Hand_Fractures.pdf

Hand Fractures

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Hand Fractures Bennets Fracture

Classification

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 o

st

Up to 30 of angulation of the 1 metacarpal base can be accommodated due the large ROM at the trapezio-metacarpal joint Bennett's Fracture

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A fractur fracture-di e-disloc slocatio ation, n, firs firstt descri described bed by Bennett Bennett in 1882 1882 Mechanism of injury is an axial blow directed against the partially flexed metacarpal

Hand Fractures


Fracture line separates the major part of the metacarpal from a small volar lip fragment, producing disruption of the CMC joint An avuls avulsion ion fracture fracture occurs occurs rathe ratherr than than a pure disloca dislocation tion because because of the the streng strength th 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.


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At least least 20 method methods s of treatm treatment ent have have been been advo advocate cated d for for Bennett Bennett's 's fract fracture ure since since the the first large clinical series with x-rays in 1904 CRIF st

It is important to apply gentle traction to the 1 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

Hand Fractures


Fracture line separates the major part of the metacarpal from a small volar lip fragment, producing disruption of the CMC joint An avuls avulsion ion fracture fracture occurs occurs rathe ratherr than than a pure disloca dislocation tion because because of the the streng strength th 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.


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At least least 20 method methods s of treatm treatment ent have have been been advo advocate cated d for for Bennett Bennett's 's fract fracture ure since since the the first large clinical series with x-rays in 1904 CRIF st

It is important to apply gentle traction to the 1 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

Hand Fractures


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 metacarpal into either the trapezium, trapezoid or the 2

nd

st

metacarpal

Hand then immobilised in a POP cast for 4 weeks followed by wire removal and immobilisation Aim to reduc reduce e the the joint joint surfac surface e to < 2mm 2mm of displac displaceme ement nt 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'

Hand Fractures


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.

Hand Fractures


# 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

Incisions

Paronychia/eponychia

Felon

Web space infection

Deep fascial infection

Flexor tenosynovitis

Infections of the radial and ulnar bursae

Osteomyelitis

Human bites

Herpetic Whitlow

Mycobacterial infections

HIV and the hand

Necrotising Fasciitis

Fungal Infection

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


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.

Hand Infections


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

Hand Infections


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)

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Anatomy 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 s pread into the deep palmar space. Treatment

Hand Infections


Two longitudinal incisions, one dorsally, one ventral, but the web should not be incised. Deep fascial space infections

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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.

Hand Infections


Hand Infections

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

Hand Infections

Kanavel's four cardinal signs


Hand Infections

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.

Hand Infections


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

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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)



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)


Hand Trauma & Compartment Syndrome



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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Hand Tumours



Hand Tumours PSEUDOTUMOURS

PSEUDOTUMOURS

BENIGN TUMOURS

MALIGNANT TUMOURS

TYPES OF SURGERY

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1. Ganglia 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

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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.

Hand Tumours


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

Hand Tumours


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

Hand Tumours

MALIGNANT TUMOURS


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Very rare in hand 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



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



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

Weiland (OKU-Trauma, AAOS, 1996)

Accept no > than 0° dorsal tilt or no > than 20° volar tilt

ASSH Regional Review Course (1994)

Accept no > than 5° dorsal tilt

Trumble (ASSH Specialty Day at AAOS 1999)


Kopylov (1993, JHS[B], 30 year follow-up study)

0° tilt increased risk of DJD by 80%

Nelson, based on all of the basic sci ence 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")



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)

Accept no > than 1 mm or 2 mm step-off


Accept no > than 1 mm step-off

ASSH Specialty Day at AAOS (Trumble, 1999)

Accept no > than 1 to 2 mm step-off ("If you can see it, fix it")


Accept no > than 1 mm step-off

Baratz (ASSH Specialty Day at AAOS, 1998)

Consider reduction if step-off visible on xray

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



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



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)

Accept no > than 2 mm radial shortening






Goal: no > than 1 mm radial shortening

Baratz (ASSH Specialty Day at AAOS, 1998)

Accept no > 5 mm radial shortening; 3 mm or less is optimal

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)

