Complaints of hand and wristWim Willems

HOVUmc, Amsterdam

Program

• Basic anatomy

• Common complaints

• Practice

Anatomy

Intrinsic flexors

Volar view Dorsal view

Extrinsic flexors

Extensors

Nerves

“Elderly lady with a painful thumb”

• Female, 78 years old

• Pain thumb right hand

• Difficulty with sewing / opening pots

“Elderly lady with a painful thumb”

• Questions?

• Physical examination?

• Further examination?

• D.d.?

Arthrosis

• Start of arthrosis in DIP most common

• Heberden’s nodules

• CMC-1 (possibly afflicted relatively young)

• Grind test

Grind test

Heberden’s nodule

Treatment

Arthrosis CMC I

Injection

Splint

Avoid operation as long as possible

Arthrosis CMC I

“Finger gets stuck”

• Female, 45 year

• Right hand

• Palmar pain/ middle finger

• Impossible to straighten finger

“Finger gets stuck”

• Questions?

• Physical examination?

• Further examination?

• D.d.?

Trigger fingerTrigger finger

Pathofysiology

• Thickening of tendon / Thickening of tendon / tenosynovitis of m.flexor tenosynovitis of m.flexor digitorum communisdigitorum communis

• Finger triggersFinger triggers

Epidemiology

• Few data• life time prevalence, > 30 jr, no DM: 2.2%.

• Connected with DM, carpal tunnel syndrome, reumatic arthritis, hypothyreoidy.

Treatment

Conservative therapy

• Self limiting 10-20% ??• NSAID• Splint. 6 - 8 weeks (MCP in 10-15 degrees flexion). Effective 66% of the cases

• Steroïd injection. Effectiveness 50% - >90%

Trigger finger: Trigger finger: injection 1injection 1

• Needle: short and Needle: short and thin (eg 0,6x25mm or thin (eg 0,6x25mm or (0,45x23mm)(0,45x23mm)

• Volume: 1 ml TCA Volume: 1 ml TCA 10 mg/ml (optional 10 mg/ml (optional +1ml Xylocaine 1%)+1ml Xylocaine 1%)

• Performance: insert Performance: insert needle from distal to needle from distal to proximal along axis proximal along axis of metacarpal boneof metacarpal bone

• In MCP fold (2cm from In MCP fold (2cm from first falangeal fold)first falangeal fold)

Trigger finger: Trigger finger: injection 2injection 2

• Preferred angle 45 degreesPreferred angle 45 degrees• Ca. 1ml around tendonCa. 1ml around tendon Subcutaneous injection is as effective as Subcutaneous injection is as effective as

injection in tendon sheath injection in tendon sheath • No pressure No pressure • Effectiveness: 70-80% after 1-3 injections Effectiveness: 70-80% after 1-3 injections

Operative treatment

• Open or percutanous.• Success >90%• More complications (nerve damage, inflammation)

“Painful thumb”

• Man, 37 years

• House painter

• Pain radial side wrist

“Painful thumb”

• Questions?

• Physical examination?

• Further examination?

• D.d.?

De Quervain’s diseaseDe Quervain’s disease

• Tenosynovitis of Tenosynovitis of m.abductor pollicis m.abductor pollicis longus and m. extensor longus and m. extensor pollicis brevis (APL & pollicis brevis (APL & EPB)EPB)

• distal end radiusdistal end radius• Women > men, 35-55 yr.Women > men, 35-55 yr.• Presentation in general Presentation in general

practice: 5,6/1000practice: 5,6/1000• Often recurrent esp. Often recurrent esp.

when crepitationswhen crepitations

Etiology

• Tendons in common sheath APL & EPB irritation caused by frequent movements

• Overuse (wringing, racket sports)

• Pregnancy • Anatomic variations

M.de Quervain: onderzoekM.de Quervain: onderzoek

Finkelstein’s Finkelstein’s testtest

Treatment

• Corticosterod injection: success rate 2/3 of patients after 3 weeks. Sometimes 2nd or 3rd injection.

• Splint : unhelpful • Operation (cutting tendon sheath): longstanding complaints or failure injections

• Injection possible in pregnancy

M.de Quervain: injection M.de Quervain: injection treatmenttreatment

• Slight pronation Slight pronation

• Feel for common sheathFeel for common sheath

• Insertion of needle by Insertion of needle by small angle small angle

• 1ml TCA infiltration 1ml TCA infiltration

• Effectiveness: 70-80% Effectiveness: 70-80% after 1-3 injections after 1-3 injections

• Approach from proximal or Approach from proximal or distal possibledistal possible

Injection M. De Quervain

“Painful nightly tingling”

• Female, 52 years

• Wakes up in the early morning with painful tingling in the hand (thumb / index)

• Flapping of hand to ease complaints

“Painful nightly tingling”

• Questions?

• Physical examination?

• Further examintion?

• D.d.?

