Hand Fractures PDF

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Hand Fractures
Other
Bennets Rolando's Methods of
Classification Metacarpal
Fracture Fracture Treatment
Fractures
Zafar Naqui Edited 19.11.05 Orthoteers, Brinker
Classification [Back To Top]
It is important to distinguish the intra-articular fractures (Type I [Bennett's] + II [Rolando's]) from

the extra-articular (III + IV) fractures, as the extra-articular fractures can be managed
adequately with non-operative management
Up to 30 o of angulation of the 1 st metacarpal base can be accommodated due the large

ROM at the trapezio-metacarpal joint
Bennett's Fracture [Back To Top]
A fracture-dislocation, first described by Bennett in 1882
Mechanism of injury is an axial blow directed against the partially flexed metacarpal
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Fracture line separates the major part of the metacarpal from a small volar lip fragment,
producing disruption of the CMC joint
An avulsion fracture occurs rather than a pure dislocation because of the strength of
the anterior oblique ligament (AOL)
Displacement forces:
o The distal metacarpal fragment (containing most of articular surface) is displaced
proximally, radially, & dorsally by pull of APL.
o The displaced metacarpal is also rotated in supination by the pull of APL
o The metacarpal head is displaced into palm by pull of Adductor Pollicus
o Volar fracture fragment remains attached to CMC by volar AOL. The AOL anchors
volar lip of metacarpal to tubercle of the trapezium - hence, small volar lip fragment
remains attached to anterior oblique ligament which is attached to trapezium.
Pure dislocations are very rare and need CRIF
Concomitant fractures of the trapezium seen with Bennett's fractures have been
reported, for which ORIF is the recommended treatment
Rupture of the MP joint collateral ligaments has been reported as a concomitant (and
easily overlooked) injury with Bennett's fracture.
Methods of Treatment [Back To Top]
At least 20 methods of treatment have been advocated for Bennett's fracture since the
first large clinical series with x-rays in 1904
CRIF
It is important to apply gentle traction to the 1 st metacarpal in the correct

direction i.e. longitudinally with the thumb adducted and then reduce the
fracture finally by pushing the base of the 1 st metacarpal in a palmar direction
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If the thumb is abducted there a gap will be created at the fracture site
2 Percutaneous K-wires are then passed through the base of the 1 st

metacarpal into either the trapezium, trapezoid or the 2 nd metacarpal
Hand then immobilised in a POP cast for 4 weeks followed by wire removal and
immobilisation
Aim to reduce the joint surface to < 2mm of displacement
ORIF
Using either AO mini-screws, Herbert screws or K-wires
Important technical point is that the screw diameter must not exceed 30% of
the cortical surface of the volar lip fragment
Studies have shown a correlation between the quality of reduction and the likelihood of
subsequent arthritis, but there does not appear to be good correlation between
radiographic evidence of arthritis and significant symptoms
Rolando's Fracture [Back To Top]
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 [Back To Top]
Classified like any fracture " location, displacement etc.
Specilaist Xray " 'Brewerton metacarpal head view'
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A) MC Head Mx: Displaced head " ORIF / Kwire, small osteochondral# - excise
B) MC Neck < 15 degree " ulna gutter splint 2 week then mobilize 15-40 deg " reduce and hold
40 deg dorsal ang. in little finger can be accepted due to compensatory CMCJ.
BUT residual ang. Of >15 in index, middle finger not accept due to lack of compensation.
C) MC shaft transverse " reduce and hold

Spiral " unstable " look for malrotation " orif / kwire
D) MC base displaced " kwire

Malunion " can disturb intrinsic / extrinsics " de-rotation osteotomies
Phalangeal Fractures
Deforming forces: as the anatomy is an intercalated osseous chain # will give predictable
deformity:
A) middle phalynx - # prox to FDS insertion " dorsal angulation, # distal " volar angulation
B) prox phalynx " inerosseous attachments flex prox part and central slip extends distal part
resulting in volar angulation.
MX: mobilize uninvolved digits ASAP. NB " PIPJ most important jt for fuction and motion of
digit
Accurate # reduction where poss.
Options of fixation " incl. k wire, interosseous wire, interfragm screw, plate, ex-fix.
Complications:
stiffness: tendon adhesions " may need tenolysis of flexors / extensors

Pipj flex contracture " may need jt release
Malunion osteotomy
Symptomatic hardware r/o metalwork for symptoms +/- tenolysis
Joint Injuries
Jt stability depends on articular contour, collateral ligs, volar plate. Volar plate has strong lateral
attachments and weak distal attachment.
Goals of Mx: pain free motion, jt stability. Can take upto 12 months.
DIPJ
Mallet finger " rupture extensor +/- bone fragment from distal phalynx after forceful sudden
flexion. If >30% artic surface then risk of volar sublux of distal phalynx.
Type1 blunt trauma " loss of tendon continuity +/- bone chip
Type2 laceration causing mallet
Type3 deep abrasion, loss skin and soft tissue
Type 4 physeal # in kids, hyperflexion 20-50% artic surface or hyperextension >50% artic
surface " with volar sublux of distal phalynx
Mx closed splint 6 weeks then 4 weeks at night

ORIF if >30% artic surface / volar sublux
Complicn mallet deformity
Secondary swan-neck from dorsal sublux of lat bands
Dorsal dislocation of DIPJ

hypertext at tip can disrupt volar plate and collaterals sparing the fdp.
Closed reduction " if blocked " may be interposn of volar plate, fdp then open.
PIPJ
Collateral lig Inj RCL more frequently lnjured. Digital block helps examination. Closed mx, open
if soft- tissue interposn., continued instability. RCL to index may need surgery for pinch grip
Volar Plate Inj hyperextension inj. Splint in 20 deg flex . mobilize after 7 days
Dorsal disloc hyperextension. Xray may see small avulsion base middle phalynx.
Closed reduction. Initial extension block if unstable.
Volar disloc central slip ruptures " if post reduction ext lag then repair central slip. Complication:
if miss central slip " volar sublux of lat bands leading to boutonniere.
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# 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 http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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Hand Infections
Overview Incisions Paronychia/eponychia Felon
Infections of the radial and

Web space infection Deep fascial infection Flexor tenosynovitis
ulnar bursae
Osteomyelitis Human bites Herpetic Whitlow Mycobacterial infections
HIV and the hand Necrotising Fasciitis Fungal Infection
OVERVIEW [Back To Top]
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 [Back To Top]
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Common Hand infections
Paronychia/ eponychia [Back To Top]
Infection of the nail fold, usually with staph aureus.
If on one side (paronychia) drain by incision with blade angled away from nailbed to avoid damaging it.
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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 [Back To Top]
Subcutaneous abscess of the pulp of the finger
Anatomy
The distal finger pulp is divided into tiny compartments by strong fibrous septa traversing from skin to bone. There is also a fibrous
curtain present at the distal finger crease. Because of these, any swelling causes immediate pain. The abscess may extend into the
periosteum of the distal phalanx, around the nailbed or proximally, through the fibrous curtain, or through the skin.
Those beginning deep can cause osteomyelitis.
Treatment
Antibiotics and incision and drainage
Methods of drainage - see diagram
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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) [Back To Top]
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 spread into the deep palmar space.
Treatment
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Two longitudinal incisions, one dorsally, one ventral, but the web should not be incised.
Deep fascial space infections [Back To Top]
Anatomy
The Deep palmar space lies between the fascia covering the metacarpals and their muscles, and the fascia dorsal to the flexor
tendons. Ulnar border is the fascia of the hypothenar muscles, Radial border is the fascia of the adductor and other thenar muscles.
Divided into the middle palmar space and the thenar space by fascial plane passing between third metacarpal shaft and the fascia
dorsal to the flexor tendons of the index finger.
Middle palmar space infections
Infections here cause a severe systemic reaction, generalised swelling of the hand and fingers resembling a rubber glove and loss of
active motion of the middle and ring fingers.
Drain through a curved incision beginning at the distal palmar crease, extending ulnarward to just inside the hypothenar eminence
Thenar space;
Infections here cause systemic upset, thumb web swelling, the index finger is held flexed and there is loss of index finger and thumb
active motion.
Drain through a curved incision in the thumb web along the proximal side of the thenar crease. Avoid the recurrent branch of the
median nerve.
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Suppurative Flexor Tenosynovitis [Back To Top]
Infection in the flexor tendon sheath, can cause tendon adhesions or necrosis and rupture
Anatomy
Thumb infections can drain into the thenar space or the radial bursa
Index finger and thumb infections can spread to the thenar space
Middle , ring and little finger infections can spread to the middle palmar space
Little finger infections can spread to the middle palmar space or the ulnar bursa
See diagram
Causes
Spread from an adjacent pulp space infection, or from puncture wounds over the flexor creases
Clinical features
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Kanavel's four cardinal signs
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1. finger held in a flexed position

