Wrist and Hand: Treatment Options

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Wrist and Hand: Treatment Options David M. Kalainov and Mark S. Cohen

Disorders of the wrist and hand are common in the work environment.23 Effective management frequently depends on a multidisciplinary approach with coordinated input from a physician, hand therapist, and nurse case manager. This chapter reviews several wrist and hand conditions that may occur in an occupational setting, including tendinitis, peripheral nerve compression lesions, sprains, fractures, arthritis, ganglia, and complex regional pain syndrome. The underlying pathologies, diagnostic methods, treatment options, and projected outcome for the various conditions are discussed.

TENDINITIS Tendinitis is a general term used interchangeably with tenosynovitis, stenosing tenosynovitis, and tendovaginitis. A thin low-friction envelope that surrounds individual tendons, the tenosynovium, enhances tendon gliding around bony prominences and through retinacular sheaths. Tenosynovitis, which refers to inflammatory changes in this lining, is often associated with a systemic disease process. A more frequently encountered condition, termed stenosing tenosynovitis or tendovaginitis, involves thickening of the tendon and overlying retinacular sheath with only a paucity of tenosynovial inflammation. de Quervain disease and trigger digit are two common examples.

is occasionally palpable as are small ganglia arising from the diseased compartment. The best objective tool in confirming the diagnosis of de Quervain disease is the Finkelstein test. By maximizing the excursion of the tendons through the stenotic first dorsal compartment, this maneuver produces significant discomfort for the patient if the condition is present. Conservative treatment options for de Quervain disease include splinting, corticosteroid injections, nonsteroidal antiinflammatory medication, temporary job modifications, and therapy. Splinting alone may be beneficial for management of acute pain, but symptom recurrence is common. A single corticosteroid injection into the first extensor compartment successfully relieves pain in 60% of cases, whereas two injections may provide relief in up to 80% of cases. Because the soft tissue in this region is thin, however, repeated corticosteroid injections, with infiltration into the subcutaneous tissues, can lead to localized depigmentation, fat necrosis, and subcutaneous atrophy. If conservative measures fail, surgical release of the first extensor tendon compartment may be considered. Surgery involves incision of the retinacular sheath and division of any septae separating the abductor pollicis and extensor pollicis brevis tendons. Vigorous retraction or injury of skin sensory nerves intraoperatively can cause periincisional pain and/or numbness. A therapist may be helpful in the early postoperative period with scar desensitization and strengthening exercises. Release of the first dorsal compartment predictably leads to a satisfactory result in over 90% of cases. Patients are generally able to return to unrestricted employment within 6 to 8 weeks after surgery.

Trigger finger The flexor tendons projecting to each digit enter a retinacular sheath that begins in the distal palm. Thickening of the tendons and sheath at this point may obstruct normal tendon gliding, leading to catching and locking of the digit (Fig. 6d.2).

de Quervain disease The dorsal wrist is comprised of six retinacular compartments encompassing the extensor tendons of the wrist and hand. The first compartment, which contains the abductor pollicis longus and the extensor pollicis brevis tendons, is located directly over the styloid process of the distal radius (Fig. 6d.1). Painful restricted tendon motion through this compartment is referred to as de Quervain disease.19 de Quervain disease is frequently associated with activities involving repetitive flexion and extension of the thumb and ulnar deviation of the wrist. The condition is also associated with direct trauma, rheumatoid arthritis, gout, and diabetes mellitus. A subdivision of the compartment by a septum is thought to predispose some individuals to the development of this condition. A patient with de Quervain disease presents with symptoms of pain, swelling, and tenderness over the radial styloid. Pain can be quite severe, with guarding and limitation of wrist and thumb motion. Crepitation with thumb flexion and extension

Figure 6d.1 Wrist and finger extensor tendons. The first dorsal compartment contains the abductor pollicis longus and extensor pollicis brevis tendons (arrow). Painful restricted tendon motion through this compartment is referred to as de Quervain disease.

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area four fingerbreadths proximal to the radial styloid. Often, palpable and audible crepitus occurs in this region with active wrist motion. Other tendons occasionally involved by inflammation and stenosis include the flexor carpi radialis, the extensor carpi ulnaris, and the extensor pollicis longus. In these cases, nonoperative treatment measures that may include splinting, ice, corticosteroid injection(s), antiinflammatory medications, activity modifications, and therapy are usually successful.

CARPAL TUNNEL SYNDROME

Figure 6d.2 Digital flexor tendon sheath. Thickening of the tendons and sheath proximally may lead to triggering (arrow).

Examination often reveals a tender nodularity in the distal palm that moves with excursion of the tendons.26 Conservative care of a trigger digit entails activity modifications and a corticosteroid injection into the proximal flexor tendon sheath. Single finger involvement, a discreet palpable nodule, and a short duration of symptoms are favorable prognostic indicators. Splinting of the metacarpophalangeal joint for a brief period may be added to the treatment regimen. In individuals whose symptoms are aggravated by the use of small tools, modification of these instruments to distribute forces over a greater area with a lesser requirement for digital flexion may be beneficial. The reported success rates after an injection range from 60% to 84%. If conservative management fails, surgical treatment may be considered. Incision of the proximal portion of the flexor tendon sheath in the palm is curative in over 95% of cases. Most patients are capable of returning to unrestricted work activities within 4 to 8 weeks postoperatively.

