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Splinting in the treatment of arthritis of the first carpometacarpal joint
Splinting in the Treatment of Arthritis of the First Carpometacarpal Joint Carrie R. Swigart, MD, Richard G. Eaton, MD, Steven Z. Glickel, MD, Caryl Johnson, CHT, New York, NY Although much has been written about surgical treatment of arthritis of the first carpometacarpal joint, no literature exists on splinting as a conservative treatment. One hundred fourteen patients (130 thumbs) were retrospectively reviewed to determine the efficacy of splinting. Patients were grouped according to their stage of disease and whether they had carpometacarpal joint surgery. Seventy-six percent of patients with stage I and II disease and 54% of patients with stage III and IV disease had improvement in their symptoms with splinting. There was no significant difference in the degree of improvement between the 2 groups. All patients who had initial improvement in their symptoms with splinting had between 54% and 61% average improvement in symptom severity 6 months after splinting. All groups were found to be equally tolerant of the splinting protocol and no group had a significantly higher rate of activity modification. Overall, splinting was found to be a well-tolerated and effective conservative treatment to diminish, but not completely eliminate, the symptoms of carpometacarpal joint arthritis and inflammation. (J Hand Surg 1999;24A:86 –91. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Splinting, basal joint, arthritis, trapeziometacarpal joint.
Pain at the base of the thumb due to arthritis of the trapeziometacarpal and scaphotrapezial joints is a common problem, especially for women in the fifth to seventh decades of life. In a recent radiographic survey of postmenopausal women, the prevalence of isolated trapeziometacarpal and scaphotrapezial osteoarthritis was 25% and 2%, respectively. The prevalence of combined disease was 8%.1 Other investigators have estimated the prevalence of basal joint
From the C. V. Starr Hand Surgery Center, St Luke’s/Roosevelt Hospital Center, New York, NY. Received for publication February 9, 1998; accepted in revised form July 29, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Carrie R. Swigart, MD, Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, Sports Medicine Center, One Long Wharf, 6th Floor, New Haven, CT 06511. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01-0013$3.00/0
86 The Journal of Hand Surgery
arthritis to be between 16% and 22% for women and 2% and 5% for men.2,3 Much has been written about surgical reconstruction, but there is little mention of conservative treatment for basal joint arthritis. Several investigators mention splinting of the thumb as an option for conservative treatment, along with anti-inflammatory drugs, steroid injections, and thumb-strengthening exercises.4,5 Others qualify their reference to splinting by stating that it is often poorly tolerated, severely limits hand function, or has little efficacy.6,7 We have been unable to find any report in the English literature that either qualitatively or quantitatively evaluates the results of splinting. Our hypothesis was that splinting is more effective in the treatment of the early stages of arthritis and that regardless of stage, a significant number of patients will have sufficient relief of their symptoms to obviate or delay the need for surgical treatment. The purpose of this study is to retrospectively review a group of patients treated with splinting of the thumb
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 87
for trapeziometacarpal and scaphotrapezial arthritis to determine its effectiveness.
Materials and Methods Between December 1990 and December 1993, 125 patients (141 thumbs) were seen at our hand center for pain and disability resulting from first carpometacarpal (CMC) joint disease. Of this group, 130 thumbs in 114 patients were treated initially with a protocol of thumb splinting. Eleven of the 141 thumbs (8%) had reconstruction of the volar ligament of the first CMC joint (with or without resurfacing of the trapeziometacarpal and/or the scaphotrapezial joints) without prior splinting. The reasons for this were either that the patient had failed previous splinting or the patient did not wish to be, or could not be, immobilized. Splints were of the long opponens variety (ie, long thumb stabilizer), which is shown in Fig. 1. They were designed to eliminate motion of the wrist and thumb but not to attempt correction of any deformity. The period of splinting prescribed was 3 to 4 weeks of continuous wear followed by a “weaning” period of 3 to 4 weeks. Continuous wear was described to the patients as use of the splint at all times except for showering and bathing. During the weaning period, patients were instructed to wear the splint less for light activities, then not at all except for the heaviest of activities, but always at night. The average length of follow-up from the time of splint prescription was 54 months (range, 39 –74 months). Of the 114 pa-
tients (130 thumbs) treated initially with splinting, 24 (25 thumbs; 19%) eventually elected surgery. The group of patients treated initially with splinting consisted of 93 women (82%) and 21 men (18%). The average age was 53.8 years (range, 19 – 82 years). Thumb x-rays were obtained on all patients at their initial visit. These were used to stage the first CMC joint disease according to the criteria described by Eaton and Glickel.8 No patient received an injection of corticosteroid into the first CMC joint and thumb strengthening exercises were not prescribed. The use of anti-inflammatory medications varied with the treating physician and the patient’s tolerance for these medications. Because these data were inconsistently recorded in the chart, they were not included in this analysis. Data were collected by chart and x-ray review as well as via a postal questionnaire or telephone interview. Patient demographics according to stage are shown in Table 1. Sixty-nine (53%) thumbs presented with stage III or IV disease. Four thumbs could not be staged because degenerative changes were limited to the scaphotrapezial joint; the trapeziometacarpal joint was radiographically uninvolved. A postal questionnaire was sent to all patients treated initially with splinting. The patients were asked whether splinting of the thumb provided any relief of their symptoms. If the response was positive, they were asked to rate the percentage improvement both immediately on completing the splinting protocol and 6 months thereafter. A 100% improve-
Figure 1. Long opponens splint holding the thumb in abduction.
