12/10/2016 Disclosures TOP HAND, AND WRIST PROBLEMS: HOW TO • None SPOT THEM IN CLINIC Nicolas H. Lee, MS MD Nicolas.Lee@ucsf.edu UCSF Dept of Orthopaedic Surgery Assistant Clinical Professor Hand, Upper Extremity and Microvascular Surgery Dec. 10 th , 2016 Outline Outline • Carpal Tunnel Syndrome • Carpal Tunnel Syndrome • Trigger Finger • Trigger Finger • Basal Joint arthritis • Basal Joint arthritis • De Quervain tenosynovitis • De Quervain tenosynovitis • Mallet Finger • Mallet Finger • Ganglion cyst • Ganglion cyst 1
12/10/2016 Carpal Tunnel Syndrome • Compression of median nerve in carpal tunnel • Irritation of the nerve presents as numbness/pain 10 structures 9 flexor tendons Median nerve https://www.pinterest.com/pin/429812358163325007/ Etiology Anatomy (motor) 1. Idiopathic – most common 2. Anatomic – rare • Thenar Muscle (OAF) 3. Systemic – DM, hypothyroidism • O pponens Pollicis (deep) 4. **** Occupational Exposure • A bductor Pollicis Brevis (superficial) **** “A direct relationship between repetitive work • F lexor Pollicis Brevis activity (eg, keyboarding) and CTS has never been (superficial 1/2) objectively demonstrated.” 1 http://teachmeanatomy.info/upper-limb/muscles/hand/ 2
12/10/2016 Carpal Tunnel Syndrome Rare anatomic causes ● HPI – systemic risk factors Tenosynovitis CMC arthritis ◦ More common in: 1) Diabetics Ganglion Fracture 2) Hypothyroidism 3) Pregnancy (20-45%) Persistent Median artery Acromegaly Abnormal muscle Tumor Carpal Tunnel Syndrome ● CC: ◦ “I wake up at night and my hands are asleep” ◦ “I have to shake them to get the blood flowing again” ◦ “I have to run them under warm water and then I can go back to sleep” ◦ “Fingers go numb when I drive” ◦ “My hand goes numb when I use my cell phone” ◦ “I am always dropping things” Carpal Tunnel Syndrome ◦ “Can’t button my shirt” Cranford, C.S. et al JAAOS Sept 2007; v15 (9): 537-548 3
12/10/2016 Diagnosis Severe thenar atrophy • Thenar Muscles (APB) • Weakness • Atrophy www.eatonhand.com http://nervesurgery.wustl.edu/ Diagnosis: Tinel ’ s Sign Provocative Tests ◦ Most Common ◦ Tinel’s (tapping) ◦ Phalen’s (flexion) ◦ Durkan’s (compression) ◦ Reverse Phalen’s 4
12/10/2016 Diagnosis: Phalen ’ s Test Reverse Phalen’s test http://morphopedics.wikidot.com/carpal-tunnel-syndrome Carpal Tunnel Syndrome Durkan’s Carpal Compression ● Diagnosis is clinical! ● EMG/NCV 1. Confirmatory 2. Establish a baseline 3. Determine severity 4. r/o cervical radiculopathy 5. r/o peripheral neuropathy 5
12/10/2016 Treatment Stages � Mild • Nonoperative � Duration < 1 year • Surgical � Intermittent numbness � Normal sensory and motor � EMG: mild CTS � Moderate � Continuous numbness, paresthesia � Abnormal sensory testing � EMG: moderate CTS Refer to Hand � Severe Surgeon � Persistent loss sensory+ motor function � Thenar atrophy � EMG: severe CTS Nonoperative Treatment Carpal Tunnel Syndrome Injections • Initial treatment for most cases Indication: mild to moderate disease Mainstay: Therapeutic: � 75% of patients have symptom improvement @ 6 weeks • Night splints (neutral) • Corticosteroid injections � 20% symptom free at 1 year Adjuvant: Diagnostic: � Help isolate contribution of carpal tunnel to unclear clinical • NSAIDs presentation • Ergonomic modifications • Occupational therapy for nerve and tendon glides Prognostic • Iontophoresis � (+) response: 87% surgical success • Ultrasound therapy � (-) response: 54% surgical success 6
12/10/2016 Carpal Tunnel Syndrome Carpal Tunnel Syndrome • When to refer? • Injection Technique • Failure of non-operative treatment • Inject ulnar to palmaris longus or • Moderate to Severe CTS in-line with ring finger • Unclear diagnosis • Start at proximal wrist crease aiming 30-45 degrees distally • 25 or 27 gauge needle, 1 ½ in • 2 cc mix (10mg kenalog: 1 cc lido) Mini-Open Carpal Tunnel Release Surgery • Release transverse carpal ligament • Under local or regional (From Columbia University dept. of neurosurgery website) anesthesia Endoscopic Carpal Tunnel Release http://www.outpatientsurgery.net/ (http://wintman.podbean.com/) 7
