x
x

RHEUMATOID ARTHRITIS

Introduction

Rheumatoid arthritis (RA) is a chronic, inflammatory condition characterized by joint swelling and tenderness and synovial joint degeneration, which leads to chronic pain, extensive joint damage and severe disability.1 RA is considered an autoimmune disease, and the development and optimal use of disease-modifying antirheumatic drugs (DMARDs) have greatly improved patient management and clinical outcomes. Moreover, early diagnosis and intervention has been shown to reduce the progression of joint damage and disability.

Pathophysiology

Pathophysiology of RA involves complex cellular and molecular interactions between the innate and adaptive immune systems, and the synovium is the primary site of the inflammatory and degenerative processes. Early changes result from non-specific inflammation. In the amplification phase, T cells and B cells are activated, which in turn, activate cytokines and proteases. In the chronic phase of RA, destruction of cartilage and bone is primarily due to interleukin 1 (IL-1), tumor necrosis factor alpha (TNF-α) and IL-6.

Incidence and Related Conditions

RA prevalence estimates range from 0.5–1.0% in Europe and North America; estimates are lower in Asia (0.2–0.3%).
There are genetic (eg, human leukocyte antigen [HLA], protein tyrosine phosphatase [PTP] N22 variant) and non-genetic risk factors (eg, female gender, tobacco, bacterial and viral infection) for RA.
Cardiovascular disease is the leading cause of death among patients with RA, and osteoporosis is a major comorbidity that can result from the disease as well as the use of corticosteroids.

Differential Diagnosis

  • Psoriatic arthritis
  • Viral-induced arthritis
  • Systemic lupus erythematosus
  • Mixed connective tissue disease
  • Sjögren’s syndrome
  • Spondyloarthropathy
  • Scleroderma
  • Dermatomyositis

Radiographic Findings

In rheumatoid arthritis, typical X-ray findings can include soft tissue swelling, joint space narrowing, periarticular osteoporosis, bone erosions and eventually joint subluxation, dislocation or even auto-arthrodesis in the wrist.

ICD-10 Codes

  • RHEUMATOID ARTHRITIS

    Diagnostic Guide Name

    RHEUMATOID ARTHRITIS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    RHEUMATOID ARTHRITIS (OTHER) WITH RHEUMATOID FACTOR    
    - ELBOW M05.822M05.821 
    - WRIST M05.832M05.831 
    - HAND M05.842M05.841 
    RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR    
    - ELBOW M06.22M06.21 
    - WRIST M06.032M06.031 
    - HAND M06.042M06.041 

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Classic Rheumatoid right hand with ulnar drift of fingers and subluxed MP joints
    Classic Rheumatoid right hand with ulnar drift of fingers and subluxed MP joints
  • Classic Rheumatoid right hand with ulnar drift of fingers, subluxed MP joints with synovitis
    Classic Rheumatoid right hand with ulnar drift of fingers, subluxed MP joints with synovitis
  • Rheumatoid hand and wrist (1) subluxed distal ulna, (2) dorsal tenosynovitis, (3) MP joint synovitis
    Rheumatoid hand and wrist (1) subluxed distal ulna, (2) dorsal tenosynovitis, (3) MP joint synovitis
  • Classic Rheumatoid right hand with destroyed right MP joints
    Classic Rheumatoid right hand with destroyed right MP joints
  • Swan neck deformity secondary to rheumatoid arthritis
    Swan neck deformity secondary to rheumatoid arthritis
  • Rheumatoid hand and wrist subluxed distal ulna and ruptured extensor tendons
    Rheumatoid hand and wrist subluxed distal ulna and ruptured extensor tendons
Basic Science Photos and Related Diagrams
Basic Science Pics
  • A pyramidal approach to the treatment of RA (Ref5)
    A pyramidal approach to the treatment of RA (Ref5)
Symptoms
Pain, swelling and stiffness in multiple joints
Morning joint stiffness or stiffness after sitting.
Affected joints often symmetrical
Joints are warm and red intermittently
Complaints of fatigue, malaise, decreased appetite and weight loss
Aching pain in extremity muscles
Lumps under the skin (Rheumatoid Nodules)
Typical History

In most patients, the onset of joint pain and swelling is gradual. In a small percentage, there is an abrupt onset of polyarthritis; other may present with transient bouts of mono- or poly-arthritis. In early RA, the carpals, metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints of the fingers and interphalangeal (IP) joints of the thumbs are most frequently affected. Systemic symptoms include low-grade fever, malaise, fatigue, anorexia and weight loss. In chronic cases, rheumatoid nodules may develop on the elbows, Achilles tendons and fingers.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Xray of rheumatoid hand - Noted destroyed wrist, finger MP joints and thumb CMC joint
    Xray of rheumatoid hand - Noted destroyed wrist, finger MP joints and thumb CMC joint
  • Xray of rheumatoid hand - Noted (1&2) Replaced index and long MP joints, (3) Destroyed but stable wrist and (4) distal ulna previously resected secondary to a damaged joint and pain with forearm rotation.
    Xray of rheumatoid hand - Noted (1&2) Replaced index and long MP joints, (3) Destroyed but stable wrist and (4) distal ulna previously resected secondary to a damaged joint and pain with forearm rotation.
Treatment Options
Conservative

RA can follow a moncyclic, polycyclic or progressive course in about 35%, 50% and 15% of patients, respectively. Therefore, in any given patient, it is difficult to evaluate the effect of treatment – pharmacological, physical or surgical – independent of spontaneous, disease-related changes in activity. It is important to consider a step-wise approach to the management of RA, even within the category of conservative treatment options (see Figure).