The median nerve passes across the wrist through an unyielding fibroosseous canal, termed the carpal tunnel (Fig. 6d.3). Compression of the median nerve within this space is termed carpal tunnel syndrome. The condition occurs due to a mismatch between the volume of the canal and its contents: the median nerve and the nine digital flexor tendons. Carpal tunnel syndrome is associated with diabetes, hypothyroidism, rheumatoid arthritis, and renal failure. Other contributory risk factors include wrist fractures, aging, obesity, female gender, smoking, pregnancy, and alcoholism. In the workplace, carpal tunnel syndrome has been attributed to repetitive forceful use of the wrist and digits, repeated impact on the palm, and operation of vibratory tools. Task-related factors, however, are variable and inconsistent, and the mechanisms by which they may contribute to carpal tunnel syndrome are poorly understood. The diagnosis of carpal tunnel syndrome relies initially on the patient history.8 Symptoms may include tingling and numbness in the thumb and central digits, burning pain, weakness, and clumsiness of the hand, all corresponding to the motor and sensory distributions of the median nerve. Symptoms often appear after prolonged wrist flexion while sleeping and extended periods of wrist extension while driving. Loss of sensation (in the radial four digits) and atrophy of the thenar eminence muscles are symptoms of advanced median nerve compression. Carpal tunnel syndrome is diagnosed primarily through physical examination, including evaluation of thenar muscle

Other tendonopathies Intersection syndrome refers to tenosynovitis of the radial wrist extensor tendons where they cross the first dorsal compartment tendons in the distal forearm. Pain is typically localized to an

Figure 6d.3 Wrist magnetic resonance image, axial view. The carpal tunnel (white arrow) contains the median nerve and the nine flexor tendons. The adjacent ulnar tunnel (black arrow) contains the ulnar nerve and artery.

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Hand-Arm Vibration Syndrome

bulk and strength and performance of sensibility testing. A variety of provocative maneuvers is used to reproduce or accentuate the symptoms. Phalen’s test refers to placing the wrist in a fully flexed posture, whereas Tinel’s test refers to percussion of the median nerve over the wrist. The median nerve compression test involves direct pressure on the median nerve over the carpal canal. An electrodiagnostic study may be obtained to confirm the diagnosis of carpal tunnel syndrome and to quantify the degree of median nerve injury. In the absence of diminished sensation, muscle atrophy, or denervation potentials on electrodiagnostic testing, initial treatment for carpal tunnel syndrome involves splinting the wrist in neutral alignment and injecting corticosteroid into the carpal canal.11 A neutral wrist position relaxes the median nerve and maintains a low pressure in the carpal tunnel. Splinting and injection provide short-term relief of symptoms in over 75% of patients and continued symptomatic relief for 1 year or more in 13% to 40% of patients diagnosed early with mild symptoms. Presence of symptoms for less than 12 months, intermittent numbness, male gender, absence of advanced sensory changes, and normal thenar muscle bulk are good prognostic indicators for success. Activity modifications and use of antivibration gloves are encouraged in manual laborers.16 Associated systemic diseases such as diabetes and hypothyroidism should be recognized and appropriately managed. Ergonomic changes may be considered for general patient comfort and satisfaction. Many recommended measures have not, however, been scientifically proven to prevent or ameliorate symptoms of carpal tunnel syndrome. If patients experience only partial or temporary relief with conservative treatment measures, surgical decompression of the carpal tunnel may be considered. Individuals who report at least temporary relief after an injection are more apt to obtain similar relief from carpal tunnel release surgery.10 Newer techniques such as limited-incision carpal tunnel releases and those performed endoscopically have been developed to decrease palm discomfort and allow for a more rapid return to activities. Compared with a standard open decompression, the endoscopic procedure has been found to shorten the recovery period, but it may be associated with a higher reoperation rate and possibly an increased risk of nerve injury.20 Operative release reliably diminishes tingling in the digits, whereas improvements in numbness and weakness are less predictable. In patients with severe chronic nerve compression, it is not unusual to have permanent low-grade symptoms after uncomplicated carpal tunnel release surgery. Palm sensitivity around the scar, referred to as pillar pain, is fairly common and can be helped by scar desensitization performed by an occupational therapist. Activity restrictions in a manual laborer are typically recommended for a period of 6 to 8 weeks after surgery, with maximum medical improvement anticipated between 3 and 6 months postoperatively. Successful carpal tunnel release surgery usually produces no permanent impairment.

passes the ulnar nerve and artery. Compression of the ulnar nerve at this site can occur from trauma, use of vibrational tools, ulnar artery thrombosis or aneurysm, or presence of a space-occupying lesion such as a ganglion cyst. Symptoms include intrinsic muscle weakness, numbness, and tingling in the ring and small fingers, or a combination of motor and sensory abnormalities. The diagnosis depends on a thorough physical examination and pertinent ancillary studies. The examination should include palpation, percussion, vascular and motor evaluations, and sensory testing. Wrist radiographs are helpful in excluding a hook of hamate fracture in patients with a history of trauma. Magnetic resonance imaging (MRI) or an ultrasound study may be valuable in identifying a ganglion cyst, ulnar artery aneurysm, or arterial thrombosis. An electrodiagnostic study can assist in locating the anatomic site of compression and in determining the severity of the nerve involvement. If a specific etiology for ulnar tunnel syndrome is identified, treatment is directed toward the cause. Examples include excision of a space-occupying lesion, resection of an arterial aneurysm, and repair or resection of a hook of hamate fracture. When no cause is found, conservative treatment measures such as wrist splints, antivibration gloves, activity modifications, and nonsteroidal antiinflammatory medication are instituted. Surgery is considered in these patients only if the diagnosis is certain and nonoperative modalities fail. The procedure involves decompression of the ulnar nerve and artery in the proximal palm. Most patients with ulnar tunnel syndrome without a structural lesion do well with nonoperative management. In patients managed surgically, assistance from an occupational therapist may be beneficial in the early postoperative period. Most patients are able to return to previous employment activities in 6 to 8 weeks, with maximum medical improvement expected from 3 to 6 months postoperatively. An uncommon cause of ulnar tunnel syndrome that deserves special mention is the hypothenar hammer syndrome.6,9 This condition results from repetitive impact to the ulnar aspect of the hand leading to ulnar artery damage and formation of a pseudo-aneurysm and/or clot. Clinical findings include local tenderness and ischemic changes with numbness in the ring and small fingers. A pathologic Allen test with compression of the radial artery and impaired blood flow to the ulnar digits supports the diagnosis. The location of the lesion can be determined with ultrasonography, selective angiography, or MRI angiography. Initial treatment of hypothenar hammer syndrome includes cessation of impact trauma to the hand, elimination of tobacco products, and avoidance of prolonged cold exposure. Arterial thrombosis may be addressed nonoperatively in some individuals with injection of a thrombolytic agent or surgically in others by resecting the damaged vessel segment. Because of the potential for repeated thrombi formation and emboli to the digital arteries, an aneurysm is best managed operatively. Although residual cold intolerance can be expected, the results of surgical treatment are generally good.

ULNAR TUNNEL SYNDROME

HAND-ARM VIBRATION SYNDROME

Neuropraxia of the ulnar nerve at the wrist is referred to as ulnar tunnel syndrome.3 The ulnar tunnel, or loge of Guyon, is a fibroosseous space adjacent to the carpal tunnel through which

Hand-arm vibration syndrome, or vibration white finger, is a complex condition associated with vibration exposure and the use of hand-held vibrating tools.14,18,22 Symptoms include

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white fingers, sensory disturbances, reduced hand dexterity, and diminished grip strength. Additional symptoms may include cold intolerance, wrist and hand pain, and muscle cramps. Vibration exposure has a cumulative effect on both vessels and nerves. The duration of exposure necessary to elicit symptoms, however, has never been clearly defined. The diagnosis of hand-arm vibration syndrome is based on a history of vibration exposure and the presence of symptoms. The Stockholm workshop scales are widely used in assessing the severity of this condition in affected individuals. Electrodiagnostic and vascular flow studies are helpful in excluding other etiologies such as an arterial thrombosis or peripheral nerve compression lesion, although separate conditions may coexist. Prevention of hand-arm vibration syndrome is of paramount importance, with measures including use of well-padded antivibration gloves and frequent breaks from operating vibratory machinery. If symptoms develop, avoidance of the inciting tool(s) is essential. Discontinuation of smoking, oral vasodilators, and limitation of cold exposure may be beneficial in reducing associated digital vasospasms. In early stages, the condition is typically reversible, but in long-standing cases, blanching of the fingers may persist indefinitely despite avoidance of vibration exposure.

include wrist arthrography (Fig. 6d.4), MRI arthrography, and arthroscopy. Initial nonoperative management is indicated for acute and stable scapholunate interval injuries. Individuals with partial ligament tears and no clinical or radiographic evidence of carpal instability can be treated by temporary wrist immobilization. A nonsteroidal antiinflammatory medication and a localized cortisone injection may also be considered. Patients with chronic scapholunate ligament tears and evidence of marked degenerative arthritis can be initially managed similarly. If symptoms persist beyond approximately 4 months, surgical options may be discussed. In patients with acute and unstable scapholunate ligament injuries, early operative intervention is recommended. The decision to intervene surgically, however, depends on additional factors, including patient age, health status and expectations, and anticipated compliance with postoperative care. Because most individuals who sustain an acute scapholunate interval injury are physiologically young and active, direct ligament repair with capsular augmentation is perhaps the best means of managing this injury. However, other surgical procedures

SPRAINS A sprain constitutes an injury to one or more ligamentous structures stabilizing a joint. The complex anatomy of the wrist ligaments includes thickened bands of capsular tissue interconnecting the distal radius to the distal ulna and carpal bones, along with deeper structures such as the scapholunate and lunotriquetral interosseous ligaments linking adjacent carpal bones. The finger metacarpal and interphalangeal joints are stabilized by medial and lateral capsular thickenings termed collateral ligaments and a strong palmar structure designated the volar (palmar) plate.

Scapholunate interval Stability of the scapholunate interval depends on the integrity of the scapholunate interosseous ligament and secondary capsular ligament restraints.31 A history of falling onto the affected hand is often described in association with a scapholunate interval injury, the symptoms of which include dorsoradial wrist pain and a weakened grasp. Occasionally, active wrist flexion against resistance produces a painful snapping sensation. The diagnosis is suspected when pain is elicited with finger pressure over the scapholunate interval. The scaphoid shift test is helpful in excluding other causes of dorsoradial wrist pain, such as a ganglion cyst. A positive shift test is noted if the proximal pole of the scaphoid can be translated over the dorsal rim of the radius under dynamic load. In the initial evaluation, plain radiographs are useful. If an abnormality in carpal bone spacing is detected, comparative views of the contralateral wrist are obtained to distinguish a normal variation in carpal spacing from pathologic carpal alignment. In equivocal cases, fluoroscopic imaging can be helpful. Additional studies that may assist in making the diagnosis

Figure 6d.4 Wrist arthrogram. Radiopaque dye injected into the radiocarpal interval with leakage into the midcarpal and distal radioulnar joints. The appearance is diagnostic for tears of the scapholunate and lunotriquetral ligaments and the triangular fibrocartilage complex (TFCC).

Chapter 6d

have been described for treatment of both acute and chronic scapholunate interval trauma. Depending to a large degree on the specifics of the surgery, the course of rehabilitation and the results of treatment vary.

Lunotriquetral interval Analogous to scapholunate instability, pathologic laxity of the lunotriquetral interval requires injury to both the lunotriquetral interosseous ligament and the secondary capsular restraints.27 The spectrum of pathology ranges from partial ligament tears with retained carpal stability to complete dissociation with carpal collapse. Symptoms may include pain and crepitus with diminished wrist motion, grip weakness, and sensation that the carpus is giving way. To differentiate a lunotriquetral interval injury from other lesions that can cause ulnar-sided wrist symptoms, a careful examination is necessary. Palpation over the lunotriquetral joint predictably elicits pain. A ballottement test, performed by grasping the pisotriquetral unit between the thumb and index finger of one hand and the lunate between the thumb and index finger of the other hand, reproduces symptoms and may demonstrate abnormal joint laxity. Plain radiographs are recommended in the evaluation of ulnar-sided wrist pain. Lunotriquetral instability may not be readily apparent on standard radiographic images, however. An MRI arthrogram can assist in diagnosis and occasionally reveal other lesions contributing to the symptom complex. Initial management is typically nonoperative, involving activity modifications and a 4- to 6-week course of wrist immobilization. A midcarpal corticosteroid injection and short-term use of an antiinflammatory medication may be beneficial also. Most patients with isolated lunotriquetral ligament tears respond well to conservative treatment. Persistent pain localized to the lunotriquetral interval with failure of conservative management is an indication to intervene surgically. The result depends on a variety of factors, including chronicity of the injury, associated carpal arthrosis, and specifics of the operation performed. Surgical options include simple ligament debridement, shortening of the ulna to decompress the lunotriquetral joint, lunotriquetral ligament reconstruction, and lunotriquetral fusion. Poor response to a previous injection and/or immobilization is a strong indicator of a potential surgical failure.

Sprains

in the soft tissues distal to the tip of the ulnar styloid predictably elicits discomfort. Stress testing of the stabilizing function of the TFCC is performed by applying dorsal and palmar pressure to the interval between the distal ulna and the carpus. Wrist radiographs are recommended to assess arthritic changes, carpal instability patterns, and ulnar bone length relative to the radius (ulnar variance). MRI with or without intraarticular contrast may assist in the diagnosis. In most patients, initial treatment of a TFCC injury involves a variable period of wrist immobilization and possibly a cortisone injection into the ulnocarpal joint. Exceptions include the rare traumatic tear with gross instability at the distal radioulnar joint. These cases usually require early operative intervention. In those individuals who fail conservative measures and have significant symptoms, surgical intervention may be indicated. Simple arthroscopic debridement is effective in the management of many traumatic TFCC lesions, especially central tears (Fig. 6d.5). In individuals with positive ulnar variance or lunotriquetral instability, this can be combined with formal ulnar shortening. Open or arthroscopically assisted repairs of a peripheral tear have exhibited results similar to or better than debridement alone. The expected postoperative recovery period depends to a large extent on the details of the operation performed. After discontinuation of splint immobilization, all patients may benefit from a short period of therapy. Maximum medical improvement is expected 3 to 6 months postoperatively.

Triangular fibrocartilage complex The triangular fibrocartilage complex (TFCC) is a soft tissue structure composed of seven contiguous elements that combine to stabilize the distal radioulnar joint and suspend the ulnar carpus.15 Traumatic disruption of the TFCC can lead to ulnarsided wrist pain, instability of the distal radioulnar joint, and articular cartilage degeneration. Patients typically describe pain and a clicking sensation localized to the ulnar aspect of the wrist after known injury or repeated microtrauma. Symptoms are often aggravated by forearm rotation and ulnar deviation of the wrist. Applied pressure

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Figure 6d.5

Wrist arthroscopy.

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Gamekeeper’s thumb Disruption of the ulnar collateral ligament of the thumb metacarpophalangeal joint occurs when a significant valgus stress is applied to the joint,13 often from a fall on the outstretched thumb. The injury may result in metacarpophalangeal joint instability, causing pain with thumb motion and adversely affecting both grip and pinch strength. Two terms commonly used to describe this injury are the gamekeeper’s thumb and the skier’s thumb. The anatomy of the thumb ulnar collateral ligament is analogous to that of the collateral ligaments stabilizing the finger metacarpophalangeal and interphalangeal joints. The thumb ulnar collateral ligament ruptures most often from its distal insertion at the base of the proximal phalanx. Displacement of the ligament can occur such that it comes to lie superficial and proximal to the adductor pollicis muscle, a specific pattern of injury referred to as a Stener lesion (Fig. 6d.6). The diagnosis of a gamekeeper’s injury involves a careful examination of the involved thumb. Plain radiographs should be obtained to assess for an underlying bone injury. Stress radiographs with applied valgus force to the metacarpophalangeal joint can confirm the diagnosis and determine the degree of ligament disruption. Treatment of partial ligament tears involves a 4- to 6-week period of thumb immobilization. A hand-based spica splint or cast incorporating the thumb proximal phalanx usually suffices. A complete ligament tear is an indication for surgical intervention; in these cases a Stener lesion may preclude effective ligament healing with nonoperative treatment. The thumb is commonly immobilized for 4 weeks postoperatively. Unrestricted activities are permitted after 6 weeks in cases treated nonoperatively and after 3 months in patients managed surgically. In thumbs with partial ligament injuries, nonoperative treatment yields a stable and painless thumb with near-normal motion in most cases. In thumbs with a complete ligament

rupture treated early with surgery, more than 90% of patients can expect a good to excellent result.

Fingers The finger metacarpophalangeal and interphalangeal joints may be injured by a variety of different mechanisms, resulting in partial or complete disruption of the collateral ligaments and palmar plate. Although the closely conforming articular surfaces of the proximal and distal interphalangeal joints usually afford residual stability, the metacarpophalangeal joints are less anatomically constrained and may exhibit pathologic laxity with injury to identical periarticular structures. The diagnosis of a finger sprain is relatively straightforward. The involved joint exhibits variable swelling and limited motion with maximum tenderness in the area of soft tissue injury. Gentle stress may elicit visible or palpable joint instability. Assessment and documentation of neurovascular status commonly reveals a digital neuropraxia. Radiographs are valuable in excluding the presence of a fracture, joint subluxation, or joint dislocation. Ultrasound and MRI studies may be considered but are often unnecessary for initial diagnosis. A stable sprain of the finger metacarpophalangeal joint is treated with buddy strapping and immediate motion. Velcro straps or athletic tape is placed around the injured digit and adjacent finger, leaving the interphalangeal joints free for motion exercises. An unstable metacarpophalangeal joint may be managed by buddy strapping and/or immobilization in a handbased splint for 4 to 6 weeks. The decision to intervene surgically depends on several factors, including the presence of an associated avulsion fracture and residual joint instability with splint immobilization. Sprains of the proximal and distal interphalangeal joints are managed by finger extension splinting for a brief period followed by active motion exercises and protective buddy strapping. Progressive static or dynamic extension splinting may be indicated during the course of treatment to address a developing joint contracture. Supervised therapy is often helpful. Most finger sprains can be managed without surgical intervention. Some degree of permanent swelling is expected, and a small flexion contracture may persist. The deformity will unlikely impair hand function or preclude a return to gainful employment.

FRACTURES Distal radius

Figure 6d.6 Torn and displaced ulnar collateral ligament of the thumb metacarpophalangeal joint, termed a Stener lesion (arrow). This pattern of displacement is often responsible for failure of nonoperative management of complete ligament tears.

Distal radius fractures, commonly called Colles’, Barton’s, Smith’s, and Chauffeur’s fractures, account for 14% of all extremity injuries.12,24 Approximately 50% of these injuries involve the articular surface of the distal radius. In healthy and active individuals, restoration of bone and joint alignment is indicated to preserve function and to deter posttraumatic arthrosis. The initial examination should include an assessment for concurrent bone and soft tissue injuries with specific attention to the stability of the distal radioulnar joint. Although vascular compromise occurs rarely, neurologic symptoms are relatively

Chapter 6d

frequent and typically involve the median nerve in the carpal tunnel with paresthesias in the radial four digits. Radiographic evaluation is performed both before and after attempted closed fracture reduction (Fig. 6d.7). Assessment of the intraarticular extent of the injury is crucial. A residual joint incongruity of 2 mm or greater displacement has been associated with posttraumatic arthrosis. Special imaging studies such as computed tomography are useful when the fracture pattern and/or magnitude of displacement is difficult to determine on plain radiographs. Closed stable fractures in acceptable alignment can be treated nonoperatively. Serial radiographs are obtained, and a cast is worn for approximately 6 weeks, followed by the use of a temporary removable splint. Supervised therapy may be helpful early during the course of healing to assist with finger motion and later, after fracture consolidation, to help improve wrist motion and grip strength. Displaced and unstable fractures usually require surgery. Procedural options include the use of percutaneous pins, external fixation, open reduction and internal fixation, or a combination of methods. The results of treatment vary, depending in part on the severity of the initial injury and the extent of articular surface involvement. Although maximum medical improvement is anticipated 6 months after injury or surgery, patients may continue to demonstrate improvements in wrist motion, grip strength, and endurance for well over 1 year.

Scaphoid

Figure 6d.7

Figure 6d.8

Displaced distal radius fracture (arrow).

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Fractures

The scaphoid is the most commonly fractured carpal bone.7 This type of injury typically results from a sudden impact on the palm with the wrist hyperextended, such as occurs with a fall onto the outstretched hand. When the fracture is complete, intrinsic forces may lead to displacement of a scaphoid fracture into a flexed humpback position: The proximal pole extends, whereas the distal pole flexes. Classically, the patient presents with loss of wrist motion, snuff box tenderness, and pain with resisted forearm pronation and supination. Wrist swelling may be present, but this and other signs of local trauma are not always apparent. In many instances the presentation and diagnosis are delayed, with the injury initially attributed to a “sprain.” Although most scaphoid fractures can be detected acutely on good quality plain radiographs (Fig. 6d.8), some do not become apparent for several weeks. Specialized imaging studies, including MRI, scintigraphy, and computed tomography, are occasionally helpful in early diagnosis and subsequent management. Closed treatment is indicated for acute nondisplaced scaphoid fractures. If diagnosed promptly and immobilized for an adequate duration, more than 90% of stable scaphoid injuries heal. Surgical intervention is indicated for acute fractures that are either displaced or unstable and for older fractures that have failed to unite. Instability is defined as displacement greater

Scaphoid waist fracture (arrow).

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than 1 mm in any direction and injuries associated with loss of carpal bone alignment. Relative indications for surgical treatment include a proximal pole fracture and prolonged wrist immobilization that would be unacceptable to the patient for social and/or economic reasons. Intramedullary pins or screws have become the standard of fixation for scaphoid fractures, with union rates comparable with those reported for closed-cast treatment. When screws are used and stability is achieved, early mobilization of the wrist is often permitted. In one study of military personnel, percutaneous screw fixation of nondisplaced scaphoid fractures was shown to result in more rapid radiographic union and return to duty when compared with cast immobilization.5 Maximum medical improvement is expected 4 to 6 months after injury or surgery but is contingent upon fracture healing.

Metacarpals and phalanges Fractures involving the metacarpals and phalanges occur in multiple patterns: transverse, oblique, spiral, and comminuted.4,17 Most of these injuries may be evaluated using standard radiographs. The rotational alignment of the digit is assessed with active finger motion or by generating finger motion through a tenodesis effect with passive wrist flexion and extension. The phalanges should be parallel during extension and point toward the thenar eminence when flexed. Most metacarpal and phalangeal shaft fractures can be treated nonoperatively with protective casting or splinting. Clinical union usually requires 4 to 5 weeks for metacarpal injuries and 3 to 4 weeks for proximal and middle phalanx injuries. A distal phalanx fracture may take longer to unite. Metacarpal fractures are typically immobilized with a forearm-based cast or splint incorporating the metacarpophalangeal joint of the injured finger and one or two adjacent digits. Hand-based immobilization is indicated for proximal and middle phalanx shaft fractures, whereas distal phalanx fractures are treated with a simple finger splint. All cases require close radiographic follow-up to assess for loss of fracture alignment. Operative treatment is indicated for irreducible or unstable fractures and those associated with tendon lacerations. Articular injuries with marked incongruency and/or persistent joint subluxation are also considered for surgical repair. The type of fixation used depends on the fracture pattern, the soft tissue injury, and the judgment and experience of the surgeon. Depending in part on the severity of the fracture and associated soft tissue trauma, the reported results after nonoperative and operative treatment of metacarpal and phalangeal fractures are variable. A successful outcome requires patient compliance with treatment and an appropriately structured rehabilitation program. In most cases maximum medical improvement is anticipated approximately 3 to 4 months from injury or surgery.

affecting the hands symmetrically. The distal interphalangeal joint of the finger is the most commonly involved hand joint, followed by the thumb basilar joint. In contradistinction to systemic arthritic conditions such as rheumatoid arthritis, the finger metacarpophalangeal joints are usually spared. Although several studies have alluded to repetitive activities as having an influence on the development of osteoarthritis in the wrist and hand, a causal relationship between repetitive activities and degenerative joint disease has never been conclusively proven.

Wrist Osteoarthritis of the wrist most often develops secondary to a traumatic event. Intraarticular fractures of the distal radius, malunited scaphoid fractures, scaphoid nonunions, and intercarpal ligamentous injuries all predispose the wrist to degeneration. In many cases, however, a specific cause is never identified. Patients with wrist arthritis report pain, loss of mobility, and weakness in grip. Crepitation during motion or loading activities and swelling over the dorsal carpus are common in advanced disease. Plain radiographs confirm the diagnosis and assist in devising a treatment strategy (Fig. 6d.9). For early degenerative disease of the wrist, conservative measures are frequently successful. These include nonsteroidal

OSTEOARTHRITIS Osteoarthritis is a slowly progressive joint disease of multifactorial etiology.21,29 Cartilage degeneration and osteophyte formation are often seen in association with advancing age, characteristically

Figure 6d.9 Wrist degenerative arthritis developing after a scapholunate interval injury (arrow).

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Osteoarthritis

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antiinflammatory medication, wrist immobilization, activity modifications, and corticosteroid injection(s). Significant degenerative arthritic changes predict some degree of permanent functional impairment. Surgery is indicated if symptoms warrant and conservative treatment measures have failed. Procedures include proximal row carpectomy (excision of the three most proximal carpal bones), partial carpal bone fusions, and total wrist arthrodesis. The period of postoperative immobilization depends on the specifics of the operation performed, averaging 6 to 8 weeks for a fusion procedure. Results of surgical treatment are favorable in terms of pain relief. Motion-retaining procedures such as a partial wrist fusion and proximal row carpectomy require a considerable amount of therapy after cast removal. Total wrist fusion is the most reliable in terms of relieving pain and improving grip strength but at the expense of wrist motion. Work restrictions after surgery must be determined on an individual basis, taking into account the specific job requirements. Maximum medical improvement is anticipated 6 months postoperatively.

Thumb basilar joint The basilar joint of the thumb consists of the metacarpal base and trapezium bone.2 Arthritis around the trapezium is the second most common site for degenerative joint disease in the hand (preceded only by the distal interphalangeal joint). More frequent in females than males, the condition has been attributed to laxity of the important stabilizing ligaments of the thumb. Patients with basilar thumb joint arthritis have pain localizing to the base of the thenar muscles. Opening jars and turning door knobs are often difficult tasks to perform comfortably. As the condition advances, pinch and grip strength diminish, and thumb range of motion may decrease as well. Examination reveals a tender and enlarged basilar joint. Axial grinding of the thumb metacarpal exacerbates the pain and may elicit sensations of instability and crepitation. The Finkelstein test is usually negative, helping to distinguish basilar joint arthritis pain from de Quervain disease. The diagnosis is confirmed by plain radiographs (Fig. 6d.10). Initial treatment of basilar joint osteoarthritis includes activity modifications, splint immobilization, nonsteroidal antiinflammatory medication, thenar muscle strengthening exercises, and joint injection(s). If a patient’s symptoms are not satisfactorily relieved by conservative means, surgical intervention may be considered. The most commonly performed operation entails partial or total excision of the diseased trapezium with stabilization of the thumb metacarpal base using local tendon graft. A significant hyperextension deformity of the thumb metacarpophalangeal joint may require a concomitant procedure to stabilize the metacarpophalangeal joint. The postoperative course typically involves a 4- to 6-week period of wrist and thumb immobilization followed by a supervised therapy program. Pain relief from surgery is nearly universal but not always complete, especially in younger and more active individuals. Activity modifications in the workplace may be indicated for an extended period of time after surgery. Thumb motion and

Figure 6d.10

Thumb basilar joint arthritis (arrow).

grip/pinch strength improve slowly. Maximum medical improvement is anticipated after approximately 6 months.

Proximal interphalangeal joint Osteoarthritis of the proximal interphalangeal joint is relatively rare. The condition typically arises after a dislocation or intraarticular fracture. The earliest signs of degenerative arthritis are swelling and morning stiffness. Limited proximal interphalangeal joint motion follows with the development of marginal osteophytes (Bouchard’s nodes). Late joint degeneration leads to an angular deformity and joint instability. Radiographs confirm the diagnosis and reveal the degree of joint deterioration. Conservative treatment measures include nonsteroidal antiinflammatory medication, activity modifications, and short-term splinting. Early in the degenerative process, steroid injections can be helpful in ameliorating pain. If these measures fail and considerable symptoms persist, surgical intervention may be considered. Arthrodesis is the most reliable method of eliminating pain. Fusion of the ulnar digits at the proximal interphalangeal joint level impairs grip strength and finger dexterity to a greater

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degree than it does in the radial digits. Fusion rates vary from 84% to 100%. Implant arthroplasty also provides pain relief with the added benefit of preserving partial joint motion. Joint replacement, however, carries an attendant risk of implant breakage and should be avoided in younger patients and/or manual laborers. Maximum medical improvement is expected 3 to 6 months postoperatively.

Distal interphalangeal joint Idiopathic degeneration of the distal interphalangeal joint commonly involves multiple digits in a symmetric distribution, whereas single finger joint degeneration is more suggestive of previous injury. In most cases, symptoms are mild and functional impairment is negligible. Swelling and stiffness are common symptoms in early degeneration of the distal interphalangeal joint. As the disease progresses, joint enlargement is seen secondary to osteophyte formation (Heberden’s nodes), resulting in limited motion. Late in the disease, angular and rotational deformities occur at the finger tip. Radiographs confirm the diagnosis and demonstrate the severity of joint destruction. In most individuals, conservative care is successful. Treatment measures include nonsteroidal antiinflammatory medication, activity modifications, corticosteroid injection(s), and splinting. Surgery is reserved for symptomatic degenerative disease that does not respond to conservative measures. Distal interphalangeal joint fusion reliably relieves pain, restores stability and strength, and improves the appearance of the digit. Fusion rates vary from 80% to 100%. Maximum medical improvement is expected 2 to 4 months postoperatively.

GANGLIA Ganglia are fluid-filled structures that arise from a joint, tendon, or tendon sheath.28,30 They contain lubricating fluid called mucin that is similar in content to but more viscous than the fluid found in joints and tendon sheaths. Ganglia can emanate from almost any anatomic region, but they are most common at the wrist, the proximal margins of digital flexor tendon sheaths, and the finger distal interphalangeal joints. Cysts communicate with these structures through one or more ducts that account for their intermittent fluctuation in size. The true etiology of a ganglion is unknown, although approximately 10% have been associated with previous trauma.

