Mateusz Gładysz FESSH prep

FESSH prep Rheumatoid hand Rheumatoid wrist — caput ulnae syndrome, Vaughan Jackson and Mannerfelt lesions, Simmen classification, Darrach and Sauvé–Kapandji procedures

The rheumatoid wrist and distal radioulnar joint

Last reviewed v1.0

FESSH-034Rheumatoid hand●●● advanced

Regarding the rheumatoid wrist and distal radioulnar joint:

  1. 1.The caput ulnae syndrome, described by Bäckdahl in 1963, comprises dorsal prominence of the ulnar head with volar subluxation, ulnar translocation and supination of the carpus.

  2. 2.In the Vaughan-Jackson lesion, extensor tendon rupture begins on the ulnar side with extensor digiti minimi and the extensor digitorum communis slip to the small finger and progresses radially to the ring, long and index fingers.

  3. 3.The Mannerfelt lesion is attritional rupture of the finger extensor tendons over the dorsally subluxed ulnar head.

  4. 4.The Sauvé–Kapandji procedure removes the ulnar head and creates a pseudarthrosis of the distal ulna.

  5. 5.The Simmen (Schulthess) classification groups rheumatoid wrists by the type of destruction into ankylosing (type I), osteoarthritic (type II) and destabilising (type III) forms, and type III wrists require bony stabilisation.

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Question ID
FESSH-034
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. The caput ulnae syndrome, described by Bäckdahl in 1963, comprises dorsal prominence of the ulnar head with volar subluxation, ulnar translocation and supination of the carpus.

    True

    Synovitis of the distal radioulnar and ulnocarpal compartments, often the first part of the rheumatoid wrist to be involved, attenuates the ligamentous restraints so that the carpus subluxes volarly, slides ulnarwards and supinates away from the ulna, leaving the ulnar head dorsally prominent; strictly, the ulna is fixed and it is the radius and carpus that translate volarly. The extensor carpi ulnaris drops volar to the axis of rotation and its dislocation is strongly associated with extensor tendon rupture. The constellation was named by Bäckdahl in a 1963 monograph and is the usual prelude to attritional extensor rupture.

    • De Smet L. The distal radioulnar joint in rheumatoid arthritis. Acta Orthop Belg. 2006;72(4):381-6. PMID 17009815
    • Bäckdahl M. The caput ulnae syndrome in rheumatoid arthritis. A study of the morphology, abnormal anatomv and clinical picture. Acta Rheumatol Scand Suppl. 1963;5:1-75. PMID 13965955
    • Lim JX, Chung KC. Assessment of Progressive Hand and Wrist Deformities in the Rheumatoid Patient. Hand Clin. 2024;41(1):25-35. PMID 39521587

  2. 2. In the Vaughan-Jackson lesion, extensor tendon rupture begins on the ulnar side with extensor digiti minimi and the extensor digitorum communis slip to the small finger and progresses radially to the ring, long and index fingers.

    True

    The eroded, dorsally prominent ulnar head lies beneath the ulnar-most extensor tendons first, so extensor digiti minimi and the small-finger extensor digitorum communis rupture first; if the underlying joint is not treated the ring, long and index communis tendons follow sequentially and extensor indicis proprius may rupture last. In a 60-patient series of rheumatoid tendon ruptures the extensors to the ring and small fingers were the commonest, and early treatment of the distal radioulnar joint was recommended to forestall the cascade. Vaughan-Jackson's original 1948 report described two elderly labourers with degenerative arthritis of the distal radioulnar joint, not rheumatoid disease.

    • Mazhar T, Rambani R. Vaughan-Jackson-like syndrome as an unusual presentation of Kienböck's disease: a case report. J Med Case Rep. 2011;5:325. PMID 21787412
    • Vaughan-Jackson OJ. Rupture of extensor tendons by attrition at the inferior radio-ulnar joint; report of two cases. J Bone Joint Surg Br. 1948;30B(3):528-30. PMID 18877990
    • Moore JR, Weiland AJ, Valdata L. Tendon ruptures in the rheumatoid hand: analysis of treatment and functional results in 60 patients. J Hand Surg Am. 1987;12(1):9-14. PMID 3805649

  3. 3. The Mannerfelt lesion is attritional rupture of the finger extensor tendons over the dorsally subluxed ulnar head.

