Excision Arthroplasty for First CMC Joint Tuberculous Osteomyelitis

INTRODUCTION: Tuberculous involvement of metacarpals and phalanges is a rare presentation of extrapulmonary tuberculosis in adult. Tuberculous infection of the metacarpals, metatarsal and phalanges of hands and feet is known as tubercular dactylitis. CASE REPORT: A 65 years old female with history of pain and swelling at 1st metacarpal of left hand, since 3 months which gradual in onset and progressive in nature associated with multiple cervical swellings. While radiographs showed a pathological fracture of the 1st carpo-metacarpal joint (CMCJ) with soft tissue swelling, MRI revealed a large heterogenous lesion at the carpo-metacarpal joint of the thumb with bony erosions of the trapezium and 1st metacarpal base on T2W-STIR images. The lesion was extending upto the palmar aspect of the hand and displacing flexor pollicis longus tendon medially. During surgery, there was caseous material seen which was debrided and the fractured fragment was excised and sent for biopsy. The CMCJ was found to be unstable and a kirschner wire was used to stabilize the 1st CMCJ and immobilized in a POP splint. The biopsy of the fragment revealed tuberculous osteomyeltis. On follow-up the K-wire had backed out partially at the end of 5 weeks which was then removed and range of motion was started. At end of 1 year follow up the patient had little restriction of movement as compared to the opposite hand with no pain and hindrance in daily activity. CONCLUSION: The swelling subsided once Anti-Tubercular Treatment was started. The cervical lymphadenopathy also resolved over a period of 1 month.