88 Swigart et al / Splinting in First Carpometacarpal Arthritis
Table 1. Patient Demographics by Disease Stage Stage
No. of Patients (No. of Thumbs)
Average Age, yr (Range)
Female:Male Ratio
31 (34) 20 (23) 43 (51) 16 (18) 4 (4)
37 (19–54) 58 (37–75) 58 (42–74) 68 (49–82) 56 (48–68)
2.9:1 9.0:1 4.4:1 7.0:1 3.0:1
114 (130)
54 (19–78)
4.4:1
I II III IV ST Total
ment implied a return to unrestricted pain-free function. The questionnaire listed 5 possibilities for percentage improvement: 100%, 75%, 50%, 25%, and none at all (0%). Patients also were questioned about whether they had made any changes in their job or hobbies due to their thumb symptoms, if they had been able to wear the splint as prescribed, and if they were currently having any pain or dysfunction related to the base of the thumb. Data also were collected on whether they had undergone surgery to reconstruct the first CMC joint. The patients treated with splinting were divided into 2 groups according to stage of disease. Group A consisted of 57 thumbs (51 patients) with stage I or stage II disease; there were 41 women and 10 men with an average age of 45 years (range, 19 –75 years). Group B consisted of 69 thumbs (59 patients) with stage III or stage IV disease; there were 49 women and 10 men with an average age of 60 years (range, 42–78 years). The 4 thumbs with isolated scaphotrapezial disease were not included, leaving 126 thumbs (110 patients) for analysis. These 126 thumbs were also divided into 2 groups depending on
whether they had undergone surgery to reconstruct the CMC joint. The no-surgery group consisted of 103 thumbs (88 patients). There were 71 women and 17 men with an average age of 52 years (range, 19 – 82 years). There were 23 thumbs (22 patients) in the surgery group; 19 women and 3 men with an average age of 59 years (range, 24 –78 years). Results were analyzed using a Fisher’s exact test when comparing categorical variables, an unpaired, two-tailed Student’s t-test when comparing categorical and continuous variables, and a correlation coefficient for continuous variables. P , .05 was considered significant.
Results Seventy-four patients with 85 involved thumbs (67%) responded to the questionnaire. Six patients with 6 involved thumbs (5%) were lost to follow-up due to death or mental incapacity. Fourteen other patients (16 thumbs; 13%) could not be located. The remaining 16 patients (19 thumbs; 15%) failed to respond to 2 postal questionnaires and multiple telephone reminders. Only patients who answered the questionnaire are considered in the following results.
Group A Versus Group B A response to the questionnaire was obtained for 35 thumbs (60%) from group A (stage I and II disease). Of these, 26 thumbs (76%) had some improvement in the symptoms with splinting. The percentages of improvement immediately after and at 6 months after splinting are shown in Table 2. A response was obtained for 50 thumbs (70%) from group B (stage III and IV disease). Twenty-
Table 2. Symptom Improvement and Average Percentage Improvements by Patient Group No. of Patients (No. of Thumbs)
No. of Thumbs With Initial Improvement (%)
Average % Improvement at T 5 0
Average % Improvement at T 5 6 mo
Group A Group B
32 (35) 42 (50)
26 (76) 27 (54)
60 61
61 54
No surgery Surgery
52 (62) 22 (23)
49 (79) 4 (17)*
63 25†
63 0
Group A comprises patients with stage I and II disease and group B comprises patients with stage III and IV disease. Average % improvement refers to the patient’s estimate of their improvement; 0% implies no improvement and 100% implies complete resolution of all symptoms. T 5 0, immediately after completing the splinting protocol; T 5 6 mo, 6 months afterward. *Different from the no-surgery group; p , .0001. †Different from the no-surgery group; p 5 .001.
