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Common Hand, Wrist and Elbow Problems

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Common Hand, Wrist and Elbow Problems 12/15/2018 COMMON HAND, WRIST Disclosures AND ELBOW PROBLEMS: Research Support: HOW TO SPOT THEM IN San Francisco DPH CLINIC Standard Cyborg Nicolas H. Lee, MD UCSF Dept of Orthopaedic Surgery Assistant Clinical Professor Hand, Upper Extremity and Microvascular Surgery Dec. 15th, 2018 DIP joint pathologies Mucous Cyst – ganglion cyst of DIP joint 1. Mucous Cyst 2. Mallet Finger 3. Jersey Finger 1 12/15/2018 Xray Treatment “Jammed Finger” Mallet Finger • Recurrence rate with aspiration/needling? 40-70% • Recurrence rate with surgical debridement of osteophyte? Jersey Finger 0-3% • Do nail deformities resolve with surgery? Yes - 75% 2 12/15/2018 Mallet Finger Mallet finger Soft Tissue Mallet • 6 weeks DIP immobilization in extension • Night time splinting for 4 weeks Bony Mallet http://www.specialisedhandtherapy.com.au/ Red Flag Mallet Finger Red Flag Jersey Finger When to Refer: Flexor Digitorum Profundus (FDP) 1. Big fragment strength testing 2. Volar subluxation of the distal phalanx http://nervesurgery.wustl.edu/ http://www.orthobullets.com REFER ALL JERSEY FINGERS ASAP!!! 3 12/15/2018 Trigger Finger and Thumb Trigger finger • Presentation • Clicking or frank locking • Especially at night or morning • May also present with just pain at the A1 pulley Trigger Finger Primary Trigger Finger • Physical Examination • Most Common • Locking or clicking over the A1 pulley • “Idiopathic” • Tenderness at the A1 pulley • No known cause 4 12/15/2018 Secondary “Congenital” • Associated with known disease • Infantile form • Disease cause thickening in tendon/pulley • “congenital” is a misnomer • Diabetes • Rheumatoid arthritis • Amyloidosis • Sarcoidosis Treatment Options Trigger finger Splinting •Nonoperative • Splint to prevent MCP or •Observation PIP flexion. •Non-steroidal anti-inflammatory • Patient education medication • Symptom management • Studies show Ice •Splinting steroid injection alone is more •Corticosteroid injection effective than splints •Operative release 5 12/15/2018 Steroid Injection Injection • 60-70% can resolve after a • Combination local single injection anesthetic and steroid • Most effective if symptoms less than 6 mos • At level of A1 pulley • No difference in success • Lower success rate if injected inside or • younger patients outside of the sheath • diabetics • 10 mg kenalog • multiple fingers • 1 cc 1% lidocaine • 27 gauge needle • other upper extremity tendinopathies • Inject slowly!!! Injection in Diabetics Surgery Indications • Failure of non-surgical treatment • Patients with locked finger • Increase blood glucose • May be a first line treatment in diabetics • Greatest effect 24 hours after injection • Effect lasts up to 5 days 6 12/15/2018 Surgery - A1 Pulley Release Infantile Trigger Thumb • Nonoperative (age less than 2) • Protect the digital - Indications: age < 2, flexible deformity artery and nerve - 30-60% spontaneous resolution if age < 2 - <10% spontaneous resolution if age > 2 • Release A1 pulley 1. Passive thumb extension exercises 2. Intermittent extension splinting • Operative (A1 pulley release) - Indications: age > 2, fixed deformity beyond age 1 Thumb CMC arthritis History • Do you have difficulty: • pinching, writing • opening a tight jar • Opening doors, keys • carrying a shopping bag • using a knife to cut food 7 12/15/2018 Clinical Exam Nonoperative • Physical appearance • Tenderness Splints • Specific Tests • Custom made thermoplastic splint • Grind • Off the shelf splint CMC Protection program • Adaptive equipment • Activity modification education • Symptom management Van Heest, JAAOS 2008 Treatment: Surgical Trapeziectomy +/- Thumb CMC OA CMC Arthroplasty Fusion (Young laborer) something else • Injection • Distract the joint • Mark the site of injection • Prepare the site of injection • Max: 1 cc Joint distension = pain http://www.aafp.org/afp/20030215/745.html 8 12/15/2018 Dequervains Tenosynovitis DeQuervain’s Tenosynovitis • Tendinosis of tendons of the first dorsal compartment • Abductor pollicis longus (APL) and extensor pollicis brevis (EPB) • Sheath enclosing the tendons becomes narrowed leading to pain and inflammation Anatomy Symptoms • Pain on thumb (radial) side of wrist • Worse with lifting/ repetitive activity • Mothers of very young children • Worse at night • Worse with thumb motion Hand Surgery Update IV, Chapter 22, Figure 4a 9 12/15/2018 Symptoms Examination • More common in women (6:1 ratio) • Tenderness over tendons at thumb • Often occurs in new mothers and in later stages of side of wrist pregnancy as an overuse of the thumb • Finkelstein’s test • Pain at the thumb base or radial wrist • Place thumb in fist; move fist ulnarly, sharp • Patients will sometimes complain of ‘clunking’ of the pain over the radial wrist thumb Treatment Dequervain’s tenosynovitis • Nonoperative • Surgical • Pre-fabricated or custom made splint • Ice • Activity modification • Patient education 10 12/15/2018 DeQuervain’s Tendonitis DeQuervain’s Tendonitis • Non-operative treatment • Injection • Up to 80% success rate, but may require 2 injections • Risk of skin de-pigmentation • Injection • 1cc 1:1 mix of lidocaine 1% and water soluble steroid (less risk of skin depigmentation) • Inject inside sheath and not subQ http://www.aafp.org/afp/20030215/745.html • Combination of splint and injection not more effective than injection alone • Should see the compartment fill up www.assh.org • Generally limit injection to 2-3 max Pregnancy/lactation Surgical Treatment • Thought due to the increased fluid shifts/edema secondary to hormonal fluctuation • Indicated only after • Generally responds to splinting and/or corticosteroid failure of injection conservative • One study showed nearly 100% response to steroid treatment injection, symptoms almost always resolve at the end of lactation • Division of the fibro- osseous sheath over the tendons 11 12/15/2018 Ganglion Cyst Wrist Ganglion Cyst Dorsal – 70% Volar – 20% Occult ganglion cyst Recurrence rates Dorsal Ganglion Aspiration: 87% recurrence (single aspiration) 50-70% recurrence (repeat aspirations) Surgical: 4% recurrence rate Volar Aspiration: 85-100% recurrence • Aspiration not recommended (proximity to radial artery, palmar cutaneous branch of median nerve) Surgical: 7% – 33% recurrence rate 12 12/15/2018 Carpal Tunnel Syndrome Symptoms Numbness into any combination of the thumb, index, middle, and half of ring finger Anatomy (motor) Symptoms • Worse at night, with wrist bent (phone, driving, sleeping) • Pain/burning in the wrist, fingers, arm • Thenar Muscle • Late stage- • Opponens Pollicis - weakness • Abductor Pollicis Brevis - “clumsy” • Flexor Pollicis Brevis - “can’t button my shirt” (Superficial 1/2) - “drop objects” ASSH Patient Handout Carpal Tunnel Syndrome 13 12/15/2018 Diagnosis: Tinel’s Sign Diagnosis: Phalen’s Test Durkans (Carpal compression test) Diagnosis • Thenar Muscles (APB) • Weakness • Atrophy 14 12/15/2018 Diagnosis of Carpal Tunnel Syndrome Stages Mild Duration < 1 year Diagnosis is founded on: Intermittent numbness Normal sensory testing No weakness or atrophy • A clear history of specific symptoms. Minimal NCV changes, no denervation Moderate • Clinically apparent signs. Continuous numbness, paresthesias Increased threshold on sensory tests • Clinically measurable sensory and motor Increased distal motor latency deficits. Severe Persistent loss sensory+ motor function • Reproducible provocative diagnostic tests Thenar atrophy • And, if needed, electrodiagnostic tests. Treatment Nonsurgical Treatment • Nonoperative • Initial treatment for most cases • Surgical • Splint • night • Occupational therapy – nerve glides • Corticosteroid injection 15 12/15/2018 Carpal Tunnel Syndrome: Therapy Carpal Tunnel Syndrome . Injections • Patient education . Therapeutic . 80% of patients have symptom improvement @ 6 weeks • Night time wrist brace . Of those, only 20% are symptom free at 12 months • Nerve glides . Diagnostic • Activity modification . Help isolate contribution of carpal tunnel to current presentation . Prognostic . 93% of those that improve with injection also improve with surgery Carpal Tunnel Syndrome Surgery • Injection • Release transverse • 1 ½ inch 27 g needle carpal ligament • 1 cc of 1:1 mix lidocaine: steroid • Inject ulnar to palmaris longus or in-line with ring finger • Start at proximal wrist crease aiming 30-45 degrees distally tUNA PLT Median to RAre 16 12/15/2018 Surgical Treatment Elbow Pathologies (From Columbia University dept. of neurosurgery website) • Cubital Tunnel • Lateral Epicondylitis Adductor Pollicis and 1st dorsal interossei Cubital Tunnel atrophy • Ulnar nerve compression about the elbow • Clinical • numbness and tingling small and ring fingers • weakness of flexor digitorum profundis to small and ring finger • Froments sign • Wartenburgs sign 17 12/15/2018 Physical Exam: Intrinsics Signs (PAD, DAB) • Wartenberg’s sign • ulnar deviation of the small finger and weakness of adduction of the small finger Signs Nonoperative Management • Froment’s sign • Compensatory IP joint flexion for key pinch (weak Adductor pollicis, weak MP flexion of thumb) • Night towel splints to prevent full elbow flexion Normal Key Pinch Abnormal Key Pinch • Activity modification • Nerve glides • Patient education 18 12/15/2018 Operative Management Lateral Epicondylitis • In-situ decompression • One of the most common overuse syndromes • Subcutaneous Transposition encountered in the upper extremity • Known as tennis elbow after being described by Morris in 1882 to • Intramuscular Transposition
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