Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Phalangeal Joint Arthritis
Phalangeal Joint Arthritis
Tung B. Le MD
Dawn M. LaPorte MD
BasicsDescription
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Phalangeal joint arthritis is a
degenerative “wear and tear” process involving articular tissues that
leads to the destruction of cartilage, local bone loss, and the
formation of osteophytes. -
Most commonly affected joints are:
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DIP joints of the fingers
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PIP joints of the fingers
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CMC joint of the thumb
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Classification:
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Primary: No preexisting joint problem
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Secondary: History of trauma or other joint conditions:
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Infection
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Hemophilia
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Epidemiology
Incidence
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This condition occurs in 37.4% of people 18–79 years old (1).
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It is estimated that, after the age of 65
years, 99% of females and 78% of males will have radiographic evidence
of arthritis in the hand (2).
Prevalence
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Osteoarthritis of the hand increases in prevalence with advancing age (2), and the average age of onset is 58 years (1).
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Males are affected more commonly than females until menopause (2).
Risk Factors
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Increasing age
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Trauma
Genetics
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A single gene mutation is implicated in the development of osteoarthritis.
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For example, primary generalized
osteoarthritis, a disease commonly affecting middle-aged females and
characterized by nodular arthritis involving the DIP joint of the hand
and occasionally the knees and other joints, is thought to be the
result of a single gene mutation that substitutes cysteine for arginine
in position 519 of the type II procollagen gene (3).
Etiology
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Genetic changes in cartilage
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Mechanical changes in cartilage
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Chemical changes in cartilage
Associated Conditions
Arthritis of the hip and knee
DiagnosisSigns and Symptoms
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Rapid onset of pain in the digital joints with no specific history of trauma
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Progressive deformity of the DIP and PIP joints of the hand
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Rare involvement of the MCP joints
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Most common complaints are pain and morning stiffness
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Finger deformity in osteoarthritis in a lateral deviation pattern shown during physical examination and on radiography
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Decrease in ROM and stiffness from joint space incongruity and osteophytes that block flexion and extension
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Eventual periarticular soft-tissue contracture, further limiting joint motion
Physical Exam
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Reduced ROM
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Ankylosis
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Osteophytes
Tests
Lab
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When appropriate:
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Rheumatoid factor
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HLA-B27
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Antinuclear antibody
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ESR
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Imaging
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Plain film radiographs show the following:
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Narrowing of joint spaces
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Subchondral sclerosis
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Osteophyte formation
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Cyst formation
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Pathological Findings
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Early disease:
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Increased water content in the cartilage
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Increased proteoglycan level
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Progressive disease:
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Decrease in both cartilaginous water and proteoglycan levels
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Increased friction with motion
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Decreased shock-absorbing capability of cartilage
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Eventual progressive cartilage fissuring and destruction
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End-stage disease:
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Abnormal joint loading
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Subchondral microfractures
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Cyst formation
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Differential Diagnosis
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Gout
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Inflammatory arthropathies
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Pseudogout
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Rheumatoid arthritis
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Septic arthritis
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Trauma
P.325
TreatmentGeneral Measures
Splinting of the involved joints with well-padded splints to decrease pain and swelling
Activity
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Rest
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Avoidance of aggravating activity
Special Therapy
Physical Therapy
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Active isometric and passive ROM exercises to maintain motion
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Ultrasound and diathermy therapy to decrease the inflammation
Medication
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Analgesics (acetaminophen, aspirin)
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NSAIDs
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Local steroid injections
Surgery
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PIP joints: Arthrodesis or arthroplasty
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DIP joints: Arthrodesis
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Thumb CMC joint: Arthroplasty with tendon interposition
Follow-upPrognosis
Excellent pain control and restoration of function may
be achieved in most patients with analgesics, splinting, exercise, or
surgical management, or a combination thereof.
be achieved in most patients with analgesics, splinting, exercise, or
surgical management, or a combination thereof.
Complications
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Articular deformity
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Infection
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Malunion in attempted joint fusion
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Nonunion in attempted joint fusion
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Prosthetic dislocation or fracture
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Wear of prosthesis
Patient Monitoring
Patients are checked at 6–12-month intervals.
References
1. Swanson AB, Swanson GD. Osteoarthritis in the hand. J Hand Surg 1983;8A:669–675.
2. Naidu
S, Temple JD. Arthritis. In: Beredjiklian PK, Bozentka DJ, eds. Review
of Hand Surgery. Philadelphia: WB Saunders, 2004:171–187.
S, Temple JD. Arthritis. In: Beredjiklian PK, Bozentka DJ, eds. Review
of Hand Surgery. Philadelphia: WB Saunders, 2004:171–187.
3. Mankin
HJ, Mow VC, Buckwalter JA, et al. Articular cartilage structure,
composition, and function. In: Buckwalter JA, Einhorn TA, Simon SR,
eds. Orthopaedic Basic Science. Biology and Biomechanics of the
Musculoskeletal System, 2nd ed. Rosemont, IL: American Academy of
Orthopaedic Surgeons, 2000:443–470.
HJ, Mow VC, Buckwalter JA, et al. Articular cartilage structure,
composition, and function. In: Buckwalter JA, Einhorn TA, Simon SR,
eds. Orthopaedic Basic Science. Biology and Biomechanics of the
Musculoskeletal System, 2nd ed. Rosemont, IL: American Academy of
Orthopaedic Surgeons, 2000:443–470.
Additional Reading
Shin AY, Amadio PC. Stiff finger joints. In: Green DP, Hotchkiss RN, Pederson WC, et al., eds. Green’s Operative Hand Surgery, 5th ed. Philadelphia: Elsevier Churchill Livingstone, 2005;417–459.
MiscellaneousCodes
ICD9-CM
716.94 Arthritis of hand/fingers
Patient Teaching
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Reassure patients about the relatively benign natural course of the disease.
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Treatments often are effective in relieving pain and in preventing progressive deformity.
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Control additional articular damage by minimizing joint loading.
FAQ
Q: How is phalangeal joint arthritis diagnosed?
A:
Patients typically present with complaints of pain and bony prominence
or deformity at the affected joints. The diagnosis is made with
radiographs showing joint space narrowing and possibly osteophyte
formation.
Patients typically present with complaints of pain and bony prominence
or deformity at the affected joints. The diagnosis is made with
radiographs showing joint space narrowing and possibly osteophyte
formation.
Q: How is phalangeal arthritis treated?
A:
The 1st line of treatment is anti-inflammatory medication unless
contraindicated secondary to medical comorbidity. Therapy with
modalities may be a helpful adjunct as well as activity modification.
Splint immobilization may be helpful for an isolated digit or joint.
Persistent symptoms at the PIP joints can be treated with
corticosteroid injection. Recurrent or persistent symptoms may be
addressed surgically with fusion at the DIP joints and arthroplasty
versus fusion at the PIP joints.
The 1st line of treatment is anti-inflammatory medication unless
contraindicated secondary to medical comorbidity. Therapy with
modalities may be a helpful adjunct as well as activity modification.
Splint immobilization may be helpful for an isolated digit or joint.
Persistent symptoms at the PIP joints can be treated with
corticosteroid injection. Recurrent or persistent symptoms may be
addressed surgically with fusion at the DIP joints and arthroplasty
versus fusion at the PIP joints.