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Brief Report
Issue Date: January/February 2016
Published Online: December 18, 2015
Updated: April 30, 2020
Postoperative Therapy for Chronic Thumb Carpometacarpal (CMC) Joint Dislocation
Author Affiliations
  • Ronit Wollstein, MD, is Associate Professor of Orthopedic Surgery, Technion School of Medicine, Haifa, Israel, and Adjunct Associate Professor of Plastic Surgery, Department of Plastic Surgery, University of Pittsburgh Medical School, Pittsburgh, PA; ronitwollstein@gmail.com
  • Dafna Michael, CHT, is Hand Therapist, Carmel Lady Davis Medical Center, Haifa, Israel
  • Hani Harel, CHT, is Director of Hand Therapy, Carmel Lady Davis Medical Center, Haifa, Israel
Article Information
Arthritis / Complementary/Alternative Approaches / Hand and Upper Extremity / Musculoskeletal Impairments / Splinting / Departments / Brief Report
Brief Report   |   December 18, 2015
Postoperative Therapy for Chronic Thumb Carpometacarpal (CMC) Joint Dislocation
American Journal of Occupational Therapy, December 2015, Vol. 70, 7001350020. https://doi.org/10.5014/ajot.2016.017210
American Journal of Occupational Therapy, December 2015, Vol. 70, 7001350020. https://doi.org/10.5014/ajot.2016.017210
Abstract

Surgical arthroplasty of thumb carpometacarpal (CMC) joint osteoarthritis is commonly performed. Postoperative therapeutic protocols aim to improve range of motion and function of the revised thumb. We describe a case in which the thumb CMC joint had been chronically dislocated before surgery, with shortening of the soft-tissue dynamic and static stabilizers of the joint. The postoperative protocol addressed the soft tissues using splinting and exercises aimed at lengthening and strengthening these structures, with good results. It may be beneficial to evaluate soft-tissue tension and the pattern of thumb use after surgery for thumb CMC joint osteoarthritis to improve postoperative functional results.

The thumb carpometacarpal (CMC) joint is the most common joint in the wrist to develop osteoarthritis (OA; Gabay & Gabay, 2013). Because the thumb is involved in virtually all functional activities of the hand, OA in this joint is often symptomatic and frequently requires treatment (Spaans et al., 2015).
Some of the reasons for the pervasiveness of OA in this joint stem from its unique anatomical structure. This anatomy and its significance are still under investigation, but it appears that although the 360° of motion allowed for in this joint enables the thumb’s unique functionality, the inherent instability associated with such a wide range of motion (ROM) may result, with time and use, in the attenuation of the ligamentous structures and consequently degenerative arthritis of the joint (Crisco et al., 2014; Halilaj et al., 2014).
When conservative treatment fails, a plethora of surgical procedures are available to treat this condition (Park et al., 2008). Each procedure is followed by a postoperative hand therapy protocol that is dependent on the type of surgery, surgeon preference, and factors related to the patient. The main objectives of therapy are to increase ROM, strength, and, ultimately, function of the revised joint. These objectives are accomplished using passive and dynamic exercises and require splinting for variable periods of time.
In this article, we describe a case of chronic thumb CMC joint dislocation treated with suspension and interposition arthroplasty. Because of long-standing dislocation, the muscles and ligaments around the joint had contracted, necessitating a postoperative protocol tailored to the patient that included stretching and reeducation of the surrounding musculature. The patient’s excellent results emphasize the importance of dynamic soft-tissue evaluation and rehabilitation following surgery for the thumb CMC joint.
Case Report
A right-handed male electrician, age 56 yr, was seen in the hand clinic with a history of pain and deformity in the base of the right thumb. He had noticed these changes for about a year and a half. The patient reported no history of trauma or isolated incident but used his right hand continually at work. For about a year, he had been able to passively “push the bone back into place,” but this adjustment was painful. Pinching with the thumb required considerable effort, making it difficult to use the right hand at work. He was treated with multiple periods of splinting and had received an intraarticular injection. Recently, the thumb had begun to hurt for longer periods, even without use.
