6 ORTHO BULLETS Volume Six
Hand
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
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
I.
Table Of Contents 2. Extremity Flap Reconstruction ......... 69
Hand Introduction .................................. 0 A.
3. Skin Grafting .................................... 73
Anatomy ............................................ 1
4. Tendon Transfer Principles .............. 74
1. Extensor Tendon Compartments ........ 1 2. Ligaments of the Fingers .................... 2 3. Flexor Pulley System .......................... 9
III. A.
2. AIN Compressive Neuropathy .......... 83
5. Wrist Ligaments & Biomechanics ..... 15
3. Pronator Syndrome .......................... 85
6. Motion of the Fingers ........................ 22
B.
B.
2. Ulnar Tunnel Syndrome .................... 92
1. Physical Exam of the Hand................ 24 C.
2. Radial Tunnel Syndrome .................101
Hand Infections ............................... 33
3. Wartenberg's Syndrome ..................106
1. Paronychia ....................................... 33 2. Felon ................................................ 36 3. Pyogenic Flexor Tenosynovitis ......... 38
IV. A.
A.
Hand Deformities............................110
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
Microsurgery ........................................ 48
6. Lumbrical Plus Finger .....................117
Replantation .................................... 49
B.
Flexor Tendon Conditions ...............120
1. Fingertip Amputations & Finger Flaps ............................................................. 49
1. Trigger Finger .................................120
2. Ring Avulsion Injuries ....................... 55
3. Flexor Carpi Radialis Tendinitis .......127
3. Replantation ..................................... 59
B.
Degenerative Conditions ...................109
1. Intrinsic Minus Hand (Claw Hand) ....110
4. Deep Space & Collar Button Infections ............................................................. 40
II.
Radial Neuropathies ........................ 96 1. PIN Compression Syndrome ............. 96
3. Nerve Conduction Studies ................ 29 C.
Ulnar Neuropathies ......................... 88 1. Cubital Tunnel Syndrome ................. 88
Clinical Evaluation ........................... 24
2. Vascular Evaluation of the Hand ....... 29
Median Neuropathies ...................... 79 1. Carpal Tunnel Syndrome .................. 79
4. Blood Supply to Hand ....................... 13
7. Thumb Motion ................................... 23
Neuropathies ...................................... 78
2. Dupuytren's Disease .......................121
C.
Extensor Tendon Conditions ...........130
4. Thumb Reconstruction ..................... 63
1. De Quervain's Tenosynovitis ...........131
Reconstruction ................................ 64
2. Intersection Syndrome ....................133
1. Peripheral Nerves Injury & Repair .... 64
3. Snapping ECU .................................134
OrthoBullets 2017
D.
E.
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 Stress Syndrome) ............................... 148
9. Macrodactyly (local gigantism) ........199
Wrist Instability & Collapse ............ 150
11. Streeter's Dysplasia ......................203
1. SNAC (Scaphoid Nonunion Advanced Collapse) ............................................ 150
10. Constrictive Ring Syndrome ..........201
C.
1. Thumb Hypoplasia...........................205
2. Scapholunate Ligament Injury & DISI ........................................................... 152 3. Lunotriquetral Ligament Injury & VISI ........................................................... 156 4. SLAC (Scaphoid Lunate Advanced Collapse) ............................................ 158
2. Congenital Trigger Thumb ...............209 3. Congenital Clasped Thumb .............211 VI. A.
3. Anomalous Extensor Tendon ...........219 4. Giant Cell Tumor of Tendon Sheath .222
1. Basilar Thumb Arthritis ................... 164 B.
2. Raynaud's Syndrome.......................226
Pediatric Hand ................................... 174 A.
3. Thromboangiitis Obliterans (Buerger's disease) ..............................................229
Congenital Arm .............................. 175 1. Radial Clubhand (radial deficiency) 175 2. Ulnar Club Hand ............................. 176
4. Digital Artery Aneurysm ..................231 C.
3. Congenital Radial Head Dislocation 178
B.
Congenital Hand ............................ 183 1. Cleft Hand ...................................... 183 2. Symphalangism .............................. 185
Nail Bed ..........................................233 1. Split Nail Deformity..........................233
4. Madelung's Deformity ..................... 179 5. Congenital Radial Ulnar Synostosis 182
Vascular Conditions .......................224 1. Hypothenar Hammer Syndrome ......224
3. Wrist Arthritis ................................. 172 V.
Tumors of the hand .........................215
2. Epidermal Inclusion Cyst .................217
Arthritic conditions ........................ 164
2. DIP and PIP Joint Arthritis .............. 169
Hand Tumors & Lesions.....................214
1. Ganglion Cysts ................................215
5. CIND (carpal instability nondissociative) ................................. 162 F.
Congenital Thumb ..........................205
2. Hook Nail Deformity ........................235 D.
Tested Procedures .........................237 1. Wrist Arthroscopy ...........................237
OrthoBullets2017
| Anatomy
ORTHO BULLETS
I.Hand Introduction
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By Dr, AbdulRahman AbdulNasser
Hand Introduction | Anatomy
A. Anatomy 1. Extensor Tendon Compartments
Compartment
Tendon
Associated Pathology
1
EPB APL
De Quervain's tenosynovitis
2
ECRL ECRB
Intersection syndrome
EPL
Drummer's wrist, traumatic rupture with distal radius fx
EIP EDC Posterior interosseous nerve
Extensor tenosynovitis
4 5
EDM
Vaughn-Jackson Syndrome
6
ECU
Snapping ECU
3
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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
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By Dr, AbdulRahman AbdulNasser
Hand Introduction | Anatomy
Expansion Hood Function o works to extend PIP and DIP joint Anatomic Components o central slip functions to extend PIP inserts into base of middle phalanx o lateral band functions to extend DIP inserts into distal phalanx lumbricals, extensor indicis, dorsal and palmar interossei insert on lateral band MCP Joint Collateral Ligaments Function o stabilize MCP joint during motion MCP joint "cam" nature leads to inconstant arc of motion because of joint asymmetry caused by "snoopy head" configuration of metacarpal head collaterals looser in extension, tighten during increasing flexion as MP joint flexes, proximal phalanx moves further away from metacarpal head, tightening all the ligaments
I:2 Figure - showing shape of metacarpal head
I:3 Red, dorsal - proper ligament Green, volar - accessory ligament
Anatomic Components o radial collateral ligaments (RCL) are more horizontal than ulnar collateral ligaments (UCL) o RCL and UCL have 2 parts each: proper and accessory ligaments accessory ligament fan shaped more volar tight in extension attachment from metacarpal head at center of rotation to palmar plate and deep transverse metacarpal ligament clinical test adduction/abduction stress in extension proper ligament cord like more dorsal tight in 30 degrees of flexion - 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
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OrthoBullets2017
Hand Introduction | Anatomy
Triangular ligament Function o counteracts pull of oblique retinacular ligament, preventing lateral subluxation of the common extensor mechanism Anatomy o triangular in shape o located on dorsal side of extensor mechanism, distal to PIP joint Pathology o contracture leads to swan neck deformity Volar Plate Function o prevent hyperextension Anatomy o thickening of joint capsule volar to the MP joint o in the thumb, sesamoid bones are located here o origin: metacarpal head o insertion: periarticular surface of proximal phalanx , via checkrein ligaments Biomechanics o loose in flexion folds into metacarpal neck during flexion o tight in extension
I:8 checkrein ligaments
I:7 Volar plate
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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
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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 I:9 Bunnell single loop o flexor tendon allograft 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 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 o surface
Arch Superficial Deep
Anatomic Landmarks Kaplan's cardinal line 15mm distal 7mm distal
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Distal Wrist Crease 50mm distal 40mm distal
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
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By Dr, AbdulRahman AbdulNasser
Hand Introduction | Anatomy
Wrist Ligaments The ligaments of the wrist include o extrinsic ligaments bridge carpal bones to the radius or metacarpals include volar and dorsal ligaments o intrinsic ligaments originate and insert on carpal bones the most important intrinsic ligaments are the scapholunate interosseous ligament and lunotriquetral interosseous ligament Characteristics o volar ligaments are secondary stabilizers of the scaphoid o volar ligaments are stronger than dorsal ligaments o dorsal ligaments converge on the triquetrum Space of Poirier o center of a double "V" shape convergence of ligaments o central weak area of the wrist in the floor of the carpal tunnel at the level of the proximal capitate o between the volar radioscaphocapitate ligament and volar long radiolunate ligament (radiolunotriquetral ligament) wrist palmar flexion area of weakness disappears wrist dorsiflexion area of weakness increases o in perilunate dislocations, this space allows the distal carpal row to separate from the lunate o in lunate dislocations, the lunate escapes into this space
I: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
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By Dr, AbdulRahman AbdulNasser
Coronal MR arthrogram showing radial collateral ligament extending from radial styloid (arrows) to scaphoid (S) waist (arrowheads).
