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Anatomy & Pathophysiology

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Anatomy & Pathophysiology


DORSAL SURFACE NAIL VOLAR SURFACE WRIST THUMB MUSCLE CHART

Embryology of Upper limb DORSAL SURFACE:


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Dorsal Extensor Compartments: Comp 1 2 3 4 5 6 Tendons EPB, APL ECRL, ECRB EPL EDC, EIP EDM ECU Notes Both in separate synovial sheaths radial to Lister's tubercle ulnar to Lister's tubercle common synovial sheath Double tendon, over DRUJ lies over distal ulna Pathology De Quervains Carpal boss Rupture over Lister's tubercle Tenosynovitis & ruptures Tenosynovitis & ruptures Subluxing at ulnar styloid

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Anatomy & Pathophysiology

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Extensor Hood & Tendons:

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Anatomy & Pathophysiology

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The Lateral Bands [16] are held dorsally by the Triangular Ligament [17] and volarly by the Transverse Retinacular Ligaments [15]. The Transverse Retinacular Ligaments attach to the volar plate. Imbalance of the lateral bands results in a swan neck or boutonniere deformity. Oblique Retinacular Ligament (ORL) [13]: Described by Weitbrecht (1969). Extends from the flexor tendon sheath at the level of the proximal phalanx to the terminal tendon. Coordinates the uniform flexion & extension of the PIPJ & DIPJs. When FDP flexes the DIPJ the ORL tightens & flexes the PIPJ thro a tenodesis effect. As the extensors extend the PIPJ the ORL helps extend the DIPJ. (from 90 to 70deg. only)- Where there is loss of the terminal tendon (Mallet finger) the ORL may extend the DIPJ. Sagittal Band [5]: Connect extensor tendon to volar plate of MCPJ. Aids extension of MCPJ In hyperextension of the MCPJ the IPJs fall in to flexion because the extensor tendon distal to the sagittal band becomes lax. In this position the IPJ's can only be extended by the intrinsics. VOLAR ASPECT:

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Anatomy & Pathophysiology

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Palmar Spaces

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1) Palmar subaponeurotic space- deep to palmar aponeurosis, contains sup. palmar arch. collar-stud abscess. 2a) Ulnar & radial bursae - tendon sheaths to little finger & thumb. 2b) Tendon sheaths- drain infection thro transverse incisions over MCPJs and DIPJs, indwelling catheter for irrigation (?Jacques). 3) Midpalmar space-overlying MC's, extends to web spaces via lumbrical canals. extends under flexor retinaculum to space of Parona. 4) Thenar space- betw. thenar muscles & adductor pollicus, extends to radial side of index finger.

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Anatomy & Pathophysiology

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Lumbricals 'workhorse of the hand' two radial lumbricals supplied by median nerve; two ulnar lumbricals supplied by the ulna nerve. radial muscles are unipenniform; ulnar muscles are multipennate. The lumbrical is the only muscle which relaxes its own antagonist (FDP). Lumbrical Plus Hand = lumbricals tighter than extrinsics. Caused by FDP laceration distal to lumbrical origin Paradoxical extension - Active flexion of MCPJ causes extension of PIPJ causes Quadriga Effect (FDPs act as a single unit & individual finger flexion is not possible - can also occur after amputation where the FDP tendon is sutured to extensors)

Vessels & Nerves The superficial palmar arch is distal & supplied by ulnar artery - surface anatomy = distal palmar crease The deep arch is proximal & supplied by the radial artery - surface anatomy = Kaplan's cardinal line (from hook of Hamate to base of 1st web space) A classic complete arch is present in one third of people. Digital arteries are volar to nerves in the palm but dorsal in the fingers Finger Cross-section: Grayson's (Ground) & Cleland's (Ceiling):Tether the proximal & middle phalanges to the skin. Surround the NVB

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Anatomy & Pathophysiology

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Flexor Tendons & Pulleys: See Flexor Tendon Injuries PIPJ Anatomy:

THUMB

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The muscle forces acting on the thumb are summarised in the Diagram :

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Anatomy & Pathophysiology

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Thumb Opposition = abduction + rotation mainly at the 1st CMCJ. MCPJ & CMCJ are both modelled as universal joints (flexion-extension; abduction-adduction; axial rotation) NAIL

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WRIST

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Consists of 3 Columns: Flexion-Extension / Central Column Second mobile column Rotation Column Modeled as a universal joint. MUSCLE CHART distal carpal row & lunate scaphoid Triquetrum carpus rotates around the triquetrum independent of forearm rotation centre of rotation = capitate; dependent on carpal ligaments for stability

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Muscle

Principle Group

Origin

Insertion

Primary Action

Description

Innervation

Blood Supply

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Anatomy & Pathophysiology

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/Subgroups Arm, Anterior Deep Middle 3rd of Humerus

|Secondary Action Ulna coronoid Elbow: Flexion The main flexor of the forearm Musculocutaneous Brachial A. N. (lateral cord)

Brachialis

Arm, Anterior Coracobrachialis Deep

Coracoid Process

Middle 3rd of humerus

CORACOBRACHIALIS SYNDROME -- lose the Musculocutaneous Elbow: Flexion Musculocutaneous N. Brachial A. N. (lateral cord) and most of anterior arm Elbow: Flexion

Biceps Brachii

Arm, Anterior Superficial / Rotator Cuff

Short Head: Coracoid Process; Long Head: Supraglenoid Tubercle

Tuberosity of Radius

Forearm: Forceful supination

Head is the lateral border of rotator cuff

Musculocutaneous Brachial A. N. (lateral cord)

Triceps Brachii

Arm, Posterior

Long Head: Infraglenoid tubercle of Scapula; Lateral Olecranon of and Medial Ulna Heads: Above and below radial groove of humerus Distal Common Flexor phalanges of the 2nd Tendon and through 5th Radius digits The 1st distal phalanx The distal ulna The distal radius

Elbow: Extension

Triangular Interval and Quadrangular Space are between the two heads of the Triceps

Radial N.

Brachial A.: Deep Branch

Flexor Digitorum Forearm, Profundus Anterior Deep

Digits: Flexion of fingers

SPACE OF PARONA is directly superficial to it.

Lateral Half: Anterior Anterior Interosseus N., Interosseus A. Medial Half: Ulnar N. Anterior Interosseus N. Anterior Interosseus N. Anterior Interosseus A. Anterior Interosseus A.

Flexor Pollicis Longus Pronator Quadratus

Forearm, Anterior Deep Forearm, Anterior Deep

Digits: Flexion of thumb Forearm: Pronation (radius over ulna) with elbow extended

Flexor Digitorum Forearm, Superficialis Anterior Middle

Middle phalanges of Common Flexor the 2nd Tendon through 5th digits. Base of index Common Flexor finger Tendon metacarpal

Digits: Flexion of fingers

SPACE OF PARONA is directly deep to it.

Median N.

Radial A., Ulnar A.

Flexor Carpi Radialis

Forearm, Anterior Superficial

Wrist: Flexion, Abduction (Radial Deviation)

Median N.

Radial A., Ulnar A.

Flexor Carpi Ulnaris

Forearm, Anterior Superficial

Common Flexor The Pisiform Tendon and Bone proximal ulna

Wrist: Flexion and adduction (ulnar deviation)

CUBITAL TUNNEL SYNDROME: Ulnar N. Entrapment b/tw two Ulnar N. heads; Pisiform bone is sesamoid bone in tendon

Radial A., Ulnar A.

Forearm, Palmaris Longus Anterior Superficial

Common Flexor Tendon Humeral Head: Medial Epicondyle; Ulnar Head: Proximal Ulna

Does not pass through NONE | Wrist: the flexor retinaculum! Median N. Flexion Used in surgical tendon transfers Forearm: Pronation (Radius over Ulna) PRONATOR TERES SYNDROME -- Median Median N. N. Entrapment between the two heads Radial N.: Deep Branch Radial N.: Deep Branch Radial N.: Deep Branch

Radial A., Ulnar A.

Pronator Teres

Forearm, Anterior Superficial

Distal third of radius

Radial A., Ulnar A.

Abductor Pollicis Longus

Forearm, Posterior Deep Forearm, Posterior Deep

Radius, Ulna, 1st Metacarpal Digits: Abduction of thumb and Interosseus base Membrane Radius, Ulna, Proximal and Interosseus phalanx of the Membrane 2nd digit Radius, Ulna, Proximal and Interosseus phalanx of the Membrane 1st digit Digits: Extension of index finger Digits: Extension of thumb

Posterior Interosseus A. Posterior Interosseus A. Posterior Interosseus A.

Extensor Indicis

Extensor Pollicis Forearm, Brevis Posterior Deep

DeQuervain's Disease in Radial Bursa

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Extensor Pollicis Forearm, Longus Posterior Deep

Radius, Ulna, Distal phalanx and Interosseus of the 1st digit Membrane

Digits: Extension of thumb

DeQuervain's Disease in Radial Bursa Deep branch of the Radial N. pierces the supinator to go to posterior forearm -SUPINATOR CHANNEL SYNDROME

Radial N.: Deep Branch

Posterior Interosseus A.

Supinator

Forearm, Posterior Deep

Proximal ulna and lateral epicondyle of humerus

Proximal radius

Forearm: Supination

Radial N.: Deep Branch

Posterior Interosseus A.

Anconeus

Forearm, Posterior Superficial

Common Extensor Tendon

Elbow: Extension | Abduction of ulna during pronation

It gets the ulna out of Radial N.: Deep the way during Branch pronation of the forearm MOBILE-WAD: part of lateral compartment. May become damaged with radial fractures near the wrist

Posterior Interosseus A.

Brachioradialis

Forearm, Posterior Superficial Forearm, Posterior Superficial

Common Extensor Tendon Common Extensor Tendon Common Extensor Tendon Common Extensor Tendon Common Extensor Tendon Common Extensor Tendon

Styloid process Elbow: Power of the radius flexion

Radial N.

Radial and Posterior Interosseus Aa.

Extensor Carpi Radialis Brevis

Base of the meta carpal bones Base of the metacarpal bones

Wrist: Extension and Radial deviation (abduction) Wrist: Extension and Radial deviation (abduction)

Radial N.: Deep Branch

Posterior Interosseus A.

Forearm, Extensor Carpi Posterior Radialis Longus Superficial Forearm, Posterior Superficial Forearm, Posterior Superficial Forearm, Posterior Superficial Intrinsic Hand Hypothenar Eminence Intrinsic Hand Hypothenar Eminence

MOBILE-WAD: Part of Radial N. lateral compartment

Posterior Interosseus A.

Extensor Carpi Ulnaris Extensor Digiti Minimi

The base of Wrist: Extension and adduction (ulnar the metacarpal deviation) bones The proximal phalanx of the 5th digit All three phalanges of the 2nd through 5th digits Digits: Extension of little finger

Radial N.: Deep Branch Radial N.: Deep Branch

Posterior Interosseus A. Posterior Interosseus A.

Extensor Digitorum

Digits: Extension of fingers

The tendons split and Radial N.: Deep then reunite to insert on Branch the distal two phalanges

Posterior Interosseus A.

Abductor Digiti Minimi Flexor Digiti Minimi

Digits: Abduction of Little Finger

Ulnar N.

Palmar Metacarpal Aa. (from Ulnar A.) Palmar Metacarpal Aa. (from Ulnar A.) Palmar Metacarpal Aa. (from Ulnar A.) Anterior and Posterior Proper Digital Aa. Anterior and Posterior Proper Digital Aa. Anterior and Posterior Proper Digital Aa. Princeps Pollicis A. (from Radial A.) Princeps Pollicis A. (from Radial A.) Princeps Pollicis A. (from Radial A.)

Digits: Flexion of the little finger

Ulnar N.

Intrinsic Hand Opponens Digiti Hypothenar Minimi Eminence Dorsal Interossei Intrinsic Hand Middle Hand Posterior Tendons of the aspect of the Flexor Digitorum proximal and distal Profunda phalanges

Digits: Opposition of little finger

Ulnar N.

Digits: Abduction of Fingers Digits: Flexion of MCP joints; Extension of PIP and DIP joints Anterior to the MCP joints and posterior to the PIP and DIP joints; proprioception and kinesthesia

Ulnar N.

Lumbricals

Intrinsic Hand Middle Hand

1st and 2nd: Me dian N., 3rd and 4th: Ulnar N.

Palmar Interossei Abductor Pollicis Brevis Adductor Pollicis Flexor Pollicis Brevis

Intrinsic Hand Middle Hand Intrinsic Hand Thenar Eminence Intrinsic Hand Thenar Eminence Intrinsic Hand Thenar Eminence

Digits: Adduction of fingers

Ulnar N.

Digits: Abduction of thumb

Median N.

Digits: Adduction of thumb

Ulnar N.

Digits: Flexion of thumb

Median N.

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Opponens Pollicis

Intrinsic Hand Thenar Eminence

Digits: Opposition of thumb

Median N.

Princeps Pollicis A. (from Radial A.)

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Aphert Syndrome

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Aphert Syndrome

Aphert Syndrome. Tower skull, exophthalmos. Child of 4 y.o.

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Aphert Syndrome

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Aphert syndrome. Syndactylia of both hands all fingers. The same patient.

Syndactylia of both foot fingers. The same patient.

From:|I-Doctor Slide Gallery

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Carpometacarpal arthritis of the thumb rhizarthrosis

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Carpometacarpal arthritis of the thumb rhizarthrosis


Updated by Alex Malone, 2006 Anatomy Key joint, Saddle-shaped (Biconcavo-convex) Joint compression force = 12kg (120kg for strong grip) 3 Main ligamentous stabilisers: 1. Volar or Beak ligament (volar oblique lig., anterior oblique lig.(AOL), volar CMC lig., deep ulnar lig) trapezium to volar and ulnar side of MC base. Most important ligament primary static stabiliser, very strong Prevents dorsal translation of the MC in key pinch, allows rotational motion Important in Bennett's Fractures 2. Dorsal ligament thin & reinforced by APL 3. Lateral ligament broad running from lateral surface of trapezium to 1st MC base Pathophysiology Attritional changes in the beak ligament lead to destabilisation of the 1st CMCJ causing degenerative changes. Occur initially in the palmar contact areas of the joint. History Female:male = 10:1. Pain - aggravated by forceful pinch grip such as turning door key, holding tea cup or sewing. +/- injury. Examination Adduction-flexion deformity of the thumb reducing the thumb index web angle. 'Shoulder sign' radial prominence at base of thumb, from dorsal subluxation of MC on trapezium. Crank Test = axial loading + passive flexion & extension of 1st MC Grind Test = axial loading + rotation of 1st MC on trapezium Torque Test = Distract MC & rotate. - differentiates CMCJ OA (no pain) from de Quervain's disease (painful). Look for Trigger fingers & CTS (43% association) Radiographs AP, oblique & lateral views are usually adequate. Robert pronated view = fully pronate forearm & internally rotate shoulder. Dynamic stress views indicated where instability suspected & standard x-rays fail to show anything. AP views of both 1st CMCJs whilst pressing the radial aspects of thumb tips together. Eaton Classification I Normal joint with possible increased joint space due to synovitis II Decreased Joint space, Debris, Osteophyte formation (<2mm), up to 1/3 subluxation III Significant joint destruction with cysts and sclerosis, Osteophyte formation (>2mm), greater than 1/3 subluxation IV Involvement of multiple joint surfaces Treatment Non-operative: Always non-operative initially Splinting, Strengthening thenar muscles, Steroid injections. Surgery:

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Carpometacarpal arthritis of the thumb rhizarthrosis

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When non-operative treatment fails. Soft tissue reconstruction: for instability with no articular changes, FCR to reconstruct the beak lig. Osteotomy: abduction-extension osteotomy to off-load the palmar surface of the joint. For high demand young adults with early disease. Arthrodesis: for young high demand patients, 20% failure rate Excision Arthroplasty Trapeziectomy alone is all that is required. Rare complications are weakness, instability, proximal MC migration. Excision Arthroplasty & soft tissue reconstruction (sling procedure) Trapiezectomy & Ligament Reconstruction & Soft Tissue Interposition (LRSTI) Improved pinch strength vs trapeziectomy Dissect (avoiding radial artery & terminal branches of radial nerve) Trapeziectomy: Divide Trapezium into halves or quarters w/ osteotome or saw, & remove it piecemeal. Avoid cutting FCR. LRSTI: Drill hole in base of 1st MC perpendicular to plane of thumbnail, from radial cortex to base. Harvest 10 cms of half width FCR tendon. Pass free end of FCR through hole in base of 1st MC & out radial hole. Suture it to the soft tissues on the MC & then to itself. Insert rest of tendon into trapezium fossa as spacer. Place in volar slab, leaving IPJ free.: Mobilise at 3-6wks Complications: damage to superficial branch of radial nerve, radial artery, palmar cutaneous branch of median nerve. Arthroplasty: Experimental Only if isolated CMC joint and not STT joint disease. Most people are fine with Trapeziectomy Interpositional arthroplasty: Silicone Swanson prosthesis Problems: implant subluxation & dislocation, rapid wear, silicone synovitis Total joint arthroplasty: Constrained ball & socket design - wear rates of 34% at 5yrs. Less constrained designs in development.

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Chronic Wrist Pain

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Chronic Wrist Pain


DIFFERENTIAL DIAGNOSIS: Location Radial Cause De Quervain's tenosynovitis OA 1st CMCJ STT OA scaphoid non-union ganglion Dorsal/ Central Ganglion Keinbock's disease Scapholunate dissociation Intra-osseous ganglion SLAC Ulnar Distorted DRUJ after distal radius fracture DRUJ OA TFCC tear with ulnar impaction Unstable DRUJ Piso-triquetral OA Hamate hook fracture non-union

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Colle's Type Fracture Manipulation

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Colle's Type Fracture Manipulation


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Lateral View of Manipulation of Colle's Type Fracture

A-P View of Manipulation of Colle's Type Fracture

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Compressive Neuropathies

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Compressive Neuropathies
NERVE INJURY

MEDIAN NERVE
Anatomy Pronator Syndrome Carpal Tunnel Syndrome Anterior Interosseous Syndrome

ULNAR NERVE
Anatomy Cubital Tunnel Syndrome Entrapment in Guyon's Canal

RADIAL NERVE
Anatomy SUMMARY DIAGRAM Posterior Interosseous Syndrome BRACHIAL PLEXUS Radial Tunnel Syndrome Wartenburg Syndrome

Definition
Entrapment or constriction of a nerve by anatomical or external structures leading to demyelination and some axonal degeneration with resultant symptoms and signs of nerve disfunction. NERVE INJURY
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Pathological processes Usually neuropraxia +/- axonotmesis with different fibres damaged by varying degrees Neuropraxia Seddon 1942 Reversible physiological nerve conduction block Segmental demyelination due to compression causes loss of some types of sensation and muscle power recovers within days or weeks Axonotmesis Axonal disruption but endoneurium and nerve in continuity. Wallerian degeneration of axons occurs Axonal regeneration within hrs, 1-3mm/day Target organs atrophy, if not reinnervated within 2 yrs, don't recover Double Crush Syndrome Proximal entrapment makes nerve susceptible to effects of more distal entrapment MEDIAN NERVE

Median nerve Anatomy

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From C5,C6,C7,C8,T1 Condensation of lateral & medial cords of brachial plexus Travels lateral to brachial artery in arm, but crosses medial to artery in antecubital fossa No branches before elbow

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Compressive Neuropathies

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Between 2 heads of pronator teres at the elbow 5-6cm distal to elbow gives off anterior interosseous branch (motor to FPL, FDP index finger & pronator quadratus) Proceeds betw. FDS & FDP Palmar cutaneous branch (sensory to thenar skin) arises 5cm proximal to wrist joint & overlies flexor retinaculum Enters carpal tunnel betw. PL & FCR Recurrent motor branch to thenar muscles arises at distal end of carpal tunnel Motor -Supplies PT (pronator teres), FCR( flexorcarpi radialis), PL (palmaris longus),FDS (flexor digirorum superficialis), LOAF (radial two lumbricals, opponens pollicis, abductor pollicis, flexor pollicis brevis) - Anterior interosseous branch supplies FPL (flexor pollicis longus), radial half of FDP (flexor digitorum profundus), PQ (pronator quadratus). Sensation Radial 3 1/2 digits Autonomous zone = tip of index finger Carpal tunnel syndrome Commonest middle aged F:M = 3-5:1 Entrapment in carpal tunnel Anatomy of carpal tunnel floor and walls = bony carpus roof = flexor retinaculum /transverse carpal ligt radial attachment = tubercle of scaphoid + ridge of trapezium ulnar attachment = hook of hamate + pisiform flexor tendons run deep to nerve Contents: FPL FCR (deep to FPL) Median Nerve FDS - middle & ring lie superficial to index & little FDP
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Compressive Neuropathies

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Labels will appear as you drag your mouse over the structures Causes (ICRAMPS) Causes (ICRAMPS) Causes (ICRAMPS) Causes (ICRAMPS) I diopathic C olles, Cushings R heumatoid A cromegaly, amyloid M yxoedeoma, mass, (diabetes) mellitus P regnancy S arcoidosis, SLE Symptoms Aching and parasthesia in thumb , index middle and 1/2 of ring finger worse at night forearm pain dropping things not always classical Signs Hand normal looking If severe, thenar wasting, trophic ulcers weakness of thumb abduction Tinels sign -74% sensitivity, 91 % specificity Gentle tapping over median nerve at the wrist in a neutral position. Positive if this produces paraesthesia or dysaesthesia in the distribution of the median nerve Phalens sign "61% sensitivity, 83% specificity Elbows on the table allowing the wrists to passively flex. If symptoms provoked within 60 secs then positive Median nerve compression test - 86% sensitivity, 95% specificity* Elbow extended, forearm in supination, wrist flexed to 60 degrees, ,even digital pressure applied with one thumb over the carpal tunnel. Test positive if parasthesia or numbness within 30 secs *See JBJS 80-B 1998 pge 493, Richard Gelberman, St Louis

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Compressive Neuropathies

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Differential diagnoses Cervical radiculopathy Spinal cord lesions - tumour, MS, syrinx Peripheral neuropathy- toxic, alcoholic, ureamic, diabetic Investigations Nerve conduction studies : sensory conduction prolongation > 3.5ms distal motor latency > 4.0 ms accuracy = 85-90% 10-15% false negative Reminder of how nerve conduction studies are performed: Motor stimulus to skin over nerve, Motor Action Potential recorded in muscle supplied Latency = time between stimulus and MAP Conduction velocity , normal = 40-60 m/s compression causes reduced CV in a segment If very severe MAP also reduced Sensory SNAP recorded in proximal nerve after distal stimulation sensation often affected before motor function 'Somato sensory evoked potentials' record response in brain or spinal cord, used to diagnose brachial plexus injuries

Management Conservative Futura splint, injection (75-81% relief short term) Surgicalopen /endoscopic decompression Need to bear in mind anatomical variations Beware palmar cutaneous branch of median nerve, and motor branch 85% successful 'Lipscumb' Complications of surgery 12% Macdonald 1979 complex regional pain syndrome Tender hypertrophic scar pillar pain neuroma in palmar branch tenosynovitis / tendon adhesions bowstringing of tendons Endoscopic release Okutso, Chow and Agee one or two incisions less scarring less pillar pain quicker return of strength and to work but anecdotal reports of disasters big learning curve time consuming, expensive Pronator Teres Syndrome Compression at Lacertus fibrosus pronator teres muscle fibrous arcade of FDS
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Compressive Neuropathies

