9. Wrist Hand Peripheral Nerves Flashcards
Posterior Compartment of the Forearm Muscles
2 layers
Superficial
Deep
Superficial Layer: Brachioradialis
- Forms lateral border of cubital fossa
- Superficial on anterolateral forearm
• Posterior compartment muscle that flexes elbow (Does not cross wrist) - insert just before wrist
- P: Lateral Supracondylar ridge of humerus
- D: Lateral surface of distal radius, proximal to styloid process
- I: Radial nerve (C5,6,7)
- A: Weak flexion of forearm (esp midpronated)
Beer drinking muscle – action of holding and drinking beer
Superficial Layer: Extensor Carpi Radialis Longus
Inferior to brachioradialis
- P: Lateral Supracondylar ridge
- D: Dorsum of base of 2nd metacarpal
- I: Radial nerve (C6,7)
• A: Extend and abduct hand at wrist joint (radially deviates)
Superficial Layer: Extensor Carpi Radialis Brevis
• Shorter than longus above – arises more distally
- P: lateral epicondyle (common extensor origin)
- D: Dorsum of base of 3rd metacarpal
- I: Deep branch of radial nerve (C7, C8)
- A: Extend and abduct hand at wrist joint
- Important (esp ECRL) for clenching fist/ tight grip finger flexion – gripping something tightly you extend your wrist
- ECRL and ECRB can act synergistically with FCR to produce pure abduction
Superficial Layer: Extensor Digitorum
• Occupies much of posterior surface of forearm
- P: lateral epicondyle (common extensor origin)
- D: Extensor apparatus of fingers
- I: Deep branch of radial nerve (C7, C8)
• A: Extends fingers, primarily at MCPJs (also extends other joints) meta carpal pharyngeal joints
Superficial Layer: Extensor Digiti Minimi
- P: lateral epicondyle (common extensor origin)
- D: Extensor apparatus of little finger
- Usually divides into 2 slips – radial one joined by tendon from extensor digitorum to little finger
- (EDM is ulnar to ED)
- I: Deep branch of radial nerve (C7, C8)
• A: Extends little finger, primarily at MCPJs (also extends other joints)
Distilly it splints into 2 tendons in little finger
Superficial Layer: Extensor Carpi Ulnaris
- P: 2 heads – humeral head from lateral epicondyle (common extensor origin) – & ulnar head from posterior border of ulna
- D: Dorsal base of 5th Metacarpal. Runs in groove between ulnar head and styloid process
- I: Deep branch of radial nerve (C7, C8)
- A: Extend and adduct hand at wrist joint
- Important (like ECRL) clenching fist/ tight grip finger flexion
- ECU can act synergistically with FCU- flexor carpi ulnaris to produce pure adduction
Superficial layer muscles
Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorium Extensor digit minimi Extensor carpi ulnaris
Deep layer: Supinator
• P: osseofibrous origin = lateral epicondyle of humerus, radial collateral and anular ligament, supinator fossa and crest of ulna
Arises from humerus ulna and radius and ligaments around it
• D: Lateral (posterior and anterior) surfaces of proximal 1/3 of radius
• I: Deep branch of radial nerve (C7, C8) - passes between two heads
• A: Supinates forearm
• Deep branch of radial nerve passes between superficial and deep parts
Deep layer: Abductor Pollicis Longus
- P: Ulna, radius and interosseous membrane (distal to supinator)
- D: Base of 1st metacarpal (Nb commonly split into 2 – one may attach to trapezium)
- I: Posterior interosseous nerve (C7,8) - continuation of radial nerve
- A: Abducts thumb and extends CMC (? wrist abductor)
Deep layer: Extensor Pollicis Brevis
- P: Distal third radius and interosseous membrane
- D: Dorsal base of thumb proximal phalanx
