Arthritis of the hands: Rheumatoid Arthritis

What we got here is failure to communicate.  Some men you just can’t reach, so you get what we had here last week, which is the way he wants it.  Well he gets it!

Stother Martin as “The Captain” in the movie Cool Hand Luke

Rheumatoid arthritis is a unique and very different type of arthritis.  It is much rarer than osteoarthritis, and the treatment is much more specific and specialized.  Rheumatoid arthritis can involve practically every joint in the body, but the joints of the hand and feet are commonly involved.  There have a number of incredible advances in the medical treatment of rheumatoid arthritis and I think the general opinion among hand surgeons is that we are seeing fewer patients with severe deformities of the hand which will require surgery, which is certainly a good thing.  However enough patients still have the disease progress to the point that surgery is needed.

Rheumatoid arthritis is an auto-immune disease, which is a fancy way of saying that your own bodies immune system attacks tissue in your body.  Nothing can be done to reverse the activity that the immune system initiates, but there are more and more medications being found that can effectively control the way your body reacts and help prevent many of the progressive deformities that are seen.  Since these medications are very specialized and are constantly changing the treatment of Rheumatoid Arthritis is usually best done by a specialist in arthritis called a Rheumatologist.

There are several reasons to see a hand surgeon if you have Rheumatoid Arthritis.  Most commonly people develop severe deformities at the joint where the fingers join the hand called the metacarpal-phalangeal joint or MPJ.  The arthritis attacks the joint and causes stretching of the ligaments of the joint.  Due to the forces acting on the joint the fingers drift downward and away from the thumb.  This is known as ulnar drift.  Once the ligaments stretch out and the joint surfaces become destroyed then the only way to correct the deformity is through surgery.  Fortunately many patients can adapt and function fairly well even with severe deformities so surgery is not automatically needed in many patients.  Patients that develop severe deformity and pain will consider surgery to straighten the fingers to improve function and relieve pain.  The surgery involves removing the joint surfaces, releasing contractures around the joint and then replacing the joint with a silicone spacer joint replacement.  This is a tedious and difficult surgery that should only be done by a surgeon with special training in hand surgery.  After the surgery there is usually an extensive period of splinting and therapy that requires a great deal of effort from the patient and therapist. It is important to have a therapist who is trained in dealing with hand problems.  The surgery usually results in excellent correction of the deformities, but there is a tendency for the deformities to recur over time.  The next joint out in the finger, known as the proximal inter-phalangeal joint, can also be damaged in Rheumatoid Arthritis.  Problems at this joint don’t have to be corrected as often as problems at the MPJ, and if surgery is needed it can often be done at the same time that the MPJ’s are corrected.

Another problem patients with Rheumatoid Arthritis get in the hands is tendon swelling, or synovitis.  This can result in the tendons rupturing, or popping, and the patients loses the ability to bend the fingers.  Most often this happens on the top of the hand and the patient can’t straighten out the fingers.  This can be very disabling, and surgery is needed to remove the swollen tendon tissue and repair the tendons.  The ruptured tendons can’t be sewn back together so tendon either has to be grafted or spliced in, or more commonly another tendon is borrowed to do the job of the tendon which ruptured.  This is called a tendon transfer.  This surgery works well to restore the function lost by a tendon rupture.  One other factor that leads to tendon ruptures are bone spurs caused by the arthritis.  If spurs are involved they have to be removed, and sometimes entire pieces of bone have to be removed.

The other tendon that is prone to rupture in Rheumatoid Arthritis is the tendon that bends the thumb down.  This tendon can be grafted or a tendon transferred just like on the back of the hand.

Rheumatoid arthritis can involve the wrist, and if the joint becomes very painful surgery can be used to help with pain relief.  Joint replacements are available for the wrist but they aren’t done very often due to high complication rates.  Modifications and improvements in the design of the joints are occurring, and one day wrist joint replacement may be done more often.  The most common surgery that is done for Rheumatoid Arthritis of the wrist is a fusion, or arthrodesis, where the joint surfaces are cleaned out and immobilized so that they fuse together.  This is a great way to relieve pain but results in a stiff wrist.

