RHEUMATOID IN
HAND
THE
LIGHT
0. Until
ten
rheumatoid but more
or
fifteen
years
tendon as an
ruptures inevitable
fascinating. and
of the
It has
hand
new
research
revealed
problems
light
that
this
presented
to our
understanding
of the
in the control
normal,
of this
which
disease
and
disabilities
of
the
in 1946 by radio-ulnar
mechanisms
and
function
hand
in
accounts
and
field,
limited
is still
underlying
and
incomplete.
possibly
even
that
the
small
muscles
deformities. limited
gains
from
pursuit of this in the hand
problem but also
we may
expect
Moreover,
its cure.
accepted proved
the deformities, and
of rheumatoid
Nevertheless, and function
the discovery joint. These
was being deformities
of the tendons
of standard
surgery are likely to be undone by progress of the disease. will add not only to our knowledge of abnormal anatomy advances
by
was aroused at the inferior
on the abnormal
is a sterile
ENGLAND
much in the rheumatoid hand The study of rheumatoid
the anatomy
shortcomings
I
it was believed that surgery had little to offer: affections, as in hand surgery in general, has
My own interest of extensor tendons
into
the
be argued
the
IMBALANCE. LONDON,
because rheumatoid
me that far too of arthritis.
thrown
time
has
It may
countries. rupture
convinced consequence
at the same
ago
neglected in these
CONSIDERED
TENDON
J. VAUGHAN-JACKSON,
arthritis were recently interest
been awakened in many of two cases of attrition
DEFORMITIES OF
Surgeons
must
well be ready
with
a knowledge of the mechanical problems involved and of what may be expected from reconstructive surgery. Even without such advance in control of the disease it is still necessary to reassess the part that surgery can take in the treatment of disabilities of the hand in rheumatoid
showing
1 flexion
phalangeal
joints.
FIG.
I-land
arthritis. has
Too
become
throughout
is too
there
arthritis
has
been
a tendency
to his disability.
time
that
Too
something
often
could
deformity
at
to avoid
operation
surgeons
watch
have
been
done
the
metacarpo-
simply
because
the deformity to
prevent
it,
the patient
increase until
in
steadily the
end
late. normal
stability:
depending 764
often
adapted the
The of
in rheumatoid
alignment I)
on
stability
the
balance
and
posture
depending
of
of a joint, on
the
the
extrinsic
intrinsic
forces
or complex
of joints,
structure
acting
of
upon THE
JOURNAL
depends
the
the
joint:
joint, OF
BONE
on
two
including AND
kinds
2) stability
and
JOINT
gravity. SURGERY
it
RHEUMATOID
Derangement
HAND
of either
DEFORMITIES
of these
CONSIDERED
forms
IN
of stability
THE
may
other. Rheumatoid arthritis in the hand causes obvious of joints, and we may therefore forget that in addition periostitis, process.
myositis, We assume
ankylosis are it is remembered we are bound
primary, that to look
of incomplete factors
neuritis, too easily
when in fact tendon rupture more critically
or complete
upsetting
tenosynovitis, that structural
muscle
cause
TENDON
secondary
disturbance to arthritis
765
IMBALANCE
derangement
of the
of the intrinsic there may also
structure be osteitis,
as part of the rheumatoid as deformity, dislocation and
often secondary to an extrinsic imbalance. When function by an extreme form of muscle imbalance deformities (Fig. 1). In this paper some examples
with
balance,
OF
and even dermatitis joint changes such
they are disturbs at these
interference
normal
LIGHT
tendon
will
action,
and
of deformity
from
extrinsic
be presented. of extensor urn (IV & V) and sor digiti minirni ornpartrnent under dorsal :arpal ligament laid open, wing hole in tendon ‘e with roughened ulna .,cting
nuous .eaths
remains
)istol stumps gitorum (IV ,tensor digiti
In
1948
two
of
typical
findings
ATTRITION
RUPTURES
of
painless
cases
sudden
of extensor & V) and rninimi
2
FIG.
Diagram
of tendon
in attrition tendons.
