B Gjt
Figure 72 3. Exposure of the PIP joint release of collateral ligaments. Figure 72 4. Drawing showing a small bur being used to shape the proximal bone into a rounded cone and the distal articular surface into a cup. Figure 72 4. Drawing showing a small bur being used to shape the proximal bone into a rounded cone and the distal articular surface into a cup. Upon delivery of the articular surfaces into the operative field, all articular cartilage is removed. The proximal bone is then shaped into...
B Dsh
joint. Once this dissection is complete, Hohmann-type retractors can be used to aid in exposure. The surgeon must be mindful of the important volar neurovascular structures as well as the posterior interosseous nerve. The osteotomy is then performed around the previously placed Steinmann pin Fig. 81 2B . The site for the cut is chosen with fluoroscopic guidance such that it is within the mass, distal to the elbow joint, and perpendicular to the longitudinal axis of the ulna. The sagittal saw is...
Diagnosis Xcl
Volar Intraarticular Fracture Dislocation of the Ring Finger MP Joint The radial collateral ligament is presumably still attached to the small fracture fragment, but the ulnar collateral ligament must be completely disrupted to permit this degree of displacement. Figure 50 2. Lateral radiograph of a complex volar fracture-dislocation ofthe left ring finger metacarpopha-langeal joint. Figure 50 1. Posteroante-rior radiograph of a complex volar fracture-dislocation of the left ring finger...
L
Figure 30 1. Physical exam will localize pain and swelling over the region of the radial styloid. De Quervains Tenosynovitis of the Right Wrist De Quervains disease may be caused by any condition that produces a swelling or a thickening of the tendons of the first dorsal compartment of the wrist Fig. 30 3A . It is a stenosing tenosynovitis of the abductor pollicis longus APL and extensor pollicis brevis EPB tendons Fig. 30-3B . This typically occurs in the third, fourth, and fifth decades of...
Alternative Techniques
The lateral V-Y flap technique uses flaps from the lateral side of the digit to close fingertip defects. Digital anesthesia is obtained with metacarpal block. The bone is debrided and the wound is irrigated. The dorsal incision is made from the amputation site to 2 mm lateral to the nail fold and continued proximally midway between the palmar and dorsal surfaces of the bone. The incision length is twice the width of the flap. The oblique incision is made from the palmar edge of the defect to...
Diagnosis Qac
The scaphoid is the most frequently injured carpal bone. Scaphoid injuries are most commonly seen in young men, are often misdiagnosed as sprained wrists, and are rarely seen in children because the distal radial physis usually fails first. Fractures are localized within the proximal, middle waist , or distal third of the bone. The incidence of avascular necrosis increases as fractures are located more prox-imally in poorly vascularized areas Fig. 56 3 . Most scaphoid fractures occur at the...
Surgical Management Sps
The arm was prepped with antiseptic soap, draped with a sterile field, exsanguinated, and the tourniquet elevated to 250 mm Hg for less than 2 hours. Disposable, sterile plastic finger traps with a traction tower provided distraction of the MP joint. We used the minifluoroscopy unit to locate the exact location of the joint to minimize the chance of cartilage injury while establishing joint portals Fig. 43 1 . Using minifluoroscopic assistance, we marked the proposed dorsal-ulnar and...
J
Figure 10 2. Unusual presentation of a human bite of Figure 10 2. Unusual presentation of a human bite of the ulna aspect of the hand affecting the 5th volar MP. bite Fig. 10-2 . The most common site of injury is the third and fourth digits at the metacarpophalangeal joint. Osteochondral fractures are common. Bite wounds to the hand may cause cellulitis and abscess. Human bite wounds are particularly virulent because of the gram-positive and anaerobic bacteria present in the mouth. Patients who...
