How is a type I swan-neck deformity in rheumatoid arthritis (RA) treated?

Updated: Jan 11, 2019
  • Author: Michael Neumeister, MD, FRCSC, FACS; Chief Editor: Joseph A Molnar, MD, PhD, FACS  more...
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Answer

The treatment of type I deformity is focused on correcting PIP joint hyperextension and restoring DIP joint extension. Conservative treatment can be used, with Silver Ring splints (Silver Ring Splint Co., Charlottesville, Va) employed to permit active PIP flexion and limit hyperextension of the PIP joint. Alternatively, an inexpensive figure-8 thermoplastic splint can be fashioned by a hand therapist. These splints can be useful in the early stages of the disease. [11]

Van der Giesen et al found that silver ring splints and commercial prefabricated thermoplastic splints were equally effective in treating swan neck deformities in patients with RA. [12] In a randomized crossover trial, 47 patients used both splints for 4 weeks, with a washout period of 2 weeks, and then used the preferred splint for another 12 weeks. Improvement in dexterity, as measured with the Sequential Occupational Dexterity Assessment (SODA) score, was similar with the 2 splints. Patients using the silver ring splint had SODA score improvement of 11.2; those using thermoplastic splints had improvement of 10.8. The only difference in overall clinical outcome or patient satisfaction was a significantly higher score in 3 items of satisfaction in the silver-ring-splint group. [12]

If splints are not tolerated, several procedures can be considered, including DIP joint fusion (soft-tissue procedures at the DIP joint are unsuccessful) and PIP joint flexor tenodesis, in which a volar zigzag incision is made over the PIP joint to expose the flexor tendon sheath; the sheath is opened proximally to the A1 pulley, and the flexor digitorum superficialis is separated from the sheath, creating a slight flexion contracture of the PIP joint. Another option is retinacular ligament reconstruction and dermodesis, in which an elliptic wedge of skin is removed from the volar aspect of the PIP joint, and the skin defect is closed with the digit in flexion. However, this procedure is usually only of temporary value, because the skin stretches out with time.


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