PG Session: Power Ortho: Hand & Wrist/ Kyle Bickel, MD, FACS

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Shannon Leo Atkinson
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WOHC 2012 Hand & Wrist Kyle D. Bickel, M.D., FACS The Hand Center of San Francisco Disclosure Information Western Occupational Health Conference 2012 Kyle D.

1 WOHC 2012 Hand & Wrist Kyle D. Bickel, M.D., FACS The Hand Center of San Francisco Disclosure Information Western Occupational Health Conference 2012 Kyle D. Bickel, MD, FACS I have no pertinent financial relationships to disclose I will not discuss off-label or investigational use in my presentation Hand & Wrist Problems in Occ Health Survey Carpal Tunnel Syndrome in the Workplace is: A. Always occupationally related B. Sometimes occupationally related C. Never occupationally related D. There is inadequate high-level evidence to determine the causal effect of occupation in almost all work environments

2 Hand & Wrist Problems in Occ Health Survey Carpal Tunnel Syndrome in the Workplace is: A. Always occupationally related B. Sometimes occupationally related C. Never occupationally related D. There is inadequate high-level evidence to determine the causal effect of occupation in almost all work environments Hand & Wrist Problems in Occ Health Nerve compressions Scope of Practice CTS, Cubital Tunnel Sx, Radial Tunnel Sx Tendonitis/Overuse Syndromes Lifting injuries and Falls Ligament tears, Fractures, Sprains, Dislocations CMC (basilar) joint arthritis Equipment trauma Lacerations, Crush injuries, Amputations, Burns, etc Hand & Wrist Problems in Occ Health Where is Repetitive Stress Injury (RSI)? My disclaimer Repetitive stress is a mechanism, not a diagnosis Many diagnoses occur as a result of repetition Tendonitis, Strains, Arthroses The term RSI is a label that obscures diagnosis RSI undermines timely and accurate treatment The term RSI should not be used

Peripheral Compressive Neuropathies Carpal Tunnel Syndrome (CTS) Def: A symptomatic compressive neuropathy of the median nerve at the wrist Increased pressure in the carpal tunnel Decreased function

3 Peripheral Compressive Neuropathies Carpal Tunnel Syndrome (CTS) Def: A symptomatic compressive neuropathy of the median nerve at the wrist Increased pressure in the carpal tunnel Decreased function of the nerve at that level Incidence: 1-3/1,000/year ( %) Prevalence: 50/1,000 (5%) Carpal Tunnel Syndrome Anatomy CTS in the Workplace CTS vs. Fracture (Foley, Am J Ind Med, 2007) 2 year review of cases in WA 6 yr pre-injury income recovery CTS = 0.5 Frx CTS excess earnings losses $45K-$89K/claim

4 CTS Diagnosis Clinical: History & Exam Validated Symptom Criteria (CTS-6) 1. Numbness/tingling in median n distribution 2. Nocturnal numbness 3. Weakness and/or atrophy of thenar muscles 4. Tinel sign 5. Positive Phalen s test 6. Loss of 2-pt discrimination (Graham, J Hand Surg, 2006) CTS Diagnosis What is the Role of NCS/EMG testing? No significant added value to CTS-6 No predictive value re function or symptom severity High level (II&III) evidence for NCS with + clinical criteria when surgery is considered Clinical criteria are still the gold standard CTS Causation Causative factors with strong evidence Structural, Genetic, Biologic (Ring, JHS 2008) Age, Weight, Female, Smoking, Occupational vibration exposure (Nathan, JHS 2002 &2005) Prolonged handheld vibratory tool use, Repetitious forceful gripping (Palmer, Occ Med 2007) Causative factors with poor evidence Keyboard use, Clerical activities

CTS Treatment AAOS Treatment Guidelines for CTS Early CTS: Mild symptoms,

Surgery Persistent or Advanced CTS: Moderate symptoms, Recurrence after

CTS Surgical Treatment Open CTR & Endoscopic CTR Numerous comparison

outcomes at 1 yr: No difference RTW time: No consistent difference

5 CTS Treatment AAOS Treatment Guidelines for CTS Early CTS: Mild symptoms, No denervation Splinting Local steroid injection Oral steroids Ultrasound Surgery Persistent or Advanced CTS: Moderate symptoms, Recurrence after non-surgical treatment, Clinical or electrodiagnostic denervation Surgery CTS Surgical Treatment Open CTR & Endoscopic CTR Numerous comparison studies Safety: No difference Efficacy: No difference Subjective pt outcomes at 1 yr: No difference RTW time: No consistent difference Functional status at 1 yr: No difference OCTR vs. ECTR remains a matter of choice CTR Technique

