Wrist and Hand Osteoarthritis

Clinically Relevant Anatomy and Epidemiology

                                                 Image:Hand_and_wrist_bones_II.JPG

                                                    

The wrist and hand are composed of 27 bones: 8 bones of the wrist, 5 metacarpals and 14 bones of the phalanges. In this degenerative disorder, the articular cartilage wears away, exposing the bones. Cartilage is an elastic connective tissue whose purpose is to allow for a smooth, gliding motion between joints[1].


Image:Wrist_osteoarthritis_intro01.jpg                                 Image:Finger_arthritis.jpg


Incidence:
• Most common musculoskeletal disorder worldwide affecting the hands
• Age
   o  Incidence increases after 55 in women
   o  Rate of progression increases with age[2]
• Gender
   o  More common and more severe in women
      • Observed sex differences become evident after menopause[3]
   o  The typical locations of degeneration in patients with osteoarthritis are the distal and interphalangeal joints of the hand[4] 
• Genetics
   o  Women
      • Gene mutations that code for collagen II may increase the risk of developing early OA
      • Role of human leukocyte antigen (HLA) types regarding the risk of OA remains much debated
• Handedness
   o  HOA mostly occurs on the dominant hand[5]


Prevalence:
• Continuing to increase as the majority of our population increases

Pathological Process

Osteoarthritis is a disorder of the entire synovial joint organ and involves more structures than articular cartilage. The tissue changes that occur in the hand and wrist are a result of imbalance between catabolic and anabolic repair activity[2]. Current evidence states that the subchondral bone may be the primary etiologic agent in osteoarthritis and joint cartilage is simply the final target of the process. Periarticular bone changes occur very early in the development of OA and these changes can be segregated into distinct patterns based on the anatomic location and pathogenic mechanisms[6]. There is a progressive increase in subchondral plate thickness, alterations in the architecture of subchondral trabecular bone, formation of new bone at joint margins (osteophytes), and development of sub chondral bone cysts. Once the pathology reaches the articular cartilage, the cartilage thins and the joint space narrows. This causes sclerosis of the subchondral bone due to the new mechanical load placed on the affected joint[2].

Clinical Presentation[4]

• Pain
• Swelling
• Stiffness, particularly in the mornings

Pain, swelling and stiffness primarily targeted to DIP, PIP, thumb base, index and middle MCP joints.

• Muscle weakness
• Difficulty gripping and twisting objects (doorknobs)
• Presence of Heberden (on distal IP joints) or Bouchard nodes (on proximal IP joints) or bony enlargements.
  * clinical hallmark*

Heberden.jpg                  Bouchard's.jpg

Diagnostic Procedures

• Diagnosis difficult to make due to the number of joints involved, the broad spectrum of severity and possible subsets of  criteria which may exist.


• Imaging:
  o   Radiographs (gold standard). Note joint space narrowing; osteophytes; subchondral bone: sclerosis, cysts, erosion[4]
      • Kellgren-Lawrence grading allows a wide range of interpretations for each grade, reducing inter-observer reliability
      • Verbruggen and colleagues suggest an easy and reproducible scoring method, using numeric scores for radiographs[5]
  o MRI
  o Scintigraphy

Use of radiographs is the form of imaging most seen clinically.


• Laboratory markers such as rheumatoid factor (RF) and erythrocyte sedimentation rate (ESR). Blood tests are not required but recommended to exclude potential coexisting diseases[4].


                                 Image:EULAR_risk_factors.jpg


Risk Factors[4]:
• female gender
• increasing age over 40
• menopausal status
• family history
• obesity
• higher bone density
• greater forearm mm strength
• joint laxity
• prior hand injury
• occupational and recreation-related usage

Altman Diagnostic Criteria 1990 (Sn .92, Sp .98)[7]
• Presence of hand pain, aching, or stiffness plus
• hard tissue enlargement of at least 2 of 10 selected joints
• plus less than 3 swollen metacarpophalangeal joint
• plus either hard tissue enlargement of at least 2 distal interphalangeal
• joints or deformity of at least 1 of 10 selected joints

Outcome Measures[1],[8]

• Score for Assessment and quantification of Chronic Rheumatic Affections of the Hands (SACRAH)
• Functional Index for Osteoarthritis of the Hand (FIHOA)
• DASH/QuickDash

Management / Interventions

 • Conservative Treatment
         o A Systematic Review of Conservative Interventions for Osteoarthritis of the Hand[9]
          