Arthroscopic photograph showing radioscaphocapitate (right) and long radiolunate (left) ligaments
Hand Introduction | Anatomy
Diagram of radioscaphocapitate ligament
Diagram showing radioscaphocapitate (thin arrow) and long radiolunate (thick arrow) ligaments
Sagittal MR arthrogram showing short radiolunate ligament (3)
Coronal T1-weighted MR arthrogram showing radioscaphocapitate ligament (black arrow) and volar radiolunate ligament (white arrow)
Axial MR arthrogram showing radioscapholunate neurovascular bundle (4). The intrinsic scapholunate ligament (11) is also visible
Cadaveric specimen showing short radiolunate ligament (3)
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OrthoBullets2017
Diagram showing volar ulnolunate and volar ulnotriquetral ligaments extending from volar radioulnar ligament (part of TFCC) to insert on the lunate and triquetrum respectively
Hand Introduction | Anatomy
MR arthrogram showing volar ulnotriquetral ligament (white arrow) extending from volar radioulnar ligament (black arrow) to triquetrum
MR arthrogram showing volar ulnolunate ligament (white arrow) extending from volar radioulnar ligament (black arrow) to lunate
Illustration showing DISI and VISI deformities Diagram of dorsal radiotriquetral and dorsal intercarpal ligament
Coronal MRA showing dorsal radiotriquetral ligament (black arrows) and dorsal intercarpal ligament (white arrows)
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By Dr, AbdulRahman AbdulNasser
Hand Introduction | Anatomy
Intrinsic (Interosseous) ligaments Proximal row o scapholunate ligament primary stabilizer of scapholunate joint composed of 3 components dorsal portion thickest and strongest prevents translation volar portion prevents rotation proximal portion no significant strength disruption leads to lunate extension when the scaphoid flexes creating DISI deformity o lunotriquetral ligament composed of 3 components dorsal volar proximal disruption leads to lunate flexion when the scaphoid is normally aligned creating VISI deformity (in combination with rupture of dorsal radiotriquetral rupture) Distal row o trapeziotrapezoid ligament o trapeziocapitate ligament o capitohamate ligament Palmar midcarpal o scaphotrapeziotrapezoid o scaphocapitate o triquetralcapitate o triquetralhamate
Coronal T1-weighted MRI showing normal scapholunate ligament (arrow)(S, scaphoid; L, lunate; T, triquetrum
Scapholunate ligament from a radial perspective, showing its 3 components - palmar (SLIp), dorsal (SLId), proximal (SLIpx). Other ligaments seen include long radiolunate (LRL), short radiolunate (SRL), radioscapholunate (RSL) and dorsal scaphotriquetral (ST)
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Coronal MR arthrogram showing normal lunotriquetral ligament (arrow) (S, scaphoid; L, lunate; T, triquetrum)
OrthoBullets2017
Hand Introduction | Anatomy
Diagram showing distal row dorsal interosseous ligaments (TT, trapeziotrapezoid; CT, trapezocapitate; CH, capitohamate
Coronal MR arthrogram showing scaphotrapeziotrapezoid ligament (arrow)
Normal scaphotrapeziotrapezoid ligament
6. Motion of the Fingers
v MCP
Flexion 70% Interosseous o palmar adductors o dorsal interosseous 30% lumbricals o 2nd & 3rd digit by median n. o 4th & 5th digit by ulnar n.
Extension Extensor Digitorum sagittal band
PIP
Flexor Digitorum Superficialis Flexor Digitorum Profundus
Extensor Digitorum central slip Lumbricals (via lateral bands) Dorsal interosseous
DIP
Flexor Digitorum Profundus
Extensor Digitorum terminal tendon lumbricals via lateral bands
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By Dr, AbdulRahman AbdulNasser
Hand Introduction | Clinical Evaluation
7. Thumb Motion
Thumb Motion Extension Flexion Abduction Adduction Opposition
MCP Extensor Pollicis Brevis Extensor Pollicis Longus Flexor Pollicis Brevis Abductor Pollicis Brevis Adductor Pollicis Opponens Pollicis
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IP Extensor Pollicis Longus Flexor Pollicis Longus NA NA NA
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 Scapholunate (SL) instability - dynamic
Watson test 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) I:22 Clinical photo of a black spots (melanoma) patient with thenar atrophy o trophic changes (i.e. increased hair growth or altered sweat production) secondary to carpal tunnel syndrome can represent derangement of sympathetic nervous system 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) Joint effusion (infection, inflammation, trauma)
I :24 A clinical picture of a patient with a 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
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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
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By Dr, AbdulRahman AbdulNasser
Hand Introduction | Clinical Evaluation
Special Tests Palpation o grind test used to test for pathology at the thumb carpometacarpal joint (CMC) examiners applies axial load to first metacarpal and rotates or "grinds" it positive findings: pain, crepitus, instability o Finkelstein's used to test for DeQuervain's tenosynovitis patient makes fist with fingers overlying thumb examiner gently ulnarly deviates the wrist positive findings: pain along the 1st compartment Range of motion o flexor profundus used to test continuity of FDP tendons MCP + PIP joints held in extension while patient asked to flex FDP, thereby isolating FDP (from FDS) as the only tendon capable of flexing the finger o flexor sublimus used to test for continuity of FDS tendon MCP, PIP and DIP of all fingers held in extension with hand flat and palm up; the finger to be tested is then allowed to flex at PIP joint.
o Bunnel's
test examiner passively flexes PIPJ twice first with MCP in extension next with MCP held in flexion intrinsic tightness present if PIP can be flexed easily when MCP is flexed but NOT when MCP is extended extrinsic tightness present if PIP can be flexed easily when MCP is extended but NOT when MCP is flexed Stability assessment o scaphoid shift test (Watson's test) tests for scapholunate ligament tear examiner places thumb on distal pole of scaphoid on palmar side of wrist and applies constant pressure as the wrist is radially and ulnarly deviated dorsal wrist pain or "clunk" may indicate instability o lunotriquetral ballottement tests for lunotriquetral ligament tear examiner secures the pisotriquetral unit with the thumb and index finger of one hand and the lunate with the other hand anterior and posterior stresses are placed on the LT joint positive findings are increased laxity and accompanying pain - 27 -
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Hand Introduction | Clinical Evaluation
o midcarpal
instability examiner stabilizes distal radius and ulna with non-dominant hand and moves patients wrist from radial deviation to ulnar deviation, whilst applying an axial load a positive test occurs when a clunk is felt when the wrist is ulnarly deviated o ulnar carpal abutement tests for TFCC tear or ulnar-carpal impingement examiner ulnarly deviates wrist with axial compression positive if test reproduces pain or a 'pop' or 'click' is heard o Gamekeeper's tests for ulnar collateral ligament tear at MCP of thumb examiner stresses first MCPJ into radial deviation with MCPJ in fully flexed and extended positions positive test if > 30 degrees of laxity in both positions (or gross laxity compared to other side) Nerve assessment o Tinel's tests for carpal tunnel syndrome examiner percusses with two fingers over distal palmar crease in the midline positive if patient reports paresthesias in median nerve distribution
o Phalen's
tests for carpal tunnel syndrome with the hands pointed up, the patient's wrist is allowed to flex by gravity in palmar flexion for 2 minutes maximum positive if patient reports paresthesias in median nerve distribution
o Froment's
sign tests for ulnar nerve motor weakness patient asked to hold a piece of paper between thumb and radial side of index positive if as the paper is pulled away by the examiner the patient flexes the thumb IP joint in an attempt to hold on to paper
o Wartenberg's
sign tests ulnar nerve motor weakness patient asked to hold fingers fully adducted with MCP, PIP, and DIP joints fully extended positive if small finger drifts away from others into abduction
o Jeanne's
sign tests for ulnar nerve motor weakness ask patient to demosntrate key pinch positive finding if patients first MCP joint is hyperextended
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By Dr, AbdulRahman AbdulNasser
Hand Introduction | Clinical Evaluation
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)
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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 Condition Normal
Hand Introduction | Clinical Evaluation
Findings on NCV Latency Conduction Velocity Amplitude Evoked Response Upper limb (>45m/s), Normal Normal Normal lower limb (>40m/s) Normal Normal Decreased Prolonged Increased Decreased Normal/decreased Absent/prolonged Normal or polyphasic, Normal Normal Decreased prolonged duration Normal Normal Decreased Normal
Axonal Demyelinating Anterior horn cell disease Myopathy Neuromuscular Normal junction Neuropraxia Absent proximal to lesion Neuropraxia distal to Normal lesion Axonotmesis Absent proximal to lesion Axonotmesis distal to Absent lesion Neurotmesis Absent proximal to lesion Neurotmesis distal to Absent lesion
Normal
Decreased
Normal
Absent
Absent
Absent
Normal
Normal
Normal
Absent
Absent
Absent
Absent
Absent
Normal
Absent
Absent
Absent
Absent
Absent
Absent
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 -
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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 Condition
Insertional Activity
Normal
Normal
Axonal neuropathy
Increased
Demyelinating neuropathy Normal Anterior horn cell disease Increased Inflammatory Myopathy
Increased
Noninflammatory
Normal
Neuromuscular junction disorder
Normal
Neurapraxia
Normal
Axonotmesis
Increased
Neurotmesis
Increased
Spontaneous Activity
Minimal Activity
Biphasic/triphasic potentials Fibrillations/positive sharp Biphasic/triphasic waves potentials Biphasic/triphasic Silent potentials Fibrillations/fasciculations, Large polyphasic positive sharp waves potentials Small polyphasic Fibrillations, myotonia potentials Small polyphasic Normal potentials Biphasic/triphasic potentials Normal (decreased amplitude/duration) Silent None Fibrillations/positive sharp None waves Fibrillations/positive sharp None waves Silent
