Hand Surgery and Rheumatology - the interface · What is Hand Surgery? PRINCIPALS Painfree anaesthesia Minimally invasive incisions Consideration of Anatomy and Pathological processes

Andrew Cavallo Plastic Reconstructive and Hand Surgeon

Jennifer Mathias Hand Therapist

Melbourne Hand Therapy

Elgar Hill Plastic and Hand Clinic 7/28 Arnold St Box Hill 3127

The Interface

Team Work

Rheumatologist

Hand Surgeon

Hand Therapist

Radiologist

Psychologist

The Patient!

8/27/2014 Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic and Hand Clinic

The Interface

What is Hand Therapy?

Undergraduate training in Occupational Therapy or Physiotherapy

Postgraduate training in Hand and Upper Limb Rehabilitation, Master of Science (Hand Therapy)

Hospital based work

Associated with Plastics, Orthopaedics, Rheumatology clinics

Private practice (generally associated with a Hand Surgeon)

The Interface

What is Hand Surgery?

PRINCIPALS

Painfree anaesthesia

Minimally invasive incisions

Consideration of Anatomy and

Pathological processes

Early Protected Mobilisation

Troublefree recovery

Manage patients expectations

The Interface

ANATOMY

8/27/2014

Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic and

Hand Clinic

The Interface

ANATOMY

8/27/2014


Hand Clinic

The Interface Overview

Common conditions referred to Hand Therapists and Hand Surgeons by Rheumatologists

Rheumatoid arthritis

MCP joints

PIP joints

Thumb

OA CMC joint

IP joints

DIP ganglions

Scleroderma

Tenosynovitis- Trigger finger / thumb / De Quervains

Carpal Tunnel Syndrome

Dupuytren’s disease

The Interface

RHEUMATOID ARTHRITIS

Assessment

Clinical

Serological

Radiological

Functional

8/27/2014


Hand Clinic

The Interface


Soft Tissues- Nodules

8/27/2014


Hand Clinic

The Interface


Flexor Tendons

Carpal Tunnel Syndrome

Flexor Tendon rupture

8/27/2014


Hand Clinic

The Interface


Extensor Tendons

Wrist

Rupture

8/27/2014


Hand Clinic

The Interface


Extensor Tendons

8/27/2014


Hand Clinic

The Interface


Extensor Tendons

Rupture

Tendon Subluxation

8/27/2014


Hand Clinic

The Interface


Joints

MP

Ulnar Drift Deformity

Palmar Subluxation

Weak Grip and Pinch

8/27/2014


Hand Clinic

The Interface


Joints

MP- Synovitis-destruction-replacement

8/27/2014


Hand Clinic

The Interface


Joints

MP replacement

8/27/2014


Hand Clinic

The Interface


Joints

MP replacement

8/27/2014


Hand Clinic

The Interface


Joints

PIP – Boutonniere

Soft tissue rebalance/fusion

8/27/2014


Hand Clinic

The Interface


Joints

PIP and DIP – Swan neck

Soft tissue rebalance/fusion

8/27/2014


Hand Clinic

The Interface

Swan neck deformities

Boutonniere deformities

http://www.google.com.au/url?sa=i&rct=j&q=splinting+for+swan+neck+deformity&source=images&cd=&cad=rja&docid=f8StXS9goCNc2M&tbnid=5GNhaXg3qQ1VMM:&ved=0CAUQjRw&url=http://pinterest.com/earlalea/ehlers-danlos/&ei=qbSFUe_XIMrwkQXbuYD4Bw&bvm=bv.45960087,d.aGc&psig=AFQjCNHhZf1koRIcRn59sLguqKvGBuSAYg&ust=1367803368492040

http://www.google.com.au/url?sa=i&rct=j&q=splinting+for+boutonniere+deformity&source=images&cd=&docid=sNulsranhRIn3M&tbnid=XIjZ-0Ged2uyhM:&ved=0CAUQjRw&url=https://www.ncmedical.com/item_1748.html&ei=dLWFUZfhGc2alQWFpYHIBg&bvm=bv.45960087,d.dGI&psig=AFQjCNGNpb5K7y23lWPhkL4scurTmHAnog&ust=1367803558065233