Past medical history and review of systems was negative. The patient did not take any medication on a regular basis. Examination revealed a clearly dislocated right thumb CMC joint that could be relocated with pain. The right thumb was about 2 cm shorter than the left thumb and was unstable. The patient did not demonstrate generalized hyperlaxity, although the metacarpophalangeal (MCP) joint of the thumb was unstable, falling into subluxation in flexion during pinch. He could not abduct his thumb and used it only in key pinch. Radiographs demonstrated dislocation with the trapezium tilted radially and evidence of some calcification in the soft tissues. The base of the metacarpal had a rounded appearance (Figure 1).
Figure 1.
Posteroanterior radiograph of the hand illustrating a dislocation of the carpometacarpal joint of the thumb.
Figure 1.
Posteroanterior radiograph of the hand illustrating a dislocation of the carpometacarpal joint of the thumb.
×
The patient was treated surgically to remove the trapezium. Half of the flexor carpi radialis (FCR) was used to suspend the thumb metacarpal through a drill hole, and some of the tendon was used as interposition wound around the intact half of the FCR. The base of the metacarpal was almost completely devoid of cartilage and rounded off. It was decided not to perform an arthrodesis because it was our impression that the alignment would exert shear forces on the fusion mass, create difficulty in bone healing, and load an already compromised MCP joint.
The patient was seen by an occupational therapist 5 days after surgery. At that time mild swelling appeared in the wrist and hand. Pain as evaluated using a visual analog scale was 4/10. The thumb had been lengthened considerably by the surgery and was now the same length as the left thumb.
On initial postoperative evaluation, the wrist was in 30° of flexion and the thumb was in a position of palmar adduction with loss of web space (Figure 2). The MCP and interphalangeal (IP) joints were in neutral. The clinical presentation was explained by tightness of the capsular structures, which had become contracted during the long period of dislocation, and by contracture of the dynamic stabilizers of the CMC joint and the thumb, specifically the flexor pollicis longus (FPL), extensor pollicis longus (EPL), and adductor pollicis, as well as possibly the tendons of the first extensor compartment, which are palmar abductors. Tightness of these structures would explain the position of the joints of the wrist and the thumb as a whole.
Figure 2.
Postoperative photograph showing the small web space and limitation of thumb abduction compared with the unaffected side.
Figure 2.
Postoperative photograph showing the small web space and limitation of thumb abduction compared with the unaffected side.
×
The standard postoperative protocol for this surgical procedure consists of thumb spica splinting for 2–2.5 wk and active ROM and exercises for activities of daily living (ADLs) started immediately thereafter, emphasizing isometric abduction of the thenar muscles initially. Exercises also include active flexion at the CMC joint at first to the radial fingers and gradually toward the little finger and are performed progressively from distal to proximal on the finger. Edema control and scar treatment are implemented as necessary. Strengthening is paced with increasing ROM.
Because of the change in this patient’s anatomy after surgery, the therapeutic protocol took into account the contracted soft tissues that had been pulled out to length and the patterns of thumb use that had developed over years of chronic dislocation. Moreover, the demands of the patient’s job as an electrician necessitated both fine manipulation and gross motor strength, which needed to be addressed as well. In a deviation from the standard protocol, the patient was splinted for a prolonged period to stretch out the soft tissues and emphasis was placed on changing his pattern of thumb use while taking into account his specific functional demands.
The treating therapist (Hani Harel) performed all measurements and tests. The patient was evaluated often during postoperative therapy by the team, including the surgeon (Ronit Wollstein).
