Approach to Hand Conditions

Alphonsus Chong

Department of Orthopaedic Surgery, YLLSOM, NUS

Department of Hand and Reconstructive Microsurgery, NUH

Scope

• Introduction – (Slides will be available)

• Traumatic injuries – open and closed

• Peripheral nerve problems

• Masses in the hand and wrist

• Tendinopathy and tendinitis

• Deformity

History Taking

• Pain – different aspects

• Deformity

– Congenital

– Acquired - ? Traumatic

• Decreased range of motion

• Weakness

• Numbness

• Others e.g. triggering, instability

• Handedness

• Job

• Hobbies

• Previous injury/ surgery

Expose both sides: subcutaneous border of ulna and elbow- rheumatoid nodules

Scars, wasting, deformity

Completeness and fluidity of motion

Scars, wasting, deformity

Quick Nerve Screen

Median Nerve Radial Nerve

Ulnar nerve

Traumatic Injuries – Open Injuries

Assessment of Hand – Work through the tissues(see Apley)

• Skin – note size and types of wounds

• Vessels - circulation

• Nerves – sensation and motor

• Muscle and Tendons – individual flexor and extensor tendon testing

• Bones & Joints – appropriate x-rays to assess fractures/ dislocation

What do you see?

• LOOK

• Skin

• Vessels

• Nerves

• Tendons

• Bone and joint

• LOOK – Loss of cascade

• Skin – lacerations

• Vessels – Color looks fine; check cap refill, turgor, temperature

• Nerves – 2 PD of RF and SF

• Tendons – FDP and FDS RF and SF

• Bone and joint – X-rays; also to check for foreign bodies

Wrist Injuries

• Distal radius fractures

• Scaphoid fractures

• Perilunate and lunate dislocations

Distal Radius Fractures (DR Fx)

• Distal 3 cm of the radius

• Very common

• Varied in appearance

• Avoid eponyms

• Classification

– AO

– Practical

Typical “Colles” type osteoporotic fracture:

Extra-articular, dorsal angulation, loss of

radial height

Practical assessment of distal radius fractures (DR Fx)

• Open or not?

• Intra or extra-articular

• Assess displacement:

– Shortening

– Angulation

– Translation

– Rotation

• Let’s try

DR Fx: Mechanism and associated injuries

• “FOOSH” injury

• Associated injuries

– Ulna styloid -> TFCC

– Ulna head

– Scaphoid and other carpal fractures

• Complications

• Early

– Median nerve compression

• Intermediate

– Extensor Pollicis Longus rupture

– Reflex sympathetic dystrophy/ CRPS

• Late

– Malunion

– Stiffness of hand and wrist

Treatment options• Conservative (Min displacement,

unfit)

– immobilization – plaster, thermoplastic splint

– Manipulation and reduction if displaced

• Open reduction and internal fixation– Plates and screws (mostly volar

plate now)

– Wires

• External fixation

• Homework: typical indications for ORIF

Internal fixation: volar locking plate

External fixator

Kirschner wires

and external

fixator

Scaphoid fractures

• Common fracture

• Easy to miss – initial symptoms, x-ray problems

• Vascularity issues non-healing/ Avascular necrosis if not treated well SNAC

Poor Vascularity

70-80% of

blood supply

20-30% of

blood supply

Clinical assessment scaphoid fractures

• 16-40s male

• Fall

• Radial sided wrist pain

– ? Scaphoid fracture

– ? DR fracture

– ? 1st CMCJ fracture/dislocation

– Sprain/ contusion

Snuffbox tender Axial grind

Tuberosity tenderness Resisted pronation

Ulnar deviated

“Scaphoid” view

PA

view

Lateral view

Semi-

pronated

view

Semi-

pronated

view

Semi-

supinated

view

Herbert Classification

Bone grafting in delayed or non-union

• Most acute scaphoid fractures – scaphoid cast

• Late presentation / inadequate treatment / failed casting non union

– Need bone grafting and fixation (usually with a “headless” screw)

2 Months post-op

Perilunate Dislocation

• 20 year old construction worker

– Fell from 1 storey high

– Landed on left UE

– Felt immediate sharp pain over the left wrist a/w swelling and deformity

– Also abrasions shoulder, face

• Possible diagnoses?

