Thumb Pain, Dr. Alfred V. Hess

All right. Thank you. So I was given the task of doing thumb pain and three topics that caused thumb pain.
And these are Dequervain’s CMC arthritis, and game keepers thumb. So Dequervain’s is tenosynovitis of the first dorsal compartment of the wrist. The wrist has six dorsal compartments. It has a dorsal retinaculum and all this the extensive tendons of the wrist and fingers are separated into those six dorsal compartments. The first dorsal compartment is the one that goes to the thumb it’s the abductor policies longest and they extend their policies forever. Dequervain’s starts with the insidious onset of pain it’s in the radial aspect of the wrist it’s exacerbated with fun movements and usually occurs in the fifth or sixth decade of life. This is not a sports injury per say. It’s six times more common in women and the other population that we see it it is postpartum women physical findings is there’s tenderness over the radio styloid. There’s swelling over the radio stylized. And there’s a positive Finkelstein’s test. And you see that those pictures showing the positive Finkelstein’s test and that has put your thumb in like a baby does put your thumb in your palm and then have the patient honorably deviate. That elicits pain right over the radio styloid. Treatment is usually splinting at first and then corticosteroids injections in our office.
So splinting really doesn’t work but it feels good it causes them not to only deviate the wrist and therefore when they’re doing their 80 ls there they’re not in pain. Corticosteroids injection works it works it works about 50 percent of the time and that’s what we do in the office for patients that are willing. We use one see it’s less down once you see a lidocaine you put it into the first dorsal compartment you can see it go up the thumb. This is the technique that I use. Other people use different techniques going proximal to distal. But or distal the proximal. But this you can feel the tendon sheath fill and they usually tolerate this injection pretty well much better than trigger finger injections. If that if the O, the complications of injections, I put this in here just to make sure that we know that, and those are injury to the dorsal sensory branch of the radial nerve which is very uncommon. And then depigmentation and fat necrosis from steroid injection which you see a picture of down there which is OK it occurs occasionally and when a young woman gets that she’s not very excited about it.
And so you have to tell your patients that this could occur. So if that all fails then you go on to surgery and surgery is probably one of the most common things that we do in hand surgery it’s one of those bread and butter little surgeries that we do probably do a few every week and this is just a little video that goes through it. It’s by the Academy you can do it under local and you make an incision over the radial styloid and you release that the first dorsal.
Compartment excuse me. And when you release the first dorsal compartment, they don’t have pain anymore because the pain is caused by the increased friction that occurs in that first dorsal compartment with the centimeters. And as those tendons excursion, you have excursion through that compartment. They get pain and when you release the compartment there is no longer that problem with the tendons rubbing up against the side of the compartment and they get relief of pain and this is almost universally successful. The you put them in a thumb spike a splint afterwards I have them take that thumb side spike a splint off in five days and put a Band-Aid on it. And some of them don’t even come back to see me they’re happy. So the next one they’re going to go over is CMC arthritis and this also is a big one in my practice and an all hands surgeons practice.
This is the number one reason for a hand surgeon to operate on the hand for osteoarthritis of the hand it’s arthritis of the trapezial metacarpal joint or the first Si and joint also called the basal joined on the phone. So who gets it. It’s women tend to 1 or 20 to one. It is it’s mostly all women average age 50 whites greater than Asians and their main complaint is pain with pinching pain with trying to open a jar pain with trying to do anything that requires the thumb which is about everything you do with your hand.
Why do women get it more than men? There’s no there’s no explanation so on physical examination of the hand the patients come in and they’ll say I have you know I have this terrible pain it’s on this side of my wrist it goes up the arm and it’s been occurring it’s getting worse and worse and worse and don’t tell me have arthritis because I won’t accept it. So.
The physical findings though are a positive grind. That’s the number one thing that we do and that’s where you take the thumb and you just put it through a range of motion kind of a grinding range of twisting range of motion and that really hurts. Conservative treatment for early arthritis is splinting. thumb post splints are available by the dozens. You can see them on Amazon. We like we have in our office one that is a wraps around the thumb it is made of neoprene because it allows them to be more functional the use of non-steroidal anti-inflammatory arthritis medicine and injection. And injection is very hard to do. It’s not as easy to do as that first dorsal compartment. And so I recommend that if you’re not really good at it you should do it under ultrasonic guidance because it’s easier to find that very thin arthritic joint here.
