shaff hand wrist...ulnar nerve compression at the elbow numbness to small and ring finger causes...

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Hand and Wrist Injuries

John J Shaff, PA-CHand Surgery Specialists, P.C.

Hmmm...

The field of hand surgery deals with both surgical and non-surgical

treatment of conditions and problems that may take place in the hand or upper extremity (from the tip of the

hand to the shoulder).

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About me

Graduated Midwestern 2004General Orthopedics & Trauma 2004 to 07Hand and Upper Extremity 2007-15CAQ OrthopedicsTwo Boys, 3 and 5Run to burn off the crazy

Why/How did I get into Hand Surgery?

Objectives

-Review the most common hand and wrist issues-Describe the initial evaluation of these issues from a

Primary care perspective-Initial treatment-Recognize when to refer to a specialist

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Function of the Hand & Wrist

Multiple functionsDelicate, fine motions

Powerful, grasping tasks

Support / transfer force for changing positions

Sensory organ: perception of surroundings

Communication / express emotions

Complex anatomical structure“Structure follows function”

HAND FUNCTIONS

45% GRASP

45% PINCHSide pinch (key pinch)

Tip pinch (writing)

Chuck pinch (thumb to index/ring)

5% HOOK Carry bag

5% PAPERWEIGHT

HAND AND WRIST

HAND WRIST

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Anatomy – Hand and Wrist

BonesDistal radius

Distal ulna

Carpus (8 individual bones)

Metacarpal

Phalanges

JointsRadiocarpal joint

Distal radioulnar joint (DRUJ)

Intercarpal & midcarpal joints

Ligaments

HAND & FINGER ANATOMY

9 Finger FlexorsMedian nerveTransverse carpal ligament5 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

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HISTORY

Age

Handedness

Chief complaint

Occupation

Previous injury

Previous surgery

Sx related to specific activities

What exacerbates

What improves

Frequency

Duration

HISTORY

4 principle mechanisms of injury

Throwing

Weight bearing

Twisting

Impact

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PHYSICAL EXAMInspection

Palpation

Range of Motion

Neurologic Exam

Special Tests

INSPECTION

Observe upper extremity as patient enters room

Examine hand in function

Deformities

Attitude of the hand

INSPECTIONPalmar Surface

Creases

Thenar and Hypothenar Eminence

Arched Framework

Hills and Valleys

Web Spaces

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Cascade sign

Assure all fingers point to scaphoid area when flexed at PIPs

Types of Injuries

“Reactive” TraumaCumulative Trauma, Repetitive Strain

Gradual Injury

Acute InjuriesOpen vs. Closed

Reactive Trauma

Occurs in response to chronic exposure

Does not effect everyone

Pre-disposing factorsunderlying medical conditions

reactive physiology

environmental/social/emotional/financial stressors

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Reactive Trauma

Examples

Tendonitis/Tenosynovitis

Compressive Neuropathy

Epicondylitis

Myofascial Pain

Tenosynovitis

Swelling of the lining of a tendon

Specific, localizable and identifiable

Examples

trigger finger

deQuervain’s

intersection syndrome

some ganglions (e.g. flexor sheath ganglion)

Wrist Case

34-year-old female hairdresser with thumb pain for 2-3 months

Gradual onset

Now thumb hurts with any movement

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1st Dorsal CompartmentDeQuervains

Abductor Pollicis Longus and Extensor Pollicis Brevis

Radial border of Anatomic Snuff Box

Site of stenosing tenosynovitisDe Quervain’s TenosynovitisFinkelstein’s Test

DEQUERVAIN’S TENOSYNOVITIS

It’s time to refer if...

Tenosynovitis

no improvement with 4-6 weeks of

splinting

therapy (CHT)

steriod injection

co-morbid diabetes mellitus or RA

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Trigger Finger

Stenosing flexor tenosynovitis

Painful snap or lock

Palpate nodule as digit flexed and extended

It’s time to refer if...

Trigger Finger

no improvement with rest

splinting

steriod injection -*****caution*****

co-morbid diabetes mellitus or RA

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Compressive Neuropathy

Median NerveCarpal Tunnel Syndrome

Pronator/Anterior Interosseous Syndrome

Ulnar NerveCubital Tunnel Syndrome

Guyon’s Canal Syndrome

Radial NerveRadial Tunnel Syndrome

Wartenburg’s Syndrome

Carpal Tunnel Syndrome

CausesBMI

diabetes

thyroid disease

pregnancy

occupational

idiopathic

Diagnosisnighttime numbness

morning paresthesia

provocative testing

electrodiagnostic studies

Treatmentcurable only by surgery

non-surgical (palliation)

splinting (sleep only)

corticosteroids

activity modification

antidepressants

modalities

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Carpal Tunnel Syndrome

Entrapment of the median nervePhalen’s and Tinel’s Test

2 point discrimination

SymptomsAching in hand and arm

Nocturnal or AM paresthesias

“Shaking” to obtain relief

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It’s time to refer if...

Carpal Tunnel Syndrome

no improvement with six weeks of

night time wrist splinting

activity modification

Vit B6 100mg QD

any evidence of thenar weakness

Tip: send patient with NCV/EMG

Thenar atrophy

Cubital Tunnel Syndrome

Ulnar nerve compression at the elbow

Numbness to small and ring finger

Causesexternal compression

elbow trauma (dislocation, fracture)

anatomic abnormalities

Can lead to permanent weakness

Residual symptoms after surgery common

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Cubital Tunnel Syndrome

It’s time to refer if...