http://www.google.com.au/url?sa=i&rct=j&q=swan+neck+deformity&source=images&cd=&docid=BUxSjTzqyeSjzM&tbnid=2pa2woXO0547BM:&ved=0CAUQjRw&url=http://doctorsgates.blogspot.com/2010/10/swan-neck-deformity.html&ei=PjKGUYyzKo6ekQWQ7ICYCw&bvm=bv.45960087,d.dGI&psig=AFQjCNEEGvFyDHNhz9EtbOAgVupDIMP7Rg&ust=1367835565447215

http://www.google.com.au/url?sa=i&rct=j&q=boutonniere+deformity&source=images&cd=&docid=wI-XZnrk4N3M0M&tbnid=pxWTv-E37xA7jM:&ved=0CAUQjRw&url=http://handtoelbow.com/pip-joint-deformity/&ei=izKGUY7_EofPkwWj7ICwAQ&bvm=bv.45960087,d.dGI&psig=AFQjCNH6oYbkIDy-v0x1hunybSTe9_HrtA&ust=1367835634599361

The interface - Rheumatoid thumb

Classification Primary

site of joint

deformity

Deformity Splint

Type 1 (Boutonniere) MCP joint MCP flexed

IP hyperextended

Custom made thumb

MCP joint extension

immobilisation splint

Type 2 CMC joint CMC flexed and adducted

MCP flexed

IP hyperextended

CMC and MCP

extension


Type 3 (Swan neck) CMC joint CMC subluxed, flexed and

adducted

MCP hyperextended

IP flexed

CMC immobilisation

splint with block to

prevent MCP joint

hyperextension

Type 4

(Gamekeeper’s)

MCP joint Laxity of UCL MCP joint


Type 5 MCP joint MCP hyperextended

IP joint flexed

Extension restriction

splint

Type 6 General Bone loss and loss of joint

stability

CMC, MCP and IP

splint as indicated Andrew Cavallo and Jennifer Mathias Elgar Hill

Plastic and Hand Clinic

The Interface


Thumb

8/27/2014


Hand Clinic

The Interface

SPLINTS

http://www.google.com.au/url?sa=i&rct=j&q=judy+colditz+hand+therapy&source=images&cd=&cad=rja&docid=f9wExlTikte8LM&tbnid=apq_aJWfDnxPEM:&ved=0CAUQjRw&url=https://www.ncmedical.com/item_1393.html&ei=tLZ4UdWCBNCSiAfTmoDgBw&bvm=bv.45645796,d.aGc&psig=AFQjCNEQjnrdEgMjGozw98nFgar9jD-PwQ&ust=1366951951519809

http://www.google.com.au/url?sa=i&rct=j&q=judy+colditz+hand+therapy&source=images&cd=&docid=3Zvz5BgsAeM2sM&tbnid=cTvnevNX5teCwM:&ved=0CAUQjRw&url=http://www.handlab.com/products/Thumb-Mechanics-DVD-Set.asp&ei=RLd4UfvxMYO4iQec24HgAQ&bvm=bv.45645796,d.aGc&psig=AFQjCNEQjnrdEgMjGozw98nFgar9jD-PwQ&ust=1366951951519809

The interface - RA

Conservative

Splinting

Education (joint protection)

Heat (hot packs / wax baths)

Gentle range of motion

The Interface - Treatment of RA

Splinting

Anti-deformity Splints

Night resting splints

http://www.google.com.au/url?sa=i&rct=j&q=soft+splinting+for+MCP+joint+deviation&source=images&cd=&cad=rja&docid=aryY838u72pjCM&tbnid=k-r55FUIU59tmM:&ved=0CAUQjRw&url=http://www.protherapysupplies.com/Shop-By-Condition/Arthritis/3pp-Ulnar-Deviation-Finger-Splint-Radial&ei=k7R7Ua6dBcmPkgWsoICoBQ&psig=AFQjCNHZNhwnqd5Okm3pj_ASwW_1T2F5tQ&ust=1367147998918436

