375 OSTEOARTHRITIS OF THE TRAPEZIOSCAPHOID JOINT A. CAROLINE PATTERSON Isolated osteoarthritis (OA) of the trapezioscaphoid (TS) joint is little recognized. Nine cases that were examined clinically and radiologically are described. Of these 4 had isolated TS OA, 3 also had generalized OA, and 2 also had rheumatoid arthritis. Symptoms and signs, including pain in the wrist and thumb base, radial and volar swelling, and tenderness over the scaphoid, allowed distinction from other causes of pain at the thumb base. A wrist-working splint was beneficial in relieving pain. Degenerative arthritis (OA) of the trapezio scaphoid (TS) joint as a symptomatic isolated carpal lesion has been largely unrecognized. In contradistinction, degenerative arthritis of the first carpometacarpal (CM) joint is a well-recognized condition (1) that may present as an isolated lesion on one or both sides (2) or may be one of many joints affected in primary generalized OA, with or without Heberden's and/or Bouchards nodes (3). Carstam et a1 (4) de- scribe TS OA in 15 of a series of 48 patients presenting with volar wrist swelling. Twelve had TS OA only and 3 also had first carpometacarpal joint OA. In several patients the volar wrist swelling was thought to be a ganglion, but arthrographic studies revealed a communication between the TS joint and the peritendinous space of the flexor carpi radialis tendon, suggesting that the observed swelling was in fact synovial in origin. Sims and Bentley (5) state that a considerable proportion of patients with first CM OA also had arthritis in the TS joint and occasionally in the remaining joints of the carpus, and Sharp (6) notes that if TS OA coexists with first CM OA the symptoms of the former are obscured by those of the latter, but he does not mention isolated TS OA. This paper presents 9 cases in which the presence of OA in the TS joint on one or both sides was radiologically observed. The patients were assessed clinically by the author, and all had standard wrist and hand radiographs taken. From the Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British CASE REPORTS Columbia, Canada; and The Arthritis Centre, B.C., Division of Case 1. This 59-year-old tailoress complained of pain The Canadian Arthritis and Rheumatism Society, Vancouver, about the velar aspect of the right wrist and as a British Columbia, Canada. changed her occupation. On examination there was slight A' Patterson' M'B'. M'RCP' (London!' swelling on the radial side of the volar aspect of the wrist F.R.C.P.(C).: Division of Rheumatology, Department of Medicine, University of British Columbia. joint, pressure on which reproduced pain, as did pres- Address reprint requests to Dr. A. Caroline Patterson, Sure in the snuff box. 895 West 10th Avenue, Vancouver, B.C. V5Z 1L7, Canada. Submitted for publication August 29, 1974; accepted X-ray (Figure 1) showed narrowing and sclerosis of the right TS joint and an osteophyte on the lateral aspect December 4, 1975. of the trapezium. Arthritis and Rheumatism, Vol. 18, No. 4 Uuly-August 1975)
376 PATTERSON Fig 1. Case 1. Close-up of right wrist, showing osteoarthritis of trapezioscaphoid joint. A wrist-working splint relieved the pain. Case 2. This 53-year-old female typist complained of pain in both wrists, aggravated by manual activity, interfering with her work, and becoming worse when she employed a power grip. Examination showed tenderness in the anatomical snuff box and over the proximal skin crease of the wrist on the radial side; pain was reproduced by force flexion and extension of the wrist. X-ray showed bilateral narrowing and sclerosis of the TS joint. A working splint was provided for the right wrist and was helpful. Case 3. This 56-year-old female shop clerk, first seen in 1971, complained of pain in both wrists, worse on the left. She had also noticed some weakness of grip and had to change her job. She was seen again in 1974 and then stated that she had pain in the distal interphalangeal joints, that some functions were impaired, and that she had trouble opening jars and cans. No swelling of the wrist was noted. On examination in 1974 both wrists were tender over the proximal skin crease of the wrist on the radial side and in the anatomical snuff box. There was no swelling and the web space was normal. X-ray showed narrowing of the TS joint on the right and narrowing and sclerosis with a minor osteophyte on the left. A working splint was provided but the patient found it cumbersome. Fig 2. Case 5, left side. OA of PIPS, DIPS, first CM, and TS joints. Case 4. This 55-year-old housewife complained of generalized aches and pains and of wrist pain. On examination she had signs slightly suggestive of first carpometacarpal (first CM) joint OA on both sides, but there was tenderness over the left