Beruflich Dokumente
Kultur Dokumente
ORTHO BULLETS
Volume
Six
Hand
2017
Collected By : Dr AbdulRahman AbdulNasser
drxabdulrahman@gmail.com
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
ORTHO BULLETS
I.Hand Introduction
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
A. Anatomy
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OrthoBullets2017 Hand Introduction | Anatomy
Extensor Ligaments
Lumbrical tendon passes volar to transverse metacarpal ligament
Interossei tendons pass dorsal to transverse metacarpal ligament
Retinacular Ligaments
Function
o retain and position common extensor mechanism during PIP and DIP flexion
o similar to sagittal band function
Anatomic Components
o oblique band (oblique retinacular ligament of Landsmeer)
function
links motion of DIP and PIP
lies volar to axis of PIP, but dorsal to axis of DIP
anatomy
origin: from lateral volar aspect of proximal phalanx,
insertion: to lateral terminal extensor dorsally (crosses collateral ligaments)
biomechanics
with PIP flexion, ligament relaxes to allow DIP flexion
with PIP extension, ligament tights to facilitate DIP extension
pathology
contracture causes volar displacement of lateral bands and a resulting Boutonniere
Deformity
reconstruction of oblique retinacular ligament used to treat swan neck deformity
if ORL is tight,
resting finger position is DIP extended, PIP flexed
unable to flex DIP if PIP is extended
able to flex DIP only after PIP is flexed
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
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OrthoBullets2017 Hand Introduction | Anatomy
Anatomic Components
o Cleland's ligaments (remember "C" for ceiling)
dorsal to digital nerves
not involved in Dupuytren's disease
o Grayson's ligament (remember "G" for ground)
volar to digital nerves
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Expansion Hood
Function
o works to extend PIP and DIP joint
Anatomic Components
o central slip
functions to extend PIP
inserts into base of middle phalanx
o lateral band
functions to extend DIP
inserts into distal phalanx
lumbricals, extensor indicis, dorsal and palmar
interossei insert on lateral band
MCP Joint Collateral Ligaments
Function
o stabilize MCP joint during motion
MCP joint "cam" nature leads to inconstant arc of motion because of joint asymmetry
caused by "snoopy head" configuration of metacarpal head
collaterals looser in extension, tighten during increasing flexion
as MP joint flexes, proximal phalanx moves further away from metacarpal head,
tightening all the ligaments
I:2 Figure - showing shape of metacarpal head I:3 Red, dorsal - proper ligament Green, volar - accessory ligament
Anatomic Components
o radial collateral ligaments (RCL) are more horizontal than ulnar collateral ligaments (UCL)
o RCL and UCL have 2 parts each: proper and accessory ligaments
accessory ligament
fan shaped
more volar
tight in extension
attachment
from metacarpal head at center of rotation
to palmar plate and deep transverse metacarpal ligament
clinical test
adduction/abduction stress in extension
proper ligament
cord like
more dorsal
tight in 30 degrees of flexion
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OrthoBullets2017 Hand Introduction | Anatomy
attachment
from posterior tubercle of metacarpal head (dorsal to mid axis)
to proximal phalanx base
clinical test : adduction/abduction stress in 30 degrees flexion to isolate proper ligaments
Sagittal Bands
Function
o keep extensor mechanism tracking in the midline during flexion of MP joint
Anatomy
o origin: palmar plate
o insertion: extensor mechanism (curves around radial and ulnar side of MP joint)
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
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OrthoBullets2017 Hand Introduction | Anatomy
Triangular ligament
Function
o counteracts pull of oblique retinacular ligament,
preventing lateral subluxation of the common
extensor mechanism
Anatomy
o triangular in shape
o located on dorsal side of extensor mechanism, distal
to PIP joint
Pathology
o contracture leads to swan neck deformity
Volar Plate
Function
o prevent hyperextension
Anatomy
o thickening of joint capsule volar to the MP joint
o in the thumb, sesamoid bones are located here
o origin: metacarpal head
o insertion: periarticular surface of proximal phalanx , via checkrein ligaments
Biomechanics
o loose in flexion
folds into metacarpal neck during flexion
o tight in extension
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Annular ligaments
o A2 and A4 are critical to prevent bowstringing
most biomechanically important
o A1, A3, and A5 overlie the MP, PIP and DIP joints respectively
originate from palmar plate
o A1 pulley most commonly involved in trigger finger
Cruciate pulleys
o function to prevent sheath collapse and expansion during digital motion
o facilitates approximation of annular pulleys during flexion
o 3 total at the level of the joints
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OrthoBullets2017 Hand Introduction | Anatomy
Flexor Pulley System-Thumb
Types of
annular
variable pulley:
Type 1
Type 2
Type3
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OrthoBullets2017 Hand Introduction | Anatomy
Pulley Reconstruction
Goals
o preserve or reconstruct 3 or more pulleys
o A2 is important
o unclear if A4 reconstruction is absolutely necessary (can be sacrificed during acute flexor tendon
surgery)
Graft material
o extensor retinaculum
synovialized pulley surface, provides least gliding resistance
o excised tendon material
o palmaris or plantaris
o FDS
o flexor tendon allograft I:9 Bunnell single loop
Techniques
o first excise all scar dorsal to the flexor tendon
o around-the-bone (encircling technique)
single-loop (Bunnell)
triple loop (Okutsu)
biomechanically strongest construct
complications
most worrisome is phalangeal fracture
stiffness I:10 Okutsu triple loop
persistent bowstringing
inadequate tensioning
failure to remove scar tissue dorsal to tendon (tendon is not pressed against bone)
o nonencircling reconstruction
ever-present-rim (Kleinert)
belt-loop (Karev)
extensor retinaculum (Lister)
palmaris longus transplantation through volar plate (Doyle and Blythe)
Location Specific
o proximal phalanx (for A2 pulley)
use 3 loops (around-the-bone) - strongest reconstruction
pass DEEP to extensor mechanism
o middle phalanx (for A4 pulley)
use 2 loops (around-the-bone)
pass SUPERFICIAL to extensors
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Superficial Arch
Anatomy
o deep to palmar fascia
o distal to the deep arch I:13 Superficial Arch
o surface marking
at the level of a line drawn across the palm parallel to the distal edge of the fully abducted
thumb
Blood supply
o predominant supply is ulnar artery
o minor supply from superficial branch of radial artery
Branches of superficial arch (from ulnar to radial)
o 1st branch
is the deep branch that provides the minor supply to the deep palmar arch
o 2nd branch
is the ulnar digital artery of the little finger
the proper digital artery to the ulnar side of the little finger arises directly from the
superficial arch
o 3rd, 4th, 5th, and 6th branches
are the common palmar digital arteries
in the palm, the digital arteries are volar to the digital nerves
in the digits, the digital arteries are dorsal to the digital nerves
in the digits, the neurovascular bundle is volar to Cleland's ligament
o multiple branches to intrinsic muscles and skin
The superficial arch is complete (branches to all digits) in 80% of individuals
Deep Arch
Anatomy
o deep to the flexor tendons (FDS, FDP)
o proximal to the superficial arch
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OrthoBullets2017 Hand Introduction | Anatomy
o at the level of the base of the metacarpals
o surface marking
1 fingerbreadth proximal to a line drawn
across the palm parallel to the distal edge of
the fully abducted thumb
1 fingerbreadth proximal to the superficial
arch
Blood supply
o predominant supply is the deep branch of the
radial artery
o minor supply from the deep branch of the ulnar
artery
Branches of the deep arch (from radial to ulnar)
I:14 Deep Arch
o princeps pollicis
runs between 1st dorsal interosseus and adductor pollicis
o branch to the radial side of the index finger
the proper digital artery to the radial side of the IF arises directly from the deep arch
o branches to the 3 common digital arteries in the 2nd, 3rd, and 4th web spaces
The deep arch is complete (branches to all digits) in 97% of individuals
Anatomic Landmarks
Arch Kaplan's cardinal line Distal Wrist Crease
Superficial 15mm distal 50mm distal
Deep 7mm distal 40mm distal
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Digital Arteries
Common digital arteries arise from the superficial palmar arch
Divide into proper digital arteries at the web spaces
Gives dorsal branches distal to the PIP joints
Dominant arteries are found on the median side of the digit (closer to midline)
o in the index finger, the ulnar digital artery is dominant
o in the little finger, the radial digital artery is dominant
in the middle and ring fingers, ulnar and radial digital
arteries are dominant respectively, but dominance is less obvious
Dorsal Arteries
Blood supply
o posterior interosseous artery
o dorsal perforating branch of anterior interosseous artery
Form a dorsal carpal arch which gives rise to dorsal metacarpal arteries
o useful for dorsal metacarpal artery flaps
o 1st and 2nd dorsal metacarpal artery are more consistent than 3rd and 4th
Veins
Deep veins
o veins follow the deep arterial system as venae comitantes
Superficial veins
o found at the hand dorsum
o contribute to the basilic and cephalic vein system
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OrthoBullets2017 Hand Introduction | Anatomy
Wrist Biomechanics
Three biomechanic concepts have been proposed:
Link concept
o three links in a chain composed of radius, lunate and capitate
head of capitate acts as center of rotation
proximal row (lunate) acts as a unit and is an intercalated
segment with no direct tendon attachments
distal row functions as unit
o advantage
efficient motion (less motion at each link)
strong volar ligaments enhance stability
o disadvantage
I:16 Link Concept
more links increases instability of the chain
scaphoid bridges both carpal rows
resting forces/radial deviation push the scaphoid into flexion and push the triquetrum into
extension
ulnar deviation pushes the scaphoid into extension
Column concept
o lateral (mobile) column
comprises scaphoid, trapezoid and trapezium
scaphoid is center of motion and function is mobile
o central (flexion-extension) column
comprises lunate, capitate and hamate
luno-capitate articulation is center of motion
motion is flexion/extension
o medial (rotation) column
comprises triquetrum and distal carpal row
motion is rotation
Rows concept I:17 Rows concept I:18 Column concept
o comprises proximal and distal rows
scaphoid is a bridge between rows
o motion occurs within and between rows
Carpal Relationships
Carpal collapse
o normal ratio of carpal height to 3rd metacarpal height is 0.54
Ulnar translation
o normal ratio of ulna-to-capitate length to 3rd metacarpal height is 0.30
Load transfer
o distal radius bears 80% of load
o distal ulna bears 20% of load
ulna load bearing increases with ulnar lengthening
ulna load bearing decreases with ulnar shortening
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Wrist Ligaments
The ligaments of the wrist include
o extrinsic ligaments
bridge carpal bones to the radius or metacarpals
include volar and dorsal ligaments
o intrinsic ligaments
originate and insert on carpal bones
the most important intrinsic ligaments are the scapholunate interosseous ligament and
lunotriquetral interosseous ligament
Characteristics
o volar ligaments are secondary stabilizers of the scaphoid
o volar ligaments are stronger than dorsal ligaments
o dorsal ligaments converge on the triquetrum
Space of Poirier
o center of a double "V" shape convergence of ligaments
o central weak area of the wrist in the floor of the carpal tunnel at the level of the proximal capitate
o between the volar radioscaphocapitate ligament and volar long radiolunate ligament
(radiolunotriquetral ligament)
wrist palmar flexion
area of weakness disappears
wrist dorsiflexion
area of weakness increases
o in perilunate dislocations, this space allows the distal carpal row to separate from the lunate
o in lunate dislocations, the lunate escapes into this space
I:21 Volar ligaments of the wrist I:20 Dorsal ligaments of the wrist
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Sagittal MR arthrogram showing short radiolunate Cadaveric specimen showing short radiolunate ligament
ligament (3) (3)
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OrthoBullets2017 Hand Introduction | Anatomy
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Intrinsic (Interosseous) ligaments
Proximal row
o scapholunate ligament
primary stabilizer of scapholunate joint
composed of 3 components
dorsal portion
thickest and strongest
prevents translation
volar portion
prevents rotation
proximal portion
no significant strength
disruption leads to lunate extension when the scaphoid flexes
creating DISI deformity
o lunotriquetral ligament
composed of 3 components
dorsal
volar
proximal
disruption leads to lunate flexion when the scaphoid is normally aligned
creating VISI deformity (in combination with rupture of dorsal radiotriquetral rupture)
Distal row
o trapeziotrapezoid ligament
o trapeziocapitate ligament
o capitohamate ligament
Palmar midcarpal
o scaphotrapeziotrapezoid
o scaphocapitate
o triquetralcapitate
o triquetralhamate
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OrthoBullets2017 Hand Introduction | Anatomy
v Flexion Extension
MCP 70% Interosseous Extensor Digitorum sagittal band
o palmar adductors
o dorsal interosseous
30% lumbricals
o 2nd & 3rd digit by median n.
o 4th & 5th digit by ulnar n.
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
7. Thumb Motion
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OrthoBullets2017 Hand Introduction | Clinical Evaluation
B. Clinical Evaluation
Inspection
Skin
o discoloration
erythema (cellulitis)
white (arterial insufficiency)
blue/purple (venous congestion)
black spots (melanoma) I:22 Clinical photo of a
patient with thenar atrophy
o trophic changes (i.e. increased hair growth or altered sweat production)
secondary to carpal tunnel
can represent derangement of sympathetic nervous system syndrome
o scars/wounds
Swelling
Muscle atrophy
o thenar atrophy
median nerve involvement : caused by carpal tunnel
syndrome
o interossei atrophy
ulnar nerve involvement
I:23 Clinical photo of a patient with interossei muscle
caused by cubital tunnel or cervical radiculopathy atrophy secondary to cubital tunnel syndrome
o subcutaneous atrophy
locally post-steroid injection
Deformity
o asymmetry
o angulation
o rotation
o absence of normal anatomy (previous amputation)
o cascade sign
fingers converge toward the scaphoid tubercle when flexed at the MCPJ and PIPJ
if one or more fingers do not converge, then trauma to the digits has likely altered normal
alignment
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
Palpation
Masses (ganglions, nodules)
Temperature
o warm: infection, inflammation
o cool: vascular pathology
Tenderness
Crepitus (fracture)
Clicking or snapping (tendonitis)
I :24 A clinical picture of a patient with a
Joint effusion (infection, inflammation, trauma)
dorsal wrist ganglion
Range of Motion
Active and passive
o Finger
MCP: 0° extension to 85° of flexion
PIP: 0° extension to 110° of flexion
DIP: 0° extension to 65° of flexion
o Wrist
60° flexion
60° extension
50° radioulnar deviation arc
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
Special Tests
Palpation
o grind test
used to test for pathology at the thumb carpometacarpal
joint (CMC)
examiners applies axial load to first metacarpal and rotates
or "grinds" it
positive findings: pain, crepitus, instability
o Finkelstein's
used to test for DeQuervain's tenosynovitis
patient makes fist with fingers overlying thumb
examiner gently ulnarly deviates the wrist
positive findings: pain along the 1st compartment
Range of motion
o flexor profundus
used to test continuity of FDP tendons
MCP + PIP joints held in extension while patient asked to flex FDP,
thereby isolating FDP (from FDS) as the only tendon capable of
flexing the finger
o flexor sublimus
used to test for continuity of FDS tendon
MCP, PIP and DIP of all fingers held in extension with hand flat
and palm up; the finger to be tested is then allowed to flex at PIP
joint.
o Bunnel's test
examiner passively flexes PIPJ twice
first with MCP in extension
next with MCP held in flexion
intrinsic tightness present if PIP can be flexed
easily when MCP is flexed but NOT when
MCP is extended
extrinsic tightness present if PIP can be flexed
easily when MCP is extended but NOT when MCP is flexed
Stability assessment
o scaphoid shift test (Watson's test)
tests for scapholunate ligament tear
examiner places thumb on distal pole of scaphoid on palmar side of wrist and applies
constant pressure as the wrist is radially and ulnarly deviated
dorsal wrist pain or "clunk" may indicate instability
o lunotriquetral ballottement
tests for lunotriquetral ligament tear
examiner secures the pisotriquetral unit with the thumb and index finger of one hand and the
lunate with the other hand
anterior and posterior stresses are placed on the LT joint
positive findings are increased laxity and accompanying pain
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OrthoBullets2017 Hand Introduction | Clinical Evaluation
o midcarpal instability
examiner stabilizes distal radius and ulna with non-dominant hand and moves patients wrist
from radial deviation to ulnar deviation, whilst applying an axial load
a positive test occurs when a clunk is felt when the wrist is ulnarly deviated
o ulnar carpal abutement
tests for TFCC tear or ulnar-carpal impingement
examiner ulnarly deviates wrist with axial compression
positive if test reproduces pain or a 'pop' or 'click' is heard
o Gamekeeper's
tests for ulnar collateral ligament tear at MCP of thumb
examiner stresses first MCPJ into radial deviation with MCPJ in fully
flexed and extended positions
positive test if > 30 degrees of laxity in both positions (or gross laxity
compared to other side)
Nerve assessment
o Tinel's
tests for carpal tunnel syndrome
examiner percusses with two fingers over distal palmar crease in the
midline
positive if patient reports paresthesias in median nerve distribution
o Phalen's
tests for carpal tunnel syndrome
with the hands pointed up, the patient's wrist is allowed to flex by gravity
in palmar flexion for 2 minutes maximum
positive if patient reports paresthesias in median nerve distribution
o Froment's sign
tests for ulnar nerve motor weakness
patient asked to hold a piece of paper between thumb and radial side of
index
positive if as the paper is pulled away by the examiner the patient flexes
the thumb IP joint in an attempt to hold on to paper
o Wartenberg's sign
tests ulnar nerve motor weakness
patient asked to hold fingers fully adducted with MCP, PIP, and DIP
joints fully extended
positive if small finger drifts away from others into abduction
o Jeanne's sign
tests for ulnar nerve motor weakness
ask patient to demosntrate key pinch
positive finding if patients first MCP joint is hyperextended
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
Introduction
Definition
o comprises nerve conduction velocity (NCV) studies and electromyography (EMG)
o used to localize areas of compression and neuropathy
o distinguish
lower vs upper motor neuron lesions
spinal root, trunk, division, cord or peripheral nerve lesion
o determine severity and prognosis
neuropraxia has good prognosis
axonotmesis/neurotmesis has poor prognosis
o demonstrate denervation, reinnervation, aberrant reinnervation, motor end plate lesion
o valuable in worker's compensation patients with secondary gain issues
Indications
o carpal tunnel syndrome
o cubital tunnel syndrom
o cervical radiculopathy
o lumbar radiculopathy
o nerve dysfunction of the shoulder (e.g., scapular winging)
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OrthoBullets2017 Hand Introduction | Clinical Evaluation
Nerve Conduction Velocity
Definition
o tests performed on peripheral nerves to determine their response to electrical stimuli
Technique
o constant voltage electric stimulator evokes a response from muscle (motor nerve study) or along
the nerve (sensory nerve study)
standard stimulus is 0.1 to 0.2ms square wave
o for motor nerve studies, an additional stimulus is measured along the proximal segment between
2 points on the nerve
to overcome inherent delay across neuromuscular junction if the recording electrode were
placed on the muscle
Measures
o NCV = distance divided by latency
distance traveled is from the cathode of the stimulating electrode to the recording electrode
latency is the time from the onset of stimulus to the onset of response
onset latency = time from site of stimulation + time to activate postynaptic terminal
(neuromuscular transmission time) + time for action potential to propagate along muscle
membrane to recording potential
NCV is determined by
myelin thickness
internode distance
temperature
age
NCV in newborns are 50% of adult values
NCV in 1 year olds are 75% of adult values
NCV in 5year olds are 100% of adult values
o Amplitude
from baseline to negative peak (in mV)
area under peak is proportional to number of muscle fibers depolarized
provides estimate of number of functioning axons and muscles
o Duration
reflects range of conduction velocities and synchrony of contraction of muscle fibers
if there are axons with different CVs (acute demyelination), duration will be greater
o Late responses evaluate proximal nerve lesions (near spinal cord, e.g. Guillain-Barre syndrome)
F-wave amplitude
H-reflex
stimulate Iα fibers at knee, with recording at the soleus (S1 root)
affected by sensory neuropathies, motor neuropathies of the tibial or sciatic nerves, and
S1 root lesions
Demyelination leads to
o increase latencies (slowing) of NCV
distal sensory latency of > 3.2 ms are abnormal for CTS
motor latencies > 4.3 ms are abnormal for CTS
o decreased conduction velocities less specific than latencies
velocity of < 52 m/sec is abnormal
- 30 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
Findings on NCV
Condition Latency Conduction Velocity Amplitude Evoked Response
Upper limb (>45m/s),
Normal Normal Normal Normal
lower limb (>40m/s)
Axonal Normal Normal Decreased Prolonged
Demyelinating Increased Decreased Normal/decreased Absent/prolonged
Anterior horn cell Normal or polyphasic,
Normal Normal Decreased
disease prolonged duration
Myopathy Normal Normal Decreased Normal
Neuromuscular
Normal Normal Decreased Normal
junction
Neuropraxia
Absent Absent Absent Absent
proximal to lesion
Neuropraxia distal to
Normal Normal Normal Normal
lesion
Axonotmesis
Absent Absent Absent Absent
proximal to lesion
Axonotmesis distal to
Absent Absent Absent Normal
lesion
Neurotmesis
Absent Absent Absent Absent
proximal to lesion
Neurotmesis distal to
Absent Absent Absent Absent
lesion
Electromyography
Definition
o to study electrical activity of individual muscle fibers and motor units
o differentiate between diseases of nerve roots, peripheral nerves or skeletal muscles
o determine if disease is acute or chronic, and if there is reinnervation
o determine if there is nerve continuity
Technique
o insert needle electrode through the skin into muscle to determine insertional and spontaneous
activity
Types of activity
o insertional activity
shows state of muscle and innervating nerve as needle is inserted
normal muscle has baseline electrical activity
abnormal insertional activity (>300-500ms) shows early denervation
polymyositis
myotonic disorders
myopathies
reduced insertional activity occurs after prolonged denervation
muscle undergoes fibrosis
o contraction activity
patient is asked to contract muscle and shape/size/frequency of motor unit potentials are
recorded
o spontaneous activity
normal spontaneous activity includes end plate potentials and end plate spikes
- 31 -
OrthoBullets2017 Hand Introduction | Clinical Evaluation
abnormal spontaneous activity indicates some nerve/muscle damage
sharp waves
fibrillations
spontaneous action potentials from single muscle fibers caused by oscillations in
resting membrane potential of denervated fibers
seen 3-5wk after nerve lesion begins, and stays until it resolves or muscle becomes
fibrotic
also seen in muscle disorders e.g. muscular dystrophy
fasciculations
spontaneous discharge of group of muscle fibers
found in amyotrophic lateral sclerosis, progressive spinal muscle atrophy and anterior
horn degenerative diseases e.g. polio, syringomyelia
seen as "undulating bag of worms" on physical exam
complex repetitive discharges
myokimic discharges
Findings on EMG
Insertional
Condition Spontaneous Activity Minimal Activity Interference
Activity
Biphasic/triphasic
Normal Normal Silent Complete
potentials
Fibrillations/positive sharp Biphasic/triphasic
Axonal neuropathy Increased Incomplete
waves potentials
Biphasic/triphasic
Demyelinating neuropathy Normal Silent Incomplete
potentials
Fibrillations/fasciculations, Large polyphasic
Anterior horn cell disease Increased Incomplete
positive sharp waves potentials
Small polyphasic
Inflammatory Myopathy Increased Fibrillations, myotonia Early
potentials
Small polyphasic
Noninflammatory Normal Normal Early
potentials
Biphasic/triphasic
Neuromuscular junction potentials
Normal Normal Early/normal
disorder (decreased
amplitude/duration)
Neurapraxia Normal Silent None None
Fibrillations/positive sharp
Axonotmesis Increased None None
waves
Fibrillations/positive sharp
Neurotmesis Increased None None
waves
- 32 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
C. Hand Infections
All hand trauma topics moved to volume one of trauma except hand infections
1. Paronychia
Introduction
A soft tissue infection of the proximal or lateral nail fold
Epidemiology
o incidence
most common hand infection (one third of all hand infections)
o demographics
usually in children
more common in women (3:1)
o location
most commonly involve the thumb
Pathophysiology
o organism
acute infection
adults - usually caused by Staphylococcus aureus
children - usually mixed oropharyngeal flora
diabetics - mixed bacterial infection
chronic infection
Candida albicans (more common in diabetics)
often unresponsive to antibiotics
Classification
Acute paronychia
o minor trauma from nail biting, thumb sucking, manicure
Chronic paronychia
o occupations with prolonged exposure to water and irritant acid/alkali chemicals e.g. dishwashers,
florists, gardeners, housekeepers, swimmers, bartenders
o risk factors for chronic paronychia
diabetes
psoriasis
steroids
retroviral drugs (indinavir and lamivudine)
indinavir is most common cause of paronychia in HIV positive patients
resolves when medication is discontinued
Anatomy
Nail organ
o adds to stability of finger tip by acting as counterforce to finger pulp
o thermoregulation (glomus bodies of nail bed and nail matrix)
o allows "extended precision grip" (using opposed thumbnail and index fingernail to pluck out a
splinter)
- 33 -
OrthoBullets2017 Hand Introduction | Hand Infections
Nail plate
o made of keratin, grows at 3mm/month, faster in summer
o fingernails grow faster than toenails (fingernails take 3-6 months to regrow, and toenails take 12-
18 months)
o growing part is under proximal eponychium
Perionychium
o comprises hyponychium, eponychium and paronychium
Presentation
Symptoms
o acute paronychia
pain and
nail fold tenderness
erythema I:28 Green discoloration from
Pseudomonas
swelling
o chronic paronychia
recurrent bouts of low-grade inflammation (less severe than acute paronychia)
Physical exam
o acute paronychia
fluctuance
nail plate discoloration (green discoloration suggests Pseudomonas)
o chronic paronychia
nail plate hypertrophy (fungal infection)
nail fold blunting and retraction after repeated bouts of inflammation
prominent transverse ridges on nail plate
Differentials
Herpetic whitlow
Felon
Onychomycosis
Psoriasis
Glomus tumor
Mucous cyst
- 34 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
Treatment
Acute paronychia
o nonoperative
warm soaks, oral antibiotics and avoidance of nail biting
indications
swelling only, but no fluctuance
medications : augmentin or clindamycin
o operative
I&D with partial or total nail bed removal followed by oral abx
indications
fluctuance (indicates abscess collection)
nail bed mobility (indicates tracking under the nail)
follow with oral antibiotics and routine dressing change
Chronic paronychia
o nonoperative
warm soaks, avoidance of finger sucking, topical antifungals
indications
first line of treatment
medications
miconazole is commonly used
o operative
marsupialization (excision of dorsal eponychium down to level of germinal matrix)
indications
severe cases that fail nonoperative treatment
technique
combine with nail plate removal
leave to heal by secondary intention
Techniques
I&D with partial or total nail bed removal
o approach
may be done in emergency room
incision into sulcus between lateral nail plate and lateral nail fold
o technique
preserve eponychial fold by placing materials (removed nail) between skin and nail bed
if abscess extends proximally over eponychium (eponychia), a separate counterincision is
needed over the eponychium
obtain gram stain and culture
Complications
Eponychia : spread into eponychium
Runaround infection : involvement of both lateral nail folds
Felon
o spread volarward to pulp space
o I&D of finger pulp is necessary
Flexor tenosynovitis : volar spread into flexor sheath
Subungual abscess ("floating nail") : nail plate removal is necessary
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OrthoBullets2017 Hand Introduction | Hand Infections
2. Felon
Introduction
Infection of finger tip pulp
o usually thumb and index finger
Pathophysiology
o mechanism
penetrating injury including
blood glucose needle stick
splinters
local spread
may spread from paronychia
no history of injury in 50% of patients
o pathoanatomy
swelling and pressure within micro-compartments, leading to "compartment syndromes" of
the pulp
o organism
Staphylococcus aureus
most common organism
gram negative organisms
found in immunosuppressed patients
Eikenella corrodens
found in diabetics who bite their nails
Anatomy
Fingertip micro-compartments
o pulp fat is separated by fibrous vertical septae running
from distal phalanx bone to dermis
Presentation
Symptoms
o pain, swelling
Physical exam
o tenderness on distal finger
Treatment
Operative
o I&D in emergency room followed by IV antibiotics
indications
most cases due to risk of finger tip compartment syndrome
Techniques
Fingertip irrigation & debridement
o approach
keep incision distal to DIP crease
to prevent DIP flexion crease contracture and prevent
extension into flexor sheath I:29 Felon drainage - mid lateral
approach
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
mid-lateral approach
indicated for deep felons with no foreign body and not
discharging
incision on ulnar side for digits 2,3 and 4 and radial side for
thumb and digit 5 (non-pressure bearing side of digit)
volar longitudinal approach
most direct access
indicated for superficial felons, foreign body penetration or
visible drainage
incisions to avoid
fishmouth incisions - leads to unstable finger pulp
double longitudinal or transverse incision - injury to digital
nerve and artery I:30 Mid lateral incision
o debridement
avoid violating flexor sheath or DIP joint to avoid spread into
these spaces
break up septa to decompress infection and prevent compartment
syndrome of fingertip
obtain gram stain and culture
hold antibiotics until culture obtained
o postoperative
routine dressing changes
Complications
Finger tip compartment syndrome
Flexor tenosynovitis
Osteomyelitis
Digital tip necrosis I:31 longitudinal incision
I:32 RECOMMENDED: "J shaped" lateral or volar longitudinal. NOT RECOMMENDED: fishmouth and double lateral incisions
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OrthoBullets2017 Hand Introduction | Hand Infections
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
o anatomy
variations common
sheaths extends from
index, middle, and ring fingers
from DIP to just proximal to A1 pulley
thumb (flexor pollicus longus sheath)
from IP joint to as proximal as radial bursa (in wrist)
little finger
from DIP joint to as proximal as ulnar bursa (in wrist)
Presentation
Symptoms
o pain and swelling
typically present in delayed fashion (over last 24-48 hours)
usually localized to palmar aspect of one digit
Physical exam
o Kanavel signs (4 total)
flexed posturing of the involved digit
tenderness to palpation over the tendon sheath
marked pain with passive extension of the digit
fusiform swelling of the digit
o increased warmth and erythema of the involved digit
Imaging
Radiographs
o recommended views
radiographs usually not required, but may be useful to
rule out foreign object
MRI
o cannot distinguish infectious flexor tenosynovitis from
inflammatory but may help determine the extent of the
ongoing process
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OrthoBullets2017 Hand Introduction | Hand Infections
Treatment
Nonoperative (rare)
o hospital admission, IV antibiotics, hand immobilization, observation
indications : early presentation
modalities
splinting
outcomes
if signs of improvement within 24 hours, no surgery is required
Operative
o I&D followed by culture-specific IV antibiotics
indications
low threshold to operative once suspected (orthopaedic emergency)
late presentation
no improvement after 24 hours of non-operative treatment (confirmed diagnosis)
technique (see below)
Technique
I&D of flexor tendon
o approach
full open exposure using long midaxial or Bruner incision
two small incisions placed distally at A5 pulley and proximally at A1 pulley and using an
angiocatheter
Complications
Stiffness
Tendon or pulley rupture
Spread of infection
Loss of soft tissue
Osteomyelitis
Anatomy
Thenar space
o a bursa (potential space) just palmar to adductor pollicis and dorsal to flexor tendons
o separated from midpalmar potential space by a fascial septum
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
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OrthoBullets2017 Hand Introduction | Hand Infections
Midpalmar space
o located dorsal and radial to hypothenar space
Hypothenar space
o located palmar to fifth metacarpal, dorsal and radial to hypothenar fascia, ulnar to hypothenar
septum
Presentation
History
o may or may not have penetrating trauma
Symptoms
o pain
o swelling
Physical exam
o pain with flexion of fingers
thenar
pain with thumb flexion
hypothenar
pain with small finger flexion
midpalmar
pain with small, ring, and small finger flexion
o thenar and midpalmar spaces
often have loss of palmar concavity secondary to swelling
Imaging
Radiographs
o indicated if there is suspicion for a foreign body
MRI
o indications
help define extent of infection
Treatment
Operative
o incision and drainage in conjunction with IV
antibiotics
indications I:33 Abscess in the Thenar Space: Debridement of infection
is best approached in the style of tumor management -
standard of care for deep space infections excision, rather than scrubbing. The abscess margins were
and collar button abscesses not well defined. The infection involved a volume from the
skin, superficial palmar fascia, down through the carpal
technique tunnel to the adductor muscle. Branches of the median nerve
use volar and dorsal incisions for collar and the superficial palmar arch are visible here. Excisional
debridement, wound care, intravenous antibiotics, and
button abscesses delayed closure at five days resulted in cure. Courtesy of Dr.