Physical Examination Boi
The patient's left ring finger appeared to be rotationally malaligned Fig. 42 1A , compared with the right hand Fig. 42 1B . She was tender to palpation over the middle ring finger metacarpals as well as the index proximal phalanx. The hand was neurovascularly intact with normal two-point discrimination to less than 6 mm. Her skin appeared intact, without any lacerations, and there was good capillary refill. Figure 42 1. A Malalignment of the left ring finger overlapping the small finger. B...
Complications Nsg
Studies have shown that open injury or delayed treatment may lead to adverse outcomes. Delayed treatment may be due to missed diagnosis. Chondral fractures not treated can lead to deterioration of the joint. A missed diagnosis of dorsal subluxation of the triquetrum may lead to pain and loss of motion. Continued instability following surgery is a complication that can be avoided with adequate immobilization and surgical technique. Adequate exposure and obtaining interoperative radiographs can...
Pitfalls Kwd
Unrecognized subluxation of the DRUJ Pronation contracture Failure of fixation secondary to comminution. Figure 60 1. Anteroposterior AP A and lateral B radiographs of the patient's wrist immediately after injury, demonstrating displacement, angulation, shortening, and comminution. Figure 60 1. Anteroposterior AP A and lateral B radiographs of the patient's wrist immediately after injury, demonstrating displacement, angulation, shortening, and comminution. Figure 60 2. AP A and lateral B...
Pitfalls Pja
To avoid nerve injury to the thumb, utilize loupe dissection. Avoid releasing the A1 pulley in patients with RA. Anteroposterior AP and splay lateral radiographs reveal no osteophytes or evidence of osteoarthritis. No soft tissue masses are noted. Figure 29 3. The pathophysiology of the trigger finger. Figure 29 3. The pathophysiology of the trigger finger. Osteoarthritis with osteophytes Trigger finger Flexor Stenosing Tenosynovitis of the Right Middle Finger Trigger Finger The digital flexor...
Suggested Readings Nwe
Axelrod TS, McMurtry RY. Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius. J Hand Surg Am 1990 15A 1-11. Bradway JK, Amadio PC, Cooney WP. Open reduction and internal fixation of displaced, comminuted intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1989 71A 839-847. Cooney WP. Fractures of the distal radius. A modern treatment-based classification. Orthop Clin North Am 1993 24 211-216. Cooney WP, Berger RA....
Emla
Sympathetic blockade Stellate ganglion Lumbar sympathetic IV regional NSAID, nonsteroidal antiinflammatory drug TCA, tricyclic antidepressant TENS, transcutaneous electrical nerve stimulation SSRI, selective serotonin reuptake inhibitor. NSAID, nonsteroidal antiinflammatory drug TCA, tricyclic antidepressant TENS, transcutaneous electrical nerve stimulation SSRI, selective serotonin reuptake inhibitor. Figure 19 1. Anatomy of the neck and placement of the needle for a stellate ganglion block.
Info Xxg
proximal phalangeal condylar fractures, 250 Management algorithms, frostbite injuries, 11, 11-12 Manske classification, hypoplastic thumb, 506, 506, 511 Martin-Gruber anastomosis, ulnar tunnel syndrome, 90 Medial epicondylectomy, cubital tunnel syndrome, 85-86 carpal tunnel syndrome, 64 65, 64-66 pronator syndrome, 71 73, 71-74 Melone classification system, intraarticular distal radius fracture, 381, 382 Membrane stabilizing medication, complex regional pain syndrome reflex sympathetic...
Surgical Management Hnv
Six weeks after injury, the patient was referred with the established diagnosis of a Bennett's fracture. Informed consent was obtained, including discussion of the risks and benefits of the various treatment options. Problems discussed included stiffness, loss of motion, pain syndromes, infection, and possible need for future surgical removal of hardware all concepts important to the patient's profession. The patient agreed to surgical treatment. Surgical management consisted of an attempted...
