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Heberden’s Nodes of the Fingers

Author: DAVID P JOHNSON MB ChB FRCS FRCS. MD
Consultant Orthopaedic Surgeon

Heberden’s nodes are hard lumps or bony swellings that occur in the distal interphalangeal joints (DIP) (the most distal joints closest to the end of the fingers and toes). They are a sign of the development of osteoarthritis and are caused by formation of spurs or osteophytes of the joint. Heberden’s nodes are more common in women than in men, and there seems to be a genetic component involved in predisposition to the condition. The lumps are named after William Heberden (1710–1801). Bouchard’s nodes may also be present; these are similar bony growths in the more proximal interphalangeal (PIP) joints or the middle joints of the fingers, and are also associated with osteoarthritis. Bony bumps are also common at the base of the thumb in the first carpometacarpal joint. These bumps do not have a nickname. The name comes from the joint between the bone of the wrist (carpal) and the bone of the thumb (metacarpal).

Heberden was a very famous British doctor. Dr. Bouchard was a famous French doctor who studied arthritis patients at the turn of the last century. The Heberden’s and Bouchard’s nodes may not be painful, but they are often associated with limitation of motion of the joint. The characteristic appearances of these finger nodes can be helpful in diagnosing osteoarthritis.

Heberden’s nodes typically develop in middle age. They start as a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and stiffness of the joint and of the finger. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth. Sometimes there is also a sideways inclination of the finger. Heberden’s nodes are a sign of the disease of degenerative arthritis of the finger joints or osteoarthritis or “wear and tear” arthritis. Osteoarthritis is also known as degenerative arthritis because of the degeneration of the cartilage that causes it. Among the over 100 different types of arthritis conditions, osteoarthritis is the most common and affects over 20 million people in the United States alone. Osteoarthritis occurs more frequently as we age. Before age 45, osteoarthritis occurs more frequently in men. After age 55 years, it affects women more frequently. Osteoarthritis causes no symptoms in many patients. Symptoms of osteoarthritis include local pain, stiffness, tenderness, and occasionally swelling in the affected joints.

Diagnosis
The diagnosis of Heberden’s nodes is made on the history of pain and stiffness of the fingers and the visual appearances on examination. Sometimes, blood tests or X-rays can be helpful to better understand the degree and character of the osteoarthritis affecting a certain joint. It can also be helpful for monitoring and to exclude other conditions.

Treatment
Treatment may not be necessary for osteoarthritis of the hands when there are minimal or no symptoms.

Some patients get significant relief of pain symptoms by dipping their hands in warm water of hot wax dips in the morning. The wax can often be obtained at local pharmacies or medical supplies stores. The hot wax hardens on the hands and thereby provides a warm covering over the hands. The hardened wax then can be reused by peeling it off the hands and storing it for future use. Warm water soaks and night-time cotton gloves can help to keep the hands warm during sleep. Gentle range of motion exercising regularly can help to preserve function of the joints. These exercises are easiest to perform after early morning hand warming.

Pain-relieving creams that are applied to the skin over the affected joints can provide relief of daytime minor arthritis pain. For additional relief of mild symptoms, local ice application can sometimes be helpful, especially toward the end of the day. Occupational therapists can assess daily activities and determine which additional techniques may help patients at work or home.

When symptoms are troubling and persist, however, initial treatment with heat/cold applications and topical pain creams can be helpful. Additional treatment might include pain and anti-inflammatory medications, with or without food supplements, such as glucosamine and/or chondroitin. Glucosamine and chondroitin have been independently shown to relieve the pain and stiffness of some (but not all) patients with osteoarthritis. These supplements are available in pharmacies and health food stores without a prescription. If patients do not benefit after a trial of perhaps two or three months then the supplements are unlikely to be helpful in the longer term. The manufacturers sometimes make claims that these supplements “rebuild” cartilage. This claim has not been adequately verified by scientific studies to date.

Other treatments worth trying include:
• Warm wax or water baths.
• Analgesic or pain relieving gel.
• Vitamin E hand gel.
• Glucosamine sulphate
• Chondroitin sulphate
• Omega-3 or fish oil
• Weight loss
• Anti-inflammatory medication, Naproxen, diclofenac, Ibuprofen etc
• Analgesics or pain killers such as paracetamol,

Omega-3 or fish oils is a dietary supplement that has been noted to have some anti-inflammation properties and reduce the inflammation of arthritis. Obesity has long been known to be a risk factor for osteoarthritis of the knee and weight reduction for patients with early signs of osteoarthritis may delay the progression of the osteoarthritis.

Pain medications or analgesics may be helpful. Commonly used drugs include paracetamol, codeine phosphate or anti-inflammatory drugs. However in more severe cases a stronger analgesic may be necessary such as Tramadol. Anti-inflammatory medications is a powerful agent against the pin of osteoarthritis however prolonged use may precipitate indigestion, gastric bleeding and side effects.

Alternative Diagnosis
Mucous cysts can occur in the same place on the dorsum of the fingers adjacent to either the distal interphylangeal joint or the proximal interphylangeal joint. The present with more redness, pain and a little surrounding inflammation. The cysts are softer and translucent to light as compared to Heberden’s nodes which are hard bony lumps emanating from and fixed to the joint. Mucous cysts are not associated with osteoarthritis, finger joint stiffness, and usually occur alone. If troublesome they may be aspirated with a needle, or removed surgically.