scaphoid bone. X-ray showed narrowing and sclerosis only of the left TS joint. Case 5. This right-handed sedentary male worker who had never challenged his hands presented in 1973 complaining of.pain in the wrists and hands for 1 year. The pain was chieflly in the PIP and DIP joints and he specifically denied wrist pain. On examination there was bony thickening characteristic of OA of the DIP joints and also of the long finger PIP joint on either side. Extension and abduction of the thumbs were reduced, and clinically there was OA of the left first CM joint. X-ray (Figure 2) showed narrowing, sclerosis, and bony proliferation of the DIP and PIP joints bilaterally. The right first CM joint and TS joint appeared normal;
OSTEOARTHRITIS OF THE TRAPEZIOSCAPHOID JOINT 377 Fig 3. Case 9. Erosions at both long finger PIP joints. Narrowing and sclerosis of left TS joint. on the left the first CM joint and the TS joint were narrowed and sclerotic and there were marginal osteophytes at the contiguous surfaces of the TS joint. Case 6. This 73-year-old female housewife complained of inability to lift heavy objects because of bilateral wrist pain and had also noted painless deformity of the hands. The pain was felt equally throughout both wrists and also at the base of both thumbs. On examination she had Heberden's and Bouchard's nodes, obvious first CM OA on both sides, and reduction in extension and abduction of the thumb. Tenderness was present over the proximal wrist crease at the radial side of the wrists and in the anatomical snuff box and there was slight swelling on the volar aspect of the wrists, which appeared to be soft tissue in origin. There was also tenderness of the first CM joint and power grip was weak bilaterally. X-rays showed OA of all the DIP joints, and gross OA of both first CM joints with subluxation of the first metacarpal on the left. There was narrowing and sclerosis of the TS joint on both sides. Wrist-working splints were provided but the patient found them uncomfortable. Case 7. This 67-year-old female housewife previously known to have OA of the cervical and lumbar spines com- plained of pain all over the body. She also complained of soreness of her DIP joints for some years but had no specific wrist complaints. On examination she had obvious OA in all the DIPs and some PIPs. Right wrist extension was limited to 35' and tenderness was noted on the volar aspect, radial side. X-ray showed OA of all the DIP joints with less marked changes in the PIP joints and marginal sclerosis about the first CM joint on both sides. Both TS joints showed gross narrowing and sclerosis of the articular surfaces. There was an osteophyte on the lateral border of the trapezium on the left side. Case 8. This 67-year-old female housewife had had generalized joint pain since 1940, when a diagnosis of rheumatoid arthritis was made. In 1974 she complained of pain in her hands and wrists for many years with recently noted deformity at the base of the thumb, and also difficulty in turning taps, opening jars, and carrying out her housework. On examination she had obvious OA of the hands, including the PIPS, DIPs, and both first CM joints. There was loss of web space on the left, but no wrist tenderness or swelling. X-ray showed no features of rheumatoid arthritis, but obvious OA in the PIP and DIP joints, and also of the
378 PATTERSON Table 1. Clinical Details of 9 Patients with Osteoarthritis of the Trapexioscaphoid Joint OA TS OA 1st CM Joint Joint OA DIPS Case Sex Age R L R L R L RA 1 F 59 - - - 2 F 53-3 F 56 + 4 F 55 - - 5 M 61 - - 6 F 73 7 F 67 + + 8 F 67 + + + 9 M 52 - + - - - - - - - - - - - - + Possible - - - Definite first CM joints. There was gross narrowing and sclerosis of the TS joint on the left side only. Case 9. This 52-year-old self-employed decorator had had rheumatoid arthritis since 1964, affecting chiefly his feet and hands. He had had no complaints of wrist pain until he noticed some swelling on the volar aspect of the right wrist 2 months prior to examination. The swelling was in the center of the wrist. On examination the right and left index finger PIP joints were swollen and warm, rompatible with rheumatoid arthritis. The right wrist showed mild volar tenosynovitis. There was no swelling on the radial side. The left wrist showed no swelling or tenderness but tenderness in the anatomical snuff box on that side. X-rays (Figure 3) of the hands and wrists showed erosions typical of rheumatoid arthritis on the left and right long finger PIP joints. There was narrowing and sclerosis of the left TS joint, but no other degenerative change. DISCUSSION Nine patients are presented, all of whom have radiologic evidence of OA of the TS joint in one or both wrists. They fall into three groups (Table 1): I. OA of the TS joint only. 11. OA of the TS joint plus OA in other areas. 