Complaints of hand and wrist Wim Willems HOVUmc, Amsterdam

Program Basic anatomy Common complaints Practice

Anatomy

Intrinsic flexors Volar viewDorsal view

Extrinsic flexors

Extensors

Nerves

“Elderly lady with a painful thumb” Female, 78 years old Pain thumb right hand Difficulty with sewing / opening pots

“Elderly lady with a painful thumb” Questions? Physical examination? Further examination? D.d.?

Arthrosis Start of arthrosis in DIP most common Heberden’s nodules CMC-1 (possibly afflicted relatively young) Grind test

Heberden’s nodule

Treatment

Arthrosis CMC I Injection Splint Avoid operation as long as possible

Arthrosis CMC I

“Finger gets stuck” Female, 45 year Right hand Palmar pain/ middle finger Impossible to straighten finger

“Finger gets stuck” Questions? Physical examination? Further examination? D.d.?

Trigger finger

Pathofysiology Thickening of tendon / tenosynovitis of m.flexor digitorum communisThickening of tendon / tenosynovitis of m.flexor digitorum communis Finger triggersFinger triggers

Epidemiology Few data life time prevalence, > 30 jr, no DM: 2.2%. Connected with DM, carpal tunnel syndrome, reumatic arthritis, hypothyreoidy.

Treatment

Conservative therapy Self limiting 10-20% ?? NSAID Splint weeks (MCP in degrees flexion). Effective 66% of the cases Steroïd injection. Effectiveness 50% - >90%

Trigger finger: injection 1 Needle: short and thin (eg 0,6x25mm or (0,45x23mm)Needle: short and thin (eg 0,6x25mm or (0,45x23mm) Volume: 1 ml TCAVolume: 1 ml TCA 10 mg/ml (optional +1ml Xylocaine 1%) Performance: insert needle from distal to proximal along axis of metacarpal bonePerformance: insert needle from distal to proximal along axis of metacarpal bone In MCP fold (2cm from first falangeal fold)In MCP fold (2cm from first falangeal fold)

Trigger finger: injection 2 Preferred angle 45 degreesPreferred angle 45 degrees Ca. 1ml around tendonCa. 1ml around tendon Subcutaneous injection is as effective as injection in tendon sheath Subcutaneous injection is as effective as injection in tendon sheath No pressureNo pressure Effectiveness: 70-80% after 1-3 injectionsEffectiveness: 70-80% after 1-3 injections

Operative treatment Open or percutanous. Success >90% More complications (nerve damage, inflammation)

“Painful thumb” Man, 37 years House painter Pain radial side wrist

“Painful thumb” Questions? Physical examination? Further examination? D.d.?

De Quervain’s disease Tenosynovitis of m.abductor pollicis longus and m. extensor pollicis brevis (APL & EPB)Tenosynovitis of m.abductor pollicis longus and m. extensor pollicis brevis (APL & EPB) distal end radiusdistal end radius Women > men, yr.Women > men, yr. Presentation in general practice: 5,6/1000Presentation in general practice: 5,6/1000 Often recurrent esp. when crepitationsOften recurrent esp. when crepitations

Etiology Tendons in common sheath APL & EPB irritation caused by frequent movements Overuse (wringing, racket sports) Pregnancy Anatomic variations

M.de Quervain: onderzoek Finkelstein’s test

Treatment Corticosterod injection: success rate 2/3 of patients after 3 weeks. Sometimes 2nd or 3rd injection. Splint : unhelpful Operation (cutting tendon sheath): longstanding complaints or failure injections Injection possible in pregnancy

M.de Quervain: injection treatment Slight pronationSlight pronation Feel for common sheathFeel for common sheath Insertion of needle by small angleInsertion of needle by small angle 1ml TCA infiltration1ml TCA infiltration Effectiveness: 70-80% after 1-3 injectionsEffectiveness: 70-80% after 1-3 injections Approach from proximal or distal possibleApproach from proximal or distal possible

Injection M. De Quervain

“Painful nightly tingling” Female, 52 years Wakes up in the early morning with painful tingling in the hand (thumb / index) Flapping of hand to ease complaints

“Painful nightly tingling” Questions? Physical examination? Further examintion? D.d.?