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 89
Table 3. Prior Symptom Duration According to Patient Group No. of Patients*/ No. of Thumbs (% Total Thumbs)
Symptom Duration Before Treatment (mo, Average 6 SD)
Group A Group B
22/25 (71) 36/41 (82)
13 6 19 35 6 61
No surgery Surgery
42/51 (82) 14/15 (65)
28 6 56 27 6 30
*Those patients whose records contained information regarding their prior symptom duration.
seven thumbs (54%) had some improvement in symptoms with splint wear. Although the percentage of thumbs that were relieved was lower than for group A, the difference was not significant (p 5 .056, Fisher’s exact test). The percentage improvements for thumbs in group B are shown in Table 2. These average percentage improvements did not significantly differ from group A either immediately after or 6 months after splinting (p 5 .71 and p 5 .60 respectively, Student’s t-test). There were 2 thumbs in group A that eventually underwent surgery. In both cases the patients answered the questionnaire; neither had any improvement in their symptoms with splinting. Of the 21 thumbs in group B that underwent surgery, patients representing 17 of them answered the questionnaire. Only 3 of these 17 thumbs had any initial alleviation of symptoms with splinting. The average percentage improvement immediately after splinting was only 25%; by 6 months, none had any continued relief. In group A there were 9 thumbs that failed splinting, ie, the patients reported no relief of symptoms. Of these, 2 eventually underwent surgery. In the 7 others, although still symptomatic, the patients declined surgical reconstruction. In group B 23 thumbs had symptoms that failed to be relieved with splinting. Fourteen thumbs went on to surgery. For the remaining 9 thumbs the patients either modified their activities and lifestyle or declined surgery for other reasons. The duration of symptoms before the patient’s initial presentation was also compared for groups A and B. Chart documentation existed for 25 thumbs (71%) in group A and 41 thumbs (82%) in group B. The average symptom durations before treatment are shown in Table 3. Although there was a trend for patients with more advanced disease to have been
symptomatic longer before their first visit, the difference between the 2 groups was not significant (p 5 .09, Student’s t-test). Patients in groups A and B were also compared with respect to changes in employment or hobbies necessitated by their thumb symptoms. Eleven patients (34%) in group A and 10 patients (24%) in group B had given up one or more specific activities due to thumb pain or dysfunction (Table 4). The modifications in activity were most often a decrease in crafts, such as needlepoint, knitting, and woodworking, or altering athletic activities. No patient changed jobs because of thumb symptoms. There was no significant difference in the observed frequency of a lifestyle modification between group A and group B (p 5 .32, Fisher’s exact test). Groups A and B were also compared with respect to their ability to tolerate wearing the splint as prescribed (Table 4). Twenty-four patients (75%) in group A and 29 patients (69%) in group B were able to wear the splint as prescribed. There was no statistical difference in splint acceptance and compliance between the 2 groups (p 5 .57, Fisher’s exact test). For those patients who were not able to tolerate the splints as prescribed, the most common reason offered was that the splint was too restrictive and uncomfortable. Driving, writing, and sports were mentioned most often as the activities that were difficult to perform while wearing a splint.
Nonsurgical Versus Surgical Cases When only the patients who did not have surgery are considered, 49 thumbs (79%) had some symptomatic relief with splinting. Their average improvements immediately after splinting and 6 months later are shown in Table 2. Of the patients who went on to have surgery, only 4 thumbs (17%) had any relief of symptoms with splinting. This was a significantly lower percentage of thumbs than those that did not
Table 4. Activity Modification and Splint Compliance According to Patient Group No. of Patients With Activity Modification (%)
No. of Patients Able to Comply With Splinting (%)
Group A Group B
11 (34) 10 (24)
24 (75) 29 (69)
No surgery Surgery
17 (33) 4 (18)
40 (77) 12 (54)
90 Swigart et al / Splinting in First Carpometacarpal Arthritis
undergo surgery (p , .01, Fisher’s exact test). At 6 months none of the thumbs had any residual relief and 2 of the 4 had undergone surgery by that time. The duration of symptoms before the patient’s first visit was compared between the patients who had surgery and those who did not. Documentation existed for 51 thumbs (82%) of those who did not have surgery and for 15 thumbs (65%) of those who did. Their average symptom duration before their initial visit is shown in Table 3. There was no significant difference between the groups, (p 5 .95, Student’s t-test). Patients who went on to have surgery were compared with those who did not with respect to any changes in their hobbies or employment and tolerance of splint wear. Seventeen patients (33%) who did not have surgery and 4 patients (18%) who did modified their activities in some way directly related to their thumb pain (Table 4). The difference between the 2 groups was not statistically significant (p 5 .33, Fisher’s exact test). Forty patients (77%) who did not have surgery and 12 patients (54%) who did were able to comply with the splinting protocol (Table 4). Although a much greater percentage of patients who did not have surgery were able to comply with splint wear, the difference between the groups was not significant (p 5 .054, Fisher’s exact test). Forty-five thumbs (70%) that did not undergo surgery had some persistent pain at the time of review. Twenty-four thumbs (37%) had symptoms of equal or greater magnitude to those at the time of the initial visit. Of the thumbs that did undergo surgery, 8 (38%) had some symptoms, including occasional stiffness and pain. According to the patients, these symptoms were much less severe than before surgery.
