Subodh Deshmukh Consultant Hand and upper limb surgeon The Royal Orthopaedic Hospital

 Bony anatomy leads to inherent stability

 Complex of 3 joints:-

 Humero-ulnar – Complex hinge – Flexion/extention

 Radio capitellar – pronation/supination  Complex bony &  Proximal radio ulna ligamentous anatomy – pronation / supination

 Ulnar nerve  Pain & stiffness

 Radial nerve  Locking- loose bodies

 Median nerve  Pins & needles , hand weakness  Cutaneous nerves Look: scars, sinuses, muscle wasting, deformities Feel: Tender areas, palpate lumps  : lateral epicondylitis (extensor)  Golfers Elbow: medial epicondylitis (flexor) Move: active and passive ROM Flexion/Ext,  Olecranon Pronation/supination  Osteoarthritis Measure: Muscle girth in forearm, and arm  Cubital Tunnel Syndrome (ulnar nerve compression) Special tests: elbow flexion test for cubital tunnel syndrome

 Tennis elbow:  Often middle aged (35 - 50) – Lateral elbow pain reproduction on resisted  Pain can commence after minor trauma. wrist extension(Mills' Test)  May be recent history of excessive activity involving that elbow (rarely tennis ! Dusting, sweeping, heavy gardening etc).  Golferʼs elbow:  Golferʼs elbow similar history but medial pain less common than tennis – Medial elbow pain reproduction on resisted wrist flexion.

 Non operative  Operative  Gradual onset pain and stiffness  Can be pos-trauma e.g fractures/ fracture – Activity modification – decompression – NSAIDS dislocation – Clasp – Physiotherapy  Treatment is symptomatic with Rest, physiotherapy – Ultrasound – Streroid injections and analgesia.  May lead to loose body formation and may require arthroscopic removal and debridement  In extreme cases joint replacement can be considered  Pain/paraesthesia in ulnar nerve distribution  Provocation of symptoms on forced elbow flexion for > 20 secs  Weakness in hand and loss of dexterity  Hypothenar muscle wasting  Intermetacarpal Guttering  Wasting of the first dorsal interosseous and Adductor Pollicis  +ve Fromentʼs sign, inability to hold paper between fingers +ve Fromentʼs sign Intrinsic muscle wasting  INVESTIGATIONS: +ve nerve conduction studies showing slowing in Ulnar nerve conduction velocities across the elbow joint

 MANAGEMENT – Cubital tunnel decompression

– Ulnar nerve anterior Transposition

 Inflammation of  Management olecranon bursa  May resolve spontaneously  Can be pain free  May require incision and drainage  May require excision  May get infected by inoculation by foreign bodies

 Flexor and extensor retinaculum. – Median nerve passes deep to FR with flexor tendons. Except for palmar cutaneous branch which is superficial  Sensory supply to hand from ulna, median and radial nerves.  Nerve compression Syndromes – Carpal Tunnel Syndrome – Cubital Tunnel Syndrome

 Arthritis – rheumatoid – osteoarthritis

 Trauma – Tendon injuries – Chronic injuries

 Swellings

 Dupuytrens

 Wrist pain  hand dominance – specific wrist pathology or generalised  history of previous injury condition – e.g. Collesʼ fracture, scaphoid fracture – onset  job / occupation  rapid: trauma or infection – ability to continue with this  slow: degenerative – what does job involve? – association with other joint problems  hobbies – other obvious conditions e.g. RA – musical instruments

 night pain  Hand pain  pattern of symptoms – Many similar features to wrist pain – aggravating and relieving factors – Specific location e.g. base of thumb – worse after activity / use – Neurological origins  pain distribution  swelling of the wrist/surrounding tissues – carpal tunnel syndrome – ulnar neuritis  precipitating events  Functional problems: – holding paper up – lack of grip strength – night time symptoms – dropping items and “clumsiness” – other medical conditions Thyroid, RA, DM – triggering of fingers  lack of ability to straighten fingers

Look: scars, sinuses, muscle wasting, deformities Feel: Tender areas, palpate lumps  swellings – rapidity of onset Move: active and passive ROM – soft or hard Measure: Muscle girth in forearm, – diffuse single or multiple Special tests: Tinelʼs and phalenʼs test, muscle  other swellings on bony areas in the body power of the intrinsics, thenar and hypothenar muscles and long flexors and extensors of the fingers, instability signs in MCPJ of the thumb in Gamekeeperʼs thumb

Testing APB Testing FPL Testing Opponens pollicis Testing opponens pollicis Hypothenar mucles and Partial claw due to ulnar nerve Firsr dorsal interosseous Interossei testing involvement. Lumbricals of index and middle fingers still working because they are supplied by median nerve and prevent clawing of those two Total clawing due to median fingers and ulnar nerve involvement

Testing for Flexor digitorum Testing for Flexor digitorum superficialis profundus

Testing Extensor pollicis longus Testiing EDC action  very common  females often  may not be symptomatic  symptoms do not necessarily correlate with x-rays Preop xray Post trapeziectomy

