[The rheumatic hand]

Abstract

The hand (wrist and fingers) is one of the regions most frequently affected by rheumatic arthritis (RA). The nature of the alterations involved means it is possible to interpret the clinical picture as RA even from the external appearance. Obviously the functional handicap affects activities of daily living, and the insult to the patient's aesthetic sensibilities imposes an additional, psychological, burden. A generally satisfactory limitation of damage can only be expected from professionals who work well together as a team. The ability to devise a therapy plan with the right priorities is the mark of those who have mastered the art of surgery for rheumatic conditions. Operative treatment presupposes failure of a conservative therapy carried out according to modern views. In addition to operations on the affected joints, operations on the tendons of the hand are also highly significant in terms of function. The interventions that can be performed on the joints embrace synovectomies, arthroplasties and arthrodeses. In the last 20 years the absolute number of joint synovectomies has fallen, since at least in treatment of the early stages radiosynoviorthesis has become increasingly important, especially for the metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints. Operative synovectomy is now considered when radiosynoviorthesis fails or in more advanced stages (Larsen 3) and when reconstruction procedures (especially on the tendons) are necessary. The chances are also better with open synovectomy (with or without resection of the head of the ulna) at the wrist. The results of synovectomy are not so impressive from the radiological aspect as from the clinical viewpoint, since as a result of the removal or attenuation of pain the function is often improved to the status of more than 10 years before and valuable time is thus gained. When the destruction is too far advanced arthroplasty is considered, especially for the MP joints but increasingly also for the PIP joints. Arthrodesis is a still highly valuable procedure for the wrist, since there is no really satisfactory artificial joint. An arthroplasty can only be successful if the tendons are intact. Tenosynovectomy and repair of ruptures have a good prognosis if appropriate techniques are used. The correction of such typical deformities of the fingers as buttonhole and swan neck deformity requires some of the technically more demanding operations.