Hand osteoarthritis

Definition

Osteoarthritis of the hand is a degenerative condition resulting in progressive wear of all the joints of the hand and fingers.

Left: normal hand; Right: severe osteoarthritic hand with periarticular osteopenia (bone loss)
Elderly woman with advanced hand osteoarthritis showing Heberden's and Bouchard's nodes

Pathology

Osteoarthritis of the hand is a complex pathology also called arthrosis as opposed to arthritis, which produces similar symptoms but involves a chronic inflammatory process. The condition affects the joints of the metacarpal bones articulating with the proximal phalanges (knuckles) as well as each inter-phalangeal joint of the fingers and thumbs. In the elderly population osteoarthritis is the most common disease as the articular cartilage covering bone extremities of the joints has worn-out. 

These degenerative changes of the cartilage increase the shock impacts to the joints producing over time bone erosion, pain, joint stiffness and swelling, leading to damage of the ligaments, finger misalignment or other deformities. The consequent weakness of the tendons causes the fingers to bend towards the little finger (ulnar deviation). When the pathology affects the distal joints of the fingers, small mucous cysts may develop at the lateral side of the distal inter-phalangeal joints. The accumulation of calcific spurs mostly in middle-aged women forms the so-called Heberden’s nodes. When located in the proximal inter-phalangeal joints they are named Bouchard’s nodes.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Intra-articular avulsion fractures in the joint capsule of the middle (left) and ring finger (right). Such injuries within the joints can trigger osteoarthritic changes later on

Causes

Hand osteoarthritis can be the consequence of previous injuries of the joint surface as well as joint dislocations that failed to heal completely. Alterations in the integrity of the cartilage and bone anatomy increase the pressure on the joints, which gradually deteriorate. Traumatic injury to the joint causes friction during movement and aggravates cartilage damage. In this case the pathology is named post-traumatic osteoarthritis.

Psoriatic arthropathy of both hands with early arthritis mutilans

Risk factors

There are a various risk factors leading to hand osteoarthritis; the main ones being:

Ageing (1 in 5 adults are affected)

Overuse

Females are more frequently affected and at earlier age than males

Mechanical injury

Familiar/genetic predisposition (autoimmune diseases: rheumatoid arthritis, psoriatic arthritis, lupus erythematous)

 

Pain to the finger joints is a common symptom of hand osteoarthritis

Symptoms

The symptoms of hand osteoarthritis progress in parallel with the severity of the disease. The main symptoms are: 

Early stage: pain with movement that eases off with activity

Advanced stage: chronic pain also without movement

Swelling of the joints of the hand, thumb and fingers

Fluid accumulation in the joint

Redness

Noise when moving the hand and fingers (crepitus)

Stiffness of the joint

Reduced range of motion

Hand/finger deformity

Weakness

Widespread joint pathology in rheumatoid arthritis

Measurement of the range of movement of all the hand joints is performed to determine how osteoarthritis has affected their function

Diagnosis

The diagnosis of hand osteoarthritis begins with a medical history in which the patient provides the examiner the description of past injuries, definition of pain characteristics and familiar predisposition to osteoarthritis. The specialist performs the physical examination of the hand and fingers initially with passive actions and subsequently with active exercises to assess changes in the range of movement. Both extremities are compared in their anatomical and functional condition. X-rays are taken to visualise changes in bone and cartilage integrity. Occasionally blood tests are requested to exclude chronic medical conditions (rheumatoid arthritis, etc.)

Treatment

Antiinflammatory therapy is the first resource for treating hand osteoarthritis

Nonoperative treatment

In most patients hand osteoarthritis is treated conservatively unless the pathology is so advanced to severely compromise the anatomy and function of the hand or when pain has become unsustainable. Traditional conservative management includes:

Anti-inflammatory therapy with NSAIDs to reduce swelling, pain and facilitate the movement of the hand and finger joints

Cold or heat pads to provide comfort and reduce inflammation

Local steroid injection in more severe symptoms

Anti-rheumatic drugs

Temporary immobilisation with a brace or splint to attenuate acute symptoms

Physical and occupational therapy to modify activities and reduce pain

Gentle exercise to strengthen hands and fingers and increase range of movement

Surgical treatment of hand rheumatoid arthritis: arthrodesis of ring finger's PIP joint; arthroplasty with a silicone prosthesis at the index finger's MCP joint

Surgical treatment

Surgery is necessary in case of strong pain or with advanced deformity of the hand and finger joints that severely affect the function of the extremity and patients’ quality of life. Numerous methods are available depending on the aetiology causing osteoarthritis.

Reconstructive surgery is indicated in specific osteoarthritis of the base of the thumb in which the arthritic bone is replaced with a forearm tendon.

Arthroscopy of the hand is now possible thanks to the development of small equipment. This is an exploratory minimally invasive surgery to assess the in situ damage of bones, cartilage and ligaments. It can be used to repair small tears of soft tissue and remove cartilage fragments following injury.

Arthrodesis or joint fusion refers to the fusion of both articulating extremities with a metal plate. The bones will grow together and flexion/extension of the joint will no longer be possible. This surgery usually resolves pain but is functionally debilitating.

Arthroplasty or joint replacement prosthesis is recommended in case of chronic rheumatoid arthritis where both sides of the joint are compromised and fusion is not possible.

Gentle hand exercises wit a soft ball help restoring strength to the hands and fingers

Rehabilitation

Whether treated conservatively or surgically, a number of exercises guided by a physiotherapist or hand-therapist are recommended to acquire flexibility, function and strength to the hand and fingers. Initially the patient is guided through gentle exercises while keeping the hand immersed in a bowl of soft warm wax. The use of ice packs onto the joints before and after motion can be beneficial. Post-surgery physiotherapy can begin at a time directed by the surgeon depending on the type of procedure. The initial care includes:

Immobilisation with a cast or splint for 10-14 days or longer for 4-6 weeks

Hand elevation

Ice pads to reduce inflammation and swelling

Treatment with analgesics and NSAIDs

It is critical to restrain from carrying heavy bags to avoid aggravating symptoms of hand osteoarthritis 

Prevention

Hand osteoarthritis is a condition difficult to prevent. However, at the onset of the degenerative changes, the patient is advised to reduce stress to the joints to minimise future damage of the hand and fingers. It is recommended to modify those daily activities as follows:

Use careful movements when twisting, pulling or pushing objects

Avoid carrying heavy weights and bags

Practice regular exercise to maintain flexibility and strength to the hands and fingers

Wear a taping/splint during manual work or when returning to sport