Treatment of posttraumatic arthrosis

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Patients who present with symptomatic post-traumatic CMC arthrosis generally complain of pain over the involved joint aggravated by gripping, shaking hands, and occupation-specific or sports-specific activities. A percentage of these patients present simply to determine the cause for their intermittent discomfort, but a number of others have daily, bothersome complaints. Frequently subtle instability is present on examination and may be a significant contributing factor.

First line treatment is nonoperative for this population of patients. It involves education, activity modification, local treatment with ice, intermittent splinting, and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Because these joints are often quite narrowed and difficult to inject, cortisone is rarely employed. Patients who have frequent and disabling symptoms require surgical intervention. The most common and accepted surgical treatment is arthrodesis; however, in specific cases of fifth CMC joint arthritis, some surgeons have successfully used resection arthroplasty [13], silicone implant arthroplasty [14], tendon interposition arthroplasty [15], and arthroscopic assessment followed by limited open joint debridement.

Gainor and coworkers [15] reviewed their experience in eight patients who underwent interposi-tional arthroplasty for treatment of fifth CMC joint post-traumatic arthritis. A limited resection of either the metacarpal base or distal hamate was performed, followed by interposition of palmaris longus, repair of the dorsal carpometacarpal ligament, and temporary joint pinning. At an average

Fifth Cmc Fracture Dislocation
Fig. 1. (A) Anteroposterior (AP) and (B) lateral radiographs depicting a missed fifth CMC joint fracture/dislocation 4 months postinjury.

final follow-up of 5 years, there was no evidence of instability. Net increase in grip strength averaged 30%. All patients rated their functional result and cosmetic appearance as good or excellent despite an average 4 mm loss of length of the fifth ray. Radiographs revealed "egg cup'' remodeling or meta-physeal hypertrophy.

This author has used a 0.8 mm investigational arthroscope (InnerVue, Arthrotek, Biomet Corporation, Warsaw, Indiana) to evaluate the fifth

CMC joint and to direct limited open debridement of the joint in select athletes who have mild arthritic changes unresponsive to conservative management. This intervention has provided effective short- and medium-term relief of symptoms, and has allowed virtually uninterrupted sports participation. It is likely that as arthroscopic instrumentation improves and techniques evolve, this approach will find its place in the hand surgeon's armamentarium.

Broken Thumb Radiographs
Fig. 2. (A) AP and (B) lateral radiographs following ORIF of the dorsal hamate fracture with two 2.0-mm screws, reconstruction of the dorsal ligament, and joint reduction and stabilization with two K-wires.
Fig. 3. Lateral radiograph 6 months after reconstruction, showing a healed hamate and a stable fifth CMC joint.

Patients who have missed fracture/dislocations of the finger CMC joints represent the largest group requiring surgical treatment, especially when multiple CMC joints are involved. These injuries are easily overlooked on cursory examination of standard plain radiographs in victims of high-energy trauma, especially by physicians immersed in the care of life threatening injuries. Surgical options include delayed reconstruction by open reduction and internal fixation as well as CMC joint arthrodesis.

Open reduction and internal fixation (ORIF) should be considered in subacute or early chronic cases in which the fracture dislocations involve the fourth and fifth CMC joints, with the goal being maintenance of ulnar column mobility (Fig. 1). Successful ORIF should take place no more than 4 to 6 months following the initial injury, and requires a reconstructable dorsal carpal lip as well as intact cartilaginous surfaces. The technique involves stabilization of the dorsal carpal fracture with screws or Kirschner wires (K-wires), followed by reduction and pinning of the joint and repair of the dorsal ligaments and capsule (Fig. 2). Though there are no large case series, this approach has been effective in the hands of this author and others (Fig. 3) [9,16].

When the radial CMC joints are involved or in chronic cases, concern turns to restoring stability rather than mobility (Figs. 4 and 5). In this situation, arthrodesis is the treatment of choice, and will yield a predictably good result if performed with surgical precision [17]. Typically a cancellous or corticocancellous graft is obtained from the dorsal distal radius, the joint is meticulously decorticated and reduced, then stabilized with a miniplate or K-wires (Fig. 6).

5th Cmc Fracture Dislocation
Fig. 4. (A) AP and (B) lateral radiographs revealing missed third and fourth CMC joint fracture dislocations in a severely traumatized patient 6 months following the injury.
Computertomographie Verletzung Fuss

Fig. 5. Sagittal CT scan images detailing the bony destruction of the third (A) and fourth (B) CMC joints.

Fig. 5. Sagittal CT scan images detailing the bony destruction of the third (A) and fourth (B) CMC joints.

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  • raakel
    How do you treat posttraumatic arthrosis?
    10 months ago

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