1. Common Conditions of the Hand
(2013)
Rex Moulton-Barrett, MD
Plastic and Reconstructive Surgery
Alameda and Brentwood California

2. Relevant Anatomy
• Bones: 27
• Extensor Tendons:11 extrinsic
• Flexor Tendons: 13 extrinsic
• Intrinsic Muscles/Tendons: 16
• Ligaments:MCP/IP- Primary & Accessory
Transverse Palmer
• Accessory Apparatus: Capsules
Volar Plate
Retinaculae: Flex, Ext

13. Relevant Physiology
• Median Neuropathy
• Ulnar Neuropathy
• Radial Neuropathy
• Peripheral Neuropathy
• Radiculopathy
• Reflex Sympathetic Dystrophy Syndrome
• Injury Splinting in Intrinsic Plus Position
• Splinting CTS in wrist neutral/extension
• Splinting Cubital Tunnel < 45 degree flexion

14. Median Neuropathy
• Motor: thumb opposition and abduction
radial 2 lumbricals
• Sensory: radial 3 1/2 fingers

15. Splinting CTS in wrist neutral/extension

16. • Motor: All intrinsics except thumb
opposition & abduction
radial 2 lumbricals
• Sensory: Ulnar 1 1/2 sensory
Ulnar Neuropathy

17. Splinting Cubital Tunnel < 45 degree
flexion

18. Radial Neuropathy
Supplies wrist extensors, needed for flexor tendon lengthening for grip strength and
because of median and ulnar nerve overlap small sensory area dorsal 1st web

19. Peripheral Neuropathy
• Typical stocking / glove distribution
• Causes: Diabetes Mellitus,
EtOH /B12/ folate deficiency
Drugs: chemotherapy > nifedipine

20. Radiculopathy
• Dermatome specific
• Congenital: Brachial Plexopathy
• Acquired: Usually Mechanical:
disc or osteophyte
direct injury or tear/stretch
cervical rib

21. Injury Splinting in Intrinsic Plus
Position

22. Reflex Sympathetic Dystrophy Syndrome: RSD
Complex Regional Pain Syndrome: CRPS
• Usually triggered by trauma: more extensive: more likely
• Use of axillary block in hand surgery somewhat protective
• Stages:
1. Burning pain, can be continuous and intense
hyperhidrosis, cool, Raynaud’s phenomenom, reddish color
2. Pain more proximal
hair thinning, shiney nail pitting, osteoporosis,
joint capsular thickening
3. Pain affects entire limb, muscle wasting, tendon contractures
joint deterioration/subluxation and osteoporsis worsens

23. Clinical History
• Right or left hand dominant
• Take relevant history: mechanism
• If chronic: frequency/repetition of trauma
work type
work position / posture / torque
ergonomics
home support
secondary gain

24. Clinical Exam
• Note: overall body habitus: obesity, macromastia
• Note: posture and shoulder position
• Note forearm and upper arm features
• Note external features: volar=palmar and dorsal
• Note: comparative grip strength

26. Volar External Features

27. Dorsal External Features

28. Cascade/Attitude
• Normal
• Abnormal

29. Index Finger Opposition: Median Nerve

30. Little Finger Opposition: Median>Ulnar

31. Dorsal Interossei (DAB): Ulnar

32. Intrinsic Plus: Ulnar >> Median
Palmer Interossei ( PAD) and Lumbricals

33. Gross Grasp: Median>Radial>Ulnar

34. Dynomamometer
>15% difference ?

35. Finkelstein Test: de Quervain’s Tenosynovitis

36. Thumb Trigger Nodule

37. Index Trigger Nodule

38. Extensor Tenosynovitis/Tennis Elbow/Lateral
Epiconylitis
Radial Tunnel/Posterior Interosseous Nerve Entrapment

39. Tinel at elbow

40. Tinel at Wrist

41. Allen Test: Dominant Ulnar > Radial Artery
8.1%
May be higher in populations with h/o ABG’s
1. Elevate hand 30 seconds
2. Make fist elevated
3. Apply pressure over Radial and Ulnar Arteries
4. Open hand while elevated, it should be blanched
5. Release one vessel pressure, should refill in 7 seconds

42. Moving 2 Point Discrimination

43. Phalen’s Test: 1 minute

44. Common Conditions of the Hand
1995: National Center Health Statistics
• Open wound finger>hand>forearm
• Contusion of the upper extremity
• Sprain to the wrist
• Fractures: radius/ulna>humerus>phalanges>carpal>metacarpels
• Burns to the hands, fingers and thumb
• Carpel Tunnel Syndrome
• Osteoarthritis upper extremity
• Rheumatoid arthritis
• Other compressive neuropathies: Cubital Tunnel
• No mention of masses / tumors / tendon injuries / infections

