eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity
Interphalangeal Joint Arthritis
Updated: Jan 16, 2008
Introduction
Osteoarthritis of the hand preferentially involves the distal interphalangeal (DIP) joint and the carpometacarpal (CMC) joint of the thumb.1 The proximal interphalangeal (PIP) joint is affected less commonly.
The term "osteoarthritis" has been used in the past to describe degenerative changes in the articular cartilage. However, a more descriptive term might be primary idiopathic osteoarthritis.
For excellent patient education resources, visit eMedicine's Arthritis Center; Bone, Joint, and Muscle Center; and Hand, Wrist, Elbow, and Shoulder Center. Also, see eMedicine's patient education articles Osteoarthritis and Rheumatoid Arthritis.
See also the following on eMedicine:
Osteoarthritis [in the Orthopedic Surgery section]
Osteoarthritis [in the Rheumatology section] Osteoarthritis, Primary [in the Radiology section]
See also the following on Medscape:
Resource Center Arthritis
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
CME Adipokines As Emerging Mediators of Immune Response and Inflammation
CME Eight-Week Exercise Program May Benefit Elderly Patients With Arthritis
CME FDA Approvals: Voltaren, Menactra, Erbitux
Bone Mineral Density Increased in Patients With Hand Osteoarthritis
Finger Length Pattern Linked to Osteoarthritis
History of the Procedure
Arthrodesis has been the time-honored surgical choice for the degenerated PIP joint. In the late 1950s, Brannon and Klein developed total joint arthroplasty for the PIP joint.2 Adrian Flatt then reported his experience with a metallic, hinged prosthesis for the rheumatoid arthritis of the PIP and metacarpophalangeal (MCP) joints.3 These devices routinely failed due to loosening or cortical breakout that was primarily caused by an artificially high center of rotation.
Numerous total joint devices have been introduced to reconstruct the PIP joint, but regardless of design, these devices typically fail due to difficulties in restoring the biomechanics of the joint. In 1970, Swanson developed the silicone interpositional arthroplasty for the PIP joint.4 Although this device is a joint spacer and not a total joint replacement, pain relief has been predictable, but durability has been suboptimal. The silicone PIP joint spacer remains the preferred choice for the prosthetic reconstruction of the PIP joint.5
Surface replacement arthroplasty (SRA) was developed as the first prosthetic device for the PIP joint that closely resembles the anatomic configuration of the phalangeal head and the articular base of the middle phalanx.6 Short-term results have indicated good function and durability.
See also the following on eMedicine:
Rheumatoid Arthritis [in the Physical Medicine and Rehabilitation section]
Rheumatoid Arthritis [in the Rheumatology section]
Rheumatoid Arthritis, Hands [in the Radiology section]
See also the following topics on Medscape:
Resource Center Rheumatoid Arthritis
CME Anti-TNF Therapy-α Safety Update (Slides With Transcript)
CME Current Opportunities for Improving Patient Outcomes in Rheumatoid Arthritis (Slides With Transcript)
CME Current Opportunities for Improving Patient Outcomes in Rheumatoid Arthritis (Slides With Audio)
CME Managing the Patient Throughout the Course of RA: Three Case Studies
Problem
The arthritic PIP joint demonstrates fusiform joint swelling. With progression of the condition, marginal osteophytes (Bouchard nodes) become evident with progressive lateral deviation of the digits (see Image 1).
During finger flexion, overlapping of the digits increases the functional impairment of the hand. Swan-neck and boutonniere deformities occur infrequently. Erosive osteoarthritis is an aggressive form of this condition that primarily affects the PIP and DIP joints in middle-aged women.7
See also the following on eMedicine:
Boutonniere Deformity
Swan-Neck Deformity
See also the following related topics on Medscape:
CME Assessing the Hands and Wrists in Elderly People
Frequency
Interphalangeal joint arthritis is often found in persons aged 65 years and older, with a predisposition for women, especially in the interphalangeal joints and the CMC joint of the thumb. The prevalence of osteoarthritis in the joints of the hand increases with age; osteoarthritis is found to occur in 85% of adults aged 75-79 years.
Etiology
A multitude of hypotheses have been suggested for the factors that are involved in osteoarthritis. Alterations in cartilage metabolism, trauma, infection, joint laxity, diet, hormonal changes, gout, calcium pyrophosphate deposition, microfractures, and immunologic factors have all been implicated in the etiology of osteoarthritis. In addition, genetic factors play a role in some forms of osteoarthritis.
