An Evaluation of Variations in the Carpal Tunnel Dimensions of Adult Subjects in a Hospital-Based Population: An Ultrasonographic Cross-Sectional Study

Background The carpal tunnel is a groove that spans the palm as a 'U.' The ulnar and radial sides of the wrist are made up of the scaphoid tubercle and trapezium while the palmar aspect is made up of carpal bones. Our study aimed to see whether there were differences in carpal tunnel size between men and women. Material and methods The study was conducted on 65 healthy adults, 13 (20%) were males and 52 (80%) were females (both non-pregnant and pregnant). Inclusion criteria were healthy adults and bilaterally symmetrical limbs. Exclusion criteria were chronic disease, diabetes, hypertension, immunological disorders, any visible abnormalities, and a history of upper extremity pain on either side. A high-resolution ultrasound machine with a linear transducer was used to perform an ultrasound scan of the carpal tunnel. The anteroposterior dimension was measured at the midline, or along the axis of the middle finger, and the transverse diameter was measured at the midpoint of the flexor retinaculum. The cross-sectional area of the tunnel was measured at its largest diameter within the carpal tunnel. All the dimensions were measured in centimeters. Results The mean transverse diameter of the right side was 1.824 ± 0.223 cm (p-value 0.002) and of the left side was 1.742 ± 0.197 cm (p-value 0.004). The mean cross-sectional area of the carpal tunnel on the right side was 1.417 ± 0.379 cm2 (p-value 0.008) and on the left side was 1.306 ± 0.303 cm2 (p-value 0.004), respectively. Age, sex, weight, and BMI were discussed. The carpal tunnels of females were found to be comparatively squarer and smaller than those of males. Conclusion The transverse diameter and cross-sectional area of the carpal tunnel and their correlation with carpal tunnel syndrome are predicted by age, sex, weight, and BMI. Both sexes had the same wrist ratio.

The Role of the Flexor Carpi Radialis Groove in Trapeziometacarpal Osteoarthritis

BACKGROUND

Thumb carpometacarpal (CMC) osteoarthritis (OA) is a common condition. The contribution of surrounding ligaments and tendons to the stability of the CMC joint is likely altered in OA. The flexor carpi radialis (FCR) tendon runs in the trapezial FCR groove and is often noted to be frayed during CMC arthroplasty. We hypothesized that decreased integrity of the FCR tendon is related to FCR groove morphology and is associated with increased severity of CMC OA.

METHODS

We examined 3-dimensional surface models based on computed tomography (CT) scans of explanted trapezia from patients who underwent thumb CMC arthroplasty. Fraying of the FCR tendon was rated intraoperatively. Measurements were taken of the FCR groove to evaluate its morphology. Preoperative thumb CMC radiographs for each patient were scored using the modified Eaton classification system and the Thumb Osteoarthritis Index. Differences in the tendon groups were examined, and multivariable linear regression models were used to test the association between tendon group and FCR groove measurement.

RESULTS

There were 136 patients who were categorized into 4 tendon groups: intact, minor fraying, fraying, and ruptured. There were no differences between the tendon groups on any measures.

CONCLUSIONS

Our findings do not demonstrate a significant influence of FCR groove morphology on FCR tendon fraying in CMC arthroplasty patients. We also did not find a significant association between the FCR tendon state and degree of radiographic CMC OA. Further studies should investigate the in vivo FCR tendon to evaluate its tearing and inflammation in relation to basilar thumb pain.

Osteoid Osteoma of the Trapezium: A Rare Case Report and Literature Review

Osteoid osteoma is the most common benign osteogenic bone neoplasm. Osteoid osteomas are typically located in the metaphysis and diaphysis of long bones, especially the tibia and femur. However, less common sites of the skeleton can be affected as well, including carpal bones. Among carpal bones, the scaphoid and the capitate are the most affected. Osteoid osteoma of the trapezium is an extremely rare entity, with only seven cases reported in recent literature. We present a case of a 29-year-old male with persistent left wrist pain who was diagnosed with an osteoid osteoma of the trapezium bone. The diagnosis was based on the patient's history, clinical examination and findings from the CT scan, MRI, and plain radiographs. The patient was treated with an excision biopsy with no additional bone grafting. After a follow-up period of 12 months, no pain or signs of recurrence were present. We conducted a literature review to elucidate the clinical presentation as well as the proper diagnostic tools and therapeutic methods for this rare occurrence.