The Interface

VASCULAR

Scleroderma

Raynauds

8/27/2014


Hand Clinic

The Interface Scleroderma

Skin care

Hand and nail care

Protection from heat and cold

Raynaud’s phenomenon

Housework and activities

Exercises

Splints

http://www.google.com.au/url?sa=i&rct=j&q=scleroderma&source=images&cd=&cad=rja&docid=GKJbLOPqCj-rWM&tbnid=EFZXmMmVq-IkuM:&ved=0CAUQjRw&url=http://www.thegeminigeek.com/how-to-get-rid-of-scleroderma/&ei=0auFUd6WAYjxlAWm0YDoCQ&bvm=bv.45960087,d.aGc&psig=AFQjCNFctUtbIljJsM-wFvqZ1X6xIRNXhw&ust=1367801091649997

The Interface

PSORIATIC ARTHRITIS

8/27/2014


Hand Clinic

The Interface

GOUT

8/27/2014


Hand Clinic

The Interface

OSTEOARTHRITIS

Joints - CMC

Joints - MP

Joints - PIP

Joints - DIP

8/27/2014


Hand Clinic

The Interface

Ist CMC OA

8/27/2014


Hand Clinic

The Interface

Ist CMC OA

http://www.google.com.au/url?sa=i&source=images&cd=&cad=rja&docid=Z5EI7KifnvVYFM&tbnid=UMoBzr0QhH1paM:&ved=0CAgQjRwwAA&url=http://rotplombe.biz/29/cmc-arthritis&ei=HxZ2UYWQLaSSiAe-j4DQBA&psig=AFQjCNHOI6hKT2TgVpD_5ZwS-96UzKDskQ&ust=1366779807790844

The Interface - Signs of thumb base OA

Deformity

Tenderness

Stiffness

Swelling

Weak pinch and grip

Poor function

The interface- CMC Assessment

X-rays

Reported history of pain

and function

Clinical assessment

(palpation and grind test)

Lateral pinch strength

assessment

Andrew Cavallo and Jennifer Mathias Elgar Hill


http://www.sciencedirect.com/science/article/pii/S1877056809000954#gr2

The Interface

Eaton Radiological Classification

Stage 1 almost normal

Stage 2 decreased Jt space

Osteophyte<2mm

Stage 3 Subluxation >1/3

Osteophyte>2mm

Stage 4 ST/ TT / IFcmc

Andrew Cavallo and Jennifer Mathias

Elgar Hill Plastic and Hand Clinic

http://www.google.com.au/url?sa=i&rct=j&q=stt+joint+osteoarthritis&source=images&cd=&docid=3-mzF5vTrLdamM&tbnid=_2NKd6TP5z735M:&ved=0CAUQjRw&url=http://www.shoulderelbowhand.co.uk/wrist_arthritis.html&ei=XfB1UcqKN_G0iQfGvoGgAg&bvm=bv.45512109,d.aGc&psig=AFQjCNFyOyVg_77PLJdBpygct9m77cqW8A&ust=1366770122630228

The Interface – 1st CMC

Conservative management - Splinting

http://www.google.com.au/url?sa=i&rct=j&q=thumb+splints&source=images&cd=&cad=rja&docid=mcKqGViVwlaoGM&tbnid=NOMXGUe8oMDFhM:&ved=0CAUQjRw&url=http://www.disability-warehouse.co.uk/product/comfort-cool-thumb-cmc-restriction-splint-small-left&ei=fCpuUeWFOYXDkQWFioHAAQ&bvm=bv.45368065,d.dGI&psig=AFQjCNEaYLSdKEgzGsUL5lrLfSmI5ZXmKQ&ust=1366260729688660

The Interface

1st CMC OA

Splinting


Heat (hot pack / wax baths)


Steroid Injection

Surgery

The Interface CMC joint surgical procedures

Ligament Reconstruction (LR)

MC osteotomy

CMC joint arthrodesis

Denervation

CMC joint replacement

Trapeziectomy +/- LR or TI or LRTI

Trapeziectomy (complete/partial) + interpositional arthroplasty



The Interface - Interposition Materials

Biological (Autograft / Allograft)

FCR / PL

Costochondral interposition graft

Fascia Lata / Graft jacket (acellular dermis)

Prosthetic Material

Silicone rubber button

Gelfoam

Gortex

Polypropylene (Marlex)

Polyurethane Urea (Artelon)

Pyrocarbon- Ascension PyroDisk

-Tornier Pyrocardan

Artelon

PyroDisk

Pyrocardan



The Interface Pyrocardan CMC Interposition Implant

Indications

Stage 1,2 and early 3 CMC OA (Eaton Classification)

Benefits

Short term- Minimally invasive and short recovery period

Trapezium preserving, offers greater salvage opportunities

?Long Term results



The Interface

Partial trapeziectomy and interposition with the Pyrocardan

CMC joint implant.