Chronic Lacerations of Extensor Tendons
Angela A. Wang and Michelle Gerwin Carlson History and Clinical Presentation A 66-year-old right hand dominant man sustained a deep laceration to the dorsum of his right wrist when a plate glass mirror fell on it. He was evaluated at a local emergency room and was informed he would need surgery, but he wanted to be treated at another institution. Seventeen days later, he presented to the office with the complaint that he could not lift his fingers. A well-healed 5-cm transverse laceration is...
Complications Bhp
Radial styloid fracture management should consider the spectrum of associated injuries, and when surgery is indicated, incisions should be chosen to minimize soft tissue problems. Patient demands, bone quality, and other mitigating circumstances will temper the treatment logic for each individual. Postoperative complications are increased with the degree of invasiveness chosen for a particular injury pattern. Acute carpal tunnel syndrome is not common with radial styloid fractures, and some...
Pitfalls Wvb
A humpback deformity of the scaphoid is a relative contraindication for a vascularized, pedicled bone graft because correction of the deformity is very difficult when performing the graft. Adequate correction of the deformity is more reliably accomplished from a palmar Russe approach with conventional trapezoidal corticocan-cellous bone grafting and Herbert screw fixation. The scaphoid nonunion may not be readily identifiable because the cartilage may be partially intact or fibrous tissue may...
Pitfalls Bzh
Surgery should be approached with caution. Surgery should not disturb compensatory maneuvers necessary for function. Avoid surgery on pterygium cubitale. the hand resting on the flank. The left forearm was fixed in 30 degrees of pronation and appeared foreshortened compared with the right. The right wrist had full flexion extension with apparent absence of the ring and small rays and a three-digit hand thumb, index, and long Fig. 77-1B . These digits appeared normal and possessed full motion...
Info Hux
Tomoradiograph revealing typical small round lu-sclerosis and a cortical reaction. osteoma lesion at the proximal interphalangeal PIP joint. area of PIP joint, suggestive of osteoid osteoma. Figure 90 3. Computed tomography scan demonstrating osteoid Figure 90 4. Nuclear bone scan showing increased uptake at the osteoma lesion at the proximal interphalangeal PIP joint. area of PIP joint, suggestive of osteoid osteoma. Osteoid osteoma is a benign, solitary, painful osteoblastic lesion containing...
Diagnostic Studies Yqr
Initial imaging of the patient should include a zero posteroanterior PA x-ray of the wrist Fig. 56 2 . If the fracture is not seen, the patient should have PA x-rays of the wrist in radial and ulnar deviation scaphoid and longitudinal profile with the elbow flexed at 90 degrees . These views are used to better define the anatomy of the scaphoid and allow visualization of its margins. A clenched fist with radial and ulnar deviation views may also diagnose a scapholunate ligament tear as the...
Info Axe
A 44-year-old right hand dominant cabinet maker presented to the emergency room after accidentally cutting the fingers of his right hand with a table saw. The patient completely amputated his index finger through the middle phalanx just distal to the proximal interphalangeal PIP joint and his small finger through the proximal phalanx. The long and ring fingers were lacerated from the volar aspect through the flexor tendons and distal aspect of the proximal phalanges, but were held on by dorsal...
Info Odp
condylar fractures, 246-230, 247 250 distal interphalangeal joint dislocations, 296 fractures, 230 dorsal dislocation, 287-288, 287-294 Dupuytren's contracture, 167-169 flexor digitorum profundus avulsion injuries, 219-222, 219-224 fractures, 238-244, 239-240, 242-243 high radial nerve palsy, 140, 140 hypoplastic thumb, type II reconstruction, lateral dislocation, 282-285, 283-284 metacarpal neck fractures, 252 osteoarthritis, silastic implants, 425-426, 425-431, 428, 430 pronator syndrome, 70...
Surgical Management Ikf
Most acute perilunate dislocations require surgery. Closed reduction is possible, but it is unlikely that the reduction will be maintained by immobilization. A ligamentous injury alone can be treated with a dorsal approach only however, the status of the median nerve may require a combined dorsal and palmar approach. For the dorsal approach, an incision is made in line with Lister's tubercle. An interval between the third and fourth dorsal compartments is made by dividing the distal portion of...
