Common Hand Conditions SHAMIM UMARJI MA (Oxon) FRCS (Tr & Orth) CONSULTANT TRAUMA & ORTHOPAEDIC SURGEON

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Allan Taylor
5 years ago
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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

Baron Dupuytren 1777-1835 Napolean s Haemorrhoids Born into poverty Kidnapped by

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

16 Management No evidence for : Physio/splinting Calcium channel blockers Interferon Azathioprine 5FU USS DXT Minimally invasive: Percutaneous needle fasciotomy Clostridial Collagenase (Xiapex)

20 Radiotherapy

21 Management Surgery Fasciectomy Dermofasciectomy (revision)

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

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

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

Hand / wrist Injections. MATS. June Condition Symptoms Conservative Treatments Location of injection CBA for surgery

Hand / wrist Injections. MATS. June 2018. Condition Symptoms Conservative Treatments Location of injection CBA for surgery Carpal Tunnel Tingling / numbness in median nerve distribution (lateral 3 fingers)