Symmetry means the defeat of the joints of the same name on both sides. In addition, in RA, the entire joint is involved in the process, in contrast to osteoarthritis, when only those areas that are most exposed to mechanical stress are affected.
9. What is pannus?
The primary focus of the inflammatory process in RA is localized in the synovial membrane of the joint. The inflammatory infiltrate consists of mononuclear cells, mainly T-lymphocytes, as well as activated macrophages and plasma cells, some of which produce rheumatoid factor. Synovial cells proliferate rapidly, the synovial membrane swells, thickens, forms outgrowths into the underlying tissues. Such a synovium is called a pannus; it has the ability to grow into bone and cartilage tissue, leading to the destruction of the joint structures.
It is important to note that polymorphonuclear leukocytes (PMNL) are practically not found in the synovial membrane, while they predominate in the synovial fluid. Proteolytic enzymes of neutrophils also contribute to the destruction of articular cartilage.
10. List the most common hand deformities in RA. Fusiform swelling- synovitis of the proximal interphalangeal joints, which acquire the shape of a spindle.
Deformation of the "boutonniere" type ("buttonholes")- persistent flexion of the proximal interphalangeal joint and extension of the distal interphalangeal joint, caused by the weakness of the central fibers of the extensor tendon and the displacement of the lateral fibers of this extensor to the palmar side; as a result, the finger seems to be threaded through the buttonhole.
Swan neck deformity- developed due to persistent contraction of the flexor muscles of the metacarpophalangeal joints, their contractures, as well as overextension in the proximal interphalangeal joints and flexion in the distal interphalangeal joints.
Ulnar deviation of fingers with incomplete dislocations in the metacarpophalangeal joints.
A. Deformities of the fingers of the "swan neck" type (II-IV fingers) and of the "boutonniere" type (V finger). B. Ulnar deviation of the fingers (note rheumatoid nodules). (From: Revised Clinical Slide Collection on the Rheumatic Diseases. Atlanta, American College of Rheumatology, 1991; with permission.)
11. List the most common deformities of the feet during pa.
Inflammatory process in the metatarsophalangeal joints leads to subluxation of the metatarsal heads and, ultimately, to the most common deformity of the toes in patients with RA - "claw-like fingers" or "hammer-like" fingers. These people have problems with wearing shoes because they often rub the tips of their toes, which can cause calluses or ulcers. In addition, the fibro-fatty "cushions" that are normally located under the heads of the metatarsal bones are displaced, exposing the latter. In this case, the process of walking is accompanied by very strong pain, callosities develop on the plantar surface of the distal phalanges (patients compare their sensations with walking on sharp stones). The involvement of the metatarsal joints in the process leads to a flattening of the arch and valus deformity of the foot.
These deformations can be the result of both insufficient and excessive activity of the muscles described. The following conditions cause abnormal position of the fingers(fig. 106).
- Rupture of the tendon extension of the extensors at the level of the triangular ligament passing between the two lateral cords, the elasticity of which is necessary to restore their dorsal position during extension of the proximal interphalangeal joint. As a result, the posterior surface of the proximal interphalangeal joint bulges out through the ruptured stretching, and the lateral cords are displaced to the sides of the joint, which remains in a bent position. The same deformity can be caused by crossing the common extensor of the fingers at the level of the proximal interphalangeal joint (boutonniere deformity).
- Rupture of the extensor tendon near its proximal attachment to P 3 causes flexion in the distal interphalangeal joint, which can be corrected passively, but not actively. This flexion is due to FDP contraction not balanced by EDC. In this way, a hammer toe is formed.
- Rupture of the extensor tendon proximal to the metacarpophalangeal joint leads to flexion of this joint due to the predominant action of the tendon extension of the extensors.
- FDS laceration or paralysis leads to overextension in the proximal interphalangeal joint due to the greater activity of the interosseous muscles. This "reverse" position of the proximal interphalangeal joint is accompanied by slight flexion at the distal interphalangeal joint due to the relative shortening of the FDP due to overextension at the proximal interphalangeal joint.
- Paralysis or injury of the FDP tendon makes active flexion in the distal interphalangeal joint impossible.
- Interosseous muscle paralysis leads to overextension of the metacarpophalangeal joint under the action of EDC and excessive flexion in the proximal and distal interphalangeal joints under the action of FDS and FDP.
