2nd Metacarpophalangeal Joints Research Articles

Relationship between Clinical, Serological and Ultrasound Assessment of Rheumatoid Arthritis Activity

Abstract Background Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic inflammation of synovial tissue that leads to damage of cartilage and bone, resulting in irreversible joint destruction. Aim of the Work Our study’s aim was to assess the relationship between systematic ultrasound (US) evaluation using 7-joint and 12-joint scores and both clinical and serological evaluations in the determination of disease activity in rheumatoid arthritis patients. Also, we assessed the difference between both scores to know which is more accurate in assessing disease activity. Patients and Methods It was a cross sectional study that was carried out on fifty-five Egyptian RA patients diagnosed according to the 2010 American College of Rheumatology (ACR)/EULAR criteria. Patients were recruited from the rheumatology outpatient clinic at Ain Shams university hospital. Results Regarding 7-joint score parameters, mean and standard deviation for GS synovitis was 5.72 ± 4.44, PD synovitis was 3.74 ± 5.24, GS tenosynovitis was 1.15 ± 1.68, PD tenosynovitis was 1.76 ± 3.44 and erosions 1.07 ± 1.37. Regarding the examined areas for 7-joint score, wrist dorsal synovitis was the most common synovitis (98%), 2nd metacarpo-phalangeal joint (56%) then 2nd metatarso-phalangeal joint (49%). Wrist dorsal tenosynovitis (36%) was the most frequent tenosynovitis. Radial (33%), dorsal erosions (18%) of 2nd metacarpo-phalangeal joint and radial erosions (13%) of 5th metatarso-phalangeal joint were the most common erosions found. Our study detected significant positive correlation (P value <0.05 and positive correlation coefficient) between majority of 7-joint and 12-joint score parameters (both GS and PD) and clinical disease activity variables, ESR, CRP and platelet count. Our study showed highly significant positive correlation (P value <0.01 and positive correlation coefficient) between all parameters of 7-joint and 12-joint scores. We found that 12 joint score is slightly better than 7 joint score in accuracy and sensitivity in assessing rheumatoid arthritis disease activity despite being more time-consuming. Conclusion The 7-joint and 12-joint ultrasound scores were simple and practical sum scoring systems for use in the detection of synovitis in patients with RA and in assessment of disease activity in synovium. The correlations between the clinical disease activity indices, ESR, CRP, platelet count and components of the 7-joint and 12-joint scores may indicate their value in assessment of disease activity and severity up to date. The composite score (Combined synovitis score) for 12-joint score was significantly differentiating between moderate-severe patient groups (classified according to DAS28) with P value 0.029, so 12-joint score was better in identifying minimal difference in disease activity despite being time-consuming.

E064 A rare hereditary haemochromatosis type three (3) related arthritis

Abstract Background/Aims Arthritis is a common manifestation in hereditary haemochromatosis (HHC). Haemochromatosis arthropathy frequently involves small joint of hands especially the metacarpo-phalangeal joints (MCPJs) and hence is one of the differentials when assessing for rheumatoid arthritis, psoriatic arthritis along with osteoarthritis but requires a high index of suspicion. We report a case of Haemochromatosis arthropathy where the arthropathy was due to type 3 hereditary haemochromatosis (HHC) which is a much rarer form and requires specialist genetic testing. Methods A 38-year-old lady was referred with abnormal iron profile and ten-month history of small joint arthralgia mainly affecting the index and middle finger in right hand with occasional swelling. She had a normal body mass index with minimal alcohol intake. Clinical examination showed low grade synovitis in index finger metacarpo-phalangeal joint (MCPJ). Blood investigations for Rheumatoid arthritis and connective tissue diseases were negative with normal CRP & ESR, Ferritin was slightly raised at 236 and transferrin saturation was 100% on two successive occasions, LFTs were normal. Xray of hands showed slight narrowing of 2nd MCPJ and US hands showed thickened synovium but no erosions or Doppler activity in 2nd MCPJ. Results Based on these, possible hereditary haemochromatosis (HHC) arthropathy was considered. By that time, she had been seen by the hepatology service where no evidence of iron deposition in other organs was found. Surprisingly her genetic testing for hereditary haemochromatosis (HHC) (Cys282Y/H63D in HFE gene) was negative resulting in most common HFE-related HHC excluded. Iron studies were repeated which were still raised, hence after discussion with hepatologist and biochemist the plan was made to investigate for rarer form of hereditary haemochromatosis (HHC), genetic tests showed that she had TFR2 variant mutation which would be consistent with type 3 hereditary haemochromatosis (HHC), which is inherited in autosomal recessive pattern. Venesections were started with ferritin levels improving to less than 50 with plans to monitor arthralgia to see if there is any improvement over time. Conclusion Metacarpo-phalangeal joints (MCPJs) involvement is common in various arthropathies. This case highlights the importance of considering other, much rarer forms of hereditary haemochromatosis (HHC) as treatment will help in preventing iron deposition in other organs like liver, heart, pancreas etc. These conditions are very rare and there is need to create awareness of genetic testing as hereditary haemochromatosis (HHC) arthropathy does present not uncommonly to rheumatology services and requires dedicated non-HFE molecular panel. Disclosure H. Umair: None. M. Kazmi: None.

