Download assessment and management of hand

ASSESSMENT AND MANAGEMENT OF HAND
PATHOLOGY
MR. A. FRANKLIN, ChM, FRCS
CONSULTANT ORTHOPAEDIC SURGEON
BROMLEY MEDICAL CHAMBERS
THE HAND IS ONE OF THE MOST EASILY ACCESSIBLE PARTS
OF THE BODY, BUT OFTEN THE LEAST WELL ASSESSED
CLINICALLY, ESPECIALLY WITH RESPECT TO FUNCTION.
APPEARANCE IS OF FAR LESS IMPORTANCE OVERALL THAN
FUNCTION
AN ANATOMICALLY ‘PERFECT’ BUT STIFF HAND IS MORE VISIBLY
‘ABNORMAL’ THAN ONE WHICH IS BEING USED NORMALLY
DESPITE DEFORMITY
PRESENTATIONS
PAIN (HAND, WRIST AND EXTENSION PROXIMALLY)
SWELLING
DISCOLOURATION
STIFFNESS (DIGITS, WRIST)
TINGLING/NUMBNESS
WEAKNESS
CLUMSINESS (LOSS OF FINE MOVEMENT)
TRAUMA
DEFORMITY
THE CAUSE FOR THE PRESENTING HAND SYMPTOMS MAY BE
ARISING ELSEWHERE
1. MORE PROXIMALLY IN THE ARM
2. IN THE NECK
3. SYSTEMIC DISEASE (METABOLIC, INFLAMMATORY, VASCULAR,
NEUROLOGICAL)
4. NON ORGANIC
DEFORMITY
CONGENITAL
 CLAW HAND
 MISSING/VESTIGIAL DIGITS
 SYNDACTYLY (LINKAGE BETWEEN FINGERS)
1. COMPLETE
2. PARTIAL
DEFORMITY
ACQUIRED
DEFORMITIES OF DIGITS
 AMPUTATIONS AT VARIOUS LEVELS
 RAY AMPUTATIONS
 POST TRAUMATIC ROTATION
DEFORMITIES OF JOINTS




HEBERDEN’S NODES (DIPJ)
MALLET DEFORMITY (DIPJ)
BOUTONNIERE (DIPJ)
ULNAR DEVIATION (MCPS)
DUPUYTREN’S CONTRACTURE
DEVELOPMENT OF FIBROUS BANDS IN THE SUBCUTANEOUS TISSUES
OF THE PALM AND DIGITS, CAN ALSO OCCUR ON THE SOLES OF THE
FEET
CAUSES
ALCOHOLISM, DIABETES, REPETITIVE TRAUMA, SOLITARY FALL ON
TO THE PALM, GENETIC, IDIOPATHIC, (ANTI-EPILEPTIC DRUGS)
NERVE FUNCTIONS AND EXAMINATION
1.
MOTOR
RADIAL NERVE – WRIST EXTENSORS (EXTENSION OF WRIST AND DIGITS AGAINST
RESISTANCE)
MEDIAN NERVE – FINE MOVEMENT OF THUMB AND INDEX FINGERS, THENAR
MUSCLES AND MEDICAL LUMBRICALS (OPPOSITION OF THE THUMB, ABDUCTION OF
THUMB AGAINST RESISTANCE, EVIDENCE OF THENAR WASTING)
ULNAR NERVE – ADDUCTION OF THE THUMB, INTEROSSEOUS MUSCLE POWER,
LATERAL LUMBRICALS (ABDUCTION OF FINGERS AGAINST RESISTANCE, ADDUCTION
OF THUMB AGAINST RESISTANCE, FROMENT’S TEST)
2.
SENSORY
RADIAL NERVE – RADIAL ASPECT OF THE DORSUM OF THE HAND INCLUDING THUMB
INDEX AND MIDDLE FINGERS, RADIAL HALF OF RING FINGER ALL AS FAR AS THE DIP
JOINT (SENSATION IN DORSAL WEB SPACE BETWEEN THUMB AND INDEX FINGER)
MEDIAN NERVE – FLEXOR SURFACE OF THE THUMB, INDEX, MIDDLE AND RADIAL
HALF OF RING FINGERS AND THENAR EMINENCE (SENSATION TO TOUCH)
ULNAR NERVE – FLEXOR SURFACE OF ULNAR HALF OF RING FINGER AND LITTLE
FINGER, HYPOTHENAR EMINENCE (SENSATION TO TOUCH)
NAMED TESTS
PHALEN’S
HYPERSENSITIVITY OF NERVE TO PRESSURE
TINEL’S
HYPERSENSITIVITY OF NERVE TO PERCUSSION
FROMENT’S
WEAKNESS OF THUMB ADDUCTION WHILE
HOLDING PAPER (i.e. ULNAR NERVE
ABNORMALITY)
FINKELSTEIN’S
SEVERE PAIN REACTION ON RADIAL SIDE TO
PASSIVE ULNAR ADDUCTION OF WRIST WITH
CLENCHED HAND
SPECIFIC CONDITIONS
RHEUMATOID ARTHRITIS (SWOLLEN, INFLAMMED & DEFORMED
JOINTS)
OSTEOARTHRITIS (COMMONEST SITE, 1ST CARPOMETACARPAL JOINT)
PSORIATIC ARTHROPATHY (PROXIMAL INTERPHALANGEAL JOINT)
REYNAUD’S DISEASE/PHENOMENON (DISCOLOURATION/ POOR
CAPILLARY FILLING)
COMPLEX REGIONAL PAIN SYNDROME 1 (SUDECK’S
OSTEODYSTROPHY) FOLLOWING TRAUMA (SWELLING, COLOUR
CHANGE, COLD TO TOUCH, HYPERSENSITIVITY) – OSTEOPENIA ON XRAY
DE QUERVAIN’S TENOVAGINITIS (TENDER RADIAL BORDER OF WRIST,
PAIN ON RADIAL BORDER WITH RESISTED EXTENSION OF THUMB,
POSITIVE FINKELSTEIN’S TEST)
TRIGGER FINGER OR THUMB (LOOK FOR FLEXOR TENDON SHEATH
NODULES)
CARPAL TUNNEL SYNDROME (+ve TINEL’S AND PHALEN’S TESTS,
THUMB ABDUCTOR WEAKNESS, WASTED THENAR MUSCLES)
ULNAR NEURITIS (WASTED HYPOTHENAR EMINENCE, WEAK THUMB
ADDUCTOR, WEAK FINGER ABDUCTORS, +ve TINEL’S, PHALEN’S AND
FROMENT’S TESTS)
DUPUYTRENS CONTRACTURE
ISOLATED NODULES OR STRANDS IN THE PALM
LITTLE FINGER, INITIALLY CAUSING MCP FLEXION
RING AND LITTLE FINGERS COMBINED
MIDDLE AND RING FINGERS COMBINED
INDEX FINGER OR THUMB (UNCOMMON)
FIRST WEB SPACE
TREATMENTS
1.
HAND THERAPY
2.
ANALGESIA (ORAL MEDICATION/ TOPICAL GEL)
3.
INJECTIONS
4.
SPLINTAGE (FIXED/DYNAMIC)
5.
SURGERY (NB: AT LEAST 50% OF THE FINAL FUNCTIONAL
OUTCOME DEPENDS ON POST-OP REHABILITATION)