Update on Management of Common Hand Disorders Dr. PC Ho
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1 Update on Management of Common Hand Disorders Dr. PC Ho Head, Division of Hand & Microsurgery Department of Orthopaedic & Traumatology Prince of Wales Hospital
2 Common Hand Disorders Compression Neuropathy Lumps & Bumps Tendon related pathology Arthritis Infection Hand Injury
3 Common Presenting Symptoms Pain (hand/wrist/elbow) Paraesthesia Lumps and bumps Deformity Stiffness Paralysis/Paresis Loss of function
4 General Concept Hand as Tissue Composite Structural specialization for functional adaptation High functional demand
5 Basic Hand Functions Grasp & Release Pinch Sensation Communication Cosmesis Self-image
6 4 Functional Units Moran & Berger Hand Clin Opposable Thumb 2. Stable I/F & M/F for pinch and power 3. Flexible R/F & L/F as mobile unit 4. Wrist for positioning
7 9 Tissues Composite Skin Nail & Nail Bed Nerve Vessel Tendon Ligament Bone Cartilage Muscle
8 Dorsal Skin 3 cm excursion & 25% in area on fisting
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10
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12 Palmar Skin Thick, hairless, glabrous Resist Shear Facilitate Grasping, Cushioning and Molding of Objects Tactile function
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14 Timed Allen s Test
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16 Hand Circulation Peripheral pulse Colour Capillary Refill Tugor Temperature Sensation
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18 Extensor & Flexor Mechanism Closely related to bony architecture Need perfect gliding mechanism in extremely confined spaces Prone to develop adhesion
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21 Function of Pulley System Isolated excision of the A2 pulley in experimental studies decreases total range of motion by 1.6% to 10%. Manske PR 1983 Lin GT 1989 Tang JB 1995
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23 Joint Relationship 85% Arc of Motion in MCPJ & PIPJ Importance of Collateral Ligament Highly Mobile CMCJ of Thumb
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26 General Approach to hand disorders Part of systemic problem Referred symptom Regional /localized pathology
27 Compression Neuropathy Carpal Tunnel Syndrome Cubital Tunnel Syndrome Thoracic Outlet Syndrome Double Crash Syndrome Radial Tunnel Syndrome AIN/PIN Compression Pronator Teres Syndrome Ulnar Tunnel Syndrome..
28 Compression Neuropathy Need to be distinguished from : Cervical radiculopathy/myelopathy Brachial plexopathy Peripheral neuropathy
29 Diagnosis Predictable site of compression Typical symptoms Neurological deficit in peripheral nerve pattern (if +ve) Provocative tests Electrodiagnostic tests (CTS & CuTS)
30 Carpal Tunnel Syndrome Common in yrs old F:M =3-4:1 Idiopathic in majority Need to r/o secondary causes DM : without neuropathy 14% with neuropathy 30% Pregnancy 50% Obesity Hypothyroidism Renal disease/amyloidosis Acromegaly Inflammatory arthritis Watch out for congenital anomaly in younger patients
31 Pathophysiology Mechanical factor vs ischemia Resting pressure : Normal mmHg CTS patient 30mmHg Pressure study : 20-30mmHg venous occlusion/axonal transport 60-80mm Hg intraneural vascular occlusion mmHg conduction block
32 Carpal Tunnel Syndrome Provocative Tests (beware false ve) Direct Compression test (Durkan s sign) Phalen test Percussion test (Tinel Sign) Reverse Phalen Sphygomanometer compression test Thenar wasting APB strength Sensory deficit : monofilament test, vibrometry, 2 points discrimination Tenosynovitis, SOL Double crash syndrome TOS Pronator Teres syndrome
33 Conservative Rx Splint Local steroid injection Medication: Oral steroid Pyridoxine Anti-diuretics NSAID Physiotherapy Ultrasound Iontophoresis Exercise Yoga Tendon & nerve gliding Improve failure rate from 71% to 43% Activity modification
34 Indication for surgery Fail to conservative Rx for 3-6 months Sensory deficit Motor deficit CTS 2 to SOL in carpal tunnel Poor prognostic signs (Kaplan) Age >50 Duration > 10 months Constant paraesthesia Phalen test +ve in <30 sec. Stenosing flexor tenosynovitis
35 Open Release Success : 86.8% -91% Failure rate : 7-25% Prolonged scar sensitivity : 36% Hypertrophic scar : 1-5 % Palmer cut. nerve injury : 4-6.5% Neurapraxia : 6.5% Grip weakness up to 3-6 months Hour-glass Deformity
36 Endoscopic carpal tunnel release (ECTR)
37 Endoscopic carpal tunnel release (ECTR)
38 Cubital Tunnel Syndrome Ulnar nerve entrapment at elbow Subtle loss of motor functions Clumsiness Dropping things Weakness Dystonia like Myelopathy/T1 vs Ulnar nerve Proximal vs distal compression Claw hand Dorsal sensory spare FDP(V), FCU NCT false ve in 50%
39 Cubital Tunnel Syndrome Look for elbow sign Cubital valgus ROM Ulnar nerve thickening Tinel sign Subluxability of nerve Osteophyte Elbow flexion test Look for wrist sign Wrist deformity Direct compression Guyon canal Tinel sign
40 Elbow pathology Lateral condyle non-union OA elbow Subluxable ulnar nerve
41 Sites of Compression
42 Conservative Rx Absence of any detectable sensory/motor deficit Soft elbow splint in extension Adjust elbow posture/loading Avoid prolonged elbow flexion for 3 months (80%) Local steroid Depigmentation Fat necrosis Nerve injury NSAID, pyridoxine
43 Surgical Rx Decompression in situ Decompression + medial epicondylectomy (King & Morgan 1950) Anterior transposition of ulnar nerve Sub-cutaneous (Roux 1897, Curtis 1898) Sub-muscular (Learmonth 1942) Intra-muscular (Adson 1918) Ulnar tunnel plasty
44 Decompression in situ
45 M Anterior Transposition of Ulnar Nerve
46 Medial Epicondylectomy
47 Thoracic Outlet Syndrome Compression of brachial plexus between 1 st rib and clavicle Commonly affect C8/T1 Fibrosis /edema around scalene muscle Fibrous band Cervical rib (rare) Pancoast tumour Fracture clavicle, 1 st /2 nd rib C2
48 Above : Scalene muscles Clavicle Below: Deep to pectoralis Minor muscle Anatomically : thoracic outlet consists of region above the clavicle, Occupied by layers of the scalene muscles; deep to the clavicle, and Below it, deep to the pectoralis minor muscle. The important neuro- Vascular structures within it are : the brachial plexus, and the Subclavian vessels. Neurogenic or Vasogenic symptoms are produced When these structures are compressed.
