Rheumatoid arthritis is an inflammatory joint disease that affects small and big joint. Rheumatoid arthritis is an autoimmune disease that causes severe self-destructive inflammation. Immune system mostly attacks the soft tissue resulting in chronic inflammation. Synovial membrane is predominantly attacked by autoimmune cells.1 Synovial membrane (synovium) secretes viscous fluid, which lubricates the joint. Inflammation of synovium causes thickening of the synovial membrane and increased synovial secretion. Joint effusion (collection of fluid in joint) and stretched tendon and ligament results in lax joint, which in later stage dislocates. The inflammation spreads to adjacent cartilage, ligaments and periosteum of the bone. Initial symptoms are often observed in hands, wrists, ankles and feet joints. Causes of rheumatoid arthritis are unknown though past research suggests genetic abnormality may initiate the autoimmune reaction within the joint. Rheumatoid arthritis can be a progressive disease. Rheumatoid arthritis results in joint impairment of hand and disability.2
Epidemiology of Rheumatoid Arthritis of Hands
- Sex- Females are three times more likely than men to develop this disease.
- Age- Symptoms are observed between ages 20 to 40 years.
- Chronic Viral Infection- Viral infection may trigger the autoimmune reaction.
Symptoms of Rheumatoid Arthritis of Hands
Pain Symptoms of Rheumatoid Arthritis of Hands
- Intensity of the Pain- Pain is mild to moderate and localized over fingers mostly at Metacarpo-Phalangeal joint during the early stage of the disease. Pain responds to non-steroidal anti-inflammatory medications (NSAIDs). During the late stage of the disease pain may not respond to NSAIDs.
- Duration of Pain- Pain is on and off, often with period of less or no pain for several days during earlier stage of the disease. During later stage pain is continuous.
- Pain Associated with Joint Dislocation- Pain is often excruciating during late stage caused by Metacarpo-Phalangeal or Inter-Phalangeal dislocation.
- Morning Pain- Finger and hand pain caused by rheumatoid arthritis is often most severe in the morning. Pain intensity reduces as day progresses.
Joint Swelling Symptoms of Rheumatoid Arthritis of Hands
Patient often complaints of joint swelling. It is at time difficult to find the swelling in the initial phase of the disease if all the joint of finger and hand are simultaneously affected.
Generalized Symptoms of Rheumatoid Arthritis of Hands
- Fever- Fever is observed during early stage of the disease. Fever often accompanies the inflammation of Inter-Phalangeal joint, which is tender on touch.
- Weakness- Patient complaints of generalized weakness during inflammatory phase, early stage of the disease.
- Fatigue and Tiredness- Symptoms of fatigue and tiredness are observed during all the stages of rheumatoid arthritis of hand. During initial phase of joint inflammation the tiredness is caused by severe inflammation involving multiple joints.
- Loss of Appetite.
- Numbness- Patients often have problems with numbness and tingling in their hand (carpal tunnel syndrome) because the swelling of the tendons causes pressure on the adjacent nerve. They may make a squeaky sound as they move joints (crepitus) and sometimes the joints snap or lock because of the swelling.
Signs of Rheumatoid Arthritis of Hands
Joint Deformity Signs for Rheumatoid Arthritis of Hands
Following abnormalities causes hand and finger joint deformity-
- Joint Swelling- Joint swelling is caused by increased synovial fluid collection in the joint.
- Joint Subluxation- Overstretching of the joint causes separation of the bone resulting in partial dislocation.
- Joint Dislocation- Overstretching of the joint eventually causes tear of ligament resulting in mal-alignment of the link and overlapping of the adjacent bones in palm and fingers. The dislocation of Inter-phalangeal and Metacarpo-Phalangeal joint causes severe deformity of the joint.
- Ulnar Deviation- Ulnar deviation follows Inter-Phalangeal and Metacarpo-Phalangeal joint subluxation or ligament tear. Ulnar deviation is an angulation of the fingers.
Morning Joint Stiffness Signs for Rheumatoid Arthritis of Hands
Joint stiffness with severe pain is often observed in the morning. Patient is unable to move joints of the hand and fingers for about 30 to 45 minutes in the morning. Pain intensity and stiffness reduces later in the day.
Joint Swelling Signs for Rheumatoid Arthritis of Hands
- Joint Inflammation- Joint swelling is observed in fingers during early stage of the disease because of inflammation causing tissue edema. Joint swelling is associated with severe tenderness because of inflammation.
- Excessive Synovial Fluid- Joint swelling caused by excessive synovial fluid is soft and fluctuating. The increased synovial fluid secretion by synovial membrane is observed during inflammation of synovium and is continuous in later stage.
- Joint Subluxation or Dislocation- Joint swelling is also exaggerated once the joint is dislocated as a result of over stretching of the ligament and tendons. The soft tissue of the joint is over stretched by excessive synovial fluid causing breakage of link between bone and dislocation in late stage.
