Hand

Compartment Syndromes

Upper limb fasciotomyForearm Fasciotomy Closure

 

1.  Antebrachial Compartment Syndrome

 

Aetiology

 

Supracondylar fracture of humerus

Both bone forearm fractures

 

Examination

 

Tense compartments

Pain +++

Passive extension of the digits or wrist increases pain

Paresthesias in median nerve distribution

 

Forearm Fasciotomy 

 

Decompression extending from elbow to wrist

 

Compartments (3)

- mobile wad

- volar

- dorsal

 

Incision

- medial arm

- across elbow

- continue as Henry approach into forearm

- can continue into palm as CTD incision

 

Release

- lacertus fibrosus  (releases median nerve at elbow)

- fascia of forearm (releases superficial volar)

- deep fascial compartments (FCU / FDP / FPL)

- mobile wad

 

Remeasure dorsal compartment

- often decompression of volar compartment will reduce dorsal pressures

 

Consequences

 

Volkmann's ischemic contracture

- result of delayed diagnosis

- severe muscle fibrosis & neuropathy 

- clawing of fingers

 

Muscles most commonly affected

- FDP

- FPL

 

Transfers

- BR to FPL

- ECRL to FDP

 

Compartment Syndrome of Hand

 

Aetiology

 

Iatrogenic injuries

- arterial line or infiltration of IV medications

Crushing trauma

IV drug abuse

High pressure injections

- i.e. paint guns

 

Clinically

 

Hand compartment syndromes lack abnormalities in sensory nerves

- no nerves are found within compartment

- non specific aching of the hand

 

Increased pain, loss of digital motion, continued swelling 

- tight swollen hand in a intrinsic minus position

- MP extension and PIP flexion

- intrinsic tightness (increased PIPJ motion with MCPJ flexion v extension)

 

Pressure measurement 

 

Should have a lower threshold than in leg compartments 

- pressures greater than 15-20 mmHg is a relative indication for release

 

Compartments

 

10 separate osteofascial compartments 

- dorsal interossei (4) 

- palmar interossei (3) 

- adductor pollicis (1)

- thenar and hypothenar  (2)

 

Decompression

 

CTD

- release thenar / hypothenar / adductor pollicis

- 2 x dorsal incisions over MC 2 and 4

 

 

Dupuytren's Disease

Background

Definition Dupuytrens

 

Palmar Fibromatosis 

 

Aetiology

 

AD with variable penetration

 

Pathogenesis

 

Murrell's Theory of Pathogenesis

 

1. Microvascular ischaemia

 

2. Leads to conversion of 

- ATP to Hypoxanthine

- Endothelial Xanthine Hydrogenase to Xanthine Oxidase

 

3. Xanthine Oxidase converts Hypoxanthine to Uric Acid

- gives off OH-

 

4 OH- releases Free Radicals 

- stimulate fibroblast proliferation & increased Type III Collagen

 

5  Fibroblasts strangle microvessels

- Vicious Cycle  

 

Luck's three stages of Dupuytren's contracture 

 

1st stage (proliferative) stage 

- increased cellularity

- number of large myofibroblasts

 

2nd (involutional) stage 

- dense myofibroblast network aligned to long axis of collagen bundles

- the ratio of Type III collagen to Type I collagen is inc

 

3rd (residual) stage 

- myofibroblasts disappear 

- fibrocytes are dominant cell type

- dense collagen cord remains

 

Myofibroblasts 

 

Cell of origin for the nodular myofibroblast is unknown 

- fibroblast / smooth muscle cell / pericyte

- Contractile cell

- nodules composed of myofibroblasts 

- No myofibroblasts in cords

 

Dupuytren's diathesis 

 

Aggressive early-onset form of the disease which involves the multiple areas

- usually have family history

- disease recurs rapidly following treatment

 

Feet (Ledderhose, 1897)

Penis (Peyronie) 

Garrod knuckle pads on dorsum PIPJs

 

Associations

 

Chronic alcoholism 

- ? metabolic effect on fat and prostaglandin metabolism

 

Diabetes mellitus 

- may be related to the diabetic microangiopathy

 

Epilepsy 

- likely effect of antiepileptic drugs on collagen metabolism

 

Smoking

 

Chronic pulmonary disease

 

Occupational hand trauma 

- controversial 

- probably only aggravation due to traumatizing an early nodule

 

Epidemiology

 

Age 50-70

Male 7:1

 

Caucasians

- especially celtics / vikings heritage

- rare in blacks & asians

 

Anatomy

 

A.  Involved anatomy

 

1.  Pre-tendinous Bands

- part of the palmar aponeurosis in palm

- common site of disease

- palpable nodule is pathognomonic of Dupuytren's

 

2.  Spiral Band

- continuation of pre-tendinous band into finger

- spirals deep to NV bundle then becomes superficial to bundle

 

3.  Natatory Ligament

- pass between the web spaces

- frequently diseased and prevents abduction

 

4.  Lateral Digital Sheet

- condensation of superficial fascia on either side of the finger

- receives fibres from the natatory ligament, spiral band, Grayson's and Cleland's ligaments

 

5.  Grayson's Ligaments

- hold skin during flexion and extension

- pass from fibrous tendon sheath to the lateral digital sheet

- volar to the NV bundle

- almost always involved in Dupuytren's

 

B.  Not involved anatomy

 

Skoog's fibres 

- transverse palmar fibres 

- run from flexor sheath to flexor sheath at the level of the A1 pulley

- the nerve is always deep to the fibres

- part of palmar aponeurosis

- deep to pre-tendinous band

- don't become diseased

 

Cleland's Ligaments

- hold skin during flexion and extension

- firm fascial structures 

- pass from the side of the phalanges to the skin

- dorsal to the neurovascular bundle

- involved in Dupuytren's only through mingling with the lateral digital sheet

 

MEM: Dave Christie Goes Volar

(Dorsal Cleland's, Grayson's Volar)

 

Site

 

LF / RF most commonly affected

MF / IF are sometimes affected

1st web sometimes affected

 

Pathology

 

5 Major Pathological cords

 

1.  Pretendinous cord

 

In palm / other 4 in finger

- diseased pretendinous band

- causes MCPJ deformity

 

2.  Central cord 

 

Diseased central fibrofatty tissue

- large nodule often present in cord just proximal to PIPJ

- causes PIPJ deformity

 

3.  Spiral cord 

 

Pathological spiral band

- usually connects to the P2 (bone and tendon sheath)

- displaces neurovascular bundle volarly

 

Difficult to predict presence

- associated with more severe contractures

 

4. Lateral Cord 

 

Diseased lateral digital sheath

- intimately adherent to skin (sharp dissection required)

- contributes to DIPJ +/- PIPJ

 

5. Natatory Cord 

 

Diseased Natatory ligament

- causes web contracture

 

3 Minor Cords

 

1.  Retrovascular Cord 

 

Involves longitudinal fibers dorsal to the bundle

- commonly seen in combination with other cords

- causes DIPJ extension with lateral cord

 

2.  Abductor Digiti Minimi Cord 

 

Cord arises from abductor digiti minimi

- from MT junction 

- to ulnar side of the base of P2

- commonly adheres to the lateral skin

 

3.  Intercommissural Cords / 1st Web 

 

Pathological changes in 

- pre-tendinous band (radial longitudinal fiber)

- superficial transverse fibers of the palm (proximal transverse commissural ligament)

- the first web natatory ligaments (Grapow's ligament)

 

Contractures

 

1.  PIPJ Contracture 

 

4 components

- Central cord 

- Spiral cord 

- Lateral cord 

- Retrovascular cord

 

Correction sequence

- resection pathological cords

- capsulotomy, release check rein ligaments

- release of accessory collateral ligaments performed

- release of volar plate 

 

2.  MCPJ Contracture

 

Always correctable by removal of central band

- Flexion deformity does not lead to collateral shortening 

 

3.  DIPJ Hyperextension

Occurs in advanced disease

- contracture of retro-vascular + lateral cord

 

History

 

Usually mildly painful nodules to begin

- palm of RF and LF rays

- very short lived

 

Severe night pain

- suspect fibrosarcoma

 

Progressive contracture of MCP, then PIPJ

- nodule over PIPJ warning of impending PIPJ contracture

 

Difficulty putting hands in pockets

- difficult gripping

- poke themselves in the eye

 

Diasthesis

- foot, penis

 

Examination

 

Nodules / dimples / pits

- palm, fingers

 

Contractures

- MCPJ

- PIPJ

- DIPJ extension

- web space contractures / natatory cords

 

PIPJ Contracture

- Examine PIPJ with MCPJ flexed

- eliminate effect of cord

- establish if any joint contracture

 

Diasthesis

- feet, Garrod's pads

 

Hueston Table Top Test

- Royal Melbourne hospital

- palm down on table

- positive if can slide pen under

- MCPJ contracture 30-40o

 

Surgery

Indications 

 

1. Significant functional impairment

 

2. PIPJ contracture

- originally thought to intervene early

- Macfarlane showed residual FFD always about 30o

- may need to release  check rein ligaments / accessory collateral ligaments

 

3. MCPJ contracture >30o

 

4. Trigger fingers

- must do limited fasciectomy 

- otherwise may get exacerbation

 

5. CTS 

- treat dupuytren's 1st then carpal tunnel if doesn't settle

 

Contraindications

 

Advanced RA

Trophic changes due to vascular insufficiency

Unfit for GA

 

Risk for Recurrence

 

Diathesis

- Garrod's pads highest risk

- foot and penis involvement

Family History

Bilateral / Radial and ulna involvement / multiple digits

Males

Young patients and patients > 75

 

Options

 

Fasciotomy

Partial Fasciectomy

Complete Fasciectomy

Dermatofasciectomy and STSG

Amputation

 

Fasciotomy

 

Division of fascial cord

- Temporary method to relieve a severe MCPJ contracture

- not definitive therapy

- not in digits because high risk of neurovascular injury

- useful in elderly patients 

- results are better with dense mature cords 

 

Partial Fasciectomy

 

Dupuytrens surgery

 

Most common procedure

 

Recurrence rates of 50%

- need for repeat surgical procedure is only 15%

 

Technique

 

Longitudinal incision with Z plasty at end of case

- probably better with severe contracture as allows skin closure

- easier to protect NV bundles

- z at 60o

 

Careful flap elevation

- easy to button hole through skin

 

Dissection of NV bundles

- under then over spiral bands

 

Resection of diseased tissue

 

PIPJ  contracture > 30o

- MUA

- released check rein / accessory collateral / volar plate /  capsulotomy / flexor sheath

- note that a extended finger which does not flex is more debilitating than a FFD

 

Skin gaps

- due to large contractures

- FTSG

- McCash open technique (secondary healing)

 

Closure

- let down tourniquet for haemostasis

- consider drain

- check finger vascularity

 

Post-op

 

POP backslab in POSI

Wound check at 7 days

ROS 2 weeks

Night splint in extension for 3/12

 

Complete Fasciectomy 

 

Abandoned due high complication rate

- does not completely prevent recurrence of the disease

 

Dermatofasciectomy & FTSG

 

Indications

- recurrent disease

- young with diathesis / aggressive disease

- Recurrence under grafts very rare (Hueston)

- the FTSG as a fire break

 

Amputation

 

Rarely necessary

- may be indicated if severe PIPJ flexion 

- skin from involved finger may be used to cover palmar skin defect

- finger is filleted & skin folded into palm as pedicle with neurovascular bundles

 

Adjunctive Procedures

 

Trigger Fingers 

 

Excise diseased fascia with release of the A1 pulley

 

Pulley release without local diseased fascial excision

- may instigate a rapid progression of the Dupuytren's disease

 

Carpal Tunnel Syndrome 

 

Prophylactic CTD at time of fasciectomy is unwise

- accelerated scar formation may cause poor result

 

Partial Fasciectomy with CTD at later date

 

Complications 

 

Haematoma

- can be a problem for the skin

- lead to necrosis

 

Vascular Impairment/ Flap Necrosis

- finger white at end of procedure

- often due to vessel stretched after significant release

- bend fingers, leave tourniquet down

- papaverine on vessels as antispasmodic

- warm hand

- inspect vessels for damage

- wait

 

Nerve Injury

 

Reflex sympathetic dystrophy 

 

Finger Fractures

Incidence

 

1 / 1000 per year female

1.5 / 1000 per year male

 

Phalangeal fractures

- represent more than half of all hand fractures

 

Goals of Treatment

 

Restore normal function of the finger

 

1.  Restoration of bony anatomy

 

