Transcript Surgical therapy

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HAND AND WRIST DISEASES 
Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is the most
commonly diagnosed and treated
entrapment neuropathy. The syndrome is
characterized by pain, paresthesia, and
weakness in the median nerve distribution of
the hand. Surgical and nonsurgical treatments
exist that can produce excellent outcomes for
patients.
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RELEVANT ANATOMY
The carpal canal is a fibro-osseous tunnel at the wrist
through which 9 flexor tendons and the median nerve pass.
The carpal bones define the dorsal aspect of the carpal
canal and are shaped in a concave arch. The palmar
aspect of the carpal canal is defined by the flexor
retinaculum, which bridges the 2 sides of the carpal arch.
Intrinsic and extrinsic ligaments of the wrist and hand
further stabilize the carpal bones. The carpal canal is
narrowest at the level of the hook of the hamate, where
the canal averages 20 mm in width.
CTS
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Etiology
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1-local median nerve compression at the wrist, with ischemia and
impaired axonal transport of the median nerve across the wrist.
Compression results from elevated pressures within the carpal canal.
Elevated pressures can develop within the carpal canal even though
the canal is not a separate, closed compartment within the upper
extremity. Direct pressure or a space-occupying lesion within the carpal
canal can increase pressure on the median nerve and produce CTS.
Fracture callus, osteophytes, anomalous muscle bodies, tumors,
hypertrophic synovium, and infection, as well as gout and other
inflammatory conditions, can produce increased pressure within the
carpal canal. Extremes of wrist flexion and extension also elevate
pressure within the carpal canal.
2-systemic conditions are strongly associated with CTS. These
conditions may directly or indirectly affect microcirculation, pressure
thresholds for nerve conduction, nerve cell body synthesis, and axon
transport or interstitial fluid pressures. Perturbations in the endocrine
system, as observed in individuals with diabetes and hypothyroidism
and in women who are pregnant, are linked to CTS. Conditions
affecting metabolism (eg, alcoholism, renal failure with hemodialysis,
mucopolysaccharidoses
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Clinical
Acute CTS can develop following a major trauma to the upper
extremity (typically a distal radius fracture), a carpal dislocation,
or a crush injury. Swelling, pain, and paresthesia in the median
nerve distribution of the hand (palmar and radial) are observed.
In the more common idiopathic or chronic CTS, symptoms are
more gradual in onset. Pain and paresthesia in the median nerve
distribution of the hand are common. Symptoms are often worse
at night and can wake a patient from sleep. As the condition
worsens, daytime paresthesia becomes common and is often
aggravated by daily activities, such as driving, combing the hair,
and holding a book or phone. Weakness can be present. With
long-standing or severe cases of CTS, thenar atrophy is
frequently observed.
Because of the motor and sensory disturbances, manual
dexterity is diminished, and difficulty with such daily activities as
buttoning clothes and holding small objects is often encountered.
Pain and paresthesia can also occur proximally in the forearm,
elbow, shoulder, and neck in up to one third of patients(double
crush phenomena). Pain and paresthesia in the hand are not
always isolated to median nerve distribution but can involve the
ulnar aspect or the entire hand.
Carpal tunnel syndrome
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Provocative tests :-
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Phalen wrist flexion test - The patient's elbows are
placed on a table, with the forearms perpendicular
to the table and the wrists flexed. This position is
held for 60 seconds. The test is positive if numbness
or paresthesia develops in radial-sided digits.
Tinel test - The examiner taps along the course of
the median nerve on the volar aspect of the wrist.
The test is positive if paresthesia is elicited in the
median nerve distribution.
Carpal compression test - Direct application of
pressure of 150 mm Hg or even pressure from both
thumbs of the examiner is exerted on the patient's
carpal canal and is maintained for 30 seconds. The
test is positive if pain, numbness, or paresthesia
develops in the radial-sided digits.
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CTS
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Electrophysiologic diagnostic studies –:
1-Nerve conduction:-Median motor and sensory latencies, as
well as conduction velocities, are measured across the wrist. A
sensory latency of greater than 3.5 milliseconds or a motor
latency of greater than 4.5 milliseconds is considered an
abnormal finding.