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Interference Complete Incomplete Incomplete Incomplete Early Early
Early/normal None None None
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 -
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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 1218 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 I:28 Green discoloration from erythema 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 -
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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 approach
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mid lateral
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 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:30 Mid lateral incision
I:31 longitudinal incision
I:32 RECOMMENDED: "J shaped" lateral or volar longitudinal. NOT RECOMMENDED: fishmouth and double lateral incisions
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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 -
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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
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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 standard of care for deep space infections and collar button abscesses technique use volar and dorsal incisions for collar button abscesses avoid skin in actual web space
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I:33 Abscess in the Thenar Space: Debridement of infection is best approached in the style of tumor management excision, rather than scrubbing. The abscess margins were not well defined. The infection involved a volume from the skin, superficial palmar fascia, down through the carpal tunnel to the adductor muscle. Branches of the median nerve and the superficial palmar arch are visible here. Excisional debridement, wound care, intravenous antibiotics, and delayed closure at five days resulted in cure. Courtesy of Dr. Charles Eaton
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 -
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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 o granulomas may or may not demonstrate acid-fast bacilli on AFB stain Cultures and sensitivities are key to diagnosis - 44 -
I:34 Lowenstein-Jensen Agar growing M. Marinum
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 -
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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 (papule) at site of penetration with additional o Sporothrix schenckii a common soil organism 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
[email protected] In July 2017
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Microsurgery | Hand Infections
ORTHO BULLETS
II. Microsurgery
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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 -
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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 & MCP
• Reverse cross finger
4. Volar Thumb
• Moberg Advancement Volar Flap (if < 2 cm)
• Axial flag flap from long finger • 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
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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 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 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 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 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 o indications : lesions to dorsal hand - 52 -
II:1 V-Y advancement flap
II:2 Cross finger flap
II:3 Axial flag flap from long finger
II:4 Moberg advancement volar flap
II:5 Neurovascular island flap
By Dr, AbdulRahman AbdulNasser
Microsurgery | Replantation
V-Y advancement flap
Cross finger flap
Thenar flap - 53 -
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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 insufficient bony support o treatment variety of reconstructive procedures have been described - 54 -
II:6 Hook nail deformity
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 II:7 Mechanism of ring avulsion. Soft tissue (skin, vessels, nerves) are working with machinery 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
Class
Urbaniak Classification Description
Class I
Circulation adequate
Class II Class III
Circulation inadequate Complete degloving or complete amputation
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Treatment Standard bone and soft tissue care Vessel repair Amputation
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Class Class I Class II Class III Class IV
Microsurgery | Replantation
Kay, Werntz and Wolff Classification Description Treatment Standard bone and soft Circulation adequate tissue repair Arterial compromise only Vessel repair Inadequate circulation with bone, tendon, or nerve Amputation injury. Complete degloving or complete amputation. Amputation
Class I injury. Circumferential skin injury with laceration of extensor tendon, FDS, FDP and open dislocation of PIPJ and injury to volar plate. One intact neurovascular bundle maintained good circulation.
Class IIA injury. Only tendons and bone remained intact. DIPJ was dislocated and all neurovascular structures were severed, leaving the digit avascular with no capillary refill.
Class III injury. Complete amputation of the ring finger at the PIPJ level (A). Successful replantation was achieved (B) but the patient had limited range of motion and was out of work for 18 months.
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, often at DIPJ level)
II:8 Urbaniak Class III avulsion. Note trailing 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.
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By Dr, AbdulRahman AbdulNasser
Microsurgery | Replantation
Complications Complications of replantation o cold intolerance (70%) o revascularization/replantation failure factors include most significant factor is repair of <2 veins vascular damage up to digital pulp smoking and level of bone injury have not been found to affect survival o flexion contracture o malunion o revision surgery Complications of revision amputation o hyperaesthesia
3. Replantation Introduction Trauma is the most common etiology for upper extremity replantation Epidemiology o incidence 90% of upper extremity amputation occurred after trauma o demographics 4:1 male-to-female ratio o location most amputations occur at the level of the digits Pathophysiology o mechanism of traumatic amputation sharp dissection blunt dissection avulsion crush Presentation History o timing of injury o type and location of amputation number of digits involved o preservation of amputated tissue o associated injury o past medical history Examination o stump examined for zone of injury tissue viability supporting tissue structures contamination o amputated portion inspected - 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
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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
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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
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OrthoBullets2017
Microsurgery | Reconstruction
o neuron
cell cell body - the metabolic center that makes up < 10% of cell mass axon - primary conducting vehicle dendrites - thin branching processes that receive input from surrounding nerve cells Blood supply o extrinsic vessels run in loose connective tissue surrounding nerve trunk o intrinsic vessels plexus lies in epineurium, perineurium, and endoneurium Physiology o presynaptic terminal & depolarization electrical impulse transmitted to other neurons or effector organs at presynaptic terminal resting potential established from unequal distribution of ions on either side of the neuron membrane (lipid bilayer) action potential transmitted by depolarization of resting potential caused by influx of Na across membrane through three types of Na channels voltage gate channels mechanical gated channels chemical-transmitter gated channels o nerve fiber types
Fiber Type A B C
Diameter (uM) 10-20 <3 < 1.3
Myelination heavy moderate none
Speed fast medium slow
Example touch ANS 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
no recovery unless surgical repair performed fibrillations and positive sharp waves on EMG
Seddon Myelin Degree Type Intact Neurapraxia 1st No Axonotmesis 2nd No Neurotmesis 3rd No
Microsurgery | Reconstruction
Axon Intact Yes No No
Endoneurim Intact Yes Yes No
Wallerian Degen. No Yes Yes
Reversible reversible reversible 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 Grade I II III IV V
Myelin Sheath Disrupted Disrupted Disrupted Disrupted Disrupted
Axon Intact Disrupted Disrupted Disrupted Disrupted
Endoneurim Intact Intact Disrupted Disrupted Disrupted
Perineurium Intact Intact Intact Disrupted Disrupted
Epineurium Intact Intact Intact Intact 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
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By Dr, AbdulRahman AbdulNasser
Microsurgery | Reconstruction
Nerve grafting o autologous graft indications ≥ 3cm gap digital nerve defects at wrist to common digital nerve bifurcation - use sural nerve at MCP to DIP level - use lateral antebrachial cutaneous nerve at DIP level - use AIN, PIN or medial antebrachial cutaneous nerve outcomes gold standard for segmental defects > 5cm o collagen conduit tensioned closures inhibit Schwann cell activation and axon regeneration, compromise perfusion and lead to scarring collagen conduits allow nutrient exchange and accessibility to neurotrophic factors to the axonal growth zone during regeneration indications defects ≤ 2cm outcomes equal results to autologous grafting when gap ≤5mm quality of nerve recovery drops with gaps >5mm o allograft off-the-shelf option for defects up to 5cm
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
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By Dr, AbdulRahman AbdulNasser
Microsurgery | Reconstruction
Techniques Fingertips & Hand See Finger amputation and Flaps Arm Flaps • 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. Lateral arm flap
lateral arm flap.
medial gastrocnemius flap used for coverage in the proximal third of tibia.
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gracilis flap harvest.
OrthoBullets2017
Groin flap
Index metacarpal transposition
Microsurgery | Reconstruction
Proximally pedicled fibula graft while Figure B shows a distally pedicled fibula graft.
deep transvers intermetacarpal ligament reconstruction.
Radial bone graft used to treat scaphoid nonunion.
