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RA Hand Surgery Indications — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisRA Hand Surgery IndicationsSCE Rheumatology

A 60-year-old woman with longstanding rheumatoid arthritis has a stable, passively correctable thumb boutonniere deformity, with metacarpophalangeal joint flexion and interphalangeal joint hyperextension. Her inflammatory disease is controlled, and she is receiving hand therapy and splinting. Which new development is the clearest indication for prompt specialist hand-surgical opinion before irreversible damage occurs?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Sudden loss of ring- and little-finger extension following dorsal wrist pain

Explanation lettering: C = shown as B · D = shown as C · B = shown as D

Sudden loss of ring- and little-finger extension after dorsal wrist symptoms suggests rheumatoid extensor tendon rupture, classically sequential rupture associated with distal radioulnar joint disease. NICE recommends specialist surgical opinion for imminent or actual tendon rupture before damage or deformity becomes irreversible. Other referral indications include persistent pain, worsening function, progressive deformity or persistent localised synovitis despite optimal non-surgical management, as well as nerve compression. Cosmetic improvement should not be the dominant objective. Options B and E describe problems responding to conservative treatment, while the stable, asymptomatic deformity in C does not itself require prompt surgery. Cosmetic concern alone in A is insufficient. Early recognition matters because additional adjacent tendons may rupture and delayed reconstruction may be more complex.

Reference: National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management (NG100), section 1.10, Timing and referral for surgery. 2018, updated 2020. https://www.nice.org.uk/guidance/ng100/chapter/Recommendations