A patient who has had rheumatoid arthritis (RA) for years comes to the clinic to ask about changes in her hands. Which changes are associated with chronic RA?

A. Dupuytren contractures: This condition involves hyperplasia of the palmar fascia, causing the digits to curl into the palm. It is a fibrotic connective tissue disorder rather than an inflammatory joint disease. It is not a characteristic pathological feature of chronic rheumatoid arthritis. B. Bouchard nodules: These are hard, bony outgrowths located at the proximal interphalangeal (PIP) joints. They are classic markers of osteoarthritis, representing osteophyte formation due to mechanical wear. They do not typically occur in the systemic inflammatory process of RA. C. Heberden nodules: These bony overgrowths occur at the distal interphalangeal (DIP) joints of the fingers. Like Bouchard nodules, they are diagnostic signs of degenerative joint disease (osteoarthritis) rather than inflammatory arthritis. Rheumatoid arthritis rarely involves the distal interphalangeal joints. D. Swan-neck contractures: This deformity involves hyperextension of the PIP joint with concurrent flexion of the DIP joint. It results from chronic inflammation and destruction of the joint capsule and ligaments in RA. It is a hallmark sign of advanced, chronic rheumatoid disease.