I. Primary Osteoarthritis
A. Overview
1. The prevalence of primary osteoarthritis (OA) increases with age.
2. The incidence is similar in men and women until menopause, after which time the incidence is higher in women.
3. Different patterns are seen in different races: thumb carpometacarpal (CMC) joint OA is more common in Caucasians. The prevalence of hand OA is higher in Native Americans than in either Caucasians or African Americans.
4. Joints are affected in the following order: distal interphalangeal (DIP) > thumb CMC > proximal interphalangeal (PIP) > metacarpophalangeal (MCP).
5. OA in one joint in a row predicts subsequent OA in the other joints of that row.
B. Thumb CMC Joint
1. Symptoms
a. Pain occurs at the base of the thumb, particularly with actions that generate stress across the joint (eg, pinch).
b. Pain is elicited by pressure over the dorsal, volar, or radial CMC capsule.
2. Differential diagnosis
a. de Quervain tenosynovitis
b. Scaphotrapeziotrapezoid (STT) arthritis
c. Scaphoid nonunion
d. Radioscaphoid arthritis
3. Imaging studies—Radiographs taken with the beam centered on the trapezium and the metacarpal and the thumb flat on the cassette (hyperpronated) (
Figure 1).
*Charles Day, MD, MBA, or the department with which he is affiliated has received research or institutional support from Wright Medical, SBi, and A.M. Surgical.
4. Treatment
a. Nonsurgical treatment is indicated for all stages initially and consists of splinting, nonsteroidal anti-inflammatory drugs (NSAIDs), and steroid injections.
b. Surgical treatment, for patients with severe pain and disability independent of radiographic findings, results in improved grip and pinch strength. OA of the thumb CMC joint most commonly needs surgical treatment (
Table 1).
[Figure 1. Drawing showing positioning of the hand on the radiographic cassette for the hyperpronated view.]
[Table 1. Radiographic Staging* and Treatment of Thumb CMC Arthritis]
C. DIP Joint
1. Etiology and symptoms
a. The DIP joint is subject to more wear and tear because it sustains the highest joint forces in the hand.
b. Pain
c. Deformity
d. Heberden nodes
e. Mucous cyst (often associated with an osteophyte), which might lead to draining sinus tract, septic arthritis, or nail ridging
f. Nail plate involvement characterized by loss of normal gloss, splitting, and deformity
2. Treatment
a. For mucous cyst, aspiration or open excision of the cyst, followed by debridement of the distal phalangeal osteophytes to prevent recurrence
b. For DIP joint arthrosis, joint arthrodesis in flexion of 10° to 20° is indicated. Use of a headless screw has the highest fusion rate. Although arthroplasty and arthrodesis provide similar function and pain relief, arthroplasty is rarely performed.
D. PIP joint
1. Symptoms
a. Bouchard nodes
b. Joint contractures with fibrosis of the collateral ligaments
2. Treatment
a. For predominant contracture with minimal joint involvement, collateral ligament excision, volar plate release, and osteophyte excision are indicated.
b. In long and ring fingers with intact bone stock and no angulation or rotational deformity, arthroplasty is indicated.
c. In border digits, arthrodesis is indicated. Headless screw fixation has the highest fusion rate. Angles of fusion: index, 30°; long, 35°; ring, 40°; small, 45°.
E. STT Joint
1. Etiology and symptoms
a. Sometimes posttraumatic in origin, resulting from rotary subluxation of the scaphoid
b. Scapholunate advanced collapse (SLAC) wrist seen in 15% of patients
2. Treatment
a. When the thumb CMC joint is not involved (consider confirming this with arthroscopy), STT arthrodesis is indicated.
b. For pantrapezial arthrosis, trapeziectomy is indicated.
F. Pisotriquetral joint
1. Etiology and symptoms
a. Sometimes posttraumatic in origin
b. Pain at the base of the hypothenar eminence is symptomatic.
c. Symptoms elicited by loading of the pisotriquetral joint
2. Lateral radiographs with the forearm in 30° of supination (carpal tunnel view) reveal the arthritic joint.
3. Treatment
a. Nonsurgical treatment consists of splinting and corticosteroid injections.
b. Pisiform excision is indicated only in refractory cases.
