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