The patient is a 68 year old woman with a history of hypercholesterolemia and hypothyroidism who presents to her physicians office complaining of progressive bilateral hand pain and worsening contractures of her fingers. She relates that she has had “arthritis” for many years, and it is now so severe that she is unable to care for herself. She denies any fevers or weight loss, and the remainder of her review of systems is unremarkable. Physical examination reveals marked bony hypertrophy at the PIP and DIP joints bilaterally, with severe contracture of her right index and ring fingers. Laboratory evaluation is unrevealing. Radiographs of the hands are obtained.
X-rays of the hands (Films 1-4)) show marked degenerative changes with osteophytosis (red arrows) and subchondral sclerosis at the IP joint of the thumb, DIP joints, and PIP joints bilaterally. Multiple central erosions (yellow arrows) are noted at several DIP and PIP joints. The MCP and carpal joints are spared. (yellow box)
Diagnosis and Discussion
Correct Diagnosis: Erosive osteoarthritis
Erosive osteoarthritis is a severe and debilitating form of degenerative joint disease occurring primarily in postmenopausal women. It is seen most commonly in the hands, with a predilection for the DIP and PIP joints. Because it can present as an acute to subacute onset symmetric inflammatory arthritis with morning stiffness, it is often initially mistaken for rheumatoid or psoriatic arthritis. However, the absence of systemic symptoms, skin rash, or seropositivity coupled with the marked degenerative changes seen clinically and radiographically help confirm the diagnosis.
X-rays of the hands usually reveal severe degenerative changes with osteophytosis and subchondral sclerosis at the DIP and PIP joints of the fingers, and the CMC and IP joints of the thumb. Central erosions due to destruction of articular cartilage are seen with relative sparing of the joint margins. Deformity at the distal joints with sparing of the MCPs can lead to mediolateral subluxation and contractures.
Treatment is conservative, unless joint destruction and/or contractures require surgical arthrodesis, arthroplasty, or tendon repair. Both oral and intra-articular corticosteroids have been used with some success in this condition. The prognosis is good; in most patients the inflammatory arthritis remits after several years, leaving more classic residual osteoarthritic deformities.
- Belhorn LR, Hess EV. Erosive Osteoarthritis. Semin Arth Rheum 22 (5):298-306, 1993.
- Cobby M., Cushnaghan J., Creamer P., Dieppe P., Watt I. Erosive Osteoarthritis: is it a separate disease entity? Clin Radiol 42(4): 258-63, 1990.