avoid skin in actual web space Charles Eaton
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
5. Herpetic Whitlow
Introduction
A viral infection of the hand caused by herpes simplex virus (HSV-1)
Epidemiology
o demographics
occurs with increased frequency in medical and dental personnel
most common infection occurring in a toddler’s and preschooler’s hand
Pathophysiology
o viral shedding occurs while vesicles are forming bullae
Presentation
Symptoms
o intense burning pain followed by erythema
o malaise
Physical exam
o erythema followed by small, vesicular rash
over the course of 2 weeks, the vesicles may come together to form bullae
the bullae will crust over and ultimately lead to superficial ulceration
o fever and lymphadenitis may be found
Studies
Tzank smear
o diagnosis confirmed by culture, antibody titers or Tzank smear
Treatment
Nonoperative
o observation +/- acyclovir
indications
standard of treatment
outcomes
self limiting, with resolution of symptoms in 7-10 days
acyclovir may shorten the duration of symptoms
recurrence may precipitated by fever, stress and sun exposure
Operative
o surgical debridement
indications
none
surgical treatment associated with superinfections, encephalitis, and death and should
be avoided
Complications
Superinfections
o often the result of surgical intervention
in pediatric patients, an infection of the digits may occur and require treatment with an oral
antibiotic (penicillinase resistant) ifor 10 days
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OrthoBullets2017 Hand Introduction | Hand Infections
Presentation
Symptoms
o cutaneous rash with discomfort
Physical exam
o papules, ulcers, and nodules are common, especially on the hands
many times presents with a single nodule that may ultimately spread
to the lymph nodes
indistinguishable from tuberculous mycobacterial infection
Studies
Histology I:34 Lowenstein-Jensen
o granulomas may or may not demonstrate acid-fast bacilli on AFB stain Agar growing M. Marinum
Cultures and sensitivities are key to diagnosis
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
o Lowenstein-Jensen culture agar
M. marinum incubated specifically at 30 to 32° C
M. avium intracellulare incubated at room temperature
Treatment
Nonoperative
o oral antibiotics
indications
if diagnosed at early stage
medications
ethambutol, tetraycline, trimethoprim-sulfamethoxazole, clarithromycin, azithromycin
add rifampin if osteomyelitis present
Operative
o surgical debridement + oral antibiotics in combination for 3 to 6 months
indications
later stage disease
use a combination of above medications
7. Fungal Infections
Introduction
Cutaneous fungal infections of the hand are rare and usually mild
o more common to have fungal infection in macerated skin areas (skin folds)
Prognosis
o usually resolve spontaneously
o May have serious infection in immunocompromised host
Classification
Infections divided into three categories
o cutaneous : includes nail bed infections (onychomycosis)
o subcutaneous : includes sporothrix schenckii from rose thorn prick
o deep
orthopaedic manifestation
tenosynovial
septic arthritis
osteomyelitis
organisms include
endemic
coccidiomycosis
histoplasmosis
blastomycosis
opportunistic include
candidiasis
mucormycosis
cryptococcocis
asperfillosisi
requires surgical debridement
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OrthoBullets2017 Hand Introduction | Hand Infections
Onychomycosis
Introduction
o defined as fungal infection in vicinity of nail bed (cutaneous)
o most common organisms are
trichophyton rubrum
a destructive nail plate infection
candida
chronic infection of nail fold
Treatment
o topic antifungal treatment & nail plate removal
indications : first line of treatment
o systemic griseofulvin or ketoconazole
indications
recalcitrant cases
Sporothrix schenckii
Introduction I:35 Sporothrix schenckii: local ulceration
o Sporothrix schenckii a common soil organism (papule) at site of penetration with additional
lesions in region on lymphatic vessels.
o a subcutaneous infection
o rose thorn in classic mechanism of subcutaneous transmission
Presentation
o physical exam
will show local ulceration (papule) at site of penetration
with time additional lesions form in region on lymphatic vessels
may show proximal lymph node involvement
Evaluation
o S schenckii isolated at room temperature on Sabouraud dextrose agar
Treatment
o oral itraconazole for 3 to 6 months
indications
mainstay of treatment
has replaced potassium iodide due to side effects which included
thyroid dysfunction
rash
GI symptoms
Coccidiomycosis
Introduction
o found in southwest arid regions (e.g., new mexico)
o often a deep infection
Presentation
o manifestations include
subclinical pulmonary involvement
orthopaedic manifestations
synovitis
arthritis
periarticular osteomyelitis
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
Treatment
o amphotericin B & surgical debridement
Histoplasmosis
Introduction
o histoplasma capsulatum infection
o found in Mississippi River Valleys and Ohio
Presentation
o usually subclinical
o often found incidentally on CXR
o may present with tenosynovial infection
Evaluation
o diagnosed by skin testing
Treatment
o amphotericin B & surgical debridement / tenosynovectomy
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In July 2017
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OrthoBullets2017 Microsurgery | Hand Infections
ORTHO BULLETS
II. Microsurgery
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
A. Replantation
Anatomy
Fingertip anatomy
o eponychium
soft tissue on the dorsal surface just proximal to the nail
o paronychium
lateral nail folds
o hyponychium
plug of keratinous material situated beneath the distal edge of the nail where the nail bed
meets the skin
o lunula
white portion of the proximal nail
demarcates the sterile from germinal matrix beneath
o nail bed
sterile matrix
where the nail adheres to the nail bed
germinal matrix
proximal to the sterile matrix
responsible for 90% of nail growth
Presentation
History
o mechanism
avulsion
laceration
crush
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OrthoBullets2017 Microsurgery | Replantation
Physical exam
o inspection
often, characteristics of laceration will guide management
presence or absence of exposed bone
o range of motion : flexor and extensor tendon involvement
Imaging
Radiographs
o required imaging : AP/lateral radiographs to assess for bony involvement
Treatment
Nonoperative
o healing by secondary intention
indications
adults and children with no bone or tendon exposed with < 2cm of skin loss
children with exposed bone
Operative
o primary closure (revision amputation)
indications
finger amputation with exposed bone and the ability to rongeur bone proximally without
compromising bony support to nail bed
o full thickness skin grafting from hypothenar region
indications
fingertip amputation with no exposed bone and > 2cm of tissue loss
o flap reconstruction
indications
exposed bone or tendon where rongeuring bone proximally is not an option
Surgical Techniques
Secondary intention
o technique
initial treatment with irrigation and soft dressing
after 7-10 days, soaks in water-peroxide solution daily followed by application of soft
dressing and fingertip protector
complete healing takes 3-5 weeks
Full thickness skin grafting from hypothenar region
o technique
split thickness grafts not used because they are
contractile
tender
less durable
donor site is closed primarily
graft is sutured over defect
cotton ball secured over graft helps maintain coaptation with underlying tissue
o post-operative care
cotton ball removed after 7 days
range of motion encouraged after 7 days
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
Primary closure with removal of exposed bone (revision amputation)
o technique
must ablate remaining nail matrix
prevents formation of irritating nail remnants
if flexor or extensor tendon insertions cannot be preserve, disarticulate DIP joint
transect digital nerves and remaining tendons as proximal as possible
palmar skin is brought over bone and sutured to dorsal skin
Flap reconstruction (see below)
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OrthoBullets2017 Microsurgery | Replantation
Flap Reconstruction Techniques
V-Y advancement flap
o indications
straight or dorsal oblique finger tip lacerations
Digital island artery
o indications
straight or dorsal oblique finger tip lacerations II:1 V-Y advancement flap
volar oblique finger tip lacerations
o advantages : best axial pattern flap
Cross finger flap
o indications
volar oblique finger tip lacerations in
patients > 30 years
o advantages
leads to less stiffness
Reverse cross finger flap
o indications
II:2 Cross finger flap
dorsal finger & MCP lacerations
Thenar flap
o indications
volar oblique finger tip lacerations to
index or middle finger in patients < 30
years
o advantages
improved cosmesis
Axial flag flap from long finger
o indications
II:3 Axial flag flap from long finger
volar proximal finger
dorsal proximal finger & MCP lacerations
Moberg advancement volar flap
o indications : volar thumb if < 2 cm
Neurovascular island flap
o indications : volar thumb up to 4 cm
First dorsal metacarpal artery flap
II:4 Moberg advancement volar flap
o indications
dorsal thumb lacerations
volar thumb lacerations if > 2 cm
o technique
based on 1st dorsal metacarpal artery
Z-plasty with 60 degrees flaps
o indications : first web space lacerations
o technique : can lead up to 75% increase in length
Posterior interosseous fasciocutaneous flap
o indications : first web space lacerations
Groin flap
II:5 Neurovascular island flap
o indications : lesions to dorsal hand
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
Thenar flap
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OrthoBullets2017 Microsurgery | Replantation
Classification
Urbaniak Classification
Class Description Treatment
Standard bone and soft tissue
Class I Circulation adequate
care
Class II Circulation inadequate Vessel repair
Class III Complete degloving or complete amputation Amputation
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Kay, Werntz and Wolff Classification
Class Description Treatment
Standard bone and soft
Class I Circulation adequate
tissue repair
Class II Arterial compromise only Vessel repair
Inadequate circulation with bone, tendon, or nerve
Class III Amputation
injury.
Class IV Complete degloving or complete amputation. Amputation
Class I injury. Class IIA injury. Only tendons and bone Class III injury. Complete amputation of
Circumferential skin remained intact. DIPJ was dislocated the ring finger at the PIPJ level (A).
injury with laceration and all neurovascular structures were Successful replantation was achieved
of extensor tendon, severed, leaving the digit avascular (B) but the patient had limited range of
FDS, FDP and open
with no capillary refill. motion and was out of work for 18
dislocation of PIPJ
and injury to volar months.
plate. One intact
neurovascular bundle
maintained good
circulation.
Presentation
History
o may have history of working with machinery, getting caught in door
Symptoms
o pain
o bleeding
o lack of sensation at tip
Physical exam
o inspection
irrigate wound and inspect for visible avulsed vessel,
nerve, tendon, damaged skin edges
staggered injury pattern
proximal skin avulsion (from PIPJ to base of digit)
distal bone fracture or dislocation (distal to PIPJ, II:8 Urbaniak Class III avulsion. Note trailing
often at DIPJ level) flexor tendon avulsed proximally at
musculotendinous junction
Imaging
Radiographs
o recommended views
Xray both segments (the amputated part, if present, and the remaining digit)
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
II:9 Radiograph of amputate shows level of amputation. Bone fracture/dislocation is distal to level of skin avulsion
Treatment
Initial
o place amputated part, if present, in bag with saline-moistened gauze, followed by bag of ice
water
o antibiotics and tetanus prophylaxis
Operative
o replantation +/- vein graft, DIPJ fusion
indications
disruption of venous drainage only
disruption of venous and arterial flow (requires revascularization)
requires intact PIPJ and FDS insertion
contraindication
complete amputation (especially proximal to PIPJ and FDS insertion) is relative
contraindication to replantation
outcomes
survival
lower overall survival for avulsed digits replantation (60%) than finger replantation in
general (90%)
lower survival for complete (66%) vs incomplete avulsion replantation (78%)
lower survival for avulsed thumb (68%) than finger (78%) replantation
surgeons more likely to attempt technically difficult avulsed thumb replantation
where conditions not favorable because of importance of thumb to hand function
(unlike other digits, where revision amputation would be performed instead)
sensibility
most achieve protective sensibility (2PD 9mm)
better sensibility with incomplete avulsion replantation (8mm) than complete (10mm)
range of motion
average total arc of motion (TAM) of 170-200 degrees
better TAM with incomplete avulsion replantation (199 degrees) than complete (174
degrees)
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o revision amputation
indications
complete degloving
bony injury with nerve and vessel injury
bony amputation proximal to FDS insertion or proximal to PIPJ
replantation likely to leave poor hand function
consider revision amputation or ray amputation
Surgical Technique
Replantation/revascularization
o approach
under operating microscope mid-lateral approach to digit
o technique
arteries
thorough debridement of nonviable tissue
thorough arterial debridement (inadequate debridement leads to failure)
repair using vein grafts because of significant vascular damage
may need another step-down vein graft because of difficulty in arterial size matching
(small artery, large vein graft)
may reroute arterial pedicle from adjacent digit
disadvantage is this sacrifices major artery from adjacent digit
veins
repair at least 2 veins
important factor in revascularization failure
bone
if amputation occurs at DIPJ, perform primary arthrodesis of DIPJ
skin
perform full-thickness skin grafts or venous flaps to prevent tight closure or may utilize
commercially available synthetic acellular dermal matrix.
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
Complications
Complications of replantation
o cold intolerance (70%)
o revascularization/replantation failure
factors include
most significant factor is repair of <2 veins
vascular damage up to digital pulp
smoking and level of bone injury have not been found to affect survival
o flexion contracture
o malunion
o revision surgery
Complications of revision amputation
o hyperaesthesia
3. Replantation
Introduction
Trauma is the most common etiology for upper extremity replantation
Epidemiology
o incidence
90% of upper extremity amputation occurred after trauma
o demographics
4:1 male-to-female ratio
o location
most amputations occur at the level of the digits
Pathophysiology
o mechanism of traumatic amputation
sharp dissection
blunt dissection
avulsion
crush
Presentation
History
o timing of injury
o type and location of amputation
number of digits involved
o preservation of amputated tissue
o associated injury
o past medical history
Examination
o stump examined for
zone of injury
tissue viability
supporting tissue structures
contamination
o amputated portion inspected
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segmental injury
bone and soft tissue envelope
contamination
Indications
Indications for replantation after trauma
o primary indications
thumb at any level
multiple digits
through the palm
wrist level or proximal to wrist
almost all parts in children
o relative indications
individual digits distal to the insertion of flexor digitorum superficialis [FDS] (Zone I)
ring avulsion
through or above elbow
Contraindications to replantation
o primary contraindications
severe vascular disorder
mangled limb or crush injury
segmental amputation
prolonged ischemia time with large muscle content (>6 hours)
o relative contraindications
single digit proximal to FDS insertion (Zone II)
medically unstable patient
disabling psychiatric illness
tissue contamination
prolonged ischemia time with no muscle content (>12 hours)
Treatment
Transport of amputated tissue
o indications
any salvageable tissue should be transported with the patient to hospital
o modality
keep amputated tissue wrapped in moist gauze in lactate ringers solution
place in sealed plastic bag and place in ice water (avoid direct ice or dry ice)
wrap, cover and compress stump with moistened gauze
Operative
o time to replantation
proximal to carpus
warm ischemia time < 6 hours
cold ischemia time < 12 hours
distal to carpus (digit)
warm ischemia time < 12 hours
cold ischemia time < 24 hours
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
Postoperative Care
Environment
o keep patient in warm room (80°F)
o avoid caffeine, chocolate, and nicotine
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Replant monitoring
o skin temperature most reliable
concerning changes include a > 2° drop in skin temp in less than one hour or a temperature
below 30° celsius
o pulse oximetry
< 94% indicates potential vascular compromise
Anticoagulation
o adequate hydration
o medications (aspirin, dipyridamile, low-molecular weight dextram, heparin)
Arterial Insufficiency
o treat with
release constricting bandages
place extremity in dependent position
consider heparinization
consider stellate ganglion blockade
early surgical exploration if previous measures unsuccessful
o thrombosis secondary to vasospasm is most common cause of early replant failure
Venous congestion
o treatment
elevate extremity
leech application
releases Hirudin (powerful anticoagulant)
Aeromonos hydrophila infection can occur (prophylax with Bactrim or ciprofloxacin)
heparin soaked pledgets if leeches not available
Complications
Replantation failure
o most frequently cause within 12 hours is arterial thrombosis from persistent vasospasm
Stiffness
o replanted digits have 50% of total motion
o tenolysis is most common secondary surgery
Myonecrosis
o greater concern in major limb replantation than in digit replantation
Myoglobinuria
o caused by muscle necrosis in larger replants (forearm and arm)
o can lead to renal failure and be fatal
Reperfusion injury
o mechanism thought to be related to ischemia-induced hypoxanthine conversion to xanthine
o allopurinol is the best adjunctive therapy agent to decrease xanthine production
Infection
Cold intolerance
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
4. Thumb Reconstruction
Introduction
Region A
Primary closure
Toe to Thumb (wrap
around)
Local flaps
Region B
Web deepening
Metacarpal lengthening
Toe to thumb
Region C
Toe to thumb
Osteoplastic thumb
reconstruction
Dorsal rotational flap
Region D
Pollicization
Reconstruction of the thumb requires an intact carpometarcarpal joint that not only is stable, but is
appropriately functional.
