Hand PDF

Sholahuddin Rhatomy,MD
ORTHOPAEDI
HAND
Rhatomy,MD
Orthopaedi UI
DAFTAR ISI
1. Hand Anatomy & Mechanics…………………………………………………………… 3

2. Flexor Tendon Injuries of the Hand…………………………………………………….. 11
3. Extensor Tendon Injuries……………………………………………………………….. 23
4. Fingertip & Nailbed Injuries……………………………………………………………. 28
5. Coverage of Hand Wounds……………………………………………………………… 31
6. Hand Amputations………………………………………………………………………. 33
7. Hand Replantation……………………………………………………………………… 35
8. Hand Infections………………………………………………………………………… 40
9. RHEUMATOID ARTHRITIS…………………………………………………………. 46
10. Carpometacarpal arthritis of thumb – RHIZARTHROSIS……………………………. 55
11. Dupuytren's Contracture…………………………………………………………….… 59
12. Trigger Finger / Tenosynovitis………………………………………………………… 66
13. Nerve Compression in Upper limb……………………………………………………. 70
14. MEDIAN NERVE .......................................................................................................... 70
15. ULNAR NERVE…......................................................................................................... 75
16. RADIAL NERVE…........................................................................................................ 79
17. Nerve Injuries - General Principles………………………………………………….… 81
18. Nerve repair …………………………………………………………………………… 92
19. Nerve grafting …………………………………………………………………………. 93
20. Hand - Tendon Transfers – Principles………………………………………………… 95
21. BRACHIAL PLEXUS………………………………………………………………… 98
22.SUPRASCAPULARNERVE…………………………………………………………. 105
23. LONG THORACIC NERVE………………………………………………………… 106
24. AXILLARY NERVE………………………………………………………………… 107
25. MUSCULOCUTANEOUS NERVE…………………………………………………. 108
26. RADIAL NERVE INJURY & TENDON TRANSFERS……………………………. 109
27. MEDIAN NERVE INJURY & TENDON TRANSFERS……………………………. 112
28. Sprengel's shoulder …………………………………………………………………… 118
29. Madelung’s deformity…………………………………………………….………..… 119
30 Hand Fractures………………………………………………………………………… 120
31. Fractures of Scaphoid………………………………………………………………… 152
32 Distal Radius Fractures……………………………………………………….………. 160
33. Keinbock's Disease…………………………………………………………………… 169
34. De Quervain’s Disease……………………………………………………………….. 173
35 RSD…………………………………………………………………………………… 177
Orthopaedi UI
Hand Anatomy & Mechanics
DORSAL SURFACE (Extrinsic extensor mechanism)

Dorsal Extensor Compartments
Comp Tendons Notes Pathology
1 EPB, APL Both in separate synovial sheaths De Quervains
2 ECRL, ECRB Radial to Lister's tubercle Carpal boss
3 EPL Ulnar to Lister's tubercle Rupture over Lister's tubercle
4 EDC, EIP Common synovial sheath Tenosynovitis & ruptures
5 EDM Double tendon, over DRUJ Tenosynovitis & ruptures
6 ECU Lies over distal ulna Subluxing at ulnar styloid
Junctura tendinae
• Origin - most commonly extensor tendon of ring finger

• Insertion - after diverging distally, attach to extensor tendons of middle & little fingers
• Function - limits independent extension of ulnar 3 digits
• Patho - lacerations to extensor tendon of middle & little digits proximal to junctura -> adequate
extension may still exist
Orthopaedi UI
Extensor Hood
• Sagittal band/dorsal hood [5]

• Connect extensor tendon to volar plate of MCPJ
• Functions
• Aids extension of MCPJ
• Stabilizes extensor tendon in midline
• Prevents dorsal bowstringing
• Limits excursion of EDC
• Patho
• Lacerations - loss of extension
• Ruptures - ulnar dislocation of extensor tendons (middle finger most common)
• Claw hand deformity - in hyperextension of MCPJ
• Extensor tendon distal to sagittal band becomes lax -> IPJs fall in to
flexion
• In this position IPJ's can only be extended by intrinsics (which are not
working)
Extensor Tendons
• Divides into 3 slips

• Central
• Joined by interosseous medial band
• Inserts into dorsal base of P2
• 2 lateral
• Diverge to join interossei & lumbrical bands, forming conjoined lateral bands to
insert into dorsal base of P3
• Lateral bands [16] are held dorsally by Triangular Ligament [17] & volarly by
Transverse Retinacular Ligaments [15]
• Function
• Central slip - extension of PIPJ
• Conjoined tendon - extension of DIPJ
• Patho
• Central slip
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Orthopaedi UI
• Adhesion to P1 after lacerations/#

• Buttonniere deformity
• Conjoined tendon
• Mallet deformity
• Buttonniere deformity
Interosseous aponeurotic expansion
• 3rd, deep belly of 1st, 2nd & 4th dorsal interossei & all volar interossei insert into interosseous
hood
• Most proximal portion - transverse fibres over extensor tendon
• Distal portion - increasingly oblique converging fibres inserting into lateral tubercles at dorsal
base of P2
• Function
• Transverse proximal portion aids in MCPJ flexion
• Other portion aids in PIPJ extension
• Patho - intrinsic plus deformity from adherence, contracture, spasm
Retinacular Ligaments
• Transverse Retinacular Ligament [15]

• Attaches lateral bands to volar plate at PIPJ
• Prevents excessive dorsal shift of lateral bands
• Imbalance of lateral bands results in
• Swan neck deformity - attenuation -> excessive dorsal shift of lateral bands
• Boutonniere deformity - tightening -> volar shift of lateral bands
• Oblique Retinacular Ligament (ORL) [13]
• Described by Weitbrecht (1969)
• Extends from flexor tendon sheath at level of P1 to terminal extensor tendon, volar to axis
of PIPJ
• Functions
• Coordinates uniform flexion & extension of PIPJ & DIPJs
• When FDP flexes DIPJ, ORL tightens & flexes PIPJ through a
tenodesis effect
• As extensors extend PIPJ, ORL helps extend DIPJ (from 90 to 70o only)
• Where there is loss of terminal tendon (Mallet finger), ORL may extend DIPJ
• Patho - Dupuytren's contracture
• Triangular Ligament [17]
• Transverse fascia connecting 2 lateral bands over P2
• Prevents volar shift of lateral bands
• Patho - Boutonniere deformity
Interosseous muscles
• Anatomy
• Dorsal interossei
• 1st, 2nd & 4th dorsal interossei
• Superficial belly - adjacent sides of contiguous MC -> base of P1
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Orthopaedi UI
• Deep belly - radial side of 2nd & 3rd MC -> dorsal aponeurosis
•3rd dorsal interossei - only 1 belly
• Dorsal aspect of 3rd & 4th MC -> dorsal aponeurosis
• Volar interossei
• Shafts of contiguous MC -> dorsal aponeurosis
• Function
• Abduct fingers away from midline of middle finger
• Flex MCPJ
• Extend IPJ
Lumbricals
• Anatomy
• Origin
• 1st & 2nd - FDP of index & middle fingers, respectively
• 3rd & 4th - contiguous FDP of middle & ring, & ring & little fingers, respectiely
• Pass volar to transverse MC ligament & volar to axis of MCPJ
• Insertion into dorsal expansion by joining radial lateral band at midportion of P1
• Functions
• Extends IPJ, irrespective of MCPJ position
• Facilitates IPJ extension by pulling FDP distally
• Initiates MCPJ flexion
• Radial deviation of digits
Intrinsic Minus Hand (Claw hand)
• Deformity
• MCPJ hyperextension
• PIP & DIPJ semiflexed
• MC arch flattened
• In thumb, on pinch
• IPJ hyperflexion (Froment's sign)
• MCPJ hyperextension (Jeanne's sign)
• Mechanism
• Loss of intrinsics
• Unopposed extensors -> MCPJ hyperextension & volar plate elongation
• Blocking effect of sagittal band at MCPJ prevents distal extensor pull through
• Unopposed flexors -> PIP & DIPJ flexion
• In thumb, decreased force of MCPJ flexion & IPJ extension
• Causes
• Ulnar nerve palsy
• High - mild clawing of ring & little fingers
• Low - more clawing of ring & little fingers
• Median & ulnar nerve palsy
• High - full extension
• Low - all fingers may claw
• Volkmann's ischemic contracture
Orthopaedi UI
Intrinsic Plus Hand
• Deformity
• MCPJ flexion
• PIP & DIPJ hyperextension
• Thumb MCPJ flexion, IPJ hyperextension
• Thumb adduction
• Mechanism
• Extensor tightness of PIPJ - PIPJ flexion becomes less when MCPJ fully flexed,
vice versa
• Intrinsic tightness - PIPJ flexion becomes more when MCPJ fully flexed, vice versa
• Causes
• Ischemia
• Spasm
• Fibrosis
• Paradoxical extension, eg. FDP laceration distal to lumbrical origin
VOLAR SURFACE
Palmar Spaces
• Palmar subaponeurotic space

• Deep to palmar aponeurosis
• Contains superficial palmar arch
• Collar-stud abscess
• Ulnar & radial bursae
• Tendon sheaths to little finger & thumb

• Tendon sheaths
• Drain infection through transverse incisions over MCPJs & DIPJs
• Indwelling catheter for irrigation (?Jacques)
Orthopaedi UI
• Palmar fascial space
• Lies between fascia covering MC's & contiguous muscles & fascia dorsal to flexor
tendons
• Unar border: fascia of hypothenar muscles
• Radial border: fascia of adductor & other thenar muscles
• Divided into midpalmar space & thenar space by fascial membrane that passes obliquely
from 3rd MC shaft to fascia dorsal to flexor tendons of index finger
• Midpalmar space
• Overlying MC's
• Extends to web spaces via lumbrical canals
• Extends under flexor retinaculum to space of Parona
• Thenar space
• Between thenar muscles & adductor pollicus
• Extends to radial side of index finger
Lumbricals
• 'Workhorse of hand'
• Origin: FDP tendon
• Insertion: radial lateral band of extensor expansion
• Pass volar to transverse metacarpal ligament
• 2 radial lumbricals supplied by median nerve; 2 ulnar lumbricals supplied by ulnar nerve
• Radial muscles are unipenniform; ulnar muscles multipennate
• Only muscle which relaxes its own antagonist (FDP)
• Lumbrical Plus Hand
• = lumbricals tighter than extrinsics
• Caused by FDP laceration distal to lumbrical origin
• Paradoxical extension - active flexion of MCPJ causes extension of PIPJ
• Causes Quadrigia Effect (FDPs act as a single unit & individual finger flexion not possible
- can also occur after amputation where FDP tendon is sutured to extensors)
Orthopaedi UI
Vessels & Nerves
• Superficial palmar arch

• Distal
• Supplied predominantly by ulnar artery
• Surface anatomy = distal palmar crease
• Deep palmar arch
• Proximal
• Supplied predominantly by deep branch of radial artery as it passes between 2 heads of
1st dorsal interosseous
• Surface anatomy = Kaplan's cardinal line (from hook of Hamate to base of 1st web
space)
• Classic complete (codominant) arch is present in 1/3 of people
• Princeps pollicis artery
• Continuation of deep branch of radial artery
• Bifurcates into thumb digital arteries after giving off a branch to radial side of index finger
• Common digital arteries
• 3 in 2nd through 4th web spaces
• Bifurcates into proper digital arteries
• Digital arteries
• To ulnar side of little finger - 1st branch off superficial arch
• Volar to nerves in palm but dorsal in fingers
Digital Cutaneous Ligaments
• Grayson's (Ground) & Cleland's (Ceiling) ligaments

• Tether proximal & middle phalanges to skin
• Stabilizes NVB with finger flexion & extension
Orthopaedi UI
Flexor Tendons & Pulleys

PIPJ Anatomy
THUMB
• Muscle forces acting on thumb
• Thumb opposition = abduction + rotation mainly at 1st CMCJ

• MCPJ & CMCJ are both modelled as universal joints (flexion-extension; abduction-adduction;
axial rotation)
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Orthopaedi UI
NAIL
WRIST
• Consists of 3 columns
Flexion-Extension / Central Centre of rotation = capitate

Distal carpal row & lunate
Column Dependent on carpal ligaments for stability
Second mobile column Scaphoid
Carpus rotates around triquetrum
Rotation Column Triquetrum
independent of forearm rotation
• Modeled as a universal joint
Flexor Tendon Injuries of the Hand

ACUTE FLEXOR TENDON REPAIR
Anatomy
• Flexor tendon sheath
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Orthopaedi UI
• Flexor sheath of thumb & little finger continuos with radial & ulnar bursae, respectively
• Sheath of index, middle & ring originates at level of MC neck (distal palmar crease)
• Double-walled fibroosseous tunnel sealed at both ends
• Inner visceral & outer parietal layers -> synovial fluid -> nutrition & lubrication
• Retinacular portion with a series of thickened areas called pulleys
• Floor formed by volar plates of MP & PIPJ & periosteum of underlying bones
• Pulley system
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Orthopaedi UI
• Thickened areas within flexor sheath

• Function
• Annular pulleys prevent bowstringing of flexor tendons & subsequent loss of
motion during flexion
• Cruciate pulleys enable sheath to conform to position of flexion by permitting
annular pulleys to approximate each other
• A2 & A4 most important in preventing bowstringing
• Thumb
• A1
• A2
• Oblique pulley over proximal phalanx most important
Tendon Nutrition
• Vinculae
• Remnants of mesotenon & provide blood supply & nutrition to flexor tendons
• Vincular system supplied by transverse communicating branches of common digital
artery
• Enter dorsal portion of each tendon
• Nutrition of tendons also derived from synovial sheaths -> thus early mobilisation postop
important
Types of Injury
• Position of hand at time of injury determines tendon retraction

• Flexed fingers - distal tendon retracts
• Extended fingers - proximal tendon retracts
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Orthopaedi UI
Zones
Only FDP injured

Tight A4 pulley makes repair difficult
Zone I FDS insertion to FDP insertion
Aim to advance FDP stump to reattach to terminal phalanx
Advancement >1 cm -> flexion contracture & quadrigia effect
2 slips of FDS; vincula
FDS & FDP injured
Zone II Zone I to proximal part of A1 pulley
Termed no man's land by Bunnell - high incidence of poor results
after attempted primary repair
Easily repaired with good results
Zone III Zone II to distal edge of flexor retinaculum
Don't suture lumbrical muscle around tendon repair
Tansverse carpal ligament repaired in a lengthened fashion
Zone IV Within carpal tunnel
Close quarters & synovial sheaths -> adhesions likely
Can use mattress sutures if many tendons need repair
Zone V Zone IV to musculotendinous junction
Favourable prognosis unless concomitant neurovascular injury
Thumb T1 FPL insertion to A2 pulley FPL tendon lacerations often retract into thenar area or wrist
Unlike fingers, FPL often lacks a vinculum & does not have a
lumbrical, & therefore tendon is free to retract
Thumb T2 Zone 1 to distal part A1 pulley Repair requires an incision proximal to carpal tunnel & 'pull-
through'
Rupture rate 20% cf 2-5% in fingers
Thumb T3 Zone 2 to carpal tunnel Also damage thenar muscles & recc. br. median nerve
Contraindications to repair
• Failed primary repair worse than no repair!