2.  Early motion

- inherent fracture stability

- splinting

- adequate internal fixation

- dynamic external fixation

 

Examination

 

Obvious swelling / bruising / deformity

 

Compound injuries

 

Rotational alignment

1.  With active flexion, all fingers point towards scaphoid tuberosity

2.  Evidence digital overlap (see below)

3.  Plane of nail beds all in same plane

- LF often slightly different rotation

 

Finger MalrotationFinger rotation normal

 

Tendon avulsion

 

X-rays

 

3 planes centred on MCPJ  middle finger

- AP

- lateral

- oblique

 

Care to look for subtle evidence joint subluxation

 

Principles Closed Treatment

 

POSI (Position of Safe Immobilisation)

- 20o wrist extension

- flexion of MCPJ to 60 - 70o

- IP joints in extension

- thumb in abduction

 

Acceptable alignment

 

Pun etal JBJS Am 1989

- 10o angulation in both planes

- no rotation

- 50% overlay

 

Surgical approaches

 

A.  Midaxial

- dorsal to NV bundle

- make dots on flexion creases with finger flexed

- this marks incision

- approach P1 by excision of one sagittal band

- less tendon disruption

- more difficult visualisation / access

 

B.  Midlateral

- volar to NV bundle

 

C.  Dorsal approach

- direct doral incision

- divide extensor hood over P1

- between lateral bands P2

- repair extensor mechanism at end

- risks scarring down of extensor tendon to implant

 

Types of injuries

 

1.  Extra-articular fractures

 

A.  Distal phalanx tuft fractures

B.  Shaft fractures of the distal, middle and proximal phalanges

 

2.  Joint injuries

 

DIPJ   

- dislocations

- mallet

- Pilon fractures

- Flexor tendon avulsion           

 

PIPJ    

- dorsal dislocations

- dorsal fracture dislocations

- volar dislocations

- Pilon fractures

- Condylar fractures

 

MCPJ dislocations

 

Tuft fractures

 

Most common hand injury

- usually crush mechanism

 

Management

- trephination of subungal haematoma (relieves pain)

- repair nail bed disruption

- irrigation and washout of open injuries

 

Distal phalangeal shaft fractures

 

Distal Phalanx Fracture 1Distal Phalanx Fracture 2

 

Non displaced fractures

– splint DIPJ for 2-3 weeks

 

Displaced

- higher energy fractures

- washout open wounds

- repair nail bed

- bony reduction with percutaneous K wire

- distal phalanx just under nail bed

 

Shaft fractures middle / proximal phalanges

 

Undisplaced

- usually stable

- buddy strap 3-4 weeks

 

Finger Fracture Undisplaced

 

Displaced

 

Finger Phalangeal Shaft FractureProximal Phalanx Shaft Fracture

 

Unstable fractures

- oblique, spiral, comminuted fractures

 

Transverse fractures P1 / characteristic deformity

- insertion of intrinsics at base PP flex fragment

- insertion of central slip to MP extend fragment

 

Finger Phalangeal Shaft Fracture Lateral

 

Fractures of P2 distal to insertion FDS / characteristic deformity

- FDS will flex fragment

- extensor tendon will extend fragment

 

Closed reduction

- relaxation of intrinsics

- axial traction

- reduction of deformity / POSI

 

ORIF

 

A.  Transverse fractures

- cross K wire

- Lister’s intra-osseous wire fixation

- plating

 

Hand Phalange Circular WireFinger Cross K Wires

 

B.  Long oblique / spiral fractures

 

Definition

- fracture must be at lease 2 x diameter bone

- can treat with 2 x lag screws

- one perpedicular to fracture to lag

- one perpendicular to shaft to resist shear

 

Options

- percutaneous K wires / screw fixation / plating

 

FInger Lag Screws

 

DIPJ Dislocations

 

Dorsal

- most common

- closed reduction with dorsal traction

- failed closed reduction – volar plate, FDP

- 60% injuries open

- splint joint in flexion 2- 3/52 weeks

- ROM at 1/52

 

Volar

- rare

- failed closed reduction – extensor tendon

- DIPJ extension splint 6-8/52

 

Mallet fractures

 

Mallet Finger

 

Mechanism

- axial load

- extensor tendon attached to bony fragment

 

Closed treatment

- mallet splint (Stack)

- expect 10o extensor lag with mild loss ROM

- good results with non – op management

 

ORIF

 

Bony Mallet Thumb

 

Indication

- volar subluxation of distal phalanx

- fragment > 50% joint surface

- chronic > 12 weeks old

 

Open treatment

- high incidence of complications

- percutaneous K wire recommended

 

Technique

1.  Reduce and axial K wire

2.  Dorsal blocking K wire / axial K wire

 

Wehbe and Schneider JBJS Am 1984

- 21 patients with intra-articular fractures

- 15 treated non operatively

- 6 treated operatively

- nil improvement in outcome

- worsened surgical morbidity

 

Pilon fractures base distal phalanx

 

Impaction injuries

 

Management

- ORIF very difficult

- all attempts at closed reduction +/- percutaneous pinning should be made

- fallback of arthrodesis / arthroplasty

 

FDP avulsions

 

Leddy and Packer classification

I   Vinculae are ruptured, tendon retracts to palm

II  Vinculae intact, tendon remains at PIPJ

III Large bony fragment, ensnared beyond A4 pulley

 

Type 1

- must be operated within 10 days to avoid contractures

- otherwise 2 stage reconstruction

 

Type 2 / 3

- can operate within 6 weeks

- ORIF large fragments

 

Condylar fractures of head of P1 / P2

 

Mechanism

- torsional and valgus impaction

 

London classification

Type 1  Unicondylar, undisplaced

Type 2  Unicondylar, displaced

Type 3  Bicondylar

 

Displaced unicondylar

- percutaneous K wire

- ORIF with screw

 

Finger Unicondylar Displaced FractureFinger Unicondylar Fracture ORIF APFinger Unicondylar Fracture ORIF Lateral

 

Open reduction

- P1 – between central slip and lateral band

- P2 – lateral to terminal extensor tendon

- must preserve collateral ligament which supplies blood

 

Type III bicondylar fractures

- difficult fractures

- 90 degree condylar plate

- lag screw and plate

- high risk of joint stiffness

 

PIPJ Dislocations

 

Types

- Dorsal

- Lateral

- Volar

 

Stabilisers

 

Proper collateral ligaments

- primary stabilisers

- insert volar third of the base of PP

 

Accessory collateral ligaments

- inserts on and stabilises lateral margin of volar plate

 

Volar plate

- thick distally

- thin proximally, allowing collapse during flexion

 

Dorsal dislocations PIPJ

 

Most common joint injury of the hand

- hinge joint permitting 110o ROM

- volar plate fails distally

- collateral ligaments may be intact

- may be a fracture

 

Mechanism

- hyperextension

- axial loading of the flexed fingertip

 

Stability

- dependant on integrity of the collateral ligaments

- if fragment is > 40 – 50%, the attachment of the true collateral ligament is lost

- unstable

 

Eaton Classification

 

I Simple hyperextension

- buddy strap, early ROM

 

II Dorsal dislocation

- reduced and assess stability

- buddy strap if stable

- extension splint 10o further than instability

- each week extend further by 10o

- early aggressive ROM program

 

Dorsal Dislocation Simple

 

IIIA  fracture < 40% volar articular surface

- closed treatment with extension block

 

Finger Dorsal Dislocation Extension Blocking Splint

 

IIIB fracture > 40% + Pilon fractures

- inherently unstable

- extension blocking requires extreme flexion for stability, so risk of flexion contracture is high

- aim for congruent articular surface and early ROM

 

PIPJ Dislocation and Large Bony Fragment

 

IIIB Treatment Options

 

1.  Dorsal Blocking K wire

2.  Slade Dynamic Distraction External Fixator

3.  Compass Hinge

4.  Volar Plate Arthroplasty

 

Dorsal Blocking K wire

 

Technique

- flexion P2

- dorsal entry into P1

- 40o flexion

- early removal at 3/52

- Improvement compared to extension blocking

 

Suzuki / Slade Dynamic Distraction external fixator

 

Concept

- closed reduction through ligamentotaxis

- early motion of PIPJ

 

Technique

- transverse K wire in rotational centre / head P1

- transverse K wire distal P2

- attached by rubber bands

- third K wire mid-diaphysis P2,  prevents dorsal translation of MP

 

Deshmuhk S etal JBJS Br July 2004

- 12 patients complex fracture dislocations PIPJ

- treated with modified pin / rubber band system

- average 84o ROM

- nil radiological osteolysis or clinical osteomyelitis

- all returned to occupation

 

Hotchkiss designed PIP compass hinge

 

Technique

- K wire to centre head of P1 to set centre rotation

- 2 x  K wires each in P1 / P2

- barrel over centre of rotation

- options of active motion, passive ROM, locked

 

Bain I JBJS Br 1998

- 12 patients

- mean range of motion 12 – 86o

- only half presented within 2 week of injury

- combined operation with ORIF and volar plate arthroplasty

- nil osteomyelitis

- hinge on for 6 weeks

 

Volar plate arthroplasty / Volar plate advancement

 

Technique

- incise accessory collaterals to release volar plate

- excise bony fragment

- suture proximal volar plate into defect

- pass sutures through drill holes in base P2

- tie over button dorsally

- dorsal blocking splint 4 - 6 / 52

 

Finger Volar Plate Arthroplasty

 

Volar PIPJ dislocations

 

Finger Volar DislocationFinger Post Volar Dislocation

 

A.  Straight volar dislocation

 

Assessment of central slip post reduction critical

- if can active extend to within 30o, splint extended

- if nil active, surgical repair to prevent boutonniere

 

B.  Volar rotary subluxation

- condyle button holes between central slip and lateral band

- irreducible dislocation

 

Lateral PIPJ dislocations

 

Rupture of one collateral ligament and volar plate

- may be bony avulsion

 

Management

- reduce and hold in extension 2/52, then protected ROM

- can perform primary repair or reconstruct

 

MCPJ Dislocation

 

Simple

- volar plate not interposed

- MCPJ 90o hyper-extended

- reduce via wrist flexion and volar translation of PP

- avoid hyperextension and axial distraction which may convert this injury to a complex dislocation

- extension blocking splint 3-4 weeks

 

Complex

- volar plate / lumbrical tendon / flexor tendons interposed

- joint space widened

- requires open reduction, dorsal or volar

- volar more direct but risk NV bundles

- protected motion post operatively

 

MCPJ Destruction

 

Cause

- infection

- trauma

 

Options

- joint replacement

- fusion

 

MCPJ DestructionMCPJ Fusion APMCPJ Fusion Lateral

 

MCPJ Replacement

 

 

Finger Soft Tissue Injuries

Detipping Injury

 

Definition

 

Distal to insertion of flexor and extensor tendons

 

Anatomy

 

Thick skin

- fibrofatty tissue

- fibrous septa from dermis to periosteum of skin

 

Nail complex

 

1.  Nail Plate

 

2.  Nail Bed

- adherent to thin periosteum of P3

 

A.  Proximal germinal matrix

- proximal part

- limit is semilunar lunula

- produces 90% thickness of nail plate

 

B.  Sterile matrix

- adherent to nail plate

- contributes little to thickness

 

3.  Paronychium

- surrounding skin on dorsum of fingertip

 

4.  Eponychium 

- covers nail plate proximally

 

5.  Hyponychium

- thick skin below distal edge of nail

 

Classification

 

A Oblique facing up

B Transverse

C Oblique facing down

D Oblique facing laterally

 

Tissue involved

- Pulp only

- Nail bed

- Bone

 

Goals

 

1.  Preserve functional length 

2.  Preserve useful sensibility

3.  Prevent Neuromas

4.  Prevent joint contractures

5.  Short morbidity with early return to work

 

Management Pulp Loss

 

Pulp loss Finger

 

Options

 

1.  Primary healing

- best option

 

2.  Secondary healing

- < 1 cm2 area to cover

- 90% 5 year satisfaction

 

3.  Skin grafting

- 50% 5 year satisfaction

- most are painful

 

4.  Flaps

 

Local flaps / VY flaps

- Atasoy single volar

- Kutlers lateral flaps

 

Regional Flaps

- Cross-finger

- Thenar flap

 

4.  Formalisation

 

If bone on view and patient doesn't want flap

- take bone to level distal to extensor / flexor tendons

- remove nail bed in full (bilateral eponychial incisions)

 

Bone on View

 

Options

 

1.  Shorten and cover

2.  Preserve length and flap

3.  Secondary intention

- rarely a good option except in children

 