  • Classes of drugs
    • NSAIDS and cyclooxygenase-2 (COX-2) inhibitors
    • DMARDs and biologics (see Table)
    • Corticosteroids
Table. Disease-modifying antirheumatic drugs (DMARDs)6
MedicationMechanism of ActionMonitoringSide Effects
MethotrexateReduces adenosineCBC, LFTsNausea, stomatitis, hepatotoxicity
HydroxychloroquineUnknownRetina examRare vision loss
SulfasalazineUnknownCBC, LFTsNausea, diarrhea
LeflunomideInhibits pyrimidine synthesisLFTsDiarrhea, rash, hepatoxicity
AzathioprineInhibits purine synthesisCBC, LFTsNausea, pancytopenia
EtanerceptBlocks TNFScreen for TBInfection
InfliximabBlocks TNFScreen for TBInfection
AbataceptBlocks TNFScreen for TBInfection
AnakinraBlocks IL-1NoneInfection
AbataceptInhibits T-cellsNoneInfection activation
RituximabDepletes B-cellsNoneInfection, lymphocytes

CBC, complete blood count; IL-1, interleukin-1 receptor; LFT, liver function test; TB, tuberculosis; TNF, tumor necrosis factor

Operative
  • Fusion with internal fixation
  • Tenosynovectomy
  • Arthrodesis
  • Arthroplasty
  • Interposition arthroplasty
Treatment Photos and Diagrams
  • Index MP joint replacement for RA. (1) Metacarpal head, (2) Silicone prosthesis, (3) Joint capsule for later repair (4) Extensor tendon
    Index MP joint replacement for RA. (1) Metacarpal head, (2) Silicone prosthesis, (3) Joint capsule for later repair (4) Extensor tendon
  • Index MP joint replacement for RA - Silicone prosthesis not attached to bone but flexes and pistons back and forth in bones to provide motion.
    Index MP joint replacement for RA - Silicone prosthesis not attached to bone but flexes and pistons back and forth in bones to provide motion.
  • Extensor tendon ruptures in RA; Ulna suluxates dorsally because it's arthritic rough edges wear through the DRUJ capsule and then cut the tendons.
    Extensor tendon ruptures in RA; Ulna suluxates dorsally because it's arthritic rough edges wear through the DRUJ capsule and then cut the tendons.
  • RA: (1) Retracted opened DRUJ capsule, (2) Distal with absent cartilage, (3) Hypertrophic dorsal tenosynovitis, & (4) Ruptured tendon end.
    RA: (1) Retracted opened DRUJ capsule, (2) Distal with absent cartilage, (3) Hypertrophic dorsal tenosynovitis, & (4) Ruptured tendon end.
  • RA: Repaired extensor tendons with tendon transfers.
    RA: Repaired extensor tendons with tendon transfers.
  • RA: FPL and FDP II Ruptures - Note lack of thumb and index flexion
    RA: FPL and FDP II Ruptures - Note lack of thumb and index flexion
  • RA: FPL and FDP II Ruptures: (1) Transfer FDS IV to replace FPL, (2) Median Nerve, (3&4) Ruptured flexor tendons
    RA: FPL and FDP II Ruptures: (1) Transfer FDS IV to replace FPL, (2) Median Nerve, (3&4) Ruptured flexor tendons
CPT Codes for Treatment Options

Per an agreement between Hand Surgery Resource, LLC and the American Medical Association (AMA) users are required to accept the following End User Point and Click Agreement in order to view CPT content on this website.  Please read and then click "Accept" at the bottom to indicate your acceptance of the agreement.

End User Point and Click Agreement

CPT codes, descriptions and other data only are copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. The AMA reserves all rights to approve any license with any Federal agency.

You, as an individual, are authorized to use CPT only as contained in Hand Surgery Resource solely for your own personal information and only within the United States for non-commercial, educational use for the purpose of education relating to the fundamental principles of hand surgery and the common diseases, disorders and injuries affecting the human hand. You agree to take all necessary steps to ensure your compliance with the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 330 N. Wabash Avenue, Chicago, IL 60611. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt.

