Rhizarthrosis

Original Editor - Jona Van den Broeck Top Contributors - Kirenga Bamurange Liliane, Lucinda hampton, Kim Jackson, Anas Mohamed, Jona Van den Broeck and Rosie Swift

Introduction

Trapeziometacarpal (TMC) arthritis ( also known as Rhizarthrosis ) is arthritis of the first carpometacarpal (CMC) joint of the thumb. The CMC joint of the thumb (pollex), or TMC joint plays a critical role in the normal functioning of the thumb. It is the most important joint connecting the wrist to the metacarpus. Osteoarthritis of the TMC is a severely disabling condition; up to twenty times more common among elderly women than in average.

Eitiology

Believed causes of TMC arthritis are: excessive repetitive use of the CMC joint of the thumb; a subluxation; a lesion of the ligaments or a fracture.
Laxity of the CMC joint is a key factor in causing TMC arthritis. The laxity, which can be hereditary, results in an increased risk for ligament injuries. These injuries are regarded as a primary stimulus in the development of arthritis. Laxity of the CMC joint also causes a hyperextension, which is another primary stimulus for the development of arthritis.
Another common cause for TMC arthritis is weakness of the cross links of the fingers (ligg. oblique anterior). These ligaments are the most important stabilisers of the fingers. 

Symptoms

The first signs of arthritis in the thumb are

• pain, tenderness, and stiffness at the base of your thumb. This occurs with gripping, pinching, or clasping something between the thumb and index fingers or when a mild force, such as when you twist a key in a lock or turn a door handle. An ache after activity can also be a feature.

• Decreased strength and range of motion eg opening jars or doing up buttons may become difficult.

• Appearance. The joint may become swollen or develop a bony bump. The joint may appear squarish and enlarged.

Diagnosis

• Noticeable lumps or swelling on the first CMC joint
• Thumb CMC grind test
• Plain radiographs showing degenerative changes (bone spurs, thinning of cartilage, loss of joint space)in affected joints are usually diagnostic.

Treatment

Conservative measures are the first options for CMC arthritis and can ameliorate symptoms in most cases. These include

• Behaviour modification eg Try to avoid: clenching your hands when carrying things; repetitive movements that involve pinching or twisting.
• Physiotherapy
• Pain relief,
• Splinting, and
• Corticosteroid injections

^{Physiotherapy}

Techniques include

• range-of-motion and stretching exercises to improve thumb motion.

• Advances to include strength exercises for the thumb and fingers.
• Dexterity and fine motor exercises for the hand and thumb.
• Clinical trials have provided evidence that a combination of joint mobilization, neural mobilization, and exercise helps with CMC joint pain.
• Application of therapeutic heat or cold
• Therapeutic US
• Splinting, designed to help reduce pain, prevent deformity, or prevent deformity from getting worse. Often only to wear at night, during flare ups and when doing heavy work with hand.

injections

Injections of hyaluronic acid or cortisol are useful. A combination of ultrasound and injections is proved to be more effective than a therapy that is based on only one of these treatments.¹¹

(c) Tractions

Tractions can be used in case of intra-articular fractures of the thumb metacarpal and fractures of the trapezium.
Already the day after the surgery, the revalidation can be started with tractions by a physiotherapist. Within three days, the patient should be self-capable of moving the thumb. Tractions have to be executed over a period of six weeks. This treatment is proved to diminish the pain and to improve the mobility of the joint. After eight to ten weeks, there shouldn’t be any pain left and the patient should be able to move his joint in the whole range of motion. No complications are known for this treatment. ¹²
Tractions are also a good prevention for collapse of the joint and subluxation of the thumb.
Immobilisation of the thumb would cause more pain and movement restriction than an immediate treatment. If the patient’s thumb is immobilised, there is a risk of varus deformity of the thumb. This is difficult to treat, because of the complete loss of abduction and extension.

Other treatments

(a) Medication

There are anti-inflammatory agents and injections based on cortisol, but these can be responsible for side effects like an increased sugar quality in blood, diminished endosperm synthesis and osteoporosis.⁶

(b) Brace

A brace can diminish stress on the joints, so pain and wear don’t occur, but it causes also an increased movement restriction.⁶

(c) Surgery

If the diagnosis of ‘rhizarthrosis’ is determined too late, none of the above treatments will be helpful. Because of severe pain and movement restriction, surgery could be inevitable. In this case, there will often be opted for a prosthesis.
But patients of younger age or with a history of earlier surgeries in the surrounding of this joint might be excluded from a prosthesis.  In this case, a tendon transplantation could be an alternative.
If the surgery is finished successfully, the patient will be expected at the physiotherapist after three weeks of gypsum. Care must be taken to avoid complications like infections, dislocation of the prosthesis or nerve damage.¹

References

1http://www.orthopedie-azdamiaan.be/Ned/aandoeningen/hand_pols/duimartrose.htm; evidence level F
2Dupeyron A, Ehrler S and Isner-Horobeti ME; Rhizarthrosis and orthotic treatment. Review of literature; Service de médecine physique et réadaptation, hôpital de Hautepierre, avenue Molière, 67098, Strasbourg, France ; 2001 ; evidence level D
3Mechael Schünke, Erik Schulte, Udo Shumacher, Markus Voll and Karl Werker; Prometheus: Algemene anatomie en bewegingsapparaat; Bohn Stafleu van Loghum; 2010; evidence level F
4 Jennifer Moriatis Wolf MD, Star Schreier MD, Scott Tomsick MD, Allison Williams PhD en Brian Petersen MD; Radiographic Laxity of the Trapeziometacarpal Joint Is Correlated With Generalized Joint Hypermobility; Department of Orthopaedic Surgery, University of Colorado-Denver, and the Division of Nursing/Research, Denver Veterans Administration Medical Center, Denver, CO, USA. [email protected]; 2011; evidence level C
5R. J. Poulter en T. R. C. Davis ; Management of hyperextension of the metacarpophalangeal joint in association with trapeziometacarpal joint osteoarthritis; of Trauma and Orthopaedics, Queens Medical Campus, Nottingham University Hospitals, Nottingham, UK; 2011; evidence level A
6http://users.telenet.be/zeldzame.ziekten/List.s/Corti(2).htm#Bijwerkingen; evidence level F
7Pedro A. Gondim Teixeira, Patrick Omoumi, Debra J. Trudell, Samuel R. Ward, Alain Blum en Donald L. Resnick; High-resolution ultrasound evaluation of the trapeziometacarpal joint with emphasis on the anterior oblique ligament (beak ligament); Service d'imagerie Guilloz, CHU Hôpital Central, 10 boulevard du Recteur Senn, appt. 220, 3eme étage, 54000, Nancy, France. [email protected]; 2010; evidence level E
8Physiotherapist Wim Van den Broeck; Graduated VUB (1986); Belgium; °1964; evidence level F
9 evidence level D
10http://www.kinos-team.be/therapieconcepten/manuele-therapie/neurodynamische-technieken/; evidence level F
11Di Sante L, Cacchio A, Scettri P, Paoloni M, Ioppolo F en Santilli V ; Ultrasound-guided procedure for the treatment of trapeziometacarpal osteoarthritis; Physical Medicine and Rehabilitation Unit, Azienda Policlinico Umberto I, Rome, Italy, [email protected].; 2011; evidence level F
12Gelberman RH, Vance RM en Zakaib GS; Fractures at the base of the thumb: treatment with oblique traction; 1979; evidence level D