                                                                Summary of Key Evidence

Intervention Results Level of Evidence
Hand Exercises
  • Increased Grip Strength
  • Improved Function
  • Improved ROM
  • Pain Reduction
Moderate
Joint Protection Exercises and Provision of Adaptive Equipment
  • Increased Hand Function
  • Pain Reduction
Moderate
Paraffin
  • Pain Reduction
  • Improved ROM
  • Improved Function
Weak
Low-level Continuous Heat Wrap
  • Pain Reduction
  • Increased Grip Strength
Moderate
CMC Orthotics (splints)
  • Hand Pain Redcution
  • Improved Hand Function
  • Increased Grip Strength
Moderate


•Pharmacological Treatment
    o Intra-articular steroid injections
    o Analgesics
    o NSAIDS
             • All can improve function but serve as temporary relief
• Surgery
    o 1st CMC joint replacement
    o Total wrist fusion
    o Partial wrist fusion
    o Total wrist replacement[10]

Differential Diagnosis[4]

• psoriatic arthritis (one ray or just DIP joints targeted)
• rheumatoid arthritis (targets MCP, PIP, wrist joints)
• gout (elevated serum urate levels)
• hemochromatosis (targets MCP and wrist joints)
• Reiter’s arthritis


The diagnosis of hand and wrist osteoarthritis is based upon a combination of findings from the clinical manifestations, radiographic changes and laboratory tests, rather than a single criterion.

Key Evidence

Diagnosing hand osteoarthritis:
• Zhang W, Doherty M, Leeb BF, et al. EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT. Ann Rheum Dis. 2009; 68:8-17.

Conservative treatment for hand osteoarthritis:
• Valdes K, Marik T. A systematic review of conservative interventions for osteoarthritis of the hand. Journal of Hand Therapy. 2010; 23: 334–351.

• Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient with Radial Wrist Pain: A Case Report. Journal of Orthopaedic and Sports Physical Therapy. 2004; 34 (12): 761-769.

Resources

http://www.arthritis.org/

   o   About the Arthritis
   o   Living with Arthritis
   o   Fighting for You


 https://www.cdc.gov/arthritis/
http://ww1.fightarthritispain.org/


   o  Online community
   o  Movement Tracker
   o  Exercise videos
   o  Risk assessment
   o  Podcasts


http://orthoinfo.aaos.org/

Case Studies

Walker et al. (2004) used an impairment based manual physical therapy approach in which the intervention included manual physical therapy in the clinic and self-mobilizations as part of a home exercise program. This impairment based approach appears to be beneficial in the treatment of CMC joint dysfunction and lead to the expeditious resolution of pain and return to full activity. Results demonstrate the clinically significant differences on the PSFS and NPRS and can be seen on the diagram below[11].


                            Walker.jpg

Recent Related Research (from Pubmed)

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References

  1. 1.0 1.1 Kaufmann RA, Logters TT, Verbruggen G, Windolf J, Goitz RJ. Osteoarthritis of the Distal Interphalangeal Joint. Journal of Hand Surgery. 2010; 35A: 2117-2125.
  2. 2.0 2.1 2.2 Goodman CC, Fuller KS. Pathology: implications for the physical therapist. Third Edition. St. Louis, MO: Saunders Elsevier; 2009.
  3. Kalichman L, Hernández-Molina G. Hand osteoarthritis: an epidemiological perspective. Seminars in Arthritis and Rheumatism. 2010; 39:465-476.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 Zhang W, Doherty M, Leeb BF, et al. EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT. Annals of Rheumatic Diseases. 2009; 68:8-17.
  5. 5.0 5.1 Feydy A, Pluot E, Guerini H, Drape JL. Role of imaging in spine, hand, and wrist osteoarthritis. 2009; 605-649.
  6. Goldring SR. The role of bone in osteoarthritis pathogenesis. Rheumatic Disease Clinics of North America. 2008; 34: 561–571.
  7. Altman, RD. Classification of disease: osteoarthritis. Seminars in Arthritis and Rheumatism. 1991; 20(6): 40-47.
  8. Maheu E, Berenbaum F. Time for new outcome measures in hand osteoarthritis? Nature Clinical Practice Rheumatology. 2009; 5: 136-138.
  9. Valdes K, Marik T. A systematic review of conservative interventions for osteoarthritis of the hand. Journal of Hand Therapy. 2010; 23: 334–351.
  10. Talwalkar SC, Hayton MJ, Stanley JK. Wrist osteoarthritis. Scandinavian Journal of Surgery. 2008; 97: 305–309.
  11. Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient with Radial Wrist Pain: A Case Report. Journal of Orthopaedic and Sports Physical Therapy. 2004; 34 (12): 761-769.