This is one of those splints that you can find on Amazon that therapists can make custom splints if they like. These are rigid splints. The basal joints so there are encumbering the advanced arthritis though those are better that are Grade 2 3 and 4 and I won’t go into the grading system here but there’s multiple treatments that you can do you can do arthrodesis. You can do a trapeziectomy. Plus or minus distraction interposition which means stuffing something in their ligaments reconstruction and that’s forming a sling an implant or through a plastic. This is one of the first. Operations that was done back in the late 60s and it was excised excision of the trapeze and using a part of the FCR as a suspension and interposition now there are multiple ways to do this and the all the. People that do implants and the medical supply industry has caught on to this and they’re developing new things all the time to try to get part of this because we really do a lot of these surgeries this is just one of this is Arthrex tightrope which works pretty well and you can see there there’s the trapeze him that is gone.
There are a lot of other things that are out there that do interposition there. Atelon was one of them that was this interposition into the joint to try to get rid of the pain of the arthritis but this caused a reaction that usually failed within a year. There are multiple implants just like having a total knee. We’re doing arthroplasty so you would think like if you do a total knee or a total hip then an implant would work pretty good. But the basal joint is a is a really strange joint. It has just this you know circuit suction range of motion and the articulation there. There is a lot of sliding back and forth between those two. And so none of these have caught on. With hand surgeons. There are some that are really trying but none of them have caught on. The real interest in doing this is to to gain better pinch strength in a younger patient to do an implant but it’s not proven really you know it hasn’t caught on yet.
It’s showing you how one of their surgeries that they do is kind of that you can do with their implants and it’s similar to what we do to all of us up here is that we do it sort of suspension arthroplasty. Using a piece of the tendon the abductor policies longest in suspending the first metacarpal to the base of the second metacarpal. And that works pretty well. There are multiple ways to do it but the literature says that trapeze the economy is all that matters as long as you take the trapezium out of there that you’ll get pain relief. And so there is there is literature from across the pond that says that that’s all you really need to do you don’t need all these expensive things in the United States. You’re still going to get a suspension arthroplasty when you go to most hand surgeons by far. Post-operative leave when you have that done you have to your two weeks in a splint you tell you the patients that they’ll have.
Usually this is our protocol removable splint. After 2 weeks until week 6. Then you win out of it usually takes about three months to get over a suspension arthroplasty the last thing is owner collateral ligament injury. Now this is a real sports medicine thing because this usually occurs in sports. OK. It is. It is the. Injury to the owner collateral ligament of the metal carpal phalanges joint of the thumb. And it’s called Game keepers thumb because in jolly old England they used to have the you know the gentry used to have game keepers and that’s how they killed the game before they aired it is they just broke their necks and these guys would come up with these injuries of their thumb.
But it can also be called skiers thumb falling on an out falling on your hand with with a pole in your hand really causes a lot of these injuries in the you know in the United States. It’s also in multiple sports you can see it in football if you catch your thumb on somebodies helmet it can do that and biking if you go over the handlebars and your thumbs are still on the handlebars and car accidents if your hand is on the steering wheel and you get pushed forward. It can happen.
So there are a lot of different..it’s all about how the candles perform but it has a lot of strong structures that keep it stable. And it’s all about stability. Stability is the key. And when the owner collateral ligament goes you can’t pinch because you pinch the owner collateral ligament has to be intact. So usually we just treat these people in a cast or splint and for six to eight weeks and they get better unless they have a stent or a lesion and stent or lesions are caused by the ligament coming back upon the injury and going behind the abductor app and neurosis and not being able to come down to bone and therefore no amount of immobilization will allow it to heal.
So treatment is operative is to make sure there’s not a fracture but hardly ever MRIs.
You can look at a stent or a lesion. You usually can tell by palpation and that gross instability. This is the surgery. It’s just a small. Segment of the surgery that’s already open and you can see the collateral ligament so you’re going through the aponeurosis and then you can see the collateral ligament underneath it and then you take a suture anchor usually and put place it into the proximal phalanx of the thumb and secure it down. Sometimes they make ligament can be destroyed and a number of ways and it can be torn in the middle or it can be torn off a bone. And if it if it’s over eight weeks or nine weeks then it’s probably not reconstructed because it rolls up into a ball when there’s a stent or a lesion and then you may have to do a either a graft. Or some of the newer techniques that are available for an internal brace and then post-operative course is a mobilization for six weeks and a thumb spike a splint. And then after that we come out of it. And do you have a removable splint for like four to six weeks.
All right. That’s it. Thank you very much.