Treatment
Toe to thumb procedure
o great toe receives blood supply from the first dorsal metatarsal artery and dorsalis pedis
The Morrison/wrap around flap allow for maintenance of length of the hallux. Size and
appearance are best replicated.
o second toe is not as stable for transfer
Vascular pedicle can be based on
dorsalis pedis /1st dorsal metatarsal artery
2nd dorsal metatarsal artery
Web deepening
o Z plasty (2 or 4 flap)
2 flaps provide greater depth
if completed at 45 degrees, relative length is increased by 50%; 60 degrees leads to an
increase in length of 75%
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o Brand flap
index finger is used to provide a full thickness (dermoepidermal flap)
can close the donor site primarily
o Dorsal rectangular flaps
Take from dorsum of metacarpals
May require skin grafting
o Arterialized palmar flap
o May use axial or island flaps (locally vs distally)
Osteoplastic reconstruction
o Iliac crest is used to establish mechanical length to the thumb
o an island flap from the radial aspect of the 4th ray is combined with a reverse radial forearm flap
to aid in coverage
B. Reconstruction
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
o regeneration process after transection
distal segment undergoes Wallerian degeneration (axoplasm and myelin are degraded distally
by phagocytes)
existing Schwann cells proliferate and line up on basement membrane
proximal budding (occurs after 1 month delay) leads to sprouting axons that migrate at
1mm/day to connect to the distal tube
o variables affecting regeneration
contact guidance with attraction to the basal lamina of the Schwann cell
neurotropism
neurotrophism
neurotrophic factors (factors enhancing growth and preferential attraction to other nerves
rather than other tissues)
Prognosis
o factors affecting success of recovery following repair
age
is single most important factor influencing success of nerve recovery
level of injury
is second most important (the more distal the injury the better the chance of recovery)
sharp transections
have better prognosis than crush injuries
repair delay
worsen prognosis of recovery (time limit for repair is 18 months)
o return of function
pain is first modality to return
Anatomy
Highly organized structure consisting of nerve fibers, blood vessels, and connective tissue
Functional structures
o epineural sheath
surrounds peripheral nerve
o epineurium
surrounds a group of fascicles to form peripheral nerve
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OrthoBullets2017 Microsurgery | Reconstruction
o neuron cell
cell body - the metabolic center that makes up < 10% of cell mass
axon - primary conducting vehicle
dendrites - thin branching processes that receive input from surrounding nerve cells
Blood supply
o extrinsic vessels
run in loose connective tissue surrounding nerve trunk
o intrinsic vessels
plexus lies in epineurium, perineurium, and endoneurium
Physiology
o presynaptic terminal & depolarization
electrical impulse transmitted to other neurons or effector organs at presynaptic terminal
resting potential established from unequal distribution of ions on either side of the neuron
membrane (lipid bilayer)
action potential transmitted by depolarization of resting potential
caused by influx of Na across membrane through three types of Na channels
voltage gate channels
mechanical gated channels
chemical-transmitter gated channels
o nerve fiber types
Classification
Seddon Classification
o neurapraxia
same as Sunderland 1st degree, "focal nerve compression"
nerve contusion leading to reversible conduction block without Wallerian degeneration
histology
histopathology shows focal demyelination of the axon sheath (all structures remain intact)
usually caused by local ischemia
electrophysiologic studies
nerve conduction velocity slowing or a complete conduction block
no fibrillation potentials
prognosis
recovery prognosis is excellent
o axonotmesis
same as Sunderland 2nd degree
axon and myelin sheath disruption leads to conduction block with Wallerian degeneration
endoneurium remains intact
fibrillations and positive sharp waves on EMG
o neurotmesis
complete nerve division with disruption of endoneurium
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
no recovery unless surgical repair performed
fibrillations and positive sharp waves on EMG
Sunderland Classification
o 1st degree
same as Seddon's neurapraxia
o 2nd degree
same as Seddon's axonotmesis
o 3rd degree
included within Seddon's neurotmesis
injury with endoneurial scarring
most variable degree of ultimate recovery
o 4th degree
included within Seddon's neurotmesis
nerve in continuity but at the level of injury there is complete scarring across the nerve)
o 5th degree
included within Seddon's neurotmesis
Sunderland Myelin
Axon Endoneurim Perineurium Epineurium
Grade Sheath
I Disrupted Intact Intact Intact Intact
II Disrupted Disrupted Intact Intact Intact
III Disrupted Disrupted Disrupted Intact Intact
IV Disrupted Disrupted Disrupted Disrupted Intact
V Disrupted Disrupted Disrupted Disrupted Disrupted
Evaluation
EMG
o often the only objective evidence of a compressive neuropathy (valuable in workcomp patients
with secondary gain issues)
o characteristic findings
denervation of muscle
fibrillations
positive sharp waves (PSW)
fasiculations
neurogenic lesions
fasiculations
myokymic potentials
myopathies
complex repetitive discharges
myotonic discharges
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OrthoBullets2017 Microsurgery | Reconstruction
NCV
o focal compression / demyelination leads to
increase latencies (slowing) of NCV
distal sensory latency of > 3.2 ms are abnormal for CTS
motor latencies > 4.3 ms are abnormal for CTS
decreased conduction velocities less specific that latencies
velocity of < 52 m/sec is abnormal
motor action potential (MAP) decreases in amplitude
sensory nerve action potential (SNAP) decreases in amplitude
Treatment
Nonoperative
o observation with sequential EMG
indications
neuropraxia (1st degree)
axonotmesis (2nd degree)
Operative
o surgical repair
indications
neurotomesis (3rd degree)
o nerve grafting
indications
defects > 2.5 cm
type of autograft (sural, saphenous, lateral antebrachial, etc)
no effect on functional recovery
Surgical Techniques
Direct muscular neurotization
o insert proximal nerve stump into affected muscle belly
o results in less than normal function but is indicated in certain cases
Epineural Repair
o primary repair of the epineurium in a tension free fashion
o first resect proximal neuroma and distal glioma
o it is critical to properly align nerve ends during repair to maximize potential of recovery
Fasicular repair
o indications
three indications exist for grouped fascicular repair
median nerve in distal third of forearm
ulnar nerve in distal third of forearm
sciatic nerve in thigh
o technique
similar to epineural repair, but in addition repair the perineural sheaths (individual fascicles
are approximated under a microscope)
o outcomes
no improved results have been demonstrated over epineural repair
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
Nerve grafting
o autologous graft
indications
≥ 3cm gap
digital nerve defects
at wrist to common digital nerve bifurcation - use sural nerve
at MCP to DIP level - use lateral antebrachial cutaneous nerve
at DIP level - use AIN, PIN or medial antebrachial cutaneous nerve
outcomes
gold standard for segmental defects > 5cm
o collagen conduit
tensioned closures inhibit Schwann cell activation and axon regeneration, compromise
perfusion and lead to scarring
collagen conduits allow nutrient exchange and accessibility to neurotrophic factors to the
axonal growth zone during regeneration
indications
defects ≤ 2cm
outcomes
equal results to autologous grafting when gap ≤5mm
quality of nerve recovery drops with gaps >5mm
o allograft
off-the-shelf option for defects up to 5cm
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
Techniques
Fingertips & Hand
See Finger amputation and Flaps
Arm Flaps
Lateral arm flap • Lateral arm defects
• Blood supply by posterior radial collateral artery (branch of profunda brachii)
Leg Muscle Flaps
Medial Gastroc flap • Used for medial and midline defects over proximal third of tibia
• Pedicle supplied by medial sural artery
Lateral Gastroc
• Used for lateral defects over proximal third of tibia
flap
Soleus • Used for wounds over middle third of tibia
• Supplied by branches of the popliteal artery trunk, the posterior tibial artery
(medial), and the peroneal artery (proximal)
Gracilis • Most common donor for free muscle transfer
• Nerve is anterior division of obturator nerve
• Artery is branch of medial femoral circumflex artery
Free flaps • Used for wound coverage over distal third of tibia, or in the middle and
proximal leg when soleus and gastrocnemius are damaged
Groin flap • Axial flap that has been a mainstay of providing soft-tissue coverage of the
upper extremity
• Based on the superficial circumflex iliac artery
Bone Flaps
Free iliac crest • Based on deep circumflex iliac vessels
• Useful for metaphyseal reconstruction
Free fibula • Useful for diaphyseal reconstruction
• Based on peroneal artery pedicle
Vascular bone • Gaining popularity osteonecrosis of scaphoid fractures
graft from radius • Harvested from dorsal aspect of distal radius
• Based on 1-2 intercompartmental superretinacular artery (branch of radial
artery)
• Indicated to reduce the space left between the index and ring finger following
Index metacarpal
middle ray amputation. An alternative technique is deep transvers
transposition
intermetacarpal ligament reconstruction.
Little metacarpal • Indicated to reduce the space left between the middle and little finger
transposition following ring ray amputation.
Technique
Ladder of reconstruction
o in order of increasing complexity
primary closure
secondary closure
healing by secondary intention
skin graft
local flap
regional flap
free tissue transfer
Complications
Flap Failure
o inadequate arterial flow
treatment II:10 Clinical photograph showing venous congestion after
immediate return to operating room free anterolateral thigh flap to the forearm.
o inadequate venous outflow
treatment
loosen dressings, removal of selected sutures
return to operating room if not relieved by above measure
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
Donor site morbidity
o may be cosmetically unacceptable
o pain related to grafting
o seroma
treatment
aspiration
excision if encapsulated
Nonunion for vascularized bone transfer
o incidence
may be as high as 32% if no additional bone graft is used
3. Skin Grafting
Introduction
A skin graft is an avascular graft and consists of
o partial-thickness dermal tissue
o full-thickness dermal tissue
Donor site
o most commonly autologous
Goals of treatment
o cover deep structures
o create a barrier to bacteria,
o restore dynamic function of the limb
o prevent joint contractures
Indications
o well-perfused wound beds over muscle or subcutaneous tissue
Contraindications
o wounds with exposed bone, tendon, nerves, or blood vessels
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
should transfer motor grade 5
o appropriate tensioning
o appropriate excursion
can adjust with pulley or tenodesis effect
Smith 3-5-7 rule
3 cm excursion - wrist flexors, wrist extensors
5 cm excursion - EDC, FPL, EPL
7 cm excursion - FDS, FDP
o surgical priorities
elbow flexion (musculocutaneous n.)
shoulder stabilization (suprascapular n.)
brachiothoracic pinch (pectoral n.)
sensation C6-7 (lateral cord)
wrist extension and finger flexion (lateral and posterior cords)
o selection
determine what function is missing
determine what muscle-tendon units are available
evaluate the options for transfer
o basic principles
donor must be expendable and of similar excursion and power
one tendon transfer performs one function
synergistic transfers rehabilitate more easily
it is optimal to have a straight line of pull
one grade of motor strength is lost following transfer
Prognosis
o age
leading prognostic factor
worse after age 30
o location
distal is better than proximal
Presentation
Physical exam
o brachial plexus injury
Horner's sign
correlates with C8-T1 avulsion
often appears 2-3 days following injury
severe pain in anesthetic limb
indication of root avulsion
loss of rhomboid function
indication of root avulsion
o radial nerve palsy
classified according to location of lesion proximal or distal to the origin of PIN
low radial nerve palsy
PIN syndrome
high radial nerve palsy
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OrthoBullets2017 Microsurgery | Reconstruction
loss of radial nerve proper function (triceps, brachioradialis, ECRL plus muscles
innervated by PIN)
o median nerve palsy
classified according to location of lesion proximal or distal to the origin of AIN
low median nerve palsy
loss of thumb opposition (APB function)
high median nerve palsy
loss of thumb opposition
loss of thumb, index finger, and middle finger flexion
o ulnar nerve palsy
low ulnar nerve palsy
loss of power pinch
II:11 Wartenberg sign
abduction of the small finger (Wartenberg sign)
clawing
results from imbalance between intrinsic and extrinsic muscles
high ulnar nerve palsy
loss of ring and small finger FDP function
primary distinguishing deficit
clawing less pronounced because extrinsic flexors are not functioning
Studies
Sensory and motor evoked potentials
o better than standard EMG/NCS
Treatment
Nonoperative
o physical therapy, splinting, and antispasticity medications
indications
decreased passive range of motion
spasticity
Operative
o early surgical intervention (3 weeks to 3 months)
indications
total or near-total brachial plexus injury
high energy injury
o late surgical intervention (3 to 6 months)
indications
partial upper-level brachial plexus palsy
low energy injury
postoperative care
protect for 3-4 weeks then begin ROM
continue with protective splint for 3-6 weeks
synergistic transfers are easier to rehabilitate (synergistic actions occur together in normal
function, e.g., finger flexion and wrist extension)
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
Specific Transfers & Indications
Goal to regain FROM: Donor tendon (working) TO: Recipient Tendon (deficient)
Axillary nerve palsy
Shoulder stability glenohumeral arthrodesis glenohumeral arthrodesis
(flail shoulder)
Musculocutaneous nerve palsy
Elbow flexion pectoralis major, latissimus dorsi to biceps
Elbow flexion common flexor mass point more proximal on humerus
(Steindler flexorplasty)
Radial nerve & PIN palsy
Elbow extension deltoid, latissimus dorsi, or biceps to triceps
Wrist extension PT ECRB
Finger extension FDS, FCR, or FCU EDC
Thumb extension PL or FDS EPL
Low median nerve palsy
Thumb opposition FDS (ring) base proximal phalanx or APB tendon
and abduction (use FCU as pulley - classic Bunnell
opponensplasty)
EIP APB (pulley around ulnar side of wrist)
High median nerve palsy
Thumb IP flexion BR FPL
Index and long FDP of ring and small finger (ulnar FDP of index and middle (side-to-side
finger flexion nerve) transfer)
Ulnar nerve palsy
Thumb adduction FDS or ECRB adductor pollicis
Finger abduction APL, ECRL, or EIP 1st dorsal interosseous
(index most
important)
Reverse clawing FDS, ECRL (must pass volar to lateral bands of ulnar digits
effect transverse metacarpal ligament to flex
proximal phalanx)
Complications
Adhesions
o necessitate aggressive therapy and possible secondary tenolysis
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OrthoBullets2017 Neuropathies | Reconstruction
ORTHO BULLETS
III.Neuropathies
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By Dr, AbdulRahman AbdulNasser Neuropathies | Median Neuropathies
A. Median Neuropathies
Presentation
Symptoms
o numbness and tingling in radial 3-1/2 digits
o clumsiness
o pain and paresthesias that awaken patient at night
o self administered hand diagram
the most specific test (76%) for carpal tunnel syndrome
Physical exam
III:1 thenar atrophy
o inspection may show thenar atrophy
o carpal tunnel compression test (Durkan's test)
is the most sensitive test to diagnose carpal tunnels syndrome
performed by pressing thumbs over the carpal tunnel and holding pressure for 30 seconds.
onset of pain or paresthesia in the median nerve distribution within 30 seconds is a
positive result.
o Phalen test
wrist volar flexion for ~60 sec produces symptoms
less sensitive than Durkin compression test
o Tinel's test
provocative tests performed by tapping the median nerve over the volar carpal tunnel
o Semmes-Weinstein testing
most sensitive sensory test for detecting early carpal tunnel syndrome
measures a single nerve fiber innervating a receptor or group of receptors
o innervation density test
static and moving two-point discrimination
measures multiple overlapping of different sensory units and complex cortical integration
the test is a good measure for assessing functional nerve regeneration after nerve repair
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By Dr, AbdulRahman AbdulNasser Neuropathies | Median Neuropathies
Imaging
Radiographs
o not necessary for diagnosis
Studies
Diagnostic criteria
o numbness and tingling in the median nerve distribution
o nocturnal numbness
o weakness and/or atrophy of the thenar musculature
o positive Tinel sign
o positive Phalen test
o loss of two point discrimination
EMG and NCV
o overview
often the only objective evidence of a compressive neuropathy (valuable in work comp
patients with secondary gain issues)
not needed to establish diagnosis (diagnosis is clinical) but recommended if surgical
management is being considered
o demyelination leads to
NCV
increase latencies (slowing) of NCV
distal sensory latency of > 3.2 ms
motor latencies > 4.3 ms
decreased conduction velocities less specific than latencies
velocity of < 52 m/sec is abnormal
EMG
test the electrical activity of individual muscle fibers and motor units
detail insertional and spontaneous activity
potential pathologic findings
increased insertional activity
sharp waves
fibrillations
fasciculations
complex repetitive discharges
Histology
o nerve histology characterized by
edema, fibrosis, and vascular sclerosis are most common findings
scattered lymphocytes
amyloid deposits shown with special stains in some cases
Treatment
Nonoperative
o NSAIDS, night splints, activity modifications
indications
first line of treatment
modalities
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OrthoBullets2017 Neuropathies | Median Neuropathies
Technique
Open carpal tunnel release
o antibiotics
prophylactic antibiotics, systemic or local, are not indicated for patients undergoing a clean,
elective carpal tunnel release
o technique
internal neurolysis, tenosynovectomy, and antebrachial fascia release do not improve
outcomes
Guyon's canal does not need to be released as it is decompressed by carpal tunnel release
lengthened repair of transverse carpal ligament only required if flexor tendon repair
performed (allows wrist immobilization in flexion postoperatively)
o complications
correlate most closely with experience of surgeon
incomplete release
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By Dr, AbdulRahman AbdulNasser Neuropathies | Median Neuropathies
progressive thenar atrophy due to injury to an unrecognized transligamentous motor branch
of the median nerve
Endoscopic carpal tunnel release
o advantage is accelerated rehabilitation
o long term results same as open CTR
o most common complication is incomplete division of transverse carpal ligament
Presentation
Symptoms
o motor deficits only
o no complaints of pain, unlike other median compression
neuropathies (carpal tunnel syndrome and pronator syndrome)
Physical exam
o weakness of grip and pinch, specifically thumb, index and middle finger flexion
o patient unable to make OK sign (test FDP and FPL)
o pronator quadratus weakness shown with weak resisted pronation with elbow maximally flexed
o distinguish from FPL attritional rupture (seen in rheumatoids) by passively flexing and extending
wrist to confirm tenodesis effect in intact tendon
if tendons intact, passive wrist extension brings thumb IP joint and index finger DIP joint into
relatively flexed position
Evaluation
NCV / EMG
o helpful to make diagnosis
o may reveal abnormalities in the FPL, FDP index and middle finger and pronator quadratus
muscles
o assess severity of neuropathy
o may rule out more proximal lesions
Treatment
Nonoperative
o observation, rest and splinting in 90° flexion
indications
in vast majority of patients, unless clear space occupying mass
majority will improve with nonoperative management
technique : elbow splinting in 90 degrees of flexion (8-12 weeks)
Operative
o surgical decompression of AIN
indications
if nonoperative treatment fails after several months
approximately 75% success rate of surgical decompression
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By Dr, AbdulRahman AbdulNasser Neuropathies | Median Neuropathies
Techniques
Surgical decompression of AIN
o technique
release of superficial arch of FDS and lacertus fibrosus
detachment of superficial head of pronator teres
ligation of any crossing vessels
removal of any space occupying lesion
Complications
Recurrence
3. Pronator Syndrome
Introduction
A compressive neuropathy of the median nerve at the level of the elbow
Epidemiology
o more common in women
o common in 5th decade
o has been associated with well-developed forearm muscles (e.g.
weight lifters)
Pathoanatomy
o 5 potential sites of entrapment include
supracondylar process
residual osseous structure on distal humerus present in 1% of
population
ligament of Struthers
travels from tip of supracondylar process to medial epicondyle
not to be confused with arcade of Struthers which is a site of ulnar compression
neuropathy in cubital tunnel syndrome
bicipital aponeurosis (a.k.a. lacertus fibrosus)
between ulnar and humeral heads of pronator teres
FDS aponeurotic arch
Associated conditions
o commonly associated with medial epicondylitis
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OrthoBullets2017 Neuropathies | Median Neuropathies
Presentation
Symptoms
o paresthesias in thumb, index, middle finger and radial half of ring finger as seen in carpal tunnel
syndrome
in pronator syndrome paresthesias often made worse with repetitive pronosupination
o should have characteristics differentiating from carpal tunnel syndrome (CTS)
aching pain over proximal volar forearm
sensory disturbances over the distribution of palmar cutaneous branch of the median
nerve (palm of hand) which arises 4 to 5 cm proximal to carpal tunnel ( see photos next page)
lack of night symptoms
Physical exam
o provocative tests are specific for different sites of entrapment
positive Tinel sign in the proximal anterior forearm but no Tinel sign at wrist nor provocative
symptoms with wrist flexion as would be seen in CTS
resisted elbow flexion with forearm supination (compression at bicipital aponeurosis)
resisted forearm pronation with elbow extended (compression at two heads of pronator teres)
resisted contraction of FDS to middle finger (compression at FDS fibrous arch)
o possible coexisting medial epicondylitis
Imaging
Radiographs
o recommended views
elbow films are mandatory
o findings
may see supracondylar process
Studies
EMG and NCV
o may be helpful if positive but are usually inconclusive
o may exclude other sites of nerve compression or identify double-crush syndrome
Treatment
Nonoperative
o rest, splinting, and NSAIDS for 3-6 months
indications
mild to moderate symptoms
technique
splint should avoid forearm rotation
Operative
o surgical decompression of median nerve
indications
only when nonoperative management fails for 3-6 months
technique
decompression of the median nerve at all 5 possible sites of compression
outcomes
of surgical decompression are variable
80% of patients having relief of symptoms
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
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OrthoBullets2017 Neuropathies | Ulnar Neuropathies
B. Ulnar Neuropathies
Anatomy
Ulnar nerve
o pierces intramuscular septum at arcade of Struthers 8 cm proximal to the medial epicondyle as it
passes from the anterior to posterior compartment of the arm
o enters cubital tunnel
Cubital tunnel
o roof
formed by FCU fascia and Osborne's ligament (travels from the medial epicondyle to the
olecranon)
o floor
formed by posterior and transverse bands of MCL and elbow joint capsule
o walls
formed by medial epicondyle and olecranon
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
Presentation
Symptoms
o paresthesias of small finger, ulnar half of ring finger, and ulnar dorsal hand
exacerbating activities include
cell phone use (excessive flexion)
occupational or athletic activities requiring repetitive elbow flexion and valgus stress
o night symptoms
caused by sleeping with arm in flexion
Physical exam
o inspection and palpation
interosseous and first web space atrophy
ring and small finger clawing
observe ulnar nerve subluxation over the medial epicondyle as the elbow moves through a
flexion-extension arc
o sensory
decreased sensation in ulnar 1-1/2 digits
o motor
loss of the ulnar nerve results in paralysis of intrinsic muscles (adductor pollicis, deep head
FPB, interossei, and lumbricals 4 and 5) which leads to
weakened grasp
from loss of MP joint flexion power
weak pinch
from loss of thumb adduction (as much as 70% of pinch strength is lost)
Froment sign
compensatory thumb IP flexion by FPL (AIN) during key pinch
compensates for the loss of MCP flexion by adductor pollicis (ulna n.)
adductor pollicis muscle normally acts as a MCP flexor, first metacarpal
adductor, and IP extensor
Jeanne sign
compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.)
with key pinch
Compensates for loss of IP extension and thumb adduction by adductor pollicis
(ulna n.)
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OrthoBullets2017 Neuropathies | Ulnar Neuropathies
Studies
EMG / NCV
o helpful in establishing diagnosis and prognosis
o threshold for diagnosis
conduction velocity <50 m/sec across elbow
low amplitudes of sensory nerve action potentials and compound muscle action potentials
Treatment
Nonoperative
o NSAIDs, activity modification, and nighttime elbow extension splinting
indications
first line of treatment with mild symptoms
technique
night bracing in 45° extension with forearm in neutral rotation
outcomes
management is effective in ~50% of cases
Operative
o in situ ulnar nerve decompression without transposition
approach
elbow medial approach
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
indications
when nonoperative management fails
before motor denervation occurs
technique
open release of cubital tunnel retinaculum
endoscopically-assisted cubital tunnel release
favorable early results but lacks long-term data
outcomes
meta-analyses have shown similar clinical results with significantly fewer complications
compared to decompression with transposition
80-90% good results when symptoms are intermittent and denervation has not yet
occurred
poor prognosis correlates most with intrinsic muscle atrophy
o ulnar nerve decompression and anterior transposition
indications
failed in situ release
throwing athlete
patient with poor ulnar nerve bed from tumor, osteophyte, or heterotopic bone
technique
subcutaneous, submuscular, or intramuscular transposition
outcomes
similar outcomes to in situ release but increased risk of creating a new point of
compression
o medial epicondylectomy
indications
visible and symptomatic subluxating ulnar nerve
technique
in situ release with medial epicondylectomy
outcomes
risk of destabilizing the medial elbow by damaging the medial ulnar collateral ligament
Complications
Recurrence
o secondary to inadequate decompression, perineural scarring, or tethering at the intermuscular
septum or FCU fascia
o higher rate of recurrence than after carpal tunnel release
Neuroma formation
o iatrogenic injury to a branch of the medial antebrachial cutaneous nerve may cause persistent
posteromedial elbow pain
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OrthoBullets2017 Neuropathies | Ulnar Neuropathies
Anatomy
Guyon’s canal
o course
is approximately 4 cm long
begins at the proximal extent of the transverse carpal ligament and ends at the aponeurotic
arch of the hypothenar muscles
o contents
ulnar nerve bifurcates into the superficial sensory and deep motor branches
o boundaries and zones (see table below)
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
III:2 Zones of the ulnar tunnel (Zone 1: ulnar nerve, motor and sensory. Zone 2: deep motor branch. Zone 3: superficial sensory branch.)
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OrthoBullets2017 Neuropathies | Ulnar Neuropathies
Deep branch of the ulnar nerve
o innervates all of the interosseous muscles and the 3rd and 4th lumbricals.
o Innervates the hypothenar muscles, the adductor pollicis, and the medial head (deep) of the
flexor pollicis brevis (FPB)
Classification
Presentation varies based on location of compression within Guyon's canal and may be
o Motor only
o Sensory only
o Mixed Motor & Sensory
Presentation
Presentation varies based on location of compression within Guyon's canal and may be
o pure motor
o pure sensory
o mixed motor and sensory
Symptoms
o pain and paresthesias in ulnar 1-1/2 digits
o weakness to intrinsics, ring and small finger digital flexion or thumb adduction
Physical exam
o inspection & palpation
clawing of ring and little fingers
caused from loss of intrinsics flexing the MCPs and extending the IP joints
Allen test
helps diagnose ulnar artery thrombosis
o neurovascular exam
ulnar nerve palsy results in paralysis of the intrinsic muscles (adductor pollicis, deep head
FPB, interossei, and lumbricals 4 and 5)
weakened grasp
from loss of MP joint flexion power
weak pinch
from loss of thumb adduction (as much as 70% of pinch strength is lost)
Froment sign
IP flexion compensating for loss of thumb adduction when attempting to hold a piece of
paper
loss of MCP flexion and adduction by adductor pollicis (ulnar n.)
compensatory IP hyperflexion by FPL (AIN)
Jeane's sign
a compensatory thumb MCP
hyperextension and thumb adduction by EPL (radial
n.)
compensates for loss of IP extension and thumb
adduction by adductor pollicis (ulna n.)
Wartenberg sign
abduction posturing of the little finger III:3 Wartenberg sign
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
Imaging
Radiographs
o useful to evaluate hook of hamate fractures
CT scan
o useful to evaluate hook of hamate fractures
MRI
o useful to evaluate for a ganglion cysts
Studies
NCS and EMG
o helpful in establishing diagnosis and prognosis
o threshold for diagnosis
conduction velocity <50 m/sec across elbow
low amplitudes of sensory nerve action potentials and compound muscle action potentials
Differential
How to differentiate ulnar tunnel syndrome from cubital tunnel syndrome
o cubital tunnel demonstrates
less clawing
sensory deficit to dorsum of the hand
motor deficit to ulnar-innervated extrinsic muscles
Tinel sign at the elbow
positive elbow flexion test
Treatment
Nonoperative
o activity modification, NSAIDS and splinting
indications
as a first line of treatment when symptoms are mild
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OrthoBullets2017 Neuropathies | Radial Neuropathies
Operative
o local decompression
indications
severe symptoms that have failed nonoperative treatment
o tendon transfers
indications
correction of clawed fingers
loss of power pinch
Wartenberg sign (abduction of small finger)
o carpal tunnel release
indications
patients diagnosed with both ulnar tunnel syndrome and CTS
Techniques
Local surgical decompression
o release hypothenar muscle origin
o decompress ganglion cysts
o resect hook of hamate
o vascular treatment of ulnar artery thombosis
o explore and release all three zones in Guyon's canal
Tendon transfers
o correct claw fingers
possible grafts include ECRL, ECRB, palmaris longus
tendons must pass volar to transverse metacarpal ligament in order to flex the proximal
phalanx
attach with either a two or four-tailed graft to the A2 pulley of the ring and small fingers
o restore power pinch
Smith transfer using ECRB or FDS of ring finger
o restore adduction of small finger
transfer ulnar insertion of EDM to A1 pulley or radial collateral ligament of the small finger
Complications
Recurrance
C. Radial Neuropathies
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
o mechanism of injury
microtrauma
from repetitive pronosupination movements
trauma
fracture/dislocation (e.g., monteggia fx, radial head
fx, etc)
space filling lesions
e.g. ganglion, lipomas, etc
inflammation
e.g. rheumatoid synovitis of radiocapitellar joint
iatrogenic (surgery)
o pathoanatomy:
five potential sites of compression include
fibrous tissue anterior to the radiocapitellar joint
between the brachialis and brachioradialis
“leash of Henry”
are recurrent radial vessels that fan out across
the PIN at the level of the radial neck
extensor carpi radialis brevis edge
medio-proximal edge of the extensor
carpi radialis brevis
"arcade of Fröhse"
which is the proximal edge of the superficial portion of the supinator
supinator muscle edge
distal edge of the supinator muscle
Anatomy
PIN
o origin
PIN is a branch of the radial nerve that provides motor innervation to the extensor
compartment
o course
passes between the two heads of origin of the supinator muscle
direct contact with the radial neck osteology
passes over abductor pollicis longus muscle origin to reach interosseous membrane
transverses along the posterior interosseous membrane
o innervation
motor
common extensors
ECRB (often from radial nerve proper, but can be from PIN)
Extensor digitorum communis (EDC)
Extensor digiti minimi (EDM)
Extensor carpi ulnaris (ECU)
deep extensors
Supinator
Abductor pollicis longus (APL)
Extensor pollicus brevis (EPB)
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OrthoBullets2017 Neuropathies | Radial Neuropathies
III:4 Bifurcation of the radial nerve (R) into the PIN and superficial radial nerve (SR). The PIN passes between the superficial (Ss) and deep
(Sd) heads of the supinator before entering the posterior compartment of the forearm.