Little metacarpal transposition
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 free anterolateral thigh flap to the forearm. immediate return to operating room o inadequate venous outflow treatment loosen dressings, removal of selected sutures return to operating room if not relieved by above measure
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By Dr, AbdulRahman AbdulNasser
Microsurgery | Reconstruction
Donor site morbidity o may be cosmetically unacceptable o pain related to grafting o seroma treatment aspiration excision if encapsulated Nonunion for vascularized bone transfer o incidence may be as high as 32% if no additional bone graft is used
3. Skin Grafting Introduction A skin graft is an avascular graft and consists of o partial-thickness dermal tissue o full-thickness dermal tissue Donor site o most commonly autologous Goals of treatment o cover deep structures o create a barrier to bacteria, o restore dynamic function of the limb o prevent joint contractures Indications o well-perfused wound beds over muscle or subcutaneous tissue Contraindications o wounds with exposed bone, tendon, nerves, or blood vessels 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 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
o appropriate
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)
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By Dr, AbdulRahman AbdulNasser
Microsurgery | Reconstruction
Specific Transfers & Indications Goal to regain Shoulder stability (flail shoulder) Elbow flexion Elbow flexion
Elbow extension Wrist extension Finger extension Thumb extension Thumb opposition and abduction
Thumb IP flexion Index and long finger flexion Thumb adduction Finger abduction (index most important) Reverse clawing effect
FROM: Donor tendon (working) TO: Recipient Tendon (deficient) Axillary nerve palsy glenohumeral arthrodesis glenohumeral arthrodesis Musculocutaneous nerve palsy pectoralis major, latissimus dorsi to biceps common flexor mass point more proximal on humerus (Steindler flexorplasty) Radial nerve & PIN palsy deltoid, latissimus dorsi, or biceps to triceps PT ECRB FDS, FCR, or FCU EDC PL or FDS EPL Low median nerve palsy FDS (ring) base proximal phalanx or APB tendon (use FCU as pulley - classic Bunnell opponensplasty) EIP APB (pulley around ulnar side of wrist) High median nerve palsy BR FPL FDP of ring and small finger (ulnar FDP of index and middle (side-to-side nerve) transfer) Ulnar nerve palsy FDS or ECRB adductor pollicis APL, ECRL, or EIP 1st dorsal interosseous
FDS, ECRL (must pass volar to transverse metacarpal ligament to flex proximal phalanx)
lateral bands of ulnar digits
Complications Adhesions o necessitate aggressive therapy and possible secondary tenolysis
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OrthoBullets2017
Neuropathies | Reconstruction
ORTHO BULLETS
III.Neuropathies
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By Dr, AbdulRahman AbdulNasser
Neuropathies | Median Neuropathies
A. Median Neuropathies 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 -
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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)
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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
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OrthoBullets2017
Neuropathies | Median Neuropathies
Presentation Symptoms o paresthesias in thumb, index, middle finger and radial half of ring finger as seen in carpal tunnel syndrome in pronator syndrome paresthesias often made worse with repetitive pronosupination o should have characteristics differentiating from carpal tunnel syndrome (CTS) aching pain over proximal volar forearm sensory disturbances over the distribution of palmar cutaneous branch of the median nerve (palm of hand) which arises 4 to 5 cm proximal to carpal tunnel ( see photos next page) lack of night symptoms Physical exam o provocative tests are specific for different sites of entrapment positive Tinel sign in the proximal anterior forearm but no Tinel sign at wrist nor provocative symptoms with wrist flexion as would be seen in CTS resisted elbow flexion with forearm supination (compression at bicipital aponeurosis) resisted forearm pronation with elbow extended (compression at two heads of pronator teres) resisted contraction of FDS to middle finger (compression at FDS fibrous arch) o possible coexisting medial epicondylitis Imaging Radiographs o recommended views elbow films are mandatory o findings may see supracondylar process Studies EMG and NCV o may be helpful if positive but are usually inconclusive o may exclude other sites of nerve compression or identify double-crush syndrome Treatment Nonoperative o rest, splinting, and NSAIDS for 3-6 months indications mild to moderate symptoms technique splint should avoid forearm rotation Operative o surgical decompression of median nerve indications only when nonoperative management fails for 3-6 months technique decompression of the median nerve at all 5 possible sites of compression outcomes of surgical decompression are variable 80% of patients having relief of symptoms - 86 -
By Dr, AbdulRahman AbdulNasser
Neuropathies | Ulnar Neuropathies
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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
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By Dr, AbdulRahman AbdulNasser
Neuropathies | Ulnar Neuropathies
Presentation Symptoms o paresthesias of small finger, ulnar half of ring finger, and ulnar dorsal hand exacerbating activities include cell phone use (excessive flexion) occupational or athletic activities requiring repetitive elbow flexion and valgus stress o night symptoms caused by sleeping with arm in flexion Physical exam o inspection and palpation interosseous and first web space atrophy ring and small finger clawing observe ulnar nerve subluxation over the medial epicondyle as the elbow moves through a flexion-extension arc o sensory decreased sensation in ulnar 1-1/2 digits o motor loss of the ulnar nerve results in paralysis of intrinsic muscles (adductor pollicis, deep head FPB, interossei, and lumbricals 4 and 5) which leads to weakened grasp from loss of MP joint flexion power weak pinch from loss of thumb adduction (as much as 70% of pinch strength is lost) Froment sign compensatory thumb IP flexion by FPL (AIN) during key pinch compensates for the loss of MCP flexion by adductor pollicis (ulna n.) adductor pollicis muscle normally acts as a MCP flexor, first metacarpal adductor, and IP extensor Jeanne sign compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch Compensates for loss of IP extension and thumb adduction by adductor pollicis (ulna n.) - 89 -
OrthoBullets2017
Neuropathies | Ulnar Neuropathies
The illustration demonstrates the Left hand demonstrates 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.
Froment sign
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
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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)
Floor Roof Ulnar border Radial border
Zone 1
Zone 2 Zone 3
Boundaries of Guyon's canal Transverse carpal ligament, hypothenar muscles Volar carpal ligament Pisiform and pisohamate ligament, abductor digiti minimi muscle belly Hook of hamate Zones of Guyon's canal Location Common Causes of Compression Symptoms Proximal to Ganglia and hook of hamate fractures Mixed motor and bifurcation of the sensory nerve Surrounds deep Ganglia and hook of hamate fractures Motor only motor branch Surrounds Ulnar artery thrombosis or aneurysm Sensory only superficial sensory branch
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By Dr, AbdulRahman AbdulNasser
Neuropathies | Ulnar Neuropathies
III:2 Zones of the ulnar tunnel (Zone 1: ulnar nerve, motor and sensory. Zone 2: deep motor branch. Zone 3: superficial sensory branch.)
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OrthoBullets2017
Neuropathies | Ulnar Neuropathies
Deep branch of the ulnar nerve o innervates all of the interosseous muscles and the 3rd and 4th lumbricals. o Innervates the hypothenar muscles, the adductor pollicis, and the medial head (deep) of the flexor pollicis brevis (FPB)
Classification Presentation varies based on location of compression within Guyon's canal and may be o Motor only o Sensory only o Mixed Motor & Sensory Presentation Presentation varies based on location of compression within Guyon's canal and may be o pure motor o pure sensory o mixed motor and sensory Symptoms o pain and paresthesias in ulnar 1-1/2 digits o weakness to intrinsics, ring and small finger digital flexion or thumb adduction Physical exam o inspection & palpation clawing of ring and little fingers caused from loss of intrinsics flexing the MCPs and extending the IP joints Allen test helps diagnose ulnar artery thrombosis o neurovascular exam ulnar nerve palsy results in paralysis of the intrinsic muscles (adductor pollicis, deep head FPB, interossei, and lumbricals 4 and 5) weakened grasp from loss of MP joint flexion power weak pinch from loss of thumb adduction (as much as 70% of pinch strength is lost) Froment sign IP flexion compensating for loss of thumb adduction when attempting to hold a piece of paper loss of MCP flexion and adduction by adductor pollicis (ulnar n.) compensatory IP hyperflexion by FPL (AIN) Jeane's sign a compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) compensates for loss of IP extension and thumb adduction by adductor pollicis (ulna n.) Wartenberg sign abduction posturing of the little finger III:3 Wartenberg sign
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By Dr, AbdulRahman AbdulNasser
Neuropathies | Ulnar Neuropathies
Carpal tunnel view radiograph CT scan of hook of hamate nonunion a gradient echo MRI showing hook of hamate will also show an nonunion ulnar artery aneurysm
Angiogram showing ulnar artery thrombosis (arrow). 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
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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 demonstrates fluid anterior to the radius (arrow) and edema in the supinator (arrowheads).
Transverse T1-weighted MRI showing hypertrophic leash of Henry (arrows) (SRN, superficial radial nerve; PIN, posterior interosseous nerve)
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Transverse T1-weighted MRI showing normal leash of Henry (arrows)(SRN, superficial radial nerve; PIN, posterior interosseous nerve)
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%
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OrthoBullets2017
Neuropathies | Radial Neuropathies
3. Wartenberg's Syndrome
Introduction Definition o compressive neuropathy of the superficial sensory radial nerve (SRN) o also called "cheiralgia paresthetica" o sensory manifestation only o no motor deficits Epidemiology o incidence rare o demographics male:female ratio is 1:4, more common in women age bracket is 20-70 years Pathoanatomy o SRN compressed by scissoring action of brachioradialis and ECRL tendons during forearm pronation o also by fascial bands at its exit site in the subcutaneous III:7 With the forearm SUPINATED, SRN lies plane between BR and ECRL without compression. With the forearm PRONATED, ECRL crosses Associated conditions beneath BR, creating scissoring (pinching) of the o associated with De Quervain's disease in 20-50% SRN. Prognosis o spontaneous resolution of symptoms is common o treatment outcomes 74% success after surgical decompression Anatomy The superficial sensory branch of the radial nerve o arises from the bifurcation of the radial nerve in the proximal forearm o travels deep to the brachioradialis in the forearm o emerges from between brachioradialis and ECRL 9cm proximal to radial styloid o bifurcates proximal to the wrist dorsal branch lies 1-3cm radial to Lister's tubercle supplies 1st and 2nd web space palmar branch passes within 2cm of 1st dorsal compartment, directly over EPL supplies dorsolateral thumb - 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 o diagnostic wrist block may temporarily relieve pain
III:8 Palmar ulnar flexion of the wrist puts maximum traction on the nerve
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
[email protected] In July 2017
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Radial Neuropathies
ORTHO BULLETS
IV. Degenerative Conditions
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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. This makes grasping large objects challenging. o proximal muscle slide 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 -
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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
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 o
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 -
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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 -
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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 joints. phalanx 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 -
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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 Grade I Grade II Grade III Grade IV
Green Classification Palm pain and tenderness at A-1 pulley Catching of digit Locking of digit, passively correctable 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 -
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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 joint consistent with Garrod disease pretindinous cord 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 IV:7 Spiral Cord cause of PIP contracture 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 contracture of the ring finger ask patient to place palm flat on table 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 -
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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 McCash technique in which the transverse perform in office using 22G or 25G needle 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 -
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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 to the radiocarpal joint, is o FCR tendon musculotendinous for 8cm proximal enveloped by sheath from musculotendinous origin to trapezium to the RC joint, and is completely tendinous distal to that. no fibrous sheath distal to trapezium 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 -
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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 ulnarly.
