Finger contractures due to tendon lesions as a mode of presentation of rheumatoid arthritis.

Contractures of the fingers producing a claw hand may be due to nerve lesions (ulnar palsy), muscle lesions (haemophilia or traumatic Volkman's contracture and dermatomyositis), skin lesions (scleroderma), fascial lesions (Dupuytren's contracture), joint lesions (rheumatoid arthritis or osteo-arthritis), or lesions of the tendons and tendon sheaths. The most common lesion of the tendon is a traumatic thickening leading to the 'snapping finger, usually single, occasionally multiple, and often related to occupation. In gout, uric acid accumulations may occur in the tendon, producing limitation or even "ankylosis" of the fingers without the joints themselves being involved. In rheumatic fever, nodules may form in the tendons of the palm, producing a sticking finger (Scheele, 1885; Keil, 1938; Berkowitz, 1912), but these invariably straighten out again without residue in the course of a few days or weeks (Bywaters, 1951). Similar contractures occur in the palindromic type of rheumatoid arthritis (Bywaters, 1949), and in cases of lupus erythematosus. These reversible contractures need no special therapeutic measures. In rheumatoid arthritis, however, tendon lesions are not only common, occurring in 48 per cent. of cases (Helweg, 1924), 47 per cent. (Edstrom, 1945), or 42 per cent. (Kellgren and Ball, 1950), but are of the greatest importance from the therapeutic viewpoint. Left untreated, they not only produce such limitation of finger extension that the patient becomes severely handicapped, but, after a time, they may become irreversible through secondary changes in other tissues. It is, therefore, important from the practical aspect to recognize these changes early. While there is little difficulty in their recognition in a frank case of rheumatoid arthritis, it is perhaps rather more difficult to diagnose the tendinous lesions of rheumatoid arthritis in the absence of arthritis. This paper, therefore, describes three cases where the tendon lesions were the presenting sign and joint lesions were either absent or asymptomatic and minimal. A fourth case where joint lesions preceded tendon involvement is included for the discussion of treatment. The methods used to assess the results of treatment included measurements of gripping strength (Ansell and Bywaters, 1952) and of the palmar contact area. To obtain the latter the palmar aspect of the hand was well inked and then pressed firmly on to paper secured on a flat table. The inked area was then measured with a planimeter.