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Updated: Dec 23 2023

DIP and PIP Joint Arthritis

Images oa.jpg cyst_moved.jpg
  • Summary
    • Arthritis of the DIP and PIP joints are very common forms of osteoarthritis seen in the hand and can be associated with pain and deformity.
    • Diagnosis is made radiographically with joint space narrowing seen in the DIP and PIP joints of the fingers. Mucous cysts are often present on clinical inspection of the DIP joint.
    • Treatment is observation if patient is minimally symptomatic. Operative mucous cyst excision, osteophyte resection, or joint fusion may be indicated depending on severity of symptoms and the stage of disease.
  • Epidemiology
    • Incidence
      • Common
        • DIP arthritis is the most common arthritis of the hand
          • DIP > thumb CMC > PIP > MCP 
  • Etiology
    • 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)
  • Diagnosis
    • Radiographic
      • diagnosis confirmed by history, physical exam, and radiographs
  • 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
          • 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
          • unlike pyrocarbon (unconstrained) implants, linked silicone implants do not depend on soft tissue competence (i.e. collateral ligaments, volar plate) for stability
          • indications
            • central digits (long and ring finger)
            • good bone stock
            • no angulation or deformity
          • outcomes
            • Volar approach has better range of motion and lower revision rate, compared to dorsal approach
            • Consistent improvements in pain but no significant improvement in PIPJ ROM, grip strength or outcome scores
    • Erosive osteoarthritis
      • nonoperative
        • splints, NSAIDs
          • indications
            • tolerable symptoms
      • operative
        • fusion
          • indications
            • intolerable deformity
          • technique
            • position of fusion same as above
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