The 10 Most Common Hand Pathologies In Adults. 1. Carpal Tunnel and Cubital Tunnel

Transcription

1 The 10 Most Common Hand Pathologies In Adults Bobbi Jacobsen PA C 1. Carpal Tunnel and Cubital Tunnel CARPAL TUNNEL (median nerve) ( ) Pain and numbness Distal, proximal radiating Sensory disturbance Distribution Duration Motor Loss hand weakness 1

2 1. Carpal Tunnel Diagnostic Tools: EXAM: Swelling Muscle wasting Sensory disturbance Provocative signs Tinels Phalens Digital compression test EMG 1. Carpal Tunnel Treatment options: Conservative treatment Rest, Ice, Wrist splints, NSAIDS, edema control. Resolution of the underlying cause/manage systemic disease. Ergonomical work station changes. Vit B 6 Cortisone injections 20% Can be used to confirm diagnosis Surgery endoscopic carpal tunnel release. Indications for surgery: Failed conservative treatment Constant numbness Denervation of APB Relative indications >3yrs Proximal symptoms Clumsiness 2

3 1. Cubital Tunnel CubitalTunnel Ulnar Nerve Pain or numbness radiating to the ring and little fingers, medial elbow pain, or forearm pain along the ulnar nerve distribution. Diagnostic Tools: Positive Tinel s over the ulnar nerve at the elbow. EMG positive for ulnar neuropathy localized to the elbow. X ray if there is a history of a condylar fracture. Treatment: Cannot safely do an injection. Ulnar nerve night time splinting. Surgical open cubital tunnel release or ulnar nerve transposition. 2. CMC Joint Arthritis Pain at the base of the thumb, decreased grip strength, pain with thumbopposition activities/pinch, decreased dexterity. 3

4 2. CMC Joint Arthritis Diagnostic Tools: EXAM: CMC joint pain. Positive grind test. X ray findings get zancolli view. 2. CMC Joint Arthritis Treatment options: Collum splint, PT, activity modifications, NSAIDS. Cortisone injections 3 4 months minimum between injections. CMC joint anchovy procedure with FCR transfer removal of the trapezium and a transfer of the flexor carpi radialis (FCR) tendon into the empty space. 4

5 3. De Quervain s Tenosynovitis First dorsal compartment pain over the radial styloid or at the base of the thumb, pain with thumb pinching and with ulnar wrist deviation. Swelling or a cyst in the first dorsal compartment or over the radial styloid. Diagnostic Tools: EXAM: Positive Finkelstein test. First dorsal compartment pain/swelling. Beware of CMC joint DJD. 3. De Quervain s Tenosynovitis Treatment options: Conservative treatment: NO splinting Dr. Lang does not recommend splinting has been shown to prolong healing. NSAIDS PT Pain Cream Avoid activities that cause the pain. Corticosteroid injection highly effective in treating max 2 and caution with diabetics and caution not to inject the SQ. Surgical release of the tendon sheath or decompression of the first dorsal compartment. 5

6 4. Trigger Finger Catching, clicking, pain or locking of a digit with motion. Digit often is locked in the morning in flexion. Painful nodule in the palm, A1 pulley pain. Diagnostic Tools: Exam findings include triggering, locking, a tender nodule proximal to the MP joint and/or tenderness of the A1 pulley. 4. Trigger Finger Treatment options: Corticosteroid injection 2 max. 90% effective, 1 st injection. of the remaining 10%, 90% of those patients will gain complete resolution with the 2 nd injection. Results best with single digit, discreet nodule, short duration Poor results with diabetic patients, multiple digits, >6mo duration. Surgical release of the A1 pulley. 6

7 5. Scaphoid Fractures A fall onto an outstretched hand. Anatomical snuffbox pain, wrist or hand pain. Risks if not diagnosed and treated properly are a non union fracture, avascular necrosis or post traumatic arthritis. 5. Scaphoid Fractures Diagnostic Tools: Exam findings, tenderness, history, swelling X ray making certain to include the navicular view. CT or MRI if there is snuffbox tenderness and a negative x ray. Volar Radioscaphocapitate ligament. 7

8 5. Scaphoid Fractures Treatment options: If the fracture is a completely non displaced distal third or waist fracture, then you can treat tthis with a short arm thumb spica cast for 6 weeks making certain to do serial x rays weekly to watch for displacement or central clearing, followed by 4 6 weeks of thumb spica splinting. These patients need to be seen at 3 months for follow up exam and x rays. If they have tenderness or x ray concerns, order a CT or MRI. 5. Scaphoid Fractures 8

9 5. Scaphoid Fractures Treatment Options: If the fracture is displaced at all or a proximal fracture, then refer because there is a higher likelihood they will require surgical treatment, an ORIF with bone grafting. 5. Scaphoid Fractures 9

10 6. Distal Radius Fractures Acute wrist pain, swelling, deformity, and loss of motion after a fall or trauma. Check neurovascular status, median nerve and radial nerve. Distal radius frx complications: EPL rupture rare Up to 14% get RSD Take into account the patient s age, activity level, bone strength 6. Distal Radius Fractures 1. Colles extra articular dorsal displacement 2. Smith s reverse Colles with anterior displacement 3. Barton s volar or dorsal 4. Comminuted intra articular, die punch 5. Radial styloid Example of Barton s Fx Die punch: depression of the lunate fossa 10

