Introduction Arthritis of the carpal-metacarpal (CMC) joint Epidemiology race thumb CMC arthritis is more common in Caucasians hand OA is more common in native Americans than Caucasians/African Americans common arthritis of the hand 2nd only to DIP arthritis DIP > thumb CMC > PIP > MCP OA in 1 joint in a row (proximal row) predicts for OA in other joints in same row Pathoanatomy theorized to be due to attenuation of anterior oblique ligament (Beak ligament) leading to instability, subluxation, and arthritis of CMC joint Associated conditions MCP hyperextension deformity Anatomy Trapezial metacarpal joint is a biconcave saddle joint Trapezium has a palmar groove for flexor carpi radialis (FCR) tendon Ligaments anterior oblique ligament (Beak ligament) primary stabilizing restraint to subluxation of CMC joint intermetacarpal ligaments posterior oblique ligament dorsal-radial capsule (injured in dorsal CMC dislocation) Biomechanics CMC joint reactive force is 13X applied pinch force Classification Eaton and Littler Classification of Basilar Thumb Arthritis Stage I slight joint space widening (pre-arthritis) Stage II slight narrowing of CMC joint with sclerosis, osteophytes <2mm Stage III marked narrowing of CMC joint with osteophytes, osteophytes >2mm Stage IV pantrapezial arthritis (STT involved) Presentation Symptoms pain at base of thumb difficulty pinching and grasping concomitant carpal tunnel syndrome up to 50% incidence Physical exam painful CMC grind test combined axial compression and circumduction swelling and crepitus metacarpal adduction and web space contractures are later findings may have adjacent MCP fixed hyperextension (zig-zag or "Z" deformity) occurs during pinch as a sequlae of CMC arthritis Imaging Radiographs technique X-ray beam is centered on trapezium and metacarpal with thumb flat on cassette and thumb hyperpronated findings joint space narrowing osteophytes may show MCP hyperextension Differential Diagnosis de Quervains tenosynovitis STT arthritis scaphoid nonunion/SNAC radioscaphoid arthritis Treatment Nonoperative NSAIDS, thumb spica bracing, symptomatic treatment, steroid injections indications indicated as first line of treatment for mild symptoms hyaluronic acid injections show no difference for the relief of pain and improvement in function when compared to placebo and corticosteroids Operative closing wedge dorsal extension osteotomy of 1st metacarpal indications for early Stage I disease technique redirects the force to the dorsal, more uninvolved portion of the first carpometacarpal joint outcomes gained in popularity 93% have symptom improvement at 7 years ligament reconstruction with FCR indications Stage I disease when joint is hypermobile and unstable (pain with varus valgus stress) trapeziectomy + LRTI (ligament reconstruction and tendon interposition) indications Stage II-IV disease most common procedure and favored in most patients technique there are many different surgical options available trapezial excision is most important, regardless of other specifics of CMC arthroplasty FCR tendon most commonly used in reconstruction to suspend metacarpal alternatively, ECRL or APL may be used for suspension or PL around FCR to correct subluxation outcomes can expect ~25% subsidence postoperatively postoperatively with no change in outcomes results in improved grip and pinch strengths hematoma arthroplasty (trapezial resection alone without LRTI) indications Stage II-IV disease technique trapezium resection and pinning of thumb metacarpal without LRTI outcomes comparable outcomes to trapeziectomy + LRTI excision of proximal third of trapezioid indications concomitant scaphotrapezioid arthritis (present in 62%), especially in Eaton-Littler stage IV CMC arthroscopy and debridement indications early stages of disease trapeziometacarpal (CMC) arthrodesis indications Stage II-III disease in young male heavy laborers preserves grip strength contraindications scaphotrapeiotrapezoidal (STT) arthritis technique CMC joint fused in 35° radial abduction 30° palmar abduction 15° pronation outcomes good pain relief, stability, and length preservation decreased ROM; inability to put hand down flat nonunion rate of 12% volar capsulodesis, EPB tendon transfer, sesamoid fusion, or MCP fusion indications thumb MCP hyperextension instability (hyperextension > 30°) otherwise a Swan neck deformity will arise see below (Complications) for algorithm silicone replacements indications not recommended complications of prosthesis fracture, subluxation, or silicone synovitis Complications 1st metacarpal subsidence and narrowing of trapezial space height after trapeziectomy ± tendon suspension salvage treatment LRTI with ECRL tendon or APL tendon if FCR is already used /ruptured MCP hyperextension deformity treatment depends on degree of hyperextension <10° - no surgical intervention 10-20° - percutaneous pinning of MCP in 25-35° flexion x 4wk ± EPB tendon transfer 20-40° - volar capsulodesis or sesamoidesis >40° - MCP fusion
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.95) A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of motion of her thumb is seen in Figure B. What is the most likely cause of her deformity? Review Topic QID: 4730 FIGURES: A B 1 Type II hypoplastic thumb 1% (50/3991) 2 Median nerve neuropathy 4% (161/3991) 3 Lupus thumb deformity 5% (188/3991) 4 Extensor tendon rupture 6% (224/3991) 5 Osteoarthritis of the trapeziometacarpal joint 84% (3344/3991) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ09.122) A 60-year-old man has chronic pain at the base of this thumb and weakness on attempted thumb pinch. A radiograph is shown in Figure A. Which injection would likely reduce his pain and increase his function? Review Topic QID: 2935 FIGURES: A 1 Saline 0% (9/2158) 2 Steroid 42% (902/2158) 3 Hylan 1% (29/2158) 4 All of the above are equally effective 54% (1158/2158) 5 All of the above are detrimental 2% (48/2158) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ11.246) A 68-year-old female office assistant reports left thumb pain that has progressively worsened over the past 2 years. She is left hand dominant and reports difficulty with opening jars and holding a coffee cup. On examination of the left hand she has a positive thumb carpometacarpal grind test and has a fixed deformity at the thumb metacarpalphalangeal joint. Figure A demonstrates the left hand grasping an object and Figure B shows a radiograph of the left thumb. What is the most appropriate next step in treatment? Review Topic QID: 3669 FIGURES: A B 1 Carpometacarpal joint fusion and metacarpophalangeal joint volar capsulodesis 7% (189/2676) 2 Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint volar capsulodesis 13% (340/2676) 3 Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint fusion 68% (1822/2676) 4 Carpometacarpal joint resection arthroplasty and temporary metacarpophalangeal joint percutaneous pin fixation 6% (153/2676) 5 Carpometacarpal joint fusion and metacarpophalangeal joint fusion 6% (148/2676) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3
Trapezium excision and LRTI for basilar thumb arthritis Hand - Basilar Thumb Arthritis - Surgical Techniques This video shows step-by-step technique for trapezium excision and LRTI (ligamen... 2/23/2013 6884 views CMC grind test Hand - Basilar Thumb Arthritis - Physical Exam This video (without audio) portrays how to properly perform the CMC grind test f... 2/23/2013 7429 views
Basal joint arthritis (C1185) Hand - Basilar Thumb Arthritis HPI - Patient is a healthy 66 year old right hand dominant female with several years of right greater than left pain at the base of her thumbs. She has used oral NSAIDs and topical voltaren gel, tried 3 corticosteroid injections in her right basal joint (helpful for a short time) and has used a thumb spica splint with minimal relief of her pain. What is your preferred method to treat 1st CMC arthritis secondary to primary osteoarthritis surgically? 3/29/2012 351 3 17