Hand CASE 20
CASE 20
A 69-year-old female presents to office with pain in the right thumb for several years. She has noticed that she has difficulty with holding door knobs, carrying heavy plates, and turning the key in her car. The pain keeps her awake at night, and she has tried various anti-inflammatory medications with limited success. Radiographs are shown in Figure 4–15A and B.
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Figure 4–15 A–B
The most likely diagnosis is:
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Osteoarthritic basal joint of the thumb
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Trigger thumb
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Carpal tunnel syndrome
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Scaphotrapezial trapezoidal arthritis
Discussion
The correct answer is (A). This is a classic clinical appearance and radiographic presentation in a patient with an arthritic basal joint of the thumb. Basal joints are saddle-shaped biconcave joints, which allow the thumb motion in multiple axes. They tend to degenerate with age and patients oftentimes present with symptomatic degeneration of the basal joint in their 50s and 60s. Women appear to be affected 7 to 10 times more than men. The classic presentation is a prominence at the base of the thumb with difficulty involving actions as those described above.
During the course of clinical examinations, which of the following findings might be expected?
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Tenderness over the basal joint of the thumb
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Positive distraction rotation test
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Positive grind test
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Difficulty with painful pinch
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All of the above
Discussion
The correct answer is (E). During the course of the clinical examination, attention should be paid to inspection which usually reveals the presence of fairly large prominence over the basal joint of the thumb as the metacarpal base subluxes from its articulation with the trapezium. This development of the thumb is often referred to as the “shoulder sign.” However, this may not be obvious in the early stages of the pathological process. In the early stage of the pathological process, tenderness maybe elicited at the base of the thumb just proximal to the metacarpal base. Grasping the thumb and rotating while putting gentle traction on it can also provoke pain. This is known as the distraction rotation test. Conversely, holding the metacarpal and firmly grinding it against the trapezium (after cautioning the patient that this maneuver could hurt) is known as the grind test. In patients who present with advanced radiographic degenerative changes, it is quite common to have all these signs clinically evident. Patients who present with earlier stages of the radiographic disease process may not present with the grind test.
The patient is keen to avoid surgery and would like to pursue nonoperative means.
Which of the following would be a reasonable choice of treatment for this patient?
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Splinting with a short opponens splint
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Splinting with a long opponens splint
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Neoprene thumb wrap
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Placement of a steroid injection and any of the splints mentioned above
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All of the above
Discussion
The correct answer is (E). Patients who present with degenerative basal joint arthritis and who are unwilling to consider surgical intervention even in the age group as this patient is, can be treated with a variety of nonoperative interventions. These include: a short course of anti-inflammatory medication after carefully
monitoring the renal function in conjunction with the primary care doctor, use of a splint or sleeve as suggested above, or placement of a steroid injection. While comfort and convenience of short splints are often felt to be superior to that of a long splint, the longer splint appears to give the greater degree of support spanning across the CMC joint. However, there is no data to show the superiority of a short opponens splint, long opponens splint, or a Neoprene sleeve over each other. It appears at this time that the decision for a splint is often times guided by patient comfort and choice and personal preferences of the treating physician. The use of a steroid injection can provide patient’s long lasting relief; however, they should be cautioned that placement of steroid injections can be painful for the first 24 to 48 hours, and the duration of relief remains unpredictable. They should also be cautioned that any steroid injections can be associated with side effects such as subcutaneous fat atrophy and localized depigmentation.
Objectives: Did you learn...?
Describe the clinical and radiographic signs of osteoarthritis of the thumb? Identify various treatment options?