Sie sind auf Seite 1von 247

6

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.

The site was collected to PDF files, to make it


easy to navigate through topics, a well-organized
index is included in table of contents at the
beginning of each volume, another way for e-book
users is bookmarks function of your favorite PDF
viewer, it easily accessed through PC or any
smart device, and easily can reach to any topic in
the e-book.

To be easy to study, all trauma topics collected


in one volume , in volume one you find adult trauma
topics including spine trauma, hand trauma, foot
and ankle trauma, and pediatric trauma, also
chapter of infections (adult osteomyelitis, septic
arthritis , wound & hardware infections, necrotizing
fasciitis and Gas gangrene) all these topics moved
from trauma to pathology volume eight.
In other volumes you will find a note about any
topics that moved to trauma volume.
Also any text that copied from another source than orthobullets.com formatted in a red box like this.

Dr, AbdulRahman AbdulNasser


OrthoBullets 2017 Table Of Contents
2. Extremity Flap Reconstruction ......... 69
I. Hand Introduction .................................. 0
3. Skin Grafting .................................... 73
A. Anatomy ............................................ 1
4. Tendon Transfer Principles .............. 74
1. Extensor Tendon Compartments ........ 1
III. Neuropathies ...................................... 78
2. Ligaments of the Fingers .................... 2
A. Median Neuropathies ...................... 79
3. Flexor Pulley System .......................... 9
1. Carpal Tunnel Syndrome .................. 79
4. Blood Supply to Hand ....................... 13
2. AIN Compressive Neuropathy .......... 83
5. Wrist Ligaments & Biomechanics ..... 15
3. Pronator Syndrome .......................... 85
6. Motion of the Fingers ........................ 22
B. Ulnar Neuropathies ......................... 88
7. Thumb Motion ................................... 23
1. Cubital Tunnel Syndrome ................. 88
B. Clinical Evaluation ........................... 24
2. Ulnar Tunnel Syndrome .................... 92
1. Physical Exam of the Hand................ 24
C. Radial Neuropathies ........................ 96
2. Vascular Evaluation of the Hand ....... 29
1. PIN Compression Syndrome ............. 96
3. Nerve Conduction Studies ................ 29
2. Radial Tunnel Syndrome .................101
C. Hand Infections ............................... 33
3. Wartenberg's Syndrome ..................106
1. Paronychia ....................................... 33
IV. Degenerative Conditions ...................109
2. Felon ................................................ 36
A. Hand Deformities............................110
3. Pyogenic Flexor Tenosynovitis ......... 38
1. Intrinsic Minus Hand (Claw Hand) ....110
4. Deep Space & Collar Button Infections
............................................................. 40 2. Intrinsic Plus Hand ..........................111
5. Herpetic Whitlow .............................. 43 3. Boutonniere Deformity ....................112
6. Atypical Mycobacterium Infections ... 44 4. Swan Neck Deformity ......................115
7. Fungal Infections .............................. 45 5. Quadriga Effect ...............................116
II. Microsurgery ........................................ 48 6. Lumbrical Plus Finger .....................117
A. Replantation .................................... 49 B. Flexor Tendon Conditions ...............120
1. Fingertip Amputations & Finger Flaps 1. Trigger Finger .................................120
............................................................. 49 2. Dupuytren's Disease .......................121
2. Ring Avulsion Injuries ....................... 55 3. Flexor Carpi Radialis Tendinitis .......127
3. Replantation ..................................... 59 C. Extensor Tendon Conditions ...........130
4. Thumb Reconstruction ..................... 63 1. De Quervain's Tenosynovitis ...........131
B. Reconstruction ................................ 64 2. Intersection Syndrome ....................133
1. Peripheral Nerves Injury & Repair .... 64 3. Snapping ECU .................................134
OrthoBullets 2017

D. Wrist Conditions ............................ 136 3. Camptodactyly ................................186


1. Ulnar Variance ............................... 136 4. Clinodactyly ....................................189
2. Ulnocarpal Abutment Syndrome ..... 138 5. Syndactyly ......................................191
3. Ulnar Styloid Impaction Syndrome . 141 6. Poland Syndrome ............................193
4. Kienbock's Disease ........................ 143 7. Apert Syndrome ..............................194
5. Preiser's Disease (Scaphoid AVN) .. 148 8. Polydactyly of Hand .........................195
6. Gymnast's Wrist (Distal Radial Physeal 9. Macrodactyly (local gigantism) ........199
Stress Syndrome) ............................... 148 10. Constrictive Ring Syndrome ..........201
E. Wrist Instability & Collapse ............ 150 11. Streeter's Dysplasia ......................203
1. SNAC (Scaphoid Nonunion Advanced C. Congenital Thumb ..........................205
Collapse) ............................................ 150
1. Thumb Hypoplasia...........................205
2. Scapholunate Ligament Injury & DISI
........................................................... 152 2. Congenital Trigger Thumb ...............209

3. Lunotriquetral Ligament Injury & VISI 3. Congenital Clasped Thumb .............211


........................................................... 156 VI. Hand Tumors & Lesions.....................214
4. SLAC (Scaphoid Lunate Advanced A. Tumors of the hand .........................215
Collapse) ............................................ 158
1. Ganglion Cysts ................................215
5. CIND (carpal instability
2. Epidermal Inclusion Cyst .................217
nondissociative) ................................. 162
3. Anomalous Extensor Tendon ...........219
F. Arthritic conditions ........................ 164
4. Giant Cell Tumor of Tendon Sheath .222
1. Basilar Thumb Arthritis ................... 164
B. Vascular Conditions .......................224
2. DIP and PIP Joint Arthritis .............. 169
1. Hypothenar Hammer Syndrome ......224
3. Wrist Arthritis ................................. 172
2. Raynaud's Syndrome.......................226
V. Pediatric Hand ................................... 174
3. Thromboangiitis Obliterans (Buerger's
A. Congenital Arm .............................. 175
disease) ..............................................229
1. Radial Clubhand (radial deficiency) 175
4. Digital Artery Aneurysm ..................231
2. Ulnar Club Hand ............................. 176
C. Nail Bed ..........................................233
3. Congenital Radial Head Dislocation 178
1. Split Nail Deformity..........................233
4. Madelung's Deformity ..................... 179
2. Hook Nail Deformity ........................235
5. Congenital Radial Ulnar Synostosis 182
D. Tested Procedures .........................237
B. Congenital Hand ............................ 183
1. Wrist Arthroscopy ...........................237
1. Cleft Hand ...................................... 183
2. Symphalangism .............................. 185
OrthoBullets2017 | Anatomy

ORTHO BULLETS

I.Hand Introduction

- 0 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy

A. Anatomy

1. Extensor Tendon Compartments

Compartment Tendon Associated Pathology


EPB De Quervain's tenosynovitis
1
APL
ECRL Intersection syndrome
2
ECRB
EPL Drummer's wrist, traumatic rupture with distal
3
radius fx
EIP Extensor tenosynovitis
4 EDC
Posterior interosseous nerve
5 EDM Vaughn-Jackson Syndrome
6 ECU Snapping ECU

- 1 -
OrthoBullets2017 Hand Introduction | Anatomy

2. Ligaments of the Fingers

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

- 2 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy

‎I:1 Illustration - showing Oblique retinacular ligament


 contrast this with intrinsic tightness, where there is decreased PIP flexion when
the MCP is extended, and improved PIP flexion when the MCP is flexed
 contrast this with extrinsic tightnes (extensor tendon tightness), where there is
increased PIP flexion when MCP is extended, and decreased PIP flexion when
MCP is flexed
o transverse band
 function
 with PIP flexion, pull lateral bands volarly over PIP
 with PIP extension, prevents excessive dorsal translation of lateral bands
 anatomy
 origin: from edge of flexor tendon sheath at PIP
 insertion: lateral border of conjointed lateral bands
 pathology
 attenuation leads to dorsal translation of lateral bands and a resulting swan neck
deformity
 contracture (with attenuation of triangular ligament) leads to volar translation of lateral
bands and resulting boutonniere deformity
Digital Cutaneous Ligaments
 Function
o tether skin to deeper layers of fascia and bone to prevent excessive mobility of skin and improve
grip
o stabilize the digital neurovascular bundle with finger flexion and extension

- 3 -
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

- 4 -
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

- 5 -
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

Deep Transverse Metacarpal Ligament


 Function
o prevents metacarpal heads from splaying apart (abduction)
o allows some dorsal-volar translation
 Anatomic components
o connects 2nd to 5th metacarpal heads together at volar plate of the MP joint

‎I:4 Deep Transverse Metacarpal Ligament


Natatory Ligament (Superficial Transverse Metacarpal Ligament)
 Function : resists abduction
 Anatomic components
o most superficial MP joint ligament
o origin: from distal to the MP joint
o insertion: proximal phalanx of all 5 fingers (runs in the web space)

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)
- 6 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy

‎I:5 Natatory Ligament

‎I:6 Sagittal Bands

- 7 -
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

‎I:7 Volar plate ‎I:8 checkrein ligaments

- 8 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy

3. Flexor Pulley System


Flexor Pulley System-Fingers

 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

- 9 -
OrthoBullets2017 Hand Introduction | Anatomy
Flexor Pulley System-Thumb

 Oblique pulley (3-5mm)


o originates at proximal half of proximal phalanx
o most important pulley in thumb
o functions like cruciate pulley in fingers
 in fingers A1-A2-C1-A3
 in thumb A1-Av-oblique-A2
o facilitates full excursion of FPL
o prevents bowstringing of FPL
 bowstringing will occur if both A1 and oblique pulleys are cut
 Annular pulleys
o A1 pulley (4-8mm)
 at the level of the volar plate at the MCP joint
 ~6mm in length
 radial digital nerve is closest (2.7mm)
 ulnar digital nerve is less close (5.4mm)
 bowstringing will occur if both A1 and oblique pulleys are cut
o Av pulley (annular variable pulley) (4-8mm)
 between A1 and oblique pulleys
 previously thought to be part of oblique pulley
 function
 helps prevent bowstringing
 3 types
 Type I - transverse, parallel to A1, with gap between Av and A1
 Type II - no gap between Av and A1
 Type III - triangular/oblique Av pulley with fibers converging to radial side
o A2 pulley (5-10mm)
 contributes least to arc of motion of thumb
 if A2 is intact, cutting A1 or oblique pulley will not result in bowstringing
- 10 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy

Types of
annular
variable pulley:

Type 1

Type 2

Type3

- 11 -
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

‎I:12 belt-loop (Karev)

‎I:11 ever-present-rim (Kleinert)

