x
x

OSTEOARTHRITIS FINGER/THUMB (MP, PIP, DIP & IP)

Introduction

Osteoarthritis (OA), a degenerative joint disease, is the most common form of arthritis. OA causes bone change, loss of cartilage, and joint swelling. Ultimately, osteoarthritis causes damaged joint surfaces which rub against each other and cause more joint damage. OA of the hand is a complex disorder because the 29 bones of the hand and wrist contain multiple small joints that allow fine movement. The impact of OA on hand function depends on the digits affected. The thumb and index finger are important for pinching and fine motions, while the middle, ring, and small fingers are important for grip. OA in any of the three radial digits is associated with more severe upper-extremity disabilities. Older age and gender are well-known risk factors for OA.  Hand OA is especially common in women.

Pathophysiology

  • Normally, a dynamic remodeling process balances degradation and synthesis of the extracellular matrix. 
  • When the balance of degradation and synthesis of the extracellular matrix is lost then osteoarthritis develops.
  • In OA, degrading enzymes are overexpressed, and collagen is lost.
  • Inflammatory repair attempts are overwhelmed by progressive disease activity.

Related Anatomy

  • Two of the most common sites where OA occurs:
    • Distal interphalangeal (DIP) joint
    • Proximal interphalangeal (PIP) joint
  • Of all the joints in the body, the DIP and PIP joints of the hand are least likely to be symptomatic. Frequently the thumb IP joints and the thumb MP joints are also at risk for OA.
  • OA involving the index, long, ring and little MP joints is relatively rare; however, trauma and hemochromatosis can accelerate OA in these MP joints.

Prevalence and Related Conditions

  • Incidence rates of OA in specific joints of the hand vary widely.
  • Prevalence of radiographic OA in the hand increases with age. Prevalence is high among the elderly, ranging from 13–47% in Asian populations and 80–94% in white populations.
  • In one Korean study population (N=378) with a mean age of 75 years, prevalence was 58% in men and 67% in women.
  • The radiographic signs of OA and the symptoms of OA frequently do not correlate very closely.  Patients will present with mild radiographic joint changes and significant pain while other patients have severe radiographic changes and NO symptoms.

Differential Diagnosis

  • Bursitis
  • Gout
  • Injury (occupational, sport-related, trauma)
  • Lupus
  • Malignancy
  • Periostitis
  • Polymyalgia rheumatica
  • Rheumatoid arthritis
  • Sepsis
  • Tendonitis 
ICD-10 Codes

  • OSTEOARTHRITIS FINGER/THUMB (MP, PIP, DIP & IP)

    Diagnostic Guide Name

    OSTEOARTHRITIS FINGER/THUMB (MP, PIP, DIP & IP)

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    OSTEOARTHRITIS FINGERS (MP, PIP, DIP, IP) (HERBEDEN'S NODES)M15.1   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Osteoarthritis Finger and Thumb
  • Severe diffuse bilateral hand Osteoarthritis in patient with severe cubital tunnel syndromes.
    Severe diffuse bilateral hand Osteoarthritis in patient with severe cubital tunnel syndromes.
  • Classic appearance of OA involving the DIP joints (arrows). These DIP OA findings are called Herberden's Nodules.
    Classic appearance of OA involving the DIP joints (arrows). These DIP OA findings are called Herberden's Nodules.
  • OA involving the DIP joint, Herberden's Nodule (arrow).
    OA involving the DIP joint, Herberden's Nodule (arrow).
  • OA left ring finger PIP joint (arrow). Note enlarged joint size and lack of flexion (insert).
    OA left ring finger PIP joint (arrow). Note enlarged joint size and lack of flexion (insert).
  • OA right long finger PIP joint. Note joint deformity and lack of flexion (insert).
    OA right long finger PIP joint. Note joint deformity and lack of flexion (insert).
  • OA left thumb IP joint. Note joint dorsal deformity (arrows).
    OA left thumb IP joint. Note joint dorsal deformity (arrows).
Symptoms
Pain frequently occurs after increased use of hands; may be dull or burning
Hypertrophic and swollen joints are common in severe OA cases, especially in the DIP joints
Warmth around joints with crepitus and/or joint instability
Patients with DIP OA may present with mucoid cysts as a presenting complaint
Weak pinch is commonly associated with OA of the thumb CMC, MP, and/or IP joints.
Typical History

