COMMON HAND PROBLEMS RELATED TO WORK Prasad G. Kilaru MD Plastic, Reconstructive & Hand Surgery

Agenda Injury types Basic anatomy Mechanism of action Diagnosis Treatment  Prevention  Education

Repetitive Stress Injury Nerve: Carpal tunnel syndrome, cubital tunnel syndrome Tendon: Connects muscle to bone Repetitive injury at muscle insertion Trigger digit, DeQuervain’s tenosynovitis Repetitive injury at muscle origin Lateral epicondylitis, Medial epicondylitis Ligament: Connects bone to bone Chronic collateral ligament injury, TFCC injury Joint Problems Ganglion cyst, Mucous cyst, Basal joint arthritis

Traumatic Injury Tendon injury Bony Injury Nerve Injury Joint Injury Flexor, extensor, muscle belly injury Injury to tendon insertion Mallet finger, Flexor tendon avulsion Bony Injury Nerve Injury Joint Injury Sprain, dislocation

Anatomy - Nerve Median nerve – Mixed nerve Ulnar nerve – Mixed nerve Sensory – Volar aspect of palm and radial 3 ½ fingers Motor – Major finger and wrist flexors, thenar muscles and radial lumbricals Ulnar nerve – Mixed nerve Sensory – Ulnar aspect of volar and dorsal palm and ulnar 1 ½ fingers Motor – Ulnar wrist and finger flexors and intrinsic muscles of the hand

Anatomy - Nerve

Anatomy - Nerve Radial nerve – Mixed nerve Sensory to palm and fingers Sensory – Dorsal aspect of hand and radial 3 ½ fingers dorsally Motor – Extensors of the elbow, wrist and fingers Sensory to palm and fingers Volarly – Radial 3 ½ fingers and palm – Median nerve, Ulnar 1 ½ fingers and palm – Ulnar nerve Dorsally – Radial 3 ½ fingers and hand – Radial nerve, Ulnar 1 ½ fingers and hand – Ulnar nerve

Anatomy Carpal Tunnel

Anatomy of Flexor Pulley System

Anatomy – Extensor Compartmetns

Mechanism of Action Repeated movement/use causes swelling over affected region Repeated movement/use despite swelling causes worsening of swelling Feedback loop set up with worsening symptoms Depending on the structure effected – numbness, pain, locking etc.

Nerve Compression Syndromes Median nerve compression (carpal tunnel syndrome) occurs from compression of the nerve at the wrist Ulnar nerve compression can occur at the wrist or elbow Radial nerve compression usually occurs in the forearm Pressure buildup can occur from decrease in the size of the tunnel(bone overgrowth, fracture) or increase in the volume of the contents of the tunnel(tendinitis, fluid buildup etc.)

Tendinopathies Repeated movement/use of tendons causes tendons to swell up and get trapped in tunnels either over fingers or wrist (trigger finger, DeQuervain’s tenosynovitis) Repeated movement/use at tendon origin causes microtears which cause chronic tears near common extensor (lateral epicondylitis) or common flexor (medial epicondylitis) origin

Nerve Compression Signs & Symptoms Symptoms commonly include pain, numbness, tingling and in late stages weakness in grip Symptoms are usually felt at night and can occasionally wake patients from sleep The numbness is usually along the distribution of the effected nerve Severe cases can result in muscle wasting with weakness and permanent sensory loss

Nerve Compression Diagnosis History and physical examination are usually indicative of nerve compression Tinel’s sign, nerve compression test, Phalen’s test are all positive Nerve conduction study and EMG are often confirmatory

Tendinopathy Diagnosis Usually presents with locking or snapping of the finger or thumb on flexion that holds the finger in flexion(trigger finger) There is usually tenderness over the MP joint volarly and a nodule or thickening is usually palpable in the same region(trigger finger) Pain over the first dorsal compartment at the anatomic snuff box (deQuervain’s tenosynovitis) Finkelstein’s test is usually positive (deQuervain’s tenosynovitis)

Tendinopathy Diagnosis Patients usually have point tenderness over the lateral or medial epicondyle (epicondylitis) Pain can be reproduced by wrist or finger extension (lateral epicondylitis) or flexion (medial epicondylitis)

Treatment Options Noninvasive options – Initial approach Ergonomic evaluation Work modification, Splints/braces that immobilize the affected area NSAIDS or steroidal anti-inflammatories Topical anti-inflammatory modalities, ice, Physical therapy

Treatment Options Steroid injections Surgical options At least 3-4 months apart, no more then 2 a year Avoid injections near nerves Side effects Surgical options When conservative measures fail or cannot be implemented In late cases – severe compression on NCS/EMG

Treatment Options For compressive pathology - basic principle is to release the area of constriction transverse carpal ligament for carpal tunnels syndrome A1 pulley for trigger digits First dorsal compartment release For nerve compression, surgery reverses symptoms for early cases and prevents progression of disease in late cases “Wont get any worse – how much better depends on extent of the damage” Surgery usually a cure – recurrence rare

Treatment Options For tendinopathies, surgery considered when conservative therapy fails Requires debridement of the inflamed tendon and associated bone spurs and reattachment of the extensor/flexor origin Recovery longer with surgery around elbow Therapy needed for splinting, movement etc.

Preventive Measures Prevention of repetitive trauma Ergonomic evaluation and implementation Regular stretching and strengthening “Preparation for a marathon” Learning to recognize early symptoms Preventive maneuvers

Education Teaching patients to recognize early symptoms Preventive measures Medication Splinting Anti-inflammatory modalities Stretching and strengthening exercises

Ligament Injuries Chronic collateral ligament injuries TFCC injury Usually common to the MP joint of the thumb Splinting, casting, surgery TFCC injury Involves ulnar aspect of wrist Related to trauma or repetitive injury Splinting, steroid injections, casting, surgery

Basal Joint Arthritis CMC joint of the thumb most common site for degenerative arthritis in the hand Related to chronic repetitive use or previous injuries to the thumb Starts with pain at the base of the thumb, progressing to weakness Treatment entails rest, NSAIDs, splinting, steroid injections and surgery

Ganglion Cysts Common soft tissue mass over the hand or fingers, is a ganglion occasionally associated with repetitive or strenuous activity Can be volar or dorsal, over the wrist or fingers Treatment If asymptomatic, can be left alone Aspiration of the cyst, rupture(by over inflation) or infiltration with steroids has a high rate of recurrence(>50%) If symptomatic, resection is usually recommended

Mallet Finger “Droop” of the DIP joint of a finger with intact passive extension, but no active extension Usually due to avulsion of the tendinous insertion of the extensor tendon or a fracture avulsion at the base of the distal phalanx This requires splinting in extension for a prolonged period of time and if a fracture is present or is chronic may require surgical correction

Summary Careful history and physical examination usually goes a long way in obtaining a diagnosis Rest, splinting and NSAIDS a good start for most repetitive injuries Ergonomic evaluation can resolve or prevent many cumulative trauma disorders Early referral to a hand surgeon, can prevent delay in diagnosis or treatment of many common hand problems

Take Away Points Patient and employer education Prevention Early intervention Diagnosis & treatment

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