OA of the base of the thumb

Diagnosis and presentation

Description

OA at the base of the thumb or the 1st carpometacarpal joint occurs as a result of degenerative changes in the trapeziometacarpal joint. Its prevalence increases with age, studies showing it can affect 15% of the population, and is more common in postmenopausal women. Patients often present with radial sided wrist pain, weakness and grating or crepitus at the base of the thumb. Symptoms are worsened by activities involving the thumb such as pinching and gripping.

Diagnosis

History; as detailed above.

Physical examination

Grind test: Gripping the patient's metacarpal bone of the thumb and moving it in a circle and loading it with gentle axial forces. Positive response: a sudden sharp pain at the CMC joint. https://www.youtube.com/watch?v=oEJH7KFGx_Y

Palpation of CMC joint and STT (scaphoid, trapezoid and trapezium)
Z deformity

Further tests

X-rays may be considered for moderate or severe cases and in particular to aid decisions on a surgical opinion or if the patient has had poor or no response to conservative management.

Signs and Symptoms

Mild to moderate

Intermittent pain and/ or stiffness (early stage capsular stretching may exhibit hypermobility)
Some restriction of ADLs

See 1st line managment

Moderate to severe

Significant pain and restriction in range of movement
Marked restriction to ADL's

See 1st line management or 2nd line management or Surgical opinion

Differential diagnosis

Scaphoid fracture
Instability of the carpometacarpal or metacarpophalangeal joints
DeQuervain's tendinopathy
Carpal tunnel syndrome
Radial nerve or cervical root compression.
Intersection syndrome; Check whether the complaints are located at the top of the forearm, where the APL/EPB cross over the extensor carpi radialis longus/brevis (ECRL/ECRB) tendons (4-8 cm proximal to the radial styloid), which could suggest intersection syndrome.
STT (scaphoid, trapezoid and trapezium)

Management

First line management

Advice and information on osteoarthritis at the base of the thumb.

Advice on activity modification and joint protection.

Instruction on exercises to strengthen muscles surrounding the joint. Good biomechanical assessment will direct the strengthening programme for example, ensuring that no aggravation of symptoms due to inappropriately strengthening adductor pollicis.

Splinting trial - good fitting thumb spika for 6 weeks.

National OA Thumb Patient Information Leaflet

Review;

6 weeks (dependent on local procedure patient may be placed on hold)

Treatment with limited evidence

Acupuncture; although evidence shows it can be effective in reducing pain, recent NICE guidance reports it has insufficient evidence of cost-effectiveness for any recommendation to be made on its provision by the NHS.
Glucosamine products, chondroitin, topical rubefacients

Second line management

If referred from MSK Physiotherapy, ensure patient compliance with conservative management and instructions given.

Consider steroid injection and/or provision of specialist splint. Specialist splint may be custom made. CMC push splints not widely available, patients can be advised to purchase their own if they wish (patient directed Google search).

Review information on activity management and joint protection. National OA Thumb Patient Information Leaflet

Treatment with limited evidence

Acupuncture; although evidence shows it can be effective in reducing pain, recent NICE guidance reports it has insufficient evidence of cost-effectiveness for any recommendation to be made on its provision by the NHS.
Glucosamine products, chondroitin, topical rubefacients

Post operative

Post Trapeziectomy Assessment Form

NHSGGC Hand Service Orthopaedic and Therapy Post Operative Guidelines

Trapeziectomy

Day of Surgery

Check circulation, sensation and movement.
May have a cast in situ dependent on surgeon’s protocol.
Patient provided with post operative information sheet if they do not already have one.
Fit note provided for the duration of expected absence if required.

First Review Clinic (7-14 days)

Remove backslab if in situ and reduce dressing.
Check wound site and remove sutures.
Re-apply cast/ splint.
Refer to AHP for rehabilitation to be commenced once cast removed if required.
Provide patient information leaflet if the do not already have one.

Subsequent Review Clinic (4-6 weeks)

Remove cast if required.
Re-apply cast if required.
Encourage ROM

Reassurance to be given that it will be sore, no damage is being done.
Don’t force the movement as they will be acute.

Encourage regular use of analgesia if required.
Thumb range of motion exercises active and active assisted.

