Orthopaedic Surgery - Phalangeal Joint Arthritis

Basics

Phalangeal joint arthritis is a degenerative process affecting the articular cartilage and adjacent subchondral bone of the hand joints.

Progressive degeneration may lead to:

Cartilage loss

Joint-space narrowing

Subchondral bone change

Osteophyte formation

Joint deformity

Loss of motion

The joints most commonly affected are:

Distal interphalangeal (DIP) joints

Proximal interphalangeal (PIP) joints

and

Thumb carpometacarpal (CMC) joint.

The metacarpophalangeal (MCP) joints are much less commonly affected by primary osteoarthritis.

Classification

Hand arthritis can be classified as:

Primary

or

Secondary.

Primary Arthritis

Primary osteoarthritis occurs without an identifiable pre-existing joint disorder.

It is associated with:

Aging

Genetic susceptibility

Cumulative mechanical loading

Secondary Arthritis

Secondary arthritis develops after another process has damaged the joint.

Potential causes include:

Trauma

Previous infection

Inflammatory rheumatologic disease

Hemophilia

Hereditary hemochromatosis

Gout

Calcium pyrophosphate deposition disease (CPPD)

Epidemiology

Radiographic degenerative changes of the hand are extremely common with advancing age.

Older studies estimated radiographic hand osteoarthritis in as many as:

Approximately 75% of adults in selected older populations.

However, most radiographic disease is:

Asymptomatic.

Clinically significant symptoms occur in a much smaller proportion, historically:

Less than approximately 20%.

Risk Factors

Important risk factors include:

Increasing age

Previous trauma

Prior joint infection

Hemophilia

Hemochromatosis

Crystal deposition disease

Repetitive mechanical loading

Genetics

Osteoarthritis has an important hereditary component.

Rather than being caused by one gene in most patients, susceptibility is generally:

Polygenic and multifactorial.

Genetic variants affecting cartilage matrix, bone metabolism, and joint development may influence the risk of developing hand osteoarthritis.

Etiology

Degenerative arthritis may result from a combination of:

Mechanical cartilage injury

Biochemical alteration of cartilage

Genetic predisposition

Crystal deposition

Previous inflammation or trauma

Associated Conditions

Patients with hand osteoarthritis may also have degenerative arthritis involving other joints, particularly the:

Hip

and

Knee.

Diagnosis

Diagnosis is based on:

History

Physical examination

and

Plain radiographs.

Laboratory testing is reserved mainly for patients in whom an inflammatory, infectious, or metabolic cause is suspected.

Signs and Symptoms

Common symptoms include:

Joint pain

Morning stiffness

Reduced motion

Progressive enlargement or deformity of the finger joints

Pain

Pain may begin without a clear traumatic event.

It can be:

Intermittent initially

and become progressively more persistent as degeneration advances.

Pain is commonly aggravated by:

Gripping

Pinching

Repetitive hand use

Morning Stiffness

Patients frequently report:

Morning stiffness

or stiffness after inactivity.

In primary osteoarthritis, this is generally shorter in duration than the prolonged stiffness associated with many inflammatory arthropathies.

Joint Deformity

Progressive osteophyte formation and bony hypertrophy can produce visible enlargement of:

DIP joints

and

PIP joints.

DIP Joint Disease

Bony enlargement of the DIP joints is classically referred to as:

Heberden nodes.

PIP Joint Disease

Bony enlargement involving the PIP joints is classically referred to as:

Bouchard nodes.

MCP Joint Involvement

Primary degenerative arthritis only rarely affects the MCP joints.

Prominent MCP arthritis should prompt consideration of secondary causes such as:

Rheumatoid arthritis

Hemochromatosis

CPPD

Previous trauma

Loss of Motion

Range of motion may decrease because of:

Joint incongruity

Osteophyte impingement

Tophaceous deposits

Pain

Soft-tissue contracture

End-Stage Stiffness

Progressive periarticular fibrosis may eventually produce:

Severe stiffness

or

Ankylosis.

