Term
| 4 diseases and injuries of the hand and wrist |
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Definition
Compressive neuropathy
Arthritis
Tendinopathy
Hand and wrist fractures |
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Term
| 4 types of compressive neuropathy |
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Definition
Carpal tunnel (median nerve compressed)
Cubital tunnel (ulnar nerve compressed, funny bone)
Radial tunnel
Wartenberg’s syndrome |
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Term
| carpel tunnel syndrome questions to ask for history |
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Definition
• Nightpain (due to nerve compression- dull aching pain at base of hand and palm into forearm, pts have to wake up and shake fingers out, pts sleep w wrists flexed- give brace to wear at night)
• Fingers affected (thumb, middle, index, half of the ring finger)
• Does the pain/numbness radiate from the neck or shoulder? (arthritis or dysfunction of the spine can cause compression of the nerve higher upstream, may be underlying disease/arthristi) |
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Term
| 3 types of physical exams for carpel tunnel |
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Definition
• Tinel (tap on median nerve or the ulnar nerve where it crosses the elbow)
• Phalen’s (pt keeps wrists in flexion for 30-60sec)
• Durkan’s (most sensitive, direct compression held on the carpal tunnel right at the divot btween the thenar and hypothenar eminence for 30 sec
-also look for presence or absence of thenar wasting (prolonged compression of median nerve leads to those muscles wasting away)
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Term
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Definition
ulnar nerve gives sensation to small finger and to half of the ring finger, provides a lot of the intrinsic function of a hand (abductors/adductors of fingers, flexor digitorum profundus muscles to ring and small fingers), can see profound atrophy and see the outline of the metacarpals. ulnar nerve most commonly gets compressed at osborne's fascia- between medial epicondyle and olecranon
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Term
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Definition
First: DIP (distal interphalangeal joint) arthritis (usually osteoarthritis)
• Mucus cysts (body's attempt to pad joint)
• Surgery is NOT cosmetic (fusion, eliminates motion, can no longer move DIP joint)
-Coban supportive bandage can help make DIP arthritis feel a little bit better
[image]
PIP (proximal interphalangeal joint) and MCP (metacarpal phalangeal joint) arthritis
• Rheumatoid, post- traumatic, primary Osteoarthritis
-impt for making a fist, treatment- silicone arthroplasty/rubber knuckle- make incision on back of joint, open up, take out some arthritic bone, put soft rubber spacer in
[image]
CMC (carpometacarpal) arthritis / basal joint arthritis
• Common in women (bc women have more ligamentous laxity)
-pinching, prolonged gripping can be painful, opening doors and jars is difficult, achy and persistent pain at base of thumb
-occupational therapy made splint, steroid injections, CMC arthroplasty- suture between 1st and 2nd metacarpal tightrope
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Term
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Definition
• Trapeziectomy- take out the trapezium where the metacarpal sits
• No replacement options, no implants, not stable
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Term
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Definition
slac- scapholunate advanced collapse, scapolunate ligament gets injured- pull rope too hard, punching too hard, repetitive use, lifting- can go undetected and the 2 bones (scaphoid and lunate) separate -> degeneration
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Term
| surgery options for wrist arthritis |
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Definition
pancarpal arthritis that affects all the bones in the wrist- total wrist fusion, eliminated wrist motion- maintain supination and pronation, lose flexion, extension, radial and ulnar devation
a scaphoid excision and four corner fusion. So if you have some preserved joint surfaces of the wrist, and the arthritis is really limited to the joint between the radius and the scaphoid, in this case you can actually remove the scaphoid, fuse four of the bones in their wrist together, and create a stable wrist joint that will still move but you've eliminated that arthritic surface. So that's a nice, also pretty permanent solution to certain types of arthritis. But it has to be for the right patient who has relatively limited arthritis in their wrist.
And then on the very right is a picture of a total wrist replacement. Now as I was mentioning before, knee replacements are very common. Hip replacements are very common. Wrist replacements are a lot less common. There's typically still a fair amount of lifetime restriction for what a patient can do in terms of lifting, repetitive activities after a wrist replacement, so these are really only a really good option for fairly low demand patients.
