Arthridites of the hand (excluding Rheumatoid) Flashcards
1
Q
What is the definign feature of osteoarthristis?
A
Loss of articular cartilage
2
Q
What is the epidemiology of OA of the hand
A
1/5 of the population, aged 55-65, F>M
Joints DIP>CMC>PIP
3
Q
What is the pathophysiology of OA
A
- Abnormal articular cartilage
- loss of PG, + cytokines, chondrocytes response to mechanical forces altered
- Abnormal subchondral bone
- w expousre, bone becomes sclertotic w cysts, osteophytes
- Abnormal periarticular tissue
- inflam of synovium, capsule, swelling/stiffness
4
Q
How do you classify Osteoarthritis
A
Primary
Secondary
- Trauma, Infection
- Metabolic (gout, CPPD, wilson’s D)
- Inflammatory
- Endocrinopathy (DM, acromegaly)
5
Q
Describe your physical exam for OA
A
INSPECTION
- Joint deformity, scissoring, mucous cysts, nail ridge
- Bouchard (PIP) heberden (DIP) nodes
- bilateral
- Thumb
- shoulder sign, MCP hyperextension, 1st webspace adduction contracture
PALPATION
- crepitus, swelling, tenderness,
ROM
- diminished active, also passive if advanced
Motor sensory
- concomitant CTS in 40% of pts w CMC OA
Special test
- grind test
- grip strength
- distraction (pain if synovitis)
6
Q
What are classic findings of OA on xray
A
- joint space narrowing
- subchondral cysts
- sub=chondral sclerosis
- osteophytes
7
Q
What are goals of care for patient w OA of hand
A
- Pain relief
- Function improvement
- Deformity correction
- Cosmesis
8
Q
How do you classify thumb OA?
A
Eaton Littler classification
specific to THUMB OA
9
Q
What are non-operative treatment options for OA
A
- All patients should be given non-operative treatment first for OA
- Lifestyle (rest, activity modification)
- Heat
- Splint
- NSAIDs
- Intra-articular steroids
10
Q
What are operative treatments for OA
A
Only after failed non-operative treatment
- DIP
- Mucous cyst aspiration/steroid
- Mucous cyst resection + osteophyte resect
- Arthrodesis
- PIP
- depends on patient demands
- arthrodesis vs arthroplasty
- MCP
- likely inflamamtory arthritis - treat underlying cause (hemochromatosis)
- arthrodesis vs arthroplasty
- CMC
- Tx based on stage
- arthroscopy, dorsal wedge
- isolated lig recon, isolated Trapeziectomy, LRTI, arthroplasty, arthordesis
11
Q
What are indicaitions for bone graft in OA arthrodesis
A
- revision
- loss of bone stock/insufficient
- infection
- arthritis mutilans
12
Q
Describe your operative management of DIP OA
A
OPTIONS
- Arthrodesis
- Indicated: deformity/pain/loss fx
- Key pts - need bone apposition/stock, fused at 0-5’
- Adv: resolves pain/deformity, well toelrated as DIP contributes<15% of finger flexion
- Disadv: loss of ROM
- Points: H/Y incision, rongeur/osteotomy for perfect apposition, fixation w kwire,screw,interosseous wire at 0-5’ flexion
- Arthroplasty
- indicated as above and desire to maintain some flexion
- Adv: maintained ROM
- Disadva: joint instbaility, extrusion
- silicone spacer - placed as above - average ROM 30’
- Mucous cyst
- aspiration - risk of septic arthritis, recurrence
- Excision - risk of loss of ROM, nail deformity, septic arthrosis, recurrence
13
Q
Describe your operative management of PIP OA
A
ARTHRODESIS
- Indicated: high demand hand for stable joint
- Adv: stable
- DisAdv: loss of ROM - PIPjt responsible for 85% of digit and 20% hand flexion
- dorsal longitudinal incision, splint extensor, rongeur/osteotomy or cup and cone
- fuse index 40; long 45’, ring 50’, little 55’
- Fixation: oblique lag, axial compression screw, herbert screw, interosseous wire, kwire, plate
- Risk: loss of grip strength, non/mal union, pain infection
ARTHROPLASTY
- Indicated: passive RO preserved, adequate bone stock
- Adv: maintained ROM, av jt ROM 40-60
- Disadv: infection, implant failure, instability, not achieving full ROM, peristent/recurrence deformity
- Options
- Swanson (interposition silicone spacer)
- Pyrocarbon (surface/total jt replacement)
- Therapy- 2wk cast, 4wk short arc
14
Q
Describe your operative management of MCP OA
A
ARTHRODESIS
- Salvage!!!! signifiicant disability from loss of ROM. For pain relief
- Fusion angle index 25’, long 30’. ring 35’, little 40’
- Types: hinge, fleible silicone prosthesis, surface replacement and pyrocarbon
15
Q
Between which bones is the most common form of thumb OA
A
Trapezium and 1st MC base
16
Q
What articulations exist for the trapezium
A
- 1st MC base
- 2nd MC base
- scaphoid
- trapezoid
17
Q
What are the 7 main intrinsic ligaments of the CMC joint
A
- anterior volar oblique ligament, deep and superficial
