RHEUMATOID ARTHRITIS

Arthritis in the hand is usually one of three types of arthritis: osteoarthritis, post-traumatic arthritis (which shows up after some injury), or rheumatoid arthritis. All three types take their root from arthritis, which literally means "inflamed joint." The body's joints, including those in the hand, wrist, and fingers, are all composed of two bones that meet with smooth surfaces covered with cartilage that enables them to move smoothly against each other as a matching set. When the smooth surfaces no longer fit together well, become uneven, or simply wear out from use, the joint is called arthritic. Although arthritis can show up in any joint, when it develops in the hand or fingers, it's more obvious because these joints are used so much. There are nineteen major bones in the hand, along with eight small ones and the two forearm bones that make up the wrist, so there are many joints where arthritis can present.

While osteoarthritis, post-traumatic arthritis, and rheumatoid arthritis are the most common, arthritis in the hand can also come from gout, psoriasis, or infection. 

Rheumatoid arthritis is a condition that impacts the cells that lubricate the joint and make up the lining, the synoval tissue. This condition can affect the whole body or many of its joints, usually all over the body. The synovium, or joint lining, gets inflamed and swells when rheumatoid arthritis is present, and this leads to the cartilage and bone eroding. If the swollen tissue stretches the ligaments, which hold the bones that surround the joint together, the joint may become unstable or cause a deformity. The inflammation can even influence the tendons, which are like ropes that tie the bones to the muscle, and cause them to stretch out and rupture.

Although rheumatoid arthritis can show up anywhere, with respect to the hand, it most often shows up in the wrist or the middle or end knuckles of the fingers.

No matter the type of arthritis, the joint affected will usually be stiff, swollen, and cause pain when used. If rheumatoid arthritis is present, some joints may have more swelling than others, and often the finger will look like a sausage in what's called fusiform. Other symptoms of rheumatoid arthritis may include:

• A soft lump on the back of the hand that moves with the tendon when the fingers are straightened
• Crepitus, or a creaking sound when the joint is used
• The fingers may begin edging away from the thumb
• The tendons that bend the fingers may become swollen and can cause the fingers to be numb or tingle, and when they're used there may be a clicking when the finger bends
• If the tendons are ruptured, it may be impossible to straighten some fingers or the thumb
• Wrist, finger, or thumb joints may be unstable
• In Boutonnière deformity, the middle joint of the finger is bent and the end joint hyperextends
• The middle joint in a finger may show sway-back, or hyperextension, in a finger with a bent fingertip in what's called a swan-neck deformit

The joints that are suspect will be compared by the surgeon to see if they have common symptoms. Hands and fingers will be examined clinically to help determine which type of arthritis is present. Rheumatoid arthritis will show certain features which can be seen in x-rays, including a narrowing of the space inside the joint, swelling and less dense bone near the joint, and bone erosion. If rheumatoid arthritis is suspected, blood or other lab tests may be requested. 

The goal of treatment for rheumatoid arthritis is to relieve pain and get back as much use as possible. Medication can help with the pain and inflammation if rheumatoid arthritis is in the hand, and can even slow down the growth of the disease. Treatment often includes anti-inflammatory medication and oral steroid medication, sometimes with injections of steroids.

New treatments to modify the disease have become available, including the use of anti-malarial drugs cyclosporine, methotrexate, gold, and other new drugs such as remicade or enbrel that work to suppress the natural immune system to lessen the inflammation and reduce the pain. These and other medications can be prescribed by a rheumatologist, who will monitor their use.

A hand therapist may also be recommended, who can help with exercises and splints and also with paraffin or warm wax treatments. Therapists can offer suggestions and instructions for different ways to use both the hand and fingers that can protect the joints while relieving the pain and pressure. They may also help with using devices designed to facilitate the performance normal, everyday tasks.

Tendons, as well as joints, can be affected by rheumatoid arthritis, and ones that get inflamed can click or rupture. The fingers may be stiff and unable to be bent or straightened if this happens, so the ability to grab or hold items may be reduced. Preventive surgery may be suggested to treat some cases and in an effort to remove nodules. To treat the tendons, preventive surgery may be done to remove either the rough bone or the inflamed tissue that can scrape or press on them, or the tendons, themselves, may be reinforced. If the tendon has ruptured, a hand surgeon may repair it or perform a graft or tendon transfer in addition to any of the other treatments.

If surgery is used to treat arthritic joints, it most often is done to remove the linings of the joints that are inflamed, to replace or fuse the joints, or remove bone that has become damaged or dead. The particular course of treatment depends on a number of things, including which joints need treatment, how much damage they show, the condition of nearby joints as well as the amount and nature of any loss of hand or finger use. The risks and benefits of any surgery will be made clear before any decision on a course of action is taken.

There is no cure for rheumatoid arthritis, but some deformities can be corrected through surgery. Surgery can also help with pain relief and the return of use of the hand or fingers. The best treatment comes from a combined effort between the patient and his or her hand therapist, rheumatologist, and doctor. If surgery is called for, it needs to be scheduled to take place before more severe deformities develop and when the joints can be kept for as long as possible.