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Urgent Extensor Tendon Repair — SCE Rheumatology MCQ

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HardRheumatoid ArthritisUrgent Extensor Tendon RepairSCE Rheumatology

A 42-year-old woman with rheumatoid arthritis develops progressive loss of finger extension over 2 weeks. She cannot actively extend the ring and little fingers at the metacarpophalangeal joints, although passive extension is full and wrist extension is preserved. Ultrasound demonstrates discontinuity of the corresponding extensor tendons, florid extensor tenosynovitis and attrition adjacent to an eroded, prominent distal ulna. What is the most appropriate next management?

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Correct answer: E — Urgent hand-surgery referral for tendon reconstruction and correction of the attritional wrist lesion

This is Vaughan-Jackson syndrome: sequential attritional rupture of the ulnar-sided extensor tendons, typically affecting the little and then ring finger over a diseased distal radioulnar joint. Ultrasound-confirmed tendon discontinuity distinguishes rupture from pain inhibition, tendon subluxation or posterior interosseous neuropathy. She requires urgent hand-surgical assessment because further tendons may rupture and delayed reconstruction can worsen extension lag. Surgery usually involves tendon transfer or grafting, together with treatment of the causative tenosynovitis and prominent distal ulna; simple direct repair is often impossible because a length of tendon is diseased. Splinting may provide temporary protection but is not definitive. Observation, physiotherapy and DMARD escalation alone cannot restore tendon continuity, although inflammatory disease control should be optimised alongside surgical management.

Reference: McIntyre JL, Stirling PHC, McEachan J. Outcomes of Surgical Treatment of Vaughan-Jackson Syndrome. Journal of Wrist Surgery. 2024;13(4):328-332. https://pubmed.ncbi.nlm.nih.gov/39027023/