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Trauma & Orthopaedics Revision
UPPER LIMB - Go to Main Contents
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
The shoulder joint consists of:
Glenohumeral joint
Scapulothoracic joint
AC joint and
Sternoclavicular joint
-17 muscles insert into scapula.
-Glenoid is retroverted by about 70 to the body of the scapula and tilted 30 medially in the coronal plane.
-Humeral head is retroverted by about 30 to 400
-Proximal humerus neck shaft angle is about 130 to 1400
-There is a significant mismatch between the articular surface of the humerus and the scapula
Stabilisers of the joint are mainly ligaments and muscles.
Static stabilisers are:
(1) Labrum
(2) Capsule
(3) Ligaments
(4) Coraco humeral ligament
(5) Glenohumeral ligament
Rotator interval is made of coracohumeral ligament. Inferior glenohumeral ligament complex is the most important static stabiliser.
Dynamic stabilisers are:
(1) Rotator cuff muscles and
(2) Long head of biceps
-Subscapularis: nerve to subscapular
-Supraspinatus: suprascapular nerve
-Infraspinatus: suprascapular nerve,
-Teres minor: axillary nerve
Posterior aspect of the joint - interval between the teres minor and infraspinatus is safe interval to enter the joint. Glenohumeral to scapular movement ratio generally is 20 to 10.
Acromio clavicular joint is a diarthroid joint with fibrocartilagenous disc. Stability of this joint is from acromioclavicular capsular ligament and coracoclavicular ligament, which has 2 parts - conoid and trapezoid.
Quadrangular space is bounded by subscapularis, teres major, long head of triceps and humerus. Axillary nerve and humeral circumflex artery runs through quadrangular space. Radial nerve runs through the triangular space, which is bounded by teres major, long head of triceps and humerus.
Brachial plexus has roots, trunks, divisions and three cords.
Branches of each of these sections are remembered as 310 and 355.
That means:
3 branches from roots
1 from trunk and
0 from divisions
3 branches from lateral cord
5 branches from posterior cord and
5 branches from medial cord
3 branches from the roots are: Long thoracic nerve Dorsal scapular nerve and Subclavian nerve
1 branch from trunk: Supra scapular nerve
0 from trunk
3 branches from the lateral cord:
Musculocutaneous nerve
Lateral pectoral nerve
Lateral head of median nerve
(Musculo-cutaneous nerve is the most important branch of the lateral cord and rest of the two begins with the word lateral)
5 branches from medial cord are:
Ulnar nerve
Medial pectoral nerve
Medial cutaneous nerve of the arm
Medial cutaneous nerve of forearm
Medial head of median nerve
(Ulnar nerve is the most important branch and rest of the branches begins with the word medial)
5 branches of posterior cord are:
Subscapular nerves- upper and
Subscapular nerves- lower
Thoraco dorsal nerves
Axillary nerve and
Radial nerve
(Mnemonic 2 STAR - 2 subscapular nerve, thoraco dorsal nerve, axillary nerve and radial nerve)
(1) Anterior deltopectoral approach
(2) Deltoid split approach or supero-anterior approach and some people call it as lateral approach which is most often used for rotator cuff surgery and incision should not exceed more than 5cms from the attachment of the deltoid muscle to avoid axillary nerve.
(3) Posterior approach can be either splitting through the infraspinatus muscle or interval between the infraspinatus and teres minor. Deltoid may need to be stripped from the spine of the scapula to get down to the rotator cuff.
(4) Arthroscopic portals to the shoulder joint: Posterior portals at the posterior soft spot approximately 2cm distally and 1 cm medially to the posterolateral corner of the acromion. Anterior portal is usually done inside out lateral to the coracoid process (switching stick technique) and Lateral portals to approach subacromial region, 1 or 2 within 5cms from the acromion to avoid axillary nerve damage, usually about 3cms from the acromion
(5) AC joint portals direct portals: Anterior: 1cm to the anterior edge of the AC and Posterior: 1cm posterior to the posterior edge of the AC joint.
Pathologies related to shoulder:
(1) Inflammatory changes in the subacromial bursa and rotator cuff
(2) Primary Rotator cuff involvement
(3) Long head of biceps disorders.
(4) Supraspinatus outlet problems causing subacromial impingement
Bigliani classification of acromion morphology: Type I - Flat acromion Type II - Curved acromion Type III - Prominent or hooked acromion
(5) Non-outlet source of impingement due to Greater tuberosity Severe AC separation Trapezius paralysis Surgical neck malunion
(6) Neer stages of impingement Stage I inflammation, oedema and haemorrhage in the subacromial bursa as well as rotator cuff Stage II fibrosis and tendinitis Stage III rotator cuff reaches to a point of failure
(7) Rotator cuff tear arthropathy humeral head migrates proximally to abut the C.A. arch
(8) Rupture of the rotator cuff or cuff tear due to acute trauma
Treatment of rotator cuff pathology
(1) Non-operative treatment and
(2) Operative treatment
Non-operative treatment:
(1) Physical therapy, specific rotator cuff exercises
(2) Steroid injections - should not be repeated more than 3 times a year and is only advisable in stage I and II diseases. Stage III normally does not respond to conservative measures.
MRI is the investigation of choice. CT arthrography is equally sensitive.
