Hand 2nd deformity

Trapeziometacarpal (TMC) Osteoarthritis (OA) / Rhizarthrosis

Definition

Trapeziometacarpal (TMC) OA, also known as Rhizarthrosis, is a degenerative condition affecting the trapeziometacarpal joint, which is the key joint of the thumb. This condition often leads to pain, instability, and deformity at the base of the thumb.

Epidemiology

  • More common in women, particularly those over 40 years of age.
  • Often associated with overuse of the thumb and activities that require repetitive gripping or pinching motions.
  • May be linked to other conditions like connective tissue (C.T.) syndrome and trigger thumb.

Anatomy

  • Trapeziometacarpal Joint:
    • A saddle-shaped joint at the base of the thumb.
    • The joint is stabilized by strong ligaments:
      • Volar (Beak) Ligament: Strong, key stabilizer.
      • Dorsal Ligament: Thin, provides less support.
      • Lateral Ligament: Broad, aiding in stability.

Pathophysiology

  • Attritional Changes in the Beak Ligament lead to joint instability and progressive degeneration.
  • Commonly associated with connective tissue syndromes and conditions such as trigger thumb.

Clinical Presentation (C/P)

  • Pain: Often triggered by forceful pinch grip activities (e.g., turning a door key).
  • Deformity: Adduction and flexion of the thumb.
  • Shoulder Sign: Radial prominence at the base of the thumb due to joint subluxation.
  • Special Tests:
    • Crank Test: Axial loading with passive flexion/extension of the first metacarpal.
    • Grind Test: Axial loading with rotation of the first metacarpal.
    • Torque Test: Distraction of the metacarpal with rotation to differentiate from De Quervain’s disease.

Imaging

  • X-ray:
    • AP, Lateral, and Oblique views are used to assess joint space and signs of degeneration.
    • Findings: Joint space narrowing, osteophytes, and debris.

Staging (Eaton & Littler Classification)

  1. Stage I: Normal joint space, possible widening due to synovitis.
  2. Stage II: Reduced joint space with debris and osteophytes less than 2 mm.
  3. Stage III: Reduced joint space with debris and osteophytes greater than 2 mm.
  4. Stage IV: Severe degeneration, involving scaphotrapezial osteoarthritis as well as TMC OA.

Differential Diagnosis (D.D.)

  • Radial-sided wrist pain may be caused by conditions such as:
    • Trapeziometacarpal OA
    • De Quervain’s Disease
    • Scaphoid Nonunion
    • Radioscaphoid OA
    • Scapholunate Advanced Collapse (SLAC)
    • Scaphotrapezial OA

Treatment (ttt)

Conservative Treatment (First-line)

  1. NSAIDs: For pain and inflammation.
  2. Splinting: To limit thumb movement and reduce stress on the joint.
  3. Physiotherapy: Focusing on strengthening the thenar muscles.
  4. Steroid Injections: To reduce inflammation in the joint.

Operative Treatment

  • Indication: If conservative treatments fail or if the disease is advanced.
  • Early Surgical Options:
    • Soft tissue reconstruction.
    • Synovectomy (open or arthroscopic).
    • Excision arthroplasty. Mcq ❓️(trapeziectomy + LRTI (ligament reconstruction and tendon interposition)
  • Late Surgical Options:
    • Arthrodesis: Joint fusion. young male heavy laborers. Mcq ❓️
    • Total Joint Arthroplasty: Complete joint replacement.

Complications

  • Recurrence: OA may return after treatment.
  • RSD: Nerve irritation or damage.
  • Infection: Following surgery, particularly in more invasive procedures like joint replacement.
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