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2/24/2015
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Hand and Wrist Injuries
John J Shaff, PA-CHand Surgery Specialists, P.C.
Hmmm...
The field of hand surgery deals with both surgical and non-surgical
treatment of conditions and problems that may take place in the hand or upper extremity (from the tip of the
hand to the shoulder).
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About me
Graduated Midwestern 2004General Orthopedics & Trauma 2004 to 07Hand and Upper Extremity 2007-15CAQ OrthopedicsTwo Boys, 3 and 5Run to burn off the crazy
Why/How did I get into Hand Surgery?
Objectives
-Review the most common hand and wrist issues-Describe the initial evaluation of these issues from a
Primary care perspective-Initial treatment-Recognize when to refer to a specialist
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Function of the Hand & Wrist
Multiple functionsDelicate, fine motions
Powerful, grasping tasks
Support / transfer force for changing positions
Sensory organ: perception of surroundings
Communication / express emotions
Complex anatomical structure“Structure follows function”
HAND FUNCTIONS
45% GRASP
45% PINCHSide pinch (key pinch)
Tip pinch (writing)
Chuck pinch (thumb to index/ring)
5% HOOK Carry bag
5% PAPERWEIGHT
HAND AND WRIST
HAND WRIST
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Anatomy – Hand and Wrist
BonesDistal radius
Distal ulna
Carpus (8 individual bones)
Metacarpal
Phalanges
JointsRadiocarpal joint
Distal radioulnar joint (DRUJ)
Intercarpal & midcarpal joints
Ligaments
HAND & FINGER ANATOMY
9 Finger FlexorsMedian nerveTransverse carpal ligament5 deep flexors pass through superficialis tendons
and insert on distal phalanx of each finger and thumb
4 superficial flexors insert on middle phalanx of digits 2-5
Annular ligaments = pulleys (A1-A5)PREVENT BOWSTRINGING
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HISTORY
Age
Handedness
Chief complaint
Occupation
Previous injury
Previous surgery
Sx related to specific activities
What exacerbates
What improves
Frequency
Duration
HISTORY
4 principle mechanisms of injury
Throwing
Weight bearing
Twisting
Impact
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PHYSICAL EXAMInspection
Palpation
Range of Motion
Neurologic Exam
Special Tests
INSPECTION
Observe upper extremity as patient enters room
Examine hand in function
Deformities
Attitude of the hand
INSPECTIONPalmar Surface
Creases
Thenar and Hypothenar Eminence
Arched Framework
Hills and Valleys
Web Spaces
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Cascade sign
Assure all fingers point to scaphoid area when flexed at PIPs
Types of Injuries
“Reactive” TraumaCumulative Trauma, Repetitive Strain
Gradual Injury
Acute InjuriesOpen vs. Closed
Reactive Trauma
Occurs in response to chronic exposure
Does not effect everyone
Pre-disposing factorsunderlying medical conditions
reactive physiology
environmental/social/emotional/financial stressors
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Reactive Trauma
Examples
Tendonitis/Tenosynovitis
Compressive Neuropathy
Epicondylitis
Myofascial Pain
Tenosynovitis
Swelling of the lining of a tendon
Specific, localizable and identifiable
Examples
trigger finger
deQuervain’s
intersection syndrome
some ganglions (e.g. flexor sheath ganglion)
Wrist Case
34-year-old female hairdresser with thumb pain for 2-3 months
Gradual onset
Now thumb hurts with any movement
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1st Dorsal CompartmentDeQuervains
Abductor Pollicis Longus and Extensor Pollicis Brevis
Radial border of Anatomic Snuff Box
Site of stenosing tenosynovitisDe Quervain’s TenosynovitisFinkelstein’s Test
DEQUERVAIN’S TENOSYNOVITIS
It’s time to refer if...
Tenosynovitis
no improvement with 4-6 weeks of
splinting
therapy (CHT)
steriod injection
co-morbid diabetes mellitus or RA
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Trigger Finger
Stenosing flexor tenosynovitis
Painful snap or lock
Palpate nodule as digit flexed and extended
It’s time to refer if...
Trigger Finger
no improvement with rest
splinting
steriod injection -*****caution*****
co-morbid diabetes mellitus or RA
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Compressive Neuropathy
Median NerveCarpal Tunnel Syndrome
Pronator/Anterior Interosseous Syndrome
Ulnar NerveCubital Tunnel Syndrome
Guyon’s Canal Syndrome
Radial NerveRadial Tunnel Syndrome
Wartenburg’s Syndrome
Carpal Tunnel Syndrome
CausesBMI
diabetes
thyroid disease
pregnancy
occupational
idiopathic
Diagnosisnighttime numbness
morning paresthesia
provocative testing
electrodiagnostic studies
Treatmentcurable only by surgery
non-surgical (palliation)
splinting (sleep only)
corticosteroids
activity modification
antidepressants
modalities
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Carpal Tunnel Syndrome
Entrapment of the median nervePhalen’s and Tinel’s Test
2 point discrimination
SymptomsAching in hand and arm
Nocturnal or AM paresthesias
“Shaking” to obtain relief
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It’s time to refer if...
Carpal Tunnel Syndrome
no improvement with six weeks of
night time wrist splinting
activity modification
Vit B6 100mg QD
any evidence of thenar weakness
Tip: send patient with NCV/EMG
Thenar atrophy
Cubital Tunnel Syndrome
Ulnar nerve compression at the elbow
Numbness to small and ring finger
Causesexternal compression
elbow trauma (dislocation, fracture)
anatomic abnormalities
Can lead to permanent weakness
Residual symptoms after surgery common
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Cubital Tunnel Syndrome
It’s time to refer if...