2. Sausage digit (symmetrical swelling)
3. Severe tenderness along the tendon sheath
4. 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 [Back To Top]
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 [Back To Top]
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 [Back To Top]
Usually fight bites over the 3 rd and 4 th MCP joints.
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42 different organisms have been identified in the human mouth. Most common infecting organism is still staph aureus, other common
organisms are, streptococcus, Eikenella, Enterobacter, proteus, Serratia, Neisseria, Eikennella.
Reported by Malinowski that the average delay in presentation is 2.5 days.
Treat aggressively with IV antibiotics, Cephalosporin and penicillin wash out any breached MCP joint.
Mycobacterial infections [Back To Top]
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 [Back To Top]
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 [Back To Top]
Frequently get: HSV, CMV, fungal, protozoal, mycobacterial.
Necrotising Fasciitis [Back To Top]
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 [Back To Top]
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) http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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) http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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Hand Trauma & Compartment Syndrome http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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. A carpal tunnel release

2. 2 dorsal incisions
3. A medial hypothenar incision
4. 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
PSEUDOTUMOURS BENIGN TUMOURS MALIGNANT TUMOURS TYPES OF SURGERY
PSEUDOTUMOURS [Back To Top]
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 [Back To Top]
1. Giant Cell Tumours
= pigmented villonodular synovitis

usually arises from IP joints or flexor tendon sheath
locally invasive
surrounds normal structures instead of invading them
often extends below joint ligaments
can erode bone
Macroscopically is yellow & brown or grey
Treatment = complete excision under magnification
Recurrence rate = 17 - 30%, usually recurs within 2 years of surgery.
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2. Vascular Tumours (Also see Vascular Summary )
(Also see Vascular Summary )
1. Glomus tumour
tumour of the neuromyoarterial apparatus, which functions to regulate skin circulation of the digits
neuromyoarterial apparatus is found subungually, on the finger tip pulp & the base of the foot
described by Masson in 1924
Present with triad = pain & well-localised tenderness & cold sensitivity.
tumour is small = <1cm
difficult to detect clinically except for subungual glomus which presents with a blue spot under the nail plate.
x-rays may show bone erosion of terminal phalanx
ultrasound may detect lesion
treatment = surgical excision ('shell out' lesion)
Mark the tender spot pre-op
follow the digital nerve until tumour found
Note - there may be multiple tumours.
2. A-V malformations
3. Kaposi's sarcoma
4. False aneurysm - follows trauma
5. True aneurysm - rare in hand
6. Pyogenic Granuloma
3. Neural Tumours
1. Traumatic Neuroma
2. Neurofibroma
intimately involved with nerve fascicles

cannot be removed without sacrificing nerve function
10% malignant change if associated with neurofibromatosis
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rx = decompression or excision & nerve graft
3. Neurilemoma (Schwannoma)
Well-localised, encapsulated
not intimately involved with nerve fascicles
Can be shelled out.
4. Fibrous Tumours
1. Dermatofibroma - small fibrous nodule in children
2. Desmoid tumours - rare, locally agressive, resembles fibromatosis histologically (more common on abdomen,
tibia)
3. Fibromatosis - Dupuytren's nodules
5. Bone Tumours
1. Enchondroma
solitary, cyst in long bones of hand (usually proximal phalanx)

Multiple lesions occur in Ollier's disease (multiple enchondromas) & Maffuci syndrome (enchondromas +
haemangiomas)
flecks of calcification within lesion
Can expand the bone
may fracture
malignant change in < 1% after age 30
Treat:
Intralesional excision if symptomatic & bone graft through a dorsal trap-door approach.
Also see Cartilage Producing Tumours
2, Osteoid osteoma
3. Osteochondroma [ Image ]
4. Aneurysmal bone cyst
5. Giant cell tumour of bone
6. Lipomas
1. Angiolipoma
2. lipoma of tendon sheath
3. Intraneural
4. Intraosseous
5. Intramuscular
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MALIGNANT TUMOURS [Back To Top]
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 [Back To Top]
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 http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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.
ARTICULAR RADIAL
VOLAR TILT RADIAL ANGLE
INCONGRUITY SHORTENING
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
d Jenkins (1988, JHS)
prospective study of 61 consecutive patients treated with closed reduction, cast

immobilization
statistical significant correlation with function and dorsal tilt
1 of 6 10/6/2007 12:18 PM
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
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
3 RECOMMENDATIONS
Accept no > than 0

Weiland (OKU-Trauma, AAOS, 1996) dorsal tilt or no > than
20 volar tilt
Accept no > than 5
ASSH Regional Review Course (1994)
dorsal tilt
Accept no > than 10
Trumble (ASSH Specialty Day at AAOS 1999)
dorsal tilt
0 tilt increased risk of
Kopylov (1993, JHS[B], 30 year follow-up study)
DJD by 80%
Nelson, based on all of the basic science and clincal
Accept no > than 10
studies cited above, as well as the consensus
dorsal tilt
recommendations noted above:
B INTRA-ARTICULAR INCONGRUITY [Back To Top]
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")
2 of 6 10/6/2007 12:18 PM
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

ASSH Regional Review Course
Accept no > than 1 mm step-off
(1994)
ASSH Specialty Day at AAOS Accept no > than 1 to 2 mm step-off ("If you
(Trumble, 1999) can see it, fix it")
Kopylov (1993, JHS[B], 30 year
Accept no > than 1 mm step-off
follow-up study)
Baratz (ASSH Specialty Day at AAOS,
Consider reduction if step-off visible on xray
1998)
4 CAVEAT: WE CANNOT RELIABLY MEASURE AT THE 1 MM LEVEL
a Nelson (1995, AAOS)
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method: one cadaver, simulated die punch fracture, with stepoffs of 0.0mm, 0.5
mm, 1.0 mm, and 2.0 mm; plain radiographs and CT's performed; 16 blinded
reviewers
results: cannot reliable measure with an accuracy of 1 mm, CT not more
reliable than plain films, and reviewer is not able to tell when his readings are off
by more than 1 mm
weakness of method: used model of die punch, not actual fracture; model may
have been easier to evaluate
b Kreder, et al. (J Hand Surg, 1996)
method: 16 observers examined 6 plain xrays

results: two experienced observers would be expected to disagree by 3 mm
10% of the time, and repeat measurements by the same observer would be
expected to differ by 2 mm 10% of the time
weakness of method: could not tell what actual measurement was and
therefore true accuracy of readings
c Cole, et al. (J Hand Surg, 1997)
method: 5 observers examined 19 sets of xrays, including plain films and CT

scans
results: more reproducible values were produced by CT scans, but a poor
correlation between CT and plain xray measurements
thirty percent of measurement from plain xrays significantly underestimated or
overestimated displacement compared to CT scan measurement
weakness of method: could not tell whether CT or plain film was actually more
accurate
weakness of method: could not tell what actual measurement was and
therefore true accuracy of readings
C RADIAL SHORTENING [Back To Top]
a Pogue, Viegas, Patterson, et al. (1990, JHS)

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)

immobilization
mean shortening was 4.0 mm
4 of 6 10/6/2007 12:18 PM
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

ASSH Regional Review Course
Accept no > than 3 mm radial shortening
(1994)
ASSH Specialty Day at AAOS
Accept no > than 2 mm radial shortening
(Trumble, 1999)
Kopylov (1993, JHS[B], 30 year
Goal: no > than 1 mm radial shortening
follow-up study)
Baratz (ASSH Specialty Day at AAOS, Accept no > 5 mm radial shortening; 3 mm or
1998) less is optimal
RADIAL ANGLE [Back To Top]
a Pogue, Viegas, Patterson, et al. (1990, JHS)

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)

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
Accept no > than 5 loss radial

Weiland (OKU-Trauma, AAOS, 1996)
angle
Accept no < than 15 radial
ASSH Specialty Day at AAOS (Trumble, 1999)
inclination
Kopylov (1993, JHS[B], 30 year follow-up
Goal: no loss of radial angle
study)
5 of 6 10/6/2007 12:18 PM
Baratz (ASSH Specialty Day at AAOS, 1998) Goal: no loss of radial angle
NOTES & REFERENCES [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.
[ Close Window ]
6 of 6 10/6/2007 12:18 PM
Inflammatory Arthritis http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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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:
1 of 11 10/6/2007 12:19 PM
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. Using toothbrush, hairbrush, knife, fork

