Journal of (European Volume) http://jhs.sagepub.com/

Pre- and post-operative comorbidities in idiopathic : cervical arthritis, basal arthritis of the thumb, and trigger digit J.H. Kim, H.S. Gong, H.J. Lee, Y. H. Lee, S.H. Rhee and G.H. Baek J Hand Surg Eur Vol 2013 38: 50 originally published online 2 May 2012 DOI: 10.1177/1753193412445441

The online version of this article can be found at: http://jhs.sagepub.com/content/38/1/50

Published by:

http://www.sagepublications.com

On behalf of: British Society for Surgery of the Hand

Additional services and information for Journal of Hand Surgery (European Volume) can be found at:

Email Alerts: http://jhs.sagepub.com/cgi/alerts

Subscriptions: http://jhs.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Dec 19, 2012

OnlineFirst Version of Record - May 2, 2012

What is This?

Downloaded from jhs.sagepub.com at UNIV PRINCE EDWARD ISLAND on October 27, 2014 JHS38110.1177/1753193412445441Kim et al.Journal of Hand Surgery (European Volume) 2012445441

JHS(E) Full length article

The Journal of Hand Surgery (European Volume) Pre- and post-operative comorbidities 38E(1) 50­–56 © The Author(s) 2012 Reprints and permissions: in idiopathic carpal tunnel syndrome: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193412445441 cervical arthritis, basal joint arthritis jhs.sagepub.com of the thumb, and trigger digit

J.H. Kim Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, South Korea

H.S. Gong, H.J. Lee, Y. H. Lee Department of Orthopaedic Surgery, Seoul National University College of , Seoul, South Korea

S.H. Rhee Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, South Korea

G.H. Baek Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Abstract We retrospectively reviewed 633 in 362 patients who had idiopathic carpal tunnel syndrome and underwent carpal tunnel release between 1999 and 2009. Electrophysiological studies and simple radiographs of the , cervical spine, and basal joint of the thumb were routinely checked, and patients were also assessed for the presence of trigger digit or de Quervain’s disease before and after surgery. Among 362 patients, cervical arthritis was found in 253 patients (70%), and C5-C6 arthritis was the most common site. Basal joint arthritis of the thumb was observed in 216 (34%) of the 633 hands. Trigger digit or de Quervain’s disease was observed in 85 of the 633 hands (13%) before surgery, and developed in 67 hands (11%) after surgery. Cervical arthritis, basal joint arthritis, and trigger digit commonly coexist with idiopathic carpal tunnel syndrome. Patient education about these disorders is very important when they coexist with idiopathic carpal tunnel syndrome.

Keywords Basal joint arthritis of the thumb, cervical arthritis, de Quervain’s disease, idiopathic carpal tunnel syndrome, trigger digit

Date received: 7th October 2011; revised: 18th March 2012; accepted: 22nd March 2012

Introduction

Carpal tunnel syndrome is the most common com- pain. Double crush syndrome is a general term that pressive neuropathy of the upper extremity. It fre- refers to the coexistence of dual compressive lesions quently affects women in the fifth or sixth decade of along the course of a nerve. The most common clinical life (Dawson, 1993; Mondelli et al., 2002). Trigger digit example of the double crush hypothesis is an is another common clinical disorder. The concurrence increased predisposition to carpal tunnel syndrome in of carpal tunnel syndrome and trigger digit has been patients with cervical radiculopathy. Several authors previously reported (Assmus, 2000; Harada et al., 2005; Hayashi et al., 2005; Hombal and Owen, 1970; Rottgers et al., 2009). Corresponding author: Goo Hyun Baek, Department of Orthopaedic Surgery, Seoul Cervical arthritis is a relatively common degenera- National University College of Medicine, 28 Yongon-dong, tive condition of the cervical spine that can cause sev- Chongno-gu, Seoul 110-744, South Korea eral symptoms such as neck, shoulder, and radiating Email: [email protected]

