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Approach to Hand Conditions
Alphonsus Chong
Department of Orthopaedic Surgery, YLLSOM, NUS
Department of Hand and Reconstructive Microsurgery, NUH
Scope
• Introduction – (Slides will be available)
• Traumatic injuries – open and closed
• Peripheral nerve problems
• Masses in the hand and wrist
• Tendinopathy and tendinitis
• Deformity
History Taking
• Pain – different aspects
• Deformity
– Congenital
– Acquired - ? Traumatic
• Decreased range of motion
• Weakness
• Numbness
• Others e.g. triggering, instability
• Handedness
• Job
• Hobbies
• Previous injury/ surgery
Expose both sides: subcutaneous border of ulna and elbow- rheumatoid nodules
Scars, wasting, deformity
Completeness and fluidity of motion
Scars, wasting, deformity
Quick Nerve Screen
Median Nerve Radial Nerve
Ulnar nerve
Traumatic Injuries – Open Injuries
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
• Skin
• Vessels
• Nerves
• Tendons
• Bone and joint
• LOOK – Loss of cascade
• Skin – lacerations
• Vessels – Color looks fine; check cap refill, turgor, temperature
• Nerves – 2 PD of RF and SF
• Tendons – FDP and FDS RF and 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
• 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” injury
• Associated injuries
– Ulna styloid -> TFCC
– Ulna head
– Scaphoid and other carpal fractures
• Complications
• Early
– Median nerve compression
• Intermediate
– Extensor Pollicis Longus rupture
– Reflex sympathetic dystrophy/ 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– Plates and screws (mostly volar
plate now)
– Wires
• External fixation
• Homework: typical indications for ORIF
Internal fixation: volar locking plate
External fixator
Kirschner wires
and 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
Poor Vascularity
70-80% of
blood supply
20-30% of
blood supply
Clinical assessment scaphoid fractures
• 16-40s male
• Fall
• Radial sided wrist pain
– ? Scaphoid fracture
– ? DR fracture
– ? 1st CMCJ fracture/dislocation
– Sprain/ contusion
Snuffbox tender Axial grind
Tuberosity tenderness Resisted pronation
Ulnar deviated
“Scaphoid” view
PA
view
Lateral view
Semi-
pronated
view
Semi-
pronated
view
Semi-
supinated
view
Herbert Classification
Bone grafting in delayed or non-union
• Most acute scaphoid fractures – scaphoid cast
• Late presentation / inadequate treatment / failed casting non union
– Need bone grafting and fixation (usually with a “headless” screw)
2 Months post-op
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
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
• Immobilize in position of “safety” if unsure
• Do not prolong immobilization stiffness
Intrinsic plus or “position of
safety” or Edinburgh Position
Swelling and bruising
Normal Scissoring MF nail plane
rotated
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
– Deforming forces
• Recognise injury
• Closed reduction and fixation or ORIF
Abductor
pollicis longus
Tendon
Adductor
pollicis
Volar beak
ligament
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
– Examples?
• Localization is the key
Classification of Nerve Injuries
• Physical injury
– Seddon/ Sunderland classification
– Neurapraxia• Radial nerve palsy – “Saturday night palsy” or fracture related
Sunderland (1951)
I II III IV V
Seddon (1942) Neurapraxia Axonotmesis Neurotmesis
Recovery potential
Full Full Incomplete Neuroma-in-continuity
Nil
Pathology Ionic block/segmental demyelination
Axon severed, endoneurialtube intact
Endoneurialtube torn
Only epineuriumintact
Loss of nerve continuity
Increase severity, poorer outcome
Peripheral Nerve Problems - Examples• Compressive
Neuropathies– Carpal Tunnel
Syndrome– Cubital Tunnel
Syndrome
• Nerve injury– Ulnar nerve injury– Radial nerve injury
• Other peripheral nerve problems
Carpal Tunnel
Syndrome
Cubital Tunnel
SyndromeRadial Nerve Palsy
e.g. Saturday night
palsy
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
– 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
• Phalen’s test
• Sensory Testing
– 2 point discrimination usually normal
– Semmes-Weinstein monofilament or vibration reception thresholds most sensitive
• Abductor pollicis brevis weakness
Ulnar Nerve injury and entrapment neuropathy
• Common causes – at elbow (high):
– Cubital tunnel syndrome
– Lacerations around medial side of elbow
• Lose dexterity and strength in hand
• Symptoms
– Numbness ulnar 1.5 digits
– Weakness and deformity in the hand
• Less commonly at level of the wrist (low lesion)
Ulnar nerve
around behind
the medial
epicondyle
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/PMC2
599973/
CbTS: Examination
• Tinel’s sign
• Elbow flexion test
• Mild – symptoms and sensory
• Motor signs in more severe cases
Ulnar claw, Jeanne’s sign
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