Joint Redness Signs for Rheumatoid Arthritis of Hands
Inter-Phalangeal joints are inflamed and red in the initial stage of the disease. The redness of the joint is associated with tenderness and severe pain.
Symmetric Joint Arthritis Signs for Rheumatoid Arthritis of Hands
Rheumatoid arthritis of the hand affects joints of fingers, thumb and palm. Majority of the cases of the rheumatoid arthritis of the hand are symmetric and bilateral.
Soft Lump on the Back of the Hand
- Joint changes observed in rheumatoid arthritis are often associated with soft lump on the dorsal side of the fingers and thumb.
- Lump is seen during late stage of the disease.
Inability to Straighten or Bend Fingers
During late phase of the disease, patient complaints of inability to straighten or bend fingers because of a tendon rupture
Boutonniere Deformity Signs for Rheumatoid Arthritis of Hands
Deformity in which the finger is bent toward palm at knuckle (First Inter-Phalangeal Joint). One or more than one finger is affected by rheumatoid hand disease. The second Inter-Phalangeal joint is sometime extended in opposite direction.
Swan-Neck Deformity Signs for Rheumatoid Arthritis of Hands
Deformity is observed at distal inter-phalangeal joint or joint near the tip of the finger. The distal (furthest) portion of the finger is bent permanently toward palm. The middle joint is bent in opposite direction resulting in finger looking like Swan Neck.
Investigations and Lab Tests for Rheumatoid Arthritis of Hands
X-RAY3 for Rheumatoid Arthritis of Hands
- Initial Stage – Joint space narrowing is seen on X-ray.
- Later Stage- Joint space widening is observed secondary to excessive synovial fluid secretions.
- Soft Tissue Swelling- Synovial and ligament thickening is observed in selective X-Ray.
- Bone Density4- Bone density is decreased.
MRI and Cat Scan5 for Rheumatoid Arthritis of Hands
- Findings of the X-ray- Confirmed.
- Joint Erosions- Joint erosions are observed with thinning of cartilage and ligament subluxation.
- Subcutaneous Nodules (SN)- SN are observed within subcutaneous tissue over hand and finger.
- Osteopenia- Decreased bone density.
- Synovial Membrane- Thickening of synovial membrane is better observed with MRI.
Ultrasound Tests for Rheumatoid Arthritis of Hands6
Ultrasound Study- Ultrasound study is conducted to evaluate the status of joint fluid.
Blood Examination Tests for Rheumatoid Arthritis of Hands
- Erythrocyte Sedimentation Rate (ESR)- ESR is increased in later stage of the disease, often normal in 60% of the patient during early stage of the disease affecting hand.
- Anemia- Normocytic normochromic anemia is observed secondary to blood loss in urine and stool as well as iron deficiency.
- Thrombocytosis- Platelet count is increased
- Serum Albumin- Serum albumin is low in later phase of the disease.
- Alkaline Phosphatase (AP)- AP is raised in early and late stage of the disease.
- C-reactive Protein (CRP)- CRP may be normal during early phase of the disease and positive in later phase.
- Rheumatoid Factor (RF)- May not be positive in all patients suffering with rheumatoid arthritis. The past research suggests RF is positive in only 70% of the patient suffering with rheumatoid arthritis of the hand.
- Antinuclear Antibody- The test is diagnostic test for Systemic Lupus Erythematosus (SLE) causing joint pain. But test is non-specific and often positive in rheumatoid arthritis of the hand.
Urine Analysis Tests for Rheumatoid Arthritis of Hands
- Hematuria- Blood in urine observed in later stage.
- Proteinuria- Protein in urine often observed.
Treatment of Rheumatoid Arthritis of Hands
1. Conservative Treatment for Rheumatoid Arthritis of Hands
Rest for Rheumatoid Arthritis of Hands
- Joint is immobilized during acute phase when pain is severe and joint stiffness observed in the morning.
- Joint is immobilized.
- Restriction is effective during initial stage of inflammation of joints in hand, thumb and fingers.
Exercise for Rheumatoid Arthritis of Hands
Exercise is beneficial during chronic and later stage. Yoga therapy and stretching exercises are advised to prevent weakness and atrophy of the hand muscles.
Heat Therapy for Rheumatoid Arthritis of Hands
Moist heat (heated wet towel) or hot water bag treatment is beneficial to reduce pain and improve joint movements during acute inflammation and early morning stiffness.
Cold Therapy for Rheumatoid Arthritis of Hands
- Direct application of ice covered with plastic or cloth over shoulder for 20 to 30 minutes two or three times a day
- Helps as anti-inflammatory and for chronic pain.
- Cold therapy prevents joint swelling and tissue edema.
2. Physical Therapy (PT) for Rheumatoid Arthritis of Hands
- Physical therapy is advised for morning stiffness, joint stiffness and muscle weakness.
- Physical therapy helps to prevent muscle atrophy.