– DR fx

– Perilunate / lunate dislocations

Order a true PA and lateral of the wrist

Scaphoid fracture

Break in Gilula’s lines

Dorsal perilunate

dislocation

Immediate Treatment in EMD• Manipulation and

reduction (technique in Apley’s)

• Carpal tunnel release if median nerve compression

• Needs definitive fixation

Key point – recognition of injury

“Spilled teacup” sign

Lunate Dislocation Dorsal perilunate

dislocation

Hand Fractures

• General principles

• I will discuss

– Metacarpal fractures

• understand assessment

• Treatment options

– Thumb base fractures – deforming forces in Bennett’s fx

• Read Apley’s System of Orthopaedics – Chapter on Hand Fractures

Hand Fractures – General Principles

• Most can be treated conservatively

• Rotational deformity functional problems

– Need clinical exam to diagnose

• Mild angular deformity tolerated

• Immobilize in position of “safety” if unsure

• Do not prolong immobilization stiffness

Intrinsic plus or “position of

safety” or Edinburgh Position

Swelling and bruising

Normal Scissoring MF nail plane

rotated

Darren’s x-ray

Thumb metacarpal base fractures

• Other metacarpal base fractures usually stable

– Make sure no malrotation

• Thumb metacarpal base fractures

– Epibasal/ extra-articular fractures

• > 30° angulation – web span affected

– Bennett’s fracture-subluxation

– Rolando fracture

Bennett’s fracture

• Fracture-subluxation/ fracture dislocation

• Unstable injury

– Deforming forces

• Recognise injury

• Closed reduction and fixation or ORIF

Abductor

pollicis longus

Tendon

Adductor

pollicis

Volar beak

ligament

Rolando Fracture

• T- or Y- configuration

– Or comminuted

• NO subluxation or dislocation

• High energy injuries

• Need surgery

Upper limb peripheral nerve entrapment neuropathies and injuries

• Common compressive neuropathies (entrapment syndromes):

– Nerve ischemia – episodic continuous

– Fibrosis later on

– Examples?

• Localization is the key

Classification of Nerve Injuries

• Physical injury

– Seddon/ Sunderland classification

– Neurapraxia• Radial nerve palsy – “Saturday night palsy” or fracture related

Sunderland (1951)

I II III IV V

Seddon (1942) Neurapraxia Axonotmesis Neurotmesis

Recovery potential

Full Full Incomplete Neuroma-in-continuity

Nil

Pathology Ionic block/segmental demyelination

Axon severed, endoneurialtube intact

Endoneurialtube torn

Only epineuriumintact

Loss of nerve continuity

Increase severity, poorer outcome

Peripheral Nerve Problems - Examples• Compressive

Neuropathies– Carpal Tunnel

Syndrome– Cubital Tunnel

Syndrome

• Nerve injury– Ulnar nerve injury– Radial nerve injury

• Other peripheral nerve problems

Carpal Tunnel

Syndrome

Cubital Tunnel

SyndromeRadial Nerve Palsy

e.g. Saturday night

palsy

Carpal Tunnel Syndrome

• Most common entrapment neuropathy

• Focus on clinical diagnosis

• Please read up on treatment

• Anatomy

Carpal Tunnel Syndrome - Symptomatology

• Patient profile: Female in her 40-50s

• Numbness– Classical: radial 3.5 digits – but not always so

– Intermittent vs constant

– Aggravating: night/ early morning symptoms; activity

– Relieving: shaking the hand

• Pain or tingling in the hand – may radiate proximally

• Current sensation radiating to fingertips

• Weakness and clumsiness in the hands

CTS: Some considerations:

– Difficult localization• “For example, it is difficult for people to localize sensory disturbances, so a patient with a median compression

neuropathy at the carpal tunnel often initially will insist that ‘‘the whole hand gets numb’’ including the ulnar innervated small finger.” (Beasley’s Hand Surgery)

– Diabetes mellitus

• Disorders such as diabetes can cause the peripheral nerve to be more sensitive to compression

• Not all numbness in DM patients are peripheral neuropathy

– Double crush syndrome

• Proximal nerve compression (e.g. root compression by disc) can predispose distal entrapment

• May need to treat both to relieve condition

Clinical Findings

• Tinel’s sign

• Phalen’s test

• Sensory Testing

– 2 point discrimination usually normal

– Semmes-Weinstein monofilament or vibration reception thresholds most sensitive

• Abductor pollicis brevis weakness

Ulnar Nerve injury and entrapment neuropathy

• Common causes – at elbow (high):

– Cubital tunnel syndrome

– Lacerations around medial side of elbow

• Lose dexterity and strength in hand

• Symptoms

– Numbness ulnar 1.5 digits

– Weakness and deformity in the hand

• Less commonly at level of the wrist (low lesion)

Ulnar nerve

around behind

the medial

epicondyle

Cubital Tunnel Syndrome

• Idiopathic (30-50%)

