Arthridites of the hand (excluding Rheumatoid) Flashcards Preview

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Flashcards in Arthridites of the hand (excluding Rheumatoid) Deck (27):
1

What is the definign feature of osteoarthristis?

Loss of articular cartilage

2

What is the epidemiology of OA of the hand

1/5 of the population, aged 55-65, F>M

Joints DIP>CMC>PIP

3

What is the pathophysiology of OA

  • Abnormal articular cartilage
    • loss of PG, + cytokines, chondrocytes response to mechanical forces altered
  • Abnormal subchondral bone
    • w expousre, bone becomes sclertotic w cysts, osteophytes
  • Abnormal periarticular tissue
    • inflam of synovium, capsule, swelling/stiffness

4

How do you classify Osteoarthritis

Primary

 

Secondary

  • Trauma, Infection
  • Metabolic (gout, CPPD, wilson's D)
  • Inflammatory 
  • Endocrinopathy (DM, acromegaly)

5

Describe your physical exam for OA

INSPECTION

  • Joint deformity, scissoring, mucous cysts, nail ridge
  • Bouchard (PIP) heberden (DIP) nodes
  • bilateral
  • Thumb
    • shoulder sign, MCP hyperextension, 1st webspace adduction contracture

PALPATION

  • crepitus, swelling, tenderness, 

ROM

  • diminished active, also passive if advanced

Motor sensory

  • concomitant CTS in 40% of pts w CMC OA

Special test

  • grind test
  • grip strength
  • distraction (pain if synovitis)

6

What are classic findings of OA on xray

  • joint space narrowing
  • subchondral cysts
  • sub=chondral sclerosis
  • osteophytes

7

What are goals of care for patient w OA of hand

  • Pain relief
  • Function improvement
  • Deformity correction
  • Cosmesis

8

How do you classify thumb OA?

Eaton Littler classification 

specific to THUMB OA

 

9

What are non-operative treatment options for OA

  • All patients should be given non-operative treatment first for OA
  • Lifestyle (rest, activity modification)
  • Heat
  • Splint
  • NSAIDs
  • Intra-articular steroids

10

What are operative treatments for OA

Only after failed non-operative treatment

  • DIP
    • Mucous cyst aspiration/steroid
    • Mucous cyst resection + osteophyte resect
    • Arthrodesis
  • PIP
    • depends on patient demands
    • arthrodesis vs arthroplasty
  • MCP
    • likely inflamamtory arthritis - treat underlying cause (hemochromatosis)
    • arthrodesis vs arthroplasty
  • CMC
    • Tx based on stage
    • arthroscopy, dorsal wedge
    • isolated lig recon, isolated Trapeziectomy, LRTI, arthroplasty, arthordesis

11

What are indicaitions for bone graft in OA arthrodesis

  • revision
  • loss of bone stock/insufficient
  • infection
  • arthritis mutilans

12

Describe your operative management of DIP OA

OPTIONS

  • Arthrodesis
    • Indicated: deformity/pain/loss fx
    • Key pts - need bone apposition/stock, fused at 0-5' 
    • Adv: resolves pain/deformity, well toelrated as DIP contributes<15% of finger flexion
    • Disadv: loss of ROM
    • Points: H/Y incision, rongeur/osteotomy for perfect apposition, fixation w kwire,screw,interosseous wire at 0-5' flexion
  • Arthroplasty
    • indicated as above and desire to maintain some flexion
    • Adv: maintained ROM
    • Disadva: joint instbaility, extrusion
    • silicone spacer - placed as above - average ROM 30'
  • Mucous cyst
    • aspiration - risk of septic arthritis, recurrence
    • Excision - risk of loss of ROM, nail deformity, septic arthrosis, recurrence

13

Describe your operative management of PIP OA

ARTHRODESIS

  • Indicated: high demand hand for stable joint
  • Adv: stable
  • DisAdv: loss of ROM - PIPjt responsible for 85% of digit and 20% hand flexion
  • dorsal longitudinal incision, splint extensor, rongeur/osteotomy or cup and cone
  • fuse index 40; long 45', ring 50', little 55'
  • Fixation: oblique lag, axial compression screw, herbert screw, interosseous wire, kwire, plate
  • Risk: loss of grip strength, non/mal union, pain infection

ARTHROPLASTY

  • Indicated: passive RO preserved, adequate bone stock
  • Adv: maintained ROM, av jt ROM 40-60
  • Disadv: infection, implant failure, instability, not achieving full ROM, peristent/recurrence deformity
  • Options
    • Swanson (interposition silicone spacer)
    • Pyrocarbon (surface/total jt replacement)
    • Therapy- 2wk cast, 4wk short arc

 

14

Describe your operative management of MCP OA

ARTHRODESIS

  • Salvage!!!! signifiicant disability from loss of ROM. For pain relief
  • Fusion angle index 25', long 30'. ring 35', little 40'
  • Types: hinge, fleible silicone prosthesis, surface replacement and pyrocarbon

15

Between which bones is the  most common form of thumb OA

Trapezium and 1st MC base

16

What articulations exist for the trapezium

  • 1st MC base
  • 2nd MC base
  • scaphoid
  • trapezoid

17

What are the 7 main intrinsic ligaments of the CMC joint

  • anterior volar oblique ligament, deep and superficial
  • posterior oblique ligament
  • Dorsal radial ligament
  • Dorsal central
  • Ulnar collateral ligament
  • Dorsal trapeziometacarpal

