Arthritis of the Hand and Fingers Thomas A. Wiedrich, MD 1 st Edition author: Donald H. Lee, MD.

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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

• 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

• Osteoarthritis

Long finger distal interphalangeal joint arthritisS/P fusion of index distal interphalangeal joint

• 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

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

• 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

• 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

• 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

• 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

• 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

• 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

• Surgical Indications• Pain• Deformity• Contracture• Instability

• Surgical options• Arthrodesis• Arthroplasty

• 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

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

• 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

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)

Thumb Carpometacarpal (CMC)Joint Arthritis

• 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

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

• 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 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.

• 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

• 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

• 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

• 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)

• 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

• 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• Metacarpophalangeal

joints – most commonly affected

• Clinical findings• Morning stiffness• Digital and wrist

synovitis• Ulnar drift of fingers• Radial deviation of wrist

• 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

• Rheumatoid Arthritis

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

• 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

• 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

• 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

• 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

• Thank you• Questions?

Arthritis of the Hand and Fingers Thomas A. Wiedrich, MD 1 st Edition author: Donald H. Lee, MD.

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