Mary J. Bradley

Management and referral for trigger finger/thumb

Trigger finger is a common cause of pain and disability in the hand. It is also the fourth most common reason for referral to the hand outpatient clinic and accounts for 1 in 18 of all referrals to our unit. The condition is, however, not solely managed by hand surgeons as it is often treated in the community and by specialist practitioners such as rheumatologists and endocrinologists who encounter it as a secondary manifestation of a primary systemic disorder. From a review of the literature we highlight the presentation of trigger finger, describe the processes involved in developing the condition, and rationalise the treatment options available. We have suggested guidelines and key points of note to aid practitioners in the management and referral of trigger finger and thumb in adults. We searched Medline and PubMed for relevant English language literature. We used the search terms “trigger finger” and “stenosing tenosynovitis.” We identified additional literature from the references of these papers. Trigger finger presents with discomfort in the palm during movement of the involved digits. Gradually, or in some cases acutely, the flexor tendon causes a painful click as the patient flexes and extends the digit. The patient may present with a digit locked in a particular position, usually in flexion, which may need gentle passive manipulation into full extension. Spontaneous resolution of symptoms can occur in patients with trigger thumb.w1 The condition has a reported incidence of 28 cases per 100 000 population per year, or a lifetime risk of 2.6% in the general population.1 This rises to 10% in patients with diabetes. Two peaks in incidence occur—the first under the age of eight and the second (more common) in the fifth and sixth decades of life. This bimodal distribution represents two different clinical groups, not only for …

Primary care management of carpal tunnel syndrome

Carpal tunnel syndrome of mild to moderate severity can often be effectively treated in a primary care environment. Workplace task modification and wrist splints can reduce or defer referral to hospital for surgical decompression. Nerve and tendon gliding exercises may also be of benefit. Steroid injections to the mouth of the carpal tunnel are particularly useful for symptomatic women in the third trimester of pregnancy. However inadvertent neural injection may cause disabling chronic pain. Referral to a minority of practitioners trained in the technique would ensure sufficient patient numbers to maintain skill levels.

Trends in elective hand surgery referrals from primary care.

INTRODUCTION Two prospective audits of activity in a hand unit were performed, in 1989-1990 and during 2000-2001, to identify trends in elective hand surgery referrals from primary care. PATIENTS AND METHODS Two 6-month prospective audits of activity in a hand unit were performed, including elective referrals from primary care. Data were collected on all in-district referrals with elective hand disorders. Cross boundary flow was identified to permit assessment of changes in referrals by diagnosis over a decade. RESULTS There was a 36% increase in health authority referrals for elective hand surgery over the decade (from 289 to 392 per 100,000 of population per year). The number of elective hand surgery operations rose 34% over the decade (from 149 to 199 operations per 100,000 of population per year). Carpal tunnel syndrome (the commonest reason for elective referral) almost doubled (from 59.7 to 112 per 100,000 of population per year). Referrals for ganglion, the second most common elective referral, rose modestly. Referrals for osteoarthritis (commonly basal thumb arthritis) almost trebled over the decade to become the fourth commonest condition referred to the hand unit (from 12.7 to 34 per 100,000 of population per year). Referrals for Dupuytrens disease, trigger finger and rheumatoid arthritis were relatively unchanged over the decade. Congenital hand referrals are uncommon but doubled during the decade. CONCLUSIONS Hand surgery referrals rose by 36% over the decade. Analysis of the commoner conditions referred reveal a high prevalence within the community with the possibility of increased referrals in years to come.

Providing Care for Hand Disorders: Trauma and Elective The Derby Hand Unit Experience (1989–1990)

Data was collected prospectively on all patients from one health district attending the Hand Unit at Derbyshire Royal Infirmary to determine the needs for hand surgery and the resources utilised to meet them. 475 patients per 100 000 population presented with hand injuries and 289 patients per 100,000 with elective hand disorders each year. For every 100,000 population, the trauma cases required 139 inpatient days and 1723 outpatient visits. Elective cases required 221 inpatient days and 1039 outpatient visits.

Long-term Outcome after Carpal Tunnel Decompression – A Prospective Randomised Study of the Indiana Tome and a Standard Limited Palmar Incision

This randomised trial compared the results of carpal tunnel decompression using the TM Indiana Tome (Biomet, Warsaw, Indiana, USA) and a standard limited palmar open incision. Two hundred patients were randomly selected to have a carpal tunnel decompression with either the Indiana Tome or a limited palmar technique. They were assessed clinically for 3 months and using the Levine–Katz self-assessment evaluation for 7 years. After 7 years, there were 62 returned questionnaires from the open group and 53 from the Tome group. There were no significant differences in functional scores, pain, scar tenderness, pinch and grip strength at 3 months. There were two complications in the open group and nine in the Tome group, including one median nerve injury. There was both a higher rate of immediate complications, and more recurrences and persisting symptoms at 7 years in the Indiana Tome group.

Primary care referral protocol for carpal tunnel syndrome.

Carpal tunnel syndrome is an extremely common upper limb nerve compression syndrome, widely distributed in the community. There are a variety of treatment options which may be applied to the syndrome, depending on the severity of symptoms. Some options are available in a primary care setting, others require secondary referral. This paper is a detailed review of the available literature and provides a protocol that could be used to assist in the referral of patients from primary care.