2. Dressing - bra, pulling up trousers / stockings
3. Operate remote control
4. Hobbies
3. Cosmesis - may be extremely NB to patient. A poor functional result of surgery may not be a poor result
for the patient if cosmesis improved.
EXAMINATION:
Expose above elbow.
Quick elbow, shoulder & neck assessment
Look (most NB):
1. Exensor surface
2. Flexor surface
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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. cervical spine
2. TMJ
3. Pulmonary
4. General
Investigations:
1. WBC (decr. in Felty's syndrome)

2. platelet count (decr. with NSAIDs)
3. Hb (anaemia of chronic disorders)
4. LFT (methotrexate)
5. 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 [Back To Top]
Need to consider:
How the disease affects patient as a whole

Level of disability
Aims of Treatment:
Pain relief
Improve function
Prevent further damage
Cosmesis
Principles:
Operate on proximal joints then distal

Tendons before joints
Alternate fusions with motion-sparing procedures
Staged procedures
Deciding on Type of Surgery:
Souter staging-
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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 sites-
1. Carpal tunnel
2. Palm at level of mouth of A1 pulley
3. Just distal to A2 pulley
Tendon Rupture: [Back To Top]
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
4 of 11 10/6/2007 12:19 PM
METACARPOPHALANGEAL JOINTS [Back To Top]
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):
- Good results
5 of 11 10/6/2007 12:19 PM
- 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 PIPJ stabilisers
a. volar plate insufficiency
b. FDS insufficiency
c. Generalised joint laxity
Nalebuff
Description Cause Diagnosis Treatment
Type
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Cannot Extend DIPJ

1 PIPJ flexible DIPJ mallet with PIPJ passively Fuse DIPJ
flexed
PIPJ volar plate/ Can Extend DIPJ with Extension block
FDS insufficient PIPJ passively flexed splint
FDS tenodesis
PIPJ flexion limited with Can flex PIPJ with
Tight Intrinsics (hemitenodesis or
2 MCPJ extended = ' locked MCPJ flexed (Bunnell
(~volar plate weak) sling) / volar plate
swan-neck ' Test)
advancement
PIPJ stiff, joint X-Ray - No articular/ MUA or dorsal soft

3
preserved bony changes tissue release
X-Ray - Articular/ bony

4 PIPJ stiff, joint changes arthrodesis
changes
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 Numerous soft tissue procedures with variable results, thus low tolerance for
((30-40deg.) arthrodesis
Severe (fixed) Arthrodesis - position ranging from 20deg. index to 45deg. little finger
RHEUMATOID THUMB [Back To Top]
Nalebuff
Deformity CMCJ MCPJ IPJ Initiating feature Treatment
Type
Arthroplasty MCPJ or
1 Boutonniere Abd. Flex. Hyperext. MCPJ synovitis IPJ, +/- extensor
realignment
Arthroplasty MCPJ or
Boutonniere MCPJ & CMCJ
2 Add. Flex. Hyperext. IPJ, +/- extensor
& Swan-neck synovitis
realignment
CMCJ synovitis,
3 Swan-neck Add. Hyperext. Flex. MCPJ volar plate CMCJ arthroplasty
attenuation
ulnocarpal lig. (beak) Lig. reconstruction /

4 Gamekeepers Add. Abd. -
destruction MCPJ fusion
Stretching of MCPJ
5 Neutral Hyperext. Flex. MCPJ fusion
volar plate
Arthritis
6 Short Unstable Unstable Bone destruction Fusion
mutilans
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8 of 11 10/6/2007 12:19 PM
Nalebuff
Type 1 -
Boutonniere
OTHER FORMS OF ARTHRITIS OF THE HAND [Back To Top]
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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10 of 11 10/6/2007 12:19 PM
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11 of 11 10/6/2007 12:19 PM
Jules Tinel http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Jules Tinel
1879-1952
Tinel was a French neurologist who wrote an excellent book on

the effects of nerve injuries during the First World War, and
from it one may judge how times have changed, for nerve
suture is hardly mentioned. He had a research interest in the
autonomic system, producing a thick volume on the subject; he
was noted for the ingenuity of his apparatus, which was often
constructed of Meccano.
He was born in Rouen, the fifth in a line of distinguished

doctors. His father was Professor of Anatomy at Rouen. Tinel
studied in Paris. It was when he was mobilised for the war that
he found himself in a neurological unit and was able to study
the long term effects of severe nerve injury. He gave the first
account of paroxysmal hypertension due to
phaeochromocytoma.
During the Second World War he had to leave the Hospital; his family were interned, and one
son executed by the Gestapo because they had helped run an escape route.
Tinel's Sign: 1917
Formication provoked by pressure.-;When compression or percussion is lightly applied to the

injured nerve trunk, we often find, in the cutaneous region of the nerve, a creeping sensation
usually compared by the patient to that caused by electricity.
Formication in the nerve is a very important sign, for it indicates the presence of young
axis-cylinders in process of regeneration.
This formication is quite distinct from the pain on pressure, which exists in nerve irritations.
Tenderness, indicating irritation of the axis-cylinders and not their regeneration, is almost
always local, perceived at the very spot where the nerve is compressed, or at least magnified at
this spot; it always co-exists with the pain in the muscular bellies under pressure, which are,
very often, more tender than the nerve.
Formication of regeneration, on the other hand, is but little or not at all perceived at the spot
compressed, but is felt almost entirely in the cutaneous distribution of the nerve; the
neighbouring muscles are not tender.
As a rule, it appears only about the fourth or sixth week after the wound. It enables us to
ascertain the existence of this regeneration and to follow its progress.
If it remains fixed and limited to one spot for several consecutive weeks or months, this is
because the regenerating axis-cylinders have encountered an insurmountable obstacle and are
forced together at that place as a more or less bulky neuroma.
The fixity of formication on a level with the lesion, and the complete absence of formication
below the lesion, would almost warrant our affirming the complete interruption of the nerve and
the impossibility of spontaneous regeneration.
If, on the other hand, the regenerated axis-cylinders can overcome the obstacle and make their
way into the peripheral segment of the nerve, we see a progressive migration of the formication
so provoked. Pressure on the nerve below the wound produces this sensation, and from week
to week it may be encountered at a spot farther removed from the nerve lesion. The presence
of formication provoked by pressure below the nerve lesion warrants our affirming that there is
more or less complete regeneration.
The site at which formication can be demonstrated moves along the course of the nerve at the
same pace as the axis-cylinders advance; at the same time that it extends progressively
towards the periphery it disappears at the level of the lesion.
The "formication sign" is thus of supreme importance, since it enables us to see whether the
nerve is interrupted, or is in course of regeneration; whether a nerve suture has succeeded or
failed, or whether regeneration is rapid and satisfactory, or reduced to a few significant fibres.
1 of 2 10/6/2007 12:19 PM
Jules Tinel http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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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2 of 2 10/6/2007 12:19 PM
Kienbock's Disease http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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:
Normal architecture & density, may see a linear compression # (Bone scan
Stage 1
& MRI diagnosis)
Stage 2 Increased density, normal architecture & outline; cysts
Stage 3 collapse & fragmentation
Stage 3A No carpal collapse
Stage 3B Carpal collapse (prox. migration of capitate)

Stage 4 OA
Radiograph of Keinbock 's - Note Negative

ulnar variance
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Treatment:
Remember:
Keinbock's often causes little disability

The radiological findings & symptoms do not correlate well.
No surgical procedure has been conclusively shown to prevent progression.
Surgery only indicated when pain & disability cannot be managed by splintage, analgesia & reassurance.
Surgery:
Stage 1 & 2:
Aim to prevent lunate collapse
1. Joint Levelling:
1. Radial shortening
2. Ulnar lengthening - high non-union rate.
2. Revascularisation of lunate
Pedicled vascularised graft from distal radius with pronator quadratus
dorsal digital artery placed into drill hole on lunate
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All these procedures have a 70% success rate in pain relief
Stage 3:
1. Limited carpal fusion without lunate excision

2. Limited carpal fusion with lunate excision (STT or scapho-capitate)
3. Wrist denervation
4. Proximal row carpectomy
5. 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