Accept no > than 5° loss radial angle


Accept no < than 15° radial inclination


Goal: no loss of radial angle


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


Goal: no loss of radial angle

[Back To Top]

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



Inflammatory Arthritis RHEUMATOID HAND

Clinical

Planning Treatment

Flexor Tenosynovitis

MCPJs

PIPJs

Thumb

OTHER ARTHRITIDES

RHEUMATOID ARTHRITIS

[Back To Top]

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



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



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)

Planning Treatment

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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-


Stage


Clinical

Treatment

1

Acute synovitis

medical Mx & splinting

2

Chronic synovitis

Synovectomy

3

Specific deformation

Reconstructive

4

Severe crippling

Salvage

FLEXOR TENOSYNOVITIS

[Back To Top]

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



METACARPOPHALANGEAL JOINTS

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



- 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

[Back To Top]

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 PIP J s tabilisers a. volar plate insufficiency b. FDS insufficiency c. Generalised joint laxity

Nalebuff Description Type

Cause

Diagnosis

Treatment



DIPJ mallet

Cannot Extend DIPJ with PIPJ passively flexed

Fuse DIPJ

PIPJ volar plate/ FDS insufficient

Can Extend DIPJ with PIPJ passively flexed

Extension block splint

2

PIPJ flexion limited with Tight Intrinsics MCPJ extended = ' locked (~volar plate weak) swan-neck '

Can flex PIPJ with MCPJ flexed (Bunnell Test)

FDS tenodesis (hemitenodesis or sling) / volar plate advancement

3

PIPJ stiff, joint preserved

X-Ray - No articular/ bony changes

MUA or dorsal soft tissue release

4

PIPJ stiff, joint changes

X-Ray - Articular/ bony arthrodesis changes

1

PIPJ flexible

B. Boutonniere deformity

[Back To Top]

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

Treatment

Mild (10-15deg.)

Extensor tenotomy over centre of middle phalanx

Moderate ((30-40deg.)

Numerous soft tissue procedures with variable results, thus low tolerance for arthrodesis

Severe (fixed)

Arthrodesis - position ranging from 20deg. index to 45deg. little finger

RHEUMATOID THUMB

Nalebuff Deformity Type

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CMCJ MCPJ

IPJ

Abd.

Flex.

Hyperext. MCPJ synovitis

Arthroplasty MCPJ or IPJ, +/- extensor realignment

Flex.

MCPJ & CMCJ Hyperext. synovitis

Arthroplasty MCPJ or IPJ, +/- extensor realignment

1

Boutonniere

2

Boutonniere Add. & Swan-neck

3

Swan-neck

4

Gamekeepers Add.

Arthritis mutilans

Short

Treatment

Hyperext. Flex.

CMCJ synovitis, MCPJ volar plate attenuation

CMCJ arthroplasty

Abd.

ulnocarpal lig. (beak) destruction

Lig. reconstruction / MCPJ fusion

Stretching of MCPJ volar plate

MCPJ fusion

-

Neutral Hyperext. Flex.

5

6

Add.

Initiating feature

Unstable Unstable Bone destruction

Fusion





Nalebuff Type 1 Boutonniere

OTHER FORMS OF ARTHRITIS OF THE HAND

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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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Jules Tinel



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

Jules Tinel


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



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

Normal architecture & density, may see a linear compression # (Bone scan & MRI diagnosis)

Stage 2

Increased density, normal architecture & outline; cysts

Stage 3

Stage 4

collapse & fragmentation Stage 3A

No carpal collapse

Stage 3B

Carpal collapse (prox. migration of capitate) OA

Radiograph of Keinbock 's - Note Negative ulnar variance

Kienbock's Disease


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

Kienbock's Disease


All these procedures have a 70% success rate in pain relief Stage 3: 1. 2. 3. 4. 5.

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.

