1. Common Hand Disorders
Mark Shreve, MD

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

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

4. 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)

5. 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

6. 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)

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

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

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

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

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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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)

18. 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

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

20. 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

21. 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

22. 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

23. 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

24. 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.)

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

26. 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

27. 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

28. 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

29. Trigger Thumb Open release of the A1 pulley
Local anesthesia
Digital nerves 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

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

31. 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

32. 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

33. 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

34. 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

35. 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 days

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

37. 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

38. 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

39. 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

40. 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

41. 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

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

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

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

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

46. 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

47. 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!

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

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

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

51. 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

52. 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

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

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

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

56. 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

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

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

59. 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

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

61. Distal Radius Fractures

62. ANATOMY Three concave articular surfaces Scaphoid fossa Lunate fossa
Sigmoid notch 62

63. ANATOMY
22o
11o
11mm 63

64. Classification: Type I bending/metaphyseal
This is Fernandez classification, one of the many types of classifications for distal radius fractures 64

65. Classification: Type II shearing/articular65

66. Classification: Type III compression/articular66

67. Classification: Type IV avulsion/fx dislocation67

68. Classification: TYPE V combined, high energy68

69. Hundreds of publications over the years
Vast amount of presentation
Vast amount of treatment options 69

70. AGE vs. Loss of Reduction
1 WK
2 WK
INITIAL
50%
P LOSS OF REDUCTION
Basically as age increases the chance of loss of reduction with closed treatment increases 50 20
AGE 70

71. Good functional result despite malunion
However in those over aged 65 a imperfect reduction and malunion may not lead to any loss in function 71

72. AGE Important to have a discussion in regard to treatment options
Especially the elderly patients
Get family involved in the decision making process 72

73. ARTICULAR INVOLVEMENT
DRUJ
Ulnar sided wrist pain is very common
Supination is often difficult
Lack of supination correlates with worse outcome
More aggressive about DRUJ articular involvement than RC 73

74. METHODS OF TREATMENT Casting Closed reduction casting
Closed reduction PP
External Fixation
Non-bridging EX Fix
Arthroscopic assisted reduction
Closed reduction, intramedullary (IM) nail
Open reduction, internal fixation (ORIF)
Volar
Dorsal
Combined
Bridge Plating
Fragment specific fixation 74

75. CLOSED REDUCTION Closed reduction needed for displaced fractures
Non-displaced fractures can be treated with cast
In reliable patient can be placed in splint (no data to support) 75

76. CLOSED REDUCTION ensure cast does not restrict MP flexion76

77. CLOSED REDUCTION Edema control, Elevation
All patients need early digital motion
Edema control,
Elevation
Don’t forgot about shoulder motion 77

78. Closed Reduction, Percutaneous Pinning (CRPP)
-Can be used for most fracture patterns -Shearing injuries that can not be plated -Severe soft tissue trauma -There is risk of loss of reduction -Pin-track infection -Needs cast or splint 78

79. Intramedullary NAIL Alternative to k-wire fixation
For extra-articular fractures
Need good metaphyseal bone (1.5-2 cm)
SRN irritation can be an issue
More stable than k-wires alone
Similar stability to volar plates
Can start immediate ROM
Avoid open volar soft tissue envelope
Less OR time 79

80. IM Nail 80

81. External Fixation Not commonly used Bridging or Non-Bridging
Problem is with over distraction, hand stiffness
Use mainly for severe soft tissue injury
Temporary fix until able to perform formal ORIF 81

82. External Fixation 82

83. Volar Plating

84. COMBINED Dorsal/Volar APPROACH84

85. BRIDGE PLATE Severe articular comminution Internal ex fix
Span zone of injury until fracture consolidation
Requires second procedure
Wrist stiffness is usually not a problem
Need to avoid tendon irritation and adhesions 85

86. CARPAL INJURIES 86

87. ULNA STYLOID FRACTURES
Ulnar sided wrist pain is common in post operative period
Presence of ulnar styloid fracture should create concern for DRUJ instability
Incidence 3 to 37%
Need to asses normal side
Increased motion compared to contra-lateral side
Fluoroscopic evaluation if in doubt 87

88. ULNA STYLOID FRACTURES
DISTAL ULNA FRACTURES 88

89. Carpal tunnel syndrome
Acute CTS
Develops over 6-8 hours after injury
Progressive
Painful
Median nerve contusion
Can be present at time of injury
Improves with reduction
Is not progressive 89

90. Complications of Volar Plating
41 pts.
Retrospective review
21% complication rate
10% loss of reduction
7% HWR for tendon irritation
2.5% hand stiffness
Tamara JHS 2006
Functional Outcome & Complications after Volar Plating for Dorsally Displaced Unstable Fractures of Distal Radius 90

91. Tendon Irritation Can have flexor and extensor tendon irritation
Pts will generally complain of pain with motion after fracture has healed
FPL common on flexor
EDC common for extensor
HWR prior to rupture 91

92. Hand Stiffness Not well reported in the literature
Can occur even with non-operative treatment
Very difficult to treat especially in the elderly patients
Prevention, early digital motion, edema control 92

93. REHABILITATION Tenuous Fixation
Depends on level of confidence with fixation
Stable fixation
Start digital ROM
Edema control
Forearm rotation
Removable Splint
Wrist F/E 3 days
Strengthening at 6 wks
Tenuous Fixation
Start Digital ROM
Edema Control
Forearm rotation
CAST until fracture has consolidated
Wrist F/E 4-6 weeks
Strengthening at wks 93

94. REHABILITATION Lonzano-Calderon JBJS 2008
Moblization following volar plate fixation of fractures of the distal part of radius
Prospective study
Looked at 2 vs 6 weeks of post op immobilization
No difference in final ROM
But it does take longer to obtain ROM 94

95. SUMMARY Distal Radius and ulna fractures are common
Variety of treatment modalities
Be familiar with all methods of treatment
Patient selection is important for good outcome
Post op rehab is essential for good outcome 95

96. Thank You