Is the swelling at the proximal interphalangeal joint of my ring finger in a patient over 40 with brief morning stiffness a Heberden node?

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No, this is NOT a Heberden node—it is a Bouchard node.

The swelling you describe at the proximal interphalangeal (PIP) joint is by definition a Bouchard node, not a Heberden node, which occurs exclusively at the distal interphalangeal (DIP) joint. 1

Anatomical Distinction

  • Heberden nodes are posterolateral firm/hard swellings that occur specifically at the distal interphalangeal (DIP) joints—the joints closest to the fingertips. 1

  • Bouchard nodes are posterolateral firm/hard swellings that occur at the proximal interphalangeal (PIP) joints—the middle joints of the fingers. 1

  • Since your patient has swelling at the PIP joint of the ring finger, this is anatomically a Bouchard node, not a Heberden node. 1

Clinical Context Supporting Hand Osteoarthritis

Your patient's presentation is consistent with hand osteoarthritis (HOA):

  • Age over 40 years is a significant risk factor for HOA (OR 3.68,95% CI 2.66 to 5.09), and a confident clinical diagnosis can be made in adults over 40 with typical features. 1

  • Brief morning or inactivity stiffness (as opposed to prolonged stiffness >30 minutes) is characteristic of osteoarthritis rather than inflammatory arthritis like rheumatoid arthritis. 1, 2

  • Both Heberden and Bouchard nodes are clinical hallmarks of HOA and associate strongly with underlying osteophyte formation (OR 5.15,95% CI 4.37 to 6.08). 1, 3

  • The PIP joint is one of the characteristic target joints for HOA, along with DIP joints and the thumb base. 1

Diagnostic Confidence

When Bouchard nodes are present in a patient over 40 with activity-related pain and brief morning stiffness affecting characteristic joint sites, you can confidently diagnose hand osteoarthritis without requiring radiographs or laboratory tests. 2

The probability of HOA increases substantially when multiple features are present together—for example, the combination of age over 40, nodes (whether Heberden or Bouchard), and joint space narrowing increases diagnostic probability to 88%. 1

Common Pitfall to Avoid

Do not confuse the anatomical location: Heberden = DIP joints (fingertips), Bouchard = PIP joints (middle knuckles). This distinction is critical for accurate clinical documentation and communication. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Heberden’s Nodes as the Pathognomonic Indicator of Hand Osteoarthritis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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