A 53-year-old woman presented with thumb pain that occurred when gripping her tennis racquet, taking pans out of the oven and writing. She even had problems lifting a wine glass.
On examination, there was 'shouldering' of the joint, the thumb metacarpal was pulled into the palm (adducted) and a compensatory hyperextension of the metacarpal joint, which enabled her to grasp larger objects.
An X-ray of the thumb revealed arthritis of the CMCJ, with the three classic signs of osteoarthritis (joint space narrowing, sclerosis and cyst formation).
After one injection, the patient opted for surgery and within four months, she was back on the tennis court.
The hand, more specifically the distal interphalangeal joint (DIPJ), is the area of the body most affected by osteoarthritis.
The second most affected joint is the base of the thumb - the carpometacarpal joint (CMCJ).
Hand arthritis is more common in postmenopausal females and there is often a family history. The disease affects the proximal interphalangeal joint (PIPJ) and the metacarpophalangeal joint (MCPJ) more rarely; these joints are affected more by rheumatoid arthritis.
Arthritis in any joint invariably presents with pain and a reduced range of movement. The hand is no exception.
The hand has many functions (grasping, touching, communication) and is used in every activity. It is only when something goes wrong with the hand that its importance is appreciated.
Arthritic fingers will cause pain when lifting, carrying and grasping.
Thumb osteoarthritis will cause pain when handling large objects or pinching.
Confirmation of the diagnosis is by X-ray of the affected digit. Note that X-rays of the hand or wrist do not image the thumb well.
Distal interphalangeal joint
The DIPJ is the joint most affected by osteoarthritis. Heberden's nodes are characteristic and are in fact osteophytes around the arthritic joint.
There can also be small ganglia, known as mucous cysts, present.
These can groove the nail and may discharge a clear, jelly-like substance.
Pain from the DIPJ can subside with time, but may take 10 or so years to do so.
Pain in the CMCJ occurs when unscrewing jars and bottles, peeling potatoes, pulling up tights/trousers and starting the car (key pinch).
On examination, you will see 'shouldering' of the joint - a lump at the base of the metacarpal (see case study). The thumb span may be reduced as the thumb is adducted into the palm (thumb in palm deformity).
Initially, analgesia using paracetamol, then ibuprofen (or a combination of the two) may be tried. Splints can be prescribed, either off the shelf or from the occupational therapy department (patients often do not like these because they prevent them from using their thumb).
Physiotherapy is ineffective for osteoarthritis in the hand.
Steroid injections can be given in the GP surgery. Three joint injections can be administered (generally not more, because the second works less well than the first and the third, even less well).
Once conservative measures have been exhausted, the patient should be referred to the hand surgeon.
For the DIPJ, mucous cysts can be burst, but the majority recur and generally need a referral to the hand surgeon. DIPJ arthritis, if very painful, is treated with a joint fusion.
In CMCJ, once the analgesic ladder becomes ineffective, referral to a hand surgeon is necessary.
A trapeziectomy (an excision arthroplasty) is likely to be recommended in this case.
Trapeziectomy is a day-case procedure, under a regional block or general anaesthetic. The patient has a plaster for two to four weeks. Hand therapy may be necessary for six weeks. This operation is 90% successful and the pain commonly never recurs.
The PIPJ and the MCPJs are affected more rarely. The PIPJ can be treated with fusion or replacement. Fusion is a reliable operation, but patients often baulk at losing movement. Replacement for the MCPJ does very well.
Hand arthritis is a condition that presents very frequently in primary care and much of the management can take place very simply in clinics. There are also some reliable surgical procedures that can help patients to lead more comfortable and fulfilling lives.
- Mr Field is a consultant orthopaedic hand surgeon, Gloucestershire Hospitals NHS Foundation Trust