RHEUMATOID HAND DEFORMITIES CONSIDERED

RHEUMATOID IN HAND THE LIGHT 0. Until ten rheumatoid but more or fifteen years tendon as an ruptures inevitable fascinating. and of the ...
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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.

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