- posterior oblique ligament
- Dorsal radial ligament
- Dorsal central
- Ulnar collateral ligament
- Dorsal trapeziometacarpal
18
Q
What is your DDX of base of thumb pain
A
- Arthritis
- OA
- Rheumatoid
- SLAC
- STT arthritis isolated
- Inflammatory
- Gout, CPPD
- Tendinopathy
- FCR tendonitis
- Dequervains
- Intersection syndrome
- UCL injury
- Neuropathy
- DRSN neuritis
- CTS
*
19
Q
What is the pathophysiology of CMC thumb arthritis
A
- Anterior volar oblique ligament Attrition
- Ligament lixity
- abnormal joint position/loading
- biomechanical damage to articular surface
20
Q
What are special views for diagnosis of thumb CMC OA
A
- Roberts view: AP of thumb with hand hyperpronated
- TM stress view: bilateral radial thub tip aainst each other and 30’ PA
21
Q
What are operative interventions for Stage 1 CMC thumb OA
A
- Goal: offload palmar cartilage, prevent further subluxation, stabilize joint
- ARTHROSCOPY
- Adv: minimally invasive
- Disadv: may not provide benefit
- Synovetcomy, debridment, volar thermal capsulorrhaphy
- DORSAL WEDGE OSTEOTOMY
- Adv: high pt satisfaction, improved grip and pinch strength, improved pain
- Disadv: nil
- transverse partial osteotomy 1cm distal to CMC jt, 2nd 30’ oblique 5mm distal to 1st. Extend and compress MC and kwire 6wks
- VOLAR LIGAMENT RECON
- Adv: improves pain
- DisAdv; less effective for men
- pass radial half of FCR through MC and secure to APL
22
Q
What are operative interventions for Stage 2-4 Thumb CMC OA
A
TRAPEZIECTOMY
- Indication - low demand hand - elderly. Stage 2-4
- Adv- good pain relief.
- Disadv- Loss of key/tip pinch and grip strength, loss of Tm space height
- Excision of Tm, Kwire to hold out to length x4wks
LRTI
- Indication - low demand hand. Stage 2-4
- Adv - good pain, long lasting result
- disadv - as Tmectomy - no diff in strength/pain relief in RCT -
- Tmectomy then using FCR/APL through bone tunnel in MC, volar ligament reconstructed and dorsal subluxation reduced
ARTHRODESIS
- Indication - High demand hand young male - stage 2/3, not for STT arthritis
- Adv: good pain relief, good grip srength
- Dsiadv- loss of ROM, non-union, prominent hardware, infection,
- With BG, cerclage/kwire/tension band, screw fixation
- Fusion at 35’ radial and palmar abduction, 10’ ext, 15’ pronated
ARTHROPLASTY
- Indicated- no proximal migration of MC, good bone stock
- Adv- maintained ROM
- Disadv- loosening hardware, silicone synovitis
- Silicone, pyrocarbon hemiarthroplasty
23
Q
What is the difference b/w psoriatic arthritis and RA and OA
A
- asymmetric joint involvement
- PIP jt most commonly affected
- associated dactylitis, PIP flexion contracture
- Arthristis mutilans with lots of osteolysis
- no subcutaneous nodules
- similar hand defomrity to RA
24
Q
What is you management of pt w PA of the hands?
A
Hx
- loss of ROM, pain, function, deformity
PE
- jt deformity, stiffness, PIP jt contractures, dactylitis
Inv
- Xray - osteolysis, A. mutilans, pencil-in-cup deformity
TREATMENT
Non-op
- NSAIDs, chemotherapeutics, systemic steroids
Operative
- PIPj: arthrodesis
- MCPjt: arthroplasty
- DP jt - no tx as these autofuse
25
Q
What is your maangement of SLE patient w hand arthritis
A
Hx
- morning stiffness, raynauds phenomenon, pain
PE
- maculopapular rash fingers and palms, symmetri jt swelling
- jt deformities - MCP ulnar deviation and volar subluxation of PP. PIP/DIP hyperextension (swan/bouton)
Xray
- joint deformities w manintained jt spcae - may no have ANY BONE EROSION - all ligamentous (VP)
TREATMENT
Non-op
- multidisciplinary team, NSAIDS,s systemic steroids, hand threapy, splints (swan/boutonniere)
Operative
- MCP - swanson silicone arthroplasty
- PIP DIP - soft tissue reliangnment vs arthrodesis
26
Q
What is your management of a patient with gout?
A
Hx
- monoarticular painful jt, 50% involve 1st MTP.
PE
- monoarticular acute jt swelling, hot tender, red. tophi
Inv
- early normal, late osteolytic lesions
TREATMENT
Non-op
- treat acute attack w indomethacin, lower uric acid, longterm colchicine
Operative
- remove tophi if mechanical obstruction, hindrance of ROM, painful. Arthrodesis if jt destruction
27
Q
What is your management of a patient with Scleroderma?
A
Hx
- C- calcinosis, R - raynauds, E - esophageal dysmotility, S - sclerodactyly, T - telanigectasia
PE
- tendon rupture, PIP contracture, progressive,
INDICATIONS for surgery
- finger/thumb deformties
- vascular insufficiecy
- calcinosis
TREATMENT
- DIP - arhtodesis vs amp
- PIP - arthodesis
- MCP arthroplasty
