COMMON HAND COMMON HAND PROBLEMS RELATED PROBLEMS RELATED

TO WORKTO WORK

Prasad G. Kilaru MD

Plastic, Reconstructive & Hand Surgery

AgendaAgenda

Injury typesBasic anatomy Mechanism of actionDiagnosisTreatment Prevention Education

Repetitive Stress InjuryRepetitive Stress Injury Nerve:

– Carpal tunnel syndrome, cubital tunnel syndrome

Tendon: Connects muscle to bone– Repetitive injury at muscle insertion

Trigger digit, DeQuervain’s tenosynovitis

– Repetitive injury at muscle origin Lateral epicondylitis, Medial epicondylitis

Ligament: Connects bone to bone– Chronic collateral ligament injury, TFCC injury

Joint Problems– Ganglion cyst, Mucous cyst, Basal joint arthritis

Traumatic InjuryTraumatic Injury

Tendon injury– Flexor, extensor, muscle belly injury– Injury to tendon insertion

Mallet finger, Flexor tendon avulsion

Bony InjuryNerve InjuryJoint Injury

– Sprain, dislocation

Anatomy - NerveAnatomy - Nerve

Median nerve – Mixed nerve– Sensory – Volar aspect of palm and radial 3 ½ fingers– Motor – Major finger and wrist flexors, thenar muscles

and radial lumbricals

Ulnar nerve – Mixed nerve– Sensory – Ulnar aspect of volar and dorsal palm and

ulnar 1 ½ fingers– Motor – Ulnar wrist and finger flexors and intrinsic

muscles of the hand

Anatomy - NerveAnatomy - Nerve

Anatomy - NerveAnatomy - Nerve

Radial nerve – Mixed nerve– Sensory – Dorsal aspect of hand and radial 3 ½ fingers

dorsally– Motor – Extensors of the elbow, wrist and fingers

Sensory to palm and fingers– Volarly – Radial 3 ½ fingers and palm – Median nerve,

Ulnar 1 ½ fingers and palm – Ulnar nerve– Dorsally – Radial 3 ½ fingers and hand – Radial nerve,

Ulnar 1 ½ fingers and hand – Ulnar nerve

Anatomy Carpal TunnelAnatomy Carpal Tunnel

Anatomy of Flexor Pulley SystemAnatomy of Flexor Pulley System

Anatomy – Extensor Anatomy – Extensor CompartmetnsCompartmetns

Mechanism of ActionMechanism of Action

Repeated movement/use causes swelling over affected region

Repeated movement/use despite swelling causes worsening of swelling

Feedback loop set up with worsening symptoms Depending on the structure effected – numbness,

pain, locking etc.

Nerve Compression SyndromesNerve Compression Syndromes

Median nerve compression (carpal tunnel syndrome) occurs from compression of the nerve at the wrist

Ulnar nerve compression can occur at the wrist or elbow Radial nerve compression usually occurs in the forearm Pressure buildup can occur from decrease in the size of the

tunnel(bone overgrowth, fracture) or increase in the volume of the contents of the tunnel(tendinitis, fluid buildup etc.)

TendinopathiesTendinopathies

Repeated movement/use of tendons causes tendons to swell up and get trapped in tunnels either over fingers or wrist (trigger finger, DeQuervain’s tenosynovitis)

Repeated movement/use at tendon origin causes microtears which cause chronic tears near common extensor (lateral epicondylitis) or common flexor (medial epicondylitis) origin

Nerve Compression Signs & Nerve Compression Signs & SymptomsSymptoms

Symptoms commonly include pain, numbness, tingling and in late stages weakness in grip

Symptoms are usually felt at night and can occasionally wake patients from sleep

The numbness is usually along the distribution of the effected nerve

Severe cases can result in muscle wasting with weakness and permanent sensory loss

Nerve Compression DiagnosisNerve Compression Diagnosis

History and physical examination are usually indicative of nerve compression

Tinel’s sign, nerve compression test, Phalen’s test are all positive

Nerve conduction study and EMG are often confirmatory

Tendinopathy DiagnosisTendinopathy Diagnosis

Usually presents with locking or snapping of the finger or thumb on flexion that holds the finger in flexion(trigger finger)

