12/10/2016 TOP HAND, AND WRIST Disclosures PROBLEMS: HOW TO • None SPOT THEM IN CLINIC Nicolas H. Lee, MS MD [email protected] UCSF Dept of Orthopaedic Surgery Assistant Clinical Professor Hand, Upper Extremity and Microvascular Surgery Dec. 10 th , 2016 Outline Outline • Carpal Tunnel Syndrome •Carpal Tunnel Syndrome • Trigger Finger • • Basal Joint arthritis Trigger Finger • Basal Joint arthritis • De Quervain tenosynovitis • De Quervain tenosynovitis • Mallet Finger • Mallet Finger • Ganglion cyst • Ganglion cyst 1 12/10/2016 Carpal Tunnel Syndrome • Compression of median nerve in carpal tunnel • Irritation of the nerve presents as numbness/pain 10 structures 9 flexor tendons Median nerve https://www.pinterest.com/pin/429812358163325007/ Anatomy (motor) Etiology 1. Idiopathic – most common 2. Anatomic – rare • Thenar Muscle (OAF) 3. Systemic – DM, hypothyroidism • Opponens Pollicis (deep) 4. **** Occupational Exposure • Abductor Pollicis Brevis (superficial) **** “A direct relationship between repetitive work • Flexor Pollicis Brevis activity (eg, keyboarding) and CTS has never been (superficial 1/2) objectively demonstrated.” 1 http://teachmeanatomy.info/upper-limb/muscles/hand/ 2 12/10/2016 Rare anatomic causes Carpal Tunnel Syndrome ● HPI – systemic risk factors Tenosynovitis CMC arthritis ◦ More common in: Ganglion Fracture 1) Diabetics 2) Hypothyroidism 3) Pregnancy (20-45%) Persistent Median artery Acromegaly Abnormal muscle Tumor Carpal Tunnel Syndrome ● CC: ◦ “I wake up at night and my hands are asleep” ◦ “I have to shake them to get the blood flowing again” ◦ “I have to run them under warm water and then I can go back to sleep” ◦ “Fingers go numb when I drive” ◦ “My hand goes numb when I use my cell phone” ◦ “I am always dropping things” Carpal Tunnel Syndrome Cranford, C.S. et al JAAOS Sept 2007; ◦ “Can’t button my shirt” v15 (9): 537-548 3 12/10/2016 Diagnosis Severe thenar atrophy • Thenar Muscles (APB) • Weakness • Atrophy http://nervesurgery.wustl.edu/ www.eatonhand.com Provocative Tests Diagnosis: Tinel ’s Sign ◦ Most Common ◦ Tinel’s (tapping) ◦ Phalen’s (flexion) ◦ Durkan’s (compression) ◦ Reverse Phalen’s 4 12/10/2016 Diagnosis: Phalen ’s Test Reverse Phalen’s test http://morphopedics.wikidot.com/carpal-tunnel-syndrome Carpal Tunnel Syndrome Durkan’s Carpal Compression ● Diagnosis is clinical! ● EMG/NCV 1. Confirmatory 2. Establish a baseline 3. Determine severity 4. r/o cervical radiculopathy 5. r/o peripheral neuropathy 5 12/10/2016 Treatment Stages • Nonoperative Mild Duration < 1 year • Surgical Intermittent numbness Normal sensory and motor EMG: mild CTS Moderate Continuous numbness, paresthesia Abnormal sensory testing EMG: moderate CTS Refer to Hand Severe Surgeon Persistent loss sensory+ motor function Thenar atrophy EMG: severe CTS Nonoperative Treatment Carpal Tunnel Syndrome Injections • Initial treatment for most cases Indication: mild to moderate disease Mainstay: Therapeutic: • Night splints (neutral) 75% of patients have symptom improvement @ 6 weeks • Corticosteroid injections 20% symptom free at 1 year Adjuvant: Diagnostic: Help isolate contribution of carpal tunnel to unclear clinical • NSAIDs presentation • Ergonomic modifications • Occupational therapy for nerve and tendon glides Prognostic • Iontophoresis (+) response: 87% surgical success • Ultrasound therapy (-) response: 54% surgical success 6 12/10/2016 Carpal Tunnel Syndrome Carpal Tunnel Syndrome • When to refer? • Injection Technique • Failure of non-operative treatment • Inject ulnar to palmaris longus or • Moderate to Severe CTS in-line with ring finger • Unclear diagnosis • Start at proximal wrist crease aiming 30-45 degrees distally • 25 or 27 gauge needle, 1 ½ in • 2 cc mix (10mg kenalog: 1 cc lido) Mini-Open Carpal Tunnel Release Surgery • Release transverse carpal ligament • Under local or regional (From Columbia University dept. of neurosurgery website) anesthesia Endoscopic Carpal Tunnel Release http://www.outpatientsurgery.net/ (http://wintman.podbean.com/) 7 12/10/2016 Outline Trigger Finger • Carpal Tunnel Syndrome • Medical Term: Stenosing tenosynovitis •Trigger Finger • Basal Joint arthritis http://quizlet.com/18888253/pd-ms- lecture-2-diseases-flash-cards/ • De Quervain tenosynovitis • 2 subtypes: • Mallet Finger 1. Nodular – localized swelling, “nodule” • Ganglion cyst * more responsive to NSAIDS/steroid injection * 93% success with injection (< 6 mos) 2. Diffuse * diabetics * 48% success with injection Trigger finger Trigger Finger • Physical Examination • Variable presentation • Tenderness at the level A1 pulley • Clicking +/- pain • Locking or clicking over the A1 pulley • Pain @ A1 pulley, no clicking • +/- nodule • Sensation of clicking at PIP joint • Pain radiating up to the forearm • Worse in the morning or night http://www.noelhenley.com/trigger-finger/ 8 12/10/2016 Primary Trigger Finger Pediatric trigger thumb • Most Common • Acquired, NOT congenital! • “Idiopathic ” • Often present with fixed flexion contracture Secondary • Recommendation: 1. Good results with release after • Associated with known disease age 1 (> 90% success) • Disease cause thickening in tendon/pulley 2. May elect to observe b/c 60% • Diabetes Spontaneously resolve within 4 • Rheumatoid arthritis years • Amyloidosis • Sarcoidosis Pediatric Trigger Finger Treatment Options (Adult) NOT the same as adult trigger finger • Nonoperative Ring Splint Always refer to hand surgeon • Observation, activity modification Anatomic anomalies frequently found • NSAIDs • Trigger finger ring/splint Treatment: A1 pulley release and resection of FDS slip • Corticosteroid injection • Operative release • Percutaneous https://www.ncmedical.com/item_1751.html • open **** Studies show steroid injection alone is more effective than splints 9 12/10/2016 Steroid Injection Injection • 70% can resolve after a single • Combination local injection anesthetic and steroid • 57% (level 1 and 2 studies) • Lower success rate • younger patients • Around the tendon in • Diffuse type area of A1 pulley • diabetics • multiple fingers • other upper extremity tendinopathies • No difference in success if injected inside or outside of • Most effective if symptoms less than 6 mos and nodular the sheath! type Risks of injection Injection in Diabetics • Infection • Fat atrophy • Bleaching of skin • Increase blood glucose • Tendon Rupture • Greatest effect 24 hours after • Hyperglycemia in diabetics injection (150% baseline) • Effect lasts up to 5 days 10 12/10/2016 Surgery Percutaneous release • Failure of non-surgical treatment • May be a first line treatment in diabetics • Locked finger http://www.amhandinst.com/triggerfinger.html Open release Trigger Finger • When to refer? • Failure of at least one injection • Locked trigger finger • Unclear diagnosis 11 12/10/2016 Outline Basal Joint = Thumb CMC joint • Carpal Tunnel Syndrome • Trigger Finger •Basal Joint arthritis • De Quervain tenosynovitis • Mallet Finger • Ganglion cyst http://www.noelhenley.com/280/joints-of-the-thumb/ Anatomy History • Do you have difficulty: • pinching, writing • opening a tight jar • Opening doors, keys • carrying a shopping bag • using a knife to cut food 12 12/10/2016 Clinical Exam Nonoperative management • Physical appearance • Tenderness • Specific Tests • Custom made • Grind thermoplastic splint • Off the shelf splint • Activity modification education • Symptom management Van Heest, JAAOS 2008 Thumb CMC OA Thumb CMC OA Injection • Injection into the CMC joint is often painful, especially in more advanced disease • Injection • Distract the joint • Mark the site of injection • Prepare the site of injection • Advance needle to bone and inject small amount http://www.aafp.org/afp/20030215/745.html • Once anesthetized, advance needle into the joint and inject Courtesy of Peter M. Murray, MD 13 12/10/2016 Treatment: Surgical Thumb CMC OA • Later stages • When to refer? • CMC arthrodesis • Failure of non-operative treatment • Unclear diagnosis • Resection arthroplasty • LRTI Outline DeQuervain ’s Tenosynovitis • Carpal Tunnel Syndrome • Trigger Finger • Tendonitis 1 st • Basal Joint arthritis dorsal •De Quervain tenosynovitis compartment • APL: Abductor • Mallet Finger pollicis longus • Ganglion cyst • EPB: Extensor pollicis brevis http://www.orthobullets.com/hand/6006/extensor-tendon-compartments 14 12/10/2016 Anatomy Surface Anatomy APL/EPB Hand Surgery Update IV, Chapter 22, Figure 4a Sheath enclosing APL/EPB becomes narrowed leading to pain and inflammation Symptoms Examination • More common in women (6:1 ratio) • Tenderness over • New mothers tendons at thumb • Pain at the radial wrist/base of thumb side of wrist • May have ‘clunking ’ of the thumb • Pain with thumb motion • Finkelstein’s test • Thumb in fist • Ulnarly deviate 15 12/10/2016 Treatment Dequervain’s tenosynovitis • Conservative • Surgical • Pre-fabricated or custom thumb spica splint • Ice • Activity modification • Patient education DeQuervain ’s Tendonitis De Quervain ’s Tendonitis • Non-operative treatment Success Rates 4: • Injection Technique • NSAIDs alone: 0% • Splinting: 14% • 2cc 1:1 mix of 1% • Injection + splint: 61% lidocaine and water • Injection alone: 83%!!! soluble steroid • Inject inside sheath in line • Injection with tendons and not www.assh.org • Up to 83% success rate, but may require 2 injections subQ • Failure: 1) Poor technique • Should see the http://www.aafp.org/afp/20030215/745.html 2) EPB subsheath compartment fill up • Risk of skin hypopigmentation • Generally limit injection to