OF
ruptures
of
EXTENSOR
spontaneous
extensor
TENDONS
rupture
of the
extensor
communis
tendons to the little and lower end of ulna were
ring fingers from attrition on a rough bony reported (Fig. 2) (Vaughan-Jackson 1948).
spicule over No reference
rupture
English
Thecasesweretherefore
was
reported
found
in the
as rarities,
but
it has
literature now
ofthepreviousthirtyyears.
become
clear
that
these
ruptures
are
two cases were followed by another in which the findings at operation detail on the basis of the findings in the original two cases. Since then have
been
seen,
and
others
have
thirty-five hands operated by operation. Some patients in the
hand
operation
were
a functioning It soon of a finger VOL.
44 B,
so great
is primarily repair became at NO.
the 4,
that
to stop (which apparent
the
1962
reported
elsewhere.
I now
The
were predicted many further
have
a personal
arthritic to such
a
original in every examples series
of
this condition, as well as a number of others not treated operation; in others the associated deformity and disability
it seemed attrition
is sometimes that those
metacarpo-phalangeal
NOVEMBER
been
upon for declined
common.
an
unjustifiable
to
of further difficult). patients joint
who were
interfere,
tendons,
and
noticed
matched
the by
because only
the
secondarily
sudden as many
purpose to achieve
painless
dropping
or
in whom
more
of
766
0. J. VAUGHAN-JACKSON
rupture
this
ofone
group
these
or more
that
fixed
subluxation
eventually
and
ofthe
or
occurs,
the
the
of cases of the
describe in of treatment.
the
History-There
seal
on
may
the the
of
in
restricted
later
under
At
by a different
ulnar
the
The
way the
next
ring
feature
little
finger.
of note
After
the
is little,
often
ring,
at all.
and
proximal
in
phalanx deformity,
it is still
correctible. have come therefore
findings,
In this
to to
and
the
results
case
the patient
with
free
tendon
action
with
mild
smouldering
“
disease,
“
joint, who is very little disabled. of a finger and will seek advice. tendons
extensors,
rupture
escape, In such
of perhaps index
will
and
index
(to
be considered
deformity).
in succession
the
slip
from
only
a few days
be
found
tendons.
the
The
middle being
will
the
ulnar
communis
finger
But
index,
from
extensor
medially and that is noticed
affected.
perhaps
a patient
starting
the
because it lies more a case the first finger
also
affecting Such
the
may
out of the to drop is
drops
and
commonest
farthest
from
after order
the danger
escapes.
Occasionally muscle belly,
severance commoner
the rupture of a tendon is accompanied by pain running up the forearm into but it is seldom more than trivial. Sometimes there is warning of impending
in the form in tendons
dorsum
incident
the
middle
while
recognisable
swan-neck
may
found,
ofcrippling
early
the
two
the
establishment
lesion
presents,
has
an interval
flexed
condition
is that
proprius of attrition.
were
arthritis, and it is not surprising that among all the inability to extend a little finger passes unnoticed. metacarpo-phalangeal joint is already hampered and
patient
which
perhaps
and
It is among
examination.
permanently
the
of interference
the
radio-ulnar dropping
finger,
interval
of casualties
the
inferior sudden
but the extensor of the usual source
a further spot,
is the
and any
In the
rupture
extreme
other
only the wrist notice at once side.
and
clinical
severance of the tendons by attrition reasons (Fig. 14). It seems important
of any
kind
deviation
on
the
development
usually has fairly advanced rheumatoid other painful troubles sudden painless Especially is this so if extension at the partly
of
recognising
which
be no history
found
metacarpo-phalangealjoints
base
of incomplete wrist for other
manner
was
ofthe
of
importance
Finally a number light at exploration detail
tendons
deformities
dislocation
setting
underlining
extensor
fiexion
of the
of local pain felt only when the which run in tight canals, such
tendon as the
is moved, extensor
but this seems to be pollicis longus on the
radius.
Clinical features-In the case of a recent rupture the first and the most striking feature is the loss of active extension at the metacarpo-phalangeal joint of the affected finger (Fig. 3). Passive extension is possible at first, but it becomes more and more restricted as time goes on
and
adaptive
shortening
takes
place.
On
the
dorsum
of the
hand
the
intact
tendons
can
be seen and felt in normal tension. A severed tendon cannot be so distinguished (Fig. 4), and its distal end, retracted somewhat distally, may be seen standing out as a slight rounded lump in contrast to the flattened gap left by the much greater retraction of the proximal end. This lump can be rolled under the examining finger and pushed from side to side. Sometimes a ruptured
tendon
neighbours.