The plan included twice-weekly therapy sessions. To maintain tension in the contracted thenar musculature and the adductor pollicis, a thumb spica splint in abduction was constructed. The splint was adjusted periodically using sponge inserts to widen the web space and increase the tension on the thenar musculature and was worn for a total of 6 wk. The original splint extended to the tip of the thumb to include the IP joint, but at 2 wk postsurgery, it was shortened to allow thumb IP joint movement, and the patient was instructed to use the thumb in ADLs to increase the stretch on the thumb musculature. During this period, the splint was inspected often (2×/wk) to make sure no pressure was developing in the area of the palmar CMC joint (Figure 3). The patient was also instructed to use the hand in the splint for activities such as writing, pinch and opposition, and grasp of small objects while gradually advancing from distal to proximal to maintain soft-tissue tension and prevent recurrence of deformity.
Figure 3.
Postoperative splint pulling the thumb into abduction.
Figure 3.
Postoperative splint pulling the thumb into abduction.
×
At 6 wk postsurgery, the splint was removed during the day, but the patient continued wearing it at night. The size of the web space in the night splint was adjusted at every session. The patient continued therapy with activities tailored to his occupational demands, which included working with a screwdriver and bolts. Emphasis was placed on performing these tasks with the thumb in a neutral position while maintaining the web space. The patient felt increased limitation during activities that required wrist supination; therefore, these types of activities were stressed (e.g., opening doors and jars, using a screwdriver). A dynamic splint was made for use during the day that consisted of a soft Velfoam® (Velcro USA, Manchester, NH) strap on the wrist with a sling for the thumb (also made out of soft Velfoam) attached to the proximal strap with a rubber band. This passively pulled the thumb out radially into abduction during activities. The patient was also encouraged to work at home and gradually progressed from weeding (strengthening pinch) to using shears (requiring power in adduction but again passively abducting the thumb). He gradually returned to work. At 4 mo, grip strength on the right side was equal to the left (unaffected) side and most pinch strength results were almost equal (Table 1). In addition, the Purdue Pegboard Test (Tiffin & Asher, 1948) results were equal for the right and left sides at 4 mo (Mandell, Nelson, & Cermak, 1984).
Table 1.
Postoperative Measurements
Postoperative Measurements×
TimeTip Pinch, R/LKey Pinch, R/LPalmar Pinch, R/LGrip Strength, R/L
12 wk5/101/224/1050/90
16 wk8/108/218/1080/80
25 wk12/910/2215/1490/80
Table Footer NoteNote. L = left; R = right. All values are an average of three measurements in pounds.
Note. L = left; R = right. All values are an average of three measurements in pounds.×
Table 1.
Postoperative Measurements
Postoperative Measurements×
TimeTip Pinch, R/LKey Pinch, R/LPalmar Pinch, R/LGrip Strength, R/L
12 wk5/101/224/1050/90
16 wk8/108/218/1080/80
25 wk12/910/2215/1490/80
Table Footer NoteNote. L = left; R = right. All values are an average of three measurements in pounds.
Note. L = left; R = right. All values are an average of three measurements in pounds.×
×
The patient’s only complaint at this time was dorsal subluxation of the MCP joint during heavy use. This complaint was addressed with a small splint to the MCP joint that he used while performing heavy tasks. The patient did not use this splint often, and a splint for the IP joint alone was added to limit IP joint flexion and allow further stretching of the EPL and FPL, thus increasing flexion with stretching the extensor in the MCP joint. This addition and consequent improvement in MCP joint flexion to 50° induced a complete disappearance of the dorsal subluxation at the MCP joint.
At 6 mo postsurgery, the patient had returned to full function, with a stable MCP joint during power pinch and grip. Grip strength was stronger in the right hand than in the left (see Table 1). The patient’s retrospective Disabilities of the Arm, Shoulder and Hand score was 100 (Institute for Work and Health, 2006); at 6 mo, it had improved to 78, with recent ipsilateral shoulder symptoms being the main factor limiting function.