Loss of function of the extensors of the wrist joint and fingers, most often observed with radial nerve palsy, leads to the appearance of a "drooping hand" (Fig. 107), characterized by excessive flexion in the wrist joint, flexion in the metacarpophalangeal joints and extension in the distal interphalangeal joints under the action of the interphalangeal joints. muscles.
With Dupuytren's contracture (Fig. 109), caused by shortening of the pre-tendinous fibers of the central palmar aponeurosis, persistent flexion of the fingers appears in the metacarpophalangeal and proximal interphalangeal joints during extension in the distal interphalangeal joints. Most often, the fourth and fifth fingers are affected, the third finger is involved in the process later, and the thumb is only in exceptional cases.
With Volkmann's contracture (Fig. 110), due to ischemic contracture of the flexor muscles, the fingers take a hook-like position, which is especially noticeable when extending a in the wrist joint and less obvious when flexed b .
The fingers can be in a hook-like position (Fig. 111) with purulent synovitis of the common flexor tendon of the fingers. This deformity is most pronounced in the medial toes, especially in the fifth. Any attempt to straighten the fingers causes severe pain.
And finally, the hand can be fixed in the position of pronounced ulnar deviation (Fig. 112), when the II-V fingers are clearly tilted to the medial side with a sharp standing of the metacarpal heads. This deformity makes one suspect the presence of rheumatoid arthritis.
"Upper limb. Physiology of the joints"
A.I. Kapanji
The content of the article
Rheumatoid Arthritis (RA)- a chronic (or subacute) disease characterized by a progressive symmetric inflammatory lesion of the joints (polyarthritis) and a number of systemic extra-articular manifestations (which justifies the use of the term "rheumatoid disease"). The incidence of RA is 1-2% in women and is 3-4 times more common than in men; this difference is less pronounced in childhood and old age. It can begin at any age, the peak incidence in women is 35-55 years, in men - 40-60 years.Etiology and pathogenesis of rheumatoid arthritis
The role of the following factors is discussed in the origin of RA:1) immune disorders with the development of autoimmune reactions to collagen or IgG;
2) genetic factors;
3) infectious agents - bacteria, mycoplasmas, viruses.
In RA, numerous autoantibodies are detected, including rheumatoid factors - antibodies, usually of the IgM class, directed against its own IgG (epitopes of its Fc-fragment), antinuclear antibodies, antibodies to cytoplasmic antigens of the cytoskeleton - vimentin and keratin. There is a defect in cellular immunity (a decrease in the number of T-suppressors). The synovial membrane is infiltrated with lymphocytes (mainly T-helpers) and plasma cells, the synovial fluid contains locally synthesized immunoglobulins (including rheumatoid factors), immune complexes, and lymphokines. The role of T-lymphocytes in the pathogenesis of RA is confirmed by a decrease in the activity of the rheumatoid process after drainage of the thoracic lymphatic duct and leukopheresis with removal of T-lymphocytes. These disorders suggest the mechanism of tissue damage. An unknown foreign antigen, localized in the synovial membrane, is processed by antigen-presenting cells (synovial membrane cells, macrophages, etc.) and causes local formation of antibodies, which occurs intensively in conditions of a deficiency of T-suppressors and an excess of T-helpers. Antibodies bind to the antigen, forming immune complexes, attract neutrophils into the synovial fluid and activate the complement system. Neutrophils and macrophages phagocytose immune complexes and release chemical mediators of inflammation - lymphokines, lysosomal enzymes, prostaglandins, leukotrienes, free oxygen radicals. Ongoing inflammation stimulates the proliferation of the synovium, proteolytic enzymes and free radicals destroy cartilage and bones. The pathogenesis of most extra-articular lesions is associated with the development of immunocomplex vasculitis.
Genetic factors are of great importance, which has been proven in studies of the frequency of RA in families and in identical twins. Some antigens of the major histocompatibility complex (HLA DR4 and HLA DW4) are found in RA patients much more often than in the population, others (HLA DRW2) - less often.
The role of infectious agents - bacteria, viruses and other microorganisms - is quite possible, but not proven and needs further study. In various experimental models, the development of arthritis is closely associated with infection, rheumatoid factors are observed in some diseases with proven persistence of the immune stimulus.
In RA, the primary development is inflammation and proliferation of the synovium. First, infiltration with mononuclear cells is noted, then the synovial cells proliferate, the villi hypertrophy, and a tumor-like aggressive granulation tissue called pannus forms along the edge of the articular cartilage. Pannus gradually penetrates into the cartilage, destroys it and fills the joint cavity, subsequently developing fibrous and bone ankylosis of the joint.
