common conditions of the hand (2013)
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Common Conditions of the Hand(2013)
Rex Moulton-Barrett, MD
Plastic and Reconstructive Surgery
Alameda and Brentwood California
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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
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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
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Median Neuropathy
• Motor: thumb opposition and abduction
radial 2 lumbricals
• Sensory: radial 3 1/2 fingers
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Splinting CTS in wrist neutral/extension
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• Motor: All intrinsics except thumb opposition & abduction
radial 2 lumbricals
• Sensory: Ulnar 1 1/2 sensory
Ulnar Neuropathy
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Splinting Cubital Tunnel < 45 degree flexion
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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
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Peripheral Neuropathy
• Typical stocking / glove distribution
• Causes: Diabetes Mellitus,
EtOH /B12/ folate deficiency
Drugs: chemotherapy > nifedipine
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Radiculopathy
• Dermatome specific
• Congenital: Brachial Plexopathy
• Acquired: Usually Mechanical:
disc or osteophyte
direct injury or tear/stretch
cervical rib
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Injury Splinting in Intrinsic Plus Position
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Reflex Sympathetic Dystrophy Syndrome: RSDComplex 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 thickening3. Pain affects entire limb, muscle wasting, tendon contractures joint deterioration/subluxation and osteoporsis worsens
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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
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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
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Volar External Features
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Dorsal External Features
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Cascade/Attitude
• Normal
• Abnormal
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Index Finger Opposition: Median Nerve
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Little Finger Opposition: Median>Ulnar
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Dorsal Interossei (DAB): Ulnar
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Intrinsic Plus: Ulnar >> Median
Palmer Interossei ( PAD) and Lumbricals
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Gross Grasp: Median>Radial>Ulnar
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Dynomamometer
>15% difference ?
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Finkelstein Test: de Quervain’s Tenosynovitis
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Thumb Trigger Nodule
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Index Trigger Nodule
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Extensor Tenosynovitis/Tennis Elbow/Lateral Epiconylitis
Radial Tunnel/Posterior Interosseous Nerve Entrapment
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Tinel at elbow
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Tinel at Wrist
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Allen Test: Dominant Ulnar > Radial Artery 8.1%May be higher in populations with h/o ABG’s
1. Elevate hand 30 seconds2. Make fist elevated3. Apply pressure over Radial and Ulnar Arteries4. Open hand while elevated, it should be blanched5. Release one vessel pressure, should refill in 7 seconds
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Moving 2 Point Discrimination
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Phalen’s Test: 1 minute
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Common Conditions of the Hand1995: 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
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Masses of the Hand90% benign
( Skin Cancers, then: ) • Ganglions 50%• Enchondromas 10%• Granular Cells Tumors 10%• Epidermal inclusion cysts• Lipomas: remove if symptomatic• Glomus Tumors• Raromas
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Ganglions
Dorsal wrist >volar/radial > DIP/osteoarthritic > flexor sheath
Scapholunate OsteophyteRadioscaphoid/Carpel ScaphoTrapezial
65% 20% 10% 5%
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Enchondromas
Solitary 85% > multiple 15%Usually arising from the shaft of the phalanx
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Granular Cell Tumors
Need to excise a margin of tendon sheath to reduce recurrence Encapsulated and yellow brown in color
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Glomus Tumors
Severe pain, temperature related, 1/4 subungalXray shows a scalloping defect secondary to cortical pressure
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Melanoma
Intermittent intense sun exposure < 50Continuous sun exposure > 50, especially dorsum handMost frequently seen in 70-80 age group female > male
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Subungal Melanoma
20-25% amelanoticOften history of traumaMean age 60’sHutchinson’s sign-> spread of pigment to surrounding tissueDD: hematoma, chronic paronychia, melanonychia, junctional nevus
Hutchinson’s sign
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Inflammatory Flexor tenosynovitis
Electricians
Hammer and jack hammer
Home construction
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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
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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
•
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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
•
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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
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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
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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
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Dupuytren’s Disease
Operate if > 30 degrees MCP flexion any PIP flexion
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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
•
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PIP OsteoarthritisPyrocarbon: graphite/ceramic
Pyrocarbon graphite/ceramic
Silicone: < 30 degrees flexion
Silicone: < 15 degrees flexion
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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
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Burns• Scar excision and early skin grafting can
reduce contracture formation
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Congenital• Amniotic bands
• Syndactyly
• Thumb duplication
• Trigger/Campytdactyly/Clindodactyly
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Hand Prostheses
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Raroma
• Tumor example of Schwannoma
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