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Nerve Injuries - Principles



Nerve Injuries - Principles Anatomy

Neuronal degeneration and regeneration

Classification of nerve injuries

Diagnostic tests

Early management of nerve injuries

Techniques of nerve repair

1. Anatomy [AlsoSee Nervous System ]

Aetiology of pe Afte

[BackTo Top]

Of spinalnerves 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 Componentsof a mixed spinalnerve Motor Thecell bodies arein theanterior horn cells and innervate skeletal muscle. Sensory Cell bodies liewithinthedorsal root ganglia. Thefibres arise inthe pain, thermal, tactileand stretchreceptors . Proprioception, finetouch and vibration from extremities and trunk These fibrespass cephala d in thedorsalcolumns and do not synapseuntilreachingthe cervicomedull ary junction. Pathway forpressure andcrude touch from extremities andtrunk These fibresenter, synapseand crossand ascend into thecontralateralventral spinothalamic tract. Pain and temperature These fibressynapse inthe spnal cord, and crossto ascend in thelateralspinothalamic tract. There is some areaof neuronal overla p explainedby branches thatascend or descendvia thedorsolateral column/fasciculu s of Lis Sympathetic The sympatheticcomponent of all 31 spinalnerves leavesthe spinal cord along only 14 motor roots (from T1 to L2). BetweenT1 and L2 there are whiterami containingsympathetic fibresto the ganglions of the sympatheticchain.S spinalnervesthrough greyrami. Gross anatomyof a spinalnerve Divides into ananterior and posterior primary ramus afterleaving theintervertbralforamen. Posterior primary ramus supplies theparaspinal muscula ture andthe skin along theposterior aspect of thetrunk neck and head Anterior primary ramus supplies everythingelse,and form plexuses Dermatome- Thearea of skin supplied by a singlespinalroot.

Microscopic anatomy



Sensoryand Sensoryand motor nervescontainboth nervescontainboth unmyel unmyelinated i nated and and myelinated i nated fibres fibres at a ratio ratio of 4:1. 4:1. Theblood supplyto supplyto the the periphe peripheralnerveentersthrou ralnerveentersthroughthe ghthe mesoneu mesoneuriu rium. m. This This bloodsupply bloodsupply is bothextrinsi bothextrinsic/se c/segmen gmentaland taland intrin intrinsic/ sic/lon longitu gitudin dinal al withinthe withinthe epineu epineuriu rium, m, perineur perineuriumand iumand endone endoneuriu urium. m. Perineurium surroun surrounds ds eachfascicle eachfascicle or funicl funicle e (bunchof (bunchof sheath sheathed ed axons) axons) it is a cellular l ular layer layer withtight withtight junc junction tions s betweencell betweencells s enclosi enclosingthe ngthe perineurial perineurial space (within (within the perineurium) perineurium) Epineurium = anyth anythingoutsid ingoutside e theperineu theperineuriu rium m whichis whichis not not nerve nerve fibreor bloodvessel mainly collagen collagen strongestsupport strongestsupportingstruc ingstructur ture e of the nerve nerve Endoneurium = collagen collagen surrounding surrounding nervef ibres. Thearrangeme Thearrangement nt of thefascicles thefascicles inthe proximalaspect proximalaspect of perpher perpheral al nerves nerves is more complexthanin e xthanin thedistalend of thenerve.

2. Neurona Neuronall Degenerat Degenerationand ionand regene regenerati ration on

[Bac [Back k ToTop]

1. Retraction Retraction 2. Inflammati Inflammation on 3. Degeneration Degeneration Any part of a neuron detached from its nucleus degenerates and is destroyed by phagocyto sis. Secondaryor Wallerian degeneration Degeneration distal to the the pointof pointof inju injury. ry. Thefundamen Thefundamental tal conceptof conceptof walleriandegene l eriandegenerati ration on is that that survivalof survivalof nerve nerve fibres fibres occurs occurs only if they they remainconnec remainconnected ted to thecellbody. commen commence ces s 2 to 3 days days afterinj afterinjur ury y thedistalsegment thedistalsegment begins begins to fragment fragment.. Cell Cell body swells migrationof migrationof nucle nucleusto usto peripher periphery y of cell cell chromatolysis chromatolysis (basophilia) (basophilia) Activat ion of Schwann cells close to the injury site By 7 daysthe Schwanncell Schwanncells aremitosing& phagocy phagocytosin tosing g cellu cellular& lar& myelin i n debris debris By 25-30 25-30 daysthe axonal axonal debris debris is cleared cleared.. Schwan Schwann n cells cells occupy occupy theempty endone endoneuri urial al tubes tubes forming forming the'bands the'bands of vonBungner' vonBungner' Thebandsact as sprouts sprouts (neuri (neurites)of tes)of regener regeneratin ating g axons axons ('pione ('pioneerin ering g axons' axons') downthe endone endoneuri urialtubes altubes -> Regener Regeneration ation.. Primary Primary or retrogra retrograde de or traumatic traumatic degenera degeneration tion Degene Degenerationproxim rationproximalto alto thepoint of detachm detachmen entt only asfar as the the nextprox nextproxima imall Nodeof Ranvie Ranvier. r. Histologically identical identical to Walleriandegeneration Walleriandegeneration