Anatomy Neuronal degeneration and regeneration Classification of nerve injuries Aetiology of peripheral nerve in
Diagnostic tests Early management of nerve injuries Techniques of nerve repair Aftertreatment
1. Anatomy [Also See Nervous System ] [Back To Top]
Of spinal nerves
Each segmental spinal nerve is formed by union of the dorsal/sensory root with the ventral/motor root at or before the intervertebral foramen
In the thoracic segments, these mixed spinal nerves maintain their autonomy, providing sensation and motor function to one intercostal segment
In all other areas (cervical, lumbar and sacral regions, plexuses are formed which provide a limb or special body segment without retaining the primitive myomeric pattern
Components of a mixed spinal nerve
Motor
The cell bodies are in the anterior horn cells and innervate skeletal muscle.
Sensory
Cell bodies lie within the dorsal root ganglia. The fibres arise in the pain , thermal, tactile and stretch receptors .
Proprioception, fine touch and vibration from extremities and trunk
These fibres pass cephalad in the dorsal columns and do not synapse until reaching the cervicomedullary junction.
Pathw ay for pressure and crude touch from extremities and trunk
These fibres enter, synapse and cross and ascend into the contralateral ventral spinothalamic tract.
Pain and temperature
These fibres synapse in the spnal cord, and cross to ascend in the lateral spinothalamic tract. There is some area of neuronal overlap explained by branches that ascend or descend via the dorsolateral column/fasciculus of Lis
Sympathetic
The sympathetic component of all 31 spinal nerves leaves the spinal cord along only 14 motor roots (from T1 to L2). Between T1 and L2 there are white rami containing sympathetic fibres to the ganglions of the sympathetic chain. S
spinal nerves through grey rami.
Gross anatomy of a spinal nerve
Divides into an anterior and posterior primary ramus after leaving the intervertbral foramen.
Posterior primary ramus supplies the paraspinal musculature and the skin along the posterior aspect of the trunk neck and head
Anterior primary ramus supplies everything else, and form plexuses
Dermatome- The area of skin supplied by a single spinal root.
Microscopic anatomy
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Sensory and motor nerves contain both unmyelinated and myelinated fibres at a ratio of 4:1.
The blood supply to the peripheral nerve enters through the mesoneurium. This blood supply is both extrinsic/segmental and intrinsic/longitudinal within the epineurium, perineurium and endoneurium.
Perineurium
surrounds each fascicle or funicle (bunch of sheathed axons)
it is a cellular layer with tight junctions between cells enclosing the perineurial space (within the perineurium)
Epineurium
= anything outside the perineurium which is not nerve fibre or blood vessel
mainly collagen
strongest supporting structure of the nerve
Endoneurium
= collagen surrounding nerve fibres.
The arrangement of the fascicles in the proximal aspect of perpheral nerves is more complex than in the distal end of the nerve.
2. Neuronal Degeneration and regeneration [Back To Top]
1. Retraction
2. Inflammation
3. Degeneration
Any part of a neuron detached from its nucleus degenerates and is destroyed by phagocytosis.
Secondary or Wallerian degeneration
Degeneration distal to the point of injury.
The fundamental concept of wallerian degeneration is that survival of nerve fibres occurs only if they remain connected to the cell body.
commences 2 to 3 days after injury
the distal segment begins to fragment.
Cell body
swells
migration of nucleus to periphery of cell
chromatolysis (basophilia)
Activation of Schwann cells close to the injury site
By 7 days the Schwann cells are mitosing & phagocytosing cellular & myelin debris
By 25-30 days the axonal debris is cleared.
Schwann cells occupy the empty endoneurial tubes forming the 'bands of von Bungner'
The bands act as sprouts (neurites) of regenerating axons ('pioneering axons') down the endoneurial tubes -> Regeneration.
Primary or retrograde or traumatic degeneration
Degeneration proximal to the point of detachment
only as far as the next proximal Node of Ranvier.
Histologically identical to W allerian degeneration
4. Regeneration
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Axonal sprouting can occur within 24 hrs of injury. All sprouts are unmyelinated to begin with.
If the sprouts manage to make distal connections then nerve fibre maturation occurs, with increase in axon & myelin thickness.
Neurites which fail to make distant connections die back & are lost to the regenerative process.
If the perineurium is not disrupted then the axons will be guided along their original pathway (1mm/day)
If the perineurium is disrupted there are neurotrophic substances (NGF - nerve growth factors) which attract the neurites to nerve tissue.
The critical gap over which this does not occur is 2mm.
Neuromas form when neurites migrate aimlessly across a large gap. They can be stump neuromas or neuromas in continuity.
4. Classification of nerve injuries [Back To Top]
[Back To Top]
Seddon Classification
Neuropraxia (nerve, non-action)
usually compression injury
local conduction block & demyelination
thick myelinated nerves mainly affected
heals by Schwann cell repair of demyelination - takes several weeks or months
Axonotmesis (cylinder, cutting)
usually traction injury, but may occur after severe compression
Wallerian degeneration occurs
endoneurial tubes are intact -> no miswiring & good regeneration
limiting factor is the distance of regeneration required
worse with proximal injuries
sensory recovery is better (sensory receptors survive longer than motor units)
Neurotmesis (nerve, cutting)
complete severance of the nerve trunk
no recovery unless repair undertaken
lots of miswiring of organs
reduced mass of innervation
Sunderland Classification
accounts for the injuries between an axonotmesis & neurotmesis
based on involvement of the perineurium
Degree of injury Degree of injury Myelin Axon Endoneurium Perineurium

Sunderland , 1978 Seddon, 1943
1 st degree Neuropraxia +/-

11 Axonotmesis + +
111 Axonotmesis + + +
1V Axonotmesis + + + +
V Neurotmesis + + + +
Mckinnon & Dellon (1988) added a 6 th degree injury = neuroma-in-continuity , where a nerve has had a disordered self -repair with a lateral neuroma. There is a mixture of injuries, when a nerve is partly severed and the remaining trun
Complex regional pain syndrome
Pain, swelling, discoloration, hyperhydrosis, osteoporosis, resulting from an abnormal and prolonged response from the sympathetic nervous system.
3% of major nerve injuries
5. Aetiologyof Peripheral nerve injuries & nbsp; [Back To Top]
Can be due to metabolic, collagen disease, malignancy, toxins, thermal or mechanical injury, but only mechanical causes mentioned here.
Mechanical causes producing primary injury include laceration, fracture, fracture manipulation, gunshot wound
Secondary injury can be due to infection, scarring, callus, vascular complications, eg. AV malformation, aneurysm, ischaemia
6. Clinical diagnosis of nerve injury and assessment post injury [Back To Top]
Requires thorough knowledge of the anatomy of nerves.
Motor function
Visible fibrillation of muscle

Power loss (MRC):
Power loss (MRC):
Power loss (MRC):
Power loss (MRC):
0 Total paralysis
1 Muscle flicker
2 muscle contraction
3 muscle contraction against gravity
4 muscle contraction against gravity and resistance
5 normal muscle contraction compared to other side
Must have full passive range of motion of joint
Muscle wasting
50-70% muscle atrophy after 2 months
Striations and motor end plates retained for approx 12 months
Method for assessing the the return of muscle function after nerve injuries (British Research Council)
M 0 No contraction
M 1 Return of perceptible contraction in proximal muscles
M 2 Return of perceptible contraction in both proximal and distal muscles
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M 3 Return of prox. and distal muscle power enough to allow the major muscle groups to act against resistance
M 4 Return of function as in stage 3 but synergistic and independent movements are possible
M 5 Complete recovery
Sensation
Sharp pin to assess pain, cotton wool to assess light touch, tips of a paper clip to assess two point discrimination.
Normal 2 point discrimination in the hand:
There is an area of complete sensory loss ' the autonomous zone ', which gets smaller even before fibres can regenerate (? Due to increased function of anastomotic branches from adjacent nerves)
A larger area of reduced sensation surrounds this = ' the intermediate zone '
When a nerve is intact and the surrounding nerves are blocked, an area of sensibility larger than the gross anatomical distribution of the nerve occurs = ' the maximal zone '
Sensibility recovery sequence:
1. Pain and temperature

2. Pseudomotor function
3. Touch (Semmes-Weinstein monofilaments: protective sensation present if able to feel 5.07 Semmes-Weinstein filament)
4. Perception of 30 Hz vibration (tested over bony prominences with a tuning fork)
5. Perception of moving touch
6. Perception of constant touch
7. Perception of 256Hz vibration
8. Stereognosis (test with heptagonal UK 50 pence coin)
Sensation assessment after peripheral nerve injury - British Medical Research Society
S 0 Absence of sensibility in the autonomous area
S 1 Recovery of deep cutaneous pain in the autonomous area

