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Rheumatoid Arthritis of the Hand
Arthritis literally means “inflamed joint.” Normally a
joint consists of two smooth, cartilage-covered bone surfaces that
fit together as a matched set and that move smoothly against one other.
Arthritis results when these smooth surfaces become irregular and don’t
fit together well anymore and essentially “wear out.” Arthritis
can affect any joint in the body, but it is most noticeable when it
affects the hands and fingers. Each hand has 19 bones, plus 8 small
bones and the two forearm bones that form the wrist. Arthritis of the
hand can be both painful and disabling. The most common forms of arthritis
in the hand are osteoarthritis, post-traumatic arthritis (after an
injury), and rheumatoid arthritis. Other causes of arthritis of the
hand are infection, gout, and psoriasis.
Rheumatoid arthritis affects the cells
that line and normally lubricate the joints (synovial tissue). This is
a systemic condition (can affect the whole body), which means that it may
affect multiple joints, usually on both sides of the body. The joint lining
(synovium) becomes inflamed and swollen and erodes the cartilage and bone.
The swollen tissue may also stretch the surrounding ligaments, which are
the connective tissues that hold the bones together, resulting in deformity
and instability. The inflammation may also spread to the tendons, which
are the rope-like structures that link muscles to bones. This can result
in stretching out of and ruptures of the tendons. Rheumatoid arthritis
of the hand is most common in the wrist and the finger knuckles (the MP
and PIP joints (see Figure 1).
Stiffness, swelling,
and pain are symptoms common to all forms of arthritis in the hand.
In rheumatoid arthritis, some joints may be more swollen than others.
There is often a sausage-shaped (fusiform) swelling of the finger. Other
symptoms of rheumatoid arthritis of the hand include:
- a soft lump
over the back of the hand that moves with the tendons that straighten
the fingers
- a creaking sound (crepitus) during movement
- a shift
in the position of the fingers as they drift away from the direction
of the thumb (see Figure 2)
- swelling and inflammation of the tendons
that bend the fingers, resulting in clicking or triggering of the
finger as it bends, and sometimes causing numbness and tingling in
the fingers (carpal tunnel syndrome)
- rupture of tendons with loss
of ability to straighten or bend certain fingers or the thumb
- unstable
joints in the wrist, fingers, and thumb
- deformity in which the middle
joint of the finger becomes bent and the end joint hyperextended
(Boutonnière deformity (see Figure
3)
- hyperextension (sway-back) at the middle joint
of the finger associated with a bent fingertip (swan-neck deformity
(see Figure 3)
Your doctor will examine you and
determine whether you have similar symptoms in other joints and assess
the impact of the arthritis on your life and activities. The clinical appearance
of the hands and fingers helps to diagnose the type of arthritis. X-rays
will also show certain characteristics of rheumatoid arthritis, such as
narrowing of the joint space, swelling and diminished bone density near
the joints, and erosions of the bone. If your doctor suspects rheumatoid
arthritis, he or she may request blood or other lab tests to confirm the
diagnosis.
Treatment is designed to relieve pain
and restore function. If you have rheumatoid arthritis in your hands,
medications can help decrease inflammation, relieve pain and slow the
progression of the disease. Anti-inflammatory medications, oral steroids,
and/or cortisone injections may be used. Several disease-modifying
treatments are now available, including anti-malarial drugs, methotrexate,
cyclosporine, gold, and other new drugs (remicade, enbrel) that help
suppress the body’s
immune system to reduce the inflammation and pain. A rheumatologist
will often prescribe and monitor these types of medications. Your physician
may also refer you to a hand therapist for exercises, splints, modalities
such as paraffin (warm wax) baths, and instruction on how to use your
hands in ways that may help relieve pain and pressure and also protect
your joints. Adaptive devices may help you cope with the activities
of daily living.
Rheumatoid arthritis often affects the tendons as well as the joints.
The tendons that become inflamed may trigger (click) or rupture. If
this happens, you may be unable to bend or straighten your fingers
or to grip properly. In certain cases, specific preventive surgery
may be recommended. Preventive surgery may include removing nodules,
releasing pressure on tendons by removing the inflamed tissue and degenerated,
rough bone that may scrape the tendons, and reinforcing the tendons.
If a tendon rupture has occurred, a hand surgeon may be able to repair
it with a tendon transfer or graft, in addition to performing these
other procedures.
Surgery to treat the arthritic joints includes removal of inflamed
joint linings, joint replacements, joint fusions, and in some cases,
removal of damaged bone. The specific procedure(s) depends on a variety
of factors, including the particular joint(s) involved, the degree
of damage present, the condition of adjacent joints, and your own needs.
Your hand surgeon can help you decide on the most appropriate treatment
for you.
Unfortunately, there is no cure for rheumatoid arthritis. However,
surgical procedures can often help correct deformities, relieve pain,
and improve function. Optimal care entails a team approach between
the rheumatologist, hand surgeon, hand therapist, and patient. It is
particularly important that surgical intervention be appropriately
timed to rebalance the hand and preserve the joints for as long as
possible, before the development of more severe deformities has occurred.
Joints affected by rheumatoid arthritis
Drift of the fingers away from the thumb
Boutonnière and swan-neck
finger deformities
© 2007 American Society for Surgery of the Hand
Developed by the ASSH Public Education Committee
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rheumatoid, arthritis, joint pain
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