ARTHRITIS & RHEUMATISMVol. 48, No. 12, December 2003, pp 3371–3376DOI 10.1002/art.11339© 2003, American College of Rheumatology

Patterns of Interphalangeal Hand Joint Involvement ofOsteoarthritis Among Men and Women

A British Cohort Study

Jason Poole,1 Avan Aihie Sayer,1 Rebecca Hardy,2 Michael Wadsworth,2

Diana Kuh,2 and Cyrus Cooper1

Objective. To characterize the pattern of involve-ment of osteoarthritis (OA) of the hand among men andwomen of the same age.

Methods. Structured hand examinations wereperformed on 1,467 men and 1,519 women who were age53 years and born in England, Scotland, or Walesduring the first week of March 1946 (identified throughthe United Kingdom National Survey of Health andDevelopment). OA at each joint site was characterizedusing a previously validated examination schedule. Theinterrelationship of involvement of different hand jointswas analyzed by logistic regression and cluster analyses.

Results. There was clear evidence of polyarticularinvolvement in the hand joints of both the men and thewomen. Among the women, 161 subjects had >4 jointsinvolved, compared with only 41 subjects expected inthis category (P < 0.001). Among the men, 87 subjectswere observed to have >4 joints involved, in contrastwith only 7 subjects expected (P < 0.001). The pattern ofhand joint involvement (characterized by clusteringprimarily by row and symmetric joint involvement,rather than clustering by ray) was found to be almostidentical between the men and the women.

Conclusion. This study confirms the existence of a

polyarticular subset of OA among men that has char-acteristics similar to those of the variant observedamong women. The data suggest that the genetic ormetabolic influences underlying this particular variantof OA acts similarly in both sexes.

Osteoarthritis (OA) is the most common jointdisorder to affect Western populations, and the hand isthe most frequent site of involvement (1). The pattern ofjoint involvement found among affected individuals andthe degree to which any pattern represents a clearlydefined subset of OA (generalized OA) remain conten-tious (2). In the first detailed study of the pattern ofinvolvement of OA of the hand, which involved hospitaloutpatients, Kellgren and Moore reported a predilectionfor the disorder at the distal interphalangeal (DIP) joint,the thumb base, and the proximal interphalangeal (PIP)joint (3). Involvement of multiple hand joints was fre-quent in these patients, and the authors proposed thatthis represented a generalized form of OA. In a subse-quent population-based study among women ages 45–64years, there was clear evidence of a pattern in this typeof hand joint involvement, with symmetric clustering byrow and by ray (4). In the present study, we attempted toreplicate this observation in a large population samplefrom Great Britain, and to distinguish the pattern ofjoint involvement between the men and the women.

SUBJECTS AND METHODS

The Medical Research Council’s National Survey ofHealth and Development provides prospective data on anational cohort of 2,815 men and 2,547 women followed up

Supported by the Medical Research Council of Great Britain.1Jason Poole, MSc, Avan Aihie Sayer, PhD, FRCP, Cyrus

Cooper, DM, FRCP, FMedSci: Southampton General Hospital, Uni-versity of Southampton, Southampton, UK; 2Rebecca Hardy, PhD,Michael Wadsworth, PhD, Diana Kuh, PhD: Royal Free and Univer-sity College Medical School, London, UK.

Address correspondence and reprint requests to Cyrus Coo-per, DM, FRCP, FMedSci, MRC Environmental Epidemiology Unit,Southampton General Hospital, Southampton SO16 6YD, UK. E-mail: cc@mrc.soton.ac.uk.

Submitted for publication February 24, 2003; accepted inrevised form August 8, 2003.

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since their birth in 1946 (5). The sample was drawn from apopulation of 13,687 subjects, representing 82% of all birthsthat took place in England, Scotland, and Wales during theweek of March 3–9, 1946. The sample chosen for followupcomprised all subjects born to nonmanual (excluding theself-employed) and agricultural workers, as well as 1 in 4subjects born to manual workers or the self-employed. Themost recent data collection was performed when the subjectswere 53 years old. Full ethics approval was obtained from therelevant multicenter research ethics committees.

Of the 4,313 subjects alive and thought to be stillresident in England, Scotland, or Wales at the time of thisstudy (80% of the original cohort), contact was attempted with3,386 of the subjects. Information was provided by 3,035subjects (90%) at the time of interview, and 2,986 subjects(88%) also agreed to undergo a hand examination. No attemptwas made to include subjects who lived abroad (11% of theoriginal cohort), who had previously declined to participate(12%), or who had died (9%) (6). Socioeconomic status wasdefined by occupational classification. The examined samplewas reasonably representative of the national cohort withregard to social class.