Operative treatment
(1) Arthroscopic subacromial decompression
(2) Arthroscopic subacromial decompression with mini open tendon repair
(3) Arthroscopic tendon repair
(4) Arthroscopic subacromial decompression with an open tendon repair is the most popular of all the options.
(5) Massive rotator cuff tear Rockwood has described subacromial decompression and debridement
Repair of Massive cuff tear:
(1) Mobilising the torn rotator cuff disease on either side
(2) The interval slide - where the complete release of the rotator interval and coracohumeral ligament down to the base of the coracoid allows supraspinatus to be mobilised
(3) Transfer of the upper portion of the subscapularis
(4) Posterior and medial aspect of the cup on the glenoid rim is mobilised
(5) Synthetic material or allografts used to bridge the interval
(6) Lattissimus dorsi transfer
Usually occurs between fifth and sixth decade of life.
2 main stages - Acute and chronic.
Pathology is the degeneration of the collagen in association with calcium salt deposition with focus of necrotic tissue and inflammation.
Acute stage treatment: Steroid injection and anti-inflammatories. Since calcium may be in a liquid form, attempt at aspiration is helpful. Physiotherapy is advisable. Arthroscopic removal of the calcific deposit is also described.
(1) Biceps tendinitis and rupture - Speed test and Yergason sign. None of these tests are specific. Treatment - Tenodesis: either direct suturing, trans-osseous suturing or key hole technique where proximal biceps tendon is held into the bone using a key hole aperture in the proximal humerus.
(2) Biceps tendon subluxation - usually associated with rotator cuff tear. Operative treatment is generally indicated.
(3) Superior labral lesion - Also called SLAP lesion. Superior labrum anterior posterior lesion
Type I - Fraying, intact anchor
Type II - Detachment of biceps anchor
Type III - Bucket handle tear of the labrum with intact biceps
Type IV - bucket handle tear into the biceps insertions. Recent reports have indicated high success rate with arthroscopic reattachment of SLAP lesion. Diagnosis is arthroscopic
ARTHRITIS AND DEGENRATIVE DISORDERS OF THE SHOULDER
(1) Osteoarthritis
(2) Rheumatoid arthritis
(3) Avascular necrosis of humerus: Aetiology - multifactorial, corticosteroid, alcohol, sickle cell disease and other causes Classification of AVN by Neer into 4 stages: Stage I subtle changes Stage II meniscal sign representing subchondral bone changes Stage III Step off sign with obvious collapse of the subchondral bone and Stage IV incrongruencies secondary to collapse
(4) Post traumatic arthritis: (i) Fractures (ii)Dislocations/subluxations (iii)After surgical intervention for instability
(5) Cuff tear arthropathy
(6) Septic arthritis
Surgical options for shoulder degeneration:
(1) Glenohumeral arthroplasty. Infection is an absolute contraindication for arthroplasty
(2) Debridement and soft tissue balancing for instability
(3) Humeral head resection can be a salvage procedure in resistant infections as well as failed arthroplasties
(4) Shoulder arthrodesis has fallen out of fashion. Common indication is in the patients who have muscle imbalance like brachial palsy
Most commonly used prosthesis design is Neer's shoulder replacements. Modular Neer shoulder replacements are also available. Surface replacement, bipolar hemiarthroplasties (in the rotator cuff deficient shoulders) is the other options. It is important to get the version of the component right.
Rehabilitation after arthroplasties: Neer's three phase programme, Phase I - Passive motion in forward elevation and external rotation; Phase II - Active assisted exercises of the shoulder generally begin at 6 to 8 weeks after surgery and Phase III - Advanced muscle stretching and progressive resistive strengthening exercises usually at 3 months.
Complications of glenohumeral arthroplasties:
(1) Infection - 0.5%
(2) Nerve injuries mainly axillary nerve
(3) Intra operative fractures
(4) Post operative instability - 1 to 2%
(5) Post operative rotator cuff tear
(6) Prosthetic loosening
Nonconstrained arthroplasty component designs are:
(1) Cemented metal humeral component and cemented polyethylene glenoid component
(2) Non-porous press-fit humeral component
(3) Porous coated humerus component causes significant bone loss during revision surgery
(4) Metal backed glenoid components are out of favour now
(5) Porous ingrowth glenoid components
In AC joints osteoarthritis, most valuable diagnostic tool is local anaesthetic injection. Treatment: Open or arthroscopic resection of distal clavicle. Mumford describes open resection.
FROZEN SHOULDER or ADHESIVE CAPSULITIS
Primary or secondary.
Secondary frozen shoulder causes can be Intrinsic or Extrinsic
Intrinsic are rotator cuff disease, post traumatic scarring.
Extrinsic causes are referred pain due to cervical, wrist, hand, elbow or myocardial infarction.
Frozen Shoulder stages of evolution are:
Stage I: Capillary proliferation or pre-adhesive stage
Stage II: Adhesive stage, which is the most painful stage
Stage III: Maturation phase, which has capsular contractures, which is relatively pain free
Stage IV: Capsular contractures
Treatment:
Goal is to relieve pain and to restore motion and function.
Available non surgical modalities:
(1) Nonsteroidal anti inflammatories
(2) Steroid injections - not advisable to use too frequently
(3) Active and active assistive range of motion and rehabilitation programmes
Operative treatment:
(1) Manipulation under anaesthesia who do not respond after 3 months of conservative management
(2) Accurate arthroscopic release of contracted capsulo ligamentous structures and bursal adhesions is known as Brisement
(3) Open release of contractures
Male predominant disorder 9 to 1, incidence 1.7% in Sweden between the ages of 18 to 70 years. Acute trauma is the most common mechanism of aetiology.
