common hand problems related to work
DESCRIPTION
COMMON HAND PROBLEMS RELATED TO WORK. Prasad G. Kilaru MD Plastic, Reconstructive & Hand Surgery. Agenda. Injury types Basic anatomy Mechanism of action Diagnosis Treatment Prevention Education. Repetitive Stress Injury. Nerve: Carpal tunnel syndrome, cubital tunnel syndrome - PowerPoint PPT PresentationTRANSCRIPT
COMMON HAND COMMON HAND PROBLEMS RELATED PROBLEMS RELATED
TO WORKTO WORK
Prasad G. Kilaru MD Plastic, Reconstructive & Hand Surgery
AgendaAgenda
Injury typesBasic anatomy Mechanism of actionDiagnosisTreatment Prevention Education
Repetitive Stress InjuryRepetitive Stress Injury Nerve:
– Carpal tunnel syndrome, cubital tunnel syndrome Tendon: Connects muscle to bone
– Repetitive injury at muscle insertion Trigger digit, DeQuervain’s tenosynovitis
– Repetitive injury at muscle origin Lateral epicondylitis, Medial epicondylitis
Ligament: Connects bone to bone– Chronic collateral ligament injury, TFCC injury
Joint Problems– Ganglion cyst, Mucous cyst, Basal joint arthritis
Traumatic InjuryTraumatic Injury
Tendon injury– Flexor, extensor, muscle belly injury– Injury to tendon insertion
Mallet finger, Flexor tendon avulsion
Bony InjuryNerve InjuryJoint Injury
– Sprain, dislocation
Anatomy - NerveAnatomy - Nerve
Median nerve – Mixed nerve– Sensory – Volar aspect of palm and radial 3 ½ fingers– Motor – Major finger and wrist flexors, thenar muscles
and radial lumbricals Ulnar nerve – Mixed nerve
– Sensory – Ulnar aspect of volar and dorsal palm and ulnar 1 ½ fingers
– Motor – Ulnar wrist and finger flexors and intrinsic muscles of the hand
Anatomy - NerveAnatomy - Nerve
Anatomy - NerveAnatomy - Nerve
Radial nerve – Mixed nerve– Sensory – Dorsal aspect of hand and radial 3 ½ fingers
dorsally– Motor – Extensors of the elbow, wrist and fingers
Sensory to palm and fingers– Volarly – Radial 3 ½ fingers and palm – Median nerve,
Ulnar 1 ½ fingers and palm – Ulnar nerve– Dorsally – Radial 3 ½ fingers and hand – Radial nerve,
Ulnar 1 ½ fingers and hand – Ulnar nerve
Anatomy Carpal TunnelAnatomy Carpal Tunnel
Anatomy of Flexor Pulley SystemAnatomy of Flexor Pulley System
Anatomy – Extensor Anatomy – Extensor CompartmetnsCompartmetns
Mechanism of ActionMechanism of Action Repeated movement/use causes swelling over
affected region Repeated movement/use despite swelling causes
worsening of swelling Feedback loop set up with worsening symptoms Depending on the structure effected – numbness,
pain, locking etc.
Nerve Compression SyndromesNerve Compression Syndromes
Median nerve compression (carpal tunnel syndrome) occurs from compression of the nerve at the wrist
Ulnar nerve compression can occur at the wrist or elbow Radial nerve compression usually occurs in the forearm Pressure buildup can occur from decrease in the size of the
tunnel(bone overgrowth, fracture) or increase in the volume of the contents of the tunnel(tendinitis, fluid buildup etc.)
