eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Swan-Neck Deformity: Workup

Author: Roberto Sandoval, MD, Consulting Staff, Department of Emergency Medicine, Anaheim Memorial Medical Center, La Palma Intercommunity Hospital
Coauthor(s): John A Kare, MD, Assistant Professor of Emergency Medicine, Charles R Drew University of Medicine and Science/UCLA, Director of Research, Department of Emergency Medicine, Martin Luther King Jr/Charles R Drew Medical Center; Eleby R Washington III, MD, FACS, Associate Professor, Department of Surgery, Division of Orthopedics, Charles R Drew University of Medicine and Science; Roman V Voytsekhovskiy, MD, Fellow in Hand Surgery, Department of Orthopedic Surgery, Rush University Medical Center; Robert R Schenck, MD, Associate Professor, Departments of Plastic and Orthopedic Surgery, Rush Medical College; Director, Section of Hand Surgery, Department of Plastic and Orthopedic Surgery, Rush University Medical Center
Contributor Information and Disclosures

Updated: Nov 2, 2007

Workup

Laboratory Studies

  • Rheumatoid factor (RF) - RF is present in most patients with RA, being evident in 80% of them. It is associated with increased morbidity. (See also the Medscape article Rheumatoid Arthritis: Deformity of the Knee, Hip, and Elbow but Not the Wrist and Fingers.)
  • Synovial fluid - Analysis of synovial fluid is extremely useful in distinguishing early RA from noninflammatory and infectious arthritides. The joint fluid from patients with RA is sterile and has pleocytosis (usually polymorphonuclear [PMN]), increased protein, and decreased viscosity and complement. It is common to have decreased viscosity and poor mucin clot formation.
  • Erythrocyte sedimentation rate (ESR) - The ESR is elevated in most patients who have RA, although a rate within the reference range does not exclude a diagnosis of the disease. This test is a good indicator of response to medical therapy and the activity of the disease in most patients.

Imaging Studies

  • Diagnosis using plain films - Early changes are limited to the soft tissues and include fusiform swelling and evident joint effusion. With progression of the disease, juxta-articular osteoporosis and erosions may become more severe, leading to cartilage destruction and narrowing of the joint space. Bone erosion characteristically occurs in the metaphyseal region and the underlying collateral ligament attachments. This erosion is manifested by malalignment, displacement, and ankylosis of the joint. These severe findings are manifestations of end-stage rheumatoid disease.

More on Swan-Neck Deformity

Overview: Swan-Neck Deformity
Workup: Swan-Neck Deformity
Treatment: Swan-Neck Deformity
Follow-up: Swan-Neck Deformity
References
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References

  1. Nalebuff EA. The rheumatoid swan-neck deformity. Hand Clin. May 1989;5(2):203-14. [Medline].

  2. Welsh RP, Hastings DE. Swan neck deformity in rheumatoid arthritis of the hand. Hand. Jun 1977;9(2):109-16. [Medline].

  3. Bickel KD. The dorsal approach to silicone implant arthroplasty of the proximal interphalangeal joint. J Hand Surg [Am]. Jul-Aug 2007;32(6):909-13. [Medline].

  4. Kiefhaber TR, Strickland JW. Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: long-term results. J Hand Surg [Am]. Nov 1993;18(6):984-9. [Medline].

  5. Aronowitz ER, Leddy JP. Closed tendon injuries of the hand and wrist in athletes. Clin Sports Med. Jul 1998;17(3):449-67. [Medline].

  6. Dearborn JT, Jergesen HE. The evaluation and initial management of arthritis. Prim Care. Jun 1996;23(2):215-40. [Medline].

  7. Gainor BJ, Hummel GL. Correction of rheumatoid swan-neck deformity by lateral band mobilization. J Hand Surg [Am]. May 1985;10(3):370-6. [Medline].

  8. Harrison BP, Hilliard MW. Emergency department evaluation and treatment of hand injuries. Emerg Med Clin North Am. Nov 1999;17(4):793-822, v. [Medline].

