Arthritis of the Fingers

Types of Arthritis Osteoarthritis Rheumatoid Arthritis Others Systemic Lupus Erythematosus Psoriatic arthritis Scleroderma Gout Pseudogout Post-traumatic Post-infectious

Osteoarthritis Degenerative arthritis Affects diarthrodial joints Most commonly affected joints Distal interphalangeal joint Thumb carpometacarpal joint Proximal interphalangeal joint Metacarpophalangeal joint rarely involved Incidence in > 65 year olds 78% of men / 99% of women

Distal Interphalangeal (DIP) Joint Osteoarthritis

Distal Interphalangeal Joint Osteoarthritis Often painless Deformities Angulatory Rotatory Marginal osteophytes Distal interphalangeal joint Heberden’s nodes Proximal interphalangeal joint Bouchard’s nodes Illustration and picture showing Heberdens’s and Bouchard’s nodes Left Image: Essentials of Hand Surgery 2002 Right Image: Courtesy of Donald H. Lee, MD

Distal Interphalangeal Joint Osteoarthritis Long finger distal interphalangeal joint arthritis S/P fusion of index distal interphalangeal joint Courtesy of Donald H. Lee, MD

Distal Interphalangeal Joint Osteoarthritis Mucous cysts Ganglion cyst in conjunction with osteoarthritis Nail deformity Mucous cyst with nail deformity Regional Review Course 1998

Distal Interphalangeal Joint Osteoarthritis Index finger mucous cyst Underlying distal interphalangeal joint osteophyte (arrow) Courtesy of Donald H. Lee, MD

Distal Interphalangeal Joint Osteoarthritis Nonsurgical Treatment Rest Activity restriction Splinting Anti-inflammatory medications

Distal Interphalangeal Joint Osteoarthritis Surgical Indications Pain Deformity Painful instability Problematic mucous cyst Progressive enlargement Repeated local trauma Nail ridging Infection

Distal Interphalangeal Joint Osteoarthritis Surgical Options Osteophyte excision Mucous cyst excision requires excision of underlying osteophyte Arthrodesis Arthroplasty Rarely performed Excision of distal interphalangeal osteophyte and mucous cyst Courtesy of Donald H. Lee, MD

Distal Interphalangeal Joint Arthrodesis Surgical implant options Kirschner wires Interosseous wires Intraosseous screw External fixator Position of arthrodesis 0 to 30 degrees of flexion More flexion in ulnar digits

Distal Interphalangeal Joint Arthrodesis Kirschner wires used for distal interphalangeal joint fusion Courtesy of Donald H. Lee, MD

Distal Interphalangeal Joint Arthrodesis Interosseous screw used for distal interphalangeal joint fusion Courtesy of Donald H. Lee, MD

Small Joint Arthrodesis Surface Preparation and shaping Cone and cup Chevron Flat angled resection

Small Joint Arthrodesis Methods of Fixation - K wires - Intraosseous wires - Interosseous screw - Plate

Proximal Interphalangeal (PIP) Joint Osteoarthritis

Proximal Interphalangeal Joint Osteoarthritis Less commonly involved than DIP joint Symptoms and clinical findings Pain Limited motion Instability Deformity Courtesy of Donald H. Lee, MD

Proximal Interphalangeal Joint Osteoarthritis Surgical Indications - Pain - Deformity - Contracture - Instability Surgical options - Arthrodesis - Arthroplasty Regional Review Course 1998

Proximal Interphalangeal Joint Arthrodesis Surface Preparation and shaping Cone and cup Chevron Flat angled resection Methods of Fixation K-wires Tension band wires Intraosseous wires Interosseous screw Plate and screws Position of arthrodesis more flexion in ulnar digits

Proximal Interphalangeal Joint Arthrodesis Cone and cup arthrodesis of proximal interphalangeal joint with tension band technique Courtesy of Donald H. Lee, MD

