Photo Rounds

Crooked fingers

A 62-year-old woman went to see her family physician (FP) because she was concerned about her fingers, which weren’t straight. She’d had increasing pain in both hands (specifically the metacarpophalangeal [MCP] joints) over the last 2 years. Her fingers were stiff in the morning, but she was able to gain some relief with ibuprofen and naproxen. Unfortunately, the pain relievers bothered her stomach. On physical exam, her fingers had an ulnar deviation and there was swelling of the MCP joints on both hands.

What's your diagnosis?


The FP made the clinical diagnosis of rheumatoid arthritis (RA) based on the patient’s bilateral MCP joint swelling, ulnar deviation, and morning stiffness.

Patients with RA initially experience swelling and stiffness in their wrists, as well as their MCP and metatarsophalangeal joints. Later, the larger joints are affected. When RA is advanced, severe destruction and subluxation occur.

Magnetic resonance imaging is helpful in identifying early RA changes, such as synovitis, effusions, and bone marrow changes. Later on, x-rays will reveal joint erosions and loss of joint space.

To treat the patient’s pain and inflammation, the FP prescribed a COX-2 inhibitor (along with a proton pump inhibitor to protect the stomach). The FP also referred her to a rheumatologist for further work-up and to determine whether a disease-modifying antirheumatic drug was in order.

Photo and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Chumley H, Usatine R. Arthritis overview. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:562-568.

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