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

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

Common Hand Conditions Carpal tunnel syndrome Dupuytren s Disease Ganglia Trigger Digits De Quervain s

Carpal Tunnel Nerve compressions common Carpal tunnel syndrome (CTS) - commonest

Carpal Tunnel Syndrome Prevalence : 7% - 16% Age / Sex 45-65 yrs F> M (3:1)

History Little finger spared Worse at night Driving, reading newspaper, holding phone Shaking hand Occupation Pregnancy Diabetic

Signs Tinel s Phalen s time it! Sensory loss Motor Proximal entrapment

DIAGNOSIS 2 out of 3 needed: Good history Good signs Positive NCS

NCS 85% sensitivity 95% specificity Atypical Neuropathy (DM) Bilateral Recurrent Disease Medicolegal

Differential Diagnosis Proximal entrapment Neck Thoracic outlet Pronator syndrome Other diagnoses De Quervains 1 st CMCJ OA

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 wealthy lady Beast at the Seine First amongst surgeons, last among men Napolean of Surgery

Male Caucasians (Viking ancestry) Japanese Genetics, autosomal dominance w variable penetrance Dupuytren s Disease Association w trauma Curse of the Macrimmonds

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

Radiotherapy

Management Surgery Fasciectomy Dermofasciectomy (revision)

Common Can affect every joint (hand/wrist) Pain, deformity, cancer phobia F>M, age 20-40 yrs No correlation w occupation Majority disappear spontaneously Ganglia

Spontaneous resolution 45% Volar 61% Dorsal Aspiration Single aspiration 59-88% recurrence 3 Serial aspirations 12-15% recurrence Steroids/hyaluronidase/ multipunctate No evidence! Management

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

Trigger Digits Flexor sheath narrows & thickens tendon does not glide Pain/snapping/locking in flexion or extension Incidence 2% normal 10% diabetics

Trigger Digits Painful, finger sticks in palm Stenosing tendovaginitis Aetiology unclear, frequent in RA and DM Little evidence re occupational links Middle aged women

Pathology Tendon entrapment due to mechanical impingement of flexors as they pass through A1 pulley A1 pulley & flexor tendon fibrocartilaginous metaplasia & hypertrophy

Which digits? Thumb 32% Index 7% Middle 26% Ring 26% Little 9%

Diagnosis Straightforward usually Locked trigger digit mistaken for: Dislocation Dupuytren s Focal dystonia Hysteria True locking: Tendon sheath tumour (rare) Loose body in MPJ

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

Injections Flexor sheath 2 ml volume of steroid & LA Success 49-78% (lower in DM) 2 nd injection increases cure rate by further 50%

Surgery Failed non-operative treatment Severe symptoms

De Quervain s Syndrome

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

Management Non operative Rest/activity modification Splint/ Hand therapy Injection (steroid / LA) Operative Release Risks: Injury to radial nerve branches

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)

Arthritis basal thumb Middle aged women radial sided wrist pain 1 st CMCJ OA De Quervains CTS STTJ OA

1 st CMCJ OA Can t open jars Can t wring out cloth Weak pinch grip (keys)

1 st CMCJ OA Non operative Lifestyle changes Splints NSAIDs/oral/topical Steroid injections Operative Trapeziectomy Arthrodesis Various implants

Summary CTS Trigger De Quervain s Ganglia Dupuytren s OA Examination Look, move, feel Special tests Management Operative vs nonoperative Anatomy Think anatomy!

Grasping the Importance of our Hands Touching Grasping Holding Feeling Manipulating Caressing

Grasping the Importance of our Hands Communication: Saying hello Waving goodbye Handshake Vitally important to who we are & how we see ourselves

Thank You Shamim Umarji shamim.umarji@stgeorges.nhs.uk