DIP and PIP Joint Arthritis

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http://upload.orthobullets.com/topic/6055/images/hand oa.jpg
http://upload.orthobullets.com/topic/6055/images/dip pip arthritis..jpg
http://upload.orthobullets.com/topic/6055/images/mucous-cyst-with-no-nail-in.jpg
http://upload.orthobullets.com/topic/6055/images/mucous cyst_moved.jpg
Introduction
  • Forms include
    • primary osteoarthritis
      • DIP
        • highest joint forces in hand
        • undergoes more wear and tear
        • associated with Heberden's nodules (caused by osteophytes)  
        • mucous cysts 
          • can lead to draining sinus
          • septic arthritis
          • nail ridging 
        • nail can be involved
          • splitting/ridging
          • deformity
          • loss of gloss
      • PIP
        • Bouchard nodes  
        • joint contractures with fibrosis of ligaments
    • erosive osteoarthritis
      • condition is self limiting, patients are relatively asymptomatic, but can be destructive to joint
      • more common in DIP
      • seen in middle aged women with a 10:1 female to male ratio
Presentation
  • Symptoms of primary osteoarthritis
    • pain
    • deformity
  • Symptoms of erosive osteoarthritis
    • intermittent inflammatory episodes
    • articular cartilage and adjacent bone destroyed
    • synovial changes similar to RA but not systemic
Imaging
  • Radiographs
    • recommended views
      • AP, lateral and oblique of hand
    • findings
      • erosive osteoarthritis will show cartilage destruction, osteophytes, and subchondral erosion (gull wing deformity)
Treatment
  • DIP Arthritis
    • nonoperative
      • observation, NSAIDs
        • indications
          • first line of treatment for mild symptoms
    • operative
      • fusion
        • indications
          • debilitating pain and deformity
        • technique
          • fusion with headless screw has highest fusion rate (nonunion in 10%)
          • 2nd and 3rd digit fused in extension
          • 4th and 5th digit fused in 10-20° flexion
  • Mucous Cyst
    • nonoperative
      • observation
        • indications
          • first line of treatment as 20-60% spontaneously resolve
    • operative
      • mucous cyst excision + osteophyte resection  
        • indications
          • impending rupture
          • may need to do local rotational flap for skin coverage
        • outcome
          • osteophytes MUST be debrided or mucous cyst will recur
  • PIP Arthritis
    • nonoperative
      • observations, NSAIDs
        • indications
          • first line of treatment in mild symptoms
    • operative 
      • collateral ligament excision, volar plate release, osteophyte excision
        • indications
          • predominant contracture with minimal joint involvement
      • fusion 
        • indications
          • border digits (index and small PIP)
          • middle and ring finger OA if there is angulation/rotation deformity, ligamentous instability or poor bone stock
        • technique
          • headless screw fixation has highest fusion rates
          • recreate normal cascade of fingers / PIPJ flexion angles
            • index- 30°, long- 35°, ring- 40°, small- 45°
      • silicone arthroplasty for middle and ring PIPJ
        • radial collateral ligament should be intact to tolerate pinch grip 
        • indications
          • central digits (long and ring finger)
          • good bone stock
          • no angulation or deformity
        • outcomes
          • results are similar for both dorsal and volar approaches
  • Erosive osteoarthritis
    • nonoperative
      • splints, NSAIDs
        • indications
          • tolerable symptoms
    • operative
      • fusion
        • indications
          • intolerable deformity
        • technique
          • position of fusion same as above
 

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Questions (2)

(OBQ10.258) A 38-year-old woman complains of a painful finger mass of 4 months duration. A photograph of the mass is provided in Figure A. The decision is made to proceed with surgical excision. Which of the following is an advantage of surgical excision with joint debridement as opposed to aspiration? Review Topic

QID:3354
FIGURES:
1

Reduced rate of infection of the DIP joint

3%

(48/1757)

2

Less post-procedure pain

0%

(8/1757)

3

Improved DIP range of motion

2%

(28/1757)

4

Decreased risk of mass recurrence

94%

(1654/1757)

5

Reduced risk of metastasis from seeding the mass into the joint

1%

(13/1757)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

Figure A demonstrates a mucous cyst. This benign mass originates from the DIP joint, and is secondary to arthritis. It may be treated with aspiration or surgical excision. However, recurrence occurs frequently with aspiration. Debridement of any osteophytes from the DIP joint is crucial to preventing recurrence with surgical excision. Rizzo et al retrospectively evaluated the results of 154 mucous cysts treated with either aspiration or surgery. Aspiration resulted in a 40% recurrence rate. There were zero recurrences with surgical excision and joint debridement.


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(OBQ07.50) A 54-year-old gentleman presents to your office with a mass on top of the distal phalanx that has enlarged over the last nine months. His main complaint is significant tenderness to palpation over the mass. There is no pain with forcible movement of his fingers. A clinical photo is shown in Figure A. A dedicated radiograph of the distal phalanx is shown in Figure B. What treatment option is most appropriate for the best patient outcome? Review Topic

QID:711
FIGURES:
1

Observe

8%

(251/3142)

2

Needle aspiration

4%

(130/3142)

3

Fusion of distal interphalangeal joint

15%

(457/3142)

4

Removal of bone spur and cyst

71%

(2246/3142)

5

Obtain infectious work-up

1%

(47/3142)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

This is a classic presentation of a mucous cyst. The most appropriate treatment would be excision of the cyst and removal of the underlying bone spur.

A mucous cyst of the hand is usually a small, soft, benign structure. They are associated with osteoarthritis and develop around bone spurs near a joint. Surgery is typically recommended if there is significant pain at the site of the cyst or with range of motion of the involved joint. Nail bed deformity may occur with disease progression if left untreated.

Rizzo et al. examined a series of 132 patients with mucous cysts, comparing outcomes between injection and surgery. They found that 60% of people with aspiration and steroid injection had complete resolution of the cyst compared to 100% with excision.

Figure A shows a small mucous cyst just proximal to the nailbed. Figure B shows a radiograph of the distal interphalangeal joint. There is extensive joint arthritis with dorsal bone spurs.

Incorrect Answers:
Answer A: Pain from a mucous cyst is usually constant, but in some people it may come and go. Rarely the cysts will resolve over time. Typically, the mucous cyst will progress with time and cause nail deformity.
Answer B: Aspiration will lead to a >40% recurrence.
Answer C: Removal of cyst and joint fusion would be indicated if there was pain with with any forcible movement of the joint.
Answer E: Infection is usually not associated with a benign mucous cyst.


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