Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Thumb Arthritis

Basics

Description
  • Degenerative joint disease commonly presents in the hand and is associated with pain, swelling, loss of motion, and, later, deformity.
  • Frequently, the thumb is the earliest site of involvement, with the CMC joint affected 1st, especially in osteoarthritis.
  • The 1st CMC joint is considered the most important joint of the hand.
  • Thumb arthritis, which may be unilateral or bilateral, occurs as commonly in the nondominant hand as in the dominant one.
  • It generally affects more females than males.
  • Various forms of arthritis affect the thumb, including:
    • Osteoarthritis
    • Rheumatoid arthritis
    • Gout
Epidemiology
Incidence
The incidence is highest in persons 55 years old.
Risk Factors
Increased body mass index
Diagnosis
Signs and Symptoms
  • Joint pain
  • Warmth
  • Swelling
  • Stiffness
  • Crepitus
  • Triggering (catching of tendon, with snapping and locking), most noticeably during activities such as pinching and grabbing
Physical Exam
  • Perform a careful and thorough examination of the hand and thumb, with attention to ROM of the joints (CMC, MCP, IP) and associated swelling, erythema, and soft-tissue masses.
  • Test for snuffbox tenderness and tendinitis (Finkelstein test).
Tests
Lab
No serum laboratory tests are needed.
Imaging
Plain radiographs reveal a loss of joint space, sclerosis, spur formation, and subchondral cysts.
Pathological Findings
  • Rheumatoid arthritis: Hypertrophic synovitis that eventually destroys joint cartilage, compresses or disrupts tendons, compresses adjacent nerves, and dislocates and erodes the joint
  • Osteoarthritis: Loss of articular cartilage associated with spur formation and loss of motion, but not associated with tendon ruptures or triggering as frequently as in rheumatoid arthritis
Differential Diagnosis
  • Ligamentous injuries
  • Tendon injuries (e.g., de Quervain tenosynovitis)
  • Scaphoid fractures
Treatment
General Measures
  • Supportive measures include rest, heat, analgesics, splint immobilization, and NSAIDs.
  • Intra-articular corticosteroid injections may be helpful during flare-ups.
  • Activity limitation or modification
  • Rheumatologic or orthopaedic consultation for those with symptoms refractory to nonoperative management
Special Therapy
Physical Therapy
  • A hand therapist can fashion a splint to immobilize the thumb while preserving wrist ROM.
  • Therapy often is helpful after surgery to reduce swelling and regain motion and function.
Medication
  • NSAIDs
  • Intra-articular steroid injection, although not shown to be effective versus placebo in CMC arthritis
Surgery
  • MCP joint:
    • Early surgical treatment may involve synovectomy of the joint and tendon advancement or tendon transfer.
    • If the joint is grossly unstable, or the articular surface is destroyed, arthrodesis (fusion) may be indicated.
  • CMC joint:
    • Treatment may involve arthroplasty, consisting of resection of the trapezium and replacement with the patient’s own tendon.
    • If arthroplasty fails, arthrodesis may be performed.
Follow-up
Prognosis
  • The prognosis is fairly good.
  • Arthrodesis is the most reliable pain relief procedure, but it results in permanent limited motion.
  • Interpositional tendon arthroplasty is the most common and overall most effective procedure for CMC arthritis.
    • Patients enjoy decreased pain and improved quality of life.

P.451
Complications
  • Surgery may be complicated by:
    • Damage to the radial sensory nerve
    • Wound infection
    • Nonunion
    • Chronic subluxation
    • An unstable joint
Patient Monitoring
Patients must be followed at 12-week intervals for assessment of function and for detecting postoperative wound complications.

Miscellaneous
Codes
ICD9-CM
716.95 Arthritic hand
FAQ
Q: How is thumb arthritis diagnosed?
A: Patients present with complaints of pain and possibly deformity. They are tender over the affected joint(s) and may have limited ROM and crepitus at the joint with motion. The diagnosis is confirmed with plain radiographs showing decreased joint space and possibly sclerosis, osteophyte formation, and/or cystic change.
Q: How is thumb CMC arthritis treated?
A: The 1st line of treatment is with splint immobilization and anti-inflammatory medication. The splint used is a hand-based thumb-keeper splint and is to be worn as much as possible during daily activity. If symptoms persist, a corticosteroid injection may be helpful. For patients with persistent or recurrent severe pain, surgical treatment is warranted, using CMC arthroplasty and tendon interposition.

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