• If only 1 tendon cut, functional result will be better than a poor repair
• Contraindications
1. Wounds liable to infection
2. Inability of patient to cooperate with rehabilitation
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Orthopaedi UI
Incisions
• Surgical approaches
• Original wound extended to allow incorporation into a zigzag incision (Bruner)
• Mid-axial incision (Strickland)
• For retracted tendons
• Try milk tendon with wrist flexed
• Small incision at distal palmar crease just proximal to A1 pulley
• Pass a silastic cannula/NG tube from distal wound through sheath to proximal wound
• Attach proximal tendon to cannula & pull through to distal wound
Technique
• Atraumatic handling of tendon ends

• Core grasping suture
• Non-absorbable 4/0 suture
• Number of grasping loops not as significant as number of suture strands that cross repair
site -> linear relationship to repair strength
• Tensile strength requirement for early active motion rehab: minimum 4-strand repair,
preferably 6
• Techniques
• End-to-End Sutures
• Conventional Bunnell stitch
• Kleinert modification of Bunnell Crisscross stitch
• Mason-Allen (Chicago) stitch
• Kessler grasping suture
• Modified Kessler suture
• Tajima suture
• Loop suture
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Orthopaedi UI
• Fishmouth End-to-End Suture (Pulvertaft)

• For suturing a tendon of small diameter to one of larger diameter
• End-to-Side Repair
• Frequently used in tendon transfers when one motor must activate
several tendons
• Running epitenon suture

• 6/0 monofilament
• Tidies repair edges -> improves gliding & avoids adhesion
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Orthopaedi UI
• Adds strength to repair (20%) & allows for less gap formation - initial event in repair
failure
• Sheath repair
• Close sheath, if possible
• But no study -> undisputed evidence that closure improves outcome
• Partial lacerations
• Repair if involving >60% because of risk of rupture
• Repair of laceration <60% detrimental to tendon strength
Multiple Flexor Tendons at Wrist (Zone 5)
• Order of repair
1. FPL
2. FDP tendons
3. FDS to middle & ring fingers
4. FDS to index & little fingers
5. Ulnar nerve
6. Ulnar artery
7. Median nerve
8. FCU
9. FCR
10. Radial artery - ligated
Post-operative program
• Early controlled motion to decrease tendon adhesions & to improve digit motion (tensile strength
& gliding function)
• FDS motion: flex PIP joint with adjacent joints held in extension to neutralise effect of
FDP
• FDP motion: immobilize PIP joint & flex DIP joint
• Flexor tendon excursion at
• DIPJ - 1.2 mm with every 10o of passive flexion, 3x more with active flexion -> early
active motion important
• PIPJ - not a problem
• 2-strand repair protocol
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Orthopaedi UI
• Kleinert Dynamic Splint

• Combines dorsal extension block with rubber-band traction proximal to wrist
• Active extension within limits of splint
• Dynamic splint assisted passive flexion
• Immediate postop
• Dorsal plaster splint with wrist neutral, MCPJ 90 flexion, IPJ full
o
extension
• D1
• Splint
• Change to Kleinert
• Same position
• Exercise
• Full active IPJ extension with MCPJ passively flexed
• Passive finger flexion, with place & hold, isolating MCPJ, PIPJ, &
DIPJ respectively
• Passive composite flexion
• 3/52
• Same splint
• Exercise
• Check tendon gliding
• If gliding excellent -> protect up to 3/52
• If adherence -> AROM
• Progress from place & hold to AROM: flat fist -> full fist ->
hooked fist
• 6/52
• Off splint
• Exercise
• Gentle active flexion: flat fist -> full fist -> hooked fist
• Minimal resistance with surgeon approval
• Light ADL
• 8/52
• Progressive strengthening exercises
• Graded work simulation initiated
• Full ADL
• Light duty
• 12/52
• Resume normal activity
• 4-strand repair protocol
• UMMC regimen
• Immediate postop
• Dorsal plaster splint with wrist neutral, MCPJ 90 flexion, IPJ full
o
extension
• D1
• Splint
• Change to thermoplastic
• Same position
• Exercise
• Full active IPJ extension with MCPJ passively flexed
• Passive finger flexion, with place & hold, isolating MCPJ, PIPJ, &
DIPJ respectively
• Passive composite flexion
• 3/52
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Orthopaedi UI
• Off splint
• Exercise
• Gentle active flexion: flat fist -> full fist -> hooked fist
• Minimal resistance with surgeon approval
• Light ADL
• 6-12/52
• Progressive strengthening exercises
• Graded work simulation initiated
• Full ADL
• Light duty
• 12/52
• Resume normal activity
• Belfast Regimen (J. Hand Surg. 14B:383-391. 1989)
• At 48 hrs postop
• Remove dressings
• Thermoplastic splint
• Wrist 20 , MCPJ 70
o o
• 2/3 up forearm, straps on palmar crease, wrist & forearm
• 1st 6/52
• Fingers - every 2 hrs
1. Passive flexion (2x/individual finger)
2. Active extension (2x/mass action)
3. Active flexion (2x/mass)
• Thumb - every 3 hrs as above
• 6/52: remove splint & progress to active flexion of individual joints
• 6-8/52: use hand, no heavy lifting
• 8-10/52: slowly increase activity, stretches into extension, fine work
• 10-12/52: driving, heavier work
• >12/52: full function (60% strength back at 16/52)
Medications
• 3 medications have been shown to decrease adhesions in animal studies

• Ibuprofen
• Beta amino propionitrile
• Steroids
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Orthopaedi UI
Complications
• Rupture - prompt reexploration & repair

• Infection
• Adhesions - prevented by early passive ROM
• Joint contractures - too tight repair or from prolonged splintage
• Bow stringing - from damaged pulleys
Tendon Healing
• Exact nature controversial

• Occurs via fibroblastic response of sheath & surrounding tissues
• Adhesion formation essential
• However, studies -> flexor tendons have intrinsic ability to heal via nutrients supplied by diffusion
from synovial fluid
Phase Days Histology Tensile strength

Inflammation 0-5 Invasion of WBC & then granulation tissue formation None
Proliferation 5-28 Fibroblast proliferation & matrix synthesis, disorganized collagen Increasing
Remodelling >28 Fibroblasts drop in number, replacement tissue matures with Will tolerate controlled
linear collagen organization active motion
• Healing phases
Effects of Time on Tendon Healing
• Strength duration curve show that repair is weakest at10-12/7 -> rupture occurs most commonly
at day 10
• Healing is weak at 4/52, but of sufficient strength to tolerate active contraction of muscle
• At 6/52, external elastic traction can be applied if force not excessive; some surgeons allow
gentle active ROM
• At 3/12, moderate stress can be applied to flexor tendon in both flexion & extension
• At 8/12, full tensile strength has been recovered
Partial Flexor Tendon Lacerations
• A partially lacerated tendon retains varying amounts of its strength

• 60% laceration can retain 50% or more
• 90% laceration can retain only slightly more than 25%
• Hariharan et al. in human cadaver tendons -> loads required to rupture 50% & 75% tendon
lacerations were higher than physiological loads during normal active motion
• Stahl, Kaufman, & Bialik
• Compared 17 repaired partial tendon lacerations (<75%) in children with 19 partial
lacerations treated with early mobilization
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Orthopaedi UI
• Outcomes were similar in both groups

• No triggering or rupture seen in early mobilization group
• Mx
• 50% or more
• Treated the same as a complete transection
• <50%, especially in 30% range
• Flap of tendon is smoothly debrided & flexor sheath repaired to help avoid
entrapment of flap or triggering of flap in defect in flexor sheath
• Postop, protect with dorsal block splinting for 6-8/52
• More forceful activities resumed gradually after ~8/52
SECONDARY FLEXOR TENDON REPAIR & RECONSTRUCTION
• Defined as delayed primary repair performed >3/52 after injury

• Contracture of muscle-tendon unit has usually occurred & tendon graft often required
Prerequisites for tendon reconstruction
• Skeletal alignment
• Good passive ROM of joints
• Adequate skin & soft tissue cover
• Adequate sensation & circulation of finger
• Motivated patient
Methods/options
• Delayed direct repair

• Single stage flexor tendon grafting, only if flexor sheath is pristine & digit has full passive ROM
• 2-stage grafting
• Tenodesis or arthrodesis
• Tendon transfer
• Amputation
Two-stage Flexor Tendon Reconstruction
• Indicated for
• Delayed or neglected flexor tendon injuries
• Tendon rupture following previous attempted repair
• Crush injuries
• Contraindications
• Infection
• Too much damage to support an implant or allow decent tendon gliding
• Loss of full passive ROM
• Isolated FDP loss but good FDS function -> risk of worsening finger function -> consider
FDP tenodesis or DIPJ fusion
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Orthopaedi UI
• 1st stage
• Aims:
1.
Joint contractures must be released
2.
Tenolysis of scarred tendons
3.
Preserve A1, A2 & A4 pulleys
4.
Finger must have free & full passive ROM
5.
Digital nerve repair or grafting
6.
Provide healthy skin (may require a flap)
7.
Full flexion on traction of silastic rod at wrist
• Techniques
Exposure
• Phalangeal incisions: midlateral or Bruner skin incision
• Neurovascular structures are identified
• Save as much as tendon sheath as possible
• While protecting annular ligaments, cruciate ligaments are opened to
allow access to tendons
Tendon debridement
• FDP
• Excise FDP tendon at level of lumbricals upto level of DIPJ
• Preserve distal 1 cm of FDP
• FDS
• 2nd incision over distal forearm
• Identify involved FDS tendon, draw it into wound, & transect it
near musculotendinous junction
Assessment of tendon environment
• Pulley reconstruction, joint release, or nerve repair should be performed
at this point
Prosthetic graft insertion
• Determine appropriate size of silicone implant
• Pass implant from proximal palm to distal forearm between FDP & FDS
• Graft is anchored distally but left free proximally at level of distal forearm
• Postop care
o o
Dorsal split with wrist in 40 of flexion & MP flexed to 60-70
Begin passive ROM on 1st postop visit
Use dynamic splint for contracture
• 2nd stage
• 2-3/12 after 1st stage when signs of infection & scarring absent
• Techniques
Distal incision made over previous incision stopping at middle of P2
Make a small longitudinal incision in distal sheath, taking care not to injure A4
pulley
Locate silicone rod at distal FDP stump
Proximal incision is reopened & proximal aspect of sheath is identified
Obtain tendon graft
Suture graft to proximal end of implant & pull it distally through sheath
Anchor distal end of tendon graft
• Remaining FDP stump is split & sutured to both sides of graft
• Use a 3-0 Prolene pull out suture tied over a button placed on finger nail
Anchoring proximal tendon end
• Proximal end is anchored after distal end, so that tensioning graft is
easier
• Postop care
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Orthopaedi UI
o
Dorsal blocking split with wrist neutral, MCPJ in 45 of flexion & IPJ neutral
Begin protected passive ROM & early controlled-motion program
Use dynamic splint for contracture
• Tendon graft options
• Palmaris longus
0. Most often used
1. Absent in 15%
• Plantaris
0. If longer graft needed -> best for multiple tendon grafts
1. Absent in 20%
• Long toe extensors - 2nd, 3rd or 4th toes
• EIP
• Fascia lata
Extensor Tendon Injuries
Anatomy of EDC
• Origin: lateral epicondyle of humerus

• Tunnel IV
• Narrow retinaculum over dorsum of wrist forms pulley system for extensor tendons
• Above wrist its 4 slips spread out joined together by juncturae
• Just ulnar to tunnel III & just radial to radioulnar articulation, transports EDC & EIP to
hand
• Junctura tendinae
• Origin - most commonly extensor tendon of ring finger
• Insertion - after diverging distally, attach to extensor tendons of middle & little fingers
• EIP has no junctura
• Function - limits independent extension of ulnar 3 digits
• Nerve supply: deep radial nerve, C6, C7, C8
• Action: extends metacarpophalangeal & carpometacarpal articulations
• Synergists: Extensor Indicis, Extensor Digiti Minimi, Lumbricals
• Note that EDC is less tolerant of shortening than FDS due to differential in tendon excursion (50
mm compared to 70 mm, respectively)
Extensor mechanism of digit
• Extensor apparatus is a "plexus of tendons with an aponeurotic sheet." Stack, 1962

• MCPJ level
• Sagittal bands
• Arise from volar plate & spans both sides of MCPJ
• Adhere to collateral ligaments & deep transverse intermetacarpal ligament
• Functions
• Aids extension of MCPJ
• Stabilizes extensor tendon in midline
• Prevents dorsal bowstringing
• Limits excursion of EDC
• EDC
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Orthopaedi UI
• Divides into 3 slips

• Central
• Joined by interosseous medial band
• Inserts into dorsal base of P2
• 2 lateral
• Diverge to join interossei & lumbrical bands, forming conjoined
lateral bands to insert into dorsal base of P3
• Lateral bands are held dorsally by Triangular Ligament & volarly
by Transverse Retinacular Ligaments
• Function
• Central slip - extension of PIPJ
• Conjoined tendon - extension of DIPJ
• Interossei
• On both sides of MCPJ, a portion of interossei insert into base of proximal
phalanx & joint capsule
• Remainder of interossei along with lumbricals insert into extensor apparatus at
level of middle phalanx, & continues distally (as lateral bands) to insert into distal
phalanx
• Phalangeal level
• EDC
Zone Classification
Zone Finger Thumb
I DIPJ IPJ
II Middle phalanx Proximal phalanx
III PIPJ MCPJ
IV Proximal phalanx Metacarpal
V MCPJ CMCJ radial styloid
VI Metacarpal
VII Dorsal wrist retinaculum
VIII Distal forearm
IX Middle & proximal forearm
Treatment
• Zone I - DIPJ
• Disruption of terminal tendon
• Extension splinting for 6/52 -> 80% good results
• Avoid hyperextension
• See mallet finger
• Zone II - middle phalanx
• At this point lateral bands are traveling in a volar to dorsal direction, & are merging with
fibers of central slip
• Usually tendon injuries are partial, since extensor tendon extends over dorsal half of digit
• <50% - immobilisation for 7-10/7
24
Orthopaedi UI
• >50%
• Lacerated tendon repaired with 4-0 Vicryl figure-of-8 sutures
• Extension splinting for 6/52
• Zone III - PIPJ
• Laceration usually transverse with minimal retraction & often extends into PIPJ
• Lateral bands often spared, but may be subluxed volarly due to disruption of triangular
ligament & contraction of transverse retinacular ligament
• Elson test - >15-20 loss of active extension with wrist & MCPJ fully flexed
o
• Left untreated, boutonniere deformity may develop