Downloaded from jhs.sagepub.com at UNIV PRINCE EDWARD ISLAND on October 27, 2014 Kim et al. 51

(Bednarik et al., 1999; Hurst et al., 1985; Kwon et al., checked. X-ray images were assessed by two radiolo- 2006; Upton and McComas, 1973) have reported the gists and two orthopaedic surgeons with more than concurrence of cervical arthritis and carpal tunnel 10 years of experience. They graded the degree of syndrome. apophyseal joint damage and intervertebral disc After the distal interphalangeal joint, the basal degeneration at every consecutive level of the cervi- joint of the thumb is the second most common site of cal spine from C2 to T1 according to the classification osteoarthritis in the hand. Basal joint arthritis of the system developed by Kellgren and Lawrence (1957). thumb usually occurs in patients over 50 years of age They also graded the degree of basal joint arthritis and has a female predominance. Armstrong et al. according to the classification described by Eaton and (1994) reported that the prevalence of basal joint Littler (1973). An assessment of whether patients had arthritis of the thumb in postmenopausal women trigger digit or de Quervain’s disease was also done. was 33%. The coexistence of basal joint arthritis and All operations were carried out by a single orthopae- carpal tunnel syndrome has also been reported dic surgeon using an open surgical technique under (Burton, 1986; Florack et al., 1992; Melone et al., local anaesthesia. Patients were routinely followed 1987; Sless and Sampson, 2007). up at 2 weeks, 6 weeks, 3 months, 6 months, and 12 In the present study, patients with idiopathic carpal months after surgery, and yearly thereafter. At every tunnel syndrome who underwent open carpal tunnel follow-up, an assessment was made for new cases of release were retrospectively reviewed. The objective trigger digit or de Quervain’s disease. Median dura- of the study was to evaluate the pre-operative occur- tion of follow-up was 36 (range 24–96) months. rence of cervical degenerative arthritis or basal joint arthritis of the thumb and the pre- and post-operative Statistical methods occurrence of trigger digit or de Quervain’s disease in patients with idiopathic carpal tunnel syndrome. The Chi-squared test was used to analyze differences in the post-operative occurrence rate of trigger digit or de Quervain’s disease according to age (< 60 or ≥ Methods 60), sex, and pre-operative presence of trigger digit or Demographic data de Quervain’s disease. A p value of < 0.05 was consid- ered statistically significant. We included all patients with idiopathic carpal tunnel syndrome who underwent open carpal tunnel release at our between August 1999 and July 2009. Results The Institutional Review Board of our hospital reviewed and approved this study. The inclusion crite- We enrolled 362 patients (633 hands) who had idio- ria were (1) a diagnosis of idiopathic carpal tunnel pathic carpal tunnel syndrome. Cervical degenerative syndrome on the basis of history, physical examina- arthritis was found in 253 patients (70%) on simple tion, and electrophysiological study, (2) open carpal radiographs. Among the 253 patients, cervical arthri- tunnel release, and (3) follow-up of more than 2 years. tis at one level was observed in 80 patients (32%) and Patients who had underlying diseases such as diabe- multilevel arthritis was found in 173 patients (68%). tes, hypothyroidism, , tuberculo- Among the 253 patients who had cervical degenera- sis, and neurologic diseases were excluded. Patients tive arthritis, 19 patients (7.5%) had neck pain and 115 who had malunited fractures of the distal radius were patients (46%) had radiating pain to the upper extrem- also excluded. ities. Cervical arthritis was most commonly observed Three hundred and sixty-two patients (37 men and at the C5-C6 level (Figure 1). Also, in nine patients 325 women) were enrolled in the present study. The electrophysiological studies were compatible with average age at time of surgery was 56.4 (SD 9.1) cervical radiculopathy. If the patient had cervical years. There were 271 patients (75%) with bilateral radiculopathy after carpal tunnel release, we first involvement and 91 patients (25%) with unilateral recommended physical and medications such involvement. as nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose tricyclic antidepressants, or gabapentin. If Clinical assessment the radiculopathy was refractory to the conservative treatments, we then recommended computed tomog- The presence of degenerative arthritis in the cervical raphy (CT) or magnetic resonance imaging (MRI), and spine and basal joint of the thumb was routinely referred the patient to the spine surgeon. Figure 2 assessed. Electrophysiological studies and simple shows the typical findings of cervical degenerative radiographs of the wrist, cervical spine, and basal arthritis at the C5-C6 level on simple radiographs and joint of the thumb taken pre-operatively were CT. Of the 362 patients, CT was done in 10 patients

