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rheumatoid arthritis, osteoarthritis, inflammatory arthritis, Lupus and scleroderma, others > Arthridites of the hand (excluding Rheumatoid) > Flashcards

Arthridites of the hand (excluding Rheumatoid) Flashcards

1
Q

What is the definign feature of osteoarthristis?

A

Loss of articular cartilage

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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

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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
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4
Q

How do you classify Osteoarthritis

A

Primary

Secondary

  • Trauma, Infection
  • Metabolic (gout, CPPD, wilson’s D)
  • Inflammatory
  • Endocrinopathy (DM, acromegaly)
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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)
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6
Q

What are classic findings of OA on xray

A
  • joint space narrowing
  • subchondral cysts
  • sub=chondral sclerosis
  • osteophytes
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7
Q

What are goals of care for patient w OA of hand

A
  • Pain relief
  • Function improvement
  • Deformity correction
  • Cosmesis
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8
Q

How do you classify thumb OA?

A

Eaton Littler classification

specific to THUMB OA

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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
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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
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11
Q

What are indicaitions for bone graft in OA arthrodesis

A
  • revision
  • loss of bone stock/insufficient
  • infection
  • arthritis mutilans
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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
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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
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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
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15
Q

Between which bones is the most common form of thumb OA

A

Trapezium and 1st MC base

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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

rheumatoid arthritis, osteoarthritis, inflammatory arthritis, Lupus and scleroderma, others (38 decks)

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