Orthopaedic Surgery - Thumb Arthritis

Basics

Thumb arthritis most commonly affects the:

Carpometacarpal joint of the thumb

also known as the:

Basal joint.

The disorder results primarily from progressive loss of:

Articular cartilage

at the articulation between the:

First metacarpal

and

Trapezium

together with varying degrees of:

Ligamentous insufficiency.

Clinical Presentation

Patients commonly present with:

Pain

Swelling

Stiffness

and reduced:

Thumb function.

Functional Disability

Functional limitation is often prominent because the thumb CMC joint is essential for:

Grip

Pinch

Opposition

and many:

Activities of daily living.

Patients may specifically report difficulty with:

Opening jars

Turning keys

Twisting lids

Gripping objects

or maintaining a firm:

Pinch or grasp.

Primary Osteoarthritis

The most common underlying disorder is:

Primary osteoarthritis.

The thumb CMC joint is one of the hand joints frequently affected by:

Degenerative arthritis.

Other Arthritides

The thumb may also be involved in:

Rheumatoid arthritis

Gout

and

Posttraumatic arthritis.

Anatomy and Biomechanics

The thumb CMC joint is a:

Saddle-shaped joint

that permits a large range of motion.

Its movements include:

Flexion

Extension

Abduction

Adduction

and

Opposition.

Mechanical Stress

Because the CMC joint combines:

High mobility

with substantial:

Pinch and grip forces

it is exposed to significant mechanical loading throughout:

Daily activities.

Ligamentous Support

Ligamentous structures help maintain:

Joint congruity

and

Stability.

Progressive ligamentous laxity can contribute to:

Subluxation

and abnormal loading of the:

Articular cartilage.

Epidemiology

Thumb CMC arthritis occurs most commonly in:

Middle-aged and older adults.

Age

Symptomatic disease commonly becomes apparent from approximately the:

Fifth decade of life onward.

Sex

The supplied source describes involvement of:

Men and women.

In clinical practice, radiographic and symptomatic basal-joint osteoarthritis is commonly encountered in:

Women after midlife.

Risk Factors

No single risk factor is required for the development of:

Primary osteoarthritis.

Potential contributors include:

Age-related cartilage degeneration

Joint laxity

Prior trauma

and repetitive mechanical:

Loading.

Diagnosis

The diagnosis is usually based on:

History

Physical examination

and

Plain radiographs.

Signs and Symptoms

The hallmark symptom is:

Pain at the base of the thumb.

Pain Pattern

Pain is typically aggravated by activities requiring:

Pinch

Grip

or

Twisting.

Examples include:

Opening jars

Turning doorknobs

Writing

and

Using keys.

Swelling

Patients may notice swelling or prominence around the:

Thumb CMC joint.

Stiffness

Progressive arthritis may produce:

Reduced motion

particularly during:

Opposition

and

Abduction.

Weakness

Patients frequently report reduced:

Pinch strength

and

Grip strength.

Physical Examination

Examination should include assessment of:

Thumb alignment

CMC motion

Tenderness

Stability

and

Pinch strength.

CMC Tenderness

Localized tenderness is usually present over the:

Thumb basal joint.

Grind Test

The:

CMC grind test

is commonly used.

The examiner applies axial compression through the first metacarpal while gently:

Rotating the metacarpal

against the:

Trapezium.

Reproduction of:

Pain

or palpable:

Crepitus

supports the diagnosis.

Subluxation

Advanced disease may produce:

Dorsoradial subluxation of the first metacarpal base.

This can create visible prominence at the:

CMC joint.

Thumb Deformity

Progressive CMC collapse may produce:

Adduction contracture of the first metacarpal

with compensatory:

Hyperextension of the MCP joint.

This may reduce the mechanical efficiency of:

Pinch.

Range of Motion

Assess:

Opposition

Palmar abduction

Radial abduction

and

MCP motion.

Laboratory Tests

There are no laboratory studies specific for:

Primary thumb osteoarthritis.

When Laboratory Testing Is Useful

Laboratory investigation may be appropriate when there is suspicion for:

Rheumatoid arthritis

Gout

Infection

or another systemic:

Inflammatory disorder.

Imaging

Plain Radiographs

Plain radiographs are highly useful for confirming:

Thumb CMC arthritis

and estimating its:

Severity.