- I: Posterior interosseous nerve (C7,8)
- A: Extends proximal phalanx at MCPJ metacarpal pharyngeal joint (extend CMC and abduct wrist)- extesnor for the thumb
Deep layer: Extensor Pollicis Longus
- P: Middle third ulna & interosseous membrane
- D: Dorsal base of thumb distal phalanx. [change its line of pull on radial tubercle = a pulley]
- I: Posterior interosseous nerve (C7,8)
- A: extends distal phalanx at IPJ intralaryngeal joint (extend MCPJ & CMC)
• Tendons of APL and EPB anteriorly and EPL posteriorly form the anatomical snuff box
Deep layer: Extensor Indicis
- P: Distal third ulna and interosseous membrane
- D: Extensor apparatus of index finger
- I: Posterior interosseous nerve (C7,8)
- A: Extends index finger, allows independent extension – extend index finger alone
Extensor Retinaculum
• Tunnels formed by attachment of retinaculum to the distal radius and ulna
• Tendons have synovial sheaths as they pass in tunnels
Keep tendons close to bone
• Wrist compartments
– 1: APL & EPB – abductor pollucis longus and extenser pollucis brevis
– 2: ECRL & ECRB –extensor carpiradiallis longus and brevis
– 3: EPL – extensor pollucis longus
– 4: EDC & EI - extensor digiti and indicies
– 5: EDM exteonsor digiti minimi
– 6: ECU extenosir carpi ulnaris
• Oblique inter-tendinous connections (Juncturae tendinum)
• Oblique inter-tendinous connections (Juncturae tendinum) [stabilize, support, limit individual movement of individual fingers]
Radial Nerve in Forearm
- Enters cubital fossa anterior to lateral epicondyle
- Between brachioradialis and brachialis
Branches
• Divides into a superficial branch and deep branches
Radial nerve Deep branch
- Posterior interossus nerve / Deep Branch passes under proximal edge of the supinator (arcade of Frohse)
- passes Between 2 superficial and deep layers of supinator
- Runs in plane between superficial and deep extensor muscles (close to posterior interosseous artery)
Radial nerve Superficial branch
- Superficial Branch travels with radial artery, deep to brachioradialis
- Emerges into subcutaneous plane (approximately 9 cm proximal to radial styloid) by passing between BR and ECRL
- NB. Posterior cutaneous nerve of forearm comes off in radial groove and runs independently
Bones of Hand
‘• 8 carpal bones, arranged into 2 rows – distal row and proximal row
- Metacarpals & phalanges similar to feet
- Each has base, shaft, head
Proximal row:
- Scaphoid (Gk Boat) – articulates proximally with radius. Largest bone in proximal row. Prominent tubercle = bridges both rows in wrist joint
- Lunate (L Moon) - articulates proximally with radius
- Triquetrum (L 3 cornered) – pyramidal bone. Articulates proximally with disc of DRUJ
- Pisiform (L pea) –lies anterior to triquetrum. A sesamoid, increases leverage of FCU flexor carpi ulnaris
Distal row
- Trapezium (G – table) – 4 sided bone. Articulates with 1st & 2nd Metacarpals and scaphoid and trapezoid. Prominent tubercle – articukatr wuth thumn
- Trapezoid – wedge shaped. Articulates with 2nd metacarpal, trapezium, capitate and scaphoid
- Capitate (L head) – largest bone. Articulates with 3rd metacarpal. With trapezoid, scaphoid, lunate and hamate
- Hamate (L little hook) – wedge shaped. Articulates with 4th & 5th metacarpals, capitate and triquetral bones. Hook of hamate anteriorly
Metacarpals & phalanges of hund
- 1st metacarpal is shortest and thickest
- Thumb has 2 phalanges, others 3
- Thumb phalanges are stouter
- Proximal, middle distal phalanges – reduce in size
- Distal phalanges flattened and expanded at end, under nailbed.
