Page 2 P H Y S I O T H E R A P Y June, 1968 The Diagnosis and Treatment of the Early Changes in the Rheumatoid Wrist and Hand L. S O L O M O N , M .D ., F .R .C .S . D e p a r t m e n t o f O r t h o p a e d i c S u r g e r y a n d R h e u m a t i s m a n d A r t h r i t i s U n i t , J o h a n n e s b u r g H o s p i t a l T h e wrist a n d h a n d a r e m o r e c o m m o n l y affe cte d in r h e u m a t o i d a r t h r i t i s t h a n a n y o t h e r site in t h e b o d y . P u l k k i (1961) f o u n d t h a t a p p r o x i m a t e l y o n e - t h i r d o f p a t i e n t s with r h e u m a t o i d d i se as e h a v e t e n o s y n o v i t i s a r o u n d t h e wrist a n d in t h e flex or s h e a t h s o f t h e fingers. M a n y m o r e ha v e sy n o v i t i s o f t h e wrist o r m e t a c a r p o p h a l a n g e a l ( M . C . P . ) j o i n t s , o f t e n a s s o c i a t e d w i t h p e r i a r t i c u l a r e r o s i o n s o n t h e bo n e. M o r e o v e r , in 95 p e r c e n t o f th e s e p a t i e n t s i n v o l v e m e n t b e c o m e s b i l at er al w it h t h e in e v i t a b l e p r o g r e s s o f t h e d ise as e ( S h o r t , B a u e r a n d R e y n o l d s , 1957). O f 136 p a t i e n t s wit h d ef in ite r h e u m a t o i d a r t h r i t i s se en in t h e A r t h r i t i s C l i n i c o f t h e J o h a n n e s b u r g H o s p i t a l b e t w e e n J a n u a r y 1965 a n d D e c e m b e r 1967, 103 h a d m a r k e d i n v o l v e ­ m e n t o f w ri sts a n d h a n d s . T h e cla ssical d e f o r m i t i e s o f t h e r h e u m a t o i d h a n d a r e t o o well k n o w n t o w a r r a n t a n o t h e r d e t a i l e d d e s c r i p t i o n ( Fi g. 1). T h e s e a r e t h e l at e effects o f t h e d i se as e a n d t r e a t m e n t s h o u l d be d i r e c t e d a t p r e v e n t i n g thi s g r i m p r o g r e s s t o w a r d s p a i n f u l d e f o r m i t y a n d lo ss o f f u n c t i o n . T h e a n a t o m i c a l d i s t o r t i o n s o f t h e seve re ly c r i p p l e d h a n d h a v e f o r s o l o ng h el d t h e lim eli ght t h a t a s t u d y o f t h e e a r l y p a t h o l o g y o f t h e d i se as e h a s been n eg l e c t e d a n d t r e a t m e n t h a s c o m e t o m e a n sa l v a g e r a t h e r t h a n p r e v e n t i o n o r cur e. t h e u l n a r h e a d reve als a p a i n f u l s u b - l u x a t i o n o f t h e r a d i o ­ u l n a r j o i n t . R a d i o g r a p h i c e x a m i n a t i o n m a y s h o w the ty p i ca l “ c y s t ” o r e r o s i o n o f t h e u l n a r st yl o i d p r o c e s s or d i s r u p t i o n o f t h e j o i n t itse lf ( Fi g. 2). F ig . 1. T h e la te d e fo rm itie s o f th e rh e u m a to id h an d . T h e p r e s e n t p a p e r de al s w i t h t h e e a r l y lesion s o f t h e r h e u m a t o i d wr ist a n d h a n d a n d t h e i r t r e a t m e n t by p h y si c al a n d su r g ic al m e a s u r e s . S y st e m i c t r e a t m e n t wi th sa lic yl ate s a n d o t h e r a n t i - i n f l a m m a t o r y a g e n t s m a y , o f c o u r s e , c o n t r o l t h e ac ti vi ty o f t h e d i se as e a n d c h e c