Hand

and Steven Maschke⁴

(3)

Department of Orthopedic Surgery, University of Wisconsin, Madison, Wisconsin, USA

(4)

Cleveland Clinic, Department of Orthopedic Surgery, Abu Dhabi, UAE

Take-Home Message

Corticosteroid injection and splinting first-line therapy for trigger digit.
Injection less effective in diabetics.
Preserve A2 and A4 pulleys in fingers and thumb oblique pulley in release.
Persistent triggering following release should warrant evaluation of Camper’s chiasm and triggering at A3.
Small but reported risks of nerve injury, recurrence, and bowstringing.

Definition

Mechanical entrapment of flexor tendons due to a mismatch between tendon size and pulley apparatus.

Etiology

Primary trigger digit: Trigger finger without underlying systemic condition
Secondary trigger digit: Trigger finger with presence of diabetes or other systemic comorbidity
Triggering at A3: Due to FDP enlargement at camper’s chiasm
- Common in RA

Pathophysiology

Pulley hypertrophy, fibrocartilaginous metaplasia of pulley and apposing flexor tendon surface, tenosynovitis (RA)

Radiographs

Helpful in nonclassic presentations

Classification

Grade I (pre-triggering): Pain, occasional catching, tenderness at A1 pulley
Grade II (active): Triggering which can be resolved actively
Grade III (passive): Triggering requiring passive manipulation for resolution
Grade IV (contracture): Fixed flexion contracture of PIP. Un-correctable

Treatment

Nonoperative:
- Splinting in extension or slight MP flexion
- Corticosteroid injections:
  
  Less efficacious in diabetics
  
  More effective than splinting alone
  
  Worse prognosis with young patients, diabetics, and multiple digit pathology
Surgical:
- Typically A1 pulley release alone.
- RA patients may require A3 pulley release or resection of one FDS slip.
- Preserve A2 and A4 in fingers and oblique pulley in thumb to avoid bowstringing.
- Release may be done percutaneously or open.

Complications

Digital nerve injury, bowstringing, and recurrence

Bibliography

Baumgarten KM. Corticosteroid injection in diabetic patients with trigger finger. A prospective, randomized, controlled double-blinded study. J Bone Joint Surg Am. 2007;89:2604. doi:10.2106/JBJS.G.00230.

Gilberts ECAM, Beekman WH, Stevens HJPD, Wereldsma JCJ. Prospective randomized trial of open versus percutaneous surgery for trigger digits. J Hand Surg Am. 2001;26:497–500. doi:10.1053/jhsu.2001.24967.

Rozental TD. Trigger finger: prognostic indicators of recurrence following corticosteroid injection. J Bone Joint Surg Am. 2008;90:1665. doi:10.2106/JBJS.G.00693.

Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. YJHSU. 2006;31:135–46. doi:10.1016/j.jhsa.2005.10.013.

2 Thumb Carpometacarpal Joint

Abhishek Julka⁵ and Steven Maschke⁶

(5)

Department of Orthopedic Surgery, University of Wisconsin, Madison, Wisconsin, USA

(6)

Cleveland Clinic, Department of Orthopedic Surgery, Abu Dhabi, UAE

Take-Home Message

Volar oblique (beak) ligament provides the primary restraint to the thumb CMC joint.
Articular degeneration begins volar and progresses radial and dorsal.
Stabilization procedures have high failure rates in late stage arthrosis.
CMC arthrodesis indicated in young patients projecting strenuous hand use.

Definition

Trapezium: Biconcave articular surface.
Arthrosis of the first carpometacarpal joint commonly known as CMC arthrosis or basilar joint arthrosis. The second most common arthrosis of the hand following the DIP; it is most common in females 40–50.

