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Complaints of hand and wrist

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Start of arthrosis in DIP most common. Heberden's nodules ... Overuse (wringing, racket sports) Pregnancy. Anatomic variations. M.de Quervain: onderzoek ... – PowerPoint PPT presentation

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Title: Complaints of hand and wrist


1
Complaints of hand and wrist
  • Wim Willems
  • HOVUmc, Amsterdam

2
Program
  • Basic anatomy
  • Common complaints
  • Practice

3
Anatomy
4
Intrinsic flexors
Volar view
Dorsal view
5
Extrinsic flexors
6
Extensors
7
Nerves
8
Elderly lady with a painful thumb
  • Female, 78 years old
  • Pain thumb right hand
  • Difficulty with sewing / opening pots

9
Elderly lady with a painful thumb
  • Questions?
  • Physical examination?
  • Further examination?
  • D.d.?

10
Arthrosis
  • Start of arthrosis in DIP most common
  • Heberdens nodules
  • CMC-1 (possibly afflicted relatively young)
  • Grind test

11
Grind test
12
Heberdens nodule
13
Treatment
14
Arthrosis CMC I
Injection Splint Avoid operation as long as
possible
15
Arthrosis CMC I
16
Finger gets stuck
  • Female, 45 year
  • Right hand
  • Palmar pain/ middle finger
  • Impossible to straighten finger

17
Finger gets stuck
  • Questions?
  • Physical examination?
  • Further examination?
  • D.d.?

18
Trigger finger
19
Pathofysiology
  • Thickening of tendon / tenosynovitis of m.flexor
    digitorum communis
  • Finger triggers

20
Epidemiology
  • Few data
  • life time prevalence, gt 30 jr, no DM 2.2.
  • Connected with DM, carpal tunnel syndrome,
    reumatic arthritis, hypothyreoidy.

21
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24
Treatment
25
Conservative therapy
  • Self limiting 10-20 ??
  • NSAID
  • Splint. 6 - 8 weeks (MCP in 10-15 degrees
    flexion). Effective 66 of the cases
  • Steroïd injection. Effectiveness 50 - gt90

26
Trigger finger injection 1
  • Needle short and thin (eg 0,6x25mm or
    (0,45x23mm)
  • Volume 1 ml TCA
  • 10 mg/ml (optional 1ml Xylocaine 1)
  • Performance insert needle from distal to
    proximal along axis of metacarpal bone
  • In MCP fold (2cm from first falangeal fold)

27
Trigger finger injection 2
  • Preferred angle 45 degrees
  • Ca. 1ml around tendon
  • Subcutaneous injection is as effective as
    injection in tendon sheath
  • No pressure
  • Effectiveness 70-80 after 1-3 injections

28
Operative treatment
  • Open or percutanous.
  • Success gt90
  • More complications (nerve damage, inflammation)

29
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30
Painful thumb
  • Man, 37 years
  • House painter
  • Pain radial side wrist

31
Painful thumb
  • Questions?
  • Physical examination?
  • Further examination?
  • D.d.?

32
De Quervains disease
  • Tenosynovitis of m.abductor pollicis longus and
    m. extensor pollicis brevis (APL EPB)
  • distal end radius
  • Women gt men, 35-55 yr.
  • Presentation in general practice 5,6/1000
  • Often recurrent esp. when crepitations

33
Etiology
  • Tendons in common sheath APL EPB irritation
    caused by frequent movements
  • Overuse (wringing, racket sports)
  • Pregnancy
  • Anatomic variations

34
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35
M.de Quervain onderzoek
  • Finkelsteins test

36
Treatment
  • Corticosterod injection success rate 2/3 of
    patients after 3 weeks. Sometimes 2nd or 3rd
    injection.
  • Splint unhelpful
  • Operation (cutting tendon sheath) longstanding
    complaints or failure injections
  • Injection possible in pregnancy

37
M.de Quervain injection treatment
  • Slight pronation
  • Feel for common sheath
  • Insertion of needle by small angle
  • 1ml TCA infiltration
  • Effectiveness 70-80 after 1-3 injections
  • Approach from proximal or distal possible

38
Injection M. De Quervain
39
Painful nightly tingling
  • Female, 52 years
  • Wakes up in the early morning with painful
    tingling in the hand (thumb / index)
  • Flapping of hand to ease complaints