The patient is typically older than 35 years and female. She will describe gradual onset of symptoms, and the main symptom will be pain. The patient is likely to have difficulty opening a jar or turning a key and may describe a grinding sensation at the affected joint. A parent may have a history of OA.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Finger/Thumb Osteoarthritis Imaging
  • Severe index DIP OA with bone loss (arrow).
    Severe index DIP OA with bone loss (arrow).
  • DIP OA little finger (arrow)
    DIP OA little finger (arrow)
  • Thumb OA of the IP joint (1), MP joint (2) and CMC joint (3).
    Thumb OA of the IP joint (1), MP joint (2) and CMC joint (3).
  • Patient complaining of thumb MP joint pain. No trigger thumb or significant MP OA identified (1) but note osteophytes and sclerosis (2) in the sesamoid metacarpal head joint.
    Patient complaining of thumb MP joint pain. No trigger thumb or significant MP OA identified (1) but note osteophytes and sclerosis (2) in the sesamoid metacarpal head joint.
  • PIP joint severe OA (1) and DIP joint OA (2).
    PIP joint severe OA (1) and DIP joint OA (2).
  • PIP joint severe OA - AP and Lateral X-ray.
    PIP joint severe OA - AP and Lateral X-ray.
Treatment Options
Treatment Goals
  • Establish an accurate diagnosis
  • Maintain function by controlling joint pain
  • Recommend appropriate medical and surgical treatment
Conservative
  • Anti-inflammatory medications (eg, acetaminophen and ibuprofen)
  • Tpocal NSAID's
  • Steroid joint injection(s) 
  • Glucosamine and chondroitin, although the evidence is not sufficiently supportive for these food supplements.
  • Hand therapy
  • Hyaluronate injections 
  • PRP injections (evidence is not especially supportive)
  • Activity modifications
  • Splinting and compression gloves
Operative
  • Reconstruction and preservation 
  • Arthrodesis 
  • Joint replacement
  • Postoperative splint or cast may be necessary
  • Hand therapy after surgery
Treatment Photos and Diagrams
Fusions for Finger Osteoarthritis
  • Fusion of little finger DIP joint for pain secondary to OA.
    Fusion of little finger DIP joint for pain secondary to OA.
  • Index PIP joint OA with swelling and deformity (arrow). Note incision plan.
    Index PIP joint OA with swelling and deformity (arrow). Note incision plan.
  • Index PIP joint OA with open extensor hood and joint capsule (1); Note synovitis (2); Note severely damaged cartilage
    Index PIP joint OA with open extensor hood and joint capsule (1); Note synovitis (2); Note severely damaged cartilage
  • Index PIP joint fusion in mild flexion with K-wire (1). Residual cartilage has been removed and head of P1 fitted into base of P2; Note sutured capsule and extensor tendontomy (2).
    Index PIP joint fusion in mild flexion with K-wire (1). Residual cartilage has been removed and head of P1 fitted into base of P2; Note sutured capsule and extensor tendontomy (2).
  • X-ray of index PIP joint fusion in mild flexion. K-wire in place.
    X-ray of index PIP joint fusion in mild flexion. K-wire in place.
Arthroplasty for Finger Osteoarthritis
  • PIP joint exposed for pyrocarbon arthroplasty (1). Note extensors left attached to dorsal P2; Periosteum and capsule being removed (2) from neck of P1.
    PIP joint exposed for pyrocarbon arthroplasty (1). Note extensors left attached to dorsal P2; Periosteum and capsule being removed (2) from neck of P1.
  • Awl opening and shaping P1 intermedullary canal for stem of prosthesis.
    Awl opening and shaping P1 intermedullary canal for stem of prosthesis.
  • Cutting guides (arrows) used to accurately cut and shape head of P1.
    Cutting guides (arrows) used to accurately cut and shape head of P1.
  • Awl opening P2 (1); Prosthesis in P2 (2).
    Awl opening P2 (1); Prosthesis in P2 (2).
  • Tamp seating permanent prothesis in P1
    Tamp seating permanent prothesis in P1
  • PIP joint pyrocarbon arthroplasty final X-ray.
    PIP joint pyrocarbon arthroplasty final X-ray.
Fusions for Thumb Osteoarthritis
  • Thumb hypertension must be controlled at the time of Thumb CMC arthroplasty. An excellent control method is thumb MP joint fusion which is also an excellent surgical treatment for MP joint OA.
    Thumb hypertension must be controlled at the time of Thumb CMC arthroplasty. An excellent control method is thumb MP joint fusion which is also an excellent surgical treatment for MP joint OA.
  • Dorsal incision is used to open the EPL/EPB interval and MP capsule. The metacarpal head cartilage is exposed (arrow).
    Dorsal incision is used to open the EPL/EPB interval and MP capsule. The metacarpal head cartilage is exposed (arrow).
  • Note normal cartilage (insert) which is being removed by a rongeur because of hyperextension in this case.
    Note normal cartilage (insert) which is being removed by a rongeur because of hyperextension in this case.
  • Metacarpal head shaped to fit into the base (cone) of the proximal phalanx (1); Cartilage cap has been remove after outlining the osteo-cartilage interval with a small K-wire and completing the removal with a small osteotome. (2)
    Metacarpal head shaped to fit into the base (cone) of the proximal phalanx (1); Cartilage cap has been remove after outlining the osteo-cartilage interval with a small K-wire and completing the removal with a small osteotome. (2)
  • Metacarpal head fitted and compressed into the base of the proximal phalanx and secured with two K-wires. First K-wire passed retrograde into IP joint, then ante-grade into the head and final through the dorsal metacarpal shaft cortex. (1-3)
    Metacarpal head fitted and compressed into the base of the proximal phalanx and secured with two K-wires. First K-wire passed retrograde into IP joint, then ante-grade into the head and final through the dorsal metacarpal shaft cortex. (1-3)
  • Final MP joint compression secured by K-wire(s). MP capsule and EPL/EPB extensor interval being sutured. (2)
    Final MP joint compression secured by K-wire(s). MP capsule and EPL/EPB extensor interval being sutured. (2)
  • Final X-ray after MP joint fusion. Note mild flexion position and second K-wire to add fixation and rotational control in this case.
    Final X-ray after MP joint fusion. Note mild flexion position and second K-wire to add fixation and rotational control in this case.
CPT Codes for Treatment Options

