 as may leave to MCP volar subluxation 

14

What is your management of FLEXOR TENDON RUPTURE?

  • Etiology: attrition across bony spicules, direct synovium invasion
  • Occurs radial to ulnar (opposite of Extensors)
  • FPL most common
    • rupture 2' osteophyte on scaphoid = Mannerfelt lesion
    • Tx
      • tenosynovectomy, osteophyte rsx
      • interpositional graft
      • IP arthrodesis
      • FDS4 trasnfer w bunnell pull out
  • FDP rupture
    • Treatment by zone only if FUNCTIONAL loss
    • Zone 2 - IP arthrodesis
    • Zone 3-4 - tenodese to adj FDP
  • FDS rupture
    • Tx by zone onl if functional loss
    • Zone 2 - 2stage recon or IP arthrodesis
    • Zone 3 -4- tenodese to adj tendon
  • Multiple flexors
    • grafts
    • trasnfers FDS to FDP
    • IP arthrodesis
    • split FDP to power >1 finger

15

What is the pathophysiology of wrist deformity in RA?

Resultant untreated RA wrist deformity is

  • volar dislocation of carpus on radius
  • destruction of carpal bones
  • dissociation of radio-ulnar joint

 

Pathophysiology on radial side

  • RSL and RC ligaments attenuation
  • scaphoid flexion deformity
  • SL dissocation
  • radiocarpal collapse

Pathophysiology on ulnar side

  • Ulnocarpal lig attenuation
  • Radioulnar dissociation
  • ECU volar displacement

NET

  • carpus supination
  • radial metacarpal shift
  • ulnar deviation of fingers

 

16

What is the management of RA wrist defomrity

  • Operative tretament only after failure of wrist stabilization, pain control, function preservation

OPTIONS

  • Synovectomy
  • ECRL trasner to ECU
  • ECU relocation form volar to dorsal
  • Wrist arthrodesis 
    • Partial - Radiolunate, radioscapholunate
    • Total - procedure of choice
    • Do darrach procedure at same time as wrist fusion
  • Wrist arthroplasty

17

Describe the operative steps of a wrist synovectomy

  • longitudinal incision
  • enter b/w 3/4 compartments w rad/ulnr based flaps
  • resect PIN
  • distract hand to enter joint
  • resect synovium, rongeur bony proimenences
  • close capsule w nonabsorbing suture

18

Describe the operative steps of a wrist arthrodesis

  • longitudinal incision
  • Expose D3 MC at proximal mid MC level
  • Excise ECRB off D3
  • incise extenor retinaculum in 3rd compartment
  • Expose dorsal radius
  • excise listers tubercle if required
  • enter joint through dorsal capsule
  • resect synovium, articular sruface as required
  • Expose capitate
  • resect PIN 1-2 cm proximal to wrist jt in 4th compartment
  • harvest and packed ICBG
  • use limited contact DCP (3.5mm 9 hole)
  • fixation at D3, capitate, dorsal radius
  • close capsule, retinaculum
  • Consider Darrch procedure at same time

19

What are your management options for RA DRUJ arthritis

  • Non-operative treatment frist
  • Operative options
    • Darrach  = distal ulnar resection
    • Bower's hemiresection interosition arthroplasty
    • Sauve-Kapanji DRUJ arthrodesis

20

What is caput ulnae syndrome?

  • Def: dorsal prominence of Ulna relative to raidus due to radioulnar dissociation (RSL/RC and ulnocarpal ligament attenuation, supination and volar displacement of carpus)
  • weakness, painful/loss ROM, crepitus, extensor tendon ruptures, tenosynovitis

21

Describe the indications and operative steps of Darrach procedure

  • Indications: elderly low demand hand with post-traumatic/OA DRUJ arthritis or RA involving DRUJ
  • First line for elderly/RA
  • Can be performed in RA pts at same time as wrist arthrodesis
  • maintain ulnar styloid, TFCC
  • Steps
    • incision from ulnar styloid to 3cm proximal, volar to ECU and raise periosteal flap
    • resection below ulnar styloid to sigmoid notch
    • soft tissue stabilization
    • splint 4wks to prevent rotation
  • Complications - convergence of radius+ ulna, ulna instability

22

Describe the indications and operative steps of Bowers hemiresection interposition arthroplasty

  • Indication: post-trauamtic/OA/RA Druj arthritis
  • 2nd choice for RA (after darrach)
  • STEPS
    • create large ulnar based retinacular flap
    • enter 5th compartment
    • capsulotomy just proximal to TFCC, keeping ofveal atatchments intact, creating second ulnar based capsular flap
    • shape ulnar head to size of ulnar shaft
    • suture both retinacular and capsular flaps to volar DRUJ capsule to cover ulna
    • Immoblization longer than darrach procedure - 3wks long arm cast, 3wks short arm, 3mths before full activity