All Patients The patients also were analyzed as a single group. Of the patients who answered the questionnaire, 53 thumbs (62%) had some relief of symptoms with splinting. Among those whose symptoms decreased, the average improvement was graded as 60% immediately after splinting and 59% 6 months later. Symptomatic improvement with splinting was not dependent on the duration of prior symptoms (p 5 .70, correlation coefficient) nor was it affected significantly by activity modification (p 5 .12, Fisher’s exact test). At the time of the follow-up examination only 7 patients (9%) were still using splints to control symptoms.
Discussion To our knowledge there are no studies that directly evaluate splinting as a conservative treatment for first CMC joint arthritis. Anecdotal mention of its use in the literature on surgical treatment lists poor patient compliance and limitation of hand function as its main disadvantages.4 –7 At the time of initial consultation, however, most patients are reticent to commit to surgery because of concern about postoperative pain and fairly prolonged immobilization and therapy. The patient and physician both benefit from the availability of a conservative treatment option to better assess the severity of the symptoms and to establish a therapeutic rapport. Splinting as a form of enforced rest may sufficiently diminish the acute inflammation so that the patient will be able to return to a normal level of function without significant pain. Dell et al9 studied patients treated nonoperatively as well as those treated with resection arthroplasty for trapeziometacarpal arthritis. In their series, 72% of the patients were treated initially with a C-splint, which is a short, hand-based splint that perhaps immobilizes the trapeziometacarpal joint less effectively than a long opponens splint. Of the 91 thumbs in the study, 16 (18%) had surgical reconstruction. It is unclear, however, how many of these patients were splinted. Their splint protocol varied according to the stage of first CMC joint disease, and the degree of improvement was not quantified. On the basis of an average 16-month follow-up period of patients treated with splinting, Dell et al felt that those with stage I disease were more likely to respond to treatment. As we hypothesized, group A did have a greater percentage of patients with symptomatic improvement with splinting than did group B. This difference was not statistically significant, however, because of the relatively limited number of patients available. Patients who had some symptomatic relief with splinting had an approximately 60% improvement both immediately and 6 months after wearing the splint. As might be expected, patients who eventually underwent surgery had a significantly greater splint failure rate than patients who did not have surgery. The lack of response to splinting was apparent immediately after splint use and did not improve at 6 months. It is noteworthy that not all patients who failed to obtain relief with splinting opted to have surgery. In group A, only 22% who did not improve with splinting chose surgical reconstruction. Sixtyone percent of patients in group B who failed splint-
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 91
ing had first CMC joint surgery. This is likely related to a multitude of factors, such as the degree to which thumb symptoms interfered with a patient’s lifestyle, tolerance for pain, and job and family demands. Among patients who did not have surgery, 33% modified their activities to reduce the stress on the thumb. The remaining 67% did not change their lifestyles and were not sufficiently impaired to opt for surgical reconstruction after splinting. Although more patients in group A modified their activities, the difference was not significant. This trend may have more to do with the younger average age and higher activity level of patients with stage I and II disease. The limitations of this study are those of every retrospective patient follow-up study. First, there was a 35% attrition rate, largely due to an inability to locate the patients because of a lack of forwarding information for home or work. Second, this study depends greatly on the patients’ ability to recollect events and their perceptions of them in the somewhat distant past. This may bias results in that patients who had surgery may have a more clear recollection of these events than those patients who were seen only once or twice for splint treatment. This limited series of patients shows that splinting of the thumb for CMC joint arthritis can be an effective conservative initial treatment. Although it certainly will not cure the pathology, it can provide sufficient relief to avoid or at least postpone surgical reconstruction in a number of patients. It is well-
tolerated and is equally effective for all stages of pathology. Further investigation in a prospective manner is needed to better determine the long-term effectiveness of splinting.
References 1. Armstrong AL, Hunter JB, Davis TRC. The prevalence of degenerative arthritis of the base of the thumb in postmenopausal women. J Hand Surg 1994;19B:340 –341. 2. Aune S. Osteo-arthritis of the first carpo-metacarpal joint: an investigation of 22 cases. Acta Chir Scand 1955;109: 449 – 456. 3. Kelsey JL, Pastides H, Kreiger N, Harris C, Chernow RA. Upper extremity disorders: a survey of their frequency and cost in the United States. St Louis: CV Mosby, 1980. 4. Lane LB, Eaton RG. Ligament reconstruction for the painful “prearthritic” thumb carpometacarpal joint. Clin Orthop 1987;220:52–57. 5. Pellegrini VD Jr, Burton RI. Surgical management of basal joint arthritis of the thumb. Part I. Long-term results of silicone implant arthroplasty. J Hand Surg 1986;11A:309 – 324. 6. Burton RI. Basal joint arthrosis of the thumb. Orthop Clin North Am 1973;4:331–348. 7. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg 1973; 55A:1655–1666. 8. Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis: staging as a rationale for treatment. Hand Clin 1987;3:455– 469. 9. Dell PC, Brushart TM, Smith RJ. Treatment of trapeziometacarpal arthritis: results of resection arthroplasty. J Hand Surg 1978;3:243–249.