Pain/function score improved

Good overall satisfaction with procedure

Pinch strength comparable to traditional procedures



The Interface - STT joint OA

http://www.google.com.au/url?sa=i&rct=j&q=stt+joint+osteoarthritis&source=images&cd=&docid=3-mzF5vTrLdamM&tbnid=_2NKd6TP5z735M:&ved=0CAUQjRw&url=http://www.shoulderelbowhand.co.uk/wrist_arthritis.html&ei=XfB1UcqKN_G0iQfGvoGgAg&bvm=bv.45512109,d.aGc&psig=AFQjCNFyOyVg_77PLJdBpygct9m77cqW8A&ust=1366770122630228

http://www.google.com.au/url?sa=i&rct=j&q=stt+joint+osteoarthritis&source=images&cd=&docid=QwfN8qCwm6i07M&tbnid=SiaIMC_pWYK1fM:&ved=0CAUQjRw&url=http://www.msdlatinamerica.com/ebooks/HandSurgery/sid905608.html&ei=d_F1Ua-qL4WriAfc3oDACg&bvm=bv.45512109,d.aGc&psig=AFQjCNFyOyVg_77PLJdBpygct9m77cqW8A&ust=1366770122630228

The Interface - PAN TRAPEZIAL OA

Trapeziectomy alone

Trapeziectomy + tendon interposition

Trapeziectomy + Suspension (APL or FCR)

Results – Excellent Pain Relief

- Very Good Movement

- Good Functional strength

The Interface

8/27/2014


Hand Clinic

The Interface

8/27/2014


Hand Clinic

The Interface

8/27/2014


Hand Clinic

The Interface

8/27/2014


Hand Clinic

PIP OA

http://www.google.com.au/url?sa=i&rct=j&q=PIP+joint+OA&source=images&cd=&docid=ul1w2N-XmM2M3M&tbnid=5M7mGWC1RuAlgM:&ved=0CAUQjRw&url=http://upperext.com/hand/hand-arthritis/&ei=5LOFUerIBYXAkAWk8oDACg&bvm=bv.45960087,d.aGc&psig=AFQjCNFqN5yHAWtk2ha3TfuO8Qu93GNLzg&ust=1367803119549601

http://www.google.com.au/url?sa=i&rct=j&q=pip+joint+swelling&source=images&cd=&cad=rja&docid=Flt0MAkfiKzi2M&tbnid=dIQfJRa5KbNVqM:&ved=0CAUQjRw&url=http://www.arthritis.co.za/rheumatoid arthritis an update.html&ei=O0SGUYCoJoeGkgWe84DgAg&bvm=bv.45960087,d.aGc&psig=AFQjCNEHGdpB9xfA-6RUrwQE-_bcfL-WCQ&ust=1367840150250051

The Interface

GANGLIONS in OA

PIP (Dorsal)

8/27/2014


Hand Clinic

The Interface – Signs of DIP joint OA

Pain and swelling

Enlargement

deformity

instability

Heberden’s nodes

mucoid cysts

The Interface – Signs of DIP joint OA

DIP Fusion

Severe Pain

Deformity

Instability

The Interface

GANGLIONS in OA

DIP ( Mucoid)

8/27/2014


Hand Clinic

The Interface

Post Traumatic Arthritis

Digits

Joints –DIP

Joints – PIP

Joints – MP

Joints- CMC

8/27/2014


Hand Clinic

The Interface


Digits

Joints –DIP

Joints – PIP

Joints – MP

Joints- CMC

8/27/2014


Hand Clinic

The Interface


PIP Replacement

8/27/2014


Hand Clinic

The Interface - IP Joint OA management

Conservative

Splinting


Heat (hot packs / wax baths)