Classification of glenohumeral joint is under the following 4 headings
(1) Mechanism
(2) Direction
(3) Circumstance
(4) Degree
(1) Mechanism: traumatic / micro trauma / atraumatic
(2) Direction: anterior / posterior / inferior / superior / multi directional
(3) Circumstance: acute / recurrent / chronic / involuntary / voluntary
(4) Degree: subluxation or dislocation
Dislocation is generally considered acute if it is within 24 hours of presentation. Recurrent if it is multiple episodes, Involuntary when individuals have no desire and Voluntary when an individual has a desire to dislocate.
ANTERIOR INSTABILITY
(1) Most frequent form of instability
(2) Apprehension test
(3) Jobe's relocation test
(4) Amount of translation compared to the normal side. Neer gliding test
(5) Radiographic findings of - Hill-Sachs defect - Anterior glenoid rim defect (west point axillary view to look for anterior glenoid rim) - Bankart lesion
Treatment - conservative / operative.
Old-fashioned operative bony procedures and soft tissue procedures like Putti Platt, Bristow (coracoid process), Magnuson stack and Weber proximal humerus osteotomy. These are not in fashion because of early OA changes after these procedures in the shoulder.
Main pathology is in the capsulo ligamentous structures of the shoulder joint or bony avulsion of the ligament in Bankart lesion.
Treatment of choice antero inferior capsular shift operations with Bankart repair procedures. Goal is to restore the anatomy
POSTERIOR SHOULDER DISLOCATION
This less common and easily missed dislocation may result from electric shock or epileptics. Posterior stress test
INFERIOR OR SUPERIOR INSTABILITY
Look for Salcus sign
MULTIDIRECTIONAL INSTABILITY
Patient will have equal displacement in all three directions. We need to differentiate between asymptomatic hyperlaxity from multi-directional instability, which is symptomatic. May have more severe component in one direction with multi directional laxity.
Multidirectional instability needs inferior capsular shift procedure. Arthroscopic capsular shift procedures have been described.
Reported carrying Angle is 6.83 in males and 12.65 in females. Average normal range of pronation / supination is from 710 of pronation to 810 of supination.
Elbow joint stability:
Medial collateral ligament, lateral ligament complex, shape of the articular surface and the anterior capsule provides stability to the joint.
Medial collateral ligament has a very strong anterior medial collateral ligament, posterior oblique portion of the medial collateral ligament and a transverse intervening segment. Medial collateral instability is difficult to repair primarily. Technique using palmaris longus graft is described.
Arthroscopic surgery of the elbow:
Portals:
Anterolateral: 1cm distal and 1cm anterior to lateral epicondyle, Beware of radial nerve
Anteromedial: 1cm proximal and 1cm anterior to medial epicondyle, Switching stick technique is helpful Midlateral portal: between capitellum, radial head and olecranon, is the safest portal
Posterior portal: Through the olecranon fossa (OK) procedure, Outer bridge and Kasiwagi technique
Rheumatoid arthritis of the elbow
Radiological Staging:
I: Osteoporosis and soft tissue damage
II: Mild or Moderate degree of bone erosion. Joint space not less than 1mm
III: More advanced with narrowing of the joint
IV: Extensive destruction of the articular cartilage
Elbow replacement:
(1) Constrained
(2) Unconstrained is more popular
KUDO or Sutter Systems are commonly used in UK. 5.5 years survival 83% reported.
Main post-op complications:
(1) Ulnar nerve injury
(2) Dislocations
Approach:
-Posterior direct triceps splitting
-Extensive posterolateral exposure
-Mayo clinic posteromedial exposure & subperiosteal dissection of the triceps
CONGENITAL ANOMALIES of the Hand and upper extremity:
Aetiology of congenital hand disorders:
(1) 30% Genetic
(2) 10% non- genetic
(3) 60% unknown
Swanson's classification:
(1) Failure of formation of parts
(2) Failure of separation of parts
(3) Duplication
(4) Overgrowth (gigantism)
(5) Undergrowth (hypoplasia)
(6) Congenital constriction bands
(7) Generalised skeletal abnormalities
Swanson's classification of Ulnar club hand
(1) Hypoplastic Ulna
(2) Total absent Ulna
(3) Humeroradial synostosis (congenital arthrodesis of the elbow joint)
(4) Deficient ulna and absent Wrist
Heikel's classification of radial club hand:
(1) Short Radius
(2) Hypoplastic radius
(3) Partial absent radius
(4) Absent radius
Associate conditions with radial club hand
(1) Fanconi's syndrome - Aplastic anaemia
(2) Thrombocytopenia - TAR syndrome
(3) Heart anomaly, Holt-Oram Lewis syndrome
(4) VATER syndrome
Treatment of radial club hand
(1) Early cases : Splinting
(2) Manipulation +/- soft tissue release
(3) Centralisation of the distal wrist over the ulna, within the first year life is preferred
Syndactyly can be
(1) Complete or incomplete
(2) Simple if only skin bridge or complex if underlying structures are duplicated
Most common site effected is between middle and ring fingers, followed by ring and little fingers. More common in white males. Associated syndromes: Poland syndrome, Streeter's dysplasia, Apert's syndrome (Acrocephalo Syndactyly)
Polydactyly:
(1) Incomplete with soft tissue only
(2) Complete finger, no duplicate metacarpal
(3) Complete with its own metacarpal
Polydactyly is also be classified as
(1) Post-axial ulnar or
(2) Pre-axial radial digit & thumb duplication
Thumb polydactyly classified by Wassel:
(1) Bifid DP
(2) Duplicate DP
(3) Bifid PP
(4) Duplicate PP
(5) Bifid Metacarpal
(6) Duplicate Metacarpal
(7) Triphalangism
Hypoplastic Thumb: Blauth
(1) Short thumb, hypoplastic thenar muscle
(2) Type 1 with adducted MCP joint
(3) Deficient metacarpal
(4) Floating thumb
(5) Absent thumb
Deviated digits:
(1) Clinodactyly : lateral plane deviation, may need closing wedge osteotomy
(2) Camptodactyly : AP plane deformity (Clino has C&'L'= lateral plane, Campto has C&'A'=AP deformity)
(3) Kirner deformity : Curling of the distal phalanx of the little finger
(4) Delta phalanx is wedged phalanx and physis
Congenital trigger finger or thumb 30% resolve by the age of 1, correct before the age of 2 to avoid fixed flexion deformity.