Arthroscopic Reduction and Internal Fixation for Peritrapezium Traumatic Axial Carpal Dislocation: A Case Report

Axial carpal dislocations and fracture-dislocations are rare injuries involving derangement of the carpal arches. Several surgical approaches have been reported as a means of treatment, including the use of closed or open reduction and internal fixation. However, to our knowledge, surgical treatment using arthroscopy has not been reported so far. Here we present the case of a 54-year-old man who experienced peritrapezium axial carpal dislocation while reversing his car. Minimally invasive surgery using arthroscopy was performed because of severe swelling of the hand. Reduction under arthroscopic assistance using midcarpal portals was performed based on the relationship between the trapezium and trapezoid, and fixed wires were inserted. Wires were removed at six weeks postoperatively, and range-of-motion exercises of the wrist joint were started. At one-year postoperative follow-up, the patient was asymptomatic, with no difficulties while performing daily activities and work. Computer tomography images revealed an anatomical carpal arch without traumatic arthrosis. Arthroscopy-assisted surgery enabled us to anatomically reduce fracture-dislocation of the trapezium and assess the injury path.

Cross-sectional changes of the distal carpal tunnel with simulated carpal bone rotation

This study simulated the cross-sectional changes in the distal carpal tunnel resulting from inward rotations of the hamate and trapezium. Rotations which decreased the carpal arch width, increased the carpal arch area. For example, simultaneous rotation of 5 degrees around the hamate and trapezium centroids decreased the carpal arch width by 1.69 ± 0.17 mm and increased the carpal arch area by 6.83 ± 0.68 mm2. Although the bone arch area decreased, decompression of the median nerve would likely occur due to the adjacent location of the nerve near the transverse carpal ligament.

An Anatomical Evaluation of the Trapezium and Its Relationship to Basilar Joint Osteophytic Change

BACKGROUND

To perform a comprehensive osteologic investigation into trapezium anatomy and investigate the relationship between anatomical factors and osteophyte formation, focusing on sex-specific differences.

METHODS

This was a cadaveric study involving 1233 trapezia and first metacarpals. Two subgroups ("Control" and "Main Study") were established. The "Control" cohort was used to identify features of the trapezium in specimens devoid of osteophytic change. The prevalence and severity of osteophytic change were investigated in the "Main Study" cohort. Sex differences were specifically assessed. Regression analyses were used to identify factors associated with osteophyte formation.

RESULTS

Three discrete surface morphologies exist at the trapezium trapeziometacarpal (TM) facet: heart, quadrilateral, and bean. Controlling for height, men have a larger trapezium TM facet surface area. However, the trapezium assumes the same off-center saddle shape in both sexes. The presence of osteophytes at the basilar joint is a common finding; no differences in osteologic prevalence exist between sexes. The progression of osteophytic change complements the radiographic Eaton-Littler classification system. The trapezium TM facet increases the surface area with incremental osteophyte involvement, with the degree of surface area expansion correlated with increases in the severity of osteophytic change. Increased age, increased surface area, bean morphology, and decreased volar joint depth are associated with more severe osteophyte formation.

CONCLUSIONS

Anatomical features of the trapezium may contribute to osteophyte development. Although the prevalence of osteophytic disease appears equal between sexes, sex differences exist in some anatomical parameters. These differences may help explain the increased prevalence of symptomatic basilar joint disease in women.

[Pain In the Thumb and Other Fingers]

Pain In the Thumb and Other Fingers Abstract. As the population ages, symptoms of osteoarthritis in the hand are seen with increasing frequency. It can lead to substantial pain, physical disability and impair the patient's capacity to work in a population with an increasing retirement age. This article gives an overview about the most prevalent forms of osteoarthritis in the hand, its diagnosis and current treatment options, stressing that the multimodal form of therapy is the most effective.

Osteosarcoma of the Trapezium

Osteogenic sarcoma is a malignant tumor that rarely affects the hand. When it does, it most often involves the phalanges or metacarpal heads. We present the case of a 51-year-old woman with a low-grade osteosarcoma affecting the trapezium bone of her left hand. A total trapeziectomy with partial removal of the first metatarsal, scaphoid, trapezoid, and capitate bones was performed, and no adjuvant therapy was administered. Six years after the intervention, the patient is disease-free, with excellent functionality and yearly imaging tests showing no signs of recurrence.

