HAND ORTHO

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Remember!!!• Down Diagnosis• In Incidence• Australia Aetiology• People Pathophysiology• Cook Clinical Features• In Investigations• Dirty Diagnostic Criteria• Tins Treatment• Pots & Prognosis• Cans Complications

TRIGGER FINGER Also known as:-• Snapping Finger• Digital Tenovaginitis Stenosans

Definition• Thickening and constriction of the mouth of a fibrous digital

sheath interference with the free gliding of the contained flexor tendons

Incidence• Peak age 50-60 yrs (adult)• Also in infants and children (infantile)• 4× F > M

SNAPPING FINGERAetiology

• Unknown

• Systemic: Collagen Vascular Diseases Rheumatoid Arthritis Diabetes Mellitus Psoriatic ArthritisHypothyroidism SarcoidosisAmyloidosis

• Highly repetitive or forceful use of the finger and thumb. Prolonged, strenuous grasping, such as with power tools, may also aggravate the condition. Thus seen in farmers, musicians, imdustrial workers

• Congenital nodule of the flexor pollicis longus

• InfectionTB

Digital Tenovaginitis Stenosans

Pathology• mismatch between the size of the flexor tendon

and its fibrous flexor sheath• proximal part of the fibrous flexor sheath at the

base of a digit becomes thickened thereby constricting the mouth of the sheath

• thus leading to disproportionate width of the tendon ie decrease in the width opposite to the constriction and swelling proximal to it

• the nodular or swollen segment enters the narrowed opening of the sheath with difficulty

• with an attempt to extend the finger associated snapping sound.

Trigger FingerClinical Features**Adults: 3rd & 4th fingers esp **Children: thumb• Tenderness at the base of affected finger• Locking of finger in full flexion • Locking may be overcome by either forceful effort

or passive extension of the fingers with the other hand

• Extension results in a click or snap• Examination reveals a palpable nodule (usually

slightly tender) at the base that will move with the tendon

**Infantile sometimes mistaken for a dislocation thumb or congenital anomaly

Snapping FingerInvestigations• Trigger finger is a clinical diagnosis. Radiological studies are of

little value.

Diagnosis ?• Clinical grading and documentation

Green’s Classification Grade 1 : Pretriggering – Pain; history of catching that is not demonstrable on clinical examination; tenderness over the A1 pulley Grade 2 : Active – Demonstrable catching but the patient can actively extend the digit Grade 3 : Passive – Demonstrable locking requiring passive extension (grade 3A) or inability to actively flex (grade 3B) Grade 4 : Contracture- Demonstrable catching with fixed flexion contracture of the proximal interphalangeal joint.

Digital Tenovaginitis Stenosans

Treatment: dependent on the severity and duration• Mild, infrequentRest To prevent the overuse of the fingers change or curtail daily activities that requires repeated gripping action.Splinting Keeping the affected finger in a splint in the extended position for several weeks will aid in resting the joint. It also prevents curling of the fingers during sleep which may exacerbate the condition on waking.Gentle Finger Exercises & massage This helps in maintaining the mobility of the fingers .Massage will help to reduce the pain. Soaking in warm waterMay help to reduce the catching sensation.

Digital Tenovaginitis Stenosans

Treatment: dependent on the severity and duration• SevereUse of non steroidal anti inflammatory drugs.This helps in reducing the inflammation and swelling of the tendon sheath Injection of steroids into the tendon sheath may help reduce inflammation. - 25 gauge needle to inject a mixture of 0.5-1.0 mL of 40 mg/mL corticosteroid (eg, methylprednisolone) and 0.5 mL of 1% lidocaine (without epinephrine). -second corticosteroid injection may be performed 3-4 weeks later. -cure rate for this conservative type of management is > 95%. It is thought however that if two injections have not solved the triggering it is unlikely that further injections will and additional injections risk weakening the tendons with subsequent tendon rupture.