Central Hand deficiencies, classified by Blauth: Cleft hand
(1) Typical
(2) Atypical severe lobster claw
(3) Absent ray
Congenital radioulnar synostosis:
Associated with foetal alcohol syndrome, consider osteotomies for disabling pronation
Congenital dislocation of the radial head is treated by late resection of the radial head if symptomatic
Madelung deformity:
Abnormal growth of the distal radial epiphyses with premature fusion of ulnar half of the distal radius.
Surgical treatment:
(1) Osteotomies of the distal radius
(2) Sauvé-Kapandgi technique
(3) Salvage: wrist arthrodesis
RHEUMATOID DISORDERS OF THE HAND AND WRIST
Clinical findings may be:
(1) Increased warmth of the hand, tenderness, swelling
(2) Synovitis with joint and tendon swellings
(3) Rheumatoid nodules
(4) Muscle wasting and decreased muscle strength due to atrophy
(5) Loss of joint motion
(6) Deformities
Deformities are:
(1) Palmar subluxation & ulnar deviation of the carpus
(2) Radial deviation and dorsal displacement of the metacarpals (opposite deformity to that at carpus)
(3) Ulnar deviation & flexion of the digits (opposite deformity to that at metacarpal joint.)
(4) Distal radio-ulnar joint subluxation - Caput ulnae syndrome due to dorsal subluxation of the ulnar head
(5) Tendon ruptures Voughan Jackson syndrome: Rupture of the extensor tendons of ring and little finger EPL rupture Wrist extensor ruptures Mannerfelt syndrome: rupture of digital flexor tendons at the wrist
(6) Deformities of the digits: Swan-neck deformity Boutonniere's deformity Joint subluxation Joint dislocation Ulnar deviation of the digits Radial deviation of the hand FFD of the joints Joint destruction Floppy joints Stiff joints
SURGERY IN RHEUMATOID
(1) Control the medically resistant inflammatory process- Tenosynovectomy
(2) Preservation of the function prior to the onset of the deformity
(3) Surgery to correct the deformity
(4) Surgery for pain
Prior to the onset of deformity:
(1) Synovectomy
(2) Carpal tunnel release
(3) Restoration of ruptured tendons
(4) Wrist rebalancing by tendon transfer and dorsal stabilisation techniques
Surgery after the onset of the deformities
(1) Darrach procedure
(2) Hemiresection arthroplasty of the distal ulna- Bower's technique
(3) Sauvé-Kapandji technique
(4) Wrist arthroplasty
(5) Wrist arthrodesis: Nalebuff's technique of steinmann pin insertion through the third metacarpal and MCP replacement. Arthrodesis using AO compression plate is also described
METACARPO-PHALANGEAL JOINT IN R.A.
Factors responsible for the deformity are:
(1) Forces normally acting: (a) Gravity (b) Lateral pinch (c) Power grasp
(2) Normal anatomy: (a) Asymmetrical shape of the metacarpal head (b) Unequal collateral ligament (c) Asymmetrical intrinsic muscle to the small finger
(3) Rheumatoid disease: (a) Synovitis (b) Collateral lig. rupture (c) Tenosynovitis (d) Joint destruction (e) Wrist deformities etc….