Changes in blood vessels (vasculitis), as well as characteristic subcutaneous (rheumatoid) nodules with an area of necrosis surrounded by macrophages and fibroblasts, are detected. Similar formations are also observed in the pleura, pericardium and lungs. Lymph node hyperplasia is often observed. Changes in the internal organs of the heart (carditis), lungs and pleura (chronic interstitial pneumonia, pleurisy), kidneys (nephritis, amyloidosis), etc. can be detected.
Clinic for rheumatoid arthritis
The onset of the disease can be different, but the most characteristic is the gradual appearance of pain and stiffness in the joints of the hands and feet, followed by the development of symmetric peripheral polyarthritis. Most often, the proximal interphalangeal, metacarpophalangeal, metatarsophalangeal, and wrist joints are affected. Less commonly, one joint is affected, such as the knee, or arthritis recurs. In 15-20% of patients, the disease begins acutely - sometimes after a mental injury or a cold - with severe joint pain and fever. Sometimes the first symptoms are weakness, malaise, or morning stiffness. Sometimes the articular syndrome is preceded by fever with chills, accompanied by lymphadenopathy, serositis, etc.In RA, all joints are affected except for the thoracic and lumbar spine. In 50% of patients, the hip joints are affected (rarely at the onset of the disease, but usually in the first years). Joint pain is stronger in the morning upon waking, then the whisker decreases and again
or lasts at night, leading to sleep disturbance. Morning stiffness of movements in all joints is characteristic; with active RA, stiffness can persist for many hours after awakening. The affected joints are swollen, often warm, and the skin color usually does not change. Edema is mild, due to effusion and proliferation of the synovium. Movements in inflammatory joints are painful and limited in volume. Muscle atrophy is characteristic.
The joints of the hands are more often affected - metacarpophalangeal, proximal interphalangeal and wrist joints. The defeat of the distal interphalangeal joints is not typical. The fingers become fusiform early, the metacarpophalangeal joints and the wrist swell. Wrist tendosynovitis can cause carpal tunnel syndrome due to compression of the median nerve. Later, as the disease progresses, there is a weakening of the joint capsule, tendon ruptures, and muscle atrophy. These changes can cause characteristic deformities, ulnar deviation (lateral deviation of the fingers), "swan neck" (flexion contracture of the distal and hyperextension of the proximal interphalangeal joints), symptom of "boutonniere" or "button loop" (flexion contracture of the proximal joint and hyperextension of the distal interphalangeal joints). These deformities, in combination with atrophy of the interosseous muscles on the dorsum of the hand, form a characteristic picture of the "rheumatoid hand".
The joints of the feet and ankles are deformed in the same way as the joints of the hands - lateral deviation of the fingers and subluxation of the metatarsophalangeal joints are noted, so that the heads of the bones can be palpated from the side of the sole.
The appearance of rheumatoid nodules in the tendons of the flexor muscles of the fingers and toes can cause sharply painful snapping of the toe.
In the knee joints, effusion, frequent subluxations due to weakening of the joint capsule and atrophy of the quadriceps femoris muscle, valgus or varus deformities are noted. The synovial space may extend to form a Baker cyst in the popliteal fossa; if the joint is torn from behind, then the synovial fluid enters the intermuscular spaces of the lower leg, causing swelling and pain, which should be differentiated from that of deep vein thrombosis. Knee deflection can also be associated with thickening of the periarticular tissues. Difficulty in extension develop early, and then flexion contractures.
A number of patients have changes in the cervical spine with pain, stiffness, sometimes neurological symptoms, subluxations in the atlantoaxial joint are possible due to softening and thinning of the transverse ligament of the atlas; ankylosis does not develop.
Among the important signs of the systemic form of RA are subcutaneous rheumatoid nodules - one of the most reliable manifestations of active rheumatoid disease, often indicating the defeat of internal organs. Rheumatoid nodules occur in 20-25% of patients and are usually localized on the extensor surfaces of the extremities, for example, the olecranon and the proximal ulna. The nodules are located under the skin, can be of different consistency - from soft, amorphous to dense masses, usually painless. They can be found in unusual places, such as on the vocal cords. Rheumatoid nodules, like rheumatoid deformities of the hand, are a marker of seropositive rheumatoid disease. Lymphadenopathy (enlargement of the elbow and other lymph nodes) is also an important indicator of the immunological activity of RA. Of rheumatic diseases, lymphogranulomatous "packets" of lymph nodes are characteristic primarily of rheumatoid disease.
