DISCLOSURE LEARNING OBJECTIVES

Transcription

1 1 THE HAND & WRIST EXAM Matthew Silvis, MD Departments of Family and Community Medicine & Orthopedics and Rehabilitation PAFP Chesapeake Escape CME Conference July 28 th, 2015 DISCLOSURE I have no financial or any other interest in any commercial product mentioned in this presentation. No conflict of interest exist. 2 LEARNING OBJECTIVES Perform a detailed hand examination. Perform a detailed wrist examination Describe the pertinent underlying anatomy of common sports medicine conditions for both the hand and the wrist and their relation to findings on physical examination. This is difficult material the anatomy is detailed and the disorders are large in number and varied. This talk is meant to provide you with a general approach and is not all inclusive. 3 1

2 OUTLINE Inspection Palpation Range of Motion Sensation Strength Specific Tests Illustrative Cases Primary survey Secondary survey Some authors recommend a regional approach Radial, dorsal, ulnar, palmar 4 FOCUSED HISTORY Detailed history (identifies problem in 70% of cases) Patient should describe in their own words Act out event Consider age of patient FOOSH injury Greenstick fracture toddler Growth plate fracture adolescent Scaphoid fracture young adult Distal radius fracture (Colle s fracture) in older adult with osteoporosis Based on physical examination, should be able to make a diagnosis or narrow the DDx dramatically Summation of anatomic locations where symptoms are provoked by palpation and where signs are produced by manipulation Imaging supportive 5 MAJOR EMERGENCIES Dyvascular hand Acute severe compression syndrome Open fractures Dislocations Traumatic amputations Denverhealth.org 6 2

3 OBSERVATION/INSPECTION: ACUTE TRAUMA Erythema, swelling, masses, skin lesions, muscle atrophy, contractures, scars, deformities Acute Severe pain, swelling, guarding may limit your exam! 7 Am Fam Physician 2001; 63: OBSERVATION/INSPECTION: HAND INFECTIONS Even smallest puncture wound could indicate open fracture Acute paronychia Pyogenic flexor tenosynovitis Felon Herpetic Whitlow 8 Am Fam Physician 2003; 68: OBSERVATION/INSPECTION: ARTHRITIS Osteoarthritis Rheumatoid Arthritis PIP, MCP joint bogginess and swelling. 1. Heberden nodes 2. Bouchard nodes Am Fam Physician 2011; 84 (11): Am Fam Physician 2012; 85 (1):

4 OBSERVATION/INSPECTION: CHRONIC Trigger finger Dupuytren s Disease Med.und.edu Healthtap.com Am Fam Physician 2007; 76: 86-9, THE POSITION OF FUNCTION Safe splint position for hand Hand is held as if holding the bowl of a wine glass Wrist should be extended 25º and should allow alignment of the thumb with the forearm MCP joint moderately flexed to 60º IP joints slightly flexed PIP, 10º DIP, 5º Thumb abducted away from the palm Am Fam Physician 2003; 68: PALPATION Mainstay of hand/wrist exam! 3 principles: Exact point of local tenderness is the location of the pathology. If one knows the exact location and underlying anatomic structure, one likely knows the diagnosis. The diagnosis is arrived at by the summation of positive and negative physical exam findings. Orthopedics is like real estate, it is all about location! 12 Hand Clin 2010; 26:

5 RANGE OF MOTION Wrist: Flexion, 70º Extension, 70º Radial deviation, 20º Ulnar deviation, 40º Forearm: Pronation, 80 Supination, 80 Faculty.washington.edu 13 SENSATION: PERIPHERAL NERVES, UPPER EXTREMITY NERVE MUSCLE AND SENSORY AREA FUNCTION Axillary Deltoid (shoulder Lateral aspect arm abduction) Musculocutaneous Biceps (elbow flexion) Lateral proximal forearm Median Ulnar Radial Flexor pollicis longus (thumb flexion) First dorsal interosseous (abduction) Extensor pollicis longus (thumb extension) Tip of thumb, volar aspect Tip of little finger, volar aspect Dorsum thumb web space 14 MOTOR EXAM Median nerve Resisted thumb abduction (palmar) Muscle belly palpated Ulnar nerve Index finger abducted against resistance 1 st dorsal interosseous muscle belly palpated Radial nerve Thumb retropulsed dorsally against resistance EPL palpated Sports Health 2009; 1 (6):

6 STRENGTH Mass/atrophy Consistency Tenderness Strength Testing 0/5: No muscle movement 1/5: Visible muscle movement but no movement at joint 2/5: Movement at the joint but not against gravity 3/5: Movement against gravity but not added resistance 4/5: Movement against resistance, less than usual 5/5: NL strength Photo-dictionary.com 16 THE DORSUM OF THE HAND 17 Am Fam Physician 2004; 69: THE PALM OF THE HAND 18 Am Fam Physician 2004; 69:

7 ANATOMY OF THE FINGER Am Fam Physician 2001; 63: Am Fam Physician 2006; 73: 810-6, SIGNS OF TENDON INJURIES Extensor tendon injury at DIP joint Mallet finger Flexor digitorum profundus tendon injury Jersey finger Am Fam Physician 2004; 69: TRIGGER FINGER Flexor tendons glide back and forth under 4 annular and 3 cruciform pulleys that keep the tendons from bowstringing The flexor tendon or first annular pulley may become thickened and narrowed from chronic inflammation and irritation Motion of tendon is limited and finger may snap or lock during flexion Long and ring fingers Idiopathic or associated with RA, DM NSAID s, injection, surgical release Methodistorthopedics.com Elementalbw.com Webmd.com 21 7

8 EXTENSOR COMPARTMENTS OF THE WRIST I: APL, EPB II: Extensor carpi radialis brevis and longus III: Extensor pollicis longus V: Extensor digiti minimi VI: Extensor carpi ulnaris IV: Extensor digitorum and extensor indicis 22 DE QUERVAIN S TENOSYNOVITIS Swelling/stenosis of the sheath that surrounds the abductor pollicus longus (APL) and extensor pollicus brevis (EPB) tendons at the wrist Pain, swelling, triggering of thumb Repetitive use Finkelstein s test Thumb spica splint, NSAID s, injection, surgical treatment Orthopaedicsurgeon.com.sg 23 DE QUERVAIN S TENOSYNOVITIS, U/S FINDINGS Tendinosis S/P Injection 24 8

9 THE BONES OF THE WRIST Am Fam Physician 2004; 69: Am Fam Physician 2005; 72: HAND AND WRIST RADIOGRAPHS 26 THE WATSON OR SCAPHOID SHIFT TEST Press scaphoid tuberosity on palmar aspect while moving the wrist from ulnar to radial deviation Painful click or pop Scaphoid instability Scapholunate separation Am Fam Physician 2004; 69: Hand Clinic 2010; 26:

10 THE SHUCK TEST Perilunate instability Wrist held in flexion Patient extends his/her fingers while physician resists + pain Am Fam Physician 2004; 69: CASE #1 16 y/o female soccer player Finger jammed after being struck with the ball + pain in 3 rd digit Obvious deformity of PIP joint appears to be dislocated dorsally How should this injury be treated? What about finger fractures? 29 FINGER DISLOCATIONS PIP joint is most commonly dislocated joint in the body Dorsal >> volar Tenderness of volar plate with obvious deformity 30 10

11 FINGER DISLOCATIONS If athlete is at event, can attempt reduction without radiography If successful, buddy tape PIP joint in slight flexion Reevaluate after athletic event at the office with radiography If reduction is immediate, no anesthesia If delayed > 1 hour, need digital block Refer if large fracture fragment or if reduction fails 31 Am Fam Physician 2006; 73: , 839. FINGER FRACTURES DIP joint Crushing injury Unless severe angulation or displacement is present, fractures should be reduced and DIP joint splinted in full extension using stack or aluminum splint for 4-6 weeks and reevaluated 32 Littleastonoasis.com DETECTING MIDDLE PHALANX FRACTURES No Rotation Rotation; fingertips should point towards scaphoid. 33 Am Fam Physician 2006; 73: , 839. Am Fam Physician 2004; 69:

12 MIDDLE PHALANX FRACTURES Need proper alignment Difficult due to tension created by extensor/flexor tendons Digital/hematoma block If reduction successful, splint PIP in extension times 6 weeks Refer if: proximal phalanx, articular surface fracture > 30%, reduction unsuccessful, rotation detected 34 CASE #2 28 y/o male wrestling coach Presents 2 months after being struck with a football 2 nd digit Unable to extend at the DIP joint This problem has persisted What is the injured structure? Can this heal without surgery? What if he couldn t flex at the DIP joint? 35 MALLET FINGER Extensor tendon injury at the DIP joint Most common closed tendon injury of the fingers Usually object strikes finger (ball) Forceful flexion of an extended DIP joint Extensor tendon stretched, partially torn, ruptured, or separated by avulsion fracture Am Fam Physician 2006; 73: 810-6,