Downloaded from jhs.sagepub.com at UNIV PRINCE EDWARD ISLAND on October 27, 2014 52 The Journal of Hand Surgery (Eur) 38(1)

Figure 1. Number of the 362 patients with cervical arthritis according to level and grade (Kellgren and Lawrence, 1957) of arthritis. and MRI in four patients. Two patients had undergone Post-operatively, among 633 hands, trigger digit or surgery for cervical arthritis before carpal tunnel de Quervain’s disease developed in 67 hands (11%). release, and two patients had undergone surgery for Multiple trigger digits or trigger digit with de Quervain’s cervical arthritis at 6 months and 1 year after carpal disease was seen in 10 of these 67 hands. Post- tunnel release, respectively. operative trigger digit developed most commonly in Of the 633 hands, basal joint arthritis of the thumb the thumb, followed by the long finger, and ring finger was observed in 216 hands (34%) on simple radio- (Table 2). Median time from surgery to the develop- graphs. The number and percentage of patients with ment of trigger digit or de Quervain’s disease was 6 basal joint arthritis of the thumb according to grade is (range 1.5–36) months. There were no significant dif- shown in Figure 3. Scaphotrapezial arthritis was ferences in the post-operative occurrence rate of trig- observed in 50 hands. Scaphotrapezial arthritis in ger digit or de Quervain’s disease according to age (< conjunction with basal joint arthritis was seen in 49 of 60 or ≥ 60), sex, and pre-operative presence of trigger these 50 hands, and primary scaphotrapezial arthritis digit or de Quervain’s disease (Table 3). In patients was seen only in one hand. Most patients who had who developed trigger digit or de Quervain’s disease scaphotrapezial arthritis were asymptomatic or post-operatively, six patients had additional opera- responded well to the conservative treatments, such tions for these conditions. as activity modification, rest, use of splints, and NSAIDs. No patient required surgical treatment such as arthroscopic debridement, resection , Discussion or scaphotrapeziotrapezoid fusion. Of 633 hands, trigger digit or de Quervain’s dis- In our study, the incidence of pre-operative trigger ease was found in 85 hands (13%) pre-operatively. digit or de Quervain’s disease in conjunction with idi- Multiple trigger digits or trigger digit with de opathic carpal tunnel syndrome was 13%. The inci- Quervain’s disease was seen in 22 of these 85 dence of trigger digit or de Quervain’s disease after hands. Pre-operative trigger digit was most com- carpal tunnel release was estimated to be 11%. The monly observed in the long finger, followed by the aetiological association (if any) between these condi- thumb, and ring finger (Table 1). We carried out car- tions is not entirely clear. However, the fact that both pal tunnel release and surgery for trigger digit or conditions coexist relatively frequently supports the de Quervain’s disease at the same time. Of the 362 hypothesis of an aetiological association. In a pro- patients, those with multiple comorbidities are spective study (Kumar and Chakrabarti, 2009), the described in Figure 4. prevalence of carpal tunnel syndrome was 43% in

Downloaded from jhs.sagepub.com at UNIV PRINCE EDWARD ISLAND on October 27, 2014 Kim et al. 53

