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

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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%

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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!!!

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Diagnosis: Tinel’s Sign Diagnosis: Phalen’s Test

Durkans (Carpal compression test) Diagnosis

• Thenar Muscles (APB) • Weakness • Atrophy

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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

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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

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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

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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

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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 be caused by lawn tennis • Submuscular transposition • Tendinosis of the components of the extensor origin • Medial epicondylectomy

Epidemiology Risk Factors

• 1-3% of population will experience in their lifetime • Manual labor with heavy tools • Equal male/ female incidence • Repetitive activities • Usual onset between age 35-50 • Dominant arm • 5-10% can be attributed to playing tennis • Poor coping mechanism • Risk increases 2-3.5x playing > 2 hr/ week • Depression • Age > 40 • Associated with hard surface, poor stroke mechanics, improper grip and racquet weight

Lateral Epicondylitis

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Clinical Presentation Clinical Presentation

• Pain over the lateral aspect of the elbow • Localized at or just distal to epicondyle • Night pain present in severe cases • Sharp/burning in nature • Stiffness upon wakening may be described by patient • Radiation along course of wrist extensors • Pain with even light daily activities • Worsened by resisted wrist extension with elbow extended • Shaving • Worsened by resisted middle finger extension with elbow extended • Picking up coffee cup • Weakness of grip • Difficulty grasping or lifting items

Lateral Epicondylitis Lateral Epicondylitis

Pathoanatomy Physical Exam

• Lateral epicondylitis begins as a microtear • Inadequate healing response • Assess for warmth or • Always involves the ECRB erythema • Deep and more superior fibers • Point tenderness just • Histologically proven tendinosis (Nirschl) distal and anterior to • Disordered collagen lateral epicondyle • Mucoid degeneration • Angiofibroplastic hyperplasia • No inflammatory component

Lateral Epicondylitis Lateral Epicondylitis

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Physical Exam Physical Exam

• Pain with resisted wrist • Assessment of grip extension strength • Long finger extension • Compare to unaffected test side • Baseline objective • Pain with passive wrist measure of severity of and digital flexion lateral epicondylitis • Can be tested serially to assess response to treatment Lateral Epicondylitis

Treatment Lateral Epicondylitis/Tennis elbow • Activity modification • Limit lifting and repetitive grasping • Lifting with elbow flexed or forearm supinated need not be • restricted Wrist brace to immobilize the wrist extensors • No vibrational tools • Equipment modification • Passive stretches (Mill’s) • Restring racquet • Ice • Change grip size • Soft tissue massage • No gloves (they increase gripping force) • Patient education • Activity modification

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Treatment Treatment

• Nirschl Exercises • Physical Therapy • Focuses on increasing strength, • Cross friction massage flexibility and endurance • Stretch wrist extensors w/ elbow • Eccentric strengthening extended • Ultrasound • Progress to isometric and • Iontophoresis concentric strengthening • NSAIDS (Oral and topical) • Resume activities with increasing duration

Lateral Epicondylitis

Treatment Other Treatments

• Corticosteroid injection • Counterforce brace • Platelet-rich Plasma • Theoretically limit muscle • Surgery expansion • Create a new more distal muscle origin • Less tensile stresses seen by injured tendon • Wrist cock-up splint • Diminishes contraction of the wrist extensors

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PRP (Platelet Rich Plasma) Do corticosteroid injections help?

Conclusions This meta-analysis showed that there is no difference in pain intensity between https://benchmarkbiomedical.com/platelet-rich-plasma/ Conclusion corticosteroid injection and placebo 6 months after injection. We interpret the weight of evidence to date as suggesting that corticosteroid injections are neither 1. Corticosteroid injections provide rapid therapeutic effect in the short- meaningfully palliative nor disease modifying when used to treat eECRB. term with recurrence of symptoms afterwards (J Hand Surg Am. 2016;41(10):988-998. Copyright 2016 by the American Society for Surgery of the Hand. All rights reserved.) 2. Platelet-rich plasma (PRP) work relatively slower but have a longer-term effect

References • Nirschl Procedure: 1. Carpal Tunnel Syndrome Arthroscopic or open ECRB debridement with resection Cranford, C.S. et al JAAOS Sept 2007; v15 (9): 537-548 of diseased tissue 2. Trigger Digits: Diagnosis and Treatment Saldana, M.J. et al J AAOS July 2001;9:246-252 3. Corticosteroid Injections in the Treatment of Trigger Finger: A Level 1 and II Systematic Review Fleisch, S. B. et al JAAOS March 2007;15:166-171 4. De Quervain Tenosynovitis of the Wrist Ilyas, A.M. et al JAAOS Dec 2007;15:757-764 5. Management of Lateral Epicondylitis: Current Concepts Calfee, R. et al JAAOS Jan 2008;16: 19-29

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Thank You

Questions?

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