13 MALLET FINGER Pain at DIP joint Inability to actively extend the joint Flexion deformity Isolate DIP to ensure no central slip injury Absence of full passive extension may indicate bony or soft tissue entrapment Bony avulsions in > 30% If no avulsion, splint in neutral or slight hyperextension for 6 weeks Then splint at night only for additional 6 weeks Conservative treatment successful for up to 3 months (delayed) Refer if: bony avulsions > 30% joint space or inability to achieve full passive extension Am Fam Physician 2012; 85: JERSEY FINGER Flexor digitorum profundus tendon injury Athlete catches finger on another player s clothing Football, rugby Forced extension of the DIP joint during active flexion Ring finger is weakest (75% of cases) Pain/swelling DIP joint Finger extended at rest Refer needs seen ASAP!!! 38 Am Fam Physician 2006; 73; 810-6, 823. Am Fam Physician 2012; 85: CASE #3 14 y/o female basketball player Dominant 3 rd digit forcefully flexed while extended during a fall + pain and swelling dorsal aspect of middle phalanx Unable to fully extend at PIP joint What is the pertinent underlying anatomy and diagnosis? 39 13

14 CENTRAL SLIP EXTENSOR TENDON INJURY PIP joint is forcefully flexed while actively extended Basketball Evaluate by holding PIP joint in flexion If PIP injured, unable to actively extend joint Passive possible Extensor tendon (central slip) at PIP ruptures; lateral bands slip volar and flex PIP Tenderness over dorsal aspect of middle phalanx Treat as if mallet finger Am Fam Physician 2006; 73: 810-6, UNTREATED CENTRAL SLIP EXTENSOR TENDON INJURY LEADS TO A BOUTONNIERE DEFORMITY Intact lateral bands slip inferiorly. Flexion PIP with hypertension of DIP and MCP joints. Orthoinfo.aaos.org Sciencedirect.com 41 CASE #4 22 y/o male boxer Missed punch Pain/swelling over distal 5 th metacarpal Loss of knuckle height What is the diagnosis? How much angulation is tolerated? worldsportedition.blog 42 14

15 BOXER S FRACTURE Fracture of the base of the 5 th metacarpal bone often caused by missed punch during boxing Most common metacarpal bone fracture Distal fracture fragment displaced volarly because of interosseous muscles Angulation at the metacarpal neck up to 40 can be tolerated but reduction should be attempted 2 nd (10 ), 3 rd (20 ), 4 th (30 ) If rotation present, refer Am Fam Physician 2006; , BOXER S FRACTURE REDUCTION Apply dorsally directed pressure to volarly displaced MCP head Volarly directed pressure to proximal fracture fragment Proximal phalanx or PIP joint can act as lever arm If reduction successful, splint in flexion for 6 weeks in ulnar gutter splint/cast 44 Am Fam Physician 2006; 73: , 839. CASE #5 23 male baseball player Direct palmar impact from swinging a baseball bat and striking the ball Pain over the ulnar side of the palm What is the pertinent underlying anatomy? True/False: This bone fragment is typically removed for treatment. Istockphoto.com 45 15

16 HOOK OF HAMATE FRACTURE Bony process Pulley for flexor tendons during power grip Baseball, golf, tennis Force transmission from bat, club, or racquet to the palm Difficult to diagnose Hook sits one thumbnail radial and distal to pisiform Carpal tunnel radiograph May need advanced imaging Excision of fragment Immobilize then for days RTP in 6-8 weeks 46 CASE #6 26 y/o male Plays in a local football league Upset and punched another player s mouth Small laceration over dorsum of hand Now, pain, swelling How should this injury be treated? Who has a dirtier mouth: humans or animals? Am Fam Physician 2003; 68: FIGHT BITE Clenched fist injury Injury with MCP in flexion, laceration Injuries to extensor tendon and/or joint capsule Human bites more virulent than animal bites Polymicrobial (~5), anaerobes Radiographs Wound should be explored, irrigated, debrided No sutures Splint in position of motion Antibiotics inpatient vs outpatient Esquire.com 48 16

17 CASE #7 18 y/o female skier Fell onto ski pole Pain ulnar side of thumb What is the likely injured structure? What is a Stenar lesion? 123rf.com 49 SKIER S THUMB Disruption of the UCL cased by forced abduction of the MCP joint Partial or complete tear with or without avulsion fracture If left untreated, joint unstable leading to weak pinch grip Diagnose 30º overall valgus laxity 15º difference between sides Lack firm endpoint Radiography (with stress views) MRI or MSK U/S if needed Am Fam Physician 2006; 73: , STENAR LESION: NOTE THAT THE PROXIMAL END OF THE UCL DISPLACES OUT OF THE ADDUCTOR APONEUROSIS Am Fam Physician 2006; 73: ,

