Hand Surgery And Rheumatology - The Interface
Andrew CavalloPlastic Reconstructive and Hand SurgeonJennifer MathiasHand TherapistMelbourne Hand TherapyElgar Hill Plastic and Hand Clinic7/28 Arnold St Box Hill 3127
The InterfaceTeam WorkRheumatologist Hand Surgeon Hand Therapist Radiologist Psychologist The Patient! 8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic and Hand Clinic
The Interface What is Hand Therapy? Undergraduate training in Occupational Therapy or PhysiotherapyPostgraduate training in Hand and Upper LimbRehabilitation, Master of Science (Hand Therapy)Hospital based workAssociated with Plastics, Orthopaedics, RheumatologyclinicsPrivate practice (generally associated with a HandSurgeon)
The Interface What is Hand Surgery?PRINCIPALSPainfree anaesthesiaMinimally invasive incisionsConsideration of Anatomy andPathological processesEarly Protected MobilisationTroublefree recoveryManage patients expectations
The InterfaceANATOMY8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceANATOMY8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceOverviewCommon conditions referred to Hand Therapists andHand Surgeons by Rheumatologists Rheumatoid arthritis MCP jointsPIP jointsThumbOA CMC jointIP jointsDIP ganglionsSclerodermaTenosynovitis- Trigger finger / thumb / De QuervainsCarpal Tunnel SyndromeDupuytren’s disease
The InterfaceRHEUMATOID ARTHRITISAssessmentClinical Serological Radiological Functional 8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISSoft Tissues- Nodules8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISFlexor Tendons Carpal Tunnel Syndrome Flexor Tendon rupture8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISExtensor Tendons Wrist Rupture8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISExtensor Tendons8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISExtensor Tendons Rupture Tendon Subluxation8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISJoints MPUlnar Drift DeformityPalmar SubluxationWeak Grip and Pinch8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISJoints MP- Synovitis-destruction-replacement8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISJoints MP replacement8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISJoints MP replacement8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISJointsPIP – Boutonniere Soft tissue rebalance/fusion8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceRHEUMATOID ARTHRITISJointsPIP and DIP – Swan neck Soft tissue rebalance/fusion8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceSwan neck deformitiesBoutonniere deformities
The interface - Rheumatoid thumbClassificationPrimarysite of jointdeformityDeformitySplintType 1 (Boutonniere)MCP jointMCP flexedIP hyperextendedCustom made thumbMCP joint extensionimmobilisation splintType 2CMC jointCMC flexed and adductedMCP flexedIP hyperextendedCMC and MCPextensionimmobilisation splintType 3 (Swan neck)CMC jointCMC subluxed, flexed andadductedMCP hyperextendedIP flexedCMC immobilisationsplint with block toprevent MCP jointhyperextensionType 4(Gamekeeper’s)MCP jointLaxity of UCLMCP jointimmobilisation splintType 5MCP jointMCP hyperextendedIP joint flexedExtension restrictionsplintType 6GeneralBone loss and loss of jointstabilityCMC, MCP and IPAndrewsplintCavallo andMathias Elgar Hillas JenniferindicatedPlastic and Hand Clinic
The InterfaceRHEUMATOID ARTHRITISThumb8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceSPLINTS
The interface - RAConservative Splinting Education (joint protection) Heat (hot packs / wax baths) Gentle range of motion
The Interface - Treatment of RASplinting Anti-deformity Splints Night resting splints
The InterfaceVASCULAR Scleroderma Raynauds8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceSclerodermaSkin care Hand and nail care Protection from heat and cold Raynaud’s phenomenonHousework and activities Exercises Splints
The InterfacePSORIATIC ARTHRITIS8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceGOUT8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceOSTEOARTHRITISJoints - CMC Joints - MP Joints - PIP Joints - DIP 8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface Ist CMC OA8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceIst CMC OA
The Interface - Signs of thumb base OA Deformity Tenderness Stiffness Swelling Weak pinch and grip Poor function
The interface- CMC AssessmentX-rays Reported history of painand function Clinical assessment(palpation and grind test) Lateral pinch strengthassessment Andrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The InterfaceEaton Radiological ClassificationStage 1 Stage 2 almost normaldecreased Jt spaceOsteophyte 2mm Stage 3Subluxation 1/3Osteophyte 2mm Stage 4ST/ TT / IFcmcAndrew Cavallo and Jennifer MathiasElgar Hill Plastic and Hand Clinic
The Interface –st1CMCConservative management - Splinting
The Interface1st CMC OA Splinting Education (joint protection) Heat (hot pack / wax baths) Gentle range of motion Steroid Injection Surgery
