Hand and Wrist Injuries. Hmmm... 2/24/2015

Transcription

1 Hand and Wrist Injuries John J Shaff, PA-C Hand Surgery Specialists, P.C. Hmmm... The field of hand surgery deals with both surgical and non-surgical treatment of conditions and problems that may take place in the hand or upper extremity (from the tip of the hand to the shoulder). 1

2 About me Graduated Midwestern 2004 General Orthopedics & Trauma 2004 to 07 Hand and Upper Extremity CAQ Orthopedics Two Boys, 3 and 5 Run to burn off the crazy Why/How did I get into Hand Surgery? Objectives -Review the most common hand and wrist issues -Describe the initial evaluation of these issues from a Primary care perspective -Initial treatment -Recognize when to refer to a specialist 2

3 Function of the Hand & Wrist Multiple functions Delicate, fine motions Powerful, grasping tasks Support / transfer force for changing positions Sensory organ: perception of surroundings Communication / express emotions Complex anatomical structure Structure follows function HAND FUNCTIONS 45% GRASP 45% PINCH Side pinch (key pinch) Tip pinch (writing) Chuck pinch (thumb to index/ring) 5% HOOK Carry bag 5% PAPERWEIGHT HAND AND WRIST HAND WRIST 3

4 Anatomy Hand and Wrist Bones Distal radius Distal ulna Carpus (8 individual bones) Metacarpal Phalanges Joints Radiocarpal joint Distal radioulnar joint (DRUJ) Intercarpal & midcarpal joints Ligaments HAND & FINGER ANATOMY 9 Finger Flexors Median nerve Transverse carpal ligament 5 deep flexors pass through superficialis tendons and insert on distal phalanx of each finger and thumb 4 superficial flexors insert on middle phalanx of digits 2-5 Annular ligaments = pulleys (A1-A5) PREVENT BOWSTRINGING 4

5 HISTORY Age Handedness Chief complaint Occupation Previous injury Previous surgery Sx related to specific activities What exacerbates What improves Frequency Duration HISTORY 4 principle mechanisms of injury Throwing Weight bearing Twisting Impact 5

6 PHYSICAL EXAM Inspection Palpation Range of Motion Neurologic Exam Special Tests INSPECTION Observe upper extremity as patient enters room Examine hand in function Deformities Attitude of the hand Creases Thenar and Hypothenar Eminence Arched Framework Hills and Valleys Web Spaces INSPECTION Palmar Surface 6

7 Cascade sign Assure all fingers point to scaphoid area when flexed at PIPs Types of Injuries Reactive Trauma Cumulative Trauma, Repetitive Strain Gradual Injury Acute Injuries Open vs. Closed Reactive Trauma Occurs in response to chronic exposure Does not effect everyone Pre-disposing factors underlying medical conditions reactive physiology environmental/social/emotional/financial stressors 7

8 Reactive Trauma Examples Tendonitis/Tenosynovitis Compressive Neuropathy Epicondylitis Myofascial Pain Tenosynovitis Swelling of the lining of a tendon Specific, localizable and identifiable Examples trigger finger dequervain s intersection syndrome some ganglions (e.g. flexor sheath ganglion) 34-year-old female hairdresser with thumb pain for 2-3 months Gradual onset Now thumb hurts with any movement Wrist Case 8

9 1st Dorsal Compartment DeQuervains Abductor Pollicis Longus and Extensor Pollicis Brevis Radial border of Anatomic Snuff Box Site of stenosing tenosynovitis De Quervain s Tenosynovitis Finkelstein s Test DEQUERVAIN S TENOSYNOVITIS It s time to refer if... Tenosynovitis no improvement with 4-6 weeks of splinting therapy (CHT) steriod injection co-morbid diabetes mellitus or RA 9

10 Trigger Finger Stenosing flexor tenosynovitis Painful snap or lock Palpate nodule as digit flexed and extended It s time to refer if... Trigger Finger no improvement with rest splinting steriod injection -*****caution***** co-morbid diabetes mellitus or RA 10

11 Compressive Neuropathy Median Nerve Carpal Tunnel Syndrome Pronator/Anterior Interosseous Syndrome Ulnar Nerve Cubital Tunnel Syndrome Guyon s Canal Syndrome Radial Nerve Radial Tunnel Syndrome Wartenburg s Syndrome Carpal Tunnel Syndrome Causes BMI diabetes thyroid disease pregnancy occupational idiopathic Diagnosis nighttime numbness morning paresthesia provocative testing electrodiagnostic studies Treatment curable only by surgery non-surgical (palliation) splinting (sleep only) corticosteroids activity modification antidepressants modalities 11

12 Carpal Tunnel Syndrome Entrapment of the median nerve Phalen s and Tinel s Test 2 point discrimination Symptoms Aching in hand and arm Nocturnal or AM paresthesias Shaking to obtain relief 12

13 It s time to refer if... Carpal Tunnel Syndrome no improvement with six weeks of night time wrist splinting activity modification Vit B6 100mg QD any evidence of thenar weakness Tip: send patient with NCV/EMG Thenar atrophy Cubital Tunnel Syndrome Ulnar nerve compression at the elbow Numbness to small and ring finger Causes external compression elbow trauma (dislocation, fracture) anatomic abnormalities Can lead to permanent weakness Residual symptoms after surgery common 13