  9. Lee SJ, Montgomery K. Athletic hand injuries. Orthop Clin North Am. Jul 2002;33(3):547-54. [Medline].

  10. Littler JW. The digital extensor-flexor system. In: Converse JM, ed. Reconstructive Plastic Surgery: Principles and Procedures in Correction, Reconstruction, and Transplantation. 2nd ed. Philadelphia, Pa: WB Saunders; 1977:6.

  11. Nalebuff EA, Millender LH. Surgical treatment of the swan-neck deformity in rheumatoid arthritis. Orthop Clin North Am. Jul 1975;6(3):733-52. [Medline].

  12. Norris ME 3rd, Samra S, DeMercurio J, et al. Free palmaris longus graft tenodesis effectively treats swan neck adduction collapse secondary to thumb basilar joint arthritis. Plast Reconstr Surg. Aug 2007;120(2):475-81. [Medline].

  13. O'Brien ET. Surgical principles and planning for the rheumatoid hand and wrist. Clin Plast Surg. Jul 1996;23(3):407-20. [Medline].

  14. Perron AD, Brady WJ, Keats TE. Orthopedic pitfalls in the emergency department: closed tendon injuries of the hand. Am J Emerg Med. Jan 2001;19(1):76-80. [Medline].

  15. Rosen A, Weiland AJ. Rheumatoid arthritis of the wrist and hand. Rheum Dis Clin North Am. Feb 1998;24(1):101-28. [Medline].

  16. Smrcka V, Dylevsky I. Treatment of congenital swan neck deformity with dynamic tenodesis of proximal interphalangeal joint. J Hand Surg [Br]. Apr 2001;26(2):165-7. [Medline].

  17. Thompson JS, Littler JW, Upton J. The spiral oblique retinacular ligament (SORL). J Hand Surg [Am]. Sep 1978;3(5):482-7. [Medline].

  18. Tuttle HG, Olvey SP, Stern PJ. Tendon avulsion injuries of the distal phalanx. Clin Orthop Relat Res. Apr 2006;445:157-68. [Medline].

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Further Reading

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Keywords

volar plate synovitis, synovitis of capsule, collateral ligament synovitis, finger deformity, arthritis, rheumatoid arthritis, hand deformity, finger deformity, rheumatoid factor, rheumatoid hand, RA, tenosynovitis, swan neck deformity, boutonniere deformity

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Contributor Information and Disclosures

Author

Roberto Sandoval, MD, Consulting Staff, Department of Emergency Medicine, Anaheim Memorial Medical Center, La Palma Intercommunity Hospital
Roberto Sandoval, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

John A Kare, MD, Assistant Professor of Emergency Medicine, Charles R Drew University of Medicine and Science/UCLA, Director of Research, Department of Emergency Medicine, Martin Luther King Jr/Charles R Drew Medical Center
John A Kare, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Student Association/Foundation, and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Eleby R Washington III, MD, FACS, Associate Professor, Department of Surgery, Division of Orthopedics, Charles R Drew University of Medicine and Science
Eleby R Washington III, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, International College of Surgeons, and National Medical Association
Disclosure: Nothing to disclose.

Roman V Voytsekhovskiy, MD, Fellow in Hand Surgery, Department of Orthopedic Surgery, Rush University Medical Center
Disclosure: Nothing to disclose.

Robert R Schenck, MD, Associate Professor, Departments of Plastic and Orthopedic Surgery, Rush Medical College; Director, Section of Hand Surgery, Department of Plastic and Orthopedic Surgery, Rush University Medical Center
Robert R Schenck, MD is a member of the following medical societies: American Association for Hand Surgery, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, American Society of Plastic Surgeons, American Society of Reconstructive Microsurgery, Chicago Medical Society, and Illinois State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Joseph E Sheppard, MD, Director of Hand and Upper Extremity, Associate Professor, Department of Orthopedic Surgery, University of Arizona
Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Society for Surgery of the Hand, Southern Orthopaedic Association, and Western Orthopaedic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert J Nowinski, DO, Clinical Assistant Professor of Orthopaedic Surgery, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic Specialists and Sports Medicine, Newark, Ohio
Robert J Nowinski, DO is a member of the following medical societies: American Medical Association and American Osteopathic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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