arthritis of the hand and fingers thomas a. wiedrich, md 1 st edition author: donald h. lee, md
TRANSCRIPT
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 arthritisS/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 Underlying distal interphalangeal joint osteophyte (arrow)
Courtesy of Donald H. Lee, MDArthritis – Hand & Fingers
• 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 K-wires)
• 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
Courtesy of Donald H. Lee, MD
Arthritis – Hand & Fingers
• 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 dressingsArthritis – 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,
MDArthritis – Hand & Fingers
Regional Review Course 1998
• Surgical Indications• Pain• Deformity• Contracture• Instability
• Surgical options• Arthrodesis• Arthroplasty
Arthritis – Hand & Fingers
• 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 cascadeArthritis – Hand & Fingers
Leibovic S et al, JHS, 2007
• 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
Converts palmar pull of flexors from distration force of dorsal side to compression force at palmar side
Courtesy of Donald H. Lee, MD
K-wire tension band construct
• 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)
Arthritis – Hand & Fingers
Bickel KD, JHS, 2007
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
Essentials of Hand Surgery 2002
• 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
• Grind test• Examine mobility of MP joint
• May need to be addressed surgically at time of CMC procedure
• Examine for CTS
Regional Review Course 1998
Arthritis – Hand & Fingers
• 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
Regional Review Course 1998
• 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 Stage 3/4
Regional Review Course 1998
• 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• Breadth of palm
increases
• Base of the thumb is the most operated upon joint (for osteoarthritis) in the Western world.
Shoulder sign
MPJ hyperextended
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
Arthritis – Hand & FingersMo JH et al, JHS, 2004
• 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
Ulnar drift of the digits and radial deviation of the wrist
Regional Review Course 1998
Arthritis – Hand & Fingers
• Rheumatoid Arthritis
Volar subluxation of MP joints and swan neck deformities of the digits
Regional Review Course 1998
• 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
Resting hand splintRegional Review Course 1998
• 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?