This
may
of paratenon which This cord may even true
state The
much
collapses transmit
in the a feeble
though
to the ends
much
of the
thinner
tendon
and
having
gap between the ends and extensor pull and so may
end
of the
ulna
can
often
be felt
to be hard
inferior radio-ulnar joint on pronation and Irrespective of the degree of involvement always
shows
disorganisation In long-standing
the dorsum
to be intact, is due
less
taut
retracted
than within
its intact a sleeve
often persists as a thin cord. mislead the surgeon from the
of affairs. lower
pain in the restricted. radiograph
appear
appearance
of the hand
bony
involvement
of the
of the inferior radio-ulnar cases with fixed flexion is commonly
thin
and
and
craggy,
lower
end
of the
joint (Fig. 5). deformity of the wasted
and
the patient
supination, the range of which of the bones of the wrist and
even THE
ulna,
often
metacarpo-phalangeal
in the presence JOURNAL
and
OF
AND
there joints
of marked BONE
suffers is often hand, a
JOINT
synovial SURGERY
is
RHEUMATOID
thickening easily
of the
made
Findings
HAND
wrist,
DEFORMITIES
and
the
CONSIDERED
absence
of tendons
at operation-The
operative
findings
are
FIG.
1-Attrition little fingers.
44 B,
LIGHT
OF
TENDON
767
IMBALANCE
standing
out
in normal
tension
so constant
and
so typical
that
is usually
It cannot NO.
4,
be denied NOVEMBER
that 1962
this
is a theoretical
it is startling
3
rupture of extensor communis Loss of active extension at the
that there should be any doubt about the nature assumed that rupture took place spontaneously
VOL.
THE
out.
Case
disease.
IN
digitorum tendons metacarpo-phalangeal
to
ring joint.
of the rupture. Nevertheless through an area of tendon possibility,
and
it may
and
it has long been weakened by the be a true
explanation
768
0. J. VAUGHAN-JACKSON
Case
1-1
.
of the extensor
Case I-The hooks
(left).
Lhe wrist
I-Typical intact
1
lump
formed
hole in the floor of the tendon compartment The abraded margin of the extensor tendon in the
Case
exposed.
tendons to the ring and little fingers is clearly the intact extensors to middle and index fingers
tendon.
grip
appearance Note
that
of the
button-hook
of a fresh abrasion there
is no
sign
by the distal stumps seen on the right with
beyond.
is held open by two skin to the ring finger is seen
retractor.
of the ulnar of any
rheumatoid THE
JOURNAL
margin
of the next
granuloma. OF
BONE
AND
JOINT
SURGERY
RHEUMATOID
when
the
rheumatoid
fibro-osseous attrition spontaneous
HAND
process
canal on
extensors
(as
a rough rupture
CONSIDERED
is assisted
in the
case
the
at
consecutive
level
cases
by
of the
patch of bare with no evident
rupturing
twenty-five
DEFORMIT1ES
friction
THE
and
extensor
bone cause
of the
the
IN
LIGHT
OF
TENDON
constriction
pollicis
the
of
longus
769
IMBALANCE
at the
tendon
in a tight
wrist).
Rupture
by
has been found in these tunnels, but so also has of attrition. However, in the case of the common
inferior
abrasion
radio-ulnar
of the
joint
tendons
and
the the
significant cause
fact
of the
is that
attrition
in
were
manifest.
9
FIG.
Case 2-The dark dot partment. The ruptured tendon has moved
It has these at least, end was
to be realised
ruptured a reaction
some there
tendons
seems
within
a day
of bone
the matter. case a rough
hole
are
conclusions
explored
tissue
late.
can The
to injury.
To
in the
or two
spicules
of the
find
rupture,
embedded
spicule
floor
be drawn
rheumatoid such
cornintact
from
and
a typical
dorsal
the
lower tendon
end
end
appearance can
of the ulna
of in part
in a tendon
as evidence that such granuloma finding
however occur.
can
be seen
when
this
it in
of an obvious
much Finally
free of rheumatoid
compartment
be,
granuloma
consistent
pathology, sometimes
in a tendon
on the
of the
true can
the
granuloma
of a rupture is not to be interpreted The consistent failure to find any
demand the recognition of the rupture through a granuloma
the microscope to decide In a typical
local
no positive
after the trauma time of the rupture.
explored
an obvious
if they
of the
months at the
cause of attrition, true that spontaneous under
that
tendons
the hole in the floor of the tendon tendon ends lie to the right: the next into position ready to be attacked.
is
it may be the finding granulations
and
felt through
is opened
(Fig.