k its p r o g r e s s in t h e h a n d s as els ew he re . I n d e e d , t h e s t a t e o f t h e i n t e r p h a l a n g e a l j o i n t s is o n e o f t h e m o r e r eli abl e m e a s u r e s o f d i se as e ac t i v i t y a n d is us ed t o e v a l u a t e t h e efficacy o f d r u g t r e a t m e n t ( B o a r d m a n a n d H a r t , 1967). In t h e m a j o r i t y o f cas es, h o w e v e r , th es e m e a s u r e s a l o n e h a v e p r o v e d i n a d e q u a t e a n d t h e h o p e s ra ise d by e a c h n e w “ w o n d e r d r u g ” h a v e a l w a y s se em ed b r i g h t e r in n e w s p r i n t t h a n in cli nical p r ac ti ce . S Y N O V I T I S O F T H E D I S T A L R A D IO - U L N A R J O I N T S y n o v i t i s o f t h e di sta l r a d i o - u l n a r j o i n t is f r e q u e n tl y t h e ea r l i es t c h a n g e in t h e wr ist o r h a n d . I f n o t specifically s o u g h t fo r, h o w e v e r , it m a y be eas ily m iss ed . T h e r e is g e n e r a l l y a sl ig h t sw el lin g a r o u n d t h e j o i n t a n d p r e s s u r e o n F ig. 2. Cy st ic er o si o n o f t he d i s t a l end o f th e uln a as soc iat ed with synovitis o f t h e r a d i o -u l n a r jo int. T h e d i a g n o s is is i m p o r t a n t f o r t hi s m a y be t h e first stag e in a r e c o g n i z a b l e m a r c h o f e v e n t s : p a i n f u l r a d i o - u l n a r j o i n t — r a d i a l d e v i a t i o n o f t h e c a r p u s ( F i g . 3)— u l n a r d ev i a­ t i o n o f t h e fi ngers t o r e s t o r e t h e a l i g n m e n t o f t h e h a n d . I t is sig ni fi ca nt t h a t t h e vas t m a j o r i t y o f p a t i e n t s w i t h e s t ab lis h ed d e f o r m i t i e s o f t h e fingers als o h a v e d ise as e o f t h e wr ist with r a d i a l d e v i a t i o n o f th e c a r p u s . C o n t r a r i w i s e , in Sti ll ’s disease w h i c h is f r e q u e n t l y as so c i a t e d wit h d y s p l a s i a o f t h e distal e n d o f t h e u l n a a n d u l n a r d e v i a t i o n o f t h e c a r p u s , t h e r e is u s u a l ly n o u l n a r d e v i a t i o n o f t h e fingers. T r e a t m e n t : S p l i n t in g o f t h e wr ist in t h e n e u t r a l p o s it io n a f f o r d s b o t h rest f o r t h e i n f la m e d j o i n t a n d a g e n t l e c o r r e c ­ t i o n o f t h e d e f o r m i t y . T h e r e s t i n g s pl in ts , w h i c h a r e m o u l d e d o u t o f p l a s te r o f P ar i s, d u r a l u m i n o r p ol y v i n y l sh ee ts, e x t e n d n o f u r t h e r t h a n t h e p a l m o f t h e h a n d t h u s a l l o w i n g full m o b i l i t y o f t h e m e t a c a r p o p h a l a n g e a l j o i n t s . T h e y a r e usua lly R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1968 P H Y S I O T H E R A P Y Page 3 wo rn o nl y at nig ht bu t. if t h e d e f o r m i t y p r og re s se s u n d e r t r e a t m e n t t h e sp l i n t s m a y be w o r n d a y a n d night. F ig. 3. R a d ia l d e v ia tio n o f th e w rist d u e to ra d io -u ln a r sy n o v itis. If th e r a d i o - u l n a r j o i n t is still in ta ct it is o u r p r a c t i c e to tr eat th e sy no v