From the Guidelines
The arthritic changes in distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints are characterized by the development of bony enlargements, such as Heberden's nodes in DIP joints and Bouchard's nodes in PIP joints, which represent osteophyte formation and joint remodeling as the cartilage degenerates, as seen in osteoarthritis, with the PIP joints being more commonly affected in rheumatoid arthritis, leading to symmetric swelling, tenderness, and eventual deformities 1.
Key Characteristics of Arthritic Changes
- The DIP joints develop Heberden's nodes, which are bony enlargements that represent osteophyte formation and joint remodeling as the cartilage degenerates.
- The PIP joints develop Bouchard's nodes, similar to Heberden's nodes, but in the PIP joints.
- In rheumatoid arthritis, the PIP joints are more commonly affected, leading to symmetric swelling, tenderness, and eventual deformities like swan neck or boutonnière deformity.
Management of Arthritic Changes
- Management typically includes NSAIDs like ibuprofen or naproxen for pain and inflammation.
- Acetaminophen can be used for pain, and topical agents like diclofenac gel can be applied to affected joints.
- Disease-modifying antirheumatic drugs (DMARDs) like methotrexate can be used for inflammatory arthritis.
- Physical therapy, joint protection techniques, and maintaining range of motion are essential non-pharmacological approaches to preserve function and limit disability, as supported by the EULAR evidence-based recommendations for the management of hand osteoarthritis 2.
Important Considerations
- The incidence of PIP joint involvement in adult onset Still's disease is around 47% to 44%, as reported in two large series 1.
- The management of arthritic changes in DIP and PIP joints should prioritize the preservation of function and limitation of disability, while also addressing pain and inflammation.
From the FDA Drug Label
Radiographic changes were also assessed in the PsA study. Radiographs of hands and wrists were obtained at baseline and months 6, 12, and 24. A modified Total Sharp Score (TSS), which included distal interphalangeal joints (i.e., not identical to the modified TSS used for RA) was used by readers blinded to treatment group to assess the radiographs. Some radiographic features specific to PsA (e.g. pencil-and-cup deformity, joint space widening, gross osteolysis, and ankylosis) were included in the scoring system, but others (e.
The arthritic changes in the distal interphalangeal (DIP) joints include:
- Pencil-and-cup deformity
- Joint space widening
- Gross osteolysis
- Ankylosis There is no information about the arthritic changes in the proximal interphalangeal (PIP) joints in the provided text. 3
From the Research
Arthritic Changes in Distal and Proximal Interphalangeal (PIP) Joints
- The distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints are commonly affected in osteoarthritis (OA) 4, 5, 6
- In rheumatoid arthritis (RA), the PIP joints are frequently involved, but the DIP joints are rarely affected 7, 8, 5
- The clinical features of RA include joint swelling, tenderness, and morning stiffness, with symmetric swelling of small joints being the most frequent finding 7
- In OA, the pain is likely due to secondary synovitis caused by molecules released from the joint cartilage, and initial treatment is always conservative 4
- Ultrasound features of nonstructural lesions in the PIP and DIP joints of patients with finger OA include effusions, synovitis, and Doppler signal abnormalities 6
- Comparison of the amount and distribution of inflammatory signs in wrist and finger joints of patients with OA and RA by fluorescence optical imaging and musculoskeletal ultrasound shows different inflammatory patterns 5
Inflammatory Changes in PIP and DIP Joints
- In RA, hand synovitis appears especially in wrist, metacarpophalangeal (MCP), and PIP joints 7, 8, 5
- In hand OA, potential inflammatory changes are mainly present in PIP and DIP joints 4, 5, 6
- Joint inflammation can be visualized by fluorescence optical imaging and musculoskeletal ultrasound 5
- Ultrasound features of nonstructural damage in the PIP and DIP joints of patients with finger OA include effusions and Doppler signal abnormalities, but no synovitis was found in the study 6
Diagnostic and Treatment Approaches
- Plain film radiography is the standard investigation to assess the extent of anatomic changes in RA patients 7
- Ultrasonography has gained acceptance for studying joint, tendon, and bursal involvement in RA, and may improve early clinical assessment and follow-up 7, 8, 6
- Optical spectral transmission measurements may be useful in monitoring joint inflammation in RA patients 8
- Treatment of OA is initially conservative, with surgery considered for severe symptoms 4