Standard Findings

Typical osteoarthritic findings include:

Joint-space narrowing

Subchondral sclerosis

Osteophyte formation

and

Subluxation.

Additional Findings

More advanced disease may demonstrate:

Subchondral cysts

Trapezial remodeling

and involvement of the:

Scaphotrapeziotrapezoid joint.

Radiographic Staging

The:

Eaton-Littler classification

is commonly used to describe radiographic severity of:

Thumb CMC osteoarthritis.

Stage I

Stage I generally represents:

Early disease

with minimal structural change and possible:

Joint-space widening from synovitis or laxity.

Stage II

Stage II demonstrates:

Joint-space narrowing

with small:

Osteophytes

and early:

Subluxation.

Stage III

Stage III shows more advanced:

Joint-space loss

Larger osteophytes

and significant:

CMC degeneration.

Stage IV

Stage IV includes thumb CMC arthritis together with degenerative involvement of the:

Scaphotrapeziotrapezoid articulation.

Pathological Findings

Typical osteoarthritic changes include:

Loss and fibrillation of articular cartilage

Subchondral sclerosis

Osteophyte formation

and

Hypertrophic bone remodeling.

Ligamentous Changes

Chronic degeneration may also result in progressive:

Ligamentous attenuation

and

Joint instability.

Differential Diagnosis

Important alternative causes of pain around the thumb and radial wrist include:

de Quervain tenosynovitis

Scaphoid fracture

Scaphoid nonunion

Scapholunate advanced collapse

and other forms of:

Posttraumatic wrist arthritis.

de Quervain Tenosynovitis

de Quervain disease causes pain over the:

First dorsal extensor compartment

near the:

Radial styloid.

Pain is typically aggravated by:

Thumb motion

and

Ulnar deviation of the wrist.

Distinguishing de Quervain Disease

Tenderness is usually located over the:

Abductor pollicis longus

and

Extensor pollicis brevis tendons

rather than directly over the:

CMC joint.

Scaphoid Fracture

Acute or chronic scaphoid fracture may cause:

Radial-sided wrist pain

and should be considered when the history includes:

Trauma

or there is:

Anatomic snuffbox tenderness.

Posttraumatic Arthritis

Chronic carpal instability or scaphoid nonunion may cause degenerative patterns such as:

SLAC wrist

or

SNAC wrist.

These may mimic or coexist with:

Thumb-base arthritis.

Treatment

Treatment depends on:

Pain severity

Functional impairment

Radiographic stage

and the patient’s:

Activity demands.

General Measures

Initial management is generally:

Nonoperative.

Activity Modification

Patients should reduce or modify activities that increase:

Thumb-base loading.

Examples include repetitive:

Pinching

Twisting

and

Heavy gripping.

Adaptive Equipment

Larger handles, jar-opening devices, ergonomic tools, and other adaptations may decrease:

Thumb CMC stress.

Splinting

A:

Thumb CMC or thumb-spica splint

can reduce painful movement and provide:

Joint support.

Effectiveness of Splinting

Splinting is often particularly useful for patients wishing to delay or avoid:

Surgery.

It may be worn during:

Provocative activities

or intermittently according to:

Symptoms.

Medication

NSAIDs

NSAIDs may provide both:

Analgesic

and

Anti-inflammatory effects.

They should be used according to the patient’s:

Gastrointestinal

Renal

and

Cardiovascular risk.

Nonnarcotic Analgesics

Acetaminophen

or other nonopioid pain medication may be appropriate for symptomatic:

Pain control.

Intra-Articular Corticosteroid Injection

Injection of:

Corticosteroid

into the CMC joint may provide:

Temporary symptomatic relief.

Role of Injection

Injection is most useful as a:

Symptom-control measure

rather than a treatment that reverses:

Structural arthritis.

Duration of benefit varies considerably between:

Patients.

Hand Therapy

A therapist experienced in hand disorders can assist with:

Splint fitting

Joint-protection techniques

Activity modification

and

Thenar strengthening.

Surgical Preparation

Hand therapy can also improve postoperative recovery by educating patients regarding:

Splinting

Range of motion

and

Rehabilitation expectations.

Surgery

Surgery is considered when symptoms remain:

Painful and functionally limiting

despite appropriate:

Nonoperative treatment.

Trapeziectomy

One of the most common operative procedures is:

Trapeziectomy

in which the arthritic:

Trapezium

is removed.