Figure 2. (A,B) Anteroposterior (AP) and lateral radiographs of the cervical spine of a 55-year-old woman. There are multiple moderate osteophytes, disc space narrowing, and some sclerosis of the end plates at the C5-C6 level compatible with grade 3 cervical degenerative arthritis. (C) Axial computed tomography (CT) image at the C5-C6 level shows a hypertrophied uncovertebral joint with neural foraminal stenosis on the left side. patients with , substantially higher than when it was severe. The incidence of trigger digit the prevalence of carpal tunnel syndrome in the gen- after carpal tunnel release was found to be variable in eral population, which is 3.8% (Atroshi et al., 1999). previous studies. Assmus (2000) demonstrated that of Hayashi et al. (2005) investigated the interactive rela- 1310 patients surgically treated for carpal tunnel syn- tionship between carpal tunnel syndrome and trigger drome, 134 (10%) had one or more trigger digits. digit, and reported that surgery was a significant risk Hombal and Owen (1970) reported that trigger digits factor for the onset of trigger digit and may have requiring surgery developed in 26% of patients after accelerated the development of trigger digit when carpal tunnel release. Hayashi et al. (2005) noted that carpal tunnel syndrome was mild to moderate, but not trigger digit developed in 52 (32%) of 164 patients

Downloaded from jhs.sagepub.com at UNIV PRINCE EDWARD ISLAND on October 27, 2014 54 The Journal of Hand Surgery (Eur) 38(1)

Figure 3. Grade (Eaton and Littler, 1973) of osteoarthritis in 216 hands with basal joint arthritis of the thumb.

Table 1. Number of hands affected by carpal tunnel and thumb. In our study, trigger digit developed most syndrome in which trigger digit or de Quervain’s disease commonly in the thumb, middle finger, and ring fin- were present pre-operatively ger, similar to the findings of previous studies. Pre-operative trigger digit and/or Number of The concurrence of cervical spondylosis and car- de Quervain’s disease hands (%) pal tunnel syndrome has been reported (Bednarik et al., 1999; Hurst et al., 1985; Kwon et al., 2006; Upton Trigger digit (1 digit) 44 (7.0) and McComas, 1973). Upton and McComas (1973) Trigger digits (2 digits) 14 (2.2) found that 62 of 85 patients with median nerve entrap- Trigger digits (3 digits) 2 (0.3) Trigger digit (1 digit) + de 5 (0.8) ment had a concomitant cervical root lesion. Hurst et Quervain’s disease al. (1985) reported that cervical arthritis was found to Trigger digits (2 digits) + de 1 (0.2) have the highest correlation with bilateral carpal tun- Quervain’s disease nel syndrome. According to the results of a retrospec- de Quervain’s disease only 19 (3.0) tive study in 277 patients with cervical radiculopathy Distribution of trigger digit or de Number of by Kwon et al. (2006), 39 patients (14%) had concomi- Quervain’s disease hands (%) tant carpal tunnel syndrome. One of the explanations for this association is double crush syndrome. Double Trigger thumb 29 (4.6) crush syndrome was first described by Upton and Trigger finger (index finger) 4 (0.6) McComas (1973), and it refers to the concept that Trigger finger (long finger) 30 (4.7) impingement of the spinal nerves and peripheral Trigger finger (ring finger) 20 (3.2) nerves of the arm may result in a more complex clini- Trigger finger (little finger) 2 (0.3) de Quervain’s disease 25 (3.9) cal presentation. In our experience, we have seen a number of patients who had symptoms of cervical arthritis, such as neck pain, shoulder pain, and radic- ulopathy, accompanied by carpal tunnel syndrome. surgically treated for carpal tunnel syndrome. An So in this study, the presence of cervical degenerative hypothesis about the development of post-operative arthritis was routinely assessed before carpal tunnel trigger digit was suggested by Hombal and Owen release. When these two conditions coexist, the sign (1970). They explained the occurrence of trigger digit of shoulder abduction relief is very useful to differen- after carpal tunnel release by a bowstring effect of tiate between the symptoms of cervical arthritis and the flexor tendons. They also reported that the thumb, those of carpal tunnel syndrome. In cervical arthritis, middle finger, and ring finger were more readily radiating pain is usually relieved by shoulder abduc- involved due to their anatomical position. In the study tion. Degenerative arthritis with uncovertebral hyper- by Assmus (2000), trigger digit developed most com- trophy at the C5-C6 level can cause symptoms of C6 monly in the middle finger, followed by the ring finger radiculopathy, such as sensory changes in the lateral

Downloaded from jhs.sagepub.com at UNIV PRINCE EDWARD ISLAND on October 27, 2014 Kim et al. 55

Figure 4. Patients with multiple comorbidities among the 362 patients.

