Common Hand and Wrist Conditions: When to Refer? Dr Tim Heath

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1 Common Hand and Wrist Conditions: When to Refer? Dr Tim Heath

2 Difficult Balance Many hand conditions can be managed non-operatively / simply Missed injury or delayed diagnosis not uncommon

3 Common Problems Foreign bodies Small wounds Finger dislocations and fractures Scaphoid fractures Wrist sprains Ganglia Carpal tunnel Trigger digits Dupuytren s disease

4 How to manage this cut?

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8 Missed Tendon / Nerve Injuries Can occur through very small holes Patients can be distracted by pain Usually detectable on clinical exam Tendon function Encourage patient OK to test for motion Reduced motion, or pain on resisted motion Can miss partial injury Nerve testing Comparative light touch (tissue) test Power testing more difficult

9 Sew Up? Yes, if: Sensation normal Tendons clinically intact Injury not likely to have entered joint Clean cut or cleanable through existing wound Follow up early and reassess Can then recheck power / motor function Nothing lost if problem noted within a few days

10 Hand Dressings Avoid tape on injured finger - tape at wrist Avoid dressing severely injured digit alone POSI splint or bandage to adjacent uninjured fingers Simple: 1. Jelonet / Mepitel 2. Gauze squares (saline soaked and dry layer) 3. Crepe bandage (where possible tip visible) 4. +/- POSI splint Avoid Telfa and pads

11 Local Anaesthetic Don t use LA to explore wound Rarely changes management Use to help clean +/- suture wound Digital block not ring block

12 Digital Block - web space method Inject digital nerves from dorsum 25 gauge needle Plain lignocaine 1-2 %; 2-3mL each side, 1ml dorsum (5-6 ml maximum)

13 Digital Block flexor sheath Single injection 25-27g needle, 45 degree angle Initially into tendon then withdraw slowly with gentle pressure until injection possible 2-3mL plain lignocaine 1-2% Finger may flex while injected Low volume, low risk of nerve injury, quick acting

14 Foreign Bodies Which ones should I have a go at removing?

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16 Foreign Bodies Don t underestimate foreign bodies! They can be VERY difficult to find (esp glass) Attempted removal can be painful, bloody, and unrewarding Don t give in to patient expectation Common cause of litigation (nerve injury) Ok to remove if already visible

17 Don t Always Take Patient Advice

18 How to treat this cut?

19 Clench Fist Injuries

20 Clench Fist Injuries MP joint lac = punch injury All require surgery!

21 Boxing Injury

22 Boxer s Fracture Usually treated with splint (therapy) MP joints FLEXED and IP joints extended Mobilise early Indications for surgery: Malrotation, intra-articular, open fracture, multiple fractures, very poor motion

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24 Punch Injury

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26 Fractures Refer all to hand therapy Custom splinting Finger exercises not obvious!? Surgery referral: Clinical deformity or instability Open injury Intra-articular (except tiny avulsion) Multiple fractures High energy (e.g crush)

27 Finger Fractures If mildly displaced, closed extra-articular fracture Therapy rest splint and gentle motion Re-xray 1 week to ensure not become more displaced

28 Oztag Injury

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30 Post close reduction

31 Mild Injury?

32 Malrotation More Obvious in Flexion

33 Metal Bar Crush

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35 Mallet Finger DIP extensor lag Passively correctable

36 Mallet Finger Tendon avulsion Small bone fragment (< 1 / 3 joint) Joint in good position SPLINT

37 Mis-caught Basketball

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40 Mallet Fracture large fragment (> 1 / 3 joint) joint subluxed SURGERY

41 Cricket ball injury right index

42 Pilon Fracture

43 Shotgun Reduction

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45 Dislocations Often underestimated Long recovery Contracture or deformity (Boutonierre) Refer all for hand therapy Refer to surgeon if: Irreducible / persistent deformity Associated fracture or open injury Joint instability Recurrent or minimal trauma

46 Dislocations Check x-ray 1 week post reduction

47 What Has Ruptured?

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49 PIP Ligaments

50 Fell off Pushbike How is treatment for this different?

51 Volar PIP Dislocation Less common More often irreducible closed Unstable after reduction Central slip extensor avulsion

52 Central slip avulsion fracture Boutonierre

53 VOLAR DISLOCATIONS PIP extension splint 8 weeks Mobilise DIP early

54 Treatment?

55 Irreducible MP Dislocations Soft tissue interposition Requires surgery

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57 Surgery for Ganglions Majority don t need treatment Aspiration very low cure rate Cortisone injection low cure rate Can be good temporary treatment To confirm cause of pain Refer if: If discharging (mucous cyst) Nerve symptoms (uncommon) Patient request: pain, appearance, large size

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59 Mucous Cyst Related to osteoarthritis X-ray (ultrasound not needed) Always coming from DIP joint Don t aspirate Only need treatment if discharging Patients may wish removed: Ugly, painful, large, nail grooving

60 Scaphoid Fracture Referral If any risks for non-union: High energy (skating, MVA) Comminuted fracture Displaced > 1mm Proximal pole Smoker Reinjury risk (skater) Delayed diagnosis > 3 weeks If patient reluctant re 6-8 weeks in cast

61 Scaphoid Fracture Undisplaced waist or tubercle fracture and no risk factors Cast treatment (6-8 weeks) 85-90% will heal Don t discharge until fracture completely united Refer if not clearly healing

62 Scaphoid # Diagnosis Fracture not visible on x-ray Radial side pain Tender snuffbox or proximal pole Scaphoid splint (not cast) while tests done Bone scan most sensitive MRI highly sensitive and more specific CT scan can be negative for 2 weeks Cast and re-examine & x-ray at 3-4 weeks

63 Skateboarding Injury treatment?

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65 Wrist Sprains Refer if: If instability symptoms click or clunk Pain persists > 2 weeks with normal x-ray Significant bruising or swelling

66 Came off Motorbike

67 Scapholunate Ligament Rupture

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69 Trigger Finger Pain in the digit but not dangerous Cortisone injection (Celestone) GP or ultrasound guided +- trigger splint for night comfort Avoid frequent heavy grip Refer if: Unresponsive / recurs after CSI Other problems: carpal tunnel, rheumatoid arthritis, prior injury, lump

70 DeQuervain s de Quervain s = wrist trigger Not damaging but often disabling Splinting more important Surgery higher risk of nerve injury (superficial radial)

71 Carpal Tunnel Syndrome Late treatment risks nerve injury Refer if: Symptoms distressing Pain and sleep disturbance present earlier than pain Night wrist splint not helpful Frequent or continuous daytime symptoms Thenar wasting or weakness Severe changes on NCS Beware patient whose severe pain resolves

72 Dupuytren s Late treatment - secondary joint stiffness No preventive treatment Rarely painful (pain suggests copathology) Cause extension deficit only Refer if: Can t put hand flat on table ~ 30 degrees MP joint or if fixed PIP flexion deformity Functional problems e.g. gloves Doubt re diagnosis

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77 Palmar Fascia

78 Collagenase Injection Newly licensed enzyme for injection Dissolves DD cords Not covered by PBS, MBS Expensive Treatment is per cord not finger Less invasive Quicker recovery

79 Collagenase Injection Only by accredited doctors Mostly surgeons treating DD Two stage treatment: Injection Extension procedure 1-2 days later Office based but rare anaphylaxis Need resuscitation equipment Not all cases suitable Less nerve injury, tendon ruptures occur

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82 Summary Many hand conditions can be managed non-operatively Hand therapy Reassurance Recognise warning signs and indications for surgical referral