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Injuries of your hand
Arthritis of your hand
Arthritis: Osteoarthritis
What is arthritis?
Arthritis literally means “inflamed joint.” Normally a joint consists of two smooth, cartilage-covered bone surfaces that fit together as a matched set and that move smoothly against one other. Arthritis results when these smooth surfaces become irregular and don’t fit together well anymore and essentially “wear out.” Arthritis can affect any joint in the body, but it is most noticeable when it affects the hands and fingers. Each hand has 19 bones, plus 8 small bones and the two forearm bones that form the wrist. Arthritis of the hand can be both painful and disabling. The most common forms of arthritis in the hand are osteoarthritis, post-traumatic arthritis (after an injury), and rheumatoid arthritis. Other causes of arthritis of the hand are infection, gout, and psoriasis. Osteoarthritis is a degenerative joint disease in which the cushioning cartilage that covers the bone surfaces at the joints begins to wear out. It may be caused by simple “wear and tear” on joints, or it may develop after an injury to a joint. In the hand, osteoarthritis most often develops in three site:
at the base of the thumb, where the thumb and wrist come together (the trapezio-metacarpal, or basilar, joint)
at the end joint closest to the finger tip (the distal interphalangeal or DIP joint)
at the middle joint of a finger (the proximal interphalangeal or PIP joint)
It also often develops in the wrist.
Signs and symptoms of arthritis of the hand:
Stiffness, swelling, and pain are symptoms common to all forms of arthritis in the hand. With osteoarthritis, bony nodules may develop at the middle, or PIP, joint of the finger (Bouchard’s nodes), and at the end-joints, or DIP, of the finger (Heberden’s nodes). A deep, aching pain at the base of the thumb is typical of osteoarthritis of the basilar joint. Swelling and a bump at the base of the thumb where it joins the wrist may also be observed. Grip and pinch strength may be diminished, causing difficulty with activities such as opening jars or turning keys. Pain, swelling, stiffness, and diminished strength are also seen with osteoarthritis of the wrist.
How is osteoarthritis diagnosed?
We will examine you and determine whether you have similar symptoms in other joints and assess the impact of the arthritis on your life and activities. The clinical appearance of the hands and fingers helps to diagnose the type of arthritis. X-rays will also show certain characteristics of osteoarthritis, such as narrowing of the joint space, the formation of bony outgrowths (osteophytes or “nodes”), and the development of dense, hard areas of bone along the joint margins.
Treatment for osteoarthritis of the hand:
Treatment is designed to relieve pain and restore function. Anti-inflammatory or other analgesic medication may be of benefit in relieving pain. Brief periods of rest may help if the arthritis has flared up. You may also be advised to wear finger or wrist splints at night and for selected activities. Often soft sleeves may be of some benefit when the rigid splints are too restrictive, especially when the arthritis is affecting the joint at the base of your thumb. Heat modalities in the form of warm wax or paraffin baths might help, and when severe swelling is present, cold modalities may be of help. It is important to maintain motion in the fingers and use the hand as productively as possible. Hand therapy is often helpful with these exercises, splints, and modalities. A cortisone injection can often provide relief of symptoms, but does not cure the arthritis. Surgery is usually not advised unless these more conservative treatments fail.
Surgery is indicated when the patient either has too much pain or too little function. In most cases, the patient knows best and actually tells the doctor when it is time for surgery. The goal is to restore as much function as possible and to eliminate the pain or reduce it to a tolerable level. One type of surgery is joint fusion, in which the arthritic surface is removed and the bones on each side of the joint are fused together, eliminating motion from the problem joint. Joint fusion may be used to relieve pain and correct deformities that interfere with functioning. Another approach is joint reconstruction, in which the degenerated joint surface is removed in order to eliminate the rough, irregular bone-to-bone contact that causes pain and restricts motion. Once the degenerated portion of the joint surface is removed, it may be replaced with rolled-up soft tissue, such as a tendon, or with a joint replacement implant. Which type of surgery is used depends on the particular joint(s) involved, your activities, and your own needs. We can help you decide which type of surgery is the most appropriate for you.