- 12 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy

4. Blood Supply to Hand


Source Arteries
 Radial artery
o runs between brachioradialis and FCR
o enters the dorsum of the carpus by passing between FCR and APL/EPB tendons (in the snuffbox)
o gives off superficial palmar branch (communicates with superficial arch)
o finally passes between 2 heads of 1st dorsal interosseous to form the deep palmar arch
 Ulnar artery
o runs under flexor carpi ulnaris
o lateral to ulnar nerve at the wrist
o enters the hand through Guyon's canal
o lies on the transverse carpal ligament
 Supplemental arteries
o anterior interosseous artery
o posterior interosseous artery
o median artery (occasionally)

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
- 13 -
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

- 14 -
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

‎I:15 Dorsal metacarpal arteries arising from


the dorsal carpal arch

5. Wrist Ligaments & Biomechanics


Wrist Planes of Motion
 Joints involved
o radiocarpal
o intercarpal
 Three axes of motion
o flexion-extension
o radial-ulnar deviation
o prono-supination
 Normal and function motion
o flexion (65 normal, 10 functional)
 40% radiocarpal, 60% midcarpal
o extension (55 normal, 35 functional)
 66% radiocarpal, 33% midcarpal
o radial deviation (15 normal, 10 functional)
 90% midcarpal
o ulnar deviation (35 normal, 15 functional)
 50% radiocarpal, 50% midcarpal

- 15 -
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

- 16 -
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:19 Space of Poirier


- 17 -
OrthoBullets2017 Hand Introduction | Anatomy
Extrinsic Ligaments
 Volar radiocarpal ligaments
o radial collateral
o radioscaphocapitate
 at risk for injury with excessively large radial styloid
 from radial styloid to capitate, creating a sling to support the waist of the scaphoid
 preserve when doing proximal row carpectomy
 acts as primary stabilizer of the wrist after PRC and prevents ulnar drift
o long radiolunate
 also called radiolunotriquetral or volar radiolunate ligament
 counteracts ulnar-distal translocation of the lunate
 abnormal in Madelung's deformity
o radioscapholunate
 Ligament of Testut and Kuentz
 only functions as neurovascular conduit
 not a true ligament
 does not add mechanical strength
o short radiolunate
 stabilizes lunate
 Volar ulnocarpal ligaments
o ulnotriquetral
o ulnolunate
o ulnocapitate
 Dorsal ligaments
o radiotriquetral
 must also be disrupted for VISI deformity to form (in combination with rupture of
lunotriquetral interosseous ligament rupture)
o dorsal intercarpal (DIC)
o radiolunate
o radioscaphoid

‎I:21 Volar ligaments of the wrist ‎I:20 Dorsal ligaments of the wrist
- 18 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy

Coronal MR arthrogram showing Diagram of radioscaphocapitate Coronal T1-weighted MR arthrogram


radial collateral ligament extending ligament showing radioscaphocapitate ligament
from radial styloid (arrows) to (black arrow) and volar radiolunate
scaphoid (S) waist (arrowheads). ligament (white arrow)

Arthroscopic photograph showing


radioscaphocapitate (right) and long
radiolunate (left) ligaments Axial MR arthrogram showing
Diagram showing radioscapholunate neurovascular
radioscaphocapitate (thin arrow) bundle (4). The intrinsic scapholunate
and long radiolunate (thick arrow) ligament (11) is also visible
ligaments

Sagittal MR arthrogram showing short radiolunate Cadaveric specimen showing short radiolunate ligament
ligament (3) (3)

- 19 -
OrthoBullets2017 Hand Introduction | Anatomy

Diagram showing volar ulnolunate


and volar ulnotriquetral ligaments
extending from volar radioulnar MR arthrogram showing volar MR arthrogram showing volar
ligament (part of TFCC) to insert on ulnotriquetral ligament (white arrow) ulnolunate ligament (white arrow)
the lunate and triquetrum extending from volar radioulnar extending from volar radioulnar
respectively ligament (black arrow) to triquetrum ligament (black arrow) to lunate

Illustration showing DISI and VISI


deformities

Diagram of dorsal radiotriquetral and Coronal MRA showing dorsal


dorsal intercarpal ligament radiotriquetral ligament (black
arrows) and dorsal intercarpal
ligament (white arrows)

- 20 -
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

Scapholunate ligament from a radial


perspective, showing its 3
Coronal T1-weighted MRI showing components - palmar (SLIp), dorsal Coronal MR arthrogram showing
normal scapholunate ligament (SLId), proximal (SLIpx). Other normal lunotriquetral ligament
(arrow)(S, scaphoid; L, lunate; T, ligaments seen include long (arrow) (S, scaphoid; L, lunate; T,
triquetrum radiolunate (LRL), short radiolunate triquetrum)
(SRL), radioscapholunate (RSL) and
dorsal scaphotriquetral (ST)

- 21 -
OrthoBullets2017 Hand Introduction | Anatomy

Diagram showing distal row dorsal


interosseous ligaments (TT, Coronal MR arthrogram showing
trapeziotrapezoid; CT, Normal scaphotrapeziotrapezoid scaphotrapeziotrapezoid ligament
trapezocapitate; CH, capitohamate ligament (arrow)

6. Motion of the Fingers

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.

PIP  Flexor Digitorum Superficialis  Extensor Digitorum central slip


 Flexor Digitorum Profundus  Lumbricals (via lateral bands)
 Dorsal interosseous

DIP  Flexor Digitorum Profundus  Extensor Digitorum terminal


tendon
 lumbricals via lateral bands

- 22 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation

7. Thumb Motion

Thumb Motion MCP IP


Extension Extensor Pollicis Brevis Extensor Pollicis Longus
Extensor Pollicis Longus
Flexion Flexor Pollicis Brevis Flexor Pollicis Longus
Abduction Abductor Pollicis Brevis NA
Adduction Adductor Pollicis NA
Opposition Opponens Pollicis NA

- 23 -
OrthoBullets2017 Hand Introduction | Clinical Evaluation

B. Clinical Evaluation

1. Physical Exam of the Hand


Overview
 An overview of some of the common physical exam manoeuvers used to examine the hand and wrist
Test Tests instability at
Watson test Scapholunate (SL) instability - dynamic
Lunotriquetral ballotment test
Lunotriquetral (LT) instability - dynamic
(Reagan test)
Kleinman shear test LT instability - dynamic
Lichtman test Midcarpal instability - dynamic
TFCC grind TFCC pathology
ECU snap test ECU instability
Piano key sign DRUJ instability
Fovea sign TFCC pathology or ulnotriquetral ligament split tear

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
- 24 -
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

‎I:25 Illustration of the flexion-extension arc of the wrist

‎I:27 Illustration demonstrating range of motion of fingers

‎I:26 Illustration of radioulnar deviation arc


- 25 -
OrthoBullets2017 Hand Introduction | Clinical Evaluation
Neurovascular Exam
 Sensation
o two-point discrimination
 Motor
o radial nerve: test thumb IP joint extension against resistence
o median nerve
 recurrent motor branch: palmar abduction of thumb
 anterior interosseous branch: flexion of thumb IP and index DIP ("A-OK sign")
o ulnar nerve: cross-fingers or abduct fingers against resistence
 Vascular
o radial pulse
o ulnar pulse
o Allen's test
o capillary refill

- 26 -
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
- 27 -
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

- 28 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation

2. Vascular Evaluation of the Hand

 Three-phase bone scan


o Phase I (2 minutes)
 shows an extremity anteriogram
o Phase II (5-10 minutes)
 shows cellulits and synovial inflammation
o Phase III (2-3 hours)
 shows bone images
 RSD diagnosed with positive phase III that does not correlate with positive Phase I and Phase
II
o Phase IV (24 hours)
 can differentiate osteomyelitis from adjacent cellulitis
 Duplex scan
o is helpful for arterial intimal lesions (true and false aneurysms)
 Arteriogram
o remains gold standard for embolic disease
o downside is it is invasive with risks
 Ultrasound duplex
o imaging is becoming more sensitive and specific
 Segmental limb pressures

3. Nerve Conduction Studies

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)

- 29 -
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
- 35 -
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

- 36 -
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

- 37 -
OrthoBullets2017 Hand Introduction | Hand Infections

3. Pyogenic Flexor Tenosynovitis


Introduction
 Infection of the synovial sheath that surrounds the flexor tendon
 Epidemiology
o incidence 2.5 to 9.4% of all hand infections
o risk factors
 diabetes
 IV drug use
 immunocompromised patients
 Pathophysiology
o mechanism
 penetrating trauma to the tendon sheath
 direct spread from
 felon
 septic joint
 deep space infection
o pathoanatomy
 infection travels in the synovial sheath that surrounds the flexor tendon
o microbiology
 Staph aureus (40-75%)
 most common
 MRSA (29%)
 intravenous drug abusers
 other common skin flora
 staph epidermidis
 beta-hemolytic streptococcus
 pseudomonas aeruginosa
 mixed flora and gram negative organsims
 in immunocompromised patients
 Eikenella
 in human bites
 Pasteurella multocida
 in animal bites
 Associated conditions
o "horseshoe abscess"
 may develop from spread pyogenic flexor tenosynovitis
 of many individuals have a connection between the sheaths of the thumb and little fingers
at the level of the wrist
 infection in one finger can lead to direct infection of the sheath on the opposite side of the
hand resulting a "horseshoe abscess"
Anatomy
 Tendon sheaths
o function
 to protect and nourish the tendons

- 38 -
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
- 39 -
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

4. Deep Space & Collar Button Infections


Introduction
 Deep space infections
o defined as infections of the
 thenar space
 most commonly infected
 hypothenar space
 midpalmar space
 rare
 Collar button abscess
o an abscess that occurs in the web space between fingers

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

- 40 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections

- 41 -
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

- 42 -
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

- 43 -
OrthoBullets2017 Hand Introduction | Hand Infections

6. Atypical Mycobacterium Infections


Introduction
 Nontuberculous mycobacterial infections
 Epidemiology
o demographics
 often found in marine workers
o location
 hand and wrist are involved in 50% of cases
o risk factors
 immunocompromised host
 Pathophysiology
o incubation
 average incubation period is two weeks, but can be up to six months
 average time to diagnosis and appropriate treatment is more than 1 year
o organisms
 widely encountered in the environment, but rarely cause human pathology
 M. marinum
 most common atypical mycobacterium infection
 more common in stagnant fresh or salt water (aquariums)
 M kansasii
 found in soil
 M terrae
 found in soil
 M. avium intracellulare
 most common in terminal AIDS patients, but can occur in non-HIV patients
 Prognosis
o natural history
 early presentation includes papules, nodules, and ulcers
 late presentation may have progressed to tenosynovitis, septic arthritis, or osteomyelitis
o morbidity & mortality
 mortality rate is 32%