Main deformity at MCP is Ulnar deviation of the MCP joint
Surgical procedures before the onset of the deformities are: Rebalancing the long extensor tendons, Intrinsic muscle transfer or division
Correction of the deformity may need, MCP joint Swanson silicone implant replacement
PIP JOINT AFFECTION IN RHEUMATOID
SWAN NECK DEFORMITY is Extension at PIPJ. Factors contributing to the deformities: Intrinsic contracture, Joint affection, Synovitis, joint destruction, soft tissue around the joint like palmer plate, capsular contracture, retinacular ligament, muscle imbalance
Staging: Nalebuff & Millinder classification:
I: Flexion of PIP in all positions of the MCPJ
II: Limited flexion of PIPJ when MCPJ is extended due to intrinsic tightness
III: Limited PIPJ movement in all positions of the MCPJ
IV: PIPJ stiff and joint destruction
Treatment of swan neck deformity:
Stage I & II: Flexor tenosynovectomy
Stage III & IV: Arthroplasty / arthrodesis
BOUTONNIERE'S DEFORMITY of the finger is flexion at PIPJ & extension at DIPJ
Two test:
(1) Elson's test is demonstrated by asking to extent the PIPJ against resistance with PIPJ held in 900 of flexion
(2) Intrinsic-intrinsic tightness test is demonstrated by extending the proximal interphalangeal joint to its maximum and demonstrating passive loss of distal interphalangeal joint flexion
Staging: Nalebuff & Millinder classification:
(1) Mild : 10 - 150 lag of extension
(2) Moderate : 30-400 of lag of extension
(3) Severe : Fixed flexion posture
Treatment for Boutonniere's
Mild: Extensor tenotomy over the middle phalanx
Moderate: central slip shortening, mobilisation of the lateral bands, tenotomy or PIP fusion
Severe: PIPJ fusion
THUMB DEFORMITIS IN RHEUMATOID
Millinder an Nalebuff classification
I: Boutonniere's deformity - flexion at MCPJ
II: Combination of Boutonnière's and Swan neck deformity (I & III)
III: Swan-neck deformity: Extension of the MCPJ with adducted CMC joint
IV: Gamekeeper's thumb
V: Arthritis Mutilans
I: Boutonniere's deformity of the Thumb subclassified:
a. Mild : Flexible MCPJ
b. Moderate : Fixed MCPJ in flexion, but passively corrects with hyperextension of the IPJ
c. Severe: FFD
Treatment:
a. Mild: Synovectomy & ext. mechanism reconstruction
b. Moderate : MCPJ arthrodesis/ arthroplasty
c. Severe : MCPJ arthrodesis/ arthroplasty
III: Swan-neck deformity of the Thumb subclassified as:
a. Mild: CMCJ minimal subluxation and deformity
b. Moderate : subluxation & deformity of the CMCJ is passively correctable
c. Severe : Dislocated CMCJ with fixed adduction contracture
Treatment:
a. Mild : conservative
b. Moderate : CMC hemiarthroplasty or interposition arthroplasty, tenodesis of MCPJ
c. Severe: CMC hemiarthroplasty, interposition arthroplasty with MCPJ fusion
Arthritis Mutilans is the severe form or variant of rheumatoid arthritis often associated with Psoriasis
Osteoarthritis in the hand: Only 15% of the men are symptomatic.
Bouchard's nodes over PIPJ
Heberdan's nodes over DIPJ
It is a debilitating fibromatosis involving palmer aponeurosis
Nodular thickenings form in the fascia and may progress into the longitudinal bands resulting in fixed flexion contracture
Dupuytren's diathesis: refers to predisposition of some patients for multiple areas of involvement, positive family history, early onset of the disease and disease affecting:
(1) Volar aspect of the hand
(2) Dorsum of the fingers- knuckle pads
(3) Plantar fibromatosis
(4) Penis: Peyronie's disease
Anatomical normal bands are:
(1) Longitudinal pretendinous bands
(2) Spiral bands
(3) Natatory ligament
(4) Lateral digital sheet
(5) Grayson's ligament
(6) Cleland's ligament
Pathological cords are:
(1) Central cord by longitudinal pretendinous band
(2) Spiral cord- spiral band, pretendinous band, lateral digital sheet, vertical band & Grayson's ligament
(3) Lateral cord - lateral digital sheet
(4) Retrovascular cord arises from digital fascia dorsal to neurovascular bundle
(5) Cord combinations : Central-lateral cord is commonest
Pathophysiology of Dupuytren's:
Nodules are formed by smooth muscle like cells called myofibroblasts. Proliferation of myofibroblasts within the nodules of the dupuytrens contracture is a slowly progressive phenomenon consisting of:
(1) Proliferative stage with increased cellularity
(2) Involutional stage and
(3) Residual stage where myofibroblasts are replaced by dense collagen cords.
Origin of myofibroblasts is unknown. Intrinsic theory states that fibroblasts differentiate into myofibroblasts and Extrinsic theory states that it has subdermal origin. Oxygen free radical is also been suggested to play a role.
Higher incidence of Dupuytren's is reported in association with Epilepsy, Diabetes mallitus, Chronic alcoholism, Chronic pulmonary TB, and Chronic lung disease. 10% will have positive family history
Treatment: Presently surgical:
Tried methods with no documented success:
(1) Injection of enzymes
(2) Cortisone
(3) Superoxide dimutase
(4) Physiotherapy, splinting
(5) Radiation
(6) Gamma interferon
Surgical treatment:
Does not cure the condition
Goal: Modify its progression, improve function. Indications:
(1) Positive table top test
(2) MCP joint FFD more than 300
(3) Any significant PIPJ contracture
(4) Night pain rare possibility of fibrosarcoma
Treatment of associated disorders:
(1) Trigger finger treatment should precede dupuytrens treatment.
(2) Carpal Tunnel syndrome treatment can weight as it may improve after correction of dupuytrens disease.