Cubital Tunnel Syndrome
no improvement with six weeks of
activity modification
elbow awareness
any evidence of intrinsic weakness
Tip: send patient with NCV/EMG
Ganglion Cyst
Typically starts as general complaints of wrist pain
Usual history of recent or remote trauma
Most common sites are dorsal wrist and volar radial
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Ganglion Cyst
Bible thumpers
It’s time to refer if...
Ganglion Cyst
4-6 weeks of splinting does not resolve
Failed aspiration
***Only attempt dorsal
Persistent pain
Acute Trauma
Fingertip Injuries
Replantation
Mutilating Trauma
Fractures
Infections
Wrist Injuries
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Fingertip Injuries
Most common finger injury
Most do not require surgery
Goals of treatmentpreservation of length
painless
appearance
Sensitivity is significant problem
Fingertip Injuries
OrthoArizona Arizona Hand & Wrist Specialists
Tuft Fracture/crush injury
Tuft fracture
Subungal Hematoma
Subtotal amputation
Volar oblique amp
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OrthoArizona Arizona Hand & Wrist Specialists
Subungual hematoma
Evacuate hematoma with 18-guage needle or electrocautery.
Dressing and splint
It’s time to refer if...
Fingertip Injuries
open injuries with tissue loss
complex lacerations
exposed bone
displaced fractures
initial attempt at close is fine
Tip: always get xrays, always, open fx needs abx
Fingertip Injury
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Fingertip Injuries
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Thenar Flap Reconstruction
Fingertip InjuriesThenar Flap Reconstruction
Fingertip Injury: Thenar Flap
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MALLET FINGER
ANATOMYDorsal avulsionExtensor digitorum tendon tear
MECHANISM:Forced flexion of extended digit
TREATMENT:No fracture: DIP extended for 8 weeksFRACTURE: if <30% joint surface, splint x 4 weeksIf >30% refer for ORIFLess than full passive extension refer
COMPLICATIONS:Pressure necrosis from splintPermanent extensor lag
MALLET FINGER
Wrist #1
24-year-old male FOOSH while skiing over the weekend
Seen at the mountain clinic and told “wrist sprain”
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Scaphoid Fracture Pathoanatomy
Blood supplied from distal poleIn children, 87% involve distal poleIn adults, 80% involve waist
Scaphoid Fracture Imaging
Initial plain films often normalBone scan
100% sensitive 92% specific at 4 daysMRI, CT scan
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SCAPHOID FRACTURE
TREATMENTInitial radiographs positive
distal third heal in approx 6-8 weeks
middle third frx heal in 8-12 weeks
proximal third heal in 12-23 weeks
Initial radiographs negativeImmobilize thumb spica cast x 7-14 days
Take out of cast, repeat xray, re-evaluate for tenderness
If +tenderness but neg radiographs…Cont. splint and MRI
Scaphoid Fracture
Treatment
Suspected fracture with normal plain films
Short arm thumb spica (splint or cast)
F/U in 7-14 days
Consider MRI
Scaphoid Fracture
TreatmentNon-displaced fracture
Long arm thumb spica cast 6 weeksThen, short arm thumb spica cast for 4-14 weeks
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Scaphoid Fracture
Refer to OrthoAngulated or displaced (1mm)Non-union or AVNScapholunate dissociationProximal fracturesLate presentationEarly return to play
Fractures
Most do not require surgery
Soft tissue injuries frequently overlooked or undertreated
Open fracturesfrequently require operation
risk of infection (osteomyelitis)
Wrist Case
25-year-old tennis player twists wrist as he falls backwards reaching for a lob
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SCAPHOLUNATE DISSOCIATION
SCAPHOLUNATE DISSOCIATION
EXAMWatson’s test (scaphoid shift test)
Scaphoid shuck test
Pain/swelling over dorsal wrist, prox row
DIAGNOSISPlain films: >3mm difference on clenched fist
Scaphoid ring sign
MR Arthrogram
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TREATMENTIf discovered within 4 weeks, surgery
After 4 weeks, conservative treatment reasonable
Bracing
NSAIDS
Referral to hand surgery to confirm if surgery needed
Fractures
FracturesMetacarpal and Phalangeal
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Distal Radius Fractures
Most common wrist fracture
Mechanism: FOOSH
Intra- vs extra-articular
Often associated with ligament injury
Intra-articular fractures should be treated by hand surgeons
1/3 develop carpal tunnel syndrome
It’s time to refer if...
Fractures
displaced or unstable
multiple
open
any wrist fracture
Tips: splint and refer early
antibiotics for all open fx
meticulous wound care
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External Fixation
Wri
st F
ract
ure
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Acute Wrist Injuries
“Wrist sprain” is a diagnosis of exclusion
Severe ligamentous injuries frequently missed
Chronic complaints = severe injury
Window of opportunity is limited
Arthroscopy has emerged as definitive diagnostic procedure in wrist pain
MRI
Every patient wants one
should be ordered selectively
sensitivity/specificity as low as 40%
rarely useful in acute management of injuries
helpful instaging of Kienbock’s disease
soft tissue/bone tumors
occult fractures
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Flexor Tendon Injuries
Should be treated by experienced hand surgeon
Nerve injuries are commonly associated
Certified hand therapist involvement essential
Stiffness is common
Injured hand will be out of commission ~12 weeks
1/3 require secondary operations
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OrthoArizona Arizona Hand & Wrist Specialists
Questions?????
602-812-7520 (Office)
www.phxhand.com