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

- 44 -
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

- 45 -
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

- 46 -
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

- 47 -
OrthoBullets2017 Microsurgery | Hand Infections

ORTHO BULLETS

II. Microsurgery

- 48 -
By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation

A. Replantation

1. Fingertip Amputations & Finger Flaps


Introduction
 Injury to the finger with variable involvement of soft tissue, bone, and tendon
 Goals of treatment
o sensate tip
o durable tip
o bone support for nail growth
 Prognosis
o improper treatment may result in stiffness and long-term functional loss

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

- 49 -
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

- 50 -
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)

Flap Techniques By Region


 Flap treatment options determined by location of lesion

1. Finger Tip Straight or Dorsal Oblique laceration


• V-Y Advancement flap
• Digital island artery
Volar Oblique laceration
• Cross finger flap (if > 30 yrs)
• Thenar flap (if< 30 yrs)
• Digital island artery
 reverse cross finger (for nail bed sterile matrix and eponychial fold
losses)

2. Volar Proximal Finger • Cross finger (if > 30 yrs)


• Axial flag flap from long finger
3. Dorsal Proximal Finger & • Reverse cross finger
MCP
• Axial flag flap from long finger
4. Volar Thumb • Moberg Advancement Volar Flap (if < 2 cm)
• FDMA (if > 2 cm)
• Neurovascular Island Flap (up to 4 cm)
5. Dorsal Thumb • FDMA
6. First Web Space • Z-plasty with 60 degree flaps
• Posterior interosseous fasciocutaneous flap (if > 75%)
7. Dorsal Hand • Groin Flap

- 51 -
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

- 52 -
By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation

V-Y advancement flap

Cross finger flap

Thenar flap
- 53 -
OrthoBullets2017 Microsurgery | Replantation

Moberg advancement volar flap

Neurovascular island flap

First dorsal metacarpal artery flap


Complications
 Flap failure
o cause
 inadequate arterial flow
 vasospasm often leads to thombosis at anastamosis
 inadequate venous outflow
 Hook nail deformity
o cause
 tight tip closure ‎II:6 Hook nail deformity
 insufficient bony support
o treatment
 variety of reconstructive procedures have been described
- 54 -
By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation

2. Ring Avulsion Injuries


Introductions
 Definition
o sudden pull on a finger ring results in severe soft tissue injury ranging from circumferential soft
tissue laceration to complete amputation
o skin, nerves, vessels are often damaged
 Epidemiology
o incidence
 150,000 incidents of amputations and
degloving in the US per year
 5% of upper limb injuries
o location
 usually only involves 1 digit (with ring)
o risk factors
 working with machinery I‎I:7 Mechanism of ring avulsion. Soft tissue (skin, vessels, nerves) are
circumferentially peeled distally together with wedding band or finger ring.
 wearing a ring
 Mechanism
o patients catch their wedding band or other finger ring on moving machinery or protruding object
o long segment of macro- and microscopic vascular injury from crushing, shearing and avulsion
 Prognosis
o outcomes of injury
 extent of injury is greater than what it appears to be
 poor prognosis because of long segment vascular injury
o treatment outcomes
 advances in interposition graft techniques have improved results with ring avulsion
replantation
Anatomy
 Muscles
o avulsed digits are devoid of muscles and will survive >12h if cooled
 Skin
o skin is the finger's strongest soft tissue
 once the skin tears, the remaining tissue quickly degloves
 Biomechanics
o Urbaniak Class I injuries at 80N of traction force
o Urbaniak Class III injuries at 154N of traction force
o Standard wedding band (3mm wide, regardless of alloy) will not open at 1000N

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
- 55 -
OrthoBullets2017 Microsurgery | Replantation
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)

- 56 -
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)
- 57 -
OrthoBullets2017 Microsurgery | Replantation
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.

- 58 -
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
- 59 -
OrthoBullets2017 Microsurgery | Replantation
 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

- 60 -
By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation

o general operative sequence of replantation


1. vascular shunt first (for proximal replantation with large muscle mass to minimize warm
ischemia time)
2. bone fixation +/- shortening (after irrigation and debridement of soft-tissue and bone)
3. extensor tendon repair
4. artery repair(repair second after bone if ischemic time is >3-4 hours)
5. venous anastomoses
6. flexor tendon repair
7. nerve repair
8. skin +/- fasciotomy
o finger order
 thumb, long, ring, small, index
o for multiple amputations structure-by-structure sequence is most efficient
 digit-by-digit sequence takes the most time

Postoperative Care
 Environment
o keep patient in warm room (80°F)
o avoid caffeine, chocolate, and nicotine

- 61 -
OrthoBullets2017 Microsurgery | Replantation
 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

- 62 -
By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation

4. Thumb Reconstruction
Introduction

Regions of Thumb Reconstruction

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%

- 63 -
OrthoBullets2017 Microsurgery | Reconstruction
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

1. Peripheral Nerves Injury & Repair


Introduction
 Mechanism
o stretching injury
 8% elongation will diminish nerve's
microcirculation
 15% elongation will disrupt axons
 examples
 "stingers" refer to neurapraxia
from brachial plexus stretch injury
 suprascapular nerve stretching
injuries in volley ball players
 correction of valgus in TKA leading to peroneal nerve palsy
o compression/crush
 fibers are deformed
 local ischemia
 increased vascular permeability
 endoneurial edema leads to poor axonal transport and nerve dysfunction
 fibroblasts invade if compression persists
 scar impairs fascicular gliding
 30mm Hg can cause paresthesias
 increased latencies
 60 mm Hg can cause complete block of conduction
o laceration
 sharp transections have better prognosis than crush injuries
 continuity of nerve disrupted
 ends retract
 nerve stops producing neurotransmitters
 nerve starts producing proteins for axonal regeneration
 Pathophysiology

- 64 -
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

 functions to cushion fascicles against external pressure


o perineurium
 connective tissue covering individual fascicles
 primary source of tensile strength and elasticity of a peripheral nerve
 provides extension of the blood-brain barrier
 provides a connective tissue sheath around each nerve fascicle
o fascicles
 a group of axons and surrounding endoneurium
o endoneurium
 fibrous tissue covering axons
 participates in the formation of Schwann cell tube
o myelin
 made by Schwann cells
 functions to increase conduction velocity

- 65 -
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

Fiber Type Diameter (uM) Myelination Speed Example


A 10-20 heavy fast touch
B <3 moderate medium ANS
C < 1.3 none slow pain

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

- 66 -
By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
 no recovery unless surgical repair performed
 fibrillations and positive sharp waves on EMG

Seddon Myelin Endoneurim Wallerian


Degree Axon Intact Reversible
Type Intact Intact Degen.
Neurapraxia 1st No Yes Yes No reversible
Axonotmesis 2nd No No Yes Yes reversible
Neurotmesis 3rd No No No Yes irreversible

 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
- 67 -
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

- 68 -
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

2. Extremity Flap Reconstruction


Introduction
 Definition of flap
o unit of tissue transferred from a donor site to a recipient site while maintaining its own vascular
supply
 Definition of pedicle
o vascular portion of the transferred tissue
o usually contains one artery and one or more veins
 Indications for flap coverage
o soft tissue injury with exposed
 bone
 tendons
 cartilage
 orthopaedic implants
 Prognosis
o free tissue transfer within 72 hours for severe trauma in the upper extremity has been shown to
decrease complication rates
Classification
 Blood supply classification
o axial pattern local flaps
 contain single arteriovenous pedicle (a "named vessel")
 indications
- 69 -
OrthoBullets2017 Microsurgery | Reconstruction
 primary/secondary closure not advisable and
 area cannot support STSG or FTSG and
 length-width ratio needed > 2:1
o random pattern flaps
 supported by numerous microcirculation with no single arteriovenous pedicle
 indications
 primary/secondary closure not advisable andarea cannot support STSG or FTSG and
 length-width ratio needed < 2:1
o venous flap
 uses veins as inflow and outflow of arterial blood
 Tissue type classification
o cutaneous
 include skin and subcutaneous tissue
o fascial flap
 include fascia with no overlying skin
 example
 temporoparietal flap
o muscle flaps
 usually requires additional transfer of a skin graft to cover muscle
 alternatively, muscle can be transposed as part of a musculocutaneous flap (composite flap)
 if motor nerve is not preserved the flap will atrophy to 50% of its original size
o bone flaps
 free fibula
 based on peroneal artery pedicle
 useful for diaphyseal reconstruction
 free iliac crest
 based on deep circumflex iliac vessels
 useful for metaphyseal reconstuction
o composite flaps
 consists of multiple tissue types
 examples : radial forearm flap (fasciocutaneous)
 Mobilization type classification
o local flap
 tissue transferred from an area adjacent to defect
o distal random pattern flap
 transfer of tissue to a noncontiguous anatomic site
 indications
 surrounding tissue will not support a local flap
 length-width ratio needed < 2:1
o distal axial pattern flap
 indications
 surrounding tissue will not support a local flap
 length-width ratio needed > 2:1
o free tissue transfer
 indicatoins
 local or distant tissue not sufficient for distal axial and random pattern flaps

- 70 -
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.

medial gastrocnemius flap used for gracilis flap harvest.


lateral arm flap. coverage in the proximal third of
tibia.
- 71 -
OrthoBullets2017 Microsurgery | Reconstruction

Proximally pedicled fibula graft


Groin flap while Figure B shows a distally Radial bone graft used to treat
pedicled fibula graft. scaphoid nonunion.

Index metacarpal transposition Little metacarpal transposition


deep transvers intermetacarpal
ligament reconstruction.

