Hand Deformities in Rheumatoid Disease
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Ann Rheum Dis: first published as 10.1136/ard.16.2.183 on 1 June 1957. Downloaded from Ann. rheum. Dis. (1957), 16, 183. HAND DEFORMITIES IN RHEUMATOID DISEASE BY D. A. BREWERTON From the Department of Physical Medicine, King's College Hospital, London (RECEIVED FOR PUBLICATION FEBRUARY 1, 1957) This is a study of hand deformities in rheumatoid rheumatic disease; fifteen were seen in the wards. None disease: their incidence, their causes, and their was bedridden. The sex ratio, age at onset, and duration of disease are effects on function. Three hundred patients with set out in Tables I and II. All age groups are repre- this disease have been examined. sented, except that, by chance, there were no men in There can be no doubt of the importance of hand whom the disease had started when under 20 years of deformities to the rheumatoid patient, nor of the age. Almost half of the patients were in the first 5-year importance of preventing hand deformities when period of disease, but after that period their numbers treating this disease. Consequently it is surprising steadily decreased, because of the artificial selection of to find that there are few detailed accounts of these hospital out-patients. Presumably many in the later deformities in the literature. Ulnar deviation and years no longer attend as they have improved; a few are its causes have been discussed at length (Fearnley, too disabled; and the rest have returned to the care of their general practitioners. Certainly those still attend- copyright. 1951; Lush, 1952; Vainio and Oka, 1953). Some ing hospital late in their disease are likely to be more of the common tendon lesions have been described disabled than the average rheumatoid patient at this in detail (Edstrom, 1945; Kellgren and Ball, 1950; stage. Snorrason, 1951; Harris, 1951; Ansell and Bywaters, 1953). Contractures of the intrinsic muscles of the TABLE I hand due to other causes have been described fully, AGE AT ONSET but there have been few details of this condition as Age at Onset Women Men Total it occurs clinically in rheumatoid disease (Kestler, (yrs) http://ard.bmj.com/ 1949; Bunnell, 1953, 1955; Harris and Riordan, 10-19 12 - 12 most have 20-29 37 2 39 1954). Of the remaining deformities, 30-39 36 11 47 at least been mentioned in the literature, but only a 40-49 .. .. 52 20 72 50-59 58 19 77 few have been described in detail with discussion of 60-69 .. .. 30 11 41 their causes. 70-79 .. .. 6 4 10 To place the prevention of hand deformities on a 80-89 .. .. 1 1 2 Total .. .. 232 68 300 sound basis, it is essential to know more about the on September 27, 2021 by guest. Protected deformities that occur. The objects of this study were to find out the incidence of the permanent deformities occurring in the rheumatoid hand; and TABLE II to discover which of these deformities were im- DURATION OF DISEASE portant in everyday function. Whenever possible the causes of the deformities were recorded. Duration(yrs)Woeof Disease Women MeMen TtaTotal 0-1 s 128 40 42l 141 40 1-2j 0-5 .- *- 28¼98 14 42 138 Material 2-5J 42) 12 j 541 5-10 .46 14 60 The patients were a typical cross-section of those seen 10-15 .39 5 44 15-20 .12 5 17 in hospitals. No special selection was made and the 20-25 .. 13 2 15 three hundred patients were seen as they attended King's Over25 .. .. 24 2 26 College Hospital and nearby hospitals in the South- East Metropolitan Region. Most of them were out- patients attending rheumatic clinics; a few were attending Patients whose hands were normal were included in other departments for reasons unrelated to their the series. 183 Ann Rheum Dis: first published as 10.1136/ard.16.2.183 on 1 June 1957. Downloaded from 184 ANNALS OF THE RHEUMATIC DISEASES Three men considered for this survey were excluded as long flexors and extensors of the fingers within the they had ankylosing spondylitis with involvement of the forearm, and for involvement of their tendons at the hands. Also excluded were two women who had wrist. psoriatic arthropathy with joint involvement confined was tested only to establish that it to the distal interphalangeal joints. Four other patients Wrist function with the rheumatoid type of arthritis and psoriasis were had no major effect on hand deformities. Record admitted to the series. was kept of pronation and supination of the fore- It must be stressed that the majority of patients were arm, wrist movements, and clinical involvement of seen, for the purpose of this survey, at only one stage in the tendons of the wrist flexors and extensors. the course of their disease. It was possible to follow The detailed examination was followed by tests only a few patients through a period when permanent of hand function to find out which deformities were deformities were developing. The incidence of various most important. Four basic grips were used deformities are given in a later section of this paper. (Fig. 1). These figures must be interpreted with the understanding that many cases were of recent onset and had yet to Grip I (Fig. la).