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Expert Hand Surgery Techniques by Dr. Michael Solomons in Cape Town

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  1. Hand Surgery Dr Michael Solomons Cape Town Dr. Michael Solomons

  2. Program • Basics • Carpal tunnel • Trigger digits • De Quervain’s • Basal Joint OA • Advanced • Flexor Tendon Surgery • Wrist Replacements Dr. Michael Solomons

  3. Carpal Tunnel Syndrome • History • Nocturnal waking • Burning pain • Parasthesia median n. • Hanging/shaking/water • Clumsiness/dropsy Dr. Michael Solomons

  4. Carpal Tunnel Syndrome • Examination • Thenar wasting • Tinel test • Phalens test • APB strength • Median n. sensation – light touch and pin prick Dr. Michael Solomons

  5. Thenar wasting Dr. Michael Solomons

  6. Tinel test • Least sensitive, most specific Phalens Test Most sensitive Dr. Michael Solomons

  7. APB strength Dr. Michael Solomons

  8. Median nerve sensation • Thumb, index, middle • Sensory splitting of ring Dr. Michael Solomons

  9. Carpal Tunnel Syndrome • Special Investigations • EMG/NCS • If atypical • Medicolegal/ “gainitis”/ WCA • “Injection test” • rbg/thyroid/urate Dr. Michael Solomons

  10. Carpal Tunnel Syndrome • treatment Dr. Michael Solomons

  11. CARPAL TUNNEL SYNDROME: INJECT, SPLINT OR OPERATE? Dr RG Graham, Dr M Solomons, Prof DA Hudson, Mr M Singer Dr RG Graham, Prof DA Hudson, Dr M Solomons, Mr M Singer The Martin Singer Hand Unit Groote Schuur Hospital University of Cape Town The Martin Singer Hand Unit Groote Schuur Hospital University of Cape Town Dr. Michael Solomons

  12. GSH STUDY • Prospective, outcome study • Minimum F/U of 1 year • Followed existing hand clinic protocol Dr. Michael Solomons

  13. METHODS • Neutral wrist splint • Continuous • 2ml of 2% lignocaine • 3mg Betamethasone Dr. Michael Solomons

  14. Symptoms repeat inject No symptoms no inject 9w Symptomatic Surgery Asymptomatic F/U  1 year Symptoms TECHNIQUE Evaluate every 3 weeks for 9 weeks Dr. Michael Solomons

  15. Ave Symptom Dur 8m Sensory Change 69% Ave age 48y Injection Complicat 0% Bilat Symptoms 42% Males 5% RESULTS 73 Patients 99 Hands Dr. Michael Solomons

  16. Surgery 9w 66% Asymptomatic 9w 22% Defaulted 12% Surgery 1y 64% Asympto 1y 36% Surgery 1y 83% Asympto 1y 17% RESULTS 70% Initial response Dr. Michael Solomons

  17. RESULTS: 1 Year • 90% pts surgery • 10% asymptomatic Dr. Michael Solomons

  18. RESULTS • All patients symptom free at • 1year became asymptomatic • after a single steroid injection. Dr. Michael Solomons

  19. SUMMARY OF RESULTS Dr. Michael Solomons

  20. RECOMMENDATIONS • Single steroid injection and/or Splint • Assess at 1 month • Symptoms surgery • No symptoms F/U for  1 year Dr. Michael Solomons

  21. 30º 5mm Injection Technique Dr. Michael Solomons

  22. Trigger Digits • Stenosing tenovaginitis • Associated with diabetes, CTS and OA • Post traumatic Dr. Michael Solomons

  23. Percutaneous Trigger Finger Release Kevin Adams Conrad Pienaar Michael Solomons The Martin Singer Hand Unit Groote Schuur Hospital Cape Town Dr. Michael Solomons

