“Doctor, my thumb hurts”

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Applied Evidence

“Doctor, my thumb hurts”

J Fam Pract. 2011 June;60(6):329-332

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References

1. Ilyas AM, Ast M, Schaffer AA, Thoder J. De Quervain tenosynovitis of the wrist. J Am Acad Orthop Surg. 2007;15:757-764.

2. Jirarattanaphochai K, Saengnipanthkul S, Vipulakorn K, et al. Treatment of de Quervain disease with triamcinolone injection with or without nimesulide. A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am. 2004;86A:2700-2706.

3. Richie A, Briner W. Corticosteroid injection for treatment of de Quervain’s tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract. 2003;16:102-106.

4. Ta KT, Eidelman D, Thomson JG. Patient satisfaction and outcomes of surgery for De Quervain’s tenosynovitis. J Hand Surg Am. 1999;24:1071-1077.

5. Wilder FV, Barrett JP, Farina EJ. Joint-specific prevalence of osteoarthritis of the hand. Osteoarthritis Cartilage. 2006;14:953-957.

6. Van Heest AE, Kallemeier P. Thumb carpal metacarpal arthritis. J Am Acad Orthop Surg. 2008;16:140-151.

7. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis Rheum. 2000;43:1905-1915.

8. Swigart CR, Eaton RG, Glickel SZ, et al. Splinting in the treatment of arthritis of the first carpometacarpal joint. J Hand Surg Am. 1999;24:86-91.

9. Berggren M, Joost-Davidsson A, Lindstrand J, et al. Reduction in the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven year prospective study. Scand J Plast Reconstr Surg Hand Surg. 2001;35:415-417.

10. Meenagh GK, Patton J, Kynes C, et al. A randomized controlled trial of intra-articular corticosteroid injection of the carpometacarpal joint of the thumb in osteoarthritis. Ann Rheum Dis. 2004;63:1260-1263.

11. Joshi R. Intraarticular corticosteroid injection for first carpometacarpal osteoarthritis. J Rheumatol. 2005;32:1305-1306.

12. Freedman DM, Clickel SZ, Eaton RG. Long-term follow-up of volar ligament reconstruction of the thumb. J Hand Surg Am. 2000;25A:297-304.

13. Cebesoy O, Kose KC, Baltaci ET, et al. Percutaneous release of the trigger thumb: is it safe, cheap and effective? Int Orthop. 2007;31:345-349.

14. Akhtar S, Bradley MJ, Quinton DN, et al. Management and referral for trigger finger/thumb. BMJ. 2005;331:30-33.

15. Patel MR, Bassini L. Trigger fingers and thumb: when to splint, inject, or operate. J Hand Surg Am. 1992;17:110>-113.

16. Rhoades CE, Gelberman RH, Manjarris JF. Stenosing tenosynovitis of the fingers and thumb. Results of a prospective trial of steroid injection and splinting. Clin Orthop Relat Res. 1984;190:236-238.

17. Maneerit J, Sriworakun C, Budhraja N, et al. Trigger thumb: results of a prospective randomized study of percutaneous release with steroid injection versus steroid injection alone. J Hand Surg Br. 2003;28:586-589.

18. Nimigan AS, Ross DC, Gan BS. Steroid injections in the management of trigger fingers. Am J Phys Med Rehabil. 2006;85:36-43.

Corticosteroid injections alone for CMC OA have had mixed results. One study compared corticosteroid injection with saline injection (n=40) and reported no difference at 24 weeks’ posttreatment.¹⁰ Another found short-term improvement from a corticosteroid injection (n=25), as measured on a visual analog scale at 1 month (P<.001), but no significant improvement in symptoms after 3 months.¹¹

Consider surgery if conservative measures fail
As with most cases of osteoarthritis, surgery for CMC OA should be considered only after failure of conservative treatment. Surgical treatment options should be individualized, depending on the extent of disease.

Resection arthroplasty of the CMC joint is the gold standard for surgical treatment of thumb CMC OA.⁶ In one small study (n=24), researchers found that 90% of patients were satisfied with the outcome after 15 years.¹² There are numerous surgical alternatives, however, and research addressing resurfacing, synthetic implants, and spacer materials is ongoing.⁶

FAST TRACK

Surgical repair of de Quervain’s tenosynovitis has a “cure rate” of >90%.