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

- 72 -
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

Split-Thickness Skin Graft (STSG)


 Indications
o well-perfused wound beds where contraction will not lead to decreased joint mobility or scar
contracture
o preferred for dorsal hand wounds
 Donor sites
o anterolateral thigh is the most common
 Graft elements
o variable based on thickness
o always contain keratinocytes
o thicker grafts contain more dermis with hair follicles and sweat glands and contract less
o nutrition is obtained by diffusion from the wound bed
 Technique
o classification
 thin (0.005-0.012 in)
 intermediate (0.012-0.018 in)
 thick (0.018-0.030 in)
o meshed v. nonmeshed grafts
- 73 -
OrthoBullets2017 Microsurgery | Reconstruction
meshed grafts provide a greater surface area
meshed grafts have a lower incidence of hematoma formation and infection leading to better
"take" of the graft
 Outcomes
o revascularization takes 2 to 3 days

Full-Thickness Skin Grafts


 Indications
o volar hand wounds and fingertips
 Donor sites
o proximal forearm
o hypothenar eminence of hand
 Graft elements
o contain full thickness of dermis and epidermis, containing hair follicles and sweat glands
o subcutaneous fat is not included because it decreases vascular ingrowth and survival
o nutrition is obtained by diffusion from the wound bed
 Technique
o apply under gentle tension over a well-perfused wound bed
o place multiple tie-over sutures to decrease shear forces
o dressing should include a medicated gauze and moist cotton
o leave dressing in place for 5 to 7 days
 Outcomes
o pros
 better reinnveration and sensation
 less scar contracture
 more durable and wear resistant to shear stresses
o cons
 hematomas and seromas can still cause failure
 revascularization takes 2 to 3 days

Other Skin Grafts


 Allograft
o indications
 used as a temporary measure to prepare the wound bed for autograft
 Xenograft
o indications
 used occasionally as biologic dressings

4. Tendon Transfer Principles


Introduction
 Principles of tendon transfersmatch muscle strength
 force proportional to cross-sectional area
 greatest force of contraction exerted when muscle is at resting length
 amplitude proportional to length of muscle
 work capacity = (force) x (amplitude)
 motor strength will decrease one grade after transfer

- 74 -
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

- 75 -
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)

- 76 -
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

- 77 -
OrthoBullets2017 Neuropathies | Reconstruction

ORTHO BULLETS

III.Neuropathies

- 78 -
By Dr, AbdulRahman AbdulNasser Neuropathies | Median Neuropathies

A. Median Neuropathies

1. Carpal Tunnel Syndrome


Introduction
 Most common compressive neuropathy
o pathologic (inflamed) synovium most common cause of idiopathic CTS
 Epidemiology
o affects 0.1-10% of general population
o risk factors
 female sex
 obesity
 pregnancy
 hypothyroidism
 rheumatoid arthritis
 advanced age
 chronic renal failure
 smoking
 alcoholism
 repetitive motion activities
 mucopolysaccharidosis
 mucolipidosis
 Pathophysiology
o mechanism
 precipitated by
 exposure to repetitive motions and vibrations
 certain athletic activities
 cycling
 tennis
 throwing
o pathoantomy
 compression may be due to
 repetitive motions in a patient with normal anatomy
 space occupying lesions (e.g., gout)
 Associated conditions
o diabetes mellitus
o hypothyroidism
o rheumatoid arthritis
o pregnancy
o amyloidosis
 Prognosis
o good prognostic indicators include
 night symptoms
 short incisions
 relief of symptoms with steroid injections
 not improved when incomplete release of transverse carpal ligament is discovered
- 79 -
OrthoBullets2017 Neuropathies | Median Neuropathies
Anatomy
 Carpal tunnel defined by
o scaphoid tubercle and trapezium radially
o hook of hamate and pisiform ulnarly
o transverse carpal ligament palmarly (roof)
o proximal carpal row dorsally (floor)
 Carpal tunnel consists of
o nine flexor tendons
o one nerve (median nerve)
o FPL is the most radial structure
 Branches of median nerve
o palmar cutaneous branch of median nerve
 lies between PL and FCR at level of the wrist flexion crease
o recurrent motor branch of median nerve
 50% are extraligamentous with recurrent innervation
 30% are subligamentous with recurrent innervation
 20% are transligamentous with recurrent innervation
 cut transverse ligament far ulnar to avoid cutting if nerve is transligamentous
 Carpal tunnel is narrowest at the level of the hook of the hamate

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

- 80 -
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

- 81 -
OrthoBullets2017 Neuropathies | Median Neuropathies

 night splints (good for patients with nocturnal symptoms only)


 activity modification (avoid aggravating activity)
o steroid injections
 indications
 adjunctive conservative treatment
 diagnostic utility in clinically and electromyographically equivocal cases
 outcomes
 80% have transient improvement of symptoms (of these 22% remain symptoms free at
one year)
 failure to improve after injection is poor prognostic factor
 surgery is less effective in these patients
 Operative
o carpal tunnel release
 indications
 failure of nonoperative treatment (including steroid injections)
 temporary improvement with steroid injections is a good prognostic factor that the
patient will have a good result with surgery)
 acute CTS following ORIF of a distal radius fx
 outcomes
 pinch strength return in 6 week
 grip strength is expected to return to 100% preoperative levels by 12 weeks postop
 rate of continued symptoms at 1+ year is 2% in moderate and 20% in moderate CTS
o revision CTR for incomplete release
 indications
 failure to improve following primary surgery
 incomplete release most common reason
 outcomes
 only 25% will have complete relief after revision CTR
 50% some relief
 25% will have no relief

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

- 82 -
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

2. AIN Compressive Neuropathy


Introduction
 A compressive neuropathy of the AIN that results in
o motor deficits only
o no cutaneous sensory changes
 Pathoanatomy
o potential sites of entrapment
 tendinous edge of deep head of pronator teres
 most common cause
 FDS arcade
 edge of lacertus fibrosus
 accessory head of FPL (Gantzer's muscle)
 accessory muscle from FDS to FDP
 abberant muscles (FCRB, palmaris profundus)
 thrombosed ulnar radial or ulnar artery
o patient with complete AIN palsy should have no motor function to all muscles innervated by
AIN
 patients with incompletes palsies or with Martin-Gruber anastamoses (anomalous anatomy in
15% of population where axons of AIN may cross over and connect to ulnar nerve and
innervate other muscle groups)
 present with intrinsic weakness
 Associated conditions
o Parsonage-Turner Syndrome
 bilateral AIN signs caused by viral brachial neuritis
 be suspicious if motor loss is preceded by intense shoulder pain and viral prodrome

Illustration of accessory head of FPL


(arrow), with humeral and ulnar origins
and inserting into the ulnar border of FPL
muscle (arrowhead)
- 83 -
OrthoBullets2017 Neuropathies | Median Neuropathies
Anatomy
 AIN is terminal motor branch of median nerve
o AIN arises from the median nerve approximately 4-6 cm distal to the medial epicondyle
o Travels between FDS and FDP initially, then between FPL and FDP, then it lies on the anterior
surface of the interosseous membrane traveling with the anterior interoseous artery to pronator
quadratus
o Terminal branches innervate the joint capsule and the intercarpal, radiocarpal and distal
radioulnar joints.
 AIN has principally motor innervation (no cutaneous sensory) and innervates 3 muscles
o FDP (index and middle finger)
o FPL
o pronator quadratus

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

- 84 -
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

- 85 -
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

- 86 -
By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies

- 87 -
OrthoBullets2017 Neuropathies | Ulnar Neuropathies

B. Ulnar Neuropathies

1. Cubital Tunnel Syndrome


Introduction
 A compressive neuropathy of the ulnar nerve
o 2nd most common compression neuropathy of the upper extremity
 Sites of entrapment
o most common
 between the two heads of FCU/aponeurosis (most common site)
 within arcade of Struthers (hiatus in medial intermuscular septum)
 between Osborne's ligament and MCL
o less common sites of compression include
 medial head of triceps
 medial intermuscular septum
 medial epicondyle
 fascial bands within FCU
 anconeus epitrochlearis (anomalous muscle from the medial olecranon to the medial
epicondyle)
 aponeurosis of FDS proximal edge
o external sources of compression
 fractures and medial epicondyle nonunions
 osteophytes
 heterotopic ossification
 tumors and ganglion cysts
 Associated conditions
o cubitus varus or valgus deformities
o medial epicondylitis
o burns
o elbow contracture release

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

- 88 -
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.)

- 89 -
OrthoBullets2017 Neuropathies | Ulnar Neuropathies

The illustration demonstrates the Left hand demonstrates Froment sign


sensory distribution of the ulnar interosseous wasting and first
nerve in the hand. web space atrophy with ring and
small finger clawing
characteristic of advanced
cubital tunnel syndrome.
 Wartenberg sign
 persistent small finger abduction and extension during attempted adduction secondary
to weak 3rd palmar interosseous and small finger lumbrical
 Masse sign
 palmar arch flattening and loss of ulnar hand elevation secondary to weak opponens
digiti quinti and decreased small finger MCP flexion
o extrinsic weakness
 Pollock's test
 shows weakness of two ulnar FDPs
o provocative tests
 Tinel sign positive over cubital tunnel
 elbow flexion test
 positive when flexion of the elbow for > 60 seconds reproduces symptoms
 direct cubital tunnel compression exacerbates symptoms

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

- 90 -
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

- 91 -
OrthoBullets2017 Neuropathies | Ulnar Neuropathies

2. Ulnar Tunnel Syndrome


Introduction
 Ulnar nerve compression neuropathy caused by direct compression in Guyon's canal
o also known as handlebar palsy (seen in cyclists)
 Pathoanatomy
o causes of compression include
 ganglion cyst (80% of nontraumatic causes)
 lipoma
 repetitive trauma
 ulnar artery thrombosis or aneurysm
 hook of hamate fracture or nonunion
 pisiform dislocation
 inflammatory arthritis
 fibrous band, muscle or bony anomaly
 congenital bands
 palmaris brevis hypertrophy
 idiopathic

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)

Boundaries of Guyon's canal


Floor Transverse carpal ligament, hypothenar muscles
Roof Volar carpal ligament
Ulnar border Pisiform and pisohamate ligament, abductor digiti minimi muscle belly
Radial border Hook of hamate
Zones of Guyon's canal
Location Common Causes of Compression Symptoms
Zone 1 Proximal to Ganglia and hook of hamate fractures
Mixed motor and
bifurcation of the
sensory
nerve
Zone 2 Surrounds deep Ganglia and hook of hamate fractures Motor only
motor branch
Zone 3 Surrounds Ulnar artery thrombosis or aneurysm Sensory only
superficial sensory
branch

- 92 -
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.)

- 93 -
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

- 94 -
By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies

Carpal tunnel view radiograph


CT scan of hook of hamate nonunion a gradient echo MRI Angiogram showing
showing hook of hamate will also show an ulnar artery
nonunion
ulnar artery thrombosis (arrow).
aneurysm The ulnar artery is
palmar and radial to
the ulnar nerve in
Guyon's canal

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

oa gradient echo MRI will also show an ulnar artery aneurysm


 Doppler US or arteriogram
o useful to diagnosis ulnar artery thrombosis and aneurysm

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

- 95 -
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

1. PIN Compression Syndrome


Introduction
 A compressive neuropathy of the PIN which affects the nerve supply of the forearm extensor
compartment
 Epidemiology
o incidence
 reported as 3 per 100,000 people yearly
o demographics
 more common in manual laborers, males and bodybuilders
 Pathophysiology

- 96 -
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)
- 97 -
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.

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

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

- 98 -
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

- 99 -
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

- 100 -
By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies

2. Radial Tunnel Syndrome


Introduction
 A compressive neuropathy of the posterior interosseous nerve (PIN) with pain only
o no motor or sensory dysfunction, and EMG/NCS is not useful
 Pathophysiology
o involves same sites of compression as PIN syndrome, which include (from proximal to distal)
 fibrous bands anterior to radiocapitellar joint
 radial recurrent vessels (leash of Henry)
 medial edge of ECRB
 proximal aponeurotic/tendinous edge of the supinator (arcade of Frohse)
 most frequent site of entrapment of the PIN
 normal radial tunnel pressure 50mmHg
 with supinator stretch (forced wrist flexion) pressure increases to 250mmHg
 distal edge of the superficial layer of the supinator
o risks
 constant prono-supination with 1kg force and elbow in 0°-45° flexion
 Associated conditions
o lateral epicondylitis
 RTS is difficult to distinguish from lateral epicondylitis and coexists in 5% of patients

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

- 101 -
OrthoBullets2017 Neuropathies | Radial Neuropathies

‎III:6 Potential sites of PIN entrapment: (1) arcade of


Frohse, (2) radiocapitellar capsule, (3) leash of Henry, (4)
fibrous medial edge of ECRB, (5) distal edge of supinator.