The InterfaceCMC joint surgical proceduresLigament Reconstruction (LR) MC osteotomy CMC joint arthrodesis Denervation CMC joint replacement Trapeziectomy /- LR or TI or LRTI Trapeziectomy (complete/partial) interpositionalarthroplasty Andrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The Interface - Interposition MaterialsBiological (Autograft / Allograft) FCR / PL Costochondral interposition graft Fascia Lata / Graft jacket (acellular dermis)Prosthetic Material Silicone rubber button Gelfoam Gortex Polypropylene (Marlex) Polyurethane Urea (Artelon) Pyrocarbon- Ascension PyroDisk-Tornier PyrocardanArtelonPyroDiskPyrocardanAndrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The InterfacePyrocardan CMC Interposition ImplantIndications Stage 1,2 and early 3 CMC OA (Eaton Classification)Benefits Short term- Minimally invasive and short recovery period Trapezium preserving, offers greater salvage opportunities ?Long Term resultsAndrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The InterfacePartial trapeziectomy and interposition with the PyrocardanCMC joint implant.Pain/function score improvedGood overall satisfaction with procedurePinch strength comparable to traditional proceduresAndrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The Interface - STT joint OA
The Interface - PAN TRAPEZIAL OATrapeziectomy aloneTrapeziectomy tendon interpositionTrapeziectomy Suspension (APL or FCR)Results – Excellent Pain Relief- Very Good Movement- Good Functional strength
The Interface8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
PIP OA
The InterfaceGANGLIONS in OA PIP (Dorsal)8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface – Pain and swelling Enlargement deformity instability Heberden’s nodes mucoid cystsSigns of DIP joint OA
The Interface –DIP Fusion Severe Pain Deformity InstabilitySigns of DIP joint OA
The InterfaceGANGLIONS in OA DIP ( Mucoid)8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfacePost Traumatic ArthritisDigits Joints –DIP Joints – PIP Joints – MP Joints- CMC8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfacePost Traumatic ArthritisDigits Joints –DIP Joints – PIP Joints – MP Joints- CMC8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfacePost Traumatic ArthritisPIP Replacement8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface - IP Joint OA managementConservative Splinting Education (joint protection) Heat (hot packs / wax baths) Gentle range of motion
The Interface - Splinting for OA and RADecrease support forincreasedfunctionDecreasestress to thejointsAssist with jointstability8/27/2014Andrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The Interface - Splints8/27/2014Andrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The Interface Rest Spread the strainJoint Protection Principles use more joints to do work use larger joints to do work Avoid gripping narrow and smallobjects Avoid deforming positions (RA) Energy Conservation
Joint Protection PrinciplesActivity Of Daily Living (ADL) Devices
Joint protectionPain free exercisesSplintingIncreased FunctionBoustedt C, Nordenskiold U, Lundgren Nilsson A. Effects of a hand-joint protection program with an addition ofsplinting and exercise: one year follow-up. Clin Rheumatol. 2009; 28: 793-9
The Interface - Hand ExercisesMust bepainfreeIncreasing gripstrengthImprovingfunctionOverall bodyconditioningReducing painImproving ROM
The InterfaceDe Quervain's Tenosynovitis Compression of the APL andEPB within the 1st dorsalcompartment Finklestein’s test - ulnardeviation of the wrist with thethumb adductedAndrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The InterfaceDEQUERVAIN’S TENOSYNOVITIS8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceDe Quervain's TenosynovitisTreatment Splinting Cortisone injection Iontophoresis withdexamethasone Surgery8/27/2014Andrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The InterfaceTRIGGER FINGER8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceTRIGGER FINGER8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceTRIGGER FINGER8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceTRIGGER THUMB8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceLateral Epicondylitis (tennis elbow) Pathology at the common extensor origin (lateral epicondyle) ECRB tendon involved (Also EDC 30%) Dominant arm more involved (2:1) Peak incidence in the fourth decade More prevalent in occupation (70%) as compared to sports
The InterfaceTreatment ModalitiesImmobilisation, Ultrasound, Splinting(proximal brace and/or wrist brace), Laser,Education, Transverse Friction Massage,Electrotherapy, Oral NSAIDS, TopicalNSAIDS, CSIs, Mobilisation, Botox,Extracorporeal Shock Wave Therapy, Ice,Stretching, Strengthening, Phonophoresis,Iontophoresis, Wait and See, ActivityModification, Elbow Joint Mobilisation,Cervical Spine mobilisation, Acupuncture,Myofascial Release, Ergonomic Adjustments,Autologous Blood Injection (ABI), GTN, etc,etc, etc .
