Wrist Hand Surgeries - Dr. Worst Flashcards
7 common Surgeries of Wrist and hand
- CTS (carpal tunnel syndrome)
- Trigger fingers
- Arthroscopy
- TFCC
- Fractures
- DSTS
- Tendon Repairs
CTS
Carpal tunnel syndrome
How common is Carpal tunnel syndrome (CTS)?
1% of population
CTS symptoms (7)
- Median nerve distribution
- Pain
- Paresthesias
- Pinch Grip weakness
- Thenar atrophy (chronic)
- Night pain (curled hand position)
- Clumsiness in hand in fine motor skills (from sensory problems, not motor)
CTS cluster of S/S (10)
- Pregnancy-fluid accumulation
- Diabetes
- Colles wrist frature
- Systemic, endocrine, metabolic disorders
- Occupational (Secretary/Power tools)
- Exam
- EMG/NVC (nerve conduction test)
- Alcoholism
- Anything with peripheral neuropathy
- Using lumbricals
f
CTS Treatments (4 general things)
- Change causative factors
- Splinting in neutral position (not cock-up)
- PT modalities, Mobs, Exercises, stretching, etc.
- Inject area (not the nerve) with corticosteroid (lidocaine, kenalog)
(modalities research doesn’t have consistant outcome)
Carpal Tunnel Release Surgery? (4 things about when it could be considered)
- symptoms > 3 months
- sensory deficits (objective)
- > 3.61 Semmes-Weinstein microfilaments
- maybe thenar atrophy/weakness
One of the most common surgeries performed
Carpal Tunnel Release Surgery types and duration
Takes ~ 10 minutes
- Open CTS release: 10-15% complications
- Arthroscopic: 2-3x more complications at 35% (bc more conservative with cutting
CTS release Surgery recovery
- Dressings
- Fingers open (increased scaring if not kept open)
- Elevation
- No evidence for immobilization
Early mobilization: gentle composite fist
- 2 weeks: sutures removed and scare management (mobs) is important
- <5% recurrance
- Tendon gliding exercises important
Wrist tendonitis/osis
same principles apply from Dr. davies lecture on tendonitis/osis for elbow
Where are the most common locations for hand tendonitis/osus?
1st, 2nd, & 6th dorsal wrist extensors
There is also Tenosynovitis
(but more along the lines of senosing tenosynovitis)
Stenosing tenosynovitis
Narrowing of a tendon sheath from chronic pressre/inflammation that leads to fibrosis
DeQuervain’s/trigger finger
What is a very good treatment for tendonosis and why?
eccentric exercises because it realigns the collagen fibers
Draw/explain Tendinosis cycle
DeQuervains
Stenosing Tenosynovitis of the abductor pollicis longus and extensor pollicis brevis at radial styloid ; Tested by Finklestein Test
Wrist sprain grades (3)
Grade I: ligaments stretched or slightly torn
Grade II: ligaments partially torn
Grade III: ligaments completely torn
Wrist sprain treatment
Splinting to help calm down
Then Therapy: gentle strenthening
TFCC Injuries (MOI)
activities that involve ulnar deviation and vibration
power tools
gymnasts
TFCC Injuries (characteristics - 5)
- Acute Onset
- CKC exposed to injury
- Typically due to hyperextension and ulnar deviation
- Easily confused with UCL sprains
- Extensor Carpi Ulnaris Tendon attaches on the TFCC
TFCC injury symptoms
deep pain on ulnar side of wrist axial loading through 5th metacarpal
Arthroscopic TFCC Repair
debridement or repair with sutures
Wafer Procedure
ulnar fovea sign
tests for TFCC injury or ulnotriquetral ligament tear (TFCC will have an associated DRUJ instability)
- palpate the soft spot between the ulnar styloid process, pisiform, anterior surface of the ulnar head, and the FCU.
- positive: reproduction of the pt’s symptoms
“wafer” prodecure (describe it, indications, contraindications)
- a wafer of up to 2-4 mm of distal ulnar head is removed, while the styloid process, TFCC, and attatched ligaments remain attached;
- the procedure is contra-indicated if more than 4 mm of positive variance;
- may be indicated for symptomatic positive ulnar variance, ulnocarpal impaction syndrome, or symptomatic TFCC tears;
saw used to cut ulnar head and remove “wafer” at lateral side of TFCC while styloid process still intact. TFCC reattached.
How many Trigger Finger people are helped in the short term by one Corticosteroid inection?
~66%
What is the primary treatment for Jersey finger
Surgical repair (mobilize ASAP!)
UCL injury to thumb is called (two names)
gamekeepers thumb
Skier’s thumb
Differential Fisting (purpose and 5 positions)
Used for Tendon Gliding
- Open hand
- MCP Flexion
- Hook Fist
- Straight Fist
- Composite Fist
UCL of thumb tear symptoms
- Painful/Swollen
- Pinching and grip difficult
- Sometimes can feel little bump where ligament should be
the UCL test tests at extension and slight flexion because there are two fiber bundles in UCL
Ganglion cysts
don’t forget about them
Bible Bump Test
Burst the Ganglion Cyst
Flexor Tendon Rehab progression
Phase I: day 5-3 weeks (PROM, AAROM, AROM)
Phase II: Weeks 4-6 (splints removed)
Phase III: Weeks 6-12
- Week 7 light resistive exericses
- Week 8 PROM bilateral comparison WNL
- Week 10-12 BEgin light ADL’s
- Week 12 All ADL’s and start resistance trn Weekss 14-16: BEgin heavy and sustained lifting ex and tight gripping ex
characteristics of Flexor Tendon Repair recovery
- Flexor tendon repair
- early protected PORM: dorsal blocking splint
- Early post -op - Progression to “careful ROM”
- Place and hold exericses (sub max isometrics) in shortended position (progression to mid-lengthend positions)
- Splinting Tech: blocking or dynamic splints ( orn 4-6 weeks)
- Tendon glide assessment
- Joint mobilizations
- Progress to resistive exercises
scaphoid has _______ blood supply making it vulnerable to _________
retrograde
avascular necrosis
scaphoid fracture healing time
usually about 4 months because of delayed union
Hamate fracture
usually when doing something with a club or holding something
Handle bars?
Lunate dislocation
usually caused by FOOSH most common dislocated carpal bone Murphy’s sign
may have pain there, but may spontaniously reduce so may not be able to feel it.
Or Capitate may drop down into the gap
Greater than 3mm gap between scaphoid and lunate on a fisted radiograph
metacarpal fractures
may have a large bump and an effect on knuckle
Usually casted and immobilized
Boxer’s Fracture
fracture of neck of 5th metacarpalfrequently sustained during a fight or from punching a wall in anger or frustrationcasted for 2-4 weeks
Can see on observation
May get Gutter splint
gutter splint
splint located on the radial or ulnar side of the wrist
Bennet fracture
- fracture of the base of the first metacarpal (thumb)
- usually extends into the joint
- usually has some dislocation.
ORIF with Kirschner pins
Thumb splint might be used
PIP Joint Sprains and dislocations
Collateral ligaments
DIP Joint fractures and Dislocations
happens
Boutonniere deformity
RA. PIP flexion, DIP hyperextension
can try splinting
What are the nodes call for RA? OA?
RA nodes= Bouchard’s nodes;
OA nodes= Heberden’s nodes
swan neck deformity
sometimes you can do this if you have hypermobility
Use swan neck splint
RA
