Hand and Wrist Injuries

1. Hand and Wrist Injuries Mark S. Rekant, MD South Jersey Hand Center Philadelphia Hand Center

2. HAND FUNCTIONS • 45% GRASP • 45% PINCH • Side pinch (key pinch) • Tip pinch (writing) • Chuck pinch (thumb to index/ring) • 5% HOOK • Carry bag • 5% PAPERWEIGHT

3. HAND & FINGER ANATOMY • 9 Finger Flexors • Median nerve • Transverse carpal ligament • 5 deep flexors pass through superficialis tendons and insert on distal phalanx of each finger and thumb • 4 superficial flexors insert on middle phalanx of digits 2-5 • Annular ligaments = pulleys (A1-A5) • PREVENT BOWSTRINGING

4. HAND ANATOMYdigits • FLEXOR • FDP • FDS • Volar plate • Extensor • Central bands • Lateral bands

5. NERVE COMPRESSION • Most common entities • Carpal tunnel syndrome • Median nerve compression at wrist • Cubital tunnel syndrome • Ulnar nerve at elbow • Radial tunnel syndrome • Radial nerve compression distal to elbow • Pronator teres syndrome • Median nerve compression just distal to elbow

6. History • General • Location • Radiation • Duration • Periodicity • Nature/time of onset • Medical • Family • Endocrine • Diabetes • Pregnancy • Hypothyroidism

7. Carpal Tunnel Syndrome • Numbness, nocturnal burning pain • Pain and paresthesias, worse at rest (night) • Clumsiness - dropping objects • Pain and numbness on driving • Pain radiating at times up arm to shoulder Symptoms

8. Carpal Tunnel SyndromeFindings • Median Nerve Entrapment in the tunnel • Pain in the wrist and hand • Awaken one from sleep/rest • Muscle wasting / atrophy

9. Physical Examination • Muscle weakness • Sensory disturbance • Tinel sign • Phalen’s test • Durkin’s CTC test

10. Carpal Tunnel SyndromeFactors • Force • Posture • Wrist alignment • Repetition • Temperature • Vibration

11. Cumulative Trauma Disorder incidence varies with age Zakaria, D “Rates of carpal tunnel syndrome, epicondylitis and rotator cuff claims in Ontario workers during 1997.” Chronic Diseases in Canada 2004: 25(2).

12. EMG/ NCV • 10% of cases of CTS may have false negative exams • 25% of asymptomatic individuals may have median nerve slowing (false positive) on electrodiagnostic testing (Erdil, Maurer and Dickerson 1997).

13. Carpal Tunnel SyndromeTreatment Options • Activity Modifications • Splinting • Cortisone Injection • Surgery

14. Carpal Tunnel Syndrome • Physical Therapy • Massage Treatment • Phonophoresis/Iontophoresis • Stretches/Exercises • Occupational Therapy • Keyboard/Mouse retraining • Biofeedback

15. CTS - SURGERY • Surgical referral is desired: • prolonged symptoms • thumb muscle atrophy • severe or progressive numbness and sensory loss • Patients with mild to moderate CTS who do not recover after four weeks of non-surgical care. • Appropriately selected candidates treated with carpal tunnel release  report good to excellent outcomes.

16. Tendinopathies Reactive Stenosing Tenosynovitis (Trigger Finger) DeQuervain’s Tenosynovitis (Disease) Intersection Syndrome Epicondylitis

17. TENDON DISORDERS • STENOSING TENOSYNOVITIS • DEQUERVAIN’S • TRIGGER FINGER / THUMB • CAUSE • TRAUMA • REPETITIVE USE • OVERUSE

18. Thumb & Finger Pulleys

19. Trigger Fingers • Tendonitis • May affect any digit including the thumb • Pain • Stiffness • Clicking or “triggering”

20. Trigger Finger Treatment Options • Splinting • Cortisone Injection • Surgical Release

21. STEROID INJECTION • Success rate for a single injection is ~60% (resolution of triggering > 4 months) • Complication rate is very low • Repeat injections (several over a 12 month period) is acceptable although success rate diminishes over time

23. SURGERY • Indications: • Symptoms for 4+ months • Failed injection • Locked finger

24. Turowski GA et al. J Hand Surg 1997: • 59 patients • 97% complete resolution • No complications

25. Other Tendinopathies Reactive • EPL Tendonitis at Lister’s tubercle • EDC IV, V • ECU Tenosynovitis • FCR Tenosynovitis

26. Lateral Epicondylitis • History • Pain Increased Activity • Job Related > Sports • P.E. • Localized Pain • Decreased Grip • Resisted Wrist Extension • Common Extensor Origin / ECRB • Inflammation / Micro-tear / Rupture

27. Differential • Intra-articular Pathology • Cervical Radiculopathy • Radial Tunnel Syndrome

28. Lateral Epicondylitis Group IGroup II • Young Athletes 35-50 yrs. • Sudden Onset Insidious Onset • Extensor Muscle Tear Overuse

29. Treatment • Rest • NSAIDS • Counter Force “Tennis Elbow” Brace • Conditioning • Improve Technique, Warm Up • Work Place Modifications • Cortisone Injection

30. Rehabilitation • Modalities • Stretches (A to Z) • Isometrics - Patient Must be Pain Free • Let Pain be Your Guide • Return to Full Activity When Pain Free / NC Grip

