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Arthritis

Arthritis: Base of the Thumb

What is arthritis at the base of the thumb?
In a normal joint, cartilage covers the ends of the bones and allows them to move smoothly and painlessly against one another. In osteoarthritis (or degenerative arthritis), the cartilage layer wears out, resulting in direct contact between the bones. In the hand, the second most common joint to develop osteoarthritis is the joint at the base of the thumb. The thumb basal joint, also known as the carpometacarpal (CMC) joint, is a specialized saddle-shaped joint that is formed by a small wrist bone (trapezium) and the first of the three bones in the thumb (metacarpal). The specialized shape of this joint allows the thumb its wide range of movement—up and down, across the palm, and the ability to pinch with the fingers (see Figure 1).

Who gets arthritis at the base of the thumb?
Arthritis at the base of the thumb is more common in women and usually starts after age 40. The cause of this form of arthritis is unknown in most cases. Past injuries to the joint, such as fractures or severe sprains, and generalized joint laxity may increase the chances of developing this form of arthritis at a younger age.

What are the symptoms and signs of arthritis at the base of the thumb?
The most common symptom of thumb basal joint arthritis is a deep, aching pain at the base of the thumb. The pain is often worsened with activities that involve pinch, including opening jars, turning door knobs or keys, and writing. As the disease progresses, patients may experience pain at rest and at night, and patients often note loss of pinch and grip strength. In severe cases, progressive destruction and mal-alignment of the joint occurs and a “bump” develops at the base of the thumb, which is caused by the thumb metacarpal moving out of position in relation to the trapezium. At this point, thumb motion becomes limited and the space between the thumb and index finger narrows, making pinch activities difficult (see Figure 2). The next joint up may hyper-extend to compensate.

How is the diagnosis made for arthritis at the base of the thumb?
The appearance of the thumb and the location of the pain are usually very helpful in identifying this condition. Applying longitudinal pressure along the thumb and twisting or grinding the basal joint is also helpful in reproducing symptoms (see Figure 3). Although x-rays help confirm the diagnosis, symptom severity often does not correlate directly with the joint’s appearance on the x-ray.

What are the treatment options for arthritis at the base of the thumb?
Less severe thumb arthritis will usually respond to non-surgical care. Pain medication, topical agents, splinting, and limited use of corticosteroid injections may help alleviate pain. A hand therapist might provide a variety of rigid and non-rigid splints to support the thumb during activities.
Patients with advanced arthritis or who do not respond to non-surgical treatment may be candidates for surgical reconstruction. A variety of surgical techniques are available that can successfully reduce or eliminate pain and improve thumb position and function. Common surgical procedures include removal of arthritic bone and joint reconstruction (joint arthroplasty), bone fusion or realignment techniques, and even arthroscopic procedures in select cases. A consultation with your treating surgeon can help decide the best options for you (see Figure 4).


Arthritis: Metacarpophalangeal (MP) Joint

What is MP Joint Arthritis?
The large joints in the hand at the base of each finger are known as the metacarpophalangeal (MP, or MCP) joints (see Figure 1). They act as complex hinge joints and are important for both power grip and pinch activities.Enter your text here...

The MP joints are less often affected by arthritic conditions than the smaller joints in the hand or the joint where the thumb joins the wrist (CMC). The most common arthritic condition affecting the MP joints is rheumatoid arthritis. In this situation, the joint lining (synovium) produces chemical factors that inflame and destroy the cartilage and soft tissue, such as ligaments and tendons. The end result is that the joint surfaces are destroyed and the fingers drift into a characteristic ulnar-deviated position, in which they point towards the little finger (see Figure 2).

Less commonly, other conditions can produce pain, deformity, and motion loss. Previous injuries can result in a gradual loss of joint cartilage (post-traumatic arthritis) with progressive pain and stiffness. Similar findings are seen with osteoarthritis. Post-traumatic and osteo-arthritis most commonly affect the thumb, index, and middle fingers, and the degree of deformity is often much less severe than in rheumatoid arthrosis. Gout, psoriasis, and infection are other less common causes of MP joint arthritis.