Table 2. Number of hands affected by carpal tunnel index finger might persist even after carpal tunnel syndrome in which trigger digit or de Quervain’s disease release. Therefore, if cervical arthritis is observed on developed post-operatively simple radiographs before surgery, it is necessary to Number of hands (%) check for the presence of neck pain, shoulder pain, and radiculopathy, and to explain to patients that the Trigger digit (1 digit) 54 (8.5%) symptoms of cervical arthritis could persist even Trigger digits (2 digits) 10 (1.6%) after carpal tunnel release. de Quervain’s disease only 3 (0.5%) Basal joint arthritis is another common arthritic Distribution of trigger digits Number of hands (%) condition that may coexist with carpal tunnel syn- Trigger thumb 32 (5.1%) drome. We can differentiate between the symptoms of Trigger finger (index finger) 3 (0.5%) basal joint arthritis and those of carpal tunnel syn- Trigger finger (long finger) 25 (3.9%) drome on the basis of the presence of tenderness at Trigger finger (ring finger) 14 (2.2%) the carpometacarpal joint of the thumb or by using Trigger finger (little finger) 0 (0%) the grind test. The concurrence of these two condi- tions has been reported (Burton, 1986; Florack et al., aspect of the forearm, thumb, and index finger. In 1992; Melone et al., 1987; Sless and Sampson, 2007). idiopathic carpal tunnel syndrome in conjunction with Burton (1986) and Melone et al. (1987) were the first C6 radiculopathy, sensory changes in the thumb and to emphasize the frequency of simultaneous carpal

Table 3. Post-operative development of trigger digit or de Quervain’s disease according to age, sex, and pre-operative presence of trigger digit or de Quervain’s disease in 362 patients

Patients with trigger digit or Patients without trigger digit or de Quervain’s disease de Quervain’s disease post-operatively, n (%) post-operatively, n (%) Age, y < 60 31 (61) 201 (65) ≥ 60 20 (39) 110 (35) Gender Male 4 (7.8) 33 (11) Female 47 (92) 278 (89) Patients who had trigger digit or 11 (22) 55 (18) de Quervain’s disease pre-operatively Patients who did not have trigger digit or 40 (78) 256 (82) de Quervain’s disease pre-operatively

