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Comprehensive Review on Rheumatoid Arthritis (RA)
Blog Presentation by Dr. Ch. Amorgianos

Indroduction

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disorder characterized by inflammation of the synovial joints. In the hand, RA often leads to joint destruction, deformity, and functional impairment. This blog explores RA’s pathophysiology, clinical signs, diagnostic markers, and modern treatment approaches, emphasizing hand-specific considerations and surgical options.

Pathophysiology

RA in the hand begins with an autoimmune attack on the synovium, resulting in chronic inflammation. Over time, this leads to:

  • Synovial hyperplasia and pannus formation that erodes cartilage and bone.

  • Cytokine involvement (TNF-α, IL-1, IL-6) driving inflammation and osteoclastic activation.

  • Ligament laxity, tendon rupture, and joint instability, leading to characteristic deformities like ulnar drift, swan-neck, and boutonnière deformities.

20 Key Signs & Facts About RA

  1. Symmetrical Joint Involvement – Affects both hands equally.
  2. Morning Stiffness – Lasts over 60 minutes.
  3. Swollen, Warm Joints – Synovial thickening with warmth and tenderness.
  4. Pain and Tenderness – Persistent and activity-related.
  5. Ulnar Drift – MCP joint fingers deviate toward the ulnar side.
  6. Boutonnière Deformity – PIP joint flexion with DIP hyperextension.
  7. Swan-Neck Deformity – PIP hyperextension with DIP flexion.
  8. Joint Erosions on Imaging – Radiographic signs of damage.
  9. Rheumatoid Nodules – Subcutaneous nodules on extensor surfaces.
  10. Soft Tissue Swelling – Extends beyond the joints.
  11. Tenosynovitis – Tendon sheath inflammation, leading to tendon rupture.
  12. Carpal Instability – Leads to wrist collapse.
  13. Reduced Range of Motion – Both active and passive.
  14. Joint Crepitus – A grating sensation upon movement.
  15. Fatigue & Anemia – Systemic symptoms linked to inflammation.
  16. Elevated Inflammatory Markers – ESR and CRP.
  17. Joint Destruction Progression – Gradual worsening over years.
  18. Response to DMARDs – Early intervention slows progression.

Latest Guidelines & Treatment Options

Medical Management

  • Early intervention with DMARDs (methotrexate) and biologic agents (TNF-α and IL-6 inhibitors) improves long-term outcomes.
  • Short-term corticosteroids help manage acute flares.

Hand-Specific Treatment

  • Conservative measures: Splinting, occupational therapy, and NSAIDs.
  • Surgical interventions for irreversible deformities:
    • Synovectomy – Removes inflamed synovium.
    • Tendon Repair/Transfer – Restores function.
    • Joint Arthroplasty – MCP or interphalangeal joint replacement.
    • Arthrodesis – Joint fusion for stability.

 

Outcomes & Considerations

Biologic therapies have improved systemic control, but hand deformities still necessitate surgical intervention. A multidisciplinary approach, combining rheumatology, hand surgery, and rehabilitation, is crucial for optimizing patient outcomes.

Conclusion

RA in the hand is a progressive autoimmune disorder requiring early and comprehensive management. Early systemic treatment with DMARDs and biologics, alongside hand-specific therapies, can improve long-term function and quality of life. For advanced cases, surgical correction remains essential to restoring hand function.

Bibliography

  1. Gelberman, R. H., et al. “Surgical Management of RA in the Hand.” J Hand Surg (Am Vol), 2019.
  2. Bishop, A. T., et al. “Outcomes of Synovectomy in RA.” Hand Clinics, 2018.
  3. Manske, P. R. “Tendon and Joint Reconstruction in RA Hands.” J Hand Surg (Eur Vol), 2017.
  4. Norris, C., et al. “Advances in Arthroplasty for RA of the Hand.” Hand Surgery, 2020.
  5. Baldwin, S. A., et al. “Multidisciplinary Approaches to RA in Hand Surgery.” Hand Clinics, 2021.

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Dr. Christodoulos Amorgianos Orthopedic Trauma Surgeon – Specialist Hand Microsurgery & Interventional Pain Specialist
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