11 6. Distal Radius Fractures Diagnostic Tools: Exam findings. PA, LAT, OBL x rays. ***lateral view, intra articular, DRUJ involvement, radial shortening. ***the normal volar tilt, the slope of the dorsal to palmar surface of the radius on the lateral view is degrees. ***Fracture of radius without ulnar styloid fracture, worry about DRUJ instability. 6. Distal Radius Fractures Treatment options: Colles Fractures: If the lateral view remains neutral or volar then it can be in a long arm cast for 3 weeks with serial x rays x 1 week, short arm cast for 2 weeks followed by PT. Surgical if dorsal displacement refer. Smith s Fracture: Refer; unstable due to muscle pull. Intra articular fracture and Die punch fractures: REFER CT scan if it is a die punch fracture or if there is articular surface depression. If more than 2mm then it is surgical. Radial styloid fracture: Look for an associated scapholunate ligamentous injuries or a scaphoid fracture. If non displaced and no associated injuries, then short arm for 4 weeks. Barton s fracture of necessity refer because these are always surgical. 11

12 6. Distal Radius Fractures Indications to refer: >10 degrees loss of angulation articular step off >2mm radial shortening comminution with intraarticular involvement Barton s should be referred Loss of reduction at follow up Surgical treatment options CRPP External Fixators ORIF 6. Distal Radius Fractures 12

13 7. Metacarpal Fractures Pain and swelling of the hand. Look for any scissoring, malrotation, or angulation. Look for finger shortening and joint step off. Diagnostic tools: PA, LAT, OBL x rays. head, neck, shaft or base fractures. oblique, spiral, and comminuted fractures tend to be unstable. CT for metacarpal base fractures looking for fracture dislocation. Thumb metacarpal base fractures REFER *Bennett s *Rolando s 7. Metacarpal Fractures Fracture dislocation MC BASE Boxer s Frx Healed Boxer s Frx 13

14 7. Metacarpal Fractures Treatment options: Metacarpal neck fracture (Boxer s fracture if 5 th MC): 10 (no compensatory motion at the CMC joint), 20, 30, 40 rule. the amount of acceptable angulation will be greater when frx occurs more distally in the neck. Casting (ulnar gutter, radial gutter) vs CRPP vs ORIF. *stable fractures without intra articular extension or rotational deformity are best treated with casting. 33 weeksof immobilization with early motion. 7. Metacarpal Fractures Metacarpal shaft fracture: displaced refer, otherwise 3 weeksof immobilization, then transition to a Galveston splint as these take a little longer to heal (4 6 weeks), still get motion going by 4 weeks because the fingers get stiff fast. less angulation can be accepted in midshaft fractures than in MC neck fractures. There is more displacement with even little angulation. refer if there are 2 adjacent metacarpals involved. Metacarpal base fracture: Caution for a fracture dislocation, CT scan. Refer if there is a fracture dislocation or displacement. 14

15 8. Lateral Epicondylitis Lateral elbow pain, worse with wrist extension. Weak grip. Overuse causes microscopic tears in the tendon. This pain may wax and wane. Diagnostic tools: Exam findings: pain with active wrist extension against resistance tennis elbow test pain with palpation over the lateral epicondyle forearm extensor muscle group pain with use. 8. Lateral Epicondylitis Treatment options: Can take 6 12 months. Conservative: Activity modifications/ergonomical work changes tennis elbow brace wrist splint pain cream PT(Nirschl exercises) ice and heat daily stretching night time extension splinting. Corticosteroid injections. Orthotripsy or surgery Sioux Falls referral after 12 months of failed conservative treatment. NOT GENERALLY A SURGICAL PROBLEM. Medial epicondylitis similar, but do not injection because of the ulnar nerve. 15

16 9. Dupuytren s Contracture Flexion contracture of the finger, palm cords, palm pits, decreased grip. Most commonly affects the ring finger and pinky. Cannot put my hands in my pockets. Diagnostic tools: Exam pits, nodules, and cord like bands of tissue that involve the palmar fascia. Flexion contracture of the finger or fingers. Treatment options: Monitor until the affected finger does not lie flat on a table or a PIP joint contracture, then surgical treatment is necessary so refer. 10. Ganglion Cysts Cysts that can originate from a tendon sheath or a joint. A cyst on the wrist or the hand, can be painful or painless. Diagnostic tools: Exam, aspiration, pathology after removal. Treatment e t options: o Observe. Aspiration, 50% curative. Removal ~97% curative. 16

17 Steroid Injections in the Hand Equipment Sterile gloves Iodinated skin prep Cold spray.5ml of 40mg/ml corticosteroid ***Only use CELESTONE for carpal tunnel!.5ml of 1% lido without epinephrine Warn patient Subcutaneous fat atrophy Skin depigmentation Dimple Steroid flare -NSAIDS and ice Images were obtained from: anatomical.medicalillustration.com AAOS Physio pedia.com Ericksonhandsx.com 3pointproducts.com morphopedics.wikidot.com radiography.net ASSH 17