Surgical options:
(1) Fasciotomy
(2) Regional fasciectomy
(3) Radical fasciectomy
(4) Dermofasciectomy for complicated and high risk cases
(5) Amputation: salvage procedure
Incisions:
(1) McCash: popularised transverse incision healed by granulation
(2) Z-plasty
(3) Brunner's zigzag incisions
Post-operative:
Static night extension splintage and active range of motion exercises during the day
Patient should be warned about following complications:
(1) Neurovascular
(2) Immediate wound problems
(3) Recurrence
(4) Amputations
(5) Neuromas
(6) Incomplete correction of the deformities in most of the cases
TENDON TRANSFERS IN THE HAND AND FOREARM
Indications & Principles:
(1) Irreparable nerve damage
(2) Loss of muscle function due to trauma
(3) Non progressive or slowly progressive neurological disorder
(4) Synergistic action muscle are used if possible
(5) Joint contracture should not be present
(6) Donor muscle should have adequate power
(7) Sufficient amplitude in the transferred muscle
Amplitude: Wrist motors: 33 mm Finger extensors: 50 mm Finger flexors: 70 mm
(1) Satisfactory straight-line pull provided to the transferred muscle.
(2) Functional integrity must be preserved, tendon not expected to perform more than one function or over on two joints
Surgical considerations:
(1) Timing of the transfer Early transfer as internal splint is been advocated by Burkenhalter : PT to ECRB in radial nerve palsy
(2) Early tendon transfers are performed for bad prognostic nerve injuries: a. Proximal nerve lesion b. Irreparable nerve damage c. Lesion with statistically shown poor chance of recovery
(3) Muscles available and muscles lost are charted and careful selection of the transfer options should be considered
Functions lost
(1) Wrist extension
(2) MCPJ extension
(3) Abd. & Ext. of Thumb
Jones transfer:
PT to ECRB = Wrist extension
Palmaris L to EPL = Thumb
FCU to EDC= MCPJ extension
Some authors believe that FCU is not dispensable muscle and use FCR instead
(1) Sensory deficit
(2) Low level lesion : opponens & abduction of the Thumb
(3) High Median nerve lesion : lost tendons are FDS, FDP of Index & Long fingers, FPL, FCR
TREATMENT:
Sensory deficit:
Full thickness pedicle skin graft transfers from little finger are described
Low level injury:
(1) One half FCU is converted into pulley, FDS of ring finger is looped through this and rooted to the base of the proximal phalanx of the thumb
(2) Camitz transfer after carpal tunnel decompression and low median nerve lesion: Palmaris longus tendon dissected with a strip of palmar fascia and inserted into APB at the PP of thumb
High level injury:
(1) FDP of the index & long fingers are tenodesed to neighbouring intact FDPs (FDS cannot be used)
(3) Brachioradialis à FPL,
ECRL or ECRB can be used
(1) Loss of intrinsic muscle of the hand and
(2) Loss of adduction of the thumb
Froment's sign is positive. Clawing of the hand is most obvious in ring and little finger
Ulnar paradox: Clawing of the hand is more obvious in low ulnar nerve lesion because of intact FCU and less obvious in high lesion.
TREATMENT:
(1) Brachioradialis à re-routed with the use of tendon graft around the base of third metacarpal and fixed to the base of PP of the thumb
(2) Loss of flexion at the MCP joint:
A. Static correction to allow MCPJ flexion are : Block passive extension of MCPJ either bone block or arthrodesis Resist the extension of MCPJ by volar plate capsulorrhaphy
B. Dynamic correction: Transfer of FDS to the lateral bands of fingers or A2 pulleys to act as flexors of MCPJ.
3. High Ulnar nerve palsy:
Address FCU & FDP of the ring & little fingers:
A. FCR split to FCU
B. FDP Tenodesed to neighbouring FDP
(1) Ganglion of the wrist: 70% of all soft tissue tumours of the hand. Most common sites: Dorsal carpal ganglion from scapulolunate ligament (60-70%), and Volar carpal ganglion from FCR and APL. Retinacular ganglion cyst appears in the A1 of A2 pulleys. Treatment : Reassurance, Aspiration followed by immobilisation, Surgical excision ( Joint capsule should not be closed after surgical excision of the ganglion)
(2) Lipoma
(3) Benign giant cell tumours of the tendon sheets, PVNS
(4) Epidermal cyst
(5) Glomus tumour: 50% in the subungual region. Severe pain and cold sensitivities. May be arising from the blood vessels. MRI is helpful. Recurrence is very common, can be multicentric
(6) Enchondromas
(7) Osteochondroma
(8) Osteoid osteoma
(9) Malignant Tumours of the Hand: Very rare, Over 40 think of metastatic diseases
Finger Flexor pulleys:
Most important pulleys are A2 & A4
Pulleys are:
A1 - MCPJ
A2 - Proximal phalanx
A3 - PIPJ
A4 - Middle phalanx shaft
In-between A pulleys are three Cruciate pulleys: C1, C2, C3.
