Abstract
Overview of osteoarthritis (OA) of the hand presenting definition, symptoms, physical examination, diagnostic studies, and treatment.
Keywords
Arthritis, degenerative arthritis, degenerative joint disease, joint destruction, osteoarthritis
| Synonyms | |
| |
| ICD-10 Codes | |
| M19.041 | Primary osteoarthritis, right hand |
| M19.042 | Primary osteoarthritis, left hand |
| M19.049 | Primary osteoarthritis, unspecified hand |
| M19.241 | Secondary osteoarthritis, right hand |
| M19.242 | Secondary osteoarthritis, left hand |
| M19.279 | Secondary osteoarthritis, unspecified hand |
| M12.541 | Traumatic arthropathy, right hand |
| M12.542 | Traumatic arthropathy, left hand |
| M12.549 | Traumatic arthropathy, unspecified hand |
Definition
Osteoarthritis (OA) of the hand is a degenerative condition of hyaline cartilage in diarthrodial joints. OA is the most common form of arthritis and is associated with aging. Genetic predisposition can determine the time of onset and severity. Other causes of arthritis such as inflammatory arthritis as in rheumatoid arthritis, crystal deposition as in gout, or infectious arthritis have pathophysiologies and treatments distinct from OA.
Presentation of arthritis in the hands can often be the first sign of OA in a patient. The early onset of OA in the hands does not indicate that a person will experience early OA of the hips or knees. When and where OA manifests is genetically mediated. Radiographic evidence of OA in the hands has a very high prevalence. Estimates of OA in the hands range from 78% in men and 99% in women over the age of 65. The base of the thumb and the distal and proximal interphalangeal (PIP) joints of the fingers are most affected.
A subset of patients may have a more aggressive course of OA than the usual insidious form. Debate continues over whether noninflammatory OA (nodal) and inflammatory OA (erosive interphalangeal) are on the spectrum of the same disease process, or are separate diseases.
Symptoms
Patients may experience pain, stiffness, limitations in function, and reduced grip strength. Although the disease process is usually insidious and gradual, symptoms may have acute onset. Symptomatic waxing and waning is common. The correlation between radiographic findings and pain intensity and magnitude of disability is limited, most likely as a reflection of the psychosocial factors that mediate the difference between disease and illness and between impairment and disability. Psychological distress and ineffective coping strategies should be identified and addressed.
Physical Examination
A hallmark of OA is development of nodes at the involved joints combined with ligamentous laxity resulting in joint malalignment. Bilateral involvement of multiple joints at the distal interphalangeal (DIP) joints and PIP joints is common. First carpometacarpal (CMC) joint squaring may be apparent. Deformity, effusions, erythema, limitation in range of motion, and swelling are characteristic. Concomitant soft tissue conditions such as de Quervain tenosynovitis and Dupuytren contractures can be associated with hand OA. These conditions can mimic or aggravate symptoms. The neurologic exam will be normal.
Interphalangeal Joints
OA of the DIP joint is characterized by enlargement of the distal joint by osteophytes, known as Heberden nodes ( Fig. 33.1 ). The second and third DIP joints of the dominant hand are usually more severely affected. Angulatory and rotatory deformities of the terminal phalanx can develop ( Fig. 33.2 ). Ganglion (or mucous) cysts are associated with OA of the distal (and less commonly the proximal) interphalangeal joints. The pressure of these cysts on the germinal matrix can cause a groove in the fingernail. The PIP joint is less commonly involved than the distal joint. The enlargement and deformity at the PIP joint is referred to as a Bouchard node.
Metacarpophalangeal Joints
Involvement of the metacarpophalangeal joints in primary idiopathic OA is relatively uncommon. The presentation at this joint is usually characterized by complaints of pain and stiffness rather than deformity.
Trapeziometacarpal Joint
Arthritis of the trapeziometacarpal joint is common. Among women aged 80 years and older, 94% have radiographic signs of arthritis; two thirds of these have severe joint destruction. Men develop arthritis more slowly than women do, but by the age of 80 years, 85% have arthritis. The process progresses from subluxation and slight narrowing of the joint to osteophyte formation, deformity, and destruction of the joint. As the disease progresses, the base of the metacarpal subluxes radially. With adduction contracture of the metacarpal toward the palm, laxity and hyperextension of the metacarpophalangeal joint develop in compensation. Axial compression and rotation and shear (the compression test) will produce crepitation and reproduce symptoms. Both active and passive movement is restricted. Grip and pinch strength gradually diminish. Screening for carpal tunnel syndrome and trigger thumb, both of which are common in this age group, is useful.
Functional Limitations
The classic forms of reported disability are activities that require a forceful grasp, such as opening a tight jar, turning a key, or opening a doorknob. Whereas fine motor tasks are often impaired by interphalangeal OA, complaints of disability are far less common; perhaps because the disease is so gradual, most patients adapt.
Diagnostic Studies
Due to their low cost and high reliability, conventional radiographs are the preferred method for evaluating hand OA. Radiographs can reveal joint space narrowing, subchondral sclerosis, osteophyte formation, erosions, and cysts. One of several scoring methods for hand OA evaluation involves classifying trapeziometacarpal arthritis into four stages. In stage I, the articular contours are normal with no subluxation or joint debris. The joint space may be widened if an effusion is present. In stage II, the thumb trapeziometacarpal joint may narrow slightly, but the joint space and articular contours are preserved. Joint debris less than 2 mm may be present. In stage III, trapeziometacarpal joint destruction is significant, with joint space narrowing, sclerosis, and cystic changes, and osteophytes larger than 2 mm on subchondral bone. Stage IV is characterized by pantrapezial arthritis, in which both the trapeziometacarpal and scaphoid trapezial joints are affected.
The pain, stiffness, and disability of hand OA are weakly to moderately associated radiographic findings. Ultrasound (US) has been found to be useful is assessing osteophyte formation with good interobserver reliability. Assessing cartilage pathology with US has shown poor interobserver reliability. MRI gives reliable assessment of inflammatory and structural features in hand OA; however, the high cost of MRI makes its routine use in treatment and management of this common condition prohibitive.
Post-traumatic arthritis
Inflammatory arthritis (e.g., Lyme disease, gout, rheumatoid arthritis, psoriatic arthritis)
Calcium pyrophosphate deposition disease
Septic arthritis
Systemic lupus erythematosus
Scleroderma
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