Pain at the base of the thumb due to arthritis of the trapeziometacarpal and scaphotrapezial joints is a common problem, especially for women in the fifth to seventh decades of life. In a recent radiographic survey of postmenopausal women, the prevalence of isolated trapeziometacarpal and scaphotrapezial osteoarthritis was 25% and 2%, respectively. The prevalence of combined disease was 8%.1 Other investigators have estimated the prevalence of basal joint
From the C. V. Starr Hand Surgery Center, St Luke’s/Roosevelt Hospital Center, New York, NY. Received for publication February 9, 1998; accepted in revised form July 29, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Carrie R. Swigart, MD, Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, Sports Medicine Center, One Long Wharf, 6th Floor, New Haven, CT 06511. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01-0013$3.00/0
86 The Journal of Hand Surgery
arthritis to be between 16% and 22% for women and 2% and 5% for men.2,3 Much has been written about surgical reconstruction, but there is little mention of conservative treatment for basal joint arthritis. Several investigators mention splinting of the thumb as an option for conservative treatment, along with anti-inflammatory drugs, steroid injections, and thumb-strengthening exercises.4,5 Others qualify their reference to splinting by stating that it is often poorly tolerated, severely limits hand function, or has little efficacy.6,7 We have been unable to find any report in the English literature that either qualitatively or quantitatively evaluates the results of splinting. Our hypothesis was that splinting is more effective in the treatment of the early stages of arthritis and that regardless of stage, a significant number of patients will have sufficient relief of their symptoms to obviate or delay the need for surgical treatment. The purpose of this study is to retrospectively review a group of patients treated with splinting of the thumb
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 87
for trapeziometacarpal and scaphotrapezial arthritis to determine its effectiveness.
Materials and Methods Between December 1990 and December 1993, 125 patients (141 thumbs) were seen at our hand center for pain and disability resulting from first carpometacarpal (CMC) joint disease. Of this group, 130 thumbs in 114 patients were treated initially with a protocol of thumb splinting. Eleven of the 141 thumbs (8%) had reconstruction of the volar ligament of the first CMC joint (with or without resurfacing of the trapeziometacarpal and/or the scaphotrapezial joints) without prior splinting. The reasons for this were either that the patient had failed previous splinting or the patient did not wish to be, or could not be, immobilized. Splints were of the long opponens variety (ie, long thumb stabilizer), which is shown in Fig. 1. They were designed to eliminate motion of the wrist and thumb but not to attempt correction of any deformity. The period of splinting prescribed was 3 to 4 weeks of continuous wear followed by a “weaning” period of 3 to 4 weeks. Continuous wear was described to the patients as use of the splint at all times except for showering and bathing. During the weaning period, patients were instructed to wear the splint less for light activities, then not at all except for the heaviest of activities, but always at night. The average length of follow-up from the time of splint prescription was 54 months (range, 39 –74 months). Of the 114 pa-
tients (130 thumbs) treated initially with splinting, 24 (25 thumbs; 19%) eventually elected surgery. The group of patients treated initially with splinting consisted of 93 women (82%) and 21 men (18%). The average age was 53.8 years (range, 19 – 82 years). Thumb x-rays were obtained on all patients at their initial visit. These were used to stage the first CMC joint disease according to the criteria described by Eaton and Glickel.8 No patient received an injection of corticosteroid into the first CMC joint and thumb strengthening exercises were not prescribed. The use of anti-inflammatory medications varied with the treating physician and the patient’s tolerance for these medications. Because these data were inconsistently recorded in the chart, they were not included in this analysis. Data were collected by chart and x-ray review as well as via a postal questionnaire or telephone interview. Patient demographics according to stage are shown in Table 1. Sixty-nine (53%) thumbs presented with stage III or IV disease. Four thumbs could not be staged because degenerative changes were limited to the scaphotrapezial joint; the trapeziometacarpal joint was radiographically uninvolved. A postal questionnaire was sent to all patients treated initially with splinting. The patients were asked whether splinting of the thumb provided any relief of their symptoms. If the response was positive, they were asked to rate the percentage improvement both immediately on completing the splinting protocol and 6 months thereafter. A 100% improve-
Figure 1. Long opponens splint holding the thumb in abduction.