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ligt of Struthers (present in 1.5 % of people) Causes Repeated minor trauma/ repetitive use of elbow fracture / fracture dislocation of elbow Tight/scarred lacertus fibrosus Tendinous bands in pronator teres Abnormal anatomy of pronator teres Tight fibrous arch at prox FDS Symptoms Aching / fatigue of forearm after heavy use Clumsiness Vague, intermittent parasthesia, but rarely numbness Signs local tenderness to deep pressure and reproduction of symptoms Tinels test pain on resisted pronation of forearm with elbow extended = Pronator teres pain on resisted elbow flexion and supination= lacertus fibrosus pain on resisted flexion of PIP joint middle finger = FDS arch Investigations NCS not much use, intermittent symptoms EMG may show evidence of reduced innervation of muscles may differentiate from CTS Management Conservative-avoidance of repetitive elbow movements, NSAIDS, Splintage with elbow flexed with pronation Surgical- Decompress all the structures Anterior Interosseous Syndrome
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Compression under humeral part of pronator teres Anterior interosseous nerve motor to FPL, radial side of FDP and pronator quadratus Does not supply skin sensation Afferent sensory fibres from capsular ligament structures of wrist and DRUJ Clinical diagnosis spontaneous vague forearm pain reduced dexterity weakness of pinch unable to make ' OK sign ' due to weakness of FPL & FDP index finger (makes square instead of circle) weak pronation with elbow in full extension (isolates PQ) direct pressure over nerve can elicit symptoms Tinels sign usually negative Investigations NCS unhelpful Management Conservative- NSAIDS, avoiding aggravating movements Surgical exploration- most common compressing structure deep head of pronator teres

ULNAR NERVE Anatomy of ulnar nerve

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Compressive Neuropathies

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C7, C8, T1 From medial & lateral cords of brachial plexus Passes through intermuscular septum in mid-arm Behind medial epicondyle Between two heads of FCU Lies anterior to FDP Gives off dorsal cutaneous branch 5cm proximal to wrist At wrist lies between FDS & FCU Through Guyons canal at wrist (betw. pisiform & hook of hamate), medial to ulnar artery Motor branch winds round hook of hamate

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Compressive Neuropathies

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Motor - to FCU, ulnar side of FDP, all small muscles of hand except LOAF Sensory - ulnar 1 1/2 digits both sides; autonomous zone = tip of little finger Compression at the elbow (Cubital tunnel syndrome)
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Entrapment at elbow, due to trauma, cubitus valgus , bony spurs, tumours Or 8cm more proximally by ' arcade of Struthers ' Or more distally by hypertrophied flexor carpi ulnaris Differential diagnosis cervical radiculopathy thoracic outlet syndrome spinal cord pathology cervical spondylosis pancoast tumour amyotrophic lateral sclerosis (MND) localised peripheral neuropathy Symptoms

Vague dull aching forearm, intermittent parasthesia, ulnar side of hand Signs- [ Diagram ] hypoasthesia ulnar side of hand + distribution of dorsal cutaneous nerve (diff. to low lesion) Tinels test , behind medial epicondyle weakness of abduction of little finger ( Wartenburgs sign ) Froments sign

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Compressive Neuropathies

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ulnar clawing if severe (Note - ulnar paradox - no clawing if FDP & intrinsics weak) wasting of 1st dorsal Interosseus and hypothenar eminence wasting ulnar border of forearm (FDP & FCU) Investigation NCS reduced nerve conduction velocity EMG evidence of denervation of muscles Management Conservative avoidance of repetitive bending of elbow; extension block night splint. injection contraindicated Surgical -controversy Decompression- J Hand Surg Am 1999 Sep; 'Cubital Tunnel Syndrome does not require transposition of the ulnar nerve' Austrian paper 1996, Steiner- 89 good or very good results at 2 years follow up transposition - subcutaneously/ submuscularly J Hand Surg Am 1999 Sept, Kleinman 'anterior transposition is the logical approach to complete nerve decompression. +/- medial epicondylectomy Results Sensation improves better than motor function can improve over 3-5 yr period Complications painful hypertrophic scar neuromas complex regional pain syndrome dislocation of nerve persistent symptoms due to inadequate decompression irritation of superficially placed nerve disruption of blood supply to nerve Ulnar tunnel syndrome ( Compression at Guyons canal) Anatomy of Guyons canal floor = transverse carpal ligt to pisiform ulnar wall = pisiform radial distal wall = hook of hamate roof = volar carpal ligt contains only ulnar nerve and art Causes repetitive indirect trauma most common tumours- ganglion, lipoma pisiform instability pisotriquetral arthritis fractured hook of hamate / pisiform ulnar artery thrombosis Symptoms weakness atrophy para / hypoasthesia ulnar side of hand motor sensory or both dorsoulnar sensory branch spared Signs local tenderness, Tinels test, phalens sign, local swelling, negative Allens test, severe ulnar clawing (remember ulnar
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Compressive Neuropathies

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paradox) Investigations NCS, show delayed motor latency from wrist to 1st dorsal interosseous Management conservative splinting avoidance of repetitive trauma Surgical decompression of motor and sensory branches +/- excision of pisiform/ hook of hamate

RADIAL NERVE

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Compressive Neuropathies

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Anatomy C5,C6,C7,C8 Continuation of posterior cord of brachial plexus in axilla Passes posteriorly through triangular interval (bordered by long head triceps, teres major, humeral shaft) with the profundi brachii artery Spiral groove around humerus over deep head of triceps origin Pierces intermuscular septum Passes betw. brachialis & brachioradialis (supplying brachioradialis & ECRL)) Anterior & lateral at cubital fossa Passes between 2 heads of supinator

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Compressive Neuropathies

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Divides into superficial branch & Posterior interosseous nerve (PIN) PIN - motor to long extensors of MCP joints and wrist except ECRL Sensory, superficial branch to dorsal radial side of hand and fingers (3 1/2); autonomous zone = 1st web space dorsum. Posterior Interrosseous Nerve syndrome (pain and paresis) Causes (FREAS) F ibrous tendinous band at origin of supinator (30% of people) R adial recurrent vessels (the leash of Henry ) (less convincing evidence) E xtensor carpi radialis brevis A rcade of Frohse S upinator (the distal border). R.A of elbow dislocation of elbow, monteggia fracture surgical resection of radial head mass lesions Symptoms pain in 50% weakness of extension of wrist and MCP joints Signs Radial deviation of wrist with dorsiflexion (ECRL supplied by Radial nerve) [See Case Study ] If partial, pseudo clawed hand Able to extend IP joints due to interrossei no loss of sensation
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Investigations NCS -decreased latency across arcade of Frohse EMG denervation fibrillations of affected muscles Treatment Conservative observe for 8-12 wks if no evidence of mass lesion Surgical decompression Radial tunnel syndrome (pain but no paresis)
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Mild compression of post interosseous nerve without paresis Causes As for posterior interosseus syndrome but not usually any mass lesions Symptoms dull aching in extensor muscle mass worse at end of day Signs local tenderness 5cm distal to lat epicondyle pain elicited by resisted active supination middle finger test. Each finger is tested under resisted extension. Testing the middle finger increases the pain. Due to ECRB inserting

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Compressive Neuropathies

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into base of 3 rd metacarpal . Performed with the elbow and middle finger completely extended with the wrist in neutral position. Firm pressure is applied by the examiner to the dorsum of the proximal phalanx of the middle finger. The test is positive if it produces pain at the edge of the ECRB in the proximal forearm. Differential diagnosis Tennis elbow Investigation NCS Increased motor latency in active forceful supination Injection of local anaesthetic into radial tunnel Management Conservative, anti inflammatories, avoidance of repetitive provoking activities Surgical, decompression. Internervous plane between ECRB and E Digitorum developed. PIN found just proximal to arcade of Frohse. Wartenberg syndrome
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Described in 1932- isolated neuritis of superficial sensory branch of radial nerve Treatment- local steroid injection, surgical exploration and release.

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Congenital Hand Disorders

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Congenital Hand Disorders


Causes of a Bent Little Finger - Q&A - Click here to view EMBRYOLOGY of the Upper Limb Weeks 4 to 6 The critical APICAL ECTODERMAL RIDGE exerts an inductive influence on the limb mesenchyme that promotes growth & development of the limbs. Factors play a vital role in this process. The upper extremity, with pronated forearms begins to rotate externally. Developmental disturbances during this period gives rise to major congenital malformations. Early suppresion of limb development causes AMELIA (complete abscence of a limb); Late suppression causes MEROMELIA (partial abscence). Weeks 7 to Birth By week 7 the ten finger rays appear and continue to differentiate till week 12 - 13 when the hands appear. The fingers develop as a result of cell death in the tissue between the digits (failure of this causes syndactyly). INTERNATIONAL CLASSIFICATION (FDD.OUC) Failure of Formation Transverse Arrest / Aplasia Amputations: arm, forearm, wrist, hand, digits Longitudinal Arrest Phocomelia: complete, proximal, distal Radial deficiencies (radial club hand) Central deficiencies (cleft hand) Ulnar deficiencies (ulnar club hand) Hypoplastic digits Failure of Differentiation A. Synostosis: elbow, forearm, wrist, metacarpals, phalanges B. Radial head dislocation C. Symphalangism D. Syndactyly Simple Complex Associated syndrome E. Contracture i. Soft tissue Arthrogryposis Pterygium cubitaIe Trigger digit Absent extensor tendons Hypoplastic thumb Thumb-clutched hand Camptodactyly Windblown Hand ii. Skeletal Cleinodactyly Kirner's deformity Delta bone Duplication (polydactyly) A. Thumb (preaxial) polydactyly B. Triphalangism/hyperphalangism C. Finger polydactyly Central polydactyly (polysyndactyly) Postaxial polydactyly Overgrowth A. Macrodactyly Undergrowth Constriction bands Generalised skeletal abnormalities Madelungs deformity SHOULDER Sprengel Shoulder Associated with Klippel-Feil syndrome, kidney disease, scoliosis, and diastematomyelia. Undescended scapula often associated with hypoplasia of the affected side. Shoulder movements, especially abduction may be restricted. Treatment only required if shoulder function is impaired or the deformity is particularly unsightly. Surgery involves releasing the vertebroscapular

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Congenital Hand Disorders

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muscles from the spine, excising the supraspinous part of the scapula along with the omovertebral bar. The scapula is then repositioned by tightening the lower muscles (Woodward Procedure). Surgery is best performed before the age of 6 years.

Left Sprengel Shoulder Congenital pseudoarthrosis of the clavicle

Bilateral Sprengel Shoulders

Caused by failure of union of the medial and lateral ossification centres of the clavicle and may be related to pressure from pulsations of the underlying subclavian artery. Every reported unilateral case has been on the right side, except when dextrocardia is present. Surgical treatment only indicated for unacceptable cosmetic deformity or functional symptoms such as mobility of the fragments or winging of the scapula. Treatment consists of ORIF with bone grafting. Union is often predictable unlike pseudoarthrosis of the tibia. Deltoid Fibrotic problems Short fibrous bands replace the deltoid muscle causing abduction contractures at the shoulder with elevation and winging of the scapula when the arms are adducted. ARM These include extra bones, absent bones, hypoplastic bones and fusions. Failure of Differentiation Failure of Formation - may be transverse (Aplasia) or axial [Picture] Most of the defects are non-genetic but some are of autosomal dominant inheritance. Amelia: complete absence of a limb Phocomelia: almost complete absence (mere stub remaining) [Picture] Ectromelia: partial absence Congenital radio-ulnar synostosis Union of the forearm bones usually proximally placing the arm in a pronated position. Associated with DDH, CTEV, chromosomal abnormalities and foetal alcohol syndrome. Two types 1 - Medullary canals are linked creating a large radius with anterior bowing 2 - Proximal radial dislocation with less extensive fusion (usually unilateral) Both types are difficult to treat. Osteotomies for disabling pronation, but if bilateral leave the dominant arm and osteotomise the other to 20-30o supination. Also see Elbow Disorders Congenital dislocation of the radial head Abnormally formed radial head on along radius with a bowed ulna. Often associated with a soft tissue disorder. Capitellum shape abnormal in congenital dislocation and normal in traumatic dislocation. Radial head excision if pain develops otherwise leave alone. Congenital pseudoarthrosis of the forearm Rare disorder associated with Neurofibromatosis. Refractory to treatment but vascularised bone grafts may be useful.

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Congenital Hand Disorders

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Congenital webbing of the elbow (Pterygium cubitale) Broad skin web crossing the elbow causing a flexion deformity and a pronated forearm. Surgery is difficult because it sometimes requires vessel and nerve lengthening. Madelung's deformity Abnormal growth of the distal radial epiphysis with premature fusion of the ulnar half of distal radial epiphysis. Can be post traumatic or congenital. First described by Madelung, who described a painful wrist deformity in a young woman in 1878. Clinical - Presents in Adolescence; median nerve irritation; wrist pain. Worsens with growth. May be associated with: Dysplasias, Turner syndrome, Langer syndrome. Radiographic Findings: increased width between the distal radius and ulna. relatively long ulna compared to radius (positive ulnar variance). decreased carpal angle. triangularization of the distal radial epiphysis. wedging of the carpus between the deformed radius and the protruding ulna, with the lunate at the apex of the wedge. Treatment includes ulnar shortening +/- dorsal radial closing wedge osteotomy for severe cases See eHand for Clinical Example Radial Hemimelia / deficiency (Radial club hand) Absence or hypoplasia of pre-axial structures: radius radial carpus (scaphoid, trapezium, trapezoid) Thumb - may be floppy (pouce flottante) or absent May occur in association with visceral anomalies (CVS/GI/GU), VATER or blood dyscrasias e.g. Fanconi's syndrome. Most common in the right hand Bilateral in 50% of cases. Classified I-IV based on how much radius is present Type I II III IV Features Short hypoplastic partially absent totally absent Treatment address thumb individualised centralisation centralisation

Treatment is difficult - mild cases - strapping & manipulation; severe cases - correction of wrist deformity (Centralisation) by fusing ulna to carpus or circular frame & provision of a thumb (Pollicisation) using Buck-Gramko method (transfer, shortening & rotation of index finger). Abnormal distribution of nerves & arteries must be appreciated prior to surgery. Ulnar Hemimelia / deficiency (post-axial) This is not associated with systemic disorders as is the radial club hand but can be associated with other musculoskeletal deformities, especially hand deformities. Only if function is severely disturbed should wrist stabilisation be performed. Reduplication of the ulna Ulna and carpus are reduplicated leaving 7/8 digits and no thumb. Treatment includes removing most abnormal digits and pollicisation to create a 5-digit hand. Central Deficiency (cleft hand / lobster claw hand / ectrodactyly) Central abscense of at least one digit other digits may fuse (syndactyly) Typical Deformity = Autosomal Dominant; often bilateral; more common in boys & may involve the feet Atypical Deformity = sporadic; associated with cardiac & GIT abnormalities HAND DEFORMITIES Goals of surgery are to preserve or improve hand function and appearance. Timing of surgery should be immediate if limb/digit threatening e.g. constriction bands. Within the first year if disorder has a tethering growth effect e.g. club hand, before 3 if development patterns are affected e.g. pollicisation and delayed until past 4 years if co-operation is

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Congenital Hand Disorders

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required e.g. tendon transfers. Digits Syndactyly (joined phalanges) Can be Simple (skin only) or Complex (bone involvement). may be Complete or Incomplete: (complete= entire length of digit is affected) Incidence = 1:2000 births commonest congenital abnormality of the hand Can be associated with many anomalies. Apert Syndrome = acrocephalosyndactyly Release performed 18 months-5years. PreOp Planning: individual Allen's tests to each involved digit radiographs to rule out tethering of digits one side of digit should be operated on at a time, in order to avoid vascular insufficiency with multiple syndactyly attention is first directed to border digits the usual strategy is to preserve as much regional skin as possible on the radial side of the involved digits (to maximize pinch sensation) and saving FTSG for ulnar side of the affected digit Clinical Images (eHand) Polydactyly (duplicated digits) Of three types Extra soft tissue only Bone, tendon and cartilage Completely developed with its own metacarpal (rare) Clinical Images Thumb Duplication (pre-axial polydactyly) Incidence = 1:1000 births Look for Cardiac anomilies & Fanconi anaemia. Wassel classification: seven subgroups depending on level of bifurcation. 1. Bifid distal phalanx 2. Duplicated distal phalanx 3. Bifid prox phalanx 4. Duplicated prox phalanx 5. Bifid metacarpal 6. Duplicated metacarpal 7. Triphalangism (single MC, dublicated PP & DP + additional phalanx at end of one)

Brachydactyly (short digits) / undergrowth Macrodactyly / overgrowth Involves enlargement of all the structures, especially the nerves of one or more digits. Can be associated with Neurofibromatosis.

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Congenital Hand Disorders

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Deviated digits Clinodactyly Skeletal abnormality causes deviation in the lateral plane. Usually involves the little finger and is caused by a trapezoidal middle phalanx. Surgical correction for cosmesis only. Camptodactyly Familial soft tissue abnormality with deviation in the sagittal plane. Commonly involves the little finger causing a flexion contracture at the PIPJ. May be ass. with Dupuytren's, Marfan's, arthrogryposis or other genetic syndromes. Few good surgical procedures exist. 2 stage correction (with ex-fix applied at the time of FDS - extensor transfer has good results. Kirner's Deformity In-curling of little finger DIPJ in prepubertal girls. Usually requires no treatment Symphalangism (Stiff PIPJ's) Secondary to congenital ankylosis of the joint. Associated with Apert Syndrome. Observe only. Delta phalanx Triangular phalanx and physis, usually of the thumb and little finger. A delta bone results in a sideways curve of the finger. Surgery only if significant deformity. Thumb anomalies (Hypoplastic thumb)

Blauth Grade

Description

Treatment

I II III

Short thumb, hypoplastic thenar muscles Grade I + Adducted MPJ Deficient metacarpal Abducted thumb

Augment intrinsics Soft tissue Z-plasty Augment/ bone graft/pollicisation

IV V

Floating thumb Absent thumb

Pollicisation Pollicisation

Congenital trigger thumb Congenital stenosis at A1 pulley. Often bilateral. 30% may resolve spontaneously by 1 year. Attempt splinting but aim to correct surgically by 3 years. Constriction band/ring (Streeter's Dysplasia) Commonly involves digits or toes (especially centrally) but can occur more proximally Associated with syndactyly, club feet and neurological abnormalities. Treatment is by Z-plasty. Congenital amputation

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Congenital Hand Disorders

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Due to either constriction bands or failure of development, most commonly very short below elbow amputation.

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CRPS

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CRPS
Also: Reflex Sympathetic Dystrophy (RSD), Sudeck's Atrophy, Causalgia First clinical description was in 1864 when Doctor Mitchell published a classic description of causalgia in a paper entitled, "Gunshot Wounds and Other Injuries of Nerves" Definition An abnormal reaction to injury characterised by pain, swelling, stiffness, vasomotor changes and osteoporosis of the affected part New Classification: CRPS type I (RSD) the clinical findings include regional pain, sensory changes, allodynia, abnormalities of temperature, abnormal sudomotor activity, edema, and an abnormal skin color that occur after a noxious event. CRPS type II (Causalgia) includes all foregoing features with a peripheral nerve lesion. Old Classification of RSD (Langford):

Minor causalgia
Purely sensory nerve to distal portion of limb

Minor Tramatic dystrophy


Most common type

Shoulder hand syndrome


Proximal trauma or painful visceral lesion (shoulder or neck injury, cervical disc, PU, MI, pancost tumour etc)

Major traumatic dystrophy


Trauma that produces swelling, redess, dysfunction eg crush injuries and colles fractures head the list

Major causalgia
Partial injury to a major mixed nerve in the proximal part of the extremity Making the Diagnosis of RSD/CRPS The diagnosis of RSD/CRPS can be made in the following context. A history of trauma to the affected area associated with pain that is disproportionate to the inciting event plus one or more of the following: 1. 2. 3. 4. Abnormal function of the sympathetic nervous system. Swelling. Movement disorder (stiffness). Changes in tissue growth (dystrophy and atrophy).

Clinical Features of RSD/CRPS 1. Pain - The hallmark of RSD/CRPS is pain and mobility problems out of proportion to those expected from the initial injury. The first and primary complaint occurring in one or more extremities is described as severe, constant, burning and/or deep aching pain. All tactile stimulation of the skin (e.g. wearing clothing, a light breeze) may be perceived as painful (allodynia). Repetitive tactile stimulation (e.g. tapping on the skin) may cause increasing pain with each tap and when the repetitive stimulation stops, there may be a prolonged after-sensation of pain (hyperpathia). There may be diffuse tenderness or point-tender spots in the muscles of the affected region due to small muscle spasms called muscle trigger points

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CRPS

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(myofascial pain syndrome). There may be spontaneous sharp jabs of pain in the affected region that seem to come from nowhere (paroxysmal dysesthesias and lancinating pains). 2. Skin changes - skin may appear shiny (dystrophy-atrophy), dry or scaly. Hair may initially grow coarse and then thin. Nails in the affected extremity may be more brittle, grow faster and then slower. Faster growing nails is almost proof that the patient has RSD/CRPS. RSD/CRPS is associated with a variety of skin disorders including rashes, ulcers and pustules. Although extremely rare, some patients have required amputation of an extremity due to life-threatening reoccurring infections of the skin. Abnormal sympathetic (vasomotor changes) activity may be associated with skin that is either warm or cold to touch. The patient may perceive sensations of warmth or coolness in the affected limb without even touching it (vasomotor changes). The skin may show increased sweating (sudomotor changes) or increased chilling of the skin with goose flesh (pilomotor changes). Changes in skin color can range from a white mottled appearance to a red or blue appearance. Changes in skin color (and pain) can be triggered by changes in the room temperature, especially cold environments. However, many of these changes occur without any apparent provocation. Patients describe their disease as though it had a mind of its own. 3. Swelling - pitting or hard (brawny) edema is usually diffuse and localized to the painful and tender region. If the edema is sharply demarcated on the surface of the skin along a line, it is almost proof that the patient has RSD/CRPS. However, some patients will show a sharply demarcated edema because they tie a band around the extremity for comfort. Therefore, one has to be certain that the sharply demarcated edema is not due to a previously wrapped bandage around the extremity.

