Approach to Hand Conditions

Alphonsus Chong

Associate Professor, Department of Orthopaedic Surgery, Singapore Senior Consultant, Department of Hand and Reconstructive Microsurgery, Singapore http://bit.ly/39fuCIK [email protected]

Scope

• Introduction – Slides at http://bit.ly/39fuCIK • And other material at: https://nus.edu/2Mh4e4s • Physical examination http://bit.ly/39fuCIK : these slides • Traumatic injuries – open and closed • Peripheral nerve problems • Masses in the hand and wrist • Tendinopathy and tendinitis • Deformity

https://nus.edu/2Mh4e4s: hand wiki

3 History Taking

• Pain – different aspects • Handedness • Deformity • Job v – Congenital • Hobbies – Acquired - ? Traumatic • Previous injury/ surgery • Decreased rangev of motion • Weakness • For acute trauma/conditions: • Numbness – Last meal v • Others e.g. triggering, instability – Mechanism of injury – Time/date of injury Expose both sides: subcutaneous border Scars, wasting, deformity of ulna and elbow- rheumatoid nodules

Completeness and fluidity of motion

Scars, wasting, deformity Quick Nerve Screen

Median Nerve Radial Nerve

Ulnar nerve Traumatic Injuries – Open Injuries

Open traumatic injuries are a staple work of hand surgeons. Assessment of Hand – Work through the tissues (see Apley)

• Skin – note size and types of wounds • Vessels - circulation • Nerves – sensation and motor • Muscle and Tendons – individual flexor and extensor tendon testing • Bones & Joints – appropriate x-rays to assess fractures/ dislocation What do you see?

• LOOK • LOOK – Loss of cascade

• Skin – lacerations • Skin • Vessels – Color looks fine; • Vessels check cap refill, turgor, • Nerves temperature • Tendons • Nerves – 2 PD of RF and SF • Tendons – FDP and FDS RF and • Bone and joint SF • Bone and joint – X-rays; also to check for foreign bodies Wrist Injuries

• Distal radius fractures • Scaphoid fractures • Perilunate and lunate dislocations Distal Radius Fractures (DR Fx)

• Distal 3 cm of the radius • Very common • Varied in appearance • Avoid eponyms (Colle’s, Barton’s etc..) • Classification – AO

– Practical Typical “Colles” type osteoporotic fracture: Extra-articular, dorsal angulation, loss of radial height Practical assessment of distal radius fractures (DR Fx) • Open or not? • Intra or extra-articular • Assess displacement: – Shortening – Angulation – Translation – Rotation • Let’s try DR Fx: Mechanism and associated injuries

• “FOOSH” (fall on outstretched • Complications hand) injury • Early • Associated injuries – Median nerve compression – Ulna styloid +/- TFCC (triangular • Intermediate fibrocartilage complex) injuries – Extensor Pollicis Longus rupture – Ulna head – Reflex sympathetic dystrophy/ – Scaphoid and other carpal fractures CRPS • Late – Malunion – Stiffness of hand and wrist Treatment options • Conservative (Min displacement, unfit) – immobilization – plaster, thermoplastic splint – Manipulation and reduction if displaced • Open reduction and internal fixation Internal fixation: volar locking plate Kirschner wires – Plates and screws (mostly volar and external plate now) fixator – Wires • External fixation • Homework: typical indications for ORIF External fixator Scaphoid fractures

• Common fracture • Easy to miss – initial symptoms, x-ray problems • Vascularity issues  non-healing/ Avascular necrosis if not treated well  SNAC

20-30% of blood supply

70-80% of blood supply Poor Vascularity

Clinical assessment scaphoid fractures

• 16-40s male • Fall • Radial sided wrist pain Snuffbox tender Axial grind differentials: – ? Scaphoid fracture – ? DR fracture Tuberosity tenderness Resisted pronation – ? 1st CMCJ fracture/dislocation – Sprain/ contusion Semi-Semi- pronatedpronated PA viewview view

Ulnar deviated Semi- “Scaphoid” view supinated view Lateral view Herbert Classification

• Not so important for medical students to know Bone grafting in delayed or non-union

• Most acute scaphoid fractures – scaphoid cast – Percutaneous screw fixation as alternative • Late presentation / inadequate treatment / failed casting  2 Months post-op non union – Need bone grafting and fixation (usually with a “headless” screw) Perilunate Dislocation

• 20 year old construction worker – Fell from 1 storey high – Landed on left UE – Felt immediate sharp pain over the left wrist a/w swelling and deformity – Also abrasions shoulder, face • Possible diagnoses? – DR fx – Perilunate / lunate dislocations Order a true PA and lateral of the wrist Scaphoid fracture Break in Gilula’s lines Dorsal perilunate dislocation

