Background Hand involvement is one of the earliest clinical manifestations of systemic sclerosis (SSc) that results in major functional compromise. Several factors may be responsible including skin and periarticular thickening, arthralgias or arthritis, tenosynovitis, Raynaud’s phenomenon, digital ulcers and calcinosis. Although hand dysfunction was investigated using different indices and instruments, to date there is no multi-elemental ultrasonographic assessment of hand structures in SSc.
Objectives To evaluate hand impairment and functional disability in SSc patients using clinical and ultrasonographic measures to guide rehabilitation programs aiming at better quality of life.
Methods Fifteen consecutive SSc patients and 10 matched healthy controls were included. Patients underwent clinical examination of hands for detection of joint involvement (tenderness, swellings or contractures), digital ulcers, and calcinosis. Skin thickness was clinically assessed using modified Rodnan skin score (mRSS) total and regional of upper limbs. Hand function assessment included pinch and grip strength, finger range of motion using finger to palm tests, Hand Mobility in Scleroderma test and Hand Functional Index. Hand disability was assessed by Health Assessment Questionnaire, Scleroderma HAQVisual Analogue Scale and Cochin scale. Hands and wrists ultrasound (US) was performed aiming at detection of any structural abnormalities as synovitis, tenosynovitis or calcinosis. US measurement of flexor retinaculum (FR) thickness, skin thickness at four sites on each upper limb corresponding to those of the upper limb mRSS were performed in all patients and controls.
Results Ten patients (66.6%) had limited and 5 (33.3%) had diffuse SSc. The mean disease duration was 7.13 ±6.96 years. All SSc patients had Raynaud’s phenomenon, nine patients (60%) had healed digital ulcers while only one had active ulcers. Seven patients (46%) had arthralgia in most of the hand joints, eight (53%) had contracures, and one had calcinosis. All patients had a significant decrease in grip strength and finger to palm tests compared to controls. Comparison of the US findings of the hands in patients to controls revealed bilateral significant increase of the middle finger dorsal skin thickness, significant increase of the mean 2nd inter-metacarpal web space skin thickness, significant increase of the mean FR thickness in SSc. There were no US detectable synovitis, or tendon pathologies, but calcinosis was detected in one SSc patient only. There were no significant correlations between US measures of skin thickness and either total or regional mRSS. Hand disability measures showed significant correlations with pinch and grip strength and with hand mobility measures which were significantly negatively correlated with US skin thickness.
Conclusions Hand disability in scleroderma is mainly related to impaired hand mobility (attributed to increased skin thickness and arthralgia) and also diminished strength (attributed to pain and disuse). Arthritis, tenosynovitis, digital ulcerations and calcinosis were not major causes of hand disability in this study. The use of US in adjunct to clinical examination refines the evaluation of hand impairment in SSc for a better design of rehabilitation oriented approach to disease management.
Disclosure of Interest None Declared