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OSTEOARTHRITIS, CARPOMETACARPAL (CMC) JOINT OF THUMB

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 >40y)/postmenopausal women
  • Associated with carpal tunnel syndrome and DeQuervain’s tenosynovitis

Differential Diagnosis

  • DeQuervain’s tenosynovitis
  • Scaphotrapeziotrapezoid (STT) arthritis
  • Scaphoid nonunion
  • Radioscaphoid arthritis
  • Trigger Thumb
  • Painful Thumb CMC Subluxation
ICD-10 Codes

OSTEOARTHRITIS, CARPOMETACARPAL (CMC) JOINT OF THUMB

Diagnostic Guide Name

OSTEOARTHRITIS, CARPOMETACARPAL (CMC) JOINT OF THUMB

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
OSTEOARTHRITIS, CARPOMETACARPAL (CMC) JOINT OF THUMB, PRIMARY   M18.12 M18.11 M18.0

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Osteoarthritis CMC joint thumb
  • Thumb CMC (Basal Joint) OA with CMC Subluxation
    Thumb CMC (Basal Joint) OA with CMC Subluxation
  • Thumb CMC (Basal Joint) OA with CMC Subluxation and MP Hyperextension
    Thumb CMC (Basal Joint) OA with CMC Subluxation and MP Hyperextension
Symptoms
Pain at the base of the thumb (especially with gripping or pinching)
Laxity of thumb CMC or MP joints
Swelling of the thumb joints
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
Work-up Options
Images (X-Ray, MRI, etc.)
  • Thumb CMC OA Stage I normal or possible widening of the joint from synovitis and/or joint effusion; joint contours intact
    Thumb CMC OA Stage I normal or possible widening of the joint from synovitis and/or joint effusion; joint contours intact
  • 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 sublux maximally.
    Thumb CMC joint stress X-ray with patient pushing tips of thumbs together forcing the thumb CMC joints to sublux maximally.
Treatment Options
Treatment Goals
  • Control thumb pain
  • Improve pinch
  • Improve grip
  • Improve patient's ability to do activities of daily living (ADL)
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)
      For ASSH's Hand-e Surgical Video of LRTI Arthroplasty by Hammert:
      For ASSH's Hand-e Surgical Video of LRTI Trapezial Excision and Suture Suspension by Ladd and Weiss:
    • Trapeziometacarpal arthrodesis
Treatment Photos and Diagrams
Surgical Treatment - Trapezial Excision, Ligament reconstruction & Fascial Arthroplasty
  • CMC OA Fascial Arthroplasty Incisions
    CMC OA Fascial Arthroplasty Incisions
  • 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
Surgical Diagrams - Trapezial Excision, Ligament reconstruction & Fascial Arthroplasty
  • The trapezium has been excised, usually in pieces. The radial half of the FCR is left intact while the ulnar half of the FCR is passed across the defect created by removing the trapezium and then through the dorsal radial corner of the CMC joint capsule (1).  Next the FCR tendon half goes around the abductor pollicis longus at its insertion site at the base of the thumb metacarpal.
    The trapezium has been excised, usually in pieces. The radial half of the FCR is left intact while the ulnar half of the FCR is passed across the defect created by removing the trapezium and then through the dorsal radial corner of the CMC joint capsule (1). Next the FCR tendon half goes around the abductor pollicis longus at its insertion site at the base of the thumb metacarpal.
  • The ulnar half of the FCR is shown going back through the dorsal radial capsule slightly more proximally and around the intact radial half of the FCR (1). Next the ulnar half of the FCR goes to the dorsal radial corner of the capsule again where it is sutured (2).
    The ulnar half of the FCR is shown going back through the dorsal radial capsule slightly more proximally and around the intact radial half of the FCR (1). Next the ulnar half of the FCR goes to the dorsal radial corner of the capsule again where it is sutured (2).
  • Next the remaining ulnar half of the FCR is sutured into a ball "anchovy" with 2-O chromic suture.  This fascial material is secured to the radial half of the FCR inside the defect made from the earlier trapezial excision.  The fascia acts as a temporary spacer to support the thumb metacarpal. After the fascia is packed into the defect, the capsule edge "A" is sutured to "B" and to the base of the  metacarpal "C".  Prior to making the fascial ball the FCR maybe extended with a palmaris longus tendon graft.
    Next the remaining ulnar half of the FCR is sutured into a ball "anchovy" with 2-O chromic suture. This fascial material is secured to the radial half of the FCR inside the defect made from the earlier trapezial excision. The fascia acts as a temporary spacer to support the thumb metacarpal. After the fascia is packed into the defect, the capsule edge "A" is sutured to "B" and to the base of the metacarpal "C". Prior to making the fascial ball the FCR maybe extended with a palmaris longus tendon graft.
CPT Codes for Treatment Options

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Common Procedure Name
Fascial arthroplasty, e.g. thumb fascial arthroplasty, (LRTI includes 26480)
CPT Description
Interposition arthroplasty, intercarpal or carpometacarpal joints
CPT Code Number
25447
Common Procedure Name
Excision trapezium, pisiform, scaphoid or hook of hamate
CPT Description
Carpectomy; one bone
CPT Code Number
25210
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Hand Therapy