Rheumatoid vasculitis- an integral part of severe rheumatoid disease. Clinically, vasculitis is manifested by arteritis of the fingertips (digital arteritis) with impaired peripheral circulation, hemorrhages, gangrene, skin ulceration, peripheral neuropathy, pericarditis, vasculitis of internal organs, abdominal syndrome. Ankle swelling due to increased vascular permeability is common. Rheumatoid vasculitis usually develops in patients with severe destructive forms of arthritis, rheumatoid nodules.
Polyneuropathy is characterized by damage to the distal parts of the nerve trunks, most often the peroneal nerve, and is accompanied by sharp pain, impaired sensitivity. Patients complain of chilliness, numbness, burning in the arms and legs (distal sensory neuropathy), paresthesia, sometimes severe movement disorders, sagging of the foot. Rheumatoid serositis often runs latent, but sometimes effusion pleurisy develops; the effusion can persist for months or even years. Pleurisy may be one of the earliest manifestations of rheumatoid disease. Prognostically, serositis, as in SLE, rheumatism, is favorable, although constrictive pericarditis may develop, requiring surgery. There are two types of rheumatoid pulmonary disease. More severe is pulmonary vasculitis, accompanied by hemoptysis, tissue destruction and the formation of vascular cavities. Sometimes fibrosing alveolitis (diffuse interstitial pulmonary fibrosis) develops, manifested by progressive shortness of breath, gross crepitus, widespread shadows on radiographs and leading to the development of cor pulmonale. A peculiar nodular pulmonary fibrosis is observed with a combination of RA and silicosis (Kaplan's syndrome). Heart damage can manifest itself as pericarditis, myocarditis, rarely endocarditis, coronary arteritis with the development of myocardial infarction, granulomatous aortitis. Heart defects (usually isolated mitral or aortic valve insufficiency) have been described. Renal involvement occurs in 20-30% of RA patients. More common is renal amyloidosis, accompanied by proteinuria, nephrotic syndrome and chronic renal failure. Less commonly, glomerulonephritis develops - within the framework of rheumatoid disease or iatrogenic, associated with treatment with gold preparations, D-penicillamine (usually membranous) or non-steroidal anti-inflammatory drugs (chronic interstitial nephritis with necrosis of the renal papillae). Cases of necrotizing vasculitis with glomerulonephritis, sometimes with crescents, sometimes associated with D-penicillamine treatment have been reported.
60-80% of patients have moderate nonspecific liver changes. Hepatosplenomegaly develops in 10-12% of patients, it is typical for some variants of RA - Felty's syndrome, Still's disease. Sometimes the cause of an enlarged liver is amyloidosis (in rare cases, proceeding with jaundice).
In the study of blood, anemia is revealed, usually normochromic, sometimes hypochromic, the severity of which corresponds to the activity of the disease. The number of leukocytes is usually normal, sometimes moderate eosinophilia is noted, and thrombocytosis is often detected. Leukopenia in combination with severe anemia and thrombocytopenia is characteristic of Felty's syndrome. ESR is always increased. The course of RA is long, undulating, with spontaneous remissions and exacerbations. In 25% of patients, exacerbations are rare, in 50% - often, in 10-15% - a progressive course leading to complete disability, in 10-15% - persistent activity with progressive deformity. Complications of RA include amyloidosis and septic arthritis, and also iatrogenic complications. Deposits of amyloidosis are found at autopsy in 20-25% of patients, however, clinical signs of damage to the kidneys, liver, and other organs are observed much less frequently. There are reports of a potentiating effect of immunosuppressants on the development of amyloidosis.
Septic arthritis can develop in the affected joints, more often in patients receiving glucocorticoids. One should think about the possibility of septic arthritis when synovitis occurs in one of the joints, accompanied by fever, leukocytosis, etc. In such cases, immediate aspiration of exudate with its examination is indicated.
Iatrogenic complications include changes in the blood system, skin and kidney damage that develop during treatment with gold preparations and D-penicillamine, damage to the gastrointestinal tract and kidneys during treatment with non-steroidal anti-inflammatory drugs.
