Complaints of hand and wrist

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Complaints of hand and wrist

• Wim Willems
• HOVUmc, Amsterdam

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Program

• Basic anatomy
• Common complaints
• Practice

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Anatomy
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Intrinsic flexors
Volar view
Dorsal view
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Extrinsic flexors
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Extensors
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Nerves
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Elderly lady with a painful thumb

• Female, 78 years old
• Pain thumb right hand
• Difficulty with sewing / opening pots

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Elderly lady with a painful thumb

• Questions?
• Physical examination?
• Further examination?
• D.d.?

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Arthrosis

• Start of arthrosis in DIP most common
• Heberdens nodules
• CMC-1 (possibly afflicted relatively young)
• Grind test

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Grind test
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Heberdens nodule
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Treatment
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Arthrosis CMC I
Injection Splint Avoid operation as long as
possible
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Arthrosis CMC I
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Finger gets stuck

• Female, 45 year
• Right hand
• Palmar pain/ middle finger
• Impossible to straighten finger

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Finger gets stuck

• Questions?
• Physical examination?
• Further examination?
• D.d.?

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Trigger finger
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Pathofysiology

• Thickening of tendon / tenosynovitis of m.flexor
  digitorum communis
• Finger triggers

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Epidemiology

• Few data
• life time prevalence, gt 30 jr, no DM 2.2.
• Connected with DM, carpal tunnel syndrome,
  reumatic arthritis, hypothyreoidy.

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Treatment
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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 - gt90

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Trigger finger injection 1

• Needle short and thin (eg 0,6x25mm or
  (0,45x23mm)
• Volume 1 ml TCA
• 10 mg/ml (optional 1ml Xylocaine 1)
• Performance insert needle from distal to
  proximal along axis of metacarpal bone
• In MCP fold (2cm from first falangeal fold)

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Trigger finger injection 2

• Preferred angle 45 degrees
• Ca. 1ml around tendon
• Subcutaneous injection is as effective as
  injection in tendon sheath
• No pressure
• Effectiveness 70-80 after 1-3 injections

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Operative treatment

• Open or percutanous.
• Success gt90
• More complications (nerve damage, inflammation)

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Painful thumb

• Man, 37 years
• House painter
• Pain radial side wrist

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Painful thumb

• Questions?
• Physical examination?
• Further examination?
• D.d.?

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De Quervains disease

• Tenosynovitis of m.abductor pollicis longus and
  m. extensor pollicis brevis (APL EPB)
• distal end radius
• Women gt men, 35-55 yr.
• Presentation in general practice 5,6/1000
• Often recurrent esp. when crepitations

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Etiology

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

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M.de Quervain onderzoek

• Finkelsteins test

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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

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M.de Quervain injection treatment

• Slight pronation
• Feel for common sheath
• Insertion of needle by small angle
• 1ml TCA infiltration
• Effectiveness 70-80 after 1-3 injections
• Approach from proximal or distal possible

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Injection M. De Quervain
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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

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Painful nightly tingling

• Questions?
• Physical examination?
• Further examintion?
• D.d.?

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Carpal tunnel syndrome
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Epidemiology

• Open population (history nerve conduction
  examination)
• Female 9
• Male 0,6
• Peak between 40-60 year

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Risk factors

• Weight
• Pregnancy
• Diabetes mellitus
• Hypo/hyperthyreoidy
• Ovariectomy
• Anatomic deviation (traumatic / RA / congenital)
• Work related

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Natural course

• ¼ - 1/3 significant improvement gt 1 year
• After pregnancy 50 without complaints

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Pathofysiology

• Narrow tunnel
• compression n. medianus in carpal tunnel
• 90 idiopatic

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Diagnosis history

• Dutch consensus (CBO 2006)
• Nightly tingling
• Median nerve area
• Sleep disturbance
• Other tingling / pains
• Flapping (Flicks sign)
• Advanced stages tingling during the day

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Sensory innervation N. Medianus
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Atypical localisations tingling sensations in
carpal tunnel syndrome

• Often outside median nerve area
• Sometimes ulnar nerve area

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Provocation tests

• CBO 2006
• Limited usefulness

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Diagnostic tests CTS
C.A.
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Tests

• Tinel percussion median nerve
• Phalen flexion during 60 seconds
• Further -sensory loss median nerve area
• -thenar dystrophy
• -dry skin (thumb / index / middle finger)

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Neurophysiological examination

• Verification of clinical diagnosis prior to
  operation

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Limitation EMG

• No golden standard
• 10-15 false negative
• No relation between complaints and results
• Results not predictive for therapy
• Value unclear for primary health care

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Treatment
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Splint

• Day and night
• Short term effective
• Minor complaints / recent onset

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Surgery

• Highly effective
• Major / recurrent complaints. Patients wish
• Open / endoscopic
• Success 75-90
• Complications damage to nerve, pain, scar,
  complex regional pain syndrome)

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Corticosteroid injection

• Several techniques
• 1. Underneath retinaculum (most common technique)
• 2. Through retinaculum
• 3. In front of retinaculum (method by Dammers)
• Safe
• Effective
• Tradition / experience / authority determines
  technique

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Medicament / Dosage

• Most common Triamcinolonacetonide 10 mg/ml
  (Kenacort A10), or methylprednisolonacetaae
  (Depo-Medrol) 40 mg/ml
• Volume 1-2ml
• Interval between injections 1-3 weeks
• Effectiveness 1st injection 80, after 2
  injections 15, after 3 injections 5

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Needle?

• -orange/ light brown (0,45x23mm)
• -light blue (0,5x25mm)
• -green (0,8x40mm)

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Localisation carpal tunnel
Os pisiforme
Os scaphoideum
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Localisation tendon m. Palmaris longus
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Tendon m. Palmaris longus

• Absent tendon ulnar to median axis

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Localisation insertion

• ulnar to tendon m. palmaris longus
• Depending on technique used
• On distal wrist line( between tuberculum of os
  scaphoid and os pisiforme)
• On proximal wrist line
• 3-4 cm before distal wrist line

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Injection underneath retinaculum

• On proximal wrist line
• Angle 30 degrees

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Injection underneath retinaculum

• Tingling while inserting needle withdraw and try
  again
• Respect resistances

Tendon m. palmaris longus
2nd wrist line
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injection through retinaculum.

• Distal wrist line
• 45 degrees

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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

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Hygiene

• Wash hands, wear gloves or disinfect fingers
• Once-only ampoules
• Change needles
• Disinfect skin

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Side effects and complications

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

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Practice

• Anatomy
• Injection