© American Society for Surgery of the Hand.
Arthritis: Base of the Thumb
What is it?
In a normal joint, cartilage covers the end of the bones and serves as a shock absorber to allow smooth, pain-free movement. In osteoarthritis (OA, or “degenerative arthritis”) the cartilage layer wears out, resulting in direct contact between the bones and producing pain and deformity. One of the most common joints to develop OA in the hand is the base of the thumb. The thumb basal joint, also called the carpometacarpal (CMC) joint, is a specialized saddle-shaped joint that is formed by a small bone of the wrist (trapezium) and the first bone of the thumb (metacarpal). The saddle shaped joint allows the thumb to have a wide range of motions, including up, down, across the palm, and the ability to pinch.
Who gets it?
OA at the base of the thumb is more commonly seen in women over the age of 40. The exact cause is unknown, but genetics, previous injuries such as fractures or dislocations, and generalized joint laxity may predispose to-wards development of this type of arthritis.
What are the symptoms and signs?
The most common symptom is pain at the base of the thumb. The pain can be aggravated by activities that require pinching, such as opening jars, turning door knobs or keys, and writing. Severity can also progress to pain at rest and pain at night. In more severe cases, progressive destruction and mal-alignment of the joint occurs, and a bump develops at the base of the thumb as the metacarpal moves out of the saddle joint. This shift in the joint can cause limited motion and weakness, making pinch difficult. The next joint above the CMC may compensate by loosening, causing it to bend further back (hyperextension).
How is the diagnosis made?
The diagnosis is made by history and physical evaluation. Pressure and movement such as twisting will produce pain at the joint. A grinding sensation may also be present at the joint. X-rays are used to confirm the diagnosis, although symptom severity often does not correlate with x-ray findings.
What are the treatment options?
Less severe thumb arthritis will usually respond to non-surgical care. Arthritis medication, splinting and limited cortisone injections may help alleviate pain. A hand therapist might provide a variety of rigid and non-rigid splints which can be used while sleeping or during activities.
Patients with advanced disease or who fail non-surgical treatment may be candidates for surgical reconstruction. A variety of surgical techniques are available that can successfully reduce or eliminate pain. Surgical procedures include removal of arthritic bone and joint reconstruction (arthroplasty), joint fusion, bone realignment, and even arthroscopy in select cases. A consultation with us can help decide the best option for you.
© American Society for Surgery of the Hand.
Rheumatoid Arthritis of the hand:
What is Rheumatoid Arthritis of the hand?
Rheumatoid arthritis affects the cells that lubricate and line joints. This tissue – synovium- becomes inflamed and swollen. The swollen tissues stretch supporting structures of the joints such as ligaments and tendons. As the support structures stretch out, the joints become deformed and unstable. The joint cartilage and bone erode. Often the joints feel hot and look red. Rheumatoid arthritis of the hand is most common in the wrist and knuckles. The disease is symmetric, thus what occurs in one hand usually occurs in the other.
Signs and symptoms of rheumatoid arthritis of the hand:
While stiffness, swelling, and pain are symptoms common to all forms of arthritis, there are some symptoms that are classic features of rheumatoid arthritis. They are:
• Firm nodules along fingers or the elbow
• Soft lump on the back of the hand that moves as the fingers straighten
• Angulation or collapse of fingers
• Sudden inability to straighten or bend a finger because of a tendon rupture
• Deformity in which the middle finger joint becomes bent ( Boutonniere deformity)
• Deformity where the end of the finger is bent and the middle joint over extends ( Swan-neck deformity-)
• Prominent bones in the wrist
In addition, patients with rheumatoid arthritis often have problems with numbness and tingling in their hand (carpal tunnel syndrome) because the swelling of the tendons causes pressure on the adjacent nerve. They may make a squeaky sound as they move joints (crepitus) and sometimes the joints snap or lock because of the swelling.