Diagnosis and differential diagnosis of rheumatoid arthritis
The diagnosis is based on a characteristic clinical picture, radiographic changes and laboratory findings.
The most important clinical signs are persistent polyarthritis with symmetrical lesions of the metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints, gradual involvement of new joints, the presence of subcutaneous rheumatoid nodules, morning stiffness for more than 30 minutes.
X-ray reveals marginal erosions (usurs), resembling mouse bites, on the surface of the affected bone. Erosions, as a rule, are small in size, irregular in shape and are not surrounded by a zone of osteosclerosis. They are observed not only in RA, but also in ankylosing spondylitis, psoriatic arthropathy, and gouty arthritis. In addition to erosion, there is a narrowing of the joint space as a result of thinning and destruction of cartilage and osteoporosis of the epiphyses of the bones. Sometimes cysts are observed, in advanced stages - destruction of the ends of the bones, ankylosis, flexion contractures. Subluxation of the joints (including the joints of the cervical spine) can be detected. The earliest changes develop in the small joints of the hands and feet, therefore, if RA is suspected, these joints should be x-rayed.
Among laboratory parameters, the most important for diagnosis is the detection of rheumatoid factors in the serum (in the Vaaler-Rose reaction). The study of synovial fluid is of certain importance - weak formation of a mucous (mucin) clot when synovial fluid is added to diluted acetic acid, low glucose content. Sometimes a biopsy of the synovium or subcutaneous rheumatoid nodule can help make the diagnosis.
When making a diagnosis, you can focus on the latest criteria of the American Rheumatological Association (1987):
1) morning stiffness lasting at least 1 hour;
2) arthritis (with swelling of many tissues or effusion) of three or more of the following joints - proximal interphalangeal, metacarpophalangeal, wrist, elbow, knee, ankle, metatarsophalangeal;
3) arthritis of the joints of the hands, with swelling of at least one of the following joints - wrist, metacarpophalangeal or proximal interphalangeal;
4) symmetric arthritis;
5) rheumatoid nodules - subcutaneous nodules on protruding areas of bones, extensor surfaces or near joints;
6) rheumatoid factor in blood serum;
7) typical radiological changes, including erosion and periarticular osteoporosis.
Symptoms meeting criteria 1-4 must persist for at least 6 weeks. RA is diagnosed if there are at least 4 criteria.
Diagnosis of advanced rheumatoid disease with typical symmetric arthritis, rheumatoid nodules and rheumatoid factor in serum is not difficult. However, in the early stages or with an erased clinical picture, differential diagnosis with a number of diseases should be carried out.
Ankylosing spondylitis, psoriasis, Reiter's syndrome, Crohn's disease, and ulcerative colitis may be associated with peripheral arthritis. The asymmetry of arthritis, lesion of mainly medium and large joints of the lower extremities, distal interphalangeal joints, sacroiliitis or spondylitis, the presence of urethritis, ulcers on the oral mucosa, iritis, colitis, seronegative arthropathies in the patient's relatives, absence of rheumatoid factor are of differential diagnostic value. For the diagnosis of ankylosing spondylitis, the presence of sacroiliitis and the detection of HLAB27 are of particular importance. In Reiter's syndrome, there are characteristic urological (urethritis, balanitis) and ocular (conjunctivitis) manifestations, sometimes short-term, requiring a targeted search. In psoriatic arthritis, typical skin and nail changes can be identified.
In SLE, peripheral arthritis is common, but less pronounced than in RA, it is usually not accompanied by erosions and persistent deformities. Rarely developing deformities (ulnar deviation, reversible deformity of the fingers in the form of a "swan neck") may be associated with damage to the periarticular tissues. Rheumatoid factors can be detected in low titers. SLE is confirmed by the presence of typical facial erythema, polyserositis (usually pleurisy), nephritis, central nervous system damage, severe leukopenia and thrombocytopenia, lupus cell phenomenon and antinuclear factor.
Deforming osteoarthritis can occur with a predominant lesion of the joints of the hands, however, even in the presence of inflammatory changes, it is easily distinguishable from RA. It affects the distal interphalangeal joints and the first metacarpophalangeal joint, rarely - the proximal interphalangeal joints, almost never the metacarpophalangeal joints.
For gout, recurrent attacks of sharply painful monoarthritis of the big toe, knee, etc. are characteristic. The joints of the hands are not affected. Subcutaneous tophi (sometimes mistaken for rheumatoid nodules), increased serum uric acid levels, crystals in tophi and synovial fluid are often found. Despite the seemingly clear differences in the clinical picture of RA and gouty arthritis, there are frequent cases of RA overdiagnosis due to gout.