it is by i n t r a - a r t i c u l a r in jec ti on o f ni t ro g e n m u s t a r d a n d b e t a m e t h a s o n e . G o o d results, wit h relief o f pain a n d sw elling f o r p e r i o d s o f s :x m o n t h s t o t w o yea rs, hav e been o b t a i n e d in at L-ast h a l f o f th e s e p a t i e n t s. F o r th e later case, wit h d i s l o c a t i o n o f t h e r a d i o - u l n a r ji int, excision o f th e di stal e n d o f ll:e u l n a a n d s y n o v e c t o m y o f t h e w rist is the t r e a t m e n t o f choi ce. S Y N O V I T I S O F T H E M E T A C A R P O P H A L A N G E A L ( M .C .P .) J O I N T S T h e sw oll en M . C . P . j o i n t s a r e t h e classic t r a d e - m a r k o f t h e r h e u m a t o i d h a n d , re co g n i se d by spe cialist a n d l a y m a n al i ke as th e sign o f a “ s p r e a d i n g a r t h r i t i s " ( Fi g . 5). F o r th e p a t i e n t t h e ea rl y m o r n i n g sw ell ing a n d stiffness o f t h e h a n d s m a y be t h e m a j o r — o r i n d e e d t h e o n l y — di sa b il i t y for sev era l y ear s. F o r t h e r h e u m a t o l o g i s t sy no v i t i s o f t h e M . C . P . a n d p r o x i m a l i n t e r p h a l a n g e a l ( P .I . P . ) j o i n t s , w i t h p e r i a r t i c u l a r e r o s i o n s a n d o s t e o p o r o s i s , m a y be t he ea rl ies t si gn o f r h e u m a t o i d dise ase , o f t e n p r e c e d i n g t h e di sc o v e ry o f po sit iv e s e ro lo gi ca l r ea ct io ns . It is at t h is st a g e t h a t t r e a t m e n t c a n be m o s t effective in p r e v e n t i n g t h e late r e su l t s o f M . C . P . a r t h r i t i s . T h e c o m b i n a t i o n o f c h r o n i c sy no vi ti s, sw ell ing o f t h e j o i n t a n d a r t i c u l a r e r o s i o n by g r a n u l a t i o n tissue will, if left u n c h e c k e d , lead i n e x o r a b l y t o c a r t i l a g e d e g e n e r a t i o n , s t r e t c h i n g o f t h e c a p s u l e a n d li g a m e n t s a n d finally d i s ­ r u p t i o n o f t h e j o i n t . F ig. 4. T h e la te effe cts o f rh e u m a to id a r th r itis . R a d io g ra p h sh o w in g d e s tru c tio n o f th e c a rp u s. S Y N O V I T I S O F T H E R A D I O - C A R P A L J O I N T P ro g re ss iv e i n v o l v e m e n t o f t h e wrist m a y lead, ul ti m at el y, t o d e s t r u c t i o n o f t h e c a r p u s (Fig . 4). In t h e e ar ly stages, howe ver , p ai n d u e t o a c u t e a n d s u b - a c u t e sy n o v i t i s m a y be o u t o f all p r o p o r t i o n t o t h e d e t e c t a b l e d a m a g e t o t h e j o i n t . Stab il ity o f th e wr ist is a l l - i m p o r t a n t in m a i n t a i n i n g c o n t r o l a n d p o w e r in t h e h a n d a n d n o t in f r e q u e n t l y t h e w ea k gri p o f t h e r h e u m a t o i d h a n d is e x a g g e r a t e d by p a i n in t he wrist. T r e a t m e n t : W h e r e g o o d m o b i l i ty o f t h e w'rist is r e ta in ed a n d t h e r a d i o g r a p h s s h o w a n i n t a c t a r t i c u l a r su r f ac e, t r e a t ­ m en t is t h e s a m e as t h a t f o r r a d i o - u l n a r sy nov it is . R e li e f o f s