Arthritis hands

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

When it comes to arthritis, the hand is often called the "mirror of disease" because so many forms of arthritis affect the hand and the pattern of disease in the hand often provides clues to diagnosis.

A hand and wrist consist of 27 bones. Joints are created whenever two or more bones meet, so there is potential for multiple arthritic problems in the hand and wrist.

Arthritis of the hand can be both painful and disabling.

Osteoarthritis is a degenerative joint disease in which the cartilage, the gristle that caps the ends of long bones, 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:

•The base of the thumb, where the thumb and wrist come together (the trapezio-metacarpal joint)

The shape of these bones gives the thumb a wide range of movement – as well as the ability to pinch.

Arthritis in the basal joint of the thumb is more common in women than in men. It usually starts after age 40. Past injuries to this joint such as fractures, sprains, etc., increase the chances of developing arthritis.

The first symptom of basal joint arthritis is pain with activities that involve gripping and pinching. These activities could include opening jars, turning door knobs, opening car doors, and turning keys. A change in humidity or temperature also may aggravate symptoms. With progression, pain becomes more frequent and pinching strength decreases. As the arthritis continues to worsen, the basal joint begins enlarges and develops a squared-off appearance. Movement of the thumb becomes limited.

Forcing the thumb firmly against the wrist while moving the joint will reproduce pain and may produce a gritty sensation. This is called a "grind" sign. Movement becomes more difficult. As the joint wears away, the thumb’s bone begins to sublux- move out of joint- with grip.

The pain of early basal joint arthritis will usually respond to non-surgical treatment: splinting the thumb, an medication, both oral and injection to reduce swelling and pain. Patients with more severe cases may require surgery.

Osteoarthritis also affects other joints in the hand:

•the middle joint of a finger (the proximal interphalangeal or PIP joint)

•the finger tip (the distal interphalangeal or DIP joint)

Rheumatoid arthritis is a systemic condition, which means that it affects multiple joints, usually in a symmetric fashion.The joint lining (synovium) becomes inflamed and swollen. The swollen tissue may stretch the surrounding ligaments, resulting in deformity and instability. The inflammation may also involve the tendons, which link muscles and bones. This can result in tears in the tendons. Rheumatoid arthritis of the hand is most common in the wrist and knuckles (the metacarpophalangeal and proximal interphalangeal joints).

Stiffness, swelling, loss of motion, and pain are symptoms common to both osteoarthritis and rheumatoid arthritis. With osteoarthritis, bony nodules may develop at the middle joints of one or more fingers (Bouchard’s nodes) and at the finger tip (Heberden’s nodes). The joints become enlarged and the fingers become crooked.

With rheumatoid arthritis, there is often sausage-shaped (fusiform) swelling of the finger. Other symptoms of rheumatoid arthritis of the hand include:

•swelling of the synovium of the wrist on the back of the hand
•creaking (crepitus) of the tendons during movement
•ulnar drift of the fingers away from the thumb
•inflammation of the finger joints to the point where there is permanent bending (Boutonnière) deformity or a "swan’s neck" deformity caused by hyperextension at the middle joint of the finger along with a bent fingertip

Psoriasis, an autoimmune skin condition, may be associated with a severe form of inflammatory arthritis. Typically, a “sausage” finger will develop. The finger will have this appearance because the joint inflammation is accompanied by severe inflammation involving the tendons.

Occasionally, the fingernails will have tiny pits or the nail will appear to separate from the nailbed.

Some forms of inflammatory arthritis are caused by crystals. Examples are gout and pseudogout. These crystals deposit out in the synovium and induce an inflammatory response. Typically, there is swelling, warmth, and pain. If left untreated, gout can lead to large soft tissue deposits of uric acid in the fingers. These are called tophi.

Systemic lupus erythematosus is an autoimmune disease that causes a symmetric inflammatory arthritis that leads to fusiform swelling of the fingers. Patients with lupus joint disease will often have symptoms involving other organ systems.

Many forms of arthritis will also cause tendon sheath inflammation. This is felt in the palm of the hand where the tendon sheaths will be swollen and tender. The fingers may catch or "trigger." Steroid injection using ultrasound guided hydrodissection technique can fix this problem without requiring surgery.

X-rays will demonstrate changes due to arthritis, but these changes are late in the course of disease. Magnetic resonance imaging (MRI) is a more sensitive procedure used for diagnosing arthritis earlier.

Blood or other lab tests may be employed to confirm the diagnosis.

Treatment is begun to relieve pain and restore function. Treatments are based on the type of arthritis, its progression and the impact on daily activities. Anti-inflammatory medications may help reduce swelling and relieve pain; prescription medications or steroid (cortisone) injections may be recommended. Topical rubs may also help with symptoms.

Rheumatoid arthritis requires aggressive treatment with disease-modifying anti-rheumatic drugs and biologic medications in order to facilitate remission.

Rest, controlled exercise, and splints may also be part of the treatment program. Assistive devices may help.

If a tendon rupture occurs, an orthopedic hand surgeon may be able to repair it with a tendon "transfer" or graft. Joint replacements for the fingers may be helpful. Wrist replacements, to date, are not very effective.

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