    False

    Mannerfelt and Norman in 1969 described attrition rupture of flexor tendons, classically flexor pollicis longus, over a bony spur on the floor of the carpal tunnel, most often the distal pole of a rotated scaphoid and less often the trapezium. The spur must be sought and removed at surgery, and thumb flexion is restored by free tendon graft, transfer of a flexor digitorum superficialis, or interphalangeal arthrodesis. Attritional extensor rupture over the ulnar head is the Vaughan-Jackson lesion. Mannerfelt's name is also attached to a technique of total wrist arthrodesis.

    • Mannerfelt L, Norman O. Attrition ruptures of flexor tendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel. A clinical and radiological study. J Bone Joint Surg Br. 1969;51(2):270-7. PMID 5770406
    • Zangger P, Simmen BR. Spontaneous ruptures of flexor tendons secondary to extreme DISI deformity of the lunate in a rheumatoid wrist. A case report. Ann Chir Main Memb Super. 1993;12(4):250-6. PMID 7694626

  4. 4. The Sauvé–Kapandji procedure removes the ulnar head and creates a pseudarthrosis of the distal ulna.

    False

    Sauvé and Kapandji in 1936 described an arthrodesis across the distal radioulnar joint combined with a segmental resection of the ulna proximal to the fusion, creating a pseudarthrosis that restores pronation and supination while the ulnar head is retained to support the ulnar carpus and the extensor carpi ulnaris; Kapandji advised filling the gap with pronator quadratus. Removal of the ulnar head is the Darrach procedure, whose most frequent complication is instability of the proximal ulnar stump with painful radioulnar impingement. Whether the Sauvé–Kapandji procedure prevents ulnar translation of the rheumatoid carpus better than the Darrach is contested; the only direct comparative cohort found no significant change after either.

    • Taleisnik J. The Sauvé-Kapandji procedure. Clin Orthop Relat Res. 1992;(275):110-23. PMID 1735199
    • Kapandji IA. The Kapandji-Sauvé operation. Its techniques and indications in non rheumatoid diseases. Ann Chir Main. 1986;5(3):181-93. PMID 3813693
    • Carl HM, Lifchez SD. Functional and Radiographic Outcomes of the Sauvé-Kapandji and Darrach Procedures in Rheumatoid Arthritis. J Hand Microsurg. 2018;11(2):71-79. PMID 31413489

  5. 5. The Simmen (Schulthess) classification groups rheumatoid wrists by the type of destruction into ankylosing (type I), osteoarthritic (type II) and destabilising (type III) forms, and type III wrists require bony stabilisation.

    True

    Simmen and Huber proposed classifying rheumatoid wrist involvement by the type rather than the extent of destruction, in contrast to degree-based systems such as Larsen's numerical grading and the Wrightington surgical staging. Type I wrists progress to spontaneous ankylosis, typical of juvenile-onset disease; type II behave like secondary osteoarthritis; type III wrists all develop an unstable radiocarpal joint with ulnar and palmar subluxation of the carpus and progressive loss of carpal height, for which an osseous stabilising procedure such as radiolunate arthrodesis is essential. Carpal height ratio, ulnar translocation and scapholunate dissociation are the three radiographic indicators that identify the unstable form early.

    • Simmen BR, Huber H. [The wrist joint in chronic polyarthritis--a new classification based on the type of destruction in relation to the natural course and the consequences for surgical therapy]. Handchir Mikrochir Plast Chir. 1994;26(4):182-9. PMID 7926987
    • Flury MP, Herren DB, Simmen BR. Rheumatoid arthritis of the wrist. Classification related to the natural course. Clin Orthop Relat Res. 1999;(366):72-7. PMID 10627720