Proximal Interphalangeal Joint Arthrodesis Courtesy of Donald H. Lee, MD

Proximal Interphalangeal Joint Arthrodesis Cone and cup arthrodesis of proximal interphalangeal joint with tension band technique Courtesy of Donald H. Lee, MD

Proximal Interphalangeal Joint Arthrodesis Arthrodesis of proximal interphalangeal joint with tension band technique Courtesy of Donald H. Lee, MD

Proximal Interphalangeal Joint Arthroplasty Indications - Pain - Need for motion Surgical Options - Resection arthroplasty - Silicone implant - Cemented PIP joint implant - Surface replacement implant Silicone implant Metal – polyethylene implant Pyrolytic carbon implant Courtesy of Donald H. Lee, MD

Proximal Interphalangeal Joint Arthroplasty Courtesy of Donald H. Lee, MD

Proximal Interphalangeal Joint Arthroplasty Silicone implant of proximal interphalangeal joint Courtesy of Donald H. Lee, MD

Thumb Carpometacarpal (CMC) Joint Arthritis

Thumb Carpometacarpal Joint Arthritis Symptoms - Pain with thumb use - Pain with gripping - Pain in thenar area Clinical findings - Pain - Local tenderness - Axial compression test - CMC grind test - Deformity Axial compression and rotation or grind test Axial compression-adduction test Essentials of Hand Surgery 2002

Thumb Carpometacarpal Joint Arthritis Clinical findings - Pain - Deformity Dorsoradial subluxation of the CMC joint due to insufficiency of the palmar oblique or beak ligament Adduction of the thumb metacarpal Hyperextension of the metacarpophalangeal joint Regional Review Course 1998

Thumb Carpometacarpal Joint Arthritis Differential diagnosis De Quervain’s (1st compartment) tenosynovitis Radial sensory neuritis 2nd compartment dorsal tenosynovitis Arthritis Metacarpophalangeal Scaphtrapeziotrapezoid Radiocarpal

Thumb Carpometacarpal Joint Arthritis Non-operative treatment - Splints - NSAIDs - Injections Regional Review Course 1998

Thumb Carpometacarpal Joint Arthritis Most commonly surgically reconstructed area with OA in arm Surgical indications - Refractory to non-operative treatment Regional Review Course 1998

Thumb Carpometacarpal Joint Arthritis Eaton classification of radiographic stages of thumb CMC OA 1 - Normal appearance 2 - Joint space narrowing osteophytes < 2mm 3 - Sclerosis, Subchondral cysts osteophytes > 2mm 4 - Pantrapezial arthritis Regional Review Course 1998

Thumb Carpometacarpal Joint Arthritis Surgical Options - Excisional arthroplasty of trapezium - Excisional arthroplasty of trapezium with rolled tendon graft - Ligament reconstruction and tendon interposition arthroplasty (LRTI) - Trapezium excision and silicone implant - Hemiarthroplasty of the trapeziometacarpal joint - Total joint implant of trapeziometacarpal joint - Trapeziometacarpal arthrodesis

Thumb Carpometacarpal Joint Arthritis Appearance of excised trapezium Courtesy of Donald H. Lee, MD

Thumb Carpometacarpal Joint Arthritis Excisional arthroplasty of trapezium with rolled tendon graft Courtesy of Donald H. Lee, MD

Thumb Carpometacarpal Joint Arthritis Thumb MCPJ hyperextension deformity < 10 degrees – no treatment 10 to 20 degrees – K-wire fixation in 10 degrees of flexion (6 weeks) > 20 degrees – volar plat capsulodesis (no arthritis) – MP arthrodesis (arthritis)

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

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

Rheumatoid Arthritis Most commonly affected joints Clinical findings Metacarpophalangeal joint Clinical findings Morning stiffness Digital and wrist synovitis Ulnar drift of fingers Radial deviation of wrist Metacarpophalangeal joint arthritis Regional Review Course 1998