The Wrist Joint (radiocarpal joint)
• Formed proximally by concave distal end of radius and articular disk and distally by convex proximal row of carpal bones (not pisiform)
- Ulna not part of wrist joint (articulates with radius at DRUJ distal radial ulna joint)
- Fibrocartilaginous, triangular articular disc (part of Triangular FibroCartilage Complex (TFCC)
- Attachments ulnar notch of radius and (lateral side of base of) styloid process of ulna
Radio carpal joint ligaments
- Palmar radiocarpal –from radius to both rows of carpal bones. Increases stability & ensures that hand follows forearm during supination
- Dorsal radiocarpal –from radius to both rows of carpal bones. Increases stability & ensures that hand follows forearm during pronation
- Ulnar collateral –from ulnar styloid process to triquetrum and pisiform
- Radial collateral –from radial styloid to scaphoid and trapezium
- Collateral ligaments prevent excessive lateral joint displacement
Flexion muscles - forearm
Flexor carpi radialis
Flexor carpi ulnaris
(assistance from finger flexors and Palmaris longus)
Extension muscles - forearm
• Extension – ECRL, ECRB, ECU (assistance from finger and thumb extensors)
Addiction muscles
• Adduction – ECU, FCU
Abduction muscles
• Abduction – APL, FCR, ECRL, ECRB
Intercarpal joints -
• Intercarpal joints - between carpal bones
Midcarpal joint
• Midcarpal joint - between prox and distal row
Joints of hand
- Intercarpal joints - between carpal bones
- Midcarpal joint - between prox and distal row
- Pisotriquetral joint
- Carpometacarpal and Intermetacarpal joints
Carpometacarpal joints
– plane type, except 1st CMC = saddle
– 2/3 CMC almost no movement, 4 slightly, 5 moderately mobile increasing movemenet as you move more medially
Palmar Fascia
• Fascia of palm is continuous with antebrachial (forearm fascia)
- Thenar and hypothenar fascia is thin Palmar aponeurosis = thick, triangular, central fascia
- Over thenar muscle
• Proximally (apex) continuous with flexor retinaculum & palmaris longus tendon
• Distally forms 4 longitudinal digital bands (rays) attach to
– bases of proximal phalanges
– become continuous with fibrous digital sheaths (= tubes that enclose synovial sheath and flexor tendons)
Palmar aponeurosis
- Thick triangular fascia
* Test for palmaris longus – feel it when press pinky finger with thumb
Hypothenar (medial) compartment
• Medial fibrous septum from medial border of palmar aponeurosis to 5th metacarpal
– Medial to septum = Hypothenar (medial) compartment
Thenar (Lateral) compartment
• Lateral fibrous septum from Lateral border of palmar aponeurosis to 3th metacarpal
– Lateral to septum is Thenar (Lateral) compartment
Central compartment
– Contain flexor tendons and their sheaths, lumbricals, superficial palmar arch, digital vessels and nerves
• Adductor and interossei compartments, contain adductor pollicis and interossei
• Adcuctor myscles
Spaces - in the forearm
- Potential deep spaces – deep to thenar and central compartment = thenar and midpalmar spaces
- (Between spaces is fibrous septum)
- Midpalmar space is continuous with anterior compartment of forearm (via carpal tunnel) - infecrion in arm can spread to forearm
Thenar Muscles - Abductor Pollicis Brevis
• Forms anterolateral part of thenar eminence
- P: Flexor retinaculum and tubercle of scaphoid (and trapezium)
- D: Lateral side of base of proximal phalanx of thumb
- I: Recurrent branch of median nerve (C8,T1)
- A: Abducts thumb, helps oppose it
Thenar Muscles - Flexor Pollicis Brevis
• Medial to APB abductor pollucis brevis
• P: 2 muscle bellies
– superficial head from flexor retinaculum & trapezium
– deep head from trapezoid & capitate
• D: Lateral side of base of proximal phalanx of thumb
–with APB via a sesamoid containing common tendon
