Updated: 11/13/2019

Basilar Thumb Arthritis

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Introduction
  • Overview
    • basilar thumb arthritis is a common form of arthritis that affects the carpal-metacarpal (CMC) joint of the thumb
      • treatment is nonoperative or operative depending on the severity of symptoms and Eaton and Littler stage of disease
  • Epidemiology
    • incidence
      • common arthritis of the hand
        • 2nd only to DIP arthritis
          • DIP > thumb CMC > PIP > MCP
      • seen in 25% of men and 40% of women aged > 75 years old
    • demographics
      • more common in women
      • thumb CMC arthritis is more common in Caucasians
        • hand OA is more common in native Americans than Caucasians/African Americans
    • risk factors
      • female gender
      • Ehler-Danlos syndrome
      • increased BMI
  • 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
    • concomitant carpal tunnel syndrome
      • occurs in up to 50%
  • Prognosis
    • OA in 1 joint in a row (proximal row) predicts for OA in other joints in same row
Anatomy
  • Osteology
    • thumb carpal-metacarpal joint is a biconcave saddle joint 
      • consists of 4 articulations
        • trapeziometacarpal (TM)
        • trapeziotrapezoid
        • scaphotrapezial (ST)
        • trapezium-index metacarpal
    • trapezium has a palmar groove for the flexor carpi radialis (FCR) tendon
  • Ligaments 
    • anterior oblique (volar beak) ligament
      • primary stabilizing static restraint to subluxation of CMC joint
      • originates from the palmar tubercle of the trapezium and inserts on the articular margin of the ulnar metacarpal base
    • intermetacarpal ligament
      • attaches from the radial base of the 2nd metacarpal to the ulnar base of the 1st metacarpal
      • primary restraint to radial translation of the base of the 1st metacarpal
        • assisted by the dorsoradial and posterior oblique ligaments
    • posterior oblique ligament
    • dorsoradial ligament
      • primary restraint to dorsal dislocation
        • injured in dorsal CMC dislocation
      • strongest and thickest ligament
  • 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
      • pain at base of thumb
      • symptoms of concomitant carpal tunnel syndrome
    • function
      • difficulty pinching and grasping
  • Physical exam
    • inspection
      • swelling and crepitus
      • metacarpal adduction and web space contractures
        • later findings
      • may have adjacent MCP fixed hyperextension (zig-zag or "Z" deformity) 
        • occurs during pinch as a sequlae of CMC arthritis
    • provocative tests
      • painful CMC grind test 
        • combined axial compression and circumduction
Imaging
  • Radiographs
    • recommended views
      • AP
      • lateral
      • Roberts view 
        • 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
      • indications
        • first line of treatment for mild symptoms
    • injections
      • indications
        • second line of treatment for mild to moderate disease
      • types
        • steroid injections
          • good evidence to support
        • hyaluronic acid injections
          • not indicated - studies show no difference for the relief of pain and improvement in function when compared to placebo and corticosteroids
  • Operative
    • CMC arthroscopic debridement
      • indications
        • early stages of disease
    • 1st metacarpal osteotomy  
      • indications
        • early Stage I-II disease
      • contraindications
        • hypermobility or fixed subluxation of the CMC joint
        • MCP hyperextension > 10°
      • technique
        • performed with closing wedge dorsal extension 
    • trapeziectomy +/- ligament reconstruction   
      • indications
        • Stage I-IV disease
      • multiple techniques with none showing clear benefit
        • trapeziectomy + LRTI (ligament reconstruction and tendon interposition)
          • most common procedure and favored in most patients
        • hematoma arthroplasty (trapeziectomy without LRTI)
        • trapeziectomy + suture suspension (suture suspension with APL to FCR)
          • newer technique growing in popularity
        • volar ligament reconstruction with FCR
          • useful for Stage I disease when joint is hypermobile and unstable (pain with varus valgus stress)
        • excision of proximal third of trapezioid 
          • ideal for patients with concomitant scaphotrapezioid arthritis (present in 62%), especially in Stage IV disease
    • CMC arthrodesis 
      • indications
        • Stage II-III disease in young male heavy laborers
          • preserves grip strength
      • contraindications
        • scaphotrapeiotrapezoidal (STT) arthritis
    • CMC denervation
      • indications
        • Stage I-IV disease
    • CMC prosthetic arthroplasty
      • indications
        • not recommended
Techniques
  • CMC Arthroscopic Debridement
    • technique
      • portals
        • dorsal 1R
          • radial to the APL tendon
        • dorsal 1U
          • ulnar to the EPB tendon between the EPL and EPB tendons
  • 1st Metacarpal Osteotomy
    • technique
      • redirects the force to the dorsal, more uninvolved portion of the 1st CMC joint
      • perform closing dorsal wedge extension osteotomy
      • fixation using K wires, intraosseous wiring, or plates
    • outcomes
      • gained in popularity
      • 93% have symptom improvement at 7 years
  • Trapeziectomy +/- Ligament Reconstruction 
    • technique
      • many different surgical options are available
        • trapezial excision is most important, regardless of other specifics of CMC arthroplasty
        • FCR tendon most commonly used in LRTI to suspend metacarpal
          • can also use ECRL or APL for suspension
          • can use PL around FCR to correct subluxation
    • outcomes
      • can expect ~25% subsidence postoperatively with no change in outcomes
      • results in improved grip and pinch strengths
  • CMC Arthrodesis
    • 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%
  • CMC Denervation
    • technique
      • can be performed using 2 incisions
        • dorsal
          • apex of the first interosseous space
        • volar
          • distal wrist flexion crease, extending from the ulnar side of the FCR tendon to the 1st extensor compartment
      • resect 4 nerves
        • thenar cutaneous branch of the median nerve
        • palmar cutaneous branch of the median nerve
        • superficial branch of the radial nerve, via the dorsal articular nerve of the 1st interosseous space of the hand
        • lateral antebrachial cutaneous nerve of the forearm, via the branch of Cruveilhier
    • complications specific to this treatment
      • injury to the sensory brach of the radial nerve
    • outcomes
      • improved hand function, grip strength, and pain
      • comparable results to trapeziectomy and CMC arthrodesis in terms of pain
      • improved ROM compared to CMC arthrodesis
  • CMC Prosthetic Arthroplasty
    • technique
      • several implant types exist
        • most experience has been using silicone implants
    • complications specific to this treatment
      • implant fracture or loosening
      • subluxation
      • silicone synovitis
Complications
  • 1st metacarpal subsidence and narrowing of trapezial space height
    • occurs after trapeziectomy ± tendon suspension
    • 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
 