Eighty-two research nurses from the National Centrefor Social Research were trained to perform a hand examina-tion using previously validated clinical criteria (7). This in-volved identification of the presence of Heberden’s nodes,Bouchard’s nodes, or squaring at the carpometacarpal (CMC)joint. Reproducibility has been previously reported, with abetween-observer kappa coefficient of 0.7–1.0 (7). Hand OAwas defined as involvement of at least 1 joint. Information onjoint pain and tenderness was collected to identify symptomaticOA. A total of 1,467 men and 1,519 women were examined,representing 98% of those who were interviewed in theirhomes.

To test for overall clustering of hand joint involvement,we first derived the prevalence of OA based on the presence ofnodes and squaring at each joint. We used these observedfrequencies to calculate the numbers of men and women in thesample who would be expected to have involvement of 0, 1, 2,3, 4, 5, or 6� joints, if the occurrence of disease in differentjoints in the same person were independent. These expectednumbers were based on a statistical Poisson distribution.Finally, we compared the observed frequencies of the numbersof joints affected per subject with those expected, and assessedthe significance of any deviation from the expected distributionusing a chi-square test.

The interrelationship of OA at different hand jointswas analyzed by logistic regression and cluster analyses. Jointswere grouped according to joint type (DIP, PIP) and hand.The association between a pair of joint groups was summarizedby an odds ratio (the likelihood of having OA in 1 joint groupif the other joint group also had OA, in relation to the odds ifthe other joint group did not have OA). Thumb interphalan-geal (IP) joints were grouped with finger DIP joints for thepurposes of this analysis. Cluster analysis (8) was used toinvestigate the clustering of involvement in individual joints,and to derive a dendrogram that illustrated the pattern ofclustering of involved joints within men and women.

Analyses were performed with the aid of Stata (version7; Stata Corporation, College Station, TX) and ClustanGraph-ics (version 4; Clustan Ltd., Edinburgh, Scotland) software.

RESULTS

Figure 1 shows the prevalence of OA at any handjoint among the 1,467 men and 1,519 women in thecohort. The prevalence in any hand joint was 30%among the women and 19% among the men. The mostfrequently involved site in both sexes was the DIP joint(prevalence of 21% in women and 14% in men). Thiswas followed in frequency by the PIP joint and thethumb base.

There was clear evidence of clustering of jointinvolvement among both the men and the women (Table1). Among the women, 161 subjects had �4 jointsinvolved, compared with only 41 subjects expected in thiscategory (P � 0.001). A similar tendency toward poly-articular disease was observed among the men, of whom87 were observed to have �4 joints involved, in contrast

Figure 1. Prevalence of hand osteoarthritis (OA) among subjects, byjoint type and sex. DIP � distal interphalangeal; PIP � proximalinterphalangeal; CMC � carpometacarpal.

Table 1. Observed and expected number of hand joints with orwithout involvement of osteoarthritis

Women Men

Observed Expected Observed Expected

No. of involvedjoints

0 1,061 497 1,187 7591 120 555 86 5002 138 310 74 1653 39 116 33 364 42 32 21 65 25 7 16 16� 94 2 50 0

�2 – 2,508 – 1,575Degrees of

freedom– 4 – 3

P – �0.001 – �0.001

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with only 7 subjects expected (P � 0.001). There was noclear threshold for the observed excess of polyarticularinvolvement among subjects of either sex. It was note-worthy, however, that among both the men and thewomen, when 4 or more joints were clinically involved,the observed joint involvement began to exceed thatexpected.

Pairwise analysis of joint involvement within in-dividuals revealed a striking similarity in the patternsbetween the men and the women (Table 2). Involvementof OA in the hand joints clustered primarily by row(DIP, PIP, or CMC joint) rather than by ray or by hand.For example, 80% of the women and 74% of the menwith involvement of at least 1 CMC joint had evidence ofbilateral disease. When associations with OA involve-ment were evaluated at the 3 discordant joint sites, therewas a stronger relationship with involvement at the DIPand PIP sites as compared with either of these sites inconjunction with the CMC joint.

