Download COMMON PROBLEMS IN HAND SURGERY

COMMON HAND
PROBLEMS RELATED
TO WORK
Prasad G. Kilaru MD
Plastic, Reconstructive & Hand Surgery
Agenda

Injury types
 Basic anatomy
 Mechanism of action
 Diagnosis
 Treatment
 Prevention
 Education
Repetitive Stress Injury

Nerve:
– Carpal tunnel syndrome, cubital tunnel syndrome

Tendon: Connects muscle to bone
– Repetitive injury at muscle insertion

Trigger digit, DeQuervain’s tenosynovitis
– Repetitive injury at muscle origin


Lateral epicondylitis, Medial epicondylitis
Ligament: Connects bone to bone
– Chronic collateral ligament injury, TFCC injury

Joint Problems
– Ganglion cyst, Mucous cyst, Basal joint arthritis
Traumatic Injury

Tendon injury
– Flexor, extensor, muscle belly injury
– Injury to tendon insertion

Mallet finger, Flexor tendon avulsion

Bony Injury
 Nerve Injury
 Joint Injury
– Sprain, dislocation
Anatomy - Nerve

Median nerve – Mixed nerve
– Sensory – Volar aspect of palm and radial 3 ½ fingers
– Motor – Major finger and wrist flexors, thenar muscles
and radial lumbricals

Ulnar nerve – Mixed nerve
– Sensory – Ulnar aspect of volar and dorsal palm and
ulnar 1 ½ fingers
– Motor – Ulnar wrist and finger flexors and intrinsic
muscles of the hand
Anatomy - Nerve
Anatomy - Nerve

Radial nerve – Mixed nerve
– Sensory – Dorsal aspect of hand and radial 3 ½ fingers
dorsally
– Motor – Extensors of the elbow, wrist and fingers

Sensory to palm and fingers
– Volarly – Radial 3 ½ fingers and palm – Median nerve,
Ulnar 1 ½ fingers and palm – Ulnar nerve
– Dorsally – Radial 3 ½ fingers and hand – Radial nerve,
Ulnar 1 ½ fingers and hand – Ulnar nerve
Anatomy Carpal Tunnel
Anatomy of Flexor Pulley System
Anatomy – Extensor
Compartmetns
Mechanism of Action

Repeated movement/use causes swelling over
affected region
 Repeated movement/use despite swelling causes
worsening of swelling
 Feedback loop set up with worsening symptoms
 Depending on the structure effected – numbness,
pain, locking etc.
Nerve Compression Syndromes




Median nerve compression (carpal tunnel syndrome)
occurs from compression of the nerve at the wrist
Ulnar nerve compression can occur at the wrist or elbow
Radial nerve compression usually occurs in the forearm
Pressure buildup can occur from decrease in the size of the
tunnel(bone overgrowth, fracture) or increase in the
volume of the contents of the tunnel(tendinitis, fluid
buildup etc.)
Tendinopathies

Repeated movement/use of tendons causes
tendons to swell up and get trapped in tunnels
either over fingers or wrist (trigger finger,
DeQuervain’s tenosynovitis)
 Repeated movement/use at tendon origin causes
microtears which cause chronic tears near
common extensor (lateral epicondylitis) or
common flexor (medial epicondylitis) origin
Nerve Compression Signs &
Symptoms

Symptoms commonly include pain, numbness,
tingling and in late stages weakness in grip
 Symptoms are usually felt at night and can
occasionally wake patients from sleep
 The numbness is usually along the distribution of
the effected nerve
 Severe cases can result in muscle wasting with
weakness and permanent sensory loss
Nerve Compression Diagnosis

History and physical examination are
usually indicative of nerve compression
 Tinel’s sign, nerve compression test,
Phalen’s test are all positive
 Nerve conduction study and EMG are often
confirmatory
Tendinopathy Diagnosis