7).
Over and over again the next remaining intact tendon has been seen not only lying close over this hole but displaying abrasion of its ulnar border in relation to the hole, the length of this abrasion corresponding exactly with the excursion of the tendon (Fig. 8). It seems clear
that
nether
the
mechanism
millstone,
the
tendon compartment is ground through movement
and
it to
the the
rough upper
separating the spicule
supination
may follow the its ends retract
first and
saws after the
lower
end
millstone
the two. of ulna across
an interval next intact
the
of the
and
the
ulna tissues
corresponds of
44 B,
NO.
4,
NOVEMBER
line
of the
tendon
to the floor
of
the
compartment tendon.
and
we know
Its that
of perhaps only a day or two. Once one falls into place and is attacked
and yet the cause of attrition may not found on many occasions to be hidden 1962
the
Once the floor of the attacks the overlying
and so the serial ruptures of tendon after tendon are produced (Fig. 9). Sometimes one can find obvious recent abrasion of the next intact tendon
soon after a rupture, on the ulna has been VOL.
over
are the grist, and perforated
in pronation
a second rupture tendon is parted turn;
is as follows: tendon
at exploration
be at all obvious. in two ways. The
The spicule commonest
a in
770
0. J. VAUGHAN-JACKSON
off the prominence
made
by the lower end of the ulna.
prominence thickened synovial pouts through the hole in the ulna could be found with
tissue from the capsule, obscuring the probe within
On the top of this inferior radio-ulnar joint it. The spicule on the this pouting tissue.
central hole. Ruptured tendon nds to the right: Note the translucent collapsed tube of paratenon in the grip of the upper hook. Follow it to the left where it is distended with fluid and the end of a ruptured tendon can be seen within it.
e
i-inc
dark
hole
over
t
lower
end
01
the
ulna
is seen
c
A strand
resembling stretched and thinned-out tendon lies be it. Follow this to the leftwhere it is seen to spread out over a bulbous ruptured tendon end similar to andat the same level as the “naked” rounded tendon stumps above it. THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
RHEUMATOID
finding
is that
pouts
a mass
through the
a case
hole
only
wrist
is
can
cases
and
hides
be found the
with
can
be seen
not prevent
range
These
(Fig.
findings
THE
LIGHT
from
within attrition
way
in the
layers
typical
tendons.
This
tendon
and
“
oftissue
the
in relation
present
at
in the
hole
in
to the hole
exploration
out
it can
affairs and will
first
feature
has
this
joint
10).
In such
floor
the
ofthe
tendon
range.
At
operation,
layer
of
synovial
in the fibrous
layer
compartment
under
the
if the dorsal
it, and
both
radio-ulnar joint. of the pronation-
after
a rupture.
strand
thin
that
of
and
unites
as a strand
on this
out
the
late
severed
stretched
“
looks
explanation
spread
At
exploration
once several of the tendons the hole may have healed.
recognised.
that
past
opaque
doubt
to reach
to be
tissue
in the
white
threw
be shown
unable
that and
the
of
like
ifthis
surface
many
of
rheumatoid
remarkably
was that
over
ends
degenerate
a
strand
of the
stretched
is dissected
severed
tendon
are
quite distinct, rounded, opaque, and yellowish within it (Fig. 12). Next, under the strand is not composed of tendon fibres, but of fibrous tissue with synovial Lastly, early exploration of these ruptured tendons demonstrates the true state of
unmistakably.
A week
a day
or so of the
tube of paratenon a little synovial
or ten days
ulna
rupture
of about the cause
removes
after
apparently it contains the
within which fluid. Moreover
Treatment-Resection
of the
radio-ulnar (Fig.
lining ofthe inferior all but a small part
soon
be
described
bluish, not at all like the look translucent as though
within
may
is the
been
finding
always
ends which the microscope elements.
rupture
admittedly
The
tendon.
inferior
pronation-supination
to the hole in the synovial closes the hole throughout
attrition
A further
these
the
771
IMBALANCE
1 1). are
a true
TENDON
proceeding
may be no spicule nor hole apparent, and one may surmise parted and retracted there is no longer an upper millstone
this
OF
a probe.
to move
to
supination there have
tissue
does
“
move in relation valvular arrangement
IN
synovial it but
in register at one point in the passively pronated and supinated,
seen
This
CONSIDERED
perforations
“
compartment are
In
DEFORMITIES
of rheumatoid
the hole
In other
are
HAND
the rupture
the strand
fibrous strand seen fluid (Fig. 11), which strand
can
the tendon the tendon
an inch of attrition
be seen
with
ends ends
have are
of the lower and “stops
end the
will look
semi-translucent
at a later stage. Earlier still in fact it may, for at exploration certainty
separated, demonstrably
to be the and
this within
it
collapsed
tube contains it (Fig. 15).