• Tardy ulnar nerve palsy

• Others

– Arthritis

– Ganglion

– Aberrant muscles (Anconeus epitrochlearis)

Cubital Tunnel Syndrome

• Patient profile: male

• Numbness/ pins and needles• RF and LF

• Aggravated by elbow flexion

• Night symptoms, intermittent symptoms

• Pain

• Weakness (“clumsiness”), deformity later

Further reading: Cutts S: Cubital tunnel

Syndrome

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2

599973/

CbTS: Examination

• Tinel’s sign

• Elbow flexion test

• Mild – symptoms and sensory

• Motor signs in more severe cases

Ulnar claw, Jeanne’s sign

Wasting of intrinsics, ulnar claw,

Wartenberg’s sign

Wartenberg’s sign

• Unopposed abduction of LF in ulnar nerve palsy

• EDQM has ulnar deviation vector

• Unopposed by palmar interossei in ulnar nerve lesions

Radial Nerve Palsy

• Disabling condition due to motor dysfunction

• Sensory loss not as critical

“Patients with a radial nerve lesion cannot hold a knife and fork easily, nor cut their fingernails. They have difficulty in fastening buttons and brushing their hair. Shaving and tying shoe-laces are also difficult to manage. Generally they have a poor grip and cannot put objects like glasses or cups down flat on a table" (Wynn Parry, 1958)

Radial Nerve Palsy

• Anatomy

– Motor

– Sensory

• Different levels and causes of lesions

“Very High”

Crutch Palsy

“High”

Saturday Night Palsy

Humeral Fractures

“Low”

Open injuries

Forearm/ elbow

fractures

Neurapraxia

Varies

Varies

Posterior Cord C5-T1

High Radial Nerve Injury

• Inability to extend wrist and finger MPJ

• Pitfalls – PIPJ and DIPJ extension is intrinsic function

• Very high radial nerve palsy

– Triceps function is lost

• PIN palsy

– Preservation of wrist extension (but radially deviated)

– No sensory loss

Wrist and digital drop

in radial nerve palsy

“Saturday night palsy”

• Males > females

• Abrupt onset of wrist and finger drop

• After sleep

– Sleep position

– Alcohol influence +/-

• Sensation MAY be preserved

• Neurapraxia will recover completely

– Improvement start mostly within 2 weeks – up to 10 weeks

Sleeping while drunk

68%

Bent arm under the

pillow20%

Unknown8%

During drinking

4%ACTIVITY

BR Han et al, 2013

Radial nerve injury with Humeral shaft fractures

• Spiral groove – susceptibility

• Timing of injury:

– At time of injury

– After manipulation

– After ORIF

• Open injuries :- explore

• Closed: mostly Sunderland 1-2

– Watch and wait

– If persists > 12 weeks NCS andexplore

Surgical options• Repair with graft• Tendon transfers

– Use median or ulnar innervated muscles to replace radial nerve innervated ones

– Pronator Teres (median nerve) to ECRB (radial nerve) for wrist extension

Other Nerve Problems

• AIN Palsy

• Thoracic outlet syndrome

• Brachial plexus injuries

– Adult traumatic

– Obstetric birth paralysis

Patient unable to do the “OK” sign on the right

because of anterior interosseous nerve palsy

Masses & Swellings (M&S) in the hand and wrist

• Common clinical problem

• Not all M&S are neoplasms

• Most neoplasms are benign

• Most common malignant ones are skin cancers

• Site a useful guide to likely cause of mass

Viral wart

Implantation dermoid Pyogenic granuloma

Dorsal wrist ganglion

Origins and Common lumps

• Neoplasms / Masses arise from the following

– Bone and cartilage

– Muscle

– Nerve

– Skin and adnexa

– Subcutaneous tissue

– Synovium and tendon

– Blood vessels

• 95% comprise:

– Ganglion

– GCT tendon sheath

– Epidermoid inclusion cysts

– Vascular masses

– lipomas

Ganglions – common sites

• Wrist

– Palmar: SL / RC jt

– Dorsal: SL jt

• Palm – Flexor tendon sheath

• PIPJ and DIPJ mucus cyst

Palmar radial side of the wrist

Dorsal side of the wrist

DIPJ ganglion

with osteoarthritis

Transillumination is

helpful

Ganglion: Treatment

• Conservative

– Leave alone (favoured)

– Aspiration - recurrence

– Rupture

• Surgical excision

– Follow the stalk down

– Contains gelatinous material

• Recurrence – quite high

Stalk of the ganglion

“glairy” “gelatinous” material

Giant cell tumor of tendon sheath (Pigmented villonodular synovitis)