88 Swigart et al / Splinting in First Carpometacarpal Arthritis
Table 1. Patient Demographics by Disease Stage Stage
No. of Patients (No. of Thumbs)
Average Age, yr (Range)
Female:Male Ratio
31 (34) 20 (23) 43 (51) 16 (18) 4 (4)
37 (19–54) 58 (37–75) 58 (42–74) 68 (49–82) 56 (48–68)
2.9:1 9.0:1 4.4:1 7.0:1 3.0:1
114 (130)
54 (19–78)
4.4:1
I II III IV ST Total
ment implied a return to unrestricted pain-free function. The questionnaire listed 5 possibilities for percentage improvement: 100%, 75%, 50%, 25%, and none at all (0%). Patients also were questioned about whether they had made any changes in their job or hobbies due to their thumb symptoms, if they had been able to wear the splint as prescribed, and if they were currently having any pain or dysfunction related to the base of the thumb. Data also were collected on whether they had undergone surgery to reconstruct the first CMC joint. The patients treated with splinting were divided into 2 groups according to stage of disease. Group A consisted of 57 thumbs (51 patients) with stage I or stage II disease; there were 41 women and 10 men with an average age of 45 years (range, 19 –75 years). Group B consisted of 69 thumbs (59 patients) with stage III or stage IV disease; there were 49 women and 10 men with an average age of 60 years (range, 42–78 years). The 4 thumbs with isolated scaphotrapezial disease were not included, leaving 126 thumbs (110 patients) for analysis. These 126 thumbs were also divided into 2 groups depending on
whether they had undergone surgery to reconstruct the CMC joint. The no-surgery group consisted of 103 thumbs (88 patients). There were 71 women and 17 men with an average age of 52 years (range, 19 – 82 years). There were 23 thumbs (22 patients) in the surgery group; 19 women and 3 men with an average age of 59 years (range, 24 –78 years). Results were analyzed using a Fisher’s exact test when comparing categorical variables, an unpaired, two-tailed Student’s t-test when comparing categorical and continuous variables, and a correlation coefficient for continuous variables. P , .05 was considered significant.
Results Seventy-four patients with 85 involved thumbs (67%) responded to the questionnaire. Six patients with 6 involved thumbs (5%) were lost to follow-up due to death or mental incapacity. Fourteen other patients (16 thumbs; 13%) could not be located. The remaining 16 patients (19 thumbs; 15%) failed to respond to 2 postal questionnaires and multiple telephone reminders. Only patients who answered the questionnaire are considered in the following results.
Group A Versus Group B A response to the questionnaire was obtained for 35 thumbs (60%) from group A (stage I and II disease). Of these, 26 thumbs (76%) had some improvement in the symptoms with splinting. The percentages of improvement immediately after and at 6 months after splinting are shown in Table 2. A response was obtained for 50 thumbs (70%) from group B (stage III and IV disease). Twenty-
Table 2. Symptom Improvement and Average Percentage Improvements by Patient Group No. of Patients (No. of Thumbs)
No. of Thumbs With Initial Improvement (%)
Average % Improvement at T 5 0
Average % Improvement at T 5 6 mo
Group A Group B
32 (35) 42 (50)
26 (76) 27 (54)
60 61
61 54
No surgery Surgery
52 (62) 22 (23)
49 (79) 4 (17)*
63 25†
63 0
Group A comprises patients with stage I and II disease and group B comprises patients with stage III and IV disease. Average % improvement refers to the patient’s estimate of their improvement; 0% implies no improvement and 100% implies complete resolution of all symptoms. T 5 0, immediately after completing the splinting protocol; T 5 6 mo, 6 months afterward. *Different from the no-surgery group; p , .0001. †Different from the no-surgery group; p 5 .001.
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 89
Table 3. Prior Symptom Duration According to Patient Group No. of Patients*/ No. of Thumbs (% Total Thumbs)
Symptom Duration Before Treatment (mo, Average 6 SD)
Group A Group B
22/25 (71) 36/41 (82)
13 6 19 35 6 61
No surgery Surgery
42/51 (82) 14/15 (65)
28 6 56 27 6 30
*Those patients whose records contained information regarding their prior symptom duration.