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
- 102 -
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)

- 103 -
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

- 104 -
By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies

radial tunnel release


 indications
 extensive nonoperative treatment fails
 outcomes
 surgical release has disappointing results
 only 50-90% good to excellent results
 delayed maximal recovery of up to 9-18 months
 lower success rate in the following groups
 concomitant multiple entrapment neuropathies (60%)
 concomitant lateral epicondylitis (40%)
 workers compensation patients (30%)

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%

- 105 -
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
- 106 -
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)

- 107 -
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

- 108 -
By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Radial Neuropathies

ORTHO BULLETS

IV. Degenerative Conditions

- 109 -
OrthoBullets2017 Degenerative Conditions | Hand Deformities

A. Hand Deformities

1. Intrinsic Minus Hand (Claw Hand)


Introduction
 Caused by imbalance between
strong extrinsics and deficient
intrinsics
 Characterized by
o MCP hyperextension
o PIP & DIP flexion
 Causes
o ulnar nerve palsy
 cubital tunnel syndrome
 ulnar tunnel syndrome
o median nerve palsy
 Volkmann's ischemic
contracture
 leprosy (Hansen's disease)
 failure to splint the hand in an intrinsic-plus posture following a crush injury
o Charcot-Marie-Tooth disease (hereditary motor-sensory neuropathy)
o compartment syndrome of the hand

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

- 110 -
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

2. Intrinsic Plus Hand


Introduction
 Caused by muscles imbalance between spastic intrinsics (interosseoi and lumbricals)
o weak extrinsics (FDS, FDP, EDC)
 Characterized by
o MCP flexion
o PIP & DIP extension
 Etiology
o trauma
 direct trauma
 indirect trauma
 vascular injury
 compartment syndrome
o rheumatoid arthritis
 MCP joint dislocations
and ulnar deviation lead
to spastic intrinsics
o neurologic pathology
 traumatic brain injury
 cerebral palsy
 cerebrovascular accident
 Parkinson's syndrome
 Pathoanatomy
o spastic intrinsics
 leads to flexion of the MCP and extension of the IP joints
o EDC weakness
 fails to provide balancing extension force to MCP joint
o FDS & FDP weakness
 fail to provide balancing flexion force to PIP and DIP joints

Presentation
 Symptoms
o difficulty gripping large objects
 Physical exam

- 111 -
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

- 112 -
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

- 113 -
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

- 114 -
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

4. Swan Neck Deformity


Introduction
 Characterized by
o hyperextension of PIP
o flexion of DIP
 Caused by
o lax volar plate
o imbalance of muscle forces on PIP (extension force > flexion force)
 Injuries include
o MCP joint volar subluxation (rheumatoid arthritis)
o mallet finger
o FDS laceration
o intrinsic contracture
 Seen in rheumatoid arthritis

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
- 115 -
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

- 116 -
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

6. Lumbrical Plus Finger


Introduction
 Characterized by paradoxical extension of the IP joints while attempting to flex the fingers
 Epidemiology
o location
 most common in middle finger (2nd lumbrical)
 FDP 3, 4, 5 share a common muscle belly
 cannot independently flex 2 digits without pulling on the third
 index finger has independent FDP belly
 when making a fist following FDP2 transection, it is possible to only contract FDS2
(and not FDP2), thus avoiding paradoxical extension
- 117 -
OrthoBullets2017 Degenerative Conditions | Hand Deformities

‎IV:2 Conditions causing lumbrical plus: (1) FDP transection, (2) FDP avulsion, (3) too long tendon graft, (4) amputation through middle
phalanx

‎IV:3 Image depicts the forces required for FDP disruption.


‎IV:4 LEFT: Attempting to make a fist following amputation
through MF middle phalanx. RIGHT: Attempting to make a fist
following same amputation, after surgical transection of MF
lumbrical.

 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

- 118 -
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)
- 119 -
OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions

B. 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

- 120 -
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

- 121 -
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
- 122 -
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

 look for MCP or PIP contracture


o look for bilateral involvement and ectopic associations (plantar fascia)
 indicative of more aggressive form (Dupuytren's diathesis)

- 123 -
OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions
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

- 124 -
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

- 125 -
OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions
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

- 126 -
By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions

3. Flexor Carpi Radialis Tendinitis


Introduction
 A condition characterized by inflammation of the FCR tendon sheath
 Demographics
o incidence
 uncommon
o risk factors
 repetitive wrist flexion
 golfers and racquet sports
 manual labor
 Pathoanatomy
o primary stenosing tenosynovitis within the fibroosseous tunnel
(see Anatomy)
o secondary tendinitis associated with
 scaphoid fracture
 scaphoid cysts
 distal radius fracture
 scaphoid-trapezium-trapezoid joint arthritis
 thumb CMC joint arthritis
 Prognosis
o prognosis is poor if the following are present
 history of overuse
 worker's compensation
 failure to respond to local injection
 long duration of symptoms

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.

 enters fibroosseous tunnel at the proximal border of the trapezium


 boundaries
 radial = body of the trapezium
 palmar = trapezial crest, transverse carpal ligament
 ulnar = retinacular septum from transverse carpal ligament (separates FCR from
carpal tunnel)
 dorsal = reflection of retinacular septum on trapezium body
 space
 within the tunnel
 the FCR tendon occupies 90% of space
 is in direct contact with the roughened surface of the trapezium
 more prone to constriction, tendinitis, attrition, rupture

- 127 -
OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions

‎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

proximal to the tunnel



 the FCR tendon occupies 50-65% of space within FCR sheath proximal to the
tunnel
 less prone to constriction
 but more prone to mechanical irritation from osteophytes
 insertion
 small slip (1-2mm) inserts into trapezial crest
 80% of remaining tendon inserts into 2nd metacarpal
 20% of remaining tendon inserts into 3rd metacarpal

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

- 128 -
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

- 129 -
OrthoBullets2017 Degenerative Conditions | Extensor Tendon Conditions
 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

C. Extensor Tendon Conditions

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

- 130 -
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
- 131 -
OrthoBullets2017 Degenerative Conditions | Extensor Tendon Conditions
 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

- 132 -
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

- 133 -
OrthoBullets2017 Degenerative Conditions | Extensor Tendon Conditions

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

- 134 -
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
- 135 -
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

 positive UV may be present in child gymnasts


 distal radial growth plate injury leading to premature
closure of distal radial physis
 Pathophysiology
o congenital
 Madelung deformity (positive UV)
 reverse Madelung deformity (negative UV)
o trauma/mechanical
 distal radius/ulnar fracture with shortening
 growth arrest (previous Salter-Harris fracture)
‎IV:19 Positive Ulnar Variance
 DRUJ injuries (Galeazzi and Essex-Lopresti)
o iatrogenic
 joint leveling procedures (radial or ulnar shortening/lengthening)
 radial head resection (positive UV)
 Associated conditions
o positive ulnar variance
 ulnar abutment syndrome
 SLD
 TFCC tears
 arthrosis
 ulnar head
 lunate
 triquetrum
 lunotriquetral ligament tears
o negative ulnar variance I‎V:20 Negative Ulnar Variance
 Kienbock's disease
 ulnar impingement syndrome
 ulna impinges on the radius proximal to the sigmoid notch

- 136 -
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

- 137 -
OrthoBullets2017 Degenerative Conditions | Wrist Conditions

2. Ulnocarpal Abutment Syndrome


Introduction
 Syndrome cause by excessive impact stress between ulna and carpal bones (primarily lunate)
o positive ulnar variance
 Pathoanatomy
o in a wrist with +2 mm ulnar variance approximately
 40% of the load goes to the ulna
 60% to the radius
o in a normal neutral wrist approximately
 20% of the load goes to the ulna
 80% to the radius
 Associated conditions
o positive ulnar variance can be seen in the setting of:
 scapholunate dissociation
 TFCC tears
 lunotriquetral ligament tears
 radial shortening from previous Colles fracture

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

- 138 -
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

- 139 -
OrthoBullets2017 Degenerative Conditions | Wrist Conditions
Techniques
 Ulnar shortening osteotomy
o approach
 subcutaneous to ulna
o technique
 often combined with arthroscopic TFCC repair

Wafer procedure for AP wrist radiograph s/p Sauve-Kapandji


treatment of ulnar positive Darrach procedure procedure
variance

Hemiresection arthroplasty for treatment ulnar head replacement


of carpal abutment

- 140 -
By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions

3. Ulnar Styloid Impaction Syndrome


Introduction
 Epidemiology
o incidence
 common cause of ulnar-sided wrist pain
o demographics
 more prevalent in Asians than Whites
 more positive ulnar variance
 Pathophysiology
o pathoanatomy
 impaction between ulnar styloid tip and triquetrum that is seen in patients with excessively
long ulnar styloids or ulna positive wrists
 Associated conditions
o radial malunion
o congenitally short radius
o premature radial physeal closure
 Prognosis
o little known about natural history

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%

Neutral Ulnar Variance Positive Ulnar Variance Negative Ulnar Variance


- 141 -
OrthoBullets2017 Degenerative Conditions | Wrist Conditions
Presentation
 Symptoms
o ulnar side wrist pain
o pain with pronation or grip
 Physical exam
o inspection
 pain and swelling
 tenderness along ulnar styloid and/or triangular fibrocartilage complex (TFCC)
o motion
 limited range of motion due to pain
o ulnar stress test
 maximum ulnar deviation, axial loading, rotation from supination to pronation to reproduce
symptoms
Imaging
 Radiographs
o posteroanterior (PA) view to determine ulnar variance
 excessive length determined by subtracting ulnar variance from ulnar styloid length and
dividing this by the width of the ulnar head (<.22 is normal)
 may exhibit subchondral sclerosis, cyst formation on ulnar side
o pronated grip PA view
 evaluate for any dynamic ulnar variance
o contralateral comparison views
 MRI
o can help evaluate TFCC and the lunotriquetral interossesous ligament (LTIL)

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

- 142 -
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.

- 143 -
OrthoBullets2017 Degenerative Conditions | Wrist Conditions
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.

- 144 -
By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions

Stage IV: Degenerative changes seen at the adjacent intercarpal joints.

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.

