Examination of the rheumatoid hand and wrist

Rheumatoid disease affects almost all of the musculoskeletal system as well as some internal organs, such as the heart and lungs, pleura, eyes, lymph nodes and vessels. In the case of the upper extremity, we should know the time of onset and type of disease, as the extent and degree of tissue involvement varies among the different types of rheumatoid disease. Surgical treatment and postoperative management will vary significantly in patients suffering from sclerodermia to those of systemic lupus erythematosus. This can also be said about the type of medication used for treating the disease, as more recent medications may alter collagen synthesis and infection rates. Before examining the hand, shoulder and elbow function should also be assessed. Clinical examination of the hand joints is most important, as all deformities, including most tendon ruptures and tendon dislocations are secondary to joint involvement. We should carefully examine for the presence and intensity of joint synovitis, and the degree of joint deformity and record the range of active and passive joint mobility. Radiological examination should be done in all cases to determine the degree of joint cartilage destruction, joint subluxation, and even joint ankylosis which is some times difficult to asses on clinical examination due to a fixed joint deformity from extraarticular causes. CAT scan examination can be useful for wrist joint assessment. Magnetic resonance examinations may be required only in certain circumstances, i.e. to determine the presence of joint or tendon synovitis not clearly assessed by clinical exploration, and the location of a flexor tendon rupture.