4. Movement Disorder - Patients with RSD/CRPS have difficulty moving because they hurt when they move. In addition, there seems to be a direct inhibitory effect of RSD/CRPS on muscle contraction. Patients describe difficulty in initiating movement, as though they have "stiff" joints. This phenomena of stiffness is most noticeable to some patients after a sympathetic nerve block when the stiffness may disappear. Decreased mobilization of extremities can lead to wasting of muscles (disuse atrophy). Some patients have little pain due to RSD/CRPS but instead they have a great deal of stiffness and difficulty initiating movement. Tremors and involuntary severe jerking of extremities may be present. Psychological stress may exacerbate these symptoms. Sudden onset of muscle cramps (spasms) can be severe and completely incapacitating. Some patients describe a slow "drawing up of muscles" in the extremity due to increased muscle tone leaving the hand-fingers or foot-toes in a fixed position (dystonia). 5. Spreading Symptoms - Initially, RSD/CRPS symptoms are generally localized to the site of injury. As time progresses, the pain and symptoms tend to become more diffuse. Typically, the disorder starts in an extremity. However, the pain may occur in the trunk or side of the face. On the other hand, the disorder may start in the distal extremity and spread to the trunk and face. At this stage of the disorder, an entire quadrant of the body may be involved. Maleki et. al. recently described three patterns of spreading symptoms in RSD/CRPS: a. A "continuity type" of spread where the symptoms spread upward from the initial site, e.g. from the hand to the shoulder. b. A "mirror-image type" where the spread was to the opposite limb. c. An "independent type" where symptoms spread to a separate, distant region of the body. This type of spread may be related to a second trauma 6. Bone changes - X-rays may show wasting of bone (patchy osteoporosis) or a bone scan may show increased or decreased uptake of a certain radioactive substance (technecium 99m) in bones after intravenous injection. 7. Duration of RSD/CRPS - The duration of RSD/CRPS varies, in mild cases it may last for weeks followed by remission; in many cases the pain continues for years and in some cases, indefinitely. Some patients experience periods of remission and exacerbation. Periods of remission may last for weeks, months, or years. Aetiology: A number of precipitating factors have been associated with RSD/CRPS including:

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CRPS

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Trauma (often minor) ranks as the leading provocative event Ischemic heart disease and myocardial infarction Cervical spine or spinal cord disorders Cerebral lesions Infections Surgery Repetitive motion disorder or cumulative trauma, causing conditions such as carpal tunnel. However, in some patients a definite precipitating event can not be identified.

Investigations: Tch Bone Scan- segmental diffuse pattern of tracer uptake (sensitive, Triphasic scan= specific).

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CRPS

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Diagnostic Sympathetic Block (stellate ganglion). Treatment Treat the cause, active ROM exercises, sympathetic blockade, TCA's, vasodilators, steroids.

Reflex Sympathetic Dystrophy Syndrome Association Of America RSDSA

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Distal Radius Fractures

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Distal Radius Fractures


Clinical Prognosis Classifications Complications Associated Injuries Indications for Reduction Treatment Recent Advances Intra-articular Fractures eRadius

Clinical

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Incidence: Commonest fracture (16% of A&E fratures), bimodal (young high energy and fit old women falling) Fractures of the distal radius are among the most common of all orthopaedic injuries accounting for nearly 1/6 of all fractures Bimodal age distribution exists, one peak in early adolescence, second in the older age. Anatomy: Cortical thinning in the metaphyseal flare predisposes to fracture. Three concave articular surfaces (scaphoid and lunate fossae, and sigmoid notch (DRUJ)) with relative strength predispose to predictable patterns of fracture propagation between scaphoid and lunate facets. Colle's: Dorsal displacement (Abraham Colles (1773-1843), Irish surgeon and anatomist) Smith's: Volar displacement (Robert William Smith (1807-1873), Irish surgeon) Barton's: Radial rim fracture with dislocation of the radiocarpal joint (can be dorsal or volar); John Rhea Barton (1794-1871) American surgeon and orthopod. Chauffeur's: Radial styloid Mechanism FOOSH; dorsi-flexion of wrist at 40 - 90 fractures distal radius Small amounts of radial shortening or dorsal tilt increases axial load in ulna. Dorsal tilt decreases contact area with the carpus, produces incongruency of the distal radioulnar joint and tightens the interosseous membrane limiting forearm rotation Scaphoid fractures occur at about 97 o Examination Check for other fractures Neurovascular assessment, particularly median nerve compression X-ray PA/Lateral (radial length = 12mm, inclination 23) Lateral (Volar tilt = 11) CT for: radiocarpal articular step-off, displacement pattern, number of fragments, volar and/or dorsal displacement and degree of involvement at radiocarpal and radioulnar joints. Check for Loss of radial height (>5mm) Loss of radial inclination (Normal 20-25 o ) Dorsal tilt (Normal 10 o volar) Radial width Comminution Ulnar fracture Indicators of Instability: 1. 2. 3. 4. 5. 6. 7. 8. 9. Intra-articular displacement (50%) dorsal or volar comminution elderly (osteoporotic) Loss of radial height (>5mm) inclination <20 Dorsal tilt > 20 Ulnar injury Fracture ulnar head/neck, diastasis DRUJ Concomitant scaphoid fracture or scapholunate dissociation >3 criteria confers >50% chance of redisplacement

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Distal Radius Fractures

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Acceptable position / Treatment aims: Volar tilt restored (within 10), radial length within 2mm, radial inclination within 5, articular step-off < 2mm. NB Axial or rotational malalignment can produce DRUJ problems Classifications
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15 different Classification systems exist! 1. Frykman Descriptive only and does not include variables, such as direction and degree of displacement or comminution Group 1 and 2 3 and 4 5 and 6 7 and 8 Extra-articular fracture distal ulna fracture Intra-articular fracture involving the radiocarpal joint distal ulna fracture Intra-articular fracture involving the DRUJ distal ulna fracture Intra-articular fracture involving the RC and DRUJ distal ulna fracture

2. McMurtry and Jupiter Group

2 parts: Barton #, Chauffeur #, Die-punch # 3 parts lunate and scaphoid fossae separate from distal radius 4 parts lunate fossa fractured into dorsal and volar fragments 5 parts or more

3. Melone Classification Sub-types of 4-part intra-articular fractures Gives some indication to treatment

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Distal Radius Fractures

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Type 1 Minimal comminution - stable

Comminuted - stable

Displacement of medial complex as a unit + anterior spike

Wide separation or rotation of the dorsal fragment + palmar fragment rotation

Types 1 and 2: MUA + POP cast Type 3: MUA + K-wire/ External fixation Type 4: ORIF 4. Universal Classification

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Distal Radius Fractures

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5. AO classification Comprehensive but has poor inter and intra observer agreement ASSOCIATED INJURIES
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Distal Radioulnar Joint - Ulnar styloid fracture - frequent - rarely unstable - usually partial TFCC tear - rarely needs treatment (50%) 1. Disruption Bony constraints cannot control Requires soft tissue stabilization Repair with sutures/suture anchors ORIF larger fragments Ulnar Head/Neck Fracture - Comminuted - very unstable

2. Median Nerve Injury (13-23%) Contusion Hematoma/Compression Traction/Neuropraxia Reduction process frequently increases intracompartmental pressure in carpal canal Early surgical decompression recommended if significant symptoms Late decompression - less successful 3. Scaphoid Fracture Look for

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Distal Radius Fractures

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If nondisplaced - percutaneous pin fixation If displaced - ORIF 4. Intercarpal Ligament Injury - Total/Partial Scapholunate - Common Lunotriquetral - Common Can see diastasis in traction x-ray Treated early with percutaneous pin fixation - usually adequate Treatment Goals and Considerations
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There are four principles in the treatment of distal radius fractures: 1. 2. 3. 4. restoration of articular congruity and axial alignment maintenance of reduction achievement of bony union restoration of hand and wrist function.

Other factors which need to be taken into consideration 1. 2. 3. 4. low functional demand significant medical illness inability to comply with postoperative instructions previous fracture and deformity

These may justify acceptance of less than anatomic results. It must be emphasised, however, that chronological age does not correlate with functional age and many of these fractures, even in older patients, will benefit from aggressive treatment. Anatomical aims To restore radial length, inclination and tilt Acceptable angulation of the distal radius: 10 o loss of normal volar angulation (i.e. No more than 0 o or 20 o volar angulation) < 5 o loss of radial inclination < 2mm shortening Accurate restoration of the articular surface < 2mm step The Evidence from eRadius Treatment options Undisplaced Cast immobilisation Most common treatment Good for stable fractures Displaced + stable Closed reduction + Cast immobilisation Displaced + unstable Closed reduction Percutaneous K-wire Classical styloid + Lister's tubercle wire placement Trans-ulnar pin placement Intra-focal wiring: Kapandji technique [ Picture ] ( Kapandji A. Ann. Chir. Main. Memb. Super. 6:57-63. 1987 ) External fixation Bridging Non-bridging Dynamic: now thought to be unsuitable as position lost when fixator is mobilised ORIF Or combination of any of the above techniques Intra-articular fractures
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Distal Radius Fractures

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Barton's fracture Volar ORIF with buttress plate via anterior approach Dorsal ORIF via dorsal approach Between extensor compartments IV and V Remove Lister's tubercle to facilitate plate positioning Chauffeur's fracture Radial styloid shear fracture (involves radioscaphoid joint) MUA + K-wire Galleazi fracture Anatomical ORIF of radius K-wire stabilisation of the DRUJ Adjuncts to intra-articular fracture management Arthroscopically Assisted Reduction Assess articular step-off or deficit, SL and LT ligaments and TFCC for tears. Delay for 5-7/7 for bleeding and swelling to resolve, wrap distal forearm and hand in Esmarch to prevent extravasation and compartment syndrome. Autogenous bone graft or Carbonated hyproxyapatite Newer precontoured, low profile and volar plates and limited ORIF (small incision, limited dissection and reduction of selective articular fragments) aim to reduce ST disruption further. Three column fixation and orthogonal plates. Also See Jesse Jupiter's Management Algorithm Prognosis
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Importantly, the position of the fracture at union rather than the position at time of presentation has the greatest correlation with long-term functional results Clinical studies have confirmed laboratory data correlating malunion with poor function, pain, decreased range of motion, decreased grip strength, and poor patient function/satisfaction have been consistently associated with poor anatomic results after fracture (McQueen M, Caspers J: Colles' fracture: Does the anatomical result affect the final function? J Bone Joint Surg 1988;70B:649-651.) Complications Early 1. 2. 3. 4. 5. 6. 7. Late 1. 2. 3. 4. 5. 6. 7. EPL rupture in 1.5% (Treatment EIP to EPL transfer ) RSD 25% Malunion Non-union - rare Adaptive carpal instability (CIA) which can be treated with corrective osteotomy Symptomatic Radiocarpal OA - 7% DRUJ OA (Treatment = Darrach's / Suave-Kapandji procedure) Associated carpal injury: fracture or ligamentous tear TFCC tear - 50% DRUJ subluxation or dislocation Acute post reduction swelling / Compartment syndrome Nerve - median most common - 13-23% Vessel - rare - radial artery commonest Tendon - rare
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Concepts in Distal Radius Fracture Management:

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Distal Radius Fractures

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Cochrane Review of Non-operative Management Indications for Reduction of Distal Radius Fractures Advances in Distal Radius Fracture Management - AAOS 1999 Percutaneous K-wires vs. ORIF eRadius - International Distal Radius Study Group Sponsored Links www.ebimedical.com www.ebimedical.com

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Dupuytrens - Related Research

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Dupuytrens - Related Research


J Hand Surg [Br]. 2003 Dec;28(6):528-30. Skin tension in the aetiology of Dupuytren's disease; a prospective trial. Citron N , Hearnden A . Nelson Hospital, Kingston Road, Wimbledon, London, UK. ncitron@4dudley.freeserve.co.uk Tension in the palmar fascia has been proposed as a factor causing Dupuytren's disease. If tension does stimulate the growth of new Dupuytren's tissue, relieving longitudinal tension should reduce the recurrence rate following surgery. Thirty patients with palmar Dupuytren's contracture of a single ray that affected only the metacarpophalangeal joint were divided into two groups. Both groups had a fasciotomy: one group through a transverse incision that was closed directly and the other through a longitudinal incision with Z-plasty closure. Half the patients (seven of 14) who had direct closure had recurrence at 2 years as compared to two of the 13 in the Z-plasty group. The trial was stopped at the interim analysis stage due to the high recurrence rate in the first group. These results are consistent with the tension hypothesis for the aetiology of Dupuytren's disease J Hand Surg [Br]. 2004 Feb;29(1):18-21. A prospective randomised clinical trial of the intra-operative use of 5-fluorouracil on the outcome of dupuytren's disease. Bulstrode NW , Bisson M , Jemec B , Pratt AL , McGrouther DA , Grobbelaar AO . From the RAFT Institute of Plastic Surgery, Mount Vernon Hospital, Northwood, HA6 2RN, UK. 5-Fluorouracil reduces proliferation rates of fibroblasts, myofibroblast differentiation and contractility of ocular fibroblasts in vitro. This double-blind randomized clinical trial assesses whether intra-operative topical treatment with 5-fluorouracil reduces the recurrence rate after limited excision of Dupuytren's tissue. Patients with two-digit disease were randomized to having 5-fluorouracil (25mg/ml) treatment for 5 minutes on one digit and placebo on the other. Fifteen patients were enrolled with 18 months follow-up. There were no peri-operative complications. Wound healing was not delayed and there was no deterioration in the flexion deformity of the 5-fluorouracil treated digits. Patients were subsequently assessed by joint angle measurement at 3, 6, 12 and 18 months. There was no significant difference between control and 5-fluorouracil treated digits.

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Dupuytren's Disease

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Dupuytren's Disease
HISTORY CLINICAL SURGICAL TECHNIQUE INCIDENCE STAGING POSTOPERATIVE CARE AETIOLOGY INDICATIONS FOR SURGERY COMPLICATIONS PATHOANATOMY AIMS OF SURGERY RELATED RESARCH

Q&A - Dupuytren's contracture - Click here to view BARON GUILLAUME DUPUYTREN (1777-1835)
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Dupuytren was born in central France. He was kidnapped as a boy by a rich woman from Toulouse on account of his good looks. He was taken to Paris and educated, but endured great poverty throughout his studies. Dupuytren became Surgeon in chief at the Hotel Dieu in Paris and worked tremendously hard and became very rich. He was described as an unpleasant person to met, yet his work was delightful to read. He was characterised as "First among surgeons, Last among men". He was an accurate clinical observer with a great interest in pathology. Dupuytren's name is most associated with the contracture of palmar fascia and a particular ankle fracture that he described. He performed his first palmar fasciotomy on a coachman at the Hotel Dieu in 1831. He wrote on many subjects, including congenital dislocation of the hip, the nature of callus formation, subungal exostosis, the Trendelenburg sign, tenotomy in torticollis and he differentiated osteosarcoma from "spina ventosa". He insisted that on his death that his post-mortem be performed in front of his own medical staff and published in the local weekly journal. INCIDENCE
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25% of males over 65yrs. Associated with: 1. 2. 3. 4. 5. 6. 7. 8. Anglo-Saxons Family history - autosomal dominant; 68% prevelance in first-degree relatives epileptics (42%) alcohol-induced liver disease diabetes mellitus COAD hypertension IHD

Similar fibromatosis lesions found with Dupuytren's: 1. Garrods knuckle pads 2. Ledderhose Disease (plantar fibromatosis), - 5% 3. Peyronie's disease (penis) - 3% Dupuytren's diathesis = more prone to recurrence & aggressive disease. 1. 2. 3. 4. young male family history bilateral

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Dupuytren's Disease

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5. fibromatosis elsewhere 6. Garrod's knuckle pads AETIOLOGY


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Oxygen free radicals stimulate myofibroblast proliferation & increases in type III collagen and platelet derived growth factor B. Two Theories: 1. Intrinsic Theory = metaplasia of existing fascia 2. Extrinsic Theory = arises in the fibrofatty subdermal tissue & attaches to the underlying fascia. PATHOANATOMY
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Superficial palmar fascia consists 3 parts: 1. Medial part covering hypothenar muscles 2. Mid-palmar fascia 3. Lateral part covering thenar muscles

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Dupuytren's Disease

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'Band' = healthy fascia; 'Cord' = diseased fascia. Pretendinous cord causes MCPJ contractures Central & spiral cords cause PIPJ contractures. The spiral cord pushes the NVB towards the skin & midline of the finger. Grayson's lig. contributes to the spiral cord , which also displaces the NVB in the finger. Cleland's lig. is not involved in Dupuytren's. Involvement of the natatory ligament causes web space contractures. In the little finger it envelopes ADM & the NVB on the ulnar side. In the index finger the natatory lig. becomes the distal commisural lig. & causes contracture betw. the index finger & thumb. The superficial transverse ligament is not involved in the disease process. It overlies the superficial palmar arterial arch. Sagittal fibres run from the mid-palmar fascia to the deep palmar fascia. They are not involved in the disease process. CLINICAL SYMPTOMS: Fingers get in the way with: washing face combing hair putting hand in pocket putting hand in glove
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Dupuytren's Disease

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racquet sports & golf HISTORY: 1. 2. 3. 4. 5. 6. 7. 8. 9. Dominance Family history Rate of progression Diabetes Epilepsy Alcohol Foot involvement Smoking Trauma

EXAMINATION: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Sex Sites of nodules & cords MCP angle - measure PIPJ angle - measure Knuckle pad (Garrod) - well-circumscribed firm dermal papules, nodules, or plaques approximately 0.5 - 3.0 cm in size, located on the extensor aspect of the PIP or MCP joints secondary Boutonniere Previous surgical scars Sensation Risk of RSD Table top test of Hueston - place the hand & fingers prone on a table. Positive = hand won't go flat. If negative surgery is not indicated.

Garrod's Knuckle Pad Staging - Woodruff, 1998: Stage 1 Description Early palmar disease with no contracture
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Management Leave alone

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Dupuytren's Disease

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2 3 4 5

One finger involved, with only MCPJ contracture One finger - MCPJ + PIPJ stage 3 + > one finger involved Finger-in-palm deformity
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Surgery Surgery not easy Surgery prolonged & only partly succesful consider amputation

INDICATIONS FOR SURGERY No absolute indications

Surgery indicated when patient is inconvenienced or incapacitated by the contracture. Tabletop test of Hueston = Patient unable to place hand flat on table due to contractures. Counsel the patient: 1. Excision of palmar nodules can leave just as painful a scar. 2. The condition is multifocal. Removing one lesion does not prevent others occurring. 3. Recurrence may occur after surgery more common in digits than palm little finger in women Dupuytren's diathesis - young, male, family history, bilateral, fibromatosis elsewhere 4. MCPJ contractures are always correctable - usually 30deg. contracture requires surgery. 5. PIPJ contractures not always correctable - usually operate on early contracture. 6. Neurovascular injury 7. Stiffness, CRPS 8. Post-operative regimen 9. Skin problems & care AIMS OF SURGERY 1. 2. 3. 4.
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Excise the diseased fascia Release digital contractures Retain full flexion of the digits Preserve neurovascular structures
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SURGICAL TECHNIQUE Anaesthetic

Brachial plexus block is ideal. Incisions Incision Advantages for pretendinous band - can be left open (McCash technique) or Full thickness graft (Hueston) Disadvantages Requires frequent dressings & cooperation post-op. Can be difficult to raise flaps if skin is thin, incr. risk of NVB damage, can cause

Transverse midpalm

Bruner's zig-zag

Good exposure

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Dupuytren's Disease

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troublesome scarring at the sides & base of finger. Longit. incision & Z-plasties Good exposure, less chance of damaging NVB Can be difficult to match incisions in 2 finger disease.

Procedures Procedure Advantages For elderly patient with MCP contracture mainly; for severe contracture with macerated skin as first stage before fasciectomy. Percutaneous fasciotomy (Luck) has high risk of NVB injury. removes the diseases tissue only most commonly performed method impossible to remove all the palmar fascia, does not always prevent recurrence, incr. swelling & joint stiffness. Disadvantages

Fasciotomy

Partial Selective Fasciectomy (Skoog)

Total Fasciectomy (McIndoe)

Removes all the palmar fascia

Dermofasciectomy (Hueston) External Fixator (Messina) Amputation Note the most common danger areas for damaging NVB:

for Dupuytren's diathesis & recurrence gentle correction for 2wks. then surgical release; under distraction the disease seems to regress! for finger-in-palm deformity with macerated skin neuromas, biomechanical

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Dupuytren's Disease

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PIP Joint Release: Gentle manipulation is preferred, followed by post-op extension splinting. Never perform volar plate capsulectomy, since it can cause stiffness Preferred method = 1. Release Cleland's ligaments 2. Release the fibrous flexor sheath 3. Release the check-rein ligaments of the volar plate 4. Release the lateral bands of the extensor mechanism (to allow the extensor tendons to shift dorsally) 5. Can use a percut. transarticular K-wire for 7-10days. For a severe flexion contracture consider arthrodesis with digital shortening. [PIPJ Anatomy] POST-OPERATIVE CARE
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Splint hand with wrist extended & fingers in a comfortably extended position. Check wounds at 48hrs. & apply Thermoplastic splint. Regular dressings for McCash open palm. Hand therapy active program scar care (massage, silicone pressure pad, compression wrap) determines 50% of the final result Continue for 3 months Night splint for 6 months. COMPLICATIONS
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Dupuytren's Disease

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digital nerve division ischaemic digit - from digital artery spasm or kinking or division haematoma skin loss / necrosis infection (treated with early debridement) (use of K wires is thought to promote infection) scar contracture joint stiffness CRPS - look for swelling, pain, stiffness, and discoloration; - causes: - neuroma formation - digital nerve scarring at the incision site; - excessive wound tension; 9. secondary carpal tunnel syndrome (from edema) 10. secondary trigger finger 11. recurrent disease BIBLIOGRAPHY: McCullough & Sinnerton. Current Orthopaedics. 10:37-42. 1996

1. 2. 3. 4. 5. 6. 7. 8.

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Hand - Tendon Transfers

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Hand - Tendon Transfers


Robert S. Boome Consultant Hand & Peripheral Nerve Surgeon, Bradford Royal Infirmary Tendon transfers are done as soon as it is considered that no further nerve recovery can take place and that the function of the hand is insufficient for normal use. The transfers are always assessed at two or three visits from the patient in which all the functioning motors are listed. The transfers needed are listed and compared to establish which is the best combination for this particular patient. Numerous complex problems eg. one of median and ulna major compromised - but still the function of the hand can be significantly improved if care is taken in making the right selection. There are no absolute contra-indications to any particular tendon transfers, excepting for the extensor carpi radialis brevis, which should never be used for transfer as it is the major wrist extensor and, if it is working well, all the other wrist extenscors can rather be sacrificed but this one should be maintained. The technique of tendon transfers for major nerve injuries in the forearm is, in principle, the careful assessment of the recovery from injury to the point that no further recovery is expected. Or, if the injury is such that no recovery is expected from the beginning, then tendon transfers can be done early. In each case the available tendons must be carefully examined and a decision made as to whether they can be sacrificed for transfer to another function and to match to a list of major functions needed by the patient and planned as such. My own experience is that median and ulnar nerves repair well at the wrist with a modified epineural repair - separating motor from sensory to make accurate repair of each nerve gives excellent recovery of intrinsic function in young individuals to the point that it is seldom necessary to do, intrinsic transfers within the hand. Even medial and ulnar nerves repaired in the acute phase at the proximal forearm may well achieve intrinsic recoveries to some degree and therefore enough time should be allowed before tendon transfers are performed in order to assess what recovery might take place. W ith all nerve injuries treated acutely, I avoid trimming of the nerve at all, excepting in crush injuries as any amount of trimming compromises the alignment of your fine fibres therefore compromises your end result. The technique of tendon transfer is such that one should be transferring a normal muscle with normal strength. Any muscle that has subsequently recovered following a nerve injury is not a suitable muscle to transfer. The patient will have inadequate control of that muscle and, apart from giving a tenodesis type of effect, the patient seldom gets useful tendon transfer function from muscles which have previously had a nerve injury. The concept of the actual surgery is such that the tendons that are transferred should be lying in as straight a line as possible. If they pass through the interosseous membrane, the muscular part of the transfer must be lying next to the membrane and not the tendonous part or one will get adhesions. All transfers that come round the outside of the distal forearm subcutaneously should not subsequently enter the hand as the course would be too long and they will tend to have a tenodesis effect. Any extensor tendon that is used for opposition for example, should come through the interosseous membrane and preferably through the fcR tunnel as this gives the best possible resu1t. Any tendon transfer that wraps around the outside of the wrist from dorsum to volar and then extends into the hand to give opposition or any other function, will tend to have very poor active sliding and therefore. Give an unsatisfactory result acting merely as a tenodesis by its own tightness. The technique of the Zancolli lassoo (for intrinsic paralysis with clawing) is done so that the a1 pulley, or the beginning of the a2 pulley is exposed from the palm and, using a small haemostat the edge of the pulley is lifted from within the tunnel until mp flexion is obtained. It is at roughly this point that the sublimus tendon is passed from within the sheath, through the sheath and back onto itself outside the sheath to give mp flexion. The tension is set so that the hand, when held in neutral, has very slight mp flexion. If the fds is paralysed, it can be put in a bit tighter and will give some form if tenodesis effect - which is also useful for the patient. It must be remembered that if there is a high ulna nerve injury, then FDS in the hand may be the only motor to the ring and little finger and therefore should not be sacrificed for a tendon transfer for a Zancolli lassoo for clawing. The function of the volar plate tenodesis, described by Zancolli, is not as satisfactory as the lasso procedure. However, it can be applied in those cases where there is not another alternative. In general principle, tendon transfers should be inserted finally into the insertion of the muscle that it is replacing, for example the Zanccilli opposition transfer - the tendon is taken through the tunnel and inserted into the abductor pollicis brevis insertion at the metacarpo-phalangeal joint of the thumb. It is not necessary to extend this any further, but just weave it into, this tendonous insertion. All tendon transfers should be held in a protective cast to take the tension off the transfer for a period of 3 to 4 weeks and then gradual dynamic function encouraged without any resistance.

