Orthopaedic aspects of rheumatoid arthritis.

Attainment of an improved bodily posture is of the utmost importance if the general resistance of the individual to the infection is to be upgraded. The typical posture of rheumatoid arthritis is one of fatigue, with " poking chin," drooping shoulders, flat chest with poor respiratory excursion, visceroptosis, sway-back from the waist, flexed knees, and pronated feet. The key-note of the corrective process is rest and remedial exercises-done at first in recumbency to eliminate the effects of gravity. Abdominal breathing, and pelvic tilting with gluteal and quadriceps contractions, can be practised by the most toxic patient, and as the general condition improves postural training in correct sitting, standing, and walking attitudes should be given. A firm mattress is a sine qua non. The interiorspring mattress and the feather bed should be firmly condemned. With local articular lesions in the acute stage the most important single aim is the prevention of deformity and the provision of rest by local splintage. The only satisfactory splintage is " tailormade" on the patient, and this, in most cases, is provided by light plaster of Paris casts. Castex splints and easily moulded light aluminium splints are successfully used, and there is an increasing use of plastics, such as perspex, but at present these need to be made on a plaster cast. Particularly insidious early deformities to be watched for are: (a) ulnar deviation of the fingers at the metacarpophalageal joints; (b) flexion contracture of the wrists; (c) adduction contractures of the shoulders; (d) backward and outward subluxation of the knees; and (e) pronation of the feet.