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Common Orthopedic Conditions of the Hand

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  Common Orthopedic Conditions of the Hand John Hubert C. Pua, M.D. Carpal Tunnel Syndrome    The median nerve is compressed in the carpal tunnel    It is the most common nerve entrapment condition in the hand    Signs and symptoms o   Wrist pain o   Numbness in the thumb, index, and middle finger o   Night time awakening o   Dropping objects, clumsiness, weakness o   Thenar muscle wasting    Provocative tests o   Phalen’s test   o   Tinel’s sign   o   Durkan’s carpal compression test      Treatment o   Conservative management:    Splinting    Non-steroidal anti-inflammatory drugs    Steroid injection    Physical therapy o   Surgical management:    Open carpal tunnel release    Endoscopic carpal tunnel release Trigger Digit    Can either be a trigger finger or trigger thumb      Characterized by catching, snapping or locking of the involved digit flexor tendon associated with dysfunction and pain      Also known as stenosing flexor tenosynovitis      Flexor Pulley System   o   Annular pulley (A1, A2, A3, A4, A5)   o   Cruciate Pulley (C1, C2, C3)      Signs and symptoms   o   Locking or catching during digit motion   o   Stiff digit   o   Pain radiating along the digit and over palm   o   Triggering   o   Palpable snapping sensation or crepitation   o   Tenderness   o   Fixed flexion deformity in late presentations      Quinnell Classification   Grade 0 Mild crepitus in the non-triggering finger Grade 1 No triggering, but uneven finger movements Grade 2 Triggering is actively correctable Grade 3 Usually correctable by the other hand Grade 4 The digit is locked    Treatment   o   Conservative management:      Splinting      NSAIDs      Steroid injection      Physical therapy   o   Surgical management:      Percutaneous release of A1 pulley      Open release of A1 pulley  De Quarvain Syndrome      It is the inflammation of the tendons located at the level of the wrist near the base of the thumb    Dorsal compartment (APL, EPB)    It is also known as Gamer’s Thum b or Washerwoman’s Sprain      Dorsal Wrist Compartment o   1st: APL, EPB o   2nd: ECRL, ECRB o   3rd: EPL o   4th: EDC, EIP o   5th: EDM o   6th: ECU    Signs and symptoms o   Pain and tenderness at the base of the thumb (radial styloid process area) aggravated by movement o   Localized swelling    Special test o   Finkelstein’s Test      Treatment o   Conservative management:    Splinting    NSAIDs    Steroid injection    Physical therapy o   Surgical management:    Open release of the 1st dorsal compartment  Ganglion Cyst      It is the most common soft tissue lesion of the hand    It is a tumor or swelling usually found at the back or palmar area of the wrist (dorsal volar ganglion cyst)    It is cystic with a thick sticky, clear, colorless,  jelly-like material inside    Also known as Bible Cyst    Signs and symptoms o   Mass change in size o   May cause some degree of pain o   Mass is firm, non-tender, and transilluminates    Treatment o   Conservative management:    Observation (50% spontaneously resolves) o   Surgical management:    Indications:    Cosmetic reasons    Symptomatic pain    Neuromuscular impingement    Aspiration    Surgical excision    Arthroscopic excision Tendon Injuries      Flexor Tendons in the Hand o   FDP, FDS, FPL    Extensor Tendons in the Hand o   EDC, EIP, EDM, EPB, EPL o   Extensor Mechanism    Verdan Zones    Physical Examination o   Evaluate the skin for any signs of infection, open wounds or lacerations o   AROM and PROM o   Asses for strength and pain with resistance    Flexion Cascade o   Observe posture of hand o   There is a normal flexion cascade of the hand    Index finger: least flexion    Little finger: greatest flexion o   Physical examination    Note position of the finger at the time of injury    Flexor tendon testing    Extensor tendon testing    Elson’s Test      For acute tears of the central slip    Passive Tenodesis Test    Cause: laceration or puncture wounds on the hand (open injury)    Damage: o   Single or multiple tendons o   Neighboring structures e.g. nerve, blood vessels and bone    Tendons can also snap if overtressed such as in sports (closed injury Flexor Tendon Injuries Zone 1      Jersey Finger    Contains only the FDP    Tendon laceration is usually very close to its insertion    Tendon to bone repair usually is required instead of tendon to tendon repair Zone 2      No man’s land      FDS and FDP within one flexor tendon sheath    Adhesion formation is amplified at Camper’s chiasm    Repair both FDP & FDS tendons Zone 3      Lumbrical muscle srcins in the zone prevents the profundus tendons from over retracting    Delayed repairs have been successful even weeks after the injury Zone 4      Tendon injuries in this zone are rare because of the protection provided by the stout transverse carpal ligament Zone 5      Proximal portion meets the musculotendinous junctions    Poor site of repair because tendons become thinner and fan out into fibers that merge with the muscle belly Extensor Tendon Injuries Zone 1      Mallet Finger    Disruption of the extensor mechanism at the DIPJ (terminal slip)     Forced flexion on an extended DIPJ resulting to tendon rupture, avulsion from its insertion or bony avulsion (bony mallet) Zone 2      Most result from laceration and crush injuries    Lacerations distal to the central slip result in a mallet deformity Zone 3      Boutonniere deformity    Disruption of the central slip    Lateral bands sublux volarly and flex the PIPJ while extending the DIP    (+) Elson’s Test   Zone 4      Partial lacerations are treated with splinting    Complete laceration are repaired and associated phalangeal fractures are fixed to restore length and allow early AROM Zone 5      Fight bite    Wound can involve the underlying extensor mechanism and extend into the joint    Rupture of sagittal band    Debridement and assessment of depth to prevent infection Zone 6      Proximal tendon lacerations frequently retract    Repair should be done if appropriate    Juncturae tendinae injuries are frequently missed Zone 7      Lacerations at the level of the extensor retinaculum    Tendons retract, scar under the retinaculum after repair    Complete release of the retinaculum results in bowstringing Zone 8      Wrist and thumb extension should be priorities when sorting out multiple extensor lacerations    Muscle bellies are repaired Management of Tendon Injuries      Tendon Repair o   <50% laceration  –  non-operative management o   >50% laceration  –  surgical management o   Repair tendon injuries early o   Perform within the first 2 weeks after injury because the tendon ends and sheaths become scarred and retract o   Repairs after 2 weeks may decrease the ultimate mobility of the fingers o   Tendon repairs are weakest at 7-10 days o   Most of its srcinal strength is regained at 21-28 days o   Maximum strength is achieved at 6 months o   Early mobilization allows increased ROM but results in decreased tendon repair strength o   Immobilization leads to increased tendon substance strength at the expense of ROM
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