This is a real-world medical entrance exam question, please give the true answer based on the question and selection. Topic name: Rheumatoid Ahritis, Subject name: Medicine
All are true about the condition except? 
Select and explain. 
A. Piano key movement of ulnar styloid, B. Z line deformity, C. Atlanto axial deformity, D. Tender Nodes
D: Tender Nodes
Answer: D: Tender Nodes 
Explanation: The image shows nodules on extensor distribution along with peripheral smear showing presence of normocytic anemia. The first differential to be considered is rheumatoid ahritis. The nodules are non-tender and are a late feature and hence not considered in diagnostic criteria for Rheumatoid ahritis. "Piano-key movement" of the ulnar styloid occurs due to inflammation about the ulnar styloid and tenosynovitis of the extensor carpi ulnaris. "Z-line deformity" is due to subluxation of the first MCP joint with hyperextension of the first interphalangeal (IP) joint due to damage to the tendons, joint capsule.