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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)