14 Cubital Tunnel Syndrome It s time to refer if... Cubital Tunnel Syndrome no improvement with six weeks of activity modification elbow awareness any evidence of intrinsic weakness Tip: send patient with NCV/EMG Ganglion Cyst Typically starts as general complaints of wrist pain Usual history of recent or remote trauma Most common sites are dorsal wrist and volar radial 14

15 Bible thumpers Ganglion Cyst It s time to refer if... Ganglion Cyst 4-6 weeks of splinting does not resolve Failed aspiration ***Only attempt dorsal Persistent pain Fingertip Injuries Replantation Mutilating Trauma Fractures Infections Wrist Injuries Acute Trauma 15

16 Fingertip Injuries Most common finger injury Most do not require surgery Goals of treatment preservation of length painless appearance Sensitivity is significant problem Fingertip Injuries Tuft Fracture/crush injury Tuft fracture Subungal Hematoma Subtotal amputation Volar oblique amp OrthoArizona Arizona Hand & Wrist Specialists 16

17 Subungual hematoma Evacuate hematoma with 18-guage needle or electrocautery. Dressing and splint OrthoArizona Arizona Hand & Wrist Specialists It s time to refer if... Fingertip Injuries open injuries with tissue loss complex lacerations exposed bone displaced fractures initial attempt at close is fine Tip: always get xrays, always, open fx needs abx Fingertip Injury 17

18 Fingertip Injuries 18

19 Thenar Flap Reconstruction Fingertip Injuries Thenar Flap Reconstruction Fingertip Injury: Thenar Flap 19

20 MALLET FINGER ANATOMY Dorsal avulsion Extensor digitorum tendon tear MECHANISM: Forced flexion of extended digit TREATMENT: No fracture: DIP extended for 8 weeks FRACTURE: if <30% joint surface, splint x 4 weeks If >30% refer for ORIF Less than full passive extension refer COMPLICATIONS: Pressure necrosis from splint Permanent extensor lag MALLET FINGER Wrist #1 24-year-old male FOOSH while skiing over the weekend Seen at the mountain clinic and told wrist sprain 20

21 Blood supplied from distal pole In children, 87% involve distal pole In adults, 80% involve waist Scaphoid Fracture Pathoanatomy Scaphoid Fracture Imaging Initial plain films often normal Bone scan 100% sensitive 92% specific at 4 days MRI, CT scan 21

22 SCAPHOID FRACTURE TREATMENT Initial radiographs positive distal third heal in approx 6-8 weeks middle third frx heal in 8-12 weeks proximal third heal in weeks Initial radiographs negative Immobilize thumb spica cast x 7-14 days Take out of cast, repeat xray, re-evaluate for tenderness If +tenderness but neg radiographs Cont. splint and MRI Scaphoid Fracture Treatment Suspected fracture with normal plain films Short arm thumb spica (splint or cast) F/U in 7-14 days Consider MRI Treatment Non-displaced fracture Long arm thumb spica cast 6 weeks Then, short arm thumb spica cast for 4-14 weeks Scaphoid Fracture 22

23 Scaphoid Fracture Refer to Ortho Angulated or displaced (1mm) Non-union or AVN Scapholunate dissociation Proximal fractures Late presentation Early return to play Fractures Most do not require surgery Soft tissue injuries frequently overlooked or undertreated Open fractures frequently require operation risk of infection (osteomyelitis) 25-year-old tennis player twists wrist as he falls backwards reaching for a lob Wrist Case 23

24 SCAPHOLUNATE DISSOCIATION SCAPHOLUNATE DISSOCIATION EXAM Watson s test (scaphoid shift test) Scaphoid shuck test Pain/swelling over dorsal wrist, prox row DIAGNOSIS Plain films: >3mm difference on clenched fist Scaphoid ring sign MR Arthrogram 24

25 TREATMENT If discovered within 4 weeks, surgery After 4 weeks, conservative treatment reasonable Bracing NSAIDS Referral to hand surgery to confirm if surgery needed Fractures Fractures Metacarpal and Phalangeal 25

26 Distal Radius Fractures Most common wrist fracture Mechanism: FOOSH Intra- vs extra-articular Often associated with ligament injury Intra-articular fractures should be treated by hand surgeons 1/3 develop carpal tunnel syndrome It s time to refer if... Fractures displaced or unstable multiple open any wrist fracture Tips: splint and refer early antibiotics for all open fx meticulous wound care 26

27 External Fixation Wrist Fracture 27

28 Acute Wrist Injuries Wrist sprain is a diagnosis of exclusion Severe ligamentous injuries frequently missed Chronic complaints = severe injury Window of opportunity is limited Arthroscopy has emerged as definitive diagnostic procedure in wrist pain MRI Every patient wants one should be ordered selectively sensitivity/specificity as low as 40% rarely useful in acute management of injuries helpful in staging of Kienbock s disease soft tissue/bone tumors occult fractures 28

29 Flexor Tendon Injuries Should be treated by experienced hand surgeon Nerve injuries are commonly associated Certified hand therapist involvement essential Stiffness is common Injured hand will be out of commission ~12 weeks 1/3 require secondary operations 29

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34 Questions????? (Office) OrthoArizona Arizona Hand & Wrist Specialists 34