  24. Trigger digits • Presentation • Triggering • Clicking • Locked • Tender A1 Dr. Michael Solomons

  25. Triggers - treatment • Injection • Triggering • Clicking • symptomatic Dr. Michael Solomons

  26. Trigger – injection technique Dr. Michael Solomons

  27. Trigger - treatment • Surgery • If locked • If lack of full flexion or extension • THUMB Dr. Michael Solomons

  28. De Quervains • Severe dorso radial wrist pain +- swelling • Tendonitis of 1st dorsal compartment (APL and EPB) • Common • Post partum Dr. Michael Solomons

  29. Making the diagnosis • Swelling – rare • Local tenderness – surprisingly uncommon • Movement of thumb often not painful • Including resisted extension • Finkelstein test – sensitive and specific Dr. Michael Solomons

  30. Finkelstein Test Dr. Michael Solomons

  31. De Q - treatment • Injection and dorsal thumb splint • 70% succesful • Rarely surgery Dr. Michael Solomons

  32. De Q – injection technique Dr. Michael Solomons

  33. Base of Thumb OA • Part of primary gen. OA • Middle age women • Pain base of thumb • Worse opening jars, taps, keys Dr. Michael Solomons

  34. Basal jt OA - clinically • Point to thenar eminence • Swollen, subluxed CMCJ • Crank/grind test strongly positive Dr. Michael Solomons

  35. Testing – basal jt OA NB: Reduce basal jt Dr. Michael Solomons

  36. Radiology Dr. Michael Solomons

  37. Basal jt OA - treatment • Inject • Dorsal thumb splint Dr. Michael Solomons

  38. Basal jt OA - surgery Dr. Michael Solomons

  39. Total Wrist Replacements • No longer experimental • New prostheses = improved results • Own series (>5 yrs) – no sepsis and no revisions • Indications: RA and low demand OA Dr. Michael Solomons

  40. Dr. Michael Solomons

  41. + ipsilateral total shoulder - same operation Dr. Michael Solomons

  42. New Advances in Flexor Tendon Surgery Dr. Michael Solomons

  43. A Randomized, Double Blind, Clinical Trial of Teno Fix™; A Novel Device for Flexor Tendon Repair Presenter: DR. MICHAEL SOLOMONS Martin Singer Hand Unit Department of Orthopaedics Groote Schuur Hospital Cape Town, South Africa Authors: B. Su, M. Solomons, A. Barrow, M. Rosenwasser, T.Senoge SASSH CAPE TOWN 2003 Dr. Michael Solomons

  44. Multi-Center Trial Sites • Three sites were chosen for this study. • Johannesburg, SA - Johannesburg General - Chris Hani Baragwanath • Cape Town, SA - Groote Schuur Hospital - Vincent Palotti Hospital • Durban, SA - Nelson Mandela School of Medicine Dr. Michael Solomons

  45. Control Repair (4 Strand Cruciate) • 4/0 or 3/0 Prolene core • 6/0 Nylon epitendinous suture Cruciate Technique (McLarney et al. ) [J Hand Surg 1999; 24(2): 295-301] Dr. Michael Solomons

  46. Teno Fix™ Repair • 2/0 Multifilament Stainless Steel Core Suture • Intra-tendinous stainless steel coil anchors capture tendon fibers on each side • 6/0 Nylon Epitendinous Suture Dr. Michael Solomons

  47. Teno Fix™ Repair Technique Dr. Michael Solomons

  48. Examples Z3 - 3 weeks Little finger Z2 - 2 weeks Index finger Dr. Michael Solomons

  49. THANK YOU docsol@absamail.co.za Dr. Michael Solomons

  50. Hand surgery by Dr Michael Solomons • is licensed under a • Creative Commons Attribution-NonCommercial-ShareAlike 2.5 • South Africa License. • This material is part of the Postgraduate Diploma in Occupational Health (DOH) - Module 3. Downloadable at vula.uct.ac.za. For more Open Education Resource (OER) visit http://opencontent.uct.ac.za/ • Permissions beyond the scope of this license may be available at www.healthedu.uct.ac.za or healthoer@uct.ac.za

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