Introduction
Trapezoid metacarpal (TMC) arthritis (also known as arthrosis) is arthritis of the first carpus metacarpal (CMC) joint of the thumb. The CMC joint or TMC joint of the thumb plays a vital role in the normal function of the thumb. It is the most important joint that connects the wrist to the wrist metacarpal. Osteoarthritis in TMC is a severely disabling disease; it occurs 20 times more frequently than average in older women. [1]
Carpometacarpal Joint of the hand
Ligaments of the TMC joint and their functions
The major ligaments of the TMC joint are as follows: [2] [3] [4]
- The dorsoradial ligaments (DRL)
- superficial anterior oblique ligament (AOL)
- The deep anterior oblique ligament (AOL)
- The intermetacarpal ligament (IML)
- The ulnar collateral ligament
- The posterior obique ligament
Table 1. Functions of the ligaments (table adapted from Blige & Karalezli 2015 [2]
Ligament Function The shortest and thickest ligament of the dorsal radius. The primary stabilizer against dorsal translation of the joint is the superficial stabilizer against volar joint subluxation by the anterior oblique, also known as the coracoid ligament. It acts as a pivot master joint stabilizer Oblique stabilization after dorsal translation Intermetacarpal stabilization Ulnar collaterals help stabilize volar joint subluxation during radial translation
Although there is controversy regarding the primary stabilizer of the TMC combination, several studies have concluded that DRL is the primary stabilizer [5] [3]
[6]
Stages of CMC
CMC stages are usually classified according to the Eaton-Litter classification obtained by radiological procedures or arthroscopy [2]. This is a staging scheme with four distinct stages based on laxity of the synovitis joint space and joint capsule [7].
Following are the four stages of Eaton-Litter classification [8]:
Stage I: Synovitis Phase
- Articular contours are normal
- TMC Joints may widen, suggesting joint effusion or ligamentous laxity
- No osteophyte formation
Stage II: Significant Capsular Laxity
- Narrowing of CMC joint
- Formation of small osteophytes on the ulnar side of the distal trapezoidal articular surface
- No or 1/3rd CMC joint subluxation
Stage III: Significant Joint Destruction
- Further narrowing of the joint space with cystic changes and osteosclerosis
- Osteophytes protruding from the distal trapezoidal ulnar border
- Radial and dorsal moderate subluxation of the base of the first metacarpal
- Mild arthrosis of navicular joint
Stage IV: Pantrapezial Arthritis
- Major subluxation of the joint
- Narrowing of the yolk sac as in section 3
- Cystic and sclerotic subchondral tumors in the sacrum
- Severe prolapse and degeneration of the scaphotrapezial joint
Etiology
Causes of TMC arthritis are:
- CMC joints used too often
- Subluxation
- Lesion of the ligaments or a fracture.
- CMC joint weakness may be an increased genetic risk factor for muscle injury triggered primarily in the development of rheumatoid arthritis. Also leads to hyperextension which is another important trigger for arthritis.[9]
- Cruciate weakness of the elbow (anterior oblique ligament). These muscles are the most important stabilizers of the elbow. [10] .
- Using the thumb in the profession, for example, physical therapists Work-related thumb pain is a common problem among physical therapists administering manual techniques. Factors that appear to be associated with thumb pain include CMC mobility and thumb strength [11].
Signs and Symptoms
The first signs of thumb arthritis are
- Painful tenderness and stiffness at the base of the thumb. This happens when you pinch or grip something between your thumb and forefinger, or when you apply light force when turning a key in a lock or turning a doorknob. Pain after activity may also be a feature.
- Reduced strength and range For example, opening cabinets or making buttons up can be difficult.
- Appearance. The joints may be swollen or bony. The joints may appear triangular and enlarged.[12]
Diagnosis
- Medical and family history
- Swelling or inflammation appearing on the first CMC joint
- Thumb CMC grind test
- Plain radiographs showing degenerative changes (bone spurs thinning of cartilage loss of joint space) in the involved joints are usually diagnostic.[13]
Differential Diagnosis
The differential diagnosis of Rhizarthrosis includes: [2] .
- De Quervain’s disease
- Trigger thumb
- Scaphoid fracture
- Flexor carpi radialis (FCR).
