Management of Wrist and Hand Injuries

Sunday General Session Management of Wrist and Hand Injuries Shaun Garff, DO Sports Medicine Physician Methodist Health System Dallas, Texas Educational Objectives By the end of this educational activity, participants should be better able to: 1. Adequately diagnose and treat wrist and hand sprains and strains. 2. Discuss various types of joint pain and arthritis. 3. Utilize joint injections when needed on the wrist and hand. 4. Implement in-office procedures and non-operative care techniques for the wrist and hands. Speaker Disclosure Dr. Garff has disclosed that he has no actual or potential conflict of interest in relation to this topic. 20

Speaker Disclosure I have no actual or potential conflicts of interest to disclose as it relates to this presentation. Shaun P. Garff, DO Physician of Sports Medicine A little about me Born and raised in San Francisco, CA Bachelors in Exercise Science from BYU Provo, UT Medical School A.T. Still University Mesa, AZ Family Medicine Residency Methodist Charlton Medical Center Dallas, TX Sports Medicine Fellowship Intermountain Health Care Provo, UT Recently Launched Sports Medicine Division for Methodist Health System Objectives By the end of this activity, the participant will be better able to: 1. Adequately diagnose and treat wrist and hand sprains and strains. 2. Discuss various types of joint pain and arthritis. 3. Utilize joint injections when needed on the wrist and hand. 4. Implement in office procedure and non operative care techniques for the wrist and hands. Location is Key Top 10 in Hand and Wrist 1

#10 Question A 56 year old female presents to your office with pain on the palmar aspect of her hand just proximal to the first knuckle of the index and middle fingers. She states that her finger gets stuck multiple times per day. What is the most definitive, non surgical treatment for her? 1. Hand therapy 2. Splint at MCP joint to avoid locking 3. Topical NSAIDs 4. Steroid injection 5. Night splinting Diagnosis of Trigger Finger Pain at the palmar MCP joint and proximal at the A1 pulley Catching or triggering of the finger with flexion/extension at the A1 pulley Ring finger is most common Tenderness to palpation over involved MCP and/or A1 pulley Palpable click with passive/active finger extension/flexion Swelling over area Mainly clinical diagnosis X rays of hand may show MCP arthritis Ultrasound Grade I II III IV Symptoms Pain at A1 Pulley Catching of Digit Locking of Digit (correct with passive extension) Fixed, Locked Digit Management of Trigger Finger Splinting Topical NSAIDs Oral NSAIDs Oral steroids Steroid Injection With or without ultrasound 75% long term relief May require repeat injection Referral for surgery Refractory cases Trigger Finger Injection 25G or 27G 1 Needle 1 2 cc local anesthetic 0.5 cc steroid 20 mg Triamcinolone Goal of injection is peri pulley or peri tendon, and not directly into the tendon 30 45 degree angle to the skin ~1 cm deep #9 Question A 40 year old female with hypothyroidism presents because of concerns for carpal tunnel syndrome. Her clinical symptoms are consistent with this diagnosis. You order a nerve conduction study which shows mild compression of the median nerve at the level of the flexor retinaculum. What would be the most appropriate next step? 1. Referral to hand surgery for carpal tunnel release as it will eventually worsen in this patient 2. Night wrist splints 3. Steroid injection in office 4. Topical NSAID therapy 2

Diagnosis of Carpal Tunnel Volar wrist pain Numbness/tingling into digits 1 3 Weakness in grip strength Pain worse at night Tinel s Sign Phalen s Test Durkan s Compression Flick Sign Thenar atrophy Grip strength Diagnosis is clinical Nerve Conduction study Ultrasound Tinel s Sign Durkan s Compression Test Thenar Atrophy Management of Carpel Tunnel Conservative Management best for Mild to Moderate Wrist splints, especially at night Activity modification Topical/Oral NSAIDs Steroid Injection 80% improve, but only 22% last >1 year Hydro dissection of the median nerve Needs Ultrasound guidance Surgical Referral for refractory moderate disease or severe disease Carpal Tunnel Injection Flexor Carpi Radialis Palmaris Longus 25G 1.5 Needle 1 2 cc local anesthetic 0.5 1 cc steroid 20 40 mg Triamcinolone Injection approaches 1. Distal 1 cm proximal and 1 cm ulnar to PL at 45 degree angle & directed toward base of thumb 2. Proximal between PL and FCR 4 cm proximal to wrist crease at 20 degree angle towards carpal tunnel Redirect needle if patient begins to feel zingers in hand #8 Question What is the most common diagnosis for radial sided hand/wrist pain in a female who gave birth within the last year? 1. Carpal Tunnel Syndrome 2. CMC Arthritis 3. De Quervain s Tenosynovitis 4. Intersection Syndrome 5. Wrist Sprain Diagnosis of De Quervain s Tenosynovitis Pain at the base of the 1 st metacarpal and/or radial side of wrist Gradual onset Worsening pain with movement or activity Tenderness to palpation over radial side of wrist Positive Finkelsteins Inflammation of the synovium at the 1 st dorsal compartment (abductor pollicis longus and extensor pollicis brevis) Clinical diagnosis May consider x ray depending on age of patient to evaluate for CMC arthritis Ultrasound 3