the 2nd and 3rd metacarpals, with a 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 radial to FCR, extending over o technique 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 -
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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 -
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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 fibroosseous compartment a distinct EPB sheath is often encountered dorsally
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Extensor Tendon Conditions
Complications Sensory branch of radial nerve injury Neuroma formation Failure to decompress with recurrence o may be caused by failure to recognize and decompress EPB or APL lying in separate subsheath/compartment Complex regional pain syndrome
2. Intersection Syndrome Introduction Due to inflammation at crossing point of 1st dorsal compartment (APL and EPB ) and 2nd dorsal compartment (ECRL, ECRB) Epidemiology o common in rowers weight lifters Pathophysiology o mechanism is repetitive wrist extension Anatomy Extensor tendon compartments See page 130 Presentation Symptoms o pain over dorsal forearm and wrist Physical exam o tenderness on dorsoradial forearm approximately 5cm proximal to the wrist joint o provocative tests crepitus over area with resisted wrist extension and thumb extension Imaging Radiographs o not required for the diagnosis or treatment of intersection syndrome MRI o indications to confirm diagnosis when clinical findings unclear o views fluid sensitive sequences (short tau inversion recovery, STIR; fat suppressed proton density, FS PD; T2-weighted) o findings most characteristic is peritendinous edema or fluid surrounding the 1st and 2nd extensor compartments other findings - tendinosis, muscle edema, tendon thickening, loss of the normal comma shape of the tendon, and juxtacortical edema may also be seen - 133 -
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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 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 o golf - 134 -
IV:15 Attenuation
IV:16Rupture
By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Extensor Tendon Conditions
ECU subsheath is part of the TFCC that is most critical to ECU stability
ECU subluxates during ulnar deviation, 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 IV:17 Axial T2 MRI of the wrist shows tearing and Ultrasound 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 -
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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 IV:18 Neutral Ulnar Variance o risk factors 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
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Wrist Conditions
Ulnar Variance Ulnar Variance
Length Difference (ulnar - radial length)
Load Passing Through Radius
Load Passing Through Ulna
Positive
+2mm
60%
40%
Positive
+1mm
70%
30%
Neutral
0 (<1mm)
80%
20%
Negative
-1mm
90%
10%
Negative
-2mm
95%
5%
Anatomy Neutral ulnar variance (ulnar zero) o difference between ulnar and radial length is <1mm Positive ulnar variance o ulnar sided wrist pain from increased impact stress on the lunate and triquetrum o UV becomes more positive in pronation o UV becomes more positive during grip Negative ulnar variance o UV decreases in supination Imaging Radiographs o recommended view PA of the wrist with shoulder abducted 90 deg, elbow flexed 90 deg, neutral forearm rotation Method to determine ulnar variance o draw 2 lines 1 line tangential to the articular surface of the ulna and perpendicular to its shaft 1 line tangential to the lunate fossa of the radius and perpendicular to its shaft. o measure the distance between these 2 lines (normal is 0mm) o if the ulnar tangent is distal to the radial tangent = positive UV o if the ulnar tangent is proximal to the radial tangent = negative UV MRI o can estimate but not quantify degree of UV o because specific wrist position cannot be duplicated in MRI Treatment Depends on specific condition o ulnar abutment syndrome o TFCC tears o Kienbock's disease
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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 -
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Degenerative Conditions | Wrist Conditions
Techniques Ulnar shortening osteotomy o approach subcutaneous to ulna o technique often combined with arthroscopic TFCC repair
Wafer procedure for treatment of ulnar positive variance
AP wrist radiograph s/p Darrach procedure
Hemiresection arthroplasty for treatment of carpal abutment
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Sauve-Kapandji procedure
ulnar head replacement
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 Variance
Length Difference (ulnar - radial length)
Load Passing Through Radius
Load Passing Through Ulna
Neutral
0 (<1mm)
80%
20%
Positive
+2.5mm
60%
40%
Negative
-2.5mm
95%
5%
Neutral Ulnar Variance
Positive Ulnar Variance - 141 -
Negative Ulnar Variance
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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
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Wrist Conditions
4. Kienbock's Disease Introduction Avascular necrosis of the lunate leading to abnormal carpal motion Epidemiology o incidence most common in males between 20-40 years old o risk factors history of trauma Pathophysiology o thought to be caused by multiple factors biomechanical factors ulnar negative variance leads to increased radial-lunate contact stress decreased radial inclination repetitive trauma IV:21 Ulnar variance refers to the position of the anatomic factors 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 -
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Classification Stage Stage I Stage II
Stage IIIA Stage IIIB Stage IV
Lichtman Classification Description Treatment No visible changes on xray, Immobilization and NSAIDS changes seen on MRI Sclerosis of lunate Joint leveling procedure (ulnar negative patients) Radial wedge osteotomy or STT fusion (ulnar neutral patients) Distal radius core decompression Revascularization procedures Lunate collapse, no scaphoid Same as Stage II above rotation Lunate collapse, fixed scaphoid Proximal row carpectomy, STT fusion, or SC rotation fusion Degenerated adjacent intercarpal Wrist fusion, proximal row carpectomy, or joints limited intercarpal fusion
Stage I: A. No visible changes on xray B. Changes seen on MRI.
Stage II: Sclerosis of lunate.
Stage IIIA: A. Radiographic view of lunate Stage IIIB: A. Radiographic view of lunate collapse collapse with no scaphoid rotation. B. CT with fixed scaphoid rotation. B. CT scan showing scan showing lunate collapse, with no lunate collapse, with fixed scaphoid rotation. scaphoid rotation.
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Wrist Conditions
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 +/- wrist swelling often tender over radiocarpal joint o range of motion decreased flexion/extension arc decreased grip strength
IV:23 CT scan of the lunate showing trabecular destruction and degenerative cystic changes.
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 o best for showing 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:24 T1 weighted MRI scan showing decreased signal intensity throughout the lunate.
IV:25 Post-operative radiograph after STT pinning in an adolescent with Kienbock's Disease.
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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 pinning in an adolescent with Kienbock's o vascularized bone grafts 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 -
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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 involvement
IV:28 Radiograph shows sclerosis and proximal 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 of the distal radial physis found in "gymnast's wrist" o wrist pain 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 and positive ulnar variance. MRI 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 irregularity of the distal radial physis found in o resection of physeal bridge 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 -
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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
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Wrist Instability & Collapse
Classification Stage I Stage II Stage III
Radiographic Classification • Arthrosis localized to the radial side of the scaphoid and radial styloid •Scaphocapitate arthrosis in addition to Stage 1 • 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 -
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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
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Wrist Instability & Collapse
Anatomy Scapholunate interosseous ligament o location c-shaped structure connecting the dorsal, proximal and volar surfaces of the scaphoid and lunate bones dorsal fiber thickened (2-3mm) compared to volar fibers o biomechanics dorsal component provides the greatest constraint to translation between the scaphoid and lunate bones proximal fibers have minimal mechanical strength Overview of wrist ligaments and biomechanics Presentation History o acute FOOSH injury vs. degenerative rupture age, nature of injury, duration since injury, degree of underlying arthritis, level of activity Symptoms o usually dorsal and radial-sided wrist pain o pain increased with loading across the wrist (e.g. push up position) o clicking or catching in the wrist o may be associated with wrist instability or weakness Physical exam o inspection may see swelling over the dorsal aspect of the wrist o palpation tenderness in the anatomical snuffbox or over the dorsal scapholunate interval (just distal to Lister's tubercle) o motion pain increased with extreme wrist extension and radial deviation o provocative tests Watson test when deviating from ulnar to radial, pressure over volar aspect of scaphoid produces a clunk secondary to dorsal subluxation of the scaphoid over the dorsal rim of the radius dorsal wrist pain or a clunk during this maneuver may indicate instability of scapholunate ligament Imaging Radiographs o recommended views AP and lateral views of the wrist o additional views radial and ulnar deviation views flexion and extension views clenched fist (can attenuate the diastasis) o findings AP radiographs SL gap > 3mm with clenched fist view (Terry Thomas sign) - 153 -
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cortical ring sign (caused by scaphoid malalignment) humpback deformity with DISI associated with an unstable scaphoid fracture scaphoid shortening Lateral radiographs dorsal tilt of lunate leads to SL angle > 70° on neutral rotation lateral capitolunate angle > 20° DISI normal carpal alignment increased SL angle Arthrography o indications : may be used as screening tool for arthroscopy o views radiocarpal and midcarpal views always assess the contralateral wrist for comparison o findings may demonstrate the presence of a tear but cannot determine the size of the tear positive finding of a tear may indicate the need for wrist arthroscopy MRI o indications : often overused as a screening modality for SLIL tears o findings requires careful inspection of the SLIL by a dedicated radiologist to confirm diagnosis low sensitivity for tears Arthroscopy o indications : considered the gold standard for diagnosis
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 indicated by the arrow.
