“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.