subodh deshmukh consultant hand and upper limb surgeon the
TRANSCRIPT
Subodh Deshmukh!Consultant Hand and upper limb surgeon!
The Royal Orthopaedic Hospital!
Complex of 3 joints:-!
Humero-ulnar!– Complex hinge!– Flexion/extention!
Radio capitellar!– pronation/supination!
Proximal radio ulna!– pronation / supination!
Bony anatomy leads to inherent stability!
Complex bony & ligamentous anatomy!
Ulnar nerve!
Radial nerve!
Median nerve!
Cutaneous nerves !
Pain & stiffness !
Locking- loose bodies !
Pins & needles , hand weakness!
Look: scars, sinuses, muscle wasting, deformities!Feel: Tender areas, palpate lumps!Move: active and passive ROM Flexion/Ext,
Pronation/supination!Measure: Muscle girth in forearm, and arm!Special tests: elbow flexion test for cubital tunnel
syndrome!
Tennis Elbow: lateral epicondylitis (extensor) ! Golfers Elbow: medial epicondylitis (flexor)! Olecranon bursitis! Osteoarthritis! Cubital Tunnel Syndrome (ulnar nerve compression)!
Often middle aged (35 - 50)! Pain can commence after minor trauma.! May be recent history of excessive activity
involving that elbow (rarely tennis ! Dusting, sweeping, heavy gardening etc).!
Golferʼs elbow similar history but medial pain less common than tennis!
Tennis elbow:!– Lateral elbow pain reproduction on resisted
wrist extension(Mills' Test)!
Golferʼs elbow:!– Medial elbow pain reproduction on resisted
wrist flexion.!
Non operative!
– Activity modification!– NSAIDS!– Clasp!– Physiotherapy!– Ultrasound!– Streroid injections!
Operative!
– decompression!
Gradual onset pain and stiffness ! Can be pos-trauma e.g fractures/ fracture
dislocation! Treatment is symptomatic with Rest, physiotherapy
and analgesia.! May lead to loose body formation and may require
arthroscopic removal and debridement! In extreme cases joint replacement can be
considered!
Pain/paraesthesia in ulnar nerve distribution! Provocation of symptoms on forced elbow flexion
for > 20 secs! Weakness in hand and loss of dexterity! Hypothenar muscle wasting! Intermetacarpal Guttering! Wasting of the first dorsal interosseous and
Adductor Pollicis! +ve Fromentʼs sign, inability to hold paper between
fingers!
+ve Fromentʼs sign" Intrinsic muscle wasting" INVESTIGATIONS: +ve nerve conduction studies
showing slowing in Ulnar nerve conduction velocities across the elbow joint!
MANAGEMENT!– Cubital tunnel decompression!
– Ulnar nerve anterior Transposition!
Inflammation of olecranon bursa!
Can be pain free!
May get infected by inoculation by foreign bodies!
Management! May resolve spontaneously! May require incision and drainage! May require excision!
Flexor and extensor retinaculum.!– Median nerve passes deep
to FR with flexor tendons. Except for palmar cutaneous branch which is superficial!
Sensory supply to hand from ulna, median and radial nerves.!
Nerve compression Syndromes!– Carpal Tunnel Syndrome!– Cubital Tunnel Syndrome!
Arthritis!– rheumatoid!– osteoarthritis!
Trauma!– Tendon injuries!– Chronic injuries!
Swellings!
Dupuytrens!
Wrist pain !– specific wrist pathology or generalised
condition!– onset!
rapid: trauma or infection! slow: degenerative!
– association with other joint problems!– other obvious conditions e.g. RA!
hand dominance! history of previous injury!
– e.g. Collesʼ fracture, scaphoid fracture! job / occupation!
– ability to continue with this!– what does job involve?!
hobbies!– musical instruments!
night pain ! pattern of symptoms!
– aggravating and relieving factors!– worse after activity / use!
swelling of the wrist/surrounding tissues!
Hand pain!– Many similar features to wrist pain!– Specific location e.g. base of thumb!– Neurological origins!
pain distribution!– carpal tunnel syndrome!– ulnar neuritis!
precipitating events!– holding paper up!– night time symptoms !– other medical conditions Thyroid, RA, DM!
Functional problems:!– lack of grip strength!– dropping items and “clumsiness”!– triggering of fingers!
lack of ability to straighten fingers!
swellings!– rapidity of onset!– soft or hard !– diffuse single or multiple!
other swellings on bony areas in the body!
Look: scars, sinuses, muscle wasting, deformities!Feel: Tender areas, palpate lumps!Move: active and passive ROM!Measure: Muscle girth in forearm,!Special tests: Tinelʼs and phalenʼs test, muscle
power of the intrinsics, thenar and hypothenar muscles and long flexors and extensors of the fingers, instability signs in MCPJ of the thumb in Gamekeeperʼs thumb!
Testing APB" Testing FPL" Testing Opponens pollicis" Testing opponens pollicis "
Hypothenar mucles and Firsr dorsal interosseous" Interossei testing"
Partial claw due to ulnar nerve involvement. Lumbricals of index and middle fingers still working because they are supplied by median nerve and prevent clawing of those two fingers"
Total clawing due to median and ulnar nerve involvement"
Testing for Flexor digitorum superficialis"
Testing for Flexor digitorum profundus"
Testing Extensor pollicis longus" Testiing EDC action"
very common! females often! may not be symptomatic! symptoms do not
necessarily correlate with x-rays!
Treatment:! !splint + analgesia! ! injection! !excision! !arthrodesis! ! replacement!
