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Want more information on anatomy before you begin looking at conditions? Head to our article on Bones of the Hand for more information!
Dupuytren’s contracture is the localised thickening and contraction of the palmar aponeurosis (the tough sheet of connective tissue under the skin of the palm) leading to flexion deformity of the adjacent fingers. Risk factors include increasing age, male sex, a family history of the condition, northern European ancestry, diabetes, smoking, high alcohol intake and epilepsy.
It presents with firm, painless nodules and cords in the palm, which can contract and pull the fingers into fixed flexion (a flexion contracture, where a finger cannot be straightened). The contracture is at the metacarpophalangeal joint (the knuckle) and/or the proximal interphalangeal joint (the middle joint of the finger). It most commonly affects the ring and little fingers (the 4th and 5th digits), and the thumb and index finger are least likely to be affected.
Early Dupuytren’s disease, with nodules or cords but no contracture or significant loss of hand function, needs no treatment beyond explanation and observation (watching for change over time). A person who develops a contracture or loses hand function should be referred to a hand surgeon. Procedures for contractures that affect hand function include needle aponeurotomy (also called needle fasciotomy: a fine needle is passed through the skin to make small cuts in the tight cord), limited fasciectomy (surgical removal of the diseased tissue from the palm and fingers) and dermofasciectomy (removal of the diseased tissue and the skin over it, which needs a skin graft). Collagenase injections (an enzyme treatment that breaks down the cord) are no longer available in the UK.
Image - The hand of a patient with Dupuytren's contracture
Creative commons source by Frank C. Müller, Baden-Baden [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
Rheumatoid Arthritis of Finger Joints
Rheumatoid arthritis (an autoimmune disease in which the immune system attacks the lining of the joints and causes inflammation) causes pain and swelling of the finger joints, often in both hands. It can cause several deformities of the hand, such as the fingers drifting sideways at the knuckles (ulnar or radial drift), and two classic patterns in the fingers:
- Swan neck deformity - hyperextension (bending backwards beyond the normal straight position) of the proximal interphalangeal joint (the middle joint of the finger) with flexion of the distal interphalangeal joint (the joint nearest the fingertip). The hyperextension is due to loose tissues on the palm side of the proximal interphalangeal joint as a result of adjacent synovitis (inflammation of the synovial membrane, the lining of the joint).
Image - A patient with swan neck deformity
Creative commons source by Phoenix119 [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
- Boutonnière deformity - flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint, so the finger looks bent at the middle joint with the fingertip bent back.
Image - A patient with Boutonnière deformity
Creative commons source by Prashanthns [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
Osteoarthritis of Finger Joints
Osteoarthritis (wear and tear of the joint cartilage) in the hand commonly affects the 1st carpometacarpal joint (the joint at the base of the thumb) and the finger joints, and osteoarthritis is more common in women than in men. It presents with pain, swelling, squaring of the hand, stiffness and Heberden’s nodes (swellings of the distal interphalangeal joints) or Bouchard’s nodes (swellings of the proximal interphalangeal joints).
Image - An X-Ray of osteoarthritis affecting the finger joints, with Heberden's and Bouchard's nodes
Creative commons source by J. Lengerke 21:37, 27. Mai 2009 (CEST) [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
Psoriatic arthritis (also called psoriatic arthropathy) is a variable inflammatory arthritis associated with psoriasis (a skin condition with scaly red patches). It may cause asymmetric oligoarthritis (a few joints affected, unevenly on the two sides of the body), symmetric polyarthritis (many joints affected, equally on both sides) or axial disease affecting the spine and sacroiliac joints (the joints between the base of the spine and the pelvis). Distal interphalangeal joints may be involved. Other features include dactylitis (swelling of a whole digit), enthesitis (inflammation where a tendon or ligament attaches to bone), and nail changes such as pitting (small dents in the nail) or onycholysis (the nail lifting away from the nail bed).
Mild symptoms can be eased with NSAIDs (non-steroidal anti-inflammatory drugs, painkillers that also reduce inflammation). DMARDs (disease-modifying anti-rheumatic drugs, which act on the disease itself rather than only easing symptoms) are used for moderate to severe symptoms and can take several months to work. Biological treatments, usually given by injection, can be used if DMARDs do not help.
Image - An MRI scan of a patient with psoriatic arthropathy
Creative commons source by Fiona McQueen, Marissa Lassere and Mikkel Østergaard [CC BY 2.0]; converted to JPEG and resized for this article
Rheumatoid nodules (firm lumps under the skin) are an extra-articular manifestation (a feature outside the joints) of rheumatoid arthritis. They affect between about 10% and a third of people with rheumatoid arthritis, depending on the study, and are more likely in smokers and in people whose blood tests positive for rheumatoid factor (an antibody linked to the disease). The nodules are usually non-tender and occur in regions exposed to minor trauma.
They do not always require treatment, but if they restrict movement or cause pain, management focuses on overall control of rheumatoid arthritis. Methotrexate, a commonly used DMARD, can rarely cause new nodules to form (methotrexate-induced accelerated nodulosis), so the effect of DMARDs on nodules can vary between drugs.
Gouty tophi are nodular masses of monosodium urate crystals (crystals made from uric acid) that are deposited in soft tissues in people with gout (a crystal arthritis caused by too much uric acid in the blood). They are a late complication of hyperuricaemia (too much uric acid in the blood): about half of people with untreated gout develop them after 10 years. Tophi usually occur over the extensor (outer) surfaces of joints such as the elbow or knee, or over the Achilles tendon. They can also occur on the fingers, the back of the hands or feet, and the helix (rim) of the ear. The nodular masses themselves are usually painless.
People with gout and tophi should be offered urate-lowering therapy (medicines that lower the level of uric acid in the blood, such as allopurinol or febuxostat), using a treat-to-target strategy (the dose is raised step by step until the blood urate level reaches a target, and a lower target, below 300 micromol/litre, is considered for people with tophi), as recommended by NICE (guideline NG219). Tophi do not routinely need to be cut out (local surgical excision); medical treatment of the underlying gout remains indicated. Specialist surgical assessment may be needed for local complications such as infection or ulceration (a break in the skin over the tophus).
Image - Gouty tophi nodules on a patient's fingers
Creative commons source by Michael (a.k.a. moik) McCullough [CC BY 2.0]; resized for this article
Reviewed by: Dr. Thomas Burnell and Dr. Marcus Judge
Edited by: Dr. Maddie Swannack
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