Common conditions of the hand (2013)

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  • 1. Common Conditions of the Hand (2013) Rex Moulton-Barrett, MD Plastic and Reconstructive Surgery Alameda and Brentwood California
  • 2. Relevant Anatomy • Bones: 27 • Extensor Tendons:11 extrinsic • Flexor Tendons: 13 extrinsic • Intrinsic Muscles/Tendons: 16 • Ligaments:MCP/IP- Primary & Accessory Transverse Palmer • Accessory Apparatus: Capsules Volar Plate Retinaculae: Flex, Ext
  • 3. Relevant Physiology • Median Neuropathy • Ulnar Neuropathy • Radial Neuropathy • Peripheral Neuropathy • Radiculopathy • Reflex Sympathetic Dystrophy Syndrome • Injury Splinting in Intrinsic Plus Position • Splinting CTS in wrist neutral/extension • Splinting Cubital Tunnel < 45 degree flexion
  • 4. Median Neuropathy • Motor: thumb opposition and abduction radial 2 lumbricals • Sensory: radial 3 1/2 fingers
  • 5. Splinting CTS in wrist neutral/extension
  • 6. • Motor: All intrinsics except thumb opposition & abduction radial 2 lumbricals • Sensory: Ulnar 1 1/2 sensory Ulnar Neuropathy
  • 7. Splinting Cubital Tunnel < 45 degree flexion
  • 8. Radial Neuropathy Supplies wrist extensors, needed for flexor tendon lengthening for grip strength and because of median and ulnar nerve overlap small sensory area dorsal 1st web
  • 9. Peripheral Neuropathy • Typical stocking / glove distribution • Causes: Diabetes Mellitus, EtOH /B12/ folate deficiency Drugs: chemotherapy > nifedipine
  • 10. Radiculopathy • Dermatome specific • Congenital: Brachial Plexopathy • Acquired: Usually Mechanical: disc or osteophyte direct injury or tear/stretch cervical rib
  • 11. Injury Splinting in Intrinsic Plus Position
  • 12. Reflex Sympathetic Dystrophy Syndrome: RSD Complex Regional Pain Syndrome: CRPS • Usually triggered by trauma: more extensive: more likely • Use of axillary block in hand surgery somewhat protective • Stages: 1. Burning pain, can be continuous and intense hyperhidrosis, cool, Raynaud’s phenomenom, reddish color 2. Pain more proximal hair thinning, shiney nail pitting, osteoporosis, joint capsular thickening 3. Pain affects entire limb, muscle wasting, tendon contractures joint deterioration/subluxation and osteoporsis worsens
  • 13. Clinical History • Right or left hand dominant • Take relevant history: mechanism • If chronic: frequency/repetition of trauma work type work position / posture / torque ergonomics home support secondary gain
  • 14. Clinical Exam • Note: overall body habitus: obesity, macromastia • Note: posture and shoulder position • Note forearm and upper arm features • Note external features: volar=palmar and dorsal • Note: comparative grip strength
  • 15. Volar External Features
  • 16. Dorsal External Features
  • 17. Cascade/Attitude • Normal • Abnormal
  • 18. Index Finger Opposition: Median Nerve
  • 19. Little Finger Opposition: Median>Ulnar
  • 20. Dorsal Interossei (DAB): Ulnar
  • 21. Intrinsic Plus: Ulnar >> Median Palmer Interossei ( PAD) and Lumbricals
  • 22. Gross Grasp: Median>Radial>Ulnar
  • 23. Dynomamometer >15% difference ?