Alternative Treatments for Osteoarthritis Patients
Conservative, non-drug treatment options should be considered first in mild conditions or at the early stages of the disease. If satisfactory relief can be achieved using non-drug options then this is to be preferred. Subsequently it may be necessary to progressing to stronger and more effective remedies. These ancillary treatment measures may include:

• Patient education and self-help programs
• Weight loss if patient is overweight
• Physical therapy for range of motion exercise, muscle strengthening, aerobic conditioning
• Supports, splints and assistive devices
• Joint taping and bracing
• Orthotics and insoles
• Occupational therapy for joint protection, energy conservation

Alternative treatments have gained popularity over the last several years. Glucosamine and chondroitin sulphate have been recommended for treatment of osteoarthritis. Some studies, however, have questioned the effectiveness of the supplements as well as the widely differing quality and content of the products sold.
Vitamins, specifically antioxidants, reportedly ease osteoarthritis and may even prevent the disease. Vitamin C has been associated with decreased pain and progression of osteoarthritis. Vitamins D and E also have been linked to osteoarthritis relief. Vitamin E hand cream may be particularly useful.

Physiotherapy is particularly useful in the early stages of the disease process. Physiotherapy can work towards improving posture and the position of joints, help with aids, splints, supports or foot orthotics. It can prescribe exercises to strengthen the muscles around joints and improve the range of motion of joints. Rehabilitation following surgery is a particular skill of the physiotherapist. Chiropractic manipulation and treatment has also been suggested as being beneficial in osteoarthritis.

Manipulation, by a chiropractor experienced with arthritis patients, may help relieve osteoarthritis stiffness and reduce pain for a while for some patients. However this is very dependent on the individual, the stiffness in any particular joint and the joint in question. It may be more useful for instance in foot, shoulder or spinal problems than those of the knee or hip joint. Podiatrists specialise in the provision of supportive insoles or orthotics and footwear for patients. This is particularly applicable to the arthritic patient. There is often a continual need for custom made orthotics which relieve pressure points, correct malaligned feet or in advanced cases manufacture custom fitted foot wear.

Topical creams and gels
Creams may be helpful in relieving the pain and swelling of arthritic joint. This may be very useful in hand and foot creams or where the muscles adjacent to the joint become still tender and painful. The creams may be simple heat rubs or a Capsaicin cream. Anti-inflammatory creams may also be helpful in a proprietary formulation of Ibuprofen cream or a simple methylsalicylate cream. For arthritic hands vitamin E hand cream may be very effective.

Medications for Osteoarthritis
Medications should be considered for treating osteoarthritis in addition to non-drug treatment options. Medications are used for the management of pain, stiffness and inflammation. Choice of medication is based on severity of the symptoms, patient tolerance and response and the risk of side effects for each individual patient.

Oral medication for osteoarthritis includes paracetamol as a simple analgesic. Anti-inflammatory medication (ibuprofen, naproxen, diclofenac or meloxicam) may be used as an analgesic, but also to reduce swelling and inflammation around a joint. If NSAID’s produce indigestion or gastritis then a COX-2 inhibitor drug such as Celebrex may be used. Stronger analgesics such as codeine phosphate or tramadol or another Opiod analgesics may be used if the pain becomes severe.

Localised Intraarticular Injections
Intraarticular injections to the joint may prove to be helpful in terms of reduced pain, reduced swelling and result in a better range of motion. The improvement may however in some situations be limited, partial or temporary for a period of six or twelve weeks duration. In the past the only option was to inject a steroid into the joint. Whilst this gave a reliable effect the duration was usually for six to twelve weeks. It has also been reported that the steroid had a deleterious effect on the chondrocytes or articular cartilage cells and so accelerated the wearing process. Steroid joint injects are still commonly performed and effective. However caution should be exercised in young people, in intra-articular use and with repeated injections.

More recently there has been the advent of Hyluronic acid injections. Hyluronic acid is the principle component of the normal synovial joint fluid. It provides a reduction in sliding friction between the bones, it is viscous and retains fluid within the joint and articular cartilage improving it’s vitality. It has also been suggested that there is an analgesic effect when injected into a joint. The injection of Hyluronic acid into a joint has also been termed Viscosupplementation.

Surgery for Osteoarthritis
Surgery is often necessary to relieve the symptoms of arthritis. It is wrong to consider it the last resort. Often judicious surgery at the appropriate time can relieve the symptoms but also alter and reduce the progression of the disease whilst improving the functioning of the joint. Thus improving significantly the quality of life as well as relieving the symptoms and delaying the progression of the disease. All too often late presentation after many years with severe chronic arthritis limits the surgical options and excludes the possibility of help from many of the more minor surgical procedures. In all cases surgery is considered after a proper appraisal of the patient, their functional limitations and their individual home, leisure and work environment. Major joint replacement surgery is a highly successful procedure in the right hands but is reserved for patients who have significant, pain and functional limitations in their activities who have failed to respond to or progressed despite other treatment options including more minor surgery such as arthroscopy if appropriate.

Surgery can relieve pain, improve joint alignment, and restore joint mobility and function. In some circumstances it can also delay the progression of the arthritis and the necessity for more major surgery such as joint replacement. The most common types of surgery used to treat osteoarthritis include: Arthroscopic surgery of the knee, shoulder, elbow ankle or wrist, Osteotomy, or joint replacement. Joint replacement is most commonly undertaken of the knee which is now more commonly undertaken than Hip joint replacement. However many other joints are now commonly replaced including the finger joints, wrist, elbow, shoulder and ankle.

Editor: David P Johnson MD.
St Mary’s Hospital. Clifton Bristol. BS8 1JU.
Web site: www.orthopaedics.co.uk
boc@orthopaedics.co.uk
© OrthopaedicsOpinionOnline 2011 www.OrthopaedicOpinionOnline.co.uk

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