S 2 Return of some degree of superficial cutaneous pain and touch in the autonomous area
S 3 Return of superficial cutaneous pain and touch throughout the autonomous area, with disappearance of any previous over response
S 4 As for 3 but also some recovery of two point discrimination in the autonomous area
S 5 Complete recovery
The best correlator of eventual function is return of 2 point discrimination (as emphasised by Moberg, 1995)
Autonomic function
There is loss of sweating , the pilomotor response and vasomotor action when a peripheral nerve is disrupted.
Pilomotor - The wrinkle test is a useful objective test - Denervated skin does not wrinkle in water
Vasomotor - Initially there may be vasodilatation in a complete lesion, pinkness for 2-3 weeks. Then coldness paleness, mottled. This may spread to more than the anatomical area of skin supplied by the nerve.
Atrophy of fingers and nails can occur.
Test sweating:
1. by rubbing smooth pen against side of finger (if finger moves with pen = sweating present)
2. Ninhydrin print test - applying nihydrin to sweat turns it purple (Moberg, 1995)
3. Look through the +20 lens of an opthalmoscope to see the beads of sweat
4. Dust the extremity with quinizarin powder. Sweating turns the powder purple
5. Absence of sweating causes an increased resistance to an electric current
If sweating still present this suggests that the nerve damage is incomplete
Hoffmann-Tinel Sign (1917)
Gentle percussion with the finger along the course of the injured nerve will produce a transient tingling sensation in the distribution of the injured nerve, persisting for several seconds.
Start distally and proceed proximally
A positive Tinel sign is evidence of regenerating axonal sprouts which have not completed myelinisation are progressing.
A distally advancing Tinel sign should be present in Sunderland 11 and 111 injuries
A type 1 injury (neuropraxia) should not produce any Tinel's sign as no new regeneration should need to occur
Type 1V and V injuries do not produce an advancing Tinel sign unless repaired
A progressing Tinel's sign is encouraging but does not necessarily mean complete recovery.
Reflexes
Complete severance of either the efferent or afferent nerve in a reflex abolishes that reflex. However, the reflex can be lost even in partial injury and is not a good guide of injury severity
7. Diagnostic tests [Back To Top]
Nerve conduction studies
Evaluation of peripheral nerves & their sensory & motor responses anywhere along their course
Stimulation of a peripheral nerve should evoke a contraction in the muscles it supplies (seen, palpated or measured electromyographically)
Latency (t) = time between onset of stimulus & the response
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Amplitude = size of response

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

Motor nerve conduction test for Ulnar nerve at wrist using ADM (from TeleEMG )
nerve above & below elbow
Sensory Nerve:
CNAP (compound nerve action potential) is measured (lower amplitude than CMAP)
a uniquely sensory nerve must be chosen for the stimulation site
V (sensory) = d / t (where V (sensory) is the segment velocity in sensory fibres; d is distance betw. stimulation site & recording cathode; t is the average latency betw. stimulus & CNAP)
Sensory nerve conduction test for Ulnar nerve across the wrist (from TeleEMG )
Collision Studies
Timing of NCS:
Immediately after section of a peripheral nerve, stimulation distally will elicit a normal response for 18-72 hrs until wallerian degeneration occurs.
Absence of distal nerve motor conduction (CMAP) after 3-7 days excludes a neuropraxia type injury.
Absence of sensory conduction (CNAP) after 7-10 days excludes a neuropraxia type injury.
Therefore the ideal time for NCS after injury is 10-14 days after injury to discern neuropraxia from axonotmesis / neurotmesis.
Neuropraxia will improve (incr. velocity & decr. latency) with repeated tests, while axonotmesis & neurotmasis will deteriorate
Somatosensory Evoked Potentials (SSEP) = stimulate peripheral sensory nerves & measure on the scalp. For study of brachial plexus & spinal cord monitoring.
Electromyography
A needle electrode in the muscle is used to record motor unit activity at rest and on attempted contraction of the muscle
Normal EMG shows no muscle activity at rest and a characteristic pattern on voluntary contraction
Normal EMG
Immediately after nerve section, EMG will be normal, although there will be no muscle response after stimulation of the nerve proximal to the nerve injury (CMAP)
Within Between 5 and 14 days positive sharp waves consistent with denervation
Positive sharp waves of Denervation
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At between 15 and 30 days, spontaneous denervation fibrillation potentials are present
Denervation fibrillation potentials
If denervation fibrillation potentials are not present by the end of the 2 nd week this is a good prognostic sign.
Evidence of reinnervation is when highly polyphasic motor unit potentials are detected at attempts at voluntary activity
Denervation fibrillations in a muscle only tell you that the muscle is not innervated. It does not determine whether the injury is 2 nd 3 rd or 4 th degree.
Reinnervation potentials by the same token can be restored after regeneration of only a few motor fibres and does not necessarily mean a good return to voluntary motor control
EMG Findings in Specific Conditions:
Condition Insertional Activity * Rest Activity ** Fibrillations *** Sharp Waves

Normal Normal Silent No No
Neuropraxia Normal Silent No No
Axonotmesis Increased Increased Yes Yes
Neurotmesis Increased Increased Yes Yes
Axonal Neuropathy Increased Increased Yes Yes
Demyelinating Neuropathy Normal Silent No No
Anterior Horn Disease Increased Increased Yes Yes
Myopathy Increased Silent Yes Yes
* Insertional Activity = needle is inserted into muscle or moved within muscle, there is a single burst of activity that usually lasts 300 to 500 ms; thought to result from mechanical stimulation or injury of the muscle fibers
** Rest Activity = differentiates neuropathic muscle atrophy from myopathic atrophy
*** Fibrillations - are action potentials that arise spontaneously from single muscle fibers; usually occur rhythmically and are though to be due oscillations of the resting membrane potential in denervated muscles. Appears 3 - 5 weeks after the n
++
Potentials - number of phases (? action potentials); indicates collateral axonal sprouting; polyphasic = > 4 phases
8. Early management of nerve injuries [Back To Top]
ABCs as with any injury

Open wound with nerve injury - thorough debridement . If wound adequately clean and general state of the patient allows, then immediate primary nerve repair is preferred
Open wound but patients general state in danger . clean wound and dress with moist dressing, attempt repair at 3-7 days
Contaminated wounds- Thorough debridement, mark ends of nerve with a suture and consider suturing to soft tisssue to avoid retraction. Repair the nerve when the soft tissues have healed at 3-6 weeks post injury
A closed injury with peripheral nerve damage . Early active motion of all affected musce groups should be started. Contractures should be prevented by passive motion. Specific effects of electrical muscle stimulation are unclear. Dynamic a
A closed fracture associated with nerve injury. Early exploration usually avoided. Assess progress of functional return using EMG, NCS and clinical assessment. However, if ORIF required explore nerve too.
If nerve deficit follows manipulation and /or casting of a closed fracture. Early exploration is favoured
9. T echniques of nerve repair (neurorrhaphy) [Back To Top]
Epineurial Perineurial Epi perineurial repair
Clinical evidence to support one over the other type of repair is meagre. The technique selected depends on the experience of the surgeon.
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Sunderland points out that fascicular repair is not possible in all cases, but most practical when
Fascicular groups are large enough to take sutures

Each fascicular group is made up of fibres to a partiicular branch occupying a constant position at the nerve ends eg. In median and ulnar nerves above the wrist and radial nerve above the elbow.
10. Aftertreatment [Back To Top]
Opinions differ as to when joints can be moved

In upper limb, immobilise in a plaster splint or cast for 4 weeks, then replace in a plastic splint, gradually extending the joint over 2-3 weeks
In lower limb immobilise for 6 weeks
Rigid splinting not justified if prognosis for nerve function doubtful
Dynamic splinting of distal joints with passive exercises to maintain motion whilst nerve recovers
11. Factors influencing regeneration after nerve repair (neurorrhaphy) [Back To Top]
Info from warzone injuries
1. Age
Worsening results with increasing age, though numbers at extremities of age are small
2. Gap between nerve ends
Nicholson, Seddon and Sakellarides noted that the upper limit of gap beyond which results will deteriorate is 2.5 cm. Methods of closing gaps;
1. nerve mobilisation
2. nerve transposition
3. joint flexion
4. nerve grafts
5. bone shortening
3. Delay between injury and repair
Delay affects motor recovery more than sensory recovery (due to the survival time of striated muscle.
Satisfactory reinnervation of muscle can occur after denervation of 12 mnths
Little evidence about sensory function return in relation to delay, but sensation can improve in as late a repair as 2 years.
Kleinert et al feel that a delayed repair of between 7 and 18 days is best for return of satifactory function. Reasonable approach is immediate repair if conditions allow and before 6 weeks in extensive soft tissue contusion, co
4. Level of injury
The more proximal the lesion, the more incomplete the recovery. Boswick et al reviewed 102 peripheral nerve injuries in 81 patients. 87% of those injuries below the elbow gained protective sensation. 14% regained normal 2 p
5. Condition of nerve ending The better the condition the more improvement
Further Reading:
Review of Orthopaedics - Mark Miller

Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998.
TeleEMG - http://www.teleemg.com/
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Replantation & Microsurgery http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Replantation & Microsurgery

Amputation defined by the anatomical site
Can be guillotine, crush or avulsion (these have the poorest results and prognosis)
Care of the amputated part
Gently irrigate with Hartmann's
Wrap in wet swab
Place in bag and place bag in ice
Ischaemia time
Warm ischaemia time Cool ischaemia time (4oc)
Digit 12 hours 24 hours
Significant amount of muscle 6 hours 12 hours
Indications for Replantation
1. Thumb amputation
2. Multiple digit amputations
3. Metacarpal amputation
4. Almost any body part in a child
5. Wrist or forearm amputation
6. Individual digit distal to FDS insertion, replantation at level distal to insertion of FDS often results in satisfactory
function [Diagram]
Contra-indications
1. Local:
1. Severely crushed or mangled parts (See MESS)
2. Amputations at multiple levels
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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
these digits is only 35o although cold intolerance and sensation are comparable to more distally amputated group
Surgical Technique (in sequence)
Bilateral midlateral incisions
Isolate vessels and nerves debride
1. Shorten and Fix Bone

2. Repair the flexor and extensor tendons (in the case of a hand replantation the flexor and extensor tendons are
repaired after arterial and venous flow has been established)
3. Repair nerves (before arteries, since tourniquet required)
4. Anastamose arteries (hand or forearm replantations, consider use of arterial shunt before the vascular
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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) 4
Limb ischaemia
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Pulse reduced or absent but perfusion normal

1*
Pulseless, paraesthesias, diminished capillary refill

2*
Cool, paralysed, insensate, numb

3*
Shock
Systolic BP always > 90 mm

0
Hypotensive transiently
1
Persistent hypotension
2
Age (years)
< 30
0
30-50
1
> 50
2
* Score doubled for ischaemia > 6 hours
Limb salvage vs. amputation. Preliminary results of the Mangled Extremity Severity Score
In both the prospective and retrospective studies, a MESS score of greater than or equal to 7 had a 100% predictable value
for amputation
Results
Adults 80% success
Children 70% success - poorer results in children reflects a more aggressive approach
Best results for thumb, hand, and distal forearm
Functional Outcome (Ch'en Criteria)
I Able to resume original work
ROM 60% of normal
Complete or nearly complete sensation
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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 http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Scaphoid Fractures
Clinical Occult Fractures Classification Treatment
Sequelae Non-union SNAC
CLINICAL [Back To Top]
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 st metacarpal

Kirk-Watson's test
Resisted pronation
X-ray
Good quality films are required

1. PA in ulnar deviation
2. Lateral with wrist in neutral
3. Scaphoid view 1 : PA 45deg. pronation & ulnar deviation; + shows STT joint [ Picture ]
4. Scaphoid view 2 : AP with 30deg supination & ulnar deviation; + shows radioscaphoid joint [ Picture]
Others:
PA with wrist in slight extension (Ziter view)
AP with clenched fist to detect a ligamentous injury
False negative rate:
Leslie and Dickson 1981 2%

Munk et al. 1995 6%
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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 [Back To Top]
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) [Back To Top]
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TREATMENT [Back To Top]
Stable non-displaced fractures
POP cast immobilisation
Type of cast immobilisation
Below elbow cast - No need to include the thumb
Position of wrist
Ulnar deviation will distract the fracture, therefore this must be avoided
Neutral in AP plane
Moulded into the palm
Duration 8 weeks
Re-examine and X-ray at 8 weeks out of plaster
If still tender then treat in cast for a further 4 weeks
At 12 weeks leave free regardless of whether there is tenderness or not
Re-X-ray at 6 months
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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
4 of 6 10/6/2007 12:23 PM
SEQUELAE OF SCAPHOID FRACTURES [Back To Top]
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) [Back To Top]
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

SNAC I Care must be taken to
preserve the
radiocarpal ligaments
RS OA + scaphocapitate (SC) OA Partial scaphoid

SNAC II 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

SNAC III 4-corner fusion
What is the aim of treating non-union? [Back To Top]
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
5 of 6 10/6/2007 12:23 PM
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
[ Close Window ]
6 of 6 10/6/2007 12:23 PM
Scapholunate Ligament Rupture http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Scapholunate Ligament Rupture
slrecon1.JPG slrecon2.JPG slrecon2a.JPG slrecon3.JPG

Scapholunate XR at 3 weeks after XR at 3 weeks after Intr-operative film
ligament rupture. Initial injury injury - clenched fist Scapholunate lig. was
XR at presentation view repaired & 2 k-wires
after fall off ladder. support POP for 6wks
Treated with Physio
[ Close Window ]
1 of 1 10/6/2007 12:24 PM
Tendon Injuries http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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Tendon Injuries
ACUTE INJURY Anatomy Tendon Nutrition Types of Injury
Contraindications Zones Incisions Technique
TENDON
Wrist Post-operative Complications
RECONSTRUCTION
ACUTE FLEXOR TENDON REPAIR [Back To Top]
Anatomy [Back To Top]
1 of 7 10/6/2007 12:25 PM
2 of 7 10/6/2007 12:25 PM
Annular & Cruciate pulleys prevent bow stringing of flexor tendons.
Thumb - Oblique pulley over proximal phalanx.
Tendon Nutrition [Back To Top]
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 [Back To Top]
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
3 of 7 10/6/2007 12:25 PM
result will be better than a poor repair.
Zones [Diagram] [Back To Top]
The tight A4 pulley makes repair

FDS insertion to FDP
Zone 1 difficult. Aim to advance FDP stump
insertion
to reattach to terminal phalanx.
Zone 1 to proximal part
Zone 2 two slips of FDS; Vincula
of A1 pulley
easily repaired with good results. Don't
Zone 2 to distal edge of
Zone 3 suture lumbrical muscle around tendon
flexor retinaculum
repair.
Zone 4 within carpal tunnel
Can use mattress sutures if many
Zone 5 proximal to carpal tunnel
tendons need repair.
FPL tendon lacerations often retract
Thumb FPL insertion to A2 into the thenar area or wrist; - unlike the
T1 pulley fingers, the FPL often lacks a vinculum
and does not have a lumbrical, and
Thumb Zone 1 to distal part A1 therefore the tendon is free to retract;
T2 pulley Repair requires an incision prox. to
carpal tunnel & ' pull-through '
Thumb also damage thenar muscles & recc. br.
Zone 2 to carpal tunnel
T3 median nerve.
Incisions [Back To Top]
4 of 7 10/6/2007 12:25 PM
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 [Back To Top]
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. FPL
2. FDP tendons
3. FDS to middle & ring fingers
4. FDS to index & little fingers
5. Ulnar nerve
6. Ulnar artery
7. Median nerve
8. FCU
9. FCR
10. Radial artery - ligated.
5 of 7 10/6/2007 12:25 PM
Post-operative program [Back To Top]
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 [Back To Top]
1. Rupture
2. Infection
3. Adhesions - prevented by early passive ROM
4. Joint contractures - too tight repair or from prolonged splintage
5. Bow stringing - from damaged pulleys
SECONDARY FLEXOR TENDON REPAIR & RECONSTRUCTION [Back To Top]
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. Adequate skin & soft tissue cover

2. Skeletal alignment
3. Good passive ROM of joints
4. Adequate sensation & circulation of finger
Methods:
1. Delayed direct repair

2. single stage flexor tendon grafting
3. two-stage grafting
4. tenodesis or arthrodesis
5. tendon transfer
6. Amputation
Two-stage Flexor Tendon Reconstruction
Contraindications:
1. Infection
2. Too much damage to support an implant or allow decent tendon gliding
3. Motivated patient
4. Experienced surgeon
5. Experienced Hand Therapist
First Stage:
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Aims:
1. Joint contractures must be released