II. Erosive Osteoarthritis
A. Overview
1. Self-limiting disease that most commonly involves the DIP joint
2. More common in women than men (10:1)
3. Radiographs reveal joint destruction with osteophytes and erosions.
B. Symptoms
1. Intermittent inflammatory episodes destroy articular cartilage and adjacent bone.
2. Synovial changes resemble RA, but unlike RA, there are no systemic effects.
C. Treatment
1. Nonsurgical treatment (splints, NSAIDs) if symptoms are tolerable
2. Arthrodesis may be indicated to correct deformity.
III. Pulmonary Hypertrophic Osteoarthropathy
A. Overview—Occurs in 5% to 10% of patients with malignant thoracic neoplasms (bronchogenic carcinoma is the most common, followed by non-small cell lung cancer). Occasionally seen in lung diseases and familial cases.
B. Symptoms
1. Burning pain with morning stiffness
2. Digital clubbing, abnormal deposition of periosteal bone, arthralagia, and synovitis
C. Radiographic appearance
1. Periosteal thickening
2. Periosteal elevation appears as a continuous sclerotic line of new bone formation.
D. Treatment—The only effective treatment is to treat the pulmonary cause of this disease, eg, bronchogenic carcinoma or pulmonary infection.
IV. Posttraumatic Arthritis
A. Overview
1. Occurs in patients following intra-articular fracture of the hand and wrist, or following destabilizing injuries of the carpus
2. Severity of radiocarpal arthrosis following distal radius fracture is not correlated with the presence of symptoms.
B. Thumb and digits—Same as in osteoarthritis.
C. SLAC wrist (
Figure 2)
1. Pathophysiology
a. Injury to the scapholunate interosseous ligament and extrinsic ligament complex attenuation lead to palmar rotary subluxation of the scaphoid.
b. The radioscaphoid joint becomes incongruous, leading to alteration in normal radioscaphoid contact forces, and arthrosis develops.
c. As the scaphoid flexes and the scapholunate diastasis increases, the capitate migrates proximally.
d. The altered intercarpal contact forces lead to arthrosis at the capitolunate joint.
e. The styloscaphoid, radioscaphoid, and capitolunate joints are affected by SLAC wrist arthritic changes.
f. The radiolunate joint is typically spared because of its spheroid shape.
2. Symptoms
a. Decreased grip and pinch strength
b. Stiffness with extension and radial deviation
[Figure 2. AP radiograph of a stage II SLAC wrist. The capitate has migrated proximally, and joint space narrowing is seen between the radial styloid and the scaphoid as well as between the proximal pole of the scaphoid and the scaphoid fossa of the distal radius.]
c. Localized tenderness at the radioscaphoid articulation
d. Wrist motion is decreased on extension and radial deviation
3. Treatment—Depends on severity of the disease, as shown in
Table 2.
D. Scaphoid nonunion advanced collapse (SNAC) wrist (
Figure 3)—History, staging, and treatment (
Table 3) are similar to SLAC wrist. The proximal scaphoid articular surface is affected and the radius is spared.
E. Ulnocarpal impingement
1. Overview
a. Degenerative condition resulting from a discrepancy in the relative length of the distal articular surfaces of the radius and ulna (positive ulnar variance). The load sharing across the wrist varies with the amount of ulnar variance (
Table 4).
b. Posttraumatic causes: distal radius fracture with shortening, Galeazzi or Essex-Lopresti fracture, epiphyseal injuries
c. Congenital causes: dyschondroplasia (Madelung deformity) and naturally occurring positive ulnar variance
2. Symptoms
|
a. |
Pain on the dorsal side of the distal radioulnar joint (DRUJ) and an intermittent clicking sensation |
|
b. |
Pain exacerbated by forearm rotation and ulnar deviation |
[Table 2. Radiographic Staging of SLAC Wrist]
[Figure 3. AP radiograph of a SNAC wrist. Joint space narrowing is seen between the distal pole of the scaphoid and the radial styloid as well as between the distal pole of the scaphoid and the trapezium and trapezoid. Minimal joint space narrowing is seen between the proximal pole of the scaphoid and the scaphoid fossa of the distal radius.]
|
c. |
Pain with axial loading of the ulnar side of the wrist |
|
d. |
Pain with dorsal and palmar displacement of the distal ulna with the wrist in ulnar deviation (positive ballottement test) |
3. Imaging studies
a. Arthrography shows triangular fibrocartilage complex (TFCC) tear and lunotriquetral ligament tear
b. MRI shows changes on the ulnar border of the lunate
4. Treatment
a. Open excision of the distal ulnar head (Wafer resection)
b. Wrist arthroscopy and arthroscopic Wafer resection (use central TFCC tear for access)
c. Ulnar-shortening osteotomy
d. When the primary reason is distal radius malunion, corrective osteotomy of the distal radius may be indicated.
e. After wrist arthrodesis, triquetral excision may be indicated.