Tendon Nutrition:
(1) Longitudinal vessels enter in the palm
(2) Segmental branches enter the tendon sheath through the vincula
(3) Vessels enter the tendon at their osseous insertion
(4) Diffusion of synovial fluids
Flexor tendon Zones:
I = Distal to superficialis insertion
II = No man's land, Within the Flexor tendon sheath
III = In the palm
IV = Carpal tunnel
V = Proximal to carpal tunnel
Modified Kessler is the commonly used stitch in acute tendon repairs
Extensor tendon Zones:
Fingers:
I = over DIP joint (Mallet)
II = Over the middle phalanx
III = Over the IPJ (Boutonniere's)
IV = Over PP finger
V = Over MCPJ
VI = Over Metacarpals
VII = Wrist level for the fingers
VIII = Distal forearm
Thumb:
I = IP joint
II = Over the PP
III = Over the MCPJ (Boutonniere's)
IV = Metacarpal
V = Wrist
VI = Distal forearm
Late Reconstruction surgeries of flexor tendons are:
(1) Secondary suturing within 4 weeks
(2) Flexor tendon grafting
(3) Staged tendon reconstruction
(4) Pulley reconstruction
(5) Flexor tenolysis
Doyles classification
I - Tendon discontinuity with or without small avulsion of bone
II - Laceration with loss of tendon continuity
III - Deep aberration with loss of substance of tendon and skin
IV - Associated with significant intra-articular injury (20-50%)
WRIST INSTABILITY AND LIGAMENTOUS INJURIES
Perilunate & Lunate dissociation:
High energy injury
Mayfield described 4 stages
(1) Scapholunate diasthesis
(2) Perilunar dislocation
(3) Lunotriquetral diasthesis
(4) Lunate volar dislocation
Pathoanatomy:
(1) Scapholunate ligament / scaphoid fracture
(2) Capitolunate dislocation
(3) Lunotriquetral disruption
(4) Dorsal lunocarpal ligament fails
(5) And the last event is lunate dislocation
TREATMENT:
(1) Associated scaphoid fracture must be internally fixed
(2) Closed reduction and percutaneous pinning
(3) If reduction is not congruent open reduction by dorsal as well as volar combined approach
We have two carpal rows, proximal and distal and they are interconnected by the scaphoid.
So we have three units in the carpus:
Proximal, Distal and Scaphoid
Carpal instability can be:
(1) Carpal instability dissociate
(2) Carpal instability non-dissociate
Dissociate means, bones within the carpal rows are dissociated due to inter-osseous ligament ruptures
Non- dissociate means, Carpal bones within the rows behave as a unit.
Next aspect to look for is the Lunate position for Dorsal or Volar intercalated segmental instability Proximal carpal row is the intercalated segment between radio-carpal and midcarpal joints, and
(1) DISI is when lunate is facing dorsally in the lateral x-ray (which can be CID OR CIND). Scapholunate angle increased
(2) VISI is when lunate is facing volar in the lateral x-ray, which again can be either CID or CIND. Scapholunate angle decreased.
X-ray views:
(1) AP : Neutral, radial & ulnar deviation
(2) True lateral: Neutral, flexion & extension. Normal Scapho-lunate angle is 30 to 600
(3) Oblique views
(4) Piso-triquetral views
(5) Wrist fist views: Terry Thomas sign. > 3 mm gap between scaphoid and lunate is abnormal
MAYO Classification of carpal instability:
I - Perilunate
II - Radiocarpal
III - Midcarpal
I. Perilunate - CID
Either DISI or VISI
a. Scapho-lunate dissociation - DISI
b. Lunotriquetral dissociation - VISI
II. Radiocarpal - CIND
a. VISI
b. DISI
c. Ulnar Translation
III Midcarpal: CIND
a. Triquetrohamate VISI > DISI
b. Scaphotrepeziotrapazoidal VISI > DISI
c. Capitolunate : DISI > VISI
d. Diffuse laxity : DISI > VISI
Treatment of perilunate instability:
DISI:
(1) Acute injury : Close reduction & pinning, if necessary open capsular reconstruction
(2) Chronic injury: a.Dynamic : dorsal capsulodesis (Blatt Procedure) b.Static : Watson triscaphii fusion
(3) Salvage procedures a. Proximal row carpectomy b. Radial styloidectomy c. 4 bone fusion d. Wrist fusion
VISI:
(1) Acute injuries : Closed treatment
(2) Chronic injuries: a.Dynamic: Ligament reconstruction, capsulodesis b.Static: Intercarpal fusion
(3) Salvage procedures : Proximal row carpectomy Wrist fusion
TFCC lesions:
(1) Traumatic
(2) Degeneration
-May not be seen on X-ray until 10-21 days
-Complications: Non-union & AVN
90% heal with good outcome
-Proximal pole AVN is prieser's disease
-Russe's bone graft technique for non-union - Volar Russe approach
-Proximal pole is better reached by dorsal approach
SCAPHO-LUNATE ADVANCED COLLAPSE (SLAC WRIST)
SLAC wrist is manifested following Scaphoid fractures or Scapholunate dissociation due to degeneration of the radioscaphoid and capitolunate joints. Radiolunate joint is spared.
Four stages described:
(1) Radial styloid and scaphoid abutment
(2) Radio scaphoid articulation affected
(3) Capito-lunate +/- Scaphocapitate
(4) Migration of the capitate proximally
AVN of Lunate
Stages & Treatment: by Stahl modified by Litchman: (X-ray)
I: Sclerosis: Conservative
II: Fragmentation: Radial shortening or ulnar lengthening
III: Collapse: Controversial, Triscaphii or capitohamate fusion to reduce load on the lunate
IV Radio-carpal degeneration: Salvage procedure: Fusion
Leffort Classification of Brachial plexus injury:
(1) Open injury
(2) Closed injury usually RTA : a.Supraclavicular : Pre ganglionic or post-ganglionic b.Infraclavicular: Usually involves branches from the trunk
(3) Radiation therapy induced
(4) Obstetric birth palsy a. Erb's palsy - Upper root b. Klumpke's - lower root c. Mixed
Bad prognostic factors:
(1) Preganglionic injury: Winging of the scapula Horner's sign Denervation of the dorsal neck muscles Pseudomeningocoele Normal histamine test
(2) High velocity injury
Erb's palsy: Waiter's tip hand: Internal rotation of the arm, extended elbow and flexed wrist.