normal carpal alignment
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DISI - Lateral radiographs
increased SL angle
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 -
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often added to a ligament repair and remains a viable alternative for a chronic instability when ligament repair is not feasible o repair technique place two k-wires in parallel into the scaphoid bone reduce the SL joint by levering the scaphoid into extension, supination and ulnar deviation and lunate into flexion and radial deviation pass the k wires into the lunate confirm reduction of the SL joint under fluoroscopy place patient in short arm cast o post-operative care remove k-wires in 8-10 weeks no heavy labor for 4-6 months Scapholunate ligament reconstruction o approach same as for repair o reconstruction FCR tendon transfer (direct SL joint reduction) ECRB tendonosis (indirect SL joint reduction) weave not recommended due to high incidence of late failure
Complications Disease progression (e.g. SLAC wrist) Arthritis Post-operative pain, stiffness, fatigue Reduced grip strength
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
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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
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 -
Watson Stage III
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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
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Wrist Instability & Collapse
Operative o radial styloidectomy and scaphoid stabilization indications Stage I technique prevents impingement between proximal scaphoid and radial styloid may be performed open or arthroscopically via 1,2 portal for instrumentation o PIN and AIN denervation indications Stage I technique since posterior and anterior interosseous nerve only provide proprioception and sensation to wrist capsule at their most distal branches, they can be safely dennervated to provide pain relief can be used in combination with below procedures for Stage II or III o proximal row carpectomy indications Stage II contraindicated if there is an incompetent radioscaphocapitate ligament contraindicated with caputolunate arthritis (Stage III) because capitate articulates with lunate fossa of the distal radius technique excising entire proximal row of carpal bones (scaphoid, lunate and triquetrum) while preserving radioscaphocapitate ligament (to prevent ulnar subluxation after proximal row carpectomy) outcomes provides relative preservation of strength and motion o scaphoid excision and four corner fusion indications Stage II or III technique also provides relative preservation of strength and motion wrist motion occurs through the preserved articulation between lunate and distal radius (lunate fossa) outcomes similar long term clinical results between scaphoid excision/ four corner fusion and proximal row carpectomy o wrist fusion indications Stage III any form of pancarpal arthritis outcomes wrist fusion gives best pain relief and good grip strength at the cost of wrist motion
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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
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Wrist Instability & Collapse
Presentation History o usually no history of trauma (midcarpal) o high energy trauma (radiocarpal) Symptoms o subluxation that may or may not be painful o complain of wrist giving way o irritating clunking sign "clunk" when wrist is moved ulnarly from flexion to extension with an axial load Physical exam o generalized ligamentous laxity Imaging Radiographs o recommended views required AP and lateral of the wrist optional cineradiographs o findings sudden subluxation of proximal carpal row with active radial or ulnar deviation on cineradiograph ulnar translation diagnosis made when >50% of lunate width is ulnarly translated off the lunate fossa of the radius
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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.
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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
IV:36 Clinical image shows correct thumb positioning for radiograph of basilar thumb arthritis.
Degenerative Conditions | Arthritic conditions
IV:35 Thumb MCP hyperextension deformity associated with late basilar thumb 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 -
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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
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By Dr, AbdulRahman AbdulNasser
Degenerative Conditions | Arthritic conditions
o silicone
replacements indications not recommended complications of prosthesis fracture, subluxation, or silicone synovitis
Complications 1st metacarpal subsidence and narrowing of trapezial space height o after trapeziectomy ± tendon suspension o salvage treatment LRTI with ECRL tendon or APL tendon if FCR is already used /ruptured MCP hyperextension deformity o treatment depends on degree of hyperextension <10° - no surgical intervention 10-20° - percutaneous pinning of MCP in 25-35° flexion x 4wk ± EPB tendon transfer 20-40° - volar capsulodesis or sesamoidesis >40° - MCP fusion
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
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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 -
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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 distal ulna resection (Darrach procedure) Sauvé-Kapandji procedure 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
I V:42 Post-operative radiograph of an ulnar head replacement.
Collected By : Dr AbdulRahman AbdulNasser
[email protected] In July 2017
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Pediatric Hand | Arthritic conditions
ORTHO BULLETS
V. Pediatric Hand
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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 V:1 TAR autosomal recessive condition with aplastic anemia 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)
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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 I
Type II
Type 0
Type III - 177 -
Type IV
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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 resection and creation o radial head resection and creation of a one-bone forearm 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 radial
head prominence have limited elbow ROM especially in extension and supination usually painless
o can
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 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
V:3 2 views of elbow demonstrate congenital dislocation of head, including a convex and posteriorly dislocated radial head.
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 -
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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 appear to be subluxed volar however this is due to the increased volar tilt which is characteristic of Madelung's deformity.
The increased volar tilt in The wrists on this patient appear to be Madelung's deformity leads the subluxed volar however this is due to clinical appearance of the wrist the increased volar tilt which is to seem subluxed in a volar characteristic of Madelung's deformity. direction.
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 o views thickening ligament from the distal radius to the lunate Treatment Nonoperative o observation indications : if asymptomatic - 180 -
:4 The thick dark band V seen on the T1 MRI is a pathologically thick short radio-lunate ligament (Vickers ligament) which can cause tethering of the volar, ulnar radial physis and cause Madelung's deformity.
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 V:5 In this patient the distal radius o technique has undergone a distal radio-ulnar release a pathologically thick ligament joint fusion to stabilize the wrist. The ulnar variance has been corrected to ligament approximately 0.5 to 1.0 cm in diameter 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 -
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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
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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 web
Thumb space severely narrowed
III
Syndactylized web
Thumb and index rays syndactylized, web space obliterated
IV
Merged web
Index ray suppressed, thumb web space merged with cleft
V
Absent web
Thumb elements suppressed, ulnar rays remain, thumb web space no longer present
Type I cleft hand showing absent middle ray with normal thumb-index web space
Type IIA cleft hand with mildly narrowed thumbindex web space prior to Zplasty.
Type IIB cleft hand with severely narrowed thumb-index web space
Type III cleft hand with syndactyly of thumb and index rays
Type IV cleft hand with merging of the web space and cleft (absent index and middle rays)
Type V cleft hand with absent thumb web space resulting from absent middle, index and thumb rays.
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By Dr, AbdulRahman AbdulNasser
Pediatric Hand | Congenital Hand
Presentation History o may have family history Symptoms o aesthetic limitation o functional limitation Physical exam o absent or shortened central (third) ray o may have absent radial digits o may have syndactyly of ulnar digits may involve feet Imaging Radiographs o recommended views AP, lateral, oblique views of bilateral hands foot radiographs if involved Treatment Nonoperative o observation indications types I (normal web) and IV (merged web), no functional impairment Operative o thumb web space, thumb, and central cleft reconstruction indications types IIA, IIB, III and V webs Technique Thumb, thumb web space reconstruction o web space deepening, tendon transfer, rotational osteotomy, toe-hand transfer o thumb web reconstruction has greater priority over correction of central cleft o thumb reconstruction should not precede cleft closure as it might compromise skin flaps Central cleft reconstruction o depends on characteristic of thumb web space o close the cleft proper with local tissues from the cleft and stabilize and close intermetacarpal space
2. Symphalangism Introduction Congenital digital stiffness that comes in two forms o hereditary symphalangism o nonherediatry symphalangism Epidemiology o location more common in ulnar digits - 185 -
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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 • Most common form
Stretching/splinting
Type II
• Same clinical features as Type I, presents in adolescence • Affects girls more often than boys From abnormal lumbrical insertion, abnormal FDS origin or insertion
If full PIP extension can be achieved actively with MCP held in flexion, digit can be explored and abnormal FDS tendon transferred to radial lateral band
Type III
• Severe contractures, multiple digits involved, presents at birth • Usually associated with a syndrome
Non-operative (unless functional deficit exists after skeletal maturity), then consider corrective osteotomy/fusion
Kirner's • Specific deformity of small finger distal phalanx with Deformity volar-radial curvature (apex dorsal-ulnar) • Often affects preadolescent girls • Often bilateral • Usually no functional deficits
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infant with Type I camtodactyly demonstrating a left hand small finger PIP flexion contracture
Pediatric Hand | Congenital Hand
patient with camtodactyly demonstrating right hand small and ring finger PIP flexion contractures
Kirner's Deformity
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 - 189 -
Delta phalanx clinodactyly
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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 V:6 delta phalanx indications 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
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Osteotomies for delta phalanx
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 acrosyndactyly. Associated conditions 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. Incomplete
Complete syndactyly the skin extends to finger tips; with incomplete, skin does not extend to fingertips
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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 ringsmall 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 o use
fasciocutaneous flaps to reconstruct the web 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 fullthickness skin graft placed in the web late creep (adolescence) is caused by discrepant growth between scar/skin graft and surrounding tissue during the growth spurt o treatment reconstruct web space with local skin flaps Nail deformities
:8 Intraoperative photo of the zigzag V technique used to release digits.
