Common Conditions of the Hand(2013)

Rex Moulton-Barrett, MD

Plastic and Reconstructive Surgery

Alameda and Brentwood California

Relevant Anatomy

• Bones: 27• Extensor Tendons:11 extrinsic• Flexor Tendons: 13 extrinsic• Intrinsic Muscles/Tendons: 16• Ligaments:MCP/IP- Primary & Accessory Transverse Palmer• Accessory Apparatus: Capsules

Volar Plate Retinaculae: Flex, Ext

Relevant Physiology• Median Neuropathy• Ulnar Neuropathy• Radial Neuropathy• Peripheral Neuropathy• Radiculopathy• Reflex Sympathetic Dystrophy Syndrome• Injury Splinting in Intrinsic Plus Position• Splinting CTS in wrist neutral/extension• Splinting Cubital Tunnel < 45 degree flexion

Median Neuropathy

• Motor: thumb opposition and abduction

radial 2 lumbricals

• Sensory: radial 3 1/2 fingers

Splinting CTS in wrist neutral/extension

• Motor: All intrinsics except thumb opposition & abduction

radial 2 lumbricals

• Sensory: Ulnar 1 1/2 sensory

Ulnar Neuropathy

Splinting Cubital Tunnel < 45 degree flexion

Radial Neuropathy

Supplies wrist extensors, needed for flexor tendon lengthening for grip strength and because of median and ulnar nerve overlap small sensory area dorsal 1st web

Peripheral Neuropathy

• Typical stocking / glove distribution

• Causes: Diabetes Mellitus,

EtOH /B12/ folate deficiency

Drugs: chemotherapy > nifedipine

Radiculopathy

• Dermatome specific

• Congenital: Brachial Plexopathy

• Acquired: Usually Mechanical:

disc or osteophyte

direct injury or tear/stretch

cervical rib

Injury Splinting in Intrinsic Plus Position

Reflex Sympathetic Dystrophy Syndrome: RSDComplex Regional Pain Syndrome: CRPS

• Usually triggered by trauma: more extensive: more likely• Use of axillary block in hand surgery somewhat protective

• Stages:1. Burning pain, can be continuous and intense hyperhidrosis, cool, Raynaud’s phenomenom, reddish color 2. Pain more proximal hair thinning, shiney nail pitting, osteoporosis, joint capsular thickening3. Pain affects entire limb, muscle wasting, tendon contractures joint deterioration/subluxation and osteoporsis worsens

Clinical History

• Right or left hand dominant • Take relevant history: mechanism• If chronic: frequency/repetition of trauma work type work position / posture / torque ergonomics home support secondary gain

Clinical Exam

• Note: overall body habitus: obesity, macromastia• Note: posture and shoulder position• Note forearm and upper arm features• Note external features: volar=palmar and dorsal• Note: comparative grip strength

Volar External Features

Dorsal External Features

Cascade/Attitude

• Normal

• Abnormal

Index Finger Opposition: Median Nerve

Little Finger Opposition: Median>Ulnar

Dorsal Interossei (DAB): Ulnar

Intrinsic Plus: Ulnar >> Median

Palmer Interossei ( PAD) and Lumbricals

Gross Grasp: Median>Radial>Ulnar

Dynomamometer

>15% difference ?

Finkelstein Test: de Quervain’s Tenosynovitis

Thumb Trigger Nodule

Index Trigger Nodule

Extensor Tenosynovitis/Tennis Elbow/Lateral Epiconylitis

Radial Tunnel/Posterior Interosseous Nerve Entrapment

Tinel at elbow

Tinel at Wrist

Allen Test: Dominant Ulnar > Radial Artery 8.1%May be higher in populations with h/o ABG’s

1. Elevate hand 30 seconds2. Make fist elevated3. Apply pressure over Radial and Ulnar Arteries4. Open hand while elevated, it should be blanched5. Release one vessel pressure, should refill in 7 seconds

Moving 2 Point Discrimination

Phalen’s Test: 1 minute

Common Conditions of the Hand1995: National Center Health Statistics

• Open wound finger>hand>forearm• Contusion of the upper extremity• Sprain to the wrist• Fractures: radius/ulna>humerus>phalanges>carpal>metacarpels• Burns to the hands, fingers and thumb• Carpel Tunnel Syndrome• Osteoarthritis upper extremity• Rheumatoid arthritis• Other compressive neuropathies: Cubital Tunnel

• No mention of masses / tumors / tendon injuries / infections

Masses of the Hand90% benign

( Skin Cancers, then: ) • Ganglions 50%• Enchondromas 10%• Granular Cells Tumors 10%• Epidermal inclusion cysts• Lipomas: remove if symptomatic• Glomus Tumors• Raromas

