Dr. Peni Kusumastuti
Dr. Peni Kusumastuti
Dr. Peni Kusumastuti
RHEUMATOID HAND
Peni Kusumastuti
Indonesia
The 3rd AOCPRM / XI Annual Scientific of Indonesian Association of PMR,
Bali , May 20-23 , 2012
Objectives
• Clinical Diagnostic Criteria
• Pathophysiology
• Treatment Planning
• Splinting Fabrication
Rheumatoid Arthritis
Swan neck
C D
• Crepitus may be
palpated or heard
during Active ROM
• Inspection the volar ,
palpate the A1 pulley
while flexes and
extends the digits
The Grind Test
Crepitous can be indicative
of damaged cartilage
Grip Strength
JAMAR Hydraulic Pinch Strength
Dynamometer Pinch meter
Sphygmomanometer
Pain
Pp
• Medication
• Splinting
• Joint Protection Principles
• Exercise
Specific Treatment : Splinting
In stage I – II
resting splints to rest the joints in position opposite of
potential deformity, to decrease muscle spasm, to
decrease inflammation and pain
Use at night or part time during the day
In Stage III
splinting and joint protection are applied to slow the
development of deformity , use as night splint or
functional day splints
In stage IV :
to ad joint stability during daily activities, increase
comfort and decrease pain. Splints likely cannot change
the deformity
The Resting Splints
To prevent further
deviation of the wrist
provide wrist ulnar
alignment with
appropriate strapping
Swan Neck Splints
• Provide stability to
the dorsaly
subluxed distal ulna
by put a gentle
ulnar-head
depression
• Can decrease pain
and increase
stability during
forearm rotation
activities
MPJ Ulnar Deviation and Palmar
Subluxation
• Requires consideration of MP
subluxation and wrist radial
deviation deformities
• Can have effect on one another
• Splint simultaneously , should be
checked carefully
avoid forcing the digits into
alignment in a splint that
aggravates the wrist
radial deviation deformity
MPJ Palmar Subluxation
• In patient with MPJ palmar subluxation at the MP
joint , avoid proximal phalanx tilts , should be glide
into position. ( A & B ). This will increase pain and
absorption of the joint surface
• Custom sized
• Can be worn full-time
SIRIS lateral-alignment
splint
Joint Protection Principles
Joint Protection Principles
Joint Protection Principles
Joint Protection Principles
Joint Protection to counteract MP Ulnar Deviation
Hand Joint
Protection
Techniques
Modalities
Thermal agents : heat and cold
Paraffin, hot packs , MWD , electro therapy
etc
Exercise :
General principles are avoiding painful
active / passive ROM ( pain free ) to
prevent overstretching of joint structures
Hydrotherapy may beneficial
Modalities
Strengthening Exercise
Should be used with caution to avoid
aggravation of deformities
Grip strengthening can place the digits in
increased ulnar deviation during flexion if
the position of the digits is unchecked
Common Names
• MP Slint
• Short Opponen Splint
• Basal Joint splint
• Gamekeeper’s thumb splint
Pattern Creation
• Mark for proximal border
just distal to wrist crease ;
should allow full wrist
motion
• Mark ulnar border at third
Immobilize MP Joint
metacarpal ; should allow
full mobility of distal arch
• Radial portion of splint
should enough to be pulled
through first web space and
adequately cover dorsum of
web space
Immobilize CMC Joint
Thumb MP immobilization Splint ( 2 )
Cut and Heat
Position patient’s forearm in slight supination
• Place thumb in palmar abduction and MP joint in
appropriate flexion
• Proximally, place and mold material across thenar
eminence to thenar crease
• Distally , wrap material through first web space
from dorsal to volar
• Mold though web space and overlap aterial onto
itself by approx. 1”
• Be sure to maintain desired thumb CMC and MP
joints position
Fit While Molding
• Proximally, place and mold material across thenar
eminence to thenar crease
• Distally , wrap material through first web space from
dorsal to volar
• Mold though web space and overlap material onto
itself by approx. 1”
• Be sure to maintain desired thumb CMC and MP js
position
• Avoid direct pressure over dorsum MPJ
• Clear IPJ flexion crease , avoid rolling material
• 1” strap around wrist
Thumb MP Immobilization Splint ( 3 )
Attention
• Avoid direct pressure over dorsum MPJ
• Clear IPJ flexion crease , avoid rolling material
• 1” strap around wrist
Thumb MP Immobilization Splint ( 4 )