Mateusz Gładysz FESSH prep

FESSH prep Rheumatoid hand Masked rupture of extensor digiti minimi, risk factors for extensor rupture, posterior interosseous nerve compression as the differential, flexor rupture site, timing of reconstruction

Tendon ruptures in rheumatoid arthritis

Last reviewed v1.0

FESSH-057Rheumatoid hand●●○ intermediate

Regarding tendon ruptures in rheumatoid arthritis:

  1. 1.Extensor digiti minimi usually ruptures first at the rheumatoid wrist, and its loss is easily missed because the common extensor still extends all four fingers together.

  2. 2.A raised serum matrix metalloproteinase-3 level is an independent predictor of spontaneous extensor tendon rupture in the rheumatoid wrist.

  3. 3.In rheumatoid arthritis, compression of the posterior interosseous nerve — a differential diagnosis of extensor tendon rupture — typically occurs beneath the extensor retinaculum from dorsal wrist tenosynovitis.

  4. 4.Rheumatoid flexor tendon ruptures most often affect the thumb, and the usual site of rupture is the carpal tunnel.

  5. 5.After extensor tendon rupture caused by a distal radioulnar joint lesion, the extension lag after reconstruction is worse when further fingers in the same hand have also ruptured.

FESSH marking: +1 per correct statement, 0 for blank, −1 for incorrect. Click the same TRUE/FALSE button twice to clear it.

Question ID
FESSH-057
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. Extensor digiti minimi usually ruptures first at the rheumatoid wrist, and its loss is easily missed because the common extensor still extends all four fingers together.

    True

    Williamson screened 550 unoperated rheumatoid wrists for loss of independent little-finger extension and found unsuspected rupture in nine (1.6%); in eight of them dorsal synovitis was absent or minimal. Carr made the same point in osteoarthritis of the distal radioulnar joint: rupture of extensor digiti minimi may be masked by the ring-finger extensor, so loss of independent little-finger extension is a valuable sign.

    • Williamson L, Mowat A, Burge P. Screening for extensor tendon rupture in rheumatoid arthritis. Rheumatology (Oxford). 2001;40(4):420-3. PMID 11312381
    • Carr AJ, Burge PD. Rupture of extensor tendons due to osteoarthritis of the distal radio-ulnar joint. J Hand Surg Br. 1992;17(6):694-6. PMID 1484257

  2. 2. A raised serum matrix metalloproteinase-3 level is an independent predictor of spontaneous extensor tendon rupture in the rheumatoid wrist.

    False

    Asano compared 25 wrists with extensor rupture and 77 without: swelling in the extensor compartments, the scallop sign and severe dorsal subluxation of the ulna were associated with rupture, but serum matrix metalloproteinase-3 was not. Ryu likewise identified dorsal dislocation of the distal ulna, a scallop sign and tenosynovitis persisting for at least 6 months as risk factors.

    • Asano K, Shinohara T, Iwatsuki K, Yamamoto M, Tatebe M, Hirata H. Risk factors for rupture of extensor tendons in the rheumatoid wrist. J Hand Surg Eur Vol. 2020;45(10):1087-1092. PMID 32493113
    • Ryu J, Saito S, Honda T, Yamamoto K. Risk factors and prophylactic tenosynovectomy for extensor tendon ruptures in the rheumatoid hand. J Hand Surg Br. 1998;23(5):658-61. PMID 9821614

  3. 3. In rheumatoid arthritis, compression of the posterior interosseous nerve — a differential diagnosis of extensor tendon rupture — typically occurs beneath the extensor retinaculum from dorsal wrist tenosynovitis.

    False

    Rheumatoid posterior interosseous nerve palsy arises at the elbow: Fernandez attributes it mainly to elbow joint swelling and compression at the arcade of Frohse, and Kishner to synovitis of the elbow. It presents as inability to extend the fingers at the metacarpophalangeal joints, and the main differential diagnosis is extensor tendon rupture; Fernandez notes that inability to extend the thumb is a useful distinguishing clue.

    • Fernandez AM, Tiku ML. Posterior interosseous nerve entrapment in rheumatoid arthritis. Semin Arthritis Rheum. 1994;24(1):57-60. PMID 7985038
    • Kishner S, Biundo JJ. Posterior interossous neuropathy in rheumatoid arthritis. J Clin Rheumatol. 1996;2(1):29-32. PMID 19078024

  4. 4. Rheumatoid flexor tendon ruptures most often affect the thumb, and the usual site of rupture is the carpal tunnel.

    True

    In Funahashi's 41 surgically treated ruptures, the thumb was most often affected (12), followed by the ring and little fingers (9 each), and ruptures were most common in the carpal tunnel (zone IV). Kobayashi traced the cause to bony spurs from rheumatoid erosion, mainly of the scaphoid or the volar distal radius.

    • Funahashi T, Suzuki T, Iwamoto T, Shizu K, Matsumura N, Ochi K, et al.. Subcutaneous flexor tendon rupture in patients with rheumatoid arthritis. Mod Rheumatol. 2016;26(6):869-872. PMID 26873301
    • Kobayashi A, Futami T, Tsukamoto Y. Flexor tendon rupture in the rheumatoid wrist caused by bony spurs in the carpal tunnel. Mod Rheumatol. 2001;11(2):136-9. PMID 24383690

  5. 5. After extensor tendon rupture caused by a distal radioulnar joint lesion, the extension lag after reconstruction is worse when further fingers in the same hand have also ruptured.

    True

    Itsubo's 74 reconstructed fingers (rheumatoid arthritis in 24 hands, osteoarthritis in 10) had a significantly larger extension lag when two or three additional fingers in the hand had ruptured; the interval from rupture to reconstruction and the reconstruction method did not materially affect the result, and the authors recommend surgery before three fingers are affected. In Gong's multicentre survey of rheumatoid patients, 76% had ruptures in more than two digits, with a mean of 2.9 months between the first and the latest rupture.

    • Itsubo T, Uchiyama S, Yamazaki H, Hayashi M, Nakamura K, Kuniyoshi K, et al.. Factors affecting extension lag after tendon reconstruction for finger extensor tendon rupture due to distal radioulnar lesion. J Orthop Sci. 2015;21(1):19-23. PMID 26755381
    • Gong HS, Lee JO, Baek GH, Kim BS, Kim JY, Lee JS, et al.. Extensor tendon rupture in rheumatoid arthritis: a survey of patients between 2005 and 2010 at five Korean hospitals. Hand Surg. 2012;17(1):43-7. PMID 22351532