F. DRUJ arthrosis
1. Symptoms
a. Pain on the dorsum of the wrist, with limitation of forearm pronation and supination
b. Snapping and crepitus
c. Clinical findings: Pain is increased with proximal rotation of the forearm and compression of the ulna against the radius.
[Table 3. Radiographic Staging of SNAC Wrist]
[Table 4. Ulnar Variance and Load Sharing Across Wrist]
2. Diagnosis confirmation: improved rotation and grip strength with injection of local anesthetic into the DRUJ
3. Differential diagnosis: important to differentiate from instability, subluxation, and ulnocarpal impaction
4. Treatment
a. Darrach resection and/or distal ulna stabilization. Most common complication: distal ulnar stump instability and radioulnar impingement.
b. Distal ulna hemiresection and tendon interposition (Bowers), which preserves the TFCC insertion
c. Metallic prosthetic replacement of ulnar head
V. Rheumatoid Arthritis
A. Overview
1. Subcutaneous nodules are the most common extra-articular manifestations of rheumatoid arthritis (RA) in the upper extremity, occurring in 20% to 25% of patients with RA.
2. In patients with juvenile rheumatoid arthritis (JRA), a positive rheumatoid factor is found only in patients 8 years of age or older at presentation.
3. Patients with JRA should be referred to an ophthalmologist because uveitis may develop.
B. Extensor tendons
1. General information—The extensor digitorum quinti (EDQ) and extensor digitorum communis (EDC) tendons to the ring and small fingers are most susceptible to rupture.
2. Symptoms and etiology
a. Tenosynovitis presents as a painless dorsal mass distal to the extensor retinaculum.
b. Caput ulnae syndrome (dorsal subluxation of the distal ulna) or volar subluxation of the carpus often contributes to tendon ruptures.
3. Differential diagnosis of inability to extend the digits includes
a. Extensor tendon rupture (no tenodesis on wrist flexion)
b. Subluxation of extensor tendon at MCP joint
c. Posterior interosseous nerve (PIN) palsy
4. Treatment (
Table 5)
a. Tenosynovectomy is indicated for cases that fail to resolve following 6 months of medical treatment and splinting.
b. Extensor carpi radialis longus (ECRL) to extensor carpi ulnaris (ECU) transfer corrects radial deviation and supination of the carpus.
c. Distal ulna resection (Darrach, hemiresection, or Sauve-Kapandji) is used to address the DRUJ.
d. Extensor indicis proprius (EIP) to EDQ transfer or EDQ to EDC piggyback transfer
e. For multiple tendon ruptures, use flexor digitorum sublimis (FDS) or palmaris graft.
[Table 5. Treatment of RA Affecting the Extensor Tendons]
C. Flexor tendons
1. Symptoms and etiology
a. Tenosynovitis in carpal tunnel may present with median nerve symptoms.
b. Tendons rupture because of attrition over bony prominences.
c. Flexor pollicis longus (FPL) rupture caused by a scaphoid spur is the most common rupture.
2. Treatment (
Table 6)
|
a. |
Synovectomy with carpal tunnel release for patients with nerve compression symptoms |
|
b. |
Synovectomy with resection of FDS slip for triggering |
|
c. |
FDS transfer or tendon graft with spur excision for FPL rupture |
|
d. |
FPL rupture with advanced disease is best treated with interphalangeal (IP) arthrodesis. |
[Table 6. Treatment of RA Affecting the Flexor Tendons]
[
Figure 4. The pathoetiology of rheumatoid carpal deformity: scaphoid flexion, scapholunate widening, lunate translocation, and secondary radioscaphoid arthrosis combined with ulnar drift of the digital MCP joints.]
|
e. |
FDS ruptures in the digits are observed. |
|
f. |
FDP ruptures in the digits are treated with synovectomy and DIP fusion. |
D. Wrist
1. Symptoms—Deformity involves supination, palmar dislocation, radial deviation, and ulnar translocation of the carpus (Figure 4).