- 145 -
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

- 146 -
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

- 147 -
OrthoBullets2017 Degenerative Conditions | Wrist Conditions

5. Preiser's Disease (Scaphoid AVN)


Introduction
 A condition caused by AVN of scaphoid
 Epidemiology
o rare condition
o average age of onset is 45 years

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

6. Gymnast's Wrist (Distal Radial Physeal Stress Syndrome)


Introduction
 Overuse syndrome of the wrist primarily affecting young gymnasts
o may lead to premature closure of distal radial physis
 Epidemiology
o up to 25% of non-elite gymnasts
 Pathophysiology
o wrist undergoes supraphysiological loads due to use as a weight bearing joint
o repetitive stress causes inflammation at growth plate of distal radius

- 148 -
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"

 usually radial sided


 may be chronic in nature
 Physical exam
o inspection
 swelling may be present at wrist
 tenderness to palpation at distal radius
o motion
 decreased wrist flexion or extension may be present

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)

- 149 -
OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse

E. Wrist Instability & Collapse

1. SNAC (Scaphoid Nonunion Advanced Collapse)


Introduction
 A condition characterized by advanced collapse and progressive arthritis of the wrist that results
from a chronic scaphoid nonunion
o see scaphoid fracture
 Pathophysiology
o pathoanatomy
 natural history of degenerative changes first occurs at the radioscaphoid area followed by
pancarpal / midcarpal arthritis
 Prognosis
o patients with scaphoid nonunions of > 5 years duration or proximal pole necrosis have less
favorable outcomes
o punctate bleeding of bone during surgery is a good prognostic indicator of union
 92% union with obvious bleeding, 71% with questionable bleeding, 0% with no bleeding
 results show decreased rate of arthritis (down to 40-50%)

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

- 150 -
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
- 151 -
OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse

2. Scapholunate Ligament Injury & DISI


Introduction
 Scapholunate ligament is important for carpal stability
o chronic scapholunate deficiency leads to DISI (see below)
 Epidemiology
o incidence
 acute injury
 occurs in approximately 10-30% of intra-articular distal radius fractures or carpal
fractures
 degenerative injury
 degenerative tears in >50% of people over the age of 80 years old
o location
 ligament has 3 components that span between the scaphoid and lunate bones
 dorsal, proximal and volar components
 incomplete tears > complete tears
 Pathophysiology
o mechanism of injury
 sudden impact force applied to the hand and wrist causing SLIL injury and scapholunate
dissociation
 injury occurs most commonly with wrist positioned in extension, ulnar deviation and carpal
supination
o pathoanatomy
 osseous
 SLIL tearing will position the scaphoid in flexion and lunate extension
 ligamentous
 diastasis of the scapholunate complex occurs with complete SLIL tears and capsule
disruption.
 Associated injuries
o DISI (dorsal intercalated segmental instability)
 scapholunate dissociation causes the scaphoid to flex palmar and the lunate to dorsiflex
 if left untreated the DISI deformity can progress into a SLAC wrist
 DISI is a form of carpal instability dissociative

- 152 -
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)
- 153 -
OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse
 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

DISI - Lateral radiographs


cortical ring sign

This image shows a clenched


fist view of the wrist (note the
position of the fingers). As you
can see, there is obvious
widening of the SL interval as normal carpal alignment increased SL angle
indicated by the arrow.

- 154 -
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

- 155 -
OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse
 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

3. Lunotriquetral Ligament Injury & VISI


Introduction
 Instability of the lunotriquetral joint caused by rupture of the
o lunotriquetral ligament and
o dorsal radiocarpal ligament (aka radiotriquetral ligament)
 Epidemiology
o LT ligament injury is less common than SL ligament injury
 Mechanism
o LT ligament injury occurs with
 wrist hyperextension or
 extension and radial deviation
o scaphoid induces the lunate into further flexion while triquetrum extends
 VISI Deformity
o stands for volar intercalated segment instability
 a type of Carpal Instability Dissociative (CID)
o caused by advanced injury with injury to
 lunotriquetral ligament
 dorsal radiotriquetral ligament
 volar radiolunate ligament

- 156 -
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

- 157 -
OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse

Volar flexion of lunate leads to SL angle < 30° Arthroscopy


Treatment
 Nonoperative
o observation
 indications
 may be attempted initially
 Operative
o CRPP (multiple K-wire fixation) with acute ligament repair +/- dorsal capsulodesis
 indications
 acute instability
 technique
 ligament reconstructions with bone-ligament-bone autograft and LT fusion have fallen
out of favor in acute setting
o LT fusion
 indications
 chronic instability
 complications
 nonunion is a known complication
o arthroscopic debridement of LT ligament with ulnar shortening
 indications
 chronic instability secondary to ulnar positive variance
 long ulna chronically impacts the triquetrum, resulting in LT tear with instability
 often associated with degenerative tear of triangular fibrocartilage complex (TFCC)

4. SLAC (Scaphoid Lunate Advanced Collapse)


Introduction
 A condition of progressive instability causing advanced arthritis of radiocarpal and midcarpal joints
o describes the specific pattern of degenerative arthritis seen in chronic dissociation between the
scaphoid and lunate
 Pathoanatomy
o chronic SL ligament injury creates a DISI deformity
 scaphoid is flexed and lunate is extended as scapholunate ligament no longer restrains this
articulation

- 158 -
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

Watson Stage I Watson Stage II Watson Stage III


Presentation
 Symptoms
o difficulty bearing weight across wrist
o patients localize pain in region of scapholunate interval
o progressive weakness of affected hand
o wrist stiffness
- 159 -
OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse
 Physical exam
o tenderness directly over scapholunate ligament dorsally
o decreased wrist ROM
o weakness of grip strength
o Watson scaphoid shift test
 patients may have positive Watson scaphoid shift test early in the process,
 will not be positive in more advanced cases as arthritic changes stabilize the scaphoid
 technique
 with firm pressure over the palmar tuberosity of the scaphoid, wrist is moved from ulnar
to radial deviation
 positive test seen in patients with scapholunate ligament injury or patients with
ligamentous laxity, where the scaphoid is no longer constrained proximally and
subluxates out of the scaphoid fossa resulting in pain
 when pressure removed from the scaphoid, the scaphoid relocates back into the scaphoid
fossa, and typical snapping or clicking occurs
 must compare to contralateral side

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

- 160 -
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

- 161 -
OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse

5. CIND (carpal instability nondissociative)


Introduction
 Defined as instability between rows (either radiocarpal or midcarpal)
o radiocarpal instability (between radius and proximal row)
o midcarpal instability (between proximal and distal row)
 Epidemiology
o incidence
 rare
 Pathophysiology and Mechanism
o radiocarpal instability ("inferior arc injury")
 high-energy injury
 ulnar translation signifies global rupture of extrinsic ligaments
 distal radius malunion is the most common cause
 may be purely ligamentous or have associated ulnar and radial styloid fractures
 Associated conditions
o intracarpal injury (scapholunate or lunotriquetral ligament)
o acute carpal tunnel syndrome
o compartment syndrome
 Prognosis
o volar dislocation is more severe than dorsal

Anatomy
 Volar extrinsic ligaments
o radioscaphocapitate (RSC)
o long radiolunate
o short radiolunate
o radioscapholunate

Classification
 Overview table of wrist instability

- 162 -
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

- 163 -
OrthoBullets2017 Degenerative Conditions | Arthritic conditions
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

1. Basilar Thumb Arthritis


Introduction
 Arthritis of the carpal-metacarpal (CMC) joint
 Epidemiology
o race
 thumb CMC arthritis is more common in Caucasians
 hand OA is more common in native Americans than Caucasians/African Americans
o common arthritis of the hand
 2nd only to DIP arthritis
 DIP > thumb CMC > PIP > MCP
 OA in 1 joint in a row (proximal row) predicts for OA in other joints in same row
 Pathoanatomy
o theorized to be due to attenuation of anterior oblique ligament (Beak ligament)
 leading to instability, subluxation, and arthritis of CMC joint
 Associated conditions
o MCP hyperextension deformity

- 164 -
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:33 Illustration shows bony anatomy of trapezium.

‎IV:34 Illustration shows volar (A) and dorsal (B) ligaments of CMC joint.

- 165 -
OrthoBullets2017 Degenerative Conditions | Arthritic conditions
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)

Stage I Stage II Stage III Stage IV


Presentation
 Symptoms
o pain at base of thumb
o difficulty pinching and grasping
o concomitant carpal tunnel syndrome
 up to 50% incidence
 Physical exam
o painful CMC grind test
 combined axial compression and circumduction
o swelling and crepitus
o metacarpal adduction and web space contractures
 are later findings
o may have adjacent MCP fixed hyperextension (zig-zag or "Z" deformity)
 occurs during pinch as a sequlae of CMC arthritis

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

- 166 -
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
- 167 -
OrthoBullets2017 Degenerative Conditions | Arthritic conditions
 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

- 168 -
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

2. DIP and PIP Joint Arthritis


Introduction
 Forms include
o primary osteoarthritis
 DIP
 highest joint forces in hand
 undergoes more wear and tear
 associated with Heberden's nodules (caused by osteophytes)
 mucous cysts
 can lead to draining sinus
 septic arthritis
 nail ridging
 nail can be involved
 splitting/ridging
 deformity
 loss of gloss
 PIP
‎IV:38 mucous cysts
 Bouchard nodes
 joint contractures with fibrosis of ligaments
o erosive osteoarthritis
 condition is self limiting, patients are relatively asymptomatic, but can be destructive to joint
 more common in DIP
 seen in middle aged women with a 10:1 female to male ratio

- 169 -
OrthoBullets2017 Degenerative Conditions | Arthritic conditions

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

- 170 -
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

- 171 -
OrthoBullets2017 Degenerative Conditions | Arthritic conditions

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

- 172 -
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

- 173 -
OrthoBullets2017 Pediatric Hand | Arthritic conditions

ORTHO BULLETS

V. Pediatric Hand

- 174 -
By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Arm

A. Congenital Arm

1. Radial Clubhand (radial deficiency)


Introduction
 A longitudinal deficiency of the radius
o likely related to sonic hedgehog gene
o thumb usually deficient as well
o bilateral in 50-72%
o incidence is 1:100,000
 Associated with
o TAR
 autosomal recessive condition with thrombocytopenia and absent radius
 different in that thumb is typically present
o Fanconi's anemia
 autosomal recessive condition with aplastic anemia ‎V:1 TAR
 Fanconi screen and chromosomal breakage test to screen
 treatment is bone marrow transplant
o Holt-Oram syndrome
 autosomal dominant condition characterized by cardiac defects
o VACTERL Syndrome
 vertebral anomalies, anal atresia, cardiac abnormalities, tracheoesophageal fistula, renal
agenesis, and limb defects)
o VATER Syndrome
 vertebral anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, renal
agenesis)
Classification
Bayne and Klug Classification
Type I Deficient distal radial epiphysis
Type II Deficient distal and proximal radial epiphyses
Type III Present proximally (partial aplasia)
Type IV Completely absent (total aplasia - most common)

