2015 Update on Hand/ Wrist Disorders. Anthony Mollano, MD

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1 2015 Update on Hand/ Wrist Disorders Anthony Mollano, MD 22nd Annual Northeast Regional Nurse Practitioner Conference May 6-8, 2015

2 DISCLOSURES There has been no commercial support or sponsorship for this program. The planners and presenters have declared that no conflicts of interest exist. The program co-sponsors do not endorse any products in conjunction with any educational activity.

3 ACCREDITATION Boston College Connell School of Nursing Continuing Education Program is accredited as a provider of continuing nursing education by the American Nurses Association Massachusetts, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation.

4 SESSION OBJECTIVES Describe treatment options for thumb basal joint arthritis. Discuss workup and treatment options for wrist injuries and arthritis. Discuss workup and treatment options for thumb sprains and ligament injuries. Identify treatment options for carpal tunnel syndrome. 22nd Annual Northeast Regional Nurse Practitioner Conference May 6-8, 2015

5 Hand/Elbow Musculoskeletal 2015 Update - Injuries and Conditions- Fingertip to the Elbow Anthony Mollano MD Hand/Wrist/Elbow Surgery Concord, NH

6

7 ACUTE HAND TENDON AND NERVE INJURIES

8 50 YEAR-OLD CUT FINGERS WHILE SLICING A BAGEL AT HOME.

9 FINGER TENDON AND NERVE LACERATIONS

10 FINGER DIGITAL NERVE LACERATION 35 year-old firefighter, had 3 week old laceration from a utility knife, reports numbness. Nerve not repairable by routine direct microsurgery repair

11 FINGER DIGITAL NERVE LACERATION Bovine collagen conduit repairs, Good outcomes, multiple studies. Nerve regeneration is slow: 1mm/day ; 1 inch/month; Up to 2 yrs in some cases.

12 WRIST COLLES RADIUS FRACTURE

13 COLLES FRACTURE 25 yo Concord pro rock climber, w/ acute deformed wrist injury, tripped down stairs texting! Same day surgery on a Monday b/c of acute CTS too.

14 COLLES FRACTURE Injury Sunday. Surgery same day seen on Monday. Outpatient surgery, 1hr; Open repair/reduction volar plate and fixed angle screws; Immediate use of hand for light ADL. At 2 m, healed, done splinting. Now 3 months after, already rock climbing. Strength and ROM improves for up to 1 yr.

15 WRIST SCAPHOID FRACTURE

16 SCAPHOID FRACTURE 21yo NEC college student, hurt wrist surfing on spring break in NC

17 SCAPHOID FRACTURE -Outpatient surgery; 30min -Mini-incision screw repair to compress one fragment into other; provides stability and compression -Early rehabilitation allowed; Removable splint used for protection

18 SCAPHOID FRACTURE Immediate ROM and light hand use for ADLs x 6wks w/ splint for protection; At 3 months, had full ROM and able to lifeguard that summer

19 Wrist Dislocations

20 Severe wrist dislocation 17yo merrimack valley quarterback, playing on a Sunday. Monday had urgent same day surgery after visit b/c of acute CTS. Pins out after 8 wks, then therapy and weight lifting all winter. Will be ready for UNH football camp this summer

21 Wrist Arthritis

22 WRIST ARTHRITIS 52yo, NH college golf coach and semi-pro golfer; severe wrist pain; can no longer golf nor write; limited ROM; poor strength; tried injections and splints for years

23 WRIST ARTHRITIS Proximal row carpectomy surgery; outpatient, 1 hr; casted 4 wks, then formal therapy 1-2 m Outcome at 3 months: satisfied; pain, function, and strength much improved; Some stiffness remains; 1-2 yrs for max conditioning and strength improvement

24 CTS

25

26 WHO GETS CARPAL TUNNEL SYNDROME?

27 CTS

28 CTS SURGERY (mini-open, 5min, local anesthesia)

29 THUMB BASAL JOINT DEGENERATIVE ARTHRITIS

30 THUMB CMC BASAL JOINT ARTHRITIS 65 year-old active retired judge with thumb pinch weakness, pain, and deformity. What s is RX?

31 THUMB CMC BASAL JOINT ARTHRITIS

32 THUMB CMC BASAL JOINT ARTHRITIS If practical treatment fails and arthritis join pain worsens, outpatient joint arthroplasty/replacement provides: great pain relief and much improved function. 1hr surgery. Cast 1 month, then brace 1 month, then therapy. In WC cases, MMI 1 year, +PIR.

33 THUMB CMC BASAL JOINT ARTHRITIS

34 SEVERE SPORTS THUMB LIGAMENT TEARS i.e. the gamekeep injury OR the ACL of the hand

35 THUMB MP LIGAMENT TEAR 16 yo bishop brady thumb MP hyperextension injury stopping hard shot

36 THUMB MP LIGAMENT TEAR

37 CUBITAL TUNNEL SYNDROME

38 Cubital Tunnel Syndrome 18 yo NC bow high baseball pitcher injured tommy john elbow ligament in elbow in spring, and stretched ulnar nerve. Ligament healed, but nerve numbness worsened with constant numbness. Old patient of mine from hockey hand hamate hook nonunion surgery when 14.

39 Ulnar nerve transpotion = NERVE is decompressed and transposition

40 ELBOW BICEPS AND TRICEPS TENDON INJURIES

41 BICEPS DISTAL RUPTURE 42 yo CJ state trooper tore elbow biceps moving furniture felt a large POP with elbow swelling

42 ELBOW DISTAL BICEPS REPAIR Super biceps repair. 1hr surgery, after one week, early progressive therapy done. Back to work light duty after 1 week, full duty after 2 months, and arm strength after 6 months.

43 ELBOW FRACTURES

44 STABLE RADIAL HEAD FXS- COMMON RX- NONOP WITH ROM/PT. IF FX WORSE- SURGERY WITH REPLACEMENT, OR RARELY EXCISION.

45 Thanks

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