Common Hand Conditions SHAMIM UMARJI MA (Oxon) FRCS (Tr & Orth) CONSULTANT TRAUMA & ORTHOPAEDIC SURGEON
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1 Common Hand Conditions SHAMIM UMARJI MA (Oxon) FRCS (Tr & Orth) CONSULTANT TRAUMA & ORTHOPAEDIC SURGEON
2 Common Hand Conditions Carpal tunnel syndrome Dupuytren s Disease Ganglia Trigger Digits De Quervain s
3 Carpal Tunnel Nerve compressions common Carpal tunnel syndrome (CTS) - commonest
4 Carpal Tunnel Syndrome Prevalence : 7% - 16% Age / Sex yrs F> M (3:1)
5 History Little finger spared Worse at night Driving, reading newspaper, holding phone Shaking hand Occupation Pregnancy Diabetic
6 Signs Tinel s Phalen s time it! Sensory loss Motor Proximal entrapment
7 DIAGNOSIS 2 out of 3 needed: Good history Good signs Positive NCS
8 NCS 85% sensitivity 95% specificity Atypical Neuropathy (DM) Bilateral Recurrent Disease Medicolegal
9 Differential Diagnosis Proximal entrapment Neck Thoracic outlet Pronator syndrome Other diagnoses De Quervains 1 st CMCJ OA
10 Treatment of CTS Non-operative Advice Splints Steroid injections Operative Carpal tunnel decompression
11
12
13 Baron Dupuytren Napolean s Haemorrhoids Born into poverty Kidnapped by wealthy lady Beast at the Seine First amongst surgeons, last among men Napolean of Surgery
14 Male Caucasians (Viking ancestry) Japanese Genetics, autosomal dominance w variable penetrance Dupuytren s Disease Association w trauma Curse of the Macrimmonds
15
16 Management No evidence for : Physio/splinting Calcium channel blockers Interferon Azathioprine 5FU USS DXT Minimally invasive: Percutaneous needle fasciotomy Clostridial Collagenase (Xiapex)
17
18
19
20 Radiotherapy
21 Management Surgery Fasciectomy Dermofasciectomy (revision)
22
23 Common Can affect every joint (hand/wrist) Pain, deformity, cancer phobia F>M, age yrs No correlation w occupation Majority disappear spontaneously Ganglia
24 Spontaneous resolution 45% Volar 61% Dorsal Aspiration Single aspiration 59-88% recurrence 3 Serial aspirations 12-15% recurrence Steroids/hyaluronidase/ multipunctate No evidence! Management
25 Surgery Excise entire ganglion inc stalk Recurrence rate 1-40% 27% continue to have pre-op symptoms Jo Dias Study 2007 Natural history 3 gps (surgery,aspiration, no Tx) No difference at 6 ys Surgical gp 8 % complication rate
26
27 Trigger Digits Flexor sheath narrows & thickens tendon does not glide Pain/snapping/locking in flexion or extension Incidence 2% normal 10% diabetics
28 Trigger Digits Painful, finger sticks in palm Stenosing tendovaginitis Aetiology unclear, frequent in RA and DM Little evidence re occupational links Middle aged women
29 Pathology Tendon entrapment due to mechanical impingement of flexors as they pass through A1 pulley A1 pulley & flexor tendon fibrocartilaginous metaplasia & hypertrophy
30 Which digits? Thumb 32% Index 7% Middle 26% Ring 26% Little 9%
31 Diagnosis Straightforward usually Locked trigger digit mistaken for: Dislocation Dupuytren s Focal dystonia Hysteria True locking: Tendon sheath tumour (rare) Loose body in MPJ
32 Treatment Options Spontaneous Resolution...29% Activity modification...can be effective Physiotherapy... Unproven NSAID...Unproven Splint...Ineffective Corticosteroid...First line treatment Surgery...Failed treatment or irreducible trigger
33 Injections Flexor sheath 2 ml volume of steroid & LA Success 49-78% (lower in DM) 2 nd injection increases cure rate by further 50%
34 Surgery Failed non-operative treatment Severe symptoms
35
36 De Quervain s Syndrome
37 De Quervain s 1895 Swiss Surgeon De Quervain 5 cases, all female Pain at radial styloid, swelling in this region, pain on thumb movements, weak grip Over-exertion / washerwoman s sprain Finkelstein: labouring classes
38 Management Non operative Rest/activity modification Splint/ Hand therapy Injection (steroid / LA) Operative Release Risks: Injury to radial nerve branches
39 Septation in 35% APL huge variability 1 slip 9% 2 slips 30% 3 slips 43 % 4 slips 26% No EPB variability Similar to other studies (Kulthani 2007, Aktan 1998) ANATOMY (Cooney)
40 Arthritis basal thumb Middle aged women radial sided wrist pain 1 st CMCJ OA De Quervains CTS STTJ OA
41 1 st CMCJ OA Can t open jars Can t wring out cloth Weak pinch grip (keys)
42 1 st CMCJ OA Non operative Lifestyle changes Splints NSAIDs/oral/topical Steroid injections Operative Trapeziectomy Arthrodesis Various implants
43 Summary CTS Trigger De Quervain s Ganglia Dupuytren s OA Examination Look, move, feel Special tests Management Operative vs nonoperative Anatomy Think anatomy!
44 Grasping the Importance of our Hands Touching Grasping Holding Feeling Manipulating Caressing
45 Grasping the Importance of our Hands Communication: Saying hello Waving goodbye Handshake Vitally important to who we are & how we see ourselves
46 Thank You Shamim Umarji
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