Osteoarthritis is a degenerative condition of the cartilage. There is no clear etiology. Osteoarthritis is not related to tumors, inflammation, infection, gout, or trauma. Osteoarthritis is different from rheumatoid arthritis—which is an inflammatory condition. This distal interphalangeal joint (DIP) is the joint that is most often involved with osteoarthritis. The trapeziometacarpal joint (TM) is the most involved joint with osteoarthritis. When the trapeziometacarpal joint is involved, it causes pain with a weak pinch and grip.
Osteoarthritis of the fingers involves the following:
DIP (Heberden’s Nodes) – Heberden’s nodes are bony swellings (osteophytes) that can develop in the distal interphalangeal joints (DIP) due to the effects of osteoarthritis on these joints. Heberden’s nodes are a sign of osteoarthritis caused by osteophyte formation (bony outgrowth) of the articular cartilage in response to repeated microtrauma at the joint. Heberden’s nodes are more common in women then in men.
PIP (Bouchard’s Nodes) – Bouchard’s nodes are also associated with osteoarthritis and they are similar bony growths which develop in the proximal interphalangeal (PIP) joints. Bouchard’s nodes, like Heberden’s nodes, may or may not be painful. Swollen, hard, and painful finger joints (Heberden’s and Bouchard’s nodes) is the classical sign of DIP and PIP joint osteoarthritis.
Mucous Cyst– Small, fluid-filled sacs that form between the DIP joint of the finger and the bottom of the fingernail are another sign of osteoarthritis. The best treatment is a surgical excision of the cyst and removal of the underlying osteophyte to decrease the risk of recurrence.
Fibular fractures are usually associated with a complex injury; however, they can be an isolated fracture. Fibular fractures typically occur with a fracture of the tibia, part of an ankle fracture, a pilon fracture, or Maisonneuve fractures. Maisonneuve fractures involve a fracture of the proximal fibula associated with an occult injury of the ankle.
Isolated fibular fractures are rare and are usually the result of a direct trauma. The fibular carries approximately 15% of the axial load and is the site of muscle attachment for the peroneus muscles and the flexor hallucis longus muscle. If the physician has a patient with a fibular fracture and no other fracture involving the tibia, they will want to rule out a possible Maisonneuve fracture, especially if there is no history of direct trauma to the leg.
The physician should look for sign of a syndesmotic injury. These signs include
- Unexplained increase in medial clear space
- Tibiofibular clear space is widened (should be less than 5mm)
The x-ray will show the fracture to be rotational or oblique.
Maisonneuve fractures will require surgery to fix the syndesmosis. The fracture will need to be reduced and fixed. Syndesmotic screws are the screw of choice. It is important to determine if the injury is a Maisonneuve fracture or an isolated fibular fracture, as an isolated fibular fracture will not need surgery.
There are 12 vertebrae in the thoracic region. The spinal canal in the thoracic region is relatively small, however, the spinal cord could be easily compressed or injured in this area. Pain in the thoracic region can occur from cardiovascular origin, tumors, infection, compression fractures, and mediastinal structures. A point of consideration is thoracic disc herniation. It occurs more in the lower thoracic region, usually during the fifth decade of life. This disc herniation causes pain to radiate to the ribs and anteriorly at the same level. A thoracic disc herniation is uncommon and most are asymptomatic.
Clinically, a thoracic disc herniation will present itself as a radicular pain, anteriorly towards the rib (nerve root irritation).Myelopathy can occur from spinal cord compression. The patient could have a gait disturbance, leg weakness, as well as bladder and bowel dysfunction. Myelopathic findings are usually subtle. The physician should look for upper motor neuron signs such as hyperreflexia, clonus, and Babinski. A diagnosis is usually determined with magnetic resonance imaging (MRI). MRIs will help in ruling out the presence of fractures, tumors, or infections. Although an MRI is the study of choice, it has a high false positive rate. Asymptomatic patients may show a thoracic disc abnormality in their MRI.
Conservative treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy. Surgery is indicated when the patient has pain that is not responding to conservative treatment for 6 months or if the patient has a thoracic disc herniation with myelopathy. Most surgeries are performed with an anterior approach with or without fusion. Fusion is done for spine instability and significant chronic pain. A laminectomy is contraindicated.
A ganglion cyst is a mass or lump that forms below the surface of the skin. It is a benign cyst that is filled with a jelly-like fluid. The term ganglion means “knot”. It is not a malignant tumor, but a soft tissue benign mass. Ganglion cysts can occur anywhere; however, they usually occur at the wrist area and may occur at the foot (usually on top). This mass can change in size, vary in size, and may grow slowly.
The mass is usually asymptomatic and typically, the patient will find the mass at the top of the foot. The patient may have a burning sensation due to nerve irritation or compression of the nerve. Sometimes, a ganglion cyst mass occurs in the tarsal tunnel area, causing tarsal tunnel syndrome. If this is the case and the pain and burning sensation is not resolved with conservative treatment, excision of the mass is probably the best option. The patient may have skin irritation, as well as difficulty in walking and wearing shoes. If the ganglion is pushing on a nerve and causing irritation, something surgical needs to be done, such as aspiration or removal. Usually, the patient’s symptoms become better after these treatments.
The physician will need to differentiate a ganglion cyst from plantar fibromatosis. Remember, ganglion cysts tend to occur at the top of the foot. Plantar fibromatosis occurs at the bottom of the foot. A ganglion cyst will transilluminate, while plantar fibromatosis will not.
Treatment typically consists of observation, shoe modification, and aspiration/injection of steroids. Surgery is performed as the last resort.