Upper Extremity: Forearm/Wrist
De Quervain’s Tenosynovitis:
Epidemiology: common in women 30-50s or newly postpartum mothers.
Pathophysiology: a stenosing tenosynovial inflammation of the 1st dorsal compartment of the wrist which includes the tendons of the abductor pollicis longus and the extensor pollicis brevis.
Presentation: pain on the radial side of the wrist and with ulnar deviation of the wrist
Diagnosis: physical examination of the wrist includes the Finkelstein Maneuver. If a patient clenches his fingers over the thumb and ulnarly deviates the wrist, it will illicit pain on the radial side of the wrist. Direct palpation of the 1st extensor compartment of the wrist will also cause pain.
Treatment: non-operative management includes: rest, NSAIDs, thumb spica splint, and steroid injection into the 1st extensor compartment. If this fails, a surgical procedure which releases the sheath of the tendons can be performed through a 2 cm incision. This incision can be hidden in the wrist crease for cosmetic appeal. There is no cast post operatively. A simple soft dressing is applied and patients can be full range of motion with the wrist as soon as they feel comfortable. The most common complication with this procedure is injury to the sensory branch of the superficial radial nerve causing numbness on the dorsal aspect of the 1st web space and thumb. This resolves in a few months.
There are multiple areas to fracture in a wrist and forearm. They essentially break down to fractures of the radius and the ulna. The more proximal or closer to the elbow the fracture, the more likely a surgery will have to be performed to align the bones correctly. Most forearm and wrist fractures in children can be treated in a cast. Occasionally, a surgical procedure will have to be performed to straighten the bones and can be casted. If this does not work, intramedullary rods can be placed and then removed at a later date. In some situations, plates and screws will have to be placed. In adults, the situation is somewhat different, non displaced fractures can be treated in a cast. If there is any displacement, then a surgical correction using plates and screws in generally recommended. Each patient is treated individually and a full discussion of the diagnosis and treatment option along with risks and benefits of both will be included.
Epidemiology: the most common hand mass. 70% are located dorsally in the Scapho Lunate articulation. The remaining 30% are located volarly: 20% from the radio carpal joint and 10% from the tendon sheath.
Presentation: mass which may be asymptomatic or may cause cosmesis issues or pain.
Diagnosis: inspection with transillumination can be helpful. Palpation of a firm, well circumscribed mass that is fixed to deep tissues but not to the skin. Allen’s test to ensure that the radial and ulnar artery flow to the hand is evaluated. Imaging studies can be used to help identify the mass. Plain xrays are normal. Ultrasound will help to differentiate from a vascular aneurysm. MRI is not generally used unless there is a question of associated injury.
Treatment: The mainstay of non-operative management is observation. There is a high likelihood that the mass will resolve on its own in children within a year. The historical treatment of rupturing the mass with a Bible is effective in the short term but has a high recurrence rate. Aspiration is a consideration with or without a steroid injection at the same time. Surgical resection is the mainstay of operative management. The most common complication is recurrence of the ganglion cyst. This is up to 20% of excisions. Physical therapy after surgical excision is common in order to restore Range of Motion.
Epidemiology: The scaphoid is the most frequently fractured carpal bone. It accounts for up to 15% of wrist injuries
Pathoanatomy: the most common mechanism of injury is an axial load across a hyper extended and radially deviated wrist. 75% of the scaphoid bone is covered by articular cartilage. The major issue with a scaphoid fracture is its blood supply. 80% of the blood supply is through the dorsal surface via a retrograde fashion. This means that Avascular Necrosis (AVN) is a real possibility if not appropriately and aggressively treated.
Presentation: pain at the wrist in the anatomic snuffbox dorsally and scaphoid tubercle volarly.
Diagnosis: physical examination with limitation in wrist ROM and pain as mentioned above. X-rays in the acute setting can show the fracture if a 3 view wrist with a scaphoid view is obtained; however, if the x-rays are negative, this does not mean there could not be an occult fracture. Follow up x-rays at 2-3 weeks is recommended. A limited MRI can be obtained with a scaphoid protocol. This is the most sensitive test.
