normal  medium  large

THUMB CARPOMETACARPAL (CMC) JOINT OSTEOARTHRITIS

Introduction

Osteoarthritis of the carpometacarpal (CMC) joint of the thumb is characterized by articular degeneration owing to compression and rotational shear forces on the trapezium. As the disease progresses, the thumb metacarpal may become dorsoradially subluxated on the trapezium, resulting in hyperextension deformity of the metacarpophalangeal (MP) joint. The thumb CMC joint is the most frequently affected joint of the hand to develop localized osteoarthritis.

Related Anatomy

  • Palmar oblique ligament (POL): superficial component originates from volar trapezium and inserts across volar beak of thumb metacarpal; deep component parallels this course and attaches to the trapezium and first metacarpal
  • Dorsoradial ligament (DRL): originates on the dorsoradial trapezium tuberosity and inserts on the base of the first metacarpal dorsally
  • Abductor pollicis longus (APL): forms the radial border of the anterior capsular recess

Incidence and Related Conditions

  • Most common joint affected by arthritis of the hand
  • More common among women (aged >40 y)/post-menopausal women
  • Associated with carpal tunnel syndrome and de Quervain’s tenosynovitis

Differential Diagnosis

  • de Quervain’s tenosynovitis
  • Scaphotrapeziotrapezoid (STT) arthritis
  • Scaphoid nonunion
  • Radioscaphoid arthritis
  • Trigger Thumb
  • Painful Thumb CMC Subluxation

Eaton and Littler's Staging for basal joint arthritis in trapezial metacarpal joint:

  1. normal or possible widening of the joint from synovitis and/or joint effussion; joint contours intact; typical patient is young female with painful lax joints; thumb cmc subluxation less than a third of the joint width
  2. narrow with debris and osteophytes less than 2 mm; minimal joint narrowing with only a few small erosions only; joint subluxed about one third of joint width; typically patients females between 40 and 50 years old
  3. narrow with debris and ostephytes greater than 2 mm; early joint narrowing with thumb cmc joint subluxed more than a third of the joint width; typical patient is female over fifthy years of age
  4. severe thumb cmc joint involvement plus scaphotrapezial joint degenerative changes; large osteophytes; possible loose bodies

ALSO SEE THE DIAGNOSTIC GUIDE: OSTEOARTHRITIS GENERAL

Clinical Presentation Photos and Related Diagrams
  • Thumb CMC (Basal Joint) OA with CMC Subluxation (Hover over right edge to see more images)
    Thumb CMC (Basal Joint) OA with CMC Subluxation (Hover over right edge to see more images)
  • Thumb CMC (Basal Joint) OA with CMC Subluxation and MP Hypertension
    Thumb CMC (Basal Joint) OA with CMC Subluxation and MP Hypertension
Symptoms
Pain at the base of the thumb (especially with gripping or pinching)
Laxity of Thumb CMC or MP Joints
Swelling of the Thumb CMC Joint
Decreased range of motion (ROM) of the thumb
Enlarged, bony or dislocated appearance of thumb joints
Hyperextension thumb MP deformity
Typical History

The typical patient presenting with thumb CMC osteoarthritis is a postmenopausal woman with complaints of thumb or radial-sided hand and wrist pain without traumatic onset that has progressively worsened over a few months to years. Pain is exacerbated with pinching and grasping activities and can be alleviated with rest or NSAIDs.