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Hand - Tendon Transfers

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W hen more than one tendon transfer is done at once, great care must be taken, ensure that the position of rest is not different for the two transfers or success will be compromised. In more elderly individuals, more than one intrinsic transfer in the hand is contra-indicated as it causes excessive swelling in the hand and can cause stiffness and oedema and, once again, compromises end results. I will divide the transfers that I prefer into the various nerve injuries and list them accordingly. Low injury (wrist) High injury (elbow)

Median nerve: Fdpi to fdp's middle at distal forearm (1) fds via fcr canal to opposition (zancolli) BRto fpl at distal forearm. (2) eip interosseous membrane to, opposition Via FCR canal (zancolli)

Ulna: 1 (a) fds middle to thumb adduction Eip to 1st dorsal (b) arthrodesis mp thumb epb to 1st dorsal 2 ring and little clawing (a) fds ring to zancolli lasoo, to ring and little (b) volar plate tenodesis (not very successful:) Combined

1 ring and little fdp to middle fdp

very difficult problem) Median and ulna: Br to fdp all fingers ecrl to thumb flexor fuse dp thumb 1 opposition eip via interosseous membrane and fcR tunnel to opposition (Zancolli) 2 pinch - arthrodesis mp thumb ePb to 1st dorsal 3 Clawing - fds middle split to lassoo index and middle (zancolli) Fds ring split to lassoo Ring and little (Zancolli) Radial: Pronator or teres to ecpb or brachioradialis (if functioning) to ECRB (Radial wrist extensors functioning:) 1 fcu to edc (subcutaneously) Pl to epl (re-route volarly) 2 fcr to edc (subcutaneously Pl to epl (re-route volarly) 3 fds ring and middle via interosseous membrane to edc, pl to epl (re-route volarly) If radial nerve might still recover keep epl in continuity and bring palmaris longus upward Epl re-routed via fcr tunnel for opposition.

Combined lesion all nerves: (perhaps only one extensor working, namely ecpb 1 Opposition tenodesis reroute epl volarly and tenodesis via fcr canal to distal radius.

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Hand - Tendon Transfers

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2 tenodesis fpl to distal radius 3 tenodesis all fdp to distal radius 4 fusion dp thumb

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Hand Fractures

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Hand Fractures
Classification Bennets Fracture Rolando's Fracture Methods of Treatment Other Metacarpal Fractures

Zafar Naqui Edited 19.11.05 Orthoteers, Brinker Classification


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It is important to distinguish the intra-articular fractures (Type I [Bennett's] + II [Rolando's]) from the extra-articular (III + IV) fractures, as the extra-articular fractures can be managed adequately with non-operative management Up to 30 o of angulation of the 1 st metacarpal base can be accommodated due the large ROM at the trapezio-metacarpal joint Bennett's Fracture
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A fracture-dislocation, first described by Bennett in 1882 Mechanism of injury is an axial blow directed against the partially flexed metacarpal

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Hand Fractures

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Fracture line separates the major part of the metacarpal from a small volar lip fragment, producing disruption of the CMC joint An avulsion fracture occurs rather than a pure dislocation because of the strength of the anterior oblique ligament (AOL) Displacement forces: o The distal metacarpal fragment (containing most of articular surface) is displaced proximally, radially, & dorsally by pull of APL. o The displaced metacarpal is also rotated in supination by the pull of APL o The metacarpal head is displaced into palm by pull of Adductor Pollicus o Volar fracture fragment remains attached to CMC by volar AOL. The AOL anchors volar lip of metacarpal to tubercle of the trapezium - hence, small volar lip fragment remains attached to anterior oblique ligament which is attached to trapezium. Pure dislocations are very rare and need CRIF Concomitant fractures of the trapezium seen with Bennett's fractures have been reported, for which ORIF is the recommended treatment Rupture of the MP joint collateral ligaments has been reported as a concomitant (and easily overlooked) injury with Bennett's fracture.

Methods of Treatment

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At least 20 methods of treatment have been advocated for Bennett's fracture since the first large clinical series with x-rays in 1904 CRIF It is important to apply gentle traction to the 1 st metacarpal in the correct direction i.e. longitudinally with the thumb adducted and then reduce the fracture finally by pushing the base of the 1 st metacarpal in a palmar direction

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Hand Fractures

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If the thumb is abducted there a gap will be created at the fracture site 2 Percutaneous K-wires are then passed through the base of the 1 st metacarpal into either the trapezium, trapezoid or the 2 nd metacarpal Hand then immobilised in a POP cast for 4 weeks followed by wire removal and immobilisation Aim to reduce the joint surface to < 2mm of displacement ORIF Using either AO mini-screws, Herbert screws or K-wires Important technical point is that the screw diameter must not exceed 30% of the cortical surface of the volar lip fragment Studies have shown a correlation between the quality of reduction and the likelihood of subsequent arthritis, but there does not appear to be good correlation between radiographic evidence of arthritis and significant symptoms Rolando's Fracture
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In 1910, Rolando described a fracture pattern differing from the classic Bennett's fracture-dislocation In addition to the volar lip fragment, a large dorsal fragment was present, resulting in a Y- or T-shaped intra-articular fracture Methods of Treatment ORIF only if the volar and dorsal fragments are large enough ORIF alone may not be sufficient, experienced AO hand surgeons reported good results with ORIEF (combination of ORIF, external fixation, and bone grafting) CRIF with K-wire fixation to the 2 nd metacarpal Severely comminuted fractures in which the joint surface is not significantly improved on the x-ray taken in traction, immobilise the thumb for a minimal period to relieve pain and then begin early active motion Because of the infrequency of Rolando's fracture, no one has reported a series comparing the results of different forms of treatment. In Green's experience, the tendency in the past has been to err on the side of overtreatment i.e., to attempt open reduction when it was virtually impossible to restore the articular surface 'We repeat that significant comminution is a definite contraindication to operative treatment of this injury.' Other Metacarpal Fractures
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Classified like any fracture " location, displacement etc. Specilaist Xray " 'Brewerton metacarpal head view'

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Hand Fractures

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A) MC Head Mx: Displaced head " ORIF / Kwire, small osteochondral# - excise B) MC Neck < 15 degree " ulna gutter splint 2 week then mobilize 15-40 deg " reduce and hold 40 deg dorsal ang. in little finger can be accepted due to compensatory CMCJ. BUT residual ang. Of >15 in index, middle finger not accept due to lack of compensation. C) MC shaft transverse " reduce and hold Spiral " unstable " look for malrotation " orif / kwire D) MC base displaced " kwire Malunion " can disturb intrinsic / extrinsics " de-rotation osteotomies Phalangeal Fractures Deforming forces: as the anatomy is an intercalated osseous chain # will give predictable deformity: A) middle phalynx - # prox to FDS insertion " dorsal angulation, # distal " volar angulation B) prox phalynx " inerosseous attachments flex prox part and central slip extends distal part resulting in volar angulation. MX: mobilize uninvolved digits ASAP. NB " PIPJ most important jt for fuction and motion of digit Accurate # reduction where poss. Options of fixation " incl. k wire, interosseous wire, interfragm screw, plate, ex-fix. Complications: stiffness: tendon adhesions " may need tenolysis of flexors / extensors Pipj flex contracture " may need jt release Malunion osteotomy Symptomatic hardware r/o metalwork for symptoms +/- tenolysis Joint Injuries Jt stability depends on articular contour, collateral ligs, volar plate. Volar plate has strong lateral attachments and weak distal attachment. Goals of Mx: pain free motion, jt stability. Can take upto 12 months. DIPJ Mallet finger " rupture extensor +/- bone fragment from distal phalynx after forceful sudden flexion. If >30% artic surface then risk of volar sublux of distal phalynx. Type1 blunt trauma " loss of tendon continuity +/- bone chip Type2 laceration causing mallet Type3 deep abrasion, loss skin and soft tissue Type 4 physeal # in kids, hyperflexion 20-50% artic surface or hyperextension >50% artic surface " with volar sublux of distal phalynx Mx closed splint 6 weeks then 4 weeks at night ORIF if >30% artic surface / volar sublux Complicn mallet deformity Secondary swan-neck from dorsal sublux of lat bands Dorsal dislocation of DIPJ hypertext at tip can disrupt volar plate and collaterals sparing the fdp. Closed reduction " if blocked " may be interposn of volar plate, fdp then open. PIPJ Collateral lig Inj RCL more frequently lnjured. Digital block helps examination. Closed mx, open if soft- tissue interposn., continued instability. RCL to index may need surgery for pinch grip Volar Plate Inj hyperextension inj. Splint in 20 deg flex . mobilize after 7 days Dorsal disloc hyperextension. Xray may see small avulsion base middle phalynx. Closed reduction. Initial extension block if unstable. Volar disloc central slip ruptures " if post reduction ext lag then repair central slip. Complication: if miss central slip " volar sublux of lat bands leading to boutonniere.

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Hand Fractures

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# Disloc includes hyperextension, impaction, shear, pilon. Mx: stable " closed extn block ORIF large fragments repair with k wire, pull out wire, compression screw. Pilon # - elevate, bone graft, k wire Volar plate arthroplasty " communited#, excise volar frag and advance volar plate to middle phalynx to resurface artic surface Traction " for highly communited. MCPJ Thumb UCL Gamekeepers. Competent UCL key to pinch grip. Stener's lesion " palpable fullness on ulnar aspect. Interposn of add pollicis between torn UCL and prox phalynx. Do stress test. Partial tears " good end points and don't open to 35deg treat conserve. Complete tear / displaced # fragment need surgery " suture anchor / pull out button. Chronic injury " ligament reconstruction or advancement of adductor pollicis to prox phalynx. Thumb RCL uncommon. Treatment guidelines similar to UCL. Finger Collaterals most mx conservative. 50 degree flexion splint if unstable. Surgery for avulsion fragment. Relative indication for RCL to index and little. Dorsal dislocn simple " reducible. Complex " irreducible " deformity not obvious, dimpling of distal palmar crease, seasmoid may be seen in jt on xray = volar plate entrapment. Open to reduce " dorsal approach avoids digital n and can treat MC head #. CMCJ Dislocn CMC of index, middle and ring are fixed jts allowing minimal gliding = # dislocn arthrodial diarthroses. CMCJ of little is more mobile like thumb's " is a saddle jt allowing rotation as well so digit can oppose the thumb. CMCJ's are held by v strong intermetacarpal ligs. Need severe force. Mx: closed reduction by traction. But need wires to stabilize " otherwise will re-sublux/dislocate.

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Hand Infections

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Hand Infections
Overview Web space infection Osteomyelitis HIV and the hand Incisions Deep fascial infection Human bites Necrotising Fasciitis Paronychia/eponychia Flexor tenosynovitis Herpetic Whitlow Fungal Infection Felon Infections of the radial and ulnar bursae Mycobacterial infections

OVERVIEW

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Hand infections less common than foot infections due to relatively good blood supply. Most infections are staph aureus, but many infections are due to multiple organisms and 30-40% grow anaerobic species.. Other organisms include streptococci, enterobacteria, pseudomonas, enterococci, bacteroides. Rarer organisms are Mycobacteria, gonococcus, pasteurella multocida (in cat or dog bites ), Eikenella corrodens (in human bites), Aeromonas hydrophilia, Haem Influenza (in children from 2 months to 3 yrs). Always take a good history, diabetes? Fight bite? Always examine the arm for spreading lymphangitis and palpate lymph nodes. Epitrochlear lymph nodes drain ring and little finger Axillary nodes drain the radial digits Cellulitis resolves with antibiotics only and elevation. Flucloxacillin and benzylpenicillin +/- Augmentin if a bite is involved. Pus under pressure requires surgical drainage THERE IS NO ALTERNATIVE. Incisions for Hand Infections
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Hand Infections

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Common Hand infections Paronychia/ eponychia


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Infection of the nail fold, usually with staph aureus. If on one side (paronychia) drain by incision with blade angled away from nailbed to avoid damaging it.

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Hand Infections

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If extending around both sides of nail and migrating under the nail, do as shown in diagram, excising the proximal one third of the nail

Felon

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Subcutaneous abscess of the pulp of the finger Anatomy The distal finger pulp is divided into tiny compartments by strong fibrous septa traversing from skin to bone. There is also a fibrous curtain present at the distal finger crease. Because of these, any swelling causes immediate pain. The abscess may extend into the periosteum of the distal phalanx, around the nailbed or proximally, through the fibrous curtain, or through the skin. Those beginning deep can cause osteomyelitis. Treatment Antibiotics and incision and drainage Methods of drainage - see diagram

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Hand Infections

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1. If superficial and pointing volarward into the whorl of the fingerprint, a vertical midline incision distal to the skin crease exactly in the midline. 2. If deep and partitioned by the septa, make incision as shown. The incision should be dorsal to the tactile surface of the pulp and no more than 3mm from the distal free edge of the nail. If not, the digital nerve can be painfully damaged. DON'T USE A FISHMOUTH INCISION, IT CAN BE SLOW TO HEAL AND CAUSE PAINFUL SCARRING.

Web space infection (collar button abscess) Anatomy

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Localised in one of the three fat filled spaces just proximal to the superficial transverse metacarpal ligt. At the level of the MCP joints. Often begins under palmar calluses in labourers. Often points dorsally where the skin is more yielding. However the palmar part is the most dangerous as it may spread into the deep palmar space. Treatment

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Hand Infections

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Two longitudinal incisions, one dorsally, one ventral, but the web should not be incised. Deep fascial space infections Anatomy The Deep palmar space lies between the fascia covering the metacarpals and their muscles, and the fascia dorsal to the flexor tendons. Ulnar border is the fascia of the hypothenar muscles, Radial border is the fascia of the adductor and other thenar muscles. Divided into the middle palmar space and the thenar space by fascial plane passing between third metacarpal shaft and the fascia dorsal to the flexor tendons of the index finger. Middle palmar space infections Infections here cause a severe systemic reaction, generalised swelling of the hand and fingers resembling a rubber glove and loss of active motion of the middle and ring fingers. Drain through a curved incision beginning at the distal palmar crease, extending ulnarward to just inside the hypothenar eminence Thenar space; Infections here cause systemic upset, thumb web swelling, the index finger is held flexed and there is loss of index finger and thumb active motion. Drain through a curved incision in the thumb web along the proximal side of the thenar crease. Avoid the recurrent branch of the median nerve.
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Hand Infections

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Hand Infections

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Suppurative Flexor Tenosynovitis

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Infection in the flexor tendon sheath, can cause tendon adhesions or necrosis and rupture Anatomy Thumb infections can drain into the thenar space or the radial bursa Index finger and thumb infections can spread to the thenar space Middle , ring and little finger infections can spread to the middle palmar space Little finger infections can spread to the middle palmar space or the ulnar bursa See diagram Causes Spread from an adjacent pulp space infection, or from puncture wounds over the flexor creases Clinical features

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Hand Infections

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Kanavel's four cardinal signs

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Hand Infections

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1. 2. 3. 4.

finger held in a flexed position Sausage digit (symmetrical swelling) Severe tenderness along the tendon sheath pain on passive extension of the finger

Management [ Diagram ] IV antibiotics if less than 48 hrs Surgical drainage if no dramatic improvement after 24 hours or presentation after 48 hrs Open , through Brunner incisions Flexor Tendon sheath irrigation. Incision at distal palmar crease and either over the distal finger crease or midlateral incision at the level of the middle phalanx. Open tendon sheath and pass a cannula into the sheath and flush through till clear, after C+S swab taken.

Case Study

Infections of the radial and ulnar bursae

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From spread fom the little finger or thumb flexor tendon sheaths To drain the radial bursa, make a lateral incision over the prox phalanx of the thumb, enter the sheath. Introduce a probe and push it towards the wrist. Make a second incision at its end. Irrigate with a cannula. To drain the ulnar bursa, open it on the ulnar side of the little finger, and again proximally at the wrist. Irrigate. The radial & ulnar bursae can communicate causing a ' Horseshoe abscess '

Osteomyelitis

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General principles the same as in larger bones, However, if amputation necessary, it should be done at the joint proximal to the infected bone or the infection will not clear. Infection of the finger pulp may erode the distal phalanx, but may improve when the overlying abscess is drained Human bite injuries
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Usually fight bites over the 3 rd and 4 th MCP joints.

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Hand Infections

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42 different organisms have been identified in the human mouth. Most common infecting organism is still staph aureus, other common organisms are, streptococcus, Eikenella, Enterobacter, proteus, Serratia, Neisseria, Eikennella. Reported by Malinowski that the average delay in presentation is 2.5 days. Treat aggressively with IV antibiotics, Cephalosporin and penicillin wash out any breached MCP joint. Mycobacterial infections Mycobacterium marinum; This usually presents as a non healing ulcer, and is frequently confused with gout or R.A. The organism is typically found around swimming pools or fish tanks. Mycobacterium Kansasii; May behave similarly. Often presents as a persistent synovitis previously attributed to R.A. Culture results can take several weeks to complete. Treat by synovectomy/ excision of lesion for diagnostic purposes, followed by antituberculous antibiotics as guided by the microbiologist Herpetic Whitlow
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Seen in medical/dental personnel Pain, swelling, tenderness and vesicular rash. Usually affects the thumb and index finger Splint, elevate and restrict patient contact Self limiting illness lasting 3 weeks Do not I+D to reduce risk of systemic infection, may recur Sporotrichosis From roses. Lymphatic spread causes discoloration and small bumps on hand and forearm. Treat with KISS ( potassium iodide solution) HIV and the hand
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Frequently get: HSV, CMV, fungal, protozoal, mycobacterial. Necrotising Fasciitis


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Streptoccocal infection (G "ve " Meleney's disease) or due to clostridia (G+ve rod). Most common is GpA B-Haemolytic strep. Low threshold for suspicion in immunocompromised " DM, CA. Need radical emergency debridement and empirical broad spectrum " penicillin, clindamycin, metronidazole, aminoglycaside. Av mortality rate is 32% so amputation needs to be considered. Fungal Infection
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Seen in immunocompromised. Get cutaneous, subcutaneous and deep. Cutaneous: chronic infection of nail fold by candida albicans " use topicals, ketoconazole. (Onychymosis= destruction nail plate.) Subcutaneous: Sporothrix schenckii From roses. Lymphatic spread causes discoloration and small bumps on hand and forearm. Treat with KISS (potassium iodide solution) Deep: tenosynovial infection, septic arthritis, osteomyelitis " need fungal cultures, debridement and IV antifungals eg amphoteracin B.

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Hand Syllabus for FRCS (Tr & Orth)

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Hand Syllabus for FRCS (Tr & Orth)


Long Cases
Rheumatoid Hand and Wrist Brachial Plexus Injuries Peripheral Nerve Injuries Short Cases Carpal Instability Carpal Tunnel Syndrome Basal Thumb Osteoarthritis Duplicated Thumb Dupuytrens Disease Kienbocks Disease Median Nerve Injury Ulnar Nerve Injury (High and Low) Perilunate Dislocation Radial Nerve Palsy Rheumatoid Hand and Wrist Ulnar Collateral Ligament Injuries Anatomy: APB wasting, Flexor tendon sheath/vinculae. Brachial plexus lesions. Childrens: Camptodactyly. Clinodactyly. Congenital bands. Delta phalanx. Enchondromata. Radial dysplasia Syndactyly. Congenital absence of thumb. Trauma: Carpal instability.Compartment syndrome. Digital nerve injury. DRUJ injury. Fingertip injuries. Finger amputations. Flexor tendon injuries, repair, rehab and late reconstruction. Frykman classification. "Mangled hand". Phalangeal fractures - classification. Scaphoid injuries/Periscaphoid injuries. Scaphoid non union. UCL injuries/Stener lesion. Nerve: Brachial plexus. Carpal tunnel syndrome. Nerve repair. Radial nerve palsy and tendon transfers. Rheumatoid: Boutonniere. Elbow replacement. MCP joint replacements. Rheumatoid shoulder/hand and wrist. Rheumatoid thumb (including Nalebuffs classification) Others: Dupuytrens. Kienbocks. RSD. TB dactylitis. Tumours. Tourniquets. Written paper Volar Bartons fracture. Fingertip injury. Extensor compartments of the wrist Identify EPB, APL, EPL and FDQ tendons Name muscles in deep flexor compt of forearm Pathoanatomy of MCPJ dislocation. Label a diagram of the brachial plexus Dupuytrens - associates, Mx of PIPJ contracture Rx options in Dupuytrens Factors influencing outcome in nerve repair Bennetts # xray - name deforming forces. Ulnar nerve anatomy at wrist Seddons classification of nerve injury EMG's & NCS of plexus injury Nerve conduction studies. Morgan M.H. B.J. Hosp Med 1989 41: 25 - 3?

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Hand Syllabus for FRCS (Tr & Orth)

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Hand Trauma & Compartment Syndrome

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Hand Trauma & Compartment Syndrome


PRINCIPLES **USE LEAST INVASIVE TECHNIQUE CONSISTENT WITH NECESSARY STABILITY ** Consider ORIF if: 1. Closed reduction fails 2. Percutaneous Fix cannot be achieved 3. # is unstable d.t. segmental bone loss or comminution. Results of injuries are: 1. Injury dependent- timing, clean/dirty, skin loss, tendon integrity, skeletal injury, NV zone, crush. 2. Patient dependent- age, job, hobbies, smoker, drugs (coffee), hand dominance, motivation, medical condition. 3. Treatment dependent. COMPARTMENT SYNDROME OF THE HAND Anatomy: The hand contains 10 separate osteofascial compartments: 4 dorsal interossei 3 palmar interossei adductor pollicis thenar muscle compartment hypothenar muscle compartment Clinical: Compartment syndrome in the hand is not associated with sensory abnormalities, as there are no nerves within the compartments. Early recognition of this complication is based on clinical examination. Increased pain, loss of digital motion, and continued swelling suggest an impending compartment syndrome. Tight swollen hand in an intrinsic minus position. Intrinsic tightness may be evident on examination by Bunnell's test Compartmental pressure measurement provides an aid to diagnosis. A lower threshold than those in leg compartments is expected > 15-20 mm is a relative indication for decompression. Treatment: All compartments can typically be released with: 1. 2. 3. 4. A carpal tunnel release 2 dorsal incisions A medial hypothenar incision A lateral thenar incision.