y m p t o m s a n d si gn s for a y e a r o r lo n ge r h a s been ac h i ev ed in t h e m a j o r i t y o f th e s e p a t i e n t s b u t u l t i m a t e l y t w o o u t o f every t h r e e h a v e r e q u i r e d s ur g ic al s y n o v e c t o m y . A s a rule this is c o m b i n e d w i t h s y n o v e c t o m y o f t h e e x t e n s o r t e n d o n s a n d excis ion o f t h e di sta l e n d o f t h e ul na. P o s t - o p e r a t i v e l y t he wrist is s p l i n t e d firmly f o r t w o we ek s a n d t h e n g r a d u a l m o v e m e n t is c o m m e n c e d . By t h e e n d o f six we ek s full m o v e m e n t is g e n e r a l l y r eg ai ne d. F ig . 5. S y n o v itis a n d sw ellin g o f th e M .C .P . jo in ts. In t h e o v e r w h e l m i n g m a j o r i t y o f su ch ca s es it is th e s e c o n d a n d t h i r d M . C . P . j o i n t s t h a t a r e affe cte d first. T o g e t h e r with th e r a d i o - c a r p a l j o i n t th ey c o n t r o l t h e r a d i a l pill ar o f t h e h a n d ; in sta b i l i t y o f t h e s e a r t i c u l a t i o n s p e r m i ts t h e m e c h a n i c a l d i s t o r t i o n s d u e t o m u s c u l a r w e a k n e s s , t e n d o n r u p t u r e o r t h e re p et it iv e fo rc e s o f gr ip a n d p r e s s u r e t h a t a c c o m p a n y t h e m o s t o r d i n a r y activities. T r e a t m e n t : T h e best h o p e o f p r e v e n t i n g t h e late c r i p p l in g d e f o r m i t i e s o f t h e r h e u m a t o i d h a n d lies in t h e e ar ly a n d effective t r e a t m e n t o f t h e M . C . P . sy nov it is . S y st e m i c t r e a t ­ m e n t d u r i n g t h e ac t i v e p h a s e o f t h e d i se as e m a y b ri n g a b o u t a r e d u c t i o n in t h e swe ll ing o f t h e j o i n t s . A s a rul e, ho w e v e r , we a r e l o a t h t o w ai t f o r thi s u n c e r t a i n o u t c o m e ; if t h e r e is a n o b v i o u s sy no v i t i s w it h visible a n d p a l p a b l e j o i n t swelling, sy s t e m i c t r e a t m e n t is c o m b i n e d wi th a d ir ec t a t t a c k u p o n th e j o i n t s . T h e resu lt s o f i n t r a - a r t i c u l a r in j ec t i o n o f n i t r o g e n m u s t a r d a n d b e t a m e t h a s o n e h a v e e n c o u r a g e d us t o us e thi s a s a first m e a s u r e in ev er y n e w case. T h e m i x t u r e u se d c o n t a i n s 20 m g. b e t a m e t h a s o n e p er ml. a n d n i t r o g e n m u s t a r d in a c o n c e n t r a t i o n o f 0.0 02 p er ce nt . J u s t e n o u g h is i nj ect ed to d i s t e n d t h e j o i n t — u su a l ly 0.5 t o 1 m l . — a n d if n ece ss ar y, all t h e M . C . P . j o i n t s a r e in jec ted at t h e s a m e sitti ng. T w e n t y - f o u r h o u r s a f t e r in j ec t i o n ice t r e a t m e n t o f th e h a n d s is c o m m e n c e d a n d m o v e m e n t s a r e e n c o u r a g e d . At n i g h t , h o w e v e r , t h e h a n d s a r e rest ed in m o u l d e d s pl in ts wit h t h e M . C . P . j o i n t s in t h e n e u t r a l p o s i t i o n . T h i s is c o n t i n u e d until p a i n a n d swe ll ing su b s i d e. T h e resul t o f t h is t r e