An 80-year-old female with DM type 2, HT and DLP, complained of having pain at multiple joints of both hands for 6 months. The pain was significant both at night and in the early morning, with around 20 minutes of morning stiffness and gelling phenomenon. Pain score was usually 6-8 on a 1-10 scale.  

Plain film of both hands was done and the result was shown above. 

Questions

1. Please describe abnormal findings of the hand film, name a specific sign

2. Which specific findings would you expect from physical examination of the patient? 

3. What is the provisional diagnosis?

4. What is the recommendation of management? 

โดย นพ.วิทัญญู ไตรเมธาศิลป์ 

ANSWERs

1. Abnormal findings of the hand film

• Narrowing of joint space, most prominent at DIPs and PIPs, with minimal narrowing at MCPs
• Subchondral bone erosion, central erosion of PIPs (gull-wing, saw-tooth appearance)
• Osteophytes at PIPs, DIP, 1st CMCs 
• Subchondral bone cysts
• Mild generalized osteopenia

2. Suspected pertinent findings from physical examination of the patient

• Squaring hand (1st CMC enlargement),
• Bony prominence at DIPs (Heberden's node) and PIPs (Bouchard’s node), Heberden(DIP)
• Subluxation at PIPs
• Hallux vagus at big toes

3. Provisional diagnosis:  Erosive inflammatory osteoarthritis (OA) of hands, fingers

4. Recommendation of management  

• Non-pharmacologic (physical, psychological, mind-body approach)
  •  1st CMC orthosis, exercise, self-management program 
  •  Heat, therapeutic cooling, paraffin, kinesiotaping, acupuncture, other joint orthosis
• Pharmacologic 
  •  Oral NSAIDs 
  •  Acetaminophen, tramadol, duloxetine, chondroitin, topical NSAIDs, IA corticosteroids 
  • Against using glucosamine, hydroxychloroquine, MTX, anti-IL1, TNF inhibitors, bisphosphonates, colchicine, vit D, fish-oil, IA HA injection, topical capsaisin

 Strongly recommended  Conditionally recommened 

เรียบเรียงโดย พญ.วิรัลพัชร มาศมหิศักดิ์ แพทย์ประจำบ้านชั้นปีที่ 2 กองอายุรกรรม รพ.ภูมิพลอดุลยเดช กรมแพทย์ทหารอากาศ

Reference:  Kolasinski, S. L., Neogi, T., Hochberg, M. C., 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the Hand, hip, and knee. Arthritis & Rheumatology, 72(2), 220–233