22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015

2015 Update on Hand/Wrist DisordersAnthony Mollano, MD

D I S C L O S U R E S

• There has been no commercial support or sponsorship for this program.

• The planners and presenters have declared that no conflicts of interest exist.

• The program co-sponsors do not endorse any products in conjunction with any educational activity.

A C C R E D I TAT I O N

Boston College Connell School of Nursing Continuing Education Program is accredited as a provider of continuing nursing education by the American Nurses Association Massachusetts, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015

S E S S I O N O B J E C T I V E S

• Describe treatment options for thumb basal joint arthritis.

• Discuss workup and treatment options for wrist injuries and arthritis.

• Discuss workup and treatment options for thumb sprains and ligament injuries.

• Identify treatment options for carpal tunnel syndrome.

Hand/Elbow Musculoskeletal “2015 Update”- Injuries and Conditions- Fingertip to the Elbow

Anthony Mollano MD Hand/Wrist/Elbow Surgery

Concord, NH

ACUTE HAND TENDON AND NERVE INJURIES

50 YEAR-OLD CUT FINGERS WHILE SLICING A BAGEL AT HOME.

FINGER TENDON AND NERVE LACERATIONS

35 year-old firefighter, had 3 week old laceration from a utility knife, reports numbness.

Nerve not repairable by routine direct microsurgery repair

FINGER DIGITAL NERVE LACERATION

Nerve regeneration is slow: 1mm/day ; 1 inch/month; Up to 2 yrs in some cases.

Bovine collagen conduit repairs, Good outcomes, multiple studies.

FINGER DIGITAL NERVE LACERATION

WRIST COLLES RADIUS FRACTURE

25 yo Concord pro rock climber, w/ acute deformed wrist injury, tripped down stairs texting! Same day

surgery on a Monday b/c of acute CTS too.

COLLES FRACTURE

Injury Sunday. Surgery same day seen on Monday. Outpatient surgery, 1hr; Open repair/reduction volar plate and fixed angle screws; Immediate use of hand for light ADL.

At 2 m, healed, done splinting. Now 3 months after, already rock climbing. Strength and ROM improves for up to 1 yr.

COLLES FRACTURE

WRIST SCAPHOID FRACTURE

21yo NEC college student, hurt wrist surfing on spring break in NC

SCAPHOID FRACTURE

-Outpatient surgery; 30min -Mini-incision screw repair to compress one fragment into other; provides stability and compression -Early rehabilitation allowed; Removable splint used for protection

SCAPHOID FRACTURE

Immediate ROM and light hand use for ADLs x 6wks w/ splint for protection; At 3 months, had

full ROM and able to lifeguard that summer

SCAPHOID FRACTURE

Wrist Dislocations

Severe wrist dislocation 17yo merrimack valley quarterback, playing on a Sunday.

Monday had urgent same day surgery after visit b/c of acute CTS. Pins out after 8 wks, then therapy and weight lifting all winter. Will

be ready for UNH football camp this summer

Wrist Arthritis

52yo, NH college golf coach and semi-pro golfer; severe wrist pain; can no longer golf nor write; limited

ROM; poor strength; tried injections and splints for years

WRIST ARTHRITIS

Proximal row carpectomy surgery; outpatient, 1 hr; casted 4 wks, then formal therapy 1-2 m

Outcome at 3 months: satisfied; pain, function, and strength much improved; Some stiffness remains; 1-2 yrs for max conditioning and strength improvement

WRIST ARTHRITIS

CTS

WHO GETS CARPAL TUNNEL SYNDROME?

CTS

SURGERY (mini-open, 5min, local anesthesia) CTS

THUMB BASAL JOINT DEGENERATIVE ARTHRITIS

65 year-old active retired judge with thumb pinch weakness, pain, and deformity. What’s is RX?

THUMB CMC BASAL JOINT ARTHRITIS

THUMB CMC BASAL JOINT ARTHRITIS

If practical treatment fails and arthritis join pain worsens, outpatient joint arthroplasty/replacement provides: great pain relief and much improved function. 1hr surgery. Cast 1 month, then brace 1 month, then therapy. In WC cases, MMI 1 year, +PIR.

THUMB CMC BASAL JOINT ARTHRITIS

THUMB CMC BASAL JOINT ARTHRITIS

SEVERE SPORTS THUMB LIGAMENT TEARS

i.e. “the gamekeep injury”

OR

the “ACL” of the hand

16 yo bishop brady thumb MP hyperextension injury stopping hard shot

THUMB MP LIGAMENT TEAR

THUMB MP LIGAMENT TEAR

CUBITAL TUNNEL SYNDROME

Cubital Tunnel Syndrome 18 yo NC bow high baseball pitcher injured “tommy john” elbow ligament in elbow in spring, and stretched ulnar nerve. Ligament healed, but nerve numbness worsened with “constant numbness”. Old patient of mine from hockey hand hamate hook nonunion surgery when 14.

“Ulnar nerve transpotion” = NERVE is decompressed and transposition

ELBOW BICEPS AND TRICEPS TENDON

INJURIES

42 yo CJ state trooper tore elbow biceps moving furniture felt a large “POP” with elbow swelling

BICEPS DISTAL RUPTURE

Super “biceps repair”. 1hr surgery, after one week, early progressive therapy done. Back to work light duty after 1 week, full duty after 2 months, and arm strength after 6 months.

ELBOW DISTAL BICEPS REPAIR

ELBOW FRACTURES

STABLE RADIAL HEAD FXS- COMMON RX- NONOP WITH ROM/PT. IF FX WORSE- SURGERY WITH REPLACEMENT, OR RARELY EXCISION.

Thanks