What Can Be Done for the Deformed Rheumatoid Hand?

THE number of ways in which rheumatoid arthritis can affect a hand and the number of different deformities it can produce are so great that in seeking a coherent view of the problem we are faced with an immediate difficulty in sorting, tidying, and classifying all these factors. In a short article it is impossible to be exhaustive and one can only illustrate principles with examples. What follows illustrates a practical approach to the problem, doubtless full of gaps and perhaps with some downright mistakes in it-but it has served the author well in studying and working in what is a young subject, which we are only beginning to understand. It must be recognized at the start that rheumatoid arthritis is unpredictable, except in its predilection for attacking women rather than men (in the ratio of 4:I). It attacks at all ages and in different guises. It may be infinitely slow or devastatingly rapid. It occurs in a 'wet' form with joint and tendon sheath effusions and exuberant synovial reactions, and in a 'dry' form in which bone and cartilage become eroded silently with little or no clinical involvement of soft tissues. It may progress inexorably, or quietly burn out at any stage. In the hand we recognize a type which hits first, mainly, and sometimes even exclusively, the wrist and inferior radio-ulnar joints. In another type the brunt falls on the metacarpophalangeal joints, in another on the proximal interphalangeal joints, in another on tendon sheaths. These are the main types though obviously overlapping occurs. But generally one hand tends to reproduce the pattern found in the other. Not only, then, can we be faced with a rich variety of patterns of deformity but also the unpredictable timing of the onset of the disease in any joint or tendon ensures that any pair of rheumatoid hands will present us with young, old and intermediate lesions for consideration. It is important to realize that the treatment of these different stages tends to be along very different lines in each of three different joints in one hand. The treatment of deformity in the rheumatoid hand demands an understanding not only of the actual mechanics of the deformity but also of the factors which influence it and change it throughout its progression from the mildest alteration in posture down to the complete dissolution and disorganization of a joint or tendon complex. The progression is as follows: a primary tendon imbalance-due to various causes which will be considered later-leads to a primary persistent abnormal posture. If, as is usually the case, adaptive shortening or adhesions of soft tissues occur they convert the persistent abnormal posture into a secondary fixed joint deformity. Progressive destruction of bone and cartilage, together with destruction of ligaments and joint capsules, progressively changes this deformity into a tertiary, modified, and final deformity, all too often in fact a total disorganization of the joint. It is very important not to have a static concept of deformity in this condition, and not to consider only the ultimate dilapidations of the rheumatoid hand. If we are to achieve anything our attention must be fixed on the earliest changes-the first hint of abnormal posture, or of those successions of abnormal postures that constitute abnormal patterns of movement. At that stage we may be able to prevent deformity. If we only consider fixed deformities we confine ourselves to salvage procedures.