1. Disruption of central slip
2. Attenuation of triangular ligament
3. Volar migration of lateral bands
• Acute boutonniere deformity
PIPJ splinting in full extension for 6/52 with active DIPJ flexion exercises
• Chronic boutonniere deformity
Achieve full passive mobility - physiotherapy or surgical release
Reconstruction
• Zone IV - proximal phalanx
• At this level only 2-3 mm of tendon excursion -> minor amounts of adhesion -> significant
amounts of loss of extension
• Partial laceration <50% should not be repaired
• Usually lateral bands spared due to volar location, however important to repair separately
if involved
• Tendon repaired with figure-of-eight 4-0 Ethibond sutures, but take care to avoid tendon
shortening
• Extension splinting for 6/52
• Zone V - MCPJ
• Human bites!
• Sagittal band injury requires individual repair with interrupted-inverted 4-0 Ethibond
sutures; otherwise -> tendon subluxation
• Early mobilisation with dynamic extension outrigger splint vs immobilisation for 3-4/52 at
o o
30 wrist extension & 45 MCPJ flexion
• Zone VI - metacarpal
• Lacerations proximal to junctura can be missed; have patient extend affected proximal
phalanx with remaining digits flexed
• Tendon defects >1 cm should not be directly opposed, since this will lead to loss of finger
flexion; consider intercalary tendon graft
• Laceration >50% repaired with a single 4-0 Ethibond modified Bunnel Weave
• Results of delayed mobilisation in wrist extension similar to dynamic extension programs
• Zone VII - wrist
• Excision of portions of retinaculum over site of repair no longer recommended
• Early mobilisation with dynamic extension outrigger splint
• Static splinting not advisable
• Zone VIII - distal forearm
• Disruption at musculotendinous junction
• Postop static immobilsation for 3-4/52
• Zone IX - proximal forearm
• Repaired with figure-of-eight Vicryl
• Immobilisation for 4/52 with wrist in extension & elbow in flexion
Tendon Repair
25
Orthopaedi UI
• Partial lacerations
• Proximal to MCPJ may or may not require repair
• At or distal to MCPJ level must be repaired
• Tendon repair techniques
• Ultimate strength of a tendon repair depends on number & size of sutures crossing
laceration site
• Resistance to gap formation depends on suture purchase
• Perhaps easiest & quickest technique is a running horizontal mattress technique
• Especially well suited for lacerations distal to MCPJ, where tendon is relatively
flat
• Allows multiple suture strands to cross repair site, & when carefully performed,
there is minimal tendon shortening
• Newport & Williams (JHS 1992 Nov)
• Kleinert modification of Bunnell technique is stronger than modified Kessler but
both are significantly stronger than horizontal matress & figure of 8
• Howard & Greenwald 1997
• MGH tendon repair technique (crossing running suture repair) signficantly more
resistant to gap formation than Bunnel or Krackow technique
• Staged extensor tendon repair
• Consists of staged tendon reconstruction using a silicone implant
• Indicated for combined extensor injuries (skin, tendon, joint capsule, & bone)
• Small skin incisions made over dorsum of finger when necessary
• Silicone rod placed along pretendinous fascia to make a premade tunnel
• Rod will help provide extension through elastic recoil of rod
• Soft tissue defects managed by STSG or by secondary intention
• Once soft tissues healed, silicone rod exchanged for a tendon graft
Postop Care
• Rehab dependent on level of extensor tendon injury

• In general
• Extensor tendon injuries proximal to MCPJ
• Keep MCPJ in extension for 1-2/52, followed by a passive extension/active
flexion splint
• PIPJ may remain free during entire postop period
• Extensor tendon injuries distal to MCPJ
• PIP & DIPJ held immobilized in extension for ~4-6/52 (as would be done for
mallet or boutoniere injury)
• Mallet finger
• 0-6/52
• Extension splint
• 6-12/52
• Off splint
• Passive DIPJ extension for 1/52
• Active DIPJ extension for 1/52
• Continue exercise until full ROM
• Night splint
• 12/52
26
Orthopaedi UI
• Unrestricted use
• Extension lag -> extension splint x 2/52
• PIPJ
• 0-6/52
• Dorsal extension splint
• 6-12/52
• Off splint
• Passive PIPJ extension for 1/52
• Active PIPJ extension for 1/52
• Continue exercise until full ROM
• Night splint
• 12/52
• Unrestricted use
• Extension lag -> extension splint x 6/52
• PP, MCPJ, MC, retinaculum
• Postop
• Volar slab with wrist 45 extension, MCP 45 flexion, PIP & DIPJ full extension
o o
• 0-4/52
• Dynamic outrigger extension splint
• Control active flexion to volar block
• Norwich regime
• Volar splint with outrigger
• Control active motion 4x/day
• Both IPJ & MCPJ in extension to resting (MCPJ in 45 flexion, IPJ in full
o
extension)
• MCPJ in extension & both IPJ in flexion to resting
Complications
• Loss of flexion can occur due to extensor tendon shortening

• Loss of flexion & extension can result from adhesions
• Extrinsic tendon tightness
• May result from crushing injuries to hand
• Test PIP flexion while MCPJ held flexed
• With extrinsic tightness, there will be more PIPJ flexion with MCPJ held extended
• With PIPJ fully flexed, MCPJ will move into extension
• Requires aggressive hand therapy, & if no improvement found, then extensor tendon
tenolysis & dorsal joint capsulotomy required
• In some cases a Littler Release may be appropriate
• A portion of extrinsic tendon excised over proximal phalanx
• Extrinsic tendon will then extend MCPJ, & intrinsic tendons will then extend PIPJ
• Intrinsic tendon tightness
• May result from crushing injuries to hand
• When MCPJ extended, flexion of PIPJ limited
• Extensor quadriga effect
• Results from shortening of 1 tendon, & resultant loss of motion of other extensor tendons
(due to interconnecting junctura)
27
Orthopaedi UI
Fingertip & Nailbed Injuries

Introduction
• Most sophisticated organ of touch

• Most common hand injury
• Inappropriate Mx -> significant disability
Anatomy
• That portion of digit distal to insertion of flexor & extensor tendons

• Volar pulp covered by highly innnervated skin
• Skin anchored to phalanx by fibrosepta
• Nail & nailbed
Classification
• By type
• Crush
• Sharp
• By level - Allen Classification
Type Level
I Distal to nailbed
II Distal to P3
III Distal to germinal matrix of nailbed
IV Proximal to nailbed
Treatment
Goals
• To provide a sensate, durable tip with adequate bony support for nail
Principles
• Preserve viable local tissue

• Choose simplest procedure consistent with
• Individual factors
• Age/sex/occupation
• Digit involved
• Nature of defects
• Size
• Shape
• Location
28
Orthopaedi UI
• Goals of Rx
• Experience of surgeon
Methods
• No bone exposed
• Surface area loss 1 cm
2
• Healing by secondary intention

• Yields satisfactory result, esp'ly in children
• Delayed healing, pyogenic granuloma, stump tenderness
• Bigger defect
• Tight tip closure avoided -> hook-nail deformity
• FTSG
• From hypothenar eminence/severed skin
• Durable cover, can use amputated segment, closure of donor site
• May not take, minimal shrinkage
• SSG
• Occasional use when other techniques not available
• Relies on graft shrinkage to reduce size of defect
• Immediate closure, rapid healing
• Hypersensitive, insensitive, breakdown & cracking, unsightly
• Nail bed - use split-thickness graft from same digit or a toe
• Bone exposed
• Primary closure with shortening & local flaps
• Exposed bone with substantial skin & pulp loss
• Best when >50% of P3 lost
• Rongeured back as long as nail bed support not compromised
• Padded coverage with sensation, 1 stage procedure
• Digital shortening, painful neuroma
• Local flaps if rongeuring bone is judged to be a bad choice
• Straight or dorsally angulated amputations
• Volar V-Y advancement flap
• Double lateral (Kutler) V-Y advancement flap
• Relies on subdermal plexus for nutrition
• Volarly angulated amputations
• Volar V-Y advancement flap
• Best for thumb, questionable use in other digits
• Near normal sensation
• Cross-finger flap
• A vascularised pedicle flap from dorsum of a finger to volar
aspect of an adjacent finger or thumb
• Skin graft for donor defect
• Problem: cold intolerance, decreased sensation, defect in normal
digit
• Thenar flap
• A vascularised pedicle flaps from thenar skin
• For index, long & ring fingers
• Preferred over cross-finger flap as no scar over dorsum of
adjacent finger
• Thenar crease flap - base perpendicular to thumb MCP flexion
crease
29
Orthopaedi UI
• Closure of defect
• H technique (Smith)
• Graft
• Suture if in thenar crease
• Can lead to joint contractures in adults as PIPJ held in flexion for
2/52
• Advantages
• Skeletal length preserved
• Pulp & contour added to tip
• Nerve endings in flap may be reinnervated
• Disadvantages
• Technically demanding
• Immobility increases joint stiffness & tendon adhesion
• Flap necrosis
• Other complex flaps
• 2nd dorsal metacarpal artery island flap
• Homodigital island flap
• Regardless of Rx options, common complaints include
• Cold intolerance
• Hyperesthesia
• Decreased sensation
Nailbed injuries
• Anatomy
• Rx principles
• Remove nail if large subungual hematoma (>50%)
• Identify & repair nailbed lacerations
• Replace nail if possible
• Graft nail deficits
• Uninjured area of remaining nail
• Toenail graft (split or full-thickness
30
Orthopaedi UI
Coverage of Hand Wounds

Factors influencing selection
• Tissues exposed
• Tissues to be reconstructed
• Function
• Sensibility
• Cosmetic
Methods of coverage
• Direct wound suture

• Primary
• Delayed
• Free skin graft
• STSG
• FTSG
• Mesh grafting
• Pedicle flaps
• Location
• Local
• Regional
• Distant
• Free
• Type
• Skin
• Fascicutaneous
• Myocutaneous
• Osteocutaneous...
Skin flaps
• Local flaps
• Random pattern flaps
• Vascular pattern lacks any bias in any particular direction
• Skin arterial supply dependent on small perforating arteries from adjacent muscle
layers
• Flap dissection superficial to fascia
• Length-breadth ratio limited to 2:1
• Examples
• Advancement flap
• Rotational flap
• Transposition
• Z-Plasty
• Cross-finger flap
• Axial pattern flaps
31
Orthopaedi UI
• Direct cutaneous A-V system present superficial to fascia supplying large skin
area
• Skin arterial supply dependent on usually single large vessel
• Flap dissection deep to fascia
• Independent length-breadth ratio
• Examples
• Iliofemoral island flap supplied by superficial circumflex iliac artery
• Fillet finger flap
• Distant flaps
• Random pattern flaps
• Cross-arm flaps
• Abdominal flaps
• Axial pattern flaps
• Deltopectoral
• Hypogastric
• Groin (iliofemoral)
Myocutaneous flaps
• Consist of skin, subcutaneous tissue, fascia, with underlying muscle

• Skin over muscle supplied in random pattern by perforating vessels
• Underlying muscle often has large axial arterial supply
• Flaps usually have no sensation
• Examples
• Latissimus dorsi flap supplied by thoracodorsal artery
• Transverse rectus abdominis supplied by superior epigastric artery
• Gracilis
Free flaps
• Based on axial pattern

• Vascular supply dependent upon single large artery & its venae comitantes
• Can be transferred to other parts of body
• Examples
• Cutaneous - lateral arm, medial arm, radial forearm, digital, dorsalis pedis, epigastric,
groin, scapular
• Muscle - latis dorsi, gracilis, pec major, rectus abdominis
• Myocutaneous - latis dorsi, gracilis
• Osseous - fibula, rib
• Osteocutaneous - iliac, intercostal
• Vascularized nerve - superficial radial nerve
• Neurovascular cutaneous
• Composite digit - great toe transfer, 2nd toe transfer
• Advantages
• 1 stage
• Closed wound
32
Orthopaedi UI
• Early mobilisation
• Improves vascularity
• Less donor scar
• Disadvantages
• Dependent on satisfactory recipient vessels
• Risk of complete flap loss
• Long operation
• Need > surgeons
• Extensive preop evaluation
• Inferior aesthetic result -> repeated defatting
Hand Amputations
Introduction
• Salvage procedure
• Primary amputation for irreversible loss of blood supply & tumours
Principles
• Function - prime importance

• Preserve functional length
• Maintain sensibility
• Cosmesis - do not ignore
• Minimise scar & contractures
• Prevent neuroma
• Shorten morbidity
Considerations
• Age & sex

• Hand dominance
• Occupation & avocations
• Patient's attitude about amputation
• Surgical
• Other fingers involved
• Delaying (use of parts)
• Future reconstruction & prosthetic fitting
• Salvage thumb
33
Orthopaedi UI
Basic concepts
• Contour articular condyles

• If tendon insertion site absent, sever tendon & allow it to retract
• Do not suture flexors to extensors
• Dissect nerves & sharp proximal transection
• Volar skin flap preferable
Finger amputations
Distal phalanx
• Fingertip amputations
• DIPJ
• Shorten & contour bone for primary closure
• No fixation of tendons indicated
Middle phalanx
• Shorten & contour bone for primary closure

• Preserve FDS insertion
Proximal phalanx
• Intrinsics control flexion

• Ray resection a consideration for index only
• Preserve long & ring to prevent gap & little finger for grip strength
• Frequently need dorsal skin flap for closure
Ray resection
• Index ray resection

• Usually a secondary procedure but may be primary in selected individuals
• Protect radial digital nerve to index
• ? transfer of 1st dorsal interosseous to long finger
• May be too strong
• May choose not to perform
• Early motion
• Cx: hyperesthesia of 1st web space
• Long & ring ray resection
• To close gap for function & cosmesis
• 2 methods
• Approximate MC heads with suturing of intermetacarpal ligaments
34
Orthopaedi UI
• Ray transposition
• Little ray resection
• Cosmetic only
• Better to preserve length for grip
• Preserve 5th MC base for ECU & FCU insertions
Thumb amputations
• Reattach whenever possible