Preop xray" Post trapeziectomy"
Post CMCJ implant arthroplasty"
Post 1st CMCJ fusion"
Other changes DIP joint arthritis (Heberdenʼs nodes)!
mucous cysts.! Treat hand therapy!
– Hot wax and NSAIDs! Arthroplasty (MCP and PIP) ! Fuse DIP! Interposition arthroplasty!
Systemic autoimmume disorder !
Predominantly synovial invovement! Goals of treatment!
– !1) pain relief !!– !2) improved function !– !3) prevent further damage !– !4) cosmesis!
Synovitis can lead to: !Cartilage destruction by pannus
(inflamatory granulation tissue)!
Tendon compression and rupture!
Nerve compression!
Erosion and dislocation of joints!
Early synovitis ! !-medical management!
Persistent synovitis !-synovectomy!
Specific deformity !-corrective reconstruction &/or ! joint replacement or joint fusion!
Severe crippling ! !-joint replacement or joint fusion!
MCP ulnar drift !– cause soft tissue stretch
and ulnar subluxation of the extensors !
Therapy and medical treatment !
Surgical rebalance of muscles and realignment of the extensor tendons !
New MCP joints!
Silastic MCPJ replacement " Pyrocarbon replacement arthroplasty"Metal on Polyethelene arthroplasty"
Hyperextended PIPJ! Flexion deformity DIPJ! Can occur due to problems
in the MCPJ (volar subluxation) or in the PIPJ (synovitis)!
Treatment:!– early – splinting!
– late – soft tissue !correction or fusion!
– sometimes treating more proximal problems may resolve the deformity!
Central slip rupture or elongation due to trauma or synovitis respectively of the PIPJ initiate the deformity!
Later on Lateral bands migrate in a palmar direction and act as flexors of the PIPJ and the deformity becomes fixed!
Therapy and splintage!
Soft tissue procedures!
PIPJ Fusion, !
PIPJ arthroplasty +/- DIPJ fusion!
PIPJ fusion"PIPJ replacement and DIPJ fusion"
Flexion of DIPJ which corrects passively.! Occurs due to rupture/avulsion of extensor
tendon from distal phalanx.!
Usually treated with mallet splint.!
Long standing and severe deformities may require DIPJ fusion!
Synovitis of the wrist is common Synovitis leads to subluxation and collapse of the wrist joint !
If medical treatment fails open synovectomy can be undertaken!
If not consider Wrist fusion or replace mentwhich provides a stable base for hand function and !
Darrach procedure (excision of the ulnar head) for painful/subluxed DRUJ!
Fibrosis of longitudinal structures in palmer fascia leading to contractures of MCPJ & PIPJ!
Can be associated with!– penile fibrosis (Peyronieʼs disease)!– sole of feet (Ledderhoseʼs disease)!
Thick knuckle pads (Garrodʼs)!
Risk factors" Northern European Races! Chronic alcoholism! Liver disease! Smoking! Diabetes! Epilepsy / Antiepileptics ! Family history
(Dupuytrenʼs diathesis)!
Consider surgery if affecting function!– Washing face - poking eye!– Hand shake!– Canʼt put hand in pocket!– Work place risks!
Types of surgery! Collagenase injection! Aponeurotomy! Partial fasciectomy! Dermofasciectomy and full thickness graft! External fixator distraction!
Partial fasciectomy"
Dermofasciectomy and full thickness skin graft "
Complications of surgery !– nerve and vessel damage!– Joint stiffness !– Haematoma and infection!– recurrrence!
Congenital or acquired !
Thickening of the flexor tendon such that it does not pass through the sheath.!
Treatment ! Local injection or ! Surgical release!
Usually occur spontaneously! Contain gelatinous fluid due to mucoid
degeneration of the synovium.! Develop around joints or tendon
sheaths, and usually communicates with the joint.!
Most common around the wrist. Dorso radial or volar radial !
Can be intermittently painlful! Treatment=aspiration or excision, ! Beware of recurrence!!
Inflammation affecting EPB and APL.tendons and their sheaths!
Women more often affected! 30-50yrs.! Finkelsteinsʼs test.! Treatment!
– Rest and NSAIDʼs.!– Corticosteroid injection.!– Surgical Decompression.!
Causes (ICRAMPS)"• Idiopathic ( commonest)"• Colles, Cushings "• Rheumatoid "• Acromegaly, amyloid "• Myxoedeoma, mass, (diabetes) mellitus "• Pregnancy "• Sarcoidosis, SLE !
Signs:!– Tinelʼs sign!– Phalenʼs sign!– Direct compression sign!– Thenar muscle wasting
and weakness!– sensory disturbance!
Consider nerve conduction tests! Non-surgical treatment:!
– splint/analgesia/injection! Surgical treatment! Open or arthroscopic carpal tunnel
Decompression has 98% success in indicated cases!
Paronychia infection of nail-fold! May require antibiotics or surgical !drainage!
Fight bites and animal bites!– innoculation of MCPJ or PIPJ with oral organisms!– Human and animal bites lead to infection with
complicated group of organisms ( e.g gram negative and anaerobes) !
– treat with considerable seriousness ( early surgical debridement and antibiotics)!
Web space infection!
Can lead to Thenar and Mid-palmar space infection which are potential spaces!
signs:!– pain (passive extension)!– flexed position !– local tenderness along tendon
sheath!– swelling!
Elevation, antibiotics, drainage and irrigation!
Untreated septic tenosynovitis leads to tendon liquefaction and finger stiffness!
Thank you!