seven thumbs (54%) had some improvement in symptoms with splint wear. Although the percentage of thumbs that were relieved was lower than for group A, the difference was not significant (p 5 .056, Fisher’s exact test). The percentage improvements for thumbs in group B are shown in Table 2. These average percentage improvements did not significantly differ from group A either immediately after or 6 months after splinting (p 5 .71 and p 5 .60 respectively, Student’s t-test). There were 2 thumbs in group A that eventually underwent surgery. In both cases the patients answered the questionnaire; neither had any improvement in their symptoms with splinting. Of the 21 thumbs in group B that underwent surgery, patients representing 17 of them answered the questionnaire. Only 3 of these 17 thumbs had any initial alleviation of symptoms with splinting. The average percentage improvement immediately after splinting was only 25%; by 6 months, none had any continued relief. In group A there were 9 thumbs that failed splinting, ie, the patients reported no relief of symptoms. Of these, 2 eventually underwent surgery. In the 7 others, although still symptomatic, the patients declined surgical reconstruction. In group B 23 thumbs had symptoms that failed to be relieved with splinting. Fourteen thumbs went on to surgery. For the remaining 9 thumbs the patients either modified their activities and lifestyle or declined surgery for other reasons. The duration of symptoms before the patient’s initial presentation was also compared for groups A and B. Chart documentation existed for 25 thumbs (71%) in group A and 41 thumbs (82%) in group B. The average symptom durations before treatment are shown in Table 3. Although there was a trend for patients with more advanced disease to have been
symptomatic longer before their first visit, the difference between the 2 groups was not significant (p 5 .09, Student’s t-test). Patients in groups A and B were also compared with respect to changes in employment or hobbies necessitated by their thumb symptoms. Eleven patients (34%) in group A and 10 patients (24%) in group B had given up one or more specific activities due to thumb pain or dysfunction (Table 4). The modifications in activity were most often a decrease in crafts, such as needlepoint, knitting, and woodworking, or altering athletic activities. No patient changed jobs because of thumb symptoms. There was no significant difference in the observed frequency of a lifestyle modification between group A and group B (p 5 .32, Fisher’s exact test). Groups A and B were also compared with respect to their ability to tolerate wearing the splint as prescribed (Table 4). Twenty-four patients (75%) in group A and 29 patients (69%) in group B were able to wear the splint as prescribed. There was no statistical difference in splint acceptance and compliance between the 2 groups (p 5 .57, Fisher’s exact test). For those patients who were not able to tolerate the splints as prescribed, the most common reason offered was that the splint was too restrictive and uncomfortable. Driving, writing, and sports were mentioned most often as the activities that were difficult to perform while wearing a splint.
Nonsurgical Versus Surgical Cases When only the patients who did not have surgery are considered, 49 thumbs (79%) had some symptomatic relief with splinting. Their average improvements immediately after splinting and 6 months later are shown in Table 2. Of the patients who went on to have surgery, only 4 thumbs (17%) had any relief of symptoms with splinting. This was a significantly lower percentage of thumbs than those that did not
Table 4. Activity Modification and Splint Compliance According to Patient Group No. of Patients With Activity Modification (%)
No. of Patients Able to Comply With Splinting (%)
Group A Group B
11 (34) 10 (24)
24 (75) 29 (69)
No surgery Surgery
17 (33) 4 (18)
40 (77) 12 (54)
90 Swigart et al / Splinting in First Carpometacarpal Arthritis
undergo surgery (p , .01, Fisher’s exact test). At 6 months none of the thumbs had any residual relief and 2 of the 4 had undergone surgery by that time. The duration of symptoms before the patient’s first visit was compared between the patients who had surgery and those who did not. Documentation existed for 51 thumbs (82%) of those who did not have surgery and for 15 thumbs (65%) of those who did. Their average symptom duration before their initial visit is shown in Table 3. There was no significant difference between the groups, (p 5 .95, Student’s t-test). Patients who went on to have surgery were compared with those who did not with respect to any changes in their hobbies or employment and tolerance of splint wear. Seventeen patients (33%) who did not have surgery and 4 patients (18%) who did modified their activities in some way directly related to their thumb pain (Table 4). The difference between the 2 groups was not statistically significant (p 5 .33, Fisher’s exact test). Forty patients (77%) who did not have surgery and 12 patients (54%) who did were able to comply with the splinting protocol (Table 4). Although a much greater percentage of patients who did not have surgery were able to comply with splint wear, the difference between the groups was not significant (p 5 .054, Fisher’s exact test). Forty-five thumbs (70%) that did not undergo surgery had some persistent pain at the time of review. Twenty-four thumbs (37%) had symptoms of equal or greater magnitude to those at the time of the initial visit. Of the thumbs that did undergo surgery, 8 (38%) had some symptoms, including occasional stiffness and pain. According to the patients, these symptoms were much less severe than before surgery.
All Patients The patients also were analyzed as a single group. Of the patients who answered the questionnaire, 53 thumbs (62%) had some relief of symptoms with splinting. Among those whose symptoms decreased, the average improvement was graded as 60% immediately after splinting and 59% 6 months later. Symptomatic improvement with splinting was not dependent on the duration of prior symptoms (p 5 .70, correlation coefficient) nor was it affected significantly by activity modification (p 5 .12, Fisher’s exact test). At the time of the follow-up examination only 7 patients (9%) were still using splints to control symptoms.