Treatment:  splint + analgesia

 injection Post CMCJ implant arthroplasty  excision

 arthrodesis Post 1st CMCJ fusion  replacement

 Systemic autoimmume disorder  Other changes DIP joint arthritis (Heberdenʼs nodes)  mucous cysts.  Predominantly synovial invovement  Treat hand therapy  Goals of treatment – Hot wax and NSAIDs – 1) pain relief  Arthroplasty (MCP and PIP) – 2) improved function  Fuse DIP – 3) prevent further damage  Interposition arthroplasty – 4) cosmesis

can lead to: Cartilage destruction by pannus (inflamatory granulation tissue)

Tendon compression and rupture

Nerve compression

Erosion and dislocation of joints  MCP ulnar drift – cause stretch  Early synovitis -medical management and ulnar subluxation of the extensors   Persistent synovitis -synovectomy Therapy and medical treatment  Surgical rebalance of  Specific deformity -corrective reconstruction &/or muscles and realignment joint replacement or joint fusion of the extensor tendons  New MCP joints

 Severe crippling -joint replacement or joint fusion

 Hyperextended PIPJ  Flexion deformity DIPJ  Can occur due to problems in the MCPJ (volar subluxation) or in the PIPJ

Metal on Polyethelene (synovitis) Silastic MCPJ replacement Pyrocarbon replacement arthroplasty arthroplasty

 Central slip rupture or  Treatment: elongation due to trauma or – early – splinting synovitis respectively of the PIPJ initiate the deformity

– late – soft tissue  Later on Lateral bands migrate correction or fusion in a palmar direction and act as flexors of the PIPJ and the deformity becomes fixed – sometimes treating more proximal problems may resolve the deformity  Therapy and splintage

 Flexion of DIPJ which corrects passively.  Soft tissue procedures  Occurs due to rupture/avulsion of extensor tendon from distal phalanx.  PIPJ Fusion,

PIPJ replacement and DIPJ  Usually treated with mallet splint. PIPJ fusion fusion  PIPJ arthroplasty +/- DIPJ fusion  Long standing and severe deformities may require DIPJ fusion

 Synovitis of the wrist is common Synovitis leads to subluxation and collapse of the wrist joint  If medical treatment fails open synovectomy can be undertaken  If not consider Wrist fusion or replace mentwhich provides a stable base for hand function and  Darrach procedure (excision of the ulnar head) for painful/subluxed DRUJ

 Fibrosis of longitudinal structures in palmer fascia leading to of MCPJ & PIPJ

 Can be associated with – penile fibrosis (Peyronieʼs disease) – sole of feet (Ledderhoseʼs disease)

 Thick knuckle pads (Garrodʼs) Partial fasciectomy Risk factors  Consider surgery if affecting function  Northern European Races – Washing face - poking eye – Hand shake  Chronic alcoholism – Canʼt put hand in pocket  Liver disease – Work place risks  Smoking  Diabetes  Types of surgery Dermofasciectomy and full thickness skin graft  Epilepsy / Antiepileptics  Collagenase injection  Family history  Aponeurotomy (Dupuytrenʼs diathesis)  Partial fasciectomy  Dermofasciectomy and full thickness graft  External fixator distraction

 Congenital or acquired  Complications of surgery – nerve and vessel damage – Joint stiffness  Thickening of the flexor tendon such – Haematoma and infection that it does not pass through the – recurrrence sheath.

 Treatment !  Local injection or  Surgical release

 Usually occur spontaneously  Contain gelatinous fluid due to mucoid degeneration of the synovium.  Inflammation affecting EPB  Develop around joints or tendon and APL.tendons and their sheaths, and usually communicates sheaths with the joint.  Women more often affected  Most common around the wrist. Dorso  30-50yrs. radial or volar radial  Finkelsteinsʼs test.  Can be intermittently painlful  Treatment  Treatment=aspiration or excision, – Rest and NSAIDʼs. – Corticosteroid injection.  Beware of recurrence! – Surgical Decompression.  Causes (ICRAMPS)  Signs: • Idiopathic ( commonest) – Tinelʼs sign • Colles, Cushings – Phalenʼs sign • Rheumatoid – Direct compression sign Acromegaly, amyloid • – Thenar muscle wasting Myxoedeoma, mass, (diabetes) mellitus • and weakness • Pregnancy • Sarcoidosis, SLE – sensory disturbance

 Consider nerve conduction tests  Paronychia infection of nail-fold  May require antibiotics or surgical  Non-surgical treatment: drainage – splint/analgesia/injection  Fight bites and animal bites  Surgical treatment – innoculation of MCPJ or PIPJ with oral organisms  Open or arthroscopic carpal tunnel – Human and animal bites lead to infection with complicated group of organisms ( e.g gram negative and Decompression has 98% success in anaerobes) indicated cases – treat with considerable seriousness ( early surgical debridement and antibiotics)

 signs: – pain (passive extension)  Web space infection – flexed position – local tenderness along tendon sheath – swelling  Can lead to Thenar and  Elevation, antibiotics, drainage and Mid-palmar space irrigation infection which are  Untreated septic leads to potential spaces tendon liquefaction and finger stiffness  Thank you