Primary care management of patients with carpal tunnel syndrome referred to surgeons: are non-operative interventions effectively utilised?

Aim: To investigate the non-operative primary care management (splintage, task modification advice, steroid injections and oral medications) of carpal tunnel syndrome before patients were referred to a hand surgeon for decompression. Design and setting: Preoperative data were obtained on age, gender, body mass index, employment, symptom duration, and preoperative clinical stage for patients undergoing carpal tunnel decompression (263 in the USA, 227 in the UK). Results: Primary care physicians made relatively poor use of beneficial treatment options with the exception of splintage in the US (73% of cases compared with 22.8% in the UK). Steroid injections were used in only 22.6% (US) and 9.8% (UK) of cases. Task modification advice was almost never given. Oral medication was employed in 18.8% of US cases and 8.9% of UK cases. Conclusions: This study analyses the non-operative modalities available and suggests that there is scope for more effective use of non-operative treatment before referral for carpal tunnel decompression.

A 6-year outcome of patients who cancelled carpal tunnel surgery

The long-term outcomes of patients with carpal tunnel syndrome who were scheduled for release but did not proceed to surgery were compared to patients who underwent surgery, matched on preoperative symptom scores. Both groups completed the Levine–Katz questionnaire 6 years after enrolment to our multicentre carpal tunnel syndrome outcomes database. Symptom and function scores improved for the surgical (n = 24) and non-surgical (n = 36) groups (p < 0.001). Improvement in symptom scores was greater in surgical patients compared to non-surgical patients (n = 24 matched pairs; p = 0.007) but improvement in function scores between groups was not significantly different (p = 0.13). For surgical patients, function and symptom scores improved by 6 months and were unchanged at 6 years. Patients planning surgical release can expect symptomatic and functional benefits within 6 months. Overall improvement was experienced by both groups, with a superior outcome achieved with surgery. The symptoms of carpal tunnel syndrome may improve without surgery, but further studies are needed to understand the natural history of the disorder.

Levine-Katz (Boston) Questionnaire analysis: means, medians or grouped totals?

were prescribed oral antibiotics on discharge. Those patients who were admitted (n1⁄4 12) were admitted to the plastic surgery or orthopaedic surgery units, with a majority being received in plastic surgery (50 from 51 patients). This is mainly attributable to the proportion of days on call for hand trauma (6:1). Of those patients who were admitted, two were transferred to the children’s hospital due to their age. Surgical exploration was performed exclusively in the emergency theatres, under general anaesthesia and tourniquet. Specialist registrars performed 100% of cases. Structural damage was revealed in 83% of cases. The injuries were flexor tendon laceration (n1⁄4 6), digital nerve damage (n1⁄4 4) or both tendon and nerve damage (n1⁄4 2). The majority of admissions were for injuries to zones II and III (5 and 6 admissions respectively). One patient presented with a laceration to the skin overlying the mandible. Oral antibiotics were prescribed on discharge to 10 patients; all were admitted patients who underwent surgery during their admission, with amoxicillin clavulanic acid (Augmentin Duo ) the antimicrobial of choice (n1⁄4 9). Fourteen patients were reviewed at least once postoperatively. Mean follow up was 8.4 weeks (range 1 to 36 weeks). Five of these patients dropped out of follow up and the remaining nine were discharged by the reviewing doctor. Six individuals, all with flexor tendon injury, were referred for physiotherapy. Longterm subjective complaints were seen in two individuals. One patient complained of stiffness and one patient complained of numbness associated with severed superficial digital nerve branch. Two flexor tendon repairs were lost to follow up. Longer follow up will be required for any meaningful conclusion to be drawn. To our knowledge, this is the first large study to clinically document the epidemiology and pathology of hand injuries caused by corrugated iron fences. The results indicate that the majority of the injuries are of a superficial nature, not particularly different from those caused by knives, glass and saws. Such injuries require similar treatment, consisting in repair of damaged structures. The majority of cases can be managed on an outpatient basis.

A prospective, longitudinal outcome study of patients with carpal tunnel surgery and the relationship of body mass index.

This study investigated whether body mass index (BMI) was associated with effectiveness of carpal tunnel release as measured by physical and self-assessment tests. This prospective, longitudinal study was conducted from March 2001 to March 2003 using 598 cases (hands) diagnosed with carpal tunnel syndrome and scheduled for surgery at The Curtis National Hand Center, Baltimore, Maryland, and at the Pulvertaft Hand Centre, Derby, England. Body mass index was calculated, and demographic, clinical, and functional data were collected preoperatively and at 6-month follow-up. Grip, pinch, and Semmes–Weinstein scores were measured preoperatively and at 6-month follow-up. Levine–Katz self-assessment scores for symptom severity and functional status were measured preoperatively and at 6-month follow-up. Grip and pinch increased, whereas Semmes–Weinstein, symptom severity, and functional scores decreased by 6-month follow-up. Cases with BMI >35 had lower grip strength and higher symptom severity in males and higher functional status in both sexes pre- and postoperatively compared to normal-weight BMI cases. BMI had no relationship to patient satisfaction. Although morbidly obese cases did worse on some physical and self-assessment tests compared to normal BMI cases preoperatively, all improved to the same extent postoperatively regardless of BMI.