1. Hand and Wrist Injuries
Mark S. Rekant, MD
South Jersey Hand Center
Philadelphia Hand Center

2. HAND FUNCTIONS 45% GRASP 45% PINCH 5% HOOK 5% PAPERWEIGHT
Side pinch (key pinch)
Tip pinch (writing)
Chuck pinch (thumb to index/ring)
5% HOOK
Carry bag
5% PAPERWEIGHT

3. HAND & FINGER ANATOMY 9 Finger Flexors Median nerve
Transverse carpal ligament
5 deep flexors pass through superficialis tendons and insert on distal phalanx of each finger and thumb
4 superficial flexors insert on middle phalanx of digits 2-5
Annular ligaments = pulleys (A1-A5)
PREVENT BOWSTRINGING

4. HAND ANATOMY digits FLEXOR Extensor FDP FDS Volar plate Central bands
Lateral bands

5. NERVE COMPRESSION Most common entities
Carpal tunnel syndrome
Median nerve compression at wrist
Cubital tunnel syndrome
Ulnar nerve at elbow
Radial tunnel syndrome
Radial nerve compression distal to elbow
Pronator teres syndrome
Median nerve compression just distal to elbow

6. History General Medical Location Radiation Duration Periodicity
Nature/time of onset
Medical
Family
Endocrine
Diabetes
Pregnancy
Hypothyroidism

7. Carpal Tunnel Syndrome
Symptoms
Numbness, nocturnal burning pain
Pain and paresthesias, worse at rest (night)
Clumsiness - dropping objects
Pain and numbness on driving
Pain radiating at times up arm to shoulder

8. Carpal Tunnel Syndrome Findings
Median Nerve Entrapment in the tunnel
Pain in the wrist and hand
Awaken one from sleep/rest
Muscle wasting / atrophy

9. Physical Examination Muscle weakness Sensory disturbance Tinel sign
Phalen’s test
Durkin’s CTC test

10. Carpal Tunnel Syndrome Factors
Force
Posture
Wrist alignment
Repetition
Temperature
Vibration

11. Cumulative Trauma Disorder incidence varies with age
Zakaria, D “Rates of carpal tunnel syndrome, epicondylitis and rotator cuff claims in Ontario workers during 1997.” Chronic Diseases in Canada 2004: 25(2).

12. EMG/ NCV 10% of cases of CTS may have false negative exams
25% of asymptomatic individuals may have median nerve slowing (false positive) on electrodiagnostic testing (Erdil, Maurer and Dickerson 1997).

13. Carpal Tunnel Syndrome Treatment Options
Activity Modifications
Splinting
Cortisone Injection
Surgery

14. Carpal Tunnel Syndrome
Physical Therapy
Massage Treatment
Phonophoresis/Iontophoresis
Stretches/Exercises
Occupational Therapy
Keyboard/Mouse retraining
Biofeedback

15. CTS - SURGERY Surgical referral is desired: prolonged symptoms
thumb muscle atrophy
severe or progressive numbness and sensory loss
Patients with mild to moderate CTS who do not recover after four weeks of non-surgical care.
Appropriately selected candidates treated with carpal tunnel release  report good to excellent outcomes.

16. Tendinopathies Reactive
Stenosing Tenosynovitis (Trigger Finger)
DeQuervain’s Tenosynovitis (Disease)
Intersection Syndrome
Epicondylitis

17. TENDON DISORDERS STENOSING TENOSYNOVITIS CAUSE DEQUERVAIN’S
TRIGGER FINGER / THUMB
CAUSE
TRAUMA
REPETITIVE USE
OVERUSE

18. Thumb & Finger Pulleys

19. Trigger Fingers Tendonitis May affect any digit including the thumb
Pain
Stiffness
Clicking or “triggering”

20. Trigger Finger Treatment Options
Splinting
Cortisone Injection
Surgical Release

21. STEROID INJECTION
Success rate for a single injection is ~60% (resolution of triggering > 4 months)
Complication rate is very low
Repeat injections (several over a 12 month period) is acceptable although success rate diminishes over time

23. SURGERY Indications: Symptoms for 4+ months Failed injection
Locked finger

24. Turowski GA et al. J Hand Surg 1997:
59 patients
97% complete resolution
No complications

25. Other Tendinopathies Reactive
EPL Tendonitis at Lister’s tubercle
EDC IV, V
ECU Tenosynovitis
FCR Tenosynovitis

26. Lateral Epicondylitis
History
Pain Increased Activity
Job Related > Sports
P.E.
Localized Pain
Decreased Grip
Resisted Wrist Extension
Common Extensor Origin / ECRB
Inflammation / Micro-tear / Rupture