Soft tissue defects Finger

 

Local Flaps

 

1.  Atasoy  VY flap

 

Advantages

- local

 

Disadvantages

- often tender and sensitive long term

- can advance only 1 cm

- suitable for defects < 1 cm

 

Technique

- nibble bone back

- incise skin in V

- must release all fibrous septa form distal phalanx

- attempt to leave small vessels

- check is bleeding

- if avascular is usually because have not released all fibrous septa

- leaves too much tension on vessels

 

2.  Kutler's bilateral VY flap

 

Similar concept

- on both sides of digit

 

3.  Modified Kleinert flap

 

Lateral VY flap

- based on digital pedicle

- more volar VY flap than Kutler's

 

Regional Flaps

 

de-puplped finger injury

 

Disadvantages

- 2 stage procedure 

- Often result in finger stiffness

- Contra-indicated if diabetes / vascular disorders

- age relative contra-indication > 40 years

 

1.  Cross finger flap

 

Rectangle of donor skin from dorsum of P2

- Hinge is mid-axial line

- Must preserve paratenon over extensor tendon

 

Full-thickness skin graft to donor site from forearm

- transversely across bicipital groove

- must remove all fat from FT graft

 

Graft sutured 75% onto dorsum of donor finger

- flap crossed onto distal finger pulp

 

Divide flap under GA 3 weeks later

 

Results

- Obtain 10mm 2 point discrimination of flap

 

2.  Thenar flap

 

Indications

- source of good quality skin

- very similar to finger pulp

- 2 cm defect

- IF / MF / RF

- often difficult to oppose LF

 

Most important point is site of flap

- Position it high and parallel to MP crease

- If low or palmar can get debilitating donor site tenderness

 

Make skin 1.5 x defect size to reconstruct pulp

- donor site closed primarily or FTG

 

3.  Abdominal Flap

 

Suture finger to border between chest / abdomen

- release 3 weeks later

- primary closure of chest wound

 

4.  Formalisation

 

 

B.  Soft Tissue Defects Thumb

 

Options

 

1.  Moberg advancement Flap

 

Indications

- only for thumb

- Cover 2cm defect

 

Technique

- mid-axial incisions from injury site to MPJ

- entire volar skin flap with both NV bundles

- flex IPJ, suture

- can do VY at base, or transverse incision and FTG at base

 

2.  Cross Finger Flap from Index Finger

 

3.  Littler Neurovascular Island flap

 

Ulna side of ring or little finger

- take on just one side

- significant secondary defect

- put a skin graft into secondary defect

- rarely first choice

 

3.  First dorsal Metacarpal Artery Flap

 

Technique

- skin over dorsum of P1 of IF

- 4-sided cut and mobilise on pedicle

- With art vein and nerve

- subcutaneous tunnel

 

4.  Free tissue transfer of great toe pulp

 

5.  Abdominal Flap

 

 

 

Gamekeeper's Thumb

Definition

 

Injury to ulnar collateral ligament of thumb MCPJ

 

Aetiology

 

Initial description

- chronic laxity of British gamekeeper's thumb's 

- no specific trauma

- secondary to breaking pheasant's neck

 

Acute trauma

- snow ski

- ball games

 

Valgus / forced abduction

 

Anatomy

 

UCL

- origin medial condyle metacarpal

- passes obliquely volarly 

- inserts on volar 1/3 of P1 and volar plate

 

Adductor aponeurosis 

- superficial to UCL

- inserts into ulna border thumb extensor mechanism

- via the ulna sesamoid

 

Examination

 

Painful, swollen MCPJ

 

Tenderness along UCL

 

Abduction Stress Test

- in full extension and 30° 

- loss of end point or 30o > other side

- indicates complete rupture

 

X-ray

 

3 types Bony avulsion

 

1. Small fragment pulled away from P1

 

Thumb Bony Gamekeepers

 

2. Large intra-articular fracture involving >1/4 articular surface

 

3. S-H III in paediatric population

 

MRI

 

Look for stenar lesion

- when distal end of UCL

- flipped superficially over adductor aponeurosis

- will not be able to heal

 

A.  Undisplaced

 

MRI UCL Proximal Undisplaced InjuryTorn UCL Minimally Displaced MRI

 

B.  Displaced UCL

 

Management

 

Non operative

 

Indications

- partial tear

- undisplaced complete tear

- undisplaced bony fragment

 

Management

 

6/52 thumb spica

 

Operative

 

Indications for surgery

- complete tear with stener lesion

- large or small displaced bony fragment

- SH III in paediatrics

- chronic injury

 

Displaced Complete tear / Stener Lesion

 

Incidence

- 18 - 43%

 

Types

 

1.   Interposition of the adductor aponeurosis

- between a completely avulsed proximal ulnar collateral ligament injury

- and the proximal phalanx ligament insertion site

 

2.  Interposition between two ends of a mid-substance ligament tear

 

Diagnosis

 

Difficult clinically

- may be able to palpate displaced UCL

 

MRI

 

Technique

 

Dorsal incision along ulna border MCPJ

- Divide Adductor pollicis aponeurosis

- leave cuff for lateral repair

- Identify and repair UCL

 

Fixation

- direct suture if able to

- bony anchors

- through drill holes and over lateral button

- cerclage wire

 

Post op

- 6/52 thumb spica

 

Gamekeepers Thumb Repair

 

Bony Avulsion

 

ORIF Indications

1.   > 25% articular surface

2.   Small avulsion fracture displaced > 5mm

3.   SH III

 

Chronic Injuries

 

1.  Dynamic tendon transfer 

 

Adductor pollicis

- release adductor pollicis from ulnar sesamoid

- attach to base P1

 

2.  Free tendon graft

 

Graft options

- palmaris longus

- fourth toe tendon

 

Technique

- figure of 8 through drill holes

- transverse drill hole base P1

- drill hole head MC

- 6/52 POP

 

3.  Static tendon transfer

 

EPB

- leave attached distally

- weave through drill holes

 

Hand Arthritis

DDx DIPJ OA

DDx

 

OA

Psoriasis

CREST (scleroderma)

 

RA (rare form)

Other seronegative arthropathies

Hyperparathyroidism

Reactive arthropathy

Gout

 

 

 

Finger OA

Epidemiology

 

Male & Females > 60 years

- X-ray evidence of OA

 

Symptomatic 

- 25% females

- 15% males

 

Affected joints

 

Base thumb

PIPJ / Bouchard's nodes

DIPJ / Heberden's nodes

 

Finger OA

 

3 Groups

 

1.  Heberden's nodes

2.  Basilar thumb & Heberden's 

3.  Heberden's and Bouchard's

 

Xray

 

Joint space narrowing

Subchondral sclerosis

Osteophyte formation

 

DIPJ OAPIPJ OA

 

Management

 

Options

 

Arthrodesis

Arthroplasty

 

DIPJ Arthrodesis

 

DIPJ OA

 

Position

- 15 - 20o flexion

 

Incision

- transverse incision over DIPJ / H

- split / divide extensor tendon

- resect with small bone cutters and nibbles

 

Options

 

A.  Headless compression screw

 

DIPJ Fusion ScrewDIPJ Fusion Screw 2

 

B.  K wire and TBW

- single intra-axial K wire

- pass retrograde first, reduce, anterograde

- Circular wire

- small drill holes and pass 25 or 26 gauge wire

- tension

 

DIPJ FusionDIPJ Fusion TBW Lateral

 

PIPJ Arthrodesis

 

Best in RF / LF

 

Position

 

IF / MF

- 25 - 35o

 

RF / LF

- 45 - 50o

 

Technique

 

Longitudinal incision

 

Options

 

A.  Reflect central slip

- leave attached distally

- lateral bands remain 

- suture repair at end

 

B.  Interval between central slip and lateral band

- reflect central slip laterally

 

Release collateral ligaments

- leave volar plate intact

- create two opposable surfaces

- saw or bone nibbler

 

Fixation

 

A.  Headless compression screw

 

B.  Crossed K wires

 

C.  Longitudinal K wire and TBW figure 8

- pass wire retrograde 

- reduce, pass distally into P2

 

PIPJ Fusion TBWPIPJ Fusion TBW 2

 

Results

 

Fusion rates about 90%

 

Arthroplasty

 

See rheumatoid hand discussion

 

 

 

Inflammatory Arthritis

Conditions

 

Acro-osteolysis

SLE

Scleroderma

Psoriasis

 

Acro-osteolysis

 

Definition

 

Absorption of distal tuft of phalanx

 

DDx

 

Psoriasis

Scleroderma / Raynauds

Frost Bite

Hyperparathyroidism

Diabetes

Vasculitis

Leprosy

RA rarely

Gout

 

SLE

 

Pathology

 

Similar hand appearances to RA

- no joint destruction even in setting gross deformity

 

Pathophysiology

 

Autoimmune disorder

 

Distension of joint from synovitis rather than destruction of joint

 

Pannus not as aggressive as RA

 

Symptoms

 

Migratory poly arthralgia

Flexor tenosynovitis

MP and PIP arthritis

Raynaud's

AVN of carpus

 

Other

- butterfly rash

- lymphadenopathy

- pleuritis / pericarditis / Glomerulonephritis

- haemolytic anaemias

 

Xray

 

Effusions

Juxtacortical osteopenia

Subluxation / dislocation

Bone infarction and abnormal calcification

 

Joint destruction = Co-existent RA

 

Diagnosis

 

ANA 

dsDNA

 

Management

 

Aimed at rebalancing soft tissues

- may be inadequate

- may have to resort to fusion

 

Scleroderma

 

Pathophysiology

 

Hand Sclerodermad Scleroderma Occluded Superficial Palmar Arch

 

Autoimmune disease

Unknown aetiology

Small vessel disease

Fibrosis in multiple organ systems

 

DDx

 

RA

- 40% patients have RF

 

Epidemiology

 

Patients female and middle ages

 

CREST Syndrome

 

1. Calcinosis

2. Raynaud's

3. Esophageal Strictures

4. Sclerodactyly

5, Telangiectasia

 

Hands

 

Stiff shiny digits

Loss of creases

Acral tapering of digits

Autoamputation (acro-osteolysis)

Telangiectasia

Calcium nodules

 

Extraskeletal 

 

Lung fibrosis

CRF

 

X-ray

 

1.  Calcium subcutaneous / extra - articular / occasionally intra-articular 

2.  Acro-osteolysis of the tufts of DP (80% patients)

 

Osteopenia

 

Joint erosion

- RA part of DDx

 

Resorption of thumb CMC

- subsequent radial subluxation of the thumb MC

 

Psoriasis

 

Psoriatic arthritis

 

Pathophysiology

 

Autoimmune disease

- seronegative arthritis

 

5-10% of RA have psoriasis

 

DDx from RA

 

Asymmetrical distribution

Seronegative

Psoriatic rash

Nail changes / pitting

 

Often less aggressive

- typically DIPJ more involved

- may have less synovitis but bone and soft tissue destruction still occur

 

Classification

 

1.  Classic - involvement of DIPJ joints of hands

2.  Deforming - with ankylosis & arthritis mutilans

3.  RA - Like - similar to RA but without RF

4.  Monarthritis

5.  Ankylosing Spondylitis - like

 

Hand X-ray

 

Periarticular phalangeal erosions

- asymmetrical

- no periarticular osteopenia

 

Periosteal new bone formation along MC / MT shafts

 

DIPJ

- typical 'Pencil in cup' deformity of DIPJ

- P3 tuft resorption & whittling

 

DIPJ Pencil in Cup

 

Juvenile Rheumatoid Arthritis

 

Differences from Adult RA

 

Usually much milder course

- 50-70% achieves remission

 

Deformity often opposite of Adult

- short ulna

- ulna hand / MC's

- radial deviation of fingers

 

Hands

 

Boutonniere deformity common

Intrinsic tightness uncommon

 

Extensor tenosynovitis signs uncommon

First sign is usually rupture of tendons with dropped wrist

 

 

Hand Infection

Bites

 

Human / Tooth Knuckle Injuries

 

Mechanism

 

Clenched knuckle

- tooth often penetrates capsule of MCPJ (60%)

- can injure the bone (58%)

- usually 3 / 4 th MCPJ

 

Associated Injury

 

Boxer's fracture

- 4th / 5th metacarpal head

 

Extensor tendon Laceration

 

Pathology

 

Up to 50% rate of infection

- septic arthritis

- tenosynovitis

- osteomyelitis

 

Organisms

 

Polymicrobial

- streptococci

- Staphylococci

- Eikenella

- anaerobes

 