See https://wiki.nus.edu.sg/x/WIVDE Immediate Treatment in EMD • Manipulation and reduction (technique in Apley’s) • Carpal tunnel release if median nerve compression • Needs definitive fixation Key point – recognition of injury

“Spilled teacup” sign

Lunate Dislocation Dorsal perilunate dislocation Hand Fractures

• General principles • I will discuss – Metacarpal fractures • understand assessment • Treatment options – Thumb base fractures – deforming forces in Bennett’s fx • Read Apley’s System of Orthopaedics – Chapter on Hand Fractures Hand Fractures – General Principles

• Most can be treated conservatively • Rotational deformity  functional problems – Need clinical exam to diagnose • Mild angular deformity tolerated Intrinsic plus or “position of • Immobilize in position of “safety” if unsure safety” or Edinburgh Position • Do not prolong immobilization  stiffness Swelling and bruising

Normal Scissoring MF nail plane rotated

See also: https://wiki.nus.edu.sg/x/j4i-Dw

Darren’s x-ray Thumb metacarpal base fractures • Other metacarpal base fractures usually stable – Make sure no malrotation • Thumb metacarpal base fractures – Epibasal/ extra-articular fractures • > 30° angulation – web span affected – Bennett’s fracture-subluxation – Rolando fracture Bennett’s fracture

• Fracture-subluxation/ fracture dislocation • Unstable injury Adductor pollicis – Deforming forces Volar • Recognise injury beak • Closed reduction and ligament fixation or ORIF

Abductor pollicis longus Tendon Rolando Fracture

• T- or Y- configuration – Or comminuted • NO subluxation or dislocation • High energy injuries • Need surgery Upper limb peripheral nerve entrapment neuropathies and injuries

• Common compressive neuropathies (entrapment syndromes): – Nerve ischemia – episodic  continuous – Fibrosis later on – Chronic problem – Examples? • Localization is the key – Confirm peripheral nerve is involved – Which level – What is the pathology – See also: https://wiki.nus.edu.sg/display/HS/Approach+to+peripheral+nerve+conditions +in+the+upper+limb Classification of Nerve Injuries

• Physical injury – Seddon/ Sunderland classification – Neurapraxia • Radial nerve palsy – “Saturday night palsy” or fracture related

Increase severity, poorer outcome

Sunderland I II III IV V (1951) Seddon (1942) Neurapraxia Axonotmesis Neurotmesis Recovery Full Full Incomplete Neuroma-in- Nil potential continuity Pathology Ionic Axon severed, Endoneurial Only epineurium Loss of nerve block/segmental endoneurial tube torn intact continuity demyelination tube intact

Peripheral Nerve Problems - Examples • Compressive Neuropathies Carpal Tunnel – Carpal Tunnel Syndrome Syndrome – Cubital Tunnel Syndrome • Nerve injury Cubital Tunnel – Ulnar nerve injury Radial Nerve Palsy Syndrome – Radial nerve injury e.g. Saturday night • Other peripheral nerve palsy problems Carpal Tunnel Syndrome

• Most common entrapment neuropathy • Focus on clinical diagnosis • Please read up on treatment • Anatomy Carpal Tunnel Syndrome - Symptomatology

• Patient profile: Female in her 40-50s • Numbness – Classical: radial 3.5 digits – but not always so (our local patients frequently complain of numbness in all digits, or poorly localize numbness in the hand) – Intermittent vs constant – Aggravating: night/ early morning symptoms; activity – Relieving: shaking the hand • Pain or tingling in the hand – may radiate proximally • Current sensation radiating to fingertips • Weakness and clumsiness in the hands CTS: Some considerations:

– Difficult localization • “For example, it is difficult for people to localize sensory disturbances, so a patient with a median compression neuropathy at the carpal tunnel often initially will insist that ‘‘the whole hand gets numb’’ including the ulnar innervated small finger.” (Beasley’s Hand Surgery) – Diabetes mellitus • Disorders such as diabetes can cause the peripheral nerve to be more sensitive to compression • Not all numbness in DM patients are peripheral neuropathy – Double crush syndrome • Proximal nerve compression (e.g. root compression by disc) can predispose distal entrapment • May need to treat both to relieve condition Clinical Findings

• Tinel’s sign • tPhalen’s tes • Sensory Testing – 2 point discrimination usually normal – Semmes-Weinstein monofilament or vibration reception thresholds most sensitive • Abductor pollicis brevis (APB) weakness – Why test the APB? Ulnar Nerve injury and entrapment neuropathy • Common causes – at elbow (high): – Cubital tunnel syndrome Ulnar nerve – Lacerations around medial side of elbow around behind the medial • Lose dexterity and strength in hand epicondyle • Symptoms – Numbness ulnar 1.5 digits – Weakness and deformity in the hand • Less commonly at level of the wrist (low lesion) Cubital Tunnel Syndrome