- Physical therapy includes following treatments-
- Heat therapy using wax and paraffin bath
- Ultrasound therapy and
- Infrared light therapy
Objectives of Physical Therapy Are As Follows-
- Muscles- Muscle stretching and strengthening
- Tendons and Ligaments- Maintain tensile strength of ligament and tendon
- Joint- Improve range of joint movement and prevent joint stiffness
3. Medications for Rheumatoid Arthritis of Hands
a. Non-Steroidal Anti-Inflammatory Medications (Drugs)- NSAIDS For Rheumatoid Arthritis of Hands
- Prescribed for inflammation and pain.
- Observed Side Effects- Stomach Pain, Gastric Ulcer and Bleeding Disorder
- Common Side Effects- Motrin, Naproxen, Daypro and Celebrex
b. Prednisone and Corticosteroid Therapy for Rheumatoid Arthritis of Hands7
- Prescribed for inflammation and for autoimmune disease.
- Chronic therapy may cause osteoporosis
c. Muscle Relaxants for Rheumatoid Arthritis of Hands
- Muscle relaxants are prescribed for muscle spasm and muscle pain.
- Most common muscle relaxants prescribed are Baclofen, Flexeril, Skelaxin and Robaxin
- Observed side effects like sleepiness and dizziness
d. Adjuvant Medications for Rheumatoid Arthritis of Hands
- Anti-Epileptic Analgesics- Most common antiepileptic prescribed as analgesics is Neurontin and Lyrica
- Anti-Depressant Analgesics- Most common antidepressant prescribed as analgesics is Cymbalta and Elavil.
e. Disease-Modifying Anti-Rheumatic Drugs (DMARDs) for Rheumatoid Arthritis of Hands 8,9
DMARDs for Rheumatoid Arthritis of Hands are used to slow the progress of the disease. DMARDs prevent permanent damage of the synovial membrane of the joint and ligaments. Following medications are often used as DMARDs.
- Methotrexate (Trexall)
- Leflunomide (Arava)
- Hdroxychloroquine (Plaquenil) and
- Sulfasalazine (Azulfidine).
f. Immunosuppressants for Rheumatoid Arthritis of Hands
Rheumatoid disease is associated with exaggerated immune activities. Following medications are used to suppress hyperactivities of immune system-
- Azathioprine (Imuran, Azasan) and
- Cyclosporine (Neoral, Sandimmune, Gengraf).
g. TNF-Alpha Inhibitors for Rheumatoid Arthritis of Hands
Rheumatoid arthritis causes increased secretion of Tumor Necrosis Factor-Alpha (TNF-alpha) within hip joint. TNF-alpha triggers inflammation. Inflammation induced by TNF-alpha factor causes pain, joint stiffness and joint swelling. Medications known as TNF-alpha inhibitors reduce production of TNF-alpha factor and provide symptomatic relief from pain, joint swelling and joint stiffness. Following medications are used to inhibit secretions of TNF- alpha factors.
- Etanercept (Enbrel)
- Infliximab (Remicade)
- Adalimumab (Humira)
- Golimumab (Simponi) and
- Certolizumab (Cimzia)
Watch 3D Video Of Rheumatoid Arthritis Of Hands
4. Interventional Treatment For Rheumatoid Arthritis of Hands
Cortisone Injection of Inflamed Joints in Palm and Fingers-
- Decreases inflammation.
- Cortisone reduces pain.
- Assists aggressive physical therapy
- Improves joint movements
5. Surgical Treatment For Rheumatoid Arthritis of Hands
a. Excision Of Tender And Painful Soft Tissues In Fingers And Hand
- Removing Subcutaneous Nodules
- Removal of Inflamed Joint Tissue- Surgery is performed to reduce pressure on tendon and ligaments resulting in pain.
- Removal of Osteophytes- Osteophytes often causes sharp pressure over tendon and cartilages resulting in pain.
b. Repair of Tendon Rupture In Fingers And Hand-
Chronic inflammation causes stretching of the joint and tear of the tendon. Tear or rupture of tendon may be associated with separation of tendon from its attachment to bone. Hand surgeon is trained to repair the tendon rupture and tendon separation from bones.
c. Joint Fusion (also called Arthrodesis) for Rheumatoid Arthritis of Hands
Procedure is performed to treat arthritis in many hand and wrist joints.
d. Reconstruction Surgery for Rheumatoid Arthritis of Hands
- Joint replacement
- Joint Fusion
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Watch 3D Video Of Surgical Treatment For Rheumatoid Arthritis Of Hands
1. Differentiating persistent from self-limiting symmetrical synovitis in an early arthritis clinic. Tunn ED, Bacon PA. Br J Rheumatol 1993;32: 97-103.
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8. The effectiveness of early treatment with second line anti-rheumatic drugs. A randomised controlled trial. van der Heide A, Jacobs JW, Bijlsma JW, et al. Ann Intern Med 1996;124: 699-707.
9. Relationships between knowledge and experience in the use of disease-modifying antirheumatic agents: a study of primary care practitioners. Stross JK. JAMA 1989;262: 2721-3.