Eikenella corrodens

- seen in 1/4 TKI

- gram negative rod / facultative anaerobe

- acts synergistically with strept and contributes to morbidity

- can be resistant to dicloxacillin

- usually sensitive to

 

Management

 

Intial treatment

- povidone-iodine + copious irrigation

 

Antibiotics

- augmentin oral

- IV penicillin

 

Surgery

- best to debrige and washout all wounds

- open skin

- inspect extensor tendon

- open capsule, washout +++

- closure capusle

- leave skin open

- day 2 steristrip skin close

 

Await cultures

- change antibiotics accordingly

 

Note

- failure of treatment with cephalosporin

- may be due to eikenella

- change to penicillin

 

Dog bites 

 

Organisms

 

Mixed growth

- Streptococci

- Staphylocci

- Pasteurella

 

Management

 

Washout & debride

Augmentin

TMP-SMX if allergic to penicillin

 

Cat Bites

 

Organisms

 

More often become infected

 

Culture

- 50% Pasturella multocida

 

Management

 

Incision and drainage

 

Antibiotics

-  Augmentin / penicillin

- 2nd or 3rd generation Cephalosporin

 

 

Felon

Definition

 

Abscess of terminal pulp

 

Aetiology

 

Puncture wound

Paronychia or subungual abscess

 

S. aureus most common

 

Management

 

Early Antibiotics and elevation

 

Usually requires incision and drainage

 

Incision 

- lateral aspect of pulp

- unilateral longitudinal incision

- non-contact side of digit

- not too volar otherwise knocks out vessels

- must divide fibrous septa

 

 

 

Flexor Tendon Sheath Infections

Aetiology

 

S. aureus / Strept

- usually a history of trauma

 

Anatomy

 

IF / MF / RF

- extend from DP to distal crease

 

LF

- extends to mid palm

- communicates with ulna bursa

 

Thumb 

- distal phalanx to volar wrist crease

- communicates with radial bursa

 

Examination

 

Kanavel's 4 signs

 

1.  Tenderness along course of flexor tendon

2.  Fusiform swelling

3.  Flexed attitude to finger

4.  Pain on passive extension of finger

 

Management

 

Early

- may settle with antibiotics if get early

- want improvement in 12 - 24 hours

- risk adhesions / tendon necrosis

 

Surgical 

 

Distal incision

- distal finger crease

 

Proximal incision

- distal palmar crease

 

Will see pus

- take swab for MCS

 

Pass infant feeding catheter

- into flexor sheath

- irrigate +++

 

IV ABx 48 hours

 

Occupational / hand therapy to prevent adhesions

 

 

 

Other

Radial & Ulnar Bursal Infections

 

Bursal Anatomy

 

Enclose flexor tendons

 

Ulnar bursa is extension of little finger synovial sheath

 

Radial is extension of thumb synovial sheath

 

Coalesce in carpal tunnel to envelope all flexors

- 50% of time radial and ulna bursa communicate

- can get horse shoe collections

 

Deep Space Infections

 

Clinical

 

Palmar pain and swelling

 

Dorsal pain and swelling

 

Anatomy

 

Midpalmar septum

- to MF Metacarpal

 

Hypothenar septum

- to LF Metacarpal

 

Potential Spaces

- thenar space

- midpalmar space

 

Thenar space

- ulnarly by midpalmar septum

- dorsally by Adductor Pollicis

- palmarly by index finger flexor tendon

 

Drainage

- dorsal incision (can spread to involve 1st dorsal interossei)

- palmar incision

 

Midpalmar Space 

- Radial border midpalmar septum

- Ulnar hypothenar septum

- Dorsally 3-5 metacarpals

- palmar flexor tendons and lumbricals

 

Management

- transverse incision across palm

 

Web Space Infection

 

Boundaries

- dorsally web skin

- Volar by transverse palmar fascia

- Radially and Ulnarly by fibrous septa

 

Management

- both dorsal and volar incisions to ensure adequate drainage

- Avoid transverse incisions --> Contracture

 

Herpetic Whitlow

 

Aetiology

 

Cut on finger

- exposed to oral secretions

 

Symptoms

 

Often extremely painful

 

Management

 

Oral antivirals

Recurrence 30 - 50%

 

Atypical Mycobacterium

 

Aetiology

 

Mycobacterium marinum

- aquatic trauma

 

Clinical

 

Abundant tenosynovitis or joint synovitis

 

May take 8 weeks to culture on LJ medium

 

Management

 

Debridement

3-6 months ABx

 

 

Paronychia

Definition

 

Paronychia is skin around nail plate

 

Eponychia is skin covering base of nail plate

 

Pathology

 

1.  Due to foreign material between nail plate and paronychium 

 

2.  By hang nail traumatising paronychium

 

Aetiology

 

Acute

- typically polymicrobial 

- aerobes and anaerobes

- Staph aureus, group A Strep, Eikinella corrodens

- Bacteroides, gram positive cocci and Fusobacterium nucleatum

 

Chronic paronychia

- atypical mycobacterium

- fungal infection

- gout

- carcinoma

 

Management

 

Non operative

- warm soaks

- splinting 

- antibiotics (Augmentin)

 

Operative

 

Decompress and drainage of abscess may be necessary

- lift nail fold off plate +/- wedge resection

- avoid eponychial nail fold incision

 

Metacarpal Fractures

Fractures

 

1.  Neck of 5th Metacarpal

2.  Metacarpal Shaft

3.  Metacarpal Head

4.  Base of Metacarpal Fracture Dislocations

5.  Base of Thumb Fractures / Bennett's / Rolanda

 

1.  Neck of 5th Metacarpal Fracture

 

Non operative Management

 

Accept 45o angulation

- will have finger extensor lag, but will recover

- can ring block and manipulate in POSI cast to improve position

 

Neck of Fifth Metacarpal Fracture

 

Operative Treatment

 

Rare

- K wire across MC head into 4th MC

 

2.  Metacarpal Shaft Fracture

 

Acceptable Deformity

 

Rotation < 5o

10o / 20o / 30o / 40o in IF / MF / RF / LF

< 5 mm shortening

 

Metacarpal Fracture Minimally Displaced

 

Operative Management

 

Options

- plate

- lag screws (if spiral fracture)

- intramedullary wires

 

Metacarpal Intramedullary Wires

 

3.  Metacarpal Head Fracture

 

Epidemiology

- uncommon

- usually in index finger

 

Indication for surgery

- > 2mm angulation

 

Options

- T plate

- headless compression screws / intra-articular

 

4.  Base of Metacarpal Fracture Dislocations

 

Can be missed

- may need CT to diagnose

 

Management

- reduce joint closed +/- open 

- dorsal approach

- K wire

 

Metacarpal Base Fracture Dislocation APMetacarpal Base Fracture Dislocation LateralBase of Metacarpal Dislocation CT

 

5.  Base of Thumb Metacarpal

 

Types

A.  Bennett's

B.  Rolando

- Y shaped intra-articular

 

A.  Bennett's Fracture

 

Bennetts Fracture APBennetts Fracture LateralBennetts CT

 

Fracture

- oblique intra-articular fracture

- small volar fragment remains in situ as attached to beak ligament

- metacarpal displaces proximally and dorsally due to APL

- inherently unstable

 

Management

- closed reduction

- longitudinal traction on metacarpal

- use thumb to reduce metacarpal shaft

- use 2 x K wires to pin metacarpal to trapezium / trapezoid

- 6 weeks in thumb spica cast

 

Bennetts FractureBennetts K wireBennetts ORIF

 

Bennett K wires

 

B.  Rolando Fracture

 

Fracture

- 2 small intra-articular fragments

- poor prognosis

 

Operative management

- for significant displacement

- dorsal approach

- protect superficial radial nerves

- between APL / EPB and EPL

- attempt to anatomically reduce and fix with plate

Nail Bed Lacerations

Subungual haematoma 

 

Management

- < 50% of nail bed -> Decompress with needle

- > 50% -> remove nail and repair bed

 

Nail bed lacerations

 

Options

 

1.  > 50% nail lost

- will get hook nail

- ablate nail bed

 

2.  < 50 % nail lost

- repair bed under magnification

- 6.0 chromic cat gut

- reduce nail plate back into fold to prevent adherence of dorsal and ventral folds

 

3.  Matrix defects

- can place nail bed material in place without sutures

- can use split thickness free nail bed graft

(i.e. from amputated digit)

 

4.  Proximal avulsion of nail plate

- always have germinal matrix laceration

- should always have 3 x horizontal mattress sutures

 

Complications

 

Hook Nail

 

Hook NailHook Nail

 

 

Replants

Replant 4 FingersReplant 4 fingers post

 

Definition

 

Replant

- reattachment of body part that has been completely severed

 

Revascularisation of incomplete Amputation

- vascular repair is necessary to prevent necrosis of the extremity

- retains some venous and lymphatic drainage albeit small

- revascularisation easier, quicker and better results

 

Mechanism of injury

 

Guillotine

Crush

Avulsion

 

Indications - Urbaniak 1987

 

Thumb 

Multiple digits

Individual digit distal to FDS insertion

Partial hand / through palm

 

Almost any body part in child

 

Wrist or forearm

 

Above or below Elbow 

- only if sharply demarcated

 

Contra-Indications

 

Adult single digit proximal to FDS insertion

- poor results / stiffness

 

Ischaemic time distal to carpus

- > 12 hours warm ischaemia time

- > 24 hours cold ischaemia time

 

Ischaemic time proximal to carpus

- > 6 hours warm ischaemia time

- > 12 hours cold ischaemia time

 

Severe crush or mangled

 

Levels

- through elbow

- high arm

 

Multiple level / segmental injury

 

Other serious injuries/diseases

 

Vessels atherosclerotic

 

Mentally unstable patient

 

Examination 

 

Chinese red line sign 

- red streak along arterial course

- due to severe traction

 

Ribbon sign

- elongated tortuous arteries with pigtail appearance

 

Considerations

 

Thumb

 

Thumb has first priority

- a successfully replanted thumb is always better than any reconstruction

- thumb provides 40% of hand function

- a fixed stump / post is very useful

 

Detipped thumb can be successful

- need dorsal veins in stump

- need 4mm of skin proximal to nail plate

- all efforts should be made to preserve thumb length even up to nail base

 

Multiple amputations

 

Replant best digit to most useful stump

When thumb intact goal is to restore palm width

 

Single digit

 

Does well if FDS intact

- allows immediate mobilisation of digit

 

P1 replants

 

Useful function does not occur

- patient will bypass finger

 

Mid-palm amputations 

 

Absolute indication for replant 

- replant far superior to prosthesis as lose sensation and power grasp

 

Proximal injuries

 

Proximal forearm, EJ and Arm 

- usually avulsion types with extensive muscle injury

- infection and muscle necrosis very common 

- usually replant not indicated

 

Patient factors

 

High demand professionals 

- may push indications eg at P1

 

Age is not a barrier 

 

Patient must be aware of chance at viability, function, time off work etc

 

Premorbid conditions must be taken into account 

- DM, Smoking, HTN, peripheral vascular disease

- patient compliance

 

Ischaemia

 

Key factor in success

 

Duration of allowed ischaemia varies from tissue to tissue

 

Recommended maximum

 

1.  Distal to carpus 

- 12 hours warm, 24 hours cool

 

Digits consist of skin, bone and subcutaneous tissue

- no muscle

- warm ischaemia tolerated for long periods

- freezing not tolerated

- digits have survived for 12 hours or longer of warm ischaemia

- when cooled replants have been performed at 36 hours

 

2.  Proximal to carpus 

- 6 hours warm, 12 hours cool

 

Major limb replants contain large volume of muscle

- only tolerate 4-6 hours of ischaemia

- because of the size of the extremity only its outer part is adequately cooled 

- the deep muscle remains relatively warm

- the allowable 6 hours can't be extended

 

Transport of part

4oC ideal

 

2 Methods

 

1. Wrapping the part in a moistened cloth of Ringer's or Saline

- placing in plastic bag and placing the bundle in ice water

 

2. Immersing the part in one of these solutions in a plastic bag 

- then putting on ice

 

No difference in outcome

 

Most important is to give clear and precise instructions to referring doctors

 

Surgeon

 

Dedicated replant team

 

Should be able to consistently achieve 90% patency rate in 1mm vessels in labratory

 

Operating theatre not the setting for practice

 

Surgical management

 

Operative Sequence for single digit

 