- 175 -
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

2. Ulnar Club Hand


Introduction
 A congenital upper extremity deformity characterized by
o deficiency of the ulna and/or the ulnar sided carpal structures
o unstable elbow and stable wrist or vice versa
 elbow abnormalities more common than wrist abnormalities
 Epidemiology
o 5-10 times less common than radial club hand
 Associated conditions
o medical
 not associated with systemic conditions like radial club hand

- 176 -
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

Type III Type IV


- 177 -
OrthoBullets2017 Pediatric Hand | Congenital Arm
Treatment
 Goals
o treatment depends on multiple factors including
 hand position, thumb function, elbow stability, syndactyly
 thumb condition is most important factor to consider for treatment
 Nonoperative
o stretching and splinting
 indications
 used in early stages of treatment
 Operative
o syndactyly release and digital rotation osteotomies
 indications
 done at 12-18 months of age ‎V:2 radial head
o radial head resection and creation of a one-bone forearm resection and creation
of a one-bone forearm
 indications
 Stage II to provide stability at the expense of forearm motion
 there is no good option for restoring elbow motion
 corrective procedures should not be performed until the child is at least 6 months old
o osteotomy of the synostosis
 indications
 may be required in Stage IV to obtain elbow motion

3. Congenital Radial Head Dislocation


Introduction
 Congenital dislocation of radial head
o can bedifferentiated from a traumatic dislocation by:
 bilateral involvement
 hypoplastic capitellum
 convex radial head
 other congenital anomalies
 lack of history of trauma
 difficult to reduce
 Pathoanatomy
o almost always posterior dislocation of radial head
o often combined with bowing and shortening of radius
 Associated conditions
o may have concurrent congenital anomalies

Anatomy
 Elbow Anatomy & Biomechanics

Presentation
 Symptoms
o patients often asymptomatic
o limited elbow ROM
 Physical exam

- 178 -
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

- 179 -
OrthoBullets2017 Pediatric Hand | Congenital Arm
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

- 180 -
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)

- 181 -
OrthoBullets2017 Pediatric Hand | Congenital Arm

5. Congenital Radial Ulnar Synostosis


Introduction
 In normal development the radius and ulna divide from distal to proximal
o therefore the synostosis is usually in proximal half
 Epidemiology
o bilateral in 60%
 Genetics
o familial cases with autosomal dominant inheritance has been reported
o patients frequently have duplication in sex-chromosome

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

- 182 -
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

- 183 -
OrthoBullets2017 Pediatric Hand | Congenital Hand
Classification

Manske and Halikis Classification


Type Description Characteristics
I Normal web Thumb space not narrowed
IIA Mildly narrowed web Thumb space mildly narrowed
IIB Severely narrowed Thumb space severely narrowed
web
III Syndactylized web Thumb and index rays syndactylized, web space obliterated
IV Merged web Index ray suppressed, thumb web space merged with cleft
Thumb elements suppressed, ulnar rays remain, thumb web space no
V Absent web
longer present

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.

- 184 -
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

- 185 -
OrthoBullets2017 Pediatric Hand | Congenital Hand
 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%

- 186 -
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

- 187 -
OrthoBullets2017 Pediatric Hand | Congenital Hand

infant with Type I patient with camtodactyly


camtodactyly demonstrating a demonstrating right hand
left hand small finger PIP small and ring finger PIP Kirner's Deformity
flexion contracture flexion contractures
Presentation
 Symptoms
o often goes unnoticed as usually only affects small finger and is very rarely associated with any
significant compromise in function
o typically painless and without motor/sensory deficits
 Physical exam
o flexion deformity of small finger PIP joint
 flexible (correctable) or fixed (non-correctable) deformity
 progressively worsens over time if untreated
 may rapidly worsen during growth spurts
o normal strength, sensation, perfusion
o usually normal DIP and MCP joint alignment, however compensatory contractures can develop
o no swelling, erythema, or warmth; not associated with inflammation

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

- 188 -
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)

Type I clinodactyly Type II clinodactyly Delta phalanx clinodactyly

- 189 -
OrthoBullets2017 Pediatric Hand | Congenital Hand
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

Opening wedge osteotomy with Z plasty Osteotomies for delta phalanx

- 190 -
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

- 191 -
OrthoBullets2017 Pediatric Hand | Congenital Hand

simple syndactyly complex syndactyly

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

- 192 -
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

- 193 -
OrthoBullets2017 Pediatric Hand | Congenital Hand
 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

- 194 -
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

Preaxial Polydactyly (Thumb Duplication)


 Epidemiology
o incidence ‎ :10 Preaxial Polydactyly (Thumb
V
 1 per 1,000 to 10,000 live births Duplication)
 Type IV most common (43%)
 Type II second most common (15%)
- 195 -
OrthoBullets2017 Pediatric Hand | Congenital Hand
o demographics
 M>F
 caucasian > African Americans
 Genetics
o inheritance pattern
 usually unilateral and sporadic
 except for Type VII which is associated with several syndrome including
 Holt-Oram syndrome
 Fanconi's anemia
 Blackfan-Diamond anemia
 imperforate anus
 cleft palate
 tibial defects
 Associated conditions
o pollex abductus
 abnormal connection between EPL and FPL tendons, seen in approximately 20% of
hypoplastic and duplicated thumbs
 suggested by abduction of affected digit + absence of IP joint crease
 Classification
Wassel Classification of Preaxial Polydactyly
Type I Bifid distal phalanx
Type II Duplicated distal phalanx
Type III Bifid proximal phalanx
Type IV Duplicated proximal phalanx (most common)
Type V Bifid metacarpal
Type VI Duplicated metacarpal
Type VII Triphalangia

- 196 -
By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand

Type II Type III : Incomplete Type IV : Duplicated


duplication at the level of proximal phalanx
proximal phalanx with
duplicated triphalangeal
thumbs.

Type VI : Duplicated metacarpal Type VII : Triphalangia


 Treatment
o operative
 goals of treatment
 to construct a thumb that is 80% of the size of the contralateral thumb
 resect smaller thumb (usually radial component)
 preserve / reconstruct medial collateral structures in order to preserve pinch function
 reconstruction of all components typically done in one procedure
 type 1 combination procedure (Bilhaut-Cloquet)
 indications
 type I, II, or III
 technique
 involves removing central tissue and combining both digits into one
 outcomes
 approximately 20% have late deformity
 problems include stiffness, angular and size deformity, growth arrest, and nail
deformities
- 197 -
OrthoBullets2017 Pediatric Hand | Congenital Hand
 type 2 combination procedure
 indications
 usually favored approach for type III and IV
 type V and VI usually require more complex transfer of intrinsics and collateral
ligaments
 technique
 preserve skeleton and nail of one component and augment with soft tissue from other
digit and ablation of lesser digit (radial digit most commonly)
 type 3 combination procedure
 indications
 when one digit has superior proximal component and one digit has superior distal
fragment (type V, VI, and VII)
 technique
 a segmental distal transfer (on-top plasty)

Postaxial Polydactyly (Small Finger Duplication)


 Epidemiology
o demographics
 10X more common in African Americans
 Genetics
o inherited as autosomal dominant (AD) in African Americans
o more complex genetics in caucasians and a thorough genetic workup should be performed
 Classification
o Type A - well formed digit
o Type B - rudimentary skin tag (vestigial digits)
 Treatment
o operative
 formal reconstruction with a Type 2 combination
 indications
 Type A
 technique
 preserve radial digit
 preserve or reconstruct collateral ligaments from
ulnar digit remnant
 preserve muscles
 tie off in nursery or amputate before 1 year of age
 indications
 Type B ‎ :11 Clinical photo demonstrating a child
V
with central polydactyly in conjunction with
Central Polydactyly syndactyly

 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

- 198 -
By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand

9. Macrodactyly (local gigantism)


Introduction
 Nonhereditary congenital digit enlargement
 Epidemiology
o demographics
 very rare
o location
 90% are unilateral
 70% involves more than one digit
 index involved most frequently
 in order of decreasing frequency, the long finger, thumb, ring, and small are also involved
 can involve digits of the hand or foot
o risk factors
 none known
 Pathophysiology
o etiology unknown
o no genetic correlations known to date
o affected digits correspond with neurologic innervation
 the median nerve being the most common
 Associated conditions
o lipfibromatous hamartoma of the median nerve is the adult homolog
o has been associated with:
 Proteus syndrome
 Banayan-Riley-Ruvalcabe's disease
 Maffucci syndrome
 Ollier’s disease
 Milroy’s disease
 Prognosis
o if static, asymmetry does not worsen
o if progressive, asymmetry worsens with time

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
- 199 -
OrthoBullets2017 Pediatric Hand | Congenital Hand
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
- 200 -
By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand

10. Constrictive Ring Syndrome


Introduction
 A malformation due to intrauterine rings or bands which constrict fetal tissue
o the anatomy promximal to the constriction or amputation is normal
o also referred to as Streeter dysplasia
 Epidemiology
o incidence
 reported incidence varies between 1/1200 and 1/15000 live births
o location
 usually affects distal extremities
 rare for only one ring to be present as an isolated malformation
o risk factors
 prematurity
 maternal illness
 low birth weight
 drug exposure
 Genetic
o sporadic condition with no evidence of hereditary disposition
 Pathoanatomy
o exact etiology unknown but theories include
 intrinsic anomaly in germ plasm resulting in the defects
 intrauterine disruption during pregnancy
 intrauterine trauma
 Associated conditions
o club foot
 most common
 Prognosis
o in rare cases, can cause limb amputation or death

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

- 201 -
OrthoBullets2017 Pediatric Hand | Congenital Hand

Degrees of Constrictive Ring Syndrome

Simple constriction Rings with distal Acrosyndactyly


rings deformity

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)

- 202 -
By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand

11. Streeter's Dysplasia


Introduction
 Amniotic band syndrome occurs when loose fibrous bands of ruptured amnion adhere to and
entangle the normal developing structures of the fetus.
o also referred to as
 amniotic disruption sequence
 constriction ring syndrome
 premature amnion rupture sequence
 Streeter's dysplasia
 Epidemiology
o incidence
 1:15,000 live births
o demographics
 affects males and females equally
o location
 occurs in hands and fingers 80% of the time
 greater than 90% occur distal to wrist
 Pathophysiology
o no firmly established etiology
o most accepted theory is that the disrupted amnion releases fibrous membranous strands which
wrap around the developing limb in a circumferential fashion
 Genetics
o inheritance pattern
 sporadic and not hereditary
 Associated conditions
o orthopaedic
 clubfoot
 syndactyly
o nonorthopaedic
 cleft palate
 cleft lip
 craniofacial defects
 Prognosis
o related to location and severity of constricting bands

