Chapters Transcript Common Conditions of the Hand and Wrist Dr. Wright provides a high level overview some common conditions of the hand and wrist. So I'm gonna introduce our next speaker. We have Doctor David Wright, who completed his medical degree. And orthopedic surgery residency at the University of California in Irvine, which he mentioned earlier. He then moved to Saint Louis to complete his fellowship in hand and microsurgery at Washington University School of Medicine, where he is currently an assistant professor with the orthopedic department. His clinical interests are carpal tunnel, cubital, Tunnel, trigger finger, arthritis of the hand and wrist. I'm gonna mess this one up. Dupuytren's disease. Um, fractures of the hand and wrist, tendon lacerations, nerve injuries, brachial plexus injuries, and seized patients at Barnes Jewish Hospital and Missouri Baptist. Is that correct? Correct. Cool. So he is going to talk about calming conditions of the hand and wrist today for us. So thank you so much. Appreciate it. Yeah, thank you. Thanks for the opportunity to speak. Um, I, uh, I'm familiar with the Saint Louis area. I was here for fellowship and I'm now just coming back. I've been in practice for a few years out in California, um, and was uh excited to come back as faculty here. So, I'm just gonna kinda do a good overview here of, I think some of the most common conditions that would be presenting to either a primary care or urgent care setting, um, for conditions of the hand and wrist. I, I tell people, the hands are like the marines, they're the first ones in and the last one's out. So, um, you know, people are constantly, um, injuring their hands, or if they have, uh, problems or pain in their hands, it certainly affects, uh, just about everyone's daily life. So, these are very common, and, um, hopefully I can help refine or review, uh, some of the uh conditions that you're already familiar with, um. See if I can get this to advance, there we go, uh, so I have no disclosures, uh, a little bit about my practice, um, I do everything, uh, basically from the hand up to the elbow. Um, I'll do, uh, fractures, um, arthritic conditions, you know, wrist fusions, um, and, uh, distal radius fractures, uh, skateboard fractures, all of that. Uh, I do do wrist arthroscopy, um, for things like, uh, TSCC tears and other, uh, wrist pathologies, and I will do elbow, um, including, uh, total elbow arthroplasty, um, in the appropriate patient. Um, my passion is, uh, nerve and microsurgery. Uh, that's what I do mostly at the downtown location, um, so this involves a lot of, uh, brachial plexus and, um, soft tissue coverage for both upper and lower extremity, um, but, uh, that's kind of a more sub-specialized area of my practice. So, uh, just, I think this is a good resource for anybody who's treating conditions of the hand. Um, and this is by the American Society for Surgery of the Hand. This is our governing body, um, and if you go to this website, it's a great resource for patients, uh, and practitioners, honestly. Um, covers everything from common conditions to safety, things like firework safety, how to get a ring off, um, you know, uh, snow blower safety, table saw safety, um, all of these are important, um, measures because as you'll see, we can do some pretty, uh, amazing things with hand surgery, but, um, oftentimes we, you know, the best means of, um, care is actually prevention. So, uh, just gonna start off with a quick case, um, put things in context, but this is probably a patient who you all have seen multiple times in your clinic. Uh, Mrs. Smith is an active 67 year old, otherwise healthy female. She's had, um, some symptoms, uh, that have been keeping her up at night, where her hand falls asleep. And uh she has to wake up multiple times a night, uh, shake out, run her hand under hot water, or um try to get up and walk around to get this to go away, and it's really affecting her quality of life because she's losing sleep over this. um, so, uh, most common, this is a, you know, classic presenting complaint for carpal tunnel syndrome. Um, nocturnal symptoms, uh, numbness and tingling. Classically, it's in, of course, the median nerve distribution, um, which is the thumb, index, middle, and radial half of the ring finger, but I'll tell you, most of my patients who come into clinic just say that their whole hand goes numb. I do find that if you ask them specifically about the small finger, uh, they will usually stop and think and realize that the small finger is not typically involved. Um, and, uh, you know, this can really, um, be bothersome to patients because it causes oftentimes nighttime awakening or symptoms, you know, while driving or holding a phone, um, in advanced stages it can cause weakness. So, uh, how do we make the diagnosis? Of course, a good history, um, and we've discussed kind of the classic presenting symptoms, um. Examination, uh, a lot of this, um, you know, there's some finer detail here, but in general, um, if you look at the photo in the middle of the slide, you can tell a big difference between the patient's, uh, left hand and their right hand. You can see this marked thenar atrophy. Um, and that is a sign of advanced carpal tunnel. Um, if you're, if the patient is complaining of weakness in the hand, or they have atrophy in the muscles of the hand, that is definitely a situation that you wanna refer over, um, because that nerve is, has been, um, significantly affected. Um, we will do provocative testing. Uh, a