Rheumatoid Arthritis Deformities seen Tenosynovitis Tendon ruptures EPL (Lister’s tubercle) Extensor tendons (distal ulna) FPL (scaphoid) Joint Synovitis Joint Arthritis Hand deformities Extensor tenosynovitis Regional Review Course 1998

Rheumatoid Arthritis Deformities seen Tenosynovitis Tendon ruptures EPL (Lister’s tubercle) Extensor tendons (distal ulna) FPL (scaphoid) Joint Synovitis Joint Arthritis Hand deformities Prominent distal ulna and ulnar extensor tendon ruptures Regional Review Course 1998

Rheumatoid Arthritis Deformities seen 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

Rheumatoid Arthritis Deformities seen 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 Volar subluxation of MP joints and swan neck deformities of the digits Regional Review Course 1998

Rheumatoid Arthritis 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

Rheumatoid Arthritis Non-operative treatment Medical management NSAIDs Disease remitting agents Rest Controlled exercises Splints Finger Resting hand splints Steroid injections Patient education Resting hand splint Regional Review Course 1998

Rheumatoid Arthritis Surgical Indications Pain relief Restoration/improvement of function Prevention of deformities Improvement of appearance

Rheumatoid Arthritis Surgical options Synovectomy - Tendons - Joint Contracture releases Tendon reconstruction - Repair - Adjacent tendon suture - Intercalated graft - Tendon transfer Arthroplasty Arthrodesis Flexor tenosynovectomy Regional Review Course 1998

Synovectomy Rheumatoid Arthritis MCP joint Joint realignment centralization of extensor tendon ulnar collateral ligament and intrinsic release reefing of radial collateral ligament cross intrinsic tendon transfers Implant arthroplasty

Rheumatoid Arthritis MCP Joint Arthroplasty Indications Pain with arthritis Severe ulnar drift with loss of function Marked flexion contractures Decreased arc of motion (< 40 deg.) Contraindications Poor bone stock Vasculitis Poor skin condition Silicone replacement of MCP joint Courtesy of Donald H. Lee, MD

Rheumatoid Arthritis MCP Joint Arthroplasty Silicone replacement of MCP joint Courtesy of Donald H. Lee, MD

Rheumatoid Arthritis PIP joint – Swan Neck Deformity Hyperextension at PIP joint, flexion at DIP joint Treatment options FDS tenodesis Oblique retinacular ligament reconstruction DIP joint arthrodesis or tenodermadesis Lateral band mobilization Arthrodesis / arthroplasty Swan neck deformity of the finger with dorsal subluxation of the lateral bands Essentials of Hand Surgery 2002

Rheumatoid Arthritis PIP joint – Boutonnière Deformity Flexion at the PIP joint, hyperextension at MCP joint Treatment Options Distal extensor tenotomy Synovectomy Central slip, lateral band reconstruction Arthrodesis / arthroplasty Boutonniere deformity of the finger with rupture of the central slip and volar subluxation of the lateral bands Essentials of Hand Surgery 2002

Rheumatoid Arthritis PIP Joint Arthroplasty Silicone replacement of PIP joint Regional Review Course 1998

Rheumatoid Arthritis Thumb Deformities Type I - Boutonnière deformity MCP synovectomy Reconstruction of extensor mechanism Arthrodesis / arthroplasty Type III – Swan neck deformity CMC joint arthroplasty MCP joint capsulodesis / arthrodesis Type II – combination of types I & III Type IV – Gamekeeper’s deformity MCP joint synovectomy Ulnar collateral ligament reconstruction MCP arthrodesis Type V – MP joint hyperextension, IP joint flexion, no CMC joint involvement Type VI – skeletal collapse & loss of bony substance Arthrodesis of distal joint

Summary Osteoarthritis commonly involves the hand, especially the distal and proximal interphalangeal and thumb carpometacarpal joints Rheumatoid arthritis commonly involves the metacarpophalangeal joints

Summary Non-operative treatment includes the use of antinflammatory medications, splints and therapeutic modalities Surgical treatment includes soft tissue reconstruction, arthroplasty and arthrodesis