Hopefully this information can help you get started learning about Rheumatoid Arthritis.

Arthritis of the hands: the fingers

“You know that you’re over the hill when your mind makes a promise that your body can’t fill”

Old Folks Boogie by the band Little Feat

Everyone has known or seen someone with arthritis of the hands.  In the original Disney animated movie “Snow White” the evil witch is transformed into an old hag, and as one of the main components of her transformation she develops deformed hands.  The Disney animators had a keen eye for anatomic details and their renderings of the animated queens hands show many of the features associated with arthritis.  The joints are swollen and bent and quite honestly are painful just to look at.  The bad news is that many of us will develop arthritis in our lives as we age, but the good news is that the arthritis that develops is very often painless and doesn’t interfere with the function of our hands.

There are three joints in the fingers that arthritis involves, so a short anatomy lesion is in order. The joint at the end of the finger just before the nail is call the distal inter-phalangeal  joint, or DIPJ.  The next joint back closer to your hand is called the proximal inter-phalangeal joint or PIPJ, and the joint that connects your finger to your hand is called the metacarpal phalangeal joint or MPJ.  Arthritis most commonly involves the DIPJ, followed by the PIPJ and least commonly in the MPJ.

The first signs of arthritis are usually swelling in the joint.  Various mechanisms lead to inflammation of the joints and in general there is very little we can do to slow down or reverse this process.  As the arthritis progresses the material lining the joint, called cartilage, begins to deteriorate.  As the cartilage wears out bone starts rubbing against bone, and bone starts forming around the periphery of the joint as well.  When all of these factors come together then the deformed joints seen in arthritis occur.  What is very interesting to me is the fact that patients can have very deformed joints with awful looking x-rays, and yet have very little if any pain.  I’ve really never read a good explanation of this phenomenon but it’s very common in my practice for me to see a patient for some other problem who will tell you they never have had any problems with their fingers despite having the deformities I talked about.

But if the joints do hurt, what can we do?  The first steps usually involves modifying activities that aggravate your hands.  Warm water or warm soaks seem to increase blood flow to the joints and can cause some temporary relief.  Sometimes the oral medicines taken for osteoarthritis know as non-steroidal anti-inflammatory drugs (NSAID’s) can help.  The two most common over the counter NSAID’s are ibuprofen and naproxen.  Mobic and Celebrex are probably the two most common prescription NSAID’s.  Physical therapy probably isn’t going to do you much good for these joints, although it can be helpful for arthritis in the thumb.  Topical medications such as Voltaren gel and compounding creams which contain a variety of medications can be used as well, but in my experience the topical medications are very hit and miss in their ability to help people.

Cortisone injections can give some short term relief.  The injections work best in the MPJ, less well in the PIPJ, and I rarely inject the DIPJ because the joint is so tight it’s difficult to get any medicine in the joint.  If you’ve tried all of these measures and you’re still miserable, then there are some surgical options available.

Although we’ve made great strides with joint replacement surgery, especially in the hip and knee, things are not so far along in the fingers.  It’s been difficult to design an efficient long lasting joint replacement for the fingers, and although there are some newer types of joints available, in general most surgeons still use silicone implant joint spacers that were developed almost 50 years ago as their main option for joint replacement surgery in the hand.  The joints work pretty well at the MPJ, okay at the PIPJ, and very few surgeons will try them at the DIPJ.  The joints can be pretty good at relieving pain, but most patients only get about half of their normal joint motion.  In addition,at the PIPJ, the silicone joints aren’t great at keeping the finger straight and stable.  Some of the newer joint designs show some promise, but I haven’t seen enough evidence that they are significantly better than silicone to change my practice.