- Scaphotrapezial arthritis
- Wrist arthritis
- Subsesamoid arthritis
Treatment
Prevention is the first option for CMC neuropathy and can improve symptoms in most cases. These include
Behaviour modification
For example try to avoid: clenching your arms when carrying objects; conventional movements involving pinching or twisting
Physiotherapy
Techniques include
- range-of-motion and stretching exercises to improve the wrist.
[14]
- Go ahead for strength exercises including for the intrinsic and extrinsic thumb muscles and finger muscles.
[15]
- Dexterity and fine motor exercises for hands and fingers. [16] .
- Use of heat or cold therapy
- Electrotherapeutic techniques used For example Therapeutic Ultrasound TENS. Ultrasound has been found to have the ability to induce many therapeutic benefits such as improved pain and positive functional outcomes for neuropathology and good phonophoresis hyaluronan implants. [17] .
- Acupuncture is administered. It may work in pain relief for some people.[18]
- Clinical trials have provided evidence that a combination of joint stimulating muscle stimulation and exercise helps CMC joint pain.[19]
- Pain splints designed to help reduce pain have prevented or prevented disability from becoming worse. To be worn at night during fires and during heavy manual labor.[16]
Rhizarthrosis splint
Pain relief
Options include
- Topical medications such as capsaicin or diclofenac applied to the skin over the joints
- Over-the-counter pain relievers, such as acetaminophen, ibuprofen or naproxen sodium
- Prescription pain relievers, such as celecoxib (Celebrex) or tramadol (Conzip Ultram)
- injection. Corticosteroid injections can temporarily relieve pain and reduce inflammation. [13]
Surgery
None of the above treatments will help if the diagnosis of “root nodule” is made too late. Surgery may be unavoidable due to severe pain and motion limitations. The following options are usually offered for surgery:[20]
- Arthroscopy: Removal of part of the trapezium bone
- Arthrodesis to fuse the first metacarpal and trapezium bones
- Arthroplasty by reconstruction of the joint using a prosthesis, such as Swanson’s trapezoidal implant arthroplasty [21] or the Artelon spacer. [twenty two]
Other treatment techniques may also include:[23]
- Denervation of the TMC joint
- Reconstruction of the volar coracoid ligament
- Suture button suspensionplasty
[24]
Complications
Possible complications after surgery include:[8]
Common complications
- Swelling
- Bruising
- Incision tenderness
- Joint Stiffness
- Mild metacarpal subsidence
2. Uncommon Complications
- Hematoma
- Infection
- Nerve irritation/numbness
- Recurrent pain
- Tendon anchovy extrusion
- Tendon adhesions or ruptures
- Deep vein thrombosis
- Pulmonary embolus
- Myocardial infarction
- Death
- Mild metacarpal subsidence
References
- ↑ Wikipedia. CMC joint. Accessed 30.09.22
- ↑ Jump up to:2.0 2.1 2.2 2.3 Bilge O, Karalezli N. Current review of trapeziometacarpal osteoarthritis (rhizarthrosis). World Journal of Rheumatology. 2015 Jul 12; 5(2):90-5. Accessed 30.09.22
- ↑ Jump up to:3.0 3.1 Lin JD, Karl JW, Strauch RJ. Trapeziometacarpal joint stability: the evolving importance of the dorsal ligaments. Clinical Orthopaedics and Related Research®. 2014 Apr 1; 472(4):1138-45. Accessed 30.09.22.
- ↑ Imaeda T, An KN, Cooney III WP, Linscheid R. Anatomy of trapeziometacarpal ligaments. The Journal of hand surgery. 1993 Mar 1; 18(2):226-31. Accessed 30.09.22.
- ↑ Ripoll G, Glumcher D, Fossati G 2019 Anatomical considerations of the thumb carpometacarpal joint ligaments, based on a case report of isolated joint dislocation (Accessed 30.09.22)
- ↑ Mayo clinic. Causes remedies for thumb arthritis. Accessed 30.09.22
- ↑ Wikipedia. Trapeziometacarpal osteoarthritis. [Accessed, 30.09.22]
- ↑ Jump up to:8.0 8.1 Thumb CMC Joint Arthroplasty. Available from:https://www.touchsurgery.com/simulations/thumb-cmc-joint-arthroplasty (Accessed 15 October 2020)
- ↑ Wolf JM, Schreier S, Tomsick S, Williams A, Petersen B. Radiographic laxity of the trapeziometacarpal joint is correlated with generalized joint hypermobility. The Journal of hand surgery. 2011 Jul 1;36(7):1165-9. Available from: https://www.jhandsurg.org/article/S0363-5023(11)00353-4/abstract (last accessed 14.4.2019)
- ↑ A. Gondim Teixeira, Pedro & Omoumi, Patrick & J Trudell, Debra & Ward, Samuel & Blum, Alain & L Resnick, Donald. (2010). High-resolution ultrasound evaluation of the trapeziometacarpal joint with emphasis on the anterior oblique ligament (beak ligament). Skeletal radiology. 40. 897-904. 10.1007/s00256-010-1068-0. Available from: https://www.researchgate.net/publication/49647832_High-resolution_ultrasound_evaluation_of_the_trapeziometacarpal_joint_with_emphasis_on_the_anterior_oblique_ligament_beak_ligament
- ↑ Snodgrass SJ, Riyett DA, Chiarelli P, Bates AM, Rowe LJ. Factors related to thumb pain in physiotherapists. Australian Journal of Physiotherapy. 2003 Jan 1;49(4):243-50. Available from:https://www.sciencedirect.com/science/article/pii/S0004951414601409 (last accessed 10.4.2020)
- ↑ Healthline. Basal joint arthritis. Available from: https://www.healthline.com/health/basal-joint-arthritis#symptoms (last accessed 14.4.2019)
- ↑ Jump up to:13.0 13.1 Mayo clinic. Thumb arthritis. Available from: https://www.mayoclinic.org/diseases-conditions/thumb-arthritis/diagnosis-treatment/drc-20378344 (last accessed 14.4.2019)
- ↑ Healing hands rehab. CMC arthritis. Available from: https://www.youtube.com/watch?v=wCIA1_tksjA&feature=youtu.be (last accessed 14.4.2019)
- ↑ LB hand therapy. Thumb stability exercises. Available from: https://www.youtube.com/watch?v=rf4R7udarNg&feature=youtu.be
- ↑ Jump up to:16.0 16.1 Central physiotherapy. Arthritis of the thumb. Available from: https://www.centralphysicaltherapy.com/Injuries-Conditions/Hand/Hand-Issues/Arthritis-of-the-Thumb/a~282/article.html (last accessed 14.4.2019)
- ↑ Srbely JZ. Ultrasound in the management of osteoarthritis: part I: a review of the current literature. The Journal of the Canadian Chiropractic Association. 2008 Mar;52(1):30. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2258240/ (last accessed 15.4.2019)
- ↑ Arthritis Foundation. Acupuncture and osteoarthritis. Available from: https://www.arthritis.org/living-with-arthritis/treatments/natural/other-therapies/mind-body-pain-relief/oa-acupuncture.php (last accessed 15.4.2019)
- ↑ Jospt. The Effectiveness of a Manual Therapy and Exercise Protocol in Patients With Thumb Carpometacarpal Osteoarthritis: A Randomized Controlled Trial. Available from: https://www.jospt.org/doi/full/10.2519/jospt.2013.4524 (last accessed 14.4.2019)
- ↑ Rhizarthrosis. Available from: http://www.baur-fromberg.de/rhizarthrosis.php (Accessed 19 October 2020)
- ↑ Ruettermann M. Changing surgical treatments of thumb carpometacarpal osteoarthritis. Journal of Hand Surgery (European Volume). 2020 Jun; 45(5):533-5.
- ↑ Gillis J, Calder K, Williams J. Review of thumb carpometacarpal arthritis classification, treatment and outcomes. Canadian Journal of Plastic Surgery. 2011 Dec; 19(4):134-8.
- ↑ Rhizarthrosis. Available from: https://www.topdoctors.co.uk/medical-dictionary/rhizarthrosis (Accessed 19 October 2020)
- ↑ Dartmouth-Hitchcock. Basal joint arthritis. Available from: https://www.youtube.com/watch?v=iSA1BSSQLPA (last accessed 15.4.2019)