• I: Superficial head: recurrent branch of median nerve (C8,T1)
• Deep head: Deep branch of the ulnar nerve (C8, T1)
• A: Flexes thumb (CMCJ and MCPJ) and aids in opposition
Thenar Muscles - Opponens Pollicis
• Deep to APB and lateral to FPB
- P: Flexor retinaculum and tubercle of trapezium (& scaphoid)
- D: Lateral side of 1st metacarpal
- I: Recurrent branch of median nerve (C8,T1)
- A: Oppose thumb = draws 1st metacarpal medially and rotates it at CMCJ
Adductor Pollicis (adductor compartment)
• P: 2 heads (Radial artery see later)
– Oblique: Bases 2nd & 3rd metacarpals, capitate
– Transverse: Shaft of 3rd metacarpal
• D: Medial side of base of proximal phalanx of thumb – via a sesamoid containing tendon
• I: Deep branch of ulnar nerve (C8, T1)
• A: adducts thumb
Hypothenar Muscles – Abductor digiti minimi
• Most superficial
- P: Pisiform
- D: Medial side of base of proximal phalanx of little finger
- I: Deep branch of ulnar nerve (C8, T1)
- A: Abducts little finger (assists in flexion of proximal phalanx)
Hypothenar Muscles – Flexor digiti minimi brevis
• Lies lateral to ADM
- P: Hook of hamate and flexor retinaculum
- D: Medial side of base of proximal phalanx of little finger
- I: Deep branch of ulnar nerve (C8, T1)
- A: Flexes proximal phalanx of little finger (at MCPJ)
Hypothenar Muscles – Opponens digiti minimi
- Deep to other 2
- P: Hook of hamate and flexor retinaculum
- D: Medial border of 5th metacarpal
- I: Deep branch of ulnar nerve (C8, T1)
- A: Draws 5th metacarpal anteriorly and rotates it laterally (at CMCJ) for opposition with thumb- make a cup in your hand
lumbricals
Arise from tnedon and isnert into tendon
4 of them
1st & 2nd
• P: lateral 2 tendons of FDP (unipennate muscles)
• D: lateral sides of extensor expansion of fingers
• I: Median nerve (C8,T1)
• A: flexes MCPJ, extends IPJ of fingers
3rd & 4th
• P: medial 3 tendons of FDP (bipennate muscles)
• D: lateral sides of extensor expansion of fingers
• I: deep branch of ulnar nerve (C8,T1)
• A: flexes MCPJ, extends IPJ of fingers
Short Muscles - Interossei
• 4 Dorsal Interossei (1st – 4th)
- Between metacarpals
- P: Adjacent sides of 2 metacarpals (bipennate)
- D: Bases of proximal phalanges and extensor expansions of fingers
- I: Deep branch of ulnar nerve (C8,T1)
- A: Abducts index and ring fingers from axial line; acts with lumbricals as above
Extensor Mechanism
- Tendons flatten at distal ends of metacarpals
- Extensor expansions (“hood”) hold tendon in middle
• Tendon divides into
– central slip, inserts into base of middle phalanx
– 2 lateral bands, insert into base of distal phalanx (unite over middle phalanx)
- Deep transverse metacarpal ligament connects (heads of) metacarpal bones
- Lumbrical tendon is anterior passes volar to ligament, on radial side of digit, attaches to radial lateral band flexes mcp joint but extends others
- Interossei tendons are posterior pass dorsal to ligament, to join lateral bands near the extensor expansion
- Note interossei and lumbricals anterior to MCPJ centre of axis => cause flexion
Finger Flexor Tendons
• Pass deep to flexor retinaculum, common flexor sheath
- Enter central compartment
- Fan out to individual digital synovial sheaths individual fingers
• FPL has own synovial sheath
– Passes between two sesamoid bones at head of 1st metacarpal
• Over proximal phalanx, FDS splits to allow passage of FDP (tendinous chiasm)
• FDS attached to margins of anterior aspect of base of middle phalanx
• FDP attaches to anterior aspect of base of distal phalanx
Finger Flexor Tendons Fibrous digital sheaths
- Strong ligamentous tunnels (contain tendons and synovial sheaths), prevent bowstringing
- Anular and Cruciform parts (pulleys) are thickened reinforcements
- Small blood vessels pass within synovial folds called vincula, from perisoteum to flexors
Ulnar Artery in the Hand
Runs on ulnar side superficial to flexor retinaculum
• Anterior to flexor retinaculum (TCL)
• Deep to palmar (volar) carpal ligament
• Between pisiform and hook of hamate via ulnar canal (Guyon’s)
• Artery lies lateral to nerve
• Divides into superficial and deep palmar arches - Superficial palmar arch is completed by branch from radial = give common digital artery
• 3 common (palmar) digital arteries
– anastomose with palmar metacarpal arteries from deep palmar arch
– divide into a pair of (proper palmar) digital arteries
– run along adjacent sides of each finger
• (sometimes) anastomoses with superficial palmar branch of the radial artery
Radial Artery in the Hand
• After branch, curves dorsally and crosses floor of anatomical snuff box
• Enters palm by passing between heads of
– 1st dorsal interosseous
– Adductor pollicis
Ends by anastomosing with deep branch of ulnar artery to form deep palmar arch
• Arch lies just distal to metacarpal bases
• 3 palmar metacarpal arteries
• Princeps pollicis artery – artery to thumb split into 2 branches
• Radialis indicis - usually from radial artery but may arise from princeps pollicis- supply radial side of index finger
Median nerve in the Hand
- median nerve passes Through carpal tunnel (with 9 tendons under flexor retinaculum, TCL)
- attachments - Tubercles of scaphoid & trapezium and pisiform & hook of hamate
Supplies
• 2 ½ thenar muscles
• 1st & 2nd lumbricals
Sensory to
• Palmar surface & sides of radial 3 digits, lateral half of ring finger and dorsum of distal halves of these digits
• Palmar cutaneous branch supplies central palm (arises proximal to flexor retinaculum)
Ulnar nerve in the Hand
2 branches
• Palmar cutaneous branch proximal to wrist
• Dorsal cutaneous branch – approx. medial half of dorsum of hand and little & ring fingers
Divides into
• superficial branch – (PB &) cutaneous branches to anterior surfaces of the medial and half digits
• deep branch – hypothenar muscles, medial 2 lumbricals, adductor pollicis, deep head of FPB and all interossei
Radial nerve in the Hand
- Superficial branch of radial nerve pierces deep fascia near dorsum of wrist
- Supplies skin and fascia over approx. lateral half of dorsum of hand, dorsum of thumb, index and middle fingers
Taking a history - what to include
- Age, handedness, occupation hobbies – right or left handed
- Presenting complaint
- Symptoms – probing qs
- Functional problems – what they can’t do due to problem
- Past medical history
- Drugs
- Allergies
- Social history
Examination
- Neck
- Nerves in upper limb are connected to neck, so pathology in neck can impact hand
- Check for pain and movement
- Shoulder
- Elbow – flex and extend
- Wrist
- Hand
Special investigations
- Blood tests
- Useful if it is an infection e.g. infection in tendon sheeth or RA (elevation of rheumatory factors)
- Imaging
- Neurophysiology
- Test of nerve and muscle action using electricity
Not always needed
4 types of Imaging in Hand surgery
- X-Rays
- Ultrasound
- CT scan
- MRI
X-Rays -views
• Minimum three views
• AP, Lateral, Oblique
Important ot have alll 3 vies as some may not spot abnormaliteis
Ultrasound
• Operator dependent
• Real time
Probe over area for suspected pathology
• Tendons and ligaments
CT scan
- Uses radiation
* Visualises bones and joints
MRI
- Uses magnetic field
* Visualises bones and soft tissues
Common Elective Hand conditions
- Arthritis
- Tendinopathies
- Nerve compressions
- Lumps – ganglia
- Dupuytren’s contracture
Arthritis
- Degeneration of the joints
- Several types
- Osteoarthritis
- Rheumatoid arthritis
- Psoriatic arthritis
- Gouty arthritis
- Post-traumatic arthritis
Osteoarthritis