The InterfaceRehabilitationEstablishing what phase of injury the pt is in1) Reactive2) DegenerativeRehab Principles Reduce pain (topical steroids, iontophoresis or cortisoneinjection) Unload tendon (Load management – education, rest,postural advice, splinting) Facilitate tendon adaptation, strengthening and stretching
The InterfaceDegenerative GroupProlotherapy (Proliferative Injection Therapy): Autologous Blood Injection (ABI)Thought to trigger inflammatory cascade and healing by either:i) ? mediators in the blood itself orii) the injection itselfNo difference between ABI and Saline (de Vos et al, 2010) High Volume Injections (HVI) – 20-30mls salineDeveloping Evidence
The InterfaceNERVE COMPRESSIONSCarpal Tunnel Guyons Tunnel Cubital Tunnel 8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface - Carpal Tunnel Syndrome Caused by compression of themedian nerve at the wristmany aetiologies Nocturnal paraesthesia inmedian innervated digits (also daily when holdingphone/steeringwheel/brushing hair) Wasting of APBAndrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The InterfaceCARPAL TUNNEL SYNDROME Tinel’s Test Phalens Test -variants NCS-amplitudelatencyaction potentialvelocity8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface - Carpal Tunnel SyndromeConservative Treatment Splinting overnightAndrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The Interface - Carpal Tunnel SyndromeTreatment Surgical decompression openAndrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The Interface - Carpal Tunnel Syndrome Treatment Splinting overnight Surgical decompression -endoscopicAndrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The Interface DUPUYTRENS CONTRACTURE8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface DUPUYTRENS CONTRACTURESuperficial fibromatosis affecting the palmar fasciae8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface - Dupuytren’s contractureHistory Felix Platter 1614 Astley Cooper 1822 Von Dupuytren 1832Features Palmar pitting Nodules Cords Contractures8/27/2014Andrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The Interface - Dupuytren’s contractureAETIOLOGY Genetic - autosomal dominant Celtic- HLA B 27DiabetesEpilepsy ? MedicationTraumaAlcohol-? coincidenceASSOCIATIONSGarrod’s Pads 40% Lederhosen’s Disease 15% Peyronie’s Disease 5% 8/27/2014Andrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The Interface - Dupuytren’s contractureSurgery indicated when MCP joint contracture reaches30ْ when PIP joint starts contracting triggering8/27/2014Andrew Cavallo and Jennifer Mathias Elgar HillPlastic and Hand Clinic
The InterfaceDUPUYTRENS CONTRACTUREMinimal Surgical ApproachesPercutaneous Needle Aponeurotomy ( - Fat Injections)Cord FasciotomySegmental Fasciectomy8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceDUPUYTRENS CONTRACTURELess Minimal Surgical ApproachesDigital FasciectomyDermoFasciectomy - Skin GraftTotal Fasciectomy8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceDUPUYTRENS CONTRACTURECollagenaseInjectNerve w Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceDUPUYTRENS CONTRACTURECollagenase - ProblemsNot yet TGA approved? 1300 out of pocket per injectionOnly One cord treatable per monthPost “op” pain, swelling, haematoma?Long term results8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceDUPUYTRENS CONTRACTURECollagenaseOh No ! Tendon RuptureWhat does it mean?8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceCOMPLEX REGIONAL PAIN SYNDROME8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceHAND INFECTIONSSeptic Arthritis Suppurative Tenosynovitis Deep Space infection 8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfacePerioperative Management of /2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceThankyou.8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The InterfaceAny Questions?8/27/2014Andrew Cavallo and Jennifer Mathias Elgar Hill Plastic andHand Clinic
The Interface What is Hand Therapy? Undergraduate training in Occupational Therapy or Physiotherapy Postgraduate training in Hand and Upper Limb Rehabilitation, Master of Science (Hand Therapy) Hospital based work Associated with Plastics, Orthopaedics, Rheumatology clini
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3 References American College of Rheumatology Slide Collection of Rheumatic Diseases, online library at www.rheumatology.org Klippel, John H., M.D., editor .
Plastic surgery Cosmetic Surgery Reconstructive Surgery Aesthetic Surgical & Non-Surgical procedures Craniofacial Surgery Rhinoplasty & Otoplasty Hand Surgery or Chiroplasty Oral and Maxillofacial Surgery Trauma Surgery Skin Rejuvenation and Resurfacing Anesthesia for Plastic Surgery