MANAGEMENT OF UNCOMMON INJURY OF 2ND METACARPOPHALANGEAL JOINT (KAPLAN'S DISLOCATION) BY OPEN DORSAL APPROACH: A CASE REPORT

Introduction: The rst Metacarpophalangeal (MCP) joint is among the most commonly injured joints in the hand, it is because of the signicant contribution of the thumb to overall hand function and its amenability to injury in work and sporting activities. In contrast to MCP dislocation of the thumb, dislocation of the other MCP joint is an uncommon. Kaplan dislocations following trauma are of rare occurrence. An uncomplicated MCP joint dislocation can be managed by closed reduction but complicated dislocation always needs open reduction for better outcome. Case Report: Here, we present a case of 26 year old male with 3 months old fracture dislocation of 2nd MCP joint Right hand, which was managed by open dorsal approach with proper reduction, k wire xation and good functional outcome. We expe Conclusion: rienced when dislocation is complete, with the head of the metacarpal displaced towards the volar side and the base of the phalanx towards the dorsal side, the dorsal approach of is found to be safe and simple with good visualization, negligible injury to Neurovascular structure and better xation

Patients with seronegative rheumatoid arthritis have a different phenotype than seropositive patients: A clinical and ultrasound study.

IntroductionRheumatoid arthritis (RA) is an inflammatory disease whose clinical phenotype largely depends on the presence of rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA). Seronegative RA appears to be a less severe disease, but this remains controversial. This study aimed to assess whether seronegative patients show a less severe disease than seropositive patients.MethodsA cross-sectional study was conducted on RA outpatients from a single center. Clinical activity scales, laboratory evaluations, and cardiovascular risk scores were assessed. Musculoskeletal ultrasound (US) examinations were performed.ResultsOne hundred and fourteen patients were enrolled. Eighty-five were seropositive (76% women) and 29 seronegative (93% women). Seropositive patients had a younger age at disease onset (43 ± 14 vs. 54 ± 11; p = 0.001) and used sulfasalazine (47 vs. 17%; p = 0.004) and glucocorticoids (36 vs. 10%; p = 0.007) more frequently. No differences in clinical activity scales and in 10-year cardiovascular risk were observed. Pathological US data were found more frequently in seropositive patients in the 2nd metacarpophalangeal (MCP) joint, both in grayscale (71 vs. 38%; p = 0.008) and in power Doppler (PD; 53 vs. 9%; p < 0.001); erosions (36 vs. 9%; p = 0.020) were also more frequent. We found greater severity of PD signals in the 2nd MCP and 3rd MCP joints of the seropositive patients, while synovitis severity was higher only in the 2nd MCP joints. The percentage of total joints with erosions (9 vs. 1%; p < 0.001) and 2nd MCP joints with erosions (25 vs. 7%; p < 0.001) was higher in seropositive patients.ConclusionRA patients show a differentiated phenotype according to their ACPA and RF status. In seronegative patients, RA begins later in life and has a lower requirement for antirheumatic therapies. On US evaluation, seropositive patients show more joint damage, especially in MCP joints. Despite this, long-term cardiovascular risk is similar among RA patients, regardless of their RF and ACPA status.