• Second most common swelling

• True neoplasm

• Sites with synovial tissue

– Palmar more common

• Firm, lobulated, eccentric mass

GCTTS

• Giant cell tumor of tendon sheath

Soft tissue mass

with scalloping of

bone

GCTTS: Treatment is excision

• Surgical excision is the only treatment

• Recommended because of continued growth

• Gross appearance

– Lobulated/ irregular

– Yellow-brown mass

• Recurrence is a problem

Epidermoid inclusion cyst

• Skin wounds may leave skin cells below the surface

• Growth of these cells lead to mass attached to the skin

• Well defined, spherical

• Overlying healed wound

• Excision is effective

Summary: Common Hand Lumps/Bumps

• Wrist – Ganglia

• Hand

– PVNS

– Skin lumps

Wrist ganglion

Flexor sheath

ganglion

PVNS

Mucus cyst

Palmar lump:

Implantation

Dermoid

Tendinopathies: Tendinitis vs Tenosynovitis vs Tenovagnitis

• Tendinitis/ tendinosis – inflammation of tendon

• Tenosynovitis – synovial sheath

– Typically infection e.g. flexor tenosynovitis

– Non-infective e.g. rheumatoid, overuse

• Tenovaginitis – Fibrous sheath affected

– vagina: latin for sheath

– Trigger finger, DeQuervain’s

• Reading: Apley 9th Ed pp 406-407

DeQuervain’s Disease/ Tenovaginitis(tenosynovitis)

• Female 30-50 years old

• New baby/ more work e.g. wringing

• Pain over the radial wrist joint near the base of the thumb

• APL and EPB tendons (1st

extensor compartment)

• Differential diagnosis?Finkelstein’s (Eichhoff’s) Test

Trigger Finger

• Stenosingtendovaginitis of flexor tendons @ A1 pulley

• Steroid injection usual first line treatment

Trigger Staging

Grade I (pretriggering) - Pain; history of catching that is not demonstrable on clinical examination; tenderness over the A1 pulley

Grade II (active) - Demonstrable catching, but with the ability to actively extend the digit maintained

Grade III (passive) - Demonstrable lockingin which passive extension is required (grade IIIA) or in which the patient is unable to actively flex (grade IIIB)

Grade IV (contracture) - Demonstrable catching, with a fixed flexion contractureof the proximal interphalangeal (PIP) joint

1st annular pulley

Deformities in the Hand

• Isolated / Limited

– Swan neck deformity

– Boutonniere

– Flexion contracture

• Generalized

– Osteoarthritis

– Rheumatoid arthritis

– Other arthropathy

Middle-aged Caucasian Male

Dupuytren’s Contracture

Swan Neck Deformity

• PIPJ hyperextension• DIPJ flexion• Do not confuse with

Boutonniere deformity– PIPJ flexed, DIPJ

hyperextended

• Seen in – RA– Secondary to mallet– “pseudo” swan neck

Hyperextension of

PIPJ

Boutonniere (“Button- hole”) Deformity

• PIPJ flexion deformity

• DIPJ hyper-extension

• Extensor central slip rupture

– Acute trauma

– RA

• Lateral bands subluxate palmarly

Hyperextension of

DIPJ

“Button-holing” of head of proximal phalanx through

hole in extensor tendon

Osteoarthritis of the hands

• Describe the deformity

• Which joints are affected?

• How does joint involvement in OA differ from Rheumatoid arthritis

• What are the expected x-ray findings?

• What are the treatment options for this?

• (Apley’s pp 424-429)

Osteoarthritis of both hands

Summary Slide

• A way to think about:• Traumatic injuries – open and closed

• Peripheral nerve problems

• Masses in the hand and wrist

• Tendinopathy and tendinitis

• Didn’t cover

– Infections, paediatric, congenital conditions – read up

• I leave you the slides, some new information, and reading and thinking to do.

Osteoarthritis of the hands

• Describe the deformity

• Which joints are affected?

• How does joint involvement in OA differ from Rheumatoid arthritis

• What are the expected x-ray findings?

• What are the treatment options for this?

• (Apley’s pp 424-429)

• Swelling, radial deviation and Herbeden’s nodes

• Fairly symmetrical deformity affecting mainly DIPJs

• DIPJs; should also look carefully at PIPJ and 1st CMCJ

• RA: DRUJ, MPJ and PIPJ; OA: PIPJ, DIPJ, 1CMCJ

• Conservative vs surgery (fusion of DIPJs)