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Question

Difficulty: MediumPhysical Examination Findings

A 42-year-old woman comes to the ambulatory care clinic with a 4-month history of worsening joint pain and stiffness in her hands. The stiffness is most severe upon awakening and typically lasts for 2 to 3 hours before gradually improving. She has noted increasing difficulty with tasks that require fine dexterity, such as typing and opening jars. Vital signs are within normal limits. On physical examination, there is bilateral, symmetrical, boggy swelling and tenderness over the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of both hands. The distal interphalangeal (DIP) joints are notably spared. There is mild atrophy of the dorsal interosseous muscles. If this patient's underlying condition continues to progress without intervention, which of the following physical examination findings is most likely to develop over time?

  1. Hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal jointAnswer
  2. B
    Hard, bony enlargements located exclusively at the distal interphalangeal joints
  3. C
    Asymmetrical swelling of an entire digit resulting in a sausage-like appearance
  4. D
    Erythematous, violaceous plaques over the dorsal surface of the interphalangeal joints
  5. E
    Nodular thickening of the palmar fascia with a fixed flexion contracture of the ring finger

Answer

Hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint
The correct answer accurately describes a swan-neck deformity. The patient's presentation of symmetrical, boggy joint swelling, tenderness of the MCP and PIP joints with DIP sparing, and prolonged morning stiffness (greater than 1 hour) is a classic presentation of rheumatoid arthritis (RA). If left untreated, chronic intra-articular inflammation leads to the progressive destruction of cartilage, bone, and supporting ligaments. A swan-neck deformity occurs due to the laxity or rupture of the volar plate at the proximal interphalangeal (PIP) joint, leading to PIP hyperextension, accompanied by the compensatory flexion of the distal interphalangeal (DIP) joint. This physical examination finding is a hallmark of advanced, unmanaged RA.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and joint involvement.
The patient has chronic, symmetrical, inflammatory polyarthritis of the MCP and PIP joints, with characteristic sparing of the DIP joints and prolonged morning stiffness.
To establish the primary underlying diagnosis based on the history and physical examination findings.
2
Synthesize the findings to determine the most likely underlying condition.
The clinical picture is highly classic for rheumatoid arthritis (RA), differentiating it from osteoarthritis or other inflammatory arthropathies.
RA preferentially affects the MCP and PIP joints and causes systemic morning stiffness lasting greater than one hour.
3
Identify the characteristic physical examination findings associated with disease progression.
Chronic, untreated RA leads to ligamentous laxity, joint subluxation, and tendon imbalances, classically causing swan-neck and boutonniere deformities in the hands.
To answer the specific question regarding the expected late-stage physical examination finding.

Key Concept

Recognizing the physical examination findings of progressive rheumatoid arthritis, specifically the swan-neck deformity, and distinguishing its specific joint distribution from other common arthritides.
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Topics

Physical Examination Findings

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