A Primary Care Hand Surgery Update:

Frontline diagnosis, management, and treatment options for common hand conditions

David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute

September 17, 2020 Disclosures

• None Objectives

• To review diagnostic pearls for common hand conditions • To review primary care treatment for common hand conditions • To review surgical treatment options for common hand conditions Outline • Finger arthritis vs trigger finger • Wrist arthritis vs ganglion cyst • Carpal tunnel syndrome vs cervical radiculopathy • Hand arthritis vs Dupuytren’s contracture • Jammed finger vs broken finger “My hands hurt” • 64F with progressive hand and finger pain and stiffness • How do you differentiate between pain from arthritis vs trigger fingers? Diagnostic Pearls • Arthritis – Worsens with use – More tender dorsally – Decreased passive ROM • Trigger finger – Loosens up with use – Point tender over A1 pulley – Preserved passive ROM Primary Care Treatment • Arthritis – Topical NSAID (e.g. Voltaren gel, Penetrex) – Paraffin bath – Arthritis compression glove • Trigger finger – NSAIDs – Nighttime splint – Corticosteroid injection • (1ml 1% lidocaine, 1 ml 0.5% marcaine, 1 ml Celestone) Hand Surgery Treatment • Arthritis – DIP joint • fusion – PIP joint • silicone arthroplasty – MCP joint • arthroplasty – Thumb CMC • trapeziectomy Hand Surgery Treatment • Trigger Finger – A1 pulley release “I have a lump on my wrist” • 58F with a gradually enlarging mass on the back of her wrist • How do you differentiate between a dorsal ganglion cyst and swelling from wrist arthritis? Diagnostic Pearls • Dorsal ganglion cyst – Pain primarily with loading wrist in extension – Discreet palpable edges of the mass – Normal radiographs • Wrist arthritis – Pain with any forceful gripping or use – More diffuse, less well- defined edges of mass – X-ray changes of SLAC arthritis Primary Care Treatment • Dorsal Ganglion Cyst – Observation – Needle aspiration • Wrist arthritis – NSAIDs – Splint – Corticosteroid injection • (1ml 1% lidocaine, 1 ml 0.5% marcaine, 1 ml Celestone) Hand Surgery Treatment • Dorsal Ganglion Cyst – Surgical excision • Wrist arthritis – Proximal row carpectomy – Scaphoidectomy and 4- corner fusion – Wrist hemiarthroplasty “My fingers fall asleep” • 70M with gradually progressive numbness and tingling in the hands • How do you differentiate between carpal tunnel syndrome and cervical radiculopathy? Diagnostic Pearls • Carpal tunnel syndrome – Often bothersome at night or in morning – N/T affecting thumb, index, middle +/- ring – Symptoms aggravated with prolonged gripping – EMG • Cervical radiculopathy – Less bothersome at night – Dermatomal distribution of N/T with more prominent arm pain/paresthesias – Symptoms aggravated with certain neck positions – MRI Primary Care Treatment • Carpal tunnel syndrome – Night time wrist splint – OT/nerve gliding exercises – Corticosteroid injection • (1ml 1% lidocaine, 1 ml 0.5% marcaine, 1 ml Celestone) • Cervical radiculopathy – NSAIDs/Medrol dose pack – Gabapentin/muscle relaxers – PT Hand Surgery Treatment • Carpal tunnel syndrome – Corticosteroid injection – Carpal tunnel release • Cervical radiculopathy – Phone-a-friend “What are these bumps on my hands?” • 45M with gradually progressive nodules on the hands • How do you differentiate between hand arthritis and Dupuytren’s contracture? Diagnostic Pearls • Dupuytren’s Contracture – Usually painless – Nodules and cords on palm – Often flexion contracture but full active flexion • Hand Arthritis – Painful – Nodules on dorsal surface of joints – Stiff in both flexion and extension Primary Care Treatment • Dupuytren’s contracture – Observation – Education/reassurance – +Tabletop test refer • Hand arthritis – Topical NSAID (e.g. Voltaren gel, Penetrex) – Paraffin bath – Arthritis compression glove Hand Surgery Treatment • Dupuytren’s contracture – Xiaflex injection – Surgical fasciectomy • Hand arthritis – As above “I jammed my finger” • 17F with sore finger after jamming it in basketball practice • How do you differentiate a sprained finger and a broken finger? Diagnostic Pearls • Sprained finger – Swollen – Tender to palpation – Negative x-ray • Finger fracture – Swollen – Tender to palpation – Positive x-ray Primary Care Treatment • Sprained finger – Buddy tape – NSAIDs – Patience • Finger fracture – Splint – BEWARE the bony fleck – Consider referral Hand Surgery Treatment • Sprained finger – Anti-edema sleeve – OT – aggressive ROM • Finger fracture – Splinting with early ROM – Closed reduction and pinning – ORIF Thank You! Questions or Comments?

[email protected] Cell 605-906-0473