Rheumatoid, Osteoarthritis, Dupuytren's

Front 1

What are the typical areas involved in rheumatoid arthritis?

Back 1

cervical spine, shoulders, elbows, hands, hips, knees and feet

Front 2

What is the pathophysiology of rheumatoid arthritis?

Back 2

Inflamed synovium invades and destroys articular cartilage

Front 3

What is the female:male ratio in rheumatoid arthritis?

Back 3

3:1

Front 4

Patients with rheumatoid arthritis need what special pre-op evaluation?

Back 4

cervical spine evaluation

Front 5

In what order do you address joints in patients with rheumatoid arthritis?

Back 5

proximal to distal

Front 6

What are common hand findings in rheumatoid arthritis?

Back 6

ulnar drift at the MCPs, caput ulna, swan-neck and boutonniere deformities, tendon ruptures, thumb deformities, radiocarpal collapse

Front 7

What are the typical x-ray changes of rheumatoid arthritis?

Back 7

periarticular erosions and osteopenia

Front 8

What is the mechanism of ulnar drift at MCPs?

Back 8

synovitis at MCP causes laxity, laxity causes ulnar deviation of the extensor tendons, radial deviation of the wrist and metacarpals alters the direction of pull of the extensor tendons

Front 9

What is the surgical treatment for ulnar drift?

Back 9

Address wrist first. If no joint destruction: synovectomy, soft tissue realignment and ulnar intrinsic release. If joint destruction: MCP implant arthroplasty

Front 10

What is a caput ulna?

Back 10

dorsal subluxation of the ulna due to distal radioulnar joint synovitis and capsule stretch

Front 11

What is Vaughn-Jackson syndrome?

Back 11

Ischemic or attritional rupture of finger extensor tendons due to dorsal ulnar subluxation

Front 12

When is operative treatment indicated in the management of caput ulna?

Back 12

Failure of medical management, pain with motion

Front 13

What is a swan-neck deformity?

Back 13

hyperextension of the PIP with flexion at the DIP

Front 14

What are the 3 distinct mechanisms of the swan-neck deformity?

Back 14

synovitis at the DIP leading to rupture of distal extensor tendon (mallet deformity); synovitis at PIP leading to volar plate laxity; or intrinsic tightness leading to MCP subluxations which causes extensor imbalance

Front 15

Correction of swan-neck deformities depends on what 2 factors?

Back 15

PIP joint mobility and destruction

Front 16

If joint fusion is necessary in correction of swan-neck deformities, at what degree of flexion are the fingers fused?

Back 16

index at 30 degrees, middle at 35 degrees, ring at 40 degrees and small finger at 45 degrees

Front 17

What is a Boutonniere deformity?

Back 17

flexion at PIP with hyperextension at the DIP and MCP

Front 18

How do you correct a Boutonniere deformity when there is a fixed flexion deformity?

Back 18

Arthrodesis vs. arthroplasty of the PIP

Front 19

What are the 4 causes of a sudden inability of a rheumatoid patient to extend a finger?

Back 19

1. extensor tendon rupture from attrition, 2. ulnar subluxation of an extensor tendon at the MCP, 3. posterior interosseous nerve palsy at the elbow, 4. palmar subluxation of the MCP

Front 20

What is the most common extensor tendon to rupure in rheumatoid patients?

Back 20

expensor pollicis longus

Front 21

What is the most common flexor tendon to rupture in patients with rheumatoid arthritis?

Back 21

flexor pollicis longus

Front 22

What is Mannerfelt's syndrome?

Back 22

Rupture of flexor pollicis longus

Front 23

What are the physical findings associated with rupture of flexor pollicis longus?

Back 23

inability to flex the thumb at the IP joint

Front 24

What are the causes of rupture of flexor pollicis longus?

Back 24

synovitis, carpal osteophyte

Front 25

How do you treat rupture of flexor pollicis longus?

Back 25

synovectomy, osteophyte resection and tendon graft or transfer

Front 26

What is the most common form of arthritis?

Back 26

osteoarthritis

Front 27

What is the pathophysiology of OA?

Back 27

cartilage changes including increased water content and altered collagen and proteoglycans that lead to cartilage destruction

Front 28

Is OA more common in men or women?

Back 28

Women

Front 29

What are the x-ray changes associated with OA?

Back 29

osteophytes, narrowed joint space, eburnation and subchondral cysts

Front 30

What are common sites affected by OA?

Back 30

DIPs and thumb carpometacarpal joints

Front 31

How do you treat OA in DIPs?

Back 31

Conservatively with rest, NSAIDs and steroid injections. If this fails, fuse joint in 10-20 degrees of flexion

Front 32

What cells are involved in the formation of Dupuytren's contractures?

Back 32

fibroblasts

Front 33

What is the male:female ratio in Dupuytren's contractures?

Back 33

10:1

Front 34

What is the inheritance pattern of Dupuytren's contractures?

Back 34

autosomal dominant with variable penetrance

Front 35

What areas of the body are most commonly affected by Dupuytren's contractures?

Back 35

palm, ring finger, small finger

Front 36

What diseases are associated with Dupuytren's contractures?

Back 36

alcoholism, diabetes, epilepsy, HIV, COPD

Front 37

What are the 3 classic findings of Dupuytren's diasthesis?

Back 37

knuckle pads, foot involvement (Ledderhose's disease), penis involvement (Peyronie's disease)

Front 38

In Dupuytren's contractures, which band does NOT become diseased forming a cord?

Back 38

Cleland's ligament (dorsal to the NV bundle)

Front 39

What are the indications for surgical correction for Dupuytren's contractures?

Back 39

Contracture causing maceration or hygeine difficulties, any PIP joint contracture, MCP joint contracture that significantly impairs ADLs

Front 40

What are the surgical options for Dupuytren's contractures?

Back 40

Subcutaneous fasciotomy (only for very sick or elderly patients), limied fasciectomy (resection of diseased tissue only), regional fasciectomy (resection of diseased tissue and a margin of healthy tissue), extensive fasciectomy (resection of diseased tissue and all potentially involved fascia), or radical fasciectomy

Front 41

What skin incision is advocated in a palmar procedure to correct Dupuytren's contractures?

Back 41

transverse incision in proximal palmar crease

Front 42

What skin incision is advocated in a finger procedure to correct Dupuytren's contractures?

Back 42

longitudinal incision broken up by Z-plasties over creases

Front 43

What are the complications of surgical correction of Dupuytren's contractures?

Back 43

hematoma, recurrence, nerve injury, vascular injury, stiffness, complex regional pain syndrome (fka reflex sympathetic dystrophy)

Front 44

In Dupuytren's contractures, what are the best predictors of neurovascular bundle displacement?

Back 44

PIP joint flexion contracture and interdigital nodule

Front 45

What structures become the spiral band in Dupuytren's contractures?

Back 45

pretendinuous band, spiral band, lateral sheet and Grayson's ligament (Plastic Surgeons Look Good)