Tinel's is tapping on the, over the course of the nerve, uh, over the volar aspect of the wrist. Phelan's, uh, is holding the wrist in a flexed position, uh, for a good 2030 seconds and seeing if that reproduces symptoms, and of course, Durkin's is. Um, holding pressure directly over the nerve. It is important to keep an eye for, um, you know, the differential. I always check my patients for concomitant spine, uh, pathology, um, so, uh, Sperling's exam, uh, looking up and to the left, uh, or to the right, and seeing if that reproduces any symptoms, um, and, uh, asking about history of spine problems or neck pain, um. This is a convenient little tool, if anyone wants to, um, you know, incorporate this into their practice, but essentially it's a scoring tool. If you, if you have um these symptoms or physical exam findings, it'll give you a score, and uh if your score is greater than 12, it's got an 89% sensitivity for carpal tunnel, and it's, this is, doesn't require electrodiagnostics, doesn't require ultrasound, um, and it's, it's a pretty high um. Highly sensitive and, and relatively good uh in terms of specificity, um, electrodiagnostic testing, of course, is largely considered kind of the gold standard for um additional testing, uh, clinical practice guidelines used to say that you had to have electrodiagnostics for everybody, um, we've gotten away from that a little bit with advances in ultrasound and being able to evaluate the nerve on ultrasound. Um, and so, uh, I do find it, as a hand surgeon, I find it to be a very nice adjunct, um, to confirm the diagnosis, and probably more importantly, to, uh, confirm the severity of the, uh, involvement, um, more severe cases of carpal tunnel, I usually am kind of encouraging the patient to consider operative intervention before the nerve changes become irreversible, um. If it's mild, usually, uh, you know, a trial of non-operative management is just fine. Um, ultrasound is an evolving area in, of course, many areas of medicine, but in hand surgery as well, um, we can now, we now have normative values for cross-sectional area of the median nerve at the wrist. So you can here at WSU send your patients for a nerve ultrasound of the median nerve to confirm carpal tunnel. So that they don't have to get poked and prodded, um, with needles during an EMG, um, a cross-sectional area of greater than 10 millimeters is diagnostic for carpal tunnel syndrome, um, and this is something that if you have ultrasound in your clinic, you can do this on your own. I, I, I do this, um, at the cam where I have an ultrasound machine. I can just ultrasound the nerve, uh, in the transverse plane, uh, measure the, you know, draw a little circumference around it, measure the cross-sectional area, and, and have a. Uh, confirmation of diagnosis right there. Um, management of carpal tunnel syndrome, uh, of course, non-operative management largely, uh, consists of nighttime wrist splinting. Um, usually I tell patients, you know, this is to allow the nerve to rest in a neutral position overnight. And um, you know, I think patients can wear the brace during the day, but a lot of them find it cumbersome, and usually they're able to avoid putting their wrists in extremes of of um flexion or extension during the day. So, really it's more of of an unconscious, you know, if they're sleeping um with their wrists in a flex position, this helps with that. Injections, we'll talk about briefly um and then of course there's surgical management. Um, in terms of occupational therapy, um, you know, there, I think that there's, there can be some educational benefit here, um, you know, therapists will talk about things like nerve glides, and that can be effective for some patients, but the evidence doesn't really support that that changes the natural course of the disease, um. There is uh moderate evidence to support no benefit of uh oral treatments, things like diuretics, non-steroidal anti-inflammatories, um, gabapentin, uh, compared to placebo. So medications aren't, don't really have a role here. Um, in terms of injections, the way I counsel patients is injections are temporary, um, and there is not an insignificant risk of injury to the nerve during an injection. Um, so, I use injections in three settings, and that is, if I'm trying to determine is this coming from the neck or from the wrist. Um, and if I do an injection in that setting, and all of the symptoms go away, then most likely things are coming, the majority of the symptoms are coming from the wrist. Um, in pregnancy, uh, pregnant patients often get, uh, carpal tunnel syndrome, and they do not have to suffer through this. Um, if you refer them to us, uh, we can give them an injection, and usually that will get them through to the end of pregnancy, um, and then symptoms typically resolve, a small portion of them do continue to have symptoms, but. Um, that's a good indication for an injection, and then, if they're symptomatic, severely symptomatic, but they just, you know, they're about to go on a trip, or they're gonna be gone for 6 months, and now it is just not a good time for surgery. Um, surgery, uh, you know, there's multiple ways to do this, um, but it is the definitive management for this, um, for this condition. Uh, and, you know, it can be done vers uh open versus an endoscopic approach. I, I like to do mine, um, wide awake, uh, with local anesthesia only. I think it is, uh, exceptionally low risk, especially for my older patient population. Uh, a lot of them have