Cluster analysis revealed the pattern of co-involvement of the individual joints in men and women.The resulting dendrograms are shown in Figure 2. Eachdendrogram represents the pattern (from left to right) inwhich OA clustered in the individual hand joints ofsubjects. Thus, the joint sites that were co-involved mostfrequently are united earliest in the dendrogram, whilethose that clustered less tightly join the pattern furtherto the right.

Among the women, the dendrogram reveals theexpected pattern, with the strongest association foundfor symmetric involvement of the same joint site inopposite hands (early clustering of the right and left

CMC, DIP, and PIP joints). There was also a strongclustering by row within any given hand, such thatinvolved DIP joints clustered with other involved DIPjoints, and involved PIP joints with other involved PIPsites. The shaded areas indicate aggregation of involvedjoint sites in individuals before the partition point (thepoint that represents the most pronounced break in theclustering process). Clustering by ray (the PIP and DIPjoints) or between the IP and CMC joints was clearly lessmarked than was clustering by row or symmetric involve-ment among the women.

The pattern of clustering among the men wasremarkably similar to that among the women. Thus, jointsites initially aggregated symmetrically and by row, be-fore clustering by ray (PIP with DIP or CMC).

DISCUSSION

This study provides clear evidence of a polyartic-ular subset of hand OA in men and women selectedfrom the general population. The DIP is the mostfrequent joint group to be involved, followed by the PIPjoints and the thumb base. Clustering within these jointgroups is greater than would be expected, as indicated bythe prevalence of involvement at these 3 sites.

OA is a group of clinically heterogeneous disor-ders, unified by the pathologic features of focal loss ofarticular cartilage with subchondral bone reaction (9).Polyarticular joint involvement in OA has been recog-nized since Haygarth noted, almost 200 years ago (10),the association between Heberden’s nodes and the in-volvement of other joint sites. The apparent prominence

Table 2. Association of the involvement of osteoarthritis between the DIP, PIP, and CMC joints of thehand, by sex*

Left CMC Right DIPLeftDIP

RightPIP Left PIP

WomenRight CMC 814.3 (80) 2.3 (11) 3.0 (12) 3.6 (12) 2.6 (10)Left CMC 2.0 (10) 2.8 (11) 3.1 (11) 2.5 (9)Right DIP 32.5 (46) 12.3 (28) 12.3 (28)Left DIP 7.4 (23) 8.8 (25)Right PIP 81.1 (55)

MenRight CMC 1,025.9 (74) 4.2 (9) 4.7 (9) 3.9 (8) 5.9 (11)Left CMC 4.4 (9) 4.5 (9) 4.3 (8) 5.0 (10)Right DIP 38.8 (45) 22.0 (30) 13.4 (26)Left DIP 18.6 (28) 22.5 (33)Right PIP 93.0 (51)

* Values are the odds ratio (all P � 0.001) (percentage of subjects) for involvement of osteoarthritis atboth joint sites in relation to those with either joint type involved. DIP � distal interphalangeal; PIP �proximal interphalangeal; CMC � carpometacarpal.

INTERPHALANGEAL HAND JOINT INVOLVEMENT IN OA 3373

of women presenting with polyarticular disease in mid-dle life fueled speculation that this particular variant ofOA might be related to menopause. However, it was notuntil 1952 that a specific clinical subset of OA wasproposed by Kellgren and Moore (3), in which �3 jointgroups or �5 joint sites were involved. In the initialstudy by Kellgren and Moore, based on 391 subjects withOA attending a hospital, about one-quarter of thesubjects had hand involvement, of whom the majoritywere women, and a predilection was seen for involve-ment of the DIP joints and thumb base. Kellgren andMoore suggested that the frequency distribution of jointinvolvement was bimodal, such that a specific subtype of

OA, designated primary generalized OA, could be iden-tified.

Several hospital and community studies (11–17)over the ensuing 2 decades documented the femalepreponderance and symmetric pattern of joint involve-ment in hand OA. Many of these studies highlighted asubset of patients who appeared to have an inflamma-tory type of OA in association with radiographic ero-sions (16–18). Debate continues as to whether this entityrepresents an overlap between OA and other inflamma-tory arthropathies, whether it constitutes evidence of asystemic predisposition to OA, or whether it is merelythe expression of severe OA involvement of the handjoints. However, in the series of 170 patients describedby Ehrlich (17), symmetric involvement was noted in theDIP (�75%), PIP (�50%), first CMC joint (�30%),and thumb base (�25%). These observations werebased on a highly selected case series and are thereforeprone to referral bias. However, it is likely that aproportion of our polyarticular cases meets this descrip-tion. We did not differentiate between the first CMCjoint and the thumb base in our study.