The decision to perform fasciotomies of the thumb and fingers is made on the degree of swelling of the fingers present.

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10/6/2007 12:17 PM

Hand Tumours

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Hand Tumours
PSEUDOTUMOURS BENIGN TUMOURS MALIGNANT TUMOURS TYPES OF SURGERY

PSEUDOTUMOURS 1. Ganglia

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1. Dorsal wrist ganglion - arises from scapholunate ligament; may have an intraosseous extension & more than one pedicle. 2. Volar wrist ganglion - usually arises from radiocarpal or scapholunate joints; Allens test for radial & ulnar artery patency pre-op. 3. Volar retinacular ganglion - Arise from A1 pulley. 4. Mucous cyst - usually dorsal DIPJ arising from an arthritic DIPJ in women; remove osteophytes at surgery. 2. Epidermoid Inclusion cyst implantation of epitheloid tissue in deeper layers from penetrating trauma usually. remove complete cyst wall. 3. Foreign body granuloma 4. Calcinosis - scleroderma or degenerative 5. Dejerine-Sottas Disease - localised swelling of peripheral nerve due to hypertrophic interstitial neuropathy; Usually median nerve; Treat with CTD (resection of lesion not possible without resecting nerve) 6. Turret exostosis - traumatic subperiosteal haemorrhage on dorsum. BENIGN TUMOURS 1. Giant Cell Tumours = pigmented villonodular synovitis usually arises from IP joints or flexor tendon sheath locally invasive surrounds normal structures instead of invading them often extends below joint ligaments can erode bone Macroscopically is yellow & brown or grey Treatment = complete excision under magnification Recurrence rate = 17 - 30%, usually recurs within 2 years of surgery.

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Hand Tumours

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2. Vascular Tumours (Also see Vascular Summary ) (Also see Vascular Summary ) 1. Glomus tumour tumour of the neuromyoarterial apparatus, which functions to regulate skin circulation of the digits neuromyoarterial apparatus is found subungually, on the finger tip pulp & the base of the foot described by Masson in 1924 Present with triad = pain & well-localised tenderness & cold sensitivity. tumour is small = <1cm difficult to detect clinically except for subungual glomus which presents with a blue spot under the nail plate. x-rays may show bone erosion of terminal phalanx ultrasound may detect lesion treatment = surgical excision ('shell out' lesion) Mark the tender spot pre-op follow the digital nerve until tumour found Note - there may be multiple tumours. 2. A-V malformations 3. Kaposi's sarcoma 4. False aneurysm - follows trauma 5. True aneurysm - rare in hand 6. Pyogenic Granuloma 3. Neural Tumours 1. Traumatic Neuroma 2. Neurofibroma intimately involved with nerve fascicles cannot be removed without sacrificing nerve function 10% malignant change if associated with neurofibromatosis

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Hand Tumours

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rx = decompression or excision & nerve graft 3. Neurilemoma (Schwannoma) Well-localised, encapsulated not intimately involved with nerve fascicles Can be shelled out. 4. Fibrous Tumours 1. Dermatofibroma - small fibrous nodule in children 2. Desmoid tumours - rare, locally agressive, resembles fibromatosis histologically (more common on abdomen, tibia) 3. Fibromatosis - Dupuytren's nodules 5. Bone Tumours

1. Enchondroma solitary, cyst in long bones of hand (usually proximal phalanx) Multiple lesions occur in Ollier's disease (multiple enchondromas) & Maffuci syndrome (enchondromas + haemangiomas) flecks of calcification within lesion Can expand the bone may fracture malignant change in < 1% after age 30 Treat: Intralesional excision if symptomatic & bone graft through a dorsal trap-door approach. Also see Cartilage Producing Tumours 2, Osteoid osteoma 3. Osteochondroma [ Image ] 4. Aneurysmal bone cyst 5. Giant cell tumour of bone 6. Lipomas 1. Angiolipoma 2. lipoma of tendon sheath 3. Intraneural 4. Intraosseous 5. Intramuscular

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Hand Tumours

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MALIGNANT TUMOURS Very rare in hand

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most common is squamous cell carcinoma Most common bone malignancy is chondrosarcoma Most common metastases to hand are lung tumours (in the terminal phalanx) Most common soft tissue sarcoma is Epitheloid . Myeloma and Lymphoma may also affect the hand. TYPES OF SURGERY FOR HAND TUMOURS

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1. Local Excision - Intralesional - e.g. giant cell tumour, lipoma, enchondroma, osteoid osteoma. 2. Marginal excision (ME) - with a minimal gap of normal tissue 3. Wide Local Excision (WE) (en bloc) - Intracompartmental - 2cm rim for benign lesion, 5cm rim for malignant lesion. 4. Radical Resection (RR) - Extracompartmental - removes entire bone or compartment (e.g. ray amputation for chondrosarcoma of proximal phalanx) 5. Amputation - digit, ray, hemi-, or below elbow.

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Indications for Reduction in Distal Radius Fractures

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Indications for Reduction in Distal Radius Fractures


David L. Nelson, MD This paper is based on a presentation given at the AAOS Summer Institute, San Diego, September, 1996, and at the International Distal Radius Fracture Conference, San Francisco, May 8-10, 1998. It has last been updated on 12/30/99. Many authors suggest that distal radial fractures be reduced anatomically, but few of them define what "anatomical" means, to the frustration to the student of distal radial fractures. This is a review of the scientific literature, both laboratory and clinical, with respect to what "anatomical" really means. Four different but interrelated characteristics have been examined.
VOLAR TILT ARTICULAR INCONGRUITY RADIAL SHORTENING RADIAL ANGLE

A VOLAR TILT [Back To Top] 1 BIOMECHANICAL STUDIES a Short, Palmer, Werner (1987, JHS) method: six cadavers, pressure-sensitive film, examine loads results: 10 dorsal tilt caused a statistically significant change in the area of maximum load, moved load more dorsally, and load was more concentrated b Pogue, Viegas, Patterson, et al. (1990, JHS) method: five cadavers, pressure-sensitive film, examine contact areas and pressures results: >25 volar tilt or >15 dorsal tilt caused a shift in the scaphoid and lunate high pressure areas and the load were more concentrated c Kihara, Palmer, and Werner (1996, JHS) method: six cadavers, motion tracked by motion sensor system, malunion simulated osteotomy in 10 increments results: pronation and supination decreased significantly with 20 dorsal angulation (30 change) 2 CLINICAL STUDIES a Gartland and Werley (1951, JBJS) review of 2132 WC cases dorsal angle had greatest effect on functional result no threshold data given or distractable from data b Taleisnik and Watson (JHS, 1984) retrospective review of 13 patients with midcarpal instability and radial malunion average dorsal tilt of 23, but occurred with as little as 8 and 10 in 2 pts resolution of midcarpal instability with corrective osteotomy c Ekenstam (1985, Scan J P & Recon) significant improvement in function, the extent of which was dependant on the dorsal tilt no threshold data given or distractable from data d Jenkins (1988, JHS) prospective study of 61 consecutive patients treated with closed reduction, cast immobilization statistical significant correlation with function and dorsal tilt no threshold data given or distractable from data

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Indications for Reduction in Distal Radius Fractures

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e McQueen (1988, JBJS[B]) 30 patients with Colles' fracture, four year follow-up as little as 10 dorsal tilt patients much more likely to have pain, stiffness, weakness, and poor function f Bickerstaff (1989, JBJS[B]) 32 patients with Colles' fracture managed with closed reduction rated for pain, ROM, strength, ADL's statistically significant correlation between dorsal tilt and outcome no threshold data given or distractable from data g Kopylov (1993, JHS[B]) retrospective review of 76 patients, 26-36 years after distal radius fracture F statistically significant correlation with DJD and dorsal tilt no threshold data given or distractable from data 3 RECOMMENDATIONS Accept no > than 0 dorsal tilt or no > than 20 volar tilt Accept no > than 5 dorsal tilt Accept no > than 10 dorsal tilt 0 tilt increased risk of DJD by 80% Accept no > than 10 dorsal tilt

Weiland (OKU-Trauma, AAOS, 1996)

ASSH Regional Review Course (1994) Trumble (ASSH Specialty Day at AAOS 1999) Kopylov (1993, JHS[B], 30 year follow-up study) Nelson, based on all of the basic science and clincal studies cited above, as well as the consensus recommendations noted above: B INTRA-ARTICULAR INCONGRUITY [Back To Top] 1 BIOMECHANICAL STUDIES a Baratz and Wroblewski (1996, JHS)

method: cadaver study of contact stresses with pressure sensitive film results: increases in contact stresses with stepoff as small as 1 mm results: carpal alignment shifts and lunate flexion reduces with stepoffs b Wagner, et al. (1996, JHS) method: cadaver study of contact stresses with pressure sensitive film results: lunate fossa depression of 3 mm caused significant pressure in scaphoid fossa results: scaphoid fossa depression of 1 mm caused increased pressure in lunate fossa limitations of both studies: pressure sensitive film can alter joint characteristics, is quasi-static, does not account for shear forces that occur during rotation of wrist, cannot account for changes over time 2 CLINICAL STUDIES a Knirk and Jupiter (1986, JBJS) retrospective study of 43 fractures with intraarticular displacement, with mean follow-up of 6.7 years stepoff > 2 mm (8 of 8): 100% radiographic DJD any radiographic stepoff (22 of 24): 91% radiographic DJD (but see eRadius - Dr. Jupiter's current [1999] opinion at Intra-articular fractures of the distal end of the radius in young adults , and scroll down to "Comment by Dr. Jupiter")

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Indications for Reduction in Distal Radius Fractures

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b Bradway, Amadio, and Cooney (1989, JBJS) retrospective study of 16 patients, mean follow-up of 4.8 years 4/4 patients with > 2 mm stepoff had DJD 3/12 patients with < 2 mm stepoff had DJD c Fernandez and Geissler (1991, JHS) retrospective radiographic review of 40 patients, but only 31with clinical follow-up follow-up averaged 4 years (range 2-8) no patient with a step-off of 1 mm or less had DJD all three patients with a step-off of 2 mm or more had pain; only 1 with no step-off had pain d Missakian, Cooney, and Amadio (1992, JHS) retrospective review of 650 patients with distal radial fractures 32 patients had intraarticular fractures treated with ORIF all patient who had > 2 mm stepoff had post-traumatic arthritis and only fair results e Kopylov (1993, JHS[B]) retrospective review of 76 patients, 26-36 years after distal radius fracture F articular incongruity was the main factor in the development of radiographic DJD and was frequently associated with pain and stiffness clinically F incongruity of > 1 mm had 250% increased risk of DRUJ DJD F incongruity of > 1 mm had 237% increased risk of RC DJD f Trumble (1994, JHS) retrospective study of 52 intraarticular fractures strongest correlation with outcome was with articular incongruity (both stepoff and gap) no threshold data given or distractable from data, but would not accept > 1 mm g Fernandez and Jupiter (1996, Fractures of the Distal Radius ) retrospective study of 40 patients with intraarticular fracture, average follow-up of 4 years 25 of 40: no step-off and no radiographic DJD or clinical pain 5 of 6 patients with step-off had pain (3 moderate, 2 severe) h Catalano, Gelberman, Gilula, et al. (1997, JHS ) retrospective study of 21 patients with intra-articular fracture, average follow-up of 7.1 years follow-up included plain xrays, CT scans, and outcomes questionnaire there was a strong association between development of DJD and step-off there was no association between functional status and radiographic DJD 3 RECOMMENDATIONS Weiland (OKU-Trauma, AAOS, 1996) ASSH Regional Review Course (1994) ASSH Specialty Day at AAOS (Trumble, 1999) Kopylov (1993, JHS[B], 30 year follow-up study) Baratz (ASSH Specialty Day at AAOS, 1998) Accept no > than 1 mm or 2 mm step-off Accept no > than 1 mm step-off Accept no > than 1 to 2 mm step-off ("If you can see it, fix it") Accept no > than 1 mm step-off Consider reduction if step-off visible on xray

4 CAVEAT: WE CANNOT RELIABLY MEASURE AT THE 1 MM LEVEL a Nelson (1995, AAOS)

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Indications for Reduction in Distal Radius Fractures

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method: one cadaver, simulated die punch fracture, with stepoffs of 0.0mm, 0.5 mm, 1.0 mm, and 2.0 mm; plain radiographs and CT's performed; 16 blinded reviewers results: cannot reliable measure with an accuracy of 1 mm, CT not more reliable than plain films, and reviewer is not able to tell when his readings are off by more than 1 mm weakness of method: used model of die punch, not actual fracture; model may have been easier to evaluate b Kreder, et al. (J Hand Surg, 1996) method: 16 observers examined 6 plain xrays results: two experienced observers would be expected to disagree by 3 mm 10% of the time, and repeat measurements by the same observer would be expected to differ by 2 mm 10% of the time weakness of method: could not tell what actual measurement was and therefore true accuracy of readings c Cole, et al. (J Hand Surg, 1997) method: 5 observers examined 19 sets of xrays, including plain films and CT scans results: more reproducible values were produced by CT scans, but a poor correlation between CT and plain xray measurements thirty percent of measurement from plain xrays significantly underestimated or overestimated displacement compared to CT scan measurement weakness of method: could not tell whether CT or plain film was actually more accurate weakness of method: could not tell what actual measurement was and therefore true accuracy of readings C RADIAL SHORTENING [Back To Top]

1 BIOMECHANICAL STUDIES a Pogue, Viegas, Patterson, et al. (1990, JHS) method: five cadavers, pressure-sensitive film, examine contact areas and pressures results: 2 mm shortening created statistically significant increase in the lunate contact areas b Adams (1993, JHS) method: six cadavers results: radial shortening was the most significant change affecting the kinematics of the DRUJ and the TFC 2 CLINICAL STUDIES a Jupiter and Masem (1988, Hand Clinics) review article, Reconstruction of Post-Traumatic Deformity of the Distal Radius > 6 mm of shortening caused DRUJ pain, decreased pro- and supination radial shortening most disabling of malunited fractures b McQueen (1988, JBJS[B]) 30 patients with Colles' fracture, four year follow-up > 2 mm shortening statistically significant increase in symptoms in terms of strength, ADL, ROM, and pain c Jenkins (1988, JHS) prospective study of 61 consecutive patients treated with closed reduction, cast immobilization mean shortening was 4.0 mm

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Indications for Reduction in Distal Radius Fractures

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strong correlation between radial length and strength and ROM mean radial shortening in patients with pain: 4.7 mm mean radial shortening in patient without pain: 2.3 mm (statistically significant) d Kopylov (1993, JHS[B]) retrospective review of 76 patients, 26-36 years after distal radius fracture, average follow-up of 30 years radial shortening most important factor after intraarticular step-off 1 mm radial shortening had a 50% increased risk of DJD in the DRUJ 1 mm radial shortening had a 20% increased risk of DJD in the RC joint 2 mm radial shortening had a 50% increased risk of DJD in the RC joint 3 RECOMMENDATIONS Weiland (OKU-Trauma, AAOS, 1996) ASSH Regional Review Course (1994) ASSH Specialty Day at AAOS (Trumble, 1999) Kopylov (1993, JHS[B], 30 year follow-up study) Baratz (ASSH Specialty Day at AAOS, 1998) RADIAL ANGLE [Back To Top] 1 BIOMECHANICAL STUDIES a Pogue, Viegas, Patterson, et al. (1990, JHS) method: five cadavers, pressure-sensitive film, examine contact areas and pressures results: decreased radial angle increased the load on the TFC and ulna b Adams (1993, JHS) method: six cadavers results: decreased radial angle disturbed the TFC and DRUJ kinematics 2 CLINICAL STUDIES a Jenkins (1988, JHS) prospective study of 61 consecutive patients treated with closed reduction, cast immobilization mean loss of radial angle was 7.8 statistically sig. correlation with decreased angle and grip strength strong correlation (but short of statistical significance) with decreased angle and decreased flexion b Kopylov (1993, JHS[B]) retrospective review of 76 patients, 26-36 years after distal radius fracture, average follow-up of 30 years F loss of radial angle of 5 increased the risk of symptoms by 90% 3 RECOMMENDATIONS Weiland (OKU-Trauma, AAOS, 1996) ASSH Specialty Day at AAOS (Trumble, 1999) Kopylov (1993, JHS[B], 30 year follow-up study) Accept no > than 5 loss radial angle Accept no < than 15 radial inclination Goal: no loss of radial angle Accept no > than 2 mm radial shortening Accept no > than 3 mm radial shortening Accept no > than 2 mm radial shortening Goal: no > than 1 mm radial shortening Accept no > 5 mm radial shortening; 3 mm or less is optimal

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Indications for Reduction in Distal Radius Fractures

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Baratz (ASSH Specialty Day at AAOS, 1998) NOTES & REFERENCES


[Back To Top]

Goal: no loss of radial angle

Diego Fernandez and Jesse Jupiter, Fractures of the Distal Radius, Springer, New York, 1995. An invaluable book for any serious student of distal radius fractures. Highly readable, well organized, authors are foremost thinkers in this area. You can either use it to manage a specific fracture when you have a problem case, or read from beginning to end for a comprehensive understanding of the topic. Trumble, Schmitt, and Vedder, Factors Affecting Functional Outcome of Displaced Intra-articular Distal Radius Fractures, JHS 1994;19A:325-340. Excellent review article that separated the radiographic results from the clinical results and correlated them, and proposed a classification scheme that will predict results. Kopylov, Johnell, Redlund-Johnell and Bengner, Fractures of the Distal End of the Radius in Young Adults: A 30-year Follow-up, JHS(B) 1993: 18B:45-49. A real long-term study, instead of the usual two or five year study. We have needed this kind of long-term study for some time; could only be done in Sweden. The results are not as bad as might have been expected after Knirk and Jupiter's 1986 paper, but the increase in risk is very real.

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Inflammatory Arthritis

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Inflammatory Arthritis
RHEUMATOID HAND MCPJs Clinical PIPJs [Back To Top] Planning Treatment Thumb Flexor Tenosynovitis OTHER ARTHRITIDES

RHEUMATOID ARTHRITIS

Systemic & soft tissue disease, affecting the skeleton secondarily. Drag mouse over image to see labels & links:

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Inflammatory Arthritis

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ClinicalAssesment

[Back To Top]

Note - The deformities depend on the direction of pull on the tendons. Get zig-zag deformity in the sagittal &/or coronal planes HISTORY: 1. Pain - due to synovitis or secondary OA 2. Loss of Function Shortened ADL assesment: 1. 2. 3. 4. Using toothbrush, hairbrush, knife, fork Dressing - bra, pulling up trousers / stockings Operate remote control Hobbies

3. Cosmesis - may be extremely NB to patient. A poor functional result of surgery may not be a poor result for the patient if cosmesis improved. EXAMINATION: Expose above elbow. Quick elbow, shoulder & neck assessment Look (most NB): 1. Exensor surface 2. Flexor surface

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Inflammatory Arthritis

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swelling wasting zig-zag deformity - coronal / sagittal MCPJs - dropped fingers, ulnar drift finger deformities Nodules Features of SLE, Psoriasis, scleroderma (see below) Note DRUJ when wrist supinated Feel: 1. Tender areas 2. Passive correctability of deformed joints (correctable = soft tissue procedures indicated) Must be tested with ligaments tight (i.e. MCPJs in flexion) 3. Ulnar collat. lig of thumb 4. Sensation Move: 1. Ask patient to extend & flex all joints fully, & oppose thumb. Note extensor lag - tendon rupture or subluxation 2. Intrinsic Tightness - Bunnell's Test in both deformed & corrected positions. 3. Individual joint movements General Medical Assesment: 1. 2. 3. 4. cervical spine TMJ Pulmonary General

Investigations: 1. 2. 3. 4. 5. WBC (decr. in Felty's syndrome) platelet count (decr. with NSAIDs) Hb (anaemia of chronic disorders) LFT (methotrexate) ADL Assesment by Hand Therapist Jebson test - writing, turning over cards, picking up small common objects, simulated feeding, stacking chequers, picking up large light & heavy objects. Moberg's pick-up test - speed at picking up small common objects (coins, paper-clips)
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Planning Treatment Need to consider:

How the disease affects patient as a whole Level of disability Aims of Treatment: Pain relief Improve function Prevent further damage Cosmesis Principles: Operate on proximal joints then distal Tendons before joints Alternate fusions with motion-sparing procedures Staged procedures Deciding on Type of Surgery: Souter staging-

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Inflammatory Arthritis

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Stage 1 2 3 4

Clinical Acute synovitis Chronic synovitis Specific deformation Severe crippling

Treatment medical Mx & splinting Synovectomy Reconstructive Salvage

FLEXOR TENOSYNOVITIS

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The most commonly affected leading to ruptures are the radial FDPs & FPL. Usually FDP to index finger (attrition on spike from scaphoid = Mannerfelt Syndrome) Clinical: puffy thick feeling palm Pinch test - thickened tenosynovium bulges out thro defects in fibrous sheath creating bulges of tissue which can be 'pinched' Test tendon function individually Test function of FDP index & FPL by asking patient to pinch. Normal = tip-to-tip; AbN = pulp-to-pulp (also occurs with AIN palsy) [also called Pinch Test by some] Management: Acute synovitis = splinting & drugs (NSAIDs, steroids) Chronic synovitis: If conservative Rx has failed after 4 months should consider surgery. Synovectomy: Three sites1. Carpal tunnel 2. Palm at level of mouth of A1 pulley 3. Just distal to A2 pulley Tendon Rupture:
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1. Primary tendon repair - rarely done as poor tissue at tendon ends 2. Primary tendon graft - fraught with difficulties & poor results; only consider for young patient. 3. Tendon transfer - limited available on flexor side (palmaris longus, brachioradialis) 4. Side-to-side suture - good in older patients; wrist level. 5. Arthrodesis - DIPJ mainly. Vaughn-Jackson Syndrome = rupture of EDC of ring & little fingers due top attrition rupture from prominent ulna ( caput ulna ) & DRUJ synovitis DD= subluxation, PIN palsy, locked trigger finger 'Tuck sign' = synovitis tucks under the skin with movement. Rx.= Darrach for pre-rupture; tendon transfer (EIP to EDM) for rupture. Mannerfelt Syndrome = FPL rupture due to carpal irregularities or volar synovitis Rx. = IPJ arthrodesis

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Inflammatory Arthritis

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METACARPOPHALANGEAL JOINTS Ulnar drift is caused by: 1. Radial deviation of wrist