Presentation
Symptoms
o insidious onset, often goes undiagnosed
o defining symptoms
pain in the forearm and wrist
location depends on site of PIN compression
e.g., pain just distal to the lateral epicondyle of the elbow may be caused by
compression at the arcade of Frohse
weakness with finger, wrist and thumb movements
Physical exam
o inspection
chronic compression may cause forearm extensor compartment muscle atrophy
o motion
weakness
finger metacarpal extension weakness
wrist extension weakness
inability to extend wrist in neutral or ulnar deviation
the wrist will extend with radial deviation due to intact ECRL (radial n.) and absent
ECU (PIN).
o provocative tests
resisted supination
will increase pain symptoms
normal tenodesis test
tenodesis test is used to differentiate from extensor tendon rupture from RA
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Evaluation
Radiographs
o indications
not commonly needed for the diagnosis of PIN compression syndrome
MRI
o indications
not commonly needed for the diagnosis of PIN compression syndrome
may be help to site and delineate the soft tissue mass responsible for compression
helpful for surgical planning of mass resection
Studies
EMG
o indications
may help identify the level of nerve compression
may be used to rule out differential diagnoses of neuropathy
Differential
Cervical spine nerve compression
Brachial plexus compression
Peripheral neuropathy
Treatment
Nonoperative
o rest, activity modification, stretching, splinting, NSAIDS
indications
recommended as first-line treatment for all cases
o lidocaine/corticosteroid injection
indications
a compressive mass, such as lipoma or ganglion, has been ruled out
isolated tenderness distal to lateral epicondyle
trial of rest, activity modification, anti-inflammatories were not effective
technique
single injection 3-4 cm distal to lateral epicondyle at site of compression
o surgical decompression
indications
symptoms persist for greater than three months of nonoperative treatment
compressive mass detected on imaging
outcomes
results are variable
spontaneous recovery of motor function was seen in 75 - 97% of non-traumatic case
series
may continue to improve for up to 18 months
Technique
Surgical decompression
o approach
anterolateral approach to elbow is most common approach
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OrthoBullets2017 Neuropathies | Radial Neuropathies
may also consider posterior approach
o decompression
decompression should begin with release of
fibrous bands connecting brachialis and brachioradialis
leash of Henry
fibrous edge of ECRB
radial tunnel, including arcade of Frosche and distal supinator
Complications
Neglected PIN compression syndrome
o muscle fibrosis of PIN innervated muscles
o resulting in tendon transfer procedures to re-establish function
Chronic pain
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Anatomy
Radial Tunnel
o 5cm in length
o from the level of the radiocapitellar joint, extending distally past the proximal edge of the
supinator
o boundaries
lateral
brachioradialis
ECRL
ECRB
medial
biceps tendon
brachialis
floor
capsule of the radiocapitellar joint
III:5 leash of Henry
PIN
o origin
PIN is a branch of the radial nerve that provides motor innervation to the extensor
compartment
o course
passes between the two heads of origin of the supinator muscle
direct contact with the radial neck osteology
passes over abductor pollicis longus muscle origin to reach interosseous membrane
transverses along the posterior interosseous membrane
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OrthoBullets2017 Neuropathies | Radial Neuropathies
o innervation
motor
common extensors
ECRB (often from radial nerve proper, but can be from PIN)
Extensor digitorum communis (EDC)
Extensor digiti minimi (EDM)
Extensor carpi ulnaris (ECU)
deep extensors
Supinator
Abductor pollicis longus (APL)
Extensor pollicus brevis (EPB)
Extensor pollicus longus (EPL)
Extensor indicis proprius (EIP)
sensory
sensory fibers to dorsal wrist capsule
provided by terminal branch which is located on the floor of the 4th extensor
compartment
no cutaneous innervation
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Presentation
Symptoms
o deep aching pain in dorsoradial proximal forearm
from lateral elbow to wrist
increases during forearm rotation and lifting activities
o muscle weakness
because of pain and not muscle denervation
Physical exam
o tenderness
over mobile wad over the supinator arch
maximal tenderness is 3-5cm distal to lateral epicondyle
more distal than lateral epicondylitis
o provocative tests
resisted long finger extension test
reproduces pain at radial tunnel (weakness because of pain)
resisted supination test (with elbow and wrist in extension)
reproduces pain at radial tunnel (weakness because of pain)
passive pronation with wrist flexion
reproduces pain at radial tunnel
passive stretch of supinator muscle increases pressure inside radial tunnel to 250mmHg
(normal 50mmHg)
radial tunnel injection test
diagnostic if injection leads to a PIN palsy and relieves pain
o sensory
may have paresthesias in the first dorsal web space
o motor
no motor manifestations
Imaging
Axial fat suppressed T2 MRI Transverse T1-weighted MRI Transverse T1-weighted MRI
demonstrates fluid anterior to showing hypertrophic leash of showing normal leash of Henry
the radius (arrow) and edema in Henry (arrows) (SRN, superficial (arrows)(SRN, superficial radial
the supinator (arrowheads). radial nerve; PIN, posterior nerve; PIN, posterior
interosseous nerve) interosseous nerve)
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OrthoBullets2017 Neuropathies | Radial Neuropathies
MRI
o usually negative
o indications
to identify muscle changes in muscles innervated by PIN
denervation edema/atrophy within the supinator/extensor
to evaluate compression sites
may show thickened edge of ECRB, prominent radial recurrent vessels (leash of Henry),
swelling of PIN
to identify other causes of entrapment (rare)
tumors, ganglia, radiocapitellar synovitis, bicipital bursitis, radial head fractures and
dislocations
Studies
Electrodiagnostic studies
o EMG/NCV are inconclusive because
PIN carries unmyelinated Group IV fibers (C-fibers, nociception) and small myelinated
Group IIA afferent fibers (temperature)
pressure on these fibers produces pain
these fibers cannot be evaluated by EMG/NCV
the large myelinated fibers of PIN remain normal, producing normal EMG/NCV
Diagnostic injection
o injection of local anesthetic (LA) into the area of localized tenderness
o ensure that LA does not spread to lateral epicondyle
Differential Diagnosis
Lateral epicondylitis
o both conditions coexist in 5% of patients
o in lateral epicondylitis, tenderness is directly over the lateral epicondyle
o in RTS, tenderness is 3-5cm distal to the lateral epicondyle
Cervical radiculopathy at C6-7
o electrodiagnostic studies may show denervation
Treatment
Nonoperative
o activity modification, temporary splinting, NSAIDS
indications
first line of treatment for at least one year
technique of activity modification
avoid prolonged elbow extension with forearm pronation and wrist flexion
o corticosteroid injection
indications
both diagnostic and therapeutic
outcomes
70% improvement at 6 weeks
60% pain free at 2 years
Operative
o radial tunnel release
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Techniques
Radial tunnel release
o approach
dorsal approaches to the PIN
3 planes have been described
between ECRB and EDC
between brachioradialis and ECRL
transmuscular brachioradialis-splitting
anterior approach to the PIN
between brachioradialis and biceps
o technique
release arcade of Frohse
release distal edge of supinator
release fibrous bands superficial to the radiocapitellar joint
o outcomes
success rate of surgical decompression is 70-90%
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OrthoBullets2017 Neuropathies | Radial Neuropathies
3. Wartenberg's Syndrome
Introduction
Definition
o compressive neuropathy of the superficial sensory radial nerve (SRN)
o also called "cheiralgia paresthetica"
o sensory manifestation only
o no motor deficits
Epidemiology
o incidence
rare
o demographics
male:female ratio is 1:4, more common in women
age bracket is 20-70 years
Pathoanatomy
o SRN compressed by scissoring action
of brachioradialis and ECRL tendons during forearm
pronation
o also by fascial bands at its exit site in the subcutaneous III:7 With the forearm SUPINATED, SRN lies
plane between BR and ECRL without compression.
With the forearm PRONATED, ECRL crosses
Associated conditions
beneath BR, creating scissoring (pinching) of the
o associated with De Quervain's disease in 20-50% SRN.
Prognosis
o spontaneous resolution of symptoms is common
o treatment outcomes
74% success after surgical decompression
Anatomy
The superficial sensory branch of the radial nerve
o arises from the bifurcation of the radial nerve in the proximal forearm
o travels deep to the brachioradialis in the forearm
o emerges from between brachioradialis and ECRL 9cm proximal to radial styloid
o bifurcates proximal to the wrist
dorsal branch lies 1-3cm radial to Lister's tubercle
supplies 1st and 2nd web space
palmar branch passes within 2cm of 1st dorsal compartment, directly over EPL
supplies dorsolateral thumb
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Presentation
History
o may have history of trauma
forearm fracture
handcuffs
tight wrist band, wristwatch band, bracelet or plaster cast
Symptoms
o ill-defined pain over dorsoradial hand (does not like to wear watch)
o paresthesias over dorsoradial hand
o numbness
o symptom aggravation by motions involving repetitive wrist flexion and ulnar deviation
o no motor weakness
Physical exam
o provocative tests
Tinel's sign over the superficial sensory radial nerve (most common exam finding)
wrist flexion, ulnar deviation and pronation for one minute
Finkelstein test increases symptoms in 96% of patients
because of traction on the nerve
Imaging
Radiographs
o of limited value
o may demonstrate old forearm fracture
Studies
Electrodiagnostic tests
o EMG and NCV of limited value
Diagnostic injection III:8 Palmar ulnar flexion of the wrist
puts maximum traction on the nerve
o diagnostic wrist block may temporarily relieve pain
Differential
De Quervain's tenosynovitis
o pain is not aggravated by wrist pronation, unlike Wartenberg Syndrome
Lateral antebrachial cutaneous nerve (LACN) neuritis
o positive Tinel's sign over LACN can be mistaken for positive Tinel's over superficial sensory
radial nerve
Intersection syndrome
o may have dorsoradial forearm swelling
o symptom exacerbation and "wet leather" crepitus on repeated wrist flexion/extension
Treatment
Nonoperative
o rest, activity modification, NSAIDS, and wrist splints
indications : first line of treatment
techniques
avoid aggravating activities
remove inciting factors (e.g. tight wristwatch band)
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OrthoBullets2017 Neuropathies | Radial Neuropathies
o corticosteroid injection
although evidence to support this is limited
Operative
o surgical decompression
indications
symptoms persist after 6 months
Surgical Technique
Surgical Decompression
o approach
longitudinal incision volar to Tinel's sign
to avoid injury to LACN
to avoid tethering of incision scar over SRN
o decompression technique
neurolysis and release of fascia between brachioradialis and ECRL
Complications
Failed decompression
Persistent pain and numbness
Wound dehiscence
Infection
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In July 2017
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Radial Neuropathies
ORTHO BULLETS
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OrthoBullets2017 Degenerative Conditions | Hand Deformities
A. Hand Deformities
Pathoanatomy
Pathoanatomic components
o loss of intrinsics
leads to loss of baseline MCP flexion and loss of IP extension
o strong extrinsic EDC
leads to unopposed extension of the MCP joint
remember the EDC is not a significant extensor of the PIP joint
most of the MCP extension forces on the terminal insertion of the central slip come from
the interosseous muscles
o strong FDP and FDS
leads to unopposed flexion of the PIP and DIP
Presentation
Symptoms
o decreased hand function
Physical exam
o MCP hyperextension and IP joint flexion
with an ulnar nerve palsy, the deformity will be worse in the 4th and 5th digits (lumbricals
innervated by the ulnar nerve)
not as severe in the 2nd and 3rd digits (lumbricals innervated by the median nerve)
o functional weakness
unable to perform prehensile grasp
diminished grip and pinch strength
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
o provocative tests
if MCP joints are brought out of hyperextension, the flexion deformity of the DIP & PIP will
correct
Treatment
Operative
o contracture release and passive tenodesis vs. active tendon transfer
indications
progressive deformity that is affecting quality of life
technique
goal is to prevent MCP joint hyperextension
Presentation
Symptoms
o difficulty gripping large objects
Physical exam
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OrthoBullets2017 Degenerative Conditions | Hand Deformities
o inspection
MCP joint flexion and IP joint extension
o provocative tests
Bunnell test (intrinsic tightness test)
differentiates intrinsic tightness and extrinsic tightness
positive test when PIP flexion is less with MCP extension than with MCP flexion
Imaging
Radiographs
o no radiographs required in diagnosis or treatment
Treatment
Nonoperative
o passive stretching
indications
mild cases
Operative
IV:1 Note the MCP flexion and IP joint extension.
o proximal muscle slide This makes grasping large objects challenging.
indications
less severe deformities when there is some remaining function of the intrinsics (e.g.,
spastic intrinsics)
o distal instrinsic release (distal to MP)
indications
more severe deformity involving both MCP and IP joints
dysfunctional intrinsic muscles (e.g., fibrotic)
Surgical Techniques
Proximal muscle slide
o techinque
subperiosteal elevation of interossei lengthens muscle-tendon unit
Distal intrinsic release
o technique
resection of intrinsic tendon distal to the transverse fibers responsible for MCP joint flexion
3. Boutonniere Deformity
Introduction
A Zone III extensor tendon injury characterized by
o PIP flexion
o DIP extension
Mechanism
o caused by rupture of the central slip over PIP joint from
laceration
traumatic avulsion (jammed finger)
capsular distension in rheumatoid arthritis
Pathoanatomy
o pathoanatomic sequence includes
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
rupture of central slip
causes the extrinsic extension mechanism from the EDC to be lost
prevents extension at the PIP joint
attenuation of triangular ligament
causes intrinsic muscles of the hand (lumbricals) to act as flexors at the PIP joint
lumbricals also extend the DIP joint without an opposing or balancing force
palmar migration of collateral bands and lateral bands
the lumbricals' pull becomes unopposed, pulling through the base of the distal phalanx
and volar to the PIP
causes PIP flexion and DIP extension
o bone deformity
injury involves all three phalanges
the middle phalanx flexes on the proximal phalanx at the PIP joint
the distal phalanx is hyperextended relative to the middle phalanx at the DIP joint
Associated conditions
o rheumatoid arthritis
o pseudo-boutonniere
refers to PIP joint flexion contracture in the absence of DIP extension
Anatomy
Muscle
o lumbrical muscles
originate from the FDP and insert on the lateral bands
Ligament anatomy
o extensor hood and central slip
the extrinsic extensor tendon joins the extensor hood at the MCP
the central portion of the extensor hood forms the central slip
the central slip inserts onto the middle phalanx and acts to extend the PIP joint
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OrthoBullets2017 Degenerative Conditions | Hand Deformities
o lateral bands
the lateral bands are formed from the deep head of the dorsal interossi combining with the
volar interossi
the lateral bands insert onto the base of the distal phalanx to extend the DIP joint
o triangular ligament
spans the two lateral bands, preventing them from subluxing volarly
o transverse retinacular ligament
prevents dorsal subluxation of the lateral bands
Blood supply
o interosseous muscles
receive blood from vessels formed by a combination of the deep palmer arch and the ulnar
artery
Presentation
Physical exam
o deformity
characterized by PIP flexion DIP extension
o Elson test
is the most reliable way to diagnose a central slip
injury before the deformity is evident
bend PIP 90° over edge of a table and extend middle phalanx
against resistance.
in presence of central slip injury there will be
weak PIP extension
the DIP will go rigid
in absence of central slip injury DIP remains floppy because the
extension force is now placed entirely on maintaining extension
of the PIP joint; the lateral bands are not activated
Imaging
Radiographs
o recommended view
radiographs are not required in evaluation and treatment of Boutonniere deformity
Treatment
Nonoperative
o splint PIP joint in full extension for 6 weeks
indications : acute closed injuries (< 4 weeks)
technique
encourage active DIP extension and flexion in splint to avoid contraction of oblique
retinacular ligament
complete part-time splinting for an additional 4-6 weeks
Operative
o primary central band repair
indications
acute displaced avulsion fx (proximal MP avulsion seen on x-ray)
open wound that needs I&D
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
o lateral band relocation vs. terminal tendon tenotomy vs. tendon reconstruction
indications
in chronic injuries after FROM is obtained with therapy or surgical release
technique
terminal tendon tenotomy (modified Fowler or Dolphin tenotomy)(never central slip
tenotomy)
secondary tendon reconstruction (tendon graft, Littler, Matev)
triangular ligament reconstruction
o PIP arthrodesis
indications
rheumatoid patients
painful, stiff and arthritic PIP joint
Pathoanatomy
Primary lesion is lax volar plate that allows hyperextension of PIP. Causes include
o trauma
o generalized ligament laxity
o rheumatoid arthritis
Secondary lesion is imbalance of forces on the PIP joint (PIP extension forces that is greater than the
PIP flexion force). Causes of this include
o mallet injury
leads to transfer of DIP extension force into PIP extension forces
o FDS rupture
leads to unopposed PIP extension combined with loss of integrity of the volar plate
o intrinsic contracture
tethering of the lateral (collateral) bands by the transverse retinacular ligament as a result of
PIP hyperextension.
if the lateral (collateral) bands are tethered, excursion is restricted and the extension force is
not transmitted to the terminal tendon, and is instead transmitted to the PIP joint
o MCP joint volar subluxation
caused by rheumatoid arthritis
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OrthoBullets2017 Degenerative Conditions | Hand Deformities
Presentation
Symptoms
o snapping and locking of the fingers
Physical exam
o hyperextension of PIP
o flexion of DIP
Imaging
Radiographs
o recommended views
AP and lateral view of the affected hand
Treatment
Nonoperative
o double ring splint
indications
can prevent hyperextension of PIP
Operative
o volar plate advancement and PIP balancing with central slip tenotomy
indications
progressive deformity
technique
address volar plate laxity with volar plate advancement
correct PIP joint muscles imbalances with either
FDS tenodesis indicated with FDS rupture
spiral oblique retinacular ligament reconstruction
central slip tenotomy (Fowler)
5. Quadriga Effect
Introduction
The quadriga effect is characterized by an active flexion lag in fingers adjacent to a digit with a
previously injured or repaired flexor digitorum profundus tendon.
Mechanism
o most commonly caused by a functional shortening of the FDP tendon due to
over-advancement of the FDP during tendon repair
>1 cm advancement associated with quadriga
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
adhesions
retraction of the tendon
"over-the-top" FDP repair of the distal phalanx after amputation
Pathoanatomy
o FDP tendons of long, ring, and little fingers share a common muscle belly
therefore excursion of the combined tendons is equal to the shortest tendon
improper shortening of a tendon during repair results in inability to fully flex adjacent
fingers
Anatomy
Flexor digitorum profundus
Zones of the flexor tendons
o most injuries resulting in quadrigia involve Zone I
Presentation
Symptoms
o inability to fully flex the fingers of the hand adjacent to the injured finger
o patient may complain of "weak grip"
Physical exam
o upon making a fist the fingers adjacent to the injured digit will not reach full flexion
o grip strength decreased
Imaging
Radiographs
o usually not required
Treatment
Nonoperative
o observation
indications
mild symptoms not affecting quality of life
Operative
o release FDP of injured digit
indications
severe symptoms limiting function
IV:2 Conditions causing lumbrical plus: (1) FDP transection, (2) FDP avulsion, (3) too long tendon graft, (4) amputation through middle
phalanx
Pathophysiology
o mechanism
FDP disruption distal to the origin of the lumbicals (most common)
can be due to
FDP transection
FDP avulsion
DIP amputation
amputation through middle phalanx shaft
"too long" tendon graft
o pathoanatomy
lumbricals originate from FDP
with FDP laceration, FDP contraction leads to pull on lumbricals
lumbricals pull on lateral bands leading to PIP and DIP extension of involved digit
with the middle finger, when the FDP is cut distally, the FDP shifts ulnarly (because of the
pull of the 3rd lumbrical origin)(bipennate)
this leads to tightening of the middle finger lumbrical (2nd lumbrical, unipennate), and
amplifies the "lumbrical plus" effect
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
Anatomy
Lumbricals
o 1st and 2nd lumbricals
unipennate
median nerve
originate from radial side of FDP2 and FDP3 respectively
o 3rd and 4th lumbricals
bipennate
ulnar nerve
3rd lumbrical originates from FDP 3 & 4
4th lumbrical originates from FDP 4 & 5
o all insert on radial side of extensor expansion
Presentation
History
o recent volar digital laceration (FDP transection) or sudden axial traction on flexed digit (FDP
avulsion)
Symptoms
o notices that when attempting to grip an object or form a fist, 1 digit sticks out or gets caught on
clothes
Physical exam
o paradoxical IP extension with grip (fingers extend while holding a beer can)
Treatment
Operative
o tenodesis of FDP to terminal IV:5 LEFT: With the fingers relaxed, the affected finger can be passively flexed
tendon or reinsertion to distal into the palm. RIGHT: With gripping, the affected middle finger extends at the IP
phalanx joints.
