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 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 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