Phillip E. Wright II
Campbell’s Operative Orthopaedics, 9th ed, 1998, Chapter 74


Rheumatoid Arthritis

– characterized by hypertrophic synovitis that erodes cartilage
– usually bilateral, symmetric involvement
– involves all the joints, but most importantly affects the MCP joints
– depending on the involvement, can cause swan-neck or boutonniere deformities of the fingers and of the thumb
– intercarpal ligament involvement can produce rotatory instability of the scaphoid.


– usually involves the first CMC joint in elderly women
– Heberden nodes – DIP
– Bouchard nodes – PIP

Systemic Lupus Erythematosis

– connective tissue disease with tendon, joint capsule, and ligamentous involvement. The deformities are often similar to rheumatoid, but are due to soft tissue abnormalities unrelated to proliferative synovitis, and the articular cartilage is usually well preserved.
– vascular phenomena such as Raynaud’s is often seen and may be amenable to digital sympathectomies

Psoriatic Arthritis

– about 95% have asymmetric peripheral joint involvement
– fusiform swelling of the entire digit
– x-ray shows erosion of terminal phalangeal tufts (acro-osteolysis), tapering of the phalanges and metacarpals, cupping of the proximal ends of phalanges and metacarpals, severe destruction or ankylosis of isolated small joints, and a predilection for IP joints with sparing of the MCP’s.

Reiter Syndrome

– triad of conjunctivitis, urethritis, synovitis
– usually asymmetric joint involvement
– 90% have remission after a week; chronic in 10%


– joints are hot, swollen, red – imitate infection
– massive monosodium urate crystal deposition can cause nerve compression, skin ischemia, ulceration
– uric acid levels are not reliable – Dx is made by joint aspiration and demonstration of negatively birefringent crystals on polarize microscopy.


– soft tissue contractures – usually synovitis is not the underlying problem
– fingertip ulceration due to vascular impairment may cause auto-amputation.
– spontaneous amputation may be better than surgery, as length will be preserved – on the other hand, if it is too painful, you may have to amputate!

Staging of Operations

– According to Ferlic, Smyth, Clayton, the surgical priorities are, in descending order, spine, foot, hip, knee, wrist, shoulder, thumb, elbow, fingers
– so in the hand – do wrist, thumb, fingers. If wrist arthrodesis is considered, do this first, as the position of the wrist influences remaining finger function. A thumb MCP fusion can be entertained at the same time, but the remainder should wait.

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