concerns about anesthesia and the risks of anesthesia, and, well, doc, I just don't want surgery because I don't wanna go under. Well, uh, this is a procedure that I most often do, uh, with local only. Um, it's great, they, they can eat and drink all day, uh, no fasting needed, um. The procedure takes about 15 minutes. Uh, I, I just inject some local, and I sit there and we have a nice conversation while I do the release. Uh, it's about 3 stitches at the end of the procedure, uh, I allow them to, uh, return to light activity within the 1st 5 days, and then normal activity within around 4 to 8 weeks after surgery, um. Just a quick note on uh open versus endoscopic, I, I will do endoscopics occasionally, but there is a slightly higher risk of um of nerve injury, and uh the total complication rate is slightly higher with endoscopic, so for a procedure that is a 2.5 centimeter open incision, um, I think the safest and most reliable way to do it is open. Um, outcomes are great. Um, most patients have symptom improvement within the 1st 1 to 2 weeks. These are some of my happiest patients, um, and, uh, what I will tell patients though, is if they do have atrophy, or they have allowed this to go for a very long time and have severe carpal tunnel syndrome, it can take up to 1 to 2 years for those patients to recover, so it is important to refer these patients early. Um, because there is a, there is a sweet spot, um, where the symptoms are severe enough that it's, you know, surgery is indicated, but not so severe that surgery is going to be ineffective. Um, Cubital tunnel syndrome, then we'll move a little bit faster through this, because, you know, in many ways it's similar to um carpal tunnel syndrome, it's slightly less common, but of course it's uh compression of the ulnar nerve at the elbow, painless, uh, painful numbness and tingling, usually in the small and ring finger, um, and typically changes with elbow position, um, again, this is largely dependent on history, um, physical exam. Uh, again, ultrasound can be, uh, pretty useful here, um, and looking at that cross-sectional area greater than 10 millimeters, and, uh, electrodiagnostic testing, I will send all of my patients with, um, cubital tunnel syndrome will get an electrodiagnostic test. Uh, largely because a lot of these patients, they just don't quite do as well as a carpal tunnel, and I like to really have a handle on how severe is their cubital tunnel before we go and do any sort of a release, uh, or transposition. Uh, non-operative management consists of nighttime elbow extension splinting, again, giving the, the nerve a chance to rest. Uh, ergonomic adjustments, this is probably, um, as equally as important in carpal tunnel, but making sure that they're not typing with their hands, uh, really high or really low, or sitting too close to the desk where their, um, elbows are really in a flex position. Um, surgery, uh, you know, consists of, uh, uh, for me, this, this is not a wide awake procedure. Um, it's a larger incision, it's at the elbow, and, uh, we really have to, uh, make sure that we do a, a, a nice wide decompression to make sure that those nerves are happy again, um. So when to refer these sorts of patients, uh, any patient with numbness and tingling in the hand or fingers, I'm happy to see them, uh, I, I love treating nerve conditions, um, whether it, I mean, even if it means I'm coming up with diagnosis of cervical radiculopathy, or thoracic outlet syndrome, or whatever the case may be, if there's paresthesias in the upper extremity. Um, happy to see it and tease out the details. Um, definitely wanna refer if there's any atrophy, uh, or weakness, uh, that's, those are signs, of course, of, of more advanced changes, um, if they're dropping things or they're, especially if they're like burning their fingertips or things like that, of course, um, those are static sensory changes that we wanna get evaluated and addressed, uh, appropriately. OK, um, trigger finger, this is probably the, um, 2nd most common thing that I see in my clinic, uh, and, um, certainly happy to see any and all of these patients. Uh, these can also, of course, be treated in a lot of primary care settings. Um, this is essentially a tendonitis of the flexor tendons, as they enter the flexor tendon sheath. Um, usually results in, uh, painful, uh, locking or clicking of the digit. Um, it happens, uh, more frequently in women, more frequently in insulin dependent diabetics, also in hypothyroidism. Um, alcoholics can be, uh, a risk factor as well. And, um, really, you know, I think, uh, one of my mentors who many of you might know, Doctor, uh, Marty Boyer, um, used to have the Boyer House rules, and rule number 7 was, it's always a trigger. If a patient comes in with pain in the hand that just can't quite be explained. It is often an uh an early trigger finger, uh, patients will complain of pain, usually it's at the distal palmar crease in the palm of the hand, um, but just generalized hand soreness can sometimes be uh a harbinger of a trigger finger, it just hasn't gotten to the locking phase yet, um. So treatment, uh, nighttime splinting, uh, can be effective, although I warn patients about this, uh, because if they, for fingers, if you are going to splint them consistently, they can get stiff, and stiffness, a stiff trigger finger is much more difficult to treat than a locking finger that is still supple. So, uh, I, I try to, if patients really are avoidant of a, a cortisone injection, which is my preferred treatment, then I will, um, refer them, uh, you know, I'll allow them for some nighttime splinting, but I, I keep a pretty close eye on them. Um, corticosteroid injection is really, I think, the mainstay. Um, you know, there, there have been, um, numerous studies on corticosteroid injections. I quote patients about a 70% chance that a single cortisone injection will make this problem go away, uh, forever, and it will not come back. So, that's a low-risk intervention. Um, I do talk to diabetic patients about the risk of increase in blood glucose, that, that is usually transient. Um, but especially if they're insulin dependent, uh, I tell them to keep a close eye on their sugars for about, uh, 2 to 3 days after an injection. Um, if they are diabetic, uh, or hypothyroid, or they have some of those other risk factors we talked about, rheumatoid, uh, or inflammatory conditions, I quote them a 50% chance that it's gonna recur after an injection. Um, and then trigger finger surgery, this is another one that I love to do, uh, again, wide awake, uh, local only, um, this is great for, again, my older patient population who are concerned about anesthetic risks, um, or if they're high risk for surgery, um, I, you know, it's about 4 cc's of local, uh, and the procedure takes about 10 minutes. The post-operative recovery and, and course is very similar to a carpal tunnel. Um, light activity within 5 days and um return to full activity within about 4 weeks. Uh, I do tell patients that it does take about 3 to 4 months for the hands to get back to feeling normal. Um, they will still have some mild persistent soreness for a few months, but most patients, um, can do everything they wanna do pretty quickly, so, um. Wonder for any patient with pain and swelling in the palm, uh, or of course catching or locking of the fingers, happy to just take care of it, um, if, uh, if it's not something that, uh, you wanna, um, manage with injections or things in your clinic. Uh, Dacobine's tenosynovitis, very similar to trigger finger, uh, won't spend much time on this, but. Um, anyone who comes in with exquisite pain over the radial styloid, um, this is similar, you know, it's in location to thumb CMC arthritis, but really the qua veins will be right over the radial styloid, so it's a little bit more proximal. Um, and again, it's an inflammation, it's a tendonitis, uh, patients, uh, commonly are and classically are, are either new parents or new grandparents, um, uh, but I've seen all kinds of patients who've come in with deer veins, so, um, it can happen in anyone, and, uh, usually this also responds well to a cortisone injection. Uh, I would say surgery is, you know, um. It's infrequently needed, um, but patients who, uh, patients do do well after surgery if, if we do need to go that route, um, again, surgery can be wide awake for that as well. Um, thumb CMC arthritis, I, I did put this in right after the Dequara veins, just because, uh, it is similar in in location, but it is just a little bit further distal, um, you know, patients will, uh, most commonly complain of trouble with pinching activity, so. Uh, the classic is someone who, uh, has trouble trimming roses or gardening. Um, these patients will complain of weakness in the hand, mostly because even if they think they can push through the pain, uh, their body will limit them from really cranking down on their, on their thumb. So, um. Uh, usually there's tenderness directly over the CMC joint. A CMC grind, uh, just kind of manipulating the thumb metacarpal will typically elicit pain, um, and very, very common, uh, in men and women, uh, especially as they get over the age of about 60, 65, um. Non-operative management. This is one where I think bracing and therapy are really mainstays. I, I, uh, recommend that to every patient who comes into my clinic. Um, I do think the therapists can do a great job with, uh, what we call joint protection exercises, essentially strengthening the thenar muscles and dynamic stabilizers, uh, around the CMC joint. So I think our therapy colleagues do a great job with this. They can provide a lot of education, and they've got some really cool tricks. Up their sleeve about ways to modify how to, how you're cutting vegetables, or, you know, trimming bushes that can avoid exacerbating the symptoms. Um, I also, uh, you know, will, uh, if the patients are able to, I'll I'll give them a topical diclofenac, and then for me, you know, there was a randomized controlled trial back in the Journal of Hand Surgery 2022. Uh, looking at CBD cream, um, you know, this was very popular in California for sure, um, you know, this is of course not the active, uh, THC, um, component, but, uh, anecdotally, I will say that patients who I prescribed CBD topical CBD cream. Uh, they tend to do better than the diclofenac, uh, and that's purely anecdotal, uh, but there was a placebo controlled trial, uh, in Journal of Hand Surgery that, that showed good efficacy, uh, for CBD cream, um, and then we talked about therapy. I personally. I steer patients away from oral anti-inflammatories for this condition, um, I think, uh, you all know better than I do, really, but I think that there's enough um evidence coming out about the cardiac risks and, you know, um, renal risks, and of course the gastric risks of chronic, um, non-strotal anti-inflammatories that I really try to get patients to use these first three options. Before doing um oral anti-inflammatories on a consistent basis. Uh, injections, these can be effective, of course, similar to any other arthritic injection, it's not gonna fix the arthritis, but a good temporizing measure. Um, I like to do my injections under ultrasound guidance, uh, just because I think this can be in an arthritic joint, it's a small joint, it's tough to get into, um, so, uh, yeah, I think I can be, uh, much more confident that I'm in the joint and providing a good, um, service to the patient. Um, surgery, uh, I, I tell patients this is a reliable surgery, uh, to get, you know, to fix the pain, but it's a long recovery. Um, most of the time, uh, you know, I'm doing a trapeziectomy where I remove the trapezium and do a suspension plasty, where I'm, uh, taking the first metacarpal to the second. Uh, and it's very reliable. Patients do well, but it, it does take about, uh, 6 months for them to get back to normal activities. Uh, I tell patients, you're gonna hate me for the 1st 4 weeks after this procedure, um, and then at 6 months, you're gonna come in and give me a hug. Um, so, uh, for young patients, if they do have arthritis, manual labors, etc. we might consider a fusion. Uh, Dupuytren's disease, uh, this is, uh, a, uh, myofibroblastic proliferation of the palmar fascia, so that is a layer that is, of course, just below the skin, uh, and it helps anchor the palmar skin, so that when we're grasping things, uh, the objects aren't sliding around because of, um, you know, loose skin like we have on the back of the hand. So, uh, that when that fascia, uh, proliferates and has an overabundance of myofibroblasts, then it can cause thickening of the fascia and eventually contracture. Um, of course, classically, this is more common in people of, uh, Caucasian or European descent, and I, I do tell patients, you know, we do not have any preventative or curative treatment. There's nothing I can do. Uh, that is gonna make this go away forever. Uh, we have temporizing measures, um, which we can talk about, uh, but I don't have a medication or even a surgery that's gonna take this out and have it never come back. Um, notably, uh, I think for, um, folks seeing them in time of presentation, splinting has not been shown to slow progression, and I think it can make the finger more stiff, so I do not do any splinting, preventative splinting. Uh, there's no evidence to support that. Uh, I talked to patients about a tabletop test. Oftentimes I'll see patients come in with just nodular disease. Uh, and I tell them, look, this is what you've got, uh, don't worry about it. A lot of patients don't actually progress to contracture, um, but if you do start to have some contracture, check your hand, put it flat on the table, uh, every once in a while, and if you can't get your hand flat on the table, that's the time to come back and see me. Uh, indications for intervention, and I say intervention because there's different options. Are MCP contracture greater than about 30 degrees, or any, really any contracture of the PIP joint. Um, so treatment options, we do have some great treatment options for this in clinic, uh, percutaneous needle fasciotomy, um, is, uh, very effective, that's my preferred treatment, uh, collagegenase injection also effective. Um, these are, uh, you know, I call them like haircuts, they're temporizing measures. Most patients will have some form of recurrence of their contracture within 5 years, but it does avoid the um longer recovery of an open surgery. Um, open surgery has the longest disease-free survival, meaning if I go take out the, um, if I go take out the diseased fascia. It's got the longest time before you're gonna have recurrence of contracture, but it, it tends to be a much longer recovery. Most of the time it takes patients a solid, you know, 2 to 3 months before they're really got their hand back with full range of motion, soft, you know, softening of the scar, um, and really like using their hand more normally. Um, And we're gonna finish up with some hand trauma, um, you know, this may not walk into, um, this particular photo probably doesn't walk into a primary care clinic, it might walk into an urgent care, um, but I, I think, you know, like we talked about, hand trauma, one of the most common things, uh, I think we've all, you know, slammed our finger in the door or some version thereof throughout the course of our lives, so. Um, these are extremely common, and I think it's nice to know what to do about it when it shows up. Um, so anytime someone comes in with trauma to the hand, uh, you know, you're gonna be looking, uh, inspection, palpation, uh, range of motion, motor and sensory exam, uh, vascular exam. So on inspection, you're looking for, um, any asymmetry, very useful to compare to the other hand. Um, patients can have, uh, congenital abnormalities or things. Oftentimes it's bilateral, so if something looks a little strange, just check the other hand, you get a good, uh, comparison. Um, angulation or rotation of the digits are important to note, and then, um, digital cascade, this is what we talk about when we're talking about digital cascade. If you just have your hand in a nice. Relaxed resting position, um, each finger should be slightly more flexed than the last, starting with the index and moving towards the small, um, if you have an abnormal cascade like this, this is a Jersey finger, um, so this patient has, um, had a, a forceful avulsion of the FDP tendon from their, uh, from their distal phalanx on the volar side, and. Um, they don't have the normal cascade, so that's an indication that, you know, this is a tendon injury, uh, and needs to be referred for further evaluation. Um, if there's rotational deformity, when the fingers come down, they should all generally point towards the scaphoid, uh, or the, the kind of inar eminence rather, um, and, um, if you start to see any rotation as the finger comes down. Uh, that's usually an indication of a fracture, uh, that needs to be addressed, um. Motor testing, um, you know, uh, we, I like to check the median, uh, radial and ulnar nerves, um, usually by checking the thenar muscle strength, giving a thumbs up, and, uh, finger abduction, um, sensory exam. Uh, you know, I'll do a very detailed sensory exam in my clinic. I think for most folks, um, if you can just feel at the tips of the fingers and ask the patients if they feel it, I will say patients love to cheat on sensory exams. Uh, I ask them to close their eyes, and I usually will try to cover the finger that I'm touching, um, so that they really have to tell me if I'm touching it or not. Um, one good trick, if you've got kids in your clinic, um, a great trick for sensory testing with a kid who won't cooperate is to soak the finger, uh, or hand in water for a few minutes. If it gets pruny, then the nerves are working. Because, uh, pruning is part of a sympathetic uh nerve response, and the sympathetics have to get there, uh, to the tips of the fingers. If, if you see that the, all the fingers are pruning, except for one finger, or even one side of one finger, that's usually an indication of a digital nerve injury or other nerve injury, um, and that patient should be referred. Uh, vascular exam, most of the time, you know, checking capillary refill is good enough, but if you're really concerned, you can put a pulse ox on the finger, uh, if it's a finger injury, and, um, a pulse ox reading of greater than 95%, uh, is 100% negative predictive value for um any type of vascular injury requiring repair. Uh, if you've got a pulse ox reading of less than 84%, you should be concerned and probably refer him to urgent care or emergency department, especially if there's a laceration, because that's a finger that could be um at risk for vascular compromise. Um, Uh, now that's of course in the context of, you know, if the patient has COPD and, and they've got a baseline, uh, uh, that's low, then, um, you know, you gotta take that into account. Um, lacerations, uh, you know, these are, of course, very common. I, I see this, I, I will say I see this a lot in, uh, in the emergency department and or urgent care, um, at least back in California where I was coming from, uh, where, you know, oh well, it's quote, just a finger, and, uh, it's just a, just a little cut or something, we'll, we'll wash it out and sew it up. Follow up with your primary care, uh, and, um, have the stitches taken out, uh, it, it does oftentimes take a pretty detailed, um, physical exam testing both digital nerves on either side of the digit, to really, uh, discern whether there's been an isolated digital nerve injury. Uh, this patient that's pictured here, is, was a, was a nice, I think she was a 14 year old girl. Who went to the emergency department after she had these lacerations, and the fingers were perfused, they washed her out, sewed her up, um, and eventually she made it to my clinic 3 months later, because she still hadn't gotten the sensation back in her fingertips, um, and she had been told, oh, don't worry, it's gonna get better, um, etc. etc. Um, but, you know, once the digital nerve is lacerated, it's not gonna come back on its own if we don't reconnect it, so, um. Uh, any finger laceration, I, I'm happy to see them. There can be subtle tendon injuries, subtle nerve injuries that are a little bit difficult to pick up, and even as a hand surgeon, there are times when I will just recommend that we, uh, even, you know, even after my physical exam, there are times where I will just tell the patient, look, we need to explore and confirm that there are no injuries, and you, you would be surprised how often. We find an injury that was just too difficult to pick up on physical exam. So, um, I have a low threshold to uh explore and repair, because it's easier to take care of it at the beginning, than it is for it to become a problem down the road, and then have to try to go back and fix a chronic injury, um, so, um, this was, oh, I'm sorry, she was 20. Uh, so this is a 20 year old female, um, and this was, this is what I found at the time of surgery, you know, she had, uh, neuroma, uh, she had a, an area that had been lacerated, uh, on both digits, uh, the ring and the, and the middle, and, um, she had a neuroma. Um, I ended up having to resect the neuroma and put in a, a digital nerve allograft, um, she eventually recovered, uh, you know, protective sensation. Um, and did well, but it took a lot longer than it needed to. Um, fractures, you know, of course, these are very common. Um, I, I just recommend, if you have a patient with a fracture, I, I would, uh, I would love to see those patients early. Um, you're welcome to splint them and give me a phone call on my cell, or text me, or whatever the case may be. Um, there's a variety of fractures that, you know, we don't need to treat with surgery. Uh, but I will tell you, in the hand, especially for those fractures that need surgery, the ones we can get to early, patients do way better. Um, once it's gotten beyond about a week and a half, things start getting tricky because I have to open the fracture. Um, I can't just pin it, uh, and. And as soon as I open a finger fracture, uh, it, you know, increases the risk of stiffness. That patient is gonna need a lot of therapy in order to get the finger back functioning like it was before. So, a lot of people say, oh, it's a, you know, just a finger fracture, um, these can be significantly, uh, life-altering. If your ring finger is not bending with the rest of your fingers, and, you know, it's always out, it's getting caught on things, it's stiff, it's rotated, um, you know, I, I've had a number of patients who have come into my clinic in uh years past who have said, oh well, uh, you know, doesn't the bone just mend itself and straighten out over time? And the answer is, unfortunately, it doesn't. Uh, it will mend itself, it will heal. But it heals where it is sitting, so if there is a malalignment at the beginning, it will heal in a malaligned position, um, so it is important, I think, to um to get these fractures taken care of. Distal radius fractures, um, you know, are a little bit unique, um, because, interestingly enough, distal radius fractures can actually tolerate quite a bit of deformity before they impact the function of the patient. Um, because there's quite a bit of motion at the wrist, um, and because the fingers have so much motion, uh, the, uh, uh, a little bit of deformity at the distal radius is actually well compensated for. So, uh, I, I will say for young patients, young being, you know, less than 65, 60, uh, for younger patients, I, I, you know, we have a generally relatively low threshold to operate if, if they want a little bit of a faster recovery, or if there's significant deformity. For, for patients, uh, who are 70 and older. Uh, I think that many of them, uh, can tolerate non-operative management very well and do, do extremely well without surgery. Um, Fingertip injuries, these are uh extremely common as well, and um I think that there's kind of some dogma and myths out there that if there's exposed bone, or, you know, uh, we need to do these sorts of fancy flap procedures and uh or you have to somehow, you know, nibble back the bone until there's no exposed bone. Um, you know, again, I'm happy to see these patients at any point. Uh, you can just send them over to, to clinic, um, but, uh, these, these injuries heal very well by secondary intention, and just dressing changes, uh, and let them granulate in. So, this was a young kid who came in. Uh, at my previous job, my residents came to me, they said, we're gonna, we're gonna rojo the bone back, and we're gonna sew this thing shut, and, uh, and then we'll send him out. And I said, no roger, don't do anything. Don't even sew it. Just give him about a week of antibiotics, some bacitracin, and daily dressing changes with gauze and erraform. And um about 12 weeks later, this is what the finger looks like. Is on the right hand side. Uh, this was with no intervention. There was no infection. Uh, we did not have to do any surgery. We did not even have to numb the finger up to, uh, put it in sutures. Uh, and he's got a, what I think is a great cosmetic result, and we've maintained massive, uh, uh, maximum length on the digit, so, um. You know, I think, um, fingertip injuries generally heal actually quite well, um, but I'm happy to see him at any time. Um, This is a more significant uh type of a finger injury, um, hopefully this doesn't, this is not walking into your clinic, um, but this is, you know, some of the stuff that we can do in hand surgery, um, if things get real severe. Um, this was a table saw injury in a young 16 year old male, um, and, uh, came in with significant multi-segmental injuries, um, in essentially all digits. Um, and spent about. 8 to 10 hours putting his hand back together, the middle finger had to be completely replanted, um, and, uh, you know, it took some time, uh, and some therapy, um, but eventually, at 9 months post-op, uh, he's actually got a, a great outcome, good range of motion, um, you'll recall the, it's actually the middle finger that was replanted, and he's got great motion there. Uh, the ring finger, which was not actually amputated, but just had a terrible fracture, uh, is the one that is stiff and can't quite get all the way down to the palm. Um, but this is, you know, what we can do with a young, healthy patient, compliant with therapy, um, even with a terrible injury, um, we can get a great outcome. So, um, this is him, he's a powerlifter, uh, this is him at one year post-op, and it's, it's this right hand that's been, um, that was his replanted hand, so, um. We can, we can definitely do some really cool stuff in hand surgery with the big traumas, um, but I think that hopefully I've done a good job covering some of the most common things, um, that we see, um, and, uh, giving you guys, um, some additional tools to think about and use in your clinics, and happy to see anyone at any time. Uh, this is my cell, personal cell, and my email, um, please give me a call, shoot me a text, uh, if you have any questions. I'm just writing down your cell, so I have it to put in the post email for all of them. Thank you so much. Um, there are a couple of questions in the chat. I don't know if you can see the chat or if you'd like me to read them to you. Um, yeah, I'll, I'll take a look at him here, um. CBD cream commercially available, uh, or does it have to be compounded by a pharmacist? Great question. Um, so, CBD cream, uh, I, I just, I actually send patients to, um, I don't technically prescribe it through