45. Masses of the Hand
90% benign
( Skin Cancers, then: )
• Ganglions 50%
• Enchondromas 10%
• Granular Cells Tumors 10%
• Epidermal inclusion cysts
• Lipomas: remove if symptomatic
• Glomus Tumors
• Raromas

46. Ganglions
Dorsal wrist >volar/radial > DIP/osteoarthritic > flexor sheath
Scapholunate OsteophyteRadioscaphoid/Carpel
ScaphoTrapezial
65% 20% 10% 5%

47. Enchondromas
Solitary 85% > multiple 15%
Usually arising from the shaft of the phalanx

48. Granular Cell Tumors
Need to excise a margin of tendon sheath to reduce recurrence
Encapsulated and yellow brown in color

49. Glomus Tumors
Severe pain, temperature related, 1/4 subungal
Xray shows a scalloping defect secondary to cortical pressure

50. Melanoma
Intermittent intense sun exposure < 50
Continuous sun exposure > 50, especially dorsum hand
Most frequently seen in 70-80 age group female > male

51. Subungal Melanoma
20-25% amelanotic
Often history of trauma
Mean age 60’s
Hutchinson’s sign-> spread of pigment to surrounding tissue
DD:
hematoma, chronic paronychia,
melanonychia, junctional nevus
Hutchinson’s sign

52. Inflammatory Flexor tenosynovitis
Electricians
Hammer and jack hammer
Home construction

53. Mallet Deformity
Type 1: closed blunt trauma, no fracture, treat with splint 6 weeks
Type 4B:20-50% articular fracture
Type 4C: > 50% fracture+volar subluxation
Stack splint

54. De Quervain’s Disease
• Injection for de Quervain's tenosynovitis: 1ml Kenalog 40, 25 G needle
• The needle is placed into the first extensor compartment and
• directed proximally toward the radial styloid
•

55. Trigger Finger
• Trigger finger injection: 0.5-1ml 25 g needle, Kenalog 40
• The needle is inserted distal to distal palmer crease
• Aim posterior towards the nodule in the direction of the metacarpal head
• Use your non-dominant hand to move PIP/DIP and free for tendon ‘scratch’
• You are trying to fill the sheath and the A1 pulley with steroid
•

56. Lateral Epicondylitis
• Steroid injection Kenalog 40
• 25 g needle onto bone
• 1 by 2cm area: stay on bone
• Radial nerve is medial
• Tennis elbow Splint
• After 3 injections consider
• Debridement of ECRL/B

57. Carpel Tunnel Syndrome:1.5% population
3 x more common in women
• Causes: WR: 47%> Dialysis, DM, Pregnancy, RA, Amyloid
• Work-up: EMG- conduction velocity> 4.5ms motor,
> 3.5ms sensory
• Management: NSA’s, splinting, ergonomics
• Steroid injections controversial in USA
• Surgery ( 85% successful ) : if medical management fails &
+ EMG
• Surgical techniques: formal long Orthopedic incision
endoscpic Chow, Agee techniques
minimal scar non-endoscopic
• Short scar associated with early rehabilitation / return to work
• Neurolysis indicated for recurrent CTS and dialysis patients

58. Cubital Tunnel Syndrome
• Usually caused by noctural hyperflexion at elbow
• 85% respond to noctural splinting
• No role for steroid injections
• Surgery for failed splinting:
• Short scar transposition & subfascial tunnel
submuscular tunnel
submuscular tunnel with
medial epicondylectomy
Entrapment or subluxation

59. Dupuytren’s Disease
Operate if > 30 degrees MCP flexion
any PIP flexion

60. CMC Arthritis
•
• Injection for first carpometacarpal joint.
• The needle should enter on the ulnar side of the extensor pollicis brevis tendon
• Gentle pull on the thumb opens the CMC joint space
• The 25-gauge needle should fall into the joint: 0.5ml Kenalog 40
•

61. PIP Osteoarthritis
Pyrocarbon: graphite/ceramic
Pyrocarbon graphite/ceramic
Silicone: < 30 degrees flexion
Silicone: < 15 degrees flexion

62. Rheumatoid Arthritis
• 3 stages: Proliferative: swollen, stiff, assoc CTS
Destructive: erosion joint capsules, bone
Reparative: fibrosis replaces inflammation
• Loss of finger flexion: FDS rupture
• Incomplete finger extension: ulnar wrist subluxation
• Mannerfelt Lesion: rupture FPL from scaphoid osteophyte
• MCP joint subluxation best treated with joint replacement
• Swan neck deformity associated with intrinsic shortening
• If wrist subluxation; distal ulna may sublux dorsally
• Darrach Procedure: resect distal Ulna & rebalance tendons
avoids tendon rupture from Ulna wear

63. Burns
• Scar excision and early skin grafting can
reduce contracture formation

64. Congenital
• Amniotic bands
• Syndactyly
• Thumb duplication
• Trigger/Campytdactyly/Clindodactyly

65. Hand Prostheses

66. Raroma
• Tumor example of Schwannoma