2. Treatment—Depends on the severity of the disease (
Table 7).
a. Partial arthrodesis (radiolunate or scaphoradiolunate) if the midcarpal joint is well preserved
b. Total wrist arthrodesis is the procedure of choice with advanced disease.
c. Total wrist arthroplasty is used for sedentary patients with good bone stock.
E. MCP Joint
1. Symptoms—Ulnar drift arises from extensor subluxation, collateral ligament laxity, synovitis, radial deviation of the wrist, and volar plate disruption.
2. Treatment—Depends on the severity of the disease (
Table 8).
[Table 7. Treatment of RA Affecting the Wrist]
[Table 8. Treatment of RA Affecting the MCP Joint]
a. Early stages are treated medically.
b. For ulnar drift with preservation of articular surface, consider soft-tissue realignment procedures (extensor relocation, intrinsic release, collateral ligament reefing).
c. MCP arthroplasty is the procedure of choice for severe joint involvement or fixed deformities.
d. Thumb MCP involvement is treated with arthrodesis in most cases. Arthroplasty is a reasonable alternative if the IP joint is also involved.
F. PIP Joint
1. Swan-neck deformity
a. Symptoms—Volar plate and collateral ligament laxity result in swan-neck deformities or hyperextension at the PIP joint with an extensor lag at the DIP joint (
Figure 5).
[Figure 5. Swan-neck deformity. A, Terminal tendon rupture may be associated with synovitis of the DIP joint, leading to DIP joint flexion and subsequent PIP joint hyperextension (a). Rupture of the flexor digitorum superficialis tendon may occur due to infiltrative synovitis which may lead to decreased volar support of the PIP joint and subsequent hyperextension deformity (b). B, Lateral-band subluxation dorsal to the axis of rotation of the PIP joint (c), contraction of the triangular ligament (d), and attenuation of the transverse retinacular ligament (e) are depicted.]
[
Figure 6. Boutonniere deformity. Primary synovitis of the PIP joint (a) may lead to attenuation of the overlying central slip (b) and dorsal capsule and increased flexion at the PIP joint. Lateral-band subluxation volar to the axis of rotation of the PIP joint (c) may lead in time to hyperextension. Contraction of the oblique retinacular ligament (d), which originates from the flexor sheath and inserts into the dorsal base of the distal phalanx, may lead to extension contracture of the DIP joint.]
b. Treatment
i. For flexible deformities, splinting is indicated to prevent PIP joint hyperextension.
ii. If splinting fails, FDS tenodesis or a Fowler central slip tenotomy should be considered to prevent hyperextension. When intrinsic tightness is present, the intrinsics should also be released.
iii. Stiff deformities are treated with dorsal capsular release, lateral band mobilization, collateral ligament release, and extensor tenolysis.
2. Boutonniere deformity
a. Presentation—The deformity consists of PIP joint flexion with hyperextension at the DIP joint and is the result of joint capsule weakening at the PIP joint with attenuation of the extensor mechanism (Figure 6).
[
Table 9. Treatment of Boutonniere Deformity]
b. Treatment (Table 9)
i. Splints are helpful for passively correctable deformities.
ii. Moderate deformities are treated with extensor reconstruction (central slip imbrication, Fowler distal tenotomy).
iii. Stiff contractures are best treated with PIP joint arthrodesis or arthroplasty.
IV. Systemic Lupus Erythematosus
A. Overview
1. Hand and wrist involvement is present in 90% of patients with systemic lupus erythematosus (SLE).
2. The clinical deformity is typically more severe than is demonstrated on radiographs.
B. Symptoms
1. Ligamentous laxity, synovitis, and Raynaud phenomenon are common.
2. Dorsal subluxation of the ulna at the DRUJ is common.
C. Treatment
1. Treatment is primarily medical. Splinting is often unsuccessful.
2. The wrist is addressed with distal ulnar arthroplasty/resection or partial/total arthrodesis.
3. Soft-tissue procedures at the MCP joint have high failure rates. Deformities are best addressed with arthroplasty or arthrodesis.
4. Arthrodesis is the treatment of choice for PIP or DIP joint deformities.
V. Psoriatic Arthritis
A. Overview
1. A patchy, scaly, red skin rash precedes joint involvement in most patients.
2. RA and antinuclear antibody (ANA) tests are usually negative.
3. Nail pitting and sausage digits are a common presentation.
4. Pencil-in-cup destruction of the joint is seen on radiographs.
B. Treatment
1. Medical treatment usually yields good results.
2. Surgical treatment is indicated for advanced joint destruction and typically involves arthrodesis or resection arthroplasty.