Ligament Reconstruction and Tendon Interposition

Trapeziectomy may be combined with:

Ligament reconstruction

and

Tendon interposition.

This is often referred to as:

LRTI.

Goal of Tendon Interposition

A portion of tendon may be used to:

Stabilize the first metacarpal

and occupy the space left after:

Trapeziectomy.

Simple Trapeziectomy

Simple trapeziectomy without formal tendon reconstruction is also an effective option in many:

Patients.

Suspensionplasty

Alternative techniques use:

Tendon

or

Suture-based suspension

to support the first metacarpal after:

Trapezial excision.

Arthrodesis

CMC arthrodesis provides very reliable:

Pain relief

and strong:

Pinch strength.

However, fusion permanently eliminates motion at the:

CMC joint.

Candidates for Arthrodesis

Fusion may be considered in selected:

Younger

High-demand

or heavy-labor patients where stability and strength are prioritized over:

Motion.

Arthroplasty

Implant arthroplasty has also been used, but implant-related complications have limited the routine use of some:

Prosthetic designs.

Silicone Arthroplasty

Traditional silicone implant arthroplasty has largely fallen out of favor because of complications including:

Implant wear

Silicone synovitis

and

Instability.

MCP Hyperextension

If significant compensatory:

MCP hyperextension

is present, an additional procedure may be required to restore:

Thumb-column stability.

Follow-Up

Patients undergoing nonoperative treatment should be monitored for:

Pain

Functional limitation

and progression of:

Deformity.

Postoperative Follow-Up

Following reconstructive surgery, patients usually require:

Immobilization

followed by structured:

Hand therapy.

Rehabilitation

Rehabilitation focuses on restoring:

Thumb motion

Pinch strength

Grip strength

and functional use of the:

Hand.

Prognosis

The overall prognosis is generally:

Good to excellent.

Pain Relief

Most appropriately selected patients experience substantial:

Pain reduction

and improved:

Quality of life.

Arthrodesis Prognosis

Arthrodesis provides reliable:

Pain relief

but at the expense of permanent:

Loss of CMC motion.

Trapeziectomy-Based Procedures

Trapeziectomy with or without ligament reconstruction or suspension remains among the most commonly used and effective surgical strategies for:

Symptomatic CMC arthritis.

Recovery Time

Recovery after reconstructive surgery can be:

Gradual

and meaningful improvement in strength may continue for:

Several months.

Complications

Potential complications include:

Persistent pain

Sensory disturbance

Residual subluxation

Weakness

and

Stiffness.

Radial Sensory Nerve Injury

The superficial radial sensory nerve is at risk during surgical exposure.

Injury may cause:

Numbness

Paresthesia

or

Dysesthesia.

Persistent Subluxation

Some degree of:

First-metacarpal subsidence or subluxation

may remain after reconstructive:

Arthroplasty.

Radiographic subsidence does not always correlate with:

Clinical outcome.

Chronic Pain

A minority of patients may continue to experience:

Persistent thumb-base pain

despite technically successful:

Surgery.

Other Surgical Complications

Additional possible complications include:

Infection

Complex regional pain syndrome

Tendon irritation

and failure of:

Fusion

when arthrodesis is performed.

Patient Monitoring

Patients should be followed by both the:

Surgeon

and, when appropriate,

Hand therapist.

Monitoring Goals

Follow-up should assess:

Pain relief

Thumb alignment

CMC stability

Range of motion

Pinch strength

and return to:

Daily activities.

Key Principle

Thumb arthritis most commonly involves the carpometacarpal joint between the first metacarpal and trapezium, where degeneration of articular cartilage and supporting ligaments produces:

Pain, weakness, stiffness, and difficulty with pinch and grip.

Diagnosis is usually established by:

Clinical examination and plain radiographs, which may show joint-space loss, subchondral sclerosis, osteophytes, and subluxation.

Initial treatment includes:

Activity modification, thumb-spica splinting, nonopioid analgesia, hand therapy, and selected intra-articular corticosteroid injection.

For persistent disabling symptoms, effective surgical options include:

Trapeziectomy with or without ligament reconstruction or suspensionplasty, arthrodesis, and selected arthroplasty procedures.

Most appropriately treated patients obtain:

Meaningful pain relief and improved hand function.