indications
FDP lacerations
do NOT suture flexor-extensor mechanisms over bone
o lumbrical release
indications
if FDP is retracted or segmental loss makes it impossible to fix
NOT done in the acute setting as it does not occur consistently enough to warrant routine
lumbrical sectioning acutely
contraindications
do not transect lumbricals 1 & 2 if there is concomitant ulnar nerve palsy
with ulnar nerve paralysis, the interosseous muscles are also lost
(interosseus muscles extend the IP joints)
technique
transect at base of flexor sheath (in the palm)
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OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions
1. Trigger Finger
Introduction
Stenosing tenosynovitis caused by inflammation of the flexor tendon sheath
Epidemiology
o more common in diabetics
o ring finger most commonly involved
Mechanism
o caused by entrapment of the flexor tendons at the level of the A1 pulley
o fibrocartilaginous metaplasia of tendon and pulley found in pathology
Associated conditions
o diabetes mellitus
o rheumatoid arthritis
o amyloidosis
Anatomy
Flexor pulleys of finger
o A1 overlie the MP joints
Muscles
o FDP
o FDS
Classification
Green Classification
Grade I Palm pain and tenderness at A-1 pulley
Grade II Catching of digit
Grade III Locking of digit, passively correctable
Grade IV Fixed, locked digit
Imaging
Radiographs
o not required in diagnosis and treatment
Presentation
Symptoms
o finger clicking
o pain at distal palm near A1 pulley
o finger becoming "locked in flexed position
Physical exam
o tenderness to palpation over A1 pulley
o a palpable bump may be present near the same location
Treatment
Nonoperative
o night splinting, activity modification, NSAIDS
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
indications : first line of treatment
o steroid injections
indications
best initial treatment for fingers, not for thumb
technique
give 1 to 3 injections in flexor tendon sheath
diabetics do not respond as well as non-diabetics
Operative
o surgical debridement and release of the A-1 pulley
indications
in cases that fail nonoperative treatment
o release of A1 pulley and 1 slip of FDS (usually ulnar slip)
indications
pediatric trigger finger
presents with Notta's nodule (proximal to A1 pulley), flexion contracture and
triggering
may need to release remaining FDS slip and A3 pulley as well
Techniques
Surgical debridement and release of the A-1 pulley
o approach
longitudinal or transverse incision
o release technique
in children, in addition to A-1 pulley release, may also need to release
one or both limbs of the sublimus tendon
A-2 pulley
A-3 pulley
o postoperative
early passive and active ROM 4 times a day
if patient does not have FROM at first post-op visit then send to PT
Complications
Radial digital nerve injury
2. Dupuytren's Disease
Introduction
A benign proliferative disorder characterized by fascial nodules and contractures of the hand
Epidemiology & genetics
o genetics
autosomal dominant with variable penetrance
o age
5-7th decade of life
o sex
2:1 male to female ratio
presents earlier in men (mean 55y) than women (mean 65y)
more severe disease in men than women
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OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions
o ethnicity
Caucasian males of northern European descent
uncommon in south Europe, south America
rare in Africa and China
o location
ring > small > middle > index
Pathophysiology
o myofibroblast is the dominant cell type
differs from fibroblast as the myofibroblast has INTRACELLULAR ACTIN filaments
aligned along long axis of cell
adjacent myofibroblasts connect via EXTRACELLULAR FIBRONECTIN to act together to
create contracted tissue
o type III collagen predominates (> type I collagen)
o cytokines have been implicated
TGFbeta1, TGFbeta2, epidermal growth factor, PDGF, connective tissue growth factor
o ectopic manifestations
Ledderhose disease (plantar fascia) 10-30%
Peyronie's disease (dartos fascia of penis) 2-8%
Garrod disease (knuckle pads) 40-50%
Associated conditions
o HIV, alcoholism, diabetes, antiseizure medications
Pathoanatomy
Nodules and Cords make up the pathologic anatomy
o nodules appear before contractile cords
Normal fascial bands become pathologic cords
o Palmar IV:6 This clinical photo demonstrates a pad at the PIP
pretindinous cord joint consistent with Garrod disease
o Palmodigital transition
natatory cord
spiral cord
o Digital
central cord - distal extent of the pretendinous cord
lateral cord
digital cord
retrovascular cord
Different named cords include but are not limited to
o spiral cord
most important cord
cause of PIP contracture
IV:7 Spiral Cord
typically inserts distally into the lateral digital sheet then into Grayson's ligament
components
pretendinous band
spiral band
lateral digital sheet
Grayson's ligament
travels under the neurovascular bundle displacing it central and superficial
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
at risk during surgical resection
best predictors of displacement are
PIP joint flexion contracture (77% positive predictive value)
interdigital soft-tissue mass (71% positive predictive value)
o central cord
from disease involving pretendinous band
inserting into flexor sheath at PIPJ level and causes MCP contracture
forms palmar nodules and pits between distal palmar crease and palmar digital crease
NOT involved with neurovascular bundle
o retrovascular cord
runs dorsal to the neurovascular bundle distally
originates from proximal phalanx, inserts on distal phlanx
causes DIP contracture
o natatory cord (from natatory ligament)
causes web space contracture
NOT involved in Dupuytren's disease
o Cleland's ligament
o transverse ligament of the palmar aponeurosis
disease only involves longitudinally oriented structures
Histopathology
Stages of Dupuytren's (Luck)
Proliferative stage Hypercellular with large myofibroblasts and immature fibroblasts
- this is a nodule
Very vascular with many gap junctions
Minimal extracellular matrix
Involutional stage Dense myofibroblast network
Fibroblasts align along tenion lines and produce more collagen
Increase ratio of type III to type I col
Residual stage Myofibroblast disappear (acellular) leaving fibrocytes as the
predominate cell line
Leaves dense collagen-rich tissue/scar
Presentation
Symptoms
o decreased ROM affecting ADL
o painful nodules
Physical exam
o nodule in the pretendinous bands of the palmar fascia
nodule beyond MCPJ is strong clue suggesting spiral
cord displacing digital nerve midline and superficial
o most commonly involve small or ring finger
o Hueston's tabletop test IV:8 Hueston's tabletop test with a PIP flexion
ask patient to place palm flat on table contracture of the ring finger
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Treatment
Nonoperative
o range of motion exercises
o injection of Clostridium histolyticum collagenase (Xiaflex)
indications : may be attempted but condition will not spontaneously resolve
technique/characteristics
has low activity against type IV collagen (in basement membrane of blood vessels and
nerves) explaining the low neurovascular complication rate
minimum dose is 10,000 units
use 0.25ml for MCP, and 0.20ml for PIP
followed by stretch manipulation within 24-48h under local anesthesia
repeat at 1mth if desired result not achieved
modalities
early efficacy seen with injections of clostridial collagenase into Dupuytren's cords
causes lysis and rupture of cords
outcomes
able to correct MCP/PIP contracture to <5°
more successful at MCP correction than PIP correction
PIP recurrence more severe than MCP recurrence
complications
minor
edema/contusion, skin tear, pain are most common
major (1%)
flexor tendon rupture, CRPS, pulley rupture
o needle aponeurotomy
indications
mild contractures (at the MCP > PIP)
medical co-morbidities that preclude surgery
technique IV:9 This clinical photo demonstrates the
perform in office using 22G or 25G needle McCash technique in which the transverse
limb is left open
followed by manipulation and night orthosis wear
outcomes
more successful for MCP contracture than PIP
less improvement and higher recurrence rate than surgery (open partial fasciectomy)
Operative
o surgical resection/fasciectomy
indications
MCP flexion contractures > 30°
PIP flexion contractures
painful nodules are not an indication for surgery
o with skin graft
rarely needed for primary cases
indications
severe, diffuse disease
multiple joint involvement
recurrences
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
technique : full thickness skin graft
outcomes
rarely fail to "take" even if placed directly over neurovascular bundles/flexor sheath
Dupuytrens recurrence is uncommon beneath a graft
Surgical Techniques
Regional/limited/ partial palmar fasciectomy
o technique
removal of all diseased tissue only in involved digits
dissect from proximal to distal
incision options - Brunner zigzag, multiple V-Y, sequential Z-plasties
o pros
most widely used surgical treatment
overlying skin is preserved
o postoperative care
early active range of motion (starting postoperative day 5-7)
night-time extension brace or splint
Total/radical palmar fasciectomy
o infrequently used
o technique
release/excision of all palmar and digital fascia including non-diseased fascia
o cons
high complication rate
little effect on recurrence rate (also high)
Open palm technique (McCash technique)
o approach
leave a transverse skin incision open at the distal palmar crease
o pros
reduced hematoma formation
reduced risk for stiffness
o outcome
longer healing
greater recurrence than if the palmar defect were covered with transposition flap or FTSG
Salvage techniques (for recurrent/advanced disease)
o Hueston dermofasciectomy (excise skin + fascia)
o arthrodesis
o amputation
Outcomes
Recurrence
o 30% at 1-2y, 15% at 3-5y, 10% at 5-10y, and <10% after 10y
o higher recurrence with non-operative measures (needle aponeurotomy and collagenase injection)
o PIP develop contratures of secondary structures that may need more comprehensive surgical
release
volar plate
accessory collateral ligaments
flexor sheath
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o risks
Dupuytren diathesis (age <50, white men, bilateral hands DD, family history, ectopic disease
outside the palm including Ledderhoses, Peyronies, Garrods pads)
patients with Dupuytren diathesis may need more aggressive followup and treatment
PIP disease
small finger contracture
Complications
Wound edge necrosis/slough
Hematoma
o most common surgical complication
o can lead to flap necrosis
Flare reaction
o pain syndrome with diffuse swelling, hyperesthesia, redness and stiffness
o treatment
cervical sympathetic blockage, progressive stress-loading in therapy
A1 pulley release
o no increase risk of CRPS with fasciectomy + carpal tunnel release
Neurovascular injury
o because of midline + superficial displacement of NV bundle by spiral cord
o identify prior to excising cord
o risk is 5-10x higher for recurrent disease
o treatment
immediate neurorrhaphy (nerve repair)
Digital ischemia
o most common reason is correction of longstanding joint contracture and vessels have inadequate
elasticity
o less commonly traction, transection, spasm, intimal hemorrhage, rupture
o treatment
allow joint to relax, warm the digit
topical lidocaine and papaverine
if thrombosed segment is identified, use interpositional vein graft
Postop swelling
o contributes to stiffness, poor wound healing
PIP complications
o stiffness, instability, flexion contracture
Infection
o increased risk with DM and PVD
o oral antibiotics for superficial infection
o surgical drainage for deep infection
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
Anatomy
Flexor carpi radialis musculotendinous unit
o FCR muscle
IV:10 FCR musculotendinous unit.
bipennate The tendon begins 15cm proximal
o FCR tendon to the radiocarpal joint, is
musculotendinous for 8cm proximal
enveloped by sheath from musculotendinous origin to trapezium to the RC joint, and is completely
no fibrous sheath distal to trapezium tendinous distal to that.
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IV:11 FCR tunnel at the level of the distal trapezium. Boundaries are the trapezial crest palmarly, IV:12 FCR insertion into the base of
trapezial body radially, trapezium-trapezoid joint and trapezoid dorsally, and retinacular septum the 2nd and 3rd metacarpals, with a
ulnarly. small slip (1-2mm) into the trapezial
crest
Presentation
Symptoms
o volar radial aspect of the wrist
Physical exam
o tenderness over volar radial forearm along FCR tendon at distal wrist flexion crease
o provocative test
resisted wrist flexion triggers pain
resisted radial wrist deviation triggers pain
Imaging
Radiographs
o findings
in primary tendinitis, radiographs are unremarkable
in secondary tendinitis, the following may be present
healed scaphoid fracture IV:13 Axial T2 MRI shows increased signal
healed distal radius fracture around FCR tendon sheath.
exostosis or arthritis of scaphotrapezoid joint or thumb CMC
MRI
o views : best seen on T2
o findings
increased signal around FCR sheath on T2 image
may find associated conditions in secondary tendinitis
ganglion
scaphoid cyst
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
Studies
Diagnostic injection
o injection of local anesthetic along FCR sheath relieves symptoms
Differentials
Thumb CMC arthritis
Scaphoid cyst
Ganglion
De Quervain's tenosynovitis
Treatment
Nonoperative
o immobilization, NSAIDS, steroid injection
indications
first line of treatment
technique
direct steroid injection in proximity, but not into tendon
outcomes
usually effective for primary tendinitis
unsuccessful in secondary tendinitis if other lesions are present (e.g. osteophytes)
Operative
o surgical release of FCR tendon sheath
indications
rarely needed but can be effective in recalcitrant cases
Surgical Technique
Surgical release of FCR tendon sheath
o approach
volar longitudinal incision starting proximal to the wrist crease,
extending over proximal thenar eminence
care taken to avoid
palmar cutaneous branch of median nerve
lateral antebrachial cutaneous nerve
superficial sensory radial nerve IV:14 Longitudinal incision
o technique radial to FCR, extending over
proximal thenar eminence
elevate and reflect thenar muscles radially
expose FCR sheath
open FCR sheath proximally in the distal forearm, and extend to the trapezial crest
at the trapezial crest, the tendon enters the FCR tunnel
at this point, incise the sheath along the ulnar margin, taking care not to injure the tendon
mobilize tendon from trapezoidal groove (releasing trapezial insertion)
Complications
Complications of disease
o FCR attrition and rupture
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Complications of surgical release
o cutaneous nerve injury
palmar cutaneous branch of median nerve
lateral antebrachial cutaneous nerve
superficial sensory radial nerve
o injury to deep palmar arch
o injury to FPL tendon (lies superficial to FCR tendon)
o injury to FCR tendon within the tunnel
decompression is easy proximal to the tunnel (incision of FCR sheath)
within FCR fibroosseous tunnel, take care to avoid cutting FCR tendon
Anatomy
Extensor tendon compartments
o Compartment 1 (De Quervain's Tenosynovitis)
APL
EPB
o Compartment 2 (Intersection syndrome)
ECRL
ECRB
o Compartment 3
EPL
o Compartment 4
EIP
EDC
o Compartment 5 (Vaughn-Jackson Syndrome)
EDM
o Compartment 6 (Snapping ECU)
ECU
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Extensor Tendon Conditions
1. De Quervain's Tenosynovitis
Introduction
A stenosing tenosynovial inflammation of the 1st dorsal compartment which includes
o abductor pollicis longus (APL)
o extensor pollicis brevis (EPB)
Epidemiology
o demographics
woman > men
30 - 50 years old
o body location
most commonly in the dominant wrist
o risk factors
overuse
golfers and racquet sports
post-traumatic
postpartum
Pathophysiology
o pathoanatomy
thickening and swelling of extensor retinaculum causes increased tendon friction
NOT considered an inflammatory process
may be related to accumulation of mucopolysaccharides
Prognosis
o most cases resolve with non-operative management
o high recurrence rate
Anatomy
Extensor tendon compartments See page 130
Presentation
Symptoms
o gradual onset
o radial sided wrist pain
o pain exacerbated by gripping and raising objects with wrist in neutral
Physical exam
o inspection
tenderness over 1st dorsal compartment at level of radial styloid
o motion
usually normal wrist motion
pain with resisted radial deviation
o neurovascular exam
normal
o provocative tests
Finkelstein maneuver
On grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over
the styloid tip is painful
more indicative of EPB > APL tendon pathology
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Eichhoff maneuver
ulnar deviated wrist while patient clenches thumb in fist, followed by relief of pain once
the thumb is extended even if the wrist remains ulnar deviated
Imaging
Radiographs
o recommended views
AP, lateral views of wrist
o indications
radiographs usually not indicated
o findings
may be used to rule out
basilar arthritis of the thumb
carpal arthritis
Treatment
Nonoperative
o rest, NSAIDS, thumb spica splint, steroid injection
indications
first line of treatment
technique
NSAIDS, rest and immobilisation usually first step
steroid injections into first dorsal compartment usually second step
outcomes
overall corticosteriods found to be superior to splinting
concomitant splinting and/or NSAIDs after steriods injection does not improve outcomes
Operative
o surgical release of 1st dorsal compartment
indications
severe symptoms
usually consider after 6 months of failed nonoperative management
technique
radial based incision proximal to the wrist
protect the superficial radial sensory nerve
Surgical Techniques
Surgical release of 1st dorsal compartment
o approach
transverse incision with release on dorsal side of 1st compartment to prevent volar
subluxation of the tendon
has variable anatomy with APL usually having at least 2 tendon slips and its own fibro-
osseous compartment
a distinct EPB sheath is often encountered dorsally
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Extensor Tendon Conditions
Complications
Sensory branch of radial nerve injury
Neuroma formation
Failure to decompress with recurrence
o may be caused by failure to recognize and decompress EPB or APL lying in separate
subsheath/compartment
Complex regional pain syndrome
2. Intersection Syndrome
Introduction
Due to inflammation at crossing point of 1st dorsal compartment (APL and EPB ) and 2nd dorsal
compartment (ECRL, ECRB)
Epidemiology
o common in
rowers
weight lifters
Pathophysiology
o mechanism is repetitive wrist extension
Anatomy
Extensor tendon compartments See page 130
Presentation
Symptoms
o pain over dorsal forearm and wrist
Physical exam
o tenderness on dorsoradial forearm
approximately 5cm proximal to the wrist joint
o provocative tests
crepitus over area with resisted wrist extension and thumb extension
Imaging
Radiographs
o not required for the diagnosis or treatment of intersection syndrome
MRI
o indications
to confirm diagnosis when clinical findings unclear
o views
fluid sensitive sequences (short tau inversion recovery, STIR; fat suppressed proton density,
FS PD; T2-weighted)
o findings
most characteristic is peritendinous edema or fluid surrounding the 1st and 2nd extensor
compartments
other findings - tendinosis, muscle edema, tendon thickening, loss of the normal comma
shape of the tendon, and juxtacortical edema may also be seen
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Treatment
Nonoperative
o rest, wrist splinting, steroid injections
indications
first line of treatment
technique
injection aimed into 2nd dorsal compartment (ECRL, ECRB)
Operative
o surgical debridement and release
indications
rarely indicated in recalcitrant cases
technique
release of the 2nd dorsal compartment approximately 6 cm proximal to radial styloid
3. Snapping ECU
Introduction
Overuse of wrist can lead to spectrum of ECU tendonitis and instability
Pathoanatomy
o ECU subluxation is secondary to attenuation or rupture of the ECU
subsheath (6th dorsal compartment)
o attenuation
remains intact but is stripped at ulnar/palmar attachment to produce a
false pouch that the ECU tendon can subluxate/dislocate into
o rupture IV:15 Attenuation
ulnar sided ECU subsheath tears
ECU subluxates on supination, and reduces on pronation
radial sided ECU subsheath tears
ECU subluxates on supination, and lies on top of the torn
subsheath on pronation
o subluxation and snapping can lead to ECU tendonitis
Risks
o tennis IV:16Rupture
o golf
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Extensor Tendon Conditions
ECU subsheath is part of the TFCC that is most critical to ECU subluxates during ulnar deviation,
ECU stability supination, wrist flexion
Anatomy
Extensor tendon compartments See page 130
ECU tendon
o ECU subsheath is part of the TFCC that is most critical to ECU stability
o ECU subluxates during ulnar deviation, supination, wrist flexion
this position has the greatest angulation of the ECU tendon with respect to the ulna
Presentation
Symptoms
o pain and snapping over dorsal ulnar wrist
Physical exam
o extension and supination of the wrist elicit a painful snap
o ECU tendon reduces with pronation
Imaging
Radiographs
o unremarkable
Ultrasound IV:17 Axial T2 MRI of the wrist shows tearing and
subluxation of the ECU tendon consistent with
o can dynamically assess ECU stability snapping ECU tendon.
MRI
o can show tendonitis, TFCC pathology, or degenerative tears of ECU
Treatment
Nonoperative
o wrist splint or long arm cast
indications
first line of treatment
technique
arm immobilized in pronation and slight radial deviation
Operative
o ECU subsheath reconstruction +- wrist arthroscopy
indications
if nonoperative management fails
technique
direct repair in acute cases
chronic cases may require a extensor retinaculum flap for ECU subsheath reconstruction
wrist arthroscopy shows concurrent TFCC tears in 50% of cases
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OrthoBullets2017 Degenerative Conditions | Wrist Conditions
D. Wrist Conditions
1. Ulnar Variance
Introduction
Definition
o length of the ulna compared to the radius
o measured in shoulder abducted 90deg, elbow flexed 90deg,
forearm neutral, hand aligned with forearm axis
Epidemiology
o demographic
male:female relationship
UV is lower in males than females
age bracket
UV increases with age
o risk factors IV:18 Neutral Ulnar Variance
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
Ulnar Variance
Ulnar Length Difference Load Passing Through Load Passing Through
Variance (ulnar - radial length) Radius Ulna
Positive +2mm 60% 40%
Positive +1mm 70% 30%
Neutral 0 (<1mm) 80% 20%
Negative -1mm 90% 10%
Negative -2mm 95% 5%
Anatomy
Neutral ulnar variance (ulnar zero)
o difference between ulnar and radial length is <1mm
Positive ulnar variance
o ulnar sided wrist pain from increased impact stress on the lunate and triquetrum
o UV becomes more positive in pronation
o UV becomes more positive during grip
Negative ulnar variance
o UV decreases in supination
Imaging
Radiographs
o recommended view
PA of the wrist with shoulder abducted 90 deg, elbow flexed 90 deg, neutral forearm rotation
Method to determine ulnar variance
o draw 2 lines
1 line tangential to the articular surface of the ulna and perpendicular to its shaft
1 line tangential to the lunate fossa of the radius and perpendicular to its shaft.
o measure the distance between these 2 lines (normal is 0mm)
o if the ulnar tangent is distal to the radial tangent = positive UV
o if the ulnar tangent is proximal to the radial tangent = negative UV
MRI
o can estimate but not quantify degree of UV
o because specific wrist position cannot be duplicated in MRI
Treatment
Depends on specific condition
o ulnar abutment syndrome
o TFCC tears
o Kienbock's disease
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Presentation
Symptoms
o pain on dorsal side of DRUJ
o increased pain with ulnar deviation of wrist
o pain with axial loading
o ulna sided wrist pain
Physical exam
o Ballottement test
dorsal and palmar displacement of ulna with wrist in ulnar deviation
positive test produces pain
o Nakamura's ulnar stress test
ulnar deviation of pronated wrist while axially loading, flexing and extending the wrist
positive test produces pain
o fovea test
used to evaluate for TFCC tear or ulnotriquetral ligament tear
performed by palpation of the ulnar wrist between the styloid and FCU tendon
Imaging
Radiographs
o recommended views
AP radiograph with wrist in neutral supination/pronation and zero rotation
required to evaluate ulnar variance
pronated grip view
increases radiographic impaction
arthrography can show TFCC tear and lunotriquetral ligament tear
o findings
ulna positive variance
sclerosis of lunate and ulnar head
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
MRI
o evaluate for TFCC tears which may be caused by ulnocarpal impingement and often influences
treatment
Differential
Ulnar sided wrist pain
o DRUJ instability or arthritis
o TFCC tear
o LT ligament tear
o pisotriquetral arthritis
o ECU tendonitis or instability
Treatment
Nonoperative
o supportive measures
indications
may attempt supportive measures as first line of treatment
Operative
o ulnar shortening osteotomy
indications
most cases of ulnar positive variance
most cases of DRUJ incongruity
o Wafer procedure
technique
2 to 4mm of cartilage and bone removed from under TFCC arthroscopically
o Darrach procedure (ulnar head resection)
indications
reserved for lower demand patients
complications
risk of proximal ulna stump instability
o Sauvé-Kapandji procedure
indications
good option for manual laborers
technique
creates a distal radioulnar fusion and a ulnar pseudoarthrosis proximal to the fusion site
through which rotation can occur
o ulnar hemiresection arthroplasty
indications
usually requires an intact or reconstructed TFCC
appropriate treatment option in the presence of post-traumatic DRUJ with concomitant
distal ulnar degenerative changes
o ulnar head replacement
indications
severe ulnocarpal arthrosis
salvage for failed Darrach
outcomes
early results are promising, long-term results pending
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OrthoBullets2017 Degenerative Conditions | Wrist Conditions
Techniques
Ulnar shortening osteotomy
o approach
subcutaneous to ulna
o technique
often combined with arthroscopic TFCC repair
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
Anatomy
Ulnocarpal joint
o transmits about 20% of the load through the wrist
increasing ulnar length by 2.5mm relative to the radius increases this load up to 50%
pronation and hand grasp both increase elative ulnar variance and transmission forces across
the wrist
Classification
Ulnar Variance
Ulnar Length Difference Load Passing Through Load Passing Through
Variance (ulnar - radial length) Radius Ulna
Neutral 0 (<1mm) 80% 20%
Positive +2.5mm 60% 40%
Negative -2.5mm 95% 5%
Treatment
Nonoperative
o activity modifications, NSAIDS, steroid injections
indications
first line of treatment
technique
rest should be tried for a minimum of 6-12 weeks
Operative
o ulnar shortening osteotomy
currently, the gold standard
o partial ulnar styloidectomy (Wafer procedure)
can be done open or arthroscopically
encouraging early results, but no superiority established
Complications
Non-union
Tendon rupture
Persistent pain/hardware irritation
Infection
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
4. Kienbock's Disease
Introduction
Avascular necrosis of the lunate leading to abnormal carpal motion
Epidemiology
o incidence
most common in males between 20-40 years old
o risk factors
history of trauma
Pathophysiology
o thought to be caused by multiple factors
biomechanical factors
ulnar negative variance
leads to increased radial-lunate contact stress
decreased radial inclination
repetitive trauma
anatomic factors IV:21 Ulnar variance refers to the position of the
cortical margin of the distal ulna relative to that
geometry of lunate of the distal radius.
vascular supply to lunate
patterns of arterial blood supply have differential incidences of AVN
disruption of venous outflow leading to increased intraosseous pressure
Prognosis
o progressive and potentially debilitating condition if unrecognized and untreated
Anatomy
Blood supply to lunate
o 3 variations
Y-pattern
X-pattern
I-pattern
31% of patients
postulated to be at the highest risk for avascular necrosis
IV:22 There are three patterns of blood supply to the lunate, X, Y and I. The I pattern is thought to be at the highest risk for AVN.
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Classification
Lichtman Classification
Stage Description Treatment
Stage I No visible changes on xray, Immobilization and NSAIDS
changes seen on MRI
Stage II Sclerosis of lunate Joint leveling procedure (ulnar negative
patients)
Radial wedge osteotomy or STT fusion (ulnar
neutral patients)
Distal radius core decompression
Revascularization procedures
Stage IIIA Lunate collapse, no scaphoid Same as Stage II above
rotation
Stage IIIB Lunate collapse, fixed scaphoid Proximal row carpectomy, STT fusion, or SC
rotation fusion
Stage IV Degenerated adjacent intercarpal Wrist fusion, proximal row carpectomy, or
joints limited intercarpal fusion
Stage I: A. No visible changes on xray B. Changes seen Stage II: Sclerosis of lunate.
on MRI.
Stage IIIA: A. Radiographic view of lunate Stage IIIB: A. Radiographic view of lunate collapse
collapse with no scaphoid rotation. B. CT with fixed scaphoid rotation. B. CT scan showing
scan showing lunate collapse, with no lunate collapse, with fixed scaphoid rotation.
scaphoid rotation.
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
Presentation
Symptoms
o dorsal wrist pain
usually activity related
more often in dominant hand
Physical exam
o inspection and palpation
IV:23 CT scan of the lunate showing
+/- wrist swelling trabecular destruction and
often tender over radiocarpal joint degenerative cystic changes.
o range of motion
decreased flexion/extension arc
decreased grip strength
Imaging
Radiographs
o recommended views
AP, lateral, oblique views of wrist
o findings (see table above)
CT
o most useful once lunate collapse has already occurred IV:24 T1 weighted MRI scan showing
decreased signal intensity throughout
o best for showing the lunate.
extent of necrosis
trabecular destruction
lunate geometry
MRI
o best for diagnosing early disease
o rule out ulnar impaction
o findings
decreased T1 signal intensity
reduced vascularity of lunate
IV:25 Post-operative radiograph after
STT pinning in an adolescent with
Kienbock's Disease.
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OrthoBullets2017 Degenerative Conditions | Wrist Conditions
Treatment
Nonoperative
o observation, immobilization, NSAIDS
indications
initial management for Stage I disease
outcomes
a majority of these patients will undergo further degeneration and require operative
management
Operative
o temporary scaphotrapeziotrapezoidal pinning
indications
adolescent with radiographic evidence of Kienbock's
and progressive wrist pain
o joint leveling procedure
indications
Stage I, II, IIIA disease with ulnar negative variance
initial operative managment
technique
can be radial shortening osteotomy or ulnar lengthening
more evidence on radial shortening
o radial wedge osteotomy
indications
Stage I, II, IIIA disease with ulnar positive or neutral
variance IV:26 Post-operative radiograph after STT
o vascularized bone grafts pinning in an adolescent with Kienbock's
Disease.
indications : Stage I, II, IIIA, IIIB disease
outcomes
early results promising, but long-term data lacking
best results in Stage III patients
o distal radius core decompression
indications : Stage I, II, IIIA disease
technique : creates a local vascular healing response
o partial wrist fusions
STT
capitate shortening osteotomy +/- capitohamate fusion
scaphocapitate
indications
Stage II disease with ulnar neutral or positive variance
Stage IIIA or IIIB disease
must address internal collapse pattern (DISI)
o proximal row carpectomy (PRC)
indications
stage IIIB disease
stage IV disease
outcomes
some studies have shown superior results of STT fusion over PRC for stage IIIB disease
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
o wrist fusion
indications
stage IV disease
technique
must remove arthritic part of joint
o total wrist arthroplasty
indications
Stage IV disease
outcomes
long-term results not available
Techniques
Vascularized bone grafts
o technique
many options have been described including
transfer of pisiform
transfer of distal radius on a vascularized pedicle of pronator quadratus
transfers of branches of the first, second, or third dorsal metacarpal arteries
4 + 5 extensor compartment artery (ECA)
temporary pinning of the STT joint, SC joint or external fixation may be used to unload
lunate after revascularization
IV:27 transfers of branches of the first, second, or third dorsal metacarpal arteries
Impact of surgical procedure on radiolunate contact stress
Operative Procedure % decrease on radiolunate contact stress
STT fusion 3%
Scaphocapitate fusion 12%
Capitohamate fusion 0%
Ulnar lengthening of 4mm 45%
Radial shortening of 4mm 45%
Capitate shortening and capitohamate fusion 66%, but 26% increase in radioscaphoid load
Complications
pending
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Presentation
Symptoms
o dorsoradial wrist pain
Imaging
Radiographs
o show sclerosis and fragmentation of proximal pole
without evidence of fracture
MRI
o can further allow classification into complete vs partial
IV:28 Radiograph shows sclerosis and proximal
involvement collapse of scaphoid consistent with Preiser's
disease.
