Rheumatoid Arthritis of the Hand
What is arthritis?
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 of the hand
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).
Signs and symptoms of rheumatoid arthritis of the hand
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)
How arthritis of the hand is diagnosed
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 of rheumatoid arthritis
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.
Figure 1: Joints affected by rheumatoid
arthritis
Figure 2: Drift of the fingers away from the
thumb
Figure 3: Boutonnière and swan-neck finger
deformities
© 2006 American Society for Surgery of the
Hand
Developed by the ASSH Public Education Committee
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