The finger joint closest to your fingernail is called the DIP joint, and it is the most common joint in the whole body to develop osteoarthritis. It causes pain, stiffness, bony swelling and a fingertip that bends sideways. Many people manage well without surgery. Where the pain is limiting, fusing the joint makes it pain free, stable and straight. The joint is then permanently stiff, but comfortable and functional, and the rest of the finger is unaffected. The operation takes 20 to 30 minutes per finger as a day procedure.
What is DIP joint osteoarthritis?
The finger joint closest to your fingernail is called the DIP, or distal interphalangeal, joint. It is a common site for osteoarthritis to cause pain, stiffness and deformity.
As the cartilage wears, the bone underneath thickens and bony lumps form on either side of the joint. These are called Heberden's nodes and they are the most recognisable feature of hand arthritis. The joint stiffens, often drifts sideways, and can become tender to knock or to grip with.
It is extremely common, particularly in women after fifty, and it runs strongly in families. Many people have visibly arthritic DIP joints that give them very little trouble, and the appearance alone is not a reason to do anything.
Symptoms
- Pain at the fingertip joint, particularly on gripping, pinching or knocking it
- Firm bony swellings on either side of the joint
- A fingertip that has drifted sideways or will not straighten
- Stiffness, often worst in the morning
- A cyst at the joint, which can groove the nail. That is a mucoid cyst, covered on our ganglion page
- Difficulty with fine pinch, buttons, and picking up small objects
An episode of redness, heat and sharp pain in one of these joints, settling over weeks and leaving the joint more deformed than before, is a recognised part of the natural history rather than an infection. It is worth having checked but it is usually the arthritis declaring itself.
Causes and risk factors
- Genetics. By far the strongest factor. DIP arthritis runs in families and often affects several fingers on both hands in the same pattern.
- Age and sex. Much more common in women, and usually becomes symptomatic after the age of fifty.
- Previous injury to the fingertip or the joint, which can bring arthritis on decades later in that one finger.
- Heavy manual use over many years, although ordinary hand use is not the cause.
It commonly occurs alongside arthritis at the base of the thumb, and finding one is a reason to ask about the other.
How it is diagnosed
By examination and an X-ray. The position of the tenderness, the bony swellings and the sideways drift are characteristic, and the X-ray confirms how much joint is left and whether the neighbouring joint is also involved.
Where several joints are inflamed rather than simply worn, particularly in a younger patient or with morning stiffness lasting hours, it is worth excluding an inflammatory arthritis, which is treated medically rather than surgically.
Non-surgical treatment
Most people should try this first and many need nothing more.
- Hand therapy. Joint protection, splinting for painful periods, and adapting the grips and tools that provoke it.
- Topical anti-inflammatory gel, which reaches a joint this superficial well.
- A small splint worn during aggravating tasks or overnight during a flare.
- Adapting how you grip. Wider handles, jar openers and pens with thicker barrels reduce the load through the fingertip.
Injections into this joint are technically difficult because it is very small and often already narrowed, and they are not a routine part of treatment here in the way they are for the thumb base.
Surgery
Where the pain is limiting and the simple measures have stopped working, the operation is a DIP joint fusion. Surgical treatment addresses the pain, the instability and the deformity by making the joint pain free, stable and straight. As a result the joint will be stiff, but comfortable and functional. The other joints of your finger are not affected.
That trade is easier than it sounds. The DIP joint contributes relatively little to how far a finger curls, and almost nothing to grip strength. Most people notice the pain has gone long before they notice the stiffness.
The operation
The operation takes place as a day surgery procedure, using general or sedation anaesthesia with a local anaesthetic for pain relief afterwards, and usually takes about 20 to 30 minutes per finger.
In most cases an H shaped incision is made over the back of the joint. Excess bony bumps are removed and the joint is placed in a straight position. A screw is placed through the fingertip bone, the DIP joint and into the middle bone of the finger. This provides a strong and stable fixation without any metalwork to be felt under your skin.
The skin is closed using sutures. A tape bandage covers the sutures under a small metal splint and soft dressings. You will be prescribed oral antibiotics for five days after surgery to reduce the risk of infection.
Recovery, week by week
Indicative, and it varies with how many fingers were treated.
Timeframe
What to expect
Day of surgery
Some or all of your fingers may feel numb or tingly for one to three days because of the local anaesthetic. You can start to move and use your thumb and the fingers not covered by the dressing for light tasks before you leave hospital.
Days 1 to 5
Keep the dressing clean and dry. You will be taking oral antibiotics for five days. On day 2 to 4 the hand therapist removes the soft dressings and fits a custom made thermoplastic removable splint on your finger, and advises you on hand use and exercises.
