What is basilar thumb arthritis?
Describe its epidemiology?
Arthritis of the Carpal- metcarpal joint
- Common arthritis of the hand
- 2nd only to DIPJ arthritis
Decribe the pathoanatomy of basilar thumb arthritis?
Due to Attenuation of the Anterior OBLIQUE Ligament - Beak Ligament
which -> instability, subluxation, arthritis of CMC joint
Can you describe the trapezial metacarpal joint anatomy?
It is bicaoncave saddle joint
Trapezium has a palmar groove for Flexor carpi radialis tendon
- anterior oblique ligament is the primary stabiliser restraint to subluxation of CMC Joint
- Intermetacarpal ligaments
- Post oblique ligaments
- Dorsal - radial capsule- ruptured in CMC dislcation
- Biomechanics- CMCJ reactive force is x13 in pinch
Describe the classfication of basilar thumb arthritis?
EATON and LITTLER
stage 1- slight joint space widening (pre-arthritis)
Stage II- slight narrowing CMCJ w sclerosis, Osteophytes <2mm
stage III- Marked narrowing CMCJ w osteophytes >2mm
Stage IV- Pantrapezial Arhtritis (STT involved)
What are the symptoms and Signs of Basilar thumb arthritis?
- Pain at base of thumb
- Difficulty pinching/ gasping
- Concomitant carpal tunnel syndrome
- Painful CMC gring test- combined axial compression/circumduction
- Swelling and crepitus
- Metacarpal adduction & web space contractures- later
- Adjacent MCP fixed hyperextension - during pinch- EPB potentiatin the mcp hyperextnesion deformity
What position is the thumb in for xray to rv cmcj ?
What is seen on the xray?
Xary beam centred on trapezum and metacarpal with thumb flat on cassett with thumb hyperpronated
eaton and littler classification
- joint space narrowing
- hyperextension of MCPJ
What is the TX for basilar thumb arthritis?
Mild symptoms- NSAIDs, BRACING (thumb spica orthrosis), Symptomatic TX
injection of hyalgan- no diff for pain relief and improvement in rom cf placebo/corticosteriods
Stage 1- ligament reconstruction with FCR-
joint hypermobile and unstable
Early stage- CMC arthroscopy and debridement
Early stages minimal arthritis- Extension osteotomy of 1st MC-
redirects forces to dorsal , more univolved portion of 1st CMCJ- studies show 93% improved at 7 years
- Stage II- IV = Trapezial resection + LTRI ( ligament reconstruction and tendon interposition)- most common
FCR/ APL/PL sounf FCR to suspend Metacarpal
expect 25% Subsidence postop- improved grip/pinch strength
- Stage II-III in young male labourers- trapeziometacarpal arthrodesis and fusion
CMCJ fused in 35 degrees abduction, 30 palmar abduction, 15 degrees pronation
OC= gd relief of pain, stability and length preservation, NU 12%, decreaed rom- unable to put hand flat on table
- MC hyperextension >30- Volar capsulodesis, EPB tendon transfer, semsoid function, MCP fusion
- Arthoplasty- silicone- not recommended- fracture/subluxation and silicone synovitis
Describe primary osetoarthritis in the DIPj?
- Highest forces in the hand- more wear and tear
- Associated with Heberden's nodes ( caused by ostephytes)
- Mucous cysts- > sinus, septoic arthritis and nail ridging
- Nails- loss gloss, deformity, splitting
Describe primary osetoarthritis in the PIPj?
- Bouchard nodes
- Joint contracture with fibrosis of ligaments
What is erosive osteoarthritis?
- Condition is self limiting,patients are relatively asymptomatic but can be destructive to joint
- More common in DIPJ
- Seen in middle aged women 10:1 F: males
Describe the symptoms of OA of hand?
Pain and deformity
Describe the Symptoms of erosive osteoarthritis?
- Intermittent inflammatory episodes
- Articular cartilahe adn adjacet bones destroyed
- Synovial changes similar to RA but not systemic
- xrays will show cartilage detruction/osteophytes/sunchondral erosion
Describe the TX for DIPJ arthritis?
Non operative- first line
- Observation & NSAIDs
- Pain/deformity= Fusion
- Rusion w headless screw most realible- NU 10%
- 2/3 digits fused in extension, 4/5 fused 10-20o
Describe the tx of mucous cyst?
Observation- first line as 20-60% resolve
Impending rupture= Cyst excision and osteophyte resection- may need local rotational flap fo rskin coverage
Describe tx of PIPJ Arthritis?
First line/ mild symptoms- Observations & NSAIDs
- Fusion- for border digits/ poor bone stock
- Headless screw highest fixation rates
- In cascade- index 30o,long 35o,ring40o,small 45o
- Silicone Arthroplasty- no angular deformity, long/ring finger, Gd bone stock
- Collateral ligament excision, volar plate release, osetophyte excision-Contracture & minimal joint movement
What is the tx of erosive osteoarthritis?
- Fusion- for intolerable deformity
Headless screw highest fixation rates
In cascade- index 30o,long 35o,ring40o,small 45o
Name the different forms of wrist arthritis?
SLAC wrist-=Scapholunate advanced collapse-most common
STT arthrosis- 2nd common
SNAC- Scaphoid non union advanced collapse
- Pisotriquetrial arthrosis
What is the mechanism of wrist arthritis?
Degenerative- primary OA
Post- traumatic-> SNAC/SLAC/DRUJ
Congential - Madelung's deformity
Idiopathic- 2ary to Keinbock's/Preiser's disease
Describe the pathoanatomy of wrist arthritis?
Injury to SL ligament --> palmar rotary subluxation of scaphoid --> incongruency of joint surfaces --> arthrosis of radiocarpal joint --> arthrosis of capitolunate joint
radiolunate typically spared
proximal portion of scaphoid remains attached to lunate while distal scaphoid flexes
leads to early arthritis between radial styloid and distal scaphoid
like SLAC, radiolunate typically spared
wrist becomes supinated, palmarly dislocated, radially deviated, and ulnarly translocated
early disruption of DRUJ leads to dorsal subluxation of ulna (Caput-ulna)
What imaging is required to identify pisotriquetral arthritis?
xray- Lateral in 30 degrees of supination
What is the TX of wrist arthritis?
- NSAIDs, Bracing, Intra-articular steriod injections
Aim at addressing diseased area
SLAC-radial styloidectomy & scaphoid satbilisation-> Pin/Ain denervation-> Prox row carpectomy->scaphoid excision & 4 corner fusion->Wrist fusion
SNAC-inlay ( russe) bone graft-> interposition (fisk) bone graft)->Vascular bone graft from radius
Pisotriquetral arthritis- excision of pisiform
DURJ abutment syndrome- Darrach's procedure,sauve- kapanje, partial ulna resection and interposition, ulnar head replacement
RA- Darrach's procedure,sauve- kapanje,Pin/Ain denervation, wrist fusion