Hand Case Study 1: RA

Phillipa Hall is a 50 year old Medical Secretary who was diagnosed with Rheumatoid
Arthritis 10 years ago. She had previously noticed an increasing ache in the hands
and wrists, which occurred intermittently. She experiences periods of worsening and
improvement in pain but deteriorating function in terms of grip and wrist extension.
She has also noticed a gradual decrease in strength affecting the muscles around her
shoulder. She lives with her husband and teenage sons, but usually does all the
domestic duties. She is finding this increasingly difficult due to her worsening
condition and has consulted her GP for review of her medication. Currently she is
taking DMARDS.

Anatomy & Pathology

RA is a chronic autoimmune disorder that most commonly causes inflammation and
tissue damage. RA is caused by synovitis, inflammation of synovial membranes and
can erode articular cartilage – with time it affects multiple joint – polyarthritis – most
commonly affects small joints – diagnosis is in the form of blood tests for antibodies.

Summary of deformities in severe arthritis of hands and wrists:

Ulnar drifting of fingers – Valgus thumb - Dislocation of meta carapalphalangeal
joints – Destruction of interphalangeal joints – wrists joints twisted to ulna – pencil
shaped ulna.

Subjective Examination
Where\What: decreased grip, reduced wrist extension – more than 1 joint – can
expect functional problems as well as problematic flexion

When: 10 years ago

How:

0-10 rating: Increasing fluctuation

24 hour cycle: expect stiffness from sleeping – worse in morning

Better for: expect heat/resting

Worse for: ice, cold, activity

Type of pain: expect aching

Past Medical History/ General History:

Red Flags and general concerns: tiredness and weight loss are common – check
these are not severe – carpal tunnel syndrome is a possibility

SH: lives with husband and teenage son – ask about domestic duties

DH: DMARD’s

Patients main outcome: better doing housework

Objective Examination

Working Hypothesis: obtain profile of the extent of RA, rule out carpal

Advice & Consent: give and obtain

General Observations: watch walking

Acute Observations:
Skin colour – n/a
Swelling – around joint
Posture – may be issue if extending to other joints
Muscle Bulk - reduced
Deformity – gauge severity

Active Tests, Passive Tests, Resisted Tests:

- All in sitting with hands and wrists across bed
-
Inferior Radioulnar – pronation supination
Radiocarpal – flex extension radial deviation ulnar deviation
Carpometacarpal joint of thumb – flexion extension abduction adduction opposition
Metacarpal phalangeal Joint – flexion extension abduction adduction
Proximal & distal interpahlangeal joints – flexion extension

Active – mimic with own hand get good record - reduced extension a problem –
expect problem in flexion
Passive - enables joints to be evaluated – bear severe deformities in mind. Look for
weakness, stiffness and deformity.
Resisted – expect weakness in surrounding muscles – record
Can also examine shoulder and inquire as to whether the RA is affecting this joint –
active, passive and resisted test should be performed in flexion extension abduction
adduction medial and internal rotation

Special Tests:
Phalens – sustained inverse prayer hands – hold for 1 minute – positive sign would be
distal tingling pain
Tinels Sign – tapping of median nerve path – produces pins and needles and pain in
palm.

Functional Tests: Dexterity tests – try picking up small objects

Strength tests – picking up objects – chair?
Endurance tests – how long can hold up chair

Palpation: feel for muscle wastage – examine for swelling – gauge deformity in
joints

Measurements: record reduced extension in passive – record expected

reduced flexion in passive – record any other problems – even draw round hands in
full spread

Advice & Possible Treatment: may have pain following examination

Pain relief from g.p. – core treatment is exercise – heat treatment can case pain –
DMARDS used early on. If severe steroids may be used - routine use of steroids can
lead to osteoporosis, weight gains & muscle wastage.