(Fig. 13). It is a procedure with hardly any penalties. It is said that patients will complain of painful clicking of
rot
“
tendons
over
resection, If the
ulna
lower
may
end
carpal
allow
the
of
arthrodesis
cases
end
I have
the radio-carpal removal of the
disease, of
the
but
the
ulnar
joint the be
any
is much provided
carpus even
may
shaft
encountered
support
radius
arthrodesis
an
of never
have
medially
point
necessary,
would
such trouble.
a
damaged by the by the lower end
to slide
to the
after such
but been
on the
where in
a radiomost
necessary
FIG.
such in
Case seen
13
2-Excised lower end end on. The uppermost had done the damage.
any
of ulna spicule
event. On more
the
often
in which
other
hand
than respect
Repair
the
operation
has
for
relief
it is, simply it is uniformly
of the
ruptured
the
next
the
at a disadvantage; acting VOL.
on 44 B,
rheumatoid lastly
is necessary
process
they
them. NO.
4,
NOVEMBER
1962
advantages
of painful
restriction
and
should
of pronation
be performed
far
and
supination,
function
but
successful. tendons
particularly, to get the metacarpo-phalangeal left in extreme flexion they are under position;
additional
will
not joints
unnatural will attack
become
to restore
working again strain. They will
them
disorganised
only
with
avidity,
and
dislocated
normal
also,
in their middle range. If first become fixed in this the greater
for their
by the unbalanced
being pulls
772
0. J. VAUGHAN-JACKSON
The
rheumatoid
“
daunting,
with
themselves
usually
results
are
promising
look
cases
on
“
of bulging (Fig. rough
these
repairs
synovial
normal
by
not
more
Fio.
to be but
undertaken
with
than
two
may
nevertheless their
the
be
tendons
surroundings.
kind of tendon repair of tendons has been
“
in which
have tissue,
comparison
14). Almost any cobbling together
“
those
are
which
unhealthy
surprisingly
not disappointing and even fairly
situation, most
battlefield
its masses
tendons
and
can work successful.
have
in this The
been
severed.
intact
tendon
14
Case 4-Despite the obvious masses of rheumatoid synovial tissue the tendons appear normal. The end of the probe indicates the hole over the ulna and immediately above it early abrasion is apparent on the ulnar margin of the tendon lifted on the hook. This attrition was discovered incidentally when the wrist was exposed for a radio-carpal arthrodesis.
It is then
possible
and
swing
line
per
tendon
If several of action Finally, has
one
must
limit
the The
a
across
is necessary
and
as the
covering
longitudinal
sliver
to the
stump
the
suture
“spring-clean”
for
operation
disease
does
except
with
not
appear
being is only
tendons-Other in the slightly
foot. less
them
from
discretion.
in those
to affect
varieties In the
transferred
common
area of cortical erosion is by far the commonest of cancellous bone.
rupture than
next Only
tendon
cases
synovial
tissue
adhering
to skin,
Adhesions
when process
one
may
disease
under
rupture
of transferred
ATTRITION
from
be,
and
its line
it is all
for
this
in any
that
reason
case,
and
heavy
steroid
will be conditions,
tendons
therapy,
in doubt. and the
Apart activity
or grafts.