1. Locate and tag vessels and nerves

2. Debride

3. Shorten and fix the bone

4. Repair extensors

5. Repair flexors

6. Anastomose the arteries

7. Repair the nerves

8. Anastomose the veins

9. Obtain skin coverage

 

Set up

- maintain body temperature by warming the patient

- axillary block to block sympathetics

- ABx, tetanus prophylaxis

- IDC

 

Approach

- longitudinal mid-lateral incisions for digital replants

 

Shorten bone

- get out of zone of injury 

- must have no tension on the grafts

- minimum 0.5 - 1cm each side

- alternative is to vein graft but is easier to shorten bone

- Shortening also helps with skin coverage

- ORIF P1

- K wire fusion DIPJ / P2

 

Extensor Tendons

- primary repair

- if inadequate extensor tendon for primary repair perform delayed repair

 

Flexor tendons 

- repaired primarily if at all possible

- otherwise 2 stage 

 

Vascular

- 10/0 nylon interrupted

- key is repair normal intima to normal intima

- adventitia is intensely thrombogenic so ensure none in repair

- strip adventitia for 1-2mm

- repair both arteries if possible otherwise vein graft

- tourniquet acceptable

- micro-clips / bulldog clips should not be applied > 30min due to intimal damage

- heparin boluses to maintain patency (5000IU in 500 mls)

- papaverine antispasmodics

- 2 veins for every artery

 

Nerve repair

- 10/0 interrupted epineural repair

- primary repair if possible

- primary nerve graft if not 

- use medial cutaneous nerve of forearm 

 

Skin

- skin closed under no tension

- digital incisions often left open to decompress repairs

- fasciotomies in larger replants

- bulky above EJ dressing with volar slab unless flexor tendon repair then dorsal slab

 

Replant at level of nail bed

 

Issue

- No dorsal veins 

 

Options

1.   Repair of volar veins (smaller and more flimsy)

2.   Anastomose one distal artery to proximal vein (AV anastomoses)

3.   Backbleeding by removing nail plate and scrapping every 2 hrs with cotton applicator and heparin dressings

4.   Medical grade leeches

 

Post-Op

 

Elevate gallows

- high dependency area

- high fluids

- anticoagulation controversial

- smoking strictly prohibited

- no caffeine

- warm ambient temperature

- colour, pulp, turgor, cap refill, and warmth all used as aids in monitoring the replant

- observations hourly for 72h then q4h

- if concern re myoglobinuria then maintain urine output high and alkalinise the urine

 

Monitoring

- if surface temperature <30°C poor perfusion of replant is certain

 

Reversal of failing patient

 

If appears threatened immediate action necessary

1. Relieve dressings or sutures

2. Either elevate or dependant position

3. Regional block for sympathetics

4. Relieve pain, fear and anxiety

5. Ensure patient warm and adequately hydrated

6. If return to OT necessary then must be within 4-6 hours of ischaemia

 

Results

 

80-85% survivability

 

Urbaniak 1985

- 51/55 survived

- ROM 82o distal to FDS

- 35o proximal to FDS

 

Ring Avulsions

 

Urbaniak Classification

 

I - circulation adequate

II - circulation inadequate

III - complete degloving / amputation

 

Major limb replantation

 

Issues

 

Amputations proximal to metacarpal level have significant muscle bulk

- to prevent myonecrosis immediate arterial inflow is necessary

- following rapid skeletal stabilisation at least one artery must be stabilised then follow sequence for digit

- extensive fasciotomies always indicated

- any exposed vessels must be covered by rotation flap etc

- return to OT at 72 hrs for inspection and DPC

 

2 most common causes of failure in major limb replants 

 

1.  Myonecrosis with subsequent infection

 

2.  Failure to adequately decompress the restored vessels

 

Rheumatoid Hand

Hand RA Exam

Screening of Joints

 

Neck

-  ROM

 

Shoulder

- behind head / to mouth

- to back pocket 

 

Elbows

- flexion / extension elbows 

- pronation / supination with thumb up & elbows by side

 

Wrist

- flexion / extension

 

Hand

- make fist with thumb in and out 

- spread fingers

 

Functional Assessment of Hand

 

Power Grip 

Precision Grip 

Hook Grip 

Lateral Pinch Grip 

Tip Pinch

 

1.  Tip to Tip Pinch Grip

- pick up coin 

 

2. Lateral pinch grip

- turn key

 

3. Precision grip

- write with pen

 

4.  Power Grip

- turn knob 

 

5.  Hook Grip

- hold suitcase / fingers

 

Look at Hands / Place on Pillow

 

Palms up

 

Scars

- CTD / flexor tendon synovectomy

Swelling

- flexor sheath synovium

Thenar & Hypothenar eminences

 

Thumb up

 

Thenar wasting

Swan neck / Boutonniere deformity

 

Rheumatoid thumb Boutonneire

 

Palms down

 

Rheumatoid Hand

 

Wrist 

- synovitis / synovectomy

- wrist fusion

- caput ulna

- radial drift 

 

MCPJ 

- ulna drift / replacement / synovitis

- tendon subluxation

 

Fingers

- Swan neck / Boutonniere deformity

- rheumatoid nodules

 

Rheumatoid Nodules

 

Feel

 

Sensation

- median nerve / CTS

- ulnar nerve

 

Move

 

Extensor tendons

- drop fingers

- DDx - locked trigger, tendon subluxation, joint subluxation, PIN palsy

 

EPL

- ruptures over Listers

- IPJ is extended by intrinsics also

 

Flexor tendons

- rupture IF & thumb (synovitis)

- rupture FPL alone over trapezial ridge (Mannerfelt)

- triggering

 

MCPJs

- ? subluxed

 

Boutonniere deformity

- degree of lag

- passively correctable

- ? arthritic changes

 

Swan neck deformity

- passively correctable

- intrinsic tightness / Bunnell test

- arthritic changes

 

Swan Neck Finger 1Rheumatoid Swan Neck Finger 1

 

Bunnell Test

- test with MCP extended and flexed

- correct ulna deviation

- invalidated by MCPJ dislocation

- with tight interossei will have reduced PIPJ flexion with MCPJ extension

Management Summary

Rheumatoid Hands Xray

 

Rheumatoid Arthritis Diagnostic Criteria

 

1987 American College of Rheumatology 

 

Need 4/7 (MAX RANS)

1. Morning Stiffness

2. Arthritis of 3 areas > 6/52

3. Xray changes

4. Rh factor

5. Arthritis of Hand > 6/52

6. Nodules

7. Symmetric Arthritis > 6/52

 

Types of Surgery

 

5 basic Groups

 

1. Synovectomy / Capsulorrhaphy

2. Tenosynovectomy

3. Tendon surgery & soft tissue balancing

4. Arthroplasty

5. Arthrodesis

 

General Principles

 

Replace all MCPJs

Fuse IF/MF PIPJs

Replace RF/LF PIPJs

Fuse DIPJs

Correct wrist deformity at same time or risk recurrence

 

Caput Ulnae Syndrome 

 

Components

- volar subluxation of ulnar carpus 

- supination of carpus on wrist 

- apparent dorsal subluxation of distal ulna 

 

Nalebuff Classification MCPJ

 

Stage I - Synovitis

- medical Rx and splinting

- synovectomy

 

Stage II - Synovitis + Ulna deviation

- medical treatment and splinting

- synovectomy + soft tissue reconstruction

 

Stage III - Moderate joint destruction

- volar subluxation and ulnar drift

- soft tissue reconstruction possible

- arthroplasty gives more reliable results

 

Stage IV - Advanced joint destruction

- fixed joint deformities

- arthroplasty with soft tissue releases

 

Causes of MCPJ Deformity

 

Ulna Drift / Ulna Dislocation

 

1.  Physiological

- gravity

- lateral pinch pressure

 

2.  Anatomic

- shape of MC heads

- collateral ligament length & orientation

- intrinsics to LF asymmetric (hypothenars strong)

 

3.  Pathological

- joint / capsule instability due to bony erosions

- collateral ligament stretching due to synovitis

- ulna/volar dislocation flexor tendons due to stretching pulleys

- ulna dislocation extensor tendons due to stretching sagittal bands

- intrinsic contracture

- radial deviation of wrist (Landsmere) redirecting line of pull of tendons

- volar / ulna carpal subluxation

 

Nalebuff Classification Thumb

 

Note: Type II now removed as Nalebuff later said doesn't exist

 

Type I - Boutonniere

- the commonest

- MCPJ flexion, IPJ hyperextension

 

Type II - Boutonniere & Swan Neck

 

Type III - Swan Neck

- second most common

- deformity is at CMC / Dorsal & radial subluxation

- hyperextension MPJ / flexion IPJ

 

Type IV - Gamekeepers

 

Type V - Stretched Volar Plate MCPJ

 

Type VI - Arthritis Mutilans

 

Swan Neck

 

Causes

 

DIPJ 

- terminal extensor tendon rupture or attenuated

- entrapped FDP

 

PIPJ 

- volar capsule stretching / FDS rupture

- contracted central extenor slip

 

MCPJ 

- intrinsic tightness 

- extrinsic weakness / MCPJ subluxation and subluxation extensor apparatus

 

Management

 

Flexible

- FDS tenodesis / Lateral band transfer

- DIPJ arthrodesis (mallet)

 

Intrinsic tightness

- above +

- intrinsic release

 

Fixed deformity

- PIPJ dorsal release

- then above

 

Arthrosis 

- arthrodesis (20/30/40/50)

- arthroplasty (LF / RF)

 

Boutonniere Finger

 

Problem

- rupture of central slip

 

Solution

- flexible - Matev's central slips reconstruction

- radial lateral band to central slip

- ulna lateral band to radial lateral band insertion

 

Rheumatoid Fingers

ConditionsBoutonniere Fingers

 

1.  PIPJ Synovitis

- synovectomy via dorsomedial approach

2.  Flexor tenosynovitis

- may cause trigger finger

- trial HCLA

- remove synovits but don't release A1 pulley

- will worsen ulna drift

3.  DIPJ

- rarely affects

- may get mallet

- arthrodesis

4.  Ankylosis

- arthrodesis / arthroplasty

5.  Unstable / flail

- arthrodesis usually best option

6.  Swan neck deformity

7.  Boutonnière deformity

 

Concepts

 

Boutonnière deformity

- usually good function

- often don't need surgical treatment

 

Hand Boutonniere Finger

 

Swan Neck

- much more debilitating

- usually need treatment

 

Swan Neck Deformity (Intrinsic Plus Deformity)

 

Deformity

 

Hyperextended PIPJ / MCPJ + DIPJ flexion

- Bunnell calls this "Intrinsic plus deformity"

 

Rheumatoid Boutonniere FingerRheumatoid Boutonniere Finger

 

Rheumatoid Finger Swan Neck XrayFinger Swan Neck

 

Cause

 

Primary process is usually synovitis

- starts at either MCPJ / PIPJ / DIPJ

 

DIPJ 

 

Dorsum

- terminal tendon ruptured or attenuated

 

Volar

- may also be due to stuck FDP

 

PIPJ 

 

Volar

- rupture of FDS due to synovitis

- volar capsule stretches due to synovitis 

 

Dorsum

- contracted central extensor slip

 

MCPJ 

 

Extrinsic

- relative shortening of long extensors

 

Intrinsic 

- relative intrinsic tightness

- also seen in CP / CVA

 

Articular 

- destruction or deformity

 

Rheumatoid Swan Neck secondary to MCPJ

 

Nalebuff Classification

 

Function depends upon PIPJ flexion

 

Bunnell Test

 

Assess Interossei Tightness

 

Positive test 

- PIPJ flexion less in MCPJ extension than with MCPJ flexion

- interossei are tighter in extension

- invalidated by MCPJ dislocation

 

Test

- hand dorsum up

- correct ulna deviation

- extend MCPJ & comment on active PIPJ range

- flex MCPJ & comment on active PIPJ range

 

Type I

- PIPJ passively correctable / regardless of MCPJ position

- Bunnell Test negative

 

Type II

- PIPJ flexion limited with extension of MCPJ

- Bunnell Test positive

- intrinsic tightness

 

Type III

- fixed PIPJ flexion regardless of MCPJ position 

- joint problem

- lateral bands dislocated dorsal to axis of rotation

 

Type IV

- joint destruction / X-ray arthritis

 

RA Swan Neck Fingers XrayRheumatoid PIPJ Destruction

 

Management

 

Aim is to create FFD

- many techniques described

 

Type 1

 

A.  Create FFD by FDS tenodesis

- use slip of FDS

- detach proximally

- pass through A2 pulley and attach to bone or on itself

- producing 20° FFD

 