Per an agreement between Hand Surgery Resource, LLC and the American Medical Association (AMA) users are required to accept the following End User Point and Click Agreement in order to view CPT content on this website.  Please read and then click "Accept" at the bottom to indicate your acceptance of the agreement.

End User Point and Click Agreement

CPT codes, descriptions and other data only are copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. The AMA reserves all rights to approve any license with any Federal agency.

You, as an individual, are authorized to use CPT only as contained in Hand Surgery Resource solely for your own personal information and only within the United States for non-commercial, educational use for the purpose of education relating to the fundamental principles of hand surgery and the common diseases, disorders and injuries affecting the human hand. You agree to take all necessary steps to ensure your compliance with the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 330 N. Wabash Avenue, Chicago, IL 60611. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt.

Common Procedure Name
PIP/DIP joint arthrodesis
CPT Description
Arthrodesis interphalangeal joint with or without internal fixation
CPT Code Number
26860
Common Procedure Name
MP joint arthrodesis
CPT Description
Arthrodesis metacarpophalangeal joint w/wo internal fixation
CPT Code Number
26850
Common Procedure Name
MP joint arthroplasty
CPT Description
Arthroplasty, metacarpophalangeal jont, each joint
CPT Code Number
26530
Common Procedure Name
PIP joint arthroplasty
CPT Description
Arthroplasty, proximal interphalangeal joint with prosthetic implant, each joint
CPT Code Number
26536
Common Procedure Name
Ulnar collateral ligament repair
CPT Description
Repair of collateral ligament, metacarpophalangeal or interphalangeal joint
CPT Code Number
26540
Common Procedure Name
Gamekeeper's repair
CPT Description
26540
Gamekeeper's repair

Primary repair collateral ligament metacarpophalangeal joint
CPT Code Number
26542
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

CPT QuickRef App.  For Apple devices: App Store. For Android devices: Google Play

CPT 2021 Professional Edition: Spiralbound

Complications

Surgical complications;

  • Infection
  • Persistent deformity
  • Pain
  • Decreased hand function
Outcomes
  • Due to the complexity of the hand, OA treatment outcomes depend on the location of disease, rapidity of disease progression, degree of degeneration, patient characteristics (eg, compliance), activities of daily living and occupation and myriad other factors.  
  • If surgery is successful, patients usually return to full function in ~3 months. 
  • Surgery is especially helpful when there are a limited number of joints with symptomatic OA.
Key Educational Points
  • A dynamic remodeling process usually maintains cartilage volume, but in OA the balance shifts, and progressive degradation results. 
  • Loss of normal joint space, bone spurs, and other changes may indicate the presence of OA
  • Mucoid cysts are frequently associated with DIP joint OA3
  • Osteoarthritis develops as abnormal joint forces stimulate the chondrocytes to release inflammatory mediators which include aggrecanases and matrix metalloproteinases (MMPs).  These proteolytic enzymes cause the cartilage matrix destruction that leads to osteoarthritis.4
  • Severe thumb MP joint osteoarthritis can be treated with MP joint arthrodesis (fusion).  Thumb MP fusion is also indicated when the thumb MP joint hyperextends excessively and a thumb CMC fascial arthroplasty is needed.5
  • Hemochromatosis is rare, but early disease often involves the index and long finger MP joints.  Additional findings include chondrocalcinosis (as seen in pseudogout) and hooked osteophytes on the radial aspect of the metacarpal head.  If expected, patients with possible hemochromatosis should be referred to a hematologist for a laboratory workup and appropriate treatment.6
  • Thumb MP joint pain can also becaused by thumb/sesamoid osteoarthritis
  • Pyrocarbon arthroplasties have a higher revision rate than other finger protheses.7
  • All finger joint arthroplasties have a limited long term longevity.
  • Finger PIP arthodeses have excellent longevity but patients miss PIP flexion.
References
  1. Deans VM, Naqui Z, Muir LT. Scaphotrapeziotrapezoidal joint osteoarthritis: A systematic review of surgical treatment. J Hand Surg Asian Pac Vol 2017;22(1):1-9.PMID: 28205478
  2. Østerås N, Kjeken I, Smedslund G, et al. Exercise for hand osteoarthritis. Cochrane Database Syst Rev2017;1:CD010388. PMID: 28141914
  3. Budoff JE. Mucous cysts. j Hand Surg Am.2010; 35A: 828-830.
  4. Carballo CB, Nakagama Y, Sekiya I, Rodeo SA. Basic science of articular cartilage. Clin sporets med. 2017; 36(3): 413-425.
  5. Poulter RJ, Davis TRC. Management of hypertension of the metacarpalphalangeal joint in association with trapezometacarpal joint osteoarthritis. J Hand Surg Eur.q2011; 30:280-284.
  6. Umberhandt R, Isaacs J. Diagnostic considerations for monarticular arthritis of the hand and wrist. J Hand Surg Am.2012; 37(7); 1480-1485.
  7. Dickson DR et al. Pyrocarbon proximal interphalangeal joint arhtroplasty: minimal five-year follow-up. J Hand Surg Am 2015; 40(11); 2142-2148.

Classics

  1. Marmor L, Peter JB. Osteoarthritis of the hand.Clin Orthop Relat Res1969;64:164-74.PMID: 5793008
  2. Plato CC, Norris AH. Osteoarthritis of the hand: age-specific joint-digit prevalence rates.  Am J Epidemiol1979;109(2):169-80. PMID: 425956
Subscribe to OSTEOARTHRITIS FINGER/THUMB (MP, PIP, DIP & IP)
⇡