Rheumatoid Arthritis: Statement Analysis
Statement (a) is CORRECT and statement (d) is CORRECT, while statements (b) and (c) are INCORRECT.
Statement-by-Statement Analysis
a) Small joints of the upper limb - CORRECT
RA characteristically involves small joints of the hands and wrists as a hallmark feature. The disease typically presents with symmetric polyarthritis affecting metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints, and wrists 1. The 2010 ACR/EULAR classification criteria specifically assign higher scores to small joint involvement, with 1-3 small joints scoring 2 points and 4-10 small joints scoring 3 points 1. Clinical examination routinely includes assessment of these joints using the 28-joint count, which encompasses PIP joints (first through fifth), MCP joints (first through fifth), and wrists bilaterally 1.
Key clinical point: Hand involvement is the typical early manifestation of RA, with synovitis causing characteristic tender swelling on palpation and severe motion impairment even before radiologic bone damage appears 2.
b) Incidence decreases after age 60 - INCORRECT
The prevalence of RA actually increases considerably with age, not decreases. The guideline evidence clearly states that RA can develop at any age with typical onset around 55 years, and the prevalence increases considerably with age, affecting approximately 6% of the white population older than 65 years 1. The prevalence increases with age up to 70 years 3. This represents a substantial increase from the general population prevalence of approximately 1% worldwide 1.
Critical distinction: While the annual incidence rate is about 0.05%, the cumulative prevalence rises dramatically in older populations due to the chronic nature of the disease and accumulation of cases over time.
c) Stiffness worsens during evening hours - INCORRECT
Morning stiffness, not evening stiffness, is the pathognomonic feature of RA. The evidence unequivocally states that patients with RA experience morning stiffness that lasts 1 hour or longer 1. This morning stiffness is a typical sign of RA and occurs before maximal improvement throughout the day 2. The clinical features of synovitis are particularly apparent in the morning, and morning stiffness duration is directly related to disease activity 2.
Clinical pitfall: Patients must be carefully informed about the difference between pain and stiffness, as morning stiffness is a subjective sign that provides important diagnostic and monitoring information 2.
d) Radial deviation of the wrist and ulnar deviation of the fingers - CORRECT
This describes the classic "Z-deformity" or "zigzag deformity" pattern seen in established RA. While not explicitly detailed in the provided evidence, this is a well-recognized deformity pattern in RA where chronic synovitis and ligamentous laxity lead to radial deviation at the wrist combined with ulnar deviation (ulnar drift) of the fingers at the MCP joints. This represents the characteristic joint destruction and deformity that occurs when RA progresses without adequate treatment.
Important context: The evidence emphasizes that RA is characteristically a symmetric erosive disease 2, and these deformities represent the anatomic consequences of progressive joint damage that modern aggressive treatment strategies aim to prevent 1.
Summary of Correct Answers
- (a) CORRECT - Small joint involvement of hands/wrists is characteristic
- (b) INCORRECT - Prevalence increases, not decreases, after age 60
- (c) INCORRECT - Morning stiffness (≥1 hour), not evening stiffness, is typical
- (d) CORRECT - Radial wrist deviation with ulnar finger deviation is a classic deformity pattern