31yo M with chronic basilar thumb and wrist pain that started after cross-country bicycle ride 5 yrs ago.

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Transcription:

31yo M with chronic basilar thumb and wrist pain that started after cross-country bicycle ride 5 yrs ago.

EPL EPB APL Full-thickness tear involving the dorsal deltoid ligament of the first carpometacarpal joint, involving the dorsal radial, dorsal central, and posterior oblique ligaments.

Thumb Trapeziometacarpal Joint Shallow saddle joint with biconcave-convex shape Concave distal trapezial surface in coronal plane (radioulnar) Convex in sagittal plane (dorso-volar) Incongruent in resting position Stable and congruent in final phase of thumb opposition Wide range of motion Flexion/extension (coronal) Abduction/adduction (sagittal) Circumduction Opposition Coronal http://radsource.us/thumb-carpometacarpal-joint/ Sagittal Stability derived from capsuloligamentous complex

Injury to Thumb Trapeziometacarpal Joint Thumb CMC is oriented along longitudinal compression axis of thumb, predisposing to OA and trauma. CMC1 is the second most common site of osteoarthrosis in the hand (after DIP). Isolated CMC1 dislocation is rare (<1% hand injuries) Usually involves near/complete tear of dorsal ligaments and partial tearing of AOL CMC1 dislocation usually accompanied by MC1 base fracture (Bennett fx, Rolando fx) https://radiopaedia.org/articles/bennett-fracture-dislocation

Ligaments of the Thumb Trapeziometacarpal Joint Dorsal Deltoid Ligament Dorsoradial ligament (DRL) Dorsal central ligament (DCL) Posterior oblique ligament (POL) Anterior oblique ligament (AOL) Superficial Deep Intermetacarpal Ligament (IML) Ulnar collateral ligament (UCL) Ligament laxity and joint hypermobility predispose to pain, joint incongruity, effusion, cartilage erosion, and subluxation

Dorsal Deltoid Ligament Capsular ligaments Best evaluated on sagittal plane DRL Origin: dorsoradial tubercle of trapezium Insertion: broadly onto dorsal edge of MC1 base Located adjacent to dorsal side of abductor pollicis longus tendon DCL and POL Origin: dorsal side of trapezium, adjacent and ulnar to DRL Insertion: dorsal and ulnar aspect of MC1, share insertion with IML DCL is deep to extensor pollicis brevis tendon POL is deep to extensor pollicis longus tendon http://radsource.us/thumb-carpometacarpal-joint/

Dorsal Deltoid Ligament Thick, organized collagen bundles Primary restraint to dorsal dislocation of CMC1 joint Has sensory innervation for proprioception, most numerous about metacarpal insertion

Anterior Oblique Ligament Bested evaluated on sagittal images http://radsource.us/thumb-carpometacarpal-joint/ saol Capsular ligament Origin: volar tubercle of trapezium, 0.5mm proximal to articular surface Insertion: broad, 2mm distal to articular margin of volar styloid process of MC1 Curtain-like, courses over volar tubercle of MC1 Located immediately deep to thenar musculature daol Intracapsular ligament A.k.a. beak ligament Origin: articular margin of trapezium at volar central apex Insertion: articular margin of MC1 base, just ulnar to volar styloid process Located deep to saol Cardoso AJR 2008

Anterior Oblique Ligament Thin, membranous, disorganized connective tissue with sparse collagen fibers and hypocellularity Prevents volar metacarpal subluxation, less important than dorsal deltoid ligament

Intermetacarpal Ligament (IML) Extracapsular ligament Origin: dorsoradial aspect of MC2, radial to insertion of extensor carpi radialis longus tendon Insertion: volar-ulnar tubercle of MC1 base Bested evaluated on sagittal images Resists radial translation of first metacarpal http://radsource.us/thumb-carpometacarpal-joint/

Ulnar collateral ligament (UCL) Extracapsular ligament Origin: distal and ulnar margin of trapezial ridge at flexor retinaculum insertion Insertion: volar-ulnar tubercle of MC1 base, superficial and ulnar to saol, slightly overlaps saol Bested evaluated on coronal images Cardoso AJR 2008 Resists extension and abduction

Acute tear of AOL usually occurs at metacarpal insertion (arrow) Acute tear of dorsal ligaments usually occurs at trapezial attachment (asterisk) http://radsource.us/thumb-carpometacarpal-joint/ Associated findings Periosteal stripping of metacarpal attachment (AOL) Subcortical bone contusion or avulsion fracture Adjacent soft tissue hematoma Dorsoradial subluxation of thumb CMC due to abductor pollicis longus tendon

AOL degeneration is a primary factor in development and progression of thumb CMC osteoarthrosis. Distal retraction of fibrocartilaginous insertion of AOL at MC1 base Volar synovial recess enlarges Osteophytosis Ganglion cyst formation Periosteal stripping and eventual detachment of AOL attachment Dorsal subluxation of MC1 Cartilage loss from volar to diffuse http://radsource.us/thumb-carpometacarpal-joint/

References 1. Cardoso FN, Kim HJ, Albertotti F, Botte MJ, Resnick D, Chung CB. Imaging the ligaments of the trapeziometacarpal joint: MRI compared with MR arthrography in cadaveric specimens. AJR Am J Roentgenol. 2009 Jan;192(1):W13-9. 2. http://radsource.us/thumb-carpometacarpal-joint/ 3. Hirschmann A, Sutter R, Schweizer A, Pfirrmann CW. The carpometacarpal joint of the thumb: MR appearance in asymptomatic volunteers. Skeletal Radiol. 2013 Aug;42(8):1105-12.

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