RECOMMENDED HAND SURGEON THERAPY ORDERS

Early edema control, elevation, and icing to exposed fingers as needed

Early AROM for shoulder and elbow to prevent stiffness

Patient education on prevention and wound management

AROM exercises for fingers to encourage edema control and finger AROM

AROM for thumb and wrist at week 3-4 (thumb IP AROM can be initiated immediately)

Splinting introduced after cast removal (to be removed for exercises and cleaning at the sink)

Strengthening at 8 weeks may begin

REVIEW OF THERAPIST INTERVENTIONS FOR OSTEOARTHRITIS

Therapy for non-operative patient to include:

Night splint in long thumb spica splint

Daytime short thumb spica splint and/or CMC ring splint (see images)

Gentle AROM exercises, tendon glides, encourage taking breaks, heat or ice x 10 minutes intermittently throughout the day for comfort and pain reduction

Review isolated thumb IP AROM within long spica splint

Gentle strengthening of intrinsic muscles while using CMC ring splint

Heat or paraffin intermittently for comfort and self management of pain

Look out for patient complaints of CTS symptoms in more advanced cases

STATUS POST CMC RECONSTRUCTION

Early hand therapist assistance and intervention:

Edema control – encourage elevation, encourage early gentle finger ROM, watch for RSD/CRPS signs

Very light compressive sleeves for fingers, thumb and/or hand

Patient education –splinting to protect the surgical site, encourage smoke free recovery, early AROM avoid excessive exercise to minimize scarring

REVIEW OF POS-TOPERATIVE CMC ARTHRITIS

Early hand therapist assistance and intervention (fourth week post-op):

At week 4 post-op, edema control – encourage elevation, review AROM for fingers, wrist, and elbow watch for RSD/CRPS signs.

Continue scar management and introduce a scar conformer such as silicone based products, (see image below)

Very light compressive sleeves for thumb and/or hand. Be aware of the tourniquet effect causing distal edema accumulation and restricted blood flow to the surgical site.

Patient education – functional task precautions, encourage a smoke free recovery, avoid excessive exercise to minimize scarring. Heavy scarring is possible at the thumb due to its multiple axes of mobility. Remind patient not to carry anything with their hand or arm.

Initiate AROM for thumb glides in flexion, extension, palmar and radial abduction.

Initiate isolated blocking exercises for IP and MCP AROM of the thumb.

Initiate AROM for wrist; and elbow & shoulder AROM if needed to prevent stiffness.

Encourage finger food tasks, in hand manipulation and coin stacking to optimize AROM and function.

Scar management, scar massage with vitamin E oil/thick vitamin E cream in light circular motions with moderate pressure 3-4 minutes twice daily. Heavy scarring is possible at the thumb due to its multiple axes of motion. (donor tendon harvest scars can become adherent)

At week 5 post-op, continue AROM thumb glides in flexion and extension and initiate thumb AROM in palmar & radial deviation, and gently introduce circumduction clockwise and counterclockwise.

At week 6, allow full light thumb and hand use reintegration for all activities of daily living.

Allow opposition of thumb to fingertips of index, long, and ring; gradually progressing to the little fingertip by week 6.

Initiate PROM for thumb and wrist in all planes within a pain free range (flexion/extension and UD/RD). Provide CMC support with PROM for thumb MCP and IP.

At week 8 initiate strengthening for thumb, fingers and wrist.

At week 8-10, progress strengthening and work hardening/work simulation as needed.

Progress PRE’s (Progressive Resistive Exercises) with theraputty, thumb plunger, pen clicks, paper ball rip and roll, grippers, clips, dumbbells, and work simulator if necessary.

Education on reintegration into functional life without reinjury. Prevention education.

  • At week 4 post-op continue scar management and introduce a scar conformer (silicone based products).
    At week 4 post-op continue scar management and introduce a scar conformer (silicone based products).
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
YouTube Video
Thumb CMC Joint Osteoarthritis
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.
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. PMID: 25171934
  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. PMID: 25077047

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. PMID: 21193136
  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. PMID: 23204884

Classics

  1. Eaton RG and Glickel SZ. Trapeziometacarpal osteoarthritis: staging as a rational for treatment. Hand Clin1987;3:455-71. PMID: 3693416
  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.

HAND THERAPY REFERENCES

  1. Cannon, et al. (2001).  Diagnosis and Treatment Manual for Physicians and Therapists, Upper extremity Rehabilitation (4th ed).  The Hand Rehabilitation Center of Indiana.
  2. Mackin, Callahan, Skirven, Schneider, and Osterman, (2002). Rehabilitation of the Hand and Upper Extremity, 1, (5th ed). St Louis, MO: Mosby Year Book, Inc.
  3. Cooper, (2014). Fundamentals of Hand Therapy; Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity, (2nd ed). Mosby, imprint of Elsevier Inc. Stanley and Tribuzi. (1992).  Concepts in Hand Rehabilitation.  F. A. Davis Company