Scar Care

Once wound has healed gently massage with an emollient hand cream 3-4 times daily.

Returning to work
- Avoid dirty environments and ensure dressing remains dry.
- Heavy lifting should be avoided for 12 weeks.
Driving
- Once feels safe to do so and they feel they are in complete control of the car. Advice that they may want to check with their insurance company.

Further review if required, depending on clinical progress.

NHSGGC Post Operative Guidance for Therapy Intervention

Trapeziectomy

This information is intended for use with all patients who have had surgical removal of the trapezium bone with or without soft tissue reconstruction. Most patients, who have undergone this operation, have done so because they are in severe pain and because conservative options have failed.

A number of these patients require minimal intervention, others will require more. To ensure effective and efficient management the clinician should have knowledge of:

How to actively and passively mobilise
The frequency of exercise
The period of time the patient should continue to do their aftercare and exercises.

The patient will usually be referred to therapy, if required, once their cast has been removed. The time a patient is in cast varies between surgeons. Please check operation notes or recent clinic letter to confirm this timeframes.

The aim of therapy is to:

Relieve pain
Improve thumb position
Improve active range of movement
Improve pinch
Improve grip
Improve function

Functional outcome measures such as the DASH or quick DASH can be used to record functional outcome if desired.

First Appointment

1.ROM

Active flexion/ extension of wrist
Active flexion/ extension of non affected digits
Active flexion/ extension of IP joint
Gentle active thumb movement into opposition and circumduction as pain allows.
Finger abduction and adduction
Maintain range of movement of elbow and shoulder

2. Exercises

Refer to exercises in the patient information leaflet (reference number to be added once confirmed by medical illustrations). Remove splint (if patient has been advised to wear one) to perform exercises. Additional exercises or modified exercises can be issued as determined by assessment and clinical need.

Regularity of exercises to be at therapist discretion, taking into consideration any post surgery inflammation and oedema. Aim for exercises to be done 4 times per day.

3. Education/ Advice

Aims:

Manage/limit oedema
Promote good scar management
Recover function

Hand Care

Oedema management:
- Patient is advised to position the forearm in elevation using pillows when sitting/ sleeping.
- Patient is advised to maintain range of movement of elbow and shoulder regularly.
Scar management
- Once the wound is healed and there is no signs of infection, massage of the scar with a non perfumed emollient should begin. Patients should be taught to use circular motions along the scar working distal to proximal to help reduction of oedema.
- If there is any concern regarding the possibility of infection e.g. foul smell, oozing wound, redness, temperature, increased pain, this must be checked ASAP with a more experienced member of staff, the dressing clinic, a medic or practice nurse.

Function

Advice on light activities only

Driving

Patient can return to driving once cast is removed, as pain allows and they feel that they are in complete control of the car. Advise that it is their responsibility to check with their insurance company before returning to driving.

4. Splint

Splinting protocols and the types of splints used vary between hospitals and surgeons, please check local protocols.

A small piece of tubi net can be worn under the splint to absorb perspiration.

If you have any splinting questions or concerns please contact your local hand therapist (refer to details at bottom of page).

Subsequent appointments

All the above advice and exercise is re-iterated and exercises progressed or modified as determined by clinical need and as pain allows.

Exercise progression

Cast removal - regain thumb range of movement and maintain/ regain all other joint range.

Improving range - continue exercise regime and progress onto strengthening as pain allows

12 weeks onward – Return to all activities where possible

Splint

The point at where discontinuation of the splint can commence varies between surgeons, please check local protocol.

Gradual withdrawal of splint for light activities is where you should guide your patient to begin. This can be increased and the patient can then be gradually weaned off the splint as pain allows.

Summary

Every patient is different. Some will require minimal intervention, others will require more. Assess and arrange for ongoing therapy, as necessary following local physiotherapy referral protocols.
This operation is a huge insult on the hand and it can take up to 9 months for the full benefit to be attained.
Some patients will inevitably encounter unexpected complications. If in doubt or any concerns please contact your local hand therapist.

Problematic Pain

Consult the Pain Service section within Exit Routes [links to CKP can we link to Exit routes on RDS?] for information and guidelines on diagnosis and management of Complex Regional Pain Syndrome.