Hand and Wrist Injuries

Treatment/ RehabilitionSelected Shoulder Issues

Dr. Mark Robinson

Mater Private Clinic

South Brisbane, Redlands

Outline of Presentation

⚫ Common Fractures and Hand Injuries

⚫ Some Elbow Issues

⚫ Rotator Cuff Tears

⚫ Frozen Shoulder

Problems in General

Practice

⚫ The Patient’s Problems

⚫ The General Practitioner's Problems

⚫ The Specialist’s Problems

⚫ When to make it the third option

Principles of Fracture

Treatment

⚫ Pain Relief⚫ Splints/Casts, Ice, Elevation, Analgesics

⚫ Prevent Mal-union⚫ Restricts Movement, Pain, Deformity

⚫ Prevent Non-union⚫ Avascular necrosis, Osteoarthritis

⚫ Protect Surrounding Structures⚫ Spinal Cord Injuries, Long Bone # (Thomas Splint)

⚫ With Associated Injuries⚫ Multiple Fractures, Open Injuries

Undisplaced vs

Displaced Fractures

⚫ Intact Periosteal

Sleeve

⚫ Protect the sleeve

⚫ Protect the bone

until union occurs

⚫ 4-8 weeks

Mallet Finger 1

Mallet Finger 2

Other Distal Phalangeal

Fractures

Volar Plate Fracture 1

Volar Plate Fracture 2

Outcomes

⚫ Instability

⚫ Mild Stiffness

⚫ Fixed Flexion

Deformity

Treatment

⚫ Hand Therapy

⚫ Extension Block Splint

⚫ Surgery if:-

⚫ Subluxed

⚫ Impacted

⚫ Displaced

Phalangeal Fracture

Metacarpal Fractures

Phalangeal and

Metacarpal Fractures

⚫ Undisplaced fractures

⚫ Look for rotation

⚫ Intact periosteal sleeve

⚫ Protect the injured digit

from its idiot “life

support system”

⚫ Prevent further injury

displacing the #

Splinting and Buddy

Taping

Scaphoid Fracture 1

Scaphoid Fracture 2

Hand Problems

⚫ Trigger Finger

⚫ de Quervain’s Tenosynovitis

⚫ Carpal Tunnel Syndrome

⚫ Ganglions

⚫ Dupuytren’s Contracture

Management Cascade

Professor John K Stanley

1. Do nothing, put up with it.

2. Physiotherapy, Splints, Activity Modification

3.Injection, Local anaesthetic and steroid

4.Surgery

5. Dr. Harry (veterinarian) Option

Trigger Finger(Stenosing Tenovaginitis)

⚫ Flexor tendons trapped by mouth of A1 pulley

and develops a nodule

⚫ Pain in palm over MP joint

⚫ Catching in flexion and/or extension

⚫ Locking in flexion or extension

⚫ Treatment Injection

Surgery

Trigger Finger

de Quervain’s

Tenosynovitis

⚫ Two tendons to base of thumb caught in

tunnel APL EPB

⚫ Pain on radial side of wrist

⚫ Swelling and tenderness over radial styloid

⚫ Finkelstein’s test positive

⚫ Treatment Rest/splints

Injection

Surgery

de Quervain’s

Tenosynovitis

Carpal Tunnel Syndrome

⚫ Compression neuropathy of median nerve

⚫ Numbness, pins & needles, nocturnal

wakening

⚫ Sensory changes, Phalen’s test, +/- NCS

⚫ Treatment Rest/splints

Injection

Surgery

Carpal Tunnel

Syndrome

Body Homeostasis

⚫ Upright posture during the day

⚫ Reclined position at night

⚫ Slight fluid accumulation in upper limbs

⚫ Symptomatic in mornings

⚫ Diuretics used as treatment in past

Nerve Conduction

Studies

⚫ Measure average velocity of nerve

conduction

⚫ Median Nerve in Carpal Tunnel

⚫ Sensitivity 93%

⚫ False Negative 7%

⚫ Ulnar Nerve in Cubital Tunnel

⚫ Sensitivity 70%

⚫ False Negative 30%

⚫ Uncomfortable!

