RA Hand Deformities — SCE Rheumatology MCQ

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EasyRheumatoid ArthritisRA Hand DeformitiesSCE Rheumatology

A 65-year-old woman has longstanding, poorly controlled rheumatoid arthritis and worsening hand function. Examination shows ulnar deviation and subluxation at the metacarpophalangeal joints, swan-neck deformities in some digits and boutonniere deformities in others. Which pathological process best explains these findings?

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Correct answer: E — Chronic rheumatoid synovitis with capsuloligamentous and extensor-mechanism damage

These are characteristic structural sequelae of longstanding rheumatoid synovitis. Synovial proliferation and pannus progressively damage the joint capsule, ligaments and extensor apparatus, producing MCP subluxation with ulnar drift. Swan-neck deformity comprises PIP hyperextension with DIP flexion, whereas boutonniere deformity comprises PIP flexion with DIP hyperextension and is associated with central-slip dysfunction. Nodal osteoarthritis predominantly causes Heberden and Bouchard nodes rather than this combined pattern. Psoriatic arthritis may cause dactylitis, DIP-predominant arthritis and arthritis mutilans, but this constellation is classically rheumatoid. Dupuytren disease is palmar fascial fibromatosis causing fixed flexion contractures, particularly of the ring and little fingers, without MCP ulnar drift or reciprocal PIP–DIP deformities.

Reference: Lim JX, Chung KC. Assessment of Progressive Hand and Wrist Deformities in the Rheumatoid Patient. Hand Clinics. 2025;41(1):25-35. https://pubmed.ncbi.nlm.nih.gov/39521587/