Subsequent population-based studies (4,11) haveconfirmed the prevalence estimates for joint involve-ment of particular sites in the hand, and have shown thatclustering occurs in women. O’Brien et al analyzed theradiographs of 1,334 men and women ages 21 years andolder who were selected from the population of NewHaven, Connecticut (11). Moderate or severe radio-graphic OA was found to have a predilection for the DIPjoints and thumb base, with the frequency of DIPinvolvement being greatest in the second finger, fol-lowed by the third and fifth fingers. They examined thefrequency distribution of affected joints and concluded,on the basis that there was no statistical evidence for abimodal distribution, that a generalized OA subset didnot exist (11,12).

In further analyses, those investigators docu-mented the predilection for right-hand involvement andshowed that among right-handed individuals, there was apredilection for right-sided DIP involvement, with left-sided thumb base involvement (12). A smaller study of134 people by Lane et al (19) failed to show a cleardifference between the distribution of OA in the rightand left hands, but did not address the question ofclustering in detail.

Finally, our group previously reported a study ofpatterns of OA hand joint involvement among 967women ages 45–64 years (4). There was clear evidenceof clustering, with symmetric involvement being thepredominant characteristic, and grouping by row and ray

Figure 2. Dendrograms showing clustering of osteoarthritis (OA)involvement in the hand joints among men and women. The dendro-grams illustrate aggregation of the involvement of OA in individualjoint sites, with shaded areas indicating a left-to-right pattern ofaggregation of involved joint sites before the partition point (brokenline), which is the point that represents the most pronounced break inthe clustering process. R� right hand; L � left hand; Th � thumb;IP � interphalangeal (see Figure 1 for other definitions).

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was also statistically significant. These findings havebeen almost completely reproduced in the present study,but we have extended our analyses to show that ageneralized polyarticular variant of hand OA may befound in men as well as in women; the pattern of jointinvolvement in the 2 sexes appears almost identical.

There are several caveats to our interpretation ofthe finding that there is a tendency to develop multiplehand joint involvement in OA that clusters by row inboth men and women. First, hand radiographs were notincluded in this study. However, we utilized a clinicalexamination system that has previously been validatedagainst hand radiographs (7), and any random misclas-sification would have obscured relationships rather thanaccentuated them. Second, the apparent multiple in-volvement of joints in the same subject might haveresulted from increased ascertainment by the trainednurses. However, the within-observer reproducibility ofthis grading system (kappa statistics �0.8 for differenthand joint groups) has previously been demonstrated tobe sufficiently high for epidemiologic studies (7), and astructured approach to each joint was required as part ofthe examination.

The prevalence rates for clinical hand OA that weobserved are similar to other population-based estimatesfor the UK. Thus, in a previous epidemiologic study oflower limb OA, our group observed the prevalence ofclinically diagnosed DIP OA among a population sampleof controls ages 45 years and older to be 19% amongmen and 29% among women (20). In a more recentsurvey of neck and upper limb disorders in the generalpopulation, we found the prevalence of Heberden’snodes to be 24% among men and 41% among women(21). Finally, the ratio of nonmanual workers to manualworkers in the study might have been altered by thesampling procedure utilized in assembling the cohort;this may have led to fewer traumatic OA cases in apopulation subsample enriched with nonmanual work-ers. However, we found no influence of adult socioeco-nomic status on the prevalence or pattern of occurrenceof hand OA in the sample.

In conclusion, we studied the distribution of handjoint involvement of OA in a series of 53-year-old menand women from a large general population sample. Ourdata support previous observations (4) in finding clearevidence of a polyarticular subset of hand OA, whichinvolved the DIP, PIP, and thumb base joints. Jointinvolvement in this subset tends primarily to cluster byrow, rather than by ray, within an individual hand. Thepattern of this involvement among men is almost indis-tinguishable from that among women, suggesting that

the genetic or metabolic influences that underlie thisparticular variant of OA act similarly in both sexes.

ACKNOWLEDGMENTS

We thank Mrs. Gill Strange for her preparation of themanuscript. We are also grateful to Sister P. Byng for assis-tance in education of the research nurses who performed thephysical examinations, and to Vanessa Cox and Warren Hilderfor help in preparing the data for analysis.