Positive Tests, Exams or Signs
Hyperligamentous Laxity
Scapho-Trapezial-Trapezoid (STT) Tenderness
Thumb (Grind) Compression Test
Finkelstein Sign
First Extensor Compartment Tenderness
Work-up Options
Radiology studies - stress X-rays
Radiology studies - Computerized tomography (CT) scanning
Radiology studies - X-ray
Sonographic studies - Ultrasound
Magnetic resonance imaging - MRI without contrast
Images (X-Ray, MRI, etc.)
  • Thumb CMC OA Stage I normal or possible widening of the joint from synovitis and/or joint effussion; joint contours intact
    Thumb CMC OA Stage I normal or possible widening of the joint from synovitis and/or joint effusion; joint contours intact (Hover over right edge to see more images)
  • Thumb CMC (Basal Joint) OA Stage II narrow with debris and osteophytes less than 2 mm; minimal joint narrowing with only a few small erosions only; joint subluxed about one third of joint width
    Thumb CMC (Basal Joint) OA Stage II narrow with debris and osteophytes less than 2 mm; minimal joint narrowing with only a few small erosions only; joint subluxed about one third of joint width
  • Another thumb CMC (Basal Joint) OA Stage II narrow with debris and osteophytes less than 2 mm; minimal joint narrowing with only a few small erosions only; joint subluxed about one third of joint width
    Another thumb CMC (Basal Joint) OA Stage II narrow with debris and osteophytes less than 2 mm; minimal joint narrowing with only a few small erosions only; joint subluxed about one third of joint width
  • Thumb CMC OA Stage III narrow with debris and osteophytes greater than 2 mm; early joint narrowing with thumb cmc joint subluxed more than a third of the joint width
    Thumb CMC OA Stage III narrow with debris and osteophytes greater than 2 mm; early joint narrowing with thumb cmc joint subluxed more than a third of the joint width
  • Thumb CMC OA Stage IV severe thumb cmc joint involvement plus scaphotrapezial joint degenerative changes; large osteophytes; possible loose bodies
    Thumb CMC OA Stage IV severe thumb cmc joint involvement plus scaphotrapezial joint degenerative changes; large osteophytes; possible loose bodies
  • Positioning of thumbs for CMC joint (arrows) stress X-ray
    Positioning of thumbs for CMC joint (arrows) stress X-ray
  • Thumb CMC joint stress X-ray with patient pushing tips of thumbs together forcing the thumb CMC joints to sublet maximally.
    Thumb CMC joint stress X-ray with patient pushing tips of thumbs together forcing the thumb CMC joints to sublet maximally.
Treatment Options
Conservative: 
  • Indicated for all stages initially
  • Modification of activities
  • Custom-fitted thumb/forearm spica orthosis
  • Splints, slings
  • NSAIDs
  • Corticosteroid injections
  • Platelet Rich Plasma (PRP) injections [Experimental]
Operative: 
  • Indicated for patients with severe pain independent of radiographic findings
    • CMC synovectomy and arthroscopic debridement
    • Arthroscopic debridement and tendon interposition
    • Partial trapeziectomy with tendon interposition
    • Arthroplasty/prosthetic arthroplasty (polyurethaneurea, biodegradable)
    • Complete trapeziectomy with ligament reconstruction and tendon interposition (LRTI)
    • Trapeziometacarpal arthrodesis
Treatment Photos and Diagrams
  • CMC OA Fascial Arthroplasty Incisions (Hover over right edge to see more images)
    CMC OA Fascial Arthroplasty Incisions (Hover over right edge to see more images)
  • CMC OA Fascial Arthroplasty Trapezium removed
    CMC OA Fascial Arthroplasty Trapezium removed
  • CMC OA Fascial Arthroplasty Palmaris Longus Graft
    CMC OA Fascial Arthroplasty Palmaris Longus Graft
  • CMC OA Fascial Arthroplasty Palmaris and half FCR
    CMC OA Fascial Arthroplasty Palmaris and half FCR
  • CMC OA Fascial Arthroplasty Suspensionplasty 1
    CMC OA Fascial Arthroplasty Suspensionplasty 1
  • CMC OA Fascial Arthroplasty Suspensionplasty 2
    CMC OA Fascial Arthroplasty Suspensionplasty 2
  • CMC OA Fascial Arthroplasty Suspensionplasty 3
    CMC OA Fascial Arthroplasty Suspensionplasty 3
  • CMC OA Fascial Arthroplasty Suspensionplasty 4
    CMC OA Fascial Arthroplasty Suspensionplasty 4
  • CMC OA Fascial Arthroplasty Suspensionplasty 5
    CMC OA Fascial Arthroplasty Suspensionplasty 5
Complications
  • Conservative: persistent pain, residual hyperextension of MP joint, progression of disease
  • Trapeziectomy/arthrodesis: decreased grip strength; decreased ROM; thumb metacarpal shortening, subluxation, dislocation, infection, nerve injury, RSD
  • LRTI: synovitis, osteolysis, first metacarpal shortening, infection, nerve injury, RSD
Outcomes
  • Corticosteroid injections: larger percentages of patients experience pain relief if treated at earlier vs later stages of disease
  • LRTI: ~90% pain relief after 3.5 years
Key Educational Points
  • Surgical treatment of CMC arthritis of the thumb is based on the severity of the symptoms independent of radiographic findings.
  • Steroid injections will most likely produce long-term results in patients with synovitis without radiographic changes, or Eaton and Littler stage 1.
Practice and CME
References

New Articles

  1. Ladd AL, Crisco JJ, Hagert E, Rose J, Weiss AP. The 2014 ABJS Nicolas Andry Award: The Puzzle of the Thumb: Mobility, Stability, and Demands in Opposition. Clin Orthop Relat Res 2014 ePub.
  2. Putnam MD, Rattay R, Wentorf F. Biomechanical Test of Three Methods to Treat Thumb CMC Arthritis. J Wrist Surg 2014;3(2):107-13.

Reviews

  1. Vermeulen GM, Slijper H, Feitz R, et al. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am 2011;36(1):157-69.
  2. Gillis J, Calder K, Williams J. Review of thumb carpometacarpal arthritis classification, treatment and outcomes. Can J Plast Surg 2011;19(4):134-138.

Classics

  1. Eaton RG and Glickel SZ. Trapeziometacarpal osteoarthritis: staging as a rational for treatment. Hand Clin 1987;3:455-71.
  2. Day, C and Rozental, T. Arthritides of the Hand and Wrist. In: JR Lieberman (ed), AAOS Comprehensive Orthopaedic Review, Section 9: Hand and Wrist, Chapter 85. American Academy of Orthopaedic Surgeons: Rosemont; 2009, pp. 917-8.
  3. Brody MJ and Bednar MS. Osteoarthritis of the Hand and Digits: Thumb. In: A-PC Weiss, CA Goldfarb, VR Hentz, RB Raven III, DJ Slutsky, SP Steinmann (eds), Textbook of Hand & Upper Extremity Surgery, Volume 1, Section II – Hand and Wrist, Chapter 17. American Society for Surgery of the Hand: Chicago; 2013, pp. 323-35.
  4. Eaton RG, Littler JW. Ligament Reconstruction for the Painful Thumb Carpometacarpal Joint.  J Bone Joint Surg 1973 Dec; 55 (8): 1655 -1666.
  5.  Eaton RG, Steven Z. Glickel SZ,  Littler JW. Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb.JHS 1985; 10(5): 645-654