Mike Foster

Hand, Wrist and Elbow

Dupuytrens Disease • First described in 1614 by

Felix Platter

• 1777 Henry Cline recognised disease involved palmar fascia

• 1822 Sir Astley Cooper advocated fasciotomy

• Popularised by Dupuytren in 1831

Pathophysiology

• Normal fascial bands • Myofibroblast

• Diseased cords form

from normal fascial bands

• Fixed flexion contracture

Associations

• Family history

• Northern European descent

• Male: Female 9:1

What the Patient Says

• I can’t get my hand in my pocket

• My finger pokes me in the eye when I wash my face

• My finger keeps catching on objects

What to Look For

• Thickening of the skin

• Tethering of palmar skin

• Surface rippling and dimpling

• Obvious cord

When to Refer

• 30 deg contracture at MCPJ

• PIPJ involvement

• Table top test

Treatment Options

• Percutaneous needle

• Fasciotomy

• Partial fasciectomy

• Dermatofasciectomy and full thickness skin graft (FTSG)

NZ Standard of Care

• Partial fasciectomy

• Brunner incisions or closure with Z plasties

• FTSG for skin deficits

Collagenase

• Collagenase Clostridium histolyticum

• An enzyme, derived from a bacteria

• Recently completed phase 3 trials

• Marketed as Xiaflex (FDA approved)

How Is It Given: Day 1

Have We Got a Video?

Skin Tears Heal Quickly

Day 1 Day 3 Day 8

CORD 1 (US) • Phase III clinical trial

• 90 day randomised, double-blind placebo controlled

• 308 patients from 16 centres

• Contractures of MCP +/- PIP of > 20° • Success = correction to less than 5° contracture • 64% joints injected with collagenase corrected • 6.8% joints injected with placebo corrected • Average contracture reduction @ 30 days

– 50.2° to 12.2° in Collagenase group – 49.1° to 45.7° in placebo group – MCP more likely to correct, corrected more fully

• 2 Flexor tendon ruptures, 1 CRPS

CORD 1 Results MCPJ PIPJ

CORD II (Australia) • Phase III clinical trial

• 90 day randomised, double-blind placebo controlled

• 66 patients

• Contractures of MCP +/- PIP of > 20° • Success = correction to less than 5° contracture • 50.7% joints injected with collagenase corrected • Average contracture reduction @ 30 days

– 70.% in Collagenase group – 13.6% in placebo group – MCP more likely to correct, corrected more fully

• 1 Pulley rupture, no tendon ruptures • CORD 3

• Injection of two digits, yet to be published

Complications • Flexor tendon ruptures • Tendonitis • Pulley Rupture • Finger deformity • Urticaria • Allergy • Immune reaction • Localised oedema • Pain • Contusion • Injection site haemorrhage • Skin tear • Complex regional pain

syndrome • Boutonnieres deformity

Probable Role of Collagenase

• When it becomes available in NZ

• MCPJ contractures

• Elderly

• Medical co-morbidities

NZ Concerns • Complications even

under experienced surgeons

• Lack of long term follow-up

• Recurrence rates • Difficulty of revision

surgery • Cost

NZ Hand Society Conference Queenstown 2012

CORD Five Year Data

• 50 % Recurrence Rate at five year • In successfully treated fingers

If orthopaedics can’t help!

Carpal Tunnel Syndrome

• Most common compressive neuropathy in the upper limb

• Women > Men

Aetiology

Anatomy • Carpus dorsally

• Transverse Carpal

Ligament volarly

• Ten structures pass through the tunnel

• Median nerve most superficial

History

• Nocturnal pain, numbness and tingling

• Thumb and radial digits

• Shaking of hand

• Dropping objects, difficulty with buttons

Symptoms

Examination

• Cervical causes, Spurling’s manoeuvre

• Tinel’s

• Phalen’s

• Durkan’s

Nerve Conduction Tests

• Distal Motor Latency > 4.5ms

• Distal Sensory Latency > 3.5ms

• Chronic cases EMG changes in APB

• Helpful in confirming diagnosis

Non-Operative Treatment

• Splinting

• NSAIDS

• Steroids

• Diuretics

Steroid Injection

• Risk to median nerve

• Useful for diagnosis

• Temporary effect

• Diabetics

• Pregnancy

Open Carpal Tunnel Release

• Gold Standard

• LA vs. GA

• Neurolysis not recommended

Complications

• Infection • Nerve injury • Haematoma • Pillar Pain • Wound Pain • CRPS

ECTR

• The standard practice in Brisbane

• Technically more demanding

• ? Less wound pain and an earlier return to work

• Need to convert to open in up to 10% cases

Have We Got A Video?

Complications

• Infection • Nerve injury • Haematoma • Pillar Pain • Wound Pain • CRPS

Open vs. Endoscopic

• 128 patients 25 to 60 years old

• Less pain in scar in ECTR group • No difference in return to work, both 28 days

My Current Practice

• Night splint for marked nocturnal symptoms

• Open carpal tunnel release as standard

• Endoscopic at patient’s request

• Endoscopic for bilateral procedures

Trigger Finger

Treatment for Trigger Finger

• Injection 10 mg Kenocort and LA

• Should inject easily

• 80 % successful

• Surgical release if failed injection or multiple fingers

Mucous Cyst

• Ganglion cyst

• Arising from degenerate DIPJ

• Can cause nail deformity

• Surgical Debridement +/- Fusion

Glomus Tumour

• Bluish discolouration under nail

• Extreme sensitivity to cold

• Severe pain

Surgical Excision

Fishmouth Incision Circumferential

Ganglions

• Most common soft tissue lump in the hand

• Dorsal arises from SL ligament

• Nuisance

• Fluctuates in size and shape

Investigation and Tx

• Trans illumination

• Aspiration

• Ultrasound solid vs. cystic

• Surgical excision

Other Lumps and Bumps

LIPOMA

Other Lumps and Bumps

PVNS

De Quervains

• Radial Sided wrist pain

• Mothers with infants

• APL and EPB form first dorsal compartment

• High incidence of separate compartments

De Quervains Dx and Tx

• Finkelsteins Test

• Splint that includes thumb

• NSAIDS

• Steroid injection

• Surgical release

CMC Joint Arthritis

• Pain at base thumb

• Difficulty opening a jam jar

• Positive Grind Test

Non Operative TX

• Activity modification

• NSAIDS

• Splint

• Injection

Operative Treatment

Trapezectomy

50 % FCR

LRTI

What NSH doesn’t take.

• Flexor tendon injuries

• Nerve injuries

Important Phone Numbers

• MMH hand acute phone 021 804 896 • MMH plastic acute phone 021 784 057 • Karen’s phone 021 414 602 • Mike’s phone 021 417 651

• Simon Chinchanwallah’s phone 027 295 0007 • Albert Yoon

Good Web Site

“orthobullets”

Thank you