Diagnosis of MP Joint Arthritis
Most patients with rheumatoid arthritis present with longstanding pain, swelling, and deformity in multiple joints of both the upper and lower extremities. They usually exhibit a characteristic ulnar drift of their fingers with loss of motion, particularly extension (straightening) of the fingers.
Incasesofosteoarthritis and post-traumatic arthritis, patients usually complain of deep, aching joint pain that is worsened by grip and pinch activities. Many of these patients will not have an obvious finger deformity, although swelling, especially in the spaces between the large knuckles, is often present.

The diagnosis is usually confirmed by plain x-rays (see Figure 3). Special x-rays to look carefully at the metacarpal head are also helpful, particularly in milder cases.

Treatment of MP Joint Arthritis
Various treatment alternatives are available, based upon the degree of the joint destruction and the patient’s complaints.

In cases of rheumatoid arthritis, there are a variety of medications that are very effective in combating the generalized inflammatory process. Consultation with physicians specialized in the treatment of these disorders (rheumatologists) can be very helpful. If medication fails to reduce symptoms or slow the destructive process, direct cortisone injections used judiciously can offer temporary improvement.

Similarly, in cases of post-traumatic arthritis, anti-inflammatory medication, activity modification, and simple splints can provide patients with symptom relief.

In cases of progressive pain, deformity, and motion loss despite medical management, certain patients may be candidates for surgical treatment.
Patients with rheumatoid disease at a stage without significant joint surface destruction may benefit from synovectomy, in which the active, inflamed lining tissue of the joint, the joint synovium, is removed in order to slow the destructive process and maintain joint cartilage. In addition, the soft tissues (ligaments and tendons) can be tightened and re-aligned as needed in order to improve function.

Patients with severe joint destruction may benefit from either a joint fusion or joint replacement. The thumb functions very well after an MP joint fusion. In the fingers, however, the loss of motion can be very disabling and joint replacement is usually preferred. Classically, replacement with silastic hinged implants has resulted in reasonable pain relief and function (see Figure 4). Silastic implants have been particularly successful in older, more sedentary patients with low demand on the use of their hands. More recent types of implants that try to replicate the joint surface may offer benefits to younger individuals and patients with more active, vigorous lifestyles.
Complications following joint replacement surgery include infection, implant loosening or dislocation, and implant breakage. Research is continuing to try to improve joint replacement and reconstruction in the hand.

Osteoarthritis of the Hand

What is arthritis?
Arthritis literally means “inflamed joint.” Normally a joint consists of two smooth, cartilage-covered bone surfaces that fit together as a matched set and that move smoothly against one other. Arthritis results when these smooth surfaces become irregular and don’t fit together well anymore and essentially “wear out.” Arthritis can affect any joint in the body, but it is most noticeable when it affects the hands and fingers. Each hand has 19 bones, plus 8 small bones and the two forearm bones that form the wrist. Arthritis of the hand can be both painful and disabling. The most common forms of arthritis in the hand are osteoarthritis, post-traumatic arthritis (after an injury), and rheumatoid arthritis. Other causes of arthritis of the hand are infection, gout, and psoriasis.

Osteoarthritis of the hand
Osteoarthritis is a degenerative joint disease in which the cushioning cartilage that covers the bone surfaces at the joints begins to wear out. It may be caused by simple “wear and tear” on joints, or it may develop after an injury to a joint. In the hand, osteoarthritis most often develops in three sites (see Figure 1):
  • at the base of the thumb, where the thumb and wrist come together (the trapezio-metacarpal, or basilar, joint)
  • at the end joint closest to the finger tip (the distal interphalangeal or DIP joint)
  • at the middle joint of a finger (the proximal interphalangeal or PIP joint)
    It also often develops in the wrist.