Physical Examination

Inspection

Look for:

Swelling

Bony enlargement

Angular deformity

Joint deviation

Skin changes

Range of Motion

Interphalangeal joints may demonstrate:

Reduced flexion

Reduced extension

Fixed contracture

or

Ankylosis.

Palpation

The affected joint may demonstrate:

Tenderness

Bony prominence

Crepitus

Soft-tissue swelling

Thumb Examination

When the thumb CMC joint is symptomatic, evaluate:

Pain with pinch

Base-of-thumb tenderness

CMC instability or crepitus

Laboratory Tests

Routine laboratory studies are not required for straightforward degenerative osteoarthritis.

If there is concern for an inflammatory, autoimmune, infectious, or metabolic condition, testing may include:

Rheumatoid factor

Anti-CCP antibodies when rheumatoid arthritis is suspected

ANA

ESR

CRP

HLA-B27 in selected clinical settings

Other investigations may be directed toward:

Gout

CPPD

Hemochromatosis

or infection.

Imaging

Plain Radiographs

Radiographs of the hand or individual affected digits are usually sufficient.

Typical findings include:

Joint-space narrowing

Subchondral sclerosis

Osteophyte formation

Subchondral cysts

Advanced Disease

Later changes may include:

Joint incongruity

Angular deformity

Bone loss

Partial subluxation

Ankylosis

Pathophysiology

Normal articular cartilage provides:

Low-friction movement

and

Shock absorption.

Osteoarthritis disrupts these functions through progressive structural and biochemical deterioration.

Early Cartilage Changes

Early degeneration may involve:

Increased cartilage water content

Altered proteoglycan metabolism

Collagen network disruption

These changes reduce the mechanical integrity of the cartilage.

Progressive Disease

As degeneration advances, cartilage develops:

Softening

Fissuring

Surface irregularity

Progressive loss of matrix

This leads to increased:

Friction

and reduced:

Shock-absorbing ability.

End-Stage Disease

With severe cartilage loss, abnormal load is transferred to:

Subchondral bone.

This may produce:

Microfracture

Sclerosis

Cyst formation

Osteophytes

Differential Diagnosis

Important alternative diagnoses include:

Gout

CPPD or pseudogout

Rheumatoid arthritis

Other inflammatory arthropathies

Septic arthritis

Post-traumatic arthritis

Gout

Gout may cause:

Acute painful swelling

Tophus formation

Erosive joint damage

Crystal identification from joint fluid can confirm the diagnosis when necessary.

CPPD

CPPD may mimic osteoarthritis but can involve:

Unusual joint distributions

and may show:

Chondrocalcinosis

on radiographs.

Rheumatoid Arthritis

Rheumatoid arthritis more commonly involves:

MCP

and

PIP joints

with relative sparing of the DIP joints.

Other clues include:

Prolonged morning stiffness

Symmetric swelling

Inflammatory laboratory abnormalities

Septic Arthritis

Acute severe pain, warmth, erythema, and swelling should raise concern for:

Joint infection, particularly if systemic symptoms are present.

Joint aspiration may be required.

Treatment

General Principles

Treatment aims to:

Reduce pain

Preserve hand function

Maintain useful motion

Correct severe deformity when necessary

Splinting

A well-padded splint can reduce:

Pain

Swelling

Mechanical irritation

Splinting is particularly useful during:

Symptomatic flare-ups

or for joints stressed repeatedly during activity.

Activity Modification

Patients should temporarily reduce or avoid activities that clearly aggravate symptoms.

Complete prolonged immobilization should generally be avoided because it may worsen:

Stiffness

Weakness

Physical Therapy and Hand Therapy

Therapy may include:

Active range-of-motion exercises

Passive stretching when appropriate

Isometric strengthening

Joint-protection techniques

The primary objective is to maintain:

Functional motion and strength.

Medication

Analgesic options may include:

Acetaminophen

and, when appropriate,

NSAIDs.

Topical NSAIDs can also be useful for superficial hand joints.