Discussion To our knowledge there are no studies that directly evaluate splinting as a conservative treatment for first CMC joint arthritis. Anecdotal mention of its use in the literature on surgical treatment lists poor patient compliance and limitation of hand function as its main disadvantages.4 –7 At the time of initial consultation, however, most patients are reticent to commit to surgery because of concern about postoperative pain and fairly prolonged immobilization and therapy. The patient and physician both benefit from the availability of a conservative treatment option to better assess the severity of the symptoms and to establish a therapeutic rapport. Splinting as a form of enforced rest may sufficiently diminish the acute inflammation so that the patient will be able to return to a normal level of function without significant pain. Dell et al9 studied patients treated nonoperatively as well as those treated with resection arthroplasty for trapeziometacarpal arthritis. In their series, 72% of the patients were treated initially with a C-splint, which is a short, hand-based splint that perhaps immobilizes the trapeziometacarpal joint less effectively than a long opponens splint. Of the 91 thumbs in the study, 16 (18%) had surgical reconstruction. It is unclear, however, how many of these patients were splinted. Their splint protocol varied according to the stage of first CMC joint disease, and the degree of improvement was not quantified. On the basis of an average 16-month follow-up period of patients treated with splinting, Dell et al felt that those with stage I disease were more likely to respond to treatment. As we hypothesized, group A did have a greater percentage of patients with symptomatic improvement with splinting than did group B. This difference was not statistically significant, however, because of the relatively limited number of patients available. Patients who had some symptomatic relief with splinting had an approximately 60% improvement both immediately and 6 months after wearing the splint. As might be expected, patients who eventually underwent surgery had a significantly greater splint failure rate than patients who did not have surgery. The lack of response to splinting was apparent immediately after splint use and did not improve at 6 months. It is noteworthy that not all patients who failed to obtain relief with splinting opted to have surgery. In group A, only 22% who did not improve with splinting chose surgical reconstruction. Sixtyone percent of patients in group B who failed splint-
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 91
ing had first CMC joint surgery. This is likely related to a multitude of factors, such as the degree to which thumb symptoms interfered with a patient’s lifestyle, tolerance for pain, and job and family demands. Among patients who did not have surgery, 33% modified their activities to reduce the stress on the thumb. The remaining 67% did not change their lifestyles and were not sufficiently impaired to opt for surgical reconstruction after splinting. Although more patients in group A modified their activities, the difference was not significant. This trend may have more to do with the younger average age and higher activity level of patients with stage I and II disease. The limitations of this study are those of every retrospective patient follow-up study. First, there was a 35% attrition rate, largely due to an inability to locate the patients because of a lack of forwarding information for home or work. Second, this study depends greatly on the patients’ ability to recollect events and their perceptions of them in the somewhat distant past. This may bias results in that patients who had surgery may have a more clear recollection of these events than those patients who were seen only once or twice for splint treatment. This limited series of patients shows that splinting of the thumb for CMC joint arthritis can be an effective conservative initial treatment. Although it certainly will not cure the pathology, it can provide sufficient relief to avoid or at least postpone surgical reconstruction in a number of patients. It is well-
tolerated and is equally effective for all stages of pathology. Further investigation in a prospective manner is needed to better determine the long-term effectiveness of splinting.
References 1. Armstrong AL, Hunter JB, Davis TRC. The prevalence of degenerative arthritis of the base of the thumb in postmenopausal women. J Hand Surg 1994;19B:340 –341. 2. Aune S. Osteo-arthritis of the first carpo-metacarpal joint: an investigation of 22 cases. Acta Chir Scand 1955;109: 449 – 456. 3. Kelsey JL, Pastides H, Kreiger N, Harris C, Chernow RA. Upper extremity disorders: a survey of their frequency and cost in the United States. St Louis: CV Mosby, 1980. 4. Lane LB, Eaton RG. Ligament reconstruction for the painful “prearthritic” thumb carpometacarpal joint. Clin Orthop 1987;220:52–57. 5. Pellegrini VD Jr, Burton RI. Surgical management of basal joint arthritis of the thumb. Part I. Long-term results of silicone implant arthroplasty. J Hand Surg 1986;11A:309 – 324. 6. Burton RI. Basal joint arthrosis of the thumb. Orthop Clin North Am 1973;4:331–348. 7. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg 1973; 55A:1655–1666. 8. Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis: staging as a rationale for treatment. Hand Clin 1987;3:455– 469. 9. Dell PC, Brushart TM, Smith RJ. Treatment of trapeziometacarpal arthritis: results of resection arthroplasty. J Hand Surg 1978;3:243–249.