2. Tenolysis of scarred tendons
3. Finger must have free & full passive ROM
4. Digital nerve repair or grafting
5. Provide healthy skin (may require a flap)
6. Full flexion on traction of the silastic rod at the wrist
7. Preserve A1, A2 & A4 pulleys
Second Stage:
2 - 3 months after first stage.
Tendon Graft options:
1. Palmaris Longus
2. Plantaris - best for multiple tendon grafts
3. Long toe extensors - 2nd, 3rd or 4th toes
4. EIP
5. Fascia Lata
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Tendon Transfer - Principles

Definition
A tendon transfer is a procedure in which the tendon of insertion or of origin of the functioning muscle is mobilised, detached or divided
and reinserted into a bony part or onto another tendon, to supplement or substitute for the action of the recipient tendon
Indications for tendon transfers
1. Irreparable nerve damage
2. Loss of function of a musculotendinous unit due to trauma or disease
3. In some nonprogressive or slowly progressive neurological disorders
Basic principles of tendon transfer
1. Mobile Joints / Correction of joint, skin and soft tissue contractures
If necessary, capsulotomy, or free flap may be necessary prior to tendon transfer
2. Adequate power of transferred tendon
Power of a muscle is determined by its cross sectional area
Only muscles with power of 4+ should be considered donors as they always lose 1 MRC grade of power
3. Sufficient amplitude (excursion / freedom of movement) in the transferred tendon
The amplitude of a muscle is a function of the sarcomere length
It is a fixed value for any muscle, but can be increased by
Freeing the muscle from its fascial attachments
Changing a muscle from monoarticular to biarticular, the amplitude is increased by movement of the extra joint that the tendon crosses
Amplitude can be limited by scarring and adhesions
As a guide, amplitudes are as follows
W rist motors 33mm
Finger extensors 50mm
Finger flexors 70mm
4. Maximal work capacity of the transfer
Power x amplitude = work capacity (Kg.M)
5. The transferred tendon should be of adequate length
A graft can be used as an extension, but all anastomoses are sources of adhesions
6. A satisfactory line of pull should be achieved
The less turns or bends through which the tendon has to pass, the less friction can reduce power and amplitude
7. An adequate glide of the transferred tendon is necessary, through unscarred natural planes
8. Functional integrity must be preserved
The transferred musculotendinous unit must be expendable
If a tendon is split and inserted into different sites only the tighter of the two will function and the other will not
In extensive paralysis
Restore function from proximal to distal
In general function is restored using the following scheme
1. Stabilisation of the shoulder
1 of 3 10/6/2007 12:26 PM
2. Flexion of elbow
3. Extension of wrist
4. Flexion of fingers
5. Reestablishment of thumb grip in opposition or lateral thumb grip
6. Finger extension
7. Restoration of function of the interrossei
Surgical considerations in tendon transfers
1. Timing
If no chance of functional recovery, transfers should be performed ASAP
Following nerve injury repair, the date of expected recovery can be calculated by measuring the distance between the injury to the most
proximal muscle supplied, assuming a rate of regeneration of 1mm/day. If reasonable return of function not present for 3 mnths after the
expected, consider tendon transfer.
Early tendon transfers - within 12 weeks of injury
2. Planning
Make a list of deficient functions
Make a list of available donor muscles
3. Techniques
1. Multiple short transverse incisions rather than long longitudinal incisions
2. Careful tendon handling
3. Good soft tissue coverage over the tendon junctures
4. Joining the tendons
1. End to end anastomoses
2. End to side anastomoses
3. Side to side anastomoses
4. Tendon weave procedures can all be used
5. Achieving proper tension - No general rule, but reasonable to place limb in the position of maximal function of the tendon transfer and
suture without tension
Nerve Injuries & Tendon Transfers in the Upper Limb
Review by Robert Boome, Consultant Peripheral Nerve Surgeon
Tendon Transfers - summary table
Low injury (wrist) High injury (elbow)
MEDIAN NERVE:
Thumb Opposition (loss of FBP) (note thumb opposition is For index and middle finger flexion
combination of flexion and adduction)
FDP of index and middle finger sutured side to side to FDP
1. Ring finger FDS transfer to APB via a pulley of ring and little fingers, +/- ECRL tendon transfer to FDP for
made in the FCU tendon at the level of the extra strength
pisiform. [Picture]
2. MCP +/or IP joint fusion For flexion of IP joint of thumb -Brachioradialis transfer to FPL
For thumb opposition -Extensor indices transfer to Abductor

pollicis brevis
2 of 3 10/6/2007 12:26 PM
ULNAR NERVE:
For Adductor pollicis and FPB (thumb opposition) +For loss of FCU - Use ECRL transfer for power
1. Absent FPB = Ring finger FDS transfer to APB via a pulley

made in the FCU tendon at the level of the pisiform.
[Picture].
2. If FPB working and adductor not = use extensor indices
transfer through interosseous membrane to adductor pollicis
For loss of action of interrosei and ulnar 2 lumbricals
1. Split tendon transfers of FDS + /- EIP & EDQ, to radial

dorsal extensor apparatus (tenodesis procedures)
2. Or stabilise MCP joint with Zancolli capsulodesis where the
volar capsule is tightened to produce slight flexion of MCP
joint (not very successful).
COMBINED MEDIAN & ULNAR NERVES:

very difficult problem
For function of the interrossei and lumbricals, to restore flexion
of MCP joint and extension of IP joints - Brands ECRB graft For function of the long flexors & interrossei and lumbricals, to
with a plantaris graft to increase length, attached to insertion of restore flexion of MCP joint and extension of IP joints - Zancolli
intrinsics Capsulodesis of MCP joints, ECRL to FDP, BR to FPL, ECU (with
free graft) to EPL
Thumb opposition - FDS (ring finger) via FCU pulley to EPL
[Picture] Thumb fusions
Thumb adduction (pinch) - EIP to Adductor pollicis
RADIAL NERVE:
(Radial wrist extensors functioning:)
wrist extension - Pronator Teres to ECRB
MCP joint extension - FCR / FCU to EDC or FDS to EDC
extension and abduction of the thumb - PL rerouted to EPL
If radial nerve might still recover keep EPL in continuity and bring
palmaris longus upward
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Ulnar Nerve Palsy Signs
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Vascular Disorders http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Vascular Disorders
Aneurysms of the Vascular
Vascular Tumours
Upper Extremity Malformations
Thoracic Outlet Occlusive Vascular
Vasospastic Disorders
Syndrome Disorders
Author: James Carmichael
Aneurysms [Back To Top]
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 [Back To Top]
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
1 of 6 10/6/2007 12:28 PM
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 [Back To Top]
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
2 of 6 10/6/2007 12:28 PM
May have no visible or palpable signs except for a bluish discoloration
Radiographs:
X-rays for apposition loss: perforating lesion of the phalanx, may also show a shelled
out lesion dorsal lesion
Treatment:
In terms of excision the tumour is usually well encapsulated and can be shelled out
Thoracic Outlet Syndrome [Back To Top]
Most often affects subclavian artery, vein, and lower trunk (C8 /T1) of brachial plexus
Both the subclavian artery and the brachial plexus traverse between the anterior and middle
scalene muscles. Most symptoms arise from neural compression
Age 18-40 (never before puberty rare after 50yr)
Aetiology :
cervical rib (< 10 % of pts with cervical ribs will have symptoms), fibrous bands, anterior
scalene muscle constriction, 2 o to clavicular # ( xs callus/ hypertrophic non-union),
pancoast tumour
In some cases, thoracic outlet syndrome will be accentuated by recurrent anterior
shoulder instability, and this may be the cause of the "dead arm syndrome"
General Examination:
Tenderness or mass in 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)
Axillary vessels and plexus bent 90 o at the junction of the glenoid and humeral head
Place extremity in full abduction, external rotation and reach back as far possible. Turn
head away and check for decrease or loss of radial pulse
Creation of a bruit in the supraclavicular area is further evidence
4. Roos ' overhead exercise test
Above head repeated forearm exercise may reproduce symptoms
Investigations:
X-ray - Cervical ribs may be seen but more commonly the cause is a fibrous band
which will not show up on X-rays
CXR to rule out pancoast tumour
MR scan to exclude cervical disc disease
Treatment
3 of 6 10/6/2007 12:28 PM
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 [Back To Top]
Raynaud's
Raynaud's phenomenon:
Episodic Digital Ischaemia
4 of 6 10/6/2007 12:28 PM
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
5 of 6 10/6/2007 12:28 PM
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Wrist Arthroscopy http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Wrist Arthroscopy
Positioning &
Indications Complications Portals Images
Preparation
Indications: [Back To Top]
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: [Back To Top]
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. traction related
2. complications incurred during the establishment of portals
3. procedure-specific complications
4. others
Positioning and Preparation: [Back To Top]
Finger traps (to index and long fingers) tied to drip-stand
1 of 3 10/6/2007 12:28 PM
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: [Back To Top]
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: [Back To Top]
2 of 3 10/6/2007 12:28 PM
Further Reading:
Wrist Arthroscopy - Wrightington Hospital