Pearls Akh
Stable Fracture Patterns Transverse Treat stable fracture pattern conservatively. When a stable fracture pattern becomes unstable it needs to be surgically stabilized. A K wire is utilized to stabilize the fracture after the interosseous wire is placed. Preserve periosteum for closure. Leave the twisted wire on the noncontact side of the finger. Start wire from that side. Leave at least 5 mm bone bridge from fracture line to wire.
B Pye
Figure 30 4. The tendons of the abductorpollicis longus APL and the extensor pollicis brevis EPB pass through a fibro-osseous tunnel formed by a groove in the radial styloid and overlying extensor reti-naculum. Fig. 30 4 . The tendons deviate as they pass through the tunnel, and the angle increases with ulnar deviation of the wrist. Anatomic studies of the fibro-osseous canal have documented that in 94 of specimens the abductor pollicis tendon has two to four slips. Multiple EPB tendons are...
Pitfalls Doy
The appearance of the wound does not determine the severity of the injury. Amputation is more likely if debridement is delayed more than 10 hours, especially with low viscosity substances. Without diagnosis and treatment, a compartment syndrome with subsequent necrosis usually destroys tissue viability. Do not use small openings for debridement. The paint stream struck the palm with such pressure that the liquid penetrated the skin and spread widely throughout the underlying fascial planes and...
Physical Examination Bop
The patient had localized tenderness at the dorsal aspect of the scapholunate joint. Scaphoid stress test resulted in pain and an audible and palpable snapping. Range of motion of the wrist was full and comparable to the contralateral side. Pinch and grip strengths were 45 of the contralateral side. Physical examination should include both extremities unless otherwise indicated, the contralateral side is an excellent measure of the patient's normal baseline regarding range of motion and level...
Ganglions
Kevin D. Plancher and Michael Bothwell A 38-year-old woman presents with a painful mass on her wrist. The patient complains about the size of this mass, and the continued disappearance and recurrence of the mass. The mass enlarges and is more painful after activity. The patient reports no history of a puncture wound or other trauma. There is no previous history of arthritis. The patient has had no previous treatment of the mass. A firm mass on the dorsum of the wrist is palpated Fig. 84 1 . The...
Info Dvz
and extent of the burn and associated injuries. Several principles should always be kept in mind. Early debridement, edema infection control, early wound coverage, and early mobilization are critical to a successful outcome. Adherence to these simple principles will likely prevent or minimize the most difficult postburn complications such as flexion contractures and boutonniere deformities. Superficial burns usually heal spontaneously within 10 days. In this representative case, the...
Pitfalls Ltc
The ruptured tendon must be repaired under the proper tension. Although tendon reconstruction under excessive tension is to be avoided, the surgeon must fix the tendon at the proper length to provide adequate power. It should also be noted that repairs usually loosen overtime. Radiographs of the right wrist were negative for bony pathology. No foreign bodies were present. Figure 35 1. under anesthesiapreopera-tively, with the wrist supported. Note the laceration on the dorsum of the wrist, and...
Pitfalls Avm
Although some authors have not recommended wrist reconstruction in these patients, it is possible to achieve elbow flexion through triceps lengthening and capsulectomy. Pins should be cut off beneath the skin to allow more prolonged retention, and ulnar osteotomy may be required in cases of severe bowing. This patient shows complete absence of radius with the frequently associated findings of an elbow contracture combined with complete absence of the thumb. The diagnosis is radial longitudinal...
Pitfalls 1
Slow rewarming may cause more tissue damage. Early debridement of blisters should be avoided. Amputation of the frostbitten part before a clear line of demarcation appears is strongly contraindicated, unless aggressive early salvage is considered. On examination, the patient denied pain, but his left hand was discolored and mottled, and he had diminished sensation. He was unable to flex or extend the fingers of his left hand. His core body temperature was 34 C, and his vital signs were normal....