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2. Stretching of the extensor mechanism by synovitis (on radial side) 3. Loss of volar plate & collat. lig. stabilisation of the flexor sheath &A2 pulley, causing ulnar displacement of the flexor tendon pull. 4. Erosion of metacarpal heads. This all causes shortening & scarring of the ulnar collat. lig. & interosseous muscle on the ulnar side. At this stage passive correction is not possible. Clinical: Main problem is inability to extend the MCPJs enough to hold large objects. (opp. to IPJ disease) Deformity - always progressive Pain Examine: Passively correct ulnar drift (soft tissue procedures are worthwhile) Ability to reduce volar subluxation Intrinsic tightness (Bunnell test) Integrity of flexor & extensor tendons (treat first) Carpal tunnel syndrome Treatment: 1. Splintage & joint protection therapy - if passively correctible 2. Surgery: Usually required 1. Soft tissue balancing Vital to ascertain which structures are tight Methods: 1. Flatt - radial incision; mobilise radial interosseous; reef hood 2. Central split in hood; double-breasting repair (preferred to Flatt) 3. Combined ulnar & radial procedures: a. Ulnar - Divide ulnar side of extensor mechanism; release ulnar collat. lig. b. Radial procedures i. reef extensor mech. ii. proximally based ulnar strip of extensor mech passed thro radial capsule to base of prox phalanx iii. reinforce radial collat lig. by reattaching it thro drill holes on metacarpal iv. Crossed intrinsic transfer - divide ulnar interoseous & attach it to the radial side of the finger next to it (lateral band or radial collat. lig.); advance 1st dorsal interosseous distally. 2. MCPJ Arthroplasty: Excision arthroplasty - causes unstable joint, shortening of ray Excision arthroplasy & soft tissue interposition - poor ROM 3. MCPJ Replacement (Swanson's): - Good results

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Inflammatory Arthritis

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- Simply a spacer with some stabilising features. - Unconstrained prostheses don't work because of damage to soft tissues by the synovitis making joint unstable & normal kinetics of the joint have been long lost. (unlike the knee) - Technique: 1. Ulnar soft tissue release of ulnar collat. lig., ulnar intrinsic & volar plate insertion. Little finger- release ADM, preserve FDM. 2. MC head resection - slightly radial direction; because of dorsal> volar erosion; don't resect too much volar cortex. 3. Rectangular holes in MC & PP 4. Insert biggest possible prosthesis 5. Reconstruct radial collat. lig. (index finger - reef; others - crossed intrinsic tranfer). 6. Post-op: i. Volar slab, well padded ii. 48hrs. - outrigger splint applying radial-deviating force iii. Continue for 3 months (with static night splint) 7. Complications: a. recurrent ulnar drift b. implant fracture c. infection d. Silicone synovitis (very rare) PROXIMAL INTERPHALANGEAL JOINTS A. Swan-neck deformity: Causes: 1. Long extensor overactivity a. MCPJ contracture b. mallet DIPJ c. extrinsic spacticity 2. Intrinsic overactivity a. intrinsic contracture b. intrinsic tightness 2ndry to MCPJ disease 3. Failure of PIPJ stabilisers a. volar plate insufficiency b. FDS insufficiency c. Generalised joint laxity
[Back To Top]

Nalebuff Description Type

Cause

Diagnosis

Treatment

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Inflammatory Arthritis

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PIPJ flexible

DIPJ mallet PIPJ volar plate/ FDS insufficient

Cannot Extend DIPJ with PIPJ passively flexed

Fuse DIPJ

Can Extend DIPJ with Extension block PIPJ passively flexed splint FDS tenodesis (hemitenodesis or sling) / volar plate advancement MUA or dorsal soft tissue release

PIPJ flexion limited with Can flex PIPJ with Tight Intrinsics MCPJ extended = ' locked MCPJ flexed (Bunnell (~volar plate weak) Test) swan-neck ' PIPJ stiff, joint preserved PIPJ stiff, joint changes X-Ray - No articular/ bony changes

X-Ray - Articular/ bony arthrodesis changes

B. Boutonniere deformity

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Rupture of central slip of extensor tendon due to synovitis of PIPJ. Lateral bands dislocate in a palmar direction, being converted from extensors to flexors. Non-surgical treatment of little benefit & can reduce function.

Deformity Mild (10-15deg.) Moderate ((30-40deg.) Severe (fixed)

Treatment Extensor tenotomy over centre of middle phalanx Numerous soft tissue procedures with variable results, thus low tolerance for arthrodesis Arthrodesis - position ranging from 20deg. index to 45deg. little finger

RHEUMATOID THUMB

[Back To Top]

Nalebuff Deformity Type

CMCJ MCPJ

IPJ

Initiating feature

Treatment Arthroplasty MCPJ or IPJ, +/- extensor realignment Arthroplasty MCPJ or IPJ, +/- extensor realignment CMCJ arthroplasty

Boutonniere

Abd.

Flex.

Hyperext. MCPJ synovitis MCPJ & CMCJ synovitis CMCJ synovitis, MCPJ volar plate attenuation

Boutonniere Add. & Swan-neck Swan-neck Add.

Flex.

Hyperext.

Hyperext. Flex.

Gamekeepers Add.

Abd.

ulnocarpal lig. (beak) Lig. reconstruction / destruction MCPJ fusion Stretching of MCPJ volar plate MCPJ fusion

5 Arthritis mutilans

Neutral Hyperext. Flex.

Short

Unstable Unstable Bone destruction

Fusion

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Inflammatory Arthritis

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Inflammatory Arthritis

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Nalebuff Type 1 Boutonniere OTHER FORMS OF ARTHRITIS OF THE HAND Systemic Lupus Erythematosus (SLE) Ligamentous laxity of the MCPJs Joint surfaces often unaffected Psoriasis DIPJ involvement Gross joint changes No tendon involvement nail changes Scleroderma calcinosis causing fingertip ulceration CREST syndrome - Calcinosis, Raynaud's syndrome, Eosophageal strictures, Sclerodactyly, Telangectasia.
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Inflammatory Arthritis

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Jules Tinel

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Jules Tinel
1879-1952 Tinel was a French neurologist who wrote an excellent book on the effects of nerve injuries during the First World War, and from it one may judge how times have changed, for nerve suture is hardly mentioned. He had a research interest in the autonomic system, producing a thick volume on the subject; he was noted for the ingenuity of his apparatus, which was often constructed of Meccano. He was born in Rouen, the fifth in a line of distinguished doctors. His father was Professor of Anatomy at Rouen. Tinel studied in Paris. It was when he was mobilised for the war that he found himself in a neurological unit and was able to study the long term effects of severe nerve injury. He gave the first account of paroxysmal hypertension due to phaeochromocytoma. During the Second World War he had to leave the Hospital; his family were interned, and one son executed by the Gestapo because they had helped run an escape route. Tinel's Sign: 1917 Formication provoked by pressure.-;When compression or percussion is lightly applied to the injured nerve trunk, we often find, in the cutaneous region of the nerve, a creeping sensation usually compared by the patient to that caused by electricity. Formication in the nerve is a very important sign, for it indicates the presence of young axis-cylinders in process of regeneration. This formication is quite distinct from the pain on pressure, which exists in nerve irritations. Tenderness, indicating irritation of the axis-cylinders and not their regeneration, is almost always local, perceived at the very spot where the nerve is compressed, or at least magnified at this spot; it always co-exists with the pain in the muscular bellies under pressure, which are, very often, more tender than the nerve. Formication of regeneration, on the other hand, is but little or not at all perceived at the spot compressed, but is felt almost entirely in the cutaneous distribution of the nerve; the neighbouring muscles are not tender. As a rule, it appears only about the fourth or sixth week after the wound. It enables us to ascertain the existence of this regeneration and to follow its progress. If it remains fixed and limited to one spot for several consecutive weeks or months, this is because the regenerating axis-cylinders have encountered an insurmountable obstacle and are forced together at that place as a more or less bulky neuroma. The fixity of formication on a level with the lesion, and the complete absence of formication below the lesion, would almost warrant our affirming the complete interruption of the nerve and the impossibility of spontaneous regeneration. If, on the other hand, the regenerated axis-cylinders can overcome the obstacle and make their way into the peripheral segment of the nerve, we see a progressive migration of the formication so provoked. Pressure on the nerve below the wound produces this sensation, and from week to week it may be encountered at a spot farther removed from the nerve lesion. The presence of formication provoked by pressure below the nerve lesion warrants our affirming that there is more or less complete regeneration. The site at which formication can be demonstrated moves along the course of the nerve at the same pace as the axis-cylinders advance; at the same time that it extends progressively towards the periphery it disappears at the level of the lesion. The "formication sign" is thus of supreme importance, since it enables us to see whether the nerve is interrupted, or is in course of regeneration; whether a nerve suture has succeeded or failed, or whether regeneration is rapid and satisfactory, or reduced to a few significant fibres.

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Jules Tinel

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Formication lasts a tolerably long time; appearing about the fourth week, it persists during the entire regeneration, i.e., for eight,

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Kienbock's Disease

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Kienbock's Disease
SUMMARY Described by Kienbock in 1910, a radiologist in Vienna. (republished article in CORR 1980, Vol 149) = collapse of the lunate due to vascular insufficiency and avascular necrosis Aetiology: Uncertain Theories: 1. Single forgotten wrist trauma 2. Repetitive microfractures that result in vascular comprimise, causing disruption of blood supply to lunate 3. Recurrent compression of lunate between capitate & distal radius which disrupts the intraosseous structures through shear stress at extreme wrist positions and/or repetitive compression loading Associated with Negative ulnar variance (of interest, there do not seem to be any reports of Kienbock's disease after the Darrach's procedure) Clinical Manifestations: Young adults wrist pain that radiates up the forearm wrist stiffness tenderness over lunate dorsally weakness of grip Radiography: Ulnar variance is measured on PA views with wrist in neutral rotation (ulna is relatively longer in supination) Lichtman Staging: Stage 1 Stage 2 Stage 3 Normal architecture & density, may see a linear compression # (Bone scan & MRI diagnosis) Increased density, normal architecture & outline; cysts collapse & fragmentation Stage 3A Stage 3B Stage 4 No carpal collapse Carpal collapse (prox. migration of capitate) OA

Radiograph of Keinbock 's - Note Negative ulnar variance

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Kienbock's Disease

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Treatment: Remember: Keinbock's often causes little disability The radiological findings & symptoms do not correlate well. No surgical procedure has been conclusively shown to prevent progression. Surgery only indicated when pain & disability cannot be managed by splintage, analgesia & reassurance. Surgery: Stage 1 & 2: Aim to prevent lunate collapse 1. Joint Levelling: 1. Radial shortening 2. Ulnar lengthening - high non-union rate. 2. Revascularisation of lunate Pedicled vascularised graft from distal radius with pronator quadratus dorsal digital artery placed into drill hole on lunate

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Kienbock's Disease

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All these procedures have a 70% success rate in pain relief Stage 3: Limited carpal fusion without lunate excision Limited carpal fusion with lunate excision (STT or scapho-capitate) Wrist denervation Proximal row carpectomy Total wrist arthrodesis - indicated in persons who use their hands for heavy labor, have severe degenerative changes, or fail to improve following other surgical procedures 6. Titanium lunate implants (+/- limited fusion) excision of lunate alone will cause the rest of the carpal bones migrate, leading to joint incongruity, limited wrist motion and grip strength, and degenerative osteoarthritis Stage 4: 1. Wrist denervation 2. Total wrist fusion. 1. 2. 3. 4. 5.

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Nerve Injuries - Principles

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Nerve Injuries - Principles


Anatomy Diagnostic tests 1. Anatomy [Also See Nervous System ] Of spinal nerves Each segmental spinal nerve is formed by union of the dorsal/sensory root with the ventral/motor root at or before the intervertebral foramen In the thoracic segments, these mixed spinal nerves maintain their autonomy, providing sensation and motor function to one intercostal segment In all other areas (cervical, lumbar and sacral regions, plexuses are formed which provide a limb or special body segment without retaining the primitive myomeric pattern Components of a mixed spinal nerve Motor The cell bodies are in the anterior horn cells and innervate skeletal muscle. Sensory Cell bodies lie within the dorsal root ganglia. The fibres arise in the pain , thermal, tactile and stretch receptors . Proprioception, fine touch and vibration from extremities and trunk These fibres pass cephalad in the dorsal columns and do not synapse until reaching the cervicomedullary junction. Pathw ay for pressure and crude touch from extremities and trunk These fibres enter, synapse and cross and ascend into the contralateral ventral spinothalamic tract. Pain and temperature These fibres synapse in the spnal cord, and cross to ascend in the lateral spinothalamic tract. There is some area of neuronal overlap explained by branches that ascend or descend via the dorsolateral column/fasciculus of Lis Sympathetic The sympathetic component of all 31 spinal nerves leaves the spinal cord along only 14 motor roots (from T1 to L2). Between T1 and L2 there are white rami containing sympathetic fibres to the ganglions of the sympathetic chain. S spinal nerves through grey rami. Gross anatomy of a spinal nerve Divides into an anterior and posterior primary ramus after leaving the intervertbral foramen. Posterior primary ramus supplies the paraspinal musculature and the skin along the posterior aspect of the trunk neck and head Anterior primary ramus supplies everything else, and form plexuses Dermatome- The area of skin supplied by a single spinal root. [Back To Top] Neuronal degeneration and regeneration Early management of nerve injuries Classification of nerve injuries Techniques of nerve repair

Aetiology of peripheral nerve in Aftertreatment

Microscopic anatomy

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Nerve Injuries - Principles

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Sensory and motor nerves contain both unmyelinated and myelinated fibres at a ratio of 4:1. The blood supply to the peripheral nerve enters through the mesoneurium. This blood supply is both extrinsic/segmental and intrinsic/longitudinal within the epineurium, perineurium and endoneurium. Perineurium surrounds each fascicle or funicle (bunch of sheathed axons) it is a cellular layer with tight junctions between cells enclosing the perineurial space (within the perineurium) Epineurium = anything outside the perineurium which is not nerve fibre or blood vessel mainly collagen strongest supporting structure of the nerve Endoneurium = collagen surrounding nerve fibres. The arrangement of the fascicles in the proximal aspect of perpheral nerves is more complex than in the distal end of the nerve.

2. Neuronal Degeneration and regeneration 1. Retraction 2. Inflammation 3. Degeneration

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Any part of a neuron detached from its nucleus degenerates and is destroyed by phagocytosis. Secondary or Wallerian degeneration Degeneration distal to the point of injury. The fundamental concept of wallerian degeneration is that survival of nerve fibres occurs only if they remain connected to the cell body. commences 2 to 3 days after injury the distal segment begins to fragment. Cell body swells migration of nucleus to periphery of cell chromatolysis (basophilia) Activation of Schwann cells close to the injury site By 7 days the Schwann cells are mitosing & phagocytosing cellular & myelin debris By 25-30 days the axonal debris is cleared. Schwann cells occupy the empty endoneurial tubes forming the 'bands of von Bungner' The bands act as sprouts (neurites) of regenerating axons ('pioneering axons') down the endoneurial tubes -> Regeneration. Primary or retrograde or traumatic degeneration Degeneration proximal to the point of detachment only as far as the next proximal Node of Ranvier. Histologically identical to W allerian degeneration 4. Regeneration

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Nerve Injuries - Principles

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Axonal sprouting can occur within 24 hrs of injury. All sprouts are unmyelinated to begin with. If the sprouts manage to make distal connections then nerve fibre maturation occurs, with increase in axon & myelin thickness. Neurites which fail to make distant connections die back & are lost to the regenerative process. If the perineurium is not disrupted then the axons will be guided along their original pathway (1mm/day) If the perineurium is disrupted there are neurotrophic substances (NGF - nerve growth factors) which attract the neurites to nerve tissue. The critical gap over which this does not occur is 2mm. Neuromas form when neurites migrate aimlessly across a large gap. They can be stump neuromas or neuromas in continuity.

4. Classification of nerve injuries [Back To Top] Seddon Classification Neuropraxia (nerve, non-action) usually compression injury

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local conduction block & demyelination thick myelinated nerves mainly affected heals by Schwann cell repair of demyelination - takes several weeks or months Axonotmesis (cylinder, cutting) usually traction injury, but may occur after severe compression Wallerian degeneration occurs endoneurial tubes are intact -> no miswiring & good regeneration limiting factor is the distance of regeneration required worse with proximal injuries sensory recovery is better (sensory receptors survive longer than motor units) Neurotmesis (nerve, cutting) complete severance of the nerve trunk no recovery unless repair undertaken lots of miswiring of organs reduced mass of innervation Sunderland Classification accounts for the injuries between an axonotmesis & neurotmesis based on involvement of the perineurium Degree of injury Sunderland , 1978 1 st degree 11 111 1V V Seddon, 1943 Neuropraxia Axonotmesis Axonotmesis Axonotmesis Neurotmesis Degree of injury Myelin Axon Endoneurium Perineurium

+/+ + + +

+
+ + +

+
+ +

+
+

Mckinnon & Dellon (1988) added a 6 th degree injury = neuroma-in-continuity , where a nerve has had a disordered self -repair with a lateral neuroma. There is a mixture of injuries, when a nerve is partly severed and the remaining trun Complex regional pain syndrome Pain, swelling, discoloration, hyperhydrosis, osteoporosis, resulting from an abnormal and prolonged response from the sympathetic nervous system. 3% of major nerve injuries

5. Aetiologyof Peripheral nerve injuries & nbsp;

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Can be due to metabolic, collagen disease, malignancy, toxins, thermal or mechanical injury, but only mechanical causes mentioned here. Mechanical causes producing primary injury include laceration, fracture, fracture manipulation, gunshot wound Secondary injury can be due to infection, scarring, callus, vascular complications, eg. AV malformation, aneurysm, ischaemia

6. Clinical diagnosis of nerve injury and assessment post injury Requires thorough knowledge of the anatomy of nerves. Motor function Visible fibrillation of muscle Power loss (MRC): Power loss (MRC): Power loss (MRC): Power loss (MRC): 0 Total paralysis 1 Muscle flicker 2 muscle contraction 3 muscle contraction against gravity 4 muscle contraction against gravity and resistance 5 normal muscle contraction compared to other side Must have full passive range of motion of joint Muscle wasting 50-70% muscle atrophy after 2 months Striations and motor end plates retained for approx 12 months

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Method for assessing the the return of muscle function after nerve injuries (British Research Council) M 0 No contraction M 1 Return of perceptible contraction in proximal muscles M 2 Return of perceptible contraction in both proximal and distal muscles

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Nerve Injuries - Principles

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M 3 Return of prox. and distal muscle power enough to allow the major muscle groups to act against resistance M 4 Return of function as in stage 3 but synergistic and independent movements are possible M 5 Complete recovery Sensation Sharp pin to assess pain, cotton wool to assess light touch, tips of a paper clip to assess two point discrimination. Normal 2 point discrimination in the hand:

There is an area of complete sensory loss ' the autonomous zone ', which gets smaller even before fibres can regenerate (? Due to increased function of anastomotic branches from adjacent nerves) A larger area of reduced sensation surrounds this = ' the intermediate zone ' When a nerve is intact and the surrounding nerves are blocked, an area of sensibility larger than the gross anatomical distribution of the nerve occurs = ' the maximal zone ' Sensibility recovery sequence: 1. 2. 3. 4. 5. 6. 7. 8. Pain and temperature Pseudomotor function Touch (Semmes-Weinstein monofilaments: protective sensation present if able to feel 5.07 Semmes-Weinstein filament) Perception of 30 Hz vibration (tested over bony prominences with a tuning fork) Perception of moving touch Perception of constant touch Perception of 256Hz vibration Stereognosis (test with heptagonal UK 50 pence coin)

Sensation assessment after peripheral nerve injury - British Medical Research Society S 0 Absence of sensibility in the autonomous area S S S S S Recovery of deep cutaneous pain in the autonomous area Return of some degree of superficial cutaneous pain and touch in the autonomous area Return of superficial cutaneous pain and touch throughout the autonomous area, with disappearance of any previous over response 4 As for 3 but also some recovery of two point discrimination in the autonomous area 5 Complete recovery
1 2 3

The best correlator of eventual function is return of 2 point discrimination (as emphasised by Moberg, 1995)
Autonomic function There is loss of sweating , the pilomotor response and vasomotor action when a peripheral nerve is disrupted. Pilomotor - The wrinkle test is a useful objective test - Denervated skin does not wrinkle in water Vasomotor - Initially there may be vasodilatation in a complete lesion, pinkness for 2-3 weeks. Then coldness paleness, mottled. This may spread to more than the anatomical area of skin supplied by the nerve. Atrophy of fingers and nails can occur. Test sweating: 1. by rubbing smooth pen against side of finger (if finger moves with pen = sweating present) 2. Ninhydrin print test - applying nihydrin to sweat turns it purple (Moberg, 1995) 3. Look through the +20 lens of an opthalmoscope to see the beads of sweat 4. Dust the extremity with quinizarin powder. Sweating turns the powder purple 5. Absence of sweating causes an increased resistance to an electric current

If sweating still present this suggests that the nerve damage is incomplete

Hoffmann-Tinel Sign (1917) Gentle percussion with the finger along the course of the injured nerve will produce a transient tingling sensation in the distribution of the injured nerve, persisting for several seconds. Start distally and proceed proximally A positive Tinel sign is evidence of regenerating axonal sprouts which have not completed myelinisation are progressing. A distally advancing Tinel sign should be present in Sunderland 11 and 111 injuries A type 1 injury (neuropraxia) should not produce any Tinel's sign as no new regeneration should need to occur Type 1V and V injuries do not produce an advancing Tinel sign unless repaired A progressing Tinel's sign is encouraging but does not necessarily mean complete recovery.

