1. Complaints of hand and wrist Wim Willems HOVUmc, Amsterdam

2. Program Basic anatomy Common complaints Practice

3. Anatomy

4. Intrinsic flexors Volar viewDorsal view

5. Extrinsic flexors

6. Extensors

7. Nerves

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

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

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

12. Heberden’s nodule

13. Treatment

14. Arthrosis CMC I Injection Splint Avoid operation as long as possible

15. Arthrosis CMC I

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

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

18. Trigger finger

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

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

24. Treatment

25. Conservative therapy Self limiting 10-20% ?? NSAID Splint. 6 - 8 weeks (MCP in 10-15 degrees flexion). Effective 66% of the cases Steroïd injection. Effectiveness 50% - >90%

26. 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)

27. 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

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

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

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

32. 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, 35-55 yr.Women > men, 35-55 yr. Presentation in general practice: 5,6/1000Presentation in general practice: 5,6/1000 Often recurrent esp. when crepitationsOften recurrent esp. when crepitations

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

35. M.de Quervain: onderzoek Finkelstein’s test

36. 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

37. 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

38. Injection M. De Quervain

39. “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

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

41. Carpal tunnel syndrome

42. Epidemiology Open population (history + nerve conduction examination):Open population (history + nerve conduction examination): –Female: 9 % –Male: 0,6% –Peak between 40-60 year

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

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

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

46. 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

47. Sensory innervation N. Medianus

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

49. Provocation tests: CBO 2006: Limited usefulness

50. testsensitivityspecificity Tinel0.25-0.600.64-0.89 Phalen0.10-0.910.33-0.86 Flick sign0.930.96 Square wrist sign 0.47-0.690.73-0.83 Pressure provocation test 0.28-0.630.33-0.74 Tourniquet test0.21-0.510.36-0.87 C.A. Diagnostic tests CTS :

51. 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)

52. Neurophysiological examination sensitivityspecificity EMG60-8295-100% Verification of clinical diagnosis prior to operation

53. 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

54. Treatment

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

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

57. 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

58. 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%

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

60. Localisation carpal tunnel Os pisiforme Os scaphoideum

61. Localisation tendon m. Palmaris longus

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

63. 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 3.3-4 cm before distal wrist line 3 12 3

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

65. 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

66. injection through retinaculum. Distal wrist line 45 degrees

67. Method by Dammers 3-4 cm before distal wrist line Needle 3-4 cm Angle 10-20 degrees Deposit fluid proximal to carpal tunnel Massage to enhance diffusion

68. 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

69. Side effects and complications Side effects Side effects -flushing: 1 day after injection -steroid-flare 24-48 hours -menstruation problems -hyperglycemia -locale effects: redness, atrophy fatty tissue, hypopigmentation ComplicationsComplications -very rare, case-reports -tendon ruptures, median neuritis (CTS), local infection

70. Practice Anatomy Injection