See also the following on eMedicine:
Calcium Pyrophosphate Deposition Disease [in the Radiology section]
Calcium Pyrophosphate Deposition Disease [in the Rheumatology section]
Gout [in the Radiology section]
Gout [in the Rheumatology section]
Gout and Pseudogout
See also the following on Medscape:
Resource Center Gout
Resource Center Trauma
CME Emerging Strategies for Effective Management of Treatment-Failure Gout (Slides with Audio)
CME Treatment-Failure Gout: Recent Insights and Advances in Definition, Diagnosis, and Treatment
Gout Linked to Lower Parkinson's Disease Risk
Osteoarthritis May Predispose to Acute Gouty Attacks
Rheumatoid Arthritis and Related Conditions - Gout: Treatment Reaction to Allopurinol -- What Next?
Pathophysiology
The composition of cartilage changes with age. The proteoglycan content decreases and the keratan sulfate is depleted, whereas the chondroitin sulfate content remains the same or increases. Synthesis of all matrix components markedly increases. The result is increasing fibrillation, fissuring, and pitting, which further progress to erosions.
Presentation
Pain, stiffness, diminished strength, and angular deformities are the most commonly reported symptoms. Early in the degenerative process, the patient reports pain that is aggravated by activities. Often, in time, pain decreases, but the deformity remains.
Radiologic findings include severe joint destruction, subchondral sclerosis, and osteophyte formation. The differential diagnosis usually includes the inflammatory arthritides, including rheumatoid arthritis. Periarticular osteopenia and involvement of the MCP joint are characteristic of rheumatoid arthritis, but these findings are usually absent in erosive osteoarthritis.
Indications
Operative treatment is indicated for the PIP joint when medical management has failed to relieve the pain, when the digit deformity is interfering with hand function, or when a significant restriction of motion limits the activities of daily living (see Treatment, Medical therapy and Surgical therapy below).
Arthrodesis of the PIP joint is indicated mainly in the index and middle finger in a young or active patient or when a significant loss of bone has occurred.8,9,10 Arthrodesis should also be considered for anyone who is highly active on a regular basis.
Arthroplasty is indicated in less-active patients with painful, stiff, arthritic joints.6,5,11,12
Relevant Anatomy
The PIP joint is a ginglymus joint, or hinged joint, with a functional stability throughout its normal arc of flexion and extension.13,14 This bicondylar joint is made up of a pair of concentric condyles that are separated by the intercondylar notch and allows a range of motion of 90-120 º. The 2 corresponding articular surfaces of the middle phalanx are separated by a median ridge. In contrast to the metacarpal articular head, the center of rotation of the phalangeal head remains constant throughout flexion and extension. This phalangeal joint configuration provides functional stability for lateral and rotatory forces. The oblique collateral ligaments arise from the dorsal and lateral aspect of each condyle to insert into the lateral tubercle, near the volar margin of the middle phalanx base. These collateral ligaments are 2-3 mm thick.
The volar plate consists of a distal portion of a thick fibrocartilaginous tissue that inserts into the volar lip of the middle phalanx base and is suspended by the transversely oriented accessory collateral ligaments. The proximal aspect of the volar plate is membranous and is attached to the neck of the proximal phalanx. The lateral portion of the volar plate thickens to form the volar check ligaments (see Image 2).
Additional stability is provided to the interphalangeal joint by the extensor aponeurosis on the dorsal surface of the digit. The central slip of the extensor digitorum communis tendon attaches to the dorsal lip of the middle phalanx.
The oblique retinacular ligament arises from the side of the proximal phalanx and passes laterally into the PIP joint to join the lateral margin of the extensor band on the dorsal lateral aspect of the middle phalanx.
The transverse retinacular ligament is superficial and runs dorsally from the volar surface of the capsule and flexor tendon sheath; it is attached to the lateral margin of the lateral tendon of the extensor mechanism.
The Cleland ligament is dorsal to the neurovascular bundle, and the transverse Grayson ligament is volar to the neurovascular bundle (see Image 3).
Schematic views of the anatomy of the PIP joint can be seen in Images 2-3, and anatomic views can be seen in Images 4-5.
Contraindications
Arthrodesis and implant arthroplasty of the PIP joint are contraindicated in the presence of recent or chronic infection or in infirm individuals who are unable to sustain the rigors of elective surgical intervention.
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Further Reading
Keywords
osteoarthritis of the hand, erosive osteoarthritis, distal interphalangeal joint, DIP joint, carpometacarpal joint, CMC joint, primary idiopathic osteoarthritis, arthrodesis, arthroplasty
