Peer Reviewed

What's Your Diagnosis?

A Woman With Worsening Hand Pain and Stiffness

Volume 62 - Issue 9 - September 2022

  • AUTHORS:
    Jonathan Thomas Mason, DO • Keith Messenger, DO • Alice Yang, MD • Alec Wilhelmi, MD • Leigh Romero, MD, CAQSM

    AFFILIATION:
    Department of Population Health, Division of Family Medicine, Dell Medical School at the University of Texas at Austin

    CITATION:
    Mason JT, Messenger K, Yang A, Wilhelmi A, Romero L. A woman with worsening hand pain and stiffness. Consultant. 2022;62(9):e12-e14.

    Received July 4, 2021. Accepted July 9, 2021. Published online December 2, 2021.

    DISCLOSURES:
    The authors report no relevant financial relationships.

    CORRESPONDENCE:
    Jonathan Mason, DO, Dell Medical School at The University of Texas at Austin, 1501 Red River Street, Austin, TX 78712 (Jonathan.mason@ascension.org)

     

    A 64-year-old woman presented to our clinic with constant pain in her left hand that had been worsening over the past 3 months. She described the pain as sharp and has experienced stiffness with the inability to fully extend her fingers. She also reported associated hand and finger swelling.

    History. The pain is aggravated by flexion of the fingers. She had been using diclofenac gel, with minimal relief. Otherwise, there were no alleviating factors. The patient denied a history of trauma. She is right-hand dominant. Her medical history includes uncontrolled type 2 diabetes, hypertension, hyperlipidemia, and depression.

    Physical examination. Findings revealed Heberden nodes, diffuse swelling of the fingers, and limited range of motion of the fingers (Figure 1). She was also unable to fully extend her second through fifth digits into an “OK” gesture. Bilateral radiography scans of her hands were conducted for further investigation (Figure 2). Results showed that her left hand had narrowing of the distal interphalangeal (DIP) joints with central collapse or erosion of joint spaces and spur formation. The radiograph of her right hand demonstrated narrowing of the DIP joints and minimal central collapse.

     

    Figure 1. The patient’s hands showed Heberden nodes (a), limited range of motion, and the inability to fully extend for second through fifth digits into an “OK” gesture (b).

    Figure 1. The patient’s hands showed Heberden nodes (a), limited range of motion, and the inability to fully extend for second through fifth digits into an “OK” gesture (b).
    Figure 1. The patient’s hands showed Heberden nodes (a), limited range of motion, and the inability to fully extend for second through fifth digits into an “OK” gesture (b).

    Figure 2. A radiograph of her left hand demonstrated narrowing of distal interphalangeal joints with central collapse or erosion of joint spaces with spur formation (a, arrows). A radiograph of her right hand demonstrated narrowing of the distal interphalangeal joints and minimal central collapse (b). Figure 2. A radiograph of her left hand demonstrated narrowing of distal interphalangeal joints with central collapse or erosion of joint spaces with spur formation (a, arrows). A radiograph of her right hand demonstrated narrowing of the distal interphalangeal joints and minimal central collapse (b).
    Figure 2. A radiograph of her left hand demonstrated narrowing of distal interphalangeal joints with central collapse or erosion of joint spaces with spur formation (a, arrows). A radiograph of her right hand demonstrated narrowing of the distal interphalangeal joints and minimal central collapse (b).

     

     

    Answer and discussion on next page.

References

1. Bernard S. Approach to Arthropathies. YouTube.com. 2016.  Accessed May 3, 2021. https://www.youtube.com/watch?v=VE9CE8pANuE&ab_channel=TheCanadianOrthopaedicAssociationBasicScienceCourse

2. Kloppenburg M, Kroon FP, Blanco FJ, et al. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Ann Rheum Dis. 2019;78(1):16-24. https://doi.org/10.1136/annrheumdis-2018-213826

3. Favero M, Ramonda R, Rossato M. Efficacy of intra-articular corticosteroid injection in erosive hand osteoarthritis: infrared thermal imaging. Rheumatology (Oxford). 2017;56(1):86. https://doi.org/10.1093/rheumatology/kew333

4. Favero M, Hoxha A, Frallonardo P, et al. Efficacy and safety of ultrasound-guided intra-articular glucocorticoid injection in erosive hand osteoarthritis. Pain Med. 2021;22(5):1229-1232. https://doi.org/10.1093/pm/pnaa261

5. Rovetta G, Monteforte P, Molfetta G, Balestra V. Chondroitin sulfate in erosive osteoarthritis of the hands. Int J Tissue React. 2002;24(1):29-32.

6. Shirinsky IV, Shirinsky VS. Treatment of erosive osteoarthritis with peroxisome proliferator-activated receptor alpha agonist fenofibrate: a pilot study. Rheumatol Int. 2014;34(5):613-616. https://doi.org/10.1007/s00296-013-2766-4

7. Fioravanti A, Fabbroni M, Cerase A, Galeazzi M. Treatment of erosive osteoarthritis of the hands by intra-articular infliximab injections: a pilot study. Rheumatol Int. 2009;29(8):961-965. https://doi.org/10.1007/s00296-009-0872-0

8. Marshall M, Nicholls E, Kwok WY, et al. Erosive osteoarthritis: a more severe form of radiographic hand osteoarthritis rather than a distinct entity? Ann Rheum Dis. 2015;74(1):136-141. https://doi.org/10.1136/annrheumdis-2013-203948

9. Ulusoy H, Akgöl G, Karaca Acet G, Kaya A, Kamanli A. Erosive osteoarthritis: presentation of a treatment-resistant case. Arch Rheumatol. 2011;26(1):53-57. doi:10.5606/tjr.2011.008

10. Lennerová T, Pavelka K, Šenolt L. Biomarkers of hand osteoarthritis. Rheumatol Int. 2018;38(5):725-735. https://doi.org/10.1007/s00296-017-3864-5

11. Filková M, Senolt L, Braun M, et al. Serum hyaluronic acid as a potential marker with a predictive value for further radiographic progression of hand osteoarthritis. Osteoarthritis Cartilage. 2009;17(12):1615-1619. https://doi.org/10.1016/j.joca.2009.06.002

12. Kingsbury SR, Tharmanathan P, Keding A, et al. Hydroxychloroquine effectiveness in reducing symptoms of hand osteoarthritis: a randomized trial. Ann Intern Med. 2018;168(6):385-395. https://doi.org/10.7326/m17-1430