Case 4 Flashcards
(21 cards)
Patient age and gender
67 yearold Female
History of present illness
A 67yearold righthand dominant female
presented with progressively worsening right thumb pain, which was severely
limiting the use of her right hand. She reported that the pain had been
present for many years without any antecedent injury. Initial conservative
treatment included a thumb wrap splint, which she was only able to tolerate
for about two hours and ultimately found to worsen her pain. She had also
previously tried a steroid patch, but discontinued it due to burning and
discomfort. Nonoperative options were discussed, but as her symptoms
remained severe and refractory to these interventions, she inquired about
further treatment options.
Relevant past medical history:
Type 2 diabetes mellitus, hypertension,
arthritis, anemia, renal calculi, gallstones, peritonitis, ureteral calculus, acid
reflux
Relevant physical findings:
Inspection of the right hand revealed a mildly
prominent right thumb CMC joint with severe tenderness localized at the base
of the right thumb CMC. There was a positive grind test and lever test with
normal neurovascular status distally. No deformity or pathology was noted
elsewhere in the right hand or wrist.
Interpretation of laboratory and imaging studies:
Preoperative radiographs of
the right wrist and hand demonstrated moderate to advanced osteoarthritis of
the carpometacarpal (CMC) joint of the right thumb, classified as Eaton stage
III, with preservation of the scaphotrapeziotrapezoidal (STT) joint and no other
significant pathology. Most recent hemoglobin A1c was 7.1%.
Diagnoses (differential diagnoses):
Right thumb carpometacarpal (CMC) joint
osteoarthritis
Treatment plan (operative and nonoperative options:
Nonop: The patient
initially trialed nonoperative measures including a thumb wrap splint
(MetaGrip) and activity modification. She reported that splinting exacerbated
her pain and was only tolerable for about two hours, providing no meaningful
symptom relief or improved function. NSAIDs and acetaminophen were part of
her regular medication regimen, but pain and functional limitation persisted.
Further nonoperative options such as steroid injections and bracing were
discussed, but given her lack of meaningful response to previous conservative
strategies and desire for definitive symptom control, it was determined
nonoperative care had been exhausted. Operative: Surgical treatment options
were discussed, specifically right thumb CMC arthroplasty with trapeziectomy
and suture button suspension to address advanced carpometacarpal arthritis
refractory to conservative measures. The aim of surgery was to reduce pain,
improve grip strength, and improve hand function.
Primary surgical indications:
Surgery was indicated due to advanced, Eaton
stage III right thumb CMC arthritis that was highly symptomatic and
functionally limiting, with pain preventing significant use of the dominant
hand. The patient’s symptoms persisted and progressed despite welldocumented trials of splinting and analgesics, and bracing was not tolerated.
Objective imaging demonstrated advanced arthritic changes with persistent
clinical findings and a failure of nonoperative modalities. Surgery was
selected to improve hand function and alleviate pain in alignment with the
patient’s expressed goals given her refractory symptoms and poor response
to conservative management.
Procedure(s) and date(s) of surgery:
04/24/2024 Right carpometacarpal
arthroplasty with suture button suspension 07/31/2024 Right carpal tunnel
release and suture button release 04/25/2025 Right thumb carpometacarpal
arthroplasty revision
Length of surgery:
1 hours 6 minutes.
EBL:
5cc
Postoperative course:
POD 0 (Op01): splint applied. PO 2 wk (Op01): thumb
spica brace applied, ROM started, WB 〈1 lb, brace full time except for
bathing/exercise. PO 9 wk (Op01): pt c/o increased thumb pain, swelling,
stiffness, new numbness in thumb/index/middle fingers, 2point discrimination
1015 mm, xray: minimal thumb subsidence, PT started, nerve conduction
study ordered. PO 12 wk (Op01): ongoing thumb pain and numbness, NCS:
mild R CTS, xray w/ minimal subsidence and possible impingement, planned
for R open carpal tunnel release + partial removal of suture button. PO 3 mo second OR performed. PO 2 wk (Op2) pt pain reported as improving, with no
further CTS. PO 4 mo (Op2) Cast applied x 6 weeks. PO 8 mo (Op2) MRI
ordered, showed possible impingement between 1st MC base and trapezoid.
PO 9 mo (Op02) proceeded with revision CMC arthroplasty w/ dermal
allograft.
Date of most recent followup:
4/25/2025
Total length of followup:
52 weeks
Is the patient happy with the outcome?
It is too early to say, but the patient
reported satisfaction with the care throughout the course of treatment. She
noted improvement in her carpal tunnel symptoms after surgical intervention
but continued to experience pain at the base of the right thumb, ultimately
wishing to proceed with revision arthroplasty after initial conservative and
surgical management did not provide lasting relief.
Are you happy with the outcome?
? Not initially but ultimately yes. The patient
experienced improvement in sensory symptoms in the median nerve
distribution after carpal tunnel release and participated in shared decisionmaking throughout her care. Despite persistent pain at the base of the thumb
following CMC arthroplasty and hardware revision, she maintained functional
use of her hand and remained engaged with her postoperative care plan.
Ultimately, further surgical intervention was warranted due to ongoing pain. I
believe she will obtain improvement of her thumb pain after revision surgery.
Complications?
Fuck yeah
If yes, describe the complication(s) and your response(s).
The patient
developed recurrent pain at the base of her right thumb following primary
CMC arthroplasty with suture button suspension. She also developed
symptomatic carpal tunnel syndrome postoperatively, which was managed
with carpal tunnel release. As she had not had improvement of her thumb
pain, I was concerned for excessive tightness of the suture button, and so I
also released the tightrope. Despite initial improvement, residual pain at the
CMC joint persisted, likely due to impingement between the first metacarpal
base and trapezoid, confirmed by imaging. A period of immobilization was
tried, but ultimately recurrent symptoms necessitated revision CMC
arthroplasty with allograft interposition.
If yes, is there anything you might do next time to avoid the complication(s)?
In
future cases, I would consider closer monitoring of suture button tension
during the primary procedure and be more vigilant for early signs of impingement between the metacarpal base and adjacent carpal bones.
Earlier imaging and targeted intervention may potentially have prevented
progression of symptoms.
What went well in this case?
The patient’s carpal tunnel symptoms resolved
after release, and she remained an active participant in her care. Shared
decisionmaking ensured the patient was engaged and informed during all
stages of management. Revision strategies were tailored to her clinical course
and imaging findings.
What might you do differently in future?
I would consider more careful
assessment of suture button tension intraoperatively and postoperative
imaging when early symptoms suggest possible impingement. I would also
explore the use of alternative suspension techniques or graft interposition at
the time of initial arthroplasty in select cases. Postoperatively, targeted
injections of local anesthetic could have been attempted to aid in diagnosis.