2- Electromyography :-This study must be performed with a
clinical differential diagnosis in mind; the abductor pollicis brevis
is the key muscle to evaluate. Positive findings in persons with
CTS include sharp waves, fibrillation potentials, and increased
insertional activity.When interpreting electrophysiologic studies,
remembering that CTS is a clinical diagnosis is important.
CTS is a constellation of signs and symptoms caused by the
compression and slowing of the median nerve at the wrist.
Electrodiagnostic studies should not be used independently in
making a diagnosis.
NERVE CONDUCTION TEST
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TREATMENT :-Medical Therapy:
Steroid injection and wrist splinting have been used effectively in
patients with milder symptoms. A study reported complete relief of all
symptoms in 76% of hands at 6 weeks after treatment, but more than
12 months after treatment, the proportion of hands experiencing
complete relief deteriorated to only 22%. Similar positive results have
been reported with steroid injection alone in a double-blind, placebocontrolled trial.
Other nonoperative treatments have been proposed, but they have not
been studied as rigorously; they include nonsteroidal antiinflammatory drugs (NSAIDs), vitamins (B complex), workstation
redesign, ergonomic tool modification, acupuncture.
Surgical Therapy:
Open and endoscopic surgical techniques have been described for
treatment of CTS. Both operative techniques are effective for the
treatment of chronic CTS. Potential benefits of the endoscopic
technique, including a more rapid functional recovery, have to be
weighed against the technique's increased cost and higher
complication rate. The reliability of and good visualization provided
by the open technique continue to make it the preferred operation for
many hand surgeons. Open release with an extended surgical incision
is recommended for acute CTS.
Carpal tunnel injection and surgical release
Dupuytren Contracture
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Dupuytren contracture, a disease of the palmar fascia,
results in the thickening and shortening of fibrous bands
in the hands and fingers. This disease entity belongs to
the group of fibromatoses that include plantar
fibromatosis (Ledderhose disease), penile fibromatosis
(Peyronie disease), and fibromatosis of the dorsal
proximal interphalangeal (PIP) joints (Garrod nodes or
knuckle pads).
Race, Sex, and Genetics:-The incidence of Dupuytren
contracture is highest in Caucasians, historically those of
Celtic descent. The disease affects men 7-15 times more
often than it does women. Dupuytren disease has long
been known to be transmitted in an autosomal dominant
fashion with variable penetrance. Neumuller et al (1994)
demonstrated an increased relative risk of 2.94 for
individuals who express human leukocyte antigen (HLA)DR3.
Dupuytren Contracture
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Dupuytren disease is an autosomal dominant
fibroproliferative disease with variable penetrance.
Associated conditions:-The incidence of Dupuytren
disease also increases with concurrent patient clinical
conditions or factors such as diabetes, smoking,
chronic alcoholism, seizures, and infection . HIV
infection,repetitive manual trauma,Age and family
history, younger individuals with a positive family history
for the Dupuytren disease have been reported, although
the disease most often affects people older than 50
years. (Rheumatoid arthritis is associated with a
decreased incidence of Dupuytren contracture).
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Clinical
The typical patient with Dupuytren disease is
aged 50 years or older and presents with a
palmar nodule and cord adherent to the
skin, as well as with a flexion
contracture ,Dupuytren disease must be
distinguished from several other conditions
that affect the hand, including trigger finger,
stenosing tenosynovitis, a ganglion cyst,
or a soft-tissue mass
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Medical therapy
In the past, nonsurgical approaches to Dupuytren contractures
such as splinting, irradiation, ultrasonography, dimethylsulfoxide,
vitamin E therapy, and allopurinol treatment were shown to be
ineffective. Steroids produced only temporary therapeutic effects,
and their use has been debated in the literature. Future
nonoperative therapies include the use of calcium channel
blockers or gamma-interferon, skeletal traction, and
percutaneous needle fasciotomy, with the last of these
showing the most promise with minimal adverse effects.
Surgical therapy
Although the option for surgery in Dupuytren disease is
considered on a case-by-case basis, guidelines for the timing of
surgery exist. In general, surgery should be performed on an
affected MCP joint if the contracture is 30° or greater. Such
contractures most likely cause some debilitation for the patient.
Usually, a limited fasciectomy of the pretendinous cord is
sufficient to establish normal function in the MCP joint and no
recurrence with a full-thickness skin graft in
dermatofasciectomy.
Hand Infections
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1-Acute paronychia involves the soft tissue around the fingernail and usually results from the inoculation
of bacteria (most commonly Staphylococcus aureus) into the paronychia tissue from nail trauma or nail
manipulation.
2-Chronic paronychia usually is caused by Candida albicans and occurs most commonly from chronic
immersion in water (as in dishwashers), previous trauma, or nail defects.
3-A felon is a subcutaneous abscess over the distal pulp of a digit or thumb. Felons usually result from a
penetrating injury. The pulp contains multiple compartments separated by fibrous septa that make
infections in this area complex.
4-Deep-space infections in the hands are possible; the 2 deep spaces in the palm are the midpalmar
space and the thenar space. Infections in these areas usually result from injuries such as bites or puncture
wounds. These infections may cause cellulitis, fluctuance, and/or pain. In addition, the second, third, and
fourth web spaces are potential sites for infection. Web-space infections can spread from the palmar
subfascial space in a dorsal direction, forming what is commonly referred to as a "collar button abscess."
On examination, patients typically have pain, swelling, and fluctuance on the palmar or dorsal web-space
surface.
5-Flexor tenosynovitis is a potentially devastating infection that can result in significant scarring of the
flexor tendon sheath with resultant compromise in hand function. These infections usually are caused by a
penetrating injury (eg, bite, puncture wound).
6-Septic arthritis usually results as a sequela after open skeletal trauma or from a bite wound. Patients
with inflammatory arthritis are at increased risk for joint-space infections. Tenderness and swelling of the
joint are signs of potential infection. Puncture wounds over the joint should suggest potential septic arthritis.
The differential diagnosis includes gout, psoriatic arthritis flare, and systemic lupus erythematosus.
Staphylococci and streptococci are most commonly isolated in septic joint cultures.
7-Osteomyelitis can occur from an acute event, such as a penetrating wound or open fracture, or as a late
sequela of a fracture or other surgery. Patients with a history of diabetes or other immunocompromising
conditions are at higher risk for osteomyelitis. Diagnosis of this condition is based on the signs seen with
other infections: cellulitis, warmth, and tenderness. In addition, recurrent infections in the same location
may be a sign of infection of the underlying bone. Laboratory studies and radiographs can assist in making
the appropriate diagnosis . The treatment consists of debridement of the devitalized bone, as well as
antibiotics, usually a prolonged course of 6 weeks.
8-Herpetic whitlow is a viral infection that is caused by the herpes simplex virus and that may resemble a
felon or paronychia. These infections usually occur in medical or dental personnel. History is an important
clue to the diagnosis. The patient first notices pain, then erythema before the development of the herpetic
vesicle.
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Clinical
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A thorough history of a hand infection includes determination of
the onset, duration, any recent trauma, and any systemic
symptoms (eg, fever, chills). Most patients present with a 2- to 3day history of cellulitis and swelling.
The physical examination should include examination of the hand,
with particular attention to cellulitis, lymphangitis, areas of
fluctuance, range of motion, foreign bodies, and the presence or
absence of Kanavel signs.The 4 Kanavel signs are used to
differentiate between infectious tenosynovitis and a superficial or
localized abscess. In the presence of infectious tenosynovitis, the
signs include intense pain, flexion posture, uniform swelling, and
percussion tenderness.
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Medical therapy
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A few important guidelines assist in the management of hand infections. First, cellulitis
must be treated with antibiotics. Most hand infections are caused by Staph aureus,and
therefore, a first-generation cephalosporin (eg, cephalexin) is usually the first drug of
choice. However, the potential exists for infections with different organisms. In fact, an
increase in the incidence of community-acquired methicillin-resistant staphylococcal
(MRSA) infections has been reported.
Animal bites require bacterial coverage that is particular to the offending animal. Human
bites require coverage for Eikenella corrodens; penicillin and a first-generation
cephalosporin are appropriate choices in these cases. Cat bites require coverage for
Pasteurella multocid; appropriate antibiotics include IV ampicillin/sulbactam or oral
amoxicillin clavulanate.
Usually, oral antibiotics are sufficient as initial treatment. Many medical professionals
recommend an initial, limited wound irrigation in the emergency department or in the
outpatient clinic. Consider IV antibiotics in patients in whom cellulitis fails to resolve with
oral antibiotics. In all cases, the final antibiotic coverage should be guided by culture and
sensitivity results. Patients with a history of immunocompromise (including those with
diabetes) should initially be treated with IV antibiotics.
Fungal infections can occur in or under the skin. Cutaneous fungal infections, or tinea, are
treated with topical agents such as miconazole or clotrimazole. The most common
subcutaneous infection is sporotrichosis; this condition can appear with an ulcerative
lesion, along with lymphadenopathy. Gardeners are most commonly infected. Oral
itraconazole for 3-6 months is the current recommended course of treatment. Fungal
abscesses or disseminated fungal infections can occur and are usually found in
immunocompromised patients.
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Surgical therapy
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As a rule, all abscess cavities must be drained. Antibiotics alone are not effective in
treating pus. If the patient does not improve with antibiotics, suspect undrained pus or a
foreign body. Immunocompromised patients should always receive IV antibiotics.
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Lab Studies
Complete blood cell (CBC) count: An elevated white blood cell count can indicate the
presence of infection.
Prothrombin time (PT) and activated partial thromboplastin time (aPTT): Obtain
these tests before surgical treatment in patients who are receiving long-term anticoagulant
therapy.
Glucose level: Check glucose levels in all patients with a history of diabetes. In those
patients with active infections, blood-glucose levels are often elevated and difficult to
control. Furthermore, blood-glucose control is important for wound healing. It is also
important to check the glucose levels of any patient who has a history of frequent or
particularly severe infections to rule out occult diabetes.
Erythrocyte sedimentation rate (ESRand CRP): are elevated in cases of septic
arthritis and osteomyelitis.
If there is a clinical suspicion of septic arthritis, a joint aspirate should be sent for
Gram staining, culturing, and sensitivity testing. In addition, cell count assessment,
glucose and protein level determinations, and crystal analysis help in distinguishing
between an infected joint and a joint with inflammatory arthritis or gout/pseudogout.
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Imaging Studies
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Plain radiographs (3 views of the hand) are important to rule out the presence of
foreign bodies, fractures, and subcutaneous air, which could indicate gas gangrene or
acute or chronic osteomyelitis.
Magnetic resonance imaging (MRI) may be helpful for assessing soft-tissue
abscess(es) and osteomyelitis.
Ultrasonography may reveal soft-tissue abscess.
Bone scanning, indium-111 (111In) radionuclide studies, or computed tomography (CT)
scanning may be useful for evaluating osteomyelitis.
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Ganglion Cyst
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Ganglion cysts are the most common soft-tissue tumors of the hand
and wrist. They can occur in patients of any age, including children;
approximately 15% of ganglion cysts occur in patients younger than
21 years. Seventy percent of ganglion cysts occur in patients
between the second and fourth decades of life. Women are affected
3 times as often as men. No predilection exists for the right or left
hand, and occupation does not appear to increase the risk of
ganglion formation.
Etiology
Uncertainty exists regarding the origin of ganglion cysts. The most
widely held physiologic explanation attributes cyst formation to
mucoid degeneration of collagen and connective tissues. This
theory implies that a ganglion represents a degenerative structure
that houses .
A more recent theory, postulated by Angelides, attributes cyst
formation to trauma or tissue irritation.Modified synovial cells lining
the synovial-capsular interface are stimulated to produce mucin.
Mucin dissects along the attached joint ligament and capsule to
form capsular ducts, which function as valvelike structures
producing lakes. The ducts and lakes of mucin eventually coalesce
to form a solitary ganglion cyst.
Ganglion cyst
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RELEVANT ANATOMY
A ganglion is a well-circumscribed mucin-filled cyst with a smooth
translucent wall that is closely associated with a joint or tendon sheath.
Ganglions are usually connected by a stalk to an underlying joint
capsule or ligament. They commonly arise from the dorsum of the wrist,
where they are specifically associated with the scapholunate ligament
of the wrist. Volar wrist ganglions are less common, and many are
associated with the scaphotrapezial joint of the wrist.
