426 excising the inflamed synovium, tightening the capsular structures and releasing the ulnar pull of the

intrinsic tendons. Mobile boutonniere and swan-neck deformities can be treated with splints; if they progress or are fixed, then surgery may be needed. Isolated tendon ruptures are repaired or bypassed by appropriate tendon transfers. These procedures are followed by splintage and hand therapy. Destruction of the MCP joints without ulnar drift can be treated with surface replacement (chrome polyethylene or pyrocarbon). Late disease In late cases deformity is combined with articular destruction; soft-tissue correction alone will not suffice. For the MCP and IP joints of the thumb, arthrodesis gives predictable pain relief, stability and functional improvement. The MCP joints of the fingers can be excised and replaced with Silastic spacers, which improve stability and correct deformity. Replacement of IP joints gives less predictable results; if deformity is very disabling (e.g. a fixed swan-neck) it may be better to settle for arthrodesis in a more functional position. At the wrist, painless stability can be regained by fusion of the radio-carpal, midcarpal and CMC joints. Wrist replacement with Silastic or metalplastic implants, whilst providing some movement, may well fail; the loss of bone stock that accompanies failure means that salvage can be very difficult.

427 The thumb in rheumatoid arthritis The combination of soft-tissue failure and joint erosion leads to characteristic deformities of the thumb: rupture of flexor pollicis longus tendon, a boutonniere lesion at the MCP joint, CMC instability, swanneck deformity and ulnar collateral ligament instability. Depending on the deformity, the patients demands and the condition of the rest of the hand, treatment may involve various combinations of splintage, tendon repair, joint fusion, excision arthroplasty and joint replacement. Treatment options are summarized in the accompanying box. Metacarpo-phalangeal deformities

Chronic synovitis of the MCP joints results in failure of the palmar plate and the collateral ligaments. The powerful flexor tendons drag the proximal phalanx palmarwards, causing subluxation of the joint. The deformity may be aggravated by primary or secondary intrinsic muscle tightness. The most obvious deformity of the rheumatoid hand is ulnar deviation of the MCP joints. There are several reasons for this: palmar grip and thumb pressure naturally tend to push the index finger ulnarwards; weakening of the collateral ligaments and the first dorsal interosseous muscle reduces the normal resistance to this force; the wrist is usually involved and, as it collapses into radial deviation, the MCP joints automatically veer in the opposite direction (the so-called zig-zag mechanism); once ulnar drift begins, it becomes self-perpetuating due to tightening of the ulnar intrinsic muscles and stretching of the radial intrinsics and the adjacent capsular structures. As the sagittal bands fail, the extensor tendon slips ulnarwards and palmarwards, accentuating the deformity even further. At an early stage, before joint destruction and softtissue instability, synovectomy may relieve pain but the joint usually stiffens somewhat. When ulnar drift has started, splintage may maintain function and retard progression. With marked deformity but little joint damage, a soft-tissue reconstruction (reefing of the radial sagittal bands, tightening of the radial collateral ligament with intrinsic muscle release and transfer) can give a satisfactory and fairly durable correction. Once there is marked damage to the joint surface, replacement with a Silastic spacer, along with the soft-tissue reconstruction, is recommended. There is no point in correcting the MCP joints unless any wrist deformity is also corrected; the tendency to zig-zag deformity will otherwise lead to recurrence of the ulnar drift.

Finger deformities Boutonnire Synovitis in the proximal IP joint causes elongation or rupture of the central slip which passes over the back of the joint before inserting into the

base of the middle phalanx. The lateral bands slip away from the central slip and pass in front of the axis of rotation of the proximal joint but remain behind the axis in the distal joint, to form the characteristic

