COMMON ORTHOPAEDIC CONDITIONS OF THE HAND AND WRIST Korsh Jafarnia, MD Methodist Center for Orthopedic Surgery & Sports Medicine Topics Carpal Tunnel Syndrome Cubital Tunnel Syndrome Trigger Finger Dupuytrens Contracture Osteoarthritis New innovative treatments Carpal Tunnel Syndrome Compression of the Median Nerve in the Carpal Tunnel Tingling and numbness in the radial digits Aggravated by driving & sleeping Relieved by shaking hand Pain which wakes them at night Hand feels swollen, stiff, cold Carpal Tunnel Syndrome Risk Factors Diabetes Hypothyroidism Rheumatoid Arthritis Pregnancy After wrist fracture Carpal Tunnel Syndrome Clinical Signs Wasting of Thenar muscles Reduced sensation +ve Phalens sign +ve Tinels test Carpal Tunnel Syndrome Clinical Signs Wasting of Thenar muscles Reduced sensation +ve Phalens sign +ve Tinels test Carpal Tunnel Syndrome Clinical Signs Wasting of Thenar muscles Reduced sensation +ve Tinels test +ve Phalens/Durkans sign Carpal Tunnel Syndrome Indications for Nerve conduction Studies Suspicion for carpal tunnel syndrome Good history but ve Tinels and/or Phalens Is Ulnar Nerve also compressed Atypical history Objective test to assess nerve flow Carpal Tunnel Syndrome Treatment Wrist Splint Steroid injection Surgical Decompression Carpal Tunnel Syndrome Steroid Injections Cochrane data base reports:- Symptoms improved at 1 month, but no significant relief beyond this. High proportion of patients treated medically will end up requiring surgery My indications for injecting Severe symptoms and patient wants immediate relief Severe symptoms in pregnancy Patient doesnt want surgery To confirm diagnosis Carpal Tunnel Syndrome Surgical Decompression Local/Regional Anaesthetic Endoscopic/Minimally invasive Flexor retinaculum divided Suture under skin RTW - days Cubital Tunnel Syndrome Compression of the Ulnar nerve in the cubital tunnel C/O parasthesia in little and ring fingers Pain radiating down from medial side elbow Weakness and muscle wasting in the hand Cubital Tunnel Syndrome Physical Signs Wasting / weakness of the intrinsic hand muscles Reduced sensation +ve Tinels over cubital tunnel +ve elbow flexion test Cubital Tunnel Syndrome Investigation & Treatment Nerve conduction studies Activity Modification Surgical decompression - Endoscopic Anterior transposition Trigger Finger Flexor tenosynovitis Nodule in flexor tendon catching in A1 pulley Finger clicking Finger sticks in flexion, extends with click Tender palm Painful / weak flexion Trigger Finger Treatment Cortisone injection into/over A1 pulley Personal Audit: 3/4 long lasting relief Literature: Range from 47% at 6 months to 87% at 42 months Trigger Finger Treatment If 2 injections fail, further unlikely to work, and therefore go for surgical release mini open vs endoscopic Dupuytrens Contracture Thickening and contracture of the palmar fascia Risk factors are diabetes, family history, etc., ?Mechanical factors Dupuytrens Contracture Consider treatment when can no longer get hand flat on table top Fasciotomy Fasciectomy Xiaflex injections Thumb Base Arthritis Radiologically evident in 33% of postmenopausal women of whom 33% are symptomatic Symptoms Pain Weakness Stiffness Deformity Swelling Signs Observation Palpation Movement Special tests Signs Observation Palpation Movement Special tests Signs Observation Palpation Movement Special tests Treatment Activity modification NSAID/Steroid injection Viscosupplementation Splint Surgery Surgery Denervation Stabilization Osteotomy Arthrodesis Resection arthroplasty Resection & LRTI Interposition arthroplasty Trapeziectomy & Ligament Reconstruction Completely remove trapezium Ligament reconstruction with FCR tendon Repair capsule Post-op. splint Recent Advancements OA of the PIPJ PIPJ Replacement OA of the DIPJ New and Innovative Treatments Xiaflex Injections for Dupuytrens Disease PRP injections jury still out Synvisc injections for the small joints of upper extremity Endoscopic Cubital & Carpal tunnel release THE END