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Arthritis of the Fingers

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

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Arthritis of the Fingers

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  1. Arthritis of the Fingers

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

  3. 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

  4. Distal Interphalangeal (DIP) Joint Osteoarthritis

  5. 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

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

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

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

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

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

  11. 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

  12. 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

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

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

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

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

  17. Proximal Interphalangeal (PIP) Joint Osteoarthritis

  18. 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

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

  20. 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

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

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

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

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

  25. 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

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

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

  28. Thumb Carpometacarpal (CMC)Joint Arthritis

  29. 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

  30. 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

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

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

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

  34. 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

  35. 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

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

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

  38. 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)

  39. 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

  40. 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

  41. Rheumatoid Arthritis • Most commonly affected joints • 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

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

  49. 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

  50. Rheumatoid Arthritis • 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

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