Management of De Quervain s Tenosynovitis Activity modification Splinting (thumb spica) NSAIDs Steroid Injection 83% of cases cured after one steroid injection Surgery referral for refractory cases for compartment release 25G 1 Needle 1 2 cc local anesthetic 0.5 cc steroid 20 mg Triamcinolone Thumb extension to visualize tendons Inject into first dorsal compartment at level of wrist crease #7 Question A 65 year old female presents to the urgent care after a fall. She landed on her right wrist in a flexed position. She denies any other injuries as a result of the fall. She has pain in her wrist and is unable to move it. What would you expect to see on a 3 view wrist x ray? 1. Smith s Fracture 2. Colle s Fracture 3. No Fracture 4. Bennett s Fracture 5. Buckle Fracture Diagnosis of Distal Radius Fractures Fracture Type Colle s Fracture Smith s Fracture FOOSH Pain at wrist Wrist Deformity Dinner Fork Tenderness Limited ROM Colle s Fracture Fall with extended wrist Dorsal angulation of distal fragment (Apex volar displacement) Smith s Fracture Fall with flexed wrist Volar angulation (Apex dorsal displacement) 3 view wrist x ray A good lateral view is important to determine displacement May consider CT if fragmented and/or comminuted Management of Distal Radius Fractures Restore adequate alignment closed reduction Surgical referral if alignment not acceptable Smith s fracture often need surgical fixation Long arm vs. short arm cast/splint Test with supination/ pronation 4 6 weeks in cast followed by brace and ROM & strengthening 4

#6 Question What is the most common type of finger dislocation? 1. Dorsal Dislocation at First MCP 2. Dorsal Dislocation at PIP 3. Volar Dislocation at PIP 4. Volar Dislocation at DIP 5. Dorsal Dislocation at DIP Diagnosis of Finger Dislocations Most commonly, hyperextension of PIP joint resulting in dorsal displacement of the middle phalanx Following trauma with axial loading (jammed finger) Pain and swelling over PIP joint Obvious deformity Check laxity of collateral ligaments with varus/valgus stress Elson test for palmar/volar dislocations (concern for central slip tear) X ray for potential avulsion and/or phalanx fractures Management of Finger Dislocations Reduction of Finger Dislocations: Distraction is key Apply pressure over the distal segment to restore normal anatomy Digital block with 1% lido can be helpful Evaluate ROM and NV exam following reduction Always get post reduction x rays With Volar dislocations Evaluate with Elson Protect the central extensor slip with splint With fractures Treat fracture as usual after the reduction Evaluate for rotational deformity Splint 4 6 weeks followed by ROM therapy Recurrent subluxations or complex fractures require surgical referral #5 Question A 14 year old female presents to your clinic with right wrist pain. She fell off the monkey bars at a local playground 2 weeks ago and has had persistent wrist pain. Her mother took her to a local urgent care immediately after the fall and was given a wrist brace after x rays were negative. reveals persistent tenderness over the radial/volar aspect of the wrist. Repeat x rays today show a scaphoid fracture. Which of the following is an indication for surgical referral? 1. She does not need a surgical referral 2. Fracture line along the most distal aspect of the scaphoid 3. Fracture in the proximal portion of the scaphoid 4. Persistent swelling of right wrist 5. Referral regardless of findings because of the scaphoid fracture 5

