Arthritis in hands

Arthritis in the hands is a common musculoskeletal condition that affects joint function, causing pain, stiffness, and deformities. It can significantly impact daily activities such as writing, gripping, and lifting objects. Early recognition and management are crucial to maintain hand function and quality of life.

Anatomy of the Hand

Bones

The human hand consists of 27 bones organized into three main groups:

• Phalanges: These are the finger bones, with three in each finger (proximal, middle, distal) and two in the thumb.
• Metacarpals: Five bones that form the middle part of the hand, connecting the wrist to the fingers.
• Carpal Bones: Eight bones arranged in two rows forming the wrist, providing flexibility and support.

Joints

The joints of the hand allow complex movements and include:

• Distal Interphalangeal (DIP) joints: Located at the tips of the fingers.
• Proximal Interphalangeal (PIP) joints: Located between the proximal and middle phalanges.
• Metacarpophalangeal (MCP) joints: Connect the fingers to the metacarpal bones.
• Carpometacarpal (CMC) joints: Connect the metacarpals to the carpal bones, enabling thumb mobility.

Soft Tissue Structures

The hand also contains several soft tissue components that support joint stability and function:

• Ligaments: Connect bones and stabilize the joints.
• Tendons: Attach muscles to bones, enabling movement.
• Synovium: A membrane lining the joints, producing synovial fluid for lubrication.

Types of Hand Arthritis

Osteoarthritis

Osteoarthritis is the most common form of hand arthritis, primarily affecting older adults. It is characterized by cartilage degradation and bone remodeling.

• Heberden’s Nodes: Bony swellings at the DIP joints.
• Bouchard’s Nodes: Bony enlargements at the PIP joints.

Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune condition causing chronic synovial inflammation. It often affects joints symmetrically and can lead to deformities.

• Symmetrical involvement of MCP and PIP joints
• Potential for joint erosion and tendon damage

Psoriatic Arthritis

Psoriatic arthritis is associated with psoriasis and may involve the fingers and nails.

• Dactylitis: Diffuse swelling of an entire finger, also called sausage finger.
• Nail changes such as pitting or onycholysis

Other Types

Less common forms of arthritis affecting the hand include:

• Gouty arthritis: Deposition of urate crystals leading to acute joint inflammation.
• Post-traumatic arthritis: Develops after fractures or joint injuries.

Etiology and Risk Factors

Genetic Factors

Genetic predisposition plays a significant role in the development of hand arthritis. Individuals with a family history of osteoarthritis or rheumatoid arthritis have an increased risk of developing the condition.

Age and Gender

Age is a major risk factor, with osteoarthritis more commonly seen in older adults. Certain types of arthritis, such as rheumatoid arthritis, are more prevalent in females, potentially due to hormonal influences.

Environmental and Lifestyle Factors

• Occupation and repetitive use: Jobs or activities that involve repetitive hand movements can increase stress on the joints.
• Previous hand injuries: Fractures, dislocations, or ligament injuries can predispose joints to arthritis.
• Obesity and systemic inflammation: Increased body weight and chronic inflammation may contribute to joint degeneration.

Pathophysiology

Osteoarthritis Mechanisms

Osteoarthritis involves progressive cartilage degradation, leading to loss of joint space and formation of osteophytes. Bone remodeling occurs in response to mechanical stress, causing deformities and reduced mobility.

Rheumatoid Arthritis Mechanisms

Rheumatoid arthritis is driven by autoimmune processes, where the immune system targets synovial tissues. Chronic inflammation leads to pannus formation, cartilage destruction, and erosion of bone structures, resulting in joint deformities.

Inflammatory Mediators

• Cytokines: Tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 (IL-1) promote inflammation and cartilage breakdown.
• Enzymes: Matrix metalloproteinases contribute to degradation of cartilage and extracellular matrix.

Clinical Features

Symptoms

• Pain and Stiffness: Often worse in the morning or after periods of inactivity.
• Swelling and Tenderness: Joints may appear enlarged or feel warm to touch.
• Decreased Grip Strength: Difficulty performing tasks such as opening jars or holding objects.

Signs

• Joint Deformities: Common patterns include swan-neck and boutonniere deformities in rheumatoid arthritis.
• Nodules and Bony Enlargements: Heberden’s and Bouchard’s nodes in osteoarthritis.
• Restricted Range of Motion: Limitation in finger flexion and extension due to pain or structural changes.

Diagnosis

History and Physical Examination

Diagnosis begins with a detailed history of symptom onset, duration, and progression. Examination includes assessment of joint swelling, tenderness, deformities, and functional impairment.

Imaging

• X-rays: Useful for identifying joint space narrowing, osteophytes, and bone erosions.
• MRI and Ultrasound: Detect synovitis, early erosions, and soft tissue involvement not visible on X-ray.

Laboratory Tests

• Rheumatoid Factor (RF): Positive in many patients with rheumatoid arthritis.
• Anti-Cyclic Citrullinated Peptide (anti-CCP) Antibodies: Highly specific for rheumatoid arthritis.
• Inflammatory Markers: Elevated ESR and CRP indicate ongoing inflammation.

Management

Non-Pharmacological Treatment

• Hand Exercises and Physiotherapy: Maintain joint mobility and improve strength.
• Splints and Orthoses: Provide support, reduce pain, and prevent deformities.
• Occupational Therapy: Adaptations to daily activities to reduce joint strain.

Pharmacological Treatment

• Analgesics: Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) to control pain.
• Disease-Modifying Antirheumatic Drugs (DMARDs): Used in rheumatoid arthritis to slow disease progression.
• Corticosteroid Injections: Reduce local inflammation and provide temporary pain relief.

Surgical Options

• Joint Fusion (Arthrodesis): Stabilizes painful joints and relieves discomfort at the cost of motion.
• Joint Replacement (Arthroplasty): Restores function in severely damaged joints.
• Synovectomy: Surgical removal of inflamed synovial tissue in rheumatoid arthritis.

Complications

• Progressive Joint Deformity: Structural changes may worsen over time if untreated.
• Loss of Hand Function: Difficulty performing daily activities due to pain or stiffness.
• Secondary Tendon Rupture: Chronic inflammation can weaken tendons, leading to rupture.
• Impact on Quality of Life: Chronic pain and functional limitation affect independence and mental health.

Prevention and Lifestyle Modifications

• Joint Protection Techniques: Avoid excessive stress on hand joints by using adaptive tools and proper ergonomics.
• Maintaining Hand Strength and Mobility: Regular exercises and stretching to preserve function and flexibility.
• Early Recognition and Treatment: Prompt evaluation of pain or swelling can prevent progression and deformities.
• Diet and Systemic Health Considerations: Balanced nutrition and maintaining healthy weight may reduce joint stress and systemic inflammation.

Prognosis

The prognosis of hand arthritis varies depending on the type, severity, and timing of intervention. Osteoarthritis generally progresses slowly and may be managed with conservative measures, while rheumatoid arthritis can lead to rapid joint destruction if untreated. Early diagnosis and appropriate treatment improve functional outcomes, reduce deformities, and enhance quality of life. Regular follow-up and adherence to therapy are key to maintaining long-term hand function.

References

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