- Autosomal dominant - Maternally inherited
- Affects multiple joints
- No effective medical treatments
- Diagnosed based on history and X-Rays
• In hands commonly first CMC joint of thumb joint and DIP most distl on fingers joints
Osteophytes, narroewing of joint space, sclerosis of bones
Osteoarthritis base of thumb
- Pain base of thumb
- Base of thumb subluxed, causes ‘squaring of thumb’ - more rectangle than square
- Grind test positive – hold aptient thumb, push it = pain
- patient struggles to use thumb so Compensates using MCP joint = hyperextension
- Results in ‘z- deformity’
Osteoarthritis base of thumb
Treatment
- Analgesics
- Splint
- Steroid injection
Surgical treatment
• Joint fusion – fuse 1st metacarpal to trapezium
• Trapeziectomy - remove trapeziuma nd reconstruct ligaments using piece of tendon
• Joint replacement – can fade overtime
Trapeziectomy
• Trapezium is removed
Maintain sapce between thumb metacarpal and scaphoid
• Ligament reconstruction may be added
- Good pain relief
- Risk of instability – MCP joint hyperextension
CMC joint fusion
—> fusion of first carpal metacarpal joint
- Gives stability
- Good for manual workers
- Unable to make a flat hand
Joint replacement
- Give relative stability
- Expensive
- Risk of failure
DIP joint arthritis – distal interphalangeal joints
- Seen as Heberden’s nodes – nodules
- Pain, loss of movements
- Mucous cysts may be seen – osteophytes corrdoe joint capsule fill with fluid
- Treated with NSAIDs, splints or joint fusion
Other hand joints
- Can affect STT joint, scaphoid, trapexium, trapzoid MCP joints or PIP joints
- Treated with NSAIDs, steroid injections, joint
- fusions or replacements
Rheumatoid Arthritis
- Autoimmune disease
- Can affect young people
- Affects multiple joints and other body systems
- Progressive
Pathology of RA
- IgMs against Fc portion of IgG
- AntigenAntibody complexes
- Inflammatory cells
- Phagocytosis of immune complexes
- release Lysozymes Free radicals Leukotrienes
- Joint destruction
Joint pathology in Rheumatoid arthritis
- Fluid in joint
- Inflamamtion of joint
- Stretch joint capusle and ligaments
- Bone erosisn
Wrist involvement
- Subluxation of the carpus
- Prominent ulna
- ‘Piano key sign’
- Pain
- Limitation of movements
- Tendon ruptures over prominent ulna or synovitis
Wrist involvement - treatment
- Wrist fusion - with minimal effort due to inflammation- but limits movement
- Wrist replacement
- Excision of distal ulna(Darrach’s procedure)
- Tendon reconstruction(EIP extensor indices propius tendon may be used) if rupture of tendons
Other joints affected
- Thumb
- MCP joints
- PIP joints
- DIP joints rarely affected
Thumb
- Can cause CMC and MCP joint
- Boutonniere or Swan neck deformity
- Treatment based on disability
- Splints, NSAIDs, joint fusion
MCP joints
- Ulnar drift of fingers
- Subluxation of the joints
- Treatment using splint, fusion or joint
- replacement
- Silicone joints - hinge to move joint , pyrocarbon joints or metal – no problem with subluxation
PIP joints
Flexion DIP
Hyperextension of PIP
- Swan neck deformity
- Boutonniere deformity
- Treatment using splints, steroid injections or surgery
- Surgery mainly joint replacement or fusion – silicone or metal
4 Tendinopathies
- Tennis elbow
- Golfer’s elbow
- De Quervain’s tenosynovitis
- Trigger fingers
Tendinopathies
Treatment principles
- Rest, splint
- NSAIDs
- Steroid injections
- Physiotherapy
- Release of tendon sheath, muscle origin – help tendon glide or reduce pain
Tennis and golfer’s elbow
—> either side of elbow joint
- Often middle aged (35 - 50)
- Pain can commence after minor trauma.
- May be recent history of excessive activity involving that elbow (rarely tennis ! Dusting,
- sweeping, heavy gardening etc).
