CASE 136

By: Dr. Nizar Al-Nakshabandi MD, FRCPC

HISTORY: 59-year-old female with long-standing finger pain now presents with lump in the left distal index finger.

What are your findings?

What is the differential diagnosis?

What are the causes?

FINDINGS:

Oblique and AP [A, B] demonstrate normal bone density. Joint space is narrowed at the DIP and PIP. Lipping osteophytes at the PIP of the second finger is seen. Floating osteophyte is present at the DIP. Furthermore, the DIP demonstrates 2 soft tissue nodules on both sides of the joint likely to be represent Heberden’s node. Mild central erosions are present centrally at the DIP and PIP. Furthermore, soft tissue swelling adjacent to the PIP likely represent Bouchard nodes. The ultrasound of the finger [C] demonstrates soft tissue nodules of the DIP with no evidence of destructive bony lesion. These are likely Heberden’s nodes.

PEARLS AND DISCUSSION:

Osteoarthritis tends to affect middle aged females.

It can be primary with no underlying cause and is usually age-related or secondary when there are other medical features such as inflammatory arthritis or trauma.

Clinically these patients have local tenderness, joint enlargement, crepitus and effusion. The presence of Heberden’s nodules and Bouchard nodules are pathognomonic for primary osteoarthritis but are not a pre-request.

Heberden’s nodules occur at the DIP on the dorsolateral aspect and are a marker of osteoarthritis. Previously they were thought to be osteophytes, but there is evidence now that Heberden’s nodules are related to ligaments as well as bones.

Bouchard nodes are clinical related to nodules at the PIP and are less common than the Heberden’s nodules. They almost always correspond to a palpable osteophyte. In addition to osteoarthritis, they can be seen in rheumatoid arthritis and are caused by antibody deposition to the synovium.

Treatment of osteoarthritis is by non-pharmacological approach with increased activity and exercise. Pharmacological approaches with non-steroidal anti-inflammatory drugs and finally surgery can be a last resort by removing the excess bony growth and reconstructing the joint. Joint fusion can be done sometimes but produces no motion in the problematic finger.

FURTHER READING:

1.      Alexander CJ: Heberden’s and Bouchard’s nodes, Ann Rheum Dis 58:675-678, 1999.

2.      McGonagle D, Tan AL, Grainger AJ et-al. Heberden's nodes and what Heberden could not see: the pivotal role of ligaments in the pathogenesis of early nodal osteoarthritis and beyond. Rheumatology (Oxford). 2008;47 (9): 1278-85. 

3.      Brant WE, Helms CA. Fundamentals of diagnostic radiology. Lippincott Williams & Wilkins. (2007) ISBN:0781765188.