Common Hand Disorders Mark Shreve, MD

Goals To identify some of the most common hand problems that we see To learn techniques for diagnosis and treatment (both non-operative and operative) of these problems Biased towards a hand surgeon’s perspective (tips and tricks I have picked up over the years)

Outline Carpal tunnel syndrome Trigger finger DeQuervain’s disease Ganglion cysts Basal joint arthritis Distal radius fractures

Outline Carpal tunnel syndrome Trigger finger DeQuervain’s disease Ganglion cysts Basal joint arthritis Distal radius fractures

Carpal Tunnel Syndrome Definition Carpal Tunnel Syndrome is a disorder caused by pressure induced dysfunction of the median nerve in the carpal tunnel of the wrist. The symptoms and signs of carpal tunnel syndrome are the symptoms and signs of distal median nerve dysfunction in the hand. Cross section of carpal tunnel (above). Area of median nerve motor and sensory function (left)

Epidemiology Idiopathic Carpal Tunnel Syndrome - 3:1 Female : Male - 4th-5th decade and beyond - Correlates most with increased Body mass index (BMI) Other Risk Factors - Diabetes, hypothyroidism, rheumatoid arthritis and pregnancy

Aggravators of Symptoms Patients will report the symptoms as worse with activities which increase the pressure on the median nerve in the carpal tunnel Driving a car Talking on a phone Holding a newspaper Operating heavy/ vibrating equipment Sleeping (when a flexed wrist posture can increase pressure)

Clinical Evaluation Observation for thenar atrophy Sensory testing Motor testing (APB) Provocative testing via median nerve compression Electrodiagnostic testing

Sensory testing First decreased sensation to light touch Then decreased 2 point discrimination (normal 3-5 mm) Two Point Discrimination Testing

Motor Testing Palpate muscle belly of APB with resistance Dorsum of hand flat on table, ask patient to palmar abduct thumb

Provocative Tests Median nerve compression test Proximal to crease Directly over TCL Reproduces numbness/tingling in median nerve distribution Most sensitive and specific

Phalen’s Test Wrist flexion with elbows relatively extended Positive if it recreates the symptoms of numbness or tingling within 60 seconds

Tinel’s (Sign) Test Direct tapping of a irritated nerve can recreate tingling in the sensory distribution of the nerve Usually positive just proximal to carpal tunnel

Electro diagnostic Testing Electrodiagnostic testing of nerves consists of Nerve Conduction Velocity (NCV) and Electromyography (EMG). These studies can help confirm the diagnosis of carpal tunnel syndrome, but do not in themselves give a diagnosis which requires treatment without co-occurring symptoms. NCV/EMG can be helpful in confirming the anatomic level of compression of a nerve and in looking for more proximal lesions or generalized neuropathies.

Prevention Control of contributing diseases Control sugar in DM Medically control tenosynovitis in RA Correct Hypothyroidism No strong evidence of prevention from work modification. Some suggestion of benefit to avoidance of continual strenuous grasping and extreme wrist positions

Treatment Treatment is based on decreasing the pressure in the carpal tunnel and thereby improving the blood flow and nourishment to the median nerve Night time splinting especially

Carpal Tunnel Injection Can be used as a diagnostic tool for carpal tunnel syndrome 93% correlation between patients with symptom relief from carpal tunnel injection and successful carpal tunnel surgery Less effective as a therapeutic for carpal tunnel syndrome (20% long term) Most effective in the early stages of carpal tunnel syndrome, pregnancy, or in patients whose medical conditions preclude surgery

Carpal Tunnel Injection Combo of lidocaine and steroid Optimal position for injection debatable Reposition if parasthesias Anticipate short-term anesthesia in the median nerve distribution of the hand (success)

Surgical Treatment Good indications Constant numbness Increased 2PD Thenar atrophy Confirmed by EMG Pain predictably gets better, numbness depends on severity of compression Mini-open vs. endoscopic

Outline Carpal tunnel syndrome Trigger finger DeQuervain’s disease Ganglion cysts Basal joint arthritis Distal radius fractures Grand Rounds 10/5/07

Types of Trigger Finger Primary or “idiopathic” trigger finger Not associated with any disease process or activity Most common Secondary: associated with a disease Diabetes Tumors Rheumatoid arthritis Amyloidosis Bony irregularities around the metacarpal head Infantile form - trigger thumb