Signs and symptoms of arthritis of the hand
Stiffness, swelling, and pain are symptoms common to all forms of arthritis in the hand. With osteoarthritis, bony nodules may develop at the middle, or PIP, joint of the finger (Bouchard’s nodes), and at the end-joints, or DIP, of the finger (Heberden’s nodes) (see Figure 2). A deep, aching pain at the base of the thumb is typical of osteoarthritis of the basilar joint. Swelling and a bump at the base of the thumb where it joins the wrist may also be observed. Grip and pinch strength may be diminished, causing difficulty with activities such as opening jars or turning keys. Pain, swelling, stiffness, and diminished strength are also seen with osteoarthritis of the wrist.
How is osteoarthritis diagnosed?

Your doctor will examine you and determine whether you have similar symptoms in other joints and assess the impact of the arthritis on your life and activities. The clinical appearance of the hands and fingers helps to diagnose the type of arthritis. X-rays will also show certain characteristics of osteoarthritis, such as narrowing of the joint space, the formation of bony outgrowths (osteophytes or “nodes”), and the development of dense, hard areas of bone along the joint margins.

Treatment for osteoarthritis of the hand
Treatment is designed to relieve pain and restore function. Anti-inflammatory or other analgesic medication may be of benefit in relieving pain. Brief periods of rest may help if the arthritis has flared up. You may also be advised to wear finger or wrist splints at night and for selected activities. Often soft sleeves may be of some benefit when the rigid splints are too restrictive, especially when the arthritis is affecting the joint at the base of your thumb. Heat modalities in the form of warm wax or paraffin baths might help, and when severe swelling is present, cold modalities may be of help. It is important to maintain motion in the fingers and use the hand as productively as possible. Hand therapy is often helpful with these exercises, splints, and modalities. A cortisone injection can often provide relief of symptoms, but does not cure the arthritis. Surgery is usually not advised unless these more conservative treatments fail.

Surgery is indicated when the patient either has too much pain or too little function. In most cases, the patient knows best and actually tells the doctor when it is time for surgery. The goal is to restore as much function as possible and to eliminate the pain or reduce it to a tolerable level. One type of surgery is joint fusion, in which the arthritic surface is removed and the bones on each side of the joint are fused together, eliminating motion from the problem joint. Joint fusion may be used to relieve pain and correct deformities that interfere with functioning. Another approach is joint reconstruction, in which the degenerated joint surface is removed in order to eliminate the rough, irregular bone-to-bone contact that causes pain and restricts motion. Once the degenerated portion of the joint surface is removed, it may be replaced with rolled-up soft tissue, such as a tendon, or with a joint replacement implant. Which type of surgery is used depends on the particular joint(s) involved, your activities, and your own needs. Your hand surgeon can help you decide which type of surgery is the most appropriate for you.

Rheumatoid Arthritis of the Hand

What is arthritis?
Arthritis literally means “inflamed joint.” Normally a joint consists of two smooth, cartilage-covered bone surfaces that fit together as a matched set and that move smoothly against one other. Arthritis results when these smooth surfaces become irregular and don’t fit together well anymore and essentially “wear out.” Arthritis can affect any joint in the body, but it is most noticeable when it affects the hands and fingers. Each hand has 19 bones, plus 8 small bones and the two forearm bones that form the wrist. Arthritis of the hand can be both painful and disabling. The most common forms of arthritis in the hand are osteoarthritis, post-traumatic arthritis (after an injury), and rheumatoid arthritis. Other causes of arthritis of the hand are infection, gout, and psoriasis.

Rheumatoid arthritis of the hand
Rheumatoid arthritis affects the cells that line and normally lubricate the joints (synovial tissue). This is a systemic condition (can affect the whole body), which means that it may affect multiple joints, usually on both sides of the body. The joint lining (synovium) becomes inflamed and swollen and erodes the cartilage and bone. The swollen tissue may also stretch the surrounding ligaments, which are the connective tissues that hold the bones together, resulting in deformity and instability. The inflammation may also spread to the tendons, which are the rope-like structures that link muscles to bones. This can result in stretching out of and ruptures of the tendons. Rheumatoid arthritis of the hand is most common in the wrist and the finger knuckles (the MP and PIP joints (see Figure 1).

