Updated: 7/1/2021

DIP and PIP Joint Arthritis

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  • 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
          • 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
    • Erosive osteoarthritis
      • nonoperative
        • splints, NSAIDs
          • indications
            • tolerable symptoms
      • operative
        • fusion
          • indications
            • intolerable deformity
          • technique
            • position of fusion same as above

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Flashcards (14)
Cards
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Questions (7)
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(SBQ17SE.30) A 28-year-old female ski instructor sustained a fracture-dislocation of her index finger proximal interphalangeal joint (PIPJ) 10 years ago in a roller derby contest. The fracture was treated with distraction arthroplasty. The patient never retained functional range of motion. Additionally, since the injury, the patient has had increasing pain and a mild, progressive rotational deformity. Her radiograph is shown in Figure A. The patient is healthy with the exception that she is homozygous for factor V Leiden. She has attempted non-operative management but her symptoms are unbearable. What surgical intervention is the most appropriate for this patient?

QID: 211435
FIGURES:
1

Ray resection

2%

(25/1537)

2

PIPJ silicone arthroplasty

18%

(284/1537)

3

PIPJ pyrocarbon arthroplasty

7%

(115/1537)

4

PIPJ arthrodesis

68%

(1048/1537)

5

Vascularized PIPJ transfer from the second toe

4%

(58/1537)

L 3 A

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(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?

QID: 3354
FIGURES:
1

Reduced rate of infection of the DIP joint

2%

(93/3770)

2

Less post-procedure pain

1%

(19/3770)

3

Improved DIP range of motion

2%

(62/3770)

4

Decreased risk of mass recurrence

94%

(3543/3770)

5

Reduced risk of metastasis from seeding the mass into the joint

1%

(37/3770)

L 1 B

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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?

QID: 711
FIGURES:
1

Observe

8%

(398/5230)

2

Needle aspiration

4%

(201/5230)

3

Fusion of distal interphalangeal joint

14%

(741/5230)

4

Removal of bone spur and cyst

72%

(3782/5230)

5

Obtain infectious work-up

2%

(86/5230)

L 3 C

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Evidence (9)
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EXPERT COMMENTS (3)
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