Radial Nerve Palsy
• Disabling condition due to motor dysfunction
• Sensory loss not as critical
“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)
Radial Nerve Palsy
• Anatomy
– Motor
– Sensory
• Different levels and causes of lesions
“Very High”
Crutch Palsy
“High”
Saturday Night Palsy
Humeral Fractures
“Low”
Open injuries
Forearm/ elbow
fractures
Neurapraxia
Varies
Varies
Posterior Cord C5-T1
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
– Preservation of wrist extension (but radially deviated)
– No sensory loss
Wrist and digital drop
in radial nerve palsy
“Saturday night palsy”
• Males > females
• Abrupt onset of wrist and finger drop
• After sleep
– Sleep position
– Alcohol influence +/-
• Sensation MAY be preserved
• Neurapraxia will recover completely
– Improvement start mostly within 2 weeks – up to 10 weeks
Sleeping while drunk
68%
Bent arm under the
pillow20%
Unknown8%
During drinking
4%ACTIVITY
BR Han et al, 2013
Radial nerve injury with Humeral shaft fractures
• Spiral groove – susceptibility
• Timing of injury:
– At time of injury
– After manipulation
– After ORIF
• Open injuries :- explore
• Closed: mostly Sunderland 1-2
– Watch and wait
– If persists > 12 weeks NCS andexplore
Surgical options• Repair with graft• Tendon transfers
– Use median or ulnar innervated muscles to replace radial nerve innervated ones
– Pronator Teres (median nerve) to ECRB (radial nerve) for wrist extension
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
• Most common malignant ones are skin cancers
• Site a useful guide to likely cause of mass
Viral wart
Implantation dermoid Pyogenic granuloma
Dorsal wrist ganglion
Origins and Common lumps
• Neoplasms / Masses arise from the following
– Bone and cartilage
– Muscle
– Nerve
– Skin and adnexa
– Subcutaneous tissue
– Synovium and tendon
– Blood vessels
• 95% comprise:
– Ganglion
– GCT tendon sheath
– Epidermoid inclusion cysts
– Vascular masses
– lipomas
Ganglions – common sites
• Wrist
– Palmar: SL / RC jt
– Dorsal: SL jt
• Palm – Flexor tendon sheath
• PIPJ and DIPJ mucus cyst
Palmar radial side of the wrist
Dorsal side of the wrist
DIPJ ganglion
with osteoarthritis
Transillumination is
helpful
Ganglion: Treatment
• Conservative
– Leave alone (favoured)
– Aspiration - recurrence
– Rupture
• Surgical excision
– Follow the stalk down
– Contains gelatinous material
• Recurrence – quite high
Stalk of the ganglion
“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
• Giant cell tumor of tendon sheath
Soft tissue mass
with scalloping of
bone
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
– PVNS
– Skin lumps
Wrist ganglion
Flexor sheath
ganglion
PVNS
Mucus cyst
Palmar lump:
Implantation
Dermoid
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
• Stenosingtendovaginitis of flexor tendons @ A1 pulley
• Steroid injection usual first line treatment
Trigger Staging
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 digit maintained
Grade III (passive) - Demonstrable lockingin which passive extension is required (grade IIIA) or in which the patient is unable to actively flex (grade IIIB)
Grade IV (contracture) - Demonstrable catching, with a fixed flexion contractureof the proximal interphalangeal (PIP) joint
1st annular pulley
Deformities in the Hand
• Isolated / Limited
– Swan neck deformity
– Boutonniere
– Flexion contracture
• Generalized
– Osteoarthritis
– Rheumatoid arthritis
– Other arthropathy
Middle-aged Caucasian Male
Dupuytren’s Contracture
Swan Neck Deformity
• PIPJ hyperextension• DIPJ flexion• Do not confuse with
Boutonniere deformity– PIPJ flexed, DIPJ
hyperextended
• Seen in – RA– Secondary to mallet– “pseudo” swan neck
Hyperextension of
PIPJ
Boutonniere (“Button- hole”) Deformity
• PIPJ flexion deformity
• DIPJ hyper-extension
• Extensor central slip rupture
– Acute trauma
– RA
• Lateral bands subluxate palmarly
Hyperextension of
DIPJ
“Button-holing” of head of proximal phalanx through
hole in extensor tendon
Osteoarthritis of the hands
• Describe the deformity
• Which joints are affected?
• 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)
Osteoarthritis of both hands
Summary Slide
• A way to think about:• Traumatic injuries – open and closed
• Peripheral nerve problems
• Masses in the hand and wrist
• Tendinopathy and tendinitis
• Didn’t cover
– Infections, paediatric, congenital conditions – read up
• I leave you the slides, some new information, and reading and thinking to do.
Osteoarthritis of the hands
• Describe the deformity
• Which joints are affected?
• 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)
• Swelling, radial deviation and Herbeden’s nodes
• Fairly symmetrical deformity affecting mainly DIPJs
• DIPJs; should also look carefully at PIPJ and 1st CMCJ
• RA: DRUJ, MPJ and PIPJ; OA: PIPJ, DIPJ, 1CMCJ
• Conservative vs surgery (fusion of DIPJs)