S2 RHEUMATOID HAND – ASSESSMENT AND PLANNING OF TREATMENT

Abstract

Rheumatoid arthritis is a whole body, lifetime incurable disease. The problems engendered by the disease process itself are highly individual, given that each set of problems that a patient has, the assessment and planning of surgery is a crucial aspect of the appropriate management of patients with polyarthritis.

The presence of deformity does not necessarily indicate a problem of function, but one has to accept that certain deformities cause more problems than others and I draw your attention to swan neck deformity being relatively function-impairing and Boutonnière deformities less so. There is always a balance between the risk of surgery and the benefits to be obtained.

The assessment is functional, anatomical, radiological, psychological, medical, financial and, finally, surgical. The functional assessment is intended to identify the problems a patient has in the activities of daily living, the anatomical assessment identifies the structures damaged which need to be prepared or replaced, the x-rays define the bone loss and, therefore, determine the limits of bony surgery, the psychological aspect identifies the patient’s capacity and willingness to be involved in often quite complex therapy programmes over a significant period of time. The medical problems of vasculitis and active disease are less frequent now but are contra-indications to surgery in the acute phases.

The financial aspects are often under-rated. The costs of maintaining someone with significant disabilities is really quite great and, therefore, although surgery may only give some small improvement in function, it often has quite a significant impact on the degree of care and help an individual needs.

Finally, the surgical assessment is to identify which structures and in which order.

In terms of planning, the surgical priorities, described by Nalebuff, are:

1 Nerves 2 Flexor tendons 3 Wrist 4 Thumb 5 MCP joints 6 Extensors 7 PIP joints 8 Distal Interphalangeal joints

Prolonged nerve compressions do not recover well; ruptures of flexor tendons are very difficult to treat; if the wrist is painful and unstable it inhibits any function that the hand might have; the thumb is 50% of hand function; metacarpophalangeal joints need to be stable and to flex approximately to 60° in order to be functional; extensor tendons need to glide and to be able to lift fingers away from the palm; the interphalangeal joints contribute greatly to the closing of grasp.

The role of the therapist is pre-operatively to assess the patient appropriately for surgery, assessing all the aspects defined above and to ensure that the patient is compliant with the treatment post-operatively. The aphorism that 20% of the effort comes from the surgeon, 50% from the therapist and 20% from the patient is probably a fairly accurate representation of the importance of therapy post-operatively. Therapy must be planned, purposeful and progressive.