REFERENCES

1. Felson DT. Epidemiology of hip and knee osteoarthritis. Epide-miol Rev 1988;10:1–28.

2. Van Saase JLCM, Van Romunde LKJ, Cats A, VandenbrouckeJP, Valkenburg HA. Epidemiology of osteoarthritis: Zoetermeersurvey. Comparison of radiological osteoarthritis in a Dutchpopulation with that in ten other populations. Ann Rheum Dis1989;48:271–80.

3. Kellgren JH, Moore R. Generalised osteoarthritis in Heberden’snodes. BMJ 1952;1:181–7.

4. Egger P, Cooper C, Hart DJ, Doyle DV, Coggon D, Spector TD.Patterns of joint involvement in osteoarthritis of the hand: theChingford study. J Rheumatol 1995;22:1509–13.

5. Wadsworth ME, Kuh DJ. Childhood influences on adult health: areview of recent work from the British 1946 national birth cohortstudy, the MRC National Survey of Health and Development.Paediatr Perinat Epidemiol 1997;11:2–20.

6. Wadsworth MEJ, Butterworth S, Hardy R, Kuh D, Richards M,Langenberg C, et al. The life course prospective design: anexample of benefits and problems associated with study longevity.Soc Sci Med. In press.

7. Hart D, Spector T, Egger P, Coggon D, Cooper C. Definingosteoarthritis of the hand for epidemiological studies: the Ching-ford study. Ann Rheum Dis 1994;53:220–3.

8. Everitt BS, Landau S, Leese M. Cluster analysis. London: Arnold;2001.

9. Altman R, Alarcon G, Appelrouth D, Bloch D, Borenstein D,Brandt K, et al. The American College of Rheumatology criteriafor the classification and reporting of osteoarthritis of the hand.Arthritis Rheum 1990;33:1601–10.

10. Haygarth J. A clinical history of diseases, part 2: a clinical historyof nodosity of the joints. London: Cadell and Davies; 1805.

11. O’Brien WM, Clement AR, Acheson RN. Symptoms and patternof osteoarthritis in the hand in the New Haven survey of jointdisease. In: Bennett PH, Wood PHN, editors. Population studiesin rheumatic diseases. Amsterdam: Excerpta Medica FoundationInternational Congress. Series no. 148; 1966. p. 398–406.

12. Acheson RN, Chan Y, Clement AR. New Haven survey of jointdiseases XII: distribution of symptoms of osteoarthritis in the handwith reference to handedness. Ann Rheum Dis 1970;29:275–85.

13. Dieppe P, Cushnaghan J. The natural course and prognosis ofosteoarthritis. In: Moskowitz R, Howell DJ, Goldberg VM, Man-kin JH, editors. Osteoarthritis: diagnosis and medical/surgicalmanagement. 2nd ed. London: Saunders; 1992. p. 399–412.

14. Strecher RM. Heberden’s nodes: a clinical description of osteoar-thritis of the finger joints. Ann Rheum Dis 1955;14:1–10.

15. Crain DC. Interphalangeal osteoarthritis. JAMA 1961;175:1049–53.

16. Peter JB, Pearson CM, Marmor L. Erosive osteoarthritis of thehands. Arthritis Rheum 1966;9:365–88.

17. Ehrlich GE. Inflammatory osteoarthritis. I. The clinical syndrome.J Chron Dis 1972;25:317–28.

INTERPHALANGEAL HAND JOINT INVOLVEMENT IN OA 3375

18. Utsinger PD, Resnick D, Shapiro RF, Wiesner KB. Roentgeno-logic, immunologic, and therapeutic study of erosive (inflamma-tory) osteoarthritis. Arch Intern Med 1978;138:693–7.

19. Lane NE, Bloch DA, Jones HH, Simpson V, Fries JF. Osteoar-thritis in the hand: a comparison of handedness and hand use.J Rheumatol 1989;16:637–42.

20. Cooper C, Inskip H, Croft P, Campbell L, Smith G, McLaren M,et al. Individual risk factors for hip osteoarthritis: obesity, hipinjury and physical activity. Am J Epidemiol 1998;147:516–22.

21. Reading I, Walker-Bone K, Palmer K, Coggon D, Cooper C. Doesphysical examination assist in the evaluation of disorders of the neckand upper limb? [abstract] Rheumatology 2003;42 Suppl 1:15.

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