Reflexes Complete severance of either the efferent or afferent nerve in a reflex abolishes that reflex. However, the reflex can be lost even in partial injury and is not a good guide of injury severity

7. Diagnostic tests

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Nerve conduction studies Evaluation of peripheral nerves & their sensory & motor responses anywhere along their course Stimulation of a peripheral nerve should evoke a contraction in the muscles it supplies (seen, palpated or measured electromyographically) Latency (t) = time between onset of stimulus & the response

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Nerve Injuries - Principles

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Amplitude = size of response Nerve Conduction Velocity (V) = d / t (d = distance between stimulating & recording electrodes) Motor Nerve: Recording electrode (cathode) placed over a muscle supplied by the nerve (over the 'motor point' = region where the nerve enters the muscle) Indifferent electrode is placed a few centimeters away Ground electrode placed over an inactive muscle nearby Stimulation site is where the nerve is superficial (eg. elbow) Stimulator is turned on until a clearly defined CMAP (compound motor action potential) appears = ' threshold ' Stimulus is increased by 50% to ' supramaximal ' ensuring complete activation of the muscle. A second stimulator is added, distal to the first stimulator & closer to the recording electrode. The segment velocity between the 2 stimulation sites is calculated: V (motor) = [d 1 -d 2 ]/ [t 1 -t 2 ] (where V (motor) = segment velocity in motor fibres; d 1 is distance betw. first (proximal) stimulation site & recording cathode; d 2 is distance betw. second (distal) stimulation site & recording cathode betw. second (distal) stimulation site & recording cathode)

Motor nerve conduction test for Ulnar nerve above & below elbow

Motor nerve conduction test for Ulnar nerve at wrist using ADM (from TeleEMG )

Sensory Nerve: CNAP (compound nerve action potential) is measured (lower amplitude than CMAP) a uniquely sensory nerve must be chosen for the stimulation site V (sensory) = d / t (where V (sensory) is the segment velocity in sensory fibres; d is distance betw. stimulation site & recording cathode; t is the average latency betw. stimulus & CNAP)

Sensory nerve conduction test for Ulnar nerve across the wrist (from TeleEMG ) Collision Studies Timing of NCS: Immediately after section of a peripheral nerve, stimulation distally will elicit a normal response for 18-72 hrs until wallerian degeneration occurs. Absence of distal nerve motor conduction (CMAP) after 3-7 days excludes a neuropraxia type injury. Absence of sensory conduction (CNAP) after 7-10 days excludes a neuropraxia type injury. Therefore the ideal time for NCS after injury is 10-14 days after injury to discern neuropraxia from axonotmesis / neurotmesis. Neuropraxia will improve (incr. velocity & decr. latency) with repeated tests, while axonotmesis & neurotmasis will deteriorate Somatosensory Evoked Potentials (SSEP) = stimulate peripheral sensory nerves & measure on the scalp. For study of brachial plexus & spinal cord monitoring. Electromyography A needle electrode in the muscle is used to record motor unit activity at rest and on attempted contraction of the muscle Normal EMG shows no muscle activity at rest and a characteristic pattern on voluntary contraction Normal EMG

Immediately after nerve section, EMG will be normal, although there will be no muscle response after stimulation of the nerve proximal to the nerve injury (CMAP) Within Between 5 and 14 days positive sharp waves consistent with denervation Positive sharp waves of Denervation

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Nerve Injuries - Principles

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At between 15 and 30 days, spontaneous denervation fibrillation potentials are present Denervation fibrillation potentials

If denervation fibrillation potentials are not present by the end of the 2 nd week this is a good prognostic sign. Evidence of reinnervation is when highly polyphasic motor unit potentials are detected at attempts at voluntary activity Denervation fibrillations in a muscle only tell you that the muscle is not innervated. It does not determine whether the injury is 2 nd 3 rd or 4 th degree. Reinnervation potentials by the same token can be restored after regeneration of only a few motor fibres and does not necessarily mean a good return to voluntary motor control EMG Findings in Specific Conditions:

Condition
Normal Neuropraxia Axonotmesis Neurotmesis Axonal Neuropathy Demyelinating Neuropathy Anterior Horn Disease Myopathy

Insertional Activity *
Normal Normal Increased Increased Increased Normal Increased Increased

Rest Activity **
Silent Silent Increased Increased Increased Silent Increased Silent

Fibrillations ***
No No Yes Yes Yes No Yes Yes

Sharp Waves
No No Yes Yes Yes No Yes Yes

* Insertional Activity = needle is inserted into muscle or moved within muscle, there is a single burst of activity that usually lasts 300 to 500 ms; thought to result from mechanical stimulation or injury of the muscle fibers ** Rest Activity = differentiates neuropathic muscle atrophy from myopathic atrophy *** Fibrillations - are action potentials that arise spontaneously from single muscle fibers; usually occur rhythmically and are though to be due oscillations of the resting membrane potential in denervated muscles. Appears 3 - 5 weeks after the n
++

Potentials - number of phases (? action potentials); indicates collateral axonal sprouting; polyphasic = > 4 phases

8. Early management of nerve injuries

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ABCs as with any injury Open wound with nerve injury - thorough debridement . If wound adequately clean and general state of the patient allows, then immediate primary nerve repair is preferred Open wound but patients general state in danger . clean wound and dress with moist dressing, attempt repair at 3-7 days Contaminated wounds- Thorough debridement, mark ends of nerve with a suture and consider suturing to soft tisssue to avoid retraction. Repair the nerve when the soft tissues have healed at 3-6 weeks post injury A closed injury with peripheral nerve damage . Early active motion of all affected musce groups should be started. Contractures should be prevented by passive motion. Specific effects of electrical muscle stimulation are unclear. Dynamic a A closed fracture associated with nerve injury. Early exploration usually avoided. Assess progress of functional return using EMG, NCS and clinical assessment. However, if ORIF required explore nerve too. If nerve deficit follows manipulation and /or casting of a closed fracture. Early exploration is favoured

9. T echniques of nerve repair (neurorrhaphy) Epineurial

[Back To Top] Perineurial Epi perineurial repair

Clinical evidence to support one over the other type of repair is meagre. The technique selected depends on the experience of the surgeon.

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Nerve Injuries - Principles

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Sunderland points out that fascicular repair is not possible in all cases, but most practical when Fascicular groups are large enough to take sutures Each fascicular group is made up of fibres to a partiicular branch occupying a constant position at the nerve ends eg. In median and ulnar nerves above the wrist and radial nerve above the elbow.

10. Aftertreatment

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Opinions differ as to when joints can be moved In upper limb, immobilise in a plaster splint or cast for 4 weeks, then replace in a plastic splint, gradually extending the joint over 2-3 weeks In lower limb immobilise for 6 weeks Rigid splinting not justified if prognosis for nerve function doubtful Dynamic splinting of distal joints with passive exercises to maintain motion whilst nerve recovers

11. Factors influencing regeneration after nerve repair (neurorrhaphy) Info from warzone injuries 1. Age

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Worsening results with increasing age, though numbers at extremities of age are small 2. Gap between nerve ends Nicholson, Seddon and Sakellarides noted that the upper limit of gap beyond which results will deteriorate is 2.5 cm. Methods of closing gaps; 1. 2. 3. 4. 5. nerve mobilisation nerve transposition joint flexion nerve grafts bone shortening

3. Delay between injury and repair Delay affects motor recovery more than sensory recovery (due to the survival time of striated muscle. Satisfactory reinnervation of muscle can occur after denervation of 12 mnths Little evidence about sensory function return in relation to delay, but sensation can improve in as late a repair as 2 years. Kleinert et al feel that a delayed repair of between 7 and 18 days is best for return of satifactory function. Reasonable approach is immediate repair if conditions allow and before 6 weeks in extensive soft tissue contusion, co 4. Level of injury The more proximal the lesion, the more incomplete the recovery. Boswick et al reviewed 102 peripheral nerve injuries in 81 patients. 87% of those injuries below the elbow gained protective sensation. 14% regained normal 2 p 5. Condition of nerve ending The better the condition the more improvement Further Reading: Review of Orthopaedics - Mark Miller Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998. Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998. Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998. Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998. TeleEMG - http://www.teleemg.com/

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Replantation & Microsurgery

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Replantation & Microsurgery


Amputation defined by the anatomical site Can be guillotine, crush or avulsion (these have the poorest results and prognosis) Care of the amputated part Gently irrigate with Hartmann's Wrap in wet swab Place in bag and place bag in ice Ischaemia time

Warm ischaemia time

Cool ischaemia time (4oc)

Digit Significant amount of muscle Indications for Replantation 1. 2. 3. 4. 5. 6.

12 hours 6 hours

24 hours 12 hours

Thumb amputation Multiple digit amputations Metacarpal amputation Almost any body part in a child Wrist or forearm amputation Individual digit distal to FDS insertion, replantation at level distal to insertion of FDS often results in satisfactory function [Diagram]

Contra-indications 1. Local: 1. Severely crushed or mangled parts (See MESS) 2. Amputations at multiple levels

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Replantation & Microsurgery

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3. Distal amputations, amputations distal to the DIP joint are difficult to replant since the digital artery begins to branch and dorsal veins are hard to find 2. General 1. Amputations in patients with other serious injuries or diseases 2. Arteriosclerotic vessels 3. Mentally unstable patients Ring Avulsion Injuries (Urbaniak classification) Class I Class II Class III circulation adequate: requires standard bone and soft tissue treatment circulation inadequate: requires vessel repair complete de-gloving injury or complete amputation

Concomitant proximal phalangeal fracture or PIP joint injury, consider amputation Complete amputations proximal to the FDS tendon insertion (male pts) should be treated with amputation although may consider proximal replant in children or females Single digit replantation proximal to FDS insertion produces a digit with significant functional impairment (avg. PIPJ ROM in these digits is only 35o although cold intolerance and sensation are comparable to more distally amputated group Surgical Technique (in sequence)

Bilateral midlateral incisions Isolate vessels and nerves debride 1. Shorten and Fix Bone 2. Repair the flexor and extensor tendons (in the case of a hand replantation the flexor and extensor tendons are repaired after arterial and venous flow has been established) 3. Repair nerves (before arteries, since tourniquet required) 4. Anastamose arteries (hand or forearm replantations, consider use of arterial shunt before the vascular

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Replantation & Microsurgery

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anastomosis; give systemic heparin) 5. Anastamose Veins (2 for each artery, or 3 veins minimum) veins are never repaired before arteries, especially in hand or forearm replants since repercussion toxins will enter into the body 6. Skin coverage 7. Skin coverage Post Op: Temperature probe Complications: Early 1. Arterial insufficiency 1. inspect and loosen dressing 2. change hand position 3. stiletto block (spasm) 4. heparin bolus (3000 to 5000 units) 5. if no improvement in 4-6 hours, return to theatre for re-do anastamosis 50-60% successful 2. Venous insufficiency Can use medical leeches, but must give antibiotics to cover for aeromonas hydrophilia 3. Infections More common in upper extremity replantations which develops myonecrosis Late 1. Functional difficulties Related to "one wound, one scar" concept with resultant loss of differential gliding between the tissues Motion of digits significantly affected by overall injury sustained, motion of PIPJ accounts for 85 % of arc of finger motion 2. Cold intolerance Thought to improve after 2 years but a recent long-term study (1995 ASSH Meeting abstract) has shown no improvement. Nerve recovery Dependent on the type and level of injury, but overall the results are comparable to isolated nerve injuries 2 point discrimination adults 11mm, children 9mm Fine tactile discrimination rarely ever returns Mangled Extremity Severity Score (MESS) (from Johansen etal. 1990)

Skeletal / soft-tissue injury

Low energy (stab; simple fracture; pistol gunshot wound) 1

Medium energy (open or multiple fractures, dislocation) 2

High energy (high speed RTA or rifle GSW) 3

Very high energy (high speed trauma + gross contamination)

Limb ischaemia

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Replantation & Microsurgery

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Pulse reduced or absent but perfusion normal 1*

Pulseless, paraesthesias, diminished capillary refill 2*

Cool, paralysed, insensate, numb 3*

Shock

Systolic BP always > 90 mm 0

Hypotensive transiently 1

Persistent hypotension 2

Age (years)

< 30 0

30-50 1

> 50 2

* Score doubled for ischaemia > 6 hours Limb salvage vs. amputation. Preliminary results of the Mangled Extremity Severity Score In both the prospective and retrospective studies, a MESS score of greater than or equal to 7 had a 100% predictable value for amputation Results Adults 80% success Children 70% success - poorer results in children reflects a more aggressive approach Best results for thumb, hand, and distal forearm Functional Outcome (Ch'en Criteria) I Able to resume original work ROM 60% of normal Complete or nearly complete sensation

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Replantation & Microsurgery

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Motor MRC 4/5 II Able to resume some suitable work ROM 40-60% of normal Nearly complete sensibility Motor MRC 3/4 III Able to perform ADL ROM 30-40% of normal Partial recovery of sensibility Motor MRC 3 IV Almost no usable function

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Scaphoid Fractures

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Scaphoid Fractures
Clinical Sequelae Occult Fractures Non-union Classification SNAC Treatment

CLINICAL History

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Forcible dorsiflexion of the wrist Palmarflexion in 3% of cases Examination Fullness in the ASB indicates an effusion in wrist Careful palpation of all the bony landmarks, with tenderness in the ASB and scaphoid tubercle Pronation followed ulnar deviation will cause pain Special tests Scaphoid compression test - longitudinal force along the 1 st metacarpal Kirk-Watson's test Resisted pronation X-ray Good quality films are required 1. PA in ulnar deviation 2. Lateral with wrist in neutral 3. Scaphoid view 1 : PA 45deg. pronation & ulnar deviation; + shows STT joint [ Picture ] 4. Scaphoid view 2 : AP with 30deg supination & ulnar deviation; + shows radioscaphoid joint Others: PA with wrist in slight extension (Ziter view) AP with clenched fist to detect a ligamentous injury False negative rate: Leslie and Dickson 1981 2% Munk et al. 1995 6%

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Scaphoid Fractures

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A- C: Scaphoid view 1 - with forearm pronated 45deg. to view profile of scaphoid & STT joint; D Scaphoid view 2 (ulnar oblique view) showing radioscaphoid joint (from Rockwood & Green)

OCCULT FRACTURES Bone Scanning

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Sensitive but not very specific CT Can still miss fractures MR Excellent sensitivity and specificity Fracture line will be visible on T2 weighted sequence as line of high signal which represents marrow oedema Changes present on MR after 12 hours CLASSIFICATION (Herbert)
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Scaphoid Fractures

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TREATMENT

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Stable non-displaced fractures POP cast immobilisation Type of cast immobilisation Below elbow cast - No need to include the thumb Position of wrist Ulnar deviation will distract the fracture, therefore this must be avoided Neutral in AP plane Moulded into the palm Duration 8 weeks Re-examine and X-ray at 8 weeks out of plaster If still tender then treat in cast for a further 4 weeks At 12 weeks leave free regardless of whether there is tenderness or not Re-X-ray at 6 months

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Scaphoid Fractures

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Operative treatment Indications Trans-scaphoid perilunate dislocations Displacement of more than 1mm in any direction Approach Volar Through bed of FCR Good for waist and distal fractures Procedure (Joe Dias): Surface: Scaphoid tubercle & FCR tendon. Inc: Longit. along FCR radial border to scaphoid tubercle, then angle radially along the direction of APB. Dissect through the bed of FCR tendon sheath. Incise & reflect the capsule & the radioscaphoid & radioscapholunate ligaments. Define the scaphotrapezoid joint by reflecting the scaphotrapezoid lig. radially. Proc: Check Herbert jig. Correct side should be showing on jig. Check long drill bit lies in correct position to spike. Insert jig by putting spike as far dorsally behind prox. pole as possible. Jig should lie 45deg. to surface & 45deg. to long axis of forearm. Check position w/ Image Intensifier. Prepare # & bone graft from iliac crest. -> Long drill right down.-> Short drill.-> Tap-> Screw as per length on jig. Avoid Scapholunate joint ! If too difficult, use an AO cancellous screw or K-wires. Dorsal Between EPL and EDC (Extensor compartments III and IV) Good for proximal 1/3 fractures Care must be taken to preserve the blood supply to the scaphoid which enters along the dorsal ridge Procedure: Inc: Longit. over Lister's tubercle. Incise extensor retinaculum & compt. 4. Reflect ECRB & EPL radially. 'L' incision of dorsal ligament reflecting flap to radial side, entering joint. Flex wrist 90deg. to expose prox. pole & #. Prepare & bone graft. Long drill in parallel with dorsal scaphoid ridge (prominent ridge on dorsum of scapoid- expose it). Check w/ II. short drill- etc. Types of internal fixation Herbert screw Herbert-Whipple screw AO low profile compression screw Acutrack screw K-wires

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Scaphoid Fractures

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SEQUELAE OF SCAPHOID FRACTURES 1. Delayed union >4 months 2. Non-union Leslie and Dickson 5% Dias et al 12.3% 3. Malunion scaphoid may heal in a flexed position "hump back" deformity 4. Avascular necrosis - See eHand Images 5. DISI

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6. Scaphoid Non-union Advanced Collapse (SNAC)

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Develops from a longstanding scaphoid non-union. Takes from 5-10 years to develop in most cases but can take up to 20 years The proximal pole of scaphoid acts like a lunate OA develops between distal scaphoid fragment & radial styloid (not between radius & proximal fragment) loss of carpal height radioscaphoid (RS) OA SNAC I Radial styloidectomy Care must be taken to preserve the radiocarpal ligaments

RS OA + scaphocapitate (SC) OA SNAC II

Partial scaphoid excision (distal pole) Proximal row carpectomy All results are better with larger proximal pole fragments Proximal pole excision or prosthetic replacement has been universally abandoned because of carpal instability

RS + SC + lunocapitate OA SNAC III

Scaphoidectomy plus 4-corner fusion

What is the aim of treating non-union?

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Correct carpal kinematics To achieve union Reduce pain Increase function Reduce the risk of developing secondary degenerative changes Non-union: No OA or AVN ORIF - for undisplaced fractures Matti- Russe inlay grafts Interposition trapezoidal graft + screw fixation inserted after excision of the non-union Non-union: AVN present but No OA

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Scaphoid Fractures

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Matti- Russe inlay grafts ORIF Vascularised bone grafts Non-union: OA present but No AVN See SNAC (above) Salvage procedures Wrist Denervation Total wrist fusion

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Scapholunate Ligament Rupture

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Scapholunate Ligament Rupture

slrecon1.JPG Scapholunate ligament rupture. Initial XR at presentation after fall off ladder. Treated with Physio

slrecon2.JPG XR at 3 weeks after injury

slrecon2a.JPG XR at 3 weeks after injury - clenched fist view

slrecon3.JPG Intr-operative film Scapholunate lig. was repaired & 2 k-wires support POP for 6wks

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10/6/2007 12:24 PM

Tendon Injuries

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Tendon Injuries
ACUTE INJURY Contraindications Wrist Anatomy Zones Post-operative Tendon Nutrition Incisions Complications Types of Injury Technique TENDON RECONSTRUCTION

ACUTE FLEXOR TENDON REPAIR Anatomy


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Tendon Injuries

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Tendon Injuries

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Annular & Cruciate pulleys prevent bow stringing of flexor tendons. Thumb - Oblique pulley over proximal phalanx. Tendon Nutrition
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The vinculae are remnants of mesotenon & provide the blood supply & nutrition to the flexor tendons. The vincular system is supplied by the transverse communicating branches of the common digital artery. Nutrition of the tendons is also derived from the synovial sheaths thus early mobilisation post-op is important. Types of Injury
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The position of the hand at the time of injury determines the tendon retraction: Flexed fingers - distal tendon retracts Extended fingers - proximal tendon retracts Contraindications to Repair
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1. Wounds liable to infection 2. Inability of patient to cooperate with rehabilitation Failed primary repair is worse than no repair! If only one tendon is cut the functional

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Tendon Injuries

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result will be better than a poor repair. Zones [Diagram]


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Zone 1 Zone 2 Zone 3 Zone 4 Zone 5 Thumb T1 Thumb T2 Thumb T3

FDS insertion to FDP insertion Zone 1 to proximal part of A1 pulley Zone 2 to distal edge of flexor retinaculum within carpal tunnel proximal to carpal tunnel FPL insertion to A2 pulley Zone 1 to distal part A1 pulley Zone 2 to carpal tunnel

The tight A4 pulley makes repair difficult. Aim to advance FDP stump to reattach to terminal phalanx. two slips of FDS; Vincula easily repaired with good results. Don't suture lumbrical muscle around tendon repair. Can use mattress sutures if many tendons need repair. FPL tendon lacerations often retract into the thenar area or wrist; - unlike the fingers, the FPL often lacks a vinculum and does not have a lumbrical, and therefore the tendon is free to retract; Repair requires an incision prox. to carpal tunnel & ' pull-through ' also damage thenar muscles & recc. br. median nerve.

Incisions

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Tendon Injuries

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Safe Volar Hand Incisions

For retracted tendons: Try milk the tendon with the wrist flexed. Small incision a the distal palmar crease just proximal to A1 pulley. Pass a silastic cannula from the distal wound through the sheath to the proximal wound. Attach the proximal tendon to the cannula & pull through to distal wound. Technique
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Core Non-absorbable 4/0 suture - Modified Kessler technique. 6/0 monofilament running epitenon suture. Close sheath, if possible. Multiple Flexor Tendons at the Wrist (Zone 5)
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Order of Repair: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. FPL FDP tendons FDS to middle & ring fingers FDS to index & little fingers Ulnar nerve Ulnar artery Median nerve FCU FCR Radial artery - ligated.

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Tendon Injuries

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Post-operative program Belfast Regimen:

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(J. Hand Surg. 14B:383-391. 1989) At 48hrs post-op remove dressings & apply splint Thermoplastic splint : wrist 20deg., MCP 70deg., 2/3 up forearm, straps on palmar crease, wrist & forearm. First 6 weeks: Fingers- Every 2hrs.- [1] Passive flexion (2x/ individual finger)- [2] Active extension (2x/ mass action)- [3] Active flexion (2x/ mass). Thumb- Every 3hrs.- as above. After 6 weeks: Remove splint & progress to active flexion of individual joints. 6-8 weeks: use hand, no heavy liting. 8-10 weeks: slowly incr. activity, stretches into extension, fine work. 10-12 weeks: Driving, heavier work. > 12 weeks: Full funtion (60% strength back at 16 weeks). Complications 1. 2. 3. 4. 5.
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Rupture Infection Adhesions - prevented by early passive ROM Joint contractures - too tight repair or from prolonged splintage Bow stringing - from damaged pulleys
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SECONDARY FLEXOR TENDON REPAIR & RECONSTRUCTION Defined as delayed primary repair performed > 3wks after injury.

