Hand CASE 19
CASE 19
A 64-year-old, right-hand-dominant, Caucasian female presents to your office with several months of pain in the right hand. More specifically, she has noticed the pain is worse on doing pinching activities and when trying to do needlepoint and crochet. In gripping these needles, she finds her index finger to be maximally painful as does the rest of the hand. When questioned closely, it appears that the index finger is the most painful. Radiographs are shown in Figure 4–14A and B.
 |
 |
Figure 4–14 A–B
The most likely diagnosis is:
-
Posttraumatic osteoarthritis of the index finger PIP
-
Erosive osteoarthritis of the index finger PIP
-
Infectious destruction of the proximal phalangeal condyle
-
Trigger finger
Discussion
The correct answer is (B). This patient has radiographs which show multifocal small joint osteoarthritic change. This is most notable in the PIP joint of the right
index finger. The PIP joint of the index finger is unique in that it provides the stability in the act of pinching against the thumb. Therefore, it is not surprising that this patient has developed symptoms of pain as well as a sense of instability on attempting to hold crochet needles.
The patient has tried anti-inflammatories with limited success. She has been seen by other physicians and has undergone a short course of splinting as well as placement of a steroid injection, again with very limited success.
The most appropriate management at this point would be which of the following?
-
Placement of steroid injection using fluoroscopy to confirm appropriate steroid placement
-
A quick cast application to hold the PIP straight and allow it to stiffen in that position
-
Arthrodesis of the index finger PIP
-
Replacement arthroplasty of the index finger PIP
-
Reconstruction of the radial collateral complex of the index finger PIP
Discussion
The correct answer is (C). This patient has radiographs that show that she has angulatory deformity with loss of the height of the ulnar condyle. She has practically no joint space remaining and more importantly has developed a deviation deformity. Therefore, this is an unstable, painful arthritic joint. As mentioned above, the index finger PIP is critical to the act of pinching. Therefore, this patient would be a suitable candidate for PIP arthrodesis. Radial collateral ligament reconstruction is unlikely to be of use since the patient has an extremely arthritic joint. Replacement arthroplasty of the PIP is suitable for the middle or ringer fingers and occasionally for the small finger; however, when the patient requires the ability to pinch strongly, it appears that replacement arthroplasties do not do as well and tend to wear out and are not as durable. Therefore, replacement arthroplasties are avoided in the index finger PIP.
The most appropriate angle and the choice of implant for fusion would be which of the following?
-
Cannulated screw arthrodesis at 30 degrees
-
Plate and screw fixation at 30 degrees
-
Tension band wire fixation at 30 degrees
-
The choice of implant is not as critical as creation of cancellous bony surfaces which oppose and compress well at an angle between 30 and 50 degrees, customized to the patient’s occupational and avocational needs
Discussion
The correct answer is (D). In most circumstances, traditional teaching has involved increasing angles of fusion for the PIP from the index finger to the small finger. However, other schools of thought believe that the appropriate angle for fusion across all digits PIPs would be 40 degrees. Regardless of traditional teaching, in the contemporary setting with patients living longer and having more vocational and avocational needs, it becomes vital to take these into account in planning of patient’s PIP arthrodesis. For most circumstances, it appears that fusion at an angle of 40 degrees for the PIP of the index finger is highly desirable.
Objectives: Did you learn...?
Describe the clinical presentation of erosive arthritis? Identify various treatment options of erosive arthritis?