31. Surgical Management • 6 to 12 Months Conservative Care • Multiple Surgical Techniques • Surgical Contraindications • Less than 6 Months Nonoperative Rx\ • Poor Compliance • Secondary Gain Issues

32. ANATOMY Dorsal avulsion Extensor digitorum tendon tear MECHANISM: Forced flexion of extended digit TREATMENT: No fracture: DIP extended for 6-8 weeks FRACTURE: if <30% joint surface, splint x 4 weeks If >30% refer for ORIF Less than full passive extension refer COMPLICATIONS: Pressure necrosis from splint Permanent extensor lag MALLET FINGER

33. MALLET FINGER

34. ANATOMY: Tendon retracts Avulsion fragment may limit retraction Blood supply compromised MECHANISM: Forced extension of flexed finger TREATMENT: Refer immediately COMPLICATIONS: Permanent loss of flexion JERSEY FINGER

35. EXAM FINDINGS: Unable to flex isolated DIP Localized tenderness along flexor tendon FDP: hold PIP straight and flex DIP FDS: hold MCP straight and flex PIP or hold all fingers in extension except affected and flex JERSEY FINGER

36. VOLAR PLATE RUPTURE • EXAM FINDINGS: • Tender volar PIP • Bruising, swelling • MECHANISM: • Hyperextension injury • Ruptures distally from attachment at middle phalanx

37. TREATMENT: Early mobilization Extension block splint Buddy tape Refer if >30% joint involved COMPLICATIONS: Swan neck deformity: extensor tendons pull PIP into hyperextension, DIP flexion VOLAR PLATE RUPTURE

38. CENTRAL SLIP AVULSION • EXAM: • Pain, swelling over dorsal PIP • PIP in 15-30 degrees flexion • May have limited extension (better at 0 degrees than 30 degrees) • TREATMENT • Refer if >30% joint surface involved with avulsion fx • PIP splint in full extension 4-5 weeks • Protect 6-8 weeks for sports • *allow DIP to flex- relocates lateral bands • COMPLICATIONS: • Boutonierre deformity

39. COLLATERAL LIGAMENT TEARS • ANATOMY: • Partial or complete tear of ulnar or radial ligaments • MECHANISM: • Varus or valgus stress to PIP, DIP or MCP • EXAM: (flex MCP, PIP 30 degrees flex) • Laxity with varus or valgus stress • Possible instability with active flex/extend

40. COLLATERAL LIGAMENT TEARS • TREATMENT: • Buddy tape for 3 weeks • If unstable with active ROM or obvious deformity refer • COMPLICATIONS: • Unstable joint

41. GAMEKEEPER’S THUMB • MECHANISM • Hyperabduction of thumb • >30 degrees or > 20 degrees difference • EXAM: • Weak, painful pinch • Pain over ulnar thumb MP joint • XRAYS BEFORE STRESS

42. SIGNS Pain over ulnar thumb Stress testing positive Testing in FULL FLEXION of MCP GAMEKEEPER’S THUMB

43. GAMEKEEPER’S THUMB • TREATMENT • No instability, no fracture= thumb spica x 6 weeks • No instability, small avulsion = thumb spica • Large avulsion or instability= thumb spica and potential surgery • COMPLICATIONS • Infection • Neuropraxia of dorsal ulnar nerve to thumb • Instability

44. THUMB CMC FRACTURE DISLOCATION(BENNETT’S FRACTURE) • Anatomy: • Anterior oblique carpometacarpal ligament holds palmar fragment in normal anatomic position • Abductor pollicis longus (APL) pulls metacarpal shaft fragment radial & dorsal • Treatment • Reduction (TAPE) • Traction, abduction, extension, pronation • Often unstable, requires surgery

45. ROLANDO’S FRACTURE • ANATOMY • 3 part fracture at metacarpal base • Comminuted with “Y” or “T” fragment • TREATMENT • May be non-surgical if highly comminuted • Surgery if fragments are large and amenable

46. DIP JOINT DISLOCATION • MECHANISM • Hyperextension, varus/valgus forces • ANATOMY • Usually dorsal • Rare, strong collateral ligaments usually prevent dislocation • TREATMENT • Dorsal block splint for 3 weeks

47. PIP JOINT DORSAL DISLOCATION • MECHANISM • Hyperextension with disruption of volar plate • ANATOMY • Loss of volar stabilizing force causes phalanx to ride dorsally • TREATMENT • Reduction: avoid longitudinal traction • Post-reduction: dorsal extension block splint with PIP blocked at 20-30 degrees flexion

48. Scaphoid Fracture Pathoanatomy • Blood supplied from distal pole • In children, 87% involve distal pole • In adults, 80% involve waist

49. Scaphoid Fracture Imaging • Initial plain films often normal • Bone scan 100% sensitive and 92% specific at 4 days • MRI, CT scan

50. SCAPHOID FRACTURE • TREATMENT • Initial radiographs positive • distal third heal in approx 6-8 weeks • middle third frx heal in 8-12 weeks • proximal third heal in 12-23 weeks • Initial radiographs negative • Immobilize thumb spica cast x 7-14 days • Take out of cast, re-evaluate for tenderness • If +tenderness but neg radiographs….