Axonal sprouting can occur within 24 hrs of injury. All sprouts are unmyelinated to begin with. If thesproutsmanage thesproutsmanage to make make distal distal connectio connections ns then then nerve nerve fibre maturati maturation on occurs, occurs, withincreasein withincreasein axon axon & myelin i n thickness. c kness. Neurite Neurites s which which failto make make distan distantt connecti connections o ns die back& arelost to theregenerati theregenerative ve process. process. If theperineuri theperineuriumis umis not disrupt disrupted ed then then theaxonswillbe guided guided along along their their originalpathw originalpathway ay (1mm/day (1mm/day)) If theperineuri theperineuriumis umis disrup disrupted ted there there areneurotroph areneurotrophic ic substan substances(NGF ces(NGF - nerve nerve growthf growthf actors) actors) which which attractthe attractthe neuritesto neuritesto nerve nerve tissue tissue.. The The critic criticalgap algap over over whichth whichthis is does does notoccur notoccur is 2mm. 2mm. Neuromasform Neuromasform whenneurit whenneurites es migrate migrate aimlessl e ssly acrossa large large gap. gap. Theycan be stump stump neurom neuromas as or neuromasin neuromasin continu continuity. ity.

4.Classi 4.Classifi fica cati tionof onof nerveinj nerveinjur urie ies s

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[Back To Top] Seddon Classification Neuropraxia (nerve, non-action) usually usually compressioninjury local local conduct conductionblock ionblock & demyeli demyelinati nation on thick thick myelinated i nated nervesmainl nervesmainly y affected affected heals heals by Schwan Schwann n cell cell repair repair of demyeli demyelinati nation on - takes takes severalweeksor severalweeksor months months

(cylinder, cutting) cutting) Axonotmesis (cylinder, usuall usually tractioninjur tractioninjury, y, but but may occur occur after severe severe compressi compression on Wallerian degeneration occurs endone endoneuri urial al tubes tubes areintact-> no miswirin miswiring g & good regene regenerati ration on limitin limiting g factoris the distan distance ce of regenera regenerationrequi tionrequired red worse with proximalinjuries sensory sensory recovery recovery is better better (sensory (sensory receptorssurvi receptorssurvive ve longer longer than than motor units) units) Neurotmesis (nerve,cutting) complete e te severanc severance e of thenervetrunk no recovery unless ess repair undertaken undertaken lots lots of miswi miswirin ring g of organ organs s reduced reduced massof innerva innervation tion Sunderland Classification accountsfor accountsfor theinjuriesbetwe theinjuriesbetween en an axonotme axonotmesis sis & neurotme neurotmesis sis based based on involve involvementof mentof the perineurium Degree of injury

Degree of injury

S under land , 1978

Myelin

Axon

Endoneurium

Perineurium

S eddon, 1943

1 st degree

Neuropraxia

+/-

11

Axonotmesis

+

+

111

Axonotmesis

+

+

1V

Axonotmesis

+

+

+

+

V

Neurotmesis

+

+

+

+

Mckin Mckinnon& non& Dellon(1988 l on(1988)) addeda addeda 6

th

+

degree degree injury u ry = neuroma-in-continuity , where where a nerve nerve hashad a disordere disordered d self-repa self-repair ir witha lateralneur lateralneuroma. oma. There There is a mixtureof mixtureof injuries, u ries, when when a nerve nerve is partlyseveredand partlyseveredand theremainingtrun theremainingtrun

