Features July 2012 Issue

Seek Help to Ease Pain, Preserve Mobility When Finger Joints Fail

Your hands and fingers contain more sensory nerve endings than just about any other area of your body. This heightened sensitivity is the reason why you can reach into your pocket and tell the difference between a nickel and a dime without looking. It’s also why it hurts so badly when you hit your thumb or fingers with a hammer.

“When you have an arthritic finger joint, it can be debilitating,” says William Seitz, MD, a Cleveland Clinic orthopaedic surgeon. “If your fingers are painful and stiff because of arthritis, you can find yourself very limited in your ability to function in all forms of daily activities.”

Simple exercises, medications and other conservative treatments can help you live with arthritic fingers. But if the pain becomes intolerable despite these therapies, surgery can ease the agony, preserve function, and potentially maintain flexibility when your finger joints deteriorate.

Faltering fingers

Rheumatoid arthritis (RA) and other inflammatory conditions traditionally have been the chief cause of arthritic damage to finger joints. RA, which often begins in the hands and feet, most commonly affects the metacarpophalangeal (MP) joint (the knuckle connecting the hand and finger) and the proximal interphalangeal (PIP) joint (the middle joint in each finger). In advanced cases, RA can cause severe finger deformities.

But since powerful disease-modifying drugs control RA much more effectively, Dr. Seitz says the majority of finger-arthritis patients do not have RA but rather osteoarthritis (OA)—the wear-and-tear arthritis caused by years of repetitive use or traumatic injuries.

Both RA and OA cause pain and stiffness that may sap your hand of strength and mobility. But the conditions require different treatments, so your doctor must carefully review your medical history, conduct a physical exam, take X-rays, and test the painful joints in order to make a correct diagnosis. Blood tests are necessary if your doctor suspects RA.

To manage pain, your doctor may recommend acetaminophen (Tylenol); nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin), naproxen (Aleve), celecoxib (Celebrex), meloxicam (Mobic) and flavocoxid (Limbrel); or a corticosteroid injection. A customized splint can ease pain and prevent deformities.

You also may be referred to a hand therapist, who can recommend exercises to maintain flexibility and ease pain in your fingers. Performing these exercises in warm water can relax the muscles and ease tension in the finger joints. Try all of these simple treatments before considering surgery, Dr. Seitz advises: “We don’t do anything surgically until you have failed conservative care, failed maintenance care, and are at a point where you say you can’t function.”

Solutions through surgery

Surgical options for finger arthritis include replacing the MP and PIP joints with prosthetic knuckles (arthroplasty) or using implants to fuse together the two bones comprising a diseased joint (arthrodesis). Newer finger-joint replacements made of pyrolytic carbon are designed to provide a higher level of function and durability. The carbon material is closer in its mechanical properties to that of natural cartilage, Dr. Seitz says. On the downside, however, the implants can squeak and sometimes do not incorporate well into the surrounding bone, causing them to loosen. “I’m all for new technology, but this particular technology hasn’t turned out to be a terribly good improvement,” he says.

For arthroplasty, Dr. Seitz prefers silicone prostheses, which feature a flexible hinge that helps maintain some flexibility in the joint. He says the implants work well in the MP joint, but they don’t provide great grip strength when replacing the PIP joint.

“For MP and PIP joints, unless the patient has a tremendous need for a power grip, we could start out with arthroplasty, and if it doesn’t work, you can always do an arthrodesis,” he says. “But these implants are not for somebody who needs to swing a sledgehammer. If that’s the situation, the answer is arthrodesis, which stabilizes the joint.”

The finger-arthritis surgery with the longest track record, arthrodesis is used in the PIP and, especially, in the distal interphalangeal (DIP) joint at the end of the finger, which doesn’t require the broader range of motion of the MP joint. With newer techniques in arthrodesis, patients can “get functional pretty quickly,” Dr. Seitz says.

For patients who require a moderate degree of grip strength, he recommends replacing the middle and ring finger PIP joints and fusing the index and small finger PIP joints, which are more susceptible to greater forces.

What to expect

Both types of surgery are done on an outpatient basis, requiring about 20-30 minutes per knuckle to complete, Dr. Seitz says. If you have a finger deformed by RA, your surgeon may use a small muscle from an adjacent finger to realign the defective finger. “Basically, our goal is to leave the operating room with a relatively symmetrical hand that’s in the best position for all the joints to work together in unison,” Dr. Seitz says.

A therapist will visit you in the recovery room and provide you with exercises to do over the next few days, and then will see you again within the first week after surgery to help fit you with protective braces or splints.

Both types of surgery can ease pain, while arthroplasty also can preserve or restore some degree of mobility, although it won’t preserve normal flexibility, Dr. Seitz notes.

“In either case, our goal is to eliminate pain, and if you can eliminate pain, you can find a way to use your hand,” Dr. Seitz says. “The surgical options can make a world of difference in terms of restoring you to function in everyday activities, whether in sports or at work.”