• Do not shorten bone
• Durable & sensate distal skin important
• See details
Wrist amputations
• Preservation of carpal bones of little value

• Wrist disarticulation generally favored over more proximal revision
• Adequate prosthetic fitting now available
• Better prosthetics suspension
• Pronation & supination preserved
Hand Replantation
Definitions
• Replantation - reattachment of a body part that has been totally severed from the body without
any attachments
• Revascularization - reconstruction of blood vessels which have been damaged in order to prevent
an ischemic body part from becoming nonviable or necrotic
• Amputation defined by anatomical site
• Can be guillotine, crush or avulsion (these have poorest results & prognosis)
Care of amputated part
• Gently irrigate with Ringer's lactate

• Wrap in moist gauze
• Place in sealed bag
35
Orthopaedi UI
• Place bag in ice
Ischaemia time
Warm ischaemia time Cool ischaemia time (4ºC)
Digit 12 hrs 24 hrs
Significant amount of muscle 6 hrs 12 hrs
Indications & Contra-indications for Replantation
• Indications
1. Thumb amputation
2. Multiple digit amputations
3. Metacarpal amputation
4. Almost any body part in a child
5. Wrist or forearm amputation
6. Individual digit distal to FDS insertion; replantation at level distal to insertion of FDS often
results in satisfactory function
Shaded area = 'No mans land' - also region where replantation does badly
• Contra-indications
• Local
1. Severely crushed or mangled parts (See MESS)
2. Signs of severe vessel trauma
• Red line sign: branch tears along vessel
• Ribbon sign: elastic recoil from traction media & intima usually separated
3. Amputations at multiple levels
4. Distal amputations; amputations distal to DIPJ difficult to replant as digital artery
begins to branch & dorsal veins hard to find
5. Individual digit proximal to FDS insertion
6. Prolonged warm ischemia
• General
1. Arteriosclerotic vessels
2. Amputations in patients with other serious injuries or diseases
3. Mentally unstable patients
4. Polytrauma
36
Orthopaedi UI
Surgical Technique
• Bilateral midlateral incisions

• Isolate vessels & nerves
• Debride
• Sequence BEFANVS
1. Shorten & fix bone
2. Repair extensor tendons
3. Repair flexor tendons (in case of hand replantation flexor & extensor tendons repaired
after arterial & venous flow established)
4. Anastomose arteries (hand or forearm replantations, consider use of arterial shunt before
vascular anastomosis; give systemic heparin)
5. Repair nerves
6. Anastomose veins: 2 for each artery, or 3 veins minimum (veins are never repaired
before arteries, especially in hand or forearm replants since reperfusion toxins will enter
into body)
7. Skin coverage
• Priority for digit replantation - thumb, middle, ring, small, index
Postop Care
• Warm room
• Adequate hydration
• Pharmacological agents in vascular surgery
• Aspirin
• Dipyridamole
• Low-molecular-weight dextran 30-40 ml/hr
• Heparin
• Nicotine, caffeine, chocolate not allowed
• Monitoring
• Close observation of color
• Capillary refill
• Doppler pulse
• Pulse oxymetry: saturation <94% -> potential vascular compromise
• Temperature probe: drop of >2 C in 1 hr or <30 C -> decreased digital perfusion
o o
37
Orthopaedi UI
Complications
• Early
1. Arterial insufficiency
• Thrombosis secondary to vasospasm most common cause
• Rx
• Inspect & loosen dressing
• Change hand position
• Stellate ganglion block (spasm)
• Heparin bolus (3000 to 5000 units)
• If no improvement in 4-6 hrs, return to theatre for re-do anastomosis ->
50-60% successful
2. Venous insufficiency
• Causes part engorgement, diminished inflow, part loss
• Rx
• Elevation
• Can use medical leeches, but must give antibiotics to cover for
Aeromonas hydrophilia
• Arteriovenous anastomosis
3. Infections
• More common in upper extremity replantations which develops myonecrosis
• Late
0. Functional difficulties
•Related to "one wound, one scar" concept with resultant loss of differential
gliding between tissues
• Motion of digits significantly affected by overall injury sustained
• Motion of PIPJ accounts for 85% of arc of finger motion
1. Cold intolerance
• Thought to improve after 2 yrs but recent long-term study (1995 ASSH Meeting
abstract) has shown no improvement
• Smoking causes a more pronounced effect on vasoconstriction in replanted digit cf normal digit
o Nicotine slows inflammatory phase of wound healing
• Decreases blood flow
• Elevates levels of vasopressin & NA -> inhibit epithelialisation
• Stimulates sympathetic ganglia & adrenal medulla
• Inhibits maturation & proliferation of erythrocyte precursors
Results
• Successful salvage depends primarily on

1. Mechanism of injury
2. Ischemia time
• Success rate
o Adults 80% success
38
Orthopaedi UI
o Children 70% success - poorer results in children reflects a more aggressive approach
o Best results for thumb, hand, & distal forearm
• Nerve recovery
o Dependent on type & level of injury, but overall results comparable to isolated nerve
injuries
o 2 point discrimination: 10 mm or less in 50% adults, 5 mm or less in most children
o Fine tactile discrimination rarely ever returns
• ROM
o Difficult to achieve
o Typically 50% of total active motion
• Pain not a problem
• Cold intolerance improves after 2-3 yrs
• Functional outcome (Ch’en Criteria)
I Able to resume original work

ROM 60% of normal
Complete or nearly complete sensation
Motor MRC 4/5
II Able to resume some suitable work
ROM 40-60% of normal
Nearly complete sensibility
Motor MRC ¾
III Able to perform ADL
ROM 30-40% of normal
Partial recovery of sensibility
Motor MRC 3
IV Almost no usable function
Ring Avulsion Injuries
• Urbaniak classification
Circulation adequate
Class 1 Requires standard bone & soft tissue Rx
Circulation inadequate
Class 2 Requires vessel repair
Class 3 Complete degloving injury or complete amputation
• Concomitant proximal phalangeal # or PIPJ injury, consider amputation

• Complete amputations proximal to FDS tendon insertion (male patients) should be treated with
amputation although may consider proximal replant in children or females
• Single digit replantation proximal to FDS insertion produces a digit with significant functional
impairment (avg PIPJ ROM only 35º although cold intolerance & sensation comparable to more
distally amputated group)
39
Orthopaedi UI
Hand Infections
Overview
• Hand infections less common than foot infections due to relatively good blood supply
• Organisms
• Most infections are Staph aureus, but many infections due to multiple organisms & 30-
40% grow anaerobic species
• Other organisms: streptococci, enterobacteria, pseudomonas, enterococci, bacteroides
• Rarer organisms: Mycobacteria, gonococci, Pasteurella multocida (in cat or dog bites),
Eikenella corrodens (in human bites), Aeromonas hydrophilia, Haem influenzae (in
children from 2/12 to 3 yrs)
• Always take a good history: diabetes? fight bite?
• Always examine arm for spreading lymphangitis & palpate LN
• Epitrochlear nodes drain ring & little finger
• Axillary nodes drain radial digits
• Cellulitis resolves with antibiotics & elevation; Flucloxacillin & benzylpenicillin +/- Augmentin if bite
involved
• Pus under pressure requires surgical drainage -> NO ALTERNATIVE
Incisions for Hand Infections
Paronychia/eponychia
• Infection of nail fold

• Most common infections in hand
• Usually with Staph aureus
• Rx
• I&D, partial/total nail plate removal, antibiotics, dressing changes
• If 1 side (paronychia) drain by incision with blade angled away from nailbed to avoid
damaging it
40
Orthopaedi UI
• If extending around both sides of nail & migrating under nail, excise proximal 1/3 of nail as shown
Felon
• Subcutaneous abscess of pulp of finger
• Pathophysiology
• Distal finger pulp divided into tiny compartments by strong fibrous septa traversing from
skin to bone
• Also a fibrous curtain present at distal finger crease
• Because of these, any swelling causes immediate pain
• Abscess may extend into periosteum of P3, around nailbed or proximally, through fibrous
curtain, or through skin
• Those beginning deep can cause OM
• Rx
• Antibiotics, & incision & drainage
• Methods of drainage
41
Orthopaedi UI
• If superficial & pointing volarward into whorl of fingerprint -> a vertical midline
incision distal to skin crease exactly in midline
• If deep & partitioned by septa
• Make midlateral incisions as shown above
• Incision should be dorsal to tactile surface of pulp & no more than 3 mm
from distal free edge of nail
• If not, digital nerve can be painfully damaged
• DON’T USE FISHMOUTH INCISION -> SLOW TO HEAL & PAINFUL
SCARRING
Deep potential space infetions

Web space infection (collar button abscess)
• Pathophysiology
• Localised in 1 of 3 fat-filled spaces just proximal to superficial transverse metacarpal
ligament at level of MCPJ
• Often begins under palmar calluses in labourers
• Often points dorsally where skin is more yielding
• However, palmar part most dangerous as it may spread into deep palmar space
• Rx
• IV antibiotics
• I&D - 2 longitudinal incisions, 1 dorsal, 1 ventral, but web should not be incised
Deep fascial space infections
• Anatomy
42
Orthopaedi UI
• Deep palmar space lies between fascia covering MC & their muscles, & fascia dorsal to
flexor tendons
• Ulnar border: fascia of hypothenar muscles
• Radial border: fascia of adductor & other thenar muscles
• Divided into middle palmar space & thenar space by fascial plane passing between 3rd
MC shaft & fascia dorsal to flexor tendons of index finger
• Middle palmar space infections
• Rare
• Cause
• Severe systemic reaction
• Generalised swelling of hand & fingers resembling rubber glove
• Loss of active motion of middle & ring fingers
• Drain through a curved incision beginning at distal palmar crease, extending ulnarward to
just inside hypothenar eminence
• Thenar space infections
• Cause
• Systemic upset
• Thumb web swelling
• Index finger held flexed
• Loss of index finger & thumb active motion
• Drain through a curved incision in thumb web along proximal side of thenar crease
• Avoid recurrent branch of median nerve
Infections of radial and ulnar bursae

43
Orthopaedi UI
• Spread from little finger or thumb flexor tendon sheaths

• To drain radial bursa
• Make a lateral incision over proximal phalanx of thumb
• Enter sheath
• Introduce a probe & push it towards wrist
• Make a 2nd incision at its end
• Irrigate with a cannula
• To drain ulnar bursa
• Open it on ulnar side of little finger, & again proximally at wrist
• Radial & ulnar bursae can communicate causing a 'horseshoe abscess'
Suppurative Flexor Tenosynovitis
• Infection in flexor tendon sheath, can cause tendon adhesions or necrosis & rupture
• Anatomy
• Thumb infections can drain into thenar space or radial bursa
• Index finger & thumb infections can spread to thenar space
• Middle, ring & little finger infections can spread to midpalmar space
• Little finger infections can spread to midpalmar space or ulnar bursa
• Causes
• Spread from adjacent pulp space infection, or from puncture wounds over flexor creases
44
Orthopaedi UI
• Organism
• Commonest: Staph aureus
• 50% mixed
• Clinical features
• Kanavel’s 4 cardinal signs
1. Finger held in flexed position
2. Sausage digit (symmetrical fusiform swelling)
3. Severe tenderness along tendon sheath
4. Pain on passive extension of finger
• Mx
• IV antibiotics if <48 hrs
• Surgical drainage if no dramatic improvement after 24 hrs or presentation >48 hrs
Open, through Brunner incisions
Incision at distal palmar crease & either over distal finger crease or midlateral
incision at level of P2
Open tendon sheath & pass a cannula into sheath & flush through till clear, after
C+S swab taken
Continuous irrigation with indwelling catheter carries risk of compartment
syndrome
Osteomyelitis
• General principles same as in larger bones

• However, if amputation necessary, it should be done at joint proximal to infected bone or infection
will not clear
• Infection of finger pulp may erode P3, but may improve when overlying abscess drained
45
Orthopaedi UI
Inflammatory Arthritis in Hand & Wrist

RHEUMATOID ARTHRITIS
Rheumatoid OA
MCP & PIPJs DIPJs & basilar joint of thumb
Clinical Bouchard's nodes Heberden's nodes
Periarticular osteoporosis Subchondral sclerosis & cysts
Periarticular swelling Swelling less pronounced
Joint space narrowing Joint space narrowing
Marginal erosions Marginal osteophytes
Joint deformity or malalignment Less common
Bony ankylosis Less common
X-rays Subchondral erosions
Clinical Assesment
• Note
• Deformities depend on direction of pull on tendons
• Get zig-zag deformity in sagittal &/or coronal planes
• HISTORY
• Pain - due to synovitis or secondary OA
• Swelling
• Deformity
• Loss of function
• Shortened ADL assessment
1. Using toothbrush, hairbrush, knife, fork
2. Dressing - bra, pulling up trousers/stockings
3. Operate remote control
4. Hobbies
46
Orthopaedi UI
• Cosmesis
• May be extremely NB to patient
• A poor functional result of surgery may not be a poor result for patient if cosmesis
improved
• EXAMINATION
• Expose above elbow
• Quick elbow, shoulder & neck assessment
• Look (most NB)
• Extensor surface
• Flexor surface
Skin
Swelling/wasting
Deformity
• Zig-zag deformity - coronal/sagittal
• MCPJs - dropped fingers, ulnar drift
• Finger deformities
Nodules
• Subcutaneous masses with collagenous matrix over bony
prominences
• Most common over olecranon & extensor surface of forearm
• Hand
• Dorsum of finger: unsightly & tender
• Volar aspect of finger: digital nerve impingement or
altered finger motion
• May erode through skin
Features of SLE, psoriasis, scleroderma (see below)
Note DRUJ when wrist supinated
• Feel
• Tender areas
• Passive correctability of deformed joints
Correctable = soft tissue procedures indicated
Must be tested with ligaments tight (ie. MCPJs in flexion)
• Ulnar collateral ligament of thumb
• Sensation
• Move
• Ask patient to extend & flex all joints fully, & oppose thumb
Note extensor lag -> tendon rupture or subluxation
• Individual joint movements
• Special
• Intrinsic tightness
Bunnell's test in both deformed & corrected positions
• NV
• Functional assessment
• General medical assessment
• Cervical spine
• TMJ
• Pulmonary
• General
Investigations
47
Orthopaedi UI
• FBC
• WBC (decr. in Felty's syndrome)
• Platelet count (decr. with NSAIDs)
• Hb (anaemia of chronic disorders)
• LFT (methotrexate)
• ADL assesment by hand therapist
• Jebson test - writing, turning over cards, picking up small common objects, simulated
feeding, stacking chequers, picking up large light & heavy objects
• Moberg's pick-up test - speed at picking up small common objects (coins, paper-clips)
Planning Treatment
• Need to consider
• How disease affects patient as a whole
• Pain
• Joint deformity
• Level of disability
• Aims of Rx
1. Pain relief
2. Improve function
3. Prevent further damage
4. Cosmesis
• Indications for surgery
0. Disabling pain
1. No level of deformity an absolute indication
• Principles
o Operate on proximal joints then distal
• Proximal joint stability provides stable foundation for distal joint movement
• Proximal joint instability may aggravate distal joint instability
o Tendons before joints
• No OA - soft tissue reconstruction
• OA - salvage
o Alternate fusions with motion-sparing procedures
• Double row fusions compromise functions at both levels, esp'ly MCPJ
• Arthroplasty at all levels -> poor strength
o Staged procedures
o Rehab of one procedure should not interfere with the other
• Deciding on type of surgery
o Souter staging
Stage Clinical Treatment

