Look at this patient's hands.

Examine this patient's joints.



· Age.

· Pain in the joints.

· Stiffness after a period of inactivity.

· Impairment of gait due to joint pain.


· Heberden's nodes (bony swellings) at the terminal interphalangeal joints.

· Squaring of the hands due to subluxation of the first metacarpophalangeal joint.

Proceed as follows:

Tell the .examiner that you would like to examine the hips and knees as these joints are usually involved (feel the knee for crepitus:

it may be red, warm and tender, and have an effusion).


This elderly patient has Heberden's nodes and squaring of the hands with involve-ment of the interphalangeal joints of the hands

(lesions) due to osteoarthrosis (aetiology) and is unable to button his clothes (functional status).

Read review: BMJ 1995; 310: 457-60; N Engl J Med 1989; 320:1322; Am J Med 1987; 83 (suppl 5A): 5.


Which other joints are frequently involved?

Spine, in particular cervical and lumbar spines.

Mention the types and a few causes of osteoarthrosis.

· Primary.

· Secondary:

Trauma - affects athletes, pneumatic drill workers, anyone doing work involving heavy lifting.

- Inflammatory arthropathies - rheumatoid arthritis, septic arthritis, gout.

- Neuropathic joints - in diabetes mellitus, syringomyelia, tabes dorsalis. -Endocrine - acromegaly, hyperparathyroidism.

-Metabolic chondrocalcinosis, haemochromatosis.

What are Heberden's nodes?

Bony swellings seen at the terminal interphalangeal joints in osteoarthrosis.

What are Bouchard's nodes?

Bony swellings at the proximal interphalangeal joints in osteoarthrosis.


What are the typical radiological features?

· Subchondral bone sclerosis and cysts.

· Osteophytes.

What will the synovial aspirate show?

Fewer than 100 white blood cells per millilitre.

What do you understand by the term 'nodal osteoarthrosis'?

Nodal osteoarthrosis is a primary generalized osteoarthrosis with characteristic features. It occurs predominantly in middle-aged

women and is autosomal dominant. It characteristically affects the terminal interphalangeal joints with the development of

Heberden's nodes. The arthritis may be acute and, although there may be marked defi~rmity, there is little disability. It can also

affect the carpometacarpal joints of the thumbs, spinal apophyseal joints, knees and hips.

How would you manage a patient with osteoarthrosis?

· Change in lifestyle: maintain optimal weight, encourage exercise, use appropriate footwear.

· Drugs: simple analgesics, rubifacients, NSAIDs for acute flare-ups, intra-articular corticosteroid injections for acute flare-ups or

patients unfit for surgery.

· Surgery: arthroscopic removal of loose body, arthroscopic washout or radio-isotope synovectomy for persistent synovitis, joint

replacement for hip and knee.

William Heberden (1710-1801) was a London physician who described the nodes as 'little hard knobs' and this was first published

posthumously in 1802.

J.K. Spender (1886), of Bath, introduced the term 'osteoarthritis'. Archibald E. Garrod, from London, established the modern usage

and clinical differentiation from rheumatoid arthritis in 1907.

In 1884, C.J. Bouchard (1837-1915) described nodes adjacent to the proximal interphalangeal joints identical to those at the distal

interphalangeal joints.