VI. Gout
A. Diagnosis—Typically made under polarized microscopy. Joint aspirate demonstrates needle-like, negatively birefringent monosodium crystals.
B. Symptoms—Peripheral joints are affected first.
[
Table 10. Treatment of Gout]
C. Treatment (Table 10)
1. Acute attacks are treated with colchicine or indomethacin.
2. Chronic cases are treated with allopurinol.
3. Surgical treatment is reserved for excision of large gouty tophi or synovectomy for recalcitrant tenosynovitis.
4. Severely involved joints are treated with arthrodesis.
VII. Calcium Pyrophosphate Deposition Disease (Pseudogout)
A. Diagnosis
1. Typically made under polarized microscopy
2. Joint aspirate demonstrates rod-shaped, weakly birefringent pyrophosphate crystals.
3. Radiographs show calcification in the knee meniscus or TFCC.
B. Symptoms—Crystals are deposited in the cartilage and symptoms can mimic infection.
C. Treatment
1. Usually nonoperative, with NSAIDs and splints
2. Intra-articular steroid injections can be helpful.
Top Testing Facts
Osteoarthritis
1. DIP joint: Heberden nodes; PIP joint: Bouchard nodes
2. Pulmonary hypertrophic osteoarthropathy is seen in bronchogenic carcinoma, small cell lung cancer.
3. Surgical treatment of CMC arthritis of the thumb is based on the severity of the symptoms independent of radiographic findings.
Posttraumatic Arthritis
1. SLAC wrist: The styloscaphoid, radioscaphoid, and capitolunate joints are affected by SLAC wrist arthritic changes.
2. SNAC wrist: The proximal scaphoid articular surface is affected, with the radius spared.
3. The load sharing across the wrist varies with ulnar variance: neutral = 80% radius, 20% ulna; +1 mm = 30% ulna; +2 mm = 40% ulna; -1 mm = 10% ulna; -2 mm = 5% ulna.
4. Severity of radiocarpal arthrosis following distal radius fracture is not correlated with the presence of symptoms.
Inflammatory Arthritides
1. Rheumatoid factor is seen only in patients who are 8 years of age or older at presentation; patients with JRA should be referred to an ophthalmologist because uveitis may develop.
2. Swan-neck deformity is associated with volar plate and collateral ligament laxity. If splinting of a flexible deformity fails, then FDS tenodesis and a Fowler central slip tenotomy should be considered.
3. Stiff swan-neck deformities are treated with dorsal capsular release, lateral band mobilization, collateral ligament release, and extensor tenolysis.
4. A boutonniere deformity consists of PIP joint flexion with hyperextension at the DIP joint. Stiff contractures are treated with PIP arthrodesis or arthroplasty.
5. In SLE, the clinical deformity is typically more severe than is seen on radiographs; soft-tissue procedures are destined to fail.
6. Acute attacks of gout are treated with colchicine or indomethacin; chronic cases are treated with allopurinol.
7. Tenosynovectomy is indicated for refractory cases of extensor tenosynovitis following 6 months of medical treatment and splinting; the EDQ and EDC tendons to the ring and little fingers are the most likely to rupture.
8. In psoriatic arthritis, RA and ANA serology is negative.
Bibliography
Boyer MI, Gelberman RH: Operative correction of swan-neck and boutonniere deformities in the rheumatoid hand. J Am Acad Orthop Surg 1999;7:92-100.
Catalano LW, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J: Displaced intra-articular fractures of the distal aspect of the radius: Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am 1997;79:1290-1302.
Day CS, Gelberman R, Patel AA, Vogt MT, Ditsios K, Boyer MI: Basal joint osteoarthritis of the thumb: A prospective trial of steroid injection and splinting. J Hand Surg Am 2004; 29:247-251.
Knirk JL, Jupiter J: Intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1986;68:647-659.
Papp SR, Athwal GS, Pichora DR, et al: The rheumatoid wrist. J Am Acad Orthop Surg 2006;14:65-77.
Watson HK, Weinzweig J, Zeppieri J: The natural progression of scaphoid instability. Hand Clin 1997;13:39-49.