1. COMMON ORTHOPAEDIC CONDITIONS OF THE HAND AND WRIST Korsh Jafarnia, MD Methodist Center for Orthopedic Surgery & Sports Medicine

2. Topics Carpal Tunnel Syndrome Cubital Tunnel Syndrome Trigger Finger Dupuytren’s Contracture Osteoarthritis New innovative treatments

3. Carpal Tunnel Syndrome Compression of the Median Nerve in the Carpal Tunnel Tingling and numbness in the radial digits Aggravated by driving & sleeping Relieved by shaking hand Pain which wakes them at night Hand feels swollen, stiff, cold

4. Carpal Tunnel Syndrome Risk Factors Diabetes Hypothyroidism Rheumatoid Arthritis Pregnancy After wrist fracture

5. Carpal Tunnel Syndrome Clinical Signs Wasting of Thenar muscles Reduced sensation +ve Phalen’s sign +ve Tinel’s test

6. Carpal Tunnel Syndrome Clinical Signs Wasting of Thenar muscles Reduced sensation +ve Phalen’s sign +ve Tinel’s test

7. Carpal Tunnel Syndrome Clinical Signs Wasting of Thenar muscles Reduced sensation +ve Tinel’s test +ve Phalen’s/Durkan’s sign

8. Carpal Tunnel Syndrome Indications for Nerve conduction Studies Suspicion for carpal tunnel syndrome Good history but –ve Tinel’s and/or Phalen’s Is Ulnar Nerve also compressed Atypical history Objective test to assess nerve flow

9. Carpal Tunnel Syndrome Treatment Wrist Splint Steroid injection Surgical Decompression

10. Carpal Tunnel Syndrome Steroid Injections Cochrane data base reports:- Symptoms improved at 1 month, but no significant relief beyond this. High proportion of patients treated medically will end up requiring surgery My indications for injecting Severe symptoms and patient wants immediate relief Severe symptoms in pregnancy Patient doesn’t want surgery To confirm diagnosis

11. Carpal Tunnel Syndrome Surgical Decompression Local/Regional Anaesthetic Endoscopic/Minimally invasive Flexor retinaculum divided Suture under skin RTW - days

12. Cubital Tunnel Syndrome Compression of the Ulnar nerve in the cubital tunnel C/O parasthesia in little and ring fingers Pain radiating down from medial side elbow Weakness and muscle wasting in the hand

13. Cubital Tunnel Syndrome Physical Signs Wasting / weakness of the intrinsic hand muscles Reduced sensation +ve Tinel’s over cubital tunnel +ve elbow flexion test

14. Cubital Tunnel Syndrome Investigation & Treatment Nerve conduction studies Activity Modification Surgical decompression - Endoscopic Anterior transposition

15. Trigger Finger Flexor tenosynovitis Nodule in flexor tendon catching in A1 pulley Finger clicking Finger sticks in flexion, extends with click Tender palm Painful / weak flexion

16. Trigger Finger Treatment Cortisone injection into/over A1 pulley Personal Audit: 3/4 long lasting relief Literature: Range from 47% at 6 months to 87% at 42 months

17. Trigger Finger Treatment If 2 injections fail, further unlikely to work, and therefore go for surgical release mini open vs endoscopic

18. Dupuytren’s Contracture Thickening and contracture of the palmar fascia Risk factors are diabetes, family history, etc., ?Mechanical factors

19. Dupuytren’s Contracture Consider treatment when can no longer get hand flat on table top Fasciotomy Fasciectomy Xiaflex injections

20. Thumb Base Arthritis Radiologically evident in 33% of postmenopausal women of whom 33% are symptomatic

21. Symptoms Pain Weakness Stiffness Deformity Swelling

22. Signs Observation Palpation Movement Special tests

23. Signs Observation Palpation Movement Special tests

24. Signs Observation Palpation Movement Special tests

25. Treatment Activity modification NSAID/Steroid injection Viscosupplementation Splint Surgery

26. Surgery Denervation Stabilization Osteotomy Arthrodesis Resection arthroplasty Resection & LRTI Interposition arthroplasty

27. Trapeziectomy & Ligament Reconstruction Completely remove trapezium Ligament reconstruction with FCR tendon Repair capsule Post-op. splint

28. Recent Advancements

29. OA of the PIPJ

30. PIPJ Replacement

31. OA of the DIPJ

32. New and Innovative Treatments  Xiaflex Injections for Dupuytrens Disease  PRP injections – jury still out  Synvisc injections for the small joints of upper extremity  Endoscopic Cubital & Carpal tunnel release

33. THE END