1 Acute synovitis Medical Mx & splinting
2 Chronic synovitis Synovectomy
3 Specific deformation Reconstructive
4 Severe crippling (deformity not correctible or OA) Salvage (arthrodesis or arthroplasty)
48
Orthopaedi UI
TENOSYNOVITIS
• Flexor
• Most commonly affected leading to ruptures are radial FDPs & FPL
• Usually FDP to index finger
• Most commonly ruptured flexor tendon: FPL
• Extensor
• Most common: dorsal wrist extensors at ulnar head & Lister tubercle
• Rupture often sequential from ulnar to radial
• 2 main causes of tendon rupture
• Chronic attrition
• Synovial invasion
• Clinical
• Symptoms
• Limited motion (passive ROM > active)
• Soft tissue swelling - tender or painless
• Tendon ruptures
• Finger triggering
• Compressive neuropathies, eg. CTS
• Signs
• Puffy thick feeling palm
• Pinch test - thickened tenosynovium bulges out through defects in fibrous sheath
creating bulges of tissue which can be 'pinched'
• Test tendon function individually
• Test function of FDP index & FPL by asking patient to pinch
• Normal = tip-to-tip
• Abnormal = pulp-to-pulp (also occurs with AIN palsy)
• Mx
• Acute synovitis
• Splinting & drugs (NSAIDs, steroids)
• Chronic synovitis
• If conservative Rx has failed after 4/12 should consider surgery
• Synovectomy
• 3 sites
1. Carpal tunnel
2. Palm at level of mouth of A1 pulley
3. Just distal to A2 pulley
• Tendon rupture
• Rx options
1. Primary tendon repair - rarely done as poor tissue at tendon ends
2. Primary tendon graft - fraught with difficulties & poor results due to
adhesions; only consider for young patient
3. Tendon transfer - limited availability on flexor side (palmaris longus,
brachioradialis)
4. Side-to-side suture - good in older patients; wrist level
5. Arthrodesis - DIPJ mainly
• Vaughn-Jackson Syndrome
Rupture of EDC of ring & little fingers due to attrition rupture from
prominent ulna (caput ulna) & DRUJ synovitis
DD: subluxation, PIN palsy, locked trigger finger
'Tuck sign' = synovitis tucks under skin with movement
49
Orthopaedi UI
Rx
Darrach for pre-rupture
Tendon transfer (EIP to EDM) for rupture
• Mannerfelt Syndrome
FPL rupture due to carpal irregularities or volar synovitis
Rx: IPJ arthrodesis
WRIST JOINTS
• Problems
• Radial deviations
• Volar displacement of carpus
• CTS
• RC joint erosion
• Caput ulna & DRUJ arthritis
• Pathophysiology
• Pannus formation in strong volar radiocarpal ligaments
• Destabilisation of scaphoid
• Volar flexion of scaphoid, carpal collapse, distal ulna subluxation alters carpal mechanics
• Supination & ulnar translation of carpus -> radial deviation of wrist & MCs
• Rx
• Synovectomy
• Difficult to complete
• Uncertain long term results
• Tendon transfer
• Relocation of subluxated ECU
• Transfer of ECRL to ECU insertion
• Arthrodesis
• Partial wrist fusion - midcarpal joint spared
• Total wrist fusion - predictable standard for advanced RA
• Reliably reduces pain
• Provides stable foundation for finger motion
• Arthroplasty
• Silicone implant
• For low demand patients
• High failure rates due to synovitis & osteolysis
• Total arthroplasty
• Metal-plastic prosthesis
• Loosening & progressive imbalance
METACARPOPHALANGEAL JOINTS
• Pathophysiology
• Ulnar drift & volar subluxation
• Anatomical
• Direction of pull of extensor & flexor tendons
• Shape of head of metacarpal (relative ulnar deficiency)
• Ulna collateral stronger than radial collateral
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Orthopaedi UI
• Presence of extensor indicis & digiti minimi on ulnar side of communis

tendon
• Physiological (Functional)
• Gravity
• Forces during pinch are in an ulnar & volar direction
• Forces sustained when rising from a chair etc
• Pathological
• Synovitis attrition of radial collaterals
• Extensor tendon subluxation
• Loss of volar plate & collateral ligament stabilisation of flexor sheath &
A2 pulley -> ulnar displacement of flexor tendon pull
• Radial deviation of wrist
• Intrinsic tendon shortening
• Articular cartilage erosions
• All these cause shortening & scarring of ulnar collateral ligament & interosseous muscle
on ulnar side
• At this stage passive correction not possible
• Clinical
• Main problem: inability to extend MCPJs enough to hold large objects (opp. to IPJ
disease)
• Deformity always progressive
• Pain
• Examine
• Passively correct ulnar drift (soft tissue procedures worthwhile)
• Ability to reduce volar subluxation
• Intrinsic tightness (Bunnell test)
• Integrity of flexor & extensor tendons (treat 1st)
• Carpal tunnel syndrome
• Rx
• Based on flexibility & OA changes of joint
• Splintage & joint protection therapy if passively correctible
• Surgery usually required
• Synovectomy & soft tissue balancing
• For patients with deformity but minimal articular destruction but limited
indications
• Vital to ascertain which structures are tight
• Methods
1. Flatt - radial incision; mobilise radial interosseous; reef hood
2. Central split in hood; double-breasting repair (preferred to Flatt)
3. Combined ulnar & radial procedures
• Ulnar - Divide ulnar side of extensor mechanism; release
ulnar collat. lig.
• Radial procedures
• Reef extensor mech.
• Proximally based ulnar strip of extensor mech
passed through radial capsule to base of
proximal phalanx
• Reinforce radial collat lig. by reattaching it thro
drill holes on metacarpal
• Crossed intrinsic transfer - divide ulnar
interosseous & attach it to radial side of finger
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Orthopaedi UI
next to it (lateral band or radial collat. lig.);

advance 1st dorsal interosseous distally
• MCPJ arthroplasty
1. Excision arthroplasty -> unstable joint, shortening of ray
2. Excision arthroplasy & soft tissue interposition -> poor ROM
• MCPJ replacement (Swanson's)
Good results - MCPJ most suitable for replacement
Simply a spacer with some stabilising features
Unconstrained prostheses don't work because of damage to soft tissues
by synovitis making joint unstable & normal kinetics of joint have been
long lost (unlike knee)
Technique
Ulnar soft tissue release of ulnar collat. lig., ulnar intrinsic & volar
plate insertion; little finger - release ADM, preserve FDM
MC head resection - slightly radial direction; because of dorsal >
volar erosion; don't resect too much volar cortex
Rectangular holes in MC & PP
Insert biggest possible prosthesis
Reconstruct radial collat. lig. (index finger - reef; others - crossed
intrinsic tranfer)
Postop
Volar slab, well padded
48 hrs - outrigger splint applying radial-deviating force
Continue for 3/12 (with static night splint)
Cx
Recurrent ulnar drift
Implant #
Infection
52
Orthopaedi UI
Type Description Cause Diagnosis Treatment

Cannot extend DIPJ
with PIPJ passively
DIPJ mallet flexed Fuse DIPJ
Extension block or double
O splint
Can extend DIPJ FDS tenodesis
PIPJ volar plate/ FDS with PIPJ passively (hemitenodesis or sling) /
1 PIPJ flexible insufficient flexed volar plate advancement
Intrinsic release
PIPJ flexion limited with Can flex PIPJ with FDS tenodesis
MCPJ extended = Tight intrinsics (~volar MCPJ flexed (hemitenodesis or sling) /
2 'locked swan-neck' plate weak) (Bunnell Test) volar plate advancement
MUA
Dorsal soft tissue release
Zancolli lateral band
Stiffness due to skin, X-ray: no transfer
PIPJ stiff, joint collat ligs, capsule, & articular/bony Landsmeers retinacular
3 preserved extensor tethering changes ligament reconstruction
X-ray: articular/bony
4 PIPJ stiff, joint changes changes Arthrodesis or arthroplasty
Silicone synovitis (very rare)
PROXIMAL INTERPHALANGEAL JOINTS
• Swan-neck deformity
• PIPJ hyperextension & DIPJ flexion
• May originate from pathology at any joint but level of most severe deformity usually to site
of origin
• Causes
1. Long extensor overactivity
a. MCPJ volar subluxation or contracture
b. Mallet DIPJ
c. Extrinsic spasticity
2. Intrinsic overactivity
a. Intrinsic contracture
b. Intrinsic tightness secondary to MCPJ disease
3. Failure of PIPJ stabilisers
a. Volar plate insufficiency or laxity
b. FDS insufficiency
c. Generalised joint laxity
• As PIPJ hyperextends, transverse retinacular ligaments tether conjoined lateral bands,
restricting their excursion & effect on DIPJ
• Nalebuff classification (based on flexibility & OA changes of joint)
•
• Boutonniere deformity
• PIPJ flexion, DIPJ & MCPJ hyperextension
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Orthopaedi UI
• Synovitis of PIPJ -> rupture of central slip of extensor tendon

• Lateral bands subluxate volarly due to incompetence of triangular ligament, & being
converted from extensors to flexors
• PIPJ flexion results, & ultimately becomes fixed
• Oblique retinacular ligaments shortened -> DIPJ hyperextension
• Non-surgical Rx of little benefit & can reduce function
Deformity Treatment
o
Mild (10-15 ) Extensor tenotomy over centre of middle phalanx
Numerous soft tissue procedures (extensor tenotomy + repair/shortening of
central slip + repair of lateral bands) with variable results, thus low tolerance for
o
Moderate ((30-40 ) arthrodesis
o o
Arthrodesis - position ranging from 20 index to 45 little finger
Severe (fixed) Arthroplasty
• Results
• DIPJ usually do well with fusion
• PIPJ replacement least successful; best results with middle & ring fingers provided MCPJ
is normal
• MCPJ most suitable for replacement
• Always combine fusion & arthroplasty in a singer finger
RHEUMATOID THUMB
• Modified Nalebuff Classification
Type Deformity CMCJ MCPJ IPJ Initiating feature Treatment

1 Boutonniere Abd. Flex. Hyperext. MCPJ synovitis Arthroplasty MCPJ or
IPJ, +/- extensor
realignment
2 Boutonniere & Add. Flex. Hyperext. MCPJ & CMCJ Arthroplasty MCPJ or
Swan-neck synovitis IPJ, +/- extensor
realignment
3 Swan-neck Add. Hyperext. Flex. CMCJ synovitis, CMCJ arthroplasty
MCPJ volar plate
attenuation
4 Gamekeeper's Add. Abd. Ulnocarpal lig. (beak) Lig. reconstruction /
destruction MCPJ fusion
5 Neutral Hyperext. Flex. Stretching of MCPJ MCPJ fusion
volar plate
6 Arthritis mutilans Short Unstable Unstable Bone destruction Fusion
54
Orthopaedi UI
Nalebuff Type 1 - Boutonniere
Carpometacarpal arthritis of thumb - RHIZARTHROSIS

ANATOMY
• Key joint of thumb

• Saddle-shaped joint
• Biconcavo-convex shape
• Joint compression force = 12 kg (120 kg for strong grip)
• 3 main ligamentous stabilisers
• Volar or Beak ligament
• Synonyms = volar oblique lig, anterior oblique lig (AOL), volar CMC lig, deep
ulnar lig
• Evolutionary remnant of bony palmar beak
• Most NB ligament - primary static stabiliser
• Prevents dorsal translation of MC in key pinch
• Allows rotational motion
• Important in Bennett's #
• Dorsal ligament
• Thin & reinforced by APL
• Lateral ligament
• Broad band running from lateral surface of trapezium to 1st MC base
PATHOPHYSIOLOGY
• Described by Pelligrini (1991) following examination of cadaveric & surgical specimens

• Attritional changes in beak ligament -> destabilisation of 1st CMCJ -> degenerative changes
• These changes initially occur in palmar contact areas of joint
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Orthopaedi UI
CLINICAL
• History
• F:M = 10:1
• Enquire about history of injury
• Pain - aggravated by forceful pinch grip eg. turning door key, holding tea cup or sewing
• Examination
• Adduction-flexion deformity of thumb reducing thumb index web angle
• 'Shoulder sign' = radial prominence at base of thumb, from dorsal subluxation of MC on
trapezium
• Tests
• Crank Test = axial loading + passive flexion & extension of 1st MC
• Grind Test = axial loading + rotation of 1st MC on trapezium
• Torque Test = distract MC & rotate - differentiates CMCJ OA from de Quervain's
disease
• Look for trigger fingers & CTS (43% association)
RADIOGRAPHS
• AP, oblique & lateral views usually adequate

• Robert pronated view = fully pronate forearm & internally rotate shoulder
• Dynamic stress views
• Indicated when instability suspected & standard X-rays fail to show anything
• = AP views of both 1st CMCJs whilst pressing radial aspects of thumb tips together
TREATMENT
• Always non-operative initially