How is rheumatoid arthritis diagnosed:
The diagnosis of rheumatoid arthritis is made based on clinical examination, x-rays, and lab tests. Rheumatoid arthritis may have a hereditary component, thus we will ask whether other family members have had rheumatoid arthritis or symptoms similar to yours. We will do a detailed examination of your hands. The clinical appearance helps to diagnose the specific type of arthritis. X-rays are often helpful; certain findings are characteristic for rheumatoid arthritis. These findings include swelling of non-bony structures, joint space narrowing, decreased bone density, and erosions near joints. There are several blood tests that are often ordered to confirm the clinical diagnosis. These are the rheumatoid factor, sedimentation rate and sometimes the anti-CCP (cyclic citrullinated peptide). MRI- a special imaging study - has also been used to help confirm the diagnosis.
Treatment of Rheumatoid:
Arthritis Treatment for rheumatoid arthritis aims to decrease inflammation, relieve pain and maintain function. While there is no cure for rheumatoid arthritis, medications are available that slow the progression of the disease. Optimal care involves a team approach among the patient, physicians, and therapists. The care of the rheumatoid patient requires not only a hand surgeon but also a hand therapist, rheumatologist, and the patient’s primary care physician. The rheumatologist is often the physician that monitors and decides the specific type of medicine that is felt to be the most effective for the patient’s stage in the disease process.
The hand therapist will provide instruction on how to use your hands in ways that help relieve pain and protect joints. Therapists also can provide exercises, splints, and adaptive devices to help you cope with activities of daily living. Rheumatoid arthritis can be a progressive disease. Surgical interventions need to be appropriately timed in order to maximize function and minimize deformity. In certain cases, preventive surgery may be recommended. Preventative surgery may include removing nodules, decreasing pressure on joints and tendons by removing inflamed tissue, or removing bone spurs that may rub on tendons or ligaments. If a tendon ruptures, a hand surgeon may be able to repair the tendon with a tendon transfer or graft. There are several types of procedures to treat joints affected by rheumatoid arthritis, including removal of inflamed joint lining, joint replacements, and joint fusions. The specific procedure(s) chosen depends on many factors. These factors include the particular joints involved, the degree of damage present, and the condition of surrounding joints. One of the most important factors in deciding the most appropriate surgical procedure is the needs of the patient. There are often many ways to treat hand deformities in rheumatoid arthritis.
© American Society for Surgery of the Hand.
Gout and Pseudogout
- Gout and pseudogout
- Calcium Pyrophosphate Deposition Disease (CPPD)
are two types of crystalline arthropathies which are disease processes that cause sore joints because salt crystals have formed in the joint. The crystals irritate the joints and sometimes surrounding tendons, causing the body to release chemicals that make the joints swollen and red. In gout, the salt produced is monosodium urate, while in pseudogout it is calcium pyrophosphate.
Both gout and pseudogout (CPPD) can affect joints outside the hand. In gout, the first joint affected is often the big toe. In pseudogout, the joints involved tend to be large joints such as the knee or wrist. Attacks can recur.
In gout, crystals develop when patients over-produce or under-excrete uric acid. Certain medications can cause rapid changes in uric acid level. These include certain blood pressure medications, diuretics, intravenous blood thinners, and a medication used for transplant patients called cyclosporin. Alcohol also increases uric acid production. Hypothyroidism, heart disease, and kidney disease have also been shown to be associated with gout. Attacks of gout have been noted after injury, surgery, infection, and the use of contrast materials for x-rays.
Calcium pyrophospate disease (CPPD)
has been noted in patients who have multiple injuries to a joint, though many patients will not have any injury prior to an attack. Unlike gout, CPPD is not associated with alcohol or dietary habits and is not induced by medications. It can occur with certain diseases like pneumonia, heart attacks, and strokes and may occur after an unrelated surgery. CPPD has been found in patients with problems with their thyroid or parathyroid and patients with iron overload (hemochromatosis).
Gout/CPPD in the hand, wrist and elbow:
The elbow, wrist, and small finger joints (DIP joints) are common sites for gout. CPPD is more common in the wrist.
Signs and Symptoms:
Both gout and pseudogout tend to present with the sudden onset of a hot, red, swollen joint. The joints are so tender that patients are reluctant to move them. Often, the affected joints appear infected.