- Golfer’s elbow similar history but medial pain less than Tennis elbow
• Tennis elbow:
• Lateral elbow pain reproduction on resisted wrist extension(Mills’ Test)= pain
• Golfer’s elbow:
• Medial elbow pain reproduction on resisted = pain
Treatment of tennis and Golfer’s elbow
- Non operative
- Activity modification
- NSAIDS
- Clasp – support muscle and ease pain
- Physiotherapy – stretched inflammaed muscles in either extensors or flexors
- Ultrasound
- Steroid injections
• Surgery
Trigger finger / thumb
- Thickening of the flexor tendon such that it does not pass through the sheath.
- Local injection injected into tendon sheath to relax It
- Surgical release
Pain over MCP joint, inability to flex finger, need other hand to flex it, or it locks
De Quervain’s Tenosynovitis
—> first extensor compartment
- Inflammation affecting APL and EPB tendons and their sheaths
- Women more often affected
- 30-50yrs
- Finkelstein’s test = make fist with thumb causes pain
- Treatment
- Rest and NSAID’s
- Corticosteroid injection
- Surgical Decompression
Nerve compressions
• Can affect Median nerve and Ulnar nerve
- Radial nerve compression rare
- Median nerve commonly at wrist- Carpal tunnel syndrome
- Ulnar nerve at Elbow- Cubital tunnel syndrome
Carpal tunnel syndrome
- Compression of median nerve under flexor retinaculum
- Retinaculum is tight or contents of carpal tunnel increase
- Pain, tingling, pins and needles in hands
- Nocturnal symptoms – flex hands at night cause symptoms and fluid shift
- Later weakness or wasting of thenar muscles
Diagnosis of carpal tunnel syndrome
- Typical history
- Examination of median nerve
- Provocative tests
- Phalen’s - flex and hold wrist = symptoms
- Carpal compression test = presure over carpal tunnel with thumb = symptoms
- Tinel’s sign
• Nerve conduction studies – conduction velocity of medial nerve across carpal tunnele
Treatment of carpal tunnel syndrome
- Splint
- Steroid injection
- Carpal tunnel release = Open procedure, Endoscopic
Cubital tunnel syndrome
- Ulnar nerve compression at elbow
- Both compression and tension on the nerve as you flex elbow
- Symptoms along ulnar nerve
- Pain, numbness, tingling – over ring and little fingers
- Weakness of small muscles of hand – interossir and abductor pollucius
- Positive elbow flexion test
Cubital tunnel syndrome
Treatment
- Activity modification - limit elbow flexion
- Splint – keep elbow straight
- Nerve gliding exercises
- Cubital tunnel release
• May need a nerve transposition or medial epicondylectomy – reduce tension on nevre
Dupuytren’s disease
- Common in Northern Europe
- ‘Viking disease’
- Causes contractures of fingers
- Associated with feet fibromatosis(Ledderhosen’s disease) and penile fibromatosis(Peyronie’s disease
Affects multiple digits and joint MCP and pip
Dupuytren’s disease
Aetiology and pathogenesis
- Genetic
- Environmental-smoking, DM, epilepsy, alcoholism
- Microngiopathy - proliferation of Myofibroblasts – produce muscle fibres causing contraxtion
‘Dupuytren’s disease
Treat ment
- Needle fasciotomy – needle brak cords and straighten finger
- Collagenase – inject enzymes into finger
- Limited fasciectomy – excise disease part
- Dermofasciectomy – excsise skin and disese
Lumps in the hand
- Ganglia – cystic swelling around tendon and joints
- Lipomas – fatty lumps
- Cysts – epithelieum lined fluid filled lumps
- Giant cell tumours of tendon sheath – solid benign
- Nerve sheath tumours
- Sarcomas- malignant tumours
Ganglia
- Usually occur spontaneously
- Contain gelatinous fluid due to mucoid degeneration of the synovium.
- Develop around joints or tendon sheaths, and usually communicates with the joint.
- Most common around the wrist.
- Dorso radial or volar radial
- Can be intermittently painful
• Treatment=aspiration or excision
Best to treat them by leaving them they will eventually go away
• Beware of recurrence!
Carpal tunnel bones
proximal to distal
Scaphoid
Lunate
Triquetrium
Pisiform
Distal row
Trapezoid
Trapezium
Capitate
Hamate