The Interface - Splinting for OA and RA

Minimise

deformities

Decrease pain

Provide

support for

increased

function

Decrease

stress to the

joints

Decrease

inflammation

Assist with joint

stability

8/27/2014



http://www.google.com.au/url?sa=i&rct=j&q=thumb+splints&source=images&cd=&cad=rja&docid=--NMdf6wbycnAM&tbnid=dyht8-WiJ3_ZBM:&ved=0CAUQjRw&url=http://www.braceability.com/bort-selladur-thumb-arthritis-treatment&ei=p15-UeGHBoSEkgW184GgDQ&bvm=bv.45645796,d.aGc&psig=AFQjCNG3yIyxT-pOiQNi8uZH-Rwmpon4AQ&ust=1367322649052728

The Interface - Splints

8/27/2014



http://www.google.com.au/url?sa=i&rct=j&q=tubular+finger+sleeves+&source=images&cd=&docid=DdfEKdkAPgcv-M&tbnid=hGfGrPFt2k5o6M:&ved=0CAUQjRw&url=http://www.rehabmart.com/category/Compression_Bandages/Elastic_Bandages.htm&ei=Mqp7UaSmA4WokQWFpoCYDg&psig=AFQjCNEm9YJFnHW_PQboOGBrygzNr53-Rw&ust=1367145384681752

The Interface - Joint Protection Principles

Rest

Spread the strain

use more joints to do work

use larger joints to do work

Avoid gripping narrow and small

objects

Avoid deforming positions (RA)

Energy Conservation

Activity Of Daily Living (ADL) Devices

Joint Protection Principles

Increased Function

Splinting

Pain free exercises

Joint protection

Boustedt C, Nordenskiold U, Lundgren Nilsson A. Effects of a hand-joint protection program with an addition of

splinting and exercise: one year follow-up. Clin Rheumatol. 2009; 28: 793-9

The Interface - Hand Exercises

Increasing grip

strength

Improving

function

Reducing pain Improving ROM

Overall body

conditioning

Must be

pain

free

The Interface

De Quervain's Tenosynovitis

Compression of the APL and

EPB within the 1st dorsal

compartment

Finklestein’s test - ulnar

deviation of the wrist with the

thumb adducted



The Interface

DEQUERVAIN’S TENOSYNOVITIS

8/27/2014


Hand Clinic

The Interface

De Quervain's Tenosynovitis

Treatment

Splinting

Cortisone injection

Iontophoresis with

dexamethasone

Surgery

8/27/2014



The Interface

TRIGGER FINGER

8/27/2014


Hand Clinic

The Interface

TRIGGER FINGER

8/27/2014


Hand Clinic

The Interface

TRIGGER FINGER

8/27/2014


Hand Clinic

http://www.google.com.au/url?sa=i&rct=j&q=splinting+for+trigger+finger&source=images&cd=&cad=rja&docid=3HzyxepZWWuciM&tbnid=3hYzlTLyXD-CTM:&ved=0CAUQjRw&url=https://www.ncmedical.com/item_1751.html&ei=Y7V7UfT3OsPFkwWjlIHQCA&bvm=bv.45645796,d.aGc&psig=AFQjCNH0LbnLwO0iTayszOXdn011O5fmsw&ust=1367148251718368

The Interface

TRIGGER THUMB

8/27/2014


Hand Clinic

The Interface

Lateral Epicondylitis (tennis elbow)

Pathology at the common extensor origin (lateral epicondyle)

ECRB tendon involved (Also EDC 30%)

Dominant arm more involved (2:1)

Peak incidence in the fourth decade

More prevalent in occupation (70%) as compared to sports

The Interface Treatment Modalities

Immobilisation, Ultrasound, Splinting

(proximal brace and/or wrist brace), Laser,

Education, Transverse Friction Massage,

Electrotherapy, Oral NSAIDS, Topical

NSAIDS, CSIs, Mobilisation, Botox,

Extracorporeal Shock Wave Therapy, Ice,

Stretching, Strengthening, Phonophoresis,

Iontophoresis, Wait and See, Activity

Modification, Elbow Joint Mobilisation,

Cervical Spine mobilisation, Acupuncture,

Myofascial Release, Ergonomic Adjustments,

Autologous Blood Injection (ABI), GTN, etc,

etc, etc….