Ganglions

Dorsal wrist >volar/radial > DIP/osteoarthritic > flexor sheath

Scapholunate OsteophyteRadioscaphoid/Carpel ScaphoTrapezial

65% 20% 10% 5%

Enchondromas

Solitary 85% > multiple 15%Usually arising from the shaft of the phalanx

Granular Cell Tumors

Need to excise a margin of tendon sheath to reduce recurrence Encapsulated and yellow brown in color

Glomus Tumors

Severe pain, temperature related, 1/4 subungalXray shows a scalloping defect secondary to cortical pressure

Melanoma

Intermittent intense sun exposure < 50Continuous sun exposure > 50, especially dorsum handMost frequently seen in 70-80 age group female > male

Subungal Melanoma

20-25% amelanoticOften history of traumaMean age 60’sHutchinson’s sign-> spread of pigment to surrounding tissueDD: hematoma, chronic paronychia, melanonychia, junctional nevus

Hutchinson’s sign

Inflammatory Flexor tenosynovitis

Electricians

Hammer and jack hammer

Home construction

Mallet Deformity

Type 1: closed blunt trauma, no fracture, treat with splint 6 weeks

Type 4B:20-50% articular fracture

Type 4C: > 50% fracture+volar subluxation

Stack splint

De Quervain’s Disease

• Injection for de Quervain's tenosynovitis: 1ml Kenalog 40, 25 G needle• The needle is placed into the first extensor compartment and • directed proximally toward the radial styloid

•

Trigger Finger

• Trigger finger injection: 0.5-1ml 25 g needle, Kenalog 40• The needle is inserted distal to distal palmer crease • Aim posterior towards the nodule in the direction of the metacarpal head• Use your non-dominant hand to move PIP/DIP and free for tendon ‘scratch’• You are trying to fill the sheath and the A1 pulley with steroid

•

Lateral Epicondylitis

• Steroid injection Kenalog 40• 25 g needle onto bone• 1 by 2cm area: stay on bone• Radial nerve is medial• Tennis elbow Splint

• After 3 injections consider• Debridement of ECRL/B

Carpel Tunnel Syndrome:1.5% population 3 x more common in women

• Causes: WR: 47%> Dialysis, DM, Pregnancy, RA, Amyloid

• Work-up: EMG- conduction velocity> 4.5ms motor,

> 3.5ms sensory

• Management: NSA’s, splinting, ergonomics

• Steroid injections controversial in USA

• Surgery ( 85% successful ) : if medical management fails &

+ EMG

• Surgical techniques: formal long Orthopedic incision

endoscpic Chow, Agee techniques

minimal scar non-endoscopic

• Short scar associated with early rehabilitation / return to work

• Neurolysis indicated for recurrent CTS and dialysis patients

Cubital Tunnel Syndrome

• Usually caused by noctural hyperflexion at elbow• 85% respond to noctural splinting• No role for steroid injections• Surgery for failed splinting:• Short scar transposition & subfascial tunnel submuscular tunnel

submuscular tunnel with medial epicondylectomy

Entrapment or subluxation

Dupuytren’s Disease

Operate if > 30 degrees MCP flexion any PIP flexion

CMC Arthritis

•

• Injection for first carpometacarpal joint. • The needle should enter on the ulnar side of the extensor pollicis brevis tendon• Gentle pull on the thumb opens the CMC joint space • The 25-gauge needle should fall into the joint: 0.5ml Kenalog 40

•

PIP OsteoarthritisPyrocarbon: graphite/ceramic

Pyrocarbon graphite/ceramic

Silicone: < 30 degrees flexion

Silicone: < 15 degrees flexion

Rheumatoid Arthritis

• 3 stages: Proliferative: swollen, stiff, assoc CTS Destructive: erosion joint capsules, bone Reparative: fibrosis replaces inflammation

• Loss of finger flexion: FDS rupture• Incomplete finger extension: ulnar wrist subluxation• Mannerfelt Lesion: rupture FPL from scaphoid osteophyte• MCP joint subluxation best treated with joint replacement• Swan neck deformity associated with intrinsic shortening• If wrist subluxation; distal ulna may sublux dorsally• Darrach Procedure: resect distal Ulna & rebalance tendons avoids tendon rupture from Ulna wear

Burns• Scar excision and early skin grafting can

reduce contracture formation

Congenital• Amniotic bands

• Syndactyly

• Thumb duplication

• Trigger/Campytdactyly/Clindodactyly

Hand Prostheses

Raroma

• Tumor example of Schwannoma