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

- 203 -
OrthoBullets2017 Pediatric Hand | Congenital Hand

Amniotic band Amniotic band Amniotic band Amniotic band


syndrome Type I syndrome Type II syndrome Type III syndrome Type IV
Presentation
 Physical exam
o normal anatomy proximal to constriction ring
o bands perpendicular to longitudinal axis of the digit or limb
 most common presentation
o central digits more commonly affected
o amputations distal to constriction site can be found
o when no amputations present look for
 secondary syndactyly
 bony fusions
 may observe sinus tracts proximally between digits

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

- 204 -
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

Classification & Treatment


 Treatment algorithm depends on presence of carpometacarpal joint stability

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

- 205 -
OrthoBullets2017 Pediatric Hand | Congenital Thumb

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
- 206 -
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
- 207 -
OrthoBullets2017 Pediatric Hand | Congenital Thumb
Blauth Classification

- 208 -
By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb

2. Congenital Trigger Thumb


Introduction
 Pediatric condition of the thumb that results in abnormal flexion at interphalangeal (IP) joint
 Epidemiology
o prevalence
 3 per 1,000 children are diagnosed by the age of 1 years
o demographics
 separate entity to adult acquired trigger thumb
 male and females affected equally
o location
 25% are bilateral
o risk factors
 etiology of pediatric trigger thumb remains unknown
 Pathophysiology
o pathoanatomy
 flexor pollicis longus (FPL) tendon is thickened due to abnormal collagen degeneration and
synovial proliferation
 increased FPL tendon diameter, compared to the A1 pulley, causes disruption of normal
tendon gliding
 Genetics
o most commonly an acquired condition
o some reports suggest autosomal dominance with variable penetration
o term congenital trigger thumb is now considered a misnomer
 Prognosis
o natural history
 usually begins with notable thumb triggering that progresses to a fixed contracture
 spontaneous resolution unlikely after age of 2 years old

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

- 209 -
OrthoBullets2017 Pediatric Hand | Congenital Thumb
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

- 210 -
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

3. Congenital Clasped Thumb


Introduction
 Congenital flexion-adduction deformity of the thumb that persists beyond the 3rd or 4th month of
life
 Epidemiology
o demographics
 male-to-female ratio is approx 2.5:1
o risk factors
 exact causative factors are not well known
 possible pre-disposing factors include
 consanguinity
 family history
 Pathophysiology
o genetics
 autosomal dominance inheritance of variable expressivity
 may be sporadic
o pathoanatomy
 attenuation or deficiency of EPB (more common, in mild cases) or EPL, or both
 associated with 1st web contracture
 contracture of adductor pollicis or first dorsal interosseous muscle
 global instability of first MP joint
 abnormal articular cartilage of first MP joint

- 211 -
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
- 212 -
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
- 213 -
OrthoBullets2017 Hand Tumors & Lesions | Congenital Thumb

ORTHO BULLETS

VI. Hand Tumors &


Lesions

- 214 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand

A. 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

- 215 -
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)

- 216 -
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

2. Epidermal Inclusion Cyst


Introduction
 A painless, benign, slow-growing soft tissue tumor that often occurs in the hand
o occurs months to years after a traumatic event
 Epidemiology
o incidence
 third most common hand tumor
o demographics
 more common in men than women
 occurs in the third to fourth decade
o location
 the distal phalanx is commonly involved
 Pathophysiology
o results from a penetrating injury that drives keratinizing epithelium into subcutaneous tissues or
bone
o cells grow slowly to produce an epithelial cell-lined cyst filled with keratin
 Prognosis
o excision is curative
o malignant transformation has not been reported

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

- 217 -
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.
- 218 -
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

3. Anomalous Extensor Tendon


Introduction
 Definition
o variations of extensor tendons of the hand
o usually discovered incidentally during surgery for other reasons (e.g.
ganglion excision)
 Epidemiology
o incidence
 not uncommon

- 219 -
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

Anomalous Extensor Muscle Forms


Anomalous extensor indicis proprius • Most common cause of symptoms
(aEIP)
Extensor digitorum brevis manus • Less common cause of symptoms because muscle
(EDBM) belly is proximal to extensor retinaculum
Extensor medii proprius (EMP)
Extensor indicis et medii communis • EIP and EIMC unlikely to be symptomatic because of
(EIMC) narrow width

Anomalous EIP. EDBM. Originating Extensor medius EIMC. It is an EIP


With fingers in from dorsal wrist proprius. Similar muscle that splits
flexion, the muscle capsule deep to the origin as EIP. to insert into both
belly of the aEIP extensor Inserts into middle index and middle
extends beyond retinaculum, finger (instead of fingers.
the 4th inserting on the index finger)
compartment, extensor hood of the
leading to pain and index of middle finger
disability

- 220 -
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

Treatment ‎VI:6 T1 weighted MRI ‎VI:5 Surgical decompression


of EDBM showing mass
 Nonoperative of the 4th extensor
centered over CMC compartment reveals an
o observation joint that is isointense anomalous EIP
relative to muscle
 indications
 first line treatment
 Operative
o surgical decompression of 4th dorsal compartment (aEIP) or reduction of muscle belly
(EDBM)
 indications
 failed conservative treatment, and symptoms, signs and imaging point to anomalous
muscle, with no associated conditions (e.g. ganglion)

- 221 -
OrthoBullets2017 Hand Tumors & Lesions | Tumors of the hand

4. Giant Cell Tumor of Tendon Sheath


Introduction
 A benign nodular tumor that is found on the tendon sheath of the hands and feet
 Also known as pigmented villonodular tumor of the tendon sheath (PVNTS)
 Epidemiology
o present in 3rd-5th decade of life
o incidence
 second most common soft-tissue tumor seen in the hand, following ganglion cyst
o location
 it is most common on palmar surface of radial three digits near DIPJ
o no reports of metastisis in literature

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

- 222 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand

Giant cell tumor of MRI: Sagittal T1 MRI: Sagittal T2 MRI: Coronal T2


tendon sheath MRI Image of MRI Image of MRI Image of
showing pressure- GCTTS GCTTS GCTTS
type bone erosion

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.

- 223 -
OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions

B. Vascular Conditions

1. Hypothenar Hammer Syndrome


Introduction
 Post-traumatic digital ischemia from thrombosis of ulnar artery at Guyon's canal.
 Epidemiology
o incidence
 rare
o demographics
 male: female ratio is 9:1
 age bracket is 40s-50s
o location
 unilateral, dominant ring finger +/- small finger
 less commonly, index and middle fingers
 thumb is spared
o risk factors
 occupations using vibrating tools such as carpenters, machinists, mechanics
 sports such as baseball catchers, mountain biking, golf, volleyball, karate
 Pathophysiology
o mechanism
 single or repetitive blunt impact on hypothenar eminence leads to ulnar artery thrombosis or
aneurysm
 hook of hamate functions as an anvil, causing thrombosis
 distal embolisation leads to ulceration, gangrene

Relationship of ulnar artery to hook of CT angiogram showing close relationship


hamate (N, ulnar nerve; A, ulnar artery; of ulnar artery (yellow arrow) to hook of
H, hook of hamate; P, pisiform; PHL hamate
pisohamate ligament; TCL, transverse
carpal ligament (floor of Guyon's canal);
VCL, volar carpal ligament (roof of
Guyon's canal)

- 224 -
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

 negative if aneurysm is present

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

- 225 -
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

 thrombosis without aneurysm < 2 weeks


o excision of involved segment and reconstruction with or without a vein graft
 indications
 digital brachial index <0.7
 thrombosis with aneurysm
 ischemia in multiple digits
 failed conservative treatment with recurrent symptoms
o arterial ligation (Leriche procedure)
 indications
 digital brachial index >0.7

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)
- 226 -
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
- 227 -
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

Allen and Brown Criteria for Raynaud's Disease


 Intermittent attacks with discoloration of acral
parts
 Bilateral involvement
 Absence of clinical arterial occlusion
 Gangrene and trophic changes are rare
 Symptoms present for >2 years
 Absence of other disease to explain findings
 Predominance in women

 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

- 228 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Vascular Conditions

3. Thromboangiitis Obliterans (Buerger's disease)


Introduction
 A nonatherosclerotic, segmental, inflammatory disease in the small and medium-sized vessels of the
hands and feet
o occurs predominantly in smokers
 Epidemiology
o incidence : 12.6 per 100,000 in the United States
o demographics
 3:1 male: female ratio
 typically affects patients < 45 years old
o risk factors
 smoking
 chewing tobacco
 Pathophysiology
o inflammation and clotting of the small vessels of hands and feet
o 3 phases
 acute
 thrombus including neutrophils and giant cells occludes the vessel lumen while sparing
the wall
 subacute
 progressive organization of the thrombus
 chronic
 inflammation has subsided
 organized thrombus and vascular fibrosis remain
 Prognosis
o depends on smoking status
 94% who quit smoking avoid amputation
 43% chance of amputation within 8 years if smoking is continued

- 229 -
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

- 230 -
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

4. Digital Artery Aneurysm


Introduction
 Aneurysm is defined as a permanent dilation of an artery with a 50% increase in its normal diameter
 Incidence
o rare
 Pathophysiology
o traumatic
 true aneurysm
 blunt trauma weakens the arterial wall causing it to dilate
 appear more uniform in shape
 false aneurysm (e.g. pseudoaneurysm)
 pentrating trauma to arterial wall replaced by organized hematoma and fibrous wall
 appear more 'sac-like' in shape
o non-traumatic
 inflammatory
 atherosclerotic

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
- 231 -
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

- 232 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Nail Bed

C. Nail Bed

1. Split Nail Deformity


Introduction
 Clinical definition
o scar that produces an 'empty' or 'blank' longitudinal area of nail between two normal regions of
nail
 Pathophysiology
o caused by scar in the germinal matrix that causes absence of nail production
o can occur as a sequelae of
 nail bed injuries
 infections (i.e. paronychia)

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

- 233 -
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

- 234 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Nail Bed

2. Hook Nail Deformity


Introduction
 Clinical definition
o nail deformity that occurs caused by volar curving of the nail matrix
 Pathophysiology
o can be caused by
 tight closure of the fingertip during treatment fo distal tip amputation
 loss of bony support under the nail bed causing volar sloping of the 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

- 235 -
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

- 236 -
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

Positioning and Scope Insertion


 Patient Position
o supine, elbow flexed to 90°
o traction tower with 10lb traction to fingers
 Landmarks
o Lister's tubercle
o Scaphoid, Lunate
o DRUJ
o ECU
 Scope insertion
o 2.7mm, 30° arthroscope is most common

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

- 237 -
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

- 238 -
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
- 239 -

Das könnte Ihnen auch gefallen