Lower hand grip in rheumatoid arthritis patients is associated with low finite element analysis using high resolution peripheral quantitative computed tomography scan of the 2nd metacarpophalangeal joint.

To evaluate hand function by hand grip test in rheumatoid arthritis (RA) patients, and its association with bone erosions and the estimated bone strength (finite element - FE analysis) through the analysis of the 2nd metacarpal head of the dominant hand using high resolution peripheral quantitative computed tomography (HR-pQCT). Eighty-two female RA patients between 18-50 years old were selected. Demographic data, Health Questionnaire Assessment Disability Index (HAQ), Disease Activity Score of 28 joints (DAS)-28, simplified disease activity index (SDAI) and the hand grip test were set. The HR-pQCT scans of 2nd metacarpophalangeal joints of the dominant hand of all patients were performed according to SPECTRA group protocols. The images were used to assess bone erosions and FE analysis. The hand grip test was categorized in 2 groups and separately compared (< 18 vs ≥18 kgf). A logistic regression was performed using hand grip test <18 kgf as a dependent variable. A significant difference was found between the 2 groups regarding HAQ, inflammatory markers (erythrocyte sedimentation rate, C-reactive protein), DAS-28, SDAI, total volume of erosion and bone strength parameter (FE analysis - Failure Load [F.Load]). The logistic regression analysis showed that the risk factors associated with hand grip test <18 kgf were higher SDAI (odds ratio [OR] 0.912; 95% CI 0.837-0.993) and lower values of bone strength parameter (F.Load) (OR 1.007; 95% CI 1.002-1.012). Lower values of hand grip test were associated with higher disease activity score-SDAI and lower bone strength of 2nd metacarpal bone head of the dominant hand evaluated here through a FE analysis using HR-pQCT scan.

2nd Metacarpophalangeal joint fracture dislocation [Kaplan’s Lesion] operated by open reduction with dorsal approach: A case report

Kaplan’s injury is the dislocations of metacarpophalangeal (MCP) joint dorsally. It may be seen in all five fingers but usually index finger is more prone to such injury. In Kaplan dislocation the head of the metacarpal button-holed through the constraint soft tissue surroundings and the volar plate goes dorsal to the metacarpal head which makes it irreducible by closed method. Both dorsal & volar approaches have been described in many literature for open reduction for the dislocation. Though, the right approach to treat such lesions is still a debate, it is the volar approach which is widely used & described more in literature. Some prefer dorsal approach. Volar approach is very prone to iatrogenic neurovascular injure.Surgical Procedure: Dorsal approach was used. This volar plate was completely dorsally dislocated. Head of metacarpal found fractured. A longitudinal incision was made over the plate & the head of the metacarpal was gently elevated & allowed to relocate. K wire was inserted through fracture fragment into the metacarpal head.Result: As follow-up after 6 weeks, the patient’s active range of motion consisted of metacarpophalyngeal joint hyperextension to 10° and 75° of flexion, proximal interphalangeal joint extension to 0° and flexion to 70°, and distal interphalangeal joint extension to 0° and flexion to 60°. Neurovascular evaluation was within normal limits. X-rays confirmed maintenance of reduction.