Gout may cause crystals to form white nodules called “tophi” that are often visible under the skin. If the skin is too swollen and stretched out, a white chalky substance may ooze from the joint.
The crystals in pseudogout are usually only visible on x-ray.
How is the diagnosis made?
The diagnosis for either disease is made based on clinical examination, x-rays, and lab tests. You will be asked questions about your symptoms and how the disease has affected your activities. Because medications and other diseases can cause gout and CPPD, you will be asked to provide a detailed medical history and an accurate medication list. A detailed examination of your hands is important as the clinical appearance helps to clarify the type of arthritis. X-rays are also helpful. Calcifications within the wrist in the region of a ligament called the triangular fibrocartilage complex (TFCC) are classic for CPPD. Uric acid does not show up on X-rays, but bone erosions at the end joint (DIP joint) are characteristic of gout. Over time, both disorders can show more advanced arthritic changes.
When possible, the best means to clarify the diagnosis is to obtain fluid from the joint. The fluid can be sent to the laboratory to see if it contains uric acid or calcium pyrophosphate crystals. A special microscope is needed to determine which type of crystal is present in the joint fluid.
Blood tests may be ordered to check for infection as well as the uric acid level. However, uric acid levels in the blood are often normal despite an attack of gout. There is no blood test for CPPD.
How are gout and pseudogout treated?
The goal of treatment for gout and CPPD is to decrease inflammation and relieve pain. Acute attacks are often treated with non-steroidal anti-inflammatory (NSAID) medication if the patient does not have other medical problems that preclude their use. Indomethacin is especially effective. When NSAID’s are contraindicated or not effective, colchicine is often helpful. Oral or injected steroids may sometimes be used, too.
Attacks of gout and pseudogout can recur. When the episodes are infrequent, an NSAID or colchicine can be used as needed for flare-ups. If the epi-sodes occur more frequently, other types of medications are often indicated. The specific type of medication is best decided by your primary care physician and/or a rheumatologist. Patients with gout may need agents that decrease the production of uric acid, such as allopurinol.
Gout and CPPD are often effectively treated non-operatively. In addition to medications, splints or compressive wraps may be helpful to decrease swelling and lessen pain.
If the disease has eroded the joints or if tendons have been compromised, surgery may be indicated to remove the crystals and stabilize the joint.
What happens if you do not receive treatment?
The acute attacks are so painful that most people seek treatment to relieve pain. Untreated gout can be very damaging to joints and tendons. The crystals can erode the joint to the point that it becomes unstable. Also, salt deposits on tendons just beneath the skin can cause the skin to break down and the tendons to rupture.
This can lead to serious infections in addition to loss of motion.
CPPD crystals are less likely to be deposited beneath the skin, so infection is less likely. The chronic deposition of the crystal in ligaments and cartilage may lead to joint destruction. Loss of motion is common, but joint instability, as found in gout, is less frequent.
© American Society for Surgery of the Hand
Psoriatic Arthritis
What is Psoriatic Arthritis?
Psoriasis is a skin disease in which patients have dry, red and scaly skin rashes that can occur on any part of the body. Between 5-20% of patients with psoriasis may develop an associated arthritis. Arthritis means inflamed joint. A normal joint consists of two cartilage-covered bone surfaces that glide smoothly against one another. In psoriatic arthritis, the lining of the joint—the synovium—becomes inflamed and swollen. The swollen tissues stretch supporting structures of the joints, such as ligaments and tendons. As these supporting structures stretch out, the joints become deformed and unstable. The gliding surface wears out, and joint cartilage and bone erode. In addition to the hands, psoriatic arthritis can affect joints in the spine, feet, and jaw.
How does psoriatic arthritis affect the hand?
The process of joint changes in psoriatic arthritis is very similar to the process seen in rheumatoid arthritis. The joints look red and swollen. Sometimes they feel warm. Patients have decreased motion and stiffness. While psoriatic arthritis can look very similar to rheumatoid arthritis, there are differences between the two diseases.