Surgical Management Ntx
The indications for surgical intervention for metacarpal shaft fractures include multiple metacarpal fractures, especially if they are comminuted, oblique, or spiral. These configurations would lack any bony or soft tissue support from adjacent digits. Open metacarpal fractures associated with soft tissue loss or extensor tendon injuries would also be an indication for operative intervention because early motion is often critical to minimize tendon adhesions and maximize digital motion. Any...
Pitfalls Gyw
Inaccurate diagnosis can lead to unnecessary surgery. Understanding anatomy in the forearm is crucial to successful recovery. Position of the patient's neck in shoulder surgery should be monitored by the anesthesiologist and surgeon. Figure 14 1. Typical pinch sign with flattening of index pulp and classic palsy of the anterior interosseous nerve with ok sign on left hand. Figure 14 1. Typical pinch sign with flattening of index pulp and classic palsy of the anterior interosseous nerve with ok...
Surgical Management Mfp
We performed an arthroscopically assisted closed reduction and fixation with per-cutaneously placed cannulated screws. Four days after referral from the emergency department, the patient was taken to the 1-day surgery center for definitive management. The patient was placed supine, using general anesthesia, exsanguination of the arm, and tourniquet control. To begin, longitudinal traction was applied through a single finger trap to the thumb with 10-12 pounds of traction. A mini-fluoroscopy...
B Oyf
radial half of the flexor profundus, and the pronator quadratus Fig. 14 4 . In most cases, the median and anterior interosseous nerves pass through the superficial and deep heads of the pronator teres Fig. 14 5 . Postoperatively, a bulky dressing and long armed splint are applied, keeping the elbow in 90 degrees of flexion and the forearm in 45 degrees of pronation. These should remain on for 10 to 14 days. They are then changed and sutures are removed. Immobilization should continue with a...
B Wio
A second subcutaneous tunnel is made across the palm to the thumb MP joint. The line of pull is estimated by placing the donor tendon to the proposed insertion site on the distal thumb metacarpal Fig. 21-3B . Regardless of the method of attachment used, the transferred tendon needs to be securely fixed in place. This can be accomplished using a bone tunnel or weaving the EIP through the abductor pollicis brevis Fig. 21-4 . The thumb is placed in full opposition to the small finger. The EIP...
Postoperative Management Mro
Ten days postoperatively, the patient's cast was changed. Radiographs revealed satisfactory position of the reduction Fig. 44 5 . Three weeks postoperatively, the longitudinal pin was removed and an ulnar gutter splint was applied. On postop day 30 the transverse pins were removed, and the patient was instructed to begin gentle range-of-motion exercises. She progressed adequately to acceptable motion with Figure 44 5. Postoperative radiographs showing Kirschner wires and reduction of the...
Osteoarthritis Proximal Interphalangeal Joint Silastic Implants
This 66-year-old right hand dominant woman had a long history of osteoarthritis involving multiple joints of the hand, and knees. She initially presented in 1989 at age 51 with atraumatic, spontaneous onset of painless distal interphalangeal DIP joint arthritis and painful degeneration in the dominant hand's basal joint requiring ligament reconstruction and tendon interposition LRTI arthroplasty. This was followed by similar basal joint symptoms in the nondominant hand requiring arthroplasty 2...
Suggested Readings Rpk
Ahmad S, Plancher KP. Carpometacarpal dislocation of the fingers. Op Tech Sports Med 1996 4 256-267. Fisher MR, Rogers LF, Hendrix RW. Systematic approach to identifying fourth and fifth carpometacarpal joint dislocation. AJR 1986 140 319-324. Gurland M. Carpometacarpal joint injuries of the fingers. Hand Clin 1992 8 733-744. Jebson PJ, Engber WD, Lange RH. Dislocation and fracture dislocation of the car-pomteacarpal joints. Orthop Rev 1994 23 19-28. Lawlis JF, Gunther SF. Carpometacarpal...