Cubital Tunnel Syndrome Ulnar Neuropathy at the Elbow Motor and sensory neuropathy Clinical Features Paresthesias in

velocity across elbow EMG abnormalities in intrinsics in advanced cases Cubital Tunnel Syndrome Treatment Mild

cubital tunnel Surgery for persistent or progressive symptoms Moderate-Severe Neuropathy Surgical Decompression

6 Cubital Tunnel Syndrome Ulnar Neuropathy at the Elbow Motor and sensory neuropathy Clinical Features Paresthesias in ulnar territory Medial elbow/forearm pain Ulnar intrinsic weakness/atrophy Electrodiagnostic Features Decr conduction velocity across elbow EMG abnormalities in intrinsics in advanced cases Cubital Tunnel Syndrome Treatment Mild Neuropathy Conservative Rx = 40-50% improvement Ergonomic changes Nerve gliding exercises Splinting & padding of cubital tunnel Surgery for persistent or progressive symptoms Moderate-Severe Neuropathy Surgical Decompression Simple, Epicondylectomy, SubQ transpo, Submusc transpo Early decompression critical Incomplete improvement is common Cubital Tunnel Release

7 Radial Tunnel Syndrome Compressive Mononeuropathy Distal to anterior interosseous and superficial sensory branches no paresthesias or weakness Purely pain syndrome NO electrodiagnostic abnormalities Tenderness in intermuscular septum Steroid injections are diagnostic Surgical decompression is often curative Tendonitis/Overuse Syndromes DeQuervain s 1 st extensor compartment Stenosing tenosynovitis/trigger finger Radial wrist extensors ECRL/ECRB Ulnar wrist extensor ECU Common features are localized inflammation, pain with passive stretch, exacerbation with use Tendonitis/Overuse Syndromes Treatment Ergonomic assessment of worksite/habits Splinting Ice/NSAIDS Hand Therapy Local steroid injections Surgical release Most resolve without surgery

specialty care and/or surgery Laceration

8 Traumatic Workplace Injuries Fractures, Dislocations, Ligament tears Lacerations, Amputations, Crush injuries Burns All warrant immediate urgent care High index of suspicion & early testing Urgent Hand Surgery consultation and TOC Require specialty care and/or surgery Laceration Paring knife laceration in a chef Laceration Timely treatment = Good results

9 Ligament Tear Complete Scapholunate Dissociation Ligament Tears MRI/A SL Ligament Repair

10 Distal Radius Fracture Fall from 12 Ladder Distal Radius Fracture ORIF Disatal Radius Fracture Results

11 Distal Radius Fracture Results CMC (Basilar) Joint Arthritis Features Ligamentous laxity and subluxation Joint space narrowing/cartilage loss Osteophyte formation Adduction collapse of 1 st web Compensatory hyperextension of MCPJ CMC Joint Arthritis Etiology Primarily gender related: F>>>M Age: >50? Activity related? Majority are genetic, idiopathic Exacerbation with forceful/repetitive use

CMC Joint Arthritis Non-operative Treatment

injection(s) Operative CMCJ arthroplasty CMCJ

resection Ligament reconstruction Tendon

implant MCPJ Capsulodesis or Fusion CMC Joint

12 CMC Joint Arthritis Non-operative Treatment Splint, ice, NSAIDs Intra-articular steroid or HA injection(s) Operative CMCJ arthroplasty CMCJ fusion CMC Joint Arthritis Arthroplasty Trapezial resection Ligament reconstruction Tendon interposition Simple trapeziectomy Alloplastic implant MCPJ Capsulodesis or Fusion CMC Joint Arthritis Arthroplasty Outcomes Pain relief Motion Strength Durability

CMC Joint Arthritis Fusion CMC Joint Arthritis Causality/Apportionment CMCJ OA generally genetic/idiopathic Exceptions: Frx/malunion, Male, Laborer Exacerbation & Need for treatment Apportionment

13 CMC Joint Arthritis Fusion CMC Joint Arthritis Causality/Apportionment CMCJ OA generally genetic/idiopathic Exceptions: Frx/malunion, Male, Laborer Exacerbation & Need for treatment Apportionment often applicable Hand & Wrist in Occ Health Causality is often questionable Patients syllogism: A: I work with my hands + B: My hands hurt = C: Work is causing my hand pain A+B does not always = C Critical thinking, Common sense, Intellectual honesty

Carpal Tunnel Syndrome/ Cubital Tunnel Syndrome. Nerve anatomy. Pathophysiology 6/14/2014. Most common compression neuropathies of the upper extremity

Carpal Tunnel Syndrome/ Cubital Tunnel Syndrome Justin Arnold MD Family Medicine Update 2014 Most common compression neuropathies of the upper extremity Increasing prevalence CTS 50/1000 subjects Up to