Psoriatic arthritis tends to:
affect men and women equally.
affect joints asymmetrically (What occurs in one hand may not occur in the other).
result in red, dry, scaly skin lesions rather than distinct nodules.
swelling in the middle (PIP) joints and deformities of the end (DIP) joint of the fingers first, rather than the large finger joint (MCP joint), wrist, or over tendons.
Signs and symptoms of psoriatic arthritis of the hand:
Stiffness, swelling, and pain are symptoms common to all forms of arthritis, and sometimes it can be difficult to determine which type of arthritis you have. Findings classic for psoriatic arthritis include:
- diffusely swollen finger—sausage digit—especially the middle joint in the finger (PIP joint).
- pitting, ridging, or crumbly appearance of nails.
- deformity at the end joint (DIP) of the finger.
- dry, red, scaly skin patches which can occur anywhere, including the earlobe and hairline.
How is psoriatic arthritis diagnosed?
The diagnosis of psoriatic arthritis is made based on clinical examination, x-rays and lab tests. You will be asked questions about your symptoms and how the disease has affected your activities. Psoriasis and psoriatic arthritis can run in families, thus we will ask if family members have psoriatic arthritis or have symptoms similar to yours. A detailed examination of your hands is important because the clinical appearance helps to clarify the type of arthritis. X-rays are also helpful. Psoriatic arthritis patients often have osteolysis—loss of bone—on their x-rays. The pencil-in-cup deformity at the DIP joint is classic for psoriatic arthritis. Other x-ray findings seen in psoriatic arthritis include swelling of non-bony structures, joint space narrowing, joint erosions and/or spontaneous joint fusions.These findings can occur with erosive osteoarthritis and rheumatoid arthritis as well.
There is no lab test specifically for psoriatic arthritis. Patients thought to have psoriatic arthritis often will have labs drawn to make sure they do not have rheumatoid arthritis or gout. Patients with psoriatic arthritis will often have an elevated inflammatory marker known as the sedimentation rate (ESR) but a negative rheumatoid factor (RF). Psoriasis is part of a larger group of inflammatory arthritis called spondyloarthropathies. On occasion, other lab tests may be requested to further characterize your arthritis. Sometimes a skin biopsy may be performed in a patient with hand symptoms and a skin lesion suspicious for psoriasis, without a known history of the disease.
Treatment of Psoriatic Arthritis:
Treatment for psoriatic arthritis aims to decrease inflammation, relieve pain, and maintain function. While there is no cure for psoriatic arthritis, medications are available to lessen symptoms and improve function. Optimal care involves a team approach among the patient, physicians, and therapists. The care of the psoriatic patient requires not only a hand surgeon but also a hand therapist, rheumatologist, and the patient’s primary care physician. The rheumatologist is often the physician that monitors and decides the specific type of medicine that is felt to be the most effective at that stage in the patient’s disease process.
The hand therapist will provide instruction on how to use your hands in ways to help relieve pain and protect joints. They may provide exercises, splints, wraps, and adaptive devices to help you cope with activities of daily living.
Psoriatic arthritis can be a progressive disease. Surgical interventions need to be appropriately timed in order to maximize function and lessen pain. Patients with psoriatic skin lesions are at increased risk for a surgical infection, so good control of the skin lesions is an important consideration when scheduling surgery.
There are many types of procedures to treat joints affected by psoriatic arthritis. The procedures range from joint replacements to joint fusions. The specific procedure(s) depends on many factors. These factors include the particular joint(s) involved, the degree of damage present, and the condition of surrounding joints. One of the most important factors in deciding the correct surgical procedure is the needs of the patient. There are often many ways to treat hand deformities in psoriatic arthritis. We can help you decide on the most appropriate treatment for you.
What happens if you have no treatment?
Psoriatic arthritis can manifest itself with different joint findings and symptoms, and these symptoms can change over time. Consequently it has been difficult to identify an individual marker for the disease. Psoriatic skin lesions do not correlate with the severity of joint involvement. Many studies show that appropriately prescribed medication can improve function and decrease pain and swelling. Studies looking at newer agents have shown delays in X-ray changes which are felt to demonstrate a slowing of the disease process. Further work is needed to understand how and to what extent medication alters the disease process.
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