The location of the radial artery is particularly important in the
assessment of volar wrist ganglions because they are often intimately
associated with this vessel. Care must be taken to preserve the radial
artery during dissection of a volar wrist ganglion because injury to this
vessel may potentially compromise circulation to the hand.
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Clinical
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Although ganglion cysts are generally asymptomatic, presenting
symptoms may include limitation of motion, pain, paresthesias, and
weakness. Ganglions are usually solitary, and they rarely exceed 2 cm
in diameter. They can involve almost any joint of the hand and wrist.
Dorsal wrist, volar wrist, volar retinacular, and distal interphalangeal
ganglion cysts constitute the vast majority of ganglions of the hand and
wrist.
Dorsal wrist ganglia occurring over the scapholunate ligament of the
wrist represent 60-70% of all ganglia. The volar wrist is the next most
common site of occurrence; 20% of all ganglia occur in the volar wrist.
The flexor tendon sheath of the fingers, particularly at the level of the
A1 pulley, is involved in 10-12% of ganglia.
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Imaging Studies
Standard plain radiographs are obtained to evaluate any
potential underlying bone or joint abnormality that may explain
the symptoms. The cyst itself is rarely visualized. For cases with
atypical presentations, and especially occult ganglia, MRI studies
have proven to be successful in confirming examination findings.
Medical therapy
The predominant current nonsurgical method of treatment
involves aspiration alone,sometimes followed by steroid injection.
This is especially successful for tendon sheath ganglions in the
hand and digits. Caution should be exercised when performing
multiple steroid injections to avoid the complications of skin and
fat atrophy and thinning, as well as hypopigmentation.
Surgical therapy
INDICATIONS:- Indications for treatment include limitation of motion,
pain, weakness, and paresthesias. Treatment is also indicated if
malignancy is a concern or if the patient finds the lesion
aesthetically displeasing..Surgical treatment involves total
ganglionectomy with removal of a modest portion of the
attached capsule.
De Quervain Tenosynovitis
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De Quervain tenosynovitis is an entrapment tendinitis of the tendons contained
within the first dorsal compartment at the wrist; it causes pain during thumb motion.
Etiology
The tendons of the abductor pollicis longus and the extensor pollicis brevis are
tightly secured against the radial styloid by the overlying extensor retinaculum. Any
thickening of the tendons from acute or repetitive trauma restrains gliding of the
tendons through the sheath. Efforts at thumb motion, especially when combined
with radial or ulnar deviation of the wrist, cause pain and perpetuate the
inflammation and swelling.
Clinical
Patients note pain resulting from thumb and wrist motion, along with tenderness
and thickening at the radial styloid. Crepitation or actual triggering is rarely noted.
Patients frequently are mothers of infants aged 6-12 months, and symptoms are
often noted in both wrists. Repetitive lifting of the baby as it grows heavier is
responsible for friction tendinitis. Day care workers and other persons who
repetitively lift infants are frequently affected as well. De Quervain tenosynovitis can
also develop in individuals who have sustained a direct blow to the area of the first
dorsal compartment.
Examination
The first dorsal compartment over the radial styloid becomes thickened and feels
bone hard; the area becomes tender. Usually, the compartment's thickening so
distorts the sparsely padded skin in this area that a visible fusiform mass is created.
The Finkelstein test (consisting of flexion of the thumb across the palm and then
ulnar deviation of the wrist) causes sharp pain at the first dorsal
compartment .Tenderness is absent over the muscle bellies proximal to the first
dorsal compartment. Tenderness and pain on axial loading are absent at the
carpometacarpal (CMC) joint unless the patient has arthritis in that joint.
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Medical therapy
Splinting of the thumb and wrist relieves symptoms, but most
patients find the loss of the thumb for functional activities too
restrictive and do not consistently wear the splints. Injection of
corticosteroid into the sheath of the first dorsal compartment
reduces tendon thickening and inflammation. A dose of 0.5 mL of
1% plain Xylocaine and 0.5 mL of a long-acting corticosteroid
preparation can be injected either sequentially or simultaneously.
One injection permanently relieves symptoms in roughly 50% of
patients. A second injection given at least a month later
permanently relieves symptoms in another 40-45% of patients.
Surgical therapy
If injection therapy fails, surgical release of the first dorsal
compartment relieves the entrapment.
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