Common Hand Conditions Research Articles

Mid-axial injection of steroid into the flexor sheath for trigger fingers.

The description of the disease called trigger finger was done by Notta, a French physician as early as 1850 [1]. Histological studies have shown metaplasia of cartilage like cells within the A1 pulley area of the flexor tendon sheath with no real evidence of inflammation [2]. It is a common hand condition seen in patients with diabetes and they are sub group known to develop recurrences after primary treatment. Howard et al. [3] in 1953 described the first use of a locally injected steroid into the tendon sheath as treatment, while in 1958 Lorthinor et al. described the first surgical decompression of the constriction [4]. Both forms of management are still practiced as primary management of the trigger finger. Numerous studies [5] have been done showing the obvious benefits of steroid injections in trigger finger treatment. The most commonly employed technique is to give a mixed solution of lignocaine and methyl prednisolone or triamcinolone administered through a palmar route directly into the palpable nodule at the A1 pulley area, withdrawing the needle from the tendon to infiltrate the tendon sheath [6]. Some techniques describe a similar approach, but with the drug administered on the far side of the tendon [5], between the tendon and the metacarpal bone. One of the obvious disadvantages of the procedure is pain. As the palmar skin has a high density of sensory receptors, some authors describe the use of a local anaesthetic injection first followed by the steroid injection through the same needle to minimize pain during the procedure. Carlson CS & Curtis RM described a technique of infiltration of the flexor sheath by a mid axial route in 1984 [7] for flexor tenosynovitis. This technique has been used in all patients requiring steroid injection for trigger finger.

Abstract: Congenital Syndactyly Reconstruction of 391 Webspaces

INTRODUCTION: Congenital syndactyly occurs in isolated and syndromic forms; method of reconstruction must be tailored to the type of syndactyly and postoperative function will depend on the preoperative state of the hand in addition to the method of reconstruction selected. We present the 18 year experience of surgical reconstruction of congenital syndactyly in all of its forms at a high throughput children’s hospital. METHODS: All patients who underwent webspace reconstruction for congenital syndactyly by the senior author over an 18 year period were included in this study. Data included demographics, medical history, anatomy and severity of syndactyly, surgical technique, follow up and need for revision. Patients who underwent hand surgery prior to their first clinic visit were excluded from outcomes analysis. Logistic regression was performed to identify factors that were associated with postoperative wound complications and revision. RESULTS: Reconstruction was performed for 182 patients with 391 webspaces; 21 patients were referred from outside surgeons and excluded from outcomes analysis. Twenty-eight patients had complications over 32 webspaces. The most common complications were web creep (n=10), scar contracture (n=6), and flexion contracture (n=5). Dorsal VY advancement flap was the most common method for reconstructing simple incomplete syndactyly and was associated with decreased risk of complication in the 3rd webspace (OR=0.427 p=0.006) while triangular flaps and skin graft was associated with increased complications (OR=2.75, p <0.001). Presence of a complicated hand anomaly did not significantly increase the likelihood of complications (p=0.21). CONCLUSION: Syndactyly is a common congenital hand condition that occurs as both an isolated anomaly and as part of several syndromic diagnoses. We describe the largest retrospective cohort of congenital syndactyly reconstruction to date and discuss important technical and clinical considerations to minimize postoperative complications and revisional surgery.

Congenital Syndactyly Reconstruction of 391 Webspaces: An 18 Year Experience: Level 4 Evidence

There is no financial information to disclose. Congenital syndactyly occurs in isolated and syndromic forms; method of reconstruction must be tailored to the type of syndactyly, and postoperative function will depend on the pre-operative state of the hand in addition to the method of reconstruction selected. All patients who underwent webspace reconstruction for congenital syndactyly by the senior author over an 18 year period were included in this study. Data included demographics, medical history, anatomy and severity of syndactyly, surgical technique, follow-up and need for revision. Patients who underwent hand surgery prior to their first clinic visit were excluded from outcomes analysis. Logistic regression was performed to identify factors that were associated with postoperative wound complications and revision. Reconstruction was performed for 182 patients with 391 webspaces; 21 patients were referred from outside surgeons and excluded from analysis. Twenty-six patients had complications (16%), of which 13 (8%) required revision. The most common complications were web creep (n = 10), scar contracture (n = 6), and flexion contracture (n = 5). Dorsal VY advancement flap was the most common method for reconstructing simple incomplete syndactyly and was associated with decreased risk of complication in the 3rd webspace (OR = 0.427, P = 0.006), while triangular flaps and skin graft were associated with increased complications (OR = 2.75, P < 0.001). Presence of a complicated hand anomaly did not significantly increase the likelihood of complications (P = 0.21). •Syndactyly is a common congenital hand condition that occurs as both an isolated anomaly and as part of several syndromic diagnoses.•We describe the largest retrospective cohort of congenital syndactyly reconstruction to date and discuss important technical and clinical considerations to minimize postoperative complications and revisional surgery.

Hand Dominance and Common Hand Conditions

The goals of this study were to (1) assess how frequently patients present for evaluation of common hand disorders in relation to hand dominance and (2) evaluate the effect of hand dominance on function in patients with these conditions. The authors hypothesized that (1) the majority of patients who seek evaluation would have a condition that affects the dominant hand, and (2) disability scores would be worse if the dominant hand is involved. They retrospectively reviewed the records of consecutive patients who presented for treatment to their institution with unilateral symptoms of 5 common disorders of the hand: carpal tunnel syndrome (CTS), de Quervain's tenosynovitis (DEQ), lateral epicondylitis (LE), hand osteoarthritis (OA), and trigger finger (TF). The authors assessed the effect of diagnosis and hand dominance on Disabilities of the Arm, Shoulder and Hand (DASH) scores. The study group comprised 1029 patients (379 men and 650 women) with a mean age of 59.5 years. Ninety percent were right-hand dominant. The dominant and nondominant hands were affected with relatively equal frequency for CTS, DEQ, OA, and TF (range, 45%-53%). Patients with LE had a significantly higher incidence of dominant hand involvement. Men had lower DASH scores than women by an average of 7.9 points, and DASH scores were significantly but slightly higher for the overall group (3.2 points) when the dominant side was affected. Men with LE and women with TF and OA had significantly higher DASH scores when their dominant extremity was affected. Common hand disorders such as CTS, DEQ, OA, and TF affect the dominant and nondominant hands in roughly equivalent proportions, whereas LE is more common on the dominant side. Dominant hand involvement results in significantly worse DASH scores, although the magnitude of this is relatively small. Women have significantly higher DASH scores than men for the conditions evaluated. [Orthopedics. 2016; 39(3):e444-e448.].

National Utilization Patterns of Steroid Injection and Operative Intervention for Treatment of Common Hand Conditions

To conduct a population-level analysis of practice trends and probability of surgery based on the number of steroid injections for common hand conditions. Patients aged at least 18 years receiving injection or surgery for carpal tunnel syndrome (CTS), trigger finger (TF), or de Quervain tenovaginitis (DQ) were identified for inclusion using the 2009 to 2013 Truven MarketScan databases. The researchers counted the number of injections performed and calculated the time between injection and operation for patients receiving both treatments. A multivariable logistic regression model was created to evaluate the odds of undergoing surgery based on the number of injections performed, controlling for patient age, sex, comorbidities, and insurance type. The study sample included 251,030 patients who underwent steroid injection or operative release for CTS (n= 129,917), TF (n= 102,778), and DQ (n= 18,335). Most patients with CTS were managed with immediate surgery (71%), whereas most patients with TF and DQ were managed initially with injection (74% and 84%, respectively). Among patients receiving both an injection and an operation, a single injection was themost common practice before surgery (69%, 58%, and 67% of patients with CTS, TF, and DQ, respectively). Multiple injections for DQ and TF were associated with relatively low predicted probability of surgery (17% and 26%, respectively, after 2 injections). However, the predicted probability of surgery after 2 injections was higher in patients with CTS (44%). Given the associated probability of surgery after multiple injections for the 3 hand conditions examined, the practice of repeat injections should be critically examined to determine whether underuse or overuse is present and whether efficiency and use of resources can be improved upon. Prognostic II.

The impact of a hand therapy screening and management clinic for patients referred for surgical opinion in an Australian public hospital

Study designRetrospective cohort study. PurposeTo measure the impact of initial treatment by a hand therapist of people referred to a hand surgeon for common hand conditions. MethodsThis retrospective cohort study included 224 patients with Carpal Tunnel Syndrome, Trigger Finger/Thumb, de Quervain's tenosynovitis, and trapeziometacarpal osteoarthrosis. All were invited to attend for assessment and non-operative treatment and were followed up for at least one year. Between groups comparisons for who attended (N = 164) and those who did not (N = 60) were conducted. Results40.8% of the non-operative treatment group and 65% of the no treatment group underwent surgery, which was statistically significant (p = 0.02). Univariate analysis found that the variable “attending non-operative treatment” was able to predict those who did not have surgery (p = 0.02). Multivariate analysis using logistic regression also showed that this was the only significant predictor of not progressing to surgery (p = 0.001). ConclusionsAssessment and treatment by a non-operative provider were associated with a decrease in the rate of operative treatment. Prospective, randomized studies could help determine if this observed difference is related to the treatment approach. Level of evidence2C

Injection Therapy in the Management of Musculoskeletal Injuries: Hand and Wrist

Injections are valuable diagnostic and therapeutic nonoperative treatments for a myriad of painful conditions affecting the hand and wrist. Corticosteroid and analgesic preparations are frequently injected for the treatment of carpal tunnel syndrome, stenosing tenosynovitis, tendinopathy, and ganglion cysts, as well as for radiocarpal and basilar joint arthrosis. Although upper extremity surgeons frequently perform injections as part of their daily practice, other clinicians may not be as familiar with the appropriate indications and proper techniques required for injection therapy in the hand and wrist. The purpose of this review is to briefly describe the clinical presentation and evaluation of common hand and wrist conditions most frequently amenable to injection therapy. Appropriate indications for injections will be presented along with a detailed description of proper injection technique.

Hand kinematics: Application in clinical practice

ABSTRACTPathological conditions of the hand consequent to injuries, paralysis, disease, arthritis and congenital difference results in loss or limitation of function, deformities, stiffness, inadequate power and poor position for pinch. The pathogenesis of deformities is influenced by bio-mechanical principles of joints and muscle function. The crippling impact of secondary changes due to edema, soft tissue contractures, muscle shortening and functional adaptations also have a mechanical basis. For clinicians and hand therapists, it is necessary to understand these fundamental principles of biomechanics to plan treatment modalities. Interpretation of mechanics of hand deformities in rheumatoid arthritis and paralysis will enable the treating team to identify the appropriate interventions of splinting, therapy and surgical procedures. Basic knowledge of the principles of hand clinical bio-mechanics will help the beginner to sail through the multitude of tendon transfers described in the text books of hand surgery and find the best solution for a particular clinical presentation. Similarly, knowledge of bio-mechanics will provide solutions to an experienced surgeon to plan treatment protocols for complex situations. The article presents a concise summary of the basic principles of hand bio-mechanics for common hand conditions seen in clinical practice. Understanding and applying these principles will help clinicians in planning and devising treatment options for common and complex hand conditions.

Hand kinematics: Application in clinical practice

Pathological conditions of the hand consequent to injuries, paralysis, disease, arthritis and congenital difference results in loss or limitation of function, deformities, stiffness, inadequate power and poor position for pinch. The pathogenesis of deformities is influenced by bio-mechanical principles of joints and muscle function. The crippling impact of secondary changes due to edema, soft tissue contractures, muscle shortening and functional adaptations also have a mechanical basis. For clinicians and hand therapists, it is necessary to understand these fundamental principles of biomechanics to plan treatment modalities. Interpretation of mechanics of hand deformities in rheumatoid arthritis and paralysis will enable the treating team to identify the appropriate interventions of splinting, therapy and surgical procedures. Basic knowledge of the principles of hand clinical bio-mechanics will help the beginner to sail through the multitude of tendon transfers described in the text books of hand surgery and find the best solution for a particular clinical presentation. Similarly, knowledge of bio-mechanics will provide solutions to an experienced surgeon to plan treatment protocols for complex situations. The article presents a concise summary of the basic principles of hand bio-mechanics for common hand conditions seen in clinical practice. Understanding and applying these principles will help clinicians in planning and devising treatment options for common and complex hand conditions.

Treatment of Common Congenital Hand Conditions

After reading this article, the participant should be able to: 1. Recognize the clinical features associated with five common congenital hand conditions. 2. Describe the indications and appropriate timing for various surgical procedures used to treat congenital hand anomalies. 3. Identify the pearls and pitfalls of these surgical treatments to avoid complications. 4. Understand the expected postoperative outcomes associated with these surgical procedures. This article provides an introduction to congenital hand differences by focusing on practical surgical strategies for treating five commonly encountered conditions, including syndactyly, constriction ring syndrome, duplicated thumb, hypoplastic thumb, and trigger thumb. The accompanying videos demonstrate common and reliable surgical techniques for syndactyly release, duplicated thumb reconstruction, and pollicization for hypoplastic thumb.

The Minimal Clinically Important Difference of the Michigan Hand Outcomes Questionnaire

To determine the change in score required in various domains of the Michigan Hand Outcomes Questionnaire (MHQ) to indicate meaningful patient improvement, or the minimal clinically important difference (MCID), for 3 common hand conditions: rheumatoid arthritis (RA), carpal tunnel syndrome (CTS) and distal radius fracture (DRF). The MHQ was administered to patients at 2 time points. Patient satisfaction was defined as a satisfaction score > or =80% of the standard deviation of that patient sample. The minimal change in score in specific MHQ domains that corresponded with patient satisfaction was determined using receiver operating characteristic curves. For CTS patients, MCIDs of 23, 13, and 8 were identified for the pain, function, and work domains, respectively. For RA patients, pain and function were also identified as having discriminative ability, with MCIDs of 11 and 13, respectively. An MCID of 3 was identified for the activities of daily living domain. For DRF patients, no MHQ domains showed discriminative ability because of the ceiling effect at the 3-month assessment period. Individual domains of the MHQ can be used to discriminate between patients who are satisfied and those who are not after either carpal tunnel release or silicone arthroplasty of the metacarpophalangeal joints for RA. Pain and function are the domains of the MHQ that are best able to discriminate between patients who are satisfied and those who are not. The identical function MCID for both RA patients and CTS patients, despite markedly different preoperative values, indicates that a standard amount of functional change may indicate patient satisfaction. High postoperative satisfaction, even only 3 months after surgery, prevented any domains from showing discriminative ability for the DRF patients.

The hand and diabetes

Several common hand conditions such as trigger finger, carpal tunnel syndrome and Dupuytren's disease occur up to four times more frequently in diabetic patients than in the general population and 40% of diabetics may have significant hand problems.1 The natural history of these conditions in diabetics and the outcome of treatment may not be the same as in the general population. In addition some diabetics develop characteristic hand problems due to restricted joint mobility. In this paper we shall review the epidemiology and outcomes of these hand conditions in diabetes.

The hand and diabetes

Several common hand conditions such as trigger finger, carpal tunnel syndrome and Dupuytren's disease occur up to four times more frequently in diabetic patients than in the general population and 40% of diabetics may have significant hand problems.1 The natural history of these conditions in diabetics and the outcome of treatment may not be the same as in the general population. In addition some diabetics develop characteristic hand problems due to restricted joint mobility. In this paper we shall review the epidemiology and outcomes of these hand conditions in diabetes.

Soft Tissue Complications Following Kirschner Wire Fixation for Fusion of Basal Joint Arthritis.

Basal joint arthritis is a common hand condition presenting with pain and swelling, often requiring surgical treatment in the late stages. Surgical options include arthrodesis, excision arthroplasty, implant arthroplasty and ligament reconstruction, and tendon interposition arthroplasty. A patient with bilateral basal joint arthritis underwent K-wire arthrodesis of the left basal joint. Subsequently, she developed complications due to impingement of the K-wire on the median nerve, superficial radial nerve, and flexor tendons of the index finger. The diagnosis was made three years post-operatively and she then underwent reconstructive surgery. Eventually she recovered with good movement and sensation of the affected digits. Although K-wire arthrodesis of basal joint is a simple and effective procedure used primarily in treatment of arthritis, this case highlights the importance of appreciating surgical anatomy and post-operative clinical features and investigations.