• Splinting
• Strengthening thenar muscles
• Steroid injections
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Orthopaedi UI
• Surgery
• When non-operative Rx fails
• Options
1. Soft tissue reconstruction alone
• For instability with no articular changes
• FCR to reconstruct beak lig
2. Osteotomy
• Abduction-extension metacarpal osteotomy to off-load palmar surface of
joint
• For high demand young adults with early disease
3. Arthrodesis
• Indications
• Single facet arthritis
• Undue laxity in an arthritic joint
• For young high demand patients
• Methods
• Bone
• K-wires
• Screws
• Plate
• TBW
• Advantages
• Good pain relief
• Stability
• Length preservation
• Disadvantages
• 20% failure rate
• Decreased ROM - unable to put hand flat on table
• STT joint not treated
4. Excision arthroplasty (trapeziectomy) alone
• Gervis 1949
• Causes weakness, instability, proximal migration of MC
5. Excision arthroplasty & soft tissue reconstruction
• = trapeziectomy & Ligament Reconstruction & Soft Tissue Interposition
(LRSTI)
• Theoretically deals with articular degeneration + instability + length
• However Davis et al.
• Only prospective randomised trial comparing trapiezectomy
alone to trapiezectomy + LRSTI
• Did not show any difference, except for pinch strength
• Technique (Nottingham)
• Incision: inverted 'Y', centred over bony prominent base of 1st
MC (over ASB)
• Dissect down to joint avoiding radial artery (at proximal end of
wound) & terminal branches of radial nerve (large)
• Trapeziectomy
• Divide trapezium into halves or quarters with osteotome
or saw, & remove it piecemeal
• Avoid cutting FCR
• LRSTI
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Orthopaedi UI
• Make hole in base of 1st MC perpendicular to plane of

thumbnail, from radial cortex to base
• Harvest half of FCR tendon through a series of oblique
incisions (Split tendon longitudinally to insertion on MC2)
• Detach a 10-12 cm strip
• To suspend MC base
• Pass free end of FCR through hole in base of
1st MC & out radial hole
• Suture it to soft tissues on MC & then to itself
• Make spacer
• Put longidudinal weaving suture in FCR remnant
& Anchovy tendon on itself
• Insert it into trapezium fossa
• Closure
• Can put K-wire across trapezium fossa if not doing
LRSTI
• Place in volar slab, leaving thumb IPJ free
• Post-op: mobilise at 3-6/52 (Davis: remove k-wire at 3/52, mobilise at
6/52)
• Cx: damage to superficial branch of radial nerve, radial artery, palmar
cutaneous branch of median nerve
6. Interpositional arthroplasty
• Silicone Swanson prosthesis ill advised
• Problems
• Implant subluxation & dislocation
• Rapid wear
• Silicone synovitis
7. Total joint arthroplasty
• Constrained ball & socket design - wear rates of 34% at 5 yrs
• Less constrained designs in development
58
Orthopaedi UI
Dupuytren's Contracture
BARON GUILLAUME DUPUYTREN (1777-1835)
• Dupuytren was born in central France. He was kidnapped as a boy by a rich woman from
Toulouse on account of his good looks. He was taken to Paris and educated, but endured great
poverty throughout his studies. Dupuytren became Surgeon in chief at the Hotel Dieu in Paris and
worked tremendously hard and became very rich. He was described as an unpleasant person to
met, yet his work was delightful to read. He was characterised as "First among surgeons, Last
among men". He was an accurate clinical observer with a great interest in pathology. Dupuytren's
name is most associated with the contracture of palmar fascia and a particular ankle fracture that
he described. He performed his first palmar fasciotomy on a coachman at the Hotel Dieu in 1831.
He wrote on many subjects, including congenital dislocation of the hip, the nature of callus
formation, subungal exostosis, the Trendelenburg sign, tenotomy in torticollis and he
differentiated osteosarcoma from "spina ventosa". He insisted that on his death that his post-
mortem be performed in front of his own medical staff and published in the local weekly journal.
DEFINITION
• A proliferative fibroplasia of palmar & digital fasciae -> formation of nodules, cords, & flexion
contractures of fingers
• 'Band' = healthy fascia
• 'Cord' = diseased fascia
AETIOLOGY
• Unknown
• Oxygen free radicals stimulate myofibroblast proliferation -> increases in type III collagen &
platelet derived growth factor B
• 2 theories
1. Intrinsic Theory = metaplasia of existing fascia
2. Extrinsic Theory = arises in fibrofatty subdermal tissue & attaches to underlying fascia
PATHOANATOMY
• Superficial palmar fascia

• Consists of 3 parts
• Medial part covering hypothenar muscles
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Orthopaedi UI
• Mid-palmar fascia
• Lateral part covering thenar muscles
• 3 components involved
1. Transverse fibres of palmar aponeurosis
• Superficial transverse ligament not involved in disease process; it
overlies superficial palmar arterial arch
• Sagittal fibres run from mid-palmar fascia to deep palmar fascia & not
involved in disease process
2. Pretendinous band
• Cord causes MCPJ contractures
3. Natatory ligament
• Causes web space contractures
• In little finger it envelopes ADM & NVB on ulnar side
• In index finger, it becomes distal commisural ligament & causes
contracture between index finger & thumb
• Digital fascia
• 4 components of normal digital fascia involved

1. Lateral sheet of Gosset
2. Spiral band
3. Grayson's ligament
• Contributes to spiral cord, which also displaces NVB in finger
• Cleland's ligament not involved in Dupuytren's
4. Retrovascular tissue
• Arises from periosteum of P1 & attaches to side of P3
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Orthopaedi UI
• MCPJ contractures
• By pretendinous cord
• PIPJ contractures
• By central, spiral & lateral cords

• As PIPJ contracture increases, spiral cord pushes NVB towards skin & midline of finger
• DIPJ contractures
• By retrovascular cord
INCIDENCE
• 25% of males >65 yrs

• M:F = 10:1
• Associated with
1. Anglo-Saxons - highest incidence in Caucasian males of Northern European &
Scandinavian ancestry
2. Family history - autosomal dominant with variable penetrance; 68% prevelance in first-
degree relatives
3. Epileptics (42%)
4. Alcohol-induced liver disease
5. Diabetes mellitus
6. COAD
7. Hypertension
8. IHD
• Similar fibromatosis lesions found with Dupuytren's
1. Garrod's knuckle pads
2. Ledderhose's disease (plantar fibromatosis) - 5%
3. Peyronie's disease (penis) - 3%
• Dupuytren's diathesis
o = more prone to recurrence & aggressive disease
o Features
1. Young
2. Male
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Orthopaedi UI
3. Family history
4. Bilateral
5. Fibromatosis elsewhere
6. Garrod's knuckle pads
CLINICAL
• SYMPTOMS
• Fingers get in the way with
• Washing face
• Combing hair
• Putting hand in pocket
• Putting hand in glove
• Racquet sports & golf
• HISTORY
• Dominance
• Family history
• Rate of progression
• Associated conditions
• Diabetes
• Epilepsy
• Alcohol
• Foot involvement
• Smoking
• Trauma
• EXAMINATION
• Ring & small fingers
• Nodules & cords
• Palpable nodule within palmar fascia = pathognomonic
• Knuckle pad (Garrod's)
• Well-circumscribed firm dermal papules, nodules, or plaques ~0.5-3.0 cm in size
• Located on extensor aspect of PIP or MCP joints
• Secondary Boutonniere
• Previous surgical scars
• Sensation
• Table top test of Hueston
• Place hand & fingers prone on a table
62
Orthopaedi UI
• +ve = hand won't go flat

• -ve = surgery not indicated
• Measure
• MCPJ angle
• PIPJ angle
• Risk of RSD
STAGING - Woodruff, 1998

Stage Description Management
1 Early palmar disease with no contracture Leave alone
2 One finger involved, with only MCPJ contracture Surgery
3 One finger - MCPJ + PIPJ Surgery not easy
4 Stage 3 + >1 finger involved Surgery prolonged & only partly successful
5 Finger-in-palm deformity Consider amputation
INDICATIONS FOR SURGERY
• No absolute indications
• Surgery indicated when patient inconvenienced or incapacitated by contracture
• Table top test of Hueston = patient unable to place hand flat on table due to contractures
• Counsel patient
1. Excision of palmar nodules can leave just as painful a scar
2. Condition is multifocal; removing one lesion does not prevent others occurring
3. Recurrence may occur after surgery
• More common in digits than palm
• Little finger in women
• Dupuytren's diathesis - young, male, family history, bilateral, fibromatosis
elsewhere
4. MCPJ contractures always correctable - usually 30o contracture requires surgery
5. PIPJ contractures not always correctable - usually operate on early contracture
6. Neurovascular injury
7. Stiffness
8. CRPS
9. Postop regimen
10. Skin problems & care
AIMS OF SURGERY
• Excise diseased fascia

• Release digital contractures
• Retain full flexion of digits
• Preserve neurovascular structures
63
Orthopaedi UI
SURGICAL TECHNIQUE
• Anaesthetic
• Brachial plexus block is ideal
• Incisions
Incision Advantages Disadvantages

Transverse midpalm For pretendinous band Requires frequent dressings &
Can be left open (McCash technique) or cooperation post-op
full thickness graft (Hueston)
Bruner's zig-zag Good exposure Can be difficult to raise flaps if skin
is thin
Incr. risk of NVB damage
Can cause troublesome scarring at
base of finger
Longitudinal incision & Good exposure Can be difficult to match incisions
Z-plasties Less chance of damaging NVB in 2 finger disease
• Procedures
Procedure Advantages Disadvantages

Fasciotomy For elderly patient with MCPJ contracture
mainly
For severe contracture with macerated
skin as 1st stage before fasciectomy
Percutaneous fasciotomy (Luck) has high
risk of NVB injury
Partial Selective Removes diseases tissue only - most
Fasciectomy (Skoog) commonly performed method
Total Fasciectomy Removes all palmar fascia Impossible to remove all palmar
(McIndoe) fascia
Does not always prevent
recurrence, incr. swelling & joint
stiffness
Dermofasciectomy For Dupuytren's diathesis & recurrence Requires FTSG
(Hueston)
External Fixator Gentle correction for 2/52, then surgical
(Messina) release; under distraction disease seems
to regress!
Amputation For finger-in-palm deformity with Neuromas, biomechanical
macerated skin
• Note most common danger areas for damaging NVB
64
Orthopaedi UI
• PIP Joint Release

• Gentle manipulation preferred, followed by postop extension splinting
• Never perform volar plate capsulectomy, since it can cause stiffness
• Preferred method
• Release Cleland's ligaments
• Release fibrous flexor sheath
• Release check-rein ligaments of volar plate
• Release lateral bands of extensor mechanism (to allow extensor tendons to shift
dorsally)
• Can use percut. transarticular K-wire for 7-10/7
• For severe flexion contracture consider arthrodesis with digital shortening
POST-OPERATIVE CARE
• Splint hand with wrist extended & fingers in comfortably extended position
• Check wounds at 48 hrs & apply thermoplastic splint
• Regular dressings for McCash open palm
• Hand therapy
• Active program
• Scar care (massage, silicone pressure pad, compression wrap)
• Determines 50% of final result
• Continue for 3/12
• Night splint for 6/12
65
Orthopaedi UI
COMPLICATIONS
• Digital nerve division

• Ischaemic digit - from digital artery spasm or kinking or division
• Haematoma
• Skin loss/necrosis
• Infection (treated with early debridement) (use of K wires is thought to promote infection)
• Scar contracture
• Joint stiffness
• CRPS - look for swelling, pain, stiffness, & discoloration; causes: neuroma formation - digital
nerve scarring at incision site; excessive wound tension
• Secondary carpal tunnel syndrome (from edema)
• Secondary trigger finger
• Recurrent disease
Trigger Finger / Tenosynovitis
Pathophysiology
• Results from localized tenosynovitis of superficial & deep flexor tendons adjacent to A1 pulley at
metacarpal head
• Inflammation causes nodular enlargement of tendon distal to pulley
• Painful clicking as inflammed tendon passes through constricted sheath as finger is flexed &
extended
• Associated disorders: RA, gout, diabetes, amyloidosis
• Occurs most often in middle or ring fingers (occassionally in thumb)
• Rheumatoid trigger finger may involve several fingers
Clinical
• Painful clicking
• Digit may lock in flexion, extension, or may be arrested in middle range
• With chronic triggering, PIPJ flexion contracture (or IPJ flexion contracture) may develop
• Determine if there is normal passive ROM in MP, PIP, & DIPJ's (true triggering -> locking as digit
is passively taken through a ROM)
• Palpation may reveal tender nodule over metacarpal head (which may imply a better prognosis
with nonoperative Rx)
• Determine if patient can flex & extend digit past triggering point without assistance
66
Orthopaedi UI
Quinnell Classification
Grade 0 No triggering, mild crepitus
Grade 1 No triggering, uneven finger movements
Grade 2 Triggering is actively correctable
Grade 3 Usually correctable by other hand
Grade 4 Digit is locked
Treatment
Nonoperative
• Should cure well over 95% of trigger finger patients

• DIPJ immobilization
• Extremely useful in preventing triggering in all fingers including thumb
• DIP immobilization (leaving PIP free), has minimal functional limitations & most patients
can work without restrictions
• Steroids
• Injection into sheath may alleviate triggering
• Try combination of 0.5 ml of dexamethasone (4 mg/ml) & 0.5 ml of 1% plain lidocaine
• Alternatively, 0.5 ml of triamcinolone & 0.5 ml of plain lidocaine
• Technique of injection
• Sterile precautions
• Inject sheath, not into tendon, #25 or #26 gauge needle
• Insert needle obliquely penetrating through flexor tendon until resistance is met
• To avoid injecting into tendon, needle is withdrawn slowly until digit flexion no
longer moves needle
• When needle lies in sheath, liquid will easily flow out & into flexor tendon sheath
• Alternatives
• Consider injecting around tendon sheath, as this also seems to improve
symptoms
• Consider injecting into A2 pulley
• Successful injection into tendon sheath will result in anesthesia in entire digit
• If painful triggering continues, consider surgery
• Contra-indications: infants & children (congenital trigger thumb)
Percutaneous technique
• Gilberts et al, compared results of open surgical technique with those of percutaneous surgical
technique for Rx of trigger digits
• 96 patients with 100 trigger digits randomized to either open (n = 46) or percutaneous (n = 54)
surgical release of 1st annular pulley
• Successfully treated in 98% of cases using open surgical technique & in 100% of cases using
percutaneous technique
• Mean operation time significantly longer with open technique
• Mean duration of postop pain & time to recovery of motor function significantly shorter with
percutaneous method
• No serious Cx in either group
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Orthopaedi UI
Operative
• Considerations
• Rheumatoid trigger finger
• Incising A1 pulley may cause
• Bowstringing of tendon
• Deviation of finger toward midline
• Propencity for anterior MCP subluxation
• Resect 1 slip of FDS (if necessary for gliding)
• Surgical approach
• Local anesthesia allows patient to actively flex & extend digit to verify complete release
• Anatomy
• Average length of A1 pulley 1 cm