Days 5 to 14
Continue to wear the finger splint at all times, except to gently clean your hand and fingers. If the tape bandage gets wet, gently dab it dry and put the splint back on. If the tape lets go, use new tape or bandaids to protect the sutures. Use the hand lightly with the splint in place and avoid heavy tasks.
One to two weeks
Most people are driving again at one to two weeks, depending on which finger was operated on and how confident you are steering safely. Office work is usually manageable over the same period.
Two weeks
Your progress is reviewed by the doctor, hand therapist or practice nurse, and the skin sutures are removed at this visit. There will still be swelling present. If needed, a new tape bandage goes on for another three to five days.
Two to six weeks
The skin heals in two to three weeks. The fingertip may remain tender or swollen for two, and sometimes six, weeks after surgery. Light manual work is generally manageable from four to six weeks.
Six weeks
You can stop using the splint and use your finger normally, and heavy work can resume. It is advised, however, to put the splint back on for heavy tasks such as gardening, contact sports and tool use for two more weeks.
Weeks to months
The patch of skin on the back of your finger between the scar and the fingernail may feel numb or tingly. Sensation in this small area recovers over weeks or months.
The screw stays in permanently and is not felt under the skin. It does not set off airport scanners and it does not need removing unless there is a problem with it.
Risks and complications
DIP joint fusion is routine and safe, and complications are uncommon. When they occur they can include:
- Wound healing problems or infection. The five days of antibiotics after surgery are there to reduce this risk.
- Bleeding or bruising.
- Nerve injury, and altered sensation in the patch of skin between the scar and the nail.
- Nail plate changes. The nail grows from immediately beneath the incision, so changes in its shape or surface can occur.
- Ongoing tenderness around the scar or slower than expected recovery.
- Imperfect position. In some cases the fingertip is not fully straight, or remains slightly curved sideways.
- Nonunion. In rare cases the bone does not fuse, or the screw may need to be removed, requiring further surgery.
When to be seen sooner
Contact us, or see your GP, if you have:
- Fingertip joint pain that is waking you at night
- A fingertip drifting sideways enough to catch on things
- A cyst at the joint that is discharging fluid, which is a route for infection into the joint
- A joint that is hot, red and swollen, which needs to be seen urgently
- Several joints becoming inflamed over a short period, particularly if you are under fifty
If you have had surgery with us and have questions or concerns afterwards, phone the rooms during office hours on (08) 7127 0365.
Frequently asked questions
Will I miss the movement in that joint?
Most people do not. The DIP joint contributes relatively little to how far the finger curls and almost nothing to grip strength, and by the time it is arthritic enough to warrant fusing it has usually stiffened considerably anyway. What you notice is that it stops hurting.
Why fuse it rather than replace it?
Because at the fingertip stability matters more than movement. This joint takes a great deal of load through a very small area every time you pinch, and a fused joint handles that indefinitely. Replacement suits the larger joints further back in the finger, where movement is worth more.
How long does the operation take, and will I be asleep?
About 20 to 30 minutes per finger, as a day surgery procedure using general or sedation anaesthesia with a local anaesthetic for comfort afterwards. You go home the same day.
Does the screw stay in?
Yes, permanently. It sits inside the bone so there is no metalwork to feel under the skin, and it does not need removing unless there is a problem. In rare cases where the bone does not fuse the screw may need to come out, which would require further surgery.
When can I drive and go back to work?
Most people are driving again at one to two weeks, depending on which finger was operated on and whether you can steer and perform an emergency stop confidently. Office work over the same period. Light manual work at four to six weeks, and heavy work after six weeks, with the splint back on for heavy tasks for a further two weeks.
Why do I need antibiotics afterwards?
You will be prescribed oral antibiotics for five days after surgery to reduce the risk of infection. The joint is small, superficial and has a screw in it, and infection around metalwork is worth taking trouble to avoid.
What is the lump next to my nail?
If it is a soft swelling that grooves the nail, it is most likely a mucoid cyst, which is a ganglion arising from this same arthritic joint. It is covered on our ganglion page and is treated differently from the arthritis itself, although the two often come as a pair.
Can more than one finger be fused at once?
Yes. The operating time increases by about 20 to 30 minutes per finger, and the splinting and recovery follow the same schedule. We will discuss how many to do in one sitting.
What does the surgery cost?
You will receive written informed financial consent setting out the surgeon, anaesthetist and hospital fees, your Medicare rebate and your health fund's contribution before anything is booked. Phone the rooms on (08) 7127 0365 for an estimate.
Do I need a referral?
A referral from your GP or another specialist means you can claim a Medicare rebate on the consultation. We can see you without one, but the rebate will not apply.
Written and clinically reviewed by Dr Paul van Minnen, MD, PhD, EBOPRAS, FRACS (Plast)
Last reviewed [publication date]