The Uncommon Trapezium Fracture: A Case Series

Background  Isolated trapezium fractures are rare and account for only 1 to 5% of all carpal fractures but are still the third most common carpal fracture. Trapezium fractures are hard to detect and easily missed on standard radiographs. Trapezium fractures can be treated conservatively, as well as operatively, the best treatment is still debatable. Damage of the joint surface between the trapezium and the base of the first metacarpal or scaphoid could cause pain and restriction of movements. Therefore, it is important to diagnose and treat the fracture at early stage, so that articular congruence is guaranteed. Case description  We present four cases of the uncommon trapezium fracture. All four cases are conservatively treated with good results, there was no need for operative treatment in all the cases. Literature review  The literature describes the possibility to use fixation techniques, only when it is not possible to reduce the displaced fracture or the residual articular step-off is too high a fixation technique should be used. Clinical relevance  Primarily, we would recommend navicular cast immobilization for 4 to 6 weeks as initial treatment.

The Trapezium Dislocation: Case Presentation, Review of the Literature, Radiographic Analysis, Proposed Classification, and Treatment

BACKGROUND

Trapezium dislocations are rare injuries.

METHODS

A PubMed search of the term "trapezium dislocation" was conducted. Publications reporting a complete trapezium dislocation were included in the review.

RESULTS

The PubMed search resulted in 168 results. Fourteen publications reporting on 16 complete trapezium dislocations met inclusion criteria. A case of delayed diagnosis of a trapezium dislocation is presented. The literature is reviewed for pertinent clinically relevant information with respect to trapezium dislocations. A systematic method for radiographic analysis of trapezium dislocations and classification are described, and a treatment algorithm is presented.

CONCLUSIONS

Trapezium dislocations are infrequent injuries with few cases reported in the literature. Given the rarity of this injury, diagnosis and appropriate treatment may be delayed due to difficulty in recognition. Using the described method of radiographic analysis, delayed diagnosis may be avoided with implementation of timely treatment.

Gastric cancer initially presenting as bone metastasis: Two case reports and a literature review

Gastric cancer frequently spreads to the regional lymph nodes, liver and lungs following surgery or late in the clinical course. However, an initial clinical presentation of bone metastasis in gastric cancer patients is relatively rare. The current study presents two cases of gastric cancer diffusely metastasized to the spinal vertebrae and with a single metastasis to the trapezium, respectively. The initial presentations were an increased alkaline phosphatase level without any symptoms associated with bone metastasis in the first case and a swelling in the right carpometacarpal joint of the thumb in the second case. These clinical manifestations are also extremely rare in gastric cancer with bone metastasis. The study emphasizes that a diagnosis of gastric cancer should be considered in patients with increased alkaline phosphatase without clinical symptoms or with a single bone metastasis.

Trapezium Bone Density-A Comparison of Measurements by DXA and CT

Bone density may influence the primary fixation of cementless implants, and poor bone density may increase the risk of implant failure. Before deciding on using total joint replacement as treatment in osteoarthritis of the trapeziometacarpal joint, it is valuable to determine the trapezium bone density. The aim of this study was to: (1) determine the correlation between measurements of bone mineral density of the trapezium obtained by dual-energy X-ray absorptiometry (DXA) scans by a circumference method and a new inner-ellipse method; and (2) to compare those to measurements of bone density obtained by computerized tomography (CT)-scans in Hounsfield units (HU). We included 71 hands from 59 patients with a mean age of 59 years (43–77). All patients had Eaton–Glickel stage II–IV trapeziometacarpal (TM) joint osteoarthritis, were under evaluation for trapeziometacarpal total joint replacement, and underwent DXA and CT wrist scans. There was an excellent correlation (r = 0.94) between DXA bone mineral density measures using the circumference and the inner-ellipse method. There was a moderate correlation between bone density measures obtained by DXA- and CT-scans with (r = 0.49) for the circumference method, and (r = 0.55) for the inner-ellipse method. DXA may be used in pre-operative evaluation of the trapezium bone quality, and the simpler DXA inner-ellipse measurement method can replace the DXA circumference method in estimation of bone density of the trapezium.