Implications for Occupational Therapy Practice
This case has the following implications for occupational therapy practice:
  • Soft-tissue imbalance may exist around the thumbs of patients with CMC joint OA as a result of the etiology and chronicity of the condition.

  • It is advantageous to evaluate soft-tissue quality and patterns of thumb use before and after surgery for thumb CMC joint OA

  • A therapeutic protocol that addresses the soft tissues surrounding the joint may improve the ultimate outcome.

Conclusion
This article describes postoperative treatment after arthroplasty for a chronic thumb CMC joint dislocation. The therapeutic protocol was adjusted to address the soft-tissue contracture and imbalance that existed because of the chronicity of the condition. The main problem was contracture of the dynamic soft tissues affecting the thumb, so therapy included splinting to maintain length and tension. Because the muscles affect all of the joints of the thumb, the patient’s recovery began at the CMC joint and later progressed to the MCP joint. The specific demands of the patient’s occupation necessitated working to change the patterns of thumb use that had been adapted to compensate for a chronically dislocated thumb in work-related activities. Because many of the surgical procedures addressing thumb CMC joint OA involve changing the biomechanics of the joint (shortening, removal of the trapezium, metacarpal osteotomy), it may be beneficial to evaluate the soft-tissue tension and the pattern of thumb use after surgery to treat any deficiencies or inequalities and thus improve functional results.
References
Crisco, J. J., Halilaj, E., Moore, D. C., Patel, T., Weiss, A. C., & Ladd, A. L. (2014). In vivo kinematics of the trapeziometacarpal joint during thumb extension–flexion and abduction–adduction. Journal of Hand Surgery, 40, 289–296. http://dx.doi.org/10.1016/j.jhsa.2014.10.062 [Article] [PubMed]
Crisco, J. J., Halilaj, E., Moore, D. C., Patel, T., Weiss, A. C., & Ladd, A. L. (2014). In vivo kinematics of the trapeziometacarpal joint during thumb extension–flexion and abduction–adduction. Journal of Hand Surgery, 40, 289–296. http://dx.doi.org/10.1016/j.jhsa.2014.10.062 [Article] [PubMed]×
Gabay, O., & Gabay, C. (2013). Hand osteoarthritis: New insights. Joint, Bone, Spine, 80, 130–134. http://dx.doi.org/10.1016/j.jbspin.2012.06.011 [Article]
Gabay, O., & Gabay, C. (2013). Hand osteoarthritis: New insights. Joint, Bone, Spine, 80, 130–134. http://dx.doi.org/10.1016/j.jbspin.2012.06.011 [Article] ×
Halilaj, E., Moore, D. C., Laidlaw, D. H., Got, C. J., Weiss, A. P., Ladd, A. L., & Crisco, J. J. (2014). The morphology of the thumb carpometacarpal joint does not differ between men and women, but changes with aging and early osteoarthritis. Journal of Biomechanics, 47, 2709–2714. http://dx.doi.org/10.1016/j.jbiomech.2014.05.005 [Article] [PubMed]
Halilaj, E., Moore, D. C., Laidlaw, D. H., Got, C. J., Weiss, A. P., Ladd, A. L., & Crisco, J. J. (2014). The morphology of the thumb carpometacarpal joint does not differ between men and women, but changes with aging and early osteoarthritis. Journal of Biomechanics, 47, 2709–2714. http://dx.doi.org/10.1016/j.jbiomech.2014.05.005 [Article] [PubMed]×
Institute for Work and Health. (2006). Disabilities of the Arm, Shoulder and Hand: The DASH. Retrieved from http://dash.iwh.on.ca/system/files/dash_questionnaire_2010.pdf