Usually presents with locking or snapping of the finger or
thumb on flexion that holds the finger in flexion(trigger
finger)
There is usually tenderness over the MP joint volarly and a
nodule or thickening is usually palpable in the same
region(trigger finger)
Pain over the first dorsal compartment at the anatomic
snuff box (deQuervain’s tenosynovitis)
Finkelstein’s test is usually positive (deQuervain’s
tenosynovitis)
Tendinopathy Diagnosis

Patients usually have point tenderness over
the lateral or medial epicondyle
(epicondylitis)
 Pain can be reproduced by wrist or finger
extension (lateral epicondylitis) or flexion
(medial epicondylitis)
Treatment Options

Noninvasive options – Initial approach
– Ergonomic evaluation
– Work modification,
– Splints/braces that immobilize the affected area
– NSAIDS or steroidal anti-inflammatories
– Topical anti-inflammatory modalities, ice,
– Physical therapy
Treatment Options

Steroid injections
– At least 3-4 months apart, no more then 2 a year
– Avoid injections near nerves
– Side effects

Surgical options
– When conservative measures fail or cannot be
implemented
– In late cases – severe compression on NCS/EMG
Treatment Options

For compressive pathology - basic principle is to
release the area of constriction
– transverse carpal ligament for carpal tunnels syndrome
– A1 pulley for trigger digits
– First dorsal compartment release

For nerve compression, surgery reverses
symptoms for early cases and prevents progression
of disease in late cases
 “Wont get any worse – how much better depends
on extent of the damage”
 Surgery usually a cure – recurrence rare
Treatment Options

For tendinopathies, surgery considered when
conservative therapy fails
 Requires debridement of the inflamed tendon and
associated bone spurs and reattachment of the
extensor/flexor origin
 Recovery longer with surgery around elbow
 Therapy needed for splinting, movement etc.
Preventive Measures

Prevention of repetitive trauma
– Ergonomic evaluation and implementation
– Regular stretching and strengthening
 “Preparation for a marathon”
– Learning to recognize early symptoms
– Preventive maneuvers
Education

Teaching patients to recognize early
symptoms
 Preventive measures
– Medication
– Splinting
– Anti-inflammatory modalities
– Stretching and strengthening exercises
Ligament Injuries

Chronic collateral ligament injuries
– Usually common to the MP joint of the thumb
– Splinting, casting, surgery

TFCC injury
– Involves ulnar aspect of wrist
– Related to trauma or repetitive injury
– Splinting, steroid injections, casting, surgery
Basal Joint Arthritis




CMC joint of the thumb most
common site for degenerative
arthritis in the hand
Related to chronic repetitive use
or previous injuries to the
thumb
Starts with pain at the base of
the thumb, progressing to
weakness
Treatment entails rest, NSAIDs,
splinting, steroid injections and
surgery
Ganglion Cysts

Common soft tissue mass over the hand or fingers,
is a ganglion occasionally associated with
repetitive or strenuous activity
 Can be volar or dorsal, over the wrist or fingers
 Treatment
– If asymptomatic, can be left alone
– Aspiration of the cyst, rupture(by over inflation) or
infiltration with steroids has a high rate of
recurrence(>50%)
– If symptomatic, resection is usually recommended
Mallet Finger



“Droop” of the DIP joint of a
finger with intact passive
extension, but no active
extension
Usually due to avulsion of the
tendinous insertion of the
extensor tendon or a fracture
avulsion at the base of the distal
phalanx
This requires splinting in
extension for a prolonged
period of time and if a fracture
is present or is chronic may
require surgical correction
Summary

Careful history and physical examination usually
goes a long way in obtaining a diagnosis
 Rest, splinting and NSAIDS a good start for most
repetitive injuries
 Ergonomic evaluation can resolve or prevent
many cumulative trauma disorders
 Early referral to a hand surgeon, can prevent delay
in diagnosis or treatment of many common hand
problems
Take Away Points

Patient and employer education
 Prevention
 Early intervention
 Diagnosis & treatment
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