Idiopathic Trigger Finger Important to establish that no other disease process or anatomic abnormality is present Probably caused by stenosis of the A1 pulley of the digital flexor sheath Stenosis of the A1 pulley stimulates nodular changes of the flexor digitorum profundus (FDP) Changes occur in the A1 pulley: fibrocartilaginous metaplasia FDP tendon becomes too big to easily slide through A1 pulley and typically causing catching and locking symptoms

Secondary Trigger Finger Associated disease processes precipitate onset of triggering mechanics Diabetes is most commonly associated disease Treatment of associated disease does not usually resolve an established triggering phenomenon

Diagnosis: History Patient describes “locking,” “clicking,” or “snapping” Often symptoms worse upon awakening Patient may describe affected finger being “stuck” in a flexed position; has to used other hand to forcibly (and painfully) straighten affected finger May complain of pain in IP joint and think problem lies there

Diagnosis: Physical Exam Active finger motion produces crepitus or palpable locking at A1 pulley; finger may actually get stuck in flexion Gentle pressure over A1 pulley (under distal palmar crease for affected finger) reproduces patient’s pain; press gently! Mild swelling may be present, but finger is usually not particularly swollen If significant swelling or any discoloration is present, suspect another diagnosis (infection, etc.)

Treatment Options Observation (patients don’t want) Non-steroidal anti-inflammatory medication (doesn’t work) Splinting (also doesn’t work) Corticosteroid injection Operative release

Steroid Injection Success rate for a single injection is in the range of 60-70% (resolution of triggering for more than 4 months) Tell patients it will likely help but not sure how much or for how long Injection directed either at A1 pulley in distal palm or into flexor sheath over proximal phalanx Repeat injections (2-3 over a 12 month period) is acceptable although success rate diminishes over time Diabetic patients with trigger digits respond less reliably to steroid injection Inform patient that blood glucose may rise for 1-5 days after injection

Trigger Finger Injection Technique At A1 pulley, digital crease, proximal phalanx To bone, back needle until flows smoothly Confirm filling of sheath by distal palpation

Operative Treatment Indicated when fails injections Number depends on how long injections lasted Adults: local anesthetic Procedure Small incision over A1 pulley in distal palm Surrounding neurovascular structures are protected A1 pulley released with longitudinal incision Hand protected for a few days in bulky bandage; early motion encouraged

Trigger Thumb Open release of the A1 pulley Local anesthesia Digital nerves (radial) @ risk in thumb Oblique pulley must be maintained Percutaneous Trigger Digit Release High success rate, low complication rate Relatively contraindicated in thumb due to potential for radial digital nerve injury

Outline Carpal tunnel syndrome Trigger finger DeQuervain’s disease Ganglion cysts Basal joint arthritis Distal radius fractures

De Quervain’s Disease Stenosing tendinitis of the1st Dorsal Compartment EPB & APL Attributed to repetitive thumb abduction & ulnar deviation of the wrist Common in new mothers Nursing with wrist in awkward position Unaccustomed lifting with ulnar to radial deviation Radial-sided wrist pain, aggravated by thumb movement & ulnar deviation of the wrist

De Quervain’s Disease - Exam Local tenderness Bone-hard thickness over 1st comp. (1-2 cm proximal to radial styloid) + Finkelstein’s test + APL and EPB stress tests EPB worse than APL may indicate separate sub sheath and less potential success with nonop tx

De Quervain’s Disease Injection: Splinting 1 injection cures ~50%, 2 cures ~90% Not contraindicated while breast feeding Complications: fat atrophy, depigmentation Splinting Long opponens splint Cumbersome  poor compliance

1st Dorsal Compartment Injection Technique Sterile skin preparation Local anesthetic delivered to the skin overlying the 1st dorsal compartment of the wrist A 25G needle advanced into the 1st dorsal compartment (lidocaine/steroid mixture) Palpable filling of 1st dorsal compartment suggests a satisfactory injection was done Sometimes feel a “pop” indicating in sheath Change direction of needle (either dorsal or volar) to get subsheath

De Quervain’s Disease - Surgery Thin incision through skin just proximal to radial styloid Watch for superficial radial nerve Look for: Separate EPB sub-sheath Multiple slips of APL tendon Complications Superficial radial nerve injury - usually neuropraxia Incomplete release of entrapment (EPB) Subluxating APL and EPB by too extensive (volar) release Volar splint 10-14 days

Outline Carpal tunnel syndrome Trigger finger DeQuervain’s disease Ganglion cysts Basal joint arthritis Distal radius fractures