18

What is your DDX of base of thumb pain

  • Arthritis
    • OA
    • Rheumatoid
    • SLAC
    • STT arthritis isolated
  • Inflammatory
    • Gout, CPPD
  • Tendinopathy
    • FCR tendonitis
    • Dequervains
    • Intersection syndrome
    • UCL injury
  • Neuropathy
    • DRSN neuritis
    • CTS
  •  

19

What is the pathophysiology of CMC thumb arthritis

  • Anterior volar oblique ligament Attrition
  • Ligament lixity
  • abnormal joint position/loading
  • biomechanical damage to articular surface

20

What are special views for diagnosis of thumb CMC OA

  • Roberts view: AP of thumb with hand hyperpronated
  • TM stress view: bilateral radial thub tip aainst each other and 30' PA

21

What are operative interventions for Stage 1 CMC thumb OA

  • Goal: offload palmar cartilage, prevent further subluxation, stabilize joint
  • ARTHROSCOPY
    • Adv: minimally invasive
    • Disadv: may not provide benefit
    • Synovetcomy, debridment, volar thermal capsulorrhaphy
  • DORSAL WEDGE OSTEOTOMY
    • Adv: high pt satisfaction, improved grip and pinch strength, improved pain
    • Disadv:  nil
    • transverse partial osteotomy 1cm distal to CMC jt, 2nd 30' oblique 5mm distal to 1st. Extend and compress MC and kwire 6wks
  • VOLAR LIGAMENT RECON
    • Adv: improves pain
    • DisAdv; less effective for men
    • pass radial half of FCR through MC and secure to APL

22

What are operative interventions for Stage 2-4 Thumb CMC OA

TRAPEZIECTOMY

  • Indication - low demand hand - elderly. Stage 2-4
  • Adv- good pain relief.
  • Disadv- Loss of key/tip pinch and grip strength, loss of Tm space height
  • Excision of Tm, Kwire to hold out to length x4wks

LRTI

  • Indication - low demand hand. Stage 2-4
  • Adv - good pain, long lasting result
  • disadv - as Tmectomy - no diff in strength/pain relief in RCT - 
  • Tmectomy then using FCR/APL through bone tunnel in MC, volar ligament reconstructed and dorsal subluxation reduced

ARTHRODESIS

  • Indication - High demand hand young male - stage 2/3, not for STT arthritis
  • Adv: good pain relief, good grip srength
  • Dsiadv- loss of ROM, non-union, prominent hardware, infection, 
  • With BG, cerclage/kwire/tension band, screw fixation
  • Fusion at 35' radial and palmar abduction, 10' ext, 15' pronated

ARTHROPLASTY

  • Indicated- no proximal migration of MC, good bone stock
  • Adv- maintained ROM
  • Disadv- loosening hardware, silicone synovitis
  • Silicone, pyrocarbon hemiarthroplasty

23

What is the difference b/w psoriatic arthritis and RA and OA

  • asymmetric joint involvement
  • PIP jt most commonly affected
  • associated dactylitis, PIP flexion contracture
  • Arthristis mutilans with lots of osteolysis
  • no subcutaneous nodules
  • similar hand defomrity to RA

24

What is you management of pt w PA of the hands?

Hx

  • loss of ROM, pain, function, deformity

PE

  • jt deformity, stiffness, PIP jt contractures, dactylitis

Inv

  • Xray - osteolysis, A. mutilans, pencil-in-cup deformity

TREATMENT
Non-op

  • NSAIDs, chemotherapeutics, systemic steroids

Operative

  • PIPj: arthrodesis
  • MCPjt: arthroplasty
  • DP jt - no tx as these autofuse

 

25

What is your maangement of SLE patient w hand arthritis

Hx

  • morning stiffness, raynauds phenomenon, pain

PE

  • maculopapular rash fingers and palms, symmetri jt swelling
  • jt deformities - MCP ulnar deviation and volar subluxation of PP. PIP/DIP hyperextension (swan/bouton)

Xray

  • joint deformities w manintained jt spcae - may no have ANY BONE EROSION - all ligamentous (VP)

TREATMENT
Non-op

  • multidisciplinary team, NSAIDS,s systemic steroids, hand threapy, splints (swan/boutonniere)

Operative

  • MCP - swanson silicone arthroplasty
  • PIP DIP - soft tissue reliangnment vs arthrodesis

26

What is your management of a patient with gout?

Hx

  • monoarticular painful jt, 50% involve 1st MTP. 

PE

  • monoarticular acute jt swelling, hot tender, red. tophi

Inv

  • early normal, late osteolytic lesions

TREATMENT

Non-op

  • treat acute attack w indomethacin, lower uric acid, longterm colchicine

Operative

  • remove tophi if mechanical obstruction, hindrance of ROM, painful. Arthrodesis if jt destruction

27

What is your management of a patient with Scleroderma?

Hx

  • C- calcinosis, R - raynauds, E - esophageal dysmotility, S - sclerodactyly, T - telanigectasia

PE

  • tendon rupture, PIP contracture, progressive, 

INDICATIONS for surgery

  • finger/thumb deformties
  • vascular insufficiecy
  • calcinosis

TREATMENT

  • DIP - arhtodesis vs amp
  • PIP - arthodesis
  • MCP arthroplasty