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Contributor: Janine Evans, MD
A 63 year-old healthy secretary presents complaining of hand and wrist pain. While the pain is bilateral, it is more problematic in her dominant hand. It was initially intermittent but she now notices it on a daily basis. She relates that she has stiffness in her hands in the morning lasting for about 15 minutes. The pain is in her finger joints but spares the MCPs. In the wrist, she points to pain at the base of her thumb rather than the wrist itself. This area is particularly painful when she grips things with her thumb such as turning her key in her car ignition or picking up a stack of files. She denies any joint swelling but admits that her fingers are getting "knobbier". She relates her mother also had very crooked fingers and complained of arthritis. She denies any other joint complaints.
On examination of the hands, she has bony enlargement with tenderness in multiple distal interphalangeal joints (DIP) and proximal interphalangeal joints (PIP). There is also increased pain at both the carpometacarpal joint and metacarpophalangeal joint (MCP) of the thumb. The other metacarpophalangeal joints and the wrist are normal. There is no synovitis. The appearance is similar to that in the attached picture.
Findings on radiograph are attached.
This patient has osteoarthritis (OA) of her hands.
A 55 year-old man with a history of RA is seen for pain in both knees with recurrent swelling of the right knee for the past 6 months. He has been seen twice at a walk-in clinic and has had the fluid drained. Each time the fluid has re-accumulated. He has tried increasing his oral prednisone from 5 mg to 20 mg a day without improvement in either the pain or the swelling. He is stiff for 10 minutes in the morning and is stiff when he arises from a chair. Walking is limited because of the pain. Because of the knee problems, he was not able to continue working and has been unemployed for the past 6 months. He denies any other joint pain on the 20 mg of prednisone.
He relates a 15 year history of RA. He was doing well on methotrexate 15 mg weekly, prednisone 5 mg a day and etanercept 50 mg weekly but had quit taking all but the prednisone roughly one year prior because he thought he was doing well.
His examination is notable for difficulty arising from the chair secondary to knee pain and stiffness. He walks with the aid of a cane. There are synovial effusions in both knees, larger on the right. No warmth is noted. Valgus deformity is present on the right. There is pain, stiffness and coarse crepitance with range of motion of both knees, more pronounced on the right. In the hands there is ulnar deviation and subluxation of the MCPs with swan-neck deformities in multiple fingers, but no synovitis. Both wrists demonstrate widening and subluxation with some loss of flexion and extension but no warmth, swelling or pain. There is a nodule at the left olecranon. The feet also show old deformities consistent with RA with subluxation of the metatarsal heads but no tenderness.
(Answer questions 1 – 5 on a piece a paper. Find Answer Key at the bottom on the page.)
1) What are the key points in her history that suggest OA?
2) What findings on physical exam support a diagnosis of osteoarthritis? Which findings help distinguish it from an inflammatory arthropathy?
3) What features on her hand X-ray are characteristic of hand OA and was the radiograph really necessary in making this diagnosis?
4) What laboratory studies are indicated?
5) What other therapeutic options could be considered in the future?
1) In this patient with RA, what would be the differential for knee pain and swelling disproportionate to the arthritis activity in the other joints?
2) What work-up would best help determine the cause of the knee problems?
3) What features of the joint fluid analysis support a diagnosis of OA?
4) What features on the knee X-ray are most characteristic of OA?
5) What evidenced-based data is there regarding joint injections, oral medications and joint replacement for OA of the knee?
1) The most characteristic clinical complaints for OA of the hands are the short duration of morning stiffness, and the distribution of joints involved: the distal finger joints and base of the thumb, with sparing of the MCPs.
2) The key distinguishing feature of OA is the lack of synovitis. Bony joint enlargement is characteristic of OA. The distribution again is more characteristic of OA than rheumatoid arthritis (RA).
3) Radiographs were not necessary in order to make the diagnosis. Joint space narrowing with osteophyte formation is characteristic for OA.
4) No laboratory studies are indicated for making a diagnosis of OA, unless other diagnoses are in your differential. Baseline laboratory measurement of blood counts, and liver and kidney function should be considered depending on what medications are instituted as therapy.
The patient is begun on daily acetaminophen and referred to occupational therapy for evaluation both for hand exercise and adaptive equipment. She is also given a splint for the carpometacarpal joint of the thumb of the dominant hand.
5) Other oral medications that could be tried include non-steroidal anti-inflammatory drugs (NSAIDs) and pain medications. Some patients respond to local injections to the thumb joints. Rarely is surgical intervention warranted.
1) Secondary osteoarthritis is dominant in the differential. Other considerations would include infection, crystal disease and active RA.
2) Joint aspiration of the involved knee for fluid analysis would be the most helpful.
3) The joint fluid is non-inflammatory, with a low total wbc. In general, wbc counts less than 3000/cu mm in synovial fluid are considered non-inflammatory.
4) Asymmetrical joint space narrowing, along with bony sclerosis are characteristic of OA. Other characteristic findings include osteophytes.
5) Joint injections with both depot corticosteroid and hyaluronate preparations have been shown to be beneficial. Oral therapies including acetaminophen and several NSAIDs have demonstrated benefit. It is not possible to have a study comparing joint replacement with a sham operation but surgical intervention in those patients who have failed all alternative treatments is generally acknowledged as providing improved mobility and pain relief.
Last updated February 2015.