a t m e n t in 22 n e w cas es (68 j o i n t s ) h a v e bee n s a t i s f a c t o r y in 75 p er c e n t , t h e r e m i ss io n o f p a i n a n d sw el lin g l as tin g f o r p e r i o d s o f six m o n t h s t o t w o y ear s. F a i l u r e to r e d u c e t h e s y n o v i t i s is r e g a r d e d as a n i n d i c a t i o n fo r s u r g ic al s y n o v e c t o m y o f t h e M . C . P . j o i n t s . I f t h e u l n a r d ri ft o f t h e fingers h a s a l r e a d y c o m m e n c e d , s y n o v e c t o m y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y June, 1968 is c o m b i n e d w i t h p l i c a t i o n o f t h e j o i n t c a p s u l e a n d r e a l i g n ­ m e n t o f t h e fin gers in t h e n e u t r a l p o s i t i o n . E X T E N S O R T E N O S Y N O V I T I S A T T H E W R I S T T e n o s y n o v i t i s o f t h e e x t e n s o r t e n d o n s u s u a l l y a c c o m p a n i e s s y n o v i t i s o f t h e wr ist j o i n t . It m a y , h o w e v e r , p r o v e t o be th e m o r e i m p o r t a n t a s p e c t o f a n y p a r t i c u l a r c as e, f o r a p e r s i s t e n t t e n o s y n v it i s w i t h i n f l a m m a t o r y e r o s i o n o f t h e e x t e n s o r t e n d o n s is a f r e q u e n t c a u s e o f t e n d o n r u p t u r e ( Fi g . 6). T r e a t m e n t : N e i t h e r local i n j e c t i o n s n o r s p l i n t s a r e o f m u c h a va il in t h e s e c a s e s a n d s y n o v e c t o m y is u s u a l l y calle d f or . T h i s m a y be c o m b i n e d w i t h s y n o v e c t o m y o f t h e wrist a n d ex c i s i o n o f t h e d i s t a l e n d o f t h e u l n a. A r t h r i t i s C l i n i c s h o w t h a t t h e l at t er is a m a j o r f a c t o r in n o less t h a n 30 p er c e n t o f p a t i e n t s w i t h p a i n a n d stiffness o f t h e h a n d s . A t h u m b p l a c e d o v e r t h e flex or t e n d o n in t h e p a l m will d i s c o v e r t h e ty p i ca l c r e p i t a t i o n o n p a s si v e flex ion a n d e x t e n s i o n o f t h e af fe cte d finger. A si m i l a r , b u t less o b v i o u s , d i s t u r b a n c e m a y be f o u n d at t h e level o f t h e P . l . P . j o i n t w h e r e t h e flex or d i g i t o r u m p r o f u n d u s p a s se s t h r o u g h t h e slips o f t h e su p er fi cia l flexor. In t h e w o r s t ca s es t h e t h i c k e n e d s h e a t h m a y b e p a l p a t e d a l o n g t h e l eng th o f t h e p r o x i m a l p h a l a n x . I n t e r f e r e n c e w i t h t h e g l i d i n g m e c h a n i s m o f t h e flex or t e n d o n is d e m o n s t r a t e d by t h e p a t i e n t ’s i na b il it y t o cu rl t h e af fe ct ed finger i n t o t h e p a l m o f t h e h a n d ( Fi g . 8). T h is f u r t h e r w e a k e n s t h e g r i p a n d c o n t r i b u t e s si g ni fi ca nt ly t o th e v u l n e r a b i l i t y o f t h e M . C . P . j o i n t s t o m e c h a n i c a l d i s t o r t i o n . F ig . 