Ms Rupi Grewal advises on the place of conservative management and the role of surgery
of conservative management and
the role of surgery
The three main reasons for patients presenting with hand problems are: pain, abnormal appearance and loss of normal function. Each of these can arise from a host of conditions, both traumatic and non-traumatic.
There is a great overlap in the non-traumatic conditions seen by the rheumatologist and hand surgeon. In general, when deciding whether to refer a patient remember any polyarthropathy or connective tissue disorder is best treated medically by the rheumatologist.
Decreased range of motion, swelling and pain are often treated by hand therapists and need early treatment. Splinting of joints and painful tendons is done by the hand therapist and is best carried out as early as possible. Splints for the hand are the equivalent of walking aids for the lower limb. Surgery is broadly indicated for pain (despite medical treatment in some conditions), loss of function (despite or not requiring splinting), deformity (increasing or interfering with function) and cosmesis.
There are a number of options for non-traumatic hand problems seen in general practice.
Overuse can produce pain and sometimes swelling around tendons. Often there is no definite history of overuse. It is not uncommon for parents of newborns to develop such conditions. The common sites of tendonitis or tenosynovitis are:
·the tendons to the thumb on the radial styloid (de Quervain's) which causes pain, especially when holding things, moving the wrist into ulnar deviation and causes localised tenderness and sometimes a thick nodule
·flexor tendons to the fingers and thumbs (triggering) the digit often gets stuck in flexion or clicks when extending; sometimes the patient presents with pain on attempting extension and inability to fully extend; it can lead to contractures if not treated; the base of the finger is usually tender and sometimes a nodule can be felt
·flexors to the wrist on the radial or ulnar side (flexor carpi radialis/ulnaris)
·flexor or extensor to the thumb
·extensors to the fingers or wrist; there is often some diffuse tender swelling along the tendons which moves with the tendon; these tendons are tender to touch and resisted motion is painful
·extensors/abductors of the thumb and wrist where they intersect, 3-4cm above the wrist, dorsoradial aspect (intersection syndrome); it is not uncommon to find painful crepitus in this region.
Treatment involves NSAIDs, splinting of wrists, modification of activities and local steroid injection. Even trigger fingers respond well to injections. If you are unsure of the diagnosis or not happy to inject, the patient is best referred to a rheumatologist (especially if there are multiple sites of involvement or a connective tissue disorder).
Patients not responding to the above treatment might need decompression and so are best referred to the hand surgeon.
Problems with the thumb extensor (extensor pollicis longus) should be referred early as it has tendency to rupture early and benefits from early synovectomy.
If tendon ruptures are suspected (traumatic, rheumatoid or inflammatory) they should be seen as soon as possible by the hand surgeon. Not all such tendons can be repaired and often need transfers or fusions if there is functional impairment (as in the distal interphalangeal joints).
This usually presents as a fixed flexion deformity of the thumb, and less commonly in the fingers. Occasionally parents may notice some triggering. It usually resolves by the age of six to 12 months otherwise it requires release. Parents can initially be taught simple stretching exercises.
The pain and swelling is best treated with medical measures as in any other joint. However, therapy for mobilisation and splinting is required earlier than other joints. This is best done by a hand therapist rather than a general physiotherapist.
Osteoarthritis responds well to injections of small amounts of steroids into the joints and splinting. It is important that the steroids do not get injected into the tendons that are very close to the joints as these could rupture. These should be performed by experienced injectors and a referral to the rheumatologist or hand surgeon is reasonable.
There are now hyaluronidase injections available for small joints, but due to the risks of soft tissue injections these often require imaging so are best done in a hospital setting. When these measures do not control the symptoms the hand surgeon can help the patient with surgery. The options vary between fusions, excision and replacement arthroplasties.
Joint replacement in hands is still in its infancy and has a much higher complication and failure rate than hip joint replacement. Also, studies are limited.
Soft tissue correction in rheumatoid hands is best done earlier rather than later. The hand surgeon works closely with the rheumatologist and the hand therapist to treat these patients.
Septic arthritis and gout can present in the hand with similar consequences as in the foot. It should be treated as septic until otherwise proven, with an urgent referral to casualty for an inflammatory screen, radiographs and intravenous antibiotics or even urgent drainage and washout. An aspirate for microbiological investigations is required.
Ligamentous injuries around the base of the thumb (metacarpophalangeal joint) are not uncommon. So-called gamekeeper's thumb (ulnar collateral ligament) is where the patient presents with difficulty and pain when using a pinch grip for writing, turning keys or grasping objects like a pint glass.
Radial collateral problems make it difficult to hold large objects and often cause a subluxation of the joint. These should be referred to the hand surgeon as soon as possible. They can be treated with splinting/repair in the early stages and require reconstruction or fusion of the joint in late presentations.
Injury to the collateral ligament/sagittal band can cause instability of the MCP joint of the fingers. It usually occurs when the finger is caught in something and forcefully pulled to one side. The patient is then unable to hold the finger in line with the others. It tends to sublux radially or ulnarwards and the patient is unable to hold objects as the finger drifts away. This requires repair/splinting/reconstruction as soon as possible. A reconstruction is done in late presentations.
Collateral ligaments of the finger joints do not usually need surgical treatment but need urgent hand therapy to maintain the range of motion which is easily lost.
Hyperextension injuries of the fingers and thumb can damage the volar plate resulting in subluxation of the joint which may require surgical reconstruction or fusion of the joint if therapy is unsuccessful. Wrist pain or painful clicking without a bony injury can also be due to rupture of intercarpal ligaments from an old injury. This may require surgery.
Any persistent bone pain should have at least a radiograph and would be reasonable to refer to the hand surgeon. Occasionally, wrist pain can be due to Kienböck's disease which is an avascular necrosis of the lunate (somewhat like Perthes) which may require further imaging, immobilisation or surgery.
Bony tumours in the hands are uncommon. Sometimes pain can be due to a pathological fracture through an enchondroma.
Nerve compression syndromes
Carpal tunnel syndrome is quite common. The patient may present with the typical story of numbness at night or vague pain, paraesthesia, dropping objects or weakness (usually due to the numbness). Splinting, local steroid injections and electromyographs precede surgery.
Long waiting times in the NHS mean that some surgeons will decompress the nerve based on the history, clinical exam, and a very good response to the steroid injections. It is not uncommon for these symptoms to be cervical in origin or have an additional proximal compression site.
Ulnar nerve symptoms are usually aggravated by keeping the elbow flexed and can be improved by wearing an elbow pad with the padding in front of the elbow, especially at night. These symptoms require an EMG to confirm the diagnosis before any decompression is undertaken as the success rate of surgery is only 75-80 per cent. Occasionally the site of the nerve compression is in the wrist.
Sometimes radial nerve compression (paraesthesia on the dorsum of the first web space) can occur and is best treated with injections at the site of compression, Tinel's sign is positive here usually proximal to the wrist (Wartenburg's syndrome). Splinting helps. Occasionally, surgical decompression is required.
Rarely, patients might present with a history of sudden onset of pain associated with muscle weakness and even wasting. This could be brachial neuralgia, confirmed with EMGs, and usually improves spontaneously.
Rupi Grewal is consultant orthopaedic surgeon, Basildon Hospital, Essex