Corticosteroid Injection

Local corticosteroid injection may provide:

Temporary pain relief

for selected symptomatic joints.

Repeated injections should be used cautiously because of potential effects on:

Cartilage

Skin

Tendons

Surgery

Surgery is considered when:

Pain remains disabling despite conservative treatment

Severe deformity interferes with function

Motion is painful and nonfunctional

Joint destruction is advanced

MCP Joint

Surgical options include:

Arthroplasty

or

Arthrodesis

depending on the digit, disease pattern, and functional requirements.

PIP Joint

Options include:

Arthroplasty

or

Arthrodesis.

The choice depends on:

Which finger is involved

Need for mobility

Joint stability

Deformity

DIP Joint

For advanced painful DIP arthritis, the standard surgical treatment is usually:

Arthrodesis.

Fusion reliably reduces pain but sacrifices:

Joint motion.

Thumb CMC Joint

Surgical treatment of advanced thumb CMC arthritis may include:

Trapeziectomy

with or without:

Tendon interposition

Suspensionplasty

or other reconstructive procedures.

Thumb MCP Joint

Severe painful thumb MCP arthritis or instability may be treated with:

Arthrodesis.

Arthrodesis

The principal advantages of fusion are:

Reliable pain relief

Stable alignment

Strong functional joint

The disadvantage is:

Permanent loss of motion at the fused joint.

DIP Fusion Position

DIP arthrodesis is usually performed in:

Near extension to slight flexion, often approximately 0–25°.

More flexion may be used for the:

Ulnar digits

to improve functional grip.

PIP Fusion Position

PIP arthrodesis is commonly performed in greater flexion.

Approximately:

40° of flexion

may be used for the index or middle finger, with progressively more flexion toward the:

Ring and small fingers.

The exact angle should be individualized according to:

Digit

Occupation

Functional demands.

Arthroplasty

Several implant designs have been used for small-joint replacement.

Silicone implants remain widely used, particularly for selected PIP joints.

Other options include:

Pyrocarbon

and

Metal-polyethylene implants.

Some implant types have historically been associated with higher rates of:

Revision

Instability

or

Mechanical complications.

Arthroscopic Debridement

Small-joint arthroscopic debridement has been described in selected patients.

Its role is limited and it is not routinely used for:

Advanced end-stage arthritis.

Follow-Up

After joint fusion, an initial postoperative wound review is followed by radiographic assessment.

Radiographs are often obtained at approximately:

6 weeks

to evaluate progression toward fusion.

Additional imaging around:

12 weeks

may be required if union remains uncertain.

Prognosis

Most patients can achieve substantial improvement in:

Pain

Hand function

Daily activity

using combinations of:

Medication

Splinting

Hand therapy

Activity modification

or

Surgery.

Complications

Progressive Deformity

Untreated advanced arthritis may lead to:

Angular deformity

Loss of alignment

Functional impairment

Infection

Infection may occur after:

Injection

or

Surgery.

Arthrodesis Complications

Fusion procedures may be complicated by:

Malunion

Nonunion

Hardware irritation

Arthroplasty Complications

Implant arthroplasty may be complicated by:

Dislocation

Implant fracture

Wear

Loosening

Recurrent deformity

Silicone Synovitis

Silicone implants can rarely produce:

Silicone synovitis

secondary to implant wear debris.

Patient Monitoring

Patients managed nonoperatively can be reassessed according to:

Symptoms

Function

Progression of deformity

Historically, follow-up at approximately:

6–12-month intervals

has been used when ongoing surveillance is required.

Key Principle

Phalangeal joint arthritis is a degenerative process characterized by cartilage loss, osteophyte formation, subchondral change, pain, stiffness, and progressive deformity of the small joints of the hand.

Treatment begins with:

Activity modification, splinting, analgesia, and preservation of motion.

When pain and dysfunction remain severe, surgical options include:

Arthrodesis for reliable pain relief and stability

or

Arthroplasty when preservation of motion is important and the joint is suitable for replacement.