Define Rheumatoid Hand Deformities. Describe its management and treatment.

Basis of the Deformities

The deformities of the rheumatoid hand result from synovitis destroying joints, capsules, ligaments and tendons, producing joint instability and tendon imbalance. They are characteristic and examinable.

Key Deformities

• Ulnar deviation of the fingers at the MCP joints (with volar subluxation).
• Swan-neck deformity — hyperextension at the PIP joint with flexion at the dip joint.
• Boutonnière (buttonhole) deformity — flexion at the PIP joint with hyperextension at the dip joint (from central slip rupture).
• Z-shaped thumb. At the wrist there is radial deviation, volar subluxation and prominence of the ulnar head (‘caput ulnae’), which can lead to extensor tendon rupture.

Management

Control of the underlying disease with DMARDs limits progression. Established deformities are managed with hand therapy, splints and functional aids, and, where function is impaired, surgery — synovectomy, tendon repair/transfer, soft-tissue realignment, joint replacement (MCP arthroplasty) or arthrodesis.

Assessment

Examination documents the pattern of deformity, the range of active and passive movement, joint stability, and — crucially — hand function (grip, pinch and the ability to perform daily tasks), because function, not appearance, drives treatment decisions. The state of the tendons is assessed (an inability to actively extend a finger that can be passively extended suggests tendon rupture rather than joint fixation), as is any neurological deficit from associated carpal tunnel syndrome, which is common in rheumatoid disease.

Principles of Treatment

Non-surgical measures — disease control with DMARDs, hand therapy, resting and working splints and adaptive aids — come first and preserve function for many patients. Surgery is considered for pain, progressive deformity, tendon rupture or functional loss, and is sequenced thoughtfully (for example, stabilising the wrist before correcting finger deformities) to give a durable, functional result.

Deformity arises from tendon and ligament imbalance, not bone alone.

• Deformities from synovitis destroying joints, ligaments and tendons.
• Ulnar deviation, swan-neck (PIP ext/dip flex), boutonnière (PIP flex/dip ext), Z-thumb.
• Caput ulnae → risk of extensor tendon rupture (urgent referral).
• Control disease with DMARDs; therapy/splints; surgery for function.