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Term
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Definition
Trigger finger
De quervain’s tenosynovitis
Intersection syndrome
FCR/FCU tendonitis |
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Term
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Definition
• Nonoperative management
• 50-80% efficacy reported in literature
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Term
| De Quervain’s Tenosynovitis |
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Definition
most common among new moms, so people who just had babies will present with this, partly because of hormonal changes and partly because of prolonged and repetitive lifting of the baby. And so this particular condition presents with pain right at the radial styloid, so just proximal to the thumb at the radial side of the wrist. It's a similar, almost the same, location as CMC pain, so basal joint pain is just distal to that spot.
called Finkelstein's maneuver, which is when the patient puts the thumb into the palm. And with passive ulnar deviation of the hand, that reproduces the pain at the radial styloid. And when it's positive, when you do this, the patient will just jump off the table. This, similar to trigger finger, also often gets better with an injection. For some patients, injections don't work. And those patients who tend to be most resistant to injections tend to have actually multiple sheaths surrounding this extensor tendon compartment. So what de Quervain's actually is is tendinitis affecting the first dorsal compartment of the wrist, which is the tendons that allow thumb motion.
[image] |
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Term
| types of hand and wrist trauma |
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Definition
Distal radius fractures
Scaphoid fractures
Mallet finger
Flexor tendon injuries |
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Term
| distal radius fractures (colle's fractures) |
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Definition
-ask about calcium and vitamin D intake—
Ulnar variance (how long ulna is compared to radius)
—Volar dorsal tilt
—Joint involvement
— Dorsal comminution
—Initial displacement
-repair through volar locking plate
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Term
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Definition
-most frequently fractured carpal bone (one of the 8 carpal bones, on radial side)
-usually form fall on outstretched hand- hockey players ect
-difficult to treat, scaphoid has retrograde blood supply and covered with cartilage so missing cambium which would help it heal, and it is unstable- moves with any flexion or extension
treat w bone graft, medial femoral condyle graft
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Term
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Definition
Mallet fingers occur with a direct blow on an extended finger. So we see this a lot in patients who play basketball, baseball, anything where you're going to risk jamming a finger. When the extensor mechanism is activated and then has a sudden force against it, that extensor mechanism at the terminal, terminal slip of the extensor will actually pull off a piece of the bone, the distal phalanx in some cases.
So the second picture in this is a diagram showing that. So that's an avulsion type injury of a mallet finger. Those actually heal pretty well, because bone tends to heal very robustly and relatively quickly.
The other type of mallet finger is when there's a failure of the tendon itself. Those heal a lot less quickly. But in both of these cases, typically non-operative management works very well if patients can comply with it. Non-operative management involves immobilizing that joint, which is the DIP joint, full time 100% of the time for six weeks. And at that point, you can start weaning them out of the splint. So it involves a fair amount of patient compliance and for some patients, it's a bit difficult. But non-operative management does work well for mallet finger.
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Term
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Definition
And then just to mention flexor tendon injury is another thing that we've developed much better and better surgery, and in particular better and better therapy options after flexor tendon injuries. So tendon injuries can occur anywhere throughout the hand. Zone 2 is particularly notable.
Zone 2 is what's called no man's land. And it used to be called no man's land, because when you had flexor tendon injuries in zone 2, which is between the FDS and the origin of the flexor tendon sheath, those injuries tended to heal very poorly. So while you could put the tendon back together and it would knit together, you would have severe stiffness of the finger and severe dysfunction. So 50 years ago, people recommended basically against doing zone 2 flexor tendon repairs.
Zone 1 tendon injuries are past where the FDS inserts. So the flexor digitorum superficialis, which inserts on the middle phalanx of the fingers, actually serves to flex the middle phalanx of the fingers. Beyond the insertion of the FDS is zone one. And so in that zone, you only have injury of the tendons, which are the tendons, which allow you to flex the DIP joints. Those, if it's an isolated injury, relatively easy and quick to repair.