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Questions (8)
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(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:
1

Type II hypoplastic thumb

1%

(56/4425)

2

Median nerve neuropathy

4%

(179/4425)

3

Lupus thumb deformity

5%

(212/4425)

4

Extensor tendon rupture

6%

(246/4425)

5

Osteoarthritis of the trapeziometacarpal joint

84%

(3705/4425)

L 1

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SUBMIT RESPONSE 5
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(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:
1

Carpometacarpal joint fusion and metacarpophalangeal joint volar capsulodesis

7%

(220/3017)

2

Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint volar capsulodesis

12%

(359/3017)

3

Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint fusion

69%

(2070/3017)

4

Carpometacarpal joint resection arthroplasty and temporary metacarpophalangeal joint percutaneous pin fixation

6%

(174/3017)

5

Carpometacarpal joint fusion and metacarpophalangeal joint fusion

6%

(169/3017)

L 3

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(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 most offer the greatest degree of symptomatic improvement? Review Topic

QID: 2935
FIGURES:
1

Saline

0%

(9/2287)

2

Steroid

41%

(945/2287)

3

Hylan

1%

(30/2287)

4

All of the above are equally effective

54%

(1238/2287)

5

All of the above are detrimental

2%

(52/2287)

L 4

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SUBMIT RESPONSE 4
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(OBQ07.92) A 56-year-old right hand dominant male presents to your office complaining of right thumb pain worsened with pincer grip and using his mobile phone. He is a writer, and is having difficulty holding his pen. Radiographs from this visit are shown in Figure A. Compared with trapeziectomy alone, which of the following treatment options is likely to result in superior pain relief and improvement of key-pinch strength? Review Topic

QID: 753
FIGURES:
1

Trapeziometacarpal corticosteroid injection followed by aggressive occupational therapy

6%

(262/4712)

2

Trapeziectomy with interpositional palmaris longus arthroplasty

10%

(480/4712)

3

Trapeziectomy, interpositional arthroplasty, and palmar oblique ligament reconstruction using flexor carpi radialis autograft

28%

(1300/4712)

4

Partial trapeziectomy with capsular interpositional arthroplasty

34%

(1610/4712)

5

None of the above

22%

(1021/4712)

L 5

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SUBMIT RESPONSE 5
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