Sometimes RA has to be differentiated from acute infectious arthritis, sarcoidosis, tuberculosis, Sjogren's syndrome, etc.
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At the onset, RA is manifested by an articular syndrome. Patients complain of pain in the small joints of the hands and feet, most intense in the morning and decreasing in the evening. The formation of arthritis is sometimes preceded by muscle pain, mild arthralgias, bursitis and tendovaginitis. It should be noted that the symptoms of the initial period of the disease (the so-called "early" RA) are not always pathognomonic, which creates certain difficulties in the diagnosis.
Joint damage in the early stages of RA may be unstable. Sometimes patients develop spontaneous remission with the disappearance of the articular syndrome. However, after a while, the pathological process resumes again with the defeat of a large number of joints, the pain becomes more severe, requiring the appointment of NSAIDs or glucocorticoids.
Symmetrical lesion of the metacarpophalangeal, interphalangeal proximal and II-V metatarsophalangeal joints is typical for RA. In the future, the wrist, knee, shoulder, hip, elbow, ankle joints, tarsal joints, cervical spine, as well as temporomandibular joints are involved in the pathological process. In the initial stage of the disease, pain occurs only with movement, but as it progresses, they bother patients at rest. Swelling and redness of the skin over the affected joints, stiffness of movements and, as a result, dysfunction of the joints develops. Typically, the process involves tendons, bursae, muscles and bones. Muscle atrophy develops on the dorsal surface of the hands.
Morning stiffness is one of the most important symptoms of RA and is diagnostically significant if its duration is more than one hour. One of the reasons for the development of morning stiffness is a violation of the normal rhythm of the production of adrenal hormones with a shift in the peak of their production to a later period of the day, as well as the accumulation of cytokines in the edematous fluid of inflamed joints during sleep.
In RA patients, active and passive movements in the affected joints are limited as a manifestation of a protective reaction in connection with pain syndrome, as well as as a result of developing muscle contractures. The progressive inflammatory process in the joints leads to a significant limitation of their mobility, the development of articular deviations, deformities and ankylosis.
Articular deviations result from the formation of an angle between two adjacent bones. This is due to the development of subluxation and prolonged contracture of individual muscle groups, which eventually become irreversible. In RA patients, ulnar deviation is often revealed - the deviation of the fingers towards the ulna (“walrus fin”) (Fig. 4.2, see color insert).
Articular deformities appear as a result of the spread of the inflammatory process to the articular cartilage and bone segments, as well as the development of contractures of nearby muscles. Due to the stretching of the joint capsule and ligaments, subluxation of the joints develops.
Ankylosis is formed as a result of the destruction of cartilage and the formation of connective tissue between the subchondral bone structures of both epiphyses (fibrous ankylosis), and then bone elements that finally fix the joint (Fig. 4.3). Developing ankylosis significantly limit the patient's mobility and lead to the development of severe functional joint failure.
Rice. 4.2. Rheumatoid arthritis. Synovitis of the metacarpophalangeal joints of the left hand. Ulnar deviation of the hands
Rice. 4.3. Rheumatoid arthritis. Multiple subluxations and ankylosis of the joints of the toes
The advanced stage of RA is characterized by some typical deformities:
... deformation of the fingers of the "swan neck" type - overextension of the proximal interphalangeal joint and flexion contracture of the distal interphalangeal joint;
... "Spider-like" hand - the patient cannot touch the table surface with his palm due to the impossibility to straighten his fingers;
... deformity of the "boutonniere" type - flexion contracture of the proximal interphalangeal joint with simultaneous hyperextension of the distal interphalangeal joint (Fig. 4.4, see colors, insert);
... valgus (varus) deformity of the knee joints. Developing changes in the joints of the hand lead to a significant violation of its function. Patients cannot perform normal movements - raise the kettle, hold the cup, open the door with the key, dress on their own, etc.
This is also facilitated by the development of extensor tenosynovitis of the fingers on the back of the hand and the long extensor of the thumb. In addition, rheumatoid nodules can form on the tendons, causing severe pain when the fingers are bent. Hand tenosynovitis may be accompanied by carpal tunnel syndrome with signs of compression neuropathy. Violates the function of the hand and the forming contracture of the thumb.