40
Painful nightly tingling
  • Questions?
  • Physical examination?
  • Further examintion?
  • D.d.?

41
Carpal tunnel syndrome
42
Epidemiology
  • Open population (history nerve conduction
    examination)
  • Female 9
  • Male 0,6
  • Peak between 40-60 year

43
Risk factors
  • Weight
  • Pregnancy
  • Diabetes mellitus
  • Hypo/hyperthyreoidy
  • Ovariectomy
  • Anatomic deviation (traumatic / RA / congenital)
  • Work related

44
Natural course
  • ¼ - 1/3 significant improvement gt 1 year
  • After pregnancy 50 without complaints

45
Pathofysiology
  • Narrow tunnel
  • compression n. medianus in carpal tunnel
  • 90 idiopatic

46
Diagnosis history
  • Dutch consensus (CBO 2006)
  • Nightly tingling
  • Median nerve area
  • Sleep disturbance
  • Other tingling / pains
  • Flapping (Flicks sign)
  • Advanced stages tingling during the day

47
Sensory innervation N. Medianus
48
Atypical localisations tingling sensations in
carpal tunnel syndrome
  • Often outside median nerve area
  • Sometimes ulnar nerve area

49
Provocation tests
  • CBO 2006
  • Limited usefulness

50
Diagnostic tests CTS
C.A.
51
Tests
  • Tinel percussion median nerve
  • Phalen flexion during 60 seconds
  • Further -sensory loss median nerve area
  • -thenar dystrophy
  • -dry skin (thumb / index / middle finger)

52
Neurophysiological examination
  • Verification of clinical diagnosis prior to
    operation

53
Limitation EMG
  • No golden standard
  • 10-15 false negative
  • No relation between complaints and results
  • Results not predictive for therapy
  • Value unclear for primary health care

54
Treatment
55
Splint
  • Day and night
  • Short term effective
  • Minor complaints / recent onset

56
Surgery
  • Highly effective
  • Major / recurrent complaints. Patients wish
  • Open / endoscopic
  • Success 75-90
  • Complications damage to nerve, pain, scar,
    complex regional pain syndrome)

57
Corticosteroid injection
  • Several techniques
  • 1. Underneath retinaculum (most common technique)
  • 2. Through retinaculum
  • 3. In front of retinaculum (method by Dammers)
  • Safe
  • Effective
  • Tradition / experience / authority determines
    technique

58
Medicament / Dosage
  • Most common Triamcinolonacetonide 10 mg/ml
    (Kenacort A10), or methylprednisolonacetaae
    (Depo-Medrol) 40 mg/ml
  • Volume 1-2ml
  • Interval between injections 1-3 weeks
  • Effectiveness 1st injection 80, after 2
    injections 15, after 3 injections 5

59
Needle?
  • -orange/ light brown (0,45x23mm)
  • -light blue (0,5x25mm)
  • -green (0,8x40mm)

60
Localisation carpal tunnel
Os pisiforme
Os scaphoideum
61
Localisation tendon m. Palmaris longus
62
Tendon m. Palmaris longus
  • Absent tendon ulnar to median axis

63
Localisation insertion
  • ulnar to tendon m. palmaris longus
  • Depending on technique used
  • On distal wrist line( between tuberculum of os
    scaphoid and os pisiforme)
  • On proximal wrist line
  • 3-4 cm before distal wrist line

1
2
3
3
64
Injection underneath retinaculum
  • On proximal wrist line
  • Angle 30 degrees

65
Injection underneath retinaculum
  • Tingling while inserting needle withdraw and try
    again
  • Respect resistances

Tendon m. palmaris longus
2nd wrist line
66
injection through retinaculum.
  • Distal wrist line
  • 45 degrees

67
Method by Dammers
  • 3-4 cm before distal wrist line
  • Needle 3-4 cm
  • Angle 10-20 degrees
  • Deposit fluid proximal to carpal tunnel
  • Massage to enhance diffusion

68
Hygiene
  • Wash hands, wear gloves or disinfect fingers
  • Once-only ampoules
  • Change needles
  • Disinfect skin

69
Side effects and complications
  • Side effects
  • -flushing 1 day after injection
  • -steroid-flare 24-48 hours
  • -menstruation problems
  • -hyperglycemia
  • -locale effects redness, atrophy fatty tissue,
    hypopigmentation
  • Complications
  • -very rare, case-reports
  • -tendon ruptures, median neuritis (CTS), local
    infection

70
Practice
  • Anatomy
  • Injection
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