Ganglion cyst 33-69% of all hand tumors Female : male (3:1) Generally occur between 2nd – 4th decades of life Rapid or gradual development of mass Arises from a joint capsule or tendon sheath Etiology Trauma Mucoid degeneration Synovial herniation

Diagnosis Mildly tender or non-tender soft-tissue mass which may vary in size Patients may complain of pain / aching, stiffness, weakness or concerns for aesthetics The mass will typically transilluminate Vascular evaluation (Allen’s test) is recommended for volar ganglions due to the potential for radial artery aneurysm

Common Locations Dorsal wrist Volar wrist Other sites… scapholunate interval, most common Volar wrist radioscaphoid and scaphotrapezial joints most common Other sites… Thumb carpometacarpal joint Flexor carpi radialis tendon sheath Distal palm / proximal digit Distal interphalangeal joint **Ganglions have been reported at almost every joint in the hand and wrist

Treatment Observation! Splinting (if symptomatic and small) Aspiration (dorsal only) Local anesthetic Need large needle (18 gauge) to let viscous material out Tell patient to massage area next few days and try to extrude more material Surgical excision Imaging preop only ?occult ganglion

Surgical Treatment Recurrence uncommon with complete excision of cyst and communicating lumen / capsular origin (~5%) Post-operative wrist splinting; begin ROM at 1-2 weeks

Outline Carpal tunnel syndrome Trigger finger DeQuervain’s disease Ganglion cysts Basal joint arthritis Distal radius fractures

Basal Joint Osteoarthritis Prevalence much higher in females Increases with age 31% in women> 55 Worse symptoms with advanced DJD

Basal Joint OA: Anatomy Biconcave saddle Axes perpendicular Incongruent in nearly all ranges Little bony stability, ligaments stabilize

Basal Joint OA: Anatomy Volar beak ligament – from trapezium to volar-ulnar MC base (beak) Tethers thumb metacarpal, limits dorsal translation during pinch

Basal Joint OA: Pathophysiology Ligament laxity and joint instability are key Women have less congruent jts more lax joints (estrogen related?) smaller contact area Resulting in higher contact stresses across joint

Basal Joint OA: Pathophysiology Attritional changes of volar beak lig with age, pinching Increased dorso-volar translation at CMC joint Shear forces in volar contact areas Volar CMC joint cartilage loss PAIN!

Basal Joint OA: Staging Stage I Articular surfaces are normal Occasional joint space widening from effusion or laxity

Basal Joint OA: Staging Stage II Slight narrowing of CMC joint Minimal subchondral sclerosis Joint debris < 2mm diameter ST joint normal

Basal Joint OA: Staging Stage III CMC joint markedly narrowed Subchondral sclerosis and cyst formation Joint debris and osteophytes > 2mm diameter ST joint normal

Basal Joint OA: Staging Stage IV CMC and ST joints involved Marked joint space narrowing Subchondral sclerosis and cyst formation Joint debris and osteophytes > 2mm diameter

Basal Joint OA: Symptoms Pain Stiffness Weakness Increased pain with forceful pinch and grasp Needlepoint, knitting Difficulty doing activities requiring torsional motion Unscrewing jar tops Turning key in a door

Basal Joint OA: Signs Tender radiovolar aspect CMC joint Grind test Crepitus Shear test Laxity in milder disease

Basal Joint OA: Signs Stiffness in more advanced disease Prominent MC base MP joint hyperextension – be aware!!!

Treatment Avoid forceful pinch Proper pinch technique Oral nonsteroidals Short or long opponens splint Cortisone injection Surgery

Thumb Carpometacarpal Injection Results Long-term relief can be expected in patients with mild disease No sustained pain relief occurs in >50% of patients with advanced thumb CMC degenerative arthritis Technique Sterile skin preparation Local anesthetic delivered over the dorsal aspect of the thumb CMC joint A 25G needle advances into thumb CMC joint. This is often difficult in patients with advanced disease since the access to the joint may be blocked with over hanging osteophytes Lidocaine/steroid mixture Capsular distension often painful for patient, often can only inject 1cc or slightly more

Surgical Treatment Based on Stage of disease Stage I – volar ligament reconstruction Reconstruct volar (beak) ligament with FCR tendon

Surgical Treatment Stage II - IV Many options LRTI LR without interposition Simple trapeziectomy +/- K wire Artelon in less advanced disease Partial trapeziectomy with interposition

Davis: Prospective, Randomized, Controlled Study 183 Patients Excise Trapezium Pin Interpose PL Ligament reconstr 1/3 Yes Published results at 1 year  no difference Updated 5 year results at ASSH meeting  no difference

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