+ DIPJ fusion

 

B.  Zancoli lateral band transfer

 

Lateral bands mobilised volar to axis of PIPJ

- raise flap of flexor retinaculum

- suture over lateral band to fix in place

- dorsal blocking splint / K wire

 

+ DIPJ fusion

 

Type II

 

Above +

 

Intrinsic release

- division of intrinsic oblique fibres

 

Anatomy

- oblique fibres which extend IPJ /  interossei

- transverse fibres flex the IPJ / lumbricals

 

Type III

 

PIPJ release first / Lateral band tenolysis / K wire

- release central slip / dorsal capsule / collateral ligs to allow flexion to >90o

- manipulate joint to flexed position

- fix with K-wire

- often stiff due to flexor synovitis

- often need flexor sheath synovectomy to get moving

 

Type IV

 

Arthroplasty RF / LF for grasp 

- arthroplasty has highest failure rate for Swan Neck 

- high recurrence and poor range

- 80% survival at 9 years

 

Fusion IF / MF for strength 

- angle of fusion a cascade 

- 20 30 40 50 (IF MF RF LF)

 

Rheumatoid Fusion PIPJ LF RF

 

Boutonniere's Deformity (Intrinsic Minus Deformity)

 

Boutonnierre Finger 1Boutonnierre Finger 2

 

Deformity

 

PIPJ flexed / DIPJ hyperextended /  MCPJ hyperextended

 

Often well tolerated & treatment not needed

 

Cause

 

1.  Central slip dysfunction

- always starts with PIPJ flexion 

 

2.  Lateral bands displace volar 

- secondary to triangular ligament stretching

 

3.  DIPJ hyperextends secondary to PIPJ flexion

- contracted oblique retinacular ligament

- becomes fixed

- examination finds limited DIPJ flexion with PIPJ in extended position

 

Nalebuff Classfication

 

Stage 1 

- mild extensor lag 10-15°

- passively correctable

 

Lateral band reconstruction

- reduce lateral bands dorsally

- suture together

 

Stage 2

- moderate 30-40° lag

- passively correctable

 

Lateral band reconstruction + Central slip shortening / reconstruction

 

Dorso-Medial Incision & Synovectomy

A. Reduce lateral bands dorsally & Suture together

B. Tenotomy Terminal slip

C. Central slip options

i)   Shorten 5 mm

ii)  Reconstruct with lateral bands (take inside half of each and suture together)

iii) Reconstruct with PL

iv) Matev central slip reconstruction

 

Matev Central Slip Reconstruction

- radial lateral band divided at level of P2 

- proximal stump rerouted through central slip 

- attached to base P2 at central slip insertion

- ulnar lateral band divided distally

- passed dorsally over P2 and attached to distal radial lateral band stump

 

Stage 3 

- severe 

- fixed with x-ray arthritic changes

 

Arthrodesis / arthroplasty

 

PIPJ replacement

 

Rheumatoid Arthritis PIPJ OA

 

Types

 

A. Pyrocarbon implants

- partially constrained press fit components

- relatively high failure rate

- can fracture when inserting and need cerclage wire

 

B.  Swanson spacer

 

Contra-Indications

 

Infection

Non reconstructable / irreparable

- extensor and flexor tendons

- collateral ligaments

 

Complications

 

Does not have same stability of MCPJ

- can dislocate

 

Technique

 

Dorsal incision

- straight or curved dorsomedially

- enter between central slip and lateral band

- can detach central slip proximally and reflect distally 

 

Release contractures

- balance soft tissues

- retain collaterals

 

Broach distally and proximally

- avoid extension at all times

 

Implant must achieve full extension

- no buckling, and no impingement

 

Repair central slip

 

Post op

- immobilise for 1 week

- dynamic extension splint 0 - 30o (Capner)

- active flexion

 

Arthrodesis PIPJ

 

Approach as above

- resect collaterals

- position as appropriate

- cross K wires / screw

Rheumatoid MCPJ

Deformity

 

Ulna drift & volar dislocation

 

Rheumatoid MCPJRheumatoid MCPJ Ulnar Deviation

 

Causes of MCPJ Deformity

 

Ulna Drift / Ulna Dislocation

 

1.  Physiological

- gravity

- lateral pinch pressure

- power grip

 

2.  Anatomic

- shape of MC heads

- collateral ligament length & orientation

- intrinsics to LF asymmetric (hypothenars strong)

 

3.  Pathological

- joint / capsule instability due to bony erosions

- collateral ligament stretching due to synovitis

- ulna/volar dislocation flexor tendons due to stretching pulleys

- ulna dislocation extensor tendons due to stretching sagittal bands

- intrinsic contracture

- radial deviation of wrist (Landsmere) redirecting line of pull of tendons

- volar / ulna carpal subluxation

 

Nalebuff Classification MCPJ

 

Stage I - Synovitis

- medical treatment and splinting

- synovectomy

 

Stage II - Synovitis + Ulna deviation

- medical treatment and splinting

- synovectomy + soft tissue reconstruction

 

Stage III - Moderate joint destruction / Volar subluxation

- soft tissue reconstruction possible

- arthroplasty gives more reliable results

 

Rheumatoid Dislocated MCPJRheumatoid Dislocated MCPJ

 

Stage IV - Advanced joint destruction

- fixed joint deformities

- arthroplasty with soft tissue releases

 

Management

 

Stage I Synovectomy MCPJ

 

Indication

- marked synovial proliferation not responding to medical treatment

- 6/12 non-operative

- painful

- concern regarding progression to deformity

 

Contraindication

- joint destruction with articular erosion

- instability

- fixed deformity or dislocation

 

Technique

- incise hood on Ulna side extensor tendon

- make sure clear under volar plate & collaterals

 

Stage II Synovitis / Ulna Deviation / Preserved MCPJ  

 

Synovectomy + Soft Tissue Reconstruction

 

1.  Ulna side release 

- divide transverse, oblique & sagittal bands

 

2.  Crossed Intrinsic Transfer

- corrects ulna drift

- ulna side intrinsics are released 

- transferred to the Ulna neighbour radial intrinsics

- reinsert through radial lateral band

- use EI for Index attach to radial side

- release EDM at little

 

3.  Extensor Tendon Relocation

- ulna sagittal band release

- radial sagittal band tightening

 

Stage III / IV Destroyed MCPJ

 

RA MCPJ Arthritis

 

Arthroplasty + ST Reconstruction as above

 

Swanson Joint Replacement

 

Swanson's Indications

- fixed or stiff MCPJs

- x-ray shows destruction or subluxation

- ulnar drift not reconstructable

- contracted intrinsic and extrinsics

- associated stiff IPJs

 

Swanson's contraindications

- infection

- inadequate skin coverage

- poor NV status

- irreparable intrinsic/extrinsic system

- insufficient bone stock

 

Aim 

- painless joint with useful arc of motion

 

Results

 

ROM

- usually > 40°

- get about 10° improvement

 

Pain

- > 80% pain relief

- no increase in strength

 

Deformity correction

- up to 40% loss over time

- loss of correction often due to inadequate soft tissue balancing

 

Survival

- 90% 10 year survival

- silicon synovitis uncommon unlike for wrist or trapezial implants

 

Technique MCPJ Swanson Arthroplasty

 

Incision

- transverse incision dorsum

- full thickness flaps preserving dorsal veins 

 

Dissection

- incise extensor hood on ulna aspect each joint

- may need formal intrinsic release but bony cuts may be enough

- incise and remove capsule and synovitis

 

MC head

- excise MC head with osteotome or nibbler sufficiently to accept implant

- with final cut at 90° to shaft

- this often means removing collaterals

- ream MC with awl or drill

 

PI

- do not resect P1 base

- just ream with awl

 

Trial

- resection of bone should allow no buckling of implant 

- no impingement of MC on P1

- insert prosthesis proximal then distally

- should have passive motion of 90°

 

Soft tissue balancing

- ulnar intrinsic release

- crossed intrinsic transfer

- extensor tendon relocation

 

 

 

 

 

Rheumatoid Thumb

Nalebuff Classification

 

Type I - Boutonniere 

- commonest

- MP flexion /  IP hyperextension

- usually EPB rupture with EPL subluxation

 

Rheumatoid Boutonniere Thumb

 

Type II

- Boutonniere & Swan Neck

- doesn't exist according to Nalebuff

 

Type III - Swan Neck

- second most common

- primary deformity is OA and dorsal subluxation of CMC

- hyperextension MPJ / IPJ flex

 

Rheumatoid Thumb Swan Neck

 

Type IV - Gamekeepers

- due to MCPJ synovitis

- stretches UCL

- either synovectomy / UCL reconstruction

- or fusion

 

Rheumatoid Gamekeepers Thumb

 

Type V - Stretched Volar Plate MCPJ

- differentiated from Swan Neck by no CMC disease

- fusion of MCPJ

 

Type VI - Arthritis Mutilans

- destruction and instability MCPJ / IPJ

- arthrodesis only option

 

RA Thumb Destruction IPJ

 

Boutonniere Deformity

 

RA Thumb Boutonniere's

 

Aetiology

 

Synovitis of MCPJ

- extensor Hood stretched

- EPB ruptures

- EPL tendon displaced Ulnarward & Volarly

- becomes flexor 

 

Management

 

1.  Flexible MCPJ

 

A.  Synovectomy of MCPJ

 

B.  EI to EPB / EPL Centralisation

 

C.  EPL transfer + fusion IPJ

- divide EPL over P2 and reattach to base P1

- good correction early 

- but 66% recurrence

 

2.  Fixed MCPJ / Flexible IPJ

 

Arthrodesis / Arthroplasty MCPJ

- arthrodesis better suited for young, high demand

- arthroplasty better suited to low demand

 

Rheumatoid MCPJ Fusion

 

3.   Fixed IPJ and MPCPJ

 

A.  Fuse both 

- best option 

 

B.  IPJ fusion / MCPJ arthroplasty

- with arthroplasty have to balance soft tissues

- reroute EPL as above

 

Swan Neck

 

Aetiology

 

RA Thumb Swan NeckRA Swan Neck Deformity

 

Disease at CMCJ

- leads to dorsal subluxation of CMCJ 

- beak ligament is not functional

- result is adduction contracture

 

MCPJ hyperextension

- ? volar plate stretches

 

IJP flexion

- ? Mallet rupture 

 

Management

 

A.  Trapeziectomy and LRTI

 

Rheumatoid Swan Thumb Trapeziectomy

 

B.  +/- MCPJ fusion

 

Thumb MCPJ Fusion

 

Tendon Injuries

Extensor Tendon Injuries

Zones

 

I DIPJ

II Middle Phalanx

III PIPJ

IV Proximal Phalanx

V MCPJ

VI Metacarpal

VII Dorsal Wrist Retinaculum

VIII Distal Forearm

IX Mid & Proximal Forearm

 

MRI Wrist Extensor Compartments

 

Anatomy

 

Sagittal bands

- stabilise EDC

- extend MCPJ

 

Lateral bands

- lumbricals extended PIPJ

 

Zone 1 Mallet Finger

 

Clinical

- loss of extension of DIPJ

- +/- Swan neck deformity

- hyperextension of PIPJ due to unopposed central slip action 

 

Issues

 

Avascular region of tendon at insertion into DIPJ

- explains poor surgical results

 

Mechanism

 

Closed

 

1.  Forced flexion of extended digit

- Rupture of tendon

- Avulsion of tendon ± small fragment of bone

 

2.  Forced hyperextension of DIPJ

- fracture of dorsal base of P3

 

Open

- Laceration over dorsum of DIPJ

 

Types

 

Type I    

- closed trauma

- no bone or < 1/3

 

Type II  

- laceration

 

Type III  

- deep abrasion

 

Type IV  

A) Transepiphyseal plate fracture in children

B) > 1/3 of joint surface

C) > 1/3 + Volar Subluxation of P3

 

Management

 

1.  No or small Bony Lesion

 

Extension splint (Stack splint) for 6 to 8 weeks

- night splinting further 6 weeks

- 80% good results if treated early

- direct repair should be avoided (poor blood)

 

2.  Bony lesion > 50% with volar subluxation

 

A.  Extension splint

B.  ORIF

- poor skin, high risk of breakdown

C. Dorsal blocking K wire / second K wire across joint

 

3.  Chronic Mallet Finger 

 

1.  Arthrodesis 

- joint incongruent, arthritic or fixed

 

2.  Reconstruction possible if supple

 

4.  Open

 

Suture skin and tendon together

 