At the DIPJ and PIPJ, another option pain relief is a fusion, or arthrodesis.  This involves removing the joint surfaces and placing a pin or screw across the joint to get the joint to fuse together.  This results in complete stiffness at the joint being fused but the other joints in the hand should still move pretty much as normal.  Fusion is a great option at the DIPJ, okay at the PIPJ, and should almost never be done at the MPJ because of the loss of function that would occur if the MPJ was fused.

This is a lot to digest at one time, but the take home message should be that arthritis in the hands is very common, but it very often it does not cause significant problems.  There are treatments available to improve your comfort and function, but none of the treatments is perfect.

Arthritis of the wrist and hands. Part 1. Arthritis of the base of the thumb

Ad hoc, ad loc and quid pro quo.  So little time, so much to know.

The Nowhere Man from the animated movie “Yellow Submarine”.

There are a number of things a patient usually doesn’t want to hear when them come to the doctor, and finding out that they have arthritis is certainly one of those things. Unfortunately, arthritis of the hands and wrist is a very common condition that patients and doctors have to deal with, and the more you know about this condition the better prepared you can be to deal with the problem and understand what a doctor can and can’t do for your arthritis.

First off, the term arthritis encompasses a wide array of conditions.  Some forms, such as Rheumatoid Arthritis, can cause crippling deformities of the hands as well as other joints. Other forms of arthritis may cause painless bumps and swelling at different joints in the hand.  Most types of arthritis in the hands follows a specific pattern and involves specific joints.  Most primary care physicians are knowledgeable about the basic forms of arthritis and the non-operative treatment for these conditions.  Patients usually wind up seeing a hand surgeon either for advice about their treatment or to consider injections or surgery after trying other less invasive measures.

I’m going to start by talking about arthritis of the thumb.  This is the most common painful area of arthritis in the hands.  The most common location is at the base of the thumb where your thumb joins to your hand.  Although the thumb can be involved in a number of different types of arthritis, most commonly arthritis of the thumb is seen in basic osteoarthritis.  Although other joints of the hand and wrist can be affected, arthritis at the base of the thumb is rarely the sign of a more aggressive, crippling if you will, arthritis of the hands.  This is a beautifully designed joint that allows us a great deal of mobility of our thumbs in a wide variety of planes of motion.  This is the joint that separates our hand function from that of primates and allows the thumb to be the dominant digit of our hands.  Alas the price we often pay for specialization is an increased tendency to break down or wear out, and that is the case with the base of the thumb.

Although some people develop arthritis of the base of the thumb after injuries, most of the time it is an insidious process that develops over many years. The cause is a wearing out or degeneration of the ligaments that support the joint. The onset can be fairly early in life (for arthritis) and I often see the problem in patients around 50 years of age.  The first symptoms are usually pain and swelling.  Patients have trouble grasping large objects and pinching smaller objects.  Both of these actions put a great deal of stress on the base of the thumb.  At first the symptoms are aggravating, but they often progress to the point where they can interfere with use of the hand and activities that people do every day.  So what do you do?

Unfortunately there are no medicines that can stop or slow down the process.  The easiest thing to do is to simply avoid activities that aggravate the pain.  You can try anti-inflammatory medications like Advil or Aleve as well.  Braces seem to help a lot, especially in the early stages of the problem.  Flexible sleeves that support the thumb usually provide enough stability and are readily available at pharmacies and other retailers.

If these measures don’t work then you have to think about other considerations such as injections or surgery.  Most hand surgeons will try a combination of steroid and local anesthetic injected directly into the joint.  My experience has been that these shots do a pretty good job of controlling pain but that they eventually wear out.  If injections don’t work or aren’t too appealing, then surgery is really the only other option.  There are a number of techniques available to treat the arthritis, but almost all of them involve removing a small bone in the wrist and stabilizing the thumb.  No matter what technique is used this is a big surgery that can take up to 3-6 months to recover from and regain full use of your hand.  I think the surgery generally works very well but as a patient you need to be aware of the long recovery and rehabilitation that is involved.

Next time I’ll plan to discuss basic osteoarthritis in the other joints of the hand.  Thanks for reading!