RUPTURES
rupture
of the
may occur
suture
is satisfactory.
this happens tenolysis is often successful. seems to have little or no bearing on the
of florid
healing
of attrition
hand,
of the tendon.
of carrying out any kind of surgical procedure to arrest the series of ruptures overrides other
OTHER
Flexor
margin severed
of the
rheumatoid
excursion of the repaired extensors; state of activity of the rheumatoid
the wisdom this the need
the
of the
to one “motor” they diverge too sharply stumps is at an angle and very inefficient.
to prevent
area
from
of approach
surrounding
lines the
distal
line
are attached to the outermost
unhealthy
for
indications
of the
separate
end
distal stumps and the pull
one
when from
to
its distal
flexor
of the
are
coming
tendons
extensors.
steadily
by attrition The
usual
to
light,
in the cause
of attrition
on the palmar surface of one of the carpal bones. Rheumatoid cause, and the erosion of cortex exposes a “glass paper” Every bone in the carpus has been implicated, the hardest THE
JOURNAL
OF
BONE
the
carpal
AND
JOINT
latest tunnel is an
arthritis surface
lesion SURGERY
RHEUMATOID
to find was
HAND
having
been
the cause
transverse the line fibres
DEFORMITIES
one
tucked
of attrition
until
sometimes but
under end
cylindrical
groups
IN THE
the
hook
of the ulna,
“cross-cut” resulting
tendons, the
intact
away
on the lower
pronation-supination of travel of the
separated
CONSIDERED
LIGHT
of the and
OF
TENDON
hamate
in that
bone.
case
In only
the rupture
attrition. In all the others in a longitudinal “combing
body
of the
tendon
was
773
IMBALANCE
one
case
was a typical
the abrasion out” of the
transformed
into
was in tendon
a sheet
of
of fibres.
FIG.
15
Case
5-Attrition sesarnoid bone.
rupture of both flexors in the little finger on a roughened The lower probe indicates the sesamoid. The proximal tendon stump peeps out of the tube of paratenon. The upper probe indicates the distal end of sublimis within this tube. The distal end of profundus peeps out from the right hand margin of the wound, where the tube of paratenon can be seen leaving the margin of sublirnis to embrace the stump of profundus.
In every do
not
and
maintain
move,
deep In this
tension. of
case,
damaged
were
attrition
after into display, would
their
text-book
way
the
tendons
an
a small
else
itself.
clinically, evidence lead one to expect.
can
it can after
picture
joint.
are ruptured as well. the loss of a sublimis.
It therefore in
difficult.
behoves
mind
in
of far more The presenting
It is by no means
the
surgeon
are
to move
fast
tendons the
by
the
surprising
damage is nearly
familiar
to find as the
flexor
under
such
that
twinges
of the
of attrition
of bone
many
slide
is in active the process
by cases
that than always
tendons they
which too, that
in a spicule
tunnel
the
activity
to
demonstrated
carpal
that
During
rest.
resulting
to all the damaged severed profundus
in the fact
according It is evident,
obscured is also
it is not
uncommon
at
versa,
fracture
So long
Free grafts adhere readily the cause and attaching the
removing
when of them.
all
widespread symptom
all the underlines
vice
be painless
a Colles’s
sublimis does not are
and
damage
interphalangeal tendons notice
that
its discomforts
That
as for instance tunnel. pathological
explored
except
superficial
lesion
or
were
observation
relationships
becoming
ones
process
old injury, the carpal With this
time
tattered,
painless,
is
rheumatoid
by the and
projecting
of these
patients
their presenting symptoms inability to flex a terminal several
profundus circumstances.
or even
all the
is intact
the
Tendon
flexor patient repairs
tendons, and the best hope lies to its nearest intact, if damaged,
neighbour. In
bone VOL.
removing
well
below
44 B, NO.
4,
the cause, the surface. NOVEMBER
1962
usually There
all one is little
can do is to excavate or no soft tissue with
and countersink which to cover
the bare it, and its
774
0. J. VAUGHAN-JACKSON
dead
white
appearance
leaves
one
with
doubts
whether
it will
be
satisfactorily
covered
spontaneously. Two
kinds
the hyperextended notably in the of the
proximal
of deformity
are
likely
to result
terminal interphalangeal thumb. Secondly, if the interphalangeal
joint
from
this
sort
of tendon
joint which cannot flexor sublimis is ruptured is lost
and
FIG.
it tends
rapidly
damage.
The
first
is
be flexed. This occurs most the flexor-extensor balance to become
hyperextended,
16
Case 6-The probe indicates the rough area in the floor of the groove for extensor pollicis longus, which has been displaced out of it and lies in the grip of the large hook.
FIG. Case
and
the
the
finger
rheumatoid
useful Attrition
soon
6-This
assumes
process
fixes
shows
the
the attrition
classical
the deformity
17
on the margin
of extensor
“swan-neck” and the finger
deformity. becomes
pollicis longus.