There is usually tenderness over the MP joint volarly and a nodule or thickening is usually palpable in the same region(trigger finger)

Pain over the first dorsal compartment at the anatomic snuff box (deQuervain’s tenosynovitis)

Finkelstein’s test is usually positive (deQuervain’s tenosynovitis)

Tendinopathy DiagnosisTendinopathy Diagnosis

Patients usually have point tenderness over the lateral or medial epicondyle (epicondylitis)

Pain can be reproduced by wrist or finger extension (lateral epicondylitis) or flexion (medial epicondylitis)

Treatment OptionsTreatment Options

Noninvasive options – Initial approach– Ergonomic evaluation– Work modification, – Splints/braces that immobilize the affected area – NSAIDS or steroidal anti-inflammatories– Topical anti-inflammatory modalities, ice, – Physical therapy

Treatment OptionsTreatment Options

Steroid injections– At least 3-4 months apart, no more then 2 a year– Avoid injections near nerves– Side effects

Surgical options – When conservative measures fail or cannot be

implemented– In late cases – severe compression on NCS/EMG

Treatment OptionsTreatment Options For compressive pathology - basic principle is to

release the area of constriction– transverse carpal ligament for carpal tunnels syndrome– A1 pulley for trigger digits– First dorsal compartment release

For nerve compression, surgery reverses symptoms for early cases and prevents progression of disease in late cases

“Wont get any worse – how much better depends on extent of the damage”

Surgery usually a cure – recurrence rare

Treatment OptionsTreatment Options

For tendinopathies, surgery considered when conservative therapy fails

Requires debridement of the inflamed tendon and associated bone spurs and reattachment of the extensor/flexor origin

Recovery longer with surgery around elbow Therapy needed for splinting, movement etc.

Preventive MeasuresPreventive Measures

Prevention of repetitive trauma – Ergonomic evaluation and implementation– Regular stretching and strengthening

“Preparation for a marathon”

– Learning to recognize early symptoms– Preventive maneuvers

EducationEducation

Teaching patients to recognize early symptoms

Preventive measures– Medication– Splinting– Anti-inflammatory modalities– Stretching and strengthening exercises

Ligament InjuriesLigament Injuries

Chronic collateral ligament injuries– Usually common to the MP joint of the thumb– Splinting, casting, surgery

TFCC injury– Involves ulnar aspect of wrist– Related to trauma or repetitive injury– Splinting, steroid injections, casting, surgery

Basal Joint ArthritisBasal Joint Arthritis

CMC joint of the thumb most common site for degenerative arthritis in the hand

Related to chronic repetitive use or previous injuries to the thumb

Starts with pain at the base of the thumb, progressing to weakness

Treatment entails rest, NSAIDs, splinting, steroid injections and surgery

Ganglion CystsGanglion Cysts

Common soft tissue mass over the hand or fingers, is a ganglion occasionally associated with repetitive or strenuous activity

Can be volar or dorsal, over the wrist or fingers Treatment

– If asymptomatic, can be left alone– Aspiration of the cyst, rupture(by over inflation) or

infiltration with steroids has a high rate of recurrence(>50%)

– If symptomatic, resection is usually recommended

Mallet FingerMallet Finger

“Droop” of the DIP joint of a finger with intact passive extension, but no active extension

Usually due to avulsion of the tendinous insertion of the extensor tendon or a fracture avulsion at the base of the distal phalanx

This requires splinting in extension for a prolonged period of time and if a fracture is present or is chronic may require surgical correction

SummarySummary

Careful history and physical examination usually goes a long way in obtaining a diagnosis

Rest, splinting and NSAIDS a good start for most repetitive injuries

Ergonomic evaluation can resolve or prevent many cumulative trauma disorders

Early referral to a hand surgeon, can prevent delay in diagnosis or treatment of many common hand problems

Take Away PointsTake Away Points

Patient and employer educationPreventionEarly interventionDiagnosis & treatment

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