Case Presentations

David Bear, MD

Hand and Upper Extremity SurgeonSlocum Center for Orthopedics and Sports Medicine

Disclosure I have nothing to disclose

Case #1 20 year old female presents with chief complaint of

inability to straighten her right ring and pinky fingers Referred for treatment of trigger fingers Denies any trauma or known cause Worsened over 6 months Negative PMH

Case #1: Differential diagnosis? Trigger fingers? Dupuytren’s contracture? Extensor tendon injury? Neurologic cause?

Peripheral nerve compression? Central nervous system?

Case #1: Physical Exam

Case #1: Physical Exam? Visual inspection Flexed posture of ring and small fingers No visible atrophy Hand appears well perfused

Case #1: Physical Exam? Palpation: No tenderness in hand/wrist/elbow No palpable masses No A1 pulley tenderness No Dupuytren’s cord/nodules

Case #1: Physical Exam? Vascular exam: 2+ radial pulse Brisk capillary refill in finger tips

Case #1: Physical Exam? Sensory exam: Decreased sensation in small finger and ulnar side of

ring fingers

Motor exam: Full passive motion in fingers No signs of triggering or tendon subluxation Weakness in the intrinsics Decreased pinch and grip strength

Case #1: Physical Exam? Special tests: Positive tinels over ulnar nerve at elbow Increased ulnar nerve numbness with elbow flexion No ulnar nerve subluxation at elbow Positive Froment sign

Case #1: Differential diagnosis? Trigger fingers? Dupuytren’s contracture? Extensor tendon injury? Neurologic cause?

Peripheral nerve compression? Central nervous system?

NEXT STEP??

Case #1: EMG/NCS NCS shows moderately severe compression of ulnar

nerve at level of the elbow No other signs of compression Could consider imaging

Diagnosis: Cubital tunnel syndrome

Plan: ?

Case #1

Case #1 Rare cause of compression found during surgery

Outcome: Patient improved and had normal function and sensation at 3 months postop. Claw deformity resolved.

Case #2 80 year old active RHD female presents with a 1 week

history of inability to extend her right middle and ring fingers.

Denies any trauma or known cause Denies pain Unable to get fingers open enough to pick things up

and complete ADLs. Enjoys sewing and now unable. PMH: HTN, hyperlipidemia

Case #2: Differential diagnosis? Trigger fingers? Dupuytren’s contracture? Extensor tendon injury? Neurologic cause?

Peripheral nerve compression? Central nervous system?

Case #2: Physical Exam Visual inspection Flexed posture of middle and ring fingers No visible atrophy Hand appears well perfused

Case #2: Physical Exam? Palpation: No tenderness in hand/wrist/elbow No palpable masses No Dupuytren’s cord

Case #2: Physical Exam Vascular exam: 2+ radial pulse Brisk capillary refill in finger tips

Case #2: Physical Exam Sensory exam: Sensation intact median/radial/ulnar nerves

Motor exam: Full passive motion in middle and ring fingers Minimal active extension in middle and ring fingers No signs of extensor tendon subluxation No triggering Normal strength otherwise in median/radial/ulnar n.

Case #2: Physical Exam

Case #2: Differential diagnosis? Trigger fingers? Dupuytren’s contracture? Extensor tendon injury? Neurologic cause?

Peripheral nerve compression? Central nervous system?

Special exam tests to help?

Case #2: Physical Exam Special tests:

Check tenodesis effect to determine nerve vs tendon rupture etiology.

No significant extension of middle/ring finger with tenodesis

Case #2: Diagnosis Diagnosis: Likely extensor tendon rupture

Ultrasound ordered and patient was found to have evidence of attritional tendon rupture of middle and ring finger extensor in her dorsal forearm.

Case #2: Plan Discussed conservative treatment vs operative

intervention. Based on difficulty with patient performing ADLs and

hobbies, decided to proceed with tendon transfer under local anesthesia.

Case #2: Local anesthesia

Case #2: OR findings

Case #2: OR after repair

Case #2: Post-op Patient tolerated surgery well Obtained about 90% improvement in function Able to successfully resume ADLs and sewing by 2

months from surgery

Thank you!

Case #3 16 year old competitive male high school baseball

player presents 2 weeks after injury during practice where he collided with another player.

Complains of ulnar sided hand pain. Initially diagnosed with a hand sprain Has been able to continue playing with some pain.

Extra Case for Home Study. Will be discusses if time allows.

Case #3 Physical exam:

Swelling over ulnar hand Tenderness over ulnar metacarpals Weak finger flexion and extension Sensation intact Any other physical exam tests?

Case #3 Obvious malrotation noted on finger flexion

Case #3

Case #3 Plan:

Elected to proceed with surgery. Discussed pins/plate and screw fixation/nail

fixation. Decided to proceed with nail fixation to allow

earlier return to baseball.

Case #3 Healed well and returned to baseball 6 weeks postop