• Proximal edge of A1 pulley lies ~2 cm from proximal finger crease
• Distal edge of A1 pulley lies ~1 cm from proximal finger crease
• Note that proximal phalangeal crease lies over mid portion of P1, & that A2 pulley
begins & ends in proximal half of P1
• Hence, tendon sheath incision which extends past level of proximal phalangeal
crease will probably incise most A2 pulley
• Incision
• Transverse 15 mm incision over affected metacarpal neck, or can be made with
reference to palmar creases mentioned above
• Incision must not violate distal palmar flexion crease
• Blunt dissection to spread subcutaneous tissue & palmar fascia to expose flexor tendons
& sheath
• Identify digital nerves
• Nerves lie on either side of tendon sheath
• Usually radial nerve more vulnerable
• Transection of pulley
• Essential to identify demarcation between A1 & A2 pulleys
• Insert an anatomy probe into this interval, then pass it proximally underneath A1
pulley
• A1 pulley should be split longitudinally along radial aspect of pulley in index, long
& ring fingers & along ulnar aspect of little finger to prevent subluxation of flexor
tendons
• Release only enough pulley, to allow full active motion without triggering
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Orthopaedi UI
• At end of procedure, move finger to ensure no more triggering

• Look for tendon pathology
• Consider delivering tendon out of its sheath using a small right angle rectractor
• If a nodule present, a piece of tendon sheath may need to be excised to allow
passage of tendon
• Trigger Thumb
• Thumb tendon sheath anatomy
• A1 pulley
• Spans MP joint, ~8 mm in width
• Note that FPB inserts just proximal to this pulley & adductor pollicis
inserts distal to A1 pulley
• Oblique pulley
• Located over mid aspect of phalanx, ~10 mm in width
• Note that adductor pollicis partially inserts into oblique pulley
• A2 pulley
• Located at most distal aspect of proximal phalanx, ~9 mm in width
• May partially span thumb IP joint
• Incision
• Proximal edge of FPL sheath annulus is directly deep to MP flexion crease of
thumb
• Transverse incision should be made at MP flexion crease or just distal to it
• Note position of lateral (radial) digital nerve to thumb in position of jeopardy
• Radial nerve lies close to deep layer of dermis at flexion crease
• Radial nerve can be injured by blunt dissection more proximally where it
diagonally crosses thumb flexor sheath
• Postop
• Adhesions may form if patient does not begin immediate motion
Prognostic factors
• Diabetes
• Poor prognostic indicator for nonoperative Rx
• May also be especially prone to develop stiffness following surgical release
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Orthopaedi UI
• Probably most important prognostic indicator of good results with nonoperative Rx: duration of
triggering prior to Rx
• Irreducibly locked trigger, often with flexion contracture of PIP joint, should certainly not be
treated by injections
Nerve Compression in Upper limb
Pathological processes of nerve injury
• Usually neuropraxia +/- axonotmesis with different fibres damaged by varying degrees
• Neuropraxia
• Reversible physiological conduction block & segmental demyelination
• Usually compression injury
• Thick myelinated nerves mainly affected
• Loss of some types of sensation & muscle power
• Heals by Schwann cell repair of demyelination
• Recovers within days or weeks
• Axonotmesis
• Axonal disruption but endoneurium & nerve in continuity
• Usually traction injury, but may occur after severe compression
• Wallerian degeneration of axons occurs
• Axonal regeneration within hrs, at 1-3 mm/day
• Endoneurial tubes intact -> no miswiring & good regeneration
• Sensory recovery better (sensory receptors survive longer than motor units)
• Limiting factor: distance of regeneration required -> worse with proximal injuries
• Target organs atrophy, if not reinnervated within 2 yrs, don’t recover
• Double Crush Syndrome
• Normal axon function dependent on factors synthesized in nerve cell body
• Proximal entrapment makes a nerve susceptible or lowers its threshold to effects of more
distal entrapment
• If only 1 site of compression is treated, symptoms may persist until the other site of
compression is addressed
MEDIAN NERVE
Anatomy
• Course
• From C5, C6, C7, C8, T1
• Condensation of lateral & medial cords of brachial plexus
• Travels lateral to brachial artery in arm, but crosses medial to artery in antecubital fossa
• No branches before elbow
• Between 2 heads of pronator teres at elbow
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Orthopaedi UI
• 5-6 cm distal to elbow gives off anterior interosseous branch (motor to FPL, FDP index
finger & pronator quadratus)
• Proceeds between FDS & FDP
• Palmar cutaneous branch (sensory to thenar skin) arises 5 cm proximal to wrist joint &
overlies flexor retinaculum
• Enters carpal tunnel between PL & FCR
• Recurrent motor branch to thenar muscles arises at distal end of carpal tunnel
• Motor
• Supplies PT (pronator teres), FCR, PL, FDS, LOAF (radial 2 lumbricals, opponens
pollicis, abductor pollicis, superficial head of flexor pollicis brevis)
• Anterior interosseous branch supplies FPL, radial half of FDP, PQ (pronator quadratus)
• Sensation
• Radial 3 1/2 digits
• Autonomous zone = tip of index finger
Carpal tunnel syndrome
• Entrapment in carpal tunnel

• Anatomy of carpal tunnel
• Floor & walls = bony carpus

• Roof = flexor retinaculum/transverse carpal ligament
• Radial attachment = tubercle of scaphoid + ridge of trapezium
• Ulnar attachment = hook of hamate + pisiform
• Flexor tendons run deep to nerve
• Contents
• FCR
• FPL (deep to FCR)
• Median Nerve
• FDS - middle & ring lie superficial to index & little
• FDP
• Incidence
• Commonest
• Middle aged
• F:M = 3-5:1
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Orthopaedi UI
• Causes (ICRAMPS)
• Idiopathic
• Colles', Cushing's
• Rheumatoid
• Acromegaly, amyloid
• Myxoedeoma, mass, (diabetes) mellitus
• Pregnancy
• Sarcoidosis, SLE
• Symptoms
• Aching & parasthesia in thumb, index, middle & 1/2 of ring finger
• Worse at night - most distinguishing symptom
• Forearm pain
• Dropping things
• Not always classical
• Signs
• Hand normal looking
• If severe, thenar wasting, trophic ulcers
• Weakness of thumb abduction
• Finger sensation tests
• Threshold tests more sensitive, eg. Semmes-Weinstein monofilament or vibration
• Innervation density tests less sensitive, eg. 2-PD
• Tinel's sign
• 74% sensitivity, 91% specificity
• Gentle tapping over median nerve at wrist in a neutral position
• +ve if this produces paraesthesia or dysaesthesia in distribution of median nerve
• Phalen's sign
• Elbows on table allowing wrists to passively flex
• +ve if symptoms provoked within 60 secs
• Median nerve compression test (JBJS 80-B 1998 pg 493, Richard Gelberman, St
Louis)
• Elbow extended, forearm in supination, wrist flexed to 60o, even digital pressure
applied with 1 thumb over carpal tunnel
• +ve if parasthesia or numbness within 30 secs
• Differential diagnoses
• Cervical radiculopathy
• Spinal cord lesions - tumour, MS, syrinx
• Peripheral neuropathy - toxic, alcoholic, ureamic, diabetic
• Ix
• Nerve conduction studies
• Sensory conduction prolongation >3.5 ms
• Distal motor latency >4.0 ms
• Accuracy = 85-90%
• 10-15% false -ve
• Reminder of how nerve conduction studies are performed
• Motor
• Stimulus to skin over nerve, Motor Action Potential recorded in muscle
supplied
• Latency = time between stimulus & MAP
• Conduction velocity, normal = 40-60 m/s
• Compression causes reduced CV in a segment
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Orthopaedi UI
• If very severe MAP also reduced

• Sensory
• SNAP recorded in proximal nerve after distal stimulation
• Sensation often affected before motor function
• ‘Somato sensory evoked potentials’ record response in brain or spinal
cord, used to diagnose brachial plexus injuries
• Mx
• Conservative
• Futura splint
• Steroid injection
• Transient relief to 80% of patients
• Most effective (40% symptom free >12/12) when symptoms <1 yr, diffuse
& intermittent numbness, normal 2-point discrimination, no weakness,
thenar atrophy, or denervation potentials on EMG, & <2 ms of
prolongation of distal motor & sensory latencies
• Pyridoxine (vitamin B6) does not appear to alter natural history
• Surgical
• Nocturnal pain
• Most reliably relieved symptom after decompression
• Therefore, best indication for surgery
• Earlier surgical intervention leads to better results
• >3 yrs: less than half as likely to have resolution of symptoms than within
3 yrs of diagnosis
• Intermittent preop numbness & paresthesias had much better sensory
recovery than constant numbness
• Open vs endoscopic decompression
• ? accelerated recovery of grip & pinch strength with endoscopic release
• However, outcome equivalent by 6/12 after surgery
• Need to bear in mind anatomical variations
• Incision from ulnar border of PL to proximal palmar crease at ulnar
border of middle finger
• Palmar cutaneous branch of median nerve between PL & FCR at wrist
level
• Recurrent motor branch
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Orthopaedi UI
• Superficial palmar arterial arch 5-8 mm distal to transverse carpal

ligament
• Results
• 85% successful ‘Lipscumb’
• MRI -> 20-30% increase in carpal tunnel volume after surgery
• Results of reoperation worse than primary surgery, with only about half
of patients achieving good results
• Cx of surgery
• Macdonald 1979: 12%
• CRPS
• Tender hypertrophic scar
• Pillar pain
• Neuroma in palmar branch
• Tenosynovitis/tendon adhesions
• Bowstringing of tendons
• Endoscopic release
• Okutso, Chow & Agee
• 1 or 2 incisions
• Advantages
• Less scarring
• Less pillar pain
• Quicker return of strength & to work
• Disadvantages
• Anecdotal reports of disasters
• Big learning curve
• Time consuming
• Expensive
Pronator Teres Syndrome
• Compression at
1. Lacertus fibrosus
2. Pronator teres muscle
3. Fibrous arcade of FDS
4. Ligament of Struthers (present in 1.5% of people)
• Causes
o Repeated minor trauma/repetitive use of elbow
o # or #-dislocation of elbow
o Tight/scarred lacertus fibrosus
o Tendinous bands in pronator teres
o Abnormal anatomy of pronator teres
o Tight fibrous arch at proximal FDS
• Symptoms
o Aching/fatigue of forearm after heavy use
o Clumsiness
o Vague, intermittent parasthesia, but rarely numbness
• Signs
o Local tenderness to deep pressure & reproduction of symptoms
o Pain on resisted pronation of forearm with elbow extended = Pronator teres
o Pain on resisted elbow flexion & supination= lacertus fibrosus
o Pain on resisted flexion of PIP joint middle finger = FDS arch
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Orthopaedi UI
o Tinel's test
• Ix
o NCS not much use, intermittent symptoms
o EMG may show evidence of reduced innervation of muscles
o May differentiate from CTS
• Mx
o Conservative
• Avoidance of repetitive elbow movements
• NSAIDs
• Splintage with elbow flexed with pronation
o Surgical
• Decompress all structures
• Relief of symptoms in 80%
Anterior Interosseous Syndrome
• Compression under humeral (deep) part of pronator teres

• AIN
• Motor to FPL, radial side of FDP & pronator quadratus
• Does not supply skin sensation
• Afferent sensory fibres from capsular ligament structures of wrist & DRUJ
• Clinical diagnosis
• Spontaneous vague forearm pain
• Reduced dexterity
• Weakness of pinch
• Unable to make 'OK sign' due to weakness of FPL & FDP index finger (makes square
instead of circle)
• Weak pronation with elbow in full extension (isolates PQ)
• Direct pressure over nerve can elicit symptoms
• Tinel's sign usually -ve
• Ix
• NCS unhelpful
• Mx
• Conservative
• NSAIDs
• Avoid aggravating movements
• Surgical exploration - most common compressing structure deep head of pronator terexs
•
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Orthopaedi UI
ULNAR NERVE
Anatomy
• From C7, C8, T1

• Direct continuation of medial cord with C7 fibres usually from lateral cord of brachial plexus
• Passes through intermuscular septum in mid-arm
• Behind medial epicondyle
• Between 2 heads of FCU
• Lies anterior to FDP
• Gives off dorsal cutaneous branch 5 cm proximal to wrist
• At wrist lies between FDS & FCU
• Through Guyon's canal at wrist (between pisiform & hook of hamate), medial to ulnar artery
• Deep motor branch winds round base of hook of hamate
• Sensory branch passes more superficially
• Motor - FCU, ulnar side of FDP, all small muscles of hand except LOAF
• Sensory
• Ulnar 1 1/2 digits both sides
• Autonomous zone = tip of little finger
Cubital tunnel syndrome
• Entrapment at elbow, due to

• Trauma
• Cubitus valgus
• Bony spurs
• Tumours
• 8 cm more proximally by ‘arcade of Struthers’
• Medial intermuscular septum
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Orthopaedi UI
• Transverse fibres of cubital tunnel roof

• Osborne fascia - medial epicondyle to olecranon
• More distally by hypertrophied FCU
• Differential diagnosis
• Cervical radiculopathy
• Cervical spondylosis
• Spinal cord pathology
• Thoracic outlet syndrome
• Pancoast tumour
• Amyotrophic lateral sclerosis (MND)
• Localised peripheral neuropathy
• Symptoms
• Vague dull aching forearm, intermittent parasthesia, ulnar side of hand
• Signs
• Wasting of 1st dorsal interosseus & hypothenar eminence

• Wasting ulnar border of forearm (FDP & FCU)
• Ulnar clawing if severe (Note: ulnar paradox - no clawing if FDP & intrinsics weak)
• Hypoasthesia ulnar side of hand & ulnar 1 1/2 digits + distribution of dorsal cutaneous
nerve (diff. to low lesion)
• Weakness of abduction of little finger (Wartenburg's sign)
• Weakness of adduction & abduction of fingers
• Froment's sign
• Weakness of FDP of ring & little fingers
• Weakness of FCU
• Tinel's test, behind medial epicondyle
• Ix
• NCS: reduced nerve conduction velocity
• EMG: evidence of denervation of muscles
• Mx
• Conservative
• Avoidance of repetitive bending of elbow
• Extension block night splint
• Injection contraindicated
• Surgical
• Controversial
• Decompression
• J Hand Surg Am 1999 Sep: ‘Cubital Tunnel Syndrome does not require
transposition of ulnar nerve’
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Orthopaedi UI
• Austrian paper 1996, Steiner: 89 good or very good results at 2 yrs follow
up
• Transposition - subcutaneously/submuscularly
• J Hand Surg Am 1999 Sep, Kleinman: ‘Anterior transposition is logical
approach to complete nerve decompression'
• +/- medial epicondylectomy
• Results
• Sensation improves better than motor function
• Can improve over 3-5 yr period
• Cx
• Painful hypertrophic scar
• Neuromas
• CRPS
• Dislocation of nerve
• Persistent symptoms due to inadequate decompression
• Irritation of superficially placed nerve
• Disruption of blood supply to nerve
Ulnar tunnel syndrome (Compression at Guyon's canal)
• Anatomy of Guyon's canal