Ganglions

⚫ Fluid filled cysts, Synovial Fluid

⚫ Wrist, flexor tendons, DIP joints

⚫ Pain, reduced ROM, cosmetic

⚫ Treatment Outcomes▪ Reassure 80%

▪ Aspirate 60%

▪ Rupture/ Steroid 50%

▪ LA Excision 30%

▪ GA Excision 5-10%

Ganglions

Dupuytren’s Contracture

⚫ Nodular contracture of the palmar fascia

⚫ Hereditary, trauma

⚫ Cords, nodules, pits

⚫ Tender nodules, contracted cords

⚫ Surgery - excision of cords, (Injection)▪ aggravation of other areas

▪ high recurrence rates

▪ risks stiffness of finger and neurovascular injury

Elbow Problems

⚫Tennis and Golfer’s Elbow

⚫Ulna nerve compression

⚫Olecranon bursitis

⚫Elbow stiffness

Tennis and Golfer’s

Elbow

⚫ Insertional enthesopathy,CEO, CFE

⚫ Angiofibroblastic hyperplasia

⚫ Accumulative micro/macrotrauma

⚫ Wrist extensors, finger flexors

⚫ Treatment Rest/splints

Injection

Surgery

Tennis and Golfer’s

Elbow

⚫ Avoid / modify initiating activities

⚫ Physio / Hand therapy, straps and splints

⚫ Injection

⚫ up to 3 attempts, steroid, blood patch

⚫ rarely successful after 6 months

⚫ Surgical release +/- repair, >50% GS Loss

Ulna Neuropathy

⚫ Compression of ulna nerve behind medial

epicondyle

⚫ 3 anatomical variants

⚫ Numbness, weakness, poor hand control

⚫ Treatment Postural changes

Night splints

Surgery

Ulna Nerve Compression

Olecranon Bursitis

⚫ Inflammation of olecranon bursa

⚫ infective or inflammatory

⚫ Fluid filled sac, thickened reactive lining

⚫ Treatment Rest/splints

Antibiotics

Surgery

Stiffness of Elbow

⚫ Loose bodies, capsule tightness, OA

⚫ Frequently post traumatic

⚫ X-ray, CT scan, 3D reconstruction

⚫ Treatment Reassure

Arthroscopy

Arthrotomy

Stiffness of Elbow 2

Shoulder Problems

⚫ Frozen Shoulder

⚫ Calcific Tendonitis

⚫ Shoulder Ultrasound

Joints of the Shoulder

⚫ Gleno-humeral

⚫ Capsule of Joint

⚫ Acromio-clavicular

⚫ Scapulo-thoracic

Biomechanics of the

Shoulder

Frozen Shoulder

Inflammatory Condition

of Joint Capsule

⚫ Adhesive Capsulitis

⚫ Pericapsulitis

⚫ Shoulder Hand

Syndrome

Frozen Shoulder

⚫ Roll over to turn off alarm clock

⚫ Into shower, can’t wash hair or back

⚫ Struggle to dress

⚫ Hurts to drive to work

⚫ Open door at parking

⚫ Helped at work by co-workers, whispers

⚫ Drive past gym on way home

⚫ Reaching in pantry

⚫ Changed for bed

⚫ Another night of broken sleep

3 Clinical Phases

⚫ Painful⚫ Constant Pain

⚫ Progressive Loss of Motion

⚫ Stiffness⚫ Less Pain, Still Stiff

⚫ “Box of Comfort”

⚫ Resolution⚫ Box Gets Bigger

Typical Presentations

Post-traumatic

⚫ Shear type injury, slip/fall

⚫ Slight pain at time

⚫ Increasing pain and progressive stiffness⚫ Weeks / months later

⚫ X-ray Normal

⚫ Ultrasound Abnormal

Typical Presentations

Clinical

⚫ Distressed when disrobing

⚫ Deltoid wasting, mild tenderness at GT

⚫ GLOBAL LOSS OF MOTION

⚫ Especially External Rotation

⚫ Aggravated by Physiotherapy

⚫ No relief from Subacromial Steroid Injection

Typical Presentations

Clinical

Typical Presentations

Investigations

⚫ X-rays Normal

⚫ Ultrasound

⚫ Biceps effusion, biceps tendonitis

⚫ Subacromial bursitis, partial tear

⚫ Too stiff to fully examine

Typical Presentations

Pictures

Treatment

⚫ Painful Phase

⚫ Hydrodilatation, steroid

⚫ Stiffness Phase

⚫ MUA, A/scopic release

⚫ Resolution

⚫ (physiotherapy)

Outcomes

⚫ Randomised study

⚫ 50 patients, 2 arms, 2 year follow-up

⚫ 1. Injection, MUA, physiotherapy

⚫ 2. Analgesics, exercise the arm

⚫ No difference at 2 years

⚫ Near full return of movement.

Can I hurt the Shoulder?

⚫ Yes

⚫ You can make it

sore.

⚫ No

⚫ You can’t damage it.

Calcific Tendonitis

⚫ Dystrophic calcification in Rotator Cuff

⚫ Large deposits = Symptomatic

⚫ Small deposits (<3mm) = Assymptomatic

⚫ Ultrasound Guided Aspiration & Injection

⚫ 67% Success Rate

Results

Rotator Cuff “Tears”

Rotator Cuff Tears

Welcome to my

Soap Box !

Recently discussed

this with Sonic

Radiologists

What is “Tear”?

⚫ The Oxford Dictionary defines “tear”

⚫ Verb⚫ Pull apart or to pieces with force

⚫ Make a hole or rent in this way

⚫ Pull violently or with some force

⚫ Violently disrupt or divide

⚫ Go or leave hurriedly

⚫ Noun⚫ Hole etc. caused by tearing

⚫ Torn part of cloth etc.

What is “Tear”?

⚫ Are you meaning noun

or verb

⚫ Patients and GPs open

the reports

⚫ Is this “tear” or “a tear”

Rotator Cuff Tears

⚫ Tempelhof et al 1999

⚫ 411 assymptomatic individuals 23% incidence

⚫ 50 – 59 13%

⚫ 60 – 69 20%

⚫ 70 – 79 31%

⚫ 80 + 51%

⚫ IFSS 2001 70-75 years Assymptomatic

⚫ 1/3 normal, 1/3 partial, 1/3 full thickness

Flip Side of Rotator Cuff

Tears

⚫ May not need surgery

⚫ Trauma = energy

⚫ May settle non-

operatively

Stem Cell Therapy

⚫ Choice Australia 2017 Publication:

⚫ https://www.choice.com.au/health-and-

body/hospitals-and-medical-procedures/medical-

treatments/articles/stem-cell-therapy

Summary

⚫ Management of Simple Hand Fractures

⚫ Non traumatic Upper Limb Conditions

⚫ Approach to Common Shoulder Problems