Hand Deformity in Rheumatoid Arthritis

The hand contains more than 25 joints which are especially susceptible to the damaging effects of rheumatoid arthritis. In fact, stiffness and swelling of the wrists and knuckles are often the very first signs of this chronic autoimmune disorder.

Rheumatoid arthritis is caused when the immune system malfunctions and attacks the joints of the body, causing pain, inflammation, fatigue, and weakness. Over time, as the disease progresses, it can lead to increased disability as the pain and restricted range of motion make it difficult to function.

When this happens in the hands, it can make opening a jar near-impossible and lead to the gradual deformity of the wrists, hands, and fingers.

As with other joints in the body, the joints in the hand are surrounded by a thin, pliable membrane known as synovium. The synovium produces synovial fluid, a thin, viscous substance that helps lubricate the joint.

With rheumatoid arthritis, the immune system sends white blood cells, called leukocytes, to attack healthy joint tissue. The synovium responds to this assault by producing layer upon layer of new synovial cells, one atop the next.

The accumulation of these tissues causes progressive deformity as they squeeze into the joint space and trigger the release of proteins that further degrade the surrounding cartilage and bone. These complex biochemical changes can affect the very architecture of the hand, causing a distortion of tendons and misalignment of bones and joints.

Rheumatoid arthritis usually develops asymmetrically, meaning that it can affect one hand differently than the other. It typically appears in one or more of the following joints in the hand:

• The metacarpophalangeal joints (the large knuckles where the fingers and thumb meet the hand)
• The proximal interphalangeal joints (the middle knuckles)
• The joints of the wrist including the carpometacarpal joint, midcarpal joint, radiocarpal joint, and the intercarpal joints

The distal interphalangeal joints (the outermost joints of the fingers and thumb) are not usually affected until the disease is advanced and the other joints have already been affected.

One of the more recognizable signs of advanced rheumatoid arthritis is a condition known as an ulnar deviation. This is where the fingers begin to drift toward the pinky due to the rupture of nearby tendons. At the same time, the wrist will begin to shift toward the thumb side of your hand.

When hand deformity occurs, it cannot be reversed by medications. Surgery may help realign the hand and restore some of the range of motion and function. It is not an easy surgery to perform and generally requires an extended recovery time with physical therapy.

Ultimately, early treatment is the best way to minimize damage and slow the progression of rheumatoid arthritis. Treatment varies by the stage of the disease:

• In early or mild rheumatoid arthritis, disease-modifying anti-rheumatic drugs (DMARDs) like Plaquenil (hydroxychloroquine) and Azulfidine (sulfasalazine) can often help.
• Moderate to severe rheumatoid arthritis typically requires more powerful DMARDs including methotrexate and Arava (leflunomide). Another class of drug, called TNF blockers, can help suppress the immune system by inhibiting an inflammatory protein known as tumor necrosis factor (TNF).

Source:

Chung, K. and Pushman, A. "Current Concepts in the Management of Rheumatoid Hand." J Hand Surg Am. 2011; 36(4):736-47. DOI: 10.1016/j.jhsa.2011.01.019.