• Idiopathic (30-50%) • Tardy ulnar nerve palsy • Others – Arthritis – Ganglion – Aberrant muscles (Anconeus epitrochlearis) Cubital Tunnel Syndrome

• Patient profile: male • Numbness/ pins and needles • RF and LF • Aggravated by elbow flexion • Night symptoms, intermittent symptoms • Pain • Weakness (“clumsiness”), deformity later

Further reading: Cutts S: Cubital tunnel Syndrome http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2599973/ CbTS: Examination

• Tinel’s sign • Elbow flexion test • Mild – symptoms and Ulnar claw, Jeanne’s sign sensory • Motor signs in more severe cases

Wasting of intrinsics, ulnar claw, Wartenberg’s sign Wartenberg’s sign

• Unopposed abduction of LF in ulnar nerve palsy • EDQM has ulnar deviation vector • Unopposed by palmar interossei in ulnar nerve lesions Finger Escape Sign

• Ono et al 1987, “Myelopathy Hand: New Clinical Signs of Cervical Cord Damage” • Finger Escape Sign (Ono 1982) – deficient abduction and/or extension of the ulnar two or three fingers • Also: – Inability to grip and release rapidly with the fingers (normal 20 times in 10 s) • See also Digiti Quinti (Hemiparesis) and Wartenberg’s sign (Cervical Myelopathy) • See wiki page for more info: https://wiki.nus.edu.sg/x/uYy-EQ Radial Nerve Palsy

“Patients with a radial nerve lesion cannot hold a knife and fork easily, nor cut their fingernails. They have difficulty in fastening buttons and brushing their hair. Shaving and tying shoe-laces are also difficult to manage. Generally they have a poor grip and cannot put objects like glasses or cups down flat on a table" (Wynn Parry, 1958) • Disabling condition due to motor dysfunction • Sensory loss not as critical Posterior Cord C5-T1 Radial Nerve Palsy “Very High” Crutch Palsy Neurapraxia • Anatomy “High” – Motor Saturday Night Palsy – Sensory Humeral Fractures Varies • Different levels and causes of lesions “Low” Open injuries Forearm/ elbow fractures Varies High Radial Nerve Injury

• Inability to extend wrist and finger MPJ • Pitfalls – PIPJ and DIPJ extension is intrinsic function • Very high radial nerve palsy – Triceps function is lost

• PIN palsy Wrist and digital drop – Preservation of wrist extension (but radially in radial nerve palsy deviated) – No sensory loss “Saturday night palsy” During drinking ACTIVITY Unknown 4% 8% • Males > females • Abrupt onset of wrist and finger drop

Bent arm • After sleep under the pillow – Sleep position 20% Sleeping – Alcohol influence +/- while drunk 68% • Sensation MAY be preserved • Neurapraxia  will recover completely – Improvement start mostly within 2 weeks – up to 10 weeks BR Han et al, 2013 Radial nerve injury with Humeral shaft fractures • Spiral groove – susceptibility Surgical options • Timing of injury: • Repair with graft – At time of injury • Tendon transfers – After manipulation – Use median or ulnar innervated – After ORIF muscles to replace radial nerve • Open injuries :- explore innervated ones – Pronator Teres (median nerve) to • Closed: mostly Sunderland 1-2 ECRB (radial nerve) for wrist – Watch and wait extension – If persists > 12 weeks  NCS andexplore Other Nerve Problems

• AIN Palsy • Thoracic outlet syndrome • Brachial plexus injuries – Adult traumatic – Obstetric birth paralysis

Patient unable to do the “OK” sign on the right because of anterior interosseous nerve palsy Masses & Swellings (M&S) in the hand and wrist • Common clinical problem • Not all M&S are neoplasms • Most neoplasms are benign Viral wart Dorsal wrist ganglion • Most common malignant ones are skin cancers Implantation dermoid Pyogenic granuloma • Site a useful guide to likely cause of mass Origins and Common lumps

• Neoplasms / Masses arise from • 95% comprise: the following – Ganglion – Bone and cartilage – GCT tendon sheath – Muscle – Epidermoid inclusion cysts – Nerve – Vascular masses – Skin and adnexa – lipomas – Subcutaneous tissue – Synovium and tendon – Blood vessels Ganglions – common sites