Acute Laceration of Flexor Tendons
A 38-year-old right hand dominant musician presents to the office 4 days following a laceration to the volar surface of his right long finger sustained after a fall onto a broken piece of glass Fig. 33-1 . He complained of pain in the right long digit with inability to actively flex his finger. He also noted decreased sensation along the ulnar aspect of his finger. He had been working prior to the accident and wished to return to playing guitar as soon as possible. He denied any past medical...
Diagnosis Mtr
The diagnosis was a Bennett's fracture and intraarticular fracture of the first metacarpal bone with two fragments the larger fragment shows subluxation from the deforming pull of the abductor pollicis longus tendon. The Bennett's fracture is the most common intraarticular injury involving the carpometacarpal joint of the thumb. Because the abductor pollicis longus tendon acts as a deforming force, stabilization by fixation is necessary. An attempt at closed reduction is recommended by applying...
A Qly
Figure 65 1. The midcarpal shift test being performed on a right wrist. A The patient's forearm is stabilized and held in a pronated position by the examiner's left hand. B With the patient's wrist held in neutral deviation, the examiner s right hand grasps the patient's right hand and, with his thumb, the examiner exerts pressure in a palmar direction on the dorsal wrist at the level of the distal capitate. C The wrist is then ulnarly deviated with the palmarly directed pressure maintained on...
Diagnostic Studies Myn
Anteroposterior, lateral, and oblique radiographs of the wrist were normal. An arthrogram was obtained Fig. 64 1 . Relative malalignment between the lunate and the triquetrum may be apparent on lateral radiographs. Bisectors of the lunate and triquetrum intersect to form an LT angle normal 14 degrees, range 3 to 31 degrees . Patients with LT dissociation will exhibit a negative angle mean value 16 degrees . A volar intercalated segmental instability VISI pattern is present in some chronic...
Suggested Readings Khb
Bennett EH. Fractures of the metacarpal bones. Dublin J Med Sci 1882 73 72-75. Billings L, Gedda KO. Roentgen examination of Bennett fracture. Acta Radiol 1952 38 471-476. Cannon SR, Dowd GS, Williams DH, Scott JM. A long-term study following Bennett fracture. J Hand Surg Br 1986 11B 426-431. Cullen JP, Parentis MA, Chinchilli VM, Pellegrini VD. Simulated Bennett fracture treated with closed reduction and percutaneous pinning, a biomechanical analysis of residual incongruity of the joint. J...
Pitfalls Eon
Do not use this technique in recurrent carpal tunnel syndrome for a repeat procedure when an open procedure was done previously. Never exert force in passing instruments across the ligament without good visualization to avoid cutting the median nerve. A positive Tinel's sign is present directly over the palmar cutaneous branch of the median nerve, which the patient says simulates her numbness and tingling to the thenar eminence. In addition to this, she has an area of numbness of 3 X 2 cm...
B Wdf
Figure 58 6. A Osteotomy often used for a humpback deformity. B Compression screw fixation in a fibrous union. C,D Donor harvest iliac crest corticocancellous graft to be used to maintain position and length for a scaphoid nonunion. C artwork and D in vivo. Figure 58 6. A Osteotomy often used for a humpback deformity. B Compression screw fixation in a fibrous union. C,D Donor harvest iliac crest corticocancellous graft to be used to maintain position and length for a scaphoid nonunion. C...
B Yys
curette, broach, and microair drill with a smooth leader point bur Fig. 73-6 . In the index finger, the medullary canal of the proximal phalanx requires the rectangular reaming to be performed in an orientation of slight rotation such that the dorsal ulnar corner is more dorsal than the dorsal radial corner, and the radial palmar corner is volar to the ulnar palmar corner of the rectangle when viewed axially. This will favor slight supination to help the index finger function in supination. In...