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 Clinical diagnosi diagnosis s of nerve injury injury and assessment assessment post post injury

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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% 50-70% muscleatrophyafter muscleatrophyafter 2 months months Striations and motor end plates retained for approx 12 months Method for assessing the the return of muscle function after nerve injuries (British Research Council) M 0 No contraction contraction M 1 Return of perceptible contraction in proximal muscles



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 o f reduced sensation surr ounds 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 Sensation assessment assessment after peripheralnerve peripheralnerve injury injury - BritishM BritishM edical edical ResearchSociety ResearchSociety 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 3 Return of superficial cutaneous pain and touch throughout the autonomous area, with disappearance of any previous over response 4 As for 3 but also som e recovery of t wo point discr imination in the autono mous area 5 Complete recovery 1 2

The best corr ela elator tor of eventual eventual function is return of 2 point dis crimination (as (as emph emphasis asis ed 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 o f finger s 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 t o an electric current

If sweating s till present present this s ugg ests tha thatt the nerve dama damage ge is incomple incomplete te

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 posit ive Tinel sign is e vidence of regenerating axonal sprouts which have not completed myelinisation are pr ogressing. A distally advancing Tinel sign should be present in Sunderland 11 and 111 injuries A type 1 injury (neuropraxia) should not pr oduce any Tinel's sign as no new regenerati on should need to occur Type 1V and V injuries do not produce an advancing Tinel sign unless repaired A progressi ng Tinel's sign is encouraging but doe s not necessarily mean com plete recover y.

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. Diagno Diagnostic stic tests tests

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Nerve conduction studies Evaluation of peripheral nerves & their sensory & motor responses anywhere along their course



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 stimul ator is added, distal to the f irst stimul ator & closer to the recording electrode. The segment velocity between the 2 stim ulation 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 & r 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 moto r conduction ( CMAP) after 3-7 days excludes a neuropraxia type injury. Absence of sensory conduction ( CNAP) a fter 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 recor d motor unit activity at re st and on attempted co ntraction o f 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



At between 15 and 30 days, spontaneous denervation fibri llation 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

Insertional Activity *

Rest Activity **

Fibrillations ***

Normal

Normal

Silent

No

Neuropraxia

Normal

Silent

No

No

Ax onotmes is

Increased

Increased

Yes

Yes

Neurotmesis

Increased

Increased

Yes

Yes

Increased

Increased

Yes

Yes

Normal

Silent

No

No

An terio r Hor n Dis ease

Increased

Increased

Yes

Yes

Myopathy

Increased

Silent

Yes

Yes

Ax onal Neuropathy Demyelinating Neuropathy

Sharp Waves No

* 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 ++

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

8. Earlymanagementof nerveinjuries

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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 un 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. Techniques ofnerve repair(neurorrhaphy) Epineurial

[Back ToTop] Perineurial

Epi perineurial repair



Sunderla nd points outthat fascicula r repair is not possib lein allcases, butmost 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. Factorsinfluencing regeneration after nerve repair(neurorrhaphy)

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Infofrom warzone injuries 1. Age Worseningresult s withincreasing age, thoughnumbers at extremitiesof age aresmall 2. Gap between nerve ends Nicholson, Seddon andSakell arides noted that theupper limit of gapbeyondwhichresults will deteriorate is 2.5 cm. Methods of closinggaps; 1. 2. 3. 4. 5.

nerve mobilisation nerve transposition joint flexion nerve grafts bone shortening

3. Delay between injury and repair Delay affectsmotor recoverymore than sensory recovery (due to the survival timeof striated muscle. Satisfactory reinnervationof musclecan occur afterdenervation of 12 mnths Little evidence about sensoryf unctionreturnin relationto dela y, butsensationcan improve in as late a repair as 2 years. Kleinertet al feel thata delayedrepair of between 7 and 18days is bestfor return of satifactory function. Reasonable approachis immediate repair if conditions allo w and before6 weeksin extensive soft tissuecontusion,co 4. Level of injury Themore proximalthe lesion,the more incomplete therecovery. Boswick et al reviewed 102 peripheralnerveinjuriesin 81 patients. 87% of those inju ries below theelbowgained protectivesensation. 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



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

o

Warm ischaemia time

Cool ischaemia time (4 c)

Digit

12 hours

24 hours

Significant amount of muscle

6 hours

12 hours

Indications for Replantation 1. 2. 3. 4. 5. 6.