Treatment
Nonoperative
o immobilization
is effective in 20% of cases
Operative
o microfracture drilling, revascularization procedure, or
allograft replacement
indications
when nonoperative management fails
techniques include
drilling
IV:29 Hand.MRI.Coronal.T1: T1
revascularization MRI image showing Preiser's Disease.
allograft replacements
o proximal row carpectomy or scaphoid excision with four corner fusion
indications
considered salvage procedures
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
o microtrauma can lead to premature closure of distal radial physis resulting in secondary
overgrowth of ulna
Associated conditions
o orthopaedic
distal ulnar overgrowth
positive ulnar variance
Prognosis
o good outcomes associated with early treatment
Presentation
Symptoms IV:30 AP and lateral radiographs demonstrating widening
o wrist pain of the distal radial physis found in "gymnast's wrist"
Imaging
Radiographs
o recommended views
AP and lateral of the wrist
o findings
widened distal radial growth plate with ill-defined borders
IV:31 AP radiograph demonstrates late
positive ulnar variance with chronic cases findings of physeal closure of the distal radius
MRI and positive ulnar variance.
o indications
chronic or cases non-responsive to treatment
o findings
paraphyseal edema
early physeal bridging
bruising of radius
Treatment
Nonoperative
o NSAIDS, rest, immobilization for 3-6 months
indications
first line of treatment
IV:32 Coronal fat suppressed proton-density
Operative weighted image demonstrates widening and
o resection of physeal bridge irregularity of the distal radial physis found in
distal physeal stress syndrome; "gymnast's
indications wrist"
small physeal closures
o ulnar epiphysiodesis and shortening with radial osteotomy as needed
indications : large physeal closures (roughly 50% of physis)
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OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse
Anatomy
Scaphoid anatomy
o blood supply
major blood supply is dorsal carpal branch (branch of the radial artery)
enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80%
of scaphoid via retrograde blood flow
minor blood supply from superficial palmar arch (branch of volar radial artery)
enters distal tubercle and supplies distal 20% of scaphoid
o motion
both intrinsic and extrinsic ligaments attach and surround the scaphoid
the scaphoid flexes with wrist flexion and radial deviation and it extends during wrist
extension and ulnar deviation (same as proximal row)
o also see Wrist Ligaments and Biomechanics for more detail
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Classification
Radiographic Classification
Stage I • Arthrosis localized to the radial side of the scaphoid and radial styloid
Stage II •Scaphocapitate arthrosis in addition to Stage 1
Stage III • Periscaphoid arthrosis (proximal lunate and capitate may be maintained)
Presentation
Symptoms
o weakness
reduced grip and pinch strength
o stiffness
stiffness with extension and radial deviation
Physical exam
o palpation
localized tenderness of the radioscaphoid articulation
o motion
decreased wrist motion on extension and radial deviation
Imaging
Radiographs
o recommended view
ap and lateral of wrist
o findings
see radiographic classification above
Treatment
Nonoperative
o observation alone
indications
medically frail and low functioning patients only
Operative
o radial styloidectomy plus scapholunate reduction and stabilization
indications : stage I
o proximal row corpectomy
indications : stage II and III
outcomes
disadvantages
reduction of wrist motion and grip strength
procedure should be avoided if there are capitate head degenerative changes
o four-corner fusion
indications
stage II and III
outcomes
retains 60% of wrist motion and 80% of grip strength
o wrist arthrodesis
indications
stage II and III
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Anatomy
Scapholunate interosseous ligament
o location
c-shaped structure connecting the dorsal, proximal and volar surfaces of the scaphoid and
lunate bones
dorsal fiber thickened (2-3mm) compared to volar fibers
o biomechanics
dorsal component provides the greatest constraint to translation between the scaphoid and
lunate bones
proximal fibers have minimal mechanical strength
Overview of wrist ligaments and biomechanics
Presentation
History
o acute FOOSH injury vs. degenerative rupture
age, nature of injury, duration since injury, degree of underlying arthritis, level of activity
Symptoms
o usually dorsal and radial-sided wrist pain
o pain increased with loading across the wrist (e.g. push up position)
o clicking or catching in the wrist
o may be associated with wrist instability or weakness
Physical exam
o inspection
may see swelling over the dorsal aspect of the wrist
o palpation
tenderness in the anatomical snuffbox or over the dorsal scapholunate interval (just distal to
Lister's tubercle)
o motion
pain increased with extreme wrist extension and radial deviation
o provocative tests
Watson test
when deviating from ulnar to radial, pressure over volar aspect of scaphoid produces a
clunk secondary to dorsal subluxation of the scaphoid over the dorsal rim of the radius
dorsal wrist pain or a clunk during this maneuver may indicate instability of
scapholunate ligament
Imaging
Radiographs
o recommended views
AP and lateral views of the wrist
o additional views
radial and ulnar deviation views
flexion and extension views
clenched fist (can attenuate the diastasis)
o findings
AP radiographs
SL gap > 3mm with clenched fist view (Terry Thomas sign)
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cortical ring sign (caused by scaphoid malalignment)
humpback deformity with DISI associated with an unstable scaphoid fracture
scaphoid shortening
Lateral radiographs
dorsal tilt of lunate leads to SL angle > 70° on neutral rotation lateral
capitolunate angle > 20°
DISI
normal carpal alignment
increased SL angle
Arthrography
o indications : may be used as screening tool for arthroscopy
o views
radiocarpal and midcarpal views
always assess the contralateral wrist for comparison
o findings
may demonstrate the presence of a tear but cannot determine the size of the tear
positive finding of a tear may indicate the need for wrist arthroscopy
MRI
o indications : often overused as a screening modality for SLIL tears
o findings
requires careful inspection of the SLIL by a dedicated radiologist to confirm diagnosis
low sensitivity for tears
Arthroscopy
o indications : considered the gold standard for diagnosis
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Treatment
Nonoperative
o NSAIDS, rest +/- immobilization
indications
acute, undisplaced SLIL injuries
chronic, asymptomatic tears
technique
splinting and close follow-up with repeat imaging and clinical response with acute
injuries
outcomes
most people feel casting alone is insufficient
may be effective with incomplete tears
Operative
o scapholunate ligament repair
indications
acute scapholunate ligament injury without carpal malalignment
chronic but reducible scapholunate ligament injuries (can peform if < 18 months from the
time of injury)
ligament pathoanatomy is ammenable to repair
o scapholunate reconstruction
indications
acute scapholunate ligament injury without carpal malalignment where pathoanatomy is
not ammenable to repair
reducible scapholunate ligament injuries > 18 months from the time of injury
o scaphoid ORIF vs. CRPP (+/- arthroscopic assistance)
indications
f pathoanatomy of SL ligament injury is a scaphoid fx than repair with ORIF vs.
CRPP (+/- arthroscopic assistance)
o stabilization with wrist fusion (STT or SLC)
indications
rigid and unreducible DISI deformity
DISI with severe DJD
technique
scaphotrapezialtrapezoidal (STT) fusion
scapholunocapitate (SLC) fusion
scapholunate fusion alone has highest nonunion rate
Technique
Scapholunate ligament direct repair SLIL with k-wires
o approach
small incision is made just distal to the radial styloid
care to avoid cutting the radial sensory nerve branches
o methods
SL joint pinning with k-wires
suture anchors with k-wires
Blatt dorsal capsulodesis
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often added to a ligament repair and remains a viable alternative for a chronic instability
when ligament repair is not feasible
o repair technique
place two k-wires in parallel into the scaphoid bone
reduce the SL joint by levering the scaphoid into extension, supination and ulnar deviation
and lunate into flexion and radial deviation
pass the k wires into the lunate
confirm reduction of the SL joint under fluoroscopy
place patient in short arm cast
o post-operative care
remove k-wires in 8-10 weeks
no heavy labor for 4-6 months
Scapholunate ligament reconstruction
o approach
same as for repair
o reconstruction
FCR tendon transfer (direct SL joint reduction)
ECRB tendonosis (indirect SL joint reduction)
weave not recommended due to high incidence of late failure
Complications
Disease progression (e.g. SLAC wrist)
Arthritis
Post-operative pain, stiffness, fatigue
Reduced grip strength
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
o VISI may occasionally be seen in uninjured wrists in patients with ligamentous laxity
this is in contrast to DISI deformity, which is always a pathologic condition
Anatomy
Lunotriquetral ligament
o C-shaped intrinsic ligament spanning the dorsal, proximal and palmar edges of the joint
o comprised of thick dorsal and volar regions and weak membranous portion
dorsal LT ligament
most important as a rotational constraint
volar LT ligament
thickest and strongest portion of the LT ligament
transmits extension moment of the triquetrum
Dorsal radiocarpal ligament (aka dorsal radiotriquetral ligament)
o extrinsic ligament that serves as a secondary restraint to VISI deformity, and loss of integrity
allows lunate to flex more easily
Volar long and short radiolunate ligaments
o extrinsic ligament that may be torn in advanced injury
Presentation
Symptoms
o ulnar sides pain that is worse with pronation and ulnar deviation (power grip)
Physical exam
o LT shuck test (aka ballottement test)
grasp the lunate between the thumb and index finger of one hand while applying alternative
dorsal and palmar loads across the triquetrum with the thumb and index of the other hand
positive test elicits pain, crepitus or increased laxity, suggesting LT interosseous injury
o Kleinman's shear test
stabilize the radiolunate joint with the forearm in neutral rotation and with the contralateral
hand load the triquetrum in the AP plane, producing shear across the LT joint
positive test produces pain or a clunk
o Lunotriquetral compression test
displacement of triquetrum ulnarly during radioulnar deviation which is associated with pain
Imaging
Radiographs
o lateral
volar flexion of lunate leads to SL angle < 30° (normal is 47°) and VISI deformity
capitolunate zigzag deformity seen with capitolunate angle increase to > 15° (lunate and
capitate normally co-linear)
o AP
unlike scapholunate dissociation, may not be widening of LT interval
break in Gilula's arc
may see proximal translation of triquetrum and/or LT overlap
Arthroscopy
o helpful in making diagnosis, as radiographs may be normal
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
scapholunate angle > 70 degrees
lunate extended > 10 degrees past neutral
o resultant scaphoid flexion and lunate extension creates
abnormal distribution of forces across midcarpal and radiocarpal joints
malalignment of concentric joint surfaces
o initially affects the radioscaphoid joint and progresses to capitolunate joint
Classification
Watson classification
o describes predictable progression of degenerative changes from the radial styloid to the entire
scaphoid facet and finally to the unstable capitolunate joint, as the capitate subluxates dorsally on
the lunate
o key finding is that the radiolunate joint is spared, unlike other forms of wrist arthritis, since there
remains a concentric articulation between the lunate and the spheroid lunate fossa of the distal
radius
Watson Stages
Stage I Arthritis between scaphoid and radial styloid
Stage II Arthritis between scaphoid and entire scaphoid facet of the radius
Stage III Arthritis between capitate and lunate
note: radiolunate joint spared
While original Watson classification describes preservation of radiolunate joint in all stages of
SLAC wrist, subsequent description by other surgeons of "stage IV" pancarpal arthritis observed in
rare cases where radiolunate joint is affected
o validity of "stage IV" changes in SLAC wrist remains controversial and presence pancarpal
arthritis should alert the clinician of a different etiology of wrist arthritis
Evaluation
Radiographs
o obtain standard PA and lateral radiographs
PA radiograph will reveal greater than 3mm diastasis between the scaphoid and lunate
Stage I SLAC wrist
PA radiograph shows radial styloid beaking, sclerosis and joint space narrowing
between scaphoid and radial styloid
Stage II SLAC wrist
PA radiograph shows sclerosis and joint space narrowing between scaphoid and the
entire scaphoid fossa of distal radius
Stage III SLAC wrist
PA radiograph shows sclerosis and joint space narrowing between the lunate and
capitate, and the capitate will eventually migrate proximally into the space created by
the scapholunate dissociation
lateral radiograph
will reveal DISI deformity and subluxation of capitate dorsally onto lunate
o stress radiographs unnecessary
MRI
o unnecessary for staging, but will show
thinning of articular surfaces of the proximal scaphoid
scaphoid facet of distal radius and capitatolunate joint with synovitis in radiocarpal and
midcarpal joints
Treatment
Nonoperative
o NSAIDs, wrist splinting, and possible corticosteroid injections
indications
mild disease
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Operative
o radial styloidectomy and scaphoid stabilization
indications
Stage I
technique
prevents impingement between proximal scaphoid and radial styloid
may be performed open or arthroscopically via 1,2 portal for instrumentation
o PIN and AIN denervation
indications
Stage I
technique
since posterior and anterior interosseous nerve only provide proprioception and sensation
to wrist capsule at their most distal branches, they can be safely dennervated to provide
pain relief
can be used in combination with below procedures for Stage II or III
o proximal row carpectomy
indications
Stage II
contraindicated if there is an incompetent radioscaphocapitate ligament
contraindicated with caputolunate arthritis (Stage III) because capitate articulates with
lunate fossa of the distal radius
technique
excising entire proximal row of carpal bones (scaphoid, lunate and triquetrum) while
preserving radioscaphocapitate ligament (to prevent ulnar subluxation after proximal row
carpectomy)
outcomes
provides relative preservation of strength and motion
o scaphoid excision and four corner fusion
indications
Stage II or III
technique
also provides relative preservation of strength and motion
wrist motion occurs through the preserved articulation between lunate and distal radius
(lunate fossa)
outcomes
similar long term clinical results between scaphoid excision/ four corner fusion and
proximal row carpectomy
o wrist fusion
indications
Stage III
any form of pancarpal arthritis
outcomes
wrist fusion gives best pain relief and good grip strength at the cost of wrist motion
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OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse
Anatomy
Volar extrinsic ligaments
o radioscaphocapitate (RSC)
o long radiolunate
o short radiolunate
o radioscapholunate
Classification
Overview table of wrist instability
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Presentation
History
o usually no history of trauma (midcarpal)
o high energy trauma (radiocarpal)
Symptoms
o subluxation that may or may not be painful
o complain of wrist giving way
o irritating clunking sign
"clunk" when wrist is moved ulnarly from flexion to extension with an axial load
Physical exam
o generalized ligamentous laxity
Imaging
Radiographs
o recommended views
required
AP and lateral of the wrist
optional
cineradiographs
o findings
sudden subluxation of proximal carpal row with active radial or ulnar deviation on
cineradiograph
ulnar translation
diagnosis made when >50% of lunate width is ulnarly translated off the lunate fossa of
the radius
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Treatment
Nonoperative
o immobilization +/- splinting
indications
first line of treatment
midcarpal instability is most amenable to splinting
Operative
o immediate open repair, reduction, and pinning
indications
ulnar translation associated with styloid fractures
outcomes
poor results with late repair
ligament reconstruction has poor long term results
o midcarpal joint fusion
indications
midcarpal instability (preferred over ligamentous reconstruction)
late diagnosis that failed nonoperative management
outcomes
will lead to 20-35% loss of motion
o osteotomy with malunion correction
indications
distal radius malunion
o wrist arthrodesis
indications : failure of above treatments
outcomes
fusion of radiocarpal joint leads to a 55-60% loss of motion
F. Arthritic conditions
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
Anatomy
Trapezial metacarpal joint is a biconcave saddle joint
Trapezium has a palmar groove for flexor carpi radialis (FCR) tendon
Ligaments
o anterior oblique ligament (Beak ligament)
primary stabilizing restraint to subluxation of CMC joint
o intermetacarpal ligaments
o posterior oblique ligament
o dorsal-radial capsule (injured in dorsal CMC dislocation)
Biomechanics
o CMC joint reactive force is 13X applied pinch force
IV:34 Illustration shows volar (A) and dorsal (B) ligaments of CMC joint.
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Classification
Eaton and Littler Classification of Basilar Thumb Arthritis
Stage I slight joint space widening (pre-arthritis)
Stage II slight narrowing of CMC joint with sclerosis, osteophytes <2mm
Stage III marked narrowing of CMC joint with osteophytes, osteophytes >2mm
Stage IV pantrapezial arthritis (STT involved)
Imaging
Radiographs
o technique
X-ray beam is centered on trapezium and metacarpal with thumb flat on cassette and thumb
hyperpronated
o findings
joint space narrowing
osteophytes
may show MCP hyperextension
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
IV:36 Clinical image shows correct thumb IV:35 Thumb MCP hyperextension
positioning for radiograph of basilar thumb deformity associated with late basilar thumb
arthritis. arthritis.
Differential Diagnosis
de Quervains tenosynovitis
STT arthritis
scaphoid nonunion/SNAC
radioscaphoid arthritis
Treatment
Nonoperative
o NSAIDS, thumb spica bracing, symptomatic treatment, steroid injections
indications
indicated as first line of treatment for mild symptoms
o hyaluronic acid injections
show no difference for the relief of pain and improvement in function when compared to
placebo and corticosteroids
Operative
o closing wedge dorsal extension osteotomy of 1st metacarpal
indications
for early Stage I disease
technique
redirects the force to the dorsal, more uninvolved
portion of the first carpometacarpal joint
outcomes
gained in popularity
93% have symptom improvement at 7 years
o ligament reconstruction with FCR
indications
Stage I disease when joint is hypermobile and unstable (pain with varus valgus stress)
o trapeziectomy + LRTI (ligament reconstruction and tendon interposition)
indications
Stage II-IV disease
most common procedure and favored in most patients
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technique
there are many different surgical options available
trapezial excision is most important, regardless of other specifics of CMC arthroplasty
FCR tendon most commonly used in reconstruction to suspend metacarpal
alternatively, ECRL or APL may be used for suspension
or PL around FCR to correct subluxation
outcomes
can expect ~25% subsidence postoperatively
postoperatively
with no change in outcomes
results in improved grip and pinch strengths
o hematoma arthroplasty (trapezial resection alone without LRTI)
indications
Stage II-IV disease
technique
trapezium resection and pinning of thumb metacarpal without LRTI
outcomes
comparable outcomes to trapeziectomy + LRTI
o excision of proximal third of trapezioid
indications
concomitant scaphotrapezioid arthritis (present in 62%), especially in Eaton-Littler stage
IV
o CMC arthroscopy and debridement
indications
early stages of disease
o trapeziometacarpal (CMC) arthrodesis
indications
Stage II-III disease in young male heavy laborers
preserves grip strength
contraindications
scaphotrapeiotrapezoidal (STT) arthritis
technique
CMC joint fused in
35° radial abduction
30° palmar abduction IV:37 CMC arthrodesis with plate & screws
15° pronation
outcomes
good pain relief, stability, and length preservation
decreased ROM; inability to put hand down flat
nonunion rate of 12%
o volar capsulodesis, EPB tendon transfer, sesamoid fusion, or MCP fusion
indications
thumb MCP hyperextension instability (hyperextension > 30°) otherwise a Swan neck
deformity will arise
see below (Complications) for algorithm
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
o silicone replacements
indications
not recommended
complications of prosthesis fracture, subluxation, or silicone synovitis
Complications
1st metacarpal subsidence and narrowing of trapezial space height
o after trapeziectomy ± tendon suspension
o salvage treatment
LRTI with ECRL tendon or APL tendon
if FCR is already used /ruptured
MCP hyperextension deformity
o treatment depends on degree of hyperextension
<10° - no surgical intervention
10-20° - percutaneous pinning of MCP in 25-35° flexion x 4wk ± EPB tendon transfer
20-40° - volar capsulodesis or sesamoidesis
>40° - MCP fusion
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nail ridging
Presentation
Symptoms of primary osteoarthritis
o pain
o deformity
Symptoms of erosive osteoarthritis
o intermittent inflammatory episodes
o articular cartilage and adjacent bone destroyed
o synovial changes similar to RA but not systemic
Imaging
Radiographs
o recommended views
AP, lateral and oblique of hand
o findings
erosive osteoarthritis will show cartilage destruction,
osteophytes, and subchondral erosion (gull wing
deformity)
Treatment
DIP Arthritis
o nonoperative
observation, NSAIDs
indications
first line of treatment for mild symptoms
o operative
fusion
indications
debilitating pain and deformity
technique
fusion with headless screw has highest fusion rate (nonunion in 10%)
2nd and 3rd digit fused in extension
4th and 5th digit fused in 10-20° flexion
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
Mucous Cyst
o nonoperative
observation
indications
first line of treatment as 20-60% spontaneously resolve
o operative
mucous cyst excision + osteophyte resection
indications
impending rupture
may need to do local rotational flap for skin coverage
outcome
osteophytes MUST be debrided or mucous cyst will recur
PIP Arthritis
o nonoperative
observations, NSAIDs
indications : first line of treatment in mild symptoms
o operative
collateral ligament excision, volar plate release, osteophyte excision
indications
predominant contracture with minimal joint involvement
fusion
indications
border digits (index and small PIP)
middle and ring finger OA if there is angulation/rotation deformity, ligamentous
instability or poor bone stock
technique
headless screw fixation has highest fusion rates
recreate normal cascade of fingers / PIPJ flexion angles
index- 30°, long- 35°, ring- 40°, small- 45°
silicone arthroplasty for middle and ring PIPJ
radial collateral ligament should be intact to tolerate pinch grip
indications
central digits (long and ring finger)
good bone stock
no angulation or deformity
outcomes
results are similar for both dorsal and volar approaches
Erosive osteoarthritis
o nonoperative
splints, NSAIDs
indications : tolerable symptoms
o operative
fusion
indications : intolerable deformity
technique
position of fusion same as above
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3. Wrist Arthritis
Introduction
Various forms of wrist arthritis based on location
o SLAC wrist (scapholunate advanced collapse)
most common
o STT arthrosis
second most common
o SNAC (scaphoid nonunion advanced collapse)
o DRUJ arthrosis
o Pisotriquetrial arthrosis
Mechanism
IV:39 STT Arthritis
o degenerative
primary OA
o posttraumatic
leads to SLAC/SNAC/DRUJ
o inflammatory
Rheumatoid arthritis
o congenital
may be secondary to Madelung's deformity
o idiopathic
may secondary to Kienbock's or Preiser's disease
Pathoanatomy IV:40 DRUJ Arthitis
o SLAC
Injury to SL ligament --> palmar rotary subluxation of
scaphoid --> incongruency of joint surfaces --> arthrosis
of radiocarpal joint --> arthrosis of capitolunate joint
radiolunate typically spared
o SNAC
proximal portion of scaphoid remains attached to lunate
while distal scaphoid flexes
leads to early arthritis between radial styloid and distal
scaphoid
like SLAC, radiolunate typically spared
o Rheumatoid arthritis
wrist becomes supinated, palmarly dislocated, radially
IV:41 Pisotriquetrial arthrosis
deviated, and ulnarly translocated
early disruption of DRUJ leads to dorsal subluxation of ulna (Caput-ulna)
Anatomy
Wrist ligaments and biomechanics
Imaging
Radiographs
o obtain standard hand series with additional views to visualize specific joints
o pisotriquetral joint (pisotriquetral arthrosis) obtain lateral in 30 degrees of supination
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
Treatment
Nonoperative
o NSAIDs, bracing, intra-articular steroid injections
indications
first line of treatment for mild to moderate symptoms
Operative
o aimed at addressing diseased area
SLAC
SNAC
Pisotriquetrial arthritis
excision of pisiform in refractory cases
DRUJ abutment syndrome & arthrosis
I V:42 Post-operative
distal ulna resection (Darrach procedure) radiograph of an
Sauvé-Kapandji procedure ulnar head
replacement.
partial ulna resection and interposition
ulnar head replacement
can be used as primary procedure, or as salvage for failed Darrach
early results are promising, long-term results pending
Rheumatoid arthritis
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In July 2017
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OrthoBullets2017 Pediatric Hand | Arthritic conditions
ORTHO BULLETS
V. Pediatric Hand
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Arm
A. Congenital Arm
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OrthoBullets2017 Pediatric Hand | Congenital Arm
Presentation
Physical exam
o deformity of hand with perpendicular relationship between forearm and wrist
o absent thumb
o perform careful elbow examination
Imaging
Radiographs
o entire radius and often thumb is absent
Laboratory
o must order CBC, renal ultrasound, and echocardiogram to screen for associated conditions
Treatment
Nonoperative
o passive stretching
target tight radial-sided structures
o observation
indicated if absent elbow motion or biceps deficiency
hand deformity allows for extra reach to mouth in presence of a stiff elbow
Operative
o hand centralization
indications
good elbow motion and biceps function intact
done at 6-12 months of age
followed by tendon transfers
contraindications
older patient with good function
patients with elbow extension contracture who rely on radial deviation
proximate terminal condition
technique
involves resection of varying amount of carpus, shortening of ECU, and, if needed, an
angular osteotomy of the ulna (be sure to spare ulnar distal physis)
may do as two stage procedure in combination with a distraction external fixator
if thumb deformity then combine with thumb reconstruction at 18 months of age
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Arm
o orthopaedic conditions
PFFD
fibula deficiency
scoliosis
phocomelia
multiple hand abnormalities
almost all patients have absent ulnar sided digits
Presentation
Symptoms
o limited function
o usually painless
Physical exam
o shortened, bowed forearm
o decrease in elbow function
o loss of ulnar digits
Classification
Bayne Classification
Type 0 • Deficiencies of the carpus and/or hand only
Type 1 • Undersized ulna with both growth centers present
Type II • Part of the ulna is missing (typically the distal ulna is absent)
Type III • Absent ulna
Type IV • Radiohumeral synostosis
There is a subtype of each classification that is based on the first webspace
• A = Normal
• B = Mild deficiency of the webspace
• C = Moderate to severe deficiency of the webspace
• D = Absent webspace
Type II
Type I
Type 0
Anatomy
Elbow Anatomy & Biomechanics
Presentation
Symptoms
o patients often asymptomatic
o limited elbow ROM
Physical exam
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Arm
o radialhead prominence
o can have limited elbow ROM
especially in extension and supination
usually painless
Imaging
Radiographs
o radial head posterior to capitellum
o radial head can be large and convex
o radius is short and bowed
Treatment
Nonoperative
o observation
indications V:3 2 views of elbow demonstrate congenital dislocation of
head, including a convex and posteriorly dislocated radial head.
first line of treatment
Operative
o radial head resection
indications
usually done in adulthood if patient has
significant pain
restricted motion
cosmetic concern of elbow
outcomes
reduces pain
may improve some elbow ROM
4. Madelung's Deformity
Introduction
A congenital dyschondrosis of the distal radial physis that leads to
o partial deficiency of growth of distal radial physis
o excessive radial inclination and volar tilt
o ulnar carpal impaction
Epidemiology
o occurs predominantly in adolescent females
common in gymnasts
Pathophysiology
o caused by disruption of the ulnar volar physis of the distal radius
repetitive trauma or dysplastic arrest
o one hypothesis is due to tethering by Vickers ligament
Vickers ligament is a fibrous band running from the distal radius to the lunate on the volar
surface of the wrist (radio-lunate ligament)
may be accompanied by anomalous palmar radiotriquetral ligament
Genetics
o autosomal dominant
Associated conditions
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o Leri-Weill dyschondrosteosis
rare genetic disorder caused by mutation in the SHOX gene
SHOX stands for short-statute homeobox-containing gene
anatomically at the tip of the sex chromosome
causes mesomelic dwarfism (short stature)
associated Madelung's deformity of the forearm
Presentation
Symptoms
o most are asymptomatic until adolescence
o symptoms include
symptoms of ulnar impaction
median nerve irritation
Physical exam
o leads to radial and volar displacement of hand
o restricted forearm rotation
The wrists on this patient The increased volar tilt in The wrists on this patient appear to be
appear to be subluxed volar Madelung's deformity leads the subluxed volar however this is due to
however this is due to the clinical appearance of the wrist the increased volar tilt which is
increased volar tilt which is to seem subluxed in a volar characteristic of Madelung's deformity.
characteristic of Madelung's direction.
deformity.
