Rheumatoid Arthritis of the Hand and Fingers
Rheumatoid Arthritis (RA) is a painful inflammatory arthritis that may affect the hand, wrist, and finger joints and even lead to joint deformities.
Bloodwork is usually ordered to confirm the diagnosis and rule out other autoimmune disorders.
Dr. Lee is one of the most experienced and innovative surgeons in the treatment of RA. He utilizes orthobiologics including platelet rich plasma (PRP) and stem cell technology to help with the nonoperative treatment of patients.
Rheumatoid Arthritis (RA) is a painful inflammatory arthritis that may affect the hand, wrist, and finger joints and even lead to joint deformities.
Why Does it Occur?
Rheumatoid Arthritis (RA) is an autoimmune disease where a patient's own immune system mistakenly attacks its own body. This attack results in significant inflammation particularly in the joints, which in the long term damages the joints. RA should not be confused with Osteoarthritis (OA). OA is joint damage that occurs as a result of trauma or wear-and-tear. OA typically worsens with age and most commonly affects the larger joints (i.e. knees, hip) of the body.
Symptoms
Rheumatoid Arthritis can affect all joints and soft tissues, although it most commonly presents as joint pain, stiffness and swelling. The pain is often symmetric, i.e. involves joints on both sides of the body, and commonly worse in the morning. Unlike OA, RA is not usually caused by trauma and the patient often experiences symptom flares. Pain is sometimes accompanied by nodules under the skin (Rheumatoid Nodules). Structural deformities (ulnar drift, swan neck deformity) and tendon ruptures leading to inability to move your fingers can furthermore be seen in more advanced disease. It is also important to note that patients with RA may experience non-orthopedic symptoms. The skin, lung, kidneys, eyes, and liver are a few of the systems that can be affected. Fatigue is also a common complaint.
Diagnostic Testing
The diagnosis can be difficult to make, and there is no one particular gold standard diagnostic test. An x-ray will typically be ordered to evaluate the joints. Bloodwork is usually ordered to confirm the diagnosis and rule out other autoimmune disorders. It is important to realize that blood tests can have both false positive and false negative errors however.
Nonoperative Treatment
Any patient with suspected RA will be referred to a Rheumatologist for further evaluation and management. The goal of early RA treatment is to prevent disease progression in hopes of preventing joint damage. Rheumatologists now have a much larger armamentarium of medications to treat RA, and therefore surgery is often not necessary
Surgical Treatment
Surgery may be recommended in cases where joint damage is severe and accompanied by severe pain and functional loss, despite medical intervention. Surgical options vary greatly depending on the areas involved and how significant the damage. Options can range from a synovectomy (cleanup of the joint), to tendon repairs, to joint replacements.
Dr. Lee is one of the most experienced and innovative surgeons in the treatment of RA. He utilizes orthobiologics including platelet rich plasma (PRP) and stem cell technology to help with the nonoperative treatment of patients. Surgically, Dr. Lee has developed novel techniques using Arthroflex to preserve motion in patients who have previously been told they require fusions, as well as for DRUJ stabilization procedures. Dr. Lee will discuss with all patients whether or not they are a good candidate for this treatment.
Learn more about scheduling surgery.
Recovery Expectations
Recovery varies widely depending on the surgery performed. In all cases, however, therapy (usually 6-12 weeks) is an extremely important aspect of the recovery process. Dr. Lee will discuss recovery expectations with all patients prior to surgery.
Immediate Post-Operative Instructions
Please refer to the following pages for more information:
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.
PRP may be considered as a treatment option for your arthritis.
Why Does it Occur?
The term arthritis refers to the wearing down of the ends of the bone at the joint. The ends of bone normally have cartilage on it, and cartilage does not have any nerve endings. Bone, however, has plenty of nerve endings. If the cartilage gets worn down enough to reach the bone layer, you will have pain. The process of arthritis also causes bone spurs and bone cysts.
Arthritis of the fingers is common and something you will likely get if you live long enough. There are, however, different types of arthritis. Osteoarthritis, or Degenerative Arthritis, is the typical type and results from from age or "wear and tear." The finger joints are just like any mechanical device that over time is subject to being worn down. Certain things can accelerate the process of arthritis. These include previous trauma, inflammatory reactions, and infections. Any fracture that goes into the joint, even if non-displaced, can initiate and accelerate the process of arthritis. Those fractures that are displaced can significantly increase the arthritic rate.
Inflammatory reactions (such as Gout or Pseudogout) cause destruction of the cartilage layer. In the case of infections, this destruction can occur relatively rapidly, even with hours. Inflammatory Arthritis such as Rheumatoid Arthritis is a whole different version of arthritis. For a complete description of Rheumatoid Arthritis, please refer to that link in the Hand and Wrist section.
Other factors include genetics and other things that we don't necessarily understand or have control over. Genetics is certainly more powerful than anyone can imagine, and definitely has a role in the development of arthritis. We certainly have seen patients with none of the above causative factors who get arthritis at a relatively early age, and vice versa.
