Hand Case Study 1: RA

Phillipa Hall is a 50 year old Medical Secretary who was diagnosed with Rheumatoid Arthritis 10 years ago. She had previously noticed an increasing ache in the hands and wrists, which occurred intermittently. She experiences periods of worsening and improvement in pain but deteriorating function in terms of grip and wrist extension. She has also noticed a gradual decrease in strength affecting the muscles around her shoulder. She lives with her husband and teenage sons, but usually does all the domestic duties. She is finding this increasingly difficult due to her worsening condition and has consulted her GP for review of her medication. Currently she is taking DMARDS.

Anatomy & Pathology
RA is a chronic autoimmune disorder that most commonly causes inflammation and tissue damage. RA is caused by synovitis, inflammation of synovial membranes and can erode articular cartilage – with time it affects multiple joint – polyarthritis – most commonly affects small joints – diagnosis is in the form of blood tests for antibodies. Summary of deformities in severe arthritis of hands and wrists: Ulnar drifting of fingers – Valgus thumb - Dislocation of meta carapalphalangeal joints – Destruction of interphalangeal joints – wrists joints twisted to ulna – pencil shaped ulna.

Subjective Examination
Where\What: decreased grip, reduced wrist extension – more than 1 joint – can expect functional problems as well as problematic flexion When: 10 years ago How: 0-10 rating: Increasing fluctuation 24 hour cycle: expect stiffness from sleeping – worse in morning Better for: expect heat/resting Worse for: ice, cold, activity Type of pain: expect aching Past Medical History/ General History:

Red Flags and general concerns: tiredness and weight loss are common – check these are not severe – carpal tunnel syndrome is a possibility SH: lives with husband and teenage son – ask about domestic duties DH: DMARD’s Patients main outcome: better doing housework

Objective Examination
Working Hypothesis: obtain profile of the extent of RA, rule out carpal Advice & Consent: give and obtain General Observations: watch walking Acute Observations:
Skin colour – n/a Swelling – around joint Posture – may be issue if extending to other joints Muscle Bulk - reduced Deformity – gauge severity

Active Tests, Passive Tests, Resisted Tests:
- All in sitting with hands and wrists across bed Inferior Radioulnar – pronation supination Radiocarpal – flex extension radial deviation ulnar deviation Carpometacarpal joint of thumb – flexion extension abduction adduction opposition Metacarpal phalangeal Joint – flexion extension abduction adduction Proximal & distal interpahlangeal joints – flexion extension Active – mimic with own hand get good record - reduced extension a problem – expect problem in flexion Passive - enables joints to be evaluated – bear severe deformities in mind. Look for weakness, stiffness and deformity. Resisted – expect weakness in surrounding muscles – record

Can also examine shoulder and inquire as to whether the RA is affecting this joint – active, passive and resisted test should be performed in flexion extension abduction adduction medial and internal rotation

Special Tests:
Phalens – sustained inverse prayer hands – hold for 1 minute – positive sign would be distal tingling pain Tinels Sign – tapping of median nerve path – produces pins and needles and pain in palm.

Functional Tests: Dexterity tests – try picking up small objects
Strength tests – picking up objects – chair? Endurance tests – how long can hold up chair

Palpation: feel for muscle wastage – examine for swelling – gauge deformity in

Measurements: record reduced extension in passive – record expected
reduced flexion in passive – record any other problems – even draw round hands in full spread

Advice & Possible Treatment: may have pain following examination
Pain relief from g.p. – core treatment is exercise – heat treatment can case pain – DMARDS used early on. If severe steroids may be used - routine use of steroids can lead to osteoporosis, weight gains & muscle wastage.

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