Zone 3 Boutonniere Lesion

 

Definition

- disruption of central slip at PIPJ

 

Mechanism

 

Closed

- forced flexion of PIPJ

- causes avulsion of central slip ± bony fragment

 

Open

- laceration over central slip

- similar progressive deformity

 

Pathology

 

Deformity usually not present at time of injury

- develops after 2-3/52

 

1. Flexion of PIPJ

- due to loss of central slip

- unopposed action of FDS

 

2. Stretching of expansion between central & lateral slips 

- transverse retinacular / triangular ligaments

 

3. Lateral bands migrate volar

- position volar to axis of rotation

 

4. Pull of lateral bands exclusively directed to DIPJ

- DIPJ hyperextends

 

5. MCPJ also hyperextends because of pull of long extensor

 

Examination

 

1.  Hold wrist and MCPJ fully flexed

- relaxes lateral bands

- unable to actively extend PIPJ

 

2.  Elson's test

- flex PIPJ to 90o over edge of table

- unable to actively extend PIPJ against resistance, will hyperextend DIPJ

 

Management

 

Closed

 

1.   Splint PIP in Extension 4/52

- Leave DIPJ free and allow ROM

 

2.  Capener Splint 4/52

 

Open

- central slip & lateral bands sutured with 5/0 nylon

- ff close to insertion, pull-out suture used

- PIPJ splinted in full extension for 6/52

- replaced with Capener splint when wound healed & sutures removed

 

Reconstruction

 

Palmaris longus weave

 

Extensor Tendon Repairs Zone 5 - 9

 

Prognosis

 

Excellent results of repair 5 proximal zones

Only 50% excellent results 4 distal zones

 

Surgery

 

Lacerations >50% zones V-VIII should be repaired

- modified Bunnell or Kessler best

- try to maintain length

 

Dynamic splinting 

 

Greatly improves results and is key 

- need 5mm excursion to prevent adhesions for flexors (Unknown for extensors)

- typical repairs shorten tendon

 

Outrigger with passive extension by rubber bands

- WJ 30o extension, MP's 10-15o flexion, IP's 0o

- allow 5mm excursion of tendon

 

 

Flexor Pulley Ruptures

Anatomy

 

5 Annular pulleys

3 Cruciate pulleys

 

Pathology

 

A1 and A5 expendable

 

Loss of other annular pulleys can lead to bowstringing

- A2 & A4 +/- A3

 

Aetiology

 

Rock climbers

- usually when slipping

 

May hear or feel a pop

 

Develop swelling / tenderness / pain

 

Bowstringing

- usually only with multiple pulley rupture

 

Investigations

 

Xray

- exclude fracture

 

Ultrasound

- very good

 

MRI

- if US inconclusive

 

Grading

 

Grade 1

- strain

- A4 tear (has good prognosis)

 

Grade 2

- partial tear A2 or A3

 

Grade 3

- complete A2 or A3 rupture

 

Grade 4

- multiple pulley rupture

- +/- lumbrical avulsion or collateral ligament damage

 

Management

 

Non operative

 

Single complete pulley ruptures

- no climbing for 6 weeks

- gradual return to climbing with pulley taping

- full return to sport at 3 months

 

Operative

 

Multiple pulley ruptures

- repair techniques poor

- reconstruction required

- A2 with palmaris longus graft

- A3 with extensor retinaculum graft

 

 

 

Flexor Tendon Background

Anatomy

 

Fascicles of long, spiraling bundles

- tenocytes & Type I collagen

- synovial cells & fibroblasts present

 

Endotenon 

- surrounds the individual collagen bundles

 

Epitenon

- fine fibrous outer layer, highly cellular, continuous with endotenon

- contains most of the blood vessels & capillaries

 

Paratenon

- thin visceral layer of adventitia on tendon

- provides nutrition & allows gliding

 

Synovial Sheaths

 - in distal palm & fingers, visceral synovial layer enclosing FDS/FDP

- parietal layer continuous with the pulleys

- tendons attached via long & short vinculae

 

Pulleys

 

Thickenings of the synovial sheath

- 5 strong annular pulleys interposed by 3 collapsible cruciate pulleys 

- allow the annular pulleys to approximate in flexion

 

A2 & A4 

- fibro-osseous annular pulleys

- arise from periosteum of the phalanx

- maintain short moment arm of tendon from joint, greatest joint rotation for least excursion

- most important

 

A1, A3, A5 

- arise from the volar plates 

- MCPJ, PIPJ & DIPJ respectively

 

Palmar Aponeurosis Pulley 

- important additional pulley

- transverse fibres of palmar fascia

 

Thumb Pulleys

- A1 (MCPJ) and A2 (IPJ)

- Oblique pulley in between and is most important

- can be excised if A1 intact

 

Flexor Tendons

 

Excursion can exceed 8cm

- in pulley area flexor tendons have segments that are avascular  

 

Actions

 

FDS 

- arises from single muscle belly

- volar aspect of humerus, radius and ulna

- separates into 4 tendons in forearm

- IF and LF deep, RF and MF superficial in carpal tunnel

- LF may be absent (20%)

- bifurcates at level A1 pulley

- 2 slips rotate around and insert volar aspect base of P2 and radial / ulna sides

 

Action

- has independent action

- FDS & interossei combine for forceful flexion

- 200N achieved in power grip

 

FDP 

- has common muscle origin

- arises volar aspect ulna and interosseous membrane

- deep to FDS

- several digits have simultaneous action

- acts as primary digital flexor 

 

Lumbricals

- arise from FDP

- lateral 2 (ulna n) bipennate, medial 2 arise from 1 tendon only (median n)

- insert on radial side of extensor expansion

- flex MCPJ and extend IPJ's

 

Vascular Supply

 

Blood vessels

 

1. Longitudinal vessels enter tendons in palm

-  Vessels enter at proximal synovial fold in distal palm

 

2. Vessels enter at osseous insertions

 

3. Segmental branches of digital arteries enter via long & short vinculae

- VBP vinculae brevis profundus 

- VLP vinculae longus profundus

- VBS vinculae brevis superficialis 

- VLS vinculae longus superficialis

 

Flexor tendons have highest vascularity dorsally

 

Synovial Fluid Diffusion

 

May function better than vascular perfusion

- composition similar to joint fluid

- imbibition process

- fluid is pumped into interstices of tendon through ridges oriented at 90° to each other during flexion and extension

- synovial sheath is critical to this process

- lacerations disrupt this mechanism

 

Avascular segments

 

1.  FDS & FDP have avascular segments over proximal phalanx under A2

 

2.  FDP has 2nd avascular segment over middle phalanx under A4

 

Tendon Biochemical Composition 

 

Composition

- Type I collagen 95%

- Type III & V collagen 5%

 

Dense, parallel collagen fibres

- Highest tensile strength of all soft tissues 

- Collagen in triple helix of tropocollagen molecules 

 

Age and immobilization

- increases collagen content 

- loss of water content, glycosaminoglycan concentration & strength

 

Exercise training

- increases collagen fibril size

- increases strength & stiffness

 

Tendon Healing  

 

Both Intrinsic & Extrinsic factors

- extrinsic - fibroblasts and inflammatory cells from periphery

- intrinsic - fibroblasts and inflammatory cells from epitenon

 

Aim is to optimize intrinsic healing and minimize extrinsic healing which may lead to development of adhesions

 

3 Phases

- inflammatory

- fibroblastic

- remodelling

 

Inflammatory Phase Day 1-4

 

Clot fills defect

- Epitenon cells migrate into & bridge the gap

- Peritendinous cells proliferate & migrate into laceration site

 

Fibroblastic Phase Day 5-28

 

Collagen secretion begins by day 5

- fibres formed in random fashion

- Fibroblasts become the predominant cell type

- Synovium is reconstituted by day 21 

- Vascularisation increases with penetration of avascular zones by new blood vessels

- Increased strength by 2 - 3 weeks

- Collagen content increases for first 4 weeks

- Collagen reorientation complete by day 28

 

Remodelling Phase Day 28-112

 

By day 28 fibroblasts longitudinally oriented 

- progressive remodeling & realignment of collagen fibrils

- By 6 weeks gap is completely filled

- By 8 weeks collagen is mature & realigned

 

By 4 months

- maturation complete 

- fibroblasts now quiescent tenocytes

- Full tensile strength only reached after physiologic loading

 

Adhesions

 

Dense adhesive scar 

- results from ingrowth of fibroblasts from the digital sheath & epitenon proliferation

 

More severe 

- immobilized tendons

- increased severity of synovial sheath injury /crush

- gaps > 3mm

 

 

 

 

Flexor Tendon Complications

Complications

 

1.  Flexor Tendon Rupture

2.  Adhesions

3.  PIPJ contractures

4.  Triggering

5.  Pulley failure

6.  Quadrigia

 

1.  Flexor Tendon Repair Rupture

 

Incidence

 

5%

 

Management Options

 

FDS only

- usually minimal impairment

 

FDP only

- may be better to fuse DIPJ

- passing tendon through FDS may give poor result

 

FDP and FDS

- repair / graft FDP

 

One Stage repair

 

Indications

1. Minimal scarring

2. Pliable joints

3. Adequate retinacular pulley system

4. Not Zone 2

 

2 Stage repair  

 

Indications

 

1.  Severe adhesions or scarred tendon bed

2.  Contractures

3.  Disruption of pulley system

4.  Missed injuries

5.  Injuries not suitable for primary repair

- usually gross contamination

 

Technique 2 Stage

 

Concept

- all anastomosis in Zone 1 and Zone 3 (not Zone 2)

 

Technique Stage 1 

 

Long Brunner incision finger

- Scarred tendon remnants excised, contractures released 

- A2/4 pulleys reconstructed if necessary

- Silastic implant sutured distally to FDP Zone 1

- proximal end zone 5 free

- need incision in palm to pass through to forearm 

 

Mobilisation regime post-op

- get finger moving / passive exercises +++

- minimise adhesions

- recreate synovial sheath for second stage

 

Pulley reconstruction

- use FDS, extensor retinaculum, PL free tendon

- A2: passed dorsal to NV bundles between phalanx and extensor tendons

- A4: superficial to extensor tendons

 

Technique Stage 2 

 

Graft options

- Palmaris longus (absent 25%)

- Plantaris (absent 20%)

- Long toe extensor (IV)

 

Timing

- performed at 3 months 

- Early, protected Post-op mobilisation

- active motion at 4 weeks

 

2.  Flexor Tenolysis

 

Diagnosis Flexor Tendon Adhesions

 

Limited active ROM > passive ROM

- tendon adhesions

 

Limited passive ROM = active ROM

- joint contracture

 

If there is a marked difference between active and passive ROM

- adhesions likely but

- need to ensure repair is intact

- feel for tendon / ultrasound

 

Timing

 

Up to 20% of patients require tenolysis

- therapy +++ for 3 - 6 months

- need to assess the amount of functional deficit of the patient

- subcutaneous tissues must be state of equilibrium (i.e. soft and supple)

 

Technique

 

Must be prepared to go on to 2-stage repair

- long brunner incision

- access tendon through sheath via less important pulleys

- early active ROM critical

 

3.  PIPJ Contractures

 

Non Operative

 

Splints

- static night time extension splints

- dynamic external fixators

 

Therapy

 

Operative

 

Access between A2 and A3 pulley

- remove cruciform pulleys

- flexor tenolysis

- release check rein ligaments

- release accessory collateral / collaterals / volar plate

- MUA

 

Results

 

Improve extension 20 - 30o

- lose equivalent amount of flexion

- change functional arc

 

4.  Triggering

 

May be triggering on A2 or A4 pulley

- Non operative treatment

 

5.  Pulley Failure and Bowstringing

 

6.  Quadriga

 

Issue

 

FDP of MF / RF / LF linked

- will only extend as much as of shortest tendon

- if limited excursion of one FDP due to repair etc

- present with limitation of all finger flexion

 

Solution

 

Release adhesions of the shortened tendon

 

 

Flexor Tendon Repair

Concepts

 

1. Core suture

 

Strength of repair proportional to

A.  Number of strands crossing the gap (not suture type)

B.  Suture size (usually non absorbable braided suture 3/0 or 4/0)

 

2. Repair strength increases more rapidly with early motion stress

 

3. Dorsal sutures are stronger but may interfere with blood supply

 

4. Repairs usually rupture at knots

 

5. Locking loops decrease pull out and increase strength

 

7. Peripheral Circumferential Suture 

- increases repair strength by 10-50%

- reduces gapping and bulk of repair significantly

- closure of epitenon with 6/0 suture

 