Common Procedure Name
Flexor tenosynovectomy
CPT Description
Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (e.g. tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors
CPT Code Number
25115
Common Procedure Name
Extensor tenosynovectomny (dorsal)
CPT Description
Synovectomy, extensor tendon sheath, wrist, single compartment
CPT Code Number
25118
Common Procedure Name
Excision trapezium for CMC arthroplasty
CPT Description
Carpectomy; one bone
CPT Code Number
25210
Common Procedure Name
Excision pyogenic granuloma (rheumatoid nodule, hemangioma)
CPT Description
Excision of benign tumor subcutaneous
CPT Code Number
26115
Common Procedure Name
Excision distal ulna or Darrach, wafer procedure
CPT Description
Excision distal ulna (Darrach proc)
CPT Code Number
25240
Common Procedure Name
Flexor tenosynovectomy palm and/or finger
CPT Description
Synovectomy tendon sheath radical (tenosynovectomy) flexor, palm or finger
CPT Code Number
26145
Common Procedure Name
MP joint arthroplasty
CPT Description
Arthroplasty, metacarpophalangeal joint, each joint
CPT Code Number
26530
Common Procedure Name
Wrist fusion complete
CPT Description
Arthrodesis, wrist, complete, with iliac or other autograft (includes obtaining graft)
CPT Code Number
25810
Common Procedure Name
PIP joint arthroplasty
CPT Description
Arthroplasty, metacarpophalangeal joint with prosthetic implant, each joint
CPT Code Number
26536
Common Procedure Name
Flexor digitorum superficialis tenodesis PIP joint
CPT Description
Tenodesis; of proximal interphalangeal joint, each joint
CPT Code Number
26471
Common Procedure Name
Extensor tendon repair
CPT Description
Tendon transfer or transplant, CM area or dorsum of hand single w/o free graft
CPT Code Number
26480
Common Procedure Name
Ulnar collateral ligament repair
CPT Description
Repair of collateral ligament, metacarpophalangeal or interphalangeal joint
CPT Code Number
26540
Common Procedure Name
MP joint arthrodesis
CPT Description
Arthrodesis metacarpophalangeal joint w/wo internal fixation
CPT Code Number
26850
Common Procedure Name
PIP/DIP joint arthrodesis
CPT Description
Arthrodesis interphalangeal joint with or without internal fixation
CPT Code Number
26860
Common Procedure Name
Tenotomy intrinsic muscles
CPT Description
Release intrinsic muscles of hand, each muscle
CPT Code Number
26593
Common Procedure Name
Gamekeeper's repair
CPT Description
Primary repair collateral ligament metacarpophalangeal joint
CPT Code Number
26542
Common Procedure Name
Tendon transfer
CPT Description
Tendon transplant or transfer flexor/extensor forearm and/or wrist, single each tendon
CPT Code Number
25310
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

CPT QuickRef App.  For Apple devices: App Store. For Android devices: Google Play

CPT 2021 Professional Edition: Spiralbound

Complications

Operative: infection, neurovascular injury, pulmonary embolus, dislocation, periprostheticosteolysis, sepsis

Outcomes

Operative: difficult to generalize owing to heterogeneity and poor design of studies conducted to date.7,8

Key Educational Points

Rheumatoid factor is seen only in patients who are 8 years of age or older at presentation.

References

Cited

  1. Aletaha D, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010;62(9):2569-81. PMID: 20872595
  2. Dougados M, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis 2014;73:62-8. PMID: 24095940
  3. Malahias M, et al. The future of rheumatoid arthritis and hand surgery – combining evolutionary pharmacology and surgical techniques. Open Orthop J 2012 6(Suppl 1:M11):88-94. PMID: 22423304
  4. Chung KC, Kotsis SV. Outcomes of hand surgery in patients with rheumatoid arthritis. Curr Opin Rheumatol 2010;22(3):336-41. PMID: 20061956
  5. Ferlic DC, et al. Medical considerations and management of rheumatoid arthritis. J Hand Surg Am 1983;8(5):662-6. PMID: 6415155
  6. Brasington R. TNF-α antagonists and other recombinant proteins for the treatment of rheumatoid arthritis. J Hand Surg Am 2009;34:349-50. PMID: 19135810
  7. Chung KC, et al. Patient outcomes following Swanson silastic metacarpophalangeal joint arthroplasty in the rheumatoid hand: a systematic overview. J Rheumatol 2000;27(6):1395-402. PMID: 10852260
  8. Alderman AK, et al. Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists. J Hand Surg Am 2003;28(1):3-11. PMID: 12563630

New Articles

  1. Lee HI, et al. Long-term results of arthroscopic wrist synovectomy in rheumatoid arthritis. J Hand Surg Am 2014;39(7):1295-300. PMID: 24861384
  2. Bidwai AS, et al. Short to medium results using the remotion total wrist replacement for rheumatoid arthritis. Hand Surg 2013;18(2):175-8. PMID: 24164120

Reviews

  1. Trieb K. Arthrodesis of the wrist in rheumatoid arthritis. World J Orthop 2014;5(4):512-5. PMID: 25232527
  2. Chim HW, et al. Update on the surgical treatment for rheumatoid arthritis of the wrist and hand. J Hand Ther 2014;27(2):134-41. PMID: 24530143

Classics

  1. Cregan JC. Indications for surgical intervention in rheumatoid arthritis of the wrist and hand.  Ann Rheum Dis 1959;18(1):29-33. PMID: 13650455
  2. Kestler OC. Histopathology of the Intrinsic Muscles of the Hand in Rheumatoid Arthritis. Ann Rheum Dis 1949;8(1):42-58. PMID: 18623795
Subscribe to RHEUMATOID ARTHRITIS
⇡