Main et poignet rhumatoïdes

Abstract

In rheumatoid arthritis (RA), wrist and hand involvement is very frequent and occurs very early. Despite heterogeneity of onset modalities, some clinical features are suggestive but not specific of the disease. These include at the initial stage, the combination of synovitis and tenosynovitis in several sites. When the disease does not include the presence of autoantibodies (50 %) and/or erosive lesoins (90 %), new imaging tools applied to those sites are of diagnosis and prognosis values (active synovitis in power doppler ultrasound ; bone oedema in MRI). New imaging modalities are emerging and those allowing quantitative evaluation of periarticular bone loss from hand joints are promising for assessment of early arthritis. Medical treatment is in accordance with recommendations for RA management. Potential impact of TNF-antagonists on tenosynovitis refractory to conventionnal DMARDs has been suggested. Radiation synovectomy for mono- or olgo-articular disease appears as helpful. Surgical steps are often required during the course of RA. Nevertheless, in the last ten years, an important decrease of surgical procedures was observed. Reaxation and stabilisation of the damaged joints or tendons are the main objectives of these interventions. The hand surgeon has numerous surgical procedure available: synovectomies, flexor or extensor tendon reconstructions, arthroplasties, arthrodeses, capsuloplasties. These techniques are described in this chapter, with their indications, limits, and complications. At the wrist level, stability and axis restoration are the main objectives. The long finger surgery must restore an efficient grasp and pinch. The rheumatoid thumb surgery is based on stability restoration that is crucial for pinch.