6. E x te n s o r te n o s y n o v itis a t th e w ris t. N o d u la r d e g e n e ra tio n o f th e te n d o n is sh ow n. F L E X O R T E N O S Y N O V I T I S A T T H E W R I S T T h e ef fects o f fl ex o r t e n o s y n o v i t i s a r e s i m i l a r to t h o s e o f e x t e n s o r t e n o s y n o v i t i s . I n a d d i t i o n , h o w e v e r , t h e b u l k y s y n o v i a l ti ss u e m a y c a u s e m e d i a n n e r v e c o m p r e s s i o n in t h e c a r p a l t u n n e l . P a r a e s t h e s i a e a n d n u m b n e s s in t h e m e d i a n n e r v e d i s t r i b u t i o n , o r w e a k n e s s o f t h e s h o r t a b d u c t o r o f t h e t h u m b , s h o u l d i m m e d i a t e l y su g g e st th i s d i a g n o s is . F ig . 8. F le x o r te n o sy n o v itis o f th e h a n d a n d fin g e rs c a u sin g in a b ility to c u r l th e a ffe c te d fin g e rs in to fu ll flex io n . T r e a t m e n t : I f t h e d i a g n o s i s is m a d e sufficiently e a r l y local i n j e c t i o n o f n i t r o g e n m u s t a r d a n d b e t a m e t h a s o n e i n t o t h e flex or s h e a t h s u s u a l l y p r o d u c e s a c o m p l e t e r e m i s s i o n o f th e syn o v i t i s . I n t h e lo n g s t a n d i n g case , h o w e v e r — a n d es p ec ia ll y in t h o s e w i t h n o d u l e s o n t h e flex or t e n d o n s — su r g i c a l s y n o ­ v e c t o m y is t h e t r e a t m e n t o f c h o i c e . N o s p l i n t s a r e a p p l i e d a f t e r th i s p r o c e d u r e a n d e a r l y m o v e m e n t s a r e e n c o u r a g e d in o r d e r t o r e -e s t a b l i s h t h e free g l i d i n g a c t i o n o f t h e flex or t e n d o n s i n t h e p a l m a n d fingers. F l e x o r s y n o v e c t o m y h a s b e e n c a r r i e d o u t in 18 p a t i e n t s . T w e l v e o f t h e s e (17 h a n d s ) h a v e b e e n f o l lo w e d f o r at least o n e y e a r a f t e r o p e r a t i o n . I n all b u t t w o o f t h e s e p a t i e n t s t h e r e h a s b e e n a n i m p r o v e m e n t in t h e r a n g e o f finger m o v e m e n t a n d in e i g h t t h e o p e r a t i o n h a s r e s t o r e d n e a r ­ n o r m a l m o b i l i t y ( F i g . 9). F ig . 7. S y n o v e c to m y a n d d e c o m p re ss io n o f th e c a r p a l tu n n e l. T r e a t m e n t : M e d i a n n e r v e d e c o m p r e s s i o n is a c h i e v e d by d i v i s i o n o f t h e t r a n s v e r s e c a r p a l l i g a m e n t a n d a ca r e f u l s y n o v e c t o m y o f t h e fl ex or t e n d o n s a s t h e y c r o s s t h e wrist ( F i g . 7). A f t e r o p e r a t i o n t h e h a n d a n d w r i st a r e s p l i n t e d f o r 48 h o u r s a n d t h e r e a f t e r m o v e m e n t s a r e e n c o u r a g e d . F L E X O R T E N O S Y N O V I T I S O F T H E F I N G E R S It is u s u a l ly t a k e n f o r g r a n t e d t h a t p a i n a n d stiffness o f t h e fi nge rs in r h e u m a t o i d d i s e a s e a r e d u e t o a p o l y a r t h r i t i s . Fig. 9. F i n g e r flexion a f t e r flex or sy no ve cto m y. T h i s b e t r a y s a f a i l u r e t o e x a m i n e th e h a n d c a r e f u l ly f o r a t e n o s y n o v i t i s o f t h e fl ex or t e n d o n s . T h e r e c o r d s o f t h e (e o n iin iie d o n p a g e 5.) R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )