Rodrick Birnie, MD, discusses Common Subacute and Chronic Hand Conditions.
[MUSIC PLAYING] DR. BIRNIE: So have you ever wondered why there are so many tunnels in the hand and wrist? They're not elastic tunnels. So they can't just distend. They are actually fibro-osseous tunnels. So if you get any swelling in these tunnels, it presses on what's in the tunnel. So they're a source of a lot of pathology. And there's also one in the elbow as well, a tunnel. And why they're there? They're very important for the function of the hand and upper extremity. OK? So take for example, the carpal tunnel. It's got all the flexor tendons in it, to the fingers, plus the nerve. So that's very important to keep those tendons up against the bones, so it actually gives you strength of your grip. What about all the tunnels on the dorsal side of the wrist? Six of them, all with extensor tendons in them. And they keep those tendons right up against the bone. So, biomechanically very strong for your extension. No bow stringing occurs there. And one of them is the source of the most common tendinitis in the wrists. And that is de Quervain's. So swelling in one of the tunnels in the back of the wrist will give you pain of tendinitis. OK? In the carpal tunnel, the nerve is the most sensitive thing. So any swelling in there will give you carpal tunnel, give you media nerve symptoms, right? So what other tunnels have we got? What about the guys who do rock climbing? You don't have any bow stringing of your flexor tendons and your fingers, right? They're kept tightly against the bone to give you that biomechanical strength of grip. And what happens if you get a swelling in the tendon running in the tunnel there? Triggering. We'll go through that in a moment. That's the source of trigger fingers. OK? Other tunnels at the elbow, we mentioned. What about the cubital tunnel, that has just a nerve in it, right? On the medial aspect of your elbow. And that is there to keep your nerve from coming around the side of your elbow and being traumatized. So it just contains the nerve, so any swelling within that tunnel, you get ulnar nerve symptoms into your small finger. So these tunnels are a source of great pathology. So that is also the reason why a drop of steroid into these tunnels, if they've swollen, can give you such remarkable results and actually cure these conditions. So we'll run through these. Of course, other conditions as well are involved in these subacute and chronic hand conditions. All right. That's a statement. OK. So here is the point about these inflammation within these tunnels. You can get trigger fingers, de Quervain's. OK. So what is trigger finger? It's where the tendon get swollen. And the tunnel actually just starts in the mid-palmar area. So when you flex your fingers, if there's a swelling of the tendon, it can stick down. And then you have to pop it open. It can be very uncomfortable, very painful, interfere with your daily function. So it's quite a problem, although not a serious problem. But interferes with activities of daily life. OK That depicts how you can examine that finger when it sticks down like that. All right. So what can we do for that? Well, you can take anti-inflammatories. You can do some splints? But what is the most effective treatment? Get that swelling down. OK. So that's why a drop of steroid in the tunnel can be very effective, can cure it, in 80%, one injection. Of course, you've got to get the injection into the tunnel. And we do mix it with a little bit of a local anesthetic, because just injecting steroid is very uncomfortable, very painful. Injecting steroid right sort of almost within the tendon, not good for the tendon. So we wouldn't do more than two injections. Two injections. And then we'd resort to surgery. And the surgery is just opening that tunnel a little bit. So that cures the triggering. What about de Quervain's? This is the commonest tendonitis of the wrist. As we mentioned, there's extensor compartments in the back of the wrist. And the commonest one to be involved with a bit of swelling is the one running on the side of the wrist. And that's the first dorsal compartment, that contains the tendons to the thumb. So patients will have a lot of pain with movements of the wrist and the thumb. So we see it pretty commonly in young women who've just had babies. And it seems to be something to do with the movements of picking up the baby, perhaps, and the repetitive type of movement. Swelling and the pain with that movement. And one way of confirming that with examination is to put the thumb in the palm, as depicted here in this picture. Thumb in the palm, and ulnarly deviate the wrist. And then you pull the patient off the ceiling because it's extraordinary painful. And pretty easy diagnosis. All right? What's the treatment? Well first of all, let's just make sure that it is de Quervain's. It's usually pretty obvious. But you've got to make sure it's not arthritis at the base of the joint that occurs in all of the patient. Best treatment, splints? No. Anti-inflammatories? No. Injection. The only problem is it's difficult to get the steroid into this tunnel. Right? You just have to get it into the tunnel, otherwise not effective. Similar to trigger finger, one injection can cure it in 80% of patients. We would do a maximum of two. And if that doesn't result in complete cure-- surgery. And what we do? We open that tunnel. Allows the tendons to be released from their pressure. OK. Let's change course a little bit and discuss masses in the hand. Ganglions. What's a ganglion? It's nothing to do with nerves. It's a cyst. It's a cyst that arises from a synovial line structure. That's why you can get ganglions coming out of joints, ganglions associated with tendon sheathes that have got a synovial lining to them. Not only in the hand do we see ganglions. You can see them in the foot. And so we'll just run through the common areas where you get ganglions. This is the commonest mass that we see in the hand. So this is the commonest one-- the dorsal wrist ganglion. It can be uncomfortable. But mainly the patients are concerned about it because it's a lump. It tends to get bigger. OK. So once the patient hears well, these things can actually disappear by themselves. You can watch them. Or you can beat them with a big book. We wouldn't do that in the clinic, usually. The patient gets a little bit shocked when you take the biggest book, PDR-- [LAUGHTER] But we would offer them an aspiration in this situation. Got to do it with a pretty thick needle, because that synovial little fluid inside there is very thick. And we'd aspirate it. Cyst collapses. And put a little bit of pressure, like a coban, on it. Keep it on for 24 hours. And so what's the chance of it not coming back? About 50-50. So most people will take an aspiration. It's not difficult. And then if it comes back again, we'd resort to surgery to get rid of it. The surgery isn't a matter of just removing the cyst. It comes out of the joint. So we have to follow the little tail down into the joint. Otherwise, it's going to recur, pretty commonly. So we have to follow that tail into the joint and make sure we remove that pedicle as well. What about the one that appears right under the radial artery, at the wrist? That can be more uncomfortable than the one dorsally. Because it causes pressure on surrounding structures. And because it comes underneath the radial artery, we wouldn't stick a big needle in that area. Because if you puncture the radial artery with an 18-gauge needle, it's not going to stop just with a bit of pressure. So we don't stick needles in that area. So either we're going to just watch it. Sometimes they disappear by themselves. Or we're going to recommend surgery. Ganglions have been never been described as turning malignant. So there's no possibility of that. Patients, when they hear that, often sort of pretty relieved and quite happy to see what happens to them. Surgery, same thing. These [INAUDIBLE] ones are much more difficult. Because we've got nerves and radial artery. And you've got to go behind it. And sometimes the ganglion cyst envelops this whole artery, actually goes around it. So much more difficult. And we've going to follow that same pedicle down into the joint and make sure we get that out as well. There's a flexor tendon sheath ganglion. Remember I said ganglions arise from synovial-lined structures? So this isn't from a joint. It's actually from the tendon sheath. Presents as a painful little lump. Sometimes can feel so hard it's like a bone. And painful with gripping. Patients often complain when they're using the steering wheel of a car. They get a lot of pain. Because of that little lump there. So if it's directly in the middle of the finger, we would consider stabbing it with an 18-gauge needle, rupturing it, in other words. But if it's at all eccentric, same thing. You don't want to mess with the nerve or digital vessel with an 18-gauge needle. It'll cut it. So we can aspirate, or rupture them. And if they don't disappear by themselves-- and why do they disappear by themselves? A patient actually accidentally will rupture it by firm gripping. So they can disappear by themselves. Patients can watch them for a while. If it causes a problem, we would remove that surgically. A mucus cyst. This is a type of ganglion as well. But it arises from the DIP joint, dorsally. OK? So it's usually associated with a bit of arthritis, usually associated with a little osteophyte. And because the germinal matrix of the nail extends so proximal, it can actually have pressure on that germinal matrix. So you can have nail deformities with this. OK? And you can get a very thinned-out sort of superficial skin over these. So, it can be very difficult to remove them, without having a big problem with skin necrosis. So when they're pretty small, we'd often just watch them. Sometimes a bit of coban just to keep some pressure on them, can actually decrease the size of them. And to remove them, we would actually do it with sometimes a bit of trepidation, because of that thin skin. And we'd have to take out the little osteophyte, as well, that's causing some irritation there. So it's not just the cyst. All right. What about the common nerve compression syndromes in the upper extremity? Well the commonest ones, as you know-- carpal tunnel, and cubital tunnel, OK? And carpal tunnel involving the median nerve. Cubital tunnel involving the ulnar nerve. So usually the carpal tunnel symptoms involve paresthesias is in the whole hand. OK. So the nerve is complaining. There's pressure on the nerve. So there is a response of paresthesia. And when does this occur particularly in carpal tunnel syndrome? At night? So if you the patient says, I've got-- there's something wrong with my circulation. I wake up every. I've got to shake up my hand. And circulation problems in the hand are extremely rare. So this is typical of median nerve symptoms. And patients will often not be sure if it involves the little finger or not. They often say, it's my whole hand. What about your little finger? Oh, yeah, I think so. Whereas with cubital tunnel, ulnar nerve, then it's usually more definite. They say, my little finger goes numb at night. So it's usually pretty clear. Just remember, not everything that causes paresthesias in the hand is carpal tunnel. We get patients referred to the clinic with, for example, paresthesias in the thumb. And they referred to as carpal tunnel. So what about the rest of your fingers? No, it's just my thumb. So what's that? How does median nerve being compressed in the tunnel affect just the thumb? Probably not carpal tunnel, right? So the point here is, you got to often look elsewhere and make sure that the compression isn't somewhere else. C6 radiculopathy. That's thumb. If the patient says, I've got paresthesias in my fingers. And what about your thumb? No, nothing in my thumb. Doesn't really make sense. Think C7 radiculopathy. OK? So the point here is, remember the nerve starts in the neck, goes all the way down the arm. So you should be checking it all the way, to make sure that it is what we think it is. OK? All right. So initially, the symptoms are intermittent, right? Patient comes in, says, I'm getting woken up virtually every night. My hand is numb and tingly. I shake it out. Then it's OK. And what about during the day? Oh well, when I drive it tends to go funny. When I read a magazine or book, I get some tingling and numbness. And now? I'm fine now. So initially, it's intermittent. But as time goes on, it can become more persistent. And the patient has symptoms all day and eventual numbness. And once the fingers go numb, the muscles start to get weaker and atrophy. SO that's more advanced. OK. So there we are. Progresses to complete numbness and loss of opposition. So remember, the median nerve innervates the thenar muscles. So in longstanding carpal tunnel, you're going to get wasting and weakness of your opposition. A wasting of those thenar muscles. You can see this pretty obvious. You can see the wasting. And look at that opposition. What is true opposition? It's pulp to pulp. So pulp of the thumb pulp of the index or long finger. And as you can see here, that patient is struggling to do that. He's coming from the side. So he's lost most of his ability to oppose the thumb. So when a patient initially presents nocturnal paresthesias, postural paresthesias. A patient says, no, I'm fine now. Nothing now. So what are we trying to do? We're trying to recreate the symptoms that they get. So there are a number of tests which we do to recreate those symptoms. That's what we're doing in the clinic. And what are these tests? Well, it is wrist flexion test and median nerve compression test. These have got eponyms. So we talk about Phalen's test, which is the wrist flexion test. We talk about Durkan's test, which is the median nerve compression test. So Tinel's sign remember, is not just for carpal tunnel. Tinel's sign just means you are getting a response from an irritated nerve. So you can tap over the course of the median nerve. And if you get tingling into the fingers, positive Tinel's sign. You can take tap over the ulnar nerve at the cubital tunnel. If you get paresthesias into the small finger-- positive Tinel's sign. So if you get Tinel's sign, doesn't mean one type of compression. OK? So how long should we put this pressure and flexion on it? Well, it's supposed to be a minute each. So that's tough sitting across from a patient doing these tests individually. And you've got to stare int each other's eyes for two minutes. So, do them together. Flexion test, and median nerve compression test. And you've only got one minute of staring into each other's eyes. And what are we waiting for? Patients say, yeah my fingers are going tingling and numb. Positive test. What happens when this has been present for a long period of time? Well, you're not going to get those tests. Because the patient's fingers are already numb and tingly. So you're not going to promote the nerve to react. So don't expect them always to be positive. It just depends on how long the patient's had it. We get patients that are 70s and 80s. How long you had them? Oh, probably a year. You've got wasting of the thenar muscles, numbness in the fingers. Well, you think those Phalen's and median nerve compression tests are going to be positive? No. I mean it's already done. So as you can see that carpal tunnel steroid injection-- really good for diagnosis mainly. But obviously put it in the tunnel, not in the nerve. Because that damages the nerve. So it's pretty skillful to be able to do it properly. And that, unfortunately, isn't curative for the vast majority of carpal tunnel. There's only like 20% if patients who are still asymptomatic a year after a carpal tunnel injection. So it's got to be pretty early, right? But it can be a great diagnostic test. Patient comes back after [INAUDIBLE]. Oh my hand was fine for weeks. But now it's coming back. Well you know, that is definitely carpal tunnel syndrome. So it's a great diagnostic test. Remember we mentioned these tunnels are fibro-osseus? In other words, anything inside the tunnel is going to press on the nerve. So the prime source of carpal tunnel is actually fluid retention. We see it in pregnancy, and also in menopause. There's imbalance. And we see patients in their 50s starting with carpal tunnel. So how many-- repetitive firm gripping is another one. Meat cutters and that. And then I've been asked this question at depositions-- how many words per minute on the computer will give you carpal tunnel? Well there isn't any answer to that, is it? I mean, there are patients that can type very fast and all day, and never get any problem. So everybody says, oh, but I don't type, when you say you've got carpal tunnel. But that isn't the cause of carpal tunnel. Vast majority of patients around menopause, right? OK. We get fluid retention. At night it gets worse because of the position of the wrists. OK. You don't sleep with your wrist dead straight. So you might sleep with extension or flexion. So you get a bit of increased pressure. There's fluid shifts at night. A little bit of extra swelling within the tunnel, and you get symptoms. Which you've got to shake your hands out. OK? There's a point about the other things. Commonest is cervical radiculopathy. Always check the neck. There is a condition called double crush. I don't know whether you've heard of it. It's quite interesting in that patients can have a little bit of carpal tunnel, a little bit of cervical radiculopathy. But having both can result in a lot of symptoms, marked symptoms. So that's an interesting thought, that there's double crush. So you treat the simplest one, which is usually the carpal tunnel. Cervical radiculopathy, kind of difficult to treat. But if you treat just the one, then symptoms can disappear. So that's double crush. OK. So we've spoken about the injection for carpal tunnel. What's the other mainstay of treatment? Night splints. We just said that you want to try and prevent the patient from sleeping with their wrists flexed or extended. Keep them dead straight. And that can help. That can help a lot. Anti-inflammatories-- Well, when you're talking fluid retention, it's not an inflammation, right? So there's nothing-- there's vitamin B6 or anything that you can give them. Any fancy medications. It's a matter of a tunnel with increased fluid. And trying to