Treatment: if there is no displacement, a thumb spica cast can be placed for a total of 3 months. A bone stimulator such as the Exogen can be applied through the cast to aid in the healing of the scaphoid fracture. If there is greater than 1mm of displacement then ORIF of the scaphoid should be performed. The patient is still treated in a thumb spica cast for 3 months with Exogen bone stimulator in my practice. The biggest complication of this diagnosis and/or procedure is failure of the bone to heal. If this occurs then a bone grafting procedure can be attempted.
Upper Extremity: Hand
Carpal Tunnel Syndrome:
Epidemiology: can affect up to 10% of the general population. Risk factors include: female gender, obesity, pregnancy, hypothyroidism, rheumatoid arthritis, and repetitive motion activities.
Pathophysiology: exposure to repetitive motions and/or vibrations such as certain athletic activities including cycling, tennis, or throwing. Work related activities commonly include typing or keyboarding.
Pathoanatomy: compression of the median nerve due to repetitive motions in a patient with normal anatomy or someone with a space occupying lesion in the carpal tunnel
Presentation: numbness and tingling in the thumb, index, long, and half of the ring fingers. Patient report clumsiness and numbness that awakens them from sleep at night. I call this the “Wake and Shake” sign. Patients report that they wake from sleep and have to shake their hands until the numbness resolves.
Diagnosis: Physical examination tests include the carpal tunnel compression test, Phalen test, and Tinel’s test. Imaging examinations do not provide any help in this diagnosis. EMG and NCS is a diagnostic test administered by a Neurologist or a PM&R physician which tests the nerve conduction velocities and electrical activity of the individual muscle units. This tests is not critical for diagnosis but can be considered prior to surgical intervention. It can help to establish a “Double Crush” situation which is where there is compression in the cervical spine in addition to compression at the wrist.
Treatment: First line of therapy would be anti-inflammatory medications, night splints, and activity modification. If this fails, a steroid injection into the carpal tunnel can help. If the non-operative treatments fails to bring lasting relief, surgical release of the carpal tunnel can help. This surgical procedure is done through a 2 cm incision at the base of the hand and takes a minimal amount of operative time. The post surgical dressing is a soft dressing giving the patient the ability to move the wrist and fingers immediately. Patients will have sutures removed at 7-10 days post operatively. They can perform outpatient formal Occupational Therapy or they can go to HEP2go.com for a home based therapy regimen. Most patients are very satisfied with this procedure as it provides lasting relief from a common problem.
Fractures of the Metacarpals and Fingers:
Epidemiology: Metacarpal fractures account for up to 40% of all hand injuries. Men aged 10-29 years old have the highest incidence of metacarpal injuries. The 5th metacarpal neck in the most commonly injured secondary to a “punching of a wall” type mechanism.
Presentation: If the fracture is the result of a fight with another human, then an inspection for the open wound is important. Typical deformity is apex dorsal with shortening and possible rotational deformity. Comparison to the contralateral side can be helpful.
Diagnosis: standard 3 view x-rays of the hand are the mainstay of diagnosis. If there is a question of dislocation that cannot be answered by x-rays, then CT scan can be helpful.
Treatment: if there is minimal displacement, then in situ casting can be utilized. If there is unacceptable alignment via angulation, shortening, or rotation, then operative management is indicated. Reduction of the fractures can be performed closed or open in the operating room. The fractures can be stabilized with a cast, pin, or plates and screws. Early mobilization is important to prevent stiffness. A good Occupational Therapist is important in regaining hand function after these injuries.
Epidemiology: patients with diabetes have a higher incidence of trigger fingers. The ring or 4th finger is the most commonly affected.
Pathophysiology: the flexor tendons at the level of the A1 pulley in the hand become entrapped. There is fibrocartilaginous metaplasia of the tendon and pulley found in pathologic specimens.
Presentation: patients complain of a clicking in the palm of the hand. If this persists, then the finger may become locked in the flexed position with manual “unlocking” becoming necessary. Patients can complain of tenderness and possible mass over the A1 pulley on the volar aspect of the hand in the region of the distal palmer crease.
Treatment: patients can attempt a course of night splinting, NSAIDs and activity modification. Next line of treatment involves a steroid injection into the flexor tendon sheath. If this fails, then a surgical release of the A1 pulley will rectify the issue. The procedure can be done under regional anesthesia as an outpatient. Patients may begin gentle range of motion of the fingers immediately post operatively. Early passive and active range of motion 4 times a day in encouraged. If patients do not have full range of motion at 10 days, then Occupational Therapy will be prescribed.