AB0648 REACTIVE ARTHRITIS IN SYPHILIS MIMICKING RHEUMATOID ARTHRITIS: A CASE REPORT

Background:Reactive arthritis is a form of spondyloarthritis with aseptic joint involvement occurring after a gastrointestinal or urogenital infection. Most commonly associated with Chlamydia trachomatis, Salmonella, Shigella, Campylobacter, and Yersinia. Syphilis is an infection caused by the spirochete Treponema pallidum and is not usually associated with reactive arthritis. Syphilis is a great imitator of other diseases due to its broad presentation including painless chancre, constitutional symptoms, adenopathy, rash, synovitis, neurological and ocular findings.Objectives:To discuss a patient who presented with symptoms of rheumatoid arthritis (RA) but was later diagnosed with syphilis.Methods:31 year old male, former tobacco smoker, referred to Rheumatology for sudden onset joint pains, elevated anti-cyclic citrullinated peptide (anti-CCP), and elevated inflammatory markers. He reported pain in bilateral wrists, fingers, and right elbow for 6 weeks. Associated with 45 minutes of morning stiffness and new onset lower back pain without stiffness. He denied trauma, fever, chills, skin rash, dysuria, or diarrhea. Initiated trial naproxen 500mg twice a day only to have minimal relief. Patient is sexually active with men and was recently diagnosed with oropharyngeal gonorrhea treated with azithromycin 4 months prior. All other STI screening including syphilis, gonorrhea, HIV were negative at that time. Patient is on emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis. He denied family history of immune mediated conditions. Exam was significant for mild synovitis of both wrists and bilateral 2nd metacarpophalangeal joints. Initial labs revealed weakly positive anti-CCP 21 (normal &lt;20), sedimentation rate 64 (normal ESR 0-15 mm/hr), C-reactive protein 24 (normal CRP 0-10 mg/L), and negative RF, ANA, HLA B27. During a short trial of prednisone taper, there was temporary improvement in symptoms, however synovitis recurred upon completion. Hydroxychloroquine (HCQ) 200mg twice a day was started for possible RA and he was referred to Ophthalmology for baseline retinopathy screening. Incidentally, he developed right sided blurry vision 2 weeks after initiation of HCQ. He was diagnosed with panuveitis of the right eye with inflammation of the optic nerve head and prednisone 40mg daily was initiated for presumed ocular manifestation of RA. However, further workup of panuveitis revealed reactive Treponema pallidum antibody and RPR quantity 1:32. Prednisone was immediately discontinued and he was referred to the emergency department for possible neurosyphilis.Results:Lumbar puncture showed cerebral spinal fluid with 260 red blood cells, 1 white blood cell, 27mg/dL protein, 60mg/dL glucose, non reactive VDRL, reactive pallidum IgG antibody, and negative cultures. Meningitis and encephalitis panels were negative. Patient completed a 14 day course of IV penicillin G with complete remission of joint pain, visual symptoms, and normalization of anti-CCP, ESR, and CRP.Conclusion:This case highlights how syphilis may mimic signs and symptoms of RA including symmetrical small joint pain, morning stiffness, elevated inflammatory markers, and positive anti-CCP. Anti-CCP is &gt;96% specific for RA but was a false positive in this patient. There have only been few reported cases noting positive anti-CCP with reactive arthritis. This is a rare case of reactive arthritis secondary to syphilis with resolution of symptoms upon treating the syphilis.

Ossa Sesamoidea - prevalence of sesamoid bones in human hands.

This study describes the morphology of sesamoid bones in the human hand. Ultrasound imaging was used to record the presence and measurements of sesamoids in 120 hands of 60 healthy, young adults of Caucasian ethnicity. The mean number of sesamoid bones was 4.16 in the left hand and 4.03 in the right hand. 21.6% of cases showed asymmetry between the right hand and the left. There was a significant difference in the prevalence of sesamoid bones between right and left hand in males in this study. Females show a higher incidence of sesamoid bones overall, but do not demonstrate a significant difference between the sides. Prevalence findings: Two in the 1st Metacarpophalangeal joint (MCPJ) in 99.2% of cases, with one case of a single bone. One in the 2nd MCPJ in 43.3% of cases. One in the 5th MCPJ in 84.2% of cases. One in the 1st Interphalangeal joint (IPJ) in 83.4%of cases. Aside from that there was one case of sesamoid in the 3rd MCPJ and separate case of sesamoid in the 3rd proximal IPJ. Moreover, this study discusses discrepancies of opinion regarding sesamoid bones in morphological research.