27. Differential Intra-articular Pathology Cervical Radiculopathy
Radial Tunnel Syndrome

28. Lateral Epicondylitis
Group I Group II
Young Athletes yrs.
Sudden Onset Insidious Onset
Extensor Muscle Tear Overuse

29. Treatment Rest NSAIDS Counter Force “Tennis Elbow” Brace Conditioning
Improve Technique, Warm Up
Work Place Modifications
Cortisone Injection

30. Rehabilitation Modalities Stretches (A to Z)
Isometrics - Patient Must be Pain Free
Let Pain be Your Guide
Return to Full Activity When Pain Free / NC Grip

31. Surgical Management 6 to 12 Months Conservative Care
Multiple Surgical Techniques
Surgical Contraindications
Less than 6 Months Nonoperative Rx\
Poor Compliance
Secondary Gain Issues

32. MALLET FINGER ANATOMY MECHANISM: TREATMENT: COMPLICATIONS:
Dorsal avulsion
Extensor digitorum tendon tear
MECHANISM:
Forced flexion of extended digit
TREATMENT:
No fracture: DIP extended for 6-8 weeks
FRACTURE: if <30% joint surface, splint x 4 weeks
If >30% refer for ORIF
Less than full passive extension refer
COMPLICATIONS:
Pressure necrosis from splint
Permanent extensor lag

33. MALLET FINGER

34. JERSEY FINGER ANATOMY: MECHANISM: TREATMENT: Tendon retracts
Avulsion fragment may limit retraction
Blood supply compromised
MECHANISM:
Forced extension of flexed finger
TREATMENT:
Refer immediately
COMPLICATIONS:
Permanent loss of flexion

35. JERSEY FINGER EXAM FINDINGS: Unable to flex isolated DIP
Localized tenderness along flexor tendon
FDP: hold PIP straight and flex DIP
FDS: hold MCP straight and flex PIP or hold all fingers in extension except affected and flex

36. VOLAR PLATE RUPTURE EXAM FINDINGS: MECHANISM: Tender volar PIP
Bruising, swelling
MECHANISM:
Hyperextension injury
Ruptures distally from attachment at middle phalanx

37. VOLAR PLATE RUPTURE TREATMENT: COMPLICATIONS: Early mobilization
Extension block splint
Buddy tape
Refer if >30% joint involved
COMPLICATIONS:
Swan neck deformity: extensor tendons pull PIP into hyperextension, DIP flexion

38. CENTRAL SLIP AVULSION EXAM: TREATMENT COMPLICATIONS:
Pain, swelling over dorsal PIP
PIP in degrees flexion
May have limited extension (better at 0 degrees than 30 degrees)
TREATMENT
Refer if >30% joint surface involved with avulsion fx
PIP splint in full extension 4-5 weeks
Protect 6-8 weeks for sports
*allow DIP to flex- relocates lateral bands
COMPLICATIONS:
Boutonierre deformity

39. COLLATERAL LIGAMENT TEARS
ANATOMY:
Partial or complete tear of ulnar or radial ligaments
MECHANISM:
Varus or valgus stress to PIP, DIP or MCP
EXAM: (flex MCP, PIP 30 degrees flex)
Laxity with varus or valgus stress
Possible instability with active flex/extend

40. COLLATERAL LIGAMENT TEARS
TREATMENT:
Buddy tape for 3 weeks
If unstable with active ROM or obvious deformity refer
COMPLICATIONS:
Unstable joint

41. GAMEKEEPER’S THUMB MECHANISM EXAM: Hyperabduction of thumb
>30 degrees or > 20 degrees difference
EXAM:
Weak, painful pinch
Pain over ulnar thumb MP joint
XRAYS BEFORE STRESS
Type I: avulsion, no displacement; Type II: avulsion, displaced; Type III: torn ligament, stable in flexion; Type IV: torn ligament, unstable flexion

42. GAMEKEEPER’S THUMB Testing in FULL FLEXION of MCP SIGNS
Pain over ulnar thumb
Stress testing positive
Testing in FULL FLEXION of MCP
With extension or slight flexion the normally taut volar plate gives MCP stability
Type I: avulsion, no displacement; Type II: avulsion, displaced; Type III: torn ligament, stable in flexion; Type IV: torn ligament, unstable flexion

43. GAMEKEEPER’S THUMB TREATMENT COMPLICATIONS
No instability, no fracture= thumb spica x 6 weeks
No instability, small avulsion = thumb spica
Large avulsion or instability= thumb spica and potential surgery
COMPLICATIONS
Infection
Neuropraxia of dorsal ulnar nerve to thumb
Instability
Stener lesion= adductor aponeurosis obstructs UCL from healing
Type I: avulsion, no displacement; Type II: avulsion, displaced; Type III: torn ligament, stable in flexion; Type IV: torn ligament, unstable flexion