Epic, um, I tell patients to go to either Whole Foods, um, or, uh, in California, we have a grocery store called Sprouts, uh, I don't, I don't think they have it out here, but. Um, those sorts of, uh, grocery stores or health stores will have CBD creams or or oils that are marketed as anti-arthritis. Um, the, the, um, concentration that was used in the study, uh, the randomized controlled trial was 6.2 mg, um, per cc, uh, of CBD. So if you wanna, you know, give them a specific uh dose to look for, but, um, I think most over the counter formulations of this, they don't have to go to a dispensary or something like that, they can, they can get this stuff from a grocery store, um, and that's usually where I will refer them. Um, hopefully that answers that question. Uh, next one says, what is your preferred steroid, uh, and milligrams, uh, for carpal tunnel injections? So I'll use, um, I will use Kenalog, uh, or Celestone, whichever is available, um, here in, in at UC Irvine, they had, um. Mostly Celestone, uh, 40 mg per mL, and same, I think that's the same concentration of Kenalog that they have here, um, and I think Kenalog is what they have in our clinics here, so I'll use 1 cc of that, and um 1 cc of 1% lidocaine without epinephrine, uh, and I will mix those, uh, in, in a single syringe. Uh, and make sure they're well mixed, and then, um, at least for me, I, I like to go, I like to, uh, use ultrasound guidance for my carpal tunnel injections, so I know exactly where the nerve is, um, but if you're gonna do it based on landmarks, uh, if the patient has a palmaris, uh, you can go just ulnar to the palmaris tendon, or. Essentially in line with the center of the ring finger or the radial border of the ring finger is at the distal wrist crease is a is a pretty safe area. Uh, but that's an injection where I'm always asking the patient, during the injection, like I tell them ahead of time, if you feel paresthesia is in your fingers while I am putting this needle in, you have to tell me, uh, and. You know, it, it's not, it's, it's pretty rare that they do, but it, it, it has certainly happened, um, where I have been putting the needle in, and they're like, oh, electric shocks going on right now into the fingers, don't inject if that's, if you get that response, redirect the needle, um, so this is a, this is a slow, for me, this is not a slam it in. And inject uh procedure. This is a, I'm slowly advancing the needle in a controlled fashion, and asking the patient to make sure that they're OK before I inject the medication. Um, And then I see, I see a lot of Dupuytren's contractures, uh, which seem to be related to alcohol use, true. Um, is there a mechanism of action known. You know, I, I, I personally have not heard of a, of a uh mechanism of action that relates or that ties alcohol to the Dupuytren's use, but it certainly is a well-known uh risk factor and association. Um, I think we're still learning a lot about Dupuytren's, and um there's a lot of research going on out there, uh, to try to figure out if we can just get rid of this, um, but unfortunately, I don't have the answer to that question. Um, and is there, uh, a relationship between duration and amount of alcohol use and severity of Dupuytren's? Man, these are good questions. You've, you've, you've stumped me. I don't think, um, I don't, I don't know of a study that I can quote that says patients who used alcohol for at least 10 years at 6 drinks per week, uh, or something like that, uh, were a higher risk, I think. Most of the studies are alcohol, yes, versus no, um, and so it's a little bit more binary, uh, and maybe not quite as much of a continuous variable in those studies, so, um. I don't have a, I don't have a straight answer for that. Uh, let's see, another one came in. Any recommendations on, oh, subungual hematomas, yeah, uh, when to refer versus decompress. So, um, I think if a subungual hematoma, um, is, it kind of depends on the, um, kind of depends on the mechanism in the exam. Uh, if there's a subungual hematoma, and it involves the entire nail plate, um. I think that that is a that is. You know, I, I probably would say just refer him over, but if you wanted to try to treat him, um. I think that a uh decompression, you know, you can use like an 18 gauge and just kind of use it as a little drill, uh, and get through the nail plate to decompress it. Um, I think that's a good method, uh, and, uh, if it, if it involves, a short, short answer is, if it involves greater than 50% of the nail plate, usually that's an indication for decompression. Although if there's any sort of a disruption in the nail plate, if you see a laceration in the nail plate, like say part of the nail is broken. Like halfway up the nail plate, and uh you have a subungual hematoma, that's an indication that there's been a nail bed laceration, and that is a nail that needs to come off, and the laceration needs to be repaired. So if you have concern for an underlying nail bed laceration, those patients should be referred over. I don't see any other questions in the Q&A, so if you all do have any questions that come up, um, you're welcome to email me or I'll have Dr. Wright's uh. Email address and his cell phone number and the follow-up email so you can always ask him as well. So thank you so much, Doctor Wright. Thank you all. Appreciate your time. Enjoy the rest of your day. Created by Presenters David Wright, MD, MSc Assistant Professor, Orthopaedic Surgery Division of Hand and Microsurgery View full profile
