Modern Study Review (AI-Generated)
High-Yield Summary
Hand arthritis encompasses a spectrum of inflammatory and degenerative conditions that significantly impair hand function and quality of life. Rheumatoid arthritis (RA) and osteoarthritis (OA) are the most common etiologies, each with distinct pathophysiology, clinical features, and treatment paradigms. Modern management emphasizes early diagnosis, targeted medical therapy, and judicious surgical intervention to optimize pain relief and preserve hand function.
Key Diagnostic Findings
| Aspect | Details |
|---|---|
| Anatomy | Hand joints commonly involved: MCP, PIP, DIP, first CMC, wrist; soft tissues including tendons and ligaments may be affected. |
| Clinical Presentation | – RA: Bilateral, symmetric MCP involvement, deformities (swan-neck, boutonniere). – OA: First CMC joint pain, Heberden (DIP) and Bouchard (PIP) nodes. – Psoriatic arthritis: Asymmetric, fusiform digit swelling, nail changes. – Gout: Acute monoarticular inflammation, erythema, swelling. – Scleroderma: Soft tissue contractures, fingertip ulceration. |
| Imaging | – RA: Marginal erosions, joint space narrowing, periarticular osteopenia. – OA: Joint space narrowing, osteophytes, subchondral sclerosis. – Psoriatic arthritis: “Pencil-in-cup” deformities, acro-osteolysis. – Gout: Soft tissue tophi, punched-out erosions with overhanging edges. – Lupus: Usually preserved cartilage, soft tissue swelling. |
| Classification Systems | – RA: 2010 ACR/EULAR criteria for diagnosis. – OA: Kellgren-Lawrence grading for radiographic severity. – Psoriatic arthritis: CASPAR criteria. – Gout: ACR/EULAR gout classification. – No universally accepted staging for hand arthritis; deformity and functional scoring used clinically. |
Current Gold Standard Treatment
| Condition | Non-Operative Indications | Operative Indications |
|---|---|---|
| Rheumatoid Arthritis | DMARDs (methotrexate), biologics, corticosteroids, splinting | Synovectomy, tendon reconstruction, joint arthroplasty, arthrodesis for severe deformity or instability |
| Osteoarthritis | NSAIDs, activity modification, splints, corticosteroid injections | Trapeziectomy with or without ligament reconstruction for first CMC arthritis; arthrodesis or arthroplasty for advanced disease |
| Psoriatic Arthritis | NSAIDs, DMARDs, biologics targeting TNF-alpha or IL-17 | Joint fusion or replacement for severe joint destruction |
| Gout | Urate-lowering therapy, NSAIDs, colchicine, corticosteroids | Surgical debridement or excision of tophi causing nerve compression or ulceration |
| Scleroderma | Vascular management, physical therapy | Amputation reserved for painful ischemic digits or non-healing ulcers |
Modern Complications & Outcomes
- Rheumatoid Arthritis: Untreated synovitis leads to joint destruction, tendon rupture, and severe deformities; early DMARD use improves long-term function. Surgical outcomes depend on disease control; wrist arthrodesis improves stability but sacrifices motion.
- Osteoarthritis: First CMC arthroplasty/trapeziectomy yields good pain relief and function; complications include persistent pain and instability.
- Psoriatic Arthritis: Joint ankylosis and deformity can be disabling; biologics improve outcomes.
- Gout: Tophi can cause nerve compression syndromes; surgical removal improves symptoms but recurrence is possible without medical control.
- Scleroderma: Digital ulcers and auto-amputation are common; surgery is palliative and reserved for refractory cases.
Classic Clinical Notes
Arthritis – Hand
Phillip E. Wright II
Campbell’s Operative Orthopaedics, 9th ed, 1998, Chapter 74
IN GENERAL
Rheumatoid Arthritis
- Characterized by hypertrophic synovitis that erodes cartilage
- Usually bilateral, symmetric involvement
- Involves all the joints, but most importantly affects the MCP joints
- Depending on the involvement, can cause swan-neck or boutonniere deformities of the fingers and of the thumb
- Intercarpal ligament involvement can produce rotatory instability of the scaphoid
Osteoarthritis
- Usually involves the first CMC joint in elderly women
- Heberden nodes – DIP
- Bouchard nodes – PIP
Systemic Lupus Erythematosis
- Connective tissue disease with tendon, joint capsule, and ligamentous involvement. The deformities are often similar to rheumatoid, but are due to soft tissue abnormalities unrelated to proliferative synovitis, and the articular cartilage is usually well preserved.
- Vascular phenomena such as Raynaud’s is often seen and may be amenable to digital sympathectomies
Psoriatic Arthritis
- About 95% have asymmetric peripheral joint involvement
- Fusiform swelling of the entire digit
- X-ray shows erosion of terminal phalangeal tufts (acro-osteolysis), tapering of the phalanges and metacarpals, cupping of the proximal ends of phalanges and metacarpals, severe destruction or ankylosis of isolated small joints, and a predilection for IP joints with sparing of the MCP’s.
Reiter Syndrome
- Triad of conjunctivitis, urethritis, synovitis
- Usually asymmetric joint involvement
- 90% have remission after a week; chronic in 10%
Gout
- Joints are hot, swollen, red – imitate infection
- Massive monosodium urate crystal deposition can cause nerve compression, skin ischemia, ulceration
- Uric acid levels are not reliable – Dx is made by joint aspiration and demonstration of negatively birefringent crystals on polarize microscopy.
Scleroderma
- Soft tissue contractures – usually synovitis is not the underlying problem
- Fingertip ulceration due to vascular impairment may cause auto-amputation.
- Spontaneous amputation may be better than surgery, as length will be preserved – on the other hand, if it is too painful, you may have to amputate!
Staging of Operations
- According to Ferlic, Smyth, Clayton, the surgical priorities are, in descending order, spine, foot, hip, knee, wrist, shoulder, thumb, elbow, fingers
- So in the hand – do wrist, thumb, fingers. If wrist arthrodesis is considered, do this first, as the position of the wrist influences remaining finger function. A thumb MCP fusion can be entertained at the same time, but the remainder should wait.
Last Updated on January 24, 2026 by orthonet
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