TendinopathiesTendinopathies
Repeated movement/use of tendons causes tendons to swell up and get trapped in tunnels either over fingers or wrist (trigger finger, DeQuervain’s tenosynovitis)
Repeated movement/use at tendon origin causes microtears which cause chronic tears near common extensor (lateral epicondylitis) or common flexor (medial epicondylitis) origin
Nerve Compression Signs & Nerve Compression Signs & SymptomsSymptoms
Symptoms commonly include pain, numbness, tingling and in late stages weakness in grip
Symptoms are usually felt at night and can occasionally wake patients from sleep
The numbness is usually along the distribution of the effected nerve
Severe cases can result in muscle wasting with weakness and permanent sensory loss
Nerve Compression DiagnosisNerve Compression Diagnosis
History and physical examination are usually indicative of nerve compression
Tinel’s sign, nerve compression test, Phalen’s test are all positive
Nerve conduction study and EMG are often confirmatory
Tendinopathy DiagnosisTendinopathy Diagnosis
Usually presents with locking or snapping of the finger or thumb on flexion that holds the finger in flexion(trigger finger)
There is usually tenderness over the MP joint volarly and a nodule or thickening is usually palpable in the same region(trigger finger)
Pain over the first dorsal compartment at the anatomic snuff box (deQuervain’s tenosynovitis)
Finkelstein’s test is usually positive (deQuervain’s tenosynovitis)
Tendinopathy DiagnosisTendinopathy DiagnosisPatients usually have point tenderness over
the lateral or medial epicondyle (epicondylitis)
Pain can be reproduced by wrist or finger extension (lateral epicondylitis) or flexion (medial epicondylitis)
Treatment OptionsTreatment Options
Noninvasive options – Initial approach– Ergonomic evaluation– Work modification, – Splints/braces that immobilize the affected area – NSAIDS or steroidal anti-inflammatories– Topical anti-inflammatory modalities, ice, – Physical therapy
Treatment OptionsTreatment Options
Steroid injections– At least 3-4 months apart, no more then 2 a year– Avoid injections near nerves– Side effects
Surgical options – When conservative measures fail or cannot be
implemented– In late cases – severe compression on NCS/EMG
Treatment OptionsTreatment Options For compressive pathology - basic principle is to
release the area of constriction– transverse carpal ligament for carpal tunnels syndrome– A1 pulley for trigger digits– First dorsal compartment release
For nerve compression, surgery reverses symptoms for early cases and prevents progression of disease in late cases
“Wont get any worse – how much better depends on extent of the damage”
Surgery usually a cure – recurrence rare
Treatment OptionsTreatment Options For tendinopathies, surgery considered when
conservative therapy fails Requires debridement of the inflamed tendon and
associated bone spurs and reattachment of the extensor/flexor origin
Recovery longer with surgery around elbow Therapy needed for splinting, movement etc.
Preventive MeasuresPreventive Measures
Prevention of repetitive trauma – Ergonomic evaluation and implementation– Regular stretching and strengthening
“Preparation for a marathon”– Learning to recognize early symptoms– Preventive maneuvers
EducationEducation
Teaching patients to recognize early symptoms
Preventive measures– Medication– Splinting– Anti-inflammatory modalities– Stretching and strengthening exercises
Ligament InjuriesLigament Injuries
Chronic collateral ligament injuries– Usually common to the MP joint of the thumb– Splinting, casting, surgery
TFCC injury– Involves ulnar aspect of wrist– Related to trauma or repetitive injury– Splinting, steroid injections, casting, surgery
Basal Joint ArthritisBasal Joint Arthritis CMC joint of the thumb most
common site for degenerative arthritis in the hand
Related to chronic repetitive use or previous injuries to the thumb
Starts with pain at the base of the thumb, progressing to weakness
Treatment entails rest, NSAIDs, splinting, steroid injections and surgery
Ganglion CystsGanglion Cysts Common soft tissue mass over the hand or fingers,
is a ganglion occasionally associated with repetitive or strenuous activity
Can be volar or dorsal, over the wrist or fingers Treatment
– If asymptomatic, can be left alone– Aspiration of the cyst, rupture(by over inflation) or
infiltration with steroids has a high rate of recurrence(>50%)
– If symptomatic, resection is usually recommended
Mallet FingerMallet Finger “Droop” of the DIP joint of a
finger with intact passive extension, but no active extension
Usually due to avulsion of the tendinous insertion of the extensor tendon or a fracture avulsion at the base of the distal phalanx
This requires splinting in extension for a prolonged period of time and if a fracture is present or is chronic may require surgical correction
SummarySummary
Careful history and physical examination usually goes a long way in obtaining a diagnosis
Rest, splinting and NSAIDS a good start for most repetitive injuries
Ergonomic evaluation can resolve or prevent many cumulative trauma disorders
Early referral to a hand surgeon, can prevent delay in diagnosis or treatment of many common hand problems
Take Away PointsTake Away Points
Patient and employer educationPreventionEarly interventionDiagnosis & treatment
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