  • 24. Finkelstein Test: de Quervain’s Tenosynovitis
  • 25. Thumb Trigger Nodule
  • 26. Index Trigger Nodule
  • 27. Extensor Tenosynovitis/Tennis Elbow/Lateral Epiconylitis Radial Tunnel/Posterior Interosseous Nerve Entrapment
  • 28. Tinel at elbow
  • 29. Tinel at Wrist
  • 30. Allen Test: Dominant Ulnar > Radial Artery 8.1% May be higher in populations with h/o ABG’s 1. Elevate hand 30 seconds 2. Make fist elevated 3. Apply pressure over Radial and Ulnar Arteries 4. Open hand while elevated, it should be blanched 5. Release one vessel pressure, should refill in 7 seconds
  • 31. Moving 2 Point Discrimination
  • 32. Phalen’s Test: 1 minute
  • 33. Common Conditions of the Hand 1995: National Center Health Statistics • Open wound finger>hand>forearm • Contusion of the upper extremity • Sprain to the wrist • Fractures: radius/ulna>humerus>phalanges>carpal>metacarpels • Burns to the hands, fingers and thumb • Carpel Tunnel Syndrome • Osteoarthritis upper extremity • Rheumatoid arthritis • Other compressive neuropathies: Cubital Tunnel • No mention of masses / tumors / tendon injuries / infections
  • 34. Masses of the Hand 90% benign ( Skin Cancers, then: ) • Ganglions 50% • Enchondromas 10% • Granular Cells Tumors 10% • Epidermal inclusion cysts • Lipomas: remove if symptomatic • Glomus Tumors • Raromas
  • 35. Ganglions Dorsal wrist >volar/radial > DIP/osteoarthritic > flexor sheath Scapholunate OsteophyteRadioscaphoid/Carpel ScaphoTrapezial 65% 20% 10% 5%
  • 36. Enchondromas Solitary 85% > multiple 15% Usually arising from the shaft of the phalanx
  • 37. Granular Cell Tumors Need to excise a margin of tendon sheath to reduce recurrence Encapsulated and yellow brown in color
  • 38. Glomus Tumors Severe pain, temperature related, 1/4 subungal Xray shows a scalloping defect secondary to cortical pressure
  • 39. Melanoma Intermittent intense sun exposure < 50 Continuous sun exposure > 50, especially dorsum hand Most frequently seen in 70-80 age group female > male
  • 40. Subungal Melanoma 20-25% amelanotic Often history of trauma Mean age 60’s Hutchinson’s sign-> spread of pigment to surrounding tissue DD: hematoma, chronic paronychia, melanonychia, junctional nevus Hutchinson’s sign
  • 41. Inflammatory Flexor tenosynovitis Electricians Hammer and jack hammer Home construction
  • 42. Mallet Deformity Type 1: closed blunt trauma, no fracture, treat with splint 6 weeks Type 4B:20-50% articular fracture Type 4C: > 50% fracture+volar subluxation Stack splint
  • 43. De Quervain’s Disease • Injection for de Quervain's tenosynovitis: 1ml Kenalog 40, 25 G needle • The needle is placed into the first extensor compartment and • directed proximally toward the radial styloid •
  • 44. Trigger Finger • Trigger finger injection: 0.5-1ml 25 g needle, Kenalog 40 • The needle is inserted distal to distal palmer crease • Aim posterior towards the nodule in the direction of the metacarpal head • Use your non-dominant hand to move PIP/DIP and free for tendon ‘scratch’ • You are trying to fill the sheath and the A1 pulley with steroid •
  • 45. Lateral Epicondylitis • Steroid injection Kenalog 40 • 25 g needle onto bone • 1 by 2cm area: stay on bone • Radial nerve is medial • Tennis elbow Splint • After 3 injections consider • Debridement of ECRL/B
  • 46. Carpel Tunnel Syndrome:1.5% population 3 x more common in women • Causes: WR: 47%> Dialysis, DM, Pregnancy, RA, Amyloid • Work-up: EMG- conduction velocity> 4.5ms motor, > 3.5ms sensory • Management: NSA’s, splinting, ergonomics • Steroid injections controversial in USA • Surgery ( 85% successful ) : if medical management fails & + EMG • Surgical techniques: formal long Orthopedic incision endoscpic Chow, Agee techniques minimal scar non-endoscopic • Short scar associated with early rehabilitation / return to work • Neurolysis indicated for recurrent CTS and dialysis patients
  • 47. Cubital Tunnel Syndrome • Usually caused by noctural hyperflexion at elbow • 85% respond to noctural splinting • No role for steroid injections • Surgery for failed splinting: • Short scar transposition & subfascial tunnel submuscular tunnel submuscular tunnel with medial epicondylectomy Entrapment or subluxation
  • 48. Dupuytren’s Disease Operate if > 30 degrees MCP flexion any PIP flexion
  • 49. CMC Arthritis • • Injection for first carpometacarpal joint. • The needle should enter on the ulnar side of the extensor pollicis brevis tendon • Gentle pull on the thumb opens the CMC joint space • The 25-gauge needle should fall into the joint: 0.5ml Kenalog 40 •
  • 50. PIP Osteoarthritis Pyrocarbon: graphite/ceramic Pyrocarbon graphite/ceramic Silicone: < 30 degrees flexion Silicone: < 15 degrees flexion
  • 51. Rheumatoid Arthritis • 3 stages: Proliferative: swollen, stiff, assoc CTS Destructive: erosion joint capsules, bone Reparative: fibrosis replaces inflammation • Loss of finger flexion: FDS rupture • Incomplete finger extension: ulnar wrist subluxation • Mannerfelt Lesion: rupture FPL from scaphoid osteophyte • MCP joint subluxation best treated with joint replacement • Swan neck deformity associated with intrinsic shortening • If wrist subluxation; distal ulna may sublux dorsally • Darrach Procedure: resect distal Ulna & rebalance tendons avoids tendon rupture from Ulna wear
  • 52. Burns • Scar excision and early skin grafting can reduce contracture formation
  • 53. Congenital • Amniotic bands • Syndactyly • Thumb duplication • Trigger/Campytdactyly/Clindodactyly
  • 54. Hand Prostheses
  • 55. Raroma • Tumor example of Schwannoma