mike foster - goodfellow unit
TRANSCRIPT
Mike Foster
Hand, Wrist and Elbow
Dupuytrens Disease • First described in 1614 by
Felix Platter
• 1777 Henry Cline recognised disease involved palmar fascia
• 1822 Sir Astley Cooper advocated fasciotomy
• Popularised by Dupuytren in 1831
Pathophysiology
• Normal fascial bands • Myofibroblast
• Diseased cords form
from normal fascial bands
• Fixed flexion contracture
Associations
• Family history
• Northern European descent
• Male: Female 9:1
What the Patient Says
• I can’t get my hand in my pocket
• My finger pokes me in the eye when I wash my face
• My finger keeps catching on objects
What to Look For
• Thickening of the skin
• Tethering of palmar skin
• Surface rippling and dimpling
• Obvious cord
When to Refer
• 30 deg contracture at MCPJ
• PIPJ involvement
• Table top test
Treatment Options
• Percutaneous needle
• Fasciotomy
• Partial fasciectomy
• Dermatofasciectomy and full thickness skin graft (FTSG)
NZ Standard of Care
• Partial fasciectomy
• Brunner incisions or closure with Z plasties
• FTSG for skin deficits
Collagenase
• Collagenase Clostridium histolyticum
• An enzyme, derived from a bacteria
• Recently completed phase 3 trials
• Marketed as Xiaflex (FDA approved)
How Is It Given: Day 1
Have We Got a Video?
Skin Tears Heal Quickly
Day 1 Day 3 Day 8
CORD 1 (US) • Phase III clinical trial
• 90 day randomised, double-blind placebo controlled
• 308 patients from 16 centres
• Contractures of MCP +/- PIP of > 20° • Success = correction to less than 5° contracture • 64% joints injected with collagenase corrected • 6.8% joints injected with placebo corrected • Average contracture reduction @ 30 days
– 50.2° to 12.2° in Collagenase group – 49.1° to 45.7° in placebo group – MCP more likely to correct, corrected more fully
• 2 Flexor tendon ruptures, 1 CRPS
CORD 1 Results MCPJ PIPJ
CORD II (Australia) • Phase III clinical trial
• 90 day randomised, double-blind placebo controlled
• 66 patients
• Contractures of MCP +/- PIP of > 20° • Success = correction to less than 5° contracture • 50.7% joints injected with collagenase corrected • Average contracture reduction @ 30 days
– 70.% in Collagenase group – 13.6% in placebo group – MCP more likely to correct, corrected more fully
• 1 Pulley rupture, no tendon ruptures • CORD 3
• Injection of two digits, yet to be published
Complications • Flexor tendon ruptures • Tendonitis • Pulley Rupture • Finger deformity • Urticaria • Allergy • Immune reaction • Localised oedema • Pain • Contusion • Injection site haemorrhage • Skin tear • Complex regional pain
syndrome • Boutonnieres deformity
Probable Role of Collagenase
• When it becomes available in NZ
• MCPJ contractures
• Elderly
• Medical co-morbidities
NZ Concerns • Complications even
under experienced surgeons
• Lack of long term follow-up
• Recurrence rates • Difficulty of revision
surgery • Cost
NZ Hand Society Conference Queenstown 2012
CORD Five Year Data
• 50 % Recurrence Rate at five year • In successfully treated fingers
If orthopaedics can’t help!
Carpal Tunnel Syndrome
• Most common compressive neuropathy in the upper limb
• Women > Men
Aetiology
Anatomy • Carpus dorsally
• Transverse Carpal
Ligament volarly
• Ten structures pass through the tunnel
• Median nerve most superficial
History
• Nocturnal pain, numbness and tingling
• Thumb and radial digits
• Shaking of hand
• Dropping objects, difficulty with buttons
Symptoms
Examination
• Cervical causes, Spurling’s manoeuvre
• Tinel’s
• Phalen’s
• Durkan’s
Nerve Conduction Tests
• Distal Motor Latency > 4.5ms
• Distal Sensory Latency > 3.5ms
• Chronic cases EMG changes in APB
• Helpful in confirming diagnosis
Non-Operative Treatment
• Splinting
• NSAIDS
• Steroids
• Diuretics
Steroid Injection
• Risk to median nerve
• Useful for diagnosis
• Temporary effect
• Diabetics
• Pregnancy
Open Carpal Tunnel Release
• Gold Standard
• LA vs. GA
• Neurolysis not recommended
Complications
• Infection • Nerve injury • Haematoma • Pillar Pain • Wound Pain • CRPS
ECTR
• The standard practice in Brisbane
• Technically more demanding
• ? Less wound pain and an earlier return to work
• Need to convert to open in up to 10% cases
Have We Got A Video?
Complications
• Infection • Nerve injury • Haematoma • Pillar Pain • Wound Pain • CRPS
Open vs. Endoscopic
• 128 patients 25 to 60 years old
• Less pain in scar in ECTR group • No difference in return to work, both 28 days
My Current Practice
• Night splint for marked nocturnal symptoms
• Open carpal tunnel release as standard
• Endoscopic at patient’s request
• Endoscopic for bilateral procedures
Trigger Finger
Treatment for Trigger Finger
• Injection 10 mg Kenocort and LA
• Should inject easily
• 80 % successful
• Surgical release if failed injection or multiple fingers
Mucous Cyst
• Ganglion cyst
• Arising from degenerate DIPJ
• Can cause nail deformity
• Surgical Debridement +/- Fusion
Glomus Tumour
• Bluish discolouration under nail
• Extreme sensitivity to cold
• Severe pain
Surgical Excision
Fishmouth Incision Circumferential
Ganglions
• Most common soft tissue lump in the hand
• Dorsal arises from SL ligament
• Nuisance
• Fluctuates in size and shape
Investigation and Tx
• Trans illumination
• Aspiration
• Ultrasound solid vs. cystic
• Surgical excision
Other Lumps and Bumps
LIPOMA
Other Lumps and Bumps
PVNS
De Quervains
• Radial Sided wrist pain
• Mothers with infants
• APL and EPB form first dorsal compartment
• High incidence of separate compartments
De Quervains Dx and Tx
• Finkelsteins Test
• Splint that includes thumb
• NSAIDS
• Steroid injection
• Surgical release
CMC Joint Arthritis
• Pain at base thumb
• Difficulty opening a jam jar
• Positive Grind Test
Non Operative TX
• Activity modification
• NSAIDS
• Splint
• Injection
Operative Treatment
Trapezectomy
50 % FCR
LRTI
What NSH doesn’t take.
• Flexor tendon injuries
• Nerve injuries
Important Phone Numbers
• MMH hand acute phone 021 804 896 • MMH plastic acute phone 021 784 057 • Karen’s phone 021 414 602 • Mike’s phone 021 417 651
• Simon Chinchanwallah’s phone 027 295 0007 • Albert Yoon
Good Web Site
“orthobullets”
Thank you