What is rheumatoid arthritis?
The most common type of inflammatory arthritis is Rheumatoid Arthritis, which affects approximately 3% of women and 1% of men in Northern Europe.
Features of rheumatoid arthritis are not seen in historical Western art and literature, suggesting that it is a modern disease in Europe. Changes of the disease are recognised in ancient Native American skeletons, leading to speculation that it was exported back to the Old World after colonialisation. The precise cause is unclear, but probably related to an auto-immune response, where the body “attacks itself”. The disease also appears to be genetically linked. Once the response is triggered, there is a release of toxic hormones and chemicals within the body, such as Tumour Necrosis Factor (TNF).
The disease affects any joint and also has other manifestations around the body. There is inflammation of the soft tissues and joint lining tissue, known as synovium, and the bone and cartilage around joints is eroded.
Making the diagnosis
The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at their necks, shoulders, elbows, wrists and hands. Stressing i.e. pushing on the affected joint is usually uncomfortable. It is necessary to demonstrate some tenderness to confirm the site of the symptoms but this should not be too painful. The specialist may measure the range of motion in the joint with a special angular ruler (goniometer). This will help guide their advice to the patient.
Hands and feet are commonly affected early in the disease.
Examination may show features of arthritis, with swelling, warmth, and stiffness, with pain on movement.
There are very characteristic patterns of disease and deformity seen in the hand and wrist.
Inflammation of the tendons “tenosynovitis” commonly affects tendons of the hand and wrist, with swelling and difficulty in movement. Eventually tendons may rupture.
Other features often seen around the body are:
Skin – subcutaneous nodules (20% of patients)
Eye – painful red eye.
Nerves - especially compression of median nerve at the wrist (Carpal Tunnel Syndrome) and ulnar nerve behind the elbow (Cubital Tunnel Syndrome).
Diagnostic features are:
1. Morning stiffness, lasting at least one hour.
2. Active arthritis of 3 or more joints simultaneously
3. Active arthritis of at least one hand joint
4. Symmetrical arthritis
5. Subcutaneous rheumatoid nodules.
6. Rheumatoid Factor
7. Xray changes of rheumatoid arthritis.
What test(s) might be performed?
Tests (also known medically as Investigations) include X-rays, scans, and blood tests. Rheumatoid factor (RF) is found in the blood tests of approximately 80% of cases (and in 1-5% of the unaffected population). Nerve tests may be arranged if it is suspected that nerves are being affected by the rheumatoid arthritis.
What are the non-operative treatments?
Longstanding, stable, mild cases can be treated with simple pain-killers and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). However, it is now believed that the disease is best treated aggressively in its early phase (first two years), before erosions and other problems can occur. This treatment is with “Disease Modifying Drugs” such as Methotrexate, Gold, Sulphasalazine, and the most recent development of “Anti-TNF” drugs.
Corticosteroid by local injection into joints or around tendons is often very helpful.
Splintage can be helpful to reduce pain and improve function. They probably do not prevent deformity in most cases.
Surgery for Rheumatoid Arthritis
Surgery is very helpful for many patients affected by rheumatoid arthritis. Surgical options for joints include fusion (arthrodesis), especially for finger joints and the wrist, and replacement (arthroplasty) for major joints including the elbow, knuckle joints and occasionally even the wrist – where we are particurly involved in research. See information sheets on individual joints/operations.
Inflamed tendons sometimes need surgical treatment, if medical treatment has not helped, in order to prevent rupture. If tendons do rupture, then transferring another less important tendon to provide power to the ruptured one is often helpful. Otherwise the gap left by the damaged tendon can be repaired with a “bridging” or “interposition” graft technique.
Nerves affected by compression from nearby joints may be helped by decompression. See Ulnar nerve decompression