49 TOS Middle aged women Obese, short neck, large breast Slouch posture Anxious personality Excessive overhead activities Neurogenic vs Vascular presentation (rare) Clinical Dx by exclusion
50 Provocative Test Roo s test Wright hyperabduction test Adson s test Costo-clavicular compression test (Halstead Maneuver) Tinel sign at Erb s point
51 Conservative Rx Anxioltyic Weight reduction Muscle relaxation/ stretching Scapular musicle strengthening Postural exercise Neck / shoulder physiotherapy Steroid injection to Erb s point
52 ical Rx Seldom required Scalenectomy 1st rib resection
53 Lumps and Bumps
54 Anatomical approach to diagnosis Skin Subcut. tissue Nerve Vessel Tendon Muscle Joint Bone
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56 General approach S/S of malignancy Recent change in size, pain, colour, discharge Constitutional symptoms Cystic lesion can be observed, aspiration to confirm nature Solid lesion require excision/incision biopsy Deep subfascial mass of >5cm treated as malignant mass until proven otherwise
57 Facts about Ganglion Most common soft tissue tumour (Stack, 1960) Never becomes malignant Can resolve spontaneously Prevalent in young adult (peak 10-30) (Janzon, 1981) Etiology never clear Majority related to wrist joint (Angelides 1976)
58 Patient s Perception Westbrook et al JHS(B) 2000 Cosmetic 38% Fear of cancer 28% Pain 26% Altered function 8%
59 The Only Absolute Indication for Operation Uncertain Diagnosis Compression neuropathy Atypical Presentation /location Painful occult ganglion
60 Observation Active neglect 40% spontaneous resolution (Zachariae 1973) Indicated in all asymptomatic cases Wait for?
61 Bible Therapy Recurrence 50-78% (Calberg 1977) Impossible to rupture in 50% (Razemon 1983) Painful & brutal
62 Aspiration Almost 100% effective Recurrence 68% (n=336) Improvement - Hyaluronidase injection 49% cure (Paul & Sochart 1997) 95% ( Otu 1992 n=340) Volar vs Dorsal ganglion
63 Open Excision Simple excision 40% (McEvedy 1954) Radical excision 1-5% (Angelides 1976, Clay 1988) Recurrence 15.4% (n=473) Essential elements: Capsular-synovial junction at SL Ligament SL Ligament left intact Repair of capsular defect contraindicated
64 Arthroscopic Excision Marsupialization procedure leaving cyst wall intact One-way valve effect (Andren & Eiken 1971) Stalk in SL capsular-ligament junction (Angelides 1976)
65 Dorsal Ganglionectomy
66 12 m PO
67 Tendon-related Pathology Tendinitis Tendinosis Tenosynovitis Tenovaginitis
68 Trigger finger Staging (Green) : I. Pain / Swelling ii. Triggering iii. Catching iv. Fixed contracture Stenosing Tenovaginitis
69 Trigger Finger Stenosing tenovaginitis of A1 pulley Common in R/F, M/F & thumb Rare in L/F Associated with DM Nodular v diffuse pulley thickening
70 DDX Dupuytren s disease Inflammatory arthritis (MCPJ) Flexor tenosynovitis Sesamoditis Tendon rupture Nerve palsy
71 Conservative Rx NSAID Physiotherapy Steroid Injection
72 Open release
73 Percutaneous Release
74 Dequervain Disease Tenovaginits of 1 st dorsal compartment (EPB/APL) DDx : Intersection syndrome, fracture of scaphoid/distal radius, 1 st CMCJ OA, Wrist arthritis Local tenderness +ve Finkelstein test -ve Radio-carpal grinding test tendon stress test
75 Conservative Rx Splint NSAID Activities modification Steroid injection
76 Complication of steroid injection Hypo-pigmentation Tendon rupture Local sepsis Fat necrosis
77 Operative Rx Open release Beware of separate compartment for APL/EPB Percutaneous/ endoscopic release
78 Arthritis Osteo-arthritis Rheumatoid arthritis Sero-negative arthritis Psoriatic arthropathy Gouty arthritis SLE
79 Osteo-arthritis 1 vs 2 1 OA common in hand (DIPJ & 1 st CMCJ) and elbow OA wrist usually 2 to trauma e.g carpal instability, carpal/distal radius fracture
80 Osteoarthritis of the first carpometacarpal joint
81 Forces down > > CMCJ the thumb IPJ MCPJ 1 kg pinch force at thumb tip -IPJ 3.68 kg -MCPJ 6.61 kg -CMCJ kg
82 Thank you
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