Thurston AJ. Current Orthopaedics. 13:120-30.1999.
[ Close Window ]
3 of 3 10/6/2007 12:28 PM
Wrist Instability http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Wrist Instability
Anatomy Classification CID CIND Axial
CIC CIA Investigations Carpal Angles Treatment
Carpal Anatomy [Back To Top]
2 carpal rows:
1. Distal
Trapezium, trapezoid, capitate, hamate bound together by strong interosseous

(intrinsic) ligaments to form distal row, which moves together as a single unit
2. Proximal
Scaphoid, lunate and triquetrum form the proximal row. It has no muscle
attachments and is inherently unstable in compression without its ligamentous
attachments. Acts as a link between the relatively rigid distal row and the radioulnar
articulations.
Intrinsic ligaments
These have their origin and insertion within the same carpal row
Distal row
To bind all the distal carpal bones together
Proximal row
Scapholunate ligament
Lunotriquetral ligament
Extrinsic ligaments
Volar
Stronger, and arranged in 2 distinct "V" shapes centred on the lunate and the capitate
The radioscapholunate ligament is now known to be a vascular pedicle rather than a
true ligament
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Dorsal
Weaker and centred on the triquetrum
Classification (Mayo) [Back To Top]
Instability may be static or dynamic
Carpal Instability Dissociative (CID) [Back To Top]
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Relates to instability between individual carpal bones of the same row
Carpal Instability Non-Dissociative (CIND) [Back To Top]
Relates to instability between carpal rows or transverse osseous segments, and can be
caused by ligament injury or bony fracture (or both)
Axial instability [Back To Top]
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
3 of 6 10/6/2007 12:29 PM
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 [Back To Top]
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 [Back To Top]
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 o
This is a description of the deformity but does not describe the pathological process
Causes: SLL injury, scaphoid #, Keinboch's and perilunate injury
Volar Intercalated Segment Instability (VISI) [Back To Top]
4 of 6 10/6/2007 12:29 PM
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 [Back To Top]
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
FCU tenodesis
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Acute perilunate dislocation
Immediate closed reduction followed by open repair of the ligaments via dorsal
approach
CIND
Acute - direct repair of the ligaments
CIC
Treat the individual components of the injury
CIA
Normally related to radial malunion therefore perform a corrective distal radial

osteotomy
[ Close Window ]
6 of 6 10/6/2007 12:29 PM
Wrist Osteoarthritis http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
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
2. disease arthrodesis
Mechanical Preiser's
AVN of scaphoid
disease
AVN Capitate
70% of people have a facet on
the medial aspect of the lunate
Hamo-lunate Hamate head excision
which can impinge on the head
Impaction (arthroscopic)
of hamate in full ulnar deviation;
diagnosed arthroscopically
STT OA ass. with chondrocalcinosis; pain
STT arthrodesis
[Radiograph] on radial deviation of wrist;
from malunion distal radius #s; Sauve-Kapandji procedure
DRUJ OA
injury to sigmoid notch [Picture]
scaphoid excision & 4 corner
Carpal
SLAC fusion
instability
(capito-hamo-triquetro-lunate)
from scapho-lunate interosseous
Dorsal rim
lig. incompetence; diagnosed
impaction
arthroscopically; precursor of
syndrome
SLAC & SNAC
Piso-triquetral
causes loose bodies in wrist joint
OA
3. Metabolic Gout
Pseudogout
4. RA
Inflammatory
Psoriasis
Scapholunate Advanced Collapse (SLAC):
common pattern of OA
may be end-stage of scapho-lunate dissociation
The structures maintaining scapho-lunate alignment fail from trauma or degeneration.
1 of 3 10/6/2007 12:33 PM
Lunate extends & scaphoid flexes -> reduces carpal height

Later proceeds to radio-carpal OA & lunocapitate & lunohamate OA
Treat with scaphoid excision + 4-corner fusion (lunocapitate & triquetrohamate)
Scaphoid Non-union Advanced Collapse (SNAC):
Develops from a longstanding scaphoid non-union.

The proximal pole of scaphoid acts like a lunate
OA develops betw. distal scaphoid fragment & radial styloid (not between radius &
proximal fragment)
Notes on some Treatments:
Neurectomy:
Limited neurectomy (Berger technique)

70% of patients have 70% pain relief at 7 years
Arthroplasty:
for low demand patients (RA) with good bone stock.

metalloplastic
Loosening = 15% over 10 years
small dislocation rate
DRUJ Procedures:
1. Darrach
Procedure
Darrach's
original
procedure
was
to
resect
the
distal
ulna
but
retain
a
strip
of
bone
2 of 3 10/6/2007 12:33 PM
on the ulnar side with the styloid & the ligaments joining this to the carpus.
(forerunner of Bower's hemiresection & soft tissue interposition)
Theoretically get subluxation of the carpus to the ulnar side.
Get instability of the stump causing discomfort in young active people.
2. Sauve-Kapandji Procedure:
Preferred option
Prevents 'ulnar subluxation' of carpus (radiocarpal joint)
Good forearm function in 80%
20% complain of troublesome clicking in forearm rotation.
may be ECU slipping over prox. ulnar stump.
may be ulnar stump abutting on distal radius
Can try tendon sling procedures
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3 of 3 10/6/2007 12:33 PM

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Hand Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...

Zafar Naqui Edited 19.11.05 Orthoteers, Brinker

Classification [Back To Top]

It is important to distinguish the intra-articular fractures (Type I [Bennett's] + II [Rolando's]) from

Up to 30 o of angulation of the 1 st metacarpal base can be accommodated due the large

Bennett's Fracture [Back To Top]

A fracture-dislocation, first described by Bennett in 1882

Pure dislocations are very rare and need CRIF

Methods of Treatment [Back To Top]

It is important to apply gentle traction to the 1 st metacarpal in the correct

2 Percutaneous K-wires are then passed through the base of the 1 st

Aim to reduce the joint surface to < 2mm of displacement

Using either AO mini-screws, Herbert screws or K-wires

Rolando's Fracture [Back To Top]

CRIF with K-wire fixation to the 2 nd metacarpal

Because of the infrequency of Rolando's fracture, no one has reported a series

Other Metacarpal Fractures [Back To Top]

Classified like any fracture " location, displacement etc.

Specilaist Xray " 'Brewerton metacarpal head view'

C) MC shaft transverse " reduce and hold

D) MC base displaced " kwire

stiffness: tendon adhesions " may need tenolysis of flexors / extensors

Mx closed splint 6 weeks then 4 weeks at night

Dorsal dislocation of DIPJ

# Disloc includes hyperextension, impaction, shear, pilon.

Thumb UCL Gamekeepers. Competent UCL key to pinch grip.

Thumb RCL uncommon. Treatment guidelines similar to UCL.

Dorsal dislocn simple " reducible.

Overview Incisions Paronychia/eponychia Felon

Infections of the radial and

Osteomyelitis Human bites Herpetic Whitlow Mycobacterial infections

HIV and the hand Necrotising Fasciitis Fungal Infection

OVERVIEW [Back To Top]

Other organisms include streptococci, enterobacteria, pseudomonas, enterococci, bacteroides.

Always take a good history, diabetes? Fight bite?

Epitrochlear lymph nodes drain ring and little finger

Pus under pressure requires surgical drainage THERE IS NO ALTERNATIVE.

Incisions for Hand Infections [Back To Top]

Common Hand infections

Paronychia/ eponychia [Back To Top]

Infection of the nail fold, usually with staph aureus.

Felon [Back To Top]

Subcutaneous abscess of the pulp of the finger

Those beginning deep can cause osteomyelitis.

Antibiotics and incision and drainage

Methods of drainage - see diagram

Web space infection (collar button abscess) [Back To Top]

Often begins under palmar calluses in labourers.

Often points dorsally where the skin is more yielding.

Deep fascial space infections [Back To Top]

Middle palmar space infections

Suppurative Flexor Tenosynovitis [Back To Top]

Kanavel's four cardinal signs

1. finger held in a flexed position

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

Infections of the radial and ulnar bursae [Back To Top]

Osteomyelitis [Back To Top]

USE LEAST INVASIVE TECHNIQUE CONSISTENT WITH NECESSARY STABILITY