The Interface Rehabilitation

Establishing what phase of injury the pt is in

1) Reactive

2) Degenerative

Rehab Principles

Reduce pain (topical steroids, iontophoresis or cortisone

injection)

Unload tendon (Load management – education, rest,

postural advice, splinting)

Facilitate tendon adaptation, strengthening and stretching

Prolotherapy (Proliferative Injection Therapy):

• Autologous Blood Injection (ABI)

Thought to trigger inflammatory cascade and healing by either:

i) ? mediators in the blood itself or

ii) the injection itself

No difference between ABI and Saline (de Vos et al, 2010)

• High Volume Injections (HVI) – 20-30mls saline

Developing Evidence

The Interface Degenerative Group

The Interface

NERVE COMPRESSIONS

Carpal Tunnel

Guyons Tunnel

Cubital Tunnel

8/27/2014


Hand Clinic

The Interface - Carpal Tunnel Syndrome

Caused by compression of the median nerve at the wrist- many aetiologies

Nocturnal paraesthesia in median innervated digits

(also daily when holding phone/steering wheel/brushing hair)

Wasting of APB



The Interface

CARPAL TUNNEL SYNDROME

Tinel’s Test

Phalens Test -variants

NCS-amplitude

latency

action potential

velocity

8/27/2014


Hand Clinic


Conservative Treatment

Splinting overnight




Treatment

Surgical decompression open




Treatment

Splinting overnight

Surgical decompression -

endoscopic



The Interface

DUPUYTRENS CONTRACTURE

8/27/2014


Hand Clinic

The Interface


8/27/2014


Hand Clinic

Superficial fibromatosis affecting the palmar fasciae

The Interface - Dupuytren’s contracture

History

Felix Platter 1614

Astley Cooper 1822

Von Dupuytren 1832

Features

Palmar pitting

Nodules

Cords

Contractures

8/27/2014




AETIOLOGY

Genetic - autosomal dominant Celtic

- HLA B 27

Diabetes

Epilepsy ? Medication

Trauma

Alcohol-? coincidence

ASSOCIATIONS

Garrod’s Pads 40%

Lederhosen’s Disease 15%

Peyronie’s Disease 5%

8/27/2014




Surgery indicated

when MCP joint contracture reaches

30 ْ

when PIP joint starts contracting

triggering

8/27/2014



The Interface


8/27/2014


Hand Clinic

Minimal Surgical Approaches

Percutaneous Needle Aponeurotomy (+- Fat Injections)

Cord Fasciotomy

Segmental Fasciectomy

The Interface


8/27/2014


Hand Clinic

Less Minimal Surgical Approaches

Digital Fasciectomy

DermoFasciectomy +- Skin Graft

Total Fasciectomy

The Interface


Collagenase

Inject

Nerve Block/”Manipulate”/Rupture

Splint

8/27/2014


Hand Clinic

http://www.google.com.au/url?sa=i&rct=j&q=hand+based+extension+splint&source=images&cd=&docid=QLCHFeSySdJrxM&tbnid=RuX95pNmLRAEdM:&ved=0CAUQjRw&url=http://advancedhand.com/category/uncategorized/feed/&ei=YjaGUZ7JK828kQXCroH4Dw&bvm=bv.45960087,d.dGI&psig=AFQjCNElEAmrz6Hh5tb5ianxFq8mo7Cyhw&ust=1367836423328489

The Interface


Collagenase - Problems

Not yet TGA approved

?$1300 out of pocket per injection

Only One cord treatable per month

Post “op” pain, swelling, haematoma

?Long term results

8/27/2014


Hand Clinic

The Interface


Collagenase

Oh No ! Tendon Rupture

What does it mean?

8/27/2014


Hand Clinic

The Interface

COMPLEX REGIONAL PAIN SYNDROME

8/27/2014


Hand Clinic

The Interface

HAND INFECTIONS

Septic Arthritis

Suppurative Tenosynovitis

Deep Space infection

8/27/2014


Hand Clinic

The Interface

Perioperative Management of Medications

8/27/2014


Hand Clinic

Prednisolone

Methotrexate

Allopurinol

The Interface

Thankyou.

8/27/2014


Hand Clinic

The Interface

Any Questions?

8/27/2014


Hand Clinic

Documents

Hand Surgery and Rheumatology - the interface · What is Hand Surgery? PRINCIPALS Painfree anaesthesia Minimally invasive incisions Consideration of Anatomy and Pathological processes