• Floor = transverse carpal ligament to pisiform
• Ulnar wall = pisiform
• Radial distal wall = hook of hamate
• Roof = volar carpal ligament
• Contains only ulnar nerve & artery
• Causes
• Repetitive indirect trauma most common
• Tumours - ganglion, lipoma
• Pisiform instability
• Pisotriquetral arthritis
• Fractured hook of hamate/pisiform
• Ulnar artery thrombosis
• Symptoms
• Weakness, atrophy, para/hypoaesthesia ulnar side of hand; motor, sensory or both
• Dorsoulnar sensory branch spared
• Signs
• Local tenderness, Tinel's test, Phalen's sign, local swelling, -ve Allen's test, severe ulnar
clawing (remember ulnar paradox)
• Ix
• NCS: delayed motor latency from wrist to 1st dorsal interosseous
• Mx
• Conservative
• Splinting
• Avoidance of repetitive trauma
• Surgical
• Decompression of motor & sensory branches
• +/- excision of pisiform/hook of hamate
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Orthopaedi UI
RADIAL NERVE
Anatomy
• From C5,C6,C7,C8
• Continuation of posterior cord of brachial plexus in axilla
• Passes posteriorly through triangular space (bordered by long head triceps, teres major, humeral
shaft) with profundi brachii artery
• Spiral groove around humerus over deep head of triceps origin
• Pierces intermuscular septum
• Passes between brachialis & brachioradialis (supplying brachioradialis & ECRL)
• Anterior & lateral at cubital fossa
• Passes between 2 heads of supinator
• Divides into superficial branch & posterior interosseous nerve (PIN)
• PIN between ECRB & EDC
• Superficial branch underneath brachioradialis
• PIN - motor to long extensors of MCP joints & wrist except ECRL
• Superficial branch
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Orthopaedi UI
• Sensory to dorsal radial side of hand & fingers (3 1/2)

• Autonomous zone = 1st web space dorsum
Posterior Interosseous Nerve Syndrome (pain & paresis)
• Causes (FREAS)
• Fibrous tendinous band at origin of supinator (30% of people)
• Radial recurrent vessels (leash of Henry) (less convincing evidence)
• Extensor carpi radialis brevis
• Arcade of Frohse
• Supinator (distal border)
• RA of elbow
• Dislocation of elbow, Monteggia #
• Surgical resection of radial head
• Mass lesions
• Symptoms
• Pain in 50%
• Weakness of extension of wrist & MCP joints
• Signs
• Radial deviation of wrist with dorsiflexion (ECRL supplied by radial nerve) [See Case
Study]
• Unable to extend MCPJ
• If partial, pseudo clawed hand
• Able to extend IP joints due to interrossei
• No loss of sensation
• Ix
• NCS: decreased latency across arcade of Frohse
• EMG: denervation fibrillations of affected muscles
• Mx
• Conservative - observe for 8-12/52 if no evidence of mass lesion
• Surgical decompression
Radial tunnel syndrome (pain but no paresis)
• Mild compression of PIN without paresis

• Causes
• As for posterior interosseus syndrome but not usually any mass lesions
• Symptoms
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Orthopaedi UI
• Dull aching in extensor muscle mass

• Worse at end of day
• Signs
• Local tenderness 5 cm distal to lateral epicondyle
• Pain elicited by resisted active supination
• Middle finger test
• Each finger is tested under resisted extension
• Testing middle finger increases pain
• Due to ECRB inserting into base of 3rd metacarpal
• Performed with elbow & middle finger completely extended with wrist in neutral
position
• Firm pressure is applied by examiner to dorsum of proximal phalanx of middle
finger
• +ve if it produces pain at edge of ECRB in proximal forearm
• Differential diagnosis - Tennis elbow
• Ix
• NCS: increased motor latency in active forceful supination
• Injection of local anaesthetic into radial tunnel
• Mx
• Conservative
• Anti-inflammatories
• Avoidance of repetitive provoking activities
• Surgical
• Decompression - internervous plane between ECRB & EDC developed -> PIN
found just proximal to arcade of Frohse
Wartenberg syndrome
• Described in 1932
• Isolated neuritis of superficial sensory branch of radial nerve
• Entrapment between brachioradialis & ECRL near junction of middle & distal 1/3 of forearm
• Rx
• Local steroid injection
• Surgical exploration & release
Nerve Injuries - General Principles

Anatomy
Components of a mixed spinal nerve
• Motor
• Cell bodies in anterior horn cells
• Innervate skeletal muscle
• Sensory
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Orthopaedi UI
• Cell bodies lie within dorsal root ganglia

• Fibres arise in pain, thermal, tactile & stretch receptors
• Pathway for proprioception, fine touch & vibration from extremities & trunk
• Fibres pass cephalad in dorsal columns & do not synapse until reaching
cervicomedullary junction
• Pathway for pressure & crude touch from extremities & trunk
• Fibres enter, synapse & cross & ascend into contralateral ventral spinothalamic
tract
• Pathway for pain & temperature
• Fibres synapse in spinal cord, & cross to ascend in lateral spinothalamic tract
• There is some area of neuronal overlap explained by branches that ascend or
descend via dorsolateral column/fasciculus of Lissauer
• Sympathetic
• Sympathetic component of all 31 spinal nerves leaves spinal cord along only 14 motor
roots (from T1 to L2)
• Between T1 & L2, white rami containing sympathetic fibres to ganglions of sympathetic
chain
• Synapses occur somewhere along sympathetic chain & then postganglionic fibres reenter
mixed spinal nerves through grey rami
Gross anatomy of a spinal nerve
• Each segmental spinal nerve is formed by union of dorsal/sensory root with ventral/motor root at
or before intervertebral foramen
• In thoracic segments, these mixed spinal nerves maintain their autonomy, providing sensation &
motor function to 1 intercostal segment
• In all other areas (cervical, lumbar & sacral), plexuses are formed which provide a limb or special
body segment without retaining primitive myomeric pattern
• Divides into an anterior & posterior primary ramus after leaving intervertebral foramen
• Posterior primary ramus supplies paraspinal musculature & skin along posterior aspect of trunk,
neck & head
• Anterior primary ramus supplies everything else, & form plexuses
• Dermatome: area of skin supplied by a single spinal root
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Orthopaedi UI
Microscopic anatomy
• Nerve - bundles of axons in connective tissue

• Nerve fibre - axons + surrounding Schwann cell sheath
• Sensory & motor nerves contain both unmyelinated & myelinated fibres at a ratio of 4:1
• Endoneurium = collagen surrounding nerve fibres (axons)
• Perineurium
• Surrounds each fascicle or funicle (bunch of sheathed axons)
• A cellular layer with tight junctions between cells enclosing perineurial space (within
perineurium)
• Epineurium
• = anything outside perineurium which is not nerve fibre or blood vessel
• Mainly collagen
• Strongest supporting structure of nerve
• Arrangement of fascicles in proximal aspect of peripheral nerves more complex than in distal end
• Blood supply to peripheral nerve enters through mesoneurium
• This blood supply is both extrinsic/segmental & intrinsic/longitudinal within epineurium,
perineurium & endoneurium
Neuronal Degeneration & Regeneration
• 4 stages
1. Retraction
2. Inflammation
3. Degeneration
• Any part of a neuron detached from its nucleus degenerates & destroyed by
phagocytosis
• Secondary or Wallerian degeneration
• Degeneration distal to point of injury
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Orthopaedi UI
• Fundamental concept of Wallerian degeneration: survival of nerve fibres

occurs only if they remain connected to cell body
• Commences 2-3/7 after injury
• Distal segment begins to fragment
• Cell body
• Swells
• Migration of nucleus to periphery of cell
• Chromatolysis (basophilia)
• Activation of Schwann cells close to injury site
• By 7/7 Schwann cells are mitosing & phagocytosing cellular & myelin
debris
• By 25-30/7 axonal debris cleared
• Schwann cells occupy empty endoneurial tubes forming 'bands of von
Bungner'
• Bands act as sprouts (neurites) of regenerating axons ('pioneering
axons') down endoneurial tubes -> regeneration
• Primary or retrograde or traumatic degeneration
• Degeneration proximal to point of detachment
• Only as far as next proximal Node of Ranvier
• Histologically identical to Wallerian degeneration
4. Regeneration
• Axonal sprouting can occur within 24 hrs of injury
• If sprouts manage to make distal connections then nerve fibre maturation occurs,
with increase in axon & myelin thickness
• Neurites which fail to make distant connections die back & lost to regenerative
process
• If perineurium not disrupted
• Axons will be guided along original pathway
• 1 mm/day
• If perineurium disrupted
• There are neurotrophic substances (NGF - nerve growth factors) which
attract neurites to nerve tissue
• Critical gap over which this does not occur -> 2 mm
• Neuromas form when neurites migrate aimlessly across a large gap; can
be stump neuromas or neuromas in continuity
• Time for full recovery of a transected nerve after repair (days) = distance from level of injury to
finger tip (mm) + 30/7 for wallerian degeneration
Classification of nerve injuries

Seddon Classification
• Neuropraxia (nerve, non-action)

• Reversible physiological conduction block & segmental demyelination
• Usually compression injury
• Thick myelinated nerves mainly affected
• Loss of some types of sensation & muscle power
• Heals by Schwann cell repair of demyelination
• Recovers within days or weeks
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Orthopaedi UI
• Axonotmesis (cylinder, cutting)

• Axonal disruption but endoneurium & nerve in continuity
• Usually traction injury, but may occur after severe compression
• Wallerian degeneration of axons occurs
• Axonal regeneration within hrs, at 1-3 mm/day
• Endoneurial tubes intact -> no miswiring & good regeneration
• Sensory recovery better (sensory receptors survive longer than motor units)
• Limiting factor: distance of regeneration required -> worse with proximal injuries
• Target organs atrophy, if not reinnervated within 2 yrs, don’t recover
• Neurotmesis (nerve, cutting)
• Complete severance of nerve trunk
• No recovery unless repair undertaken
• Lots of miswiring of organs
• Reduced mass of innervation
Sunderland Classification
• Accounts for injuries between axonotmesis & neurotmesis

• Based on involvement of perineurium
Degree of Degree of Myeli Axo Endoneuriu Perineuriu Epineuriu Tinel Tinel sign
injury injury n n m m m sign progresse
presen s distally
t
Sunderland Seddon,
, 1978 1943
1st degree Neuropraxia +/- - -
II Axonotmesi + + + +
s
III Axonotmesi + + + + +
s
IV Axonotmesi + + + + + -
s
V Neurotmesis + + + + + + -
Mckinnon & Dellon (1988)
• Added a 6th degree injury = neuroma-in-continuity, where a nerve has had a disordered self-
repair with a lateral neuroma
• There is a mixture of injuries, when a nerve is partly severed & remaining trunk sustains 1st, 2nd,
3rd or 4th degree injury
Complex regional pain syndrome
• Pain, swelling, discoloration, hyperhydrosis, osteoporosis, resulting from abnormal & prolonged
response from sympathetic nervous system
• 3% of major nerve injuries
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Orthopaedi UI
Aetiology of peripheral nerve injuries
• Can be due to metabolic, collagen disease, malignancy, toxins, thermal or mechanical injury, but
only mechanical causes mentioned here
• Mechanical causes producing primary injury include laceration, #, # manipulation, gunshot wound
• Secondary injury can be due to infection, scarring, callus, vascular Cx, eg. AV malformation,
aneurysm, ischaemia
Clinical diagnosis of nerve injury & assessment post injury
• Requires thorough knowledge of anatomy of nerves
Motor function
• Visible fibrillation of muscle

• Power loss (MRC)
• 0 - Total paralysis
• 1 - Muscle flicker
• 2 - Muscle contraction
• 3 - Muscle contraction against gravity
• 4 - Muscle contraction against gravity & resistance
• 5 - Normal muscle contraction compared to other side
• Must have full passive ROM of joint
• Muscle wasting
• 50-70% muscle atrophy after 2/12

• Striations & motor end plates retained for ~12/12
• Method for assessing return of muscle function after nerve injuries (British Research
Council)
• M0 No contraction
• M1 Return of perceptible contraction in proximal muscles
• M2 Return of perceptible contraction in both proximal & distal muscles
• M3 Return of proximal & distal muscle power enough to allow major muscle groups to act
against resistance
• M4 Return of function as in stage 3 but synergistic & independent movements possible
• M5 Complete recovery
Sensation
• Sharp pin to assess pain, cotton wool to assess light touch, tips of a paper clip to assess 2 point
discrimination
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Orthopaedi UI
• Normal 2 point discrimination in hand
• There is an area of complete sensory loss, 'autonomous zone', which gets smaller even before
fibres can regenerate (? due to increased function of anastomotic branches from adjacent nerves)
• A larger area of reduced sensation surrounds this = 'intermediate zone'
• When a nerve is intact & surrounding nerves are blocked, an area of sensibility larger than gross
anatomical distribution of the nerve occurs = 'maximal zone'
• Sensibility recovery sequence
1. Pain & temperature
2. Pseudomotor function
3. Touch (Semmes-Weinstein monofilaments: protective sensation present if able to feel
5.07 Semmes-Weinstein filament)
4. Perception of 30 Hz vibration (tested over bony prominences with tuning fork)
5. Perception of moving touch
6. Perception of constant touch
7. Perception of 256 Hz vibration
8. Stereognosis (test with heptagonal UK 50 pence coin)
• Sensation assessment after peripheral nerve injury - British Medical Research Society
o S0 Absence of sensibility in autonomous area
o S1 Recovery of deep cutaneous pain in autonomous area
o S2 Return of some degree of superficial cutaneous pain & touch in autonomous area
o S3 Return of superficial cutaneous pain & touch throughout autonomous area, with
disappearance of any previous over response
o S4 As for 3 but also some recovery of 2 point discrimination in autonomous area
o S5 Complete recovery
• Best correlator of eventual function: return of 2 point discrimination (as emphasised by
Moberg, 1995)
Autonomic function
• There is loss of sweating, pilomotor response & vasomotor action when a peripheral nerve is
disrupted
• Pilomotor
• Wrinkle test - useful objective test
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Orthopaedi UI
• Denervated skin does not wrinkle in water

• Vasomotor
• Initially there may be vasodilatation in complete lesion, pinkness for 2-3/52
• Then coldness, paleness, mottled
• This may spread to more than anatomical area of skin supplied by nerve
• Atrophy of fingers & nails can occur
• Test sweating
1. By rubbing smooth pen against side of finger (if finger moves with pen = sweating
present)
2. Ninhydrin print test - applying nihydrin to sweat turns it purple (Moberg, 1995)
3. Look through +20 lens of opthalmoscope to see beads of sweat
4. Dