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Joint Disease

Hand osteoarthritis: diagnosis, non-operative management, and surgical options for DIP, PIP, and CMC joints.

135 citationsUpdated Oct 2026

Overview

Psoriatic arthritis is primarily managed with biologic therapy and disease-modifying antirheumatic drugs, though end-stage joint destruction may necessitate surgical intervention [2]. In rheumatoid arthritis, initiating disease-modifying antirheumatic drugs within the first three months of diagnosis improves long-term outcomes [5]. Surgical indications vary by joint pathology; basal joint arthroscopy evaluates cartilage and ligament lesions to classify osteoarthritis [7], while silicone metacarpophalangeal arthroplasty requires careful consideration given advances in medical management [13]. For thumb deformities, a modified classification may support joint-preserving surgery in Type 1 rheumatoid arthritis [27], and A1 pulley release indications are evolving with the improved natural history associated with biologic DMARDs [28].

Surgical outcomes are generally acceptable but depend on disease status and timing. Interpositional arthroplasty for rheumatoid carpometacarpal disease yields acceptable functional results, though overall outcomes are influenced by disease in other joints [15]. Distal radioulnar joint surgery in rheumatoid arthritis is most effective before severe destruction, fixed contractures, or dislocation occur [29]. Silicone-rubber metacarpophalangeal arthroplasty remains acceptable for proximal interphalangeal joint function despite potential deterioration [31]. For advanced thumb metacarpophalangeal arthritis, fusion is the benchmark, though arthroplasty is a viable option to reduce pain, preserve motion, and limit adjacent joint progression [32]. In children, synovectomy for rheumatoid arthritis shows short-term results no less favorable than in adults, with abnormal growth from inflammation serving as a key indication [35].

Joint replacement procedures relieve pain and improve function more than other operative treatments for osteoarthrosis, although synthetic materials cannot fully duplicate articular cartilage properties [59]. For early-stage thumb carpometacarpal osteoarthritis, denervation, joint lavage, and capsular imbrication offer low-invasiveness alternatives with short recovery times [60]. Patients generally prefer arthroplasty over arthrodesis for proximal interphalangeal joint osteoarthritis due to preserved motion and grip strength [130]. Newer unconstrained surface replacement arthroplasties show promise in select cases of metacarpophalangeal joint osteoarthritis and inflammatory arthritis [139], and implant arthroplasty is considered for idiopathic metacarpophalangeal osteoarthritis refractory to nonsurgical measures [143]. Further study is required to clarify indications and outcomes for consistent multidisciplinary advice in rheumatoid hand operations [138].

Anatomy & Pathophysiology

Osteoarthritis Pathophysiology

Osteoarthritis is a chronic, progressive synovial joint arthrosis that afflicts 140 million people worldwide [10]. It affects all synovial joint structures, including the synovium, joint capsule, cartilage, and bone [10]. Etiological factors include biochemical, mechanical, metabolic, and genetic influences [10]. The condition is typically induced by acute or chronic mechanical injury to hyaline cartilage resulting from trauma, joint instability, ligamentous deficiency, skeletal malalignment, obesity, or anatomic deformity [10]. Mechanical overloading leads to glycosaminoglycan loss, collagen disorganization, fibrillation, tissue swelling, and surface wear [10]. This overloading incites an inflammatory response mediated by a cascade of cytokines [10]. Elevated cytokines in synovial fluid, such as interleukin 1α and tumor necrosis factor-α, induce enzyme-mediated cartilage degeneration via metalloproteinases and ADAMTS [10].

The synovial fluid’s capacity for fluid and boundary lubrication decreases due to reduced hyaluronic acid molecular weight and lubricin degradation [10]. In advanced osteoarthritis, synovial fluid contains minimal hyaluronic acid and lubricin, contributing to poor lubricity and a higher coefficient of friction similar to saline [10]. Histopathologically, the disease is characterized by simultaneous cartilage matrix degradation and repair, including chondrocyte death, replication, and regeneration [10]. The degeneration of articular cartilage is an integral part of the clinical syndrome [171]. Osteoarthritis consists of a generally progressive loss of articular cartilage accompanied by attempted repair [171]. It involves remodeling and sclerosis of subchondral bone [171], often with the formation of subchondral bone cysts and marginal osteophytes [171]. A diagnosis requires symptoms and signs including joint pain, restriction of motion, crepitus with motion, joint effusions, and deformity [171]. The condition occurs most frequently in the foot, knee, hip, spine, and hand joints [171].

Pathological features include progressive degeneration of articular cartilage with loss of chondrocytes and extracellular matrix [208]. Synovial inflammation is characterized by synovial hyperplasia and inflammatory cell infiltration [208]. Abnormal remodeling of subchondral bone is also present [208]. Pathogenesis involves the interaction of environmental risks, abnormal joint biomechanics, dysregulated pain signaling, and upregulated inflammatory pathways [208]. BCP crystals containing hydroxyapatite have been detected in 70% of osteoarthritis cases [106]. These crystals correlate with the extent of cartilage degradation and lesion severity [106]. BCP crystals activate joint cells including fibroblasts, macrophages, chondrocytes, and osteoclasts [106]. Activated joint cells produce cartilage-degrading matrix proteinases and pro-inflammatory cytokines in response to BCP crystals [106].

Rheumatoid Arthritis Pathophysiology

In rheumatoid arthritis, immune complexes within the synovial membrane lead to an inflammatory cell response that causes synovial hyperplasia and joint destruction [102]. Synovitis resulting in the release of inflammatory enzymes causes weakening of the capsular ligaments [102]. This weakening leads to valgus of the first metatarsophalangeal joint and weakening of the intrinsic muscles of the lesser toes [102]. Chronic dorsal subluxation of the metatarsophalangeal joints leads to imbalance between intrinsic and extrinsic muscles [102]. Interossei are pulled dorsal to the axis of rotation, converting them to weak extensors [102]. The most important factor in the development of finger deformities is the changes occurring in the tendons and related structures, especially in early stages [177]. Rheumatoid arthritis has a predilection for the wrists and the proximal joints of the hands and feet [40]. Physical findings tend to be symmetrical [40], and onset tends to present in a subacute manner [40].

Hand Anatomy

The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [41]. The hand is divided into five rays, each comprising a polyarticulated chain of metacarpals and phalanges [41]. The base of each metacarpal articulates with the distal row of the carpus [41], while the carpus articulates with the forearm through its proximal row [41]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration [41]. The radial ray is the shortest, made up of a metacarpal and two phalanges [41]. The trapezium is angled out in front of the carpal plane so that the first metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [41]. The thumb metacarpal is the shortest, and the index metacarpal is by far the longest [41]. The proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [41].

The hand presents a longitudinal and transverse concavity, giving it the shape of a cup with a palmar concavity when the thumb is placed next to the index finger [41]. The transverse axis of the palm is oblique, more distal at the metacarpophalangeal joint of the index finger and more proximal at the fifth metacarpophalangeal joint [41]. This transverse axis forms an acute angle of approximately 75 degrees with the longitudinal axis [41]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal [41], and at the distal ends of the other metacarpals [41]. The hand consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand [85]. It has about the same number of tendons activated by the forearm muscles [85].

The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [39]. First compartment: Contains the abductor pollicis longus and the extensor pollicis brevis [39]. The abductor pollicis longus inserts at the base of the thumb metacarpal and radially abducts the thumb [39]. The extensor pollicis brevis inserts on the dorsum of the proximal aspect of the proximal phalanx of the thumb and actively extends the metacarpophalangeal joint [39]. Second compartment: Contains the extensor carpi radialis longus and the extensor carpi radialis brevis [39]. The extensor carpi radialis longus inserts on the index metacarpal, dorsiflexes and radially deviates the wrist [39]. The extensor carpi radialis brevis inserts into the base of the middle metacarpal and provides balanced wrist dorsiflexion [39]. Third compartment: Contains the extensor pollicis longus, which turns abruptly radialward about Lister tubercle [39]. It inserts on the distal phalanx and provides forceful extension of the thumb interphalangeal joint [39]. The oblique course of the tendon provides a substantial adduction component to its pull [39]. Fourth compartment: Contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [39]. Fifth compartment: Contains the extensor digiti quinti [39].

The principal bony insertion of the extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [39]. Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [39]. Distal interphalangeal joint extension is achieved through the conjoined lateral bands composed of tendinous slips from the extrinsic and intrinsic tendons [39]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered together by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [39]. Digital extensor tendons are stabilized over the mid-line of the metacarpophalangeal joint by their attachment to sagittal band fibers [39]. These fibers insert onto the volar proximal phalanx and onto the lateral borders of the volar plate [39]. They form a sling that allows proximal extrinsic extensor tension to be transmitted to the proximal phalanx, permitting metacarpophalangeal joint extension without a tendinous insertion onto the proximal phalanx [39]. With rupture or attenuation of the sagittal band fibers, the extrinsic extensor tendon can sublux to the ulnar side of the metacarpal head causing ulnar deviation of the finger [39].

The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [39]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [39]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [39].

There are seven interosseous muscles, four dorsal and three volar [88]. The dorsal interossei are abductors [88]. They lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers [88]. The little finger is abducted by the abductor digiti quinti [88]. The volar interossei are adductors and lie to the ulnar side of the index finger and the radial side of the ring and little fingers [88]. The middle finger has two dorsal interossei and no volar interossei because the central axis of the hand lies within it [88]. Each dorsal interosseous muscle, with the exception of the third, has two muscle heads [88]. The superficial head arises most dorsally from the shaft of the contiguous metacarpals and is inserted deeply by a medial tendon onto the lateral tubercle of the base of the proximal phalanx [88]. It abducts and weakly flexes the proximal phalanx [88]. The deep head forms a lateral tendon, or lateral band, at the level of the MP joint [88]. It flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [88].

At the level of the middle of the proximal phalanx, transverse fibers arch dorsally from each lateral band to join each other over the dorsum of the finger, flexing the proximal phalanx [88]. Oblique fibers from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx, extending the middle phalanx [88]. The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [88]. The two conjoined lateral bands to each finger unite at the distal third of the middle phalanx to form the terminal tendon, which inserts at the base of the distal phalanx to extend it [88]. The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei, forming the ulnar lateral band of the little finger [88].

The three volar interossei arise from adjacent surfaces of contiguous metacarpal shafts [88]. Each volar interosseous muscle has only one muscle head and none of them insert onto the proximal phalanx [88]. The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [88]. The abductor digiti quinti and flexor digiti quinti brevis are similar in both structure and function to the superficial and deep heads of the dorsal interossei, respectively, and arise from the fifth metacarpal [88]. The abductor digiti quinti inserts onto the ulnar lateral tubercle at the base of the proximal phalanx of the little finger [88]. The flexor digiti quinti forms the ulnar lateral band [88]. The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate and inserts onto the ulnar side of the diaphysis of the fifth metacarpal, which it flexes and supinates [88].

The metacarpal arch is endowed with a great deal of adaptability because of the mobility of the peripheral metacarpals [91]. The peripheral metacarpals form the sides of the cup or the palmar gutter and can deepen the concavity as they approach each other [91]. The thumb metacarpal is independent and articulates with the trapezium [91]. The middle metacarpals are united to the carpus by the intrinsic interlocking encasement of the bones themselves [91]. The index metacarpal is the most firmly fixed [91]. The ring metacarpal is a transitional element to the fifth metacarpal and has about 10 degrees of mobility in flexion and extension [91]. The fifth metacarpal is semi-independent, articulates with the hamate, and is restrained on its radial side by its articulation with the base of the fourth metacarpal [91]. It has a range of flexion–extension of approximately 20 degrees [91]. The second to fifth metacarpals are all bound together by various fibrous structures, the most distal of which is the deep transverse intermetacarpal ligament [91]. This ligament is better named the interglenoid ligament because it ties together the anterior glenoid ligaments of the metacarpophalangeal articulations, known as the volar plates [91].

The longitudinal arches are composed of a fixed portion, the carpometacarpal, and a mobile portion, the digits [91]. The keystones of the longitudinal arches are the metacarpophalangeal articulations, whose thick anterior glenoid capsules, the volar plates, prevent hyperextension [91]. The volar plates are interconnected by the transverse interglenoid ligament [91]. The stability of the metacarpophalangeal joints is essential to the support of the longitudinal arch as well as of the transverse metacarpal arch [91]. The fourth carpometacarpal joint is the area of greatest variation in the osseous morphology at the carpometacarpal joint level in the human hand [81].

The superficial palmar fascia lies in a coronal plane beneath the palmar subcutaneous tissue [100]. It covers a triangular area of the central palm, the proximal corner facing directly proximal [100]. The palmaris longus tendon, when present, terminates in continuity with the fibers of this proximal corner [100]. Four central bands of fascia extend distally from the proximal corner toward each of the fingers [100]. There is no central band for the thumb [100]. At the distal palmar crease level, the central bands are bridged transversely by the superficial transverse palmar ligament [100]. Fibers from the central bands pass above, below, and through the superficial transverse palmar ligament [100]. Superficial fibers of the central bands stay superficial and merge with vertical retinacular fibers at the dermis’s undersurface in the distal palm in areas between skin flexion cre

Classification

Diagnostic Principles: The final diagnosis of palindromic rheumatism requires ruling out other arthritic disorders and observing a protracted, non-destructive course over time [1]. For monoarticular arthritis of the hand and wrist, subtle differences in history, examination, laboratory values, and imaging improve diagnostic acumen and expedite appropriate treatment options [4]. Diagnostic indications for basal joint arthroscopy include the assessment of painful post-traumatic basal joint lesions of cartilage and ligaments, and the evaluation of chondromalacia and ligament attenuation to help classify basal joint osteoarthritis [7].

Osteoarthritis Pathophysiology: Osteoarthritis is a chronic, synovial joint arthrosis afflicting 140 million people worldwide [10]. It is progressive, with changes in joint structure and function appearing relatively late in the disease process but accounting for long-term morbidity and disability [10]. While the etiology of osteoarthritis is multi-factorial, it is typically induced by acute or chronic mechanical injury to hyaline cartilage as a consequence of trauma, joint instability, ligamentous deficiency, skeletal malalignment, obesity, or anatomic deformity [10]. Mechanical overloading in osteoarthritis results in glycosaminoglycans loss, collagen disorganization, fibrillation, tissue swelling, and surface wear, and incites an inflammatory response mediated by a cascade of cytokines [10]. Elevated cytokines in osteoarthritis synovial fluid, such as interleukin 1α and tumor necrosis factor-α, induce enzyme-mediated cartilage degeneration [10]. In advanced osteoarthritis, synovial fluid contains minimal hyaluronic acid and lubricin, further contributing to poor lubricity and higher coefficient of friction [10].

Thiemann Disease: Thiemann disease can be distinguished from osteoarthritis, juvenile rheumatoid arthritis, and gout by its early age of onset, equal sex incidence, characteristic joint distribution, and lack of abnormal laboratory findings [20].

Rheumatoid Arthritis: The Arthritis Committee recognizes the profound importance of arthritic disorders to the general population, not only as a health problem, but for their social and economic impact [30]. The 1958 revision of diagnostic criteria for rheumatoid arthritis is hoped to aid in obtaining more uniformity in the classification of patients with rheumatoid arthritis [38]. In rheumatoid arthritis, a third dimension is crucial for classification because it is a chronic disease; the anticipation of future disease development must be considered within the framework of a classification system [134]. The Larsen, Dale, and Eek (LDE) classification published in 1977 is still widely used due to its simplicity in describing the severity of destruction in rheumatoid arthritis [134]. The LDE classification built a score for the most important joints involved in rheumatoid arthritis and calculates a single general number over all these joints [134]. The LDE classification was modified in 1995 to facilitate the classification, including osseous and joint space changes [134]. Grading of joint and bone destruction in rheumatoid arthritis has the advantage that it can be applied to different joints and may be used to quantify the severity of the disease with a total scoring of the most often involved joints [134]. Grading is mainly helpful in the course of rheumatoid arthritis to judge the progression of the destruction and its distribution [134].

Metacarpophalangeal Joint: A new classification for locked metacarpophalangeal joint should focus on the causes depending on the clinical presentation of the locking, so as to improve the correlation between clinical presentation, etiology and treatment [46].

Trapeziometacarpal Joint: Radiographic staging of trapeziometacarpal arthrosis has moderate interobserver and intra-observer reliability [56]. There is only fair inter-observer agreement in treatment recommended based on radiographic staging of trapeziometacarpal arthrosis, with a kappa of 0.33 [56]. Inclusion of patients with scaphotrapeziotrapezoid osteoarthrosis would be expected to worsen outcomes, especially if preoperatively symptomatic [66]. The Dell classification (I–IV scale) gives particular attention to the severity of joint subluxation in trapeziometacarpal joint degeneration [178]. The Eaton classification (I–IV scale) focuses on osteophytes formation in trapeziometacarpal joint degeneration [178]. The Crosby classification (0–III scale) concentrates on the scaphotrapeziumtrapezoide articulation in trapeziometacarpal joint degeneration [178]. A score composed of the sum of the Dell, Eaton–Littler, and Crosby classifications was calculated to consider all aspects of articular degeneration, whereby a score of 2 corresponds to a minimal joint degeneration and a score of 11 corresponds to a complete joint destruction [178]. Treatment choice for trapeziometacarpal arthrosis was classified as (1) education, (2) splint, (3) cortisone injection, and (4) surgery [207].

Other Considerations: A total of 24% of respondents in a UK study stated that they were aware of a classification system for grading osteoarthritis severity [67]. Of the respondents aware of a classification system for grading osteoarthritis severity, 21 were either aware of the Eaton and Littler classification system or stated grades 1–4, which are used in this system [67]. The other six respondents aware of a classification system for grading osteoarthritis severity stated a variety of other nonstandardized classification systems [67]. Characteristic roentgenographic features of hand and wrist involvement in calcium pyrophosphate dihydrate crystal deposition disease included cartilage and synovial calcification and arthropathy of the metacarpophalangeal joints and the radiocarpal compartment of the wrist, including scapholunate dissociation [68]. There are two main goals of any classification system used in medicine: to standardize communication among clinicians to group different patient populations and to provide treatment recommendations [134]. Familial clustering of severe carpometacarpal joint osteoarthritis was observed in a statewide population, indicating that genetic and environmental factors contribute to the disease process [136]. Hand osteoarthritis was defined as having a Kellgren-Lawrence score of ≥ 2 in at least two of the three groups (distal interphalangeal, proximal interphalangeal, and first carpometacarpal joints) in at least one hand [151]. The inter-rater agreement of classifying participants as “no hand osteoarthritis” versus “hand osteoarthritis” using the Kellgren-Lawrence classification showed a Kappa coefficient of 0.62 (95% CI 0.51–0.72), indicating moderate agreement [151]. Hand osteoarthritis was categorized as no hand osteoarthritis if there was no osteoarthritis or only one joint group was involved, moderate hand osteoarthritis if 2–4 joint groups were involved, and severe hand osteoarthritis if 5–6 joint groups were involved [151]. In all grades of the classification for radiographic osteolytic changes after silastic metacarpophalangeal arthroplasty, osteolysis was more frequent in the Sutter than in the Swanson group [169]. The system used to grade the location of cartilage damage in the first carpometacarpal joint divided the trapezium and metacarpal into a total of six anatomical areas: dorsoradial, voloradial, dorsoulnar, and voloulnar trapezial; volar and dorsal metacarpal [175]. The degree of cartilage lesion in the first carpometacarpal joint was graded on a five-point scale that allowed for the coding of degree of cartilage damage based on the observations of specific common types of cartilage lesions [175]. An overall joint grade for the first carpometacarpal joint was assigned to each specimen on the basis of the highest site-specific grade for that joint [175]. A decrease in the type III to type I collagen ratio was found in progressive disease stages of Dupuytren’s disease [209]. The type III collagen decreased as a percentage of the total collagen surface area from a range of 35–49% (mean 38%) in the proliferative stage (I) to a range of 21–33% (mean 27%) in the involutional stage (II) and a range of 11–19% (mean 14%) in the residual stage (III) [209]. The analysis of cellularity (number of nuclei per square millimetre) gave results of stage I range 4680–6230 (mean 5634), stage II range 3760–5970 (mean 5550), and stage III range 390–2250 (mean 1670) [209]. Type III collagen was used as an additional parameter in the existing Luck's classification staging system for Dupuytren’s disease [209]. The proposed staging system for Dupuytren’s disease based on type III collagen as a percentage of total collagen is: Luck's stage I, 35%; Luck's stage II, 420 or 535%; and stage III, 520% [209]. Green’s classification grading of trigger digit was used to compare changes in grade between initial and final assessment in a randomized clinical trial of orthoses [210].

Clinical Presentation

General Diagnostic Principles

The patient’s history and physical examination constitute the most important components of diagnosing arthritis in children, although laboratory and imaging studies can assist in differentiating disorders [16]. A careful physical examination is essential to direct care and future testing, as diagnostic tests such as imaging and serum laboratory studies can be expensive, time-consuming, and often nonspecific [17]. The diagnosis of inflammatory arthritis requires a complete review of the disease process profile, as there are no simple clinical tests that can be used to diagnose these diseases [40]. Key diagnostic features include the location of joint problems and the symmetry of presentation [40], along with the onset and chronology of the disease [40]. Age, gender, and precipitating factors can also aid in the diagnosis of inflammatory arthritis [40]. For monoarticular arthritis of the hand and wrist, subtle differences in history, examination, laboratory values, and imaging can improve diagnostic acumen and expedite appropriate treatment options [4]. Specific exfoliative cytological patterns can be readily recognized in fluids aspirated from joints in a variety of arthritides, supporting the technique as a valuable diagnostic aid [121].

Osteoarthritis

Changes in joint structure and function appear relatively late in the osteoarthritis disease process but account for long-term morbidity and disability [10]. The diagnosis of hand osteoarthritis is consistent with the American College of Rheumatology classification, radiologic criteria according to Kallman et al., and disease activity criteria according to the Doyle Articular Index [116]. Severity is determined by ACR classification and clinically assessing the presence of pain, aching or joint stiffness, bony enlargement of 2 or more of 10 selected finger joints, bony enlargement of at least a distal interphalangeal joint, fewer than 2 swollen metacarpophalangeal joints, or deformity of at least 1 of 10 selected joints [116]. The presence of osteoarthritis is confirmed by recent X-rays taken of each hand less than 1 year prior, interpreted by a radiologist and confirmed by a rheumatologist [116]. Although no disease-modifying treatment exists for hand osteoarthritis, multiple options are available for managing it in rheumatology practice with the goal of achieving symptom relief and optimizing hand function [43]. Unrecognized joint incongruity in early-stage trapeziometacarpal arthritis is likely to lead to progression of joint degeneration [12], whereas recognition of this incongruity can lead to measures that may prevent or delay progression [12]. The disease process of proximal interphalangeal joint arthritis involves a complex interplay of biochemical, metabolic, and genetic factors rather than simple mechanical stress [122].

Rheumatoid Arthritis

Early diagnosis of rheumatoid arthritis is important, and referral to a rheumatologist followed by treatment with disease-modifying antirheumatic agents has been shown to improve outcomes [18]. All patients with rheumatoid arthritis should receive one or more disease-modifying antirheumatic drugs as soon as the diagnosis is established, as evidence suggests long-term outcomes are improved when treatment begins within the first 3 months of disease [5]. Early and aggressive treatment of rheumatoid arthritis is now standard, and complete resolution of signs and symptoms is achievable in perhaps 10% of patients [9]. The severity of rheumatoid arthritis can be evaluated using Sharp scores, which include an erosion score evaluating 34 joints of the hands (total sum of points: 170) and a joint space narrowing score evaluating 36 joints of the hands (total sum of points: 144) [118].

Inflammatory and Crystal Arthropathies

Psoriatic arthritis involves the distal interphalangeal joint of the hands [40]. Other inflammatory arthritis conditions are not typically symmetrical in their physical findings [40]. Septic arthritis has a rapid onset in several hours [40]. Acute gout is characterized by acute episodes of inflammatory arthritis caused by deposition of uric acid crystals in the joints and soft tissues [21]. It typically presents as a monoarticular arthritis that most commonly affects the first metatarsophalangeal joint, termed podagra [21]. In 85%–90% of initial presentations, acute gout can involve the midfoot, ankle, or knee joint [21]. Initial presentation in the upper extremity appears to be less likely, but it can involve the elbow, wrist, and fingers [21]. Elderly women might be more likely to present with polyarticular involvement involving the fingers [21]. The shoulder is rarely affected by acute attacks of gout, but chronic gout of the shoulder has been described in case reports [21]. Gout can cause an acute carpal tunnel syndrome caused by accumulation of uric acid crystals and subsequent inflammatory response within the soft tissues of the wrist [21].

The most common complaint in acute gout is rapidly progressive joint pain over a short time course, usually less than 24 hours [21]. The affected joint is erythematous, warm, swollen, and tender to palpation [21]. Left untreated, an acute gout flare resolves over 3 to 10 days, followed by an asymptomatic phase known as the intercritical period [21]. As gout disease progresses, pain-free intervals become shorter and episodes of acute flares become more frequent [21].

The diagnosis of sea urchin spine arthritis is based on injury history, a symptom-free period, and absence of laboratory abnormalities [6]. The diagnosis of familial Mediterranean fever is clinical, based on the association of monoarticular arthritis with recurrent fever and abdominal pain, as there are no specific laboratory aids [19]. While joint involvement in familial Mediterranean fever is typically transient, permanent joint damage can occur, particularly in older children at onset [48]. The diagnosis of palindromic rheumatism requires ruling out other arthritic disorders and observing a protracted, non-destructive course over time [1]. The disorder of Thiemann's disease can be distinguished from osteoarthritis, juvenile rheumatoid arthritis, and gout by its early age of onset, equal sex incidence, characteristic joint distribution, and lack of abnormal laboratory findings [20]. The diagnosis of neuropathic arthropathy of the digit is supported by clinical, radiologic, and histologic findings after excluding infection, crystalline arthropathy, and malignancy [45]. The articular lesion in chronic post-rheumatic-fever arthritis (Jaccoud's arthritis) is distinctly different from rheumatoid arthritis, characterized by periarticular fibrosis and the absence of chronic synovitis [119].

Other Joint Conditions

The clinical manifestation of synovial chondromatosis of the shoulder is generally nonspecific, with symptoms potentially present for many years before joint function is significantly disturbed [95]. Diagnosis of trigger finger is primarily made based on history and physical examination [113]. Clinically important Dupuytren's disease is common in the general population, with a majority of diagnosed individuals undergoing treatment [109]. Physicians should be aware of Charcot joint disease presentation in patients with insensate joints to avoid overtreatment [47]. Accurate early diagnosis of irreducible volar rotatory subluxation of the proximal interphalangeal joint is important and requires careful physical examination and obtaining true lateral radiographs of the PIP joint [8]. Arthroscopy of small joints is a valuable tool for the diagnosis and treatment of osteochondral lesions such as osteochondritis dissecans [26]. Patients with degloving hand injury should be informed of the risk of destructive arthropathy, and follow-up X-ray examination is necessary even in cases with no fracture at the time of injury [14]. Joint destruction and dissemination are possible in septic monoarthritis of the first carpo-metacarpal joint caused by Mycobacterium Kansasii [22]. This case illustrates diagnostic challenges and rare early cardiac involvement, underscoring the importance of considering camptodactyly-arthropathy-coxa vara-pericarditis in the differential diagnosis of early-onset joint involvement with serosal effusions [110].

Investigations

Clinical Examination and History: Diagnostic acumen for monoarticular arthritis of the hand and wrist relies on subtle differences in history, examination, laboratory values, and imaging rather than a single pathognomonic finding [4]. Accurate early diagnosis of irreducible volar rotatory subluxation of the PIP joint requires careful physical examination and obtaining true lateral radiographs [8]. The diagnosis of sea urchin spine arthritis is based on injury history, a symptom-free period, and the absence of laboratory abnormalities [6].

Plain Radiography: Characteristic roentgenographic features of calcium pyrophosphate dihydrate crystal deposition disease in the hand and wrist include cartilage and synovial calcification and arthropathy of the metacarpophalangeal joints and the radiocarpal compartment, including scapholunate dissociation [68]. Pseudogout can mimic synovial chondromatosis clinically and roentgenographically due to extensive calcification of synovial tissue [183]. In one case of synovial chondromatosis of the interphalangeal joint, the x-ray film diagnosis was confirmed by a typical histopathologic picture [158]. The fourth carpometacarpal joint is the area of greatest variation in osseous morphology at the carpometacarpal joint level in the human hand [81]. Unrecognized joint incongruity in early-stage trapeziometacarpal arthritis is likely to lead to progression of joint degeneration, and recognition of this incongruity can lead to measures that may prevent or delay this progression [12]. In patients with established hand osteoarthritis, radiological involvement of the thumb base is associated with older age and more structural abnormalities [199]. Follow-up X-ray examination is necessary for patients with degloving hand injury even in cases with no fracture at the time of injury to monitor for destructive arthropathy [14].

MRI: MRI demonstrated erosive chondropathy of the metacarpal head in a case of a locked metacarpophalangeal joint, which was confirmed at surgical exploration [142].

CT: Arthrotomography has been found to be a useful diagnostic technique in determining the cause of a locked metacarpophalangeal joint [163].

Other Considerations: Augmenting plain radiographs with additional imaging modalities like ultrasound or dark-field imaging may aid in the diagnosis of septic arthritis of the PIP joint [148]. Even the best preoperative imaging may not demonstrate the degree of local tissue involvement in synovial chondromatosis, which can be invasive [140]. Surgical exploration is recommended for locked metacarpophalangeal joints caused by incarcerated fracture fragments because it is difficult to ascertain the definitive cause preoperatively using radiographic examination [204]. Arthroscopy of small joints is a tool for the diagnosis and treatment of osteochondral lesions such as osteochondritis dissecans [26].

Laboratory: Although many OA-related biomarkers are currently available, none can be considered as a surrogate marker of clinical and imaging features for the diagnosis or prognosis of the disease at this time [42].

Treatment

Non-Operative

Non-surgical management is the initial standard of care for most joint pathologies, with specific protocols varying by diagnosis. For thumb base osteoarthritis, a stepwise approach begins with self-management, progressing to splints and injections if symptoms persist [128]. Non-surgical treatments, including hand therapy and splinting, provide adequate pain relief for the majority of patients with carpometacarpal arthritis, particularly in early stages, and can delay or obviate the need for surgery [160]. The American College of Rheumatology strongly recommends splinting for this condition [160], while the European League Against Rheumatism 2018 guidelines reserve surgery for cases where pain persists after non-pharmacologic treatment [160].

For articular cartilage injuries, an initial trial of nonsurgical management is warranted, comprising rest, activity modification, anti-inflammatory medications, physical therapy, bracing, or injections [105]. In shoulder osteoarthritis, nonoperative modalities are utilized before surgical options, particularly for patients with moderate-to-mild disease [125]. Similarly, nonoperative treatment is almost always initiated for primary and posttraumatic elbow arthritis, though surgery may be indicated if conservative management fails [55].

Pharmacologic options include weight loss, activity modification, anti-inflammatory medications, steroid intra-articular injections, and lubricating hyaluronic acid injections [161]. Glucosamine and chondroitin sulfate may be considered reasonable as part of a multimodal approach for symptomatic primary osteoarthritis if cost is not prohibitive [108]. Local therapy with hydrocortisone is indicated for acute or chronic inflammation of one or a few peripheral joints, excluding infection-related inflammation [172]. It is also indicated for non-specific inflammation of bursae and tendon sheaths [172], and for painfully disabling joints even in the presence of widespread disease [172]. Steroid injections have shown acceptable, long-lasting results for chronic sesamoiditis of the thumb metacarpophalangeal joint [133].

Biological injection treatments for osteoarthritis are generally safe in the majority of studies [161]. However, existing literature demonstrates anti-inflammatory properties of orthobiologics without clear evidence of significant joint preservation or reversal of osteoarthritis progression [161]. Research is ongoing to identify optimal indications, preparations, and safety profiles for these therapies [161]. The effectiveness of mesenchymal stromal cells remains uncertain, with limited market authorisations [52]. This uncertainty is compounded by unclear phenotypic parameters, a lack of a coherent biological framework for therapeutic mechanism, and complex, costly manufacturing protocols that present regulatory challenges [52].

Management of nonrheumatoid inflammatory arthroses is typically medical and continues to evolve with biologically targeted medications [57]. Treating chronic musculoskeletal pain, particularly osteoarthritis, remains challenging due to incompletely understood peripheral and central pain mechanisms and the lack of safe, efficient analgesic drugs [124]. There is a notable non-pharmacological treatment gap, with most patients reporting no or mild pain and having not received non-pharmacological treatment prior to surgical consultation [135]. Considerable variation exists in the practice of both non-surgical and surgical management of base of thumb osteoarthritis [150]. The literature guiding nonoperative care of trapeziometacarpal joint osteoarthritis is characterized by a lack of homogeneity, small sample sizes, and extremely short follow-up periods [156]. Patients with thumb basal joint arthritis use cannabis-related products, with mixed reports on efficacy [120].

Operative

Indications: Surgical intervention is indicated when conservative measures fail or specific structural criteria are met. For thumb carpometacarpal arthritis, surgery is recommended only if pain persists following non-pharmacologic treatment [160]. In coxa vara in childhood, surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, whereas moderate nonprogressive deformity often does not require surgery [173]. For rheumatoid arthritis, surgery is worthwhile if pain can be significantly relieved when adequate medical treatment has failed [107]. If pain is not the primary consideration, the surgeon must have reasonable confidence that the selected procedure can restore enough function to justify the intervention [107]. Patients with end-stage joint destruction in psoriatic arthritis may require surgery [2].

Surgical Approach / Technique: The goals of surgery for rheumatoid arthritis are to relieve pain, restore function, correct or prevent deformity, and inhibit disease progression [107]. Surgery neither cures the disease nor restores the hand to normal [107]. Although many deformities are correctable, local disease progression may not be altered by surgical procedures [107]. If rheumatoid synovitis or tenosynovitis persists despite good medical treatment, synovectomy and tenosynovectomy are worthwhile prophylactic procedures that may help delay further distention of the joint capsule and ligament, as well as prevent tendon rupture [107].

For thumb carpometacarpal joint osteoarthritis, denervation, joint lavage, and capsular imbrication offer a less invasive alternative in earlier stages, with advantages including low complication rates and short recovery times [60]. Suture button suspensionplasty provides favorable outcomes, including improved range of motion and pain relief, that remain durable over time [54]. For more advanced thumb metacarpophalangeal joint arthritis, fusion is the benchmark, while arthroplasty is a viable option to reduce pain, preserve motion, and limit progression of adjacent joint disease [32]. Arthrodesis of the trapeziometacarpal joint may be used for stage II or stage III disease in the high-demand patient [64].

Treatment of the arthritic wrist requires a diversity of treatment options due to the complex integrated system of joints, rather than a single effective treatment [50]. Surgical treatments like arthroplasty are considered effective for severe cases of shoulder osteoarthritis [125]. For articular cartilage injuries, surgical management should focus on removing inflammatory mediators and restoring the osteochondral unit [105]. Options include arthroscopic débridement, bone marrow stimulation, osteochondral autograft transfer, osteochondral allograft transplantation, autologous chondrocyte implantation, and various newer, emerging techniques [105]. Arthroscopy of small joints is a tool for the diagnosis and treatment of osteochondral lesions such as osteochondritis dissecans of the metacarpal [26].

Implant Selection: Joint replacement procedures relieve pain and improve function more than other current operative treatments but are limited by the inability of synthetic materials to duplicate the properties of articular cartilage [59]. The indications for and long-term expectations of silicone metacarpophalangeal arthroplasty must be carefully examined in light of improvements in the medical management of rheumatoid disease [13]. While rheumatoid arthritis may lead to deterioration in proximal interphalangeal joint function, the overall result of silicone metacarpophalangeal arthroplasty remains acceptable with proper indications and technique [31]. Overall functional results of interpositional arthroplasty for rheumatoid carpometacarpal joint disease were generally acceptable, although often affected by the status of disease in other joints [15].

Other Considerations: Hand appearance and pain relief are highly correlated with patient satisfaction in rheumatoid arthritis surgery [107]. Soft tissue procedures for the rheumatoid swan neck finger deformity do not burn bridges, and subsequent reconstruction of the joint is still possible when and if the disease progresses [71]. In the absence of recurrent Dupuytren's disease, severe preoperative deformity, incomplete correction at surgery, and noncompliance with therapy predispose patients to worse proximal interphalangeal joint contracture [168]. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop [65]. Recommendations for the clinical management of trapeziometacarpal joint infections align with principles from large-joint infection management but are tailored to the anatomical and clinical context of the hand [63]. Surgical drainage is generally not indicated in the management of calcific periarthritis since the condition is self-limiting [190]. The treatment of index sesamoid fracture is initially conservative, but surgical excision of the bone is an effective solution in cases of failure [174].

Pain Management: There are currently no clinical practice guidelines for acute pain management in musculoskeletal injury or surgery [96]. The Centers for Disease Control and Prevention published guidelines on chronic pain and opioid use in 2016 [96]. The American Pain Society and American Society of Anesthesiologists have pain management guidelines that are more relevant for acute and postoperative pain [96]. Pain statements are included in several clinical practice guidelines of the American Academy of Orthopedic Surgeons, although there are no guidelines specifically on acute pain management for orthopedic trauma patients [96]. The Orthopedic Trauma Association is currently in progress with creating a set of clinical practice guidelines for pain management [96].

Adjuncts: Perioperative medical management considerations are critical for patients with rheumatoid arthritis. All patients with rheumatoid arthritis should receive one or more disease-modifying antirheumatic drugs (DMARDs) as soon as the diagnosis is established, as evidence suggests long-term outcomes are improved when treatment begins within the first 3 months of disease [5]. Since the introduction of DMARDs in the mid-1990s and biologics in the early 2000s, there has been an 83% reduction in rheumatoid hand surgery in the United Kingdom [107]. Rheumatoid arthritis patients may be treated with one or more drugs, such as nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, and DMARDs, which may have significant side effects [107].

Salicylates usually are discontinued 1 to 2 weeks before surgery due to their effect on platelets [107]. NSAIDs should be discontinued 2 to 5 days before surgery for rheumatoid arthritis patients [107]. Patients who have taken corticosteroids for more than a 3-week period in the previous 12 months should receive supplemental corticosteroid therapy before, during, and after surgery [107]. Side effects of patient prescription and nonprescription medications, including those used for their arthritic condition, should be considered before surgery [107]. In some cases, perioperative medical management by an internist is warranted for rheumatoid arthritis patients [107]. For minor procedures in rheumatoid arthritis patients, medications should be continued [147]. For larger procedures in rheumatoid arthritis patients, DMARDs should be discontinued 3 half-lives before surgery and resumed approximately 2 weeks after [147]. Health systems should provide first-line treatment for rheumatoid arthritis as a strategy to improve compliance with therapy and clinical outcomes, particularly in vulnerable populations [127]. Despite similar treatment, male patients with rheumatoid arthritis reported better outcomes, in particular for pain and physical function, compared to female patients [61].

If a general anesthetic is to be used during an operation on a patient with rheumatoid arthritis, the alignment and stability of the cervical spine should be investigated before surgery [107]. If the disease has been generalized and prolonged in rheumatoid arthritis, radiographs of the cervical spine are indicated to discover any subluxations [107]. The degree of cervical spine instability alerts the anesthesiologist to the possibility of spinal cord injury that may result from hyperextension or hyperflexion of the neck during intubation or maintaining a free airway [107]. Extensive involvement of the temporomandibular joint also may influence the approach to endotracheal intubation in rheumatoid arthritis patients [107].

Complications

Joint Degeneration and Instability: Observed narrowing of the scaphotrapezial joint may progress with time in young patients, potentially causing symptoms and disability [84]. In cervical rheumatoid disease, the progressive nature of the condition resulted in the recurrence of long-tract symptoms in three patients due to further subaxial subluxation distal to the original fusion site [77].

Implant Failure and Wear: The long-term survival rate of single-mobility uncemented prostheses for trapeziometacarpal osteoarthritis is satisfactory, with a critical period in the first years ranging from 83% after 5 years to 50% after 30 years [75]. Radiographic fracture following silicone metacarpophalangeal joint arthroplasty for osteoarthritis does not imply clinical deterioration [37].

Secondary Procedures and Recurrence: A total of 13% of the joints required a secondary surgical procedure following proximal interphalangeal joint pyrocarbon implantation [34]. Long-term recurrence rates for Dupuytren's disease suggest recurrence in 67% of MCP joint contractures and 100% of PIP joint contractures, though recurrence was generally less severe than the initial contracture [76].

Other Considerations: Destructive arthropathy of the interphalangeal joint can follow revascularization after degloving hand injury, and follow-up X-ray examination is necessary even in cases with no fracture at the time of injury [14].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for light activity, desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression schedules, or sling and brace removal timing.

Functional milestones: Validated patient-reported outcome measure trajectories and benchmarks are reported across several conditions. In rheumatoid arthritis, disease activity is associated with hand function impairment in patients with variable follow-up [72]. For hand osteoarthritis undergoing strength training, hand and finger function scores showed minimal dysfunction at baseline and follow-up [69]. Following percutaneous reamed arthrodesis for distal interphalangeal joint arthritis, the median VAS score for pain decreased to 0 and the Quick DASH improved to 7 at the 2-year follow-up [73]. In patients with nonrheumatic metacarpophalangeal joint arthritis undergoing silicone arthroplasty, those with more severe range of motion limitation, DASH score, and pain score experienced a greater improvement of these measures at follow-up [162].

Other Considerations: Recovery trajectories and long-term outcomes vary significantly by diagnosis and surgical intervention. In rheumatoid arthritis, complete resolution of signs and symptoms is achievable in perhaps 10% of patients [9]. Early changes in peri-articular bone density and microstructure are slow or resistant to recovery despite well-controlled inflammatory joint symptoms with early DMARD therapy [212]. Despite similar treatment, male patients reported better outcomes, particularly for pain and physical function, compared to female patients [61]. In a cohort from Nantong, China, 47.2% of people with rheumatoid arthritis experienced hand joint destruction [213]. For osteoarthritis, favorable outcomes of suture button suspensionplasty for thumb carpometacarpal joint osteoarthritis remain durable over time [54]. The MAÏA trapeziometacarpal joint prosthesis is a reliable long-term surgical procedure for trapeziometacarpal joint osteoarthritis, improving overall function beyond 10 years [181]. Post-surgical survivorship for silicone metacarpophalangeal joint arthroplasty for osteoarthritis is 97% clinically and 90% radiographically [37]. Radiographic fracture following this procedure does not imply clinical deterioration [37]. Follow-up studies indicate that metacarpophalangeal joint arthroplasty in rheumatoid arthritis improves function and deformity and achieves nearly uniform patient satisfaction [152]. At 3 years beyond operation for metacarpophalangeal joint locking, the patient was free of symptoms and had a full range of motion of the metacarpophalangeal joint [83]. The medium-term outcome for septic arthritis of the small joints of the hand appears to be more favourable than the short-term outcome [62]. Long-term recurrence rates suggest recurrence in 67% of MCP joint contractures and 100% of PIP joint contractures in Dupuytren's disease, though recurrence was generally less severe than the initial contracture [76]. Patients should be informed of the risk of destructive arthropathy following revascularization after degloving hand injury, and follow-up X-ray examination is necessary even in cases with no fracture at the time of injury [14].

Key Evidence

• [L5] The mainstay of treatment is biologic therapy in conjunction with disease-modifying antirheumatic drugs, while patients with end-stage joint destruction may require surgery. [2] (10.5435/jaaos-20-01-028)
• [L5] Subtle differences in history, examination, laboratory values, and imaging, rather than one pathognomonic finding, can improve the diagnostic acumen and expedite appropriate treatment options for monoarticular arthritis of the hand and wrist. [4] (10.1016/j.jhsa.2012.04.010)
• [L5] All patients with rheumatoid arthritis should receive one or more DMARDs as soon as the diagnosis is established, as evidence suggests long-term outcomes are improved when treatment begins within the first 3 months of disease. [5] (10.1016/j.jhsa.2008.12.008)
• [L4] Diagnosis of sea urchin spine arthritis is based on injury history, a symptom-free period, and absence of laboratory abnormalities. [6] (10.1016/j.jhsa.2007.11.016)
• [Paper] Diagnostic indications include the assessment of painful post-traumatic basal joint lesions of cartilage and ligaments, and the evaluation of chondromalacia and ligament attenuation to help classify basal joint osteoarthritis. [7] (10.1016/j.hansur.2020.05.014)
• [L4] Accurate early diagnosis by careful physical examination and obtaining true lateral radiographs of the PIP joint is important. [8] (10.1142/s2424835518720013)
• [L5] Early and aggressive treatment of rheumatoid arthritis is now standard, and complete resolution of signs and symptoms is achievable in perhaps 10% of patients. [9] (10.1016/j.jhsa.2008.11.010)
• [L5] [10] (10.1002/jor.24817)
• [L5] Unrecognized joint incongruity in early-stage trapeziometacarpal arthritis is likely to lead to progression of joint degeneration, and recognition of this incongruity can lead to measures that may prevent or delay this progression. [12] (10.1177/17531934221137780)
• [L4] Given these findings, the indications for and long-term expectations of silicone metacarpophalangeal arthroplasty must be carefully examined in light of the improvements in the medical management of rheumatoid disease. [13] (10.2106/00004623-200310000-00001)
• [Case_report] Patients should be informed of the risk of destructive arthropathy, and follow-up X-ray examination is necessary even in cases with no fracture at the time of injury. [14] (10.1177/15589447211003174)
• [L4] Overall functional results often were affected by the status of disease in other joints, but in general were acceptable. [15] (10.1016/s0363-5023(78)80002-1)
• [L5] Early diagnosis of rheumatoid arthritis is important, and referral to a rheumatologist followed by treatment with disease-modifying antirheumatic agents has been shown to improve outcomes. [18] (10.1016/j.jhsa.2011.01.036)
• [L4] The diagnosis is clinical, based on the association of monoarticular arthritis with recurrent fever and abdominal pain, as there are no specific laboratory aids. [19] (10.2106/00004623-196547080-00016)
• [L5] The disorder can be distinguished from osteoarthritis, juvenile rheumatoid arthritis, and gout by its early age of onset, equal sex incidence, characteristic joint distribution, and lack of abnormal laboratory findings. [20] (10.1016/j.hansur.2017.10.147)
• [L5] [21] (10.1016/j.jhsa.2012.04.041)
• [L5] Joint destruction and worse, dissemination are possible. [22] (10.1016/j.main.2004.11.006)
• [L4] These two cases also highlight the interest of arthroscopy of small joints as a precious tool for the diagnosis and treatment of such lesions. [26] (10.1016/j.main.2012.10.126)
• [L3] The results suggest that the modified classification may benefit the treatment of Type 1 deformity, including joint-preserving surgery. [27] (10.1177/1753193419886719)
• [L4] Indications and contraindications for A1 pulley release are evolving along with the improved natural history of RA associated with the use of biologic DMARDs. [28] (10.1177/1558944720975137)
• [L5] Surgical outcomes are best when performed before the patient displays severe joint destruction, fixed contractures, subluxation, or dislocation. [29] (10.1016/j.hcl.2005.08.009)
• [Paper] The Arthritis Committee recognizes the profound importance of arthritic disorders to the general population, not only as a health problem, but for their social and economic impact. [30] (10.1016/s0363-5023(83)80245-7)
• [L4] While rheumatoid arthritis may lead to deterioration in proximal interphalangeal joint function, the overall result remains acceptable with proper indications and technique. [31] (10.2106/00004623-199301000-00002)
• [L5] For more advanced disease, fusion is the benchmark, while arthroplasty is a viable option to reduce pain, preserve motion, and limit progression of adjacent joint disease. [32] (10.5435/jaaos-d-18-00683)
• [L4] A total of 13% of the joints required a secondary surgical procedure. [34] (10.1016/j.jhsa.2009.08.010)
• [L5] Short-term results in children are no less favorable than in adults, and the danger of abnormal growth from rheumatoid inflammation is an indication for synovectomy, especially in children with unilateral knee involvement. [35] (10.2106/00004623-197153040-00001)
• [L4] Survivorship is 97% clinically and 90% radiographically, and radiographic fracture does not imply clinical deterioration. [37] (10.1016/j.jhsa.2016.07.009)
• [L5] The revised criteria are hoped to aid in obtaining more uniformity in the classification of patients with rheumatoid arthritis and should be reviewed in two or three years. [38] (10.2106/00004623-195941040-00023)
• [L5] Although many OA-related biomarkers are currently available, none can be considered as a surrogate marker of clinical and imaging features for the diagnosis or prognosis of the disease at this time. [42] (10.1186/1471-2474-16-s1-s2)
• [L4] Although no disease-modifying treatment exists, multiple options are available for managing hand OA in rheumatology practice with the goal of achieving symptom relief and optimizing hand function. [43] (10.1016/j.jht.2022.08.001)
• [L5] The diagnosis was supported by clinical, radiologic, and histologic findings after excluding infection, crystalline arthropathy, and malignancy. [45] (10.1053/jhsu.2003.50037)
• [L4] We suggest a modification of both Posner’s definition and Harvey’s classification; a new classification should focus on the causes depending on the clinica presentation of the locking, so as to improve the correlation between clinical presentation, etiology and treatment. [46] (10.1016/j.main.2011.01.019)
• [Case_report] Physicians should be aware of this presentation in patients with insensate joints to avoid overtreatment. [47] (10.2106/00004623-199274090-00017)
• [L4] While joint involvement is typically transient, this report emphasizes that permanent joint damage can occur, particularly in older children at onset. [48] (10.2106/00004623-197557020-00023)
• [Paper] Treatment of the arthritic wrist is fascinating and challenging, requiring a diversity of treatment options due to the complex integrated system of joints, rather than a single effective treatment. [50] (10.1016/j.hcl.2005.08.013)
• [L5] The indications for abduction-extension osteotomy should be restricted to patients with early to intermediate (stage II) arthritis until pre- and post-operative radiographic evidence is available. [51] (10.1016/0266-7681(91)90004-8)
• [L4] It should be considered after conservative measures fail, as mild degenerative arthritis is not a contraindication and progressive degenerative arthritis of the radial capitate articulation did not occur. [53] (10.2106/00004623-197759040-00004)
• [L4] Favorable outcomes (improvement in range of motion and pain relief) of SBS remain durable over time. [54] (10.1016/j.jhsa.2017.03.011)
• [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. [55] (10.1155/2013/473259)
• [L5] [56] (10.1016/j.jhsa.2012.08.034)
• [L5] Management of nonrheumatoid inflammatory arthroses is typically medical in nature and continues to evolve with the development of biologically targeted medications. [57] (10.1016/j.jhsa.2015.05.029)
• [L5] The meeting formalized a cooperative study to begin in 1975 focusing on criteria for evaluating total hip and metacarpophalangeal joint replacement surgery and uniform listing of their complications. [58] (10.2106/00004623-197557040-00031)
• [L5] Joint replacement procedures relieve pain and improve function more than other current operative treatments but are limited by the inability of synthetic materials to duplicate the properties of articular cartilage; procedures that restore rather than replace the joint may offer advantages for young patients or those with less advanced disease. [59] (10.2106/00004623-199409000-00019)
• [L4] The findings indicate that the presented treatment approach could be a good alternative to more invasive surgical options in patients with earlier stages of thumb carpometacarpal joint osteoarthritis, with advantages including a low rate of complications, low invasiveness, and short recovery times. [60] (10.1177/1753193416632149)
• [L3] Despite similar treatment, male patients reported better outcomes, in particular for pain and physical function, compared to female patients. [61] (10.1186/ar2591)
• [L4] The medium-term outcome appears to be more favourable than the short-term outcome. [62] (10.1016/j.jhsb.2006.08.011)
• [L4] Recommendations align with principles from large-joint infection management but are tailored to the anatomical and clinical context of the hand. [63] (10.1177/17531934251385450)
• [L5] Arthrodesis of the TM joint may be used for stage II or stage III disease in the high-demand patient. [64] (10.1016/j.hcl.2008.03.006)
• [L4] Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop. [65] (10.2106/00004623-198567030-00013)
• [L4] [67] (10.1258/ht.2009.009001)
• [L4] Characteristic roentgenographic features included cartilage and synovial calcification and arthropathy of the metacarpophalangeal joints and the radiocarpal compartment of the wrist, including scapholunate dissociation. [68] (10.1016/s0363-5023(83)80081-1)
• [L4] Hand and finger function scores showed minimal dysfunction at baseline and follow-up. [69] (10.1197/j.jht.2007.04.005)
• [L5] These procedures do not burn bridges, and subsequent reconstruction of the joint is still possible when and if the disease progresses. [71] (10.1097/00130911-200003000-00004)
• [L3] Disease activity was associated with hand function impairment in RA patients with variable follow-up. [72] (10.1186/s12891-016-1246-x)
• [L4] At the 2-year follow-up, the median VAS score for pain decreased to 0 and the Quick DASH improved to 7. [73] (10.1177/17531934251409628)
• [L4] The long-term survival rate of single-mobility uncemented prostheses is satisfactory, with a critical period in the first years ranging from 83% after 5 years to 50% after 30 years. [75] (10.1177/17531934231221692)
• [L4] Long-term recurrence rates suggest recurrence in 67% of MCP joint contractures and 100% of PIP joint contractures, though recurrence was generally less severe than the initial contracture. [76] (10.1016/s0363-5023(09)60096-4)
• [L4] The progressive nature of cervical rheumatoid disease resulted in the recurrence of long-tract symptoms in three patients due to further subaxial subluxation distal to the original fusion site. [77] (10.2106/00004623-198163080-00003)
• [L5] The fourth carpometacarpal joint is the area of greatest variation in the osseous morphology at the carpometacarpal joint level in the human hand. [81] (10.1016/0363-5023(91)90026-8)
• [L5] At 3 years beyond operation, the patient was free of symptoms and had a full range of motion of the metacarpophalangeal joint. [83] (10.1016/s0363-5023(79)80136-7)
• [L3] The observed narrowing of the scaphotrapezial joint may well progress with time in these young patients and cause symptoms and disability. [84] (10.1016/s0266-7681(00)80003-0)
• [L5] The clinical manifestation of synovial chondromatosis of the shoulder is generally nonspecific, with symptoms potentially present for many years before joint function is significantly disturbed. [95] (10.1016/s1058-2746(98)90015-5)
• [L4] If the cost is not prohibitive, these products may be considered reasonable treatment options as part of a multimodal approach for symptomatic primary osteoarthritis. [108] (10.1016/j.jhsa.2013.05.017)
• [L3] Clinically important Dupuytren's disease is common in the general population, with a majority of diagnosed individuals undergoing treatment. [109] (10.1177/1753193416687914)
• [Case_report] This case illustrates diagnostic challenges and rare early cardiac involvement, underscoring the importance of considering CACP in the differential diagnosis of early-onset joint involvement with serosal effusions. [110] (10.1186/s12891-025-09069-x)
• [L5] [113] (10.5435/jaaos-d-19-00614)
• [L2] [116] (10.1186/s12891-018-1965-2)
• [L3] [118] (10.1186/s12891-015-0577-3)
• [Case_report] The patient's articular lesion was distinctly different from rheumatoid arthritis, characterized by periarticular fibrosis and the absence of chronic synovitis, consistent with chronic post-rheumatic-fever arthritis (Jaccoud's arthritis). [119] (10.2106/00004623-198466070-00027)
• [L4] Patients with thumb basal joint arthritis use cannabis-related products, with mixed reports on efficacy. [120] (10.1016/j.jhsa.2021.10.018)
• [L4] Specific exfoliative cytological patterns can be readily recognized in fluids aspirated from joints in a variety of arthritides, supporting the technique as a valuable diagnostic aid. [121] (10.2106/00004623-197658030-00019)
• [L5] Treatment modalities for proximal interphalangeal joint arthritis are currently limited, and the disease process involves a complex interplay of biochemical, metabolic, and genetic factors rather than simple mechanical stress. [122] (10.1016/j.jhsa.2010.09.002)
• [L5] This article reviews that treating chronic musculoskeletal pain, particularly osteoarthritis, is challenging because underlying peripheral and central pain mechanisms are not fully understood and safe, efficient analgesic drugs are unavailable. [124] (10.1007/s11914-015-0276-x)
• [L5] The article provides an overview of available treatments for shoulder osteoarthritis, noting that nonoperative modalities should be utilized before surgical options, particularly for patients with moderate-to-mild disease, while surgical treatments like arthroplasty are considered effective for severe cases. [125] (10.1155/2013/370231)
• [L3] Health systems should provide (first line) treatment for RA as a strategy to improve compliance with therapy and clinical outcomes, particularly in vulnerable populations. [127] (10.1186/ar2620)
• [L1] Non-surgical treatment provides clinically worthwhile improvements in pain and function, with a stepwise approach recommended starting with self-management, followed by splints and injections if symptoms persist. [128] (10.1177/17531934241313206)
• [L3] In aggregate, patients prefer surgical attributes characteristic of arthroplasty (ability to preserve joint motion and grip strength) relative to those associated with arthrodesis (decreased need for reoperation, lower costs, and shorter reoperation times). [130] (10.1016/j.jhsa.2018.03.001)
• [L4] Steroid injections were an acceptable treatment modality with long-lasting results for chronic sesamoiditis. [133] (10.1016/j.jhsa.2012.11.014)
• [L4] The results show a non-pharmacological treatment gap in OA care, with most patients reporting no pain or mild pain and having not received non-pharmacological treatment prior to surgical consultation. [135] (10.1186/s12891-019-2567-3)
• [L3] Familial clustering of severe CMC joint OA was observed in a statewide population, indicating that genetic and environmental factors contribute to the disease process. [136] (10.1016/j.jhsa.2022.08.004)
• [L4] Rheumatoid hand operations require more detailed study, clarifying indications and outcome to allow consistent advice to patients from all members of the multidisciplinary team. [138] (10.1177/1753193411409830)
• [L5] Newer generation unconstrained surface replacement arthroplasties have shown promise in select cases of osteoarthritis and inflammatory arthritis. [139] (10.1016/j.jhsa.2010.11.035)
• [L4] Synovial chondromatosis can be invasive, and even the best preoperative imaging may not demonstrate the degree of local tissue involvement. [140] (10.1054/jhsb.2001.0677)
• [L5] In this case, MRI demonstrated erosive chondropathy of the metacarpal head, which was confirmed at surgical exploration. [142] (10.1016/0266-7681(93)90025-b)
• [L4] Implant arthroplasty should be considered as an alternative to arthrodesis in the small subgroup of patients who present with MCP joint idiopathic osteoarthritis that has been refractory to nonsurgical treatment measures. [143] (10.1016/j.jhsa.2005.02.011)
• [L5] For minor procedures, medications should be continued, while for larger procedures, DMARDs should be discontinued 3 half-lives before surgery and resumed approximately 2 weeks after. [147] (10.1016/j.jhsa.2012.04.015)
• [L5] Augmenting plain radiographs with additional imaging modalities like ultrasound or dark-field imaging may aid in diagnosis. [148] (10.1016/j.jhsa.2021.04.004)
• [L4] There is considerable variation in the practice of both non-surgical and surgical management of base of thumb osteoarthritis. [150] (10.1302/0301-620x.102b5.bjj-2019-1464.r2)
• [L3] [151] (10.1186/s12891-024-08073-x)
• [L5] Follow-up studies show that this surgery improves function and deformity and achieves nearly uniform patient satisfaction. [152] (10.5435/00124635-200305000-00005)
• [Commentary] The literature guiding nonoperative care of OA at the TMC joint is poor, characterized by a lack of homogeneity, small sample sizes, and extremely short follow-up periods, making the conclusions of the reviewed systematic review questionable. [156] (10.1016/j.jhsa.2014.08.046)
• [L5] In this case, the x-ray film diagnosis was synovial chondromatosis and the histopathologic picture was typical of this condition. [158] (10.1016/0363-5023(94)90185-6)
• [L2] [160] (10.1177/1753193420950600)
• [L5] [161] (10.1136/jisakos-2019-000377)
• [L3] Patients with more severe range of motion limitation, DASH score, and pain score experienced a greater improvement of these measures at follow-up. [162] (10.1016/j.jhsa.2013.09.016)
• [L4] Arthrotomography has been found to be a useful diagnostic technique in determining the cause of locking. [163] (10.1016/s0363-5023(86)80063-6)
• [L2] In the absence of recurrent Dupuytren's disease, severe preoperative deformity, incomplete correction at surgery, and noncompliance with therapy predispose patients to worse PIPJ contracture. [168] (10.1016/j.jhsa.2006.11.015)
• [L1] In all grades of our classification, osteolysis was more frequent in the Sutter than in the Swanson group in this study, suggesting that use of the Sutter rather than the Swanson implant is questionable. [169] (10.1016/j.jhsb.2004.03.019)
• [L5] [171] (10.2106/00004623-199704000-00022)
• [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. [173] (10.5435/00124635-199803000-00003)
• [L5] The treatment is initially conservative, but surgical excision of the bone is an effective solution in cases of failure. [174] (10.1016/j.main.2015.01.009)
• [Paper] [175] (10.1016/s0894-1130(04)00179-6)
• [L4] The most important factor in the development of finger deformities is the changes occurring in the tendons and related structures, especially in early stages. [177] (10.2106/00004623-195739030-00006)
• [L3] [178] (10.1177/1753193412439678)
• [L4] MAÏA TMC joint prosthesis is a reliable long-term surgical procedure for TMC joint osteoarthritis, improving overall function beyond 10 years. [181] (10.1016/j.jhsa.2024.03.019)
• [L4] Pseudogout can mimic synovial chondromatosis clinically and roentgenographically due to extensive calcification of synovial tissue, but the two diseases have different treatments. [183] (10.2106/00004623-197557060-00030)
• [L5] Acute infection frequently requires surgical drainage but such treatment is generally not indicated in the management of calcific periarthritis since the condition is self limiting. [190] (10.1016/0266-7681(84)90064-0)
• [L3] In patients with established hand OA clinical involvement of the TBJ is associated with a higher clinical burden whereas radiological involvement of the TBJ is associated with older age and more structural abnormalities. [199] (10.1016/j.jht.2014.01.006)
• [L5] Surgical exploration is recommended in such cases because it is difficult to ascertain the definitive cause of locking preoperatively using radiographic examination. [204] (10.1142/s2424835518720396)
• [L4] [207] (10.1177/1558944716677937)
• [Paper] [208] (10.1186/s13018-026-06798-0)
• [L4] [209] (10.1177/1753193410362848)
• [L1] [210] (10.1016/j.jht.2018.02.007)
• [L2] Early changes in peri-articular bone density and microstructure seen in RA are consistent with changes more commonly seen in aging bone and are slow or resistant to recover despite well controlled inflammatory joint symptoms with early DMARD therapy. [212] (10.1186/s12891-017-1888-3)
• [L3] 47.2% of people with RA from Nantong China experienced hand joint destruction. [213] (10.1186/s12891-017-1548-7)

See Also

• Arthroscopy
• Joint Surgery
• Trigger Finger
• Dupuytren's Disease
• Metacarpophalangeal joint arthroplasty

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