Trigger thumb: Swelling, pain, limited motion

TT, also known as stenosing tenosynovitis, is characterized by swelling, limitation of thumb range of motion, and a “catching” sensation when the thumb is flexed. Pain is usually referred to the first dorsal compartment of the hand. The primary pathology is thickening of the A1 pulley, with resultant entrapment of the flexor tendon, thus forming a triggering mechanism.¹³

Early treatment leads to better response
Conservative treatment options for TT include splinting and corticosteroid injection; NSAIDs alone have not been found to provide any benefit.¹⁴ One study found that corticosteroid injection followed by splinting in 10° to 15° flexion for 3 to 12 weeks relieved symptoms for 66% of those with any trigger digit—but only 50% of patients with TT reported an improvement in symptoms.¹⁵

Overall, patients with TT symptoms for <4 months have been found to respond significantly better to any treatment (P=.01).¹⁶ This finding may be related to repeat injury to the tendon sheath, which leads to chronic inflammation and permanent sheath hypertrophy and scarring,¹⁶ and highlights the importance of early diagnosis and treatment.

Limited research has been done on the effect of corticosteroid injection alone on TT. Maneerit et al performed a prospective study (n=115) comparing steroid injection alone with percutaneous release combined with corticosteroid injection, and found that the injection alone was successful in improving symptoms in 47% of patients.¹⁷ (The combination of percutaneous release and steroid injection, discussed below, had a much higher success rate.)

A retrospective study of treatment for trigger digits demonstrated significant improvement with corticosteroid injection in patients who did not have diabetes; 52% had full resolution and 47% had improvement in symptoms (P=.04).¹⁸ In contrast, corticosteroid injection led to symptom resolution for only 32% of patients with diabetes.

FAST TRACK

Early diagnosis and treatment of trigger thumb is important, as repeat injury leads to chronic inflammation and permanent hypertrophy and scarring of the tendon sheath.

Surgery for TT: Percutaneous or open release
Surgical treatment options for TT include percutaneous or open release. Complications of surgical intervention for trigger digits include infection, digital nerve injury, scarring, tenderness, and joint contractures. Nimigan et al reported a 99% improvement in symptoms and return to activity with open surgical release for patients with TT (n=72).¹⁸

In the study by Maneerit et al cited earlier, percutaneous release combined with corticosteroid injection had a success rate (indicated by decreased pain and triggering) of 91%, vs a 47% response rate for the group who received corticosteroid injection alone (P=.001).¹⁷ In another study, 25 patients with TT that had failed to respond to conservative treatment underwent percutaneous release. The result: An 84% success rate, as shown by a decrease in reported pain on a visual analog scale (P<.001), with no digital nerve damage reported.¹³

Digital nerve damage is more of a concern with percutaneous release than with open release, because of the proximity of the digital nerves to the A1 pulley.¹³ Success rates for percutaneous release vary from 38% to 100%, with improvement shown after appropriate physician training.¹³

Nontraumatic thumb pain: A bottom line treatment guide

de Quervain’s tenosynovitis. Initially, corticosteroid injection has been found to be the most appropriate first-line treatment for dQT;^1,4,5 the addition of an oral nonsteroidal anti-inflammatory drug (NSAID) does not result in any additional benefit.⁵ What’s more, oral NSAIDs and thumb splinting are not effective.³ Overall, surgical repair has demonstrated the greatest success, but it is invasive and costly.^1,4

First carpometacarpal osteoarthritis. There are few valid clinical trials for CMC OA. The available evidence, however, suggests starting with NSAIDs and progressing to splinting and physical therapy, as needed. Corticosteroid injections provide no long-term pain relief.^10,11 As with osteoarthritis in general, surgery for CMC OA is usually reserved for patients who fail to respond to conservative treatments.

Trigger thumb. There are various methods and levels of success for trigger digit treatment, but few studies specifically examining treatment of TT. The evidence suggests starting with conservative treatment—corticosteroid injection and splinting—in patients who are opposed to surgery.¹⁵ Both open and percutaneous surgical release of TT have high success rates, however, and can be offered at any time.¹³