12/10/2016 Outline Trigger Finger • Carpal Tunnel Syndrome • Medical Term: Stenosing tenosynovitis • Trigger Finger • Basal Joint arthritis http://quizlet.com/18888253/pd-ms- lecture-2-diseases-flash-cards/ • 2 subtypes: • De Quervain tenosynovitis 1. Nodular – localized swelling, “nodule” • Mallet Finger * more responsive to NSAIDS/steroid injection • Ganglion cyst * 93% success with injection (< 6 mos) 2. Diffuse * diabetics * 48% success with injection Trigger Finger Trigger finger • Physical Examination • Variable presentation • Tenderness at the level A1 pulley • Clicking +/- pain • Locking or clicking over the A1 pulley • Pain @ A1 pulley, no clicking • +/- nodule • Sensation of clicking at PIP joint • Pain radiating up to the forearm • Worse in the morning or night http://www.noelhenley.com/trigger-finger/ 8
12/10/2016 Pediatric trigger thumb Primary Trigger Finger • “ Idiopathic ” • Most Common • Acquired, NOT congenital! • Often present with fixed flexion contracture Secondary • Recommendation: 1. Good results with release after • Associated with known disease age 1 (> 90% success) • Disease cause thickening in tendon/pulley 2. May elect to observe b/c 60% • Diabetes Spontaneously resolve within 4 • Rheumatoid arthritis years • Amyloidosis • Sarcoidosis Pediatric Trigger Finger Treatment Options (Adult) Ring Splint NOT the same as adult trigger finger • Nonoperative • Observation, activity modification Always refer to hand surgeon • NSAIDs Anatomic anomalies frequently found • Trigger finger ring/splint Treatment: A1 pulley release and resection of FDS slip • Corticosteroid injection • Operative release • Percutaneous https://www.ncmedical.com/item_1751.html • open **** Studies show steroid injection alone is more effective than splints 9
12/10/2016 Steroid Injection Injection • 70% can resolve after a single • Combination local injection anesthetic and steroid • 57% (level 1 and 2 studies) • Lower success rate • younger patients • Around the tendon in • Diffuse type area of A1 pulley • diabetics • multiple fingers • No difference in • other upper extremity tendinopathies success if injected inside or outside of • Most effective if symptoms the sheath! less than 6 mos and nodular type Risks of injection Injection in Diabetics • Infection • Fat atrophy • Bleaching of skin • Increase blood glucose • Greatest effect 24 hours after • Tendon Rupture injection (150% baseline) • Hyperglycemia in diabetics • Effect lasts up to 5 days 10
12/10/2016 Surgery Percutaneous release • Failure of non-surgical treatment • May be a first line treatment in diabetics • Locked finger http://www.amhandinst.com/triggerfinger.html Open release Trigger Finger • When to refer? • Failure of at least one injection • Locked trigger finger • Unclear diagnosis 11
12/10/2016 Outline Basal Joint = Thumb CMC joint • Carpal Tunnel Syndrome • Trigger Finger • Basal Joint arthritis • De Quervain tenosynovitis • Mallet Finger • Ganglion cyst http://www.noelhenley.com/280/joints-of-the-thumb/ Anatomy History • Do you have difficulty: • pinching, writing • opening a tight jar • Opening doors, keys • carrying a shopping bag • using a knife to cut food 12
12/10/2016 Clinical Exam Nonoperative management • Physical appearance • Tenderness • Specific Tests • Custom made thermoplastic splint • Grind • Off the shelf splint • Activity modification education • Symptom management Van Heest, JAAOS 2008 Thumb CMC OA Thumb CMC OA Injection • Injection into the CMC joint is often painful, especially in more advanced disease • Injection • Distract the joint • Mark the site of injection • Prepare the site of injection • Advance needle to bone and inject small amount http://www.aafp.org/afp/20030215/745.html • Once anesthetized, advance needle into the joint and inject Courtesy of Peter M. Murray, MD 13
12/10/2016 Treatment: Surgical Thumb CMC OA • Later stages • When to refer? • Failure of non-operative treatment • CMC arthrodesis • Unclear diagnosis • Resection arthroplasty • LRTI DeQuervain ’ s Tenosynovitis Outline • Carpal Tunnel Syndrome • Trigger Finger • Tendonitis 1 st • Basal Joint arthritis dorsal compartment • De Quervain tenosynovitis • APL: Abductor • Mallet Finger pollicis longus • Ganglion cyst • EPB: Extensor pollicis brevis http://www.orthobullets.com/hand/6006/extensor-tendon-compartments 14
12/10/2016 Surface Anatomy Anatomy APL/EPB Hand Surgery Update IV, Chapter 22, Figure 4a Sheath enclosing APL/EPB becomes narrowed leading to pain and inflammation Symptoms Examination • More common in women (6:1 ratio) • Tenderness over • New mothers tendons at thumb • May have ‘ clunking ’ of the thumb side of wrist • Pain at the radial wrist/base of thumb • Pain with thumb motion • Finkelstein’s test • Thumb in fist • Ulnarly deviate 15
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