Conséquences sur la force d’extension active de l’extenseur propre de l’index après prélèvement pour transfert tendineux : à propos de 19 cas cliniques

Complications following an extensor indicis proprius (EIP) tendon transfer are loss of strength, independence and mobility in index extension. The main goal of this study was to measure independent and dependent index extension strength after a tendon transfer. Secondary goals were to determine if the index kept independent extension after the transfer and to evaluate 2nd metacarpophalangeal joint (MCPJ) mobility. Our series consisted of 19 patients in whom the EIP tendon was divided proximally to the extensor hood. The EIP tendon was retrieved through a proximal approach at the distal radius level and rerouted towards a recipient tendon. At an average follow-up of 41 months, the average independent extension strength was 5.6 N for 11 N on the contralateral side and the dependent strength was 10.9 N for 20 N. No patient complained of a loss of extension strength and all had kept an independent active extension on the operated index. The 2nd MCPJ on the operated side had an independent extension lag of 17.9° for 2.6° on the contralateral side and a dependent extension lag of 10.3° for 10.5°. Two patients were impaired in their daily activities when moving the operated index. Our results show that EIP procurement for tendon transfer leads to decreased independent and dependent strength as well as decreased active extension mobility of the 2nd MCPJ. However, the functional impact was negligible and should not compromise the use of the EIP as a tendon transfer.

Ultrasound Assessment of Synovial Thickness of Some of the Metacarpophalangeal Joints of Hand in Rheumatoid Arthritis Patients and the Normal Population.

Objective. To compare ultrasound synovial thickness of the 2nd, 3rd and 4th metacarpophalangeal joints (MCPJ) in a group of patients with proven rheumatoid arthritis (RA) and a control group of normal individuals. Materials and Methods. This is a cross-sectional study comprising 30 rheumatoid arthritis patients and 30 healthy individuals. Ultrasound scans were performed at the dorsal side of 2nd, 3rd, and 4th MCPJ of both hands in RA patients and the healthy individuals. Synovial thickness was measured according to quantitative method. The synovial thickness of RA patients and healthy individuals was compared and statistical cut-off was identified. Results. Maximum synovial thickness was most often detected at the radial side of the 2nd MCPJ and 3rd MCPJ and ulnar side of the 4th MCPJ of both hands which is significantly higher (p < 0.05) in RA patients compared to healthy individuals. With high specificity (96%) and sensitivity (90%) the optimum cut-off value to distinguish RA patients and healthy individuals' synovial thickness differs for the radial side of the 2nd and 3rd MCPJ and ulnar side of the 4th MCPJ. Conclusion. Patients with early RA appear to exhibit a characteristic pattern of synovitis which shows radial side predominance in the 2nd and 3rd MCPJ and ulnar side in the 4th MCPJ.

Pollicization of the index finger in Fanconi anaemia: appearances and functionality 40 years after the intervention

Fanconi anaemia (FA) is an inherited bone marrow failure syndrome resulting from disruption of a polygenic DNA damage response pathway with variable congenital and developmental abnormalities. Radial ray and thumb abnormalities are classical diagnostic features. These can vary in their clinical severity, but often have significant impact on development and hand usage in later life. Absence or severe hypoplasia of the thumbs can be surgically managed by pollicization with ante-position of the index finger. Very long term outcome and performance in adult life is not well documented. Here we illustrate functionality and appearances of the hands of a 47-year-old woman diagnosed with FA at the age of 3 years because of right thumb absence, severe hypoplasia of the left thumb and thrombocytopenia. Surgery on both hands was carried out shortly after the diagnosis. Clinical documentation from the 1960s and 1970s is unavailable. After completing school she worked in a responsible office-based position. She married, and after several years living abroad, returned to our region and is now followed up in our FA service. She has mild thrombocytopenia with a platelet count of 117 × 109/l, but otherwise normal peripheral blood cell counts with a moderately hypoplastic bone marrow. There is no evidence of mosaicism with persistent FA characteristic G2 arrest spontaneously and with low dose mitomycin C (MMC). At the age of 47 years her hands appear as illustrated. Frequent and purposeful use of the pollicized index finger generated a thenar-like bulk between the opposed index finger and the second finger. Magnetic resonance imaging illustrates the detailed anatomy. Coronal T1 images (A & B) demonstrate normal position of digits 3, 4 and 5 (A – solid arrows) with transposition of the 2nd metacarpal (A – dashed arrow) to create a pseudo 1st metacarpal. The pseudo 1st proximal phalanx (B – dashed arrow) is seen adjacent to a tissue mass placed at the site of the original location of the 2nd metacarpo-phalangeal joint (B – solid arrow). A whole forearm maximum intensity projection from fat- saturated T1 weighted images (C) clearly demonstrates the relationship between the pseudo 1st finger position (dashed arrow), and 3rd, 4th and 5th fingers (solid arrows) with interposed fat (open arrow). Her ante-positioned index fingers had excellent functionality. An illustration of her handwriting is shown in the lower panel (A – insert). To our knowledge this is the longest follow-up ever documented of a pollicization of an index finger in FA, with a very satisfactory long-term outcome.