Contracture of the muscle-tendon unit has usually occurred & tendon graft often required. Prerequisites for tendon reconstruction: 1. 2. 3. 4. Adequate skin & soft tissue cover Skeletal alignment Good passive ROM of joints Adequate sensation & circulation of finger

Methods: 1. 2. 3. 4. 5. 6. Delayed direct repair single stage flexor tendon grafting two-stage grafting tenodesis or arthrodesis tendon transfer Amputation

Two-stage Flexor Tendon Reconstruction Contraindications: 1. 2. 3. 4. 5. Infection Too much damage to support an implant or allow decent tendon gliding Motivated patient Experienced surgeon Experienced Hand Therapist

First Stage:

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Tendon Injuries

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Aims: 1. 2. 3. 4. 5. 6. 7. Joint contractures must be released Tenolysis of scarred tendons Finger must have free & full passive ROM Digital nerve repair or grafting Provide healthy skin (may require a flap) Full flexion on traction of the silastic rod at the wrist Preserve A1, A2 & A4 pulleys

Second Stage: 2 - 3 months after first stage. Tendon Graft options: 1. 2. 3. 4. 5. Palmaris Longus Plantaris - best for multiple tendon grafts Long toe extensors - 2nd, 3rd or 4th toes EIP Fascia Lata

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Tendon Transfer - Principles

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Tendon Transfer - Principles


Definition A tendon transfer is a procedure in which the tendon of insertion or of origin of the functioning muscle is mobilised, detached or divided and reinserted into a bony part or onto another tendon, to supplement or substitute for the action of the recipient tendon Indications for tendon transfers 1. Irreparable nerve damage 2. Loss of function of a musculotendinous unit due to trauma or disease 3. In some nonprogressive or slowly progressive neurological disorders Basic principles of tendon transfer 1. Mobile Joints / Correction of joint, skin and soft tissue contractures If necessary, capsulotomy, or free flap may be necessary prior to tendon transfer 2. Adequate power of transferred tendon Power of a muscle is determined by its cross sectional area Only muscles with power of 4+ should be considered donors as they always lose 1 MRC grade of power 3. Sufficient amplitude (excursion / freedom of movement) in the transferred tendon The amplitude of a muscle is a function of the sarcomere length It is a fixed value for any muscle, but can be increased by Freeing the muscle from its fascial attachments Changing a muscle from monoarticular to biarticular, the amplitude is increased by movement of the extra joint that the tendon crosses Amplitude can be limited by scarring and adhesions As a guide, amplitudes are as follows W rist motors 33mm 50mm 70mm

Finger extensors Finger flexors

4. Maximal work capacity of the transfer Power x amplitude = work capacity (Kg.M) 5. The transferred tendon should be of adequate length A graft can be used as an extension, but all anastomoses are sources of adhesions 6. A satisfactory line of pull should be achieved The less turns or bends through which the tendon has to pass, the less friction can reduce power and amplitude 7. An adequate glide of the transferred tendon is necessary, through unscarred natural planes 8. Functional integrity must be preserved The transferred musculotendinous unit must be expendable If a tendon is split and inserted into different sites only the tighter of the two will function and the other will not In extensive paralysis Restore function from proximal to distal In general function is restored using the following scheme 1. Stabilisation of the shoulder

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Tendon Transfer - Principles

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2. Flexion of elbow 3. Extension of wrist 4. Flexion of fingers 5. Reestablishment of thumb grip in opposition or lateral thumb grip 6. Finger extension 7. Restoration of function of the interrossei

Surgical considerations in tendon transfers 1. Timing If no chance of functional recovery, transfers should be performed ASAP Following nerve injury repair, the date of expected recovery can be calculated by measuring the distance between the injury to the most proximal muscle supplied, assuming a rate of regeneration of 1mm/day. If reasonable return of function not present for 3 mnths after the expected, consider tendon transfer. Early tendon transfers - within 12 weeks of injury 2. Planning Make a list of deficient functions Make a list of available donor muscles 3. Techniques 1. Multiple short transverse incisions rather than long longitudinal incisions 2. Careful tendon handling 3. Good soft tissue coverage over the tendon junctures 4. Joining the tendons 1. End to end anastomoses 2. End to side anastomoses 3. Side to side anastomoses 4. Tendon weave procedures can all be used 5. Achieving proper tension - No general rule, but reasonable to place limb in the position of maximal function of the tendon transfer and suture without tension

Nerve Injuries & Tendon Transfers in the Upper Limb Review by Robert Boome, Consultant Peripheral Nerve Surgeon

Tendon Transfers - summary table Low injury (wrist) High injury (elbow)

MEDIAN NERVE: Thumb Opposition (loss of FBP) (note thumb opposition is combination of flexion and adduction) 1. Ring finger FDS transfer to APB via a pulley made in the FCU tendon at the level of the pisiform. [Picture] 2. MCP +/or IP joint fusion For index and middle finger flexion FDP of index and middle finger sutured side to side to FDP of ring and little fingers, +/- ECRL tendon transfer to FDP for extra strength For flexion of IP joint of thumb -Brachioradialis transfer to FPL For thumb opposition -Extensor indices transfer to Abductor pollicis brevis

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Tendon Transfer - Principles

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ULNAR NERVE: For Adductor pollicis and FPB (thumb opposition) Absent FPB = Ring finger FDS transfer to APB via a pulley made in the FCU tendon at the level of the pisiform. [Picture]. 2. If FPB working and adductor not = use extensor indices transfer through interosseous membrane to adductor pollicis 1. For loss of action of interrosei and ulnar 2 lumbricals 1. Split tendon transfers of FDS + /- EIP & EDQ , to radial dorsal extensor apparatus (tenodesis procedures) 2. Or stabilise MCP joint with Zancolli capsulodesis where the volar capsule is tightened to produce slight flexion of MCP joint (not very successful). +For loss of FCU - Use ECRL transfer for power

COMBINED MEDIAN & ULNAR NERVES: very difficult problem For function of the interrossei and lumbricals, to restore flexion of MCP joint and extension of IP joints - Brands ECRB graft with a plantaris graft to increase length, attached to insertion of intrinsics Thumb opposition - FDS (ring finger) via FCU pulley to EPL [Picture] Thumb adduction (pinch) - EIP to Adductor pollicis RADIAL NERVE: (Radial wrist extensors functioning:) wrist extension - Pronator Teres to ECRB MCP joint extension - FCR / FCU to EDC or FDS to EDC extension and abduction of the thumb - PL rerouted to EPL If radial nerve might still recover keep EPL in continuity and bring palmaris longus upward For function of the long flexors & interrossei and lumbricals, to restore flexion of MCP joint and extension of IP joints - Zancolli Capsulodesis of MCP joints, ECRL to FDP, BR to FPL, ECU (with free graft) to EPL Thumb fusions

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Ulnar Nerve Palsy Signs

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Ulnar Nerve Palsy Signs

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Vascular Disorders

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Vascular Disorders
Aneurysms of the Upper Extremity Thoracic Outlet Syndrome Vascular Malformations Occlusive Vascular Disorders Vascular Tumours Vasospastic Disorders

Author: James Carmichael Aneurysms


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Pulsatile , tender mass Vasospastic symptoms Digit ischaemia and/or gangrene from Embolic showers from mural thrombi Adjacent nerve compression May be erythematous and mimic an abscess Systolic bruit or thrill Allen's test may be positive if the aneurysm is occluded, also perform digital Allen's test Treatment Surgery recommended due to risk of thrombosis and peripheral embolism Reconstruction versus resection Choice guided by adequacy of digital blood flow after resection Vascular Malformations
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Arteriovenous Malformations High flow lesion May start small in childhood and be triggered to enlarge after trauma Spontaneous bleeding may occur Clinical Findings Possible thrill Ischaemic ulcers distal to the lesion Investigation Doppler: continuous murmur MRI: high versus low flow Contrast arteriography Treatment Resection may be dangerous Consider embolisation therapy but carries a high risk of digital ischaemia Ligation of feeding vessels of no help proximal ligation only increases collateralisation High-flow arteriovenous malformations are difficult to treat, & staged partial Excisions are mostly palliative YAG laser, used in direct contact with tissue for incision & thermal coagulation has allowed subtotal excision of complicated haemangiomas of the hand previously thought to be untreatable Laser will not stop bleeding from blood vessels with lumen diameters greater than 1 mm Venous Malformations Venous malformations, although present at birth, often are not noticed until 1 year of age They engorge when dependent, decompress when elevated, and enlarge with trauma, puberty, pregnancy, or use of oral contraceptives

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Vascular Disorders

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Frequently confused with haemangiomas Present at birth Slow steady growth Do not involute Discrete and diffuse subtypes Diff Dx 1. 2. AVM Haemangioma

Investigation MRI: can distinguish between high flow (AVM) and low flow lesions (venous malformations); Closed system venography Treatment: Low-flow venous and lymphatic malformations treated conservatively by compression garments or surgically by staged debulking Surgery complicated by bleeding or lymphatic leaks, haematoma or seroma formation, skin necrosis, scarring, ulceration, contractures, and distension of channels in the same or adjacent areas

Vascular Tumours Haemangiomas

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Benign, vascular tumour that occurs in children, usually in limbs or trunk Most common form of haemangioma has infiltrative margins composed of both large and small vessels Despite their vascular origin, haemangiomas do not metastasise or undergo malignant transformation Pyogenic granuloma variant of capillary haemangioma appears on the fingertip following a minor laceration consists of benign vascular granulation tissue May be pedunculated or polypoid Purplish red colour & friable Rx = surgical excision Glomus Tumour Glomus body is a neuromyoarterial apparatus. Controlled arteriovenous anastomosis or shunt between terminal vessels, function is to regulate peripheral blood flow in the digits. Majority of the lesions occur in females between 30-50 years Clinical features: Frequently involves nail bed with classic triad of recurrent excruciating pain, tenderness and cold sensitivity Placing involved digit in ice water will usually reproduce pain within 60 sec Nail bed ridging (and possibly a small blue spot at the base of the nail can be seen) Multiple tumours in 25% of patients

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Vascular Disorders

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May have no visible or palpable signs except for a bluish discoloration Radiographs: X-rays for apposition loss: perforating lesion of the phalanx, may also show a shelled out lesion dorsal lesion Treatment: In terms of excision the tumour is usually well encapsulated and can be shelled out Thoracic Outlet Syndrome [Back To Top]

Most often affects subclavian artery, vein, and lower trunk (C8 /T1) of brachial plexus Both the subclavian artery and the brachial plexus traverse between the anterior and middle scalene muscles. Most symptoms arise from neural compression Age 18-40 (never before puberty rare after 50yr) Aetiology : cervical rib (< 10 % of pts with cervical ribs will have symptoms), fibrous bands, anterior scalene muscle constriction, 2 o to clavicular # ( xs callus/ hypertrophic non-union), pancoast tumour In some cases, thoracic outlet syndrome will be accentuated by recurrent anterior shoulder instability, and this may be the cause of the "dead arm syndrome" General Examination: Tenderness or mass in supra- clavicular fossa Neurological Examination Compression of the inferior trunk C8/T1 Sensory changes in the ring and little finger Intrinsic weakness Vascular Examination Radial pulse obliteration is not itself specific, but loss of pulse with reproduction of symptoms is a positive test Provocative tests 1. Adson's test Arm of the affected side adducted with forearm supinated Turn head toward the affected side Extend neck and hold breath Positive test is obliteration of the radial pulse 2. Reverse Adson's test As above but head turned away from the affected side 3. Wright's test ( Hyperabduction stress test) Axillary vessels and plexus bent 90 o at the junction of the glenoid and humeral head Place extremity in full abduction, external rotation and reach back as far possible. Turn head away and check for decrease or loss of radial pulse Creation of a bruit in the supraclavicular area is further evidence 4. Roos ' overhead exercise test Above head repeated forearm exercise may reproduce symptoms Investigations: X-ray - Cervical ribs may be seen but more commonly the cause is a fibrous band which will not show up on X-rays CXR to rule out pancoast tumour MR scan to exclude cervical disc disease Treatment

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Vascular Disorders

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Non-operative (for at least 4 months) Postural re-education Activity modification Weight loss Operative (rarely required) Excision of first rib with fibrous band and anterior scalene muscle via supra- clavicular , subclavicular or axillary approach Occlusive vascular Disease [Back To Top] Tend to be unilateral conditions unlike the vasospastic conditions which tend to be bilateral Embolic Disease 20% of all arterial emboli occur in the upper limb

70% are of cardiac origin with the remainder originating from aneurysms or from Thoracic Outlet Syndrome. Treatment is by embolectomy followed by anticoagulation, if this is not possible consider thrombolysis . Post Traumatic Vascular Occlusion The most common example in the upper extremity is the hypothenar hammer syndrome where local trauma causes thrombosis of the ulna artery at Guyon's canal. The resulting ischaemia is worsened by an associated increase in sympathetic tone causing peripheral vasospasm. The thrombosis can also embolise where it is most likely to affect the ring finger

Treatment: Resection of the thrombosed segment with or without sympathectomy and / or reconstruction Effort Thrombosis of Axillary Vein Rare condition but suspect in throwing athlete with upper extremity oedema as this may indicate effort thrombosis of axillary vein Arteritis and Systemic Disorders The following should be considered as possible causes of upper limb occlusive disease: Thromboangitis obliterans ( Buergers Disease):- smoking induced vasculitis that is treated when smoking stops Giant Cell Arteritis : Can affect the subclavian and axillary arteries

Polyarteritis nodosa : Necrotising arteritis that preferentially affects the bifurcations of small vessels (e.g. the digital arteries) Connective Tissue diseases (RA, SLE etc) Can cause vascular occlusion through immune complex deposition Atherosclerosis [Back To Top]

Vasospastic Disorders Raynaud's Raynaud's phenomenon:

Episodic Digital Ischaemia

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Vascular Disorders

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Associated with connective tissue diseases, vibration, neurological disorders, arterial occlusive disorders and blood dyscrasias Raynauds Syndrome: o o o o o o o o When the syndrome occurs as part of a disease e.g.: Connective tissue disease Occlusive arterial disease Neurovascular compromise (e.g. Thoracic outlet syndrome) Haematological abnormalities (e.g. polycythaemia ) Occupational Trauma (e.g. Vibration white finger) Drugs CNS disease Misc (e.g. RSD or Malignancy

Raynaud's disease: Primary vasospastic disorder without a demonstrable or associated disease occurring mainly in young women. Diagnosis is by Allen and Brown's criteria: Intermittent Bilateral No clinical arterial occlusion Gangrene or atrophy is rare and limited to distal digit >2yr history No associated disease

Investigations: TFT's - these patients will often have a subtle hypothyroidism Cryoglobulins - many patients with significant amounts of cryoglobulins are asymptomatic others develop purpura , Raynaud's phenomenon, cyanosis, and tissue necrosis when exposed to cold Patients with mixed cryoglobulinemia frequently have vasculitis , glomerulonephritis , lymphoproliferative disorders, or chronic infection, particularly with hepatitis B virus Treatment: Protection from the cold/ heated gloves (the most effective treatment overall) Stop smoking Digital and/or cervical sympathectomy Pharmacological 1. 2. 3. 4. 5. 6. Alpha blocking agents ( dibenzyline ) Myovascular relaxants (nicotinic acid, cyclospasmol ) Catecholamine and or serotonin depletors ( reserpine ) Nifedipine Nicardipine T3

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Vascular Disorders

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Wrist Arthroscopy

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Wrist Arthroscopy
Indications Complications Positioning & Preparation Portals Images

Indications:

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1. Chronic wrist pain for > 3months 2. Guide to planning further treatment 3. Carpal instability Confirm diagnosis & additional associated damage Arthroscopic reduction & percutaneous pinning of scapholunate dissociation 4. TFCC tears - Diagnose & debride 5. Remove loose bodies 6. Excision of Dorsal wrist ganglion 7. Synovial biopsy 8. Synovectomy 9. Keinbock's disease - staging Arthroscopic debridement of the head of the capitate may unload the lunate allowing revascularisation (Lena et al.) 10. Fracture reduction of distal radius fractures & treat associated TFCC tears. 11. Bone grafting of lunate cysts & scaphoid fractures. Complications:
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Complication rate is only 0.5% Warhold & Ruth reviewed 205 wrist arthroscopies & found: 1. one stitch abscess 2. one inclusion cyst 3. 2 cases of CRPS Potential complications: 1. 2. 3. 4. traction related complications incurred during the establishment of portals procedure-specific complications others
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Positioning and Preparation:

Finger traps (to index and long fingers) tied to drip-stand

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Wrist Arthroscopy

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Elbow to be flexed 90 deg Counter traction is applied to the arm with use of a second 10 lb weight attached to sling over tourniquet on upper arm. Mark out the dorsal wrist veins before wraping out and elevating the tourniquet Gravity assistant inflow Initially inject saline to distend the capsule 2.4mm or 2.7mm wrist scope Wrist Portals:
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arthroscopic portal: - 3/4 portal: (between ECRL & EPL) - lies 1 cm distal to the Lister's tubercle; insert the scope in line with the dorsal radial slope; Instument portal: 6U portal: placed just ulnar to ECU - note the proximity of the dorsal ulnar cutaneous branch instrumentation portal 2: 4/5 portal: (between EDC & EDM) mid-carpal portal: MC portal: lies in the scaphocapitate interval; - inserted 1cm ulnarwards & 1cm distal to 3/4 portal; It is radial to the third ray, distal to the proximal row, just radial to the EDC to the index finger. 1/2 portal: between the ECRB & APL; - note that the radial artery courses along the volar aspect of this interval. Images:
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Wrist Arthroscopy

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Further Reading: Wrist Arthroscopy - Wrightington Hospital Thurston AJ. Current Orthopaedics. 13:120-30.1999.

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Wrist Instability

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Wrist Instability
Anatomy CIC Classification CIA [Back To Top] CID Investigations CIND Carpal Angles Axial Treatment

Carpal Anatomy 2 carpal rows: 1. Distal

Trapezium, trapezoid, capitate, hamate bound together by strong interosseous (intrinsic) ligaments to form distal row, which moves together as a single unit 2. Proximal Scaphoid, lunate and triquetrum form the proximal row. It has no muscle attachments and is inherently unstable in compression without its ligamentous attachments. Acts as a link between the relatively rigid distal row and the radioulnar articulations. Intrinsic ligaments These have their origin and insertion within the same carpal row Distal row To bind all the distal carpal bones together Proximal row Scapholunate ligament Lunotriquetral ligament Extrinsic ligaments Volar Stronger, and arranged in 2 distinct "V" shapes centred on the lunate and the capitate The radioscapholunate ligament is now known to be a vascular pedicle rather than a true ligament

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Wrist Instability

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Dorsal

Weaker and centred on the triquetrum Classification (Mayo) [Back To Top] Instability may be static or dynamic Carpal Instability Dissociative (CID) [Back To Top]

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Wrist Instability

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Relates to instability between individual carpal bones of the same row Carpal Instability Non-Dissociative (CIND)
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Relates to instability between carpal rows or transverse osseous segments, and can be caused by ligament injury or bony fracture (or both) Axial instability
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Involves a longitudinal force of disruption resulting in either dislocation or fracture dislocation Trans - if pathway of force is through a bone Peri - if pathway of force is around a bone Carpal Instability Complex (CIC) [Back To Top] Several patterns exist which are a combination of CID and CIND lesion It is better to describe the individual components of these injuries as it is a guide to treatment Most frequently represented by perilunate injury Mayfield classified these in 4 stages: I scapholunate ligament injury II capitolunate ligament injury III lunotriquetral ligament injury

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Wrist Instability

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IV dislocation of the lunate Carpal Injury Adaptive (CIA) [Back To Top] Secondary changes in the carpus, which results from a non-union or malunion of the distal radius or carpal bones Clinical Features History Fall on outstretched hand Often presents late as a sprained wrist which fails to resolve Examination Detailed palpation of all the landmarks Grip strength often diminished Special tests Scapholunate ballotment Kirk-Watson's test Lunotriquetral ballotment Reagan's with 2 hands Kleinman's with one hand (thought to be more sensitive) Investigations X-ray PA/lat (wrist must be neutral)/clenched fist/ulnar deviation/radial deviation/oblique Static instability, if present will show up on the x-ray Dynamic instability may not be seen even on the clenched fist view MR/CT/dynamic fluoroscopy/ arthrography may be of value in limited circumstances
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Arthroscopy Direct visualisation of the radiocarpal and midcarpal joints gives a good picture of instability as the ballotment tests can be performed whilst watching the carpal bones but the carpus is not under physiological loads Dorsal Intercalated Segment Instability (DISI) [Back To Top] When the lunate is rotated dorsally and the scapholunate angle is greater than 70 o This is a description of the deformity but does not describe the pathological process Causes: SLL injury, scaphoid #, Keinboch's and perilunate injury Volar Intercalated Segment Instability (VISI)
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Wrist Instability

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When the lunate is flexed and the scapholunate angle is less than 30 o Much less common than DISI Most commonly caused by LTL injury Treatment CID Scaphoid fracture or non-union (can lead to SNAC ) treat # or malunion Scapholunate ligament injury (can lead to SLAC ) [ Case Study ] Acute Early open repair + K-wire stabilisation up to 3 weeks Delayed open repair can be performed up to 6 months Repair is by either direct suture, pull through sutures or suture anchors Chronic Bony procedures - scapho-trapezio-trapezoid fusion (STT) Soft tissue - dorsal capsulodesis (Blatt procedure) or FCR tenodesis (Brunelli Procedure)
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Established Scapholunate advanced collapse (SLAC) Scaphoid excision and 4 corner fusion (capitate, hamate, lunate, triquetrum) Proximal row carpectomy Radial styloidectomy Wrist denervation (division of the anterior and posterior interosseous nerves at the wrist) Lunotriquetral ligament injury Rarely recognised acutely but if so then acute open repair of the ligament Lunotriquetral fusion FCU tenodesis

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Wrist Instability

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Acute perilunate dislocation Immediate closed reduction followed by open repair of the ligaments via dorsal approach CIND Acute - direct repair of the ligaments CIC Treat the individual components of the injury CIA Normally related to radial malunion therefore perform a corrective distal radial osteotomy

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Wrist Osteoarthritis

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Wrist Osteoarthritis
From: JK Stanley. Current Orthopaedics. 13:290-6.1999. May be Generalised or Localised (STT, SLAC, SNAC, rhizarthrosis) Cause 1. Idiopathic fuse scaphoid & lunate to distal radius; radio-lunate Malunion distal die punch injury of scaphoid or fusion; involvement of radius lunate fossa; 4 part #; pilon injury midcarpal jt. = proximal row carpectomy limited wrist fusion = excise distal pole of scaphoid & fuse Scaphoid SNAC wrist prox. pole to lunate to nonunion capitate (or ? radial styloidectomy?) 'hump back' deformity = scaphoid united in flexed position; may be Scaphoid rotational malunion also; osteotomy risky malunion scaphoid does not support lat. column thus incr. load central & medial columns medial column injuries -> Carpal bone capito-hamate & hamo-lunate #'s impaction Kienbock's prox. row carpectomy or wrist Arthrosis = Lichtman stage 4 disease arthrodesis 2. Mechanical Preiser's AVN of scaphoid disease AVN Capitate 70% of people have a facet on the medial aspect of the lunate Hamo-lunate Hamate head excision which can impinge on the head Impaction (arthroscopic) of hamate in full ulnar deviation; diagnosed arthroscopically STT OA ass. with chondrocalcinosis; pain STT arthrodesis [Radiograph] on radial deviation of wrist; from malunion distal radius #s; Sauve-Kapandji procedure DRUJ OA injury to sigmoid notch [Picture] scaphoid excision & 4 corner Carpal SLAC fusion instability (capito-hamo-triquetro-lunate) from scapho-lunate interosseous Dorsal rim lig. incompetence; diagnosed impaction arthroscopically; precursor of syndrome SLAC & SNAC Piso-triquetral causes loose bodies in wrist joint OA 3. Metabolic Gout Pseudogout 4. RA Inflammatory Psoriasis Scapholunate Advanced Collapse (SLAC): common pattern of OA may be end-stage of scapho-lunate dissociation The structures maintaining scapho-lunate alignment fail from trauma or degeneration. Notes Treatment

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Wrist Osteoarthritis

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Lunate extends & scaphoid flexes -> reduces carpal height Later proceeds to radio-carpal OA & lunocapitate & lunohamate OA Treat with scaphoid excision + 4-corner fusion (lunocapitate & triquetrohamate) Scaphoid Non-union Advanced Collapse (SNAC): Develops from a longstanding scaphoid non-union. The proximal pole of scaphoid acts like a lunate OA develops betw. distal scaphoid fragment & radial styloid (not between radius & proximal fragment) Notes on some Treatments: Neurectomy: Limited neurectomy (Berger technique) 70% of patients have 70% pain relief at 7 years Arthroplasty: for low demand patients (RA) with good bone stock. metalloplastic Loosening = 15% over 10 years small dislocation rate DRUJ Procedures: 1. Darrach Procedure

Darrach's original procedure was to resect the distal ulna but retain a strip of bone

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10/6/2007 12:33 PM

Wrist Osteoarthritis

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on the ulnar side with the styloid & the ligaments joining this to the carpus. (forerunner of Bower's hemiresection & soft tissue interposition) Theoretically get subluxation of the carpus to the ulnar side. Get instability of the stump causing discomfort in young active people. 2. Sauve-Kapandji Procedure: Preferred option Prevents 'ulnar subluxation' of carpus (radiocarpal joint) Good forearm function in 80% 20% complain of troublesome clicking in forearm rotation. may be ECU slipping over prox. ulnar stump. may be ulnar stump abutting on distal radius Can try tendon sling procedures

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10/6/2007 12:33 PM