23

Describe the indications and operative steps of Sauve-Kapanji Druj arthrodesis

  • Indicaitions: post-trauma, OA, RA DRUJ arthritis, ulnar trasnlocatio of carpus in RA
  • for high demand younger RA pts
  • STEPS
    • incision over 6th compartment, enter 5th compartment, retract EDM
    • L shaped capsulotomy proximal to TFCC
    • place 2 guide wires in ulnar head towards sigmoid notch
    • denude articular surfaces of DRUJ
    • insice periosteum of ulnar neck and excise 1cm of ulnar neck
    • place two compression screws across DRUJ
    • FCU tenodesis for stabilization if required
    • closure of capsule

24

What is the pathophysiology and anatomic forces leading to MCP deformity in RA

Deformity of RA MCP jt

  • ulnar subluxation of extensor tendon
  • volar ulnar deviation of PP at MCP jt

Pathophysiology and anatomic features

  • synovitis of CL, VP
  • radial carpus traslocation and volar subluxation contibute to resultin fulnar drift
  • pinch forces
  • flexor position support ulnar palmar pull
  • radial sagital band attenuation
  • shape of MC head
  • ulnar intrinsics pull

25

How do you manage RA MCP jt deformity

OPTIONS

  • MCP synovectomy and tendon rebalancing
  • MCP arthroplasty

MCP SYNOVECTOMY & TENDON REBALANCING

- controls local disease, indicated if synovitis only and joint surfaces intact

  • dorsal longitudinal incision from PIP to MCP
  • synovectomy of MCP jt
  • Tendon rebalancing
    • umbricate radial sagittal band
    • ulnar intrinsic release
    • ECD centralization with vest over pants sutures to RSband
    • Or Cross intrinsic trasnfer - divide ulnar intrinsic of D2/3/4 and release ADM and trasnfer to radial D3/4/5

MCP ARTHROPLASTY

  • indicated if joint destruction
  • Only do MCP after wrist (proximal first!)
  • Swanson silicone arthroplasty
  • combined with tendon rebalancing
    • release ulnar intrinsics
    • umbricate RSband, centralize Extensor tendon

26

what is the etiology of the boutonniere deformity in RA and resulting deformity?

ETIOLOGY - always starts at PIP

  • Synovitis of PIP capsule, leading to CS destruction/attenuation
  • flexion of PIP, hyperextension of DIP
  • volar subluxation of laterla bands
  • contracture of TRL and shortened ORL
  • lax flexors

27

How do you classify and manage boutonniere deformities in RA

Nalebuff and MIllender classification

Stage 1 => PIP full passive ROM

  • Tx: splint in trough splint and AROM fo DIP
  • PIP synovectomy
  • if ORL tight, Fowler TT tenotomy

Stage 2 =>limited PROM, joint surface intact

  • Tx: trial of splinting
  • PIP synovectomy
  • Central slip recon (shortening)
  • Fowler TT tenotomy (release ORL tightness)
  • Lateral band transfer (from conjoined T to recon CS)

Stage 3 => no passive ROM, FIXED, +jt destruction

  • Tx: PIP arthrodesis (index 40, and increase by 5)
  • Tx arthroplasty (2nd choice) - will need extensor/CS recon and requiring resection of CL (destab PIP)

28

What is the etiology of swan neck deformity in RA

ETIOLOGY:MCP SYNOVITIS

  • MCP synovitis =>dorsal => attenuation of extesnor insertion on base of PP
  • MCP synovitis =>volar =>laxity VP, adhesions and contracture of intrinsics
  • PIP synovitis =>volar =>VP laxity, TRL attenuation, FDS rupture, dorsal translocation of conjointed latral band
  • DIP synovitis =>dorsal =>TT rupture

29

How do you classify and mange swan neck deofmrity in RA

Nalebuff

Stage 1=> full PIP PROM

  • Tx: splint PIP in FLEXION, fuse DIP in extension
  • PIP ST rebalance to keep flexed (internal splint) - FDS tenodesis - one slip of FDS secured to A1/2 or through drill hole in PP. Stat AROM in DBS

Stage 2 =>limited PIP PROM, + due to intrinsic tightness (less PIP flexion with MCP hyperextension

  • Tx: MCP intrinsic release, arthoplasty if required
  • PIP FDS tenodesis
  • DIP arthrodesis

Stage 3 => limited PIP PROM in all MCP positions

  • Tx: MCP intrinsic release
  • Step wise release of PIP to restore mobility  - release conjoined lat bands, dorsal capsule, relase CL, lengthen CS then if needed FDS tenodesis
  • DIP arhtodesis

Stage 4 => limited PROM PIP and joint destruction

  • Tx: PIP arthrodesis

30

What are the preferred tratments for RA thumb deformities?

  • CMC: trapeziectomy and teodong interposition
  • MCP: arthrodesis or silicone arthroplasty
  • IP: arthrodesis