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 Etiology o thought to be linked to subclavian artery hypoplasia
:9 symbrachydactyly and shortening V of middle fingers
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 -
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carpal coalition or hypoplasia radioulnar synostosis nail agenesis
Imaging CT scan o will show absent perctoralis major Treatment Operative o syndactyly release indications performed in most patients technique complete syndactyly release produces skin deficiency that requires skin grafting perform only one side of the digit at a time to avoid vascular complications local flap is created for commisure reconstruction followed by interdigitating zigzag dorsal and palmar flaps along the medial and lateral aspect of the digit Complications Skin graft failure Excessive tension Improper flap planning Digital artery injury Web creep Nail deformity
7. Apert Syndrome Introduction Syndrome characterized by o bilateral complex syndactyly of hands and feet index, middle, and ring fingers most affected o symphalangism o premature fusion of cranial sutures (craniosynostosis) results in flattened skull and broad forehead (acrocephaly) o hypertelorism (increased distance between paired body parts, as in wide set eyes) o normal to moderately disabled cognitive function o glenoid hypoplasia o radioulnar synostosis Genetics o autosomal dominant, but most new cases are sporadic o mutation of FGFr2 gene Epidemiology o incidence is 1/80,000 live births Prognosis o spectrum of normal to moderately disabled cognitive function - 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 1 per 1,000 to 10,000 live births Type IV most common (43%) Type II second most common (15%)
:10 Preaxial Polydactyly (Thumb V Duplication)
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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
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By Dr, AbdulRahman AbdulNasser
Type II
Pediatric Hand | Congenital Hand
Type III : Incomplete duplication at the level of proximal phalanx with duplicated triphalangeal thumbs.
Type VI : Duplicated metacarpal
Type IV : Duplicated
proximal phalanx
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 -
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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
syndactyly Central Polydactyly Epidemiology o commonly associated with syndactyly extra digit may lead to angular deformity or impaired motion Treatment o osteotomy and ligament reconstructions indications perform early to prevent angular growth deformities
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By Dr, AbdulRahman AbdulNasser
Pediatric Hand | Congenital Hand
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 -
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o inspection
& palpation thick, fibrofatty tissue involving enlarged digits o ROM & instability often limited ROM due to soft tissue constraints
Imaging Radiographs o recommended views biplanar hand radiographs o findings enlarged phalanges to involved digits may see malalignment of joints or angled phalanges CT, MRI o not typically needed Studies Angiography o only needed if used for surgical planning Treatment Nonoperative o observation in mild cases Operative o epiphysiodesis indications single digit perform once digit reaches adult length of same sex parent most common approach postoperative care soft tissue care early ROM o osteotomies and shortening procedures indications thumb involvement multiple digit involvement severe deformity postoperative care local soft tissue care early ROM o amputations indications severe involvement of digit non-reconstructable digit Complications Digital stiffness Chronic digital pain or edema - 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 -
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Degrees of Constrictive Ring Syndrome
Simple constriction rings
Rings with distal deformity
Acrosyndactyly
Amputations Imaging Ultrasound o intrauterine diagnosis can be made with ultrasound at end of first trimester Treatment Operative o surgical release with multiple circumferential Z-plasties indications if circulation is compromised by edema or limb has contour deformity perform early (neonatal) technique acrosyndactyly is treated with distal release early in neonatal period intrauterine band release can be done if limb is found to be at risk of amputation (rare)
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By Dr, AbdulRahman AbdulNasser
Pediatric Hand | Congenital Hand
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
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Amniotic band syndrome Type I
Pediatric Hand | Congenital Hand
Amniotic band syndrome Type II
Amniotic band syndrome Type III
Amniotic band 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
[email protected] In July 2017
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By Dr, AbdulRahman AbdulNasser
Pediatric Hand | Congenital Thumb
C. Congenital Thumb 1. Thumb Hypoplasia Introduction Congenital underdevelopment of the thumb frequently associated with partial or complete absence of the radius Epidemiology o incidence : 1/100,000 live births o demographics male = female o location bilateral involvement in ~60% of patients right hand more common than left Pathophysiology o exact cause during embryologic development has yet to be elucidated Associated anomalies o greater than 80% of patients will have associated anomalies including VACTERL Holt-Oram thrombocytopenia-absent radius (TAR) Fanconi anemia Classification & Treatment Treatment algorithm depends on presence of carpometacarpal joint stability Blauth Classification Type
Description
Treatment
Type I
Minor hypoplasia All musculoskeletal and neurovascular components of the digit are present, just small in size
No surgical treatment required
Type II
All of the osseous structures are present (may be small) MCP joint ulnar collateral ligament instability Thenar hypoplasia
Stabilization of MCP joint Release of first web space Opponensplasty
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. Basal metacarpal aplasia with deficient CMC joint Absence of active motion at the MCP or IP joint.
Thumb amputation & pollicization
Type IV
Floating thumb Attachment to the hand by the skin and digital neurovascular structures
Type V
Complete absence of the thumb
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Presentation Physical exam o inspection extrinsic tendon abnormalities pollex abductus flexor pollicus longus attaches to normal insertion and the extensor tendon hypoplasia of thenar musculature absence of skin creases indicates muscle or tendon abnormalities excessive abduction of MCP joint 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 Imaging Radiographs o recommended views bilateral films of hand, wrist and forearm - 206 -
Pediatric Hand | Congenital Thumb
:12 Pollex abductus is considered an extrinsic V tendon abnormality where the FPL also attaches to the extensor tendon.
V:13 Arrow pointing to atrophy of the thenar musculature.
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 -
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Blauth Classification
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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 -
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Imaging Radiographs o recommended views AP and lateral views of the hand o additional views dedicated thumb views o indications recommended only if history of trauma o findings usually diagnosed based on clinical presentation radiographs are usually normal Treatment Nonoperative o passive extension exercises and observation indications not recommended for fixed deformities in older children technique passive thumb extension exercises duration based on clinical response outcomes 30-60% will resolve spontaneously before the age of 2 years old <10% will resolve spontaneously after 2 years old o intermittent extension splinting indications first line of treatment more successful than observation alone consider alongside stretching regime flexible deformity not recommended with fixed deformity in older children technique splints maintain IP joint hyperextension and prevent MCP joint hyperextension duration for 6-12 weeks outcomes 50-60% resolution in all age groups high drop out rate from therapy Operative o A1 pulley release indications fixed deformity beyond age of 12 months of age failed conservative treatment outcomes 65-95% resolution in all age groups
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By Dr, AbdulRahman AbdulNasser
Pediatric Hand | Congenital Thumb
Techniques A1 Pulley Release o open release small transverse incision in the thumb MCP flexion crease, extending over the A1 pulley protect the radial digital nerve sharp dissection of the A1 pulley identify the Notta nodule in the FPL tendon watch nodule under direct vision during passive IP extension of the thumb to ensure there is smooth FPL tendon gliding Complications Digital nerve injury o caution must be performed during release as digital nerves at high risk due to proximity to flexor tendon and A1 pulley Wound complications o scar contracture o abscess o infection IP flexion deficit Bow-stringing of flexor tendon o usually related to release of the oblique pulley
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
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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 -
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Hand Tumors & Lesions | Congenital Thumb
ORTHO BULLETS
VI. Hand Tumors & Lesions
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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%) 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
VI:1 Ganglion Cyst
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 -
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Hand Tumors & Lesions | Tumors of the hand
MRI o indications not routinely indicated o findings shows well marginated mass with homogenous fluid signal intensity Ultrasound o useful for differentiating cyst from vascular aneurysm o may provide image localization for aspiration while avoiding artery Histology Biopsy o indications not routinely indicated o findings will show mucin-filled synovial cell lined sac Treatment Nonoperative o observation indications first line of treatment in adults children 76% resolve within 1 year in pediatric patients o closed rupture home remedy high recurrence o aspiration indications second line of treatment in adults with dorsal ganglions aspiration typically avoided on volar aspect of wrist due to radial artery outcomes higher recurrence rate (50%) than surgical resection but minimal risk so reasonable to attempt Operative o surgical resection indications severe symptoms or neurovascular manifestations technique requires adequate exposure to identify origin and allow resection of stalk and a portion of adjacent capsule at dorsal DIP joint: must resect underlying osteophyte results volar ganglions have higher recurrence after resection than dorsal ganglions (15-20% recurrence)
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By Dr, AbdulRahman AbdulNasser
Hand Tumors & Lesions | Tumors of the hand
Complications With aspiration o infection (rare) o neurovascular injury With excision o infection o neurovascular injury (radial artery most common) o injury to scapholunate interosseous ligament o stiffness
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 -
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an epidermal inclusion cyst on the palmar surface of the hand.
Hand Tumors & Lesions | Tumors of the hand
well-circumscribed epidermal inclusion cyst on the palmar surface of the small finger.
an epidermal inclusion cyst on the dorsal surface of the PIP joint of the ring finger which is adherent to the overlying 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
distal phalanx reveals an Studies interosseous epidermal inclusion cyst with lytic bony erosion. Biopsy 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 The medium-power histology slide squamous epithelium. reveals an epidermal inclusion cyst characterized by a stratified squamous epithelial lining and abundant keratin.
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By Dr, AbdulRahman AbdulNasser
Hand Tumors & Lesions | Tumors of the hand
Differential Tophaceous gout Foreign body granuloma Sebaceous cyst Giant cell tumor Ganglion cyst Enchondroma Glomus tumor Treatment Nonoperative o observation indications not recommended Operative o marginal excision indications diagnosis of epidermal inclusion cyst painful lesions loss of function cosmetic concerns technique careful dissection to remove the entire capsule local curettage and bone graft may be required for lesions eroding bone amputation is an alternative with advanced bony destruction in rare circumstances outcomes marginal excision is curative low recurrence rate Complications Wound complications Infection Digital neurapraxia Recurrence o recurrence rate is low even with bony involvement
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 -
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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 With fingers in from dorsal wrist flexion, the muscle capsule deep to the belly of the aEIP extensor extends beyond retinaculum, the 4th inserting on the compartment, extensor hood of the leading to pain and index of middle finger disability
Extensor medius proprius. Similar origin as EIP. Inserts into middle finger (instead of index finger)
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EIMC. It is an EIP muscle that splits to insert into both index and middle fingers.