111. OA of the TS joint plus or minus OA in other areas, plus diagnosed rheumatoid arthritis. The average age of the 9 patients was 61 (range: 52-73), and there were 7 women and 2 men. Symptoms ranged from virtually no symptoms to wrist pains severe enough to warrant change of occupation (Cases 1 and 3). In Group I, patients with isolated TS OA, wrist pain was the presenting feature, sometimes associated with intermittent volar swelling. The pain was worse on using the hand and wrist, particularly when employing the power grip, which they noted to be weak. Signs included tenderness over the radial aspect of the wrist on the volar surface, and particularly at the level of the proximal skin crease, but not at the base of the thumb as in first CM joint OA. Tenderness could also be elicited by pressure over the scaphoid bone in the anatomical snuff box. In 2 cases slight but definite swelling of the volar aspect, radial side of the wrist, was noted and in all patients the grip was weak. In no case was there any clinical evidence of De Quervain s disease. Radiologic abnormalities in these Group I patients were confined to one or both TS joints. They included joint space narrowing, juxtaarticular sclerosis, and osteophytes on the trapezium and/or scaphoid bone. In Case 9 erosions typical of rheumatoid arthritis were seen at the PIP joints, and changes compatible with osteoarthritis at the left TS joint, but no evidence of osteoarthritis in any other joint in the hand or carpus. Treatment in the symptomatic patients included advice about ex. cessive use of the wrist, heat, and the provision of a working splint. Working splints were useful in re. lieving pain during hand activities. These simple measures proved adequate in the short period ol followup. The clinical features of patients in Group I1 were typical of diffuse osteoarthritis of the hands and carpal area and included pain in the DIPS, PIPS, and the first CM joint. Group 111 patients had additional features typical of rheumatoid arthritis. Generally pa tients in Groups I1 and 111 did not complain specifi. cally of wrist pain or in fact denied it on questioning The etiology of OA is the subject of muck speculation. TS OA has received little attention anc its cause is unknown. It has been suggested that T! OA and volar wrist ganglion are related condition! (4). Two of the patients had such swellings, bu, neither arthrograms nor excision of the swelling wa: performed and thus no comment is possible. Murle! (7) suggests that if CM arthritis is associated wit1 TS OA rheumatoid arthritis should be considered. 11 Group I1 patients there was no evidence of rheuma
OSTEOARTHRITIS OF THE TRAPEZIOSCAPHOID JOINT 379 toid arthritis. In the 2 patients in Group I11 the arthritis in the TS joint had all the radiologic features of degenerative disease. One patient in Group I when followed up in 3 years was then complaining of pain in the distal interphalangeal joints, but there were no radiologic changes of osteoarthritis in those joints. Thus in the nine cases TS arthritis did not appear to be of rheumatoid type. However, the patients have not yet been followed on a long-term basis. Sims and Bentley (5), discussing the operative treatment of carpometacarpal joint OA, noted that out of 33 patients 18 (52%) had in addition some degree of arthritis in the TS joint. It seems unlikely that isolated TS OA is as rare as its virtual absence from the literature would suggest, and one should be aware of its existence and know that it may co-exist with first CM joint OA and with rheumatoid arthritis, and should distinguish it from other causes of pain in the wrist, such as isolated first CM OA and De Quervain s disease. ACKNOWLEDGMENTS The author is grateful to Dr. H. S. Robinson for advice throughout the preparation of this report; to the Department of Biomedical Communication, University of British Columbia, for the photographs; and to Dr. G. E. Price and Dr. L. H. Truelove, who kindly referred patients for study. REFERENCES 1. Lasserre C, Pauzat D, Derennes R: Osteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg 31B358.4-536, 1949 2. Gervis WH: Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg 31B: 537-539, 1949 3. Kellgren JH, Moore R: Generalized osteoarthritis and Heberden s nodes. Br Med J 1:181, 1952 4. Carstam N, Eiken 0, Andrbn L: Osteoarthritis of the trapezio-scaphoid joint. Acta Orthop Scand 39:354-358, 1968 5. Sims CD, Bentley G: Carpometacarpal osteo-arthritis of the thumb. Br J Surg 57:442448, 1970 6. Sharp J: Osteoarthritis, Textbook of Rheumatic Diseases. Fourth edition. Edited by WSC Copeman. Edinburgh & London, E & S Livingstone Ltd, 1909, 385-427 7. Murley AHG: Carpometacarpal osteoarthritis of the thumb. Lancet 2312, 1970