Treatment:
(1) Open injuries always explored
(2) Closed injuries: Birth injuries observed upto a year with early physiotherapy input. If biceps does not recover by 3 months, it is a bad prognostic factor
(3) High velocity injuries: Early exploration is recommended, as the chance of recovery here is poor
Surgical options:
(1) Neurolysis
(2) Neurotmesis : intercostal nerves to musculocutaneous nerve
(3) Nerve interposition grafting
(4) Reconstructive procedures Principles: a. Shoulder stabilisation Triceps transfer Arthrodesis and b. Elbow flexion Steindlers flexorplasty Lattissimus dorsi transfer Pectoralis transfer Triceps transfer
NERVE ENTRAPMENT SYNDROMES IN THE UPPER EXTREMITY
Pathogenesis
(1) Anatomic
(2) Postural
(3) Developmental (bands etc)
(4) Inflammatory (tenosynovitis)
(5) Metabolic and endocrine
(6) Tumours (ganglions etc)
(7) Trauma (dislocation or compartment syndrome)
(8) Iatrogenic (injections into the nerve)
Degree of nerve damage is related to severity of compression rather than duration.
Common presentations are due to:
(1) Physiologic conduction block
(2) Neuropraxia
(3) Axonotmesis
(4) Combination
Tinel's sign, phalen's test are provocative tests. Electro diagnostic accuracy at present is 85 to 90%. 8 to 20% falls to negative rate.
Treatment:
(1) Open surgical release of transverse carpal ligament
(2) Endoscopic carpal tunnel release is not universally accepted because of complications
This is entrapment of the median nerve between the two heads of the pronator teres.
Other structures entrapping median nerve in the same region are
(1) Lacertus fibrosus which is a fibrous structure at the origin of pronator teres
(2) Ligament of struthers (a band from the distal end of the front of the humerus to the pronator teres) (arcade of struthers is different from ligament of struthers
(3) Fibrous arch of flexor digitorum superficialis.
Muscle stressing test for localisation:
(1) Pain on resisted pronation of the forearm with elbow extended implicates the pronator teres syndrome
(2) Pain on supination as well as resisted flexion implicates lacertus fibrosus
(3) Pain on resisted flexion of PIP joint of the middle finger implicates arch of flexor digitorum superficialis
Treatment mainly relies on clinical examination. Only 20% show delay in nerve conduction study
ANTERIOR-INTEROSSEOUS SYNDROME
Purely motor deficit. Mainly affect flexor pollicis longus and flexor digitorum profundus to the index finger. Tinel's sign is usually negative. EMG is helpful. Most common constricting structure is the tendinous origin of the deep head of pronator teres.
Treatment of pronator teres syndrome and anterior interosseous syndrome is surgical decompression.
Cubital Tunnel Syndrome:
Clinical testing - extreme flexion of the elbow maintained for 1 to 2 minutes. Froment's sign
Clawing of the ring and little fingers, EMG studies.
Entrapment may be:
(1) At the arcade of struthers (ligamentous structure extending from the medial head of triceps to the medial inter muscular septum)
(2) Anomalous fibrous band within the forearm
(3) In between the two heads of flexor carpi ulnaris
(4) Fibrous arch between the two heads of FCU (arcade of osborne)
Treatment options
(1) Steroid injections should be avoided
(2) Ulnar nerve neurolysis
(3) Neurolysis with anterior transposition (subcutaneous or sub muscular)
(4) Medial epicondylectomy.
ULNAR TUNNEL SYNDROME (Guyon's Canal)
This is 4cms long tunnel. Transverse carpal and piso hamate ligaments form the floor, volar carpal ligament forms the roof and pisiform and hook of hamate form the walls
Treatment: Neurolysis
MRI to rule out cystic lesions. Allen's test may be positive with ulnar artery thrombosis.
Different levels for constriction
(1) Spiral groove of the humerus, fibrous arch under the lateral head of the triceps
(2) Lateral inter muscular septum
(3) Proximal supinator
2 symptoms - Pain and weakness
2 syndromes - Radial Tunnel syndrome and Posterior interosseous nerve
POSTERIOR INTEROSSEOUS NERVE SYNDROME
Presents with pain and weakness of the wrist and fingers. No sensory deficit. MRI is sometimes helpful.
Treatment:
Surgical decompression
Resistant tennis elbow.
Entrapment sites maybe
(1) Fibrous band to the radial humeral capsule
(2) Fibrous medial edge along the ECRB
(3) Recurrent leash of vessels over the nerve
(4) Fibrous arcade of Frohse (proximal superficial edge of the supinator)
Diagnostic test is local anaesthetic injection for pain 5cms distal to the lateral epicondyle.
Clinical examination - Increased pain by resisted active supination and passive forced pronation of the forearm. Middle finger extension test may produce pain as ECRB inserts into the base of the third metacarpal.
Treatment:
Surgical decompression