Rhizarthrosis

 Introduction

Rhizarthrosis or trapeziometacarpal arthritis is a wear of the carpometacarpal joint of the thumb. This joint, covered with cartilage, is surrounded by tissue, a capsule and strong ligaments: the ligg. carpometacarpalia dorsalia and palmaria. ^1.2.3

Causes

Believed causes of rhizarthrosis are excessive repetitive use of the carpometacarpal joint of the thumb, a luxation, a lesion of the ligaments or a fracture.
Laxity of the carpometacarpal joint is a key factor in causing rhizarthrosis. 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 carpometacarpal joint also causes a hyperextension, which is another primary stimulus for the development of arthritis.^1.4.5
Another common cause for rhizarthrosis is weakness of the cross links of the fingers (ligg. oblique anterior). These ligaments are the most important stabilizers of the fingers.  ^3.7

Symptoms

As for any other type of arthritis, sufferers of rhizarthrosis experience pain during and after movement of the joint. Another characteristic sign is movement restriction of the joint.¹

Physical treatment

The physical treatment of rhizarthrosis depends on the existence of a prosthesis in the thumb. If a prosthesis is implanted, a treatment with massage and neurodynamic mobilisations is recommended. For patients without a prosthesis in the respective joint, the treatment could consist of ultrasound, therapeutic injections and tractions.⁸

(a) Massage and neurodynamic mobilisations

Mobilisations of the nerve scheme are recommended to diminish pain and increase the grip.⁹ The nerves are responsible for the transition of information from outside to the brain and in the contrary way. If they are clasped, this can be a cause for severe pain. In this case, mobility can be repaired by moving the nerves in regard to the surrounding tissue.¹⁰

(b) Therapeutic ultrasound and 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
9Villafañe JH, Silva GB en Fernandez-Carnero J ; Short-term effects of neurodynamic mobilization in 15 patients with secondary thumb carpometacarpal osteoarthritis; Physical Therapist, Department of Physical Therapy, Residenze Sanitarie Assistenziali, A. Maritano, Sangano, Italy and R.S.A Don Menzio, Avigliana, Italy; 2011; 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