Institute for Work and Health. (2006). Disabilities of the Arm, Shoulder and Hand: The DASH. Retrieved from http://dash.iwh.on.ca/system/files/dash_questionnaire_2010.pdf×
Mandell, R. J., Nelson, D. L., & Cermak, S. A. (1984). Differential laterality of hand function in right-handed and left-handed boys. American Journal of Occupational Therapy, 38, 114–120. http://dx.doi.org/10.5014/ajot.38.2.114 [Article] [PubMed]
Mandell, R. J., Nelson, D. L., & Cermak, S. A. (1984). Differential laterality of hand function in right-handed and left-handed boys. American Journal of Occupational Therapy, 38, 114–120. http://dx.doi.org/10.5014/ajot.38.2.114 [Article] [PubMed]×
Park, M. J., Lichtman, G., Christian, J. B., Weintraub, J., Chang, J., Hentz, V. R., . . . Yao, J. (2008). Surgical treatment of thumb carpometacarpal joint arthritis: A single institution experience from 1995–2005. Hand (New York, N.Y.), 3, 304–310. http://dx.doi.org/10.1007/s11552-008-9109-z [PubMed]
Park, M. J., Lichtman, G., Christian, J. B., Weintraub, J., Chang, J., Hentz, V. R., . . . Yao, J. (2008). Surgical treatment of thumb carpometacarpal joint arthritis: A single institution experience from 1995–2005. Hand (New York, N.Y.), 3, 304–310. http://dx.doi.org/10.1007/s11552-008-9109-z [PubMed]×
Spaans, A. J., van Minnen, L. P., Kon, M., Schuurman, A. H., Schreuders, A. R., & Vermeulen, G. M. (2015). Conservative treatment of thumb base osteoarthritis: A systematic review. Journal of Hand Surgery, 40, 16–21. http://dx.doi.org/10.1016/j.jhsa.2014.08.047 [Article] [PubMed]
Spaans, A. J., van Minnen, L. P., Kon, M., Schuurman, A. H., Schreuders, A. R., & Vermeulen, G. M. (2015). Conservative treatment of thumb base osteoarthritis: A systematic review. Journal of Hand Surgery, 40, 16–21. http://dx.doi.org/10.1016/j.jhsa.2014.08.047 [Article] [PubMed]×
Tiffin, J., & Asher, E. J. (1948). The Purdue Pegboard: Norms and studies of reliability and validity. Journal of Applied Physiology, 32, 234–247.
Tiffin, J., & Asher, E. J. (1948). The Purdue Pegboard: Norms and studies of reliability and validity. Journal of Applied Physiology, 32, 234–247.×
Figure 1.
Posteroanterior radiograph of the hand illustrating a dislocation of the carpometacarpal joint of the thumb.
Figure 1.
Posteroanterior radiograph of the hand illustrating a dislocation of the carpometacarpal joint of the thumb.
×
Figure 2.
Postoperative photograph showing the small web space and limitation of thumb abduction compared with the unaffected side.
Figure 2.
Postoperative photograph showing the small web space and limitation of thumb abduction compared with the unaffected side.
×
Figure 3.
Postoperative splint pulling the thumb into abduction.
Figure 3.
Postoperative splint pulling the thumb into abduction.
×
Table 1.
Postoperative Measurements
Postoperative Measurements×
TimeTip Pinch, R/LKey Pinch, R/LPalmar Pinch, R/LGrip Strength, R/L
12 wk5/101/224/1050/90
16 wk8/108/218/1080/80
25 wk12/910/2215/1490/80
Table Footer NoteNote. L = left; R = right. All values are an average of three measurements in pounds.
Note. L = left; R = right. All values are an average of three measurements in pounds.×
Table 1.
Postoperative Measurements
Postoperative Measurements×
TimeTip Pinch, R/LKey Pinch, R/LPalmar Pinch, R/LGrip Strength, R/L
12 wk5/101/224/1050/90
16 wk8/108/218/1080/80
25 wk12/910/2215/1490/80
Table Footer NoteNote. L = left; R = right. All values are an average of three measurements in pounds.
Note. L = left; R = right. All values are an average of three measurements in pounds.×
×