Inflammatory lesion of the elbow joint leads to restriction of movement with the subsequent formation of contracture in the position of half-flexion and semi-pronation, possibly pinching of the ulnar nerve with the development of paresthesia of the innervation zone.
The lesion of the shoulder joint is characterized by its swelling, pain on palpation, active and passive movements, impaired mobility with the subsequent development of muscle atrophy. The inflammatory process involves not only the synovial membrane of the joint, but also the distal third of the clavicle with the development of bursitis, synovial sheaths and muscles of the shoulder girdle, neck and chest. Anterior subluxation of the humerus is sometimes observed due to the developing weakness of the articular bag.
The hip joint in RA is relatively rarely involved in the pathological process (Fig. 4.5). Its defeat is manifested by pain syndrome with irradiation to the groin or lower gluteal region and limitation of internal rotation of the limb. There is a tendency to fix the hip in a semi-flexion position. Aseptic necrosis of the femoral head, which develops in some cases, followed by protrusion of the acetabulum, sharply restricts movement in the hip joint and requires endoprosthetics.
Arthritis of the knee joints is manifested by their painfulness when performing active and passive movements, defigation due to developing synovitis, and palpation in such cases determines the ballot of the patella. Due to the high intra-articular pressure, protrusions of the posterior volvulus of the articular bag into the popliteal fossa (Baker's cyst) are often formed. To relieve pain, patients sometimes try to keep the lower limbs in a state of flexion, which can lead over time to flexion contracture, and then ankylosis of the knee joints (Fig. 4.7). Valgus (varus) deformity of the knee joints is often formed.
Rice. 4.4. Rheumatoid arthritis. Deformation of the fingers of the "boutonniere" type
Rice. 4.5. Rheumatoid arthritis. Radiograph of the right hip joint. Narrowing of the joint space
Rice. 4.6. Rheumatoid arthritis. Synovitis and knee deflection
Rice. 4.7. Rheumatoid arthritis. Significant narrowing of the joint spaces of the knee joints
The joints of the feet, like those of the hands, are involved in the pathological process early enough, which is manifested not only by the clinical picture of arthritis, but also by early changes on the radiographs of the feet and hands. More characteristic is the defeat of the metatarsophalangeal joints of the II-IV toes, followed by the development of their defiguration due to multiple subluxations and ankylosis (Fig. 4.8, see colors, insert). Patients also often have hallux valgus. The defeat of the ankle joint is manifested by its soreness and swelling in the ankle area.
Rice. 4.8. Rheumatoid arthritis. Deformity of the joints of the toes
The defeat of the joints of the spine, as a rule, is not accompanied by their ankylosis, but is characterized by pain, especially in the cervical spine, and the development of rigidity. Sometimes there are subluxations of the atlantoaxial joint, even less often - signs of compression of the spinal cord.
The temporomandibular joints are especially often affected in childhood, but they can also be involved in the pathological process in adults. This leads to significant difficulties in opening the mouth, and is also the cause of retrognation, which gives the patient's face a "bird-like" appearance.
The sacroiliac joints in RA are rarely affected, and signs of sacroiliitis are detected only on X-ray examination.
What is the danger of a tendon rupture on a finger? The mobility of the hand is ensured by the well-coordinated work of the flexors and extensors. The former are on the palmar surface of the hand, the latter are on the back of the hand. The fingers do not have muscles, so their movements are carried out through the connective tissues. Flexors can be superficial or deep. Some of them are located on the middle phalanges, others on the nail. Tendon injuries rank first among the injuries to the hands and fingers. About 30% of them are accompanied by complete or partial tendon ruptures. This is due to the special arrangement of tissues, which makes them easy to damage.
Classification
Injuries to the ligaments of the thumb reduce the functionality of the hand by 50%, the index and middle - by 20%. They are most common among people who prefer recreational sports. Tendon ruptures are classified as open or closed, depending on the presence of skin damage. The first occurs when injured by piercing and cutting objects. The latter are diagnosed in athletes. The tendon is damaged when it is overstretched.
Tears are divided into partial and complete, the severity of the injury is assigned depending on the number of torn fibers. It is more difficult to cure total damage. A rupture of one ligament is considered isolated, several - multiple. A concomitant injury is a case of damage to muscle tissue, blood vessels and nerve endings.