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



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

circulation adequate: requires standard bone and soft tissue treatment

Class II

circulation inadequate: requires vessel repair

Class III

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 o

these digits is only 35 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)



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

4



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


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



Scaphoid Fractures Clinical

Occult Fractures

Classification

Sequelae

Non-union

SNAC

CLINICAL

Treatment

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History 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 Kirk-Watson's test Resisted pronation

st

metacarpal

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%

[ Picture]

Scaphoid Fractures


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

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Bone Scanning 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

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

Scaphoid Fractures


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

Scaphoid Fractures


SEQUELAE OF SCAPHOID FRACTURES

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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 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

Radial styloidectomy Care must be taken to preserve the radiocarpal ligaments

RS OA + scaphocapitate (SC) OA

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

Scaphoidectomy plus 4-corner fusion

SNAC I

SNAC II

SNAC III

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

Scaphoid Fractures

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



Scapholunate Ligament Rupture

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

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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

Tendon Injuries



Tendon Injuries ACUTE INJURY

Anatomy

Tendon Nutrition

Types of Injury

Contraindications

Zones

Incisions

Technique

Wrist

Post-operative

Complications

TENDON RECONSTRUCTION

ACUTE FLEXOR TENDON REPAIR Anatomy

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Tendon Injuries


Tendon Injuries


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 [Back To Top]

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

Tendon Injuries


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

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Zone 1

FDS insertion to FDP insertion

The tight A4 pulley makes repair difficult. Aim to advance FDP stump to reattach to terminal phalanx.

Zone 2

Zone 1 to proximal part of A1 pulley

two slips of FDS; Vincula

Zone 3

Zone 2 to distal edge of flexor retinaculum

easily repaired with good results. Don't suture lumbrical muscle around tendon repair.

Zone 4

within carpal tunnel

Zone 5

proximal to carpal tunnel

Thumb T1

FPL insertion to A2 pulley

Thumb T2

Zone 1 to distal part A1 pulley

Thumb T3

Zone 2 to carpal tunnel

Incisions

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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.

Tendon Injuries


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) [Back To Top]

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.

Tendon Injuries


Post-operative program

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Belfast Regimen: (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

SECONDARY FLEXOR TENDON REPAIR & RECONSTRUCTION

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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:

Tendon Injuries


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



Tendon Transfer - Principles Definition A tendon transf er is a procedur e in whi ch the tendon of ins ertion or of origin of the func tioning m uscle is mobili sed, 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 nonprogressive or slowly progressive neurological neurological disorders Basic principles of tendon transfer 1. Mobile Joints / Correction of joint, skin and soft tissue contractures If necessary, c apsulotomy, or free flap may be necessary prior to tendon transfer 2. Adequate power of transferred tendon Power of a muscle is determined by its c ross sectional sectional area Only muscles with power of 4+ should be considered donors donors as they always lose 1 MRC grade of power 3. Sufficient amplitude (excursion (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 muscle from monoarticular to biarticular, the the amplitude amplitude is increased by movement of the extra joint that that the tendon crosses Amplitude can be limi ted by s carri ng and adhesi ons As a guide, amplit udes are as follows W rist motors

33mm

Finger extensors Finger flexors

50mm 70mm

4. Maximal work capacity of the transfer Power x amplitude amplitude = work capacity (Kg.M) 5. The transferred tendon should be of adequate length A gr aft ca n be used as an ext ension, but all anastomoses are sour ces 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 r educe power and amplitude 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 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 proximal to distal In general function is restored using the following scheme 1. Stabilisation of the shoulder



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 proximal muscle supplied, assuming a rate of regeneration 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 tens ion - No general rule, but r easonable to place limb in the posit ion of maximal f unction of the tendon transf er and suture without tension

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

Tendon Transfers - summary table

L o w i n j ur y ( w r i s t )