Carpal ganglia Ganglia of the wrist are seen most frequently dorsally, near the articulation of the scaphoid and lunate bones (Fig. 6d.11). They occur less commonly at the palmar aspect of the wrist, adjacent to the flexor carpi radialis tendon. Cysts may be multiloculated and much larger than clinically apparent, extending far away from their point of origin. Patients with carpal ganglia may complain of activity-related wrist pain and weakness. Guarding with minor loss of wrist

Figure 6d.11 Wrist magnetic resonance image, axial view. Dorsal ganglion attached to the scapholunate interval (arrow).

motion secondary to pain may result. In most cases, however, the cysts yield few or no symptoms and require no specific intervention. For a symptomatic dorsal wrist ganglion, aspiration of the cyst with or without a corticosteroid injection is initially recommended and successful in up to 50% of cases. Aspiration is relatively contraindicated for volar wrist ganglia because of the close proximity of the radial artery. In these cases temporary wrist splinting and use of a nonsteroidal antiinflammatory medication may be helpful. Surgical excision of wrist ganglia is indicated for persistent pain, with reported recurrence rates averaging approximately 5%. The procedure is frequently performed in an open manner, although an arthroscopic technique for excising dorsal ganglia was recently described.25 After ganglion excision, most patients experience continued low-grade discomfort for several weeks. Supervised therapy may be helpful in diminishing pain and in restoring wrist motion and grip strength. Maximum medical improvement is anticipated 2 to 3 months postoperatively.

Retinacular cysts Ganglia arising from the digital flexor tendon sheath are termed volar retinacular ganglia or retinacular cysts. Appearing as a small bump at the base of a digit adjacent to the palmar digital flexion crease, this type of cyst commonly causes discomfort during activities that require gripping or holding objects in the palm. A painful cyst can usually be treated by needle aspiration. Surgery to excise the lesion is considered in recalcitrant cases and when the diagnosis is uncertain. A rapid return to regular work activities is expected.

Mucous cysts Cysts arising from the distal interphalangeal joint, termed mucous cysts, are invariably associated with degenerative arthritic changes in the underlying joint. Because of their location, mucous cysts

Chapter 6d

may disrupt the germinal matrix of the nail bed and lead to longitudinal nail plate grooves and ridges. Aspiration and instillation of a corticosteroid can be attempted, but this treatment is rarely curative. Because the distal interphalangeal joint is immediately deep to the skin surface, aspiration increases the likelihood of septic arthritis. Simple cyst excision carries a recurrence rate of 25% or greater. Excision of the cyst in conjunction with debridement of marginal joint osteophytes, however, is successful in over 95% of cases. Recovery after surgery is relatively rapid, and unrestricted use of the hand should be possible within 6 weeks.

COMPLEX REGIONAL PAIN SYNDROME Complex regional pain syndrome (CRPS) is a neurogenic disorder characterized by pain out of proportion to the level anticipated with the diagnosis, swelling, autonomic dysfunction, and joint stiffness.1,32 In the past, a variety of terms, including reflex sympathetic dystrophy, causalgia, Sudeck’s atrophy, and shoulder-hand syndrome, has been used to describe this condition. Type 1 CRPS develops after a noxious event without identifiable nerve injury, whereas type 2 CRPS occurs in association with a nerve injury. The pathogenesis of CRPS remains poorly understood. Autonomic hyperactivity is implicated in syndrome development, and in many cases psychologic factors seem to play a role. Initially, pain, swelling, restricted motion, and vasomotor changes (hyperhidrosis, erythema, excessive warmth) predominate the symptom complex. After several months, swelling changes from a soft to a hard brawny edema. Eventually, the skin appears shiny and glossy, and stiffness becomes marked with fixed joint contractures. The diagnosis of CRPS is made on clinical examination but may be confirmed by a variety of objective tests. Radiographs frequently reveal diffuse osteopenia secondary to bone demineralization. Three-phase bone scans show characteristic diffuse uptake in the involved areas. Thermography can depict asymmetric temperature when compared with the contralateral limb. Anesthetic blockade at the neck/shoulder level confirms the diagnosis in cases with primary involvement of the sympathetic nervous system. Successful treatment of CRPS depends on prompt diagnosis and early intervention. The appearance and persistence of inordinate pain after injury or surgery is typically the first sign. The possibility of nerve injury should be entertained and any painful stimulus (e.g., cast compression) eliminated. Active range-ofmotion exercises, edema control, interval splinting, and a stressloading program are initiated by an experienced therapist. Pharmacologic treatment measures include corticosteroids, αadrenergic blocking agents, calcium channel blockers, and regional anesthetic injections. To address marked joint contractures late in the disease process, surgical intervention may be indicated. Evidence suggests that the earlier treatment is instituted, the better the chance for a successful result. A significant percentage of patients, however, still complain of pain, cold intolerance, sensory disturbances, swelling, hand weakness, and stiffness years later. Once the chronic stages of CRPS have occurred, results are less favorable, with expected varying degrees of permanent upper extremity impairment.

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References

CONCLUSION Management of an occupational-related disorder of the wrist or hand is contingent upon the recognition of factors related to condition development, a coordinated team approach to care, and the patient’s active participation in recovery. Conservative treatment measures include supervised therapy, splinting, corticosteroid injection, oral pain medication, and activity modifications. Surgical intervention may be indicated for trauma, advanced nerve compression lesions, arterial thrombosis, recalcitrant tendonitis, symptomatic degenerative arthritis, painful ganglia, and various other conditions. The ultimate goals of treatment should include patient satisfaction, symptom resolution, and return to gainful employment.

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