Comminuted Fracture of the Body of the Trapezium and Thumb Carpometacarpal Dislocation: A Particular Pattern

Trapezium fractures are uncommon injuries. Our case is that of a thumb carpometacarpal joint dislocation associated to a partly comminuted fracture of the body of the trapezium. To the best of the authors' knowledge, this particular variation has not been previously reported in the indexed literature.

Massive trapezial metastasis from gastric adenocarcinoma resected and reconstructed with a vascularized scapular bone graft: A case report

RATIONALE

Isolated metastasis to the hand bones is very rare. Only seven cases of metastasis to the trapezium have been reported. To the best of our knowledge, this is the first report of a single metastasis to the trapezium from a gastric adenocarcinoma.

PATIENT CONCERNS

A 62-year-old man presented with pain and massive swelling in the right carpometacarpal joint of the thumb.

DIAGNOSES

The patient was diagnosed with trapezial metastasis of advanced gastric adenocarcinoma.

INTERVENTIONS

The patient underwent systemic chemotherapy with cisplatin and S-1, radiotherapy to the metastatic bone, and treatment with denosumab. One year later, the huge metastatic tumor was resected, and the hand was reconstructed using vascularized scapular bone.

OUTCOMES

Eighteen months postoperatively, the patient was satisfied with the appearance of the reconstructed hand and was able to use his right thumb in activities of daily living.

LESSONS

Although rare, metastasis to the trapezium should be considered in patients with persistent and progressive thumb CMC joint pain.

Thumb Metacarpal Subsidence After Partial Trapeziectomy With Capsular Interposition Arthroplasty: A Biomechanical Study

Background: In a cadaveric model, we evaluated thumb metacarpal subsidence, indicated by a decreased metacarpal-to-scaphoid distance, after 2 surgical procedures used to treat thumb carpometacarpal (CMC) osteoarthritis (OA): partial trapeziectomy with capsular interposition (PTCI), which involves removal of 2 mm of both the distal trapezium and base of the metacarpal; and total trapeziectomy with capsular interposition (TTCI). Methods: Nine matched pairs of cadaveric hands were randomly assigned to undergo either PTCI or TTCI. Preoperatively, physiologic forces were applied across the thumb CMC joint by loading 6 tendons, simulating lateral pinch. Anteroposterior radiographs were obtained, and the metacarpal-to-scaphoid distance on each image was estimated independently by 3 separate readers using customized software. A hand surgeon then performed the PTCI and TTCI procedures, and the measurements under loading were repeated. The results were assessed for interrater reliability. Mean values for metacarpal-to-scaphoid distance before and after the surgical procedures were compared. Results: Preoperatively, the metacarpal-to-scaphoid distance in the PTCI and TTCI groups was not significantly different. Postoperatively, metacarpal subsidence was significantly less in the PTCI group (17% compared with 34% for TTCI; P = .05). Conclusions: Metacarpal subsidence occurred after both PTCI and TTCI, but significantly less subsidence was observed after PTCI; thus, thumb length was better preserved. Previous research has shown an inverse correlation between maintenance of thumb length and overall Disabilities of the Arm, Shoulder, and Hand (DASH) score. A procedure for treating thumb CMC OA that preserves thumb length and minimizes disruption of stabilizing joint tissue may provide enhanced maintenance of thumb stability and improved patient outcomes.

First Carpo-metacarpal Joint Arthritis: Interpositional Arthroplasty using Trapezium

Thumb pain secondary to arthritis at the basal joint of the thumb is a common condition, especially in women, and can be quite disabling. An accurate diagnosis can be readily made from the history and examination. Reconstructive procedures for each stage of the disease are aimed at relieving pain and restoring thumb motion and strength. There are a number of methods available to treat this condition both conservatively and surgically with variable success rates. We present a case of a middle-aged female with first carpo-metacarpal (CMC) joint arthritis in whom we have tried a new technique in which the trapezium is excised, crushed, put in a sponge covering and then inserted back in the void created after excision. At the one-year follow-up, the patient was pain-free and had full range of thumb movement.