Cubital Tunnel Syndrome

no improvement with six weeks of

activity modification

elbow awareness

any evidence of intrinsic weakness

Tip: send patient with NCV/EMG

Ganglion Cyst

Typically starts as general complaints of wrist pain

Usual history of recent or remote trauma

Most common sites are dorsal wrist and volar radial

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Ganglion Cyst

Bible thumpers

It’s time to refer if...

Ganglion Cyst

4-6 weeks of splinting does not resolve

Failed aspiration

***Only attempt dorsal

Persistent pain

Acute Trauma

Fingertip Injuries

Replantation

Mutilating Trauma

Fractures

Infections

Wrist Injuries

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Fingertip Injuries

Most common finger injury

Most do not require surgery

Goals of treatmentpreservation of length

painless

appearance

Sensitivity is significant problem

Fingertip Injuries

OrthoArizona Arizona Hand & Wrist Specialists

Tuft Fracture/crush injury

Tuft fracture

Subungal Hematoma

Subtotal amputation

Volar oblique amp

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OrthoArizona Arizona Hand & Wrist Specialists

Subungual hematoma

Evacuate hematoma with 18-guage needle or electrocautery.

Dressing and splint

It’s time to refer if...

Fingertip Injuries

open injuries with tissue loss

complex lacerations

exposed bone

displaced fractures

initial attempt at close is fine

Tip: always get xrays, always, open fx needs abx

Fingertip Injury

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Fingertip Injuries

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Thenar Flap Reconstruction

Fingertip InjuriesThenar Flap Reconstruction

Fingertip Injury: Thenar Flap

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MALLET FINGER

ANATOMYDorsal avulsionExtensor digitorum tendon tear

MECHANISM:Forced flexion of extended digit

TREATMENT:No fracture: DIP extended for 8 weeksFRACTURE: if <30% joint surface, splint x 4 weeksIf >30% refer for ORIFLess than full passive extension refer

COMPLICATIONS:Pressure necrosis from splintPermanent extensor lag

MALLET FINGER

Wrist #1

24-year-old male FOOSH while skiing over the weekend

Seen at the mountain clinic and told “wrist sprain”

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Scaphoid Fracture Pathoanatomy

Blood supplied from distal poleIn children, 87% involve distal poleIn adults, 80% involve waist

Scaphoid Fracture Imaging

Initial plain films often normalBone scan

100% sensitive 92% specific at 4 daysMRI, CT scan

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SCAPHOID FRACTURE

TREATMENTInitial 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 negativeImmobilize thumb spica cast x 7-14 days

Take out of cast, repeat xray, re-evaluate for tenderness

If +tenderness but neg radiographs…Cont. splint and MRI

Scaphoid Fracture

Treatment

Suspected fracture with normal plain films

Short arm thumb spica (splint or cast)

F/U in 7-14 days

Consider MRI

Scaphoid Fracture

TreatmentNon-displaced fracture

Long arm thumb spica cast 6 weeksThen, short arm thumb spica cast for 4-14 weeks

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Scaphoid Fracture

Refer to OrthoAngulated or displaced (1mm)Non-union or AVNScapholunate dissociationProximal fracturesLate presentationEarly return to play

Fractures

Most do not require surgery

Soft tissue injuries frequently overlooked or undertreated

Open fracturesfrequently require operation

risk of infection (osteomyelitis)

Wrist Case

25-year-old tennis player twists wrist as he falls backwards reaching for a lob

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SCAPHOLUNATE DISSOCIATION

SCAPHOLUNATE DISSOCIATION

EXAMWatson’s test (scaphoid shift test)

Scaphoid shuck test

Pain/swelling over dorsal wrist, prox row

DIAGNOSISPlain films: >3mm difference on clenched fist

Scaphoid ring sign

MR Arthrogram

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TREATMENTIf discovered within 4 weeks, surgery

After 4 weeks, conservative treatment reasonable

Bracing

NSAIDS

Referral to hand surgery to confirm if surgery needed

Fractures

FracturesMetacarpal and Phalangeal

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Distal Radius Fractures

Most common wrist fracture

Mechanism: FOOSH

Intra- vs extra-articular

Often associated with ligament injury

Intra-articular fractures should be treated by hand surgeons

1/3 develop carpal tunnel syndrome

It’s time to refer if...

Fractures

displaced or unstable

multiple

open

any wrist fracture

Tips: splint and refer early

antibiotics for all open fx

meticulous wound care

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External Fixation

Wri

st F

ract

ure

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Acute Wrist Injuries

“Wrist sprain” is a diagnosis of exclusion

Severe ligamentous injuries frequently missed

Chronic complaints = severe injury

Window of opportunity is limited

Arthroscopy has emerged as definitive diagnostic procedure in wrist pain

MRI

Every patient wants one

should be ordered selectively

sensitivity/specificity as low as 40%

rarely useful in acute management of injuries

helpful instaging of Kienbock’s disease

soft tissue/bone tumors

occult fractures

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Flexor Tendon Injuries

Should be treated by experienced hand surgeon

Nerve injuries are commonly associated

Certified hand therapist involvement essential

Stiffness is common

Injured hand will be out of commission ~12 weeks

1/3 require secondary operations

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OrthoArizona Arizona Hand & Wrist Specialists

Questions?????

john.shaff@phxhand.com

602-812-7520 (Office)

www.phxhand.com