Joe A Shaw PA-C - 3/22/2009

Question
QUESTION: I am 40yr old female.
Pre-Op Diagnosis: CMC arthritis thumb & right
de Quervain's.
In March I underwent right CMC fascial arthroplasty using half flexor carpi radialis & palmaris longus for tendon graft along w/ first dorsal comp. release.

Post-op I have barely been able to use thumb due to pain & weakness.  They had me stop therapy for suspected sesmoid problem which recent MRI excluded, but noted changes in 2nd CMC joint.  I don't understand that.  Regardless, I've since had 2 rounds of injections into 2nd CMC & also FCR scaphoid tubercle.  They barely helped.  I am now given option to have surgery to release 2 tendons as they are suspected to be the culprits of my problem (xrays show bones aren't rubbing).  I'm not too excited about that idea as you can imagine, however, it's been 6 mos of limited ability w/lots of pain (loss of income) & I am desperate to move forward.  I have bleeding ulcers so I am not allowed to take anti-inflams so I have been on prescription pain meds which I certainly can't continue to take indefinitely.

I was wondering if you see many tendon issues post-op for this type of surgery & how people have handled it with success.  Could releasing more tendons cause yet more problems?  (It seems like Pandora's box has been opened.)

I sincerely appreciate any feedback.

ANSWER: Jayne,
There are several different procedures for this type of thing. It can be a hard thing to make better once you have it bad enough where surgery is required (CMC arthr.)
Sometimes a second surgery is needed to remove some of the bone so the joint aligns more properly and the thumb is more in a natural position and this is what is sounds like to me?
Below is a very good article and can go into much more detail than I can here. Last resort would be fusion of the joint area..helps reduce or eliminate pain but thumb usage is greatly limited.

http://xnet.kp.org/socal_rehabspecialists/ptr_library/04WristandHand%20Region/25

---------- FOLLOW-UP ----------

QUESTION: 8 wks ago I had the surgery to cleanup 1st dorsal comp.& FCR tunnel.  2wks ago the FCR tendon completely ruptured!!  I wasn't even doing anything strenuous, just tucking bedsheet in mattress.  WOW..is this painful!  Is this a common thing/risk w/using the FCR for CMC arthoplasty?  Dr. says it is most likely not salvagable.  He may go in to cleanup ends of tendon.  Don't I NEED this tendon?  What type of limitations will I have? Will not having FCR put great strain on remaining supporting tendons (other potential ruptures)?  I've been in cast for 2wks. I can finally straighten fingers w/only little pain, but I still can't open frig door, turn knobs, etc. w/out extreme pain. Will this get better?  How long?  Sorry for so many questions.  I am so overwhelmed my chain of events.  Thank You-"Jayne's In Pain"

ANSWER: Jayne,
The flexor carpi radialis is located on the upper half of the forearm.  It originates at the humerus (upper arm bone) and extends down the arm developing into a wide, flat tendon about one-third of the way down the arm and inserts in the base of the metacarpal bones of the index and middle fingers deep in the palm.  This muscle bends and turns the hand at the wrist. Several other flexors will help take up the slack,but obviously it won't be 100% normal.I don't think the others would be prone to rupture..as long as youre not major stressing it..ie wt lifting,hanging from chin-up bar.
I can't find anything on how common a FCR rupture is after using some of it for cmc repair. In general, on a normal healthy person w normal use it is rare that a FCR would rupture but it does happen.
I think it will take several mos to maybe 6 mos to see how good it will get. I would think a hand OT is in order as you progress.

---------- FOLLOW-UP ----------

QUESTION: Ruptured FCR confirmed and still causing problems...had MRI which showed "abnormally thickened retracted & wavy tendon at midforearm level likely representing complete rupture of FCR from its insertion sites at bases of 2nd & 3rd metacarpal w/tendon retracted to midforearm level.  Also subjacent increased T2 signal (synovitis?). Also edema of FCR muscle."  I am having level #5 pain w/usage & very limited.  Dr is having me try "tenz?" therapy to attempt to minimize ball of retracted tendon.  If this doesn't work I guess surgery might be the next option.  Any suggestions or insight you could offer is immensely appreciated as you have been so considerate thus far. Thanks.

Answer
Jayne,
See if you can copy/paste this link:

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7CRN-4KYXHXG-2&_user=1

Hers was treated w/o surgery, but was a straight forward FCR rupture looks like.
If it is a "TENS unit"? [acronym for Transcutaneous Electrical Nerve Stimulation] this is something that is usually used to help reduce pain.
Surgery is going to be reserved for pts who are in a lot of pain and who do not respond to conservative measures and who have lossed a lot of hand function. Hope you will respond to conservative treatment.