OSTEOARTHRITIS OF THE HAND AS TERMINAL STAGE OF RHEUMATOID

ARTHRITIS
Reza Gharba Anggara
Bekasi City General Hospital, Faculty of Medicine Trisakti University
garbanggara@yahoo.com

Abstract
Introduction
Osteoarthritis (OA) is one of the most
common form of arthritis. It is a chronic
condition in which the material that
cushions the joints, called cartilage is
breakdown. This cause the bones to rub
against each other, causing stiffness, pain,
and, loss of joint movement. Common risk
factors include increasing age, obesity,
previous joint injury, overuse of the joint,
weak thigh muscles, and genetics.
Osteoarthritis symptoms usually develop
gradually. At first, there may be soreness
or stiffness that seems more like a
nuisance than a medical concern.
Common symptoms include:
Sore or stiff joints particularly the hips,
knees, and lower back -- after inactivity or
overuse
Stiffness after resting that goes away after
movement
Pain that is worse after activity or toward
the end of the day.

Osteoarthritis, or OA, may also affect the
neck, small finger joints, the base of the
thumb, ankle, and big toe. The pain may
be moderate and come and go, without
affecting the ability to perform daily
tasks. Some peoples OA will never
progress past this early stage. Others will
have their OA get worse. The pain and
stiffness of more severe osteoarthritis may
make it difficult to walk, climb stairs,
sleep, or perform other daily tasks.
OA can also affect in our hands, hand OA
is common in four areas which is at the
wrist, basilar joint, DIP joint, and PIP
joint. Hand OA is associated with pain,
reduced grip strength, loss of range
motion, and joint stiffness leading to
impaired hand function and difficulty with
daily activities.
Rheumatoid Arthritis (RA) is a condition
in which the lining of the joints (the
synovium) become inflamed. This chronic
inflammation can lead to debilitating bone
loss and joint deformity. The disease
occurs when the immune system
mistakenly attacks healthy tissue as if it
were a foreign invader, such as an
unknown virus or bacterium.
Often, rheumatoid arthritis will first affect
the wrists, hands, ankles, or feet. However,
the disease can progress to damage the
elbows, hips, jaw, knees, neck, and
shoulders. Joints arent the only areas
affected by rheumatoid arthritis. It can
cause inflammation in other parts of the
body, including the lungs and eyes.
Some symptoms, like joint pain,
tenderness, and stiffness are experienced
by sufferers of both rheumatoid and
osteoarthritis. Others, including joint
swelling (rare in osteoarthritis) and red,
puffy hands are characteristic of
rheumatoid arthritis.
Because rheumatoid arthritis is a systemic
disease, it can cause other symptoms that
can affect the entire body, including
Fatigue
Fever
Loss of appetite
Weight loss

Discussion
How RA progresses and expresses itself
varies widely from patient to patient. This
variability can be seen in patterns of joint
involvement, as well as the degree of
disease involvement outside of the joints,
including development of rheumatoid
nodules, lung involvement, and other RA-
related complications.
1

One patient may experience RA symptoms
that affect only small joints, while another
may have symptoms that affect only large
joints. Still other patients will experience
more generalized disease that affects a
range of joints, regardless of size. There is
also wide variation among patients in how
active the disease is and how quickly
structural damage in the joints develops.
1

Early detection and treatment to control
inflammation is of critical importance in
RA, given the potential for rapid
destruction of joint and other tissue and
impairment of functioning. Although how
RA progresses in individual patients and
the pattern of joint involvement varies
widely from patient to patient, in the
majority of patients with RA (70%) some
degree of joint erosion in the hands and
feet is detectable by x-ray within the first
two years of the disease.
1

Without adequate treatment, at 20 years
after diagnosis, more than 60% of patients
with RA may develop significant
functional impairment (stage III),
including need of mobility aids, loss of
ability for self-caring, and requirement of
joint replacement, or experience loss of
independence and require daily care (stage
IV).
1


Stages of RA

I

Synovitis characterized by:
o

Swelling of synovial membrane with
excess of blood
o

Small areas of lymphocyte
infiltration in membrane
o

Synovial fluid with high cell counts
(5,000 to 60,000 per mm3)
o

X-ray shows soft tissue swelling and
possibly osteoporosis, but no
evidence of joint destruction
II

o

Proliferation of inflammation in
joint tissue, spreading into joint
cavity across joint cartilage
o

Joint cartilage shows signs of
gradual destruction
o

Loss of joint cartilage results in a
narrowing of joint
III

o

Synovial pannus forms
o

Joint cartilage becomes eroded and
bone beneath cartilage is exposed
o

X-ray shows extensive loss of
cartilage, joint erosion (around
margins), and possible deformities
IV

o

Disease reaches end stage with
inflammatory process subsiding
o

Loss of joint function
o

Subcutaneous nodules form


It is during the second stage of the
condition that the cartilage of the joints
begins to be negatively affected by the
arthritis. At the onset of the second stage,
the synovial swelling has progressed to the
point that the cells within the inflammation
have begun to divide and multiply. Over
time, this causes the tissue in the synovia
to thicken. The tissue grows and begins to
invade the joint cavity, where it will
proceed to damage the joint cartilage and
begin to cause long-term damage.
And then, in the third stage of rheumatoid
arthritis the patients begin to notice the
most severe rheumatoid arthritis
symptoms. The synovial inflammation
causes the body to release enzymes which
can erode joint cartilage. As the cartilage is
worn away, the underlying bones are no
longer protected from the enzymes. The
enzymes can begin to damage and destroy
the bones of the joints. It is this destruction
that causes the joints of arthritis sufferers
to misalign and lose their original shape.
The destruction of the joints is not only
incredibly painful for patients, but it also
causes a significant loss of mobility.
During the fourth and final stage of
rheumatoid arthritis, the original synovial
inflammation begins to subside, exposing
the damaged and twisted joints that it
leaves behind. Most often, the damaging
effects of rheumatoid can be seen in the
hands, where the joints of the fingers are
deformed. Patients have very limited joint
functionality and often suffer from a
limited range of motion in the affected
joints.
Osteoarthritis of the hand most commonly
develops at three sites on the hand -- at the
base of the thumb, at the joint closest to
the finger tip, and the middle joint of the
finger. Osteoarthritis is a degenerative
joint disease, meaning that the cartilage
covering the ends of the bones forming a
joint gradually deteriorates. Mechanical
wear-and-tear or injury can cause
osteoarthritis to develop. When an injury
changes the alignment of a joint, it can
hasten cartilage damage. The damage is
usually visible in hands with enlarged
joints and crooked fingers.
Bony nodules are common visible
characteristics with hand osteoarthritis.
Small nodules and swellings that develop
near the middle joint of the fingers are
referred to as Bouchard's nodes. When the
nodules are located at the fingertip, they
are referred to as Heberden's nodes.

X-ray evidence reveals cartilage loss, bone
spurs, and joint damage. What shows up
on x-ray might not correlate with the
amount of pain and disability the patient
are experiencing. And early osteoarthritis
damage may not be detected on x-ray.
Symptoms that are common with hand
osteoarthritis include:
stiffness
swelling
pain
limited range of motion
bony nodules
aching at the base of the thumb

It becomes more difficult to grasp objects
or make a pinching motion (like picking
up a penny). Manual dexterity, fine motor
control, and physical function are
compromised, making usual daily
tasks difficult to perform (such as turning
keys, opening doorknobs, writing).



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