Etiology

Most common in women
CMC laxity due to congenital (Ehler-Danlos), traumatic, or anatomic etiologies
Loss of articular congruity (Bennett’s fracture)

Pathophysiology

Deep anterior oblique ligament (AOL, beak ligament): Connects volar ulnar trapezium to the volar ulnar aspect of the metacarpal
- Restraint dorsal translation of the thumb metacarpal during pinch.
- Attenuation or incompetence is linked to basilar joint instability and subsequent arthrosis.
Bennett’s fractures occur through bone attached to AOL making the ligament functionally incompetent.
Decreased bony congruency may predispose to development of instability → arthrosis.
Progression of cartilage degeneration: Volar radial trapezium/volar metacarpal → dorsal trapezium/radial metacarpal.

Radiographs

AP of the wrist to visualize other areas of arthrosis.
Robert’s view: True AP of the basilar joint obtained in full forearm pronation with thumb resting on the X-ray cassette.
Lateral radiographs of the CMC articulation.
Findings are detailed in Eaton’s staging system.

Classification

Eaton classification:
- Stage I: Radiographic signs of synovitis such as widening. No signs of arthrosis
- Stage II: Joint space narrowing. Osteophytes <2 mm
- Stage III: Substantial joint space narrowing with sclerosis, osteophytes >2 mm and cyst formation
- Stage IV: Marked basilar joint degeneration with scaphotrapezial arthrosis

Treatment

Surgical:
- Stage 1–2:
  
  Volar ligament reconstruction: Reconstruction successful in early stages failing largely with presence of cartilage degeneration (stage 3 or 4).
  
  Metacarpal extension osteotomy: Redirects load to preserved dorsal articular surface.
  
  Contraindications: Dorsal articular degeneration, extension deformity >10°, substantial laxity or un-reducible subluxation.
- Stage 3–4:
  
  Trapeziometacarpal arthrodesis:
  
  Young patients placing strenuous and repetitive loads
  
  Position of fusion: 30° of palmar abduction, 20° of radial deviation and pronation
  
  Trapeziectomy: Excision of the trapezium. Small percentage of procedures complicated by proximal migration and weakness.
  
  Trapeziectomy with ligament reconstruction and tendon interposition (LRTI): Multiple tendon grafts, i.e., FCR and APL; palmaris used to reconstruct the AOL through a metacarpal bone tendon. Remaining tendon is placed into the space between scaphoid and first metacarpal.
  
  MCP joint laxity:
  
  Addressed to prevent zigzag deformity and collapse with pinch.
  
  Options: Stabilizing procedures, i.e., volar capsule reefing and arthrodesis.
  
  MCP arthrodesis: Position at 20° flexion, 5° abduction, and 5° pronation.
  
  Concomitant STT arthrosis is treated with trapezoid hemi-resection or arthrodesis.
  
  Arthroplasty: Hemi-arthroplasty and total joint arthroplasty options available. Complications of loosening particularly in younger patients.
  
  Prospective trials have found no difference between trapeziectomy with or without ligament reconstruction.
Nonoperative:
- Splinting in abduction
- Activity modification
- Corticosteroid injection: Long-term benefit debated

Complications

Dorsal surgical approach: Radial sensory nerve injury (neuropraxia, neuroma)
Trapeziectomy with or without ligament reconstruction: Weakness, proximal migration of first metacarpal, graft extrusion
CMC arthrodesis: 10 % rate of nonunion
Arthroplasty: Loosening primarily in younger patients
Patient dissatisfaction
Silicone interposition: Synovitis, fragmentation of foreign material

Bibliography

Belcher HJ, Nicholl JE. A comparison of trapeziectomy with and without ligament reconstruction and tendon interposition. J Hand Surg Br. 2000;25:350–6. doi:10.1054/jhsb.2000.0431.

Forthman CL. Management of advanced trapeziometacarpal. YJHSU. 2009;34:331–4. doi:10.1016/j.jhsa.2008.11.028.

Froimson AI. Tendon arthroplasty of the trapeziometacarpal joint. Clin Orthop Relat Res. 1970;70:191–9.

Wajon A, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2009;(4):CD004631. doi:10.1002/14651858.CD004631.pub3.