Carpal tunnel syndromeCarpal tunnel syndrome

Epidemiology

• Open population (history + nerve Open population (history + nerve conduction examination):conduction examination):

– Female: 9 %Female: 9 %– Male: 0,6%Male: 0,6%– Peak between 40-60 yearPeak between 40-60 year

Risk factors

WeightWeight PregnancyPregnancy Diabetes mellitusDiabetes mellitus Hypo/hyperthyreoidyHypo/hyperthyreoidy OvariectomyOvariectomy Anatomic deviation (traumatic / RA / Anatomic deviation (traumatic / RA / congenital) congenital)

Work related Work related

Natural course

•¼ - 1/3 significant improvement > 1 year

•After pregnancy 50% without complaints

Pathofysiology

• Narrow tunnelNarrow tunnel

• compression n. compression n. medianus in medianus in carpal tunnelcarpal tunnel

• 90% idiopatic90% idiopatic

Diagnosis: historyDiagnosis: history

Dutch consensus (CBO 2006):Dutch consensus (CBO 2006):• Nightly tinglingNightly tingling• Median nerve areaMedian nerve area• Sleep disturbanceSleep disturbance• Other tingling / pains Other tingling / pains • Flapping (Flick’s sign)Flapping (Flick’s sign)• Advanced stages: tingling during the Advanced stages: tingling during the day day

Sensory innervation N. Medianus

Atypical localisations tingling sensations in carpal tunnel syndrome• Often outside median nerve area

• Sometimes ulnar nerve area

Provocation tests:Provocation tests:

CBO 2006:CBO 2006:

Limited usefulnessLimited usefulness

test sensitivity specificity

Tinel 0.25-0.60 0.64-0.89

Phalen 0.10-0.91 0.33-0.86

Flick sign 0.93 0.96

Square wrist sign

0.47-0.69 0.73-0.83

Pressure provocation test

0.28-0.63 0.33-0.74

Tourniquet test

0.21-0.51 0.36-0.87

C.A.

Diagnostic tests CTSDiagnostic tests CTS : :

Tests

• Tinel Tinel percussion median nerve percussion median nerve

• Phalen:Phalen: flexion during 60 seconds flexion during 60 seconds

• Further:Further: -sensory loss median nerve -sensory loss median nerve area area

-thenar dystrophy -thenar dystrophy -dry skin (thumb / index / -dry skin (thumb / index /

middle middle finger)finger)

Neurophysiological Neurophysiological examinationexamination

sensitivity specificity

EMG 60-82 95-100%

• Verification of clinical diagnosis prior to operation

Limitation EMGLimitation EMG::

• No golden standardNo golden standard

• 10-15% false negative10-15% false negative • No relation between complaints and No relation between complaints and results results

• Results not predictive for therapyResults not predictive for therapy

• Value unclear for primary health careValue unclear for primary health care

Treatment

Splint

• Day and night

• Short term effective

• Minor complaints / recent onset

Surgery:

• Highly effective

• Major / recurrent complaints. Patient’s wish

• Open / endoscopic

• Success: 75-90%

• Complications: damage to nerve, pain, scar, complex regional pain syndrome)

Corticosteroid injectionCorticosteroid injection

• Several techniquesSeveral techniques1. Underneath retinaculum (most common 1. Underneath retinaculum (most common technique)technique)

2. Through retinaculum2. Through retinaculum

3. In front of retinaculum (method by 3. In front of retinaculum (method by Dammers)Dammers)

• SafeSafe• EffectiveEffective• Tradition / experience / authority Tradition / experience / authority determines techniquedetermines technique

Medicament / Dosage Medicament / Dosage

• Most common: Triamcinolonacetonide 10 Most common: Triamcinolonacetonide 10 mg/ml (Kenacortmg/ml (Kenacort®® A10), or A10), or methylprednisolonacetaae (Depo-Medrolmethylprednisolonacetaae (Depo-Medrol®®) ) 40 mg/ml40 mg/ml

• Volume: 1-2mlVolume: 1-2ml

• Interval between injections: 1-3 weeksInterval between injections: 1-3 weeks

• Effectiveness: 1Effectiveness: 1stst injection 80%, after injection 80%, after 2 injections 15%, after 3 injections 5%2 injections 15%, after 3 injections 5%

Needle?

-orange/ light brown -orange/ light brown (0,45x23mm)(0,45x23mm)

-light blue (0,5x25mm)-light blue (0,5x25mm)

-green (0,8x40mm)-green (0,8x40mm)

Localisation carpal tunnelOs pisiforme

Os scaphoideum

Localisation tendon m. Palmaris longus

Tendon m. Palmaris Tendon m. Palmaris longuslongus

• Absent Absent tendon: tendon: ulnar to ulnar to median axismedian axis

Localisation insertion:

• ulnar to tendon m. palmaris longus

• Depending on technique used:

1. On distal wrist line(= between tuberculum of os scaphoid and os pisiforme)

2. On proximal wrist line

3. 3-4 cm before distal wrist line

31 2

3

Injection underneath Injection underneath retinaculumretinaculum

• On proximal wrist On proximal wrist lineline

• Angle 30 degreesAngle 30 degrees

Injection underneath Injection underneath retinaculumretinaculum

• Tingling while Tingling while inserting inserting needle: needle: withdraw and withdraw and try againtry again

• Respect Respect resistancesresistances

2nd wrist line

Tendon m. palmaris longus

injection through retinaculum.

• Distal wrist line

• 45 degrees

Method by Dammers• 3-4 cm before distal wrist line

• Needle 3-4 cm • Angle 10-20 degrees

• Deposit fluid proximal to carpal tunnel

• Massage to enhance diffusion

HygieneHygiene

• Wash hands, wear gloves or disinfect Wash hands, wear gloves or disinfect fingersfingers

• Once-only ampoules Once-only ampoules

• Change needlesChange needles

• Disinfect skinDisinfect skin

Side effects and Side effects and complicationscomplications

• Side effectsSide effects-flushing: 1 day after injection-flushing: 1 day after injection-steroid-flare 24-48 hours-steroid-flare 24-48 hours-menstruation problems-menstruation problems-hyperglycemia-hyperglycemia-locale effects: redness, atrophy fatty -locale effects: redness, atrophy fatty tissue, hypopigmentationtissue, hypopigmentation

• ComplicationsComplications-very rare, case-reports-very rare, case-reports-tendon ruptures, median neuritis -tendon ruptures, median neuritis (CTS), local infection(CTS), local infection

Practice

• Anatomy

• Injection