44. THUMB CMC FRACTURE DISLOCATION (BENNETT’S FRACTURE)
Anatomy:
Anterior oblique carpometacarpal ligament holds palmar fragment in normal anatomic position
Abductor pollicis longus (APL) pulls metacarpal shaft fragment radial & dorsal
Treatment
Reduction (TAPE)
Traction, abduction, extension, pronation
Often unstable, requires surgery
AOCMC ligament also attaches to trapezium
Triangular fragment = palmar beak fragment

45. ROLANDO’S FRACTURE ANATOMY TREATMENT
3 part fracture at metacarpal base
Comminuted with “Y” or “T” fragment
TREATMENT
May be non-surgical if highly comminuted
Surgery if fragments are large and amenable

46. DIP JOINT DISLOCATION MECHANISM ANATOMY TREATMENT
Hyperextension, varus/valgus forces
ANATOMY
Usually dorsal
Rare, strong collateral ligaments usually prevent dislocation
TREATMENT
Dorsal block splint for 3 weeks

47. PIP JOINT DORSAL DISLOCATION
MECHANISM
Hyperextension with disruption of volar plate
ANATOMY
Loss of volar stabilizing force causes phalanx to ride dorsally
TREATMENT
Reduction: avoid longitudinal traction
Post-reduction: dorsal extension block splint with PIP blocked at degrees flexion
Bayonet deformity
Traction allows for soft tissue interposition

48. Scaphoid Fracture Pathoanatomy
Blood supplied from distal pole
In children, 87% involve distal pole
In adults, 80% involve waist

49. Scaphoid Fracture Imaging
Initial plain films often normal
Bone scan 100% sensitive and 92% specific at 4 days
MRI, CT scan

50. SCAPHOID FRACTURE TREATMENT Initial radiographs positive
distal third heal in approx 6-8 weeks
middle third frx heal in 8-12 weeks
proximal third heal in weeks
Initial radiographs negative
Immobilize thumb spica cast x 7-14 days
Take out of cast, re-evaluate for tenderness
If +tenderness but neg radiographs….

51. Scaphoid Fracture Treatment Suspected fracture with normal plain films
Short arm thumb spica (splint or cast)
F/U in 2 weeks
Consider bone scan

52. Scaphoid Fracture Treatment Non-displaced fracture
Long arm thumb spica cast 6 weeks
Then, short arm thumb spica cast for 4-14 weeks

53. Scaphoid Fracture Refer to Ortho Angulated or displaced (1mm)
Non-union or AVN
Scapholunate dissociation
Proximal fractures
Late presentation
Early return to play

54. SCAPHOLUNATE DISSOCIATION

55. SCAPHOLUNATE DISSOCIATION
EXAM
Watson’s test (scaphoid shift test)
Scaphoid shuck test
Pain/swelling over dorsal wrist, prox row
DIAGNOSIS
Plain films: >3mm difference on clenched fist
Scaphoid ring sign

56. SCAPHOLUNATE DISSOCIATION
TREATMENT
If discovered within 4 weeks, surgery
After 4 weeks, conservative treatment reasonable
Bracing
NSAIDS
Consider eval by hand surgery to confirm no surgery needed

57. Triangular Fibrocartilage Complex (TFCC) Tear
Fall on dorsiflexed and ulnar deviated wrist
Axial load with forearm in hyperpronation

58. TFCC Tear Pathoanatomy
Tear in structures of TFCC
Positive ulnar variance predisposes to injury

59. TFCC Tear History
Ulnar-sided wrist pain aggravated by pronation/ supination

60. TFCC Tear Physical
Press test
TFCC grind test
Check for DRUJ injury

61. TFCC Tear Imaging Plain films may show positive ulnar variance
Assess for fracture or ulnar subluxation
MRI or Arthrography

62. TFCC Tear Treatment
Long arm immobilization with forearm neutral for 6 wks
Refer for associated injuries including ulnar instability

63. Hook Hamate Fracture Hook of hamate fracture
Swing of golf club, bat
2% of all carpal fractures
1/3 of all hamate fractures = golf related
Distal lateral border of Guyon’s Canal
High rate of non-union
May consider early operative treatment

64. GOLFER’S FRACTURE
CARPAL TUNNEL VIEW

65. GUYON’S CANAL SYNDROME
ANATOMY
Ulnar nerve rides between pisiform and hamate
Feeds interosseous muscles, hypothenar muscles, lumbricals (intrinsic muscles)
TREATMENT
Pad area
NSAIDS
r/o hamate fracture
Pisohamate ligament
Volar carpal ligament
Transverse carpal ligament

66. MEDIAN NERVE: ANTERIOR INTEROSSEOUS SYNDROME
EXAM FINDINGS
Proximal forearm pain, worse with exercise
Weak pinch – can’t form “O”
ANATOMY
Compression of anterior interosseus median nerve branch from deep fascia of pronator teres or flexor digitorum superficialis tendon
Innervates:
flexor pollicis longus
flexor digitorum profundus
pronator quadratus