Digital Tenovaginitis Stenosans

Treatment: dependent on the severity and duration• Surgical Intervention Indications • Failure of splint / injections• Irreducibly locked finger• Trigger thumb in infants (without release via surgery these infants are likely to

develop a fixed flexion deformity of the interphalangeal joint.) Surgically incise the fibro-osseous canal to allow the thickened tendon to glide without restraint. This may be done under local anaesthesia on an outpatient basis and gives the added benefit of noting the disappearance of the pathology by asking the patient to flex and extend the affected digit. The opening of the sheath is deemed sufficient when triggering is no longer noted. Post surgery the patient should be advised to begin moving the finger to prevent tissue adhesion at the surgical site. Non-steroidal anti-inflammatory drugs and elevation are advised for a period of two to three days afterwards.A simpler procedure involves releasing the friction by percutaneously tearing the sheath with the use of a wide bore needle.

Trigger Finger Complications• Neurovascular damage*The thumb is particularly more vulnerable as the bundle lies closer to the anterior midline of the digit and is in closer proximity to the constricting tendon sheath• Infection • Stiffness and scarring.

De Quervain’s Stenosing Tenovaginits Also known as:-• Tenovaginitis of the abductor pollicis longus &

extensor pollicis brevis

Definition• Stenosing tenovagynitis of the tendons in the first

dorsal extensor compartment of the hand, causing pain over the radial styloid on movement.

Incidence• Middle aged• 5/8× ? F > M

De Quervain’s Stenosing Tenovaginits

Aetiolgy

• Unknown

• Repetitive forceful ulnar deviation of the wrist with the thumb adducted and flexed as during lifting of objects is a common inciting factor.

** Thus more common in mothers of infants , women who wash, those with jobs that require recurrent activity of the hands-typing.

• Also seen in pregnancy, congestive cardiac failure and chronic renal failure due to peripheral edema.

De Quervain’s Stenosing Tenovaginits

Pathology

• The fibrous sheaths of the abductor pollicis longus and extensor pollicis brevis tendons are thickened where they cross the tip of the radial styloid process ie. at a point where the direction of the tendons changes; thus the tendons appear normal.

• Excessive friction from overuse inflammation of the tendons within their fibrous sheath beneath the extensor retinaculum associated swelling within a confined space +/- entrapment of the superficial branch of the radial nerve.

• Nerve entrapment resultant pain & the swelling may further accentuate the obstruction to movement

De Quervain’s Stenosing TenovaginitsClinical Features

• Middle aged female, complaining of pain over the dorsolateral aspect of the wrist provoked by lifting activities or movement of the wrist and thumb.

• Examination reveals local tenderness at the point where the tendons cross the radial styloid process. The thickened fibrous sheaths are usually palpable as a firm nodule

De Quervain’s Stenosing TenovaginitsInvestigationsFinklestein's TestPlace thumb in palm and cover with all fingers and

move wrist intoulnar deviation. If pain is reproduced at radial

styloid region,then suggestive of tenosynovitis of 1st compartment

De Quervain’s Stenosing Tenovaginits

Diagnosis• Clinical

Treatment• Initially conservative ,pain persistence surgery  Conservative• Analgesia with physiotherapy and occupational modification • Rest the thumb and wrist by wearing a wrist and thumb spica splint• Steroid injections with methylprednisone to help decrease the inflammation and

swelling. This is most successful within the first six weeks after onset of the pain; injected adjacent and parallel to the tendon sheath at the area of maximal tenderness, just distal to the radial styloid. This peritendinous infiltration may be repeated one or two times at one to two week intervals, if necessary.

 Surgical• Almost always curative and performed on an outpatient basis• Involves a longitudinal incision of the tendon sheaths under local anaesthetic

( de- roofing). Take care to avoid the sensory branch of the radial nerve .This allows for unrestrained tendon gliding.

De Quervain’s Stenosing TenovaginitsComplications

• neuroma formation due to severing the branch of the radial nerve

• volar subluxation of tendon because too much of the sheath is removed

• failure to find and release a separate aberrant tendon within a separate compartment

• hypertrophy of scar due to the longitudinal skin incision

Carpal Tunnel

Carpal Tunnel Syndrome• Carpal tunnel or carpal canal is the passageway on

the palmar side of the wrist connecting the forearm to the middle compartment of the deep plane of the palm.

• Consists of:flexor digitorum profundus (4 tendons)flexor digitorum superficialis (4 tendons)flexor pollicis longus (1 tendon)median nervebonesconnective tissue lymphatics fat

Carpal Tunnel

Median NerveRemember?

Median nerve runs within the forearm beneath the flexor digitorum superficialis .