Downloaded from jhs.sagepub.com at UNIV PRINCE EDWARD ISLAND on October 27, 2014 56 The Journal of Hand Surgery (Eur) 38(1) tunnel syndrome and basal joint arthritis of the Bednarik J, Kadanka Z, Vohanka S. Median nerve monon- thumb. Florack et al. (1992) reported a concurrence europathy in spondylotic cervical myelopathy: double rate of as high as 43% of carpal tunnel syndrome and crush syndrome? J Neurol. 1999, 246: 544–51. basal joint arthritis in patients who had basal joint Burton RI. Complications following surgery on the basal arthroplasty. Several theories have been proposed to joint of the thumb. Hand Clin. 1986, 2: 265–9. Crosby EB, Linscheid RL, Dobyns JH. Scaphotrapezial trap- explain the association of carpal tunnel syndrome ezoidal arthrosis. J Hand Surg Am. 1978, 3: 223–34. and basal joint arthritis of the thumb. Melone et al. Dawson DM. Entrapment neuropathies of the upper (1987) suggested that carpal tunnel narrowing could extremities. N Engl J Med. 1993, 329: 2013–8. be explained by an osseous hypertrophy of the scaph- Eaton RG, Littler JW. Ligament reconstruction for the pain- oid and trapezium. Crosby et al. (1978) reported that ful thumb carpometacarpal joint. J Joint Surg Am. the anteroposterior diameter of the carpal tunnel was 1973, 55: 1655–66. decreased in patients with midcarpal collapse associ- Florack TM, Miller RJ, Pellegrini VD et al. The prevalence ated with scaphotrapeziotrapezoid arthritis. of carpal tunnel syndrome in patients with basal joint The results of this study suggest that trigger digit arthritis of the thumb. J Hand Surg Am. 1992, 17: 624–30. and arthritis of the cervical spine or basal joint of Harada K, Nakashima H, Teramoto K et al. Trigger dig- the thumb are commonly associated with idiopathic its-associated carpal tunnel syndrome: relationship between carpal tunnel release and trigger digits. Hand carpal tunnel syndrome. So it seems that an assess- Surg. 2005, 10: 205–8. ment of the presence of pre-operative trigger digit Hayashi M, Uchiyama S, Toriumi H et al. Carpal tunnel syn- and arthritis is needed, and if these conditions coex- drome and development of trigger digit. J Clin Neurosci. ist with idiopathic carpal tunnel syndrome, patient 2005, 12: 39–41. education regarding these associated conditions Hombal JW, Owen R. Carpal tunnel decompression and must be provided. It is also necessary to explain trigger digits. Hand. 1970, 2: 192–6. to patients that symptoms of these associated con- Hurst LC, Weissberg D, Carroll RE. The relationship of the ditions could persist even after surgery. We also double crush to carpal tunnel syndrome (an analysis of need to warn of the possibility of post-operative 1,000 cases of carpal tunnel syndrome). J Hand Surg Br. occurrence of trigger digit. 1985, 10: 202–4. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957, 16: 494–502. Conflict of interests Kumar P, Chakrabarti I. Idiopathic carpal tunnel syndrome None declared. and trigger finger: is there an association? J Hand Surg Eur. 2009, 34: 58–9. Funding Kwon HK, Hwang M, Yoon DW. Frequency and severity of carpal tunnel syndrome according to level of cervical radic- This research received no specific grant from any funding ulopathy: double crush syndrome? Clin Neurophysiol. agency in the public, commercial, or not-for-profit sectors. 2006, 117: 1256–9. Seoul National University College of Medicine/Seoul Melone CP, Beavers B, Isani A. The basal joint pain National University Hospital Institutional Review Board syndrome. Clin Orthop Relat Res. 1987, 220: 58–67. reviewed and approved our study. Mondelli M, Giannini F, Giacchi M. Carpal tunnel syndrome IRB NO: H-1008-003-325. incidence in a general population. . 2002, 58: 289–94. References Rottgers SA, Lewis D, Wollstein RA. Concomitant pres- Armstrong AL, Hunter JB, Davis TR. The prevalence of entation of carpal tunnel syndrome and trigger finger. degenerative arthritis of the base of the thumb in post- J Brachial Plex Peripher Nerve Inj. 2009, 4: 13. menopausal women. J Hand Surg Br. 1994, 19: 340–1. Sless Y, Sampson SP. Experience with transtrapezium Assmus H. Tendovaginitis stenosans: a frequent complica- approach for transverse carpal ligament release in tion of carpal tunnel syndrome. Nervenarzt. 2000, 71: patients with coexisted trapeziometacarpal joint osteo- 474–6. arthritis and carpal tunnel syndrome. Hand (NY). 2007, Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam 2: 151–4. J, Rosen I. Prevalence of carpal tunnel in a general Upton AR, McComas AJ. The double crush in nerve entrap- population. JAMA. 1999, 282: 153–8. ment syndromes. Lancet. 1973, 2: 359–62.

Downloaded from jhs.sagepub.com at UNIV PRINCE EDWARD ISLAND on October 27, 2014