Partial Tendon Lacerations

 

< 25%

- debride

 

25 - 25%

- epitenon repair

 

> 50%

- core and epitenon repair

 

Early ROM Rehabilitation

 

1.  Load at failure at 3 weeks 

- immediately mobilised tendons 3 x > immobilised tendons

- more rapid collagen realignment

- histological exam increased healing response with decreased scar response

 

2.  Early mobilization decreases adhesions

 

Early Active ROM Protocol 

 

Position in extension blocking splint

- wrist and MCPJ flexed

- DIPJ and PIPJ in extension

 

Stage 1

- passive flexion using the other hand (5 times per hour)

- active extension of finger in splint

- splint never removed

 

Stage 2

- once full passive motion gained (each hour)

- 5 x passive finger flexion & active extension

- 5 x active finger flexion & 5 active finger extension

- splint never removed

 

6 Weeks

- splint removed & active wrist movement

- no resistance

 

8 weeks 

- resistive work (sponge squeezing)

 

12 Weeks 

- normal activity

 

Incisions 

 

Brunner incisions

- incorporate laceration

- avoid sharp angles <60o

- longitudinal incisions over flexor creases avoided

 

Identify and protect NV bundles

 

Expose synovial sheath

- preserve A2 and A4

- can remove other pulleys

 

Zones of Injury

 

Zone 1 

- distal to FDS (FDP only)

 

Zone 2 

- between A1 pulley and FDS insertion (2 tendons in sheath)

 

Zone 3 

- in palm, lumbrical origin

 

Zone 4 

- in carpal tunnel

 

Zone 5 

- proximal to carpal tunnel

 

Management

 

Zone 1

 

Causes

 

1.  Open / laceration

 

2.  Rugger jersey finger

- most common RF

- caught in jersey whilst grasping

- RF forcibly extended at DIPJ while FDP is contracting maximally

- due to common muscle belly for FDP to LF, RF, MF

 

Types

 

Avulsion FDP Type 1

- FDP retracts into palm

- vinculum ruptured

- tender swelling in palm 

- may need separate palmar incision

- need to pass under A2 and A4 pulley

- suture tendon to paediatric feeding catheter

- must be repaired in 7-10 days

 

Avulsion FDP Type 2 

- most common type

- retracts to PIPJ level

- vinculum intact

- swelling at PIPJ level

- early reinsertion best

- can be repaired up to 3 months after injury 

- may progress to type 1 injury if vinculae give way

 

Avulsion FDP Type 3 

- large bony fragment

- A4 pulley catches fragment & prevents retraction

- early reattachment

 

Repair

 

1.  Tendon to tendon repair

- if possible

 

2.  Insufficient distal tendon

- prepare bony insertion

- modified Kessler into tendon

- pass suture ends through distal phalanx and nail plate

- tie over button

- use 4.0 monofilament i.e. prolene

- need to remove button and sutures at 8/52

 

3.  Bony avulsion

- ORIF / button repair

 

Zone 2 / Bunnell No Man's Land

 

Problem

- both tendons injured

- high risk of bulky repairs / adhesions / poor function

 

Technique

 

Tendon laceration

- usually distal to skin cut

- need to retrieve tendons from palm

- A2 & A4 pulleys need preservation

- FDS & FDP both repaired if possible

- may only need one limb of FDS

 

Core Suture

- 2 x modified Kessler

- can use 2 x loop sutures to create 4 strand modified Kessler

- best to use prolene as will run easier than polyfilament suture

 

Peripheral suture

- 6.0 prolene running suture

- do dorsal aspect of tendon first, then core, then complete volar aspect

- very important for strength and allowing smooth glide

 

Zone 3

 

Delayed repair up to 3 weeks possible 

- lumbrical holds tendon 

- relatively good prognosis

 

Zone 4

 

Rigid compartment

- good result more difficult to achieve

- often complicated by median nerve injury

- should repair within 3 weeks to avoid myostatic muscle contraction

 

Zone 5 

 

Loose compartment

- good prognosis but associated nerve injuries important prognostically

- quality of repair not so important

- should repair within 3 weeks otherwise muscle contraction occurs

 

 

 

 

 

Thumb Radial Collateral Ligament

Definition

 

Also known as Chauffeur's Thumb

 

Epidemiology

 

Much less common than UCL injuries

 

Issues

 

Rarely get soft tissue interposition

 

Management

 

Chronic Instability

 

1.  Repair scarred ligament

 

2.  Reconstruct with graft

 

3.  Advance Abductor pollicis

 

 

 

 

- reinsert 10mm more distally on P1

 

 

 

Tumours of the Hand

Enchondroma

Epidemiology

 

Most common bony tumour of hand

 

Risk malignant transformation isolated lesion is < 2%

- more likely in long bones than hands

 

Site

 

Proximal phalanx > middle

 

Syndromes

 

Ollier's

- multiple enchondromatosis

- risk of transformation 10 - 25%

 

Maffuci's

- enchondromas and hemangiomas

- risk transformation close to 100%

 

Prognosis

 

Observation unless

- pain

- aggressive X-ray changes

- increased uptake on bone scan

 

Biopsy to exclude malignancy

 

Pathological fracture

 

Allow fracture to heal

- enchondroma does not resolve

 

Curette and bone graft at a later date

 

Epidermal Inclusion Cyst

Epidemiology

 

Most frequent tumour around distal phalanx

 

M>F 2:1

 

Mean age 3rd decade

 

Aetiology

 

Likely traumatic 

- subcutaneous implantation of keratinising epithelium that continues to grow and produce keratin

 

Clinical

 

Painless firm swellings

Most common volar aspect P3 index / middle

 

X-ray

 

Round / oval lesion in P3

- thinning of cortex

 

Epidermal Inclusion Cyst

 

Pathology

 

Fibrous capsule with keratin filled space

Squamous epithelium

 

DDx                       

 

Foreign Body Granuloma

 

Management    

 

Curettage and bone grafting (if bony)

 

Excision of lump

- recurrence very unusual

 

 

 

Ganglion

Epidemiology

 

Most common tumour of hand

F > M

2nd - 4th decade

 

Aetiology 

 

Unknown 

 

Trauma

Mucoid degeneration of collagen tissue

Synovial herniation

 

Location

 

1.  Dorsal

- scapho-lunate ligament 

- radial to EDC

 

2.  Volar

- scapho-trapezial joint 

- between FCR and APL

 

3. Retinacular

- along flexor sheaths 

- A1 / A2 pulley

 

4. Mucoid cyst

- associated with DIPJ OA and osteophyte

 

Recurrence rate

 

Dorsal 5%

 

Volar 20%

 

Clinical

 

Most asymptomatic

- soft to firm

- 1-3 cm

- transilluminate

 

Mucoid cyst can groove nail bed

- important to remove osteophyte as well to prevent recurrence

 

Pathology

 

Cyst

- cavity lined by epithelium

- viscous mucin

- hyaluronic acid

 

Management

 

Non - operative

 

Aspiration + HCLA injection

- usually needs multiple attempts

 

Operative

 

Excision of ganglion

- find neck and dissect down to capsule

- remove capsular window

 

1.  Dorsal SLL

 

Technique

- radial side EDC

- protect SRN

- follow down

- excise neck and capsule

 

2.  Volar STJ

 

Technique

- between FCR and radial artery

- protect palmar branch median nerve

 

Complications

 

Recurrence

Nerve injury

Stiffness

Tendon damage

 

 

 

Giant cell tumour of tendon sheath

Definition

 

Benign tumour that arises from synovial tissues

- found near synovial-lined tendon sheaths

 

? Localised PVNS

 

Epidemiology

 

2nd most common tumour of the hand

 

Age 40 - 60

 

Aetiology

 

Unknown origin

- theorized to be localized form PVNS

- similar histology

- however, lacks the inflammatory component of PVS 

- is considered by most to be a benign neoplasm

- may be a reactive process to minor trauma

 

Clinical

 

Usually found near flexor tendons of hands & feet

- painless, firm and multi-lobulated mass

- usually on volar surface of finger

 

May present with

- lump

- loss of function

 

X-ray

 

Can cause bone invasion and remodelling

 

MRI

 

Low signal on T1 and T2 and arising from the flexor sheath differentiates from sarcoma

 

Pathology

 

Gross

 

Arise from synovial tissue

1. Well-circumscribed & discrete

2. Nodular & encapsulated

 

Doesn't invade surrounding tissues

 

Diagnostic colour

- yellow (cholesterol)

- brown (haemosiderin)

- grey (fibrous tissue)

 

Histology

 

Giant cell tumours prominent

- hyalinised CT

- sheets of round, oval & spindle cells

- focal collections of foam cells - xanthoma cells

- scattered haemosiderin

 

Management

 

Marginal excision + bone currettage

 

Recurrence rate

- 10% - 20%

- to due to incomplete excision or spillage

- higher with bony involvement

 

 

 

 

 

 

 

Glomus Tumour

Epidemiology

 

Rare

 

Pathology

 

Hypertrophied glomus 

- coiled AV structure involved in temperature regulation

- > 50% in subungual region

- hand is the most common site

- usually under the nail plate

 

Symptoms

 

Triad

- pain

- exquisite tenderness

- cold intolerance

 

Examination

 

Ridging of nail bed

Blue spot at base of nail

 

X-ray

 

Well defined radiolucent eccentric lesion

- base of P3

- < 1cm

 

MRI

 

Dark on T1 / Bright on T2

 

Treatment

 

Remove nail plate

Longitudinal incision in nail bed

Excise tumour and repair nail bed

Replace nail

 

Lipoma

Epidemiology

 

F>M

 

3rd - 6th decade

 

Site

 

More frequent proximal

 

Most frequent

- thenar eminence 

- proximal phalanx

 

Findings

 

Non tender, mobile, soft

 

Does not transilluminate

 

Investigations

 

Radiolucent on X ray

- Bufolini's sign

 

Surgery

 

Negligible recurrence rate

 

Other Hand Tumours

1.  Foreign Body Granuloma

 

Management

 

Curettage and bone graft (if bony)

Excision of lump 

- recurrence very unusual

 

2.  Osteochondroma

 

Xray

 

Cortical flow evident

 

3.  Brown's tumour

 

Causes

 

Primary hyperparathyroidism

Secondary hyperparathyroidism

- CRF

 

X-ray

 

Lytic lesion

- often seen in distal phalanx

 

4.  Nora's lesion

 

Bizarre parosteal osteochondroma

 

5.  Neurofibroma

 

Not possible to dissect free

- need to excise

- end to end anastomoses

 

6.  Synovial Chondromatosis

 

Diffuse swelling

 

May have calcification

 

7.  Juvenile Aponeurotic Fibroma

 

Benign fibrous tumour 

- occurs in the hands of children and young adults

- no gender predeliction 

- no tendency to involve ulnar digits as with Dupuytren's disease

 

Calcification is distinguishing feature

- locally infiltrative

 

Management

 

Requires wide local excision without sacrifice of function

- local recurrence common

 

Metastatic fibrosarcoma after local recurrence of JAF reported

- careful follow up required

 

8.  Recurring Digital Fibrous Tumor of Childhood

 

Benign fibrous tumour that develops in fingers and toes in infants and children

- distinguished histologically by intracytoplasmic inclusion bodies within proliferating fibroblasts

 

Probable viral aetiology

- usually on several digits and intradermal

- recurrence rate up to 60%

 

Marginal excision if function compromised

 

No malignant potential 

- spontaneous regression described

 

9.  Malignant Tumours

 

Metastasis

- very rare 

- 50% lung cancer

 

Chondrosarcoma

- most common 

- chemo and radio insensitive

- only treatment is surgery

 

Osteosarcoma and Ewings

- quite rare

 

Dermatofibrosarcoma / Epitheloid Sarcoma / Synovial Sarcoma

 

Sarcoma Hand0001Sarcoma Hand0001

 

Schwannoma

Definition

 

Benign tumour of Schwann cells

 

Symptoms

 

May have a positive Tinel's

 

Pathology

 

Eccentrically located in nerve

- fascicles are splayed over it

 

Isolated

- Malignant degeneration rare

 

Part of NF syndrome

- malignant degeneration may be as high as 15%

 

Management

 

Surgical excision using microscope

- dissect fascicles off Schwannoma

 

 

 

Vascular Malformation

Symptoms

 

Dull ache and heaviness

- when arm dependent

 

Management

 

Non operative

 

Compression garments

 

Operative

 

Nil recurrence with complete excisions

 

Not always possible

- multiple debulking +/- amputation