Emerges on the radial side of the tendons lying deep to the palmaris longus tendon .

Passes through the carpal tunnel but before doing so gives off a palmar cutaneous branch.

In the tunnel it lies just beneath the flexor retinaculum and comes in contact with it on bending the wrist or fingers.

In the hand it gives off a muscular recurrent branch that supplies the thenar muscles:

-flexor pollicis brevis -abductor pollicis brevis -opponens pollicis palmar digital branches which supply the radial three and a half digits as well as the nail beds and distal dorsal skin.

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

Also known as:Most common entrapment neuropathy

Definition• Compression of the median nerve within the carpal

tunnel which lies between the carpal bones and the flexor retinaculum leading to impaired sensory and motor function of the hand over the distribution of the median nerve.

Carpal Tunnel SyndromeIncidence• 30 – 60 years old• 5 × F>M

AetiologyDue to the rigidity of this canal any factor decreasing

the space will cause pressure against the structures within.Factors include anything leading to: • Increase in Volume of Contents• Decrease in size of the tunnel• Susceptibility

Carpal Tunnel SyndromeAberrant anatomy Anomalous flexor tendons Congenitally small carpal canal Ganglionic cysts Lipoma Proximal lumbrical muscle

insertion Thrombosed artery  Infections Lyme disease Mycobacterial infection Septic arthritis  Inflammatory conditions Connective tissue disease Gout or pseudogout Nonspecific flexor tenosynovitis* Rheumatoid arthritis

Metabolic conditions Acromegaly Amyloidosis Diabetes Hypothyroidism or hyperthyroidism Increased canal volume Congestive heart failure Edema Obesity Pregnancy TraumaRepetitive hand motion: finger and wrist flexion and extension Labourers using vibrating machinery as are office workers especially typists and data entry clerks

Carpal Tunnel Syndrome PathologyIncreased pressure within the carpal canalischaemia to the median nerve rather than direct nerve damage resultant symptoms.

Clinical FeaturesHistory • Pain, numbness, tingling in the distribution of the• Symptoms worse at nights with accompanying sleep disturbance

due to pain• Shaking, massaging, or elevating the hands can sometimes gain

relief.• Pain may radiate up the forearm to the elbow.• Decreased grip strength with loss of dexterity. Dropping objects and

less capable of performing fine motor movements such as gripping or pinching.

• Symptoms more common when a flexed wrist posture is assumed.

Carpal Tunnel SyndromeClinical FeaturesPhysical Examination• Initially no findings• Atrophy of thenar muscles depending on severity • Blunting of sensation over median nerve **Blunting of Sensation- this occurs over the radial 3½ digits but not over the thenar eminence which is supplied by the palmar branch of the median nerve that comes off above the flexor retinaculum and passes superficial to it. **Useful in differentiating CTS from median nerve damage at

a higher level. 

Carpal Tunnel Syndrome InvestigationsTinel’s Test • Percussing / Tapping the volar wrist over the median nerve:a positive sign if there is resulting shooting or shocking pain into hand over radial 3 ½ digits. Phalen’s Test • Holding wrist in flexion for 60 seconds:a positive sign if there is resulting tingling / paresthesia in the radial 3 ½ digits. • Loss of two point discrimination.• Nerve Conduction Studies : investigation of choice for site and severity of

compression • Electromyography • Computed Tomography Scanning: displays bony structure but not soft

tissue.• Ultra Sound: does not show soft tissue planes adequately. • Magnetic Resonance Imaging: Good soft tissue and bony imaging.

Carpal Tunnel Syndrome Daignosis• Very dependent on the history of the patient.

Treatment: Aims to relieve pain, restore normal sensation and prevent worsening 

Conservative• Treat underlying condition• Rest or Splint to restrict movement of wrist. May be worn during the day

and/or night.• NSAIDS to relieve pain.• Steroid injections may produce temporary symptomatic relief.• Approximately 80% of patients with CTSinitially respond to conservative

treatment; however, symptoms recur in 80 % of these patients after one year. 

Surgical  • More severe symptoms require surgical intervention via division of the

flexor retinaculum to decompress the median nerve. This may be performed endoscopically. NB. Physiotherapy may be needed in severe cases in order to regain proper

hand function.

Carpal Tunnel Syndrome