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NoraSuojärvi

Osteoarthritis of the Hand and Wrist

Essentials

  • Other causes of joint swelling must be distinguished from osteoarthritis.
  • In its management, it is essential to educate the patient about the condition, and for the patient to reduce strain on the affected joints, to exercise independently, possibly to wear supports and to use sufficient analgesic medication.
  • If the patient continues to suffer unduly from pain at rest, restricted movement or instability despite appropriate conservative treatment, surgical options should be considered.

Definition and aetiology

  • Primary osteoarthritis of the hand occurs most often in certain joints 1.
    • In fingers, primary osteoarthritis occurs most commonly in DIP joints but also in PIP joints.
    • Primary osteoarthritis occurs in the MCP joint of the thumb, but it is rare in MCP joints of other fingers.
    • Primary osteoarthritis of the proximal thumb joint, or CMC I joint, is very common.
  • Most cases of osteoarthritis of the wrist occur around the scaphoid bone. This is probably due to the central role of the scaphoid bone in the stability and loading of the wrist.
  • In the wrist, osteoarthritis may occur:
    • between carpal bones
    • in the joint between the carpal bones and the radius (radiocarpal joint)
    • in the joint between the carpal bones and the ulna (ulnocarpal joint)
    • in the joint between the radius and the ulna (distal radioulnar joint or DRUJ).
  • Factors predisposing to primary osteoarthritis
    • Ageing
    • Female sex
    • Heredity
    • Recurrent, long-term work or movements straining the hands or wrists
    • Hormonal and dietary causes, circulatory failure and recurrent microtrauma have also been discussed as possible aetiological factors.
  • Secondary osteoarthritis may develop in any joint after trauma or infection, for example.
  • Differential diagnosis
    • Various types of arthritis and connective tissue disorders (such as rheumatoid arthritis, psoriatic arthropathy, SLE, scleroderma, gout)
    • Anomalies (bone anomalies, accessory carpal bones)
    • Avascular necrosis of carpal bones (lunatomalacia, or Kienböck's disease Lunatomalacia (Kienböck's Disease), or Preiser's disease of the scaphoid)

Symptoms and diagnosis

  • Signs and symptoms of osteoarthritis
    • At the early stage, pain and swelling
    • As the disease progresses, restricted movement and instability of the joint
    • Fluctuation is characteristic; there may be joint symptoms for a few weeks or months, which may then subside even for a long time.
    • No general symptoms or heat of the joint, such as may occur in rheumatoid arthritis, for example.
  • Plain X-ray 2
    • Joint space narrowing
    • Subchondral sclerosis and cystic changes
    • Osteophytes
    • Radiological findings do not always correlate with the symptoms.
  • At a later stage, the joint may be deformed due to callus formation (osteophytes). In the fingers, such changes are called Heberden's (distal joints) or Bouchard's (proximal joints) nodes.
  • DIP osteoarthritis may be associated with a mucous cyst with passage of synovial fluid into the joint (Image 3).
  • As osteoarthritis progresses, the joint may gradually spontaneously become stiffer, which will alleviate the symptoms.

Treatment

Conservative treatment

  • Conservative treatment should always be used first for osteoarthritis.
    • Reduction of strain, with short absences from work, as necessary, and preferably restructuring of the job if the work puts a strain on the hands.
    • Drug therapy is symptomatic, aimed at alleviating pain.
    • Splints, supports and possible aids
    • Physiotherapy (to maintain ranges of joint motion, occupational ergonomics)
  • Drug therapy
    • Analgesics (topical NSAIDs, paracetamol, NSAIDs).
    • Intracapsular glucocorticoid injections may be helpful for short-term alleviation of symptoms in some patients.
    • Short-term use of chondroitin sulfate or glucosamine products may alleviate pain associated with hand osteoarthritis 1 3.
  • Self-care, such as cold or heat therapy of the joint
  • Protection of the joint, i.e. orthoses, splints and supports 4
    • May facilitate painless joint loading and reduce pain on and after exertion.
    • Immobilization of the joint for the night will also alleviate symptoms in the daytime and thereby maintain the range of motion and strength of the hands.
    • Splints are available at health centres, pharmacies and stores selling aids.
  • A mucous cyst with mild symptoms (dorsal to the DIP joint) does not require treatment.
    • Puncture may predispose the patient to purulent arthritis. If puncture is to be done, it should be done at a healthy skin site with good sterile technique.
    • If a cyst ruptures spontaneously, it is important to cleanse and protect the area well.
    • Patients with mucous cysts causing severe symptoms or skin breakdown can be referred for assessment by a hand surgeon Ganglion.

Surgical treatment

  • Surgery can be considered if
    • conservative treatment does not help
    • there is constant pain
    • there is clear instability or malposition of the joint.
  • Surgical treatment of hand osteoarthritis
    • Varies individually depending on patient and joint.
    • Artificial induction of joint ossification, or arthrodesis, is a permanent treatment to fix pain, instability or malposition.
    • In osteoarthritis of the proximal thumb joint, trapeziectomy (removal of the os trapezium) is usually done. The surgical method is chosen based on patient-specific considerations.
    • In selected cases with no need for significant loading of the joint, an endoprosthesis may be considered. This will not improve the mobility of the joint significantly compared to the preoperative situation but the joint will be painless. A problem related to prosthetic treatment of hand joints is that they are subject to high torsion force relative to their size.
  • Surgical treatment of wrist osteoarthritis
    • The surgical method is very patient- and joint-specific.
    • Partial or complete wrist arthrodesis (preserving pronation and supination)
    • Carpectomy
    • Partial carpectomy
    • Proximal row carpectomy
    • Distal ulnectomy
    • Ulnar osteotomy
    • Endoprosthesis of the distal radioulnar joint (DRUJ)

    References

    • Liu X, Machado GC, Eyles JP et al. Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis. Br J Sports Med 2018;52(3):167-175. [PubMed]
    • Jabbour S, Kechichian E, Haber R et al. Management of digital mucous cysts: a systematic review and treatment algorithm. Int J Dermatol 2017;56(7):701-708. [PubMed]
    • Singh JA, Noorbaloochi S, MacDonald R et al. Chondroitin for osteoarthritis. Cochrane Database Syst Rev 2015;1():CD005614. [PubMed]