get that fluid down is the important thing. If these treatments don't help, then carpal tunnel release. And what do we do in carpal tunnel release? Just want to make the tunnel bigger. Want to make the tunnel bigger so that any fluid in there isn't going to press on the nerve. How do we do that? We can do it open, with an incision. We can do that under local anaesthetic. We can do it with an endoscope, where you can put just through a little incision, can put it in, and cut the ligament. So all that we're doing is opening the tunnel. Sometimes the patients don't understand that. That we don't do anything to the nerve. Just make the tunnel bigger. Take the pressure off. So what do you think's going to happen to a 75-year-old that has had carpal tunnel for years, has numbness, lot of aching and discomfort, and what do you think is going to happen? Do you think that's going to bounce back to normal? Patient comes out of the operating room. Whoa! Thanks. That's better. No. They have to understand that the aching, discomfort, and that, and waking up at night is probably going to be completely resolved. But the numbness, can forget it. Old nerve isn't just going to get back to normal. Might be some improvement. At least it won't get worse. So you can have this bad reputation for carpal tunnel. Oh, I had that surgery. Didn't do anything. And then some patients will say, well it cured me. It's this, how long have you had it? How bad is the nerve? How old are you? Is the nerve going to be able to recover? And that's not always the case. But often even older patients will world do well as far as that discomfort, waking up at night, and achiness concerned. This is really a pretty specialized injection. It requires a lot of practice first, before you do it on the person. And this is an example of the carpal tunnel release, which is, as we said, we're just opening the tunnel. OK? Cubital tunnel. Remember, that is the ulnar nerve. Ulnar nerve to the small finger. Now this is usually more obvious. When the patient says, I've got tingling and numbness in my little finger-- well. Is it always cubital tunnel? No. What about the neck? Yes. C7, C8. Radiculopathies. So it's not always cubital tunnel, OK? And then what muscles does the ulnar nerve supply in the hand? Everything, except LOAF. Remember this from your anatomy days? All the muscles are supplied by the ulnar nerve except LOAF. And LOAF are the lumbricals to the index and long, and the thenar muscles. O A and F, OK. So you can have a lot of weakness with cubital tunnel syndrome that's been going for quite some time. Patients get disturbed at night. Because how do you sleep? You don't sleep with your arms straight out. You sleep curled up. And so there's pressure over here. And what about during the day? On the phone-- a lot of pressure. And my little finger goes numb when I'm on the phone. I've got to change hands. And then in time, you can have more persistent numbness. And it can eventually lead to weakness in your hands. Patients in the early stages done have symptoms when they see you in the office. What are tests? Same as carpal tunnel, right? We want to stir that nerve up. How do we do it? Elbow flexion and ulnar nerve compression. Luckily no eponyms for this. Do it at the same time. Just one minute for both. And patient says, yeah, my little finger's going numb. OK. You've got cubital tunnel. Tinel's sign. Tap over nerve. Patient jumps. Aha. Irritated nerve there. OK. Similar sort of things. Remember, it's a tunnel. So anything that causes a swelling in that tunnel, like inflammation, trauma, can have funny extra muscles and things that can press on the nerve. And a differential diagnosis, important one-- cervical radiculopathy. Got to check on that. How do we treat that? Well, you can tell a patient, look. You're making it worse by sleeping with your arms like this. So often they will-- oh, all right. Once they know, put a pillow there or something. Night splint you can use. Pretty uncomfortable, especially if it's bilateral. Patient sleeps with splints like that. So modification of jobs. Don't use the phone. That sort of thing. So it can settle down in the earlier stages. Some role for injections, but remember, it's just a nerve in the tunnel. You want to put it in the tunnel, not in the nerve. So that's even more difficult than the carpal tunnel injection. OK. And then surgery, what do we do? We actually take it out of the tunnel. But then, why is it in the tunnel? It's to stop it from bouncing around. So we want to then move it to the front of the elbow. So a bit of a more involved surgery than for carpal tunnel.