When prescribing treatment, it is important to determine the duration of the damage. A subcutaneous rupture that occurred less than 3 days ago is considered fresh. Injuries that occurred more than 3 days ago are called stale. Those that happened 21 or more days ago are old.
Common causes of injury
Damage to the tendons and joint capsule can be traumatic or degenerative in origin. The latter type is the result of tissue thinning, the first occurs with a sharp increase in weight. Sports injury can be of mixed origins.
The provoking factors are considered:
- a short break between workouts;
- lack of warm-up during the lesson;
- reassessment of their capabilities;
- non-observance of safety measures.
The risk group includes people who are overweight and the elderly.
Characteristic signs
Symptoms of rupture of the ligaments of the finger are determined by its localization. Damage to the tissues located on the anterior surface of the hand is accompanied by impaired flexion functions. In this case, the fingers acquire an over-extended position. When the tendons of the back of the hand are injured, the extensor abilities suffer. Damage to the nerve endings can lead to numbness and paresthesia. If at least one of the above symptoms appears, you should consult a doctor. Fresh injuries heal faster than old ones.
If a person notices that the functions of the hand are seriously impaired, he should apply a sterile bandage and a cold compress. This prevents hemorrhage and the development of puffiness. The limb needs to be raised above the head, this will slow down the speed of blood movement.
In the emergency room, the primary treatment of the wound is carried out, including the application of antiseptic solutions to the skin, stopping bleeding and suturing. After that, a tetanus vaccine is given and antibacterial drugs are administered. If a rupture of the finger extensor tendon is detected, the patient is referred to the surgeon. Without performing an operation, the brush may lose its function.
Therapeutic activities
Treatment of extensor tendon injuries can be carried out not only surgically, but also conservatively. However, this does not apply to flexor damage. For finger injuries, prolonged wearing of a plaster cast or other fixing device is indicated.
Injuries in the wrist area are treated exclusively with surgery. The ends of the torn ligament are sutured. If the damaged tissue is in the area of the distal interphalangeal joint, the splint is applied for 5-6 weeks.
Faster restoration of finger function is observed after the "suture of the extensor tendon" operation.
A fixation device after surgery is necessary to provide the joint with an extended position. You will have to wear it for at least 3 weeks. The splint must be worn on the finger at all times. Its early removal can contribute to the rupture of the scar that has begun to form, as a result of which the nail phalanx will again assume a bent position. In such cases, repeated splinting is indicated. During the treatment period, it is recommended to be under the supervision of a doctor.
In case of boutonniere-type deformation, the joint is fixed in a straight position until the damaged tissues are completely healed. Suture is necessary when the tendon contracts and completely ruptures. In the absence of treatment or improper application of the splint, the finger takes a curved state and freezes in this position. It is necessary to follow all the instructions of the traumatologist and wear the splint for at least 2 months. The doctor will tell you exactly when you can take it off.
Rupture of the extensor tendons at the level of the metacarpal, wrist, and forearm requires surgery. Spontaneous muscle contraction leads to pulling of the tendons and significant separation of the damaged fibers.
The operation is performed under local anesthesia. First, the bleeding is stopped, after which the torn ligament is sutured to the distal phalanx. If the injury is accompanied by a fracture, the bone fragment is fixed with a screw. The pin in the finger acts as a retainer.
Surgical intervention is performed on an outpatient basis, after its completion, the patient can go home.
Recovery period
Rehabilitation for a ruptured finger flexor tendon includes:
- massage;
- taking medications.
Rubbing accelerates the process of restoration of damaged tissues, increases their strength. The ligament must be worked out with the pads of the fingers, the load must be increased gradually. Movements are carried out along the damaged area of the tendon. Massage can only be started after the inflammation stage is over. The procedure should not last more than 10 minutes.
Finger development is an important part of rehabilitation. It helps to increase blood supply and tissue nutrition. You need to squeeze your hand and hold it in this position for 10 seconds. After that, the fingers are extended as far as possible and fixed in this position for 30 seconds.
You can not stretch the tendon sharply, you can do the exercises as often as you like. Do not forget that classes should be regular.
In some cases, anti-inflammatory drugs are prescribed after the splint. However, inhibition of the inflammatory process can interfere with normal tissue healing, which will lead to dysfunction of the hand.
If the pain syndrome does not disappear, it is necessary to stop exercise therapy until the condition of the ligament improves.
How long does a ruptured tendon heal? With minor injuries, recovery takes no more than a month. With a complete rupture, this period can last up to six months.
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