Signs and symptoms of rheumatoid arthritis of the hand
Stiffness, swelling, and pain are symptoms common to all forms of arthritis in the hand. In rheumatoid arthritis, some joints may be more swollen than others. There is often a sausage-shaped (fusiform) swelling of the finger. Other symptoms of rheumatoid arthritis of the hand include:

a soft lump over the back of the hand that moves with the tendons that straighten the fingers

a creaking sound (crepitus) during movement

a shift in the position of the fingers as they drift away from the direction of the thumb (see Figure 2)

  • swelling and inflammation of the tendons that bend the fingers, resulting in clicking or triggering of the finger as it bends, and sometimes causing numbness and tingling in the fingers (carpal tunnel syndrome)
  • rupture of tendons with loss of ability to straighten or bend certain fingers or the thumb
  • unstable joints in the wrist, fingers, and thumb
  • deformity in which the middle joint of the finger becomes bent and the end joint hyperextended (Boutonnière deformity (see Figure 3)
  • hyperextension (sway-back) at the middle joint of the finger associated with a bent fingertip (swan-neck deformity (see Figure 3)

How arthritis of the hand is diagnosed
Your doctor will examine you and determine whether you have similar symptoms in other joints and assess the impact of the arthritis on your life and activities. The clinical appearance of the hands and fingers helps to diagnose the type of arthritis. X-rays will also show certain characteristics of rheumatoid arthritis, such as narrowing of the joint space, swelling and diminished bone density near the joints, and erosions of the bone. If your doctor suspects rheumatoid arthritis, he or she may request blood or other lab tests to confirm the diagnosis.

Treatment of rheumatoid arthritis
Treatment is designed to relieve pain and restore function. If you have rheumatoid arthritis in your hands, medications  can help decrease inflammation, relieve pain and slow the progression of the disease. Anti-inflammatory medications, oral steroids, and/or cortisone injections may be used. Several disease-modifying treatments are now available, including anti-malarial drugs, methotrexate, cyclosporine, gold, and other new drugs (remicade, enbrel) that help suppress the body’s immune system to reduce the inflammation and pain. A rheumatologist will often prescribe and monitor these types of  medications. Your physician may also refer you to a hand therapist for exercises, splints, modalities such as paraffin (warm  wax) baths, and instruction on how to use your hands in ways that may help relieve pain and pressure and also  protect your joints. Adaptive devices may help you cope with the activities of daily living.

Rheumatoid arthritis often affects the tendons as well as the joints. The tendons that become inflamed may trigger (click) or rupture. If this happens, you may be unable to bend or straighten your fingers or to grip properly. In certain cases, specific preventive surgery may be recommended. Preventive surgery may include removing nodules, releasing pressure on tendons by removing the inflamed tissue and degenerated,  rough bone that may scrape the tendons, and reinforcing the tendons. If a tendon rupture has occurred, a hand surgeon may be able to repair it with a tendon transfer or graft, in addition to performing these other procedures.

Surgery to treat the arthritic joints includes removal of inflamed joint linings, joint replacements, joint fusions, and in some cases, removal of damaged bone. The specific procedure(s) depends on a variety of factors, including the particular joint(s) involved, the degree of damage present, the condition of adjacent joints, and your own needs. Your hand surgeon can help you decide on the most appropriate treatment for you.

Unfortunately, there is no cure for rheumatoid arthritis. However, surgical procedures can often help correct deformities, relieve pain, and improve function. Optimal care entails a team approach between the rheumatologist, hand surgeon, hand therapist, and patient. It is particularly important that surgical intervention be appropriately timed to rebalance the hand and preserve the joints for as long as possible, before the development of more severe deformities has occurred.

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