A comparative study of diagnostic and imaging techniques for osteoarthritis of the trapezium

OBJECTIVES

The aims of this study were to determine whether micro-CT is a reliable investigation method to evaluate the severity of OA in the trapezium and to develop a novel micro-CT scoring system based on a quantitative assessment of the subchondral bone thickness in order to better assess OA through an objective parameter.

METHODS

We compared different diagnostic and imaging techniques performed consecutively on each sample: X-ray, visual analysis, micro-CT and histology. OA and healthy trapezia were subjected to semi-quantitative and quantitative analyses to be classified in four degrees of severity in OA (control, OA-2, OA-3 and OA-4). Specifically, samples were analysed using Dell's score for X-ray, Brown's score for visual analysis and Mankin's score for histology. Micro-CT was scored using a novel quantitative scoring system based on subchondral bone thickness measurements. Results obtained with each technique were then compared and correlated.

RESULTS

X-ray analysis showed a higher frequency of OA-2 (27%) and OA-3 (32%) compared with OA-4 (5%), whereas visual analysis, micro-CT and histology showed a lower percentage for OA-2 (18%, 18% and 14%) and OA-3 (23%) and increased frequency for OA-4 (45%, 32% and 40%). Only the micro-CT score of subchondral bone thickness correlated significantly with all the other techniques (P < 0.05).

CONCLUSION

This is the first comparison of techniques proposing a novel scoring system based on objective and quantitative micro-CT data that can be applied as a useful diagnostic tool for OA, providing a deeper comprehension of the pathophysiology of OA in trapezium.

Sonography of trapezial ridge fractures

Trapezial ridge fractures are very rare. These can be a diagnostic challenge and one needs to have a high index of suspicion. We report two cases of trapezial ridge fractures that were diagnosed sonographically and confirmed by cross-sectional imaging (CT or MRI).

Carpal fractures

Carpal fractures are exceedingly rare clinical entities and are often associated with concomitant injuries. In this review, we focus on fractures of the carpus, excluding the scaphoid, and provide an update on the current consensus as to mechanism, diagnosis, management, outcomes, and complications after such injuries.

A three-dimensional analysis of osteoarthritic changes in the thumb carpometacarpal joint

The purpose of this study is to gain a better understanding of the changes due to osteoarthritis (OA) occurring in the thumb carpometacarpal (CMC) joint by comparing quantitative geometrical measurements in computed tomography scans of healthy and pathological joints in various stages of OA. The measurements were (1) the subluxation of the metacarpal on the trapezium, (2) distance from the scaphoid centre to the metacarpal base, and (3) distance from the metacarpal base to the articulating surface of the trapezium. The three-dimensional position of three characteristic points on the metacarpal, trapezium, and scaphoid were detected in each of the 90 wrists we scanned. The distances between the points were compared by statistical analysis. With high accuracy, we have been able to confirm and quantify that subluxation occurs in the dorso-radial direction. A significant difference in trapezium height and joint space width was found between the OA and control groups. The results indicate how to restore the centre of rotation in surgical treatment of OA with total joint arthroplasty, but the clinical relevance of these findings has to be tested in further clinical studies.

Trapezium trabecular morphology in carpometacarpal arthritis

PURPOSE

In thumb carpometacarpal osteoarthritis, current evidence suggests that degenerative, bony remodeling primarily occurs within the trapezium. Nevertheless, the pathomechanics involved and the most common sites of wear remain controversial. Quantifying structural bone morphology characteristics with high-resolution computed tomography CT (micro-CT) infer regions of load transmission. Using micro-CT, we investigated whether predominant trabecular patterns exist in arthritic versus normal trapeziums.

METHODS

We performed micro-CT analysis on 13 normal cadaveric trapeziums and 16 Eaton stage III to IV trapeziums. We computationally divided each specimen into 4 quadrants: volar-ulnar, volar-radial, dorsal-radial, and dorsal-ulnar. Measurements of trabecular bone morphologic parameters included bone volume ratio, connectivity, trabecular number, and trabecular thickness. Using analysis of variance with post hoc Bonferroni/Dunn correction, we compared osteoarthritic and normal specimen quadrant measurements.

RESULTS

No significant difference existed in bone volume fraction between the osteoarthritic and normal specimens. Osteoarthritic trapeziums, however, demonstrated significantly higher trabecular number and connectivity than nonosteoarthritic trapeziums. Comparing the volar-ulnar quadrant of osteoarthritis and normal specimens collectively, this quadrant in both consistently possessed significantly higher bone volume fraction, trabecular number, and connectivity than the dorsal-radial and volar-radial quadrants.

