Definition

Osteoarthritis of the hand is a degenerative condition of hyaline cartilage in diarthrodial joints. It is distinct from inflammatory arthropathies, such as rheumatoid arthritis, in which the primary component is an inflammatory or systemic pathophysiologic process. Idiopathic osteoarthritis excludes post-traumatic arthritis or arthritic conditions resulting from pyrophosphate deposition disease, infection, or other known causes. It is associated with aging, but variations in onset and severity seem genetically determined [1]. In particular, the early onset of osteoarthritis of the distal interphalangeal and trapeziometacarpal joints is genetically mediated separate from osteoarthritis at other joints; in other words, a 50-year-old person with severe hand arthritis is not at risk for early hip arthritis. The prevalence of osteoarthritis of the hand increases with age and is more common in men than in women until menopause. In individuals older than 65 years, osteoarthritis of the hand has been estimated to be as high as 78% in men and 99% in women [2]. The distal interphalangeal and proximal interphalangeal joints and the base of the thumb are the most affected joints.

Symptoms

Patients typically report pain, stiffness, and disability. Symptoms follow a waxing and waning course as the disease gradually and inevitably progresses. The correlation between radiographic findings and pain intensity and magnitude of disability is limited, most likely as a reflection of the psychosocial factors that mediate the difference between disease and illness and between impairment and disability. Psychological distress and ineffective coping strategies should be identified and addressed.

Physical Examination

Osteoarthritis is insidious. Although a joint “goes gray” during decades, patients often notice an acute onset of symptoms that can make it difficult for them to believe their problem is an expected slow deterioration. The hallmarks of physical examination are deformity, restriction of motion, pain, and crepitation. A careful examination of all of the joints notes any deformity, effusions, erythema, limitations in range of motion, and swelling. The findings on neurologic examination should be normal.

Interphalangeal Joints

Osteoarthritis of the distal interphalangeal joint is characterized by enlargement of the distal joint by osteophytes, forming the so-called Heberden node (Fig. 33.1). Angulatory and rotatory deformities of the terminal phalanx can develop (Fig. 33.2). Ganglion (or mucous) cysts are associated with osteoarthritis of the distal (and less commonly the proximal) interphalangeal joints. The pressure of these cysts on the germinal matrix can cause a groove in the fingernail. The proximal interphalangeal joint is less commonly involved than the distal joint. The enlargement and deformity at the proximal interphalangeal joint is referred to as a Bouchard node.

Metacarpophalangeal Joints

It is relatively uncommon for the metacarpophalangeal joints to be involved in primary idiopathic osteoarthritis. The presentation at this joint is usually characterized by complaints of pain and stiffness rather than deformity.

Trapeziometacarpal Joint

Arthritis of the trapeziometacarpal joint is associated with aging. Among women aged 80 years and older, 94% have radiographic signs of arthritis; two thirds of these have severe joint destruction [3]. Men develop arthritis more slowly than women do, but by the age of 80 years, 85% have arthritis. The process progresses from subluxation and slight narrowing of the joint to osteophyte formation, deformity, and destruction of the joint [4]. As the disease progresses, the base of the metacarpal subluxates radially, there is an adduction contracture of the metacarpal toward the palm, and laxity and hyperextension of the metacarpophalangeal joint develop in compensation. Axial compression and rotation and shear (the compression test) will produce crepitation and reproduce symptoms [5,6]. Both active and passive movement is restricted. Grip and pinch strength gradually diminish. It is useful to screen for carpal tunnel syndrome and trigger thumb, both of which are common in this age group.

Functional Limitations

The classic forms of reported disability are activities that require a forceful grasp, such as opening a tight jar, turning a key, or opening a doorknob. Whereas fine motor tasks are often impaired by interphalangeal osteoarthritis, complaints of disability are far less common; perhaps because the disease is so gradual, most patients adapt.

Diagnostic Studies

Radiographs are rarely necessary to establish a diagnosis or to guide treatment; their chief use is for ruling out other pathologic processes and increasing the patient’s understanding and acceptance of the disease process. Characteristic findings are joint space narrowing, subchondral sclerosis, osteophyte formation, and degenerative cyst formation in the subchondral bone. Eaton and Littler classified trapeziometacarpal arthritis into four radiographic stages [7