Zone two injuries, you have to repair both tendons and you also have to do it within the tendon sheath. So the reason they used to do so badly is because the tendons have to be able to glide within the tendon sheath. And we didn't have really advanced great occupational therapy protocols for how to get patients moving safely after surgery.
What made all the difference is that now we do multiple strand repairs, so very, very strong repairs of the flexor tendons, and actually allow patients to do early active motion. So very controlled and with a therapist, the patients are allowed to get moving actually within a few days of surgery. And so these days we get excellent results. So patients can actually get full range of motion back of their fingers and really full strength as well.
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Term
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Definition
| This diagram shows essentially what's happening in carpal tunnel syndrome. So the carpal tunnel itself is a channel which is made up of the carpal bones deep to the carpal tunnel itself and then the transverse carpal ligament superficially. And between those two structures runs the median nerve and nine flexor tendons, which are the flexor digitorum superficialis and flexor digitorum profundus to all four of the fingers as well as the flexor pollicis longus to the thumb. And so altogether those tendons are what allow the fingers to flex. And they are surrounded as well by the carpal tunnel |
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Term
| what causes carpel tunnel syndrome? |
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Definition
| anything that causes swelling in the body- diabetes, hypothyroidism, pregnancy, overuse, predisposition. median nerve gets compressed and over time blood flow gets cut off or damaged- poor sensation in thumb, index, middle and radial half of ring finger, can also lead to motor symptoms- thenar muscles that allow thumb opposition |
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Term
| what movements predispose someone to carpel tunnel syndrome? |
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Definition
| hammering all day/jackhammer, vibratory instrument use- hairdryer, manual labor professions, typing is protective |
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Term
| treatment for severe cubital tunnel where ulnar nerve snaps out of place |
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Definition
| ulnar nerve transposition, move in front of epicondyle |
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Term
| carpal tunnel treatment surgery |
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Definition
| endoscopically with cameras (inc incidence of injuring the nerve) but typically done with open fashion- small incision on palm and opening up the transverse carpel ligament |
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Term
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Definition
| osteoarthritis, inflammatory: lupus, rheumatoid arthritis, psoriatic arthritis, gout |
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Term
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Definition
trigger finger is caused when one of the pulleys that the flexor tendon runs in becomes hypertrophic and thickened. Patients who get trigger finger tend to be the same patients who get carpal tunnel, so patients who have diabetes, hypothyroidism, patients who overuse their hands. A lot of different things can predispose you to getting trigger finger.
Each of the tendons to the fingers run through what's called the tendon sheath, which is made up of a series of pulleys. The A1 pulley is located directly over the metacarpal head. And those pulleys are the ones that tend to become thickened, hypertrophic, and form almost a cartilage-like substance. The tendon in response gets stuck as it travels through the pulley during active flexion and extension.
So when this gets to be pretty severe, the tendon will form a nodule in response to the thickened pulley that will then pop through the pulley. So if you ask a patient to actively make a fist and straighten their fingers out, one of their fingers will get stuck and then pop open. And it's usually pretty painful when it happens.
Surgery for trigger finger is pretty simple. It's an incision directly over that pulley, and then similar to a carpal tunnel where you're opening up the transverse carpal ligament, with a trigger finger release you're opening up the tendon sheath that's become thickened. And that allows the tendon to glide again smoothly. |
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Term
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Definition
| from trigger finger release surfery. when the flexor tendon sheath, which I talked about in my last slide, can actually enclose an infection. And if you get bacteria underneath the flexor tendon sheath, which can happen in any kind of penetrating wound, it can happen as a result of this surgery, the sheath becomes essentially full of pus or pirulent fluid and that's extremely painful. So patients will present what with what's called Kanavel's signs, which should be a flexed posture of the finger, tenderness along the flexor tendon sheath, and pain on stretching of the finger, and fusiform swelling, so the finger really just looks like a big sausage. And that's really important to see and treat immediately, because untreated that can lead to prolonged stiffness and dysfunction of the finger. |
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