CONCLUSIONS

The significantly greater trabecular bone volume, thickness, and connectivity in the volar-ulnar quadrant compared with the dorsal-radial and dorsal-ulnar quadrants provides evidence that the greatest compressive loads at the first carpometacarpal joint occur at the volar-ulnar quadrant of the trapezium, representing a consistently affected region of wear in both normal and arthritic states.

CLINICAL RELEVANCE

These findings suggest that trapezial trabecular morphology undergoes pathologic alteration. This provides indirect evidence that changes in load transmission occur with thumb carpometacarpal joint arthritis development.

Extensor pollicis longus dysfunction associated with non-united fracture of the trapezium

A 26 year old man was referred to us with extensor pollicis longus dysfunction (EPL), and investigation revealed a fracture of the trapezium (left) and carpo-metacarpal joint dislocation of the thumb. Operative exploration revealed mechanical displacement of the tendon secondary to fracture dislocation of the trapezium as the cause for EPL dysfunction. The lesion was managed with an open reduction and screw fixation resulting in good functional outcome.

Combined dislocation of the trapezium and the trapezoid: a case report with review of the literature

Dislocation of the either the trapezium or the trapezoid are both rare injuries, even among carpal dislocations. We report a case of combined volar trapezium dislocation and dorsal trapezoid dislocation with other concomitant injuries. A review of the literature regarding trapezium and trapezoid dislocations as well as the treatment of these injuries is presented.

"Twist of the wrist" a rare case of carpal dislocation

A rare case of a scaphoid-trapezium dislocation is presented. The treatment was open reduction, ligament repair, and internal fixation with a Kirschner wire. After 4 weeks of immobilization, the Kirschner wire was removed, and full recovery was obtained 12 weeks after the trauma.

Surgical treatment of thumb carpometacarpal joint arthritis: a single institution experience from 1995-2005

There are numerous techniques for the surgical management of thumb carpometacarpal (CMC) joint arthritis. The four senior authors of this study employ three such techniques: trapeziectomy with hematoma distraction arthroplasty, hemitrapeziectomy with osteochondral allograft, and ligament reconstruction tendon interposition (LRTI). This study examines the three commonly utilized procedures at a single institution. This study examines the 10-year experience from 1995-2005 with a minimum 3-month follow-up. Disabilities of the arm, shoulder, and hand (DASH) scores, pre-and postoperative pinch strength, and operative time were examined. After approval from the institutional review board of our institution was obtained, all patients treated surgically by three of the senior authors were contacted via mail and phone. Each patient was asked to complete and return a DASH questionnaire. Of the 115 patients treated during that period, 60 participated in this study. Each patient's final postoperative pinch measurement was obtained from occupational therapy and clinic records. This pinch strength was compared to the preoperative pinch and contralateral pinch strength. Lastly, the total operative time for each procedure was obtained from the operative record. The only significant finding in this study was a shorter mean operative time with the trapeziectomy group (76.90 min) and osteochondral allograft group (90.45 min) when compared to the LRTI group (139.00 min; p = 0.001 and p = 0.001, respectively). We found no significant difference between groups in terms of DASH score and pinch strength. There was no difference between the techniques in terms of postoperative pinch strength and patient satisfaction measured by DASH scores. The operative times for trapeziectomy and hematoma interposition as well as the osteochondral allograft were significantly shorter than that of the LRTI. This presents further evidence that potentially, "less is more" in the treatment of thumb CMC arthritis. We used a retrospective study design to evaluate potential differences between the three surgical techniques described above, therapeutic, levels III-IV.

Management of combined open fractures of thumb metacarpal and trapezium (surgical tip)

Management of an unusual injury of combined open fractures of the first metacarpal shaft and trapezium due to crush injury in a 21-year-old man was reported in this paper. Surgical management included irrigation, debridement, and reduction of the first metacarpal fracture followed by external fixation extending from the first metacarpal to the distal radius and primary wound closure. After 1 year of surgery, follow-up functional and radiographic evaluations were satisfactory, and most of the daily activities were pain-free.