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 o indications 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)
VI:4 aEIP presenting as painful dorsal wrist mass (arrow)
Differential Ganglion Synovitis o both produce dorsal wrist pain Treatment VI:6 T1 weighted MRI VI:5 Surgical decompression of EDBM showing mass of the 4th extensor Nonoperative centered over CMC compartment reveals an joint that is isointense o observation 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)
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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
Giant cell tumor of tendon sheath showing pressuretype bone erosion
Hand Tumors & Lesions | Tumors of the hand
MRI: Sagittal T1 MRI Image of GCTTS
MRI: Sagittal T2 MRI Image of GCTTS
MRI: Coronal T2 MRI Image of GCTTS
Treatment Operative o marginal excision 5-50% recurrence rate more common if tumor extends into joints and deep to the volar plate local recurrence is usually treated with repeat excision operative approach is dependant on location and extent of the tumor
VI:7 32 y/o female with a painful R long finger mass. MRI and intraoperative findings consistent with Giant Cell tumor of tendon sheath.
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OrthoBullets2017
Hand Tumors & Lesions | Vascular Conditions
B. Vascular Conditions 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 hamate (N, ulnar nerve; A, ulnar artery; H, hook of hamate; P, pisiform; PHL pisohamate ligament; TCL, transverse carpal ligament (floor of Guyon's canal); VCL, volar carpal ligament (roof of Guyon's canal)
CT angiogram showing close relationship of ulnar artery (yellow arrow) to hook of hamate
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By Dr, AbdulRahman AbdulNasser
Hand Tumors & Lesions | Vascular Conditions
Anatomy Ulnar artery o ulnar artery branches into 2 branches as it exits Guyon's canal deep branch superficial palmar arch in Guyon's canal o relation to hook of hamate over distal 2cm, the artery is directly anterior to the hook of the hamate, covered by palmaris brevis, subcutaneous tissue and skin Presentation History o occupational or sporting risks (see above) Symptoms o pain over hypothenar eminence and ring finger may involve small, middle and index fingers o cold sensitivity o paresthesia Physical exam o inspection blanching, mottling, cyanosis, pallor, gangrene tenderness over hypothenar eminence prominent callus (calloused skin over hypothenar eminence) pulsatile mass if aneurysm is present fingertip ulcerations over ulnar digits splinter hemorrhages over ulnar digits o provocative tests Allen's test positive if occlusion is present 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 occlusion or aneurysm at the hook of the hamate
VI:8 CT angiogram showing aneurysm at hook of hamate
VI:9 Angiogram showing aneurysm at hook of hamate
Differential Raynaud's disease involves the thumb but hypothenar hammer syndrome does not
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OrthoBullets2017
Hand Tumors & Lesions | Vascular Conditions
Treatment Nonoperative o lifestyle modifications, symptomatic treatment, and vascular consult indications thrombosis without aneurysm > 2 weeks asymptomatic no threat of digital loss lifestyle modifications smoking cessation avoid recurrent trauma outcomes 80% success Operative o endovascular fibrinolysis I:10 Resection of ulnar artery aneurysm in V hypothenar hammer syndrome indications 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 I:11 The clinical photograph V o invasive studies demonstrates gangrene in a microangiology - often abnormal patient with Raynaud's phenomenon. angiography - often abnormal 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) o epidemiology seen in young premenopausal women (age <40 years) o pathophysiology similar to Raynaud's phenomenon Presentation o symptoms often bilateral slow progression o physical exam peripheral pulses usually present - 227 -
VI:12 The imaging study represents an angiogram with incomplete ulnar artery obstruction in a patient with Raynaud's phenomenon.
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
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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
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OrthoBullets2017
Hand Tumors & Lesions | Vascular Conditions
Presentation Symptoms o early disease intermittent claudication of feet, legs, hands or arms numbness and/or tingling in the limbs o late disease symptoms of critical limb ischemia rest pain Physical exam VI:13 Ulcerations are usually present prior to o inspection the onset of necrosis. ulcerations large, erythematous, superficial blood vessels necrotic distal digits in hands and feet o palpation decreased temperature in hands and feet o neurovascular diminished or absent pulses VI:14 Necrotic distal digits in a sensory findings in up to 70% of patients 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 o used to exclude alternative diagnoses Echocardiogram 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 -
I:15 Arteriogram showing classic V "corkscrew" arteries in a patient with Buerger's disease.
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 Differential Often misdiagnosed as o epidermoid cysts o arteriovenous fistulas o forieign body granulomas o ganglions o neurilemmomas
VI:17 angio–computed tomography (CT) scan: Arrow pointing to narrow artery causing decrease in flow into second webspace
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 Techniques Digital artery aneurysm repair o end-to-end anastomosis and an autogenous interpositional vein or arterial graft Complications digital ischemia chronic pain - 232 -
VI:18 Intraoperative photograph demonstrating the digital artery (white arrow), which lies dorsal to the digital nerve (black arrow) in the finger
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) 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
VI:19 Split nail
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 Recurrence of deformity Necrosis/flap failure, loss of distal tip
VI:20 example of a prosthetic that can be fitted and placed on the end of a hook nail to cover the cosmetic deformity
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By Dr, AbdulRahman AbdulNasser
Hand Tumors & Lesions | Tested Procedures
D. Tested Procedures 1. Wrist Arthroscopy Introduction Plays an important therapeutic and diagnostic role Indications o TFCC injuries o interosseous ligament injuries o anatomic reduction assistance (distal radius, scaphoid fxs) o ulnocarpal impaction o debridement of chondral lesions o removal of loose bodies o synovectomy o excision of dorsal wrist ganglia o assistance in treatment of SNAC and or SLAC wrist o septic wrist irrigation and debridement o diagnosis in unexplained mechanical wrist pain 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
3-4
Located just distal to Lister tubercle, between EPL and EDC; Established first, primary viewing portal
EPL and EDC tendons
4-5
Located in line with ring finger metacarpal, between EDC and EDM; Portal for instrumentation, visualization of TFCC
EDC and EDM tendons
6R
Located just radial to ECU tendon; Primary adjunct for visualization Dorsal sensory branch and instrumentation, ulnar-sided TFCC repairs of ulnar nerve
6U
Located just ulnar to ECU tendon; Primary adjuct for visualization and instrumentation, ulnar-sided TFCC repairs
Dorsal sensory branch of ulnar nerve
1-2
Located between APL and ECRB, along dorsal aspect of snuffbox; Not often utilized, provides access to radial styloid and radial aspect of joint, sometimes used for inflow
Superficial branch of radial nerve; Radial 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 middle finger metacarpal, between ECRB and EDC. Allows MCR visualization of scapholunate, scaphocapitate, and scaphotrapezoid joints.
ECRB and EDC tendons
Located 1 cm distal to 4-5 portal along axis of ring finger MCU metacarpal, between EDC and EDM. Allows visualization of lunocapitate, lunotriquetral, and triquetrohamate joints.
EDC and EDM tendons
STT
Located along axis of index finger metacarpal just ulnar to EPL at level of STT joint. Allows visualization of scaphotrapezial and scaphotrapezoid joints.
ECRB and ECRL tendons
First CMC Portals 1U
Located on ulnar aspect of EPL at level of first CMC joint (basal joint). Allows diagnosis of DJD of first CMC joint and arthroscopic debridement.
1R
Located on radial aspect of EPL at level of thumb CMC joint, just Superficial sensory volar to APL tendon. Allows diagnosis of DJD of first CMC joint and branch of radial nerve arthroscopic debridement.
Superficial sensory branch of radial nerve
Rehabilitation Immediate post-operative period o cast, splint or soft dressing depending on specific procedure(s) performed Rehabilitation o progression depending on specific procedure(s) performed Return to full activity o timing depending on specific procedure(s) performed
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By Dr, AbdulRahman AbdulNasser
Hand Tumors & Lesions | Tested Procedures
Complications Incidence o overall complication rate is 1-2% Dorsal sensory branch of ulnar nerve o averages 8mm from 6R portal o at risk with establishment of 6U and 6R portals to a lesser extent main ulnar nerve and artery also at risk o When performing a TFCC repair, small open incision is typically made prior to knot tying to prevent injury to this nerve. Superficial sensory branch of radial nerve o averages 16mm from 3-4 portal o at risk during arthroscopy of basal joint, as 1U and 1R portals are on either side of the first branch of this nerve o at risk during placement of 1-2 portal Radial artery Injury o Associated with establishment 1-2 portal, used for arthroscopic radial styloidectomy. Extensor tendon injury o most commonly EPL and EDM due to improper portal placement Chondral injuries o iatrogenic from scope or instrument placement Portal site infection Stiffness MCPJ pain o typically caused by over-distraction
Collected By : Dr AbdulRahman AbdulNasser
[email protected] In July 2017
Wrist Portals - 239 -