With scarcely less speed stiff in the position of least
function. ruptures
of flexor
tendons
of attrition of both flexor tendons finger was doubtless a rarity (Fig. digital sheaths, in the flexor pollicis
in fibro-osseous
tunnels-These
are
less common.
One
case
on
a roughened sesamoid bone at the base of the little 15). Attrition ruptures, however, have been seen in the longus in its sheath, and in the extensor pollicis longus THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
RHEUMATOID
on
the
cause
HAND
dorsum
of the
of attrition
changes cause,
radius,
can
longus,
for example,
some
pollicis “glass
up
but
CONSIDERED
never
be found,
are more often are fairly common
(as in doing hyperextended give
DEFORMITIES
and
IN
in the
one
tendons
may
a considerable
in the form was bone
countersinking.
No
OF
that
TENDON
radial
styloid.
perhaps
775
IMBALANCE
More
friction
and
often
no
degenerative
to blame. None the less, ruptures of these tendons, from whatever in patients with rheumatoid arthritis. Loss of the flexor pollicis
carries
warning
LIGHT
at the
surmise
penalty
in the shape
a button, winding a watch or terminal phalanx is not understood.
longus paper”
THE
of pain
ofclumsiness
sewing), and Ruptures
on movement
in fine movements
too often of these
of the tendon,
and
the reason tendons do
in one
explored because of this and found half severed on in its groove (Figs. 16 and 17). The cause of attrition subsequent
rupture
of the
tendon
case the
for the tend to
the extensor
usual piece was removed
of by
occurred.
SUMMARY 1.
The
posture
of disturbed factor
of deformed muscle
in
the
finger
balance.
joints
in
Although
development
rheumatoid
of deformity,
the
ruptures
in producing
disturbance of muscle balance. 2. The part played by tendon
arthritis
disorganisation
I would
like to record my special indebtedness Hospital, and Dr R. A. Moir at St Bartholomew’s cooperation in the study of these abnormalities, has put into producing the photographs.
Dr W. Hospital, and to Mr
close itself
is often
secondary
deformity
to
needs
of the joint
such
imbalance
analysis
may
in
terms
be the primary to
an
extrinsic
is discussed. M. Mason at great interest great skill and
S. Tegner and Dr R. Rochester, for their R. F. Ruddick for the
the London and endless care that he
REFERENCES D.
BREWERTON,
16, 183. EHRLICH, G. E., Tendons
A.
(1957):
Hand
L. T.,
PETERSON,
at the
Deformities
Wrist
in
in
L., and
SOKOLOFF,
Rheumatoid
Arthritis.
Rheumatoid
J. J. (1959):
BUNIM,
Arthritis
J. I. P. (1949): A Case of Rupture of Flexor Bone and Joint Surgery, 31-B, 521. KAPLAN, E. B. (1953): Functional and SurgicalAnatomy
and
Tendons
JAMES,
Annals
Disease.
Pathogenesis
Rheumatism,
Rheumatic
Diseases,
of Rupture
of Extensor
2, 332.
Secondary
of the Hand.
of the
to
Kienb#{246}ck’s
Philadelphia
and
Disease.
London:
Journal
of
J. B. Lippincott
Company.
V. A. I.,
LAINE,
Journal
L. R.,
STRAUB,
Associated
and with
of Bone
VOL.
44 B,
Rheumatoid
NO.
Joint
WILSON,
and
E. H.,
Rheumatoid and
Joint Hand.
4, NOVEMBER
K.
VAINI0,
Surgery,
39-A, Jun.
Rupture Surgery,
(1956): Journal
Attrition
1962
Finger
Spontaneous of Bone
Deformities Rupture
and
Tendons
of Extensor
30-B,
Proceedings
(1957):
caused
by
Rheumatoid
Arthritis.
527.
Arthritis.
0. J. (1959):
VAUGHAN-JACKSON,
in the
and
0. J. (1948):
VAUGHAN-JACKSON,
Journal
E.,
SAIRANEN,
of Bone
Joint
of Surgery,
by Attrition
Extensor 38-A,
Tendons
in
the
Hand
1,208.
at the Inferior
Radio-ulnar
Joint.
528.
Ruptures
of
of the Royal
Tendons
as a Factor
Societyof
Medicine
in the (Section
Production of Deformities of Orthopaedics), 52, 132.