OSTEOARTHRITIS OF THE PROXIMAL AND DISTAL FINGER JOINTS
Several conditions associate commonly with OA of the wrist and hand, including OA of the proximal and distal finger joints. A brief overview of each of these conditions is presented below, followed by a discussion of conservative medical management, surgical management, and appropriate therapeutic interventions. The distal interphalangeal (DIP) joint is the most common site for OA of the hands. These joints are the site for the fibrous and bony nodules known as Heberden’s nodes . Bouchard’s nodes can develop on the proximal interphalangeal (PIP) joints, and OA of these joints can cause the fingers to stiffen and swell (Harvard Health Publications, 2017). Clients experiencing OA of Conservative management Conservative therapeutic management of PIP and DIP joints focuses on pain control, prevention of deformity, and prevention of occupational dysfunction. Pain control and deformity prevention are most commonly achieved with an orthosis that holds the affected joint in a pain-free extended and laterally aligned position. For a painful DIP joint, this positioning is best accomplished with a thin thermoplastic custom orthosis held in place with hook and loop straps such as Velcro (Cooper, 2020). The orthosis can be either volar or dorsally based. A circumferential plaster cast can also be used, but might not be appropriate in the case of enlarged joints or those with nodes. Since plaster is not a water-resistant material, this will need to be replaced and refabricated often. For the PIP joint, a gutter orthosis extends from the proximal end of the proximal phalanx to just before the DIP joint. This preserves DIP joint function if the joint is not also involved. The DIP joint can be included in the orthosis if it is painful or becoming deformed (Figure 13). Figure 13: Volar-Based Proximal Interphalangeal Joint Gutter Orthosis
the hand often report that it starts with morning soreness and stiffness of the affected joints. They describe increasing difficulty with pinching and grasping, and note pain and crackling when moving the joint (Harvard Health Publications, 2017). OA of the PIP and DIP joints eventually causes enlargement of the joints and might create deformities with possible spontaneous fusion. People with OA of the hand might eventually find it impossible to open jars, turn a key, write, or type. Many people with OA of the hand find that with age, their hands thicken and become stiff. The DIP joint can also be immobilized in isolation of the PIP joint. This orthosis can be fabricated as volar based with a tip cover, or as seen in Figure 14, as a clamshell design. This orthosis protects and immobilizes painful DIP joints, and it can also be used to help a client understand the outcome of an elective joint fusion (Cooper, 2020). Figure 14: Clamshell Distal Interphalangeal Immobilization Orthosis
Source: Erin Peterson In addition to use of orthoses, a client with painful
interphalangeal joints can benefit from education concerning joint protection techniques and from adaptive equipment that makes use of the hands for functional tasks easier; less painful; and in some cases, possible. Physical agent modalities, including ice packs applied for 20 minutes, can be used to reduce pain in an acutely inflamed PIP joint. Chronic pain that is noninflammatory can also be reduced with heat modalities such as hot packs applied for 20 minutes or paraffin wax dips. Both hot packs and paraffin baths can be purchased commercially. indicated, surgeons can use a variety of implant types to achieve these objectives. Silicone The Swanson silicone arthroplasty implant remains the preferred option for many surgeons, as it continues to provide reliable outcomes with high client satisfaction (Lubahn et al., 2011). Used to maintain phalanx alignment and space at the joint, a silicone implant may not allow normal biomechanics at the PIP joint, leading to a limited arc of motion at only 25/75 degrees (Cannon, 2020; Lubahn et al., 2011). Even so, this type of implant may be appropriate for older clients or those with fewer occupational and task demands (Lubahn et al., 2011). Pyrocarbon Pyrocarbon is a strong, fatigue- and wear-resistant, ceramic-like material made of pyrolytic carbon. Pyrocarbon is the resurfacing arthroplasty of choice for many more experienced surgeons
Source: Erin Peterson
Surgical management and postsurgical occupational therapy intervention Surgical management of the PIP and DIP joints is usually undertaken as a last resort when deformities interfere with functional abilities or pain is limiting engagement in desired occupations. Proximal interphalangeal joint arthroplasty (i.e., replacement) is one surgical approach for severe OA of the PIP joint, but it can be difficult for such small joints. Arthrodesis, or fusion, of the joint is the easier surgical procedure, and the optimum choice for the DIP. It might also be the first choice for the proximal interphalangeal joint, depending on the age and lifestyle of the client. ROM is lost when a joint is fused, and although this might not be problematic for an older individual, it might interfere with function in, for example, a younger musician (Gabay & Gabay, 2013). PIP arthroplasty The goal of any arthroplasty is to restore stability to the joint and thereby reduce pain (Zhu et al., 2018). When a PIP arthroplasty is
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Book Code: PTOH1324
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