RHEUMATOID HAND: CLINICAL, RADIOLOGICAL AND GRIPSTRENGTH ASSESSMENT

Background: and common Methodology: rheumatoid rheumatology were included in this descriptive study.Patients with a history of trauma or operation in the hand or wrist joint were excluded. Results: Female were 83patients (83%) and males were 17 patients (17%). Deformities in 200 hands were reported which showed. Flexor tenosynovitis was more in the middle (56) and index (53) fingers than in other fingers, and more in the right (103) than the left (75) hand.The grip strength was impaired in all patients.Mild impairment reported in 14%, moderate impairment in 27% and severely impaired hand grip was seen in 59% of patients. Conclusion: Flexor tenosynovitis and subluxation of metacarpophalangeal


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Teno-synovitis may often accompany synovitis and spontaneous Rheumatoid tendon rupture may occur which is due primarily to the effect of tenosynovitis on the tendon and secondarily to the effect of tenosynovitis on the bone (6) .
Patients with RA in whom articular bone lesions confined to the wrist and/or carpal joints in X-ray films may follow milder disease activity than do the patients with hand and finger joint lesions.
The former patients are milder in disease activity and fewer in No. of affected joints as well as milder in clinical course and have a better prognosis (7) .
Grip force and strength are a common measurement used in the assessment of the hand function (8) (9) .
The grip can be measured in a variety of ways, the most satisfactory and reproducible being using a rubber bag attached to a sphygmomanometer (10) .
The quality of the information gained from grip strength measurement and its interpretation depends on the established reliability of the instruments, and the consistency of test administration (11) .
Grip force can be used as an indicator of improvement, for comparing the effectiveness of various treatment procedures and for the assessment of a patient's ability to return to home activities and previous employment (9) .

Aim of The Study:
To shed some light on the relationship between clinical and radiological changes of the rheumatoid hand and its function based on grip strength test.

Patients and methods:-
One hundred patients, 83 females and 17 males with a diagnosis of RA according to (ARA revised 1987 criteria for classification of RA) (12) (9) . Patients of at least two years duration, attending rheumatology unit in Baghdad teaching hospital in the period from October 1995 to April 1996, were included in this descriptive study. All patients except one were right-handed. Patients with a history of trauma or operation in the hand or wrist joint were excluded.
Postero-anterior X-ray films of both hands (including wrists) were taken for 85 patients, and their changes were read by two observers blindly and assigned by Steinbrocker radiographic stage (13) .
Stage I: No destructive changes, but periarticular osteoporosis may be present; stage II: osteoporosis and slight cartilage and/or subchondral bone destruction may present; stage III: osteoporosis and cartilage and/or bone destruction; stage IV: stage IIIfinding plus fibrous or bony ankylosis.

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Rheumatoid factor (Latex fixation test) and Erythrocytes sedimentation rate (wester green) was done for all patients.

Statistical analysis:
Chi-square test used to find the relationshipbetween different variables: clinical deformities, radiographic changes, and grip strength impairment.

Results:-
Characteristics of patients were shown in table-1,where females were 83 patients (83%) and males were 17 patients (17%) with a male to female ratio of 1:4.9.Patients with positive Rheumatoid factors(RF) constituted 69% of the total patients. The prevalence of positive RF among the two genders was close to each other (69.9% and 64.7% respectively).

Hand deformities:
Deformities in 200 hands were reported in table 2 which showed a dropped finger was seen only in one patient involving the left middle and ring fingers and the right little finger. Flexor tenosynovitis was more in the middle (56) and index (53) fingers than in other fingers, and more in the right (103) than the left (75) hand.Correctable and uncorrectable ulnar deviation and subluxation of metacarpophalangeal joints were seen only in female patients. According to table-3 dislocation of ulnar styloid was observed in 81 hands (48%), while dislocation of carpal bones was seen in 10 hands (5%).    Hand grip strength: The grip strength was impaired in all patients.Mild impairment reported in 14%, moderate impairment in 27% and severely impaired hand grip was seen in 59% of patients. Severe radiographic destructive changes (stage IV) was seen in 23 patients (27%), 15 of these patients had severe impairment of handgrip strength. The study shows a significant relationship between the hand radiographic stage and severityof grip strength impairment as shown in table-5. The study also showed no significant relationship between hand deformities and severity of handgrip strength impairment (table 6).

Discussion:-
Grip strength assessment is frequently used inclinical trials and is a sensitiveindicator of disease activity (8) .Varying the position of the forearm altered the strength of the grip (11) .Patients with rheumatoid arthritis had approximately a 75% reduction inmaximum grip strength (8) .
Only one patient had a dropped finger. The patient was female, with the seropositive disease for 12 years. Flexor tenosynovitis and subluxation of metacarpophalangeal joints were seen more in the right than the left hand and more in the index and middle fingers than in other fingers and this possibly due to excessive use of these two fingers during hand function and so greater muscles pull on the metacarpophalangeal joints of these fingers (4) .
The prevalence of correctable and uncorrectable ulnar deviation swan-neck deformity, boutonniere deformity and flexor tenosynovitis in this study was compared with Mody et al. study (4) ,correctable and uncorrectable ulnar deviation and subluxation of metacarpophalangeal joints were seen only in' female patients. The possible explanations are a relatively little number of male patients in this study and probably excessive use of the hand in homework by female patients.
Radiographic stage III was the commonest in the current study group while stage IV was the commonest group 33.3% in Regn-Smith et al. study, stage I was higher in our study than that reported by Regn-Smith et al. which was 14.8% (15) .