Symptoms
Patients with osteoarthritis often complain of pain in that joint, especially with movement, and after extended use. It can cause stiffness, especially in the morning. Some patients feel worse with weather changes or flying in an airplane. Patients may notice bumps occurring around the joint called bone spurs. These bone spurs may sometimes instigate the formation of visible cysts, called Mucous Cysts.
As the arthritis progresses, patients may even notice angular deformities and loss of range of motion of the finger.
Diagnostic Testing
An x-ray is typically first ordered. Additional testing such as an MRI, CAT scan, or blood tests may be ordered based on the patient's history and physical exam. Findings on the x-ray may show joint space narrowing, bone spurs, cysts, or sclerosis in the bone just next to the joint. It is important to note that what the joint looks like on x-ray does not necessarily correlate with what the symptoms are like.
Treatment Options
Since x-ray findings and the symptoms for arthritis don't necessarily correlate with each other, patients symptoms as the most important determining factor as to whether surgery is necessary. Surgery is only necessary when the patient feels it is necessary because of pain and/or dysfunction that is beyond what they can or want to tolerate. In general, Dr. Lee likes to start from the least invasive treatment options and move on to more invasive treatment options if the patient does not adequately improve. However, many different treatment options may be offered to cater to patient's individual needs or desires.
The non-operative treatment of arthritis can vary between activity modification to the use of splint/braces to force rest on the joint. Warmth on the affected hand such as running under warm water or using a heating pad in the morning, and relative cold or ice towards the end of the day or after significant activity can make symptoms improve. The occasional use of pain medicines such as Tylenol or NSAID's if not contraindicated for other health reasons can also help alleviate the pain.
Injections have a role in the treatment of arthritis. Some surgeons routinely use cortisone injections, however, Dr. Steven Lee tends to reserve the use of cortisone only if necessary and/or as a last resort to surgery. This is because there is evidence that cortisone can soften and degenerate the articular cartilage. This is especially a concern with multiple injections. While cortisone may be able to temporarily improve your symptoms (it's basically a very powerful anti-inflammatory, like putting 20 Ibuprofens directly into the joint), it doesn't actually make you better.
Surgical Treatment
In general, surgery is only indicated when the patient thinks it's indicated. X-ray or other radiologic studies or tests do not determine that. We have seen patients with terrible looking x-rays who are doing relatively well, and vice versa.
There are a number of different treatment options available to the patient who decided to have surgery performed. These options depend on the type of arthritis, severity of arthritis, the finger involved, and what functional demands the patient might require. In general, surgery for arthritis entails either trying to get the two worn ends of bone to not rub on each other anymore, or to fuse the joint.
Fusion of the joint involves taking the joint away and putting the two bones together so that there is no more movement in the joint. If the joint fuses successfully, this should alleviate pain, but it does so with the sacrifice of not being able to bend the joint. This may not sound great to the patient, but it is fairly predictable in alleviating pain, and believe it or not, there are some joints/fingers that really were designed for stability rather than mobility. The fusion is done by removing the remaining cartilage, which tricks the body into thinking there is a broken bone, and allowing the bones to heal as one. Hardware (pins, screws, plates) is also usually needed.
The other method of treatment is to place something between the bones. There are various ways to achieve this. The oldest and possibly most commonly performed treatment is to put a flexible Silastic spacer implant between the bones. In general, like most implants, this will eventually wear away, and may need to be revised after a varying amount of time. This depends on a number of factors, the most important being how active you are with the finger. There are also metallic versions of implants that are being utilized, similar in concept to those that are being put into knees. These have their potential issues and their results are similar to those of total knee replacements.
Dr. Steven Lee has been actively pioneering new surgical treatments for arthritis of the finger joints. His current area of interest is in trying to recreate a biologic form of arthroplasty to replace the above mentioned implants. Feel free to inquire about this innovative new treatment with Dr. Lee.
Learn more about scheduling surgery.
Post-Operative Care
The postoperative protocol depends on which surgical treatment was utilized. If a fusion was performed, then the rehabilitation will first center on allowing the bones to heal in a splint or a cast. Patients are encouraged to take 500 mg of Vitamin C daily, do everything possible to avoid additional trauma, stop smoking, abstain from dieting, and eat up to 20% more nutritional foods. Also, taking at least the recommended daily allowance of Vitamin D and Calcium (even up to twice the recommended amount from the ADA) from food or supplemental sources may help to improve healing.
Healing of the fusion can take anywhere from 4 to 12 weeks depending on a number of factors. Following surgery, patients are usually placed into a splint. Patients are typically followed up 1-2 weeks after surgery for a wound check and to see if the sutures are ready to come out. At this point, either a cast or brace will typically be placed depending on the fusion stability and patient needs. Hand/physical therapy will often be instituted once the cast/brace is removed to restore range of motion and muscle strength. This hand/physical therapy may go on for up to 6-12 weeks and is an important part of the recovery process to promote scar modulation and regain back mobility and strength.
The post-operative protocol may follow a slightly different protocol in that the Hand/physical therapy may be able to be instituted earlier depending on what tissues need to heal first.
Learn more about post-operative care.
Post-Operative Instructions
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*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.