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Osteoarthritis of the Fingers

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

 

Osteoarthritis of the Fingers
Osteoarthritis can affect joints in any part of the body, including the fingers. Finger osteoarthritis is a common condition among postmenopausal women.

Finger anatomy is complex. The bones in the palm of the hand are called metacarpal bones – one metacarpal connects to each finger and thumb. Each finger is made of small bone shafts, called phalanges. The three phalanges in each finger are separated by two joints, called interphalangeal or IP joints. The one closest to the MCP is called the proximal interphalangeal or PIPjoint. The joint near the end of the finger is called the distal interphalangel or DIP joint. The joints of the fingers work as hinge joints with the joints supported by the lateral collateral ligaments and moved by the finger flexor or extensor tendons.

We take our fingers and hands for granted. During a typical day, notice how much activity depends on hand motion. Recognize The movement of the hands and fingers is complex and an intricate complex arrangement of bones, ligaments muscles and tendons. However the hand would be useless without the tough but flexible protective skin covering. This differs widely from the dorsum of the fingers to the tough skin of the palms and finger tips. However the movement is controlled by the sensitivity of the skin, the appreciation of joint position sense, the eyes are used to guide the purposeful movement and the control of the brain is used to co-ordinate the musculature to smoothly move the hand and fingers into the desired position. This becomes very difficult for people with finger osteoarhritis and stiffness. Each movement may become complex, difficult, painful and weak for a whole variety of reasons. This can make even simple daily activities difficult for a person with osteoarthritis, or indeed any other hand problems such as rheumatoid arthritis, stiffness, paralysis or deformity.

Cause of Finger Osteoarthritis
Osteoarthritis is a degenerative joint disease or a simple wear and tear of the joint. With this type of arthritis, the covering of the bone end or articular cartilage becomes worn and deficient. Injury to a joint (sprain or fracture) can cause damage to cartilage. Even if injury does not directly cause cartilage damage, it can affect how the joint works. Joints can be misaligned after they heal from an injury. Such abnormalities can stress the joint, which can later damage cartilage.

Diagnosis of Finger Osteoarthritis.
The diagnosis of finger osteoarthritis typically starts with a medical history — a history of any injuries that may have caused the condition. A physical exam lets the doctor evaluate the range of motion in the affected finger joints and what movements provoke pain. The appearance of characteristic nodes (Bouchard’s or Heberden’s nodes) may also help with the diagnosis of finger osteoarthritis.

X-rays are usually ordered so the doctor can see images of joint damage, especially to establish how much cartilage remains or if the joint is bone-on-bone (as in the cartilage completely worn away).

Symptoms of Finger Osteoarthritis
The symptoms of finger osteoarthritis finger osteoarthritis include, pain, stiffness and swelling of the joints. Heberden’s or Bouchard’s Nodes may develop alongside the finger joints. The fingers may become stiff with limited movement and the strength may diminish which makes gripping, turning or twisting difficult. Typically, osteoarthritis pain is felt at the start of an activity, then it diminishes as the activity progresses. After the activity has stopped and during rest, pain and stiffness usually return. With advanced osteoarthritis, pain can be felt even at rest.

Treatment of Finger Osteoarthritis
It is usually the pain which send patients to seek help. Pain is usually the symptom that causes patients to seek treatment. Early treatment can help manage finger osteoarthritis. Conservative treatment measures are tried first. These may include rest, hot or cold hand baths, hand lotions or wax treatments. An early alteration of the activities which are difficult or cause pain is important. A physiotherapist or occupational therapist may help in this respect.

Drug therapy may include paracetamol or codeine phosphate for analgesia and pain relief. Anti-inflammatory medication of Ibuprofen, Naproxen or Diclfenac may be helpful both in reducing the inflammation as well as pain within the joints. Splinting of the fingers or joints during activities or at night may be helpful. A steroid injection to the joint may also be helpful in persistent cases.

When non-operative or conservative treatment fails to produce satisfactory relief, surgery may be necessary. Surgery is indicated for patients with uncontrolled pain that affects normal hand function, or where deformity and instability affects hand function. If the functional impairment occurs in the necessary activities of daily living then surgery is often advocated. Surgical options for finger osteoarthritis include arthrodesis (fusion) or joint replacement, depending on the affected joint.

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 medications
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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