DIP and PIP Joint Arthritis

Author: Jason McKean

Topic updated on 03/07/13 6:59pm

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
      - 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 is most reliable (nonunion in 10%)
      - 2nd and 3rd digit fused in extension, 4th and 5th fused in 10-20° of flexion
Mucous Cyst
- nonoperative
  - observation
    - indications
      - first line of treatment as 20-60% spontaneously resolve
- operative
  - cyst excision and osteophyte resection
    - indications
      - impending rupture
      - may need to do local rotational flap for skin coverage

PIP Arthritis
- nonoperative
  - observations, NSAIDs
    - indications
      - first line of treatment in mild symptoms
- operative
  - fusion
    - indications
      - border digits
      - poor bone stock
    - technique
      - headless screw fixation has highest fusion rates
      - recreate normal cascade of fingers
        
        index- 30°, long- 35°, ring- 40°, small- 45°
  - silicone arthroplasty
    - indications
      - long and ring finger
      - good bone stock
      - no angulation or deformity
    - outcomes
      - results are similar for both dorsal and volar approaches
  - collateral ligament excision, volar plate release, osteophyte excision
    - indications
      - predominant contracture
      - minimal joint involvement
Erosive osteoarthritis
- nonoperative
  - splints, NSAIDs
    - indications
      - tolerable symptoms
- operative
  - fusion
    - indications
      - intolerable deformity
    - technique
      - position of fusion same as above

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Qbank (1 Questions)

TAG

(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? Topic

Review Topic

FIGURES: A

1. Reduced rate of infection of the DIP joint
2. Less post-procedure pain
3. Improved DIP range of motion
4. Decreased risk of mass recurrence
5. Reduced risk of metastasis from seeding the mass into the joint

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Rizzo M, Beckenbaugh RD. Treatment of mucous cysts of the fingers: review of 134 cases with minimum 2-year follow-up evaluation. J Hand Surg Am. 2003 May;28(3):519-24 PMID:12772114 (Link to Abstract)

Question Authors:

John Badylak MD,

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ABOS II: DIP and PIP Joint Arthritis

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Rizzo M, Beckenbaugh RD. Treatment of mucous cysts of the fingers: review of 134 cases with minimum 2-year follow-up evaluation. J Hand Surg Am. 2003 May;28(3):519-24 PMID:12772114 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

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DIP and PIP Joint Arthritis

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