Diagnosis of Scaphoid Fracture FOOSH Radial sided wrist pain after trauma Often without deformity or swelling ROM often intact Tenderness in the anatomical snuffbox and/or distal to the dorsal radial tubercle. Pain with forced passive wrist extension Initial X ray may be negative Scaphoid view Follow up x rays in 7 14 days if symptoms persist 25% of fractures have normal initial x ray CT/MRI may be helpful if clinical suspicion is high Management of Scaphoid Fracture Non operative Treatment Non displaced, acute distal fractures Waist fractures in patients who need/want to avoid surgery Thumb spica cast 6 12 weeks for distal fractures & 8 16 weeks for waist fractures Long arm vs. short arm? Treat suspected fractures with immobilization initially Surgical referral Displacement Nonunion Proximal fractures Waist fractures in athletes #4 Question A 26 year old male presents with left hand pain. He tells you he has been out drinking with friends the night before and may have gotten into an altercation. He has tenderness over the dorsal/ulnar aspect of the hand. Radiographs show a 5 th metacarpal neck fracture with 30 degrees of angulation. What is the most appropriate next step in treatment? 1. Short arm cast 2. Surgical referral for pin fixation 3. Molded finger splint 4. Ulnar gutter cast 5. Compression bandage and NSAIDs Diagnosis of Metacarpal Fractures Localized pain and tenderness to the metacarpal bones Following trauma (fight, sports injury, fall, etc.) May complain of finger not straight (angular deformity) Point tenderness on the bone +/ crepitus Swelling Check for rotational deformity X ray to evaluate for displacement, rotational deformity, and/or shortening Fracture location: Head, neck, shaft, base Management of Metacarpal Fractures If alignment acceptable, splint or cast for 3 4 weeks Thumb Spica Radial Gutter Ulnar Gutter Club Surgical Referral: 6

#3 Question A 78 year old male presents to your office with right wrist pain. He states the pain is worse over the radial side of his wrist. He has trouble with it throughout the day when he tries to work in his yard. On exam he has tenderness to palpation over the base of the thumb and radial aspect of the wrist. He has a positive thumb grind test. What is the likely diagnosis? 1. Basal Joint Arthritis 2. DRUJ Arthritis 3. Scapholunate Arthritis 4. MCP Joint Arthritis 5. De Quervain s Tenosynovitis Diagnosis of Hand/Wrist Arthritis Pain at location of arthritic joint Worse with movement May be posttraumatic Tenderness to palpation over arthrosis MCP, CMC, DRUJ, Scapholunate, Radial/carpal Grind test X rays usually definitive with high clinical suspicion Management of Hand/Wrist Arthritis Braces Wrist Thumb NSAIDS (topical/oral) Steroid Injection 20mg 40mg Triamcinolone depending on the site Landmark/palpation approach vs. ultrasound Physical Therapy Surgical referral for refractory cases Fusion vs. replacement #2 Question A 24 year old male recently completed a 2600 mile cycling trip across the western United States. He complains of 3 weeks of numbness of the right pinky and ring fingers. You suspect an ulnar nerve impingement. Where has the ulnar nerve likely been impinged? 1. Cubital Tunnel 2. Carpal Tunnel 3. Guyon s Canal 4. Thoracic Outlet 5. C8 Nerve Root Diagnosis of Guyon s Canal Syndrome A.K.A Cyclist s or Handlebar Palsy Management of Guyon s Canal Syndrome Numbness of hand in ulnar nerve distribution Advanced disease may also have weakness Following some activity with repeated and persistent pressure over palmar/ulnar aspect of wrist Reproducible numbness with compression or tapping over Guyon s canal Clinical diagnosis X ray to rule out fracture or OA Nerve conduction study if more advanced symptoms Splinting/bracing NSAIDS (topical/oral) Evaluate cycling biomechanics, especially handlebar height and position Activity Modification Surgical referral for decompression for refractory cases 7

#1 Question A 16 year old basketball player comes to your office with his mother after jamming his finger last night during practice. He is concerned because he cannot extend the distal phalanx all the way and has experienced worse pain and swelling compared to previous jammed fingers. What injury does this patient have? 1. Finger Sprain 2. Distal Phalanx Fracture 3. Jersey Finger 4. Mallet Finger 5. Boutonniere Deformity Diagnosis of Mallet Finger Sudden forced flexion of DIP during active extension (jammed finger) Distal phalanx stays in flexion can t straighten my finger Following trauma Distal phalanx stuck in flexion Unable to actively extend distal phalanx, but should be able to passively extend Swelling, tenderness to palpation X rays to evaluate for bony avulsion or phalanx fracture Management of Mallet Finger Full time splinting of the DIP joint in full extension for 6 8 weeks Leave PIP joint free to maintain range of motion Surgical referral: Displaced bony fragment Joint involvement >30% Refractory palmar/volar subluxation of distal phalanx Jersey Finger Surgical Referral for reattachment within 7 10 days References Brukner & Khans, Clinical Sports Medicine, 4 th Edition Egol, Koval, Zuckerman, Handbook of fractures, 5 th Edition Eiff, Hatch, Fracture Management for Primary Care, 3 rd Edition Madden, Putukian, McCarty, Young, Netter s Sports Medicine, 2 nd Edition Orthobullets.com Sallis, Robert, ination Skills of the Musculoskeletal System, Self study program 8

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