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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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