Arthritis, Dupuytren, and Degenerative/Inflammatory Disease of the Hand
Core concepts
Degenerative and inflammatory arthritis present differently and must be distinguished. Osteoarthritis most often affects the thumb CMC, STT, and DIP joints, producing basilar thumb pain with pinch; examine with the grind test and assess CMC subluxation. Rheumatoid arthritis is symmetric and proximal, with MCP and PIP synovitis, ulnar drift, swan-neck and boutonniere deformities, tenosynovitis, and cervical spine instability that must be cleared before anesthesia. Gout favors the MCP and PIP joints with tophi; CPPD affects the radiocarpal and MCP joints.
Dupuytren disease is a fibroproliferative disorder of the palmar fascia, common in Northern European men, with nodules, cords, and a positive tabletop test. Surgery (limited fasciectomy, needle aponeurotomy, or collagenase) is indicated for functional contracture, typically MCP greater than 30 degrees or PIP greater than 20-30 degrees. Hueston's firebreak incisions and knowledge of the spiral cord and displaced digital nerve reduce complications.
Traps
Attributing a PIP contracture to Dupuytren when it is a tendon or pulley problem, ignoring recurrence rates that are higher with less extensive procedures, and missing cervical instability in rheumatoid arthritis are frequent errors. Also distinguish Dupuytren from callosity and from trigger finger.
Rule of thumb
Treat the patient, not the cord: assess MCP and PIP contractures passively, check for ectopic disease (Garrod pads, plantar fibromatosis) and family history, and quote realistic recurrence rates before surgery.