Arthritis of the Hand and Fingers
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Arthritis of the Hand and Fingers Thomas A. Wiedrich, MD 1st Edition author: Donald H. Lee, MD • Etiology of Arthritis of the Hand and Fingers • Osteoarthritis • Inflammatory arthritis • • • • • Systemic Lupus Erythematosus Psoriatic arthritis Scleroderma Gout Pseudogout • Post-traumatic • Post-infectious Arthritis – Hand & Fingers • Most commonly affected joints • • • • Distal interphalangeal joint (DIP) Thumb carpometacarpal joint (CMC) Proximal interphalangeal joint (PIP) Metacarpophalangeal (MP) joint rarely involved • Incidence in > 65 year olds • 78% of men / 99% of women Arthritis – Hand & Fingers • Interphalangeal Joint Arthritis • Often painless • Deformities • Angular • Rotatory • Marginal osteophytes • Distal interphalangeal joint • Heberden’s nodes • Proximal interphalangeal joint • Bouchard’s nodes Essentials of Hand Surgery 2002 DIP Joint Arthritis Arthritis – Hand & Fingers • Osteoarthritis Long finger distal interphalangeal joint arthritis S/P fusion of index distal interphalangeal joint Arthritis – Hand & Fingers • Mucous Cysts • May present with or without significant radiographic signs or arthitis • Cyst emanating from joint • Nail ridging may indicate more mature cyst • May have dorsal skin attenuation Regional Review Course 1998 Arthritis – Hand & Fingers Index finger mucous cyst Arthritis – Hand & Fingers Underlying distal interphalangeal joint osteophyte (arrow) Courtesy of Donald H. Lee, MD • Nonsurgical Treatment of Mucous Cysts • • • • • Rest Activity restriction/modification Splinting Anti-inflammatory medications Aspiration/Injections Arthritis – Hand & Fingers • Surgical Indications • • • • Pain Deformity Painful instability Problematic mucous cyst • Resistant to conservative measures • Aspiration with ~ 40-50% recurrence • • • • Nail ridging Progressive enlargement Repeated local trauma Infection Arthritis – Hand & Fingers • Surgical Options- Mucous Cyst • Dependent upon symptoms as well as amount of arthritic changes within joint • Simple • Mucous cyst excision • Osteophyte excision • Joint debridement • Minimal surgical complications, nail ridging can resolve in ~5/6 of cases • Joint significantly affected by arthritis • Arthrodesis Arthritis – Hand & Fingers • Surgical Implant Options • Tension band construct • Intraosseous Kirschner wires (90-90 configuration • Headless compression screw • Position of arthrodesis • Depends on fixation method and limitations with screw based on AP diameter of distal phalanx. • Between 10-30° (0-10° more likely with screw, increasing flexion with Kwires) • More flexion in ulnar digits Arthritis – Hand & Fingers • Surface Preparation And Shaping • Cone and cup • Chevron • Flat angled resection Arthritis – Hand & Fingers Leibovic S et al, JHS, 2007 Kirschner wires used for distal interphalangeal joint fusion Arthritis – Hand & Fingers Courtesy of Donald H. Lee, MD • Time to clinical union ~ 6 weeks, protect with thermoplastic splint until that time • Radiographic union in ~3 months • Results • Nonunion rates vary between 0 and 10% depending on joint fused (PIP vs DIP respectively) • Infection rate <5% (minor infection, though osteomyelitis may occur) • Soft tissue problems • More common over DIP than PIP • Avoid by not closing wound too tightly, noncompressive dressings Arthritis – Hand & Fingers PIP Joint Arthritis Arthritis – Hand & Fingers • PIP Joint Arthritis • Less frequently affected by primary OA • Typically, • Post traumatic • Inflammatory (RA) • Post infection • Presentation • PIP joints become painful and stiff with marked decreased range of motion • Arthritic process can render PIP joint unstable due to attenuation of soft tissue stabilizers Courtesy of Donald H. Lee, MD Arthritis – Hand & Fingers • Surgical Indications • • • • Pain Deformity Contracture Instability • Surgical options • Arthrodesis • Arthroplasty Arthritis – Hand & Fingers Regional Review Course 1998 • Surface Preparation and Shaping • Cup and cone • Allows rotational correction at time of fixation • Chevron • Angled resection • Methods of fixation • • • • Kirschner wires Tension band construct Intraosseous screws/wires Plate and screws • Position of arthrodesis • More flexion as one goes ulnarly to mimic cascade Leibovic S et al, JHS, 2007 Arthritis – Hand & Fingers • PIP Joint Arthrodesis With Headless Compression Screw • Technical point • Use rongeur to enlarge hole in middle phalanx to the size of proximal screw threads to prevent fracture of dorsal cortex! • If dorsal cortex is breached, must use different method of fixation or supplement this fixation Arthritis – Hand & Fingers Leibovic S et al, JHS, 2007 K-wire tension band construct Converts palmar pull of flexors from distration force of dorsal side to compression force at palmar side Courtesy of Donald H. Lee, MD • Arthroplasty • Indications • Older population • Primary or post traumatic arthritis • Contraindications • Infection • Lack of flexor/extensors • Severe periarticular bone stock loss • Incompetent collateral ligaments • Incompetent volar plate • Poor soft tissue coverage Arthritis – Hand & Fingers • Approaches • Dorsal (central slip at risk) • Tendon splitting • Chamay tendon reflecting approach • Lateral (collateral ligaments at risk) • Volar (volar plate/flexor tendons at risk) Bickel KD, JHS, 2007 Arthritis – Hand & Fingers Surface Replacement Arthroplasty Arthritis – Hand & Fingers Murray P, JHS, 2007 • Postoperative regimen • Must protect central slip/lateral band/volar plate depending upon approach for 6 weeks. Use appropriate splint for approach(ie dynamic extension splint with flexion block for dorsal approach) • Results after either Resurfacing Arthroplasty or Silicone arthroplasty • Can expect excellent pain relief • No real increases in ROM • Appearance may be better with resurfacing • Complications • Extensor lag, instability of joint, need for reoperation/loosening • Squeeking with resurfacing arthroplasty • Branam and co-authors found 8/19 squeeked! (but patients were still happy with outcome and would opt for the same procedure) Arthritis – Hand & Fingers Thumb Carpometacarpal (CMC) Joint Arthritis Arthritis – Hand & Fingers • Incidence • Framingham cohort study showed symptomatic OA in 7% women and 5% of men > 70 yo • (Zhang et al, Am J Epidemiology 2002) • Prevalence of hand arthritis approaches 67% in women > 55 yo with 21%-36% occurring at the thumb CMC joint • (Dahaghin et al, Ann Rheum Dis 2005) • Clinical Symptoms • Pain • Palmar sided • Pain with pinch • Deformity • Subluxation of the metacarpal dorsoradially with attenuation of the volar beak ligament • Thumb metacarpal assumes adducted position • MP joint extended Arthritis – Hand & Fingers • Physical Examination • Visual inspection • Shoulder sign- subluxation of metacarpal dorsoradially • MP joint may be hyperextended (thought to be compensatory, may be contributory to the process) • Examine bulk of thenar musculature (association with carpal tunnel syndrome) • Palpation/provocative maneuvers Regional Review Course 1998 • Grind test • Examine mobility of MP joint • May need to be addressed surgically at time of CMC procedure • Examine for CTS Arthritis – Hand & Fingers Essentials of Hand Surgery 2002 • Differential Diagnosis • Radial sided pain • Intersection syndrome- pain with wrist flexion and extension • DeQuervain’s tenosynovitis- Finkelstein’s maneuver • Radial impaction- pain with radial deviation • Scaphoid injury acute/chronic- pain/swelling in snuffbox, over tuberosity • Scapholunate ligament injury- dorsal sided wrist pain, scaphoid shift test • Scaphoid-trapezium-trapezoid arthritis- tenderness to palpation just distal to scaphoid • Stenosing tenosynovitis- volar sided pain at A1 pulley level, nodule. Arthritis – Hand & Fingers • Eaton Classification of Thumb CMC Arthritis • Stage 1 – Articular contours normal; joint space may be widened due to synovitis. Less than one-third subluxation on any view • Stage 2 – Slight narrowing of the joint space with osteophytes < 2 mm in size. May have more than one-third subluxation of the joint surfaces • Stage 3 –CMCJ narrowing with sclerotic or cystic changes, osteophytes > 2 mm. The STT joint remains intact • Stage 4 – Pantrapezial arthrosis – CMCJ and STT joint severe articular degeneration Regional Review Course 1998 Stage 3/4 • Non Operative Treatment • Splints • Hand or forearm based • NSAID’s • Must be selective in older patients • Injections • Randomized controlled study comparing placebo to corticosteroid injection found no difference. • Bay et al- prospective trial of injection and splinting evaluated effectiveness of 1 steroid injection and splinting x 3 weeks. • Effective in stage 1 disease, less effective in stage 2/3 and ineffective in stage 4 disease. Arthritis – Hand & Fingers Regional Review Course 1998 • Surgical Indications • Pain Refractory to nonoperative treatment • Interferes with pinch and grip • Deformity MPJ hyperextended • Breadth of palm increases • Base of the thumb is the most operated upon joint (for osteoarthritis) in the Western world. Shoulder sign Regional Review Course 1998 Arthritis – Hand & Fingers • Surgical Options • Dependent upon stage of disease • Stage I • Ligament reconstruction • Metacarpal extension osteotomy • Stages II-IV • Ligament reconstruction with or without tendon interposition • CMC arthrodesis Arthritis – Hand & Fingers • Stage I • Ligament reconstruction • 30 degree metacarpal extension osteotomy • Shifts forces dorsally away from arthritic changes on volar surface Koff MF et al, JHS, 2006 • Many options for Stage II-IV disease • Some interpose tissue within the trapezial space, others use “hematoma arthroplasty” • All are predicated on reconstruction of the volar beak ligament Mo JH et al, JHS, 2004 Arthritis – Hand & Fingers • Trapeziectomy Appearance of excised trapezium Courtesy of Donald H. Lee, MD • Thumb MCPJ Hyperextension Deformity • < 10 degrees • Leave alone • > 10 degrees • K-wire fixation in 10 degrees of flexion (6 weeks) • Extensor pollicis brevis tenotomy and tenodesis to APL (removes deforming force from thumb proximal phalanx) and K-wire fixation • Volar capsulodesis • MP arthrodesis (arthritis) Arthritis – Hand & Fingers • Clinical Outcomes After Treatment Of Thumb CMC Arthritis • Ligament reconstruction • Eaton et al reported 100% good/excellent results for stage I, 91% for stage II with 7 year follow up • Metacarpal osteotomy • Hobby et al reported good to excellent results in 95% of patients with low rate of complications • Meta-analysis by Martou found no significant benefit to ligament reconstruction • Latest Cochrane review shows trapiezectomy alone to be efficacious and safe • Thumb CMC arthrodesis • Younger patients with higher demands? • Perhaps stronger pinch • Relatively high rate of nonunion- asymptomatic Arthritis – Hand & Fingers • Inflammatory Arthritis • Systemic disorder • Skin rashes and ulcers • Organ dysfunction • Cardiac, pulmonary, renal, vascular, ocular, GI • Hematological disorders • Raynaud’s phenomenon • More common disorders • Rheumatoid arthritis • Systemic lupus erythematosus • Psoriatic arthritis • Scleroderma Arthritis – Hand & Fingers • Rheumatoid Arthritis • Systemic autoimmune disorder • Chronic systemic erosive synovitis • Deformities secondary to hypertrophied synovial tissue • Prevalence increases with age • Women:men ratio – 2.5:1 • Metacarpophalangeal joint most commonly involved • Wrist and other upper extremity joints Arthritis – Hand & Fingers • Rheumatoid Arthritis • Metacarpophalangeal joints – most commonly affected • Clinical findings • Morning stiffness • Digital and wrist synovitis • Ulnar drift of fingers • Radial deviation of wrist Regional Review Course 1998 Arthritis – Hand & Fingers • Rheumatoid Hand Deformities • Digital and wrist synovitis • Ulnar drift of fingers • Volar subluxation / dislocation of MP joints • Swan neck deformity • Boutonniere deformity • Radial deviation of wrist • Trigger fingers • Carpal tunnel syndrome Arthritis – Hand & Fingers Ulnar drift of the digits and radial deviation of the wrist Regional Review Course 1998 • Rheumatoid Arthritis Regional Review Course 1998 Volar subluxation of MP joints and swan neck deformities of the digits • Stages of Rheumatoid Joint Involvement • Stage I - Synovitis without deformity • Stage II - Synovitis with passively correctable deformity • Stage III - Fixed deformity without joint changes • Stage IV - Articular destruction Arthritis – Hand & Fingers • RA - Non-operative treatment • Medical management • NSAIDs • Disease remitting agents • Rest • Controlled exercises • Splints • Finger • Resting hand splints • Steroid injections • Patient education Regional Review Course 1998 Resting hand splint • RA - Surgical Indications • • • • Pain relief Restoration/improvement of function Prevention of deformities Improvement of appearance Arthritis – Hand & Fingers • MCP Joint • Synovectomy • Joint realignment • Centralization of extensor tendon • Ulnar collateral ligament and intrinsic release • Reefing of radial collateral ligament • Cross intrinsic tendon transfers • Implant arthroplasty Arthritis – Hand & Fingers • RA – Implant arthroplasty Indications Pain with arthritis Ulnar drift with loss of function Marked flexion contractures Decreased arc of motion (< 40 deg.) • Contraindications • Poor bone stock • Vasculitis • Poor skin condition • • • • Arthritis – Hand & Fingers • Summary • Osteoarthritis commonly involves the hand, especially the distal and proximal interphalangeal and thumb carpometacarpal joints • Rheumatoid arthritis commonly involves the metacarpophalangeal joints Arthritis – Hand & Fingers • Summary • Non-operative treatment includes the use of antinflammatory medications, splints and therapeutic modalities • Surgical treatment includes soft tissue reconstruction, arthroplasty and arthrodesis Arthritis – Hand & Fingers • Thank you • Questions?