-To pick up and manipulate small develop their deformities, whereas others in whom the objects it is essential to oppose the thumb and one of the disease was of longer duration had such joint stiffness fingers. The thumb must be capable of opposition, and that the original deforming factors had become obscured. the finger must be capable of flexion, particularly at the proximal interphalangeal joint. If this grip is impossible, Examination the patient will be unable to do up buttons, sew, or pick up small objects. A study was made of the thumb and fingers, and in Grip 2 (Fig. lb).-The second grip is required for their function. The wrist was not examined turning keys or gas taps. Its basis is a strong grip detail. between thumb and finger. Opposition of the thumb Within the hand every structure was examined and finger are required as for Grip 1, but other factors according to a detailed routine, that included are added. The joints of both thumb and finger must individual scrutiny of each joint, tendon, and be stable; the intrinsic muscles must be strong; and pain muscle. A search was made for contractures of the must not be severe. copyright. http://ard.bmj.com/ on September 27, 2021 by guest. Protected Fig. lc.-Grip 3. Fig. Id.-Grip 4. Figs I a-d. Normal hand, using four basic grips. Ann Rheum Dis: first published as 10.1136/ard.16.2.183 on 1 June 1957. Downloaded from HAND DEFORMITIES IN RHEUMATOID DISEASE 185 Grip 3 (Fig. lc).-For using objects with a handle, of its own structures. Alternatively, stretching or such as a knife, the grip is complex, involving two destructive processes may lead to increased joint separate processes. First there is a firm grip between mobility in any direction. This includes rupture the thumb, index, and middle fingers with all the require- of ligaments, and subluxation or dislocation of ments of Grip 2. Then the handle is steadied by a grip between the ring and little fingers, and the thenar joints. Tendon lesions are common and may cause eminence or palm. This grip and related modifications difficulty in active extension or flexion, even when are commonly used in daily activities. The point to the joints are mobile. The tendons may be dis- realize is that the handle is held obliquely across the located, stretched, or ruptured. The intrinsic palm. This makes loss of flexion in the ring and little muscles may be weak; and they are often the site of fingers a most important deformity of far greater contractures which hamper joint movement and functional significance than loss of flexion in the index may lead to joint deformity. and middle fingers. The mixture of these deformities and deforming Grip 4 (Fig. Jd).-A stronger grip is required for factors is capable of infinite variation so that two pulling on hand-rails or the firm use of a hammer. cases are seldom alike. It is only by analysing a Without this grip it is almost impossible to board a large number of cases that any deformity is seen in bus unaided. Adequate abduction of the thumb is all its and of necessary to get the object into the palm of the hand, guises, patterns development become and then the fingers must flex at least so that they can apparent. act as a hook. Severe loss of flexion at the proximal interphalangeal joints makes this grip impossible and is, Loss of Finger Flexion due to Joint Deformities therefore, a serious disability as it prevents many activities Four sets ofjoints contribute to finger flexion: the useful to the arthritic. carpo-metacarpal joints of the ring and little fingers, All the patients attempted these four grips, and, in the metacarpo-phalangeal joints, the proximal inter- addition, a few patients were observed at greater length phalangeal joints, and the distal interphalangeal while doing a representative series of everyday tasks. joints. Of these, the metacarpo-phalangeal and proximal interphalangeal joints are the most Natural History of Hand Deformities important. copyright. The early stages of rheumatoid disease are For everyday function, flexion is more valuable characterized by active inflammation of the joint than extension. Also, flexion of the ring and little structures, tendons, and intrinsic muscles. Usually fingers is more important than flexion of the index this inflammation is mild and progression to de- and middle fingers.