428 deformity. Early, correctable deformity responds to splinting and synovectomy; later, central slip reconstruction (an unpredictable procedure) may be required; simple division of the distal insertion is a simpler, and often effective, alternative. In fixed deformities, or those with joint damage, fusion or replacement is considered. Swan-neck Chronic synovitis may lead to swan-neck deformity by one or more of the following mechanisms: failure of the palmar plate of the PIP joint; rupture of the flexor digitorum superficialis; dislocation or subluxation of the MCP joint and consequent tightening of the intrinsic muscles. Treatment depends on a careful analysis of the cause and will include figure-of-eight splintage, tendon transfer, intrinsic release and occasionally fusion. Tenosynovitis and tendon rupture Extensor tendons Extensor tendon rupture is a common complication of chronic synovitis. Extensor digiti minimi is usually the first to go and predicts rupture of the other tendons. Treatment consists of either suturing the distal tendon stump to an adjacent tendon, inserting a bridge graft (e.g. palmaris longus) or performing a tendon transfer (e.g. extensor indicis proprius). Synovectomy and excision of the distal ulna may also be necessary. Flexor tendons Flexor tenosynovitis is one of the earliest and most troublesome features of rheumatoid disease. The restriction of finger movement is easily mistaken for arthritis; however, careful palpation of the palm and the nearby joints will quickly show where the swelling and tenderness are located. Secondary problems include carpal tunnel syndrome, triggering of one or more fingers and tendon rupture. Synovitis of the flexor digitorum superficialis also contributes to the swan-neck deformity. If carpal tunnel release is needed, the operation should include a flexor tenosynovectomy. If the flexor tendons are bulky (best felt over the proximal phalanges) and joint movement is limited, then flexor

tenosynovectomy should improve movement and, just as important, should prevent tendon rupture. Triggering, likewise, should be treated by tenosynovectomy rather than simple splitting of the sheath. Rupture of flexor digitorum profundus is best treated by distal IP joint fusion. Rupture of flexor pollicis longus (due to attrition against the underside of the distal radius or flexor synovitis) can be treated either by tendon grafting or by fusion of the thumb IP joint. OSTEOARTHRITIS Eighty per cent of people over the age of 65 have radiological signs of osteoarthritis in one or more joints of the hand; fortunately, most of them are asymptomatic. DISTAL INTERPHALANGEAL JOINTS Osteoarthritis of the DIP joints is very common in postmenopausal women. It often starts with pain in one or two fingers; the distal joints become swollen and tender, the condition usually spreading to all the fingers of both hands. On examination there is bony thickening around the joints (Heberdens nodes) and some restriction of movement. Treatment is usually symptomatic. However, if pain and instability are severe, a cortisone injection will give temporary relief. Joint fusion is a good solution. The angle of fusion is debatable. Intramedullary doublepitched screws are effective and avoid the problems of percutaneous wires. However, the final position is one of extension which slightly reduces grip in the little and ring fingers. Mucous cysts sometimes protrude between the extensor tendon and collateral ligament of an osteoarthritic DIP joint. They press on the germinal matrix of the nail, causing an unsightly groove. They occasionally ulcerate and septic arthritis can develop. If the cyst is too bothersome, excision of the cyst with the underlying osteophyte is effective. With luck, the nail will recover as well. PROXIMAL INTERPHALANGEAL JOINTS Not infrequently some of the PIP joints are involved (Bouchards nodes). These are strongly associated with osteoarthritis elsewhere in the body (polyarticular OA). The joints are swollen and tend to deviate ulnarwards due to mechanical pressure in daily activities.

429 Treatment is usually non-operative. If the joint is very painful or unstable then surgery is considered. Fusion restores reliable, pain-free pinch in the index and middle finger PIP joints; fusion of the ring and little fingers compromises grip and so joint replacement is usually preferable. Implants made from pyrocarbon, Silastic or metalpolyethylene are available. However, the results are unpredictable: some patients do very well; others have problems with deformity, instability or stiffness. Metacarpo-phalangeal joints This is an uncommon site for osteoarthritis. When it does occur, a specific cause can usually be identified: previous trauma, infection, gout or haemochromatosis. Treatment is initially non-operative with the use of analgesics, splints or local injections. Fusion of the thumb MCP gives excellent results; however in the fingers this operation has serious functional consequences and is to be avoided. The MCP joints can be replaced with pyrocarbon or metalpolyethylene implants, with encouraging early and mid-term results. Carpo-metacarpal joint of the ring and little fingers These joints can become arthritic, particularly after a fracturedislocation. Because the fourth and fifth CMC joints normally flex forwards during power grip, pain can be disabling, particularly in patients engaged in heavy manual work. If a steroid injection fails to give improvement, then surgery (usually fusion) is indicated.