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Knuckle and Finger joint arthritis

 

Osteoarthritis (OA) in the hand affects the smaller joints, typically the metacarpo-phalangeal (MCP), the proximal interphalangeal (PIP), the distal interphalangeal (DIP) and the interphalangeal (IP) joint of the thumb. Often there is a family history of the arthritis especially when it is fairly generalised throughout the hand and it is then referred to as nodal osteoarthritis. Obviously if there is only a single joint involved and there is a history of injury then it will be due the traumatic damage.

The cause of OA is still being investigated and there are a number of theories. I suspect that eventually it will turn out to be multi-factorial, probably with a strong genetic component and specific environmental factors which either precipitate the onset of the condition or promote its progression. I am not convinced that activity itself is the cause though it may make the symptoms worse once the disease has started.

Frequently the symptoms will fluctuate in intensity with good days and bad days, or good weeks and bad weeks or even good months and bad months, sometimes relating to the weather. Whilst the joints become knobbly and perhaps ugly to look at, remarkably they often still work quite well. Stiffness and pain are the most frequent symptoms but they can feel clumsy as well. Most patients learn to cope with the restriction in manipulative ability unless the joints are constantly painful. Often the joints will go through a phase of 'activity' when they are more painful and swollen and then it can settle, leaving the joints knobbly but pain free.

Treatment

Considering the number of patients I see with OA in the hand it is a small percentage who ultimately require surgery. Most patients go through phases of pain but generally cope. There is a lot interest in the 'alternative therapies' such as the fish oils, glucosamine, chondroitin, etc, etc. I believe there is now good evidence to recommend the fish oils as being important in the physiology of the joints but the evidence that the other preparations are effective in the hand is not as well established. Certainly there is a good, double blind controlled study which has shown that glucosamine is better than placebo after 2 years of treatment (in a dose of 1500mg per day) for knee osteoarthritis but I am not aware of any similar designed study which has looked at the response to glucosamine in finger OA. Acupuncture is reported to have some benefit in helping relieve pain.

Conventional treatment includes prescribing NSAIDS, physiotherapy, functional braces and finally surgery. Medical control is initiated by your GP and will depend on your general health and whether there would be any drug interactions with other medications you may be on. As already mentioned you will need to learn 'coping strategies' that is, ways of doing things differently. This can be very frustrating but I never cease to be amazed by how well patients can cope with arthritic fingers, provided they are pain free.

Surgery

Over the past decade there has been an explosion in the technology relating to finger joints, specifically the MCP and PIP joints. Unfortunately there is no replacement joint as yet for the end joint of the finger, the DIP joint. The other joints have progressed and I have been using the Avanta PIP joint for over 6 years and the results look very promising. The joint looks like a mini-knee replacement in its concept.


It is an uncemented replacement and is an attractive option to relieve pain for cases of the more generalised type of OA. In broad terms, like most joint replacements it is usually excellent at relieving pain but it is still difficult to predict the functional outcome. By this I mean I do not know how well the finger (PIP) joint will move after the surgery. It is important that you understand that no joint replacement can return the joint to normal. There is always a compromise. My view is that the critical aim is to relieve pain and if I can achieve a functional range of movement as well then that is a bonus. Often fingers that are pain-free albeit stiff still work better that a painful mobile finger. This may sound pessimistic but I am trying to be realistic, my aspiration is to recover a pain-free, mobile joint that allows most activites most of the time. Unfortunately healing is not an exact science so it is impossible to guarantee a normal finger. Because the arthritis causes stiffness and whilst this may be mainly involving the joint, it can affect also the tendons and muscles, so even though there is a new, potentially mobile joint, if the tendons are stiff then it may be difficult to recover all the desired movement.