High injury ( e l b ow )

MEDIAN NERVE: Thumb Opposition (loss of FBP) (note thumb opposition opposition is combination of flexion and adduction) 1. Ring finger FDS transfer to APB via a pulley pulley made in the FCU tendon at the level of the pisiform. [Picture [Picture]] 2. MCP +/or IP joint fusion

For index and middle finger flexion FDP of index index and middle finger sutured side to side to FDP of ring and little fingers, fingers, +/- ECRL tendon transfer to FDP for extra strength For flexion of IP joint of thumb -Brachiora - Brachioradialis dialis transfer to FPL For thumb opposition -Extensor indices transfer to Abductor pollicis brevis



ULNAR NERVE: For Adductor pollicis and FPB (thumb opposition)

+For loss of FCU - Use ECRL transfer for power

1. Absent FPB = Ring finger F DS t ransfer to AP B via a pulley made in the FCU tendon at the level of the pisiform. [Picture Picture]. ]. 2. If FPB working and adductor not = use extensor indices transfer through interosseous membrane to adductor pollicis For loss of action of interrosei and ulnar 2 lumbricals 1. Split tendon transfers of FDS + /- EIP & EDQ, 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 succ essf ul).

COMBINED MEDIAN & ULNAR NERVES: very difficult problem 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 Picture]] Thumb adduction (pinch) - EIP to Adductor pollicis RADIAL NERVE: (Radial wrist extensors functioning:) wrist extension 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

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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 to FDP, BR to FPL, ECU (with free graft) to EPL Thumb fusions

Ulnar Nerve Palsy Signs



Ulnar Nerve Palsy Signs

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Vascular Disorders



Vascular Disorders Aneurysms of the Upper Extremity

Vascular Malformations

Vascular Tumours

Thoracic Outlet Syndrome

Occlusive Vascular Disorders

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

Vascular Disorders


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

AVM

2.

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

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Haemangiomas 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

Vascular Disorders


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

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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 o

scalene muscle constriction, 2 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 supraclavicular 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) o

Axillary vessels and plexus bent 90 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

Vascular Disorders


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 supraclavicular , 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

Vasospastic Disorders

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Raynaud's Raynaud's phenomenon: Episodic Digital Ischaemia

Vascular Disorders


Associated with connective tissue diseases, vibration, neurological disorders, arterial · occlusive disorders and blood dyscrasias Raynauds Syndrome: ·

When the syndrome occurs as part of a disease e.g.:

o

Connective tissue disease

o

Occlusive arterial disease

o

Neurovascular compromise (e.g. Thoracic outlet syndrome)

o

Haematological abnormalities (e.g. polycythaemia )

o

Occupational Trauma (e.g. Vibration white finger)

o

Drugs

o

CNS disease

o

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.

Alpha blocking agents ( dibenzyline )

2.

Myovascular relaxants (nicotinic acid, cyclospasmol )

3.

Catecholamine and or serotonin depletors ( reserpine )

4.

Nifedipine

5.

Nicardipine

6.

T3

Vascular Disorders

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Wrist Arthroscopy



Wrist Arthroscopy Indications

Indications:

Complications

Positioning & Preparation

Portals

Images

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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

Positioning and Preparation:

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

Wrist Arthroscopy


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


Further Reading:

Wris t A rthroscopy - Wrig htington Hospital Thurs ton A J . C urrent Orthopaedics . 13:120-30.1999.

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Wrist Instability



Wrist Instability Anatomy

Classification

CID

CIND

Axial

CIC

CIA

Investigations

Carpal Angles

Treatment

Carpal Anatomy

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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

Wrist Instability


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]

Wrist Instability


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

Wrist Instability


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

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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

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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

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 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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o

Wrist Instability


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

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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)

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

Wrist Instability


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



Wrist Osteoarthritis From: JK Stanley. Current Orthopaedics. 13:290-6.1999.

May be Generalised or Localised (STT, SLAC, SNAC, rhizarthrosis) Cause

Notes

Treatment

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

Wrist Osteoarthritis


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

A rthroplas ty: 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

Hand_Fractures.pdf

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