Imaging
Radiographs
o can see proximal synostosis
o characteristic undergrowth of the volar, ulnar corner
of the radius
o increased radial inclination
o increased volar tilt
MRI
o indications
concern for pathologic Vickers ligament :4 The thick dark band
V
seen on the T1 MRI is a
o views pathologically thick short
thickening ligament from the distal radius to the lunate radio-lunate ligament
(Vickers ligament) which
Treatment can cause tethering of the
volar, ulnar radial physis
Nonoperative and cause Madelung's
deformity.
o observation
indications : if asymptomatic
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Arm
o restricted activity
indications
activities with repetitive wrist impaction
recommend cessation of weight-bearing activities until pain decreases
Operative
o physiolysis with release of Vickers ligament
indications
wrist pain or decreased range of motion
efficacy of prophylactic release of Vickers ligament in mild deformity in skeletally
immature patients unknown
o radial corrective osteomy +/- distal ulnar shortening osteotomy
indications
wrist pain or decreased range of motion
cosmetic deformity
functional limitations
o DRUJ arthroplasty
indications
highly controversial
painful DRUJ instability and limited supination/pronation
significant deformity may require staged procedures
Techniques
Physiolysis and release of Vickers ligament
o approach
volar approach to the distal radius
o technique
V:5 In this patient the distal radius
has undergone a distal radio-ulnar
release a pathologically thick ligament joint fusion to stabilize the wrist. The
ligament approximately 0.5 to 1.0 cm in diameter ulnar variance has been corrected to
neutral by ulnar osteotomy to
bar resection and fat grafting in the physis decrease the pressure on the ulnar
aspect of the wrist joint.
Corrective radial osteotomy +/- distal ulnar shortening osteotomy
o goals
restore mechanics of distal radius
o approach
volar approach to the distal radius
o technique
severe deformities may benefit from a staged procedure with initial distraction external
fixation to avoid neurovascular stretching injury of a single procedure
codome osteotomy allows correction of coronal and sagittal deformity
Complications
Incomplete physiolysis or premature growth arrest
Violation of radiocarpal or ulnocarpal joint
Incomplete deformity correction
Recurrent deformity
Nonunion of the osteotomy site
Continued ulnar impaction (if radial osteotomy done alone)
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Presentation
Physical exam
o children often present at 3-5 years of age
no pronation or supination
fixed in varying degree of pronation (50% of patients have > 50° of pronation)
Imaging
Radiographs
o recommended view
AP and lateral of forearm and elbow
o findings
can see proximal synostosis
radius is heavy and bowed
Studies
Chromosome analysis
o to identify duplication in sex chromosomes
Treatment
Nonoperative
o observation
indications : usually preferred treatment, especially if deformity is unilateral
Operative
o osteotomy with fusion
surgery rarely indicated
indications
indicated to obtain functional degree of pronation
unilateral : fix the forearm in pronation of 30°
bilateral
fix dominant forearm in pronation (10-20°)
nondominan forearm in neutral
technique
use percutaneous pins to aid fusion
perform at ~ 5 years of age
cannot recreate proximal radial-ulnar joint with excision alone as it will reossify and
recur
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
B. Congenital Hand
1. Cleft Hand
Introduction
Definition
o typical (central) cleft hand is characterized by absence of 1 or more central digits of the hand or
foot
also known as lobster-claw deformity
o Swanson type I failure of formation (longitudinal arrest) of central ray,
leaving V-shaped cleft in the center of the hand
o types
unilateral vs bilateral
isolated vs syndromic
Epidemiology
o incidence
rare (1:10,000 to 1:90,000)
o demographics
male:female ratio is 5:1 (more common in male)
o location
hands, usually bilateral
associated with absent metacarpals (helps differentiate from symbrachydactyly)
missing middle finger
on the ulnar side, small finger is always present
often involves feet as well
Pathogenesis
o theory is wedge-shaped degeneration of central part of apical ectodermal ridge (AER) because of
loss of function of certain genes expressed in that part of the AER
Genetics
o inheritance pattern
Autosomal dominant with reduced penetrance (70%)
inherited forms become more severe with each generation
o mutations
deletions, inversions, translocations of 7q
split hand-split foot syndrome
o affected families should undergo genetic counseling
Associated conditions
o Ectrodactyly-ectodermal dysplasia-cleft (EEC) syndrome
o sensorineural hearing loss
o syndactyly and polydactyly
Prognosis
o functional limitation dependent on involvement of 1st webspace
o aesthetically displeasing, but not functionally limiting
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Classification
Type I cleft hand showing Type IIA cleft hand with Type IIB cleft hand with
absent middle ray with mildly narrowed thumb- severely narrowed
normal thumb-index web index web space prior to Z- thumb-index web space
space plasty.
Type III cleft hand with Type IV cleft hand with Type V cleft hand with
syndactyly of thumb and merging of the web space absent thumb web space
index rays and cleft (absent index and resulting from absent
middle rays) middle, index and thumb
rays.
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Presentation
History
o may have family history
Symptoms
o aesthetic limitation
o functional limitation
Physical exam
o absent or shortened central (third) ray
o may have absent radial digits
o may have syndactyly of ulnar digits
may involve feet
Imaging
Radiographs
o recommended views
AP, lateral, oblique views of bilateral hands
foot radiographs if involved
Treatment
Nonoperative
o observation
indications
types I (normal web) and IV (merged web), no functional impairment
Operative
o thumb web space, thumb, and central cleft reconstruction
indications
types IIA, IIB, III and V webs
Technique
Thumb, thumb web space reconstruction
o web space deepening, tendon transfer, rotational osteotomy, toe-hand transfer
o thumb web reconstruction has greater priority over correction of central cleft
o thumb reconstruction should not precede cleft closure as it might compromise skin flaps
Central cleft reconstruction
o depends on characteristic of thumb web space
o close the cleft proper with local tissues from the cleft and stabilize and close intermetacarpal
space
2. Symphalangism
Introduction
Congenital digital stiffness that comes in two forms
o hereditary symphalangism
o nonherediatry symphalangism
Epidemiology
o location
more common in ulnar digits
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Pathophysiology
o failure of IP joint to differentiate during development
Genetics
o inheritance pattern (hereditary type)
autosomal dominant
Associated conditions
o syndactyly (nonhereditary type)
o Apert's syndrome (nonhereditary type)
o Poland's syndrome (nonhereditary type)
o correctable hearing loss (hereditary type)
Presentation
Physical exam
o inspection
absence of flexion and extension creases
o motion
stiff digits
Imaging
Radiographs
o IP joint space may appear narrow
Treatment
Nonoperative
o observation
no indication for surgery in children
Operative
o capsulectomy
outcome
limited success
o IP joint arthroplasty
outcome : limited success
o angular osteotomy
indications
rarely needed due to adequate digital function
o arthrodesis
indications
may be considered during adolesence to improve function and cosmesis
rarely needed due to adequate digital function
3. Camptodactyly
Introduction
Congenital digital flexion deformity that usually occurs in the PIP joint of the small finger
Epidemiology
o prevalence
less than 1%
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
o location
Unilateral (33%) or bilateral (66%)
if bilateral, can be symmetric or asymmetric
Pathophysiology
o typically caused by either
abnormal lumbrical insertion/origin
abnormal (adherent, hypoplastic) FDS insertion
other less common causes include
abnormal central slip
abnormal extensor hood
abnormal volar plate
skin, subcutaneous tissue, or dermis contracture
Genetics
o most often sporadic
o can be inherited with autosomal dominant inheritance with incomplete penetrance/variable
expressivity
Associated conditons
o can be associated with more widespread developmental dysmorphology syndromes
Classification
If full PIP extension can be achieved actively with MCP held in flexion, digit can be explored and
abnormal tendon transferred to radial lateral band
Benson Classification
Type Characteristics Treatment
Type I • Isolated anomaly of little finger, presents
in infancy and affects males and females equally Stretching/splinting
• Most common form
Type II • Same clinical features as Type I, presents in If full PIP extension can be
adolescence achieved actively with MCP
• Affects girls more often than boys held in flexion, digit can be
From abnormal lumbrical insertion, abnormal FDS explored and abnormal
origin or insertion FDS tendon transferred
to radial lateral band
Type III • Severe contractures, multiple digits involved, Non-operative (unless
presents at birth functional deficit exists
• Usually associated with a syndrome after skeletal maturity),
then consider corrective
osteotomy/fusion
Kirner's • Specific deformity of small finger distal phalanx with
Deformity volar-radial curvature (apex dorsal-ulnar)
• Often affects preadolescent girls
• Often bilateral
• Usually no functional deficits
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Imaging
Radiographs
o often normal, especially in early stages
o later stages: possible decrease in P1 head convexity; possible volar subluxation and flattening of
base of P2
Treatment
Nonoperative
o passive stretching, splinting
indications
nonoperative treatment is favored in most cases
best for PIP contracture < 30 degrees
technique
passive stretching + static splinting
outcomes
variable outcomes
best outcomes with early intervention
Operative
o FDS tenotomy +/- FDS transfer
indications
progressive deformity leading to functional impairment
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
technique
must address all abnormal anatomy
passive (correctable) deformities
FDS tenotomy, or
FDS transfer to radial lateral band if full active PIP extension can be achieved with
MCP flexion
o osteotomy vs. arthrodesis
indications
severe fixed deformities
outcomes
variable outcomes
4. Clinodactyly
Introduction
Congenital curvature of digit in radioulnar plane
o found in 25% of children with Down's syndrome and 3% of general population
Pathoanatomy
o autosomal dominant inheritance
o middle phalanx of small finger most commonly affected
Anatomy
Anatomy of ligaments of the fingers
Classification
Clinodactyly Classification
Type I • Minor angulation with normal length (most common)
Type II • Minor angulation with short length
Type III • Significant angulation and delta phalanx (c-shaped epiphysis and longitudinal
bracketed diaphysis)
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Presentation
Physical exam
o function rarely significantly compromised
o daily activities can be affected if deformity reaches 30-40 degrees
Imaging
Radiographs
o C-shaped physis can result in a delta phalanx
Treatment
Nonoperative
o observation
indications V:6 delta phalanx
favored in most cases
splinting is not indicated
Operative
o phalanx opening wedge osteotomy +/- bone excision
indications
Type III (delta phalanx)
when deformity (delta phalanx) encroaches digit space of neighboring short digit
technique
excision of extra bone
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
5. Syndactyly
Introduction
Most common congenital malformation of the limbs
Epidemiology
o incidence : 1 in 2,000 - 2,500 live births
o demographics
M>F
Caucasians > African Americans
o ray involvement
50% long-ring finger
30% ring-small finger
15% index-long finger
5% thumb-index finger
Pathophysiology
o failure of apoptosis to separate digits
Genetics
o autosomal dominant in cases of pure syndactyly
reduced penetrance and variable expression
V:7 Clinical photograph
positive family history in 10-40% of cases demonstrating an example of
Associated conditions acrosyndactyly.
o acrosyndactyly
digits fuse distally and proximal digit has fenestrations (e.g., constriction ring syndrome)
o Poland Syndrome
o Apert Syndrome
o Carpenter syndrome
acrocephalopolysyndactyly
Classification
Syndactyly Classification
Simple Only soft tissue involvement, no bony connections
Complex Side to side fusion of adjacent phalanges
Complicated Accessory phalanges or abnormal bones involved in fusion
Complete vs. Complete syndactyly the skin extends to finger tips; with
Incomplete incomplete, skin does not extend to fingertips
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complicated syndactyly.
Treatment
Operative
o digit release
indications
syndactyly
perform at ~ 1 year of age
acrosyndactyly
perform in neonatal period
Technique
Digit Release
o if multiple digits are involved perform procedure in two stages (do 1 side of a finger at a time) to
avoid compromising vasculature
o release digits with significant length differences first to avoid growth disturbances
release border digits first (ring-little, and thumb-index) at <6mths because of differential
growth rates between ring-little and between thumb-index digits
middle-ring syndactyly can be released later (2yr old) as because middle and ring digits have
similar growth rates
thus if syndactyly involving index-middle-ring-small digits, releae index-middle and ring-
small first, and leave the central syndactyly (middle-ring) for 6months later
do all releases before school age
o bilateral hand releases
perform simultaneously if child is <18mths (less active)
perform staged if child is >18mths (more active, hard to immobilize bilateral limbs
simultaneously)
o interdigitating zigzag flaps are created during release to avoid longitudinal scarring
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
o dorsal fasciocutaneous flaps to reconstruct the web
o use only absorbable sutures (5-0 chromic catgut) which have less inflammation
Complications
Web creep
o most common complication of surgical treatment (8-60%)
o causes
early creep is most commonly caused by necrosis of the
tip of the dorsal quadrilateral flap and loss of full-
thickness skin graft placed in the web
late creep (adolescence) is caused by discrepant growth
between scar/skin graft and surrounding tissue during the :8 Intraoperative photo of the zigzag
V
growth spurt technique used to release digits.
o treatment
reconstruct web space with local skin flaps
Nail deformities
6. Poland Syndrome
Introduction
A congenital disorder characterized by
o unilateral chest wall hypoplasia
due to absence of sternocostal head of pectoralis major
o hypoplasia of the hand and forearm
o symbrachydactyly and shortening of middle fingers
result of absence or shortening of the middle phalanx
simple complete syndactyly of the short digits
Epidemiology
o 1 in 32,000 live births
o occurs in 10% of syndactyly cases :9 symbrachydactyly and shortening
V
Etiology of middle fingers
o thought to be linked to subclavian artery hypoplasia
Presentation
Physical exam
o extent of hand and chest involvement varies
o chest deformities
hypoplasia or absence of the pectoralis major, pectoralis minor, deltoid, serratus anterior,
external oblique, and latissimus dorsi
Sprengel’s deformity
scoliosis
dextrocardia
absence or underdevelopment of the breast
o hand deformities
syndactyly
hypoplasia or absence of metacarpals or phalanges
absence of extensors or flexor tendons
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carpal coalition or hypoplasia
radioulnar synostosis
nail agenesis
Imaging
CT scan
o will show absent perctoralis major
Treatment
Operative
o syndactyly release
indications
performed in most patients
technique
complete syndactyly release produces skin deficiency that requires skin grafting
perform only one side of the digit at a time to avoid vascular complications
local flap is created for commisure reconstruction followed by interdigitating zigzag
dorsal and palmar flaps along the medial and lateral aspect of the digit
Complications
Skin graft failure
Excessive tension
Improper flap planning
Digital artery injury
Web creep
Nail deformity
7. Apert Syndrome
Introduction
Syndrome characterized by
o bilateral complex syndactyly of hands and feet
index, middle, and ring fingers most affected
o symphalangism
o premature fusion of cranial sutures (craniosynostosis) results in flattened skull and broad
forehead (acrocephaly)
o hypertelorism (increased distance between paired body parts, as in wide set eyes)
o normal to moderately disabled cognitive function
o glenoid hypoplasia
o radioulnar synostosis
Genetics
o autosomal dominant, but most new cases are sporadic
o mutation of FGFr2 gene
Epidemiology
o incidence is 1/80,000 live births
Prognosis
o spectrum of normal to moderately disabled cognitive function
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Presentation
Physical exam
o dysmorphic face
craniosynostosis results in flattened skull and facial features
o rosebud hands (complex syndactyly where the index, middle, and ring finger share a common
nail)
Imaging
Radiographs
o will show complex syndactyly
Treatment
Operative
o surgical release of border digits
indications
perform ~ 1 year of age
o digit reconstruction
indications : perform ~ 1.5 years of age
to convert central three digits into two digits
8. Polydactyly of Hand
Introduction
A congential malformation of the hand
Three forms exist
o preaxial polydactlyly
thumb duplication
o postaxial polydactlyly
small finger duplication
o central polydactlyly
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Epidemiology
o commonly associated with syndactyly
extra digit may lead to angular deformity or impaired motion
Treatment
o osteotomy and ligament reconstructions
indications
perform early to prevent angular growth deformities
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Classification
Functional Classification
Static Present at birth and growth is linear with other digits
Progressive Not as noticable at birth but shows disproportionate growth over time
Presentation
History
o asymmetry to digits can be present at birth or appearing over time
Symptoms
o pain
o inability to use digits
o complaints of cosmetic issues
Physical exam
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o inspection & palpation
thick, fibrofatty tissue involving enlarged digits
o ROM & instability
often limited ROM due to soft tissue constraints
Imaging
Radiographs
o recommended views
biplanar hand radiographs
o findings
enlarged phalanges to involved digits
may see malalignment of joints or angled phalanges
CT, MRI
o not typically needed
Studies
Angiography
o only needed if used for surgical planning
Treatment
Nonoperative
o observation
in mild cases
Operative
o epiphysiodesis
indications
single digit
perform once digit reaches adult length of same sex parent
most common approach
postoperative care
soft tissue care
early ROM
o osteotomies and shortening procedures
indications
thumb involvement
multiple digit involvement
severe deformity
postoperative care
local soft tissue care
early ROM
o amputations
indications
severe involvement of digit
non-reconstructable digit
Complications
Digital stiffness
Chronic digital pain or edema
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Classification
Degrees of Constrictive Ring Syndrome
Simple constriction rings Mild ring with no distal deformity or lymphedema
Rings with distal deformity Ring may cause distal lymphedema in association with
deformity
Acrosyndactyly Fusion between the more distal portions of the digits with the
space between the digits varying from broad to pinpoint in
size.
Amputations Loss of limb distal to ring
Presentation
Symptoms
o most patients get diagnosed at birth
Physical exam
o check for distal pulses and perfusion
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Amputations
Imaging
Ultrasound
o intrauterine diagnosis can be made with ultrasound at end of first trimester
Treatment
Operative
o surgical release with multiple circumferential Z-plasties
indications
if circulation is compromised by edema or limb has contour deformity
perform early (neonatal)
technique
acrosyndactyly is treated with distal release early in neonatal period
intrauterine band release can be done if limb is found to be at risk of amputation (rare)
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Classification
Patterson Classification
Type I • Simple constriction ring
Type II • Deformity distal to ring (hypoplasia, lymphedema)
• Edema may or may not be present
Type III • Fusions distally (syndactyly, acrosyndactyly)
Type D • Amputation
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Treatment
Nonoperative
o observation
indications
Type I (simple constriction ring)
Operative
o excision or release of constriction band
indications
Type I with compromise of digital circulation
o circumferential Z-plasties
indications
Type II
distal deformities present
o surgical release of syndactyly
indications
Type III with distal fusions
o reconstruction of involved digits or limb (i.e., lengthening of bone, deepening of web space)
indications
Type IV to improve function
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In July 2017
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
C. Congenital Thumb
1. Thumb Hypoplasia
Introduction
Congenital underdevelopment of the thumb frequently associated with
partial or complete absence of the radius
Epidemiology
o incidence : 1/100,000 live births
o demographics
male = female
o location
bilateral involvement in ~60% of patients
right hand more common than left
Pathophysiology
o exact cause during embryologic development has yet to be elucidated
Associated anomalies
o greater than 80% of patients will have associated anomalies including
VACTERL
Holt-Oram
thrombocytopenia-absent radius (TAR)
Fanconi anemia
Blauth Classification
Type Description Treatment
Type I Minor hypoplasia No surgical treatment
All musculoskeletal and neurovascular required
components of the digit are present, just small
in size
Type II All of the osseous structures are present (may Stabilization of MCP joint
be small) Release of first web space
MCP joint ulnar collateral ligament instability Opponensplasty
Thenar hypoplasia
Type IIIA Musculotendinous and osseous deficiencies
CMC joint intact
Absence of active motion at the MCP or IP joint
Type IIIB Musculotendinous and osseous deficiencies. Thumb amputation &
Basal metacarpal aplasia with deficient CMC pollicization
joint
Absence of active motion at the MCP or IP joint.
Type IV Floating thumb
Attachment to the hand by the skin and digital
neurovascular structures
Type V Complete absence of the thumb
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Presentation
Physical exam
o inspection
extrinsic tendon abnormalities
pollex abductus
flexor pollicus longus attaches to normal insertion
and the extensor tendon
hypoplasia of thenar musculature
absence of skin creases indicates muscle or tendon
abnormalities :12 Pollex abductus is considered an extrinsic
V
tendon abnormality where the FPL also attaches
excessive abduction of MCP joint to the extensor tendon.
o range of motion and instability
ulnar collateral ligament laxity
web-space tightness
o evaluation for associated anomalies is essential
cardiac
auscultation
echocardiography
kidneys
ultrasound
abdomen : ultrasound
V:13 Arrow pointing to atrophy of the
Imaging thenar musculature.
Radiographs
o recommended views
bilateral films of hand, wrist and forearm
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
Studies
Labs
o peripheral blood smear and complete blood count
important to rule out Fanconi anemia
Additional studies
o chromosomal challenge test : detects Fanconi anemia before bone marrow failure
Treatment
Nonoperative
o observation
indications
Type I hypoplasia where augmentation of thenar musculature (thumb abduction) is not
necessary
Operative
o opposition tendon transfer (opponensplasty)
indications
Type I hypoplasia with insufficient thumb abduction
o release of first web space, opposition transfer, stabilization of MCP joint
indications : Type II and IIIA hypoplasia
o pollicization
indications : Type IIIB, IV, V hypoplasia
Surgical Techniques
Opponensplasty (opposition transfer)
o technique
performed using
flexor digitorum superficialis or
abductor digiti minimi
First web space deepening
o technique
usually performed with Z-plasty
Stabilization of MCP joint
o technique
three options V:14 Pollicization
fusion
reconstruction of UCL with FDS
reconstruction of UCL with free tendon graft
Pollicization
o technique
plan skin incision to avoid skin grafts
isolate index finger on its neurovascular bundles
detach first dorsal and palmar interosseous muscles
shorten digit by removing index finger metacarpal and epiphyseal plate
stabilize index MCP joint
reattach and balance musculotendinous units
reconstruct long extensor tendons
rebalance flexor tendons
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Blauth Classification
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
Presentation
History
o presenting complaint is usually fixed thumb flexion deformity at the IP joint
o history of trauma is rare
o family history of disease is rare
Symptoms
o usually painless
o may be bilateral
Physical exam
o inspection
flexion deformity at the IP joint
o motion
prominence of the flexor tendon nodule, referred to as "Notta's
node"
deformity may be fixed with loss of IP joint extension
o neurovascular
usually preserved
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Imaging
Radiographs
o recommended views
AP and lateral views of the hand
o additional views
dedicated thumb views
o indications
recommended only if history of trauma
o findings
usually diagnosed based on clinical presentation
radiographs are usually normal
Treatment
Nonoperative
o passive extension exercises and observation
indications
not recommended for fixed deformities in older children
technique
passive thumb extension exercises
duration based on clinical response
outcomes
30-60% will resolve spontaneously before the age of 2 years old
<10% will resolve spontaneously after 2 years old
o intermittent extension splinting
indications
first line of treatment
more successful than observation alone
consider alongside stretching regime
flexible deformity
not recommended with fixed deformity in older children
technique
splints maintain IP joint hyperextension and prevent MCP joint hyperextension
duration for 6-12 weeks
outcomes
50-60% resolution in all age groups
high drop out rate from therapy
Operative
o A1 pulley release
indications
fixed deformity beyond age of 12 months of age
failed conservative treatment
outcomes
65-95% resolution in all age groups
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
Techniques
A1 Pulley Release
o open release
small transverse incision in the thumb MCP flexion crease, extending over the A1 pulley
protect the radial digital nerve
sharp dissection of the A1 pulley
identify the Notta nodule in the FPL tendon
watch nodule under direct vision during passive IP extension of the thumb to ensure there is
smooth FPL tendon gliding
Complications
Digital nerve injury
o caution must be performed during release as digital nerves at high risk due to proximity to flexor
tendon and A1 pulley
Wound complications
o scar contracture
o abscess
o infection
IP flexion deficit
Bow-stringing of flexor tendon
o usually related to release of the oblique pulley
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OrthoBullets2017 Pediatric Hand | Congenital Thumb
Orthopedic considerations
o common manifestations associated with disease
lower limb anomalies
congenital vertical talus
congenital talipes equinovarus (bilateral)
upper limb anomalies
flexion deformities of the four fingers
Associated conditions
o arthrogryphosis (congenital joint contractures affect two or more areas in the body)
o digitotalar dysmorphisms
o Freeman-Sheldon syndrome
o X-linked MASA syndrome
Classification
Tsuyuguchi Classification of Clasped Thumb
Type Feature
Type I (Supple clasped Thumb can be passively abducted and extended against
thumb) resistance of thumb flexors. No other digital anomaly present.