18 SKIER S THUMB TREATMENT 52 J Bone Joint Surg Am 2012; 94: CASE #8 23 y/o female field hockey player Lifting weights at the gym and trips over a free weight lying on the ground Falls onto outstretched hand (FOOSH) Pain in anatomic snuffbox What is the anatomic snuffbox? What is the likely injured structure? Why doesn t this injury heal well? 53 SCAPHOID FRACTURE Most commonly fractured carpal bone FOOSH with primarily radial load Radial sided wrist pain Tenderness of anatomic snuffbox Between first and third extensor compartments Pain with axial loading of thumb Eorthopod.com 54 18

19 Sports Health 2009; 1 (6): TYPES OF SCAPHOID FRACTURES 56 Hand Clinics 2010; 26 (1): DEDICATED SCAPHOID VIEW MRI IF NEEDED Am Fam Physician 2005; 72: Sports Health 2009; 1 (6):

20 SCAPHOID FRACTURE MANAGEMENT Complications are difficult to manage Blood supply enters distal ½ of bone Proximal pole fractures at high risk for avascular necrosis Non-displaced middle 1/3 fractures Thumb spica splint/cast Compressive screw fixation Referral to hand surgery should be strongly considered! Activemotionphysio.ca 58 SO WHAT S THE DIFFERENCE: WRIST SPLINT VERSUS THUMB SPICA SPLINT Wrist splint Thumb spica splint Breg.com Myorthomd.com 59 CASE #9 42 y/o female Extensive typing at work Tingling in digits 1-3 Discomfort radiates to forearm What is the function of the median nerve? What is the carpal tunnel? Pfflaw.com 60 20

21 CARPAL TUNNEL SYNDROME Common % population Bilateral in ~50% Especially overuse-type injuries caused by repetitive motion Median nerve distribution Pain, parethesias May radiate proximally to forearm and even arm/shoulder +/- loss of grip strength 61 Median nerve directly beneath palmaris longus tendon at midpoint of wrist medial to flexor carpi radialis tendon. 62 JAMA 2000; 283: HAND SYMPTOM DIAGRAM A, classic B, probable C, unlikely 63 Am Fam Physician 2011; 83:

22 DIAGNOSIS AND TREATMENT Tests: Flick sign 2 point discrimination test 2 points < 6 mm apart (caliper) Tinel sign Phalen maneuver Nocturnal parethesias Thenar atrophy EMG/NCS not usually indicated if high probability based on history and exam Mild neutral wrist splint, steroids, ergonomics Moderate/severe surgery (open or endoscopic) 64 CASE #10 22 y/o female school teacher Cyst like structure over dorsum of wrist Soft, painful with palpation Worsens with chalkboard writing What is a ganglion cyst and what does it arise from? Psdgraphics.com 65 GANGLION CYST Arises from the capsule of the joint or tendon synovial sheath Thick, clear, mucinous material One-way valve Dorsum of wrist, volar radial aspect of wrist, base of finger (A1 pulley of flexor tendon sheath) years of age Smooth, round, or multilobulated Mildly tender with palpation Can try aspiration Surgical excision is definitive 66 22

23 CASE #11 19 y/o rugby player Fell onto outstretched hand (FOOSH) Pain and swelling in distal forearm Point tenderness distal radius What is the likely diagnosis and treatment? 67 DISTAL RADIUS FRACTURE FOOSH injury Swelling of wrist? Gross deformity Limited ROM Point tenderness distal radius Obtain x-rays 68 Miamihandcenter.com DISTAL RADIUS FRACTURE MANAGEMENT If displaced, closed reduction Hematoma block vs sedation X-ray after reduction If stable and aligned, cast If unstable or not able to align, operative intervention Healing takes 6-8 weeks Early finger ROM and swelling control when subacute Upon healing of fracture, wrist and forearm ROM, progressive strengthening prior to RTP 69 Sports Health 2009; 1(6):

24 CASE #12 9 y/o female gymnast Progressive bilateral wrist pain made worse with wrist in extension such as when tumbling, vaulting, and back walkovers Normal ROM with swelling of the distal radius, right > left Tenderness over the dorsal-radial growth plate No snuff box tenderness What is the likely diagnosis, how is this condition treated, and are the x-ray findings reversible? 70 DISTAL RADIAL EPIPHYSITIS 71 DISTAL RADIAL EPIPHYSITIS Most common in male and female gymnasts Gymnast s wrist Radial physes appear at age months and fuse by years Radiographic findings Sclerosis (metaphyseal) Widening (radial/volar) Treatment Cessation of activities that require weightbearing, use of dowel grips, or excessive traction on the extended wrist Radiographic findings reverse in most Permanent changes have been reported Shortening of the radius Madelung s deformity Healing Negative radiographs 4 weeks Cast mainstay of treatment Just do some handstands and see how it feels Severe involvement > 6 months Slowest of all physeal injuries to heal

25 THANK YOU! ANY QUESTIONS? 73 25