Carpal tunnel syndrome

Epidemiology Open population (history + nerve conduction examination):Open population (history + nerve conduction examination): –Female: 9 % –Male: 0,6% –Peak between year

Risk factors  Weight  Pregnancy  Diabetes mellitus  Hypo/hyperthyreoidy  Ovariectomy  Anatomic deviation (traumatic / RA / congenital)  Work related

Natural course ¼ - 1/3 significant improvement > 1 year After pregnancy 50% without complaints

Pathofysiology Narrow tunnelNarrow tunnel compression n. medianus in carpal tunnelcompression n. medianus in carpal tunnel 90% idiopatic90% idiopatic

Diagnosis: history Dutch consensus (CBO 2006): Nightly tinglingNightly tingling Median nerve areaMedian nerve area Sleep disturbanceSleep disturbance Other tingling / painsOther tingling / pains Flapping (Flick’s sign)Flapping (Flick’s sign) Advanced stages: tingling during the day Advanced stages: tingling during the day

Sensory innervation N. Medianus

Atypical localisations tingling sensations in carpal tunnel syndrome Often outside median nerve area Sometimes ulnar nerve area

Provocation tests: CBO 2006: Limited usefulness

testsensitivityspecificity Tinel Phalen Flick sign Square wrist sign Pressure provocation test Tourniquet test C.A. Diagnostic tests CTS :

Tests Tinel percussion median nerveTinel percussion median nerve Phalen: flexion during 60 secondsPhalen: flexion during 60 seconds Further:-sensory loss median nerve areaFurther:-sensory loss median nerve area -thenar dystrophy -thenar dystrophy -dry skin (thumb / index / middle finger)

Neurophysiological examination sensitivityspecificity EMG % Verification of clinical diagnosis prior to operation

Limitation EMG: No golden standardNo golden standard 10-15% false negative10-15% false negative No relation between complaints and resultsNo relation between complaints and results Results not predictive for therapyResults not predictive for therapy Value unclear for primary health careValue unclear for primary health care

Treatment

Splint Day and night Short term effective Minor complaints / recent onset

Surgery: Highly effective Major / recurrent complaints. Patient’s wish Open / endoscopic Success: 75-90% Complications: damage to nerve, pain, scar, complex regional pain syndrome)

Corticosteroid injection Several techniquesSeveral techniques 1. Underneath retinaculum (most common technique) 2. Through retinaculum 3. In front of retinaculum (method by Dammers) SafeSafe EffectiveEffective Tradition / experience / authority determines techniqueTradition / experience / authority determines technique

Medicament / Dosage Most common: Triamcinolonacetonide 10 mg/ml (Kenacort ® A10), or methylprednisolonacetaae (Depo-Medrol ® ) 40 mg/mlMost common: Triamcinolonacetonide 10 mg/ml (Kenacort ® A10), or methylprednisolonacetaae (Depo-Medrol ® ) 40 mg/ml Volume: 1-2mlVolume: 1-2ml Interval between injections: 1-3 weeksInterval between injections: 1-3 weeks Effectiveness: 1 st injection 80%, after 2 injections 15%, after 3 injections 5%Effectiveness: 1 st injection 80%, after 2 injections 15%, after 3 injections 5%

Needle? -orange/ light brown (0,45x23mm) -light blue (0,5x25mm) -green (0,8x40mm)

Localisation carpal tunnel Os pisiforme Os scaphoideum

Localisation tendon m. Palmaris longus

Tendon m. Palmaris longus Absent tendon: ulnar to median axisAbsent tendon: ulnar to median axis

Localisation insertion: ulnar to tendon m. palmaris longus Depending on technique used: 1.On distal wrist line (= between tuberculum of os scaphoid and os pisiforme) 2.On proximal wrist line cm before distal wrist line

Injection underneath retinaculum On proximal wrist lineOn proximal wrist line Angle 30 degreesAngle 30 degrees

Injection underneath retinaculum Tingling while inserting needle: withdraw and try againTingling while inserting needle: withdraw and try again Respect resistancesRespect resistances 2nd wrist line Tendon m. palmaris longus

injection through retinaculum. Distal wrist line 45 degrees

Method by Dammers 3-4 cm before distal wrist line Needle 3-4 cm Angle degrees Deposit fluid proximal to carpal tunnel Massage to enhance diffusion

Hygiene Wash hands, wear gloves or disinfect fingersWash hands, wear gloves or disinfect fingers Once-only ampoulesOnce-only ampoules Change needlesChange needles Disinfect skinDisinfect skin

Side effects and complications Side effects Side effects -flushing: 1 day after injection -steroid-flare hours -menstruation problems -hyperglycemia -locale effects: redness, atrophy fatty tissue, hypopigmentation ComplicationsComplications -very rare, case-reports -tendon ruptures, median neuritis (CTS), local infection

Practice Anatomy Injection