Type II (Clasped thumb with Thumb cannot be passively extended and abducted. This may
contracture) occur with or without other digital anomaly.
Type III (Rigid clasped Clasped thumb that is associated with arthrogryposis and
thumb) marked soft-tissue deficits.
Presentation
History
o persistent flexion-adduction deformity beyond 3rd or 4th month of life, usually bilateral
o family history
o pre-natal history
Symptoms
o pain usually with a contracture
o associated with other musculo-skeletal deformities
Examination
o type of clasped thumb
o associated anomalies
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
Treatment
Nonoperative
o serial splinting and stretching for 3-6 months
indications
first-line treatment for all types
begin treatment around the age of 6 month old
outcome
good definitive results with Type I congenital deformities when one of the EPL or EPB
tendons are present
poor results with Type I deformities when both EPL/EPB tendons are absent
poor results with Type II or III deformities
Operative
o EIP tendon transfer to EPL
indications
Type I or II with residual deficiency in active extension
technique
EIP transfer to remnant of extensor tendon
o thumb reconstruction
indications
failed conservative treatment
soft-tissue deficiency in the thumb-index finger webspace (Type III)
Type II or III deformity with significant MCP joint contractures
technique
o arthrodesis
indications
severe deformities when skin release and tendon trasnfer cannot overcome joint
deformity.
Techniques
Thumb reconstruction
o delayed until the age of 3 to 5 years old
o procedure based on amount of contracture and may include
1st web widening
transposition flap of skin (dorsal rotational advancement flap)
four-flap or five-flap Z plasty
deepening the first webspace by releasing soft-tissue
releasing origins of thenar musculature from transverse carpal ligmant
releasing joint capsule of first MP joint
tendon transfer
FPL Z-lengthening in the forearm
EPB and EPL absence is best reconstructed with tendon transfer
isolated EPB absence will not usually require tendon transfer
Complications
Cosmetic appearance
Instability of the MP joint
Reduced thumb function
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OrthoBullets2017 Hand Tumors & Lesions | Congenital Thumb
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
1. Ganglion Cysts
Introduction
A mucin-filled synovial cyst caused by either
o trauma
o mucoid degeneration
o synovial herniation
Epidemiology
o incidence
It is the most common hand mass (60-70%)
o location
Dorsal carpal (70%)
originate from SL articulation
Volar carpal (20%) VI:1 Ganglion Cyst
originate from radiocarpal or STT joint
Volar retinacular (10%)
originate from herniated tendon sheath fluid
dorsal DIP joint (mucous cyst, associated with Heberden's nodes)
Pathophysiology
o filled with fluid from tendon sheath or joint
o no true epithelial lining
Associated conditions
o median or ulnar nerve compression
may be caused by volar ganglion
o hand ischemia due to vascular occlusion
may be caused by volar ganglion
Presentation
Symptoms
o usually asymptomatic
o may cause issues with cosmesis
Physical exam VI:2 mucous cyst
o inspection
transilluminates (transmits light through tissue)
o palpation
firm and well circumscribed
often fixed to deep tissue but not to overlying skin
o vascular exam
Allen's test to ensure radial and ulnar artery flow for volar wrist ganglions
Imaging
Radiographs
o Normal
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OrthoBullets2017 Hand Tumors & Lesions | Tumors of the hand
MRI
o indications
not routinely indicated
o findings
shows well marginated mass with homogenous fluid signal intensity
Ultrasound
o useful for differentiating cyst from vascular aneurysm
o may provide image localization for aspiration while avoiding artery
Histology
Biopsy
o indications
not routinely indicated
o findings
will show mucin-filled synovial cell lined sac
Treatment
Nonoperative
o observation
indications
first line of treatment in adults
children
76% resolve within 1 year in pediatric patients
o closed rupture
home remedy
high recurrence
o aspiration
indications
second line of treatment in adults with dorsal ganglions
aspiration typically avoided on volar aspect of wrist due to radial artery
outcomes
higher recurrence rate (50%) than surgical resection but minimal risk so reasonable to
attempt
Operative
o surgical resection
indications
severe symptoms or neurovascular manifestations
technique
requires adequate exposure to identify origin and allow resection of stalk and a portion of
adjacent capsule
at dorsal DIP joint: must resect underlying osteophyte
results
volar ganglions have higher recurrence after resection than dorsal ganglions (15-20%
recurrence)
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
Complications
With aspiration
o infection (rare)
o neurovascular injury
With excision
o infection
o neurovascular injury (radial artery most common)
o injury to scapholunate interosseous ligament
o stiffness
Presentation
Symptoms
o painless mass, most commonly occurring in the fingertip
o although less common, erythematous, painful lesions have been reported
Physical exam
o inspection & palpation
flesh-colored, yellow, or white in appearance
well-circumscribed, firm, slightly mobile lesions
lesions are firmer than ganglion cysts and do not transilluminate
often superficial and tethered to overlying skin
o range of motion
there may be loss of ROM when lesions are large and occur near IP joints
o neurovascular exam
sensory deficits may be evident with 2-point discrimination testing secondary to digital nerve
compression
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OrthoBullets2017 Hand Tumors & Lesions | Tumors of the hand
an epidermal inclusion
cyst on the dorsal
an epidermal inclusion cyst on well-circumscribed surface of the PIP joint of
the palmar surface of the epidermal inclusion cyst the ring finger which is
hand. on the palmar surface of adherent to the overlying
the small finger. skin.
Imaging
Radiographs
o recommended views
AP, lateral, and oblique views of the involved digit or hand
o findings
soft tissue mass may be evident
a lytic lesion of the distal phalanx may be present if the cyst erodes
into bone
may mimic a malignant or infectious process
VI:3 The AP radiograph of a
Studies distal phalanx reveals an
interosseous epidermal inclusion
Biopsy cyst with lytic bony erosion.
o indications
should be considered before surgical excision to rule out neoplasm or infection if a lytic bony
lesion is present in the distal phalanx
Histology
o gross appearance
cysts contain a thick, white keratinous material
o characteristic findings
cysts filled with keratin and lined with epithelial cells
The low-power
histology slide
reveals an epidermal
inclusion cyst where
the red arrow marks
lamellated keratin
and the green arrow
identifies stratified
squamous epithelium. The medium-power histology slide
reveals an epidermal inclusion cyst
characterized by a stratified squamous
epithelial lining and abundant keratin.
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
Differential
Tophaceous gout
Foreign body granuloma
Sebaceous cyst
Giant cell tumor
Ganglion cyst
Enchondroma
Glomus tumor
Treatment
Nonoperative
o observation
indications
not recommended
Operative
o marginal excision
indications
diagnosis of epidermal inclusion cyst
painful lesions
loss of function
cosmetic concerns
technique
careful dissection to remove the entire capsule
local curettage and bone graft may be required for lesions eroding bone
amputation is an alternative with advanced bony destruction in rare circumstances
outcomes
marginal excision is curative
low recurrence rate
Complications
Wound complications
Infection
Digital neurapraxia
Recurrence
o recurrence rate is low even with bony involvement
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OrthoBullets2017 Hand Tumors & Lesions | Tumors of the hand
Mechanism
o symptoms arise because of increased muscle volume within small muscle compartment
pain from synovitis or ischemia
Anatomy
Normal EIP
o occupies 4th dorsal extensor compartment (8-10mm wide)
o ratio of 1:1 for muscle:tendon length
o origin - posterior surface of distal third of ulna and adjacent interosseous membrane
o insertion - dorsal expansion of index finger on ulnar side of EDC
Classification
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
Presentation
Symptoms
o usually asymptomatic
discovered incidentally during surgery (e.g. ganglion removal)
o mass on the dorsum of the hand
o intermittent dorsal wrist pain if muscle bellies impinge on and occupy the narrow dorsal
compartments of the wrist
Physical Exam
o inspection
mass does not transilluminate
moves with movement of local muscles (flexion and extension of
hand and wrist)
becomes firmer with grasp
o provocative tests
resisted extension triggers pain
Imaging
MRI
VI:4 aEIP presenting as
painful dorsal wrist mass
o indications (arrow)
exclude other more common conditions e.g. ganglion
o findings
mass is isointense with muscle tissue
anomalous extensor indicis proprius (aEIP)
extensor digitorum brevis manus (EDBM)
extensor medii proprius (EMP)
extensor indicis et medii communis (EIMC)
Differential
Ganglion
Synovitis
o both produce dorsal wrist pain
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OrthoBullets2017 Hand Tumors & Lesions | Tumors of the hand
Presentation
Symptoms
o enlarging mass
o pain, worse with activity (or wearing shoes, for foot lesions)
Physical exam
o firm, nodular mass that does not transilluminate
Differential diagnosis
o ganglion cyst
cystic component
o pigmented villonodular synovitis
histologically identical
involves larger joints
o desmoid tumor
o fibroma/fibrosarcoma
o glomangioma
Imaging
Radiographs
o pressure-type bone erosion can be seen in up to 5% of patients on radiographs
Ultrasound
o able to demonstrate relationship of lesion with adjacent tendon
o homogeneously hypoechoic, although some heterogeneity may be seen in echo-texture in a
minority of cases
o most have some internal vascularity
MRI
o MRI may be helpful diagnostically
o appearance of the focal form is generally decreased signal intensity on both T1-and T2-weighted
MR imaging
Histology
Characterized by
o proliferating histiocytes, moderately cellular (sheets of rounded or polygonal cells)
o hemosiderin (brown color) may be present, but typically less than seen with PVNS
o multinucleated giant cells are common
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
Treatment
Operative
o marginal excision
5-50% recurrence rate
more common if tumor extends into joints and deep to the volar plate
local recurrence is usually treated with repeat excision
operative approach is dependant on location and extent of the tumor
VI:7 32 y/o female with a painful R long finger mass. MRI and intraoperative
findings consistent with Giant Cell tumor of tendon sheath.
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
B. Vascular Conditions
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Vascular Conditions
Anatomy
Ulnar artery
o ulnar artery branches into 2 branches as it exits Guyon's canal
deep branch
superficial palmar arch in Guyon's canal
o relation to hook of hamate
over distal 2cm, the artery is directly anterior to the hook of the hamate, covered by palmaris
brevis, subcutaneous tissue and skin
Presentation
History
o occupational or sporting risks (see above)
Symptoms
o pain over hypothenar eminence and ring finger
may involve small, middle and index fingers
o cold sensitivity
o paresthesia
Physical exam
o inspection
blanching, mottling, cyanosis, pallor, gangrene
tenderness over hypothenar eminence
prominent callus (calloused skin over hypothenar eminence)
pulsatile mass if aneurysm is present
fingertip ulcerations over ulnar digits
splinter hemorrhages over ulnar digits
o provocative tests
Allen's test VI:8 CT angiogram showing
positive if occlusion is present aneurysm at hook of hamate
Imaging
Doppler ultrasound
o indications
first line test
measure digital brachial index
<0.7 necessitates reconstruction
Angiogram, CT angiogram or MR angiogram
o indications
mandatory for diagnosis
o findings
tortuous "corkscrew" ulnar artery VI:9 Angiogram showing aneurysm
at hook of hamate
occlusion or aneurysm at the hook of the hamate
Differential
Raynaud's disease involves the thumb but hypothenar hammer syndrome does not
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
Treatment
Nonoperative
o lifestyle modifications, symptomatic treatment, and vascular consult
indications
thrombosis without aneurysm > 2 weeks
asymptomatic
no threat of digital loss
lifestyle modifications
smoking cessation
avoid recurrent trauma
outcomes
80% success
Operative
o endovascular fibrinolysis I:10 Resection of ulnar artery aneurysm in
V
indications hypothenar hammer syndrome
2. Raynaud's Syndrome
Introduction
Raynaud's Syndrome consists of both
o Raynaud's Phenomenon
vasospastic disease with a known cause
o Raynaud's Disease
vasospastic disease with no known cause (idiopathic)
Raynaud's Phenomenon
Vasospastic disease with a known underlying disease
o epidemiology
demographics
occasional female predominance
age >40 years (generally older than patients with Raynaud's disease)
location
affects the distal aspect of digits
o pathophysiology
periodic digital ischemia induced by cold temperature or sympathetic stimuli including pain
or emotional stress
triphasic color change (white-blue-red progression)
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Vascular Conditions
digits turn white from vasospasm and interruption of blood flow
blue discoloration follows from cyanosis and venous stasis
finally digits turn red as a result of rebound hyperemia
dysesthesias often follow color changes
o associated conditions
connective tissue disease
scleroderma (80-90% incidence of Raynaud's phenomenon)
SLE (18-26%)
dermatomyositis (30%)
RA (11%)
CREST syndrome
calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias
neurovascular compression (thoracic outlet syndrome)
Presentation
o symptoms
asymmetric findings
rapid progression
o physical exam
peripheral pulses often absent
frequent trophic skin changes (including ulceration and gangrene)
abnormal Allen test
Studies
o labs
blood chemistry - often abnormal
o invasive studies I:11 The clinical photograph
V
demonstrates gangrene in a
microangiology - often abnormal patient with Raynaud's
angiography - often abnormal phenomenon.
Treatment
o nonoperative
lifestyle modifications, treat underlying cause
indications
mainstay of treatment
modalities
smoking cessation and avoidance of cold exposure is critical
Raynaud's Disease
Vasospastic disease with no known cause (idiopathic)
VI:12 The imaging study
o epidemiology represents an angiogram with
seen in young premenopausal women (age <40 years) incomplete ulnar artery
obstruction in a patient with
o pathophysiology Raynaud's phenomenon.
similar to Raynaud's phenomenon
Presentation
o symptoms
often bilateral
slow progression
o physical exam
peripheral pulses usually present
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
trophic skin changes are uncommon
normal Allen test
Studies
o labs usually normal
o invasive studies usually normal
o diagnosis
based on Allen and Brown criteria
Treatment
o nonoperative
medical management
indications
first line of treatment
modalities
smoking cessation and avoidance of cold exposure is critical
thermal biofeedback techniques
medications include
calcium channel blockers
ASA
intra-arterial reserpine
dipyridamole (Persantine)
pentoxifylline (Trental)
o operative
digital sympathectomy
indications
severe cases that fail conservative treatment
microvascular reconstruction
indications
may be indicated in rare situations
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Vascular Conditions
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
Presentation
Symptoms
o early disease
intermittent claudication of feet, legs, hands or arms
numbness and/or tingling in the limbs
o late disease
symptoms of critical limb ischemia
rest pain
Physical exam
VI:13 Ulcerations are usually present prior to
o inspection the onset of necrosis.
ulcerations
large, erythematous, superficial blood vessels
necrotic distal digits in hands and feet
o palpation
decreased temperature in hands and feet
o neurovascular
diminished or absent pulses
sensory findings in up to 70% of patients VI:14 Necrotic distal digits in a
patient with Buerger's disease.
o provocative tests
positive Allen test in young smoker with digital ischemia is suggestive of disease
Imaging
Arteriography
o indications
useful for ruling-out other conditions that may mimic
Buerger's disease
o findings
"corkscrew" vessels
collateral circulation giving a "spider leg" appearance
Studies
Labs
I:15 Arteriogram showing classic
V
o used to exclude alternative diagnoses "corkscrew" arteries in a patient with
Echocardiogram Buerger's disease.
o used to exclude proximal source of emboli
Treatment
Nonoperative
o smoking cessation and symptomatic treatment
indications
all patients with Buerger's disease that use tobacco
techniques
smoking cessation
patient education
pharmacotherapy
smoking cessation groups
symptomatic treatment
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Vascular Conditions
avoid exposure to cold
gentle exercise
daily aspirin
vasodilators
outcomes
smoking cessation is the only treatment known to decrease the risk of future amputation
Operative
o surgical sympathectomy
indications (controversial)
refractory pain and digital ischemia
technique
cut nerves to the affected areas
o amputation
indications
gangrene
non-healing ulcers
refractory pain
Presentation
History
o recent blunt or penetrating hand trauma VI:16 Palpable palmar mass secondary
Symptoms to penetrating trauma
o slow-growing painful mass
o many be sensory disturbance due to compression of adjacent digital nerve
Physican exam
o palpable mass
o may be pulsatile in ~ 50% of cases
o may occur in any of the 5 digits
most common in thumb > index > ring finger
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
Imaging
Radiographs
o indication
usually not helpful
concern of destructive lesion
o findings : usually normal
Doppler ultrasound or angio–computed tomography (CT) scan
o indication : pre-operative confirmation
o findings
size and location of lesion
thrombus formation
collateral circulation
VI:17 angio–computed tomography (CT) scan:
Differential Arrow pointing to narrow artery causing decrease
in flow into second webspace
Often misdiagnosed as
o epidermoid cysts
o arteriovenous fistulas
o forieign body granulomas
o ganglions
o neurilemmomas
Treatment
Nonoperative
o observation and analgesics
indications : small, asymptomatic lesions
o ultrasound-guided thrombin injection
indications
Some reports use this techique in lesions arising more
proximal in the hand or wrist.
Operative
o surgical exploration and ligation
indications
symptomatic lesions with adequate collateral circulation
technique
ligation performed proximal and distal
o repair with interpositional grafting
indications
symptomatic lesions with inadeaquate collateral circulation
VI:18 Intraoperative photograph
Techniques demonstrating the digital artery
(white arrow), which lies dorsal to the
Digital artery aneurysm repair digital nerve (black arrow) in the
finger
o end-to-end anastomosis and an autogenous interpositional vein or
arterial graft
Complications
digital ischemia
chronic pain
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Nail Bed
C. Nail Bed
Anatomy
Perionychium
o consists of
nail bed
soft tissue beneath the nail includes
germinal matrix (proximal)
produces 90% of the nail
scarring causes absence
sterile matrix (distal) VI:19 Split nail
keeps nail adherent to nail bed
injury causes deformity
nail fold
most proximal portion of the perionychium consists of
ventral floor - germinal matrix portion of the nail bed
dorsal roof
eponychium
skin proximal to the nail that covers the nail fold
paronychium
skin on each side of the nail
hyponychium
skin distal to the nail bed
Presentation
History
o patient will report fingertip injury in the form of trauma or infection in the past
Symptoms
o common symptoms
painless
complaint is typically cosmetic in nature
Physical exam
o careful inspection of the nail to identify any 'blank' areas of nail
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OrthoBullets2017 Hand Tumors & Lesions | Nail Bed
Imaging
Radiographs
o not typically warranted
o obtain if suspicious of underlying bony etiology
Treatment
Nonoperative
o observation alone
indications
majority of patients not concerned about cosmesis
Operative
o scar resection and primary closure
indications
size < 2mm
patients have strong desire to improve cosmesis
o scar resection and full thickness nail bed graft from second toe
indications
germinal matrix and size >2mm
sterile matrix, any size
resection and primary closure rarely successful
patients have strong desire to improves cosmesis
Techniques
Scar resection and primary closure
o indicated for germinal matrix if size <2mm
Scar resection and full thickness nail bed graft from second toe
o preferred for geminal matrix if size > 2mm
Scar resection and full thickness nail bed graft from second toe
Complications
Recurrence of split nail
Persistent cosmetic deformity
Donor site morbidity
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Nail Bed
Anatomy
Perionychium
o consists of
nail bed
soft tissue beneath the nail includes
germinal matrix (proximal)
produces 90% of the nail
scarring causes absence
sterile matrix (distal)
keeps nail adherent to nail bed
injury causes deformity
nail fold
most proximal portion of the perionychium consists of
ventral floor - germinal matrix portion of the nail bed
dorsal roof
eponychium
skin proximal to the nail that covers the nail fold
paronychium
skin on each side of the nail
hyponychium
skin distal to the nail bed
Presentation
History
o patient will report fingertip injury in the form of trauma or infection in the past
Symptoms
o common symptoms
painless
complaint is typically cosmetic in nature
can become painful if it becomes in-grown
Physical exam
o careful inspection of the nail to identify any 'hooking' of the nail
Imaging
Radiographs
o typically needed to assess the bone stock/deformity of the distal phalanx tuft
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OrthoBullets2017 Hand Tumors & Lesions | Nail Bed
Treatments
Nonoperative
o observation alone
indications
majority of patients not concerned about cosmesis
o prosthetic replacement
Operative
o indications
improving cosmesis
painful, in-grown hook nail
soft tissue manipulation - shorten bone, do not maintain nail bed length
indications
majority of distal tuft maintained
when the distal nail bed has been closed/pulled over the distal tuft
soft tissue + bony support - lengthen bone, maintain nail bed length
indications
lack of distal tuft/bony support
Technique
Soft tissue manipulation
o shorten bone, perform soft tissue procedure to correct 'hooking' of nail bed that advances soft
tissue and reattach to dorsum of bone
V-Y advancement
cross-finger flap
full-thickness skin graft
Bony support procedure to maintain nail length
o options
bone graft to distal tip
free, vascularized bone graft from second toe
Complications
Lack of complete correction VI:20 example of a prosthetic that can be
fitted and placed on the end of a hook nail
Recurrence of deformity to cover the cosmetic deformity
Necrosis/flap failure, loss of distal tip
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tested Procedures
D. Tested Procedures
1. Wrist Arthroscopy
Introduction
Plays an important therapeutic and diagnostic role
Indications
o TFCC injuries
o interosseous ligament injuries
o anatomic reduction assistance (distal radius, scaphoid fxs)
o ulnocarpal impaction
o debridement of chondral lesions
o removal of loose bodies
o synovectomy
o excision of dorsal wrist ganglia
o assistance in treatment of SNAC and or SLAC wrist
o septic wrist irrigation and debridement
o diagnosis in unexplained mechanical wrist pain
Portals
Portals named for relation to extensor wrist compartments
Created with sharp skin incision followed by hemostat dissection
Photograph of right
wrist undergoing
arthroscopy showing
scope in 3-4 portal and
appropriate
positioning of 6U portal
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OrthoBullets2017 Hand Tumors & Lesions | Tested Procedures
Radiocarpal Portals
Portal Location, Function Structures at Risk
Located just distal to Lister tubercle, between EPL and EPL and EDC tendons
3-4
EDC; Established first, primary viewing portal
Located in line with ring finger metacarpal, between EDC and EDC and EDM
4-5
EDM; Portal for instrumentation, visualization of TFCC tendons
Located just radial to ECU tendon; Primary adjunct for visualization Dorsal sensory branch
6R
and instrumentation, ulnar-sided TFCC repairs of ulnar nerve
Located just ulnar to ECU tendon; Primary adjuct for visualization Dorsal sensory branch
6U
and instrumentation, ulnar-sided TFCC repairs of ulnar nerve
Located between APL and ECRB, along dorsal aspect of Superficial branch of
1-2 snuffbox; Not often utilized, provides access to radial styloid and radial nerve; Radial
radial aspect of joint, sometimes used for inflow artery
Midcarpal Portals
(necessary for complete carpal visualization, evaluating for wrist instability, and advanced
techniques)
Located 1 cm distal to 3-4 portal along axis of radial border of ECRB and EDC
middle finger metacarpal, between ECRB and EDC. Allows tendons
MCR
visualization of scapholunate, scaphocapitate, and
scaphotrapezoid joints.
Located 1 cm distal to 4-5 portal along axis of ring finger EDC and EDM
MCU metacarpal, between EDC and EDM. Allows visualization of tendons
lunocapitate, lunotriquetral, and triquetrohamate joints.
Located along axis of index finger metacarpal just ulnar to EPL at ECRB and ECRL
STT level of STT joint. Allows visualization of scaphotrapezial and tendons
scaphotrapezoid joints.
First CMC Portals
Located on ulnar aspect of EPL at level of first CMC joint (basal
Superficial sensory
1U joint). Allows diagnosis of DJD of first CMC joint and arthroscopic
branch of radial nerve
debridement.
Located on radial aspect of EPL at level of thumb CMC joint, just
Superficial sensory
1R volar to APL tendon. Allows diagnosis of DJD of first CMC joint and
branch of radial nerve
arthroscopic debridement.
Rehabilitation
Immediate post-operative period
o cast, splint or soft dressing depending on specific procedure(s) performed
Rehabilitation
o progression depending on specific procedure(s) performed
Return to full activity
o timing depending on specific procedure(s) performed
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tested Procedures
Complications
Incidence
o overall complication rate is 1-2%
Dorsal sensory branch of ulnar nerve
o averages 8mm from 6R portal
o at risk with establishment of 6U and 6R portals
to a lesser extent main ulnar nerve and artery also at risk
o When performing a TFCC repair, small open incision is typically made prior to knot tying to
prevent injury to this nerve.
Superficial sensory branch of radial nerve
o averages 16mm from 3-4 portal
o at risk during arthroscopy of basal joint, as 1U and 1R portals are on either side of the first
branch of this nerve
o at risk during placement of 1-2 portal
Radial artery Injury
o Associated with establishment 1-2 portal, used for arthroscopic radial styloidectomy.
Extensor tendon injury
o most commonly EPL and EDM due to improper portal placement
Chondral injuries
o iatrogenic from scope or instrument placement
Portal site infection
Stiffness
MCPJ pain
o typically caused by over-distraction
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In July 2017
Wrist Portals
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