SAT0394 Asymptomatic lupus arthropathy: Comparison of ultrasonographic findings with healthy people

BackgroundRecently there have been studies showing the presence of inflammatory joint activity in patients with systemic lupus erythematosous (SLE) without musculoskeletal symptoms. The predictive value of these findings remains unknown....

Individual finger synchronized robot-assisted hand rehabilitation in subacute to chronic stroke: a prospective randomized clinical trial of efficacy

Objective: To evaluate individual finger synchronized robot-assisted hand rehabilitation in stroke patients. Design: Prospective parallel group randomized controlled clinical trial. Subjects: The study recruited patients who were ≥18 years old, more than three months post stroke, showed limited index finger movement and had weakened and impaired hand function. Patients with severe sensory loss, spasticity, apraxia, aphasia, disabling hand disease, impaired consciousness or depression were excluded. Interventions: Patients received either four weeks (20 sessions) of active robot-assisted intervention (the FTI (full-term intervention) group, 9 patients) or two weeks (10 sessions) of early passive therapy followed by two weeks (10 sessions) of active robot-assisted intervention (the HTI (half-term intervention) group, 8 patients). Patients underwent arm function assessments prior to therapy (baseline), and at 2, 4 and 8 weeks after starting therapy. Results: Compared to baseline, both the FTI and HTI groups showed improved results for the Jebsen Taylor test, the wrist and hand subportion of the Fugl-Meyer arm motor scale, active movement of the 2nd metacarpophalangeal joint, grasping, and pinching power (P < 0.05 for all) at each time point (2, 4 and 8 weeks), with a greater degree of improvement for the FTI compared to the HTI group (P < 0.05); for example, in Jebsen Taylor test (65.9 ± 36.5 vs. 46.4 ± 37.4) and wrist and hand subportion of the Fugl-Meyer arm motor scale (4.3 ± 1.9 vs. 3.4 ± 2.5) after eight weeks. Conclusions: A four-week rehabilitation using a novel robot that provides individual finger synchronization resulted in a dose-dependent improvement in hand function in subacute to chronic stroke patients.

Sesamoid and accessory bones of the hand—An epidemiologic survey in a Mediterranean population

The prevalence and distribution of sesamoid and accessory bones in the hands is quite variable between different populations and ethnic groups. However, there are no published data on their distribution in Mediterranean populations. Studies on the validity of radiographic assessment for the presence of these bones are also lacking. A retrospective review of 442 radiographs of adult patients was performed in order to assess the incidence of sesamoid and accessory bones in the hands of a Mediterranean population. Additionally, two independent observers reviewed 174 radiographs and used the Kappa parameter in order to assess the validity of radiographic interpretation of radiographs for the presence of those bones. There was an incidence of 99.5% sesamoid bones (n = 440) in the 1st metacarpophalangeal (MCP) joint, 42.3% in the 2nd MCP joint (n = 187), and 41.1% (n = 182) in the 5th MCP joint. The incidence in the 1st interphalangeal joints was 26.2% (n = 116). The incidence of sesamoid bones in the 1st, 2nd, and 5th metacarpophalangeal joints in a Mediterranean population was found to be similar to that of Arab and Caucasian populations, whereas their prevalence in the 1st interphalageal joint coincided more with Arab populations. Interobserver reliability of the interpretation of radiographs for the presence of sesamoid bones in the hand was good (Kappa > 0.68) in all locations, except for the 1st MCP joint. Further research is warranted to further elucidate the genetic and/or environmental reasons for the differences between those populations.