DIPJ ganglion • Wrist with osteoarthritis – Palmar: SL / RC jt – Dorsal: SL jt

• Palm – Flexor tendon Palmar radial side of the wrist sheath • PIPJ and DIPJ mucus Dorsal side of the wrist cyst

Transillumination is helpful Ganglion: Treatment

• Conservative – Leave alone (favoured) Stalk of the – Aspiration - recurrence ganglion – Rupture • Surgical excision – Follow the stalk down – Contains gelatinous material • Recurrence – quite high

“glairy” “gelatinous” material Giant cell tumor of tendon sheath (Pigmented villonodular synovitis) • Second most common swelling • True neoplasm • Sites with synovial tissue – Palmar more common • Firm, lobulated, eccentric mass GCTTS Soft tissue mass with scalloping of • Giant cell tumorbone of tendon sheath GCTTS: Treatment is excision

• Surgical excision is the only treatment • Recommended because of continued growth • Gross appearance – Lobulated/ irregular – Yellow-brown mass • Recurrence is a problem Epidermoid inclusion cyst

• Skin wounds may leave skin cells below the surface • Growth of these cells lead to mass attached to the skin • Well defined, spherical • Overlying healed wound • Excision is effective

Summary: Common Hand Lumps/Bumps

• Wrist –Ganglia • Hand Wrist ganglion – PVNS – Skin lumps Flexor sheath ganglion Palmar lump: Implantation Dermoid PVNS

Mucus cyst Tendinopathies: Tendinitis vs Tenosynovitis vs Tenovagnitis

• Tendinitis/ tendinosis – inflammation of tendon • Tenosynovitis – synovial sheath – Typically infection e.g. flexor tenosynovitis – Non-infective e.g. rheumatoid, overuse • Tenovaginitis – Fibrous sheath affected – vagina: latin for sheath – Trigger finger, DeQuervain’s • Reading: Apley 9th Ed pp 406-407 DeQuervain’s Disease/ Tenovaginitis (tenosynovitis)

• Female 30-50 years old • New baby/ more work e.g. wringing • Pain over the radial wrist joint near the base of the thumb • APL and EPB tendons (1st extensor compartment)

• Differential diagnosis? Finkelstein’s (Eichhoff’s) Test Trigger Finger Trigger Staging st 1 annular pulley Grade I (pretriggering) - Pain; history of catching that is not demonstrable on clinical examination; tenderness over the A1 pulley Grade II (active) - Demonstrable catching, but with the ability to actively extend the • Stenosing digit maintained tendovaginitis of Grade III (passive) - Demonstrable locking in which passive extension is required flexor tendons @ (grade IIIA) or in which the patient is A1 pulley unable to actively flex (grade IIIB) • Steroid injection Grade IV (contracture) - Demonstrable catching, with a fixed flexion contracture usual first line of the proximal interphalangeal (PIP) joint treatment Deformities in the Hand

• Isolated / Limited – Swan neck deformity Middle-aged Caucasian Male Dupuytren’s Contracture – Boutonniere – Flexion contracture • Generalized – Osteoarthritis – Rheumatoid arthritis – Other arthropathy Swan Neck Deformity

Hyperextension of • PIPJ hyperextension PIPJ • DIPJ flexion • Do not confuse with Boutonniere deformity – PIPJ flexed, DIPJ hyperextended • Seen in – RA – Secondary to mallet – “pseudo” swan neck Boutonniere (“Button- hole”) Deformity Hyperextension of • PIPJ flexion deformity DIPJ • DIPJ hyper-extension • Extensor central slip rupture – Acute trauma – RA “Button-holing” of head of proximal phalanx through • Lateral bands subluxate palmarly hole in extensor tendon Osteoarthritis of the hands

• Describe the deformity • Which joints are affected? Osteoarthritis of both hands • How does joint involvement in OA differ from Rheumatoid arthritis • What are the expected x-ray findings? • What are the treatment options for this? • ( Apley’s pp 424-429) Summary Slide • A way to think about: • Traumatic injuries – open and closed • Peripheral nerve problems • Masses in the hand and wrist • Tendinopathy and tendinitis • Hand deformities • Didn’t cover – Infections Thank You

Osteoarthritis of the hands • Describe the deformity • Swelling, radial deviation and • Which joints are affected? Herbeden’s nodes • How does joint involvement in • Fairly symmetrical deformity OA differ from Rheumatoid affecting mainly DIPJs arthritis • DIPJs; should also look carefully • What are the expected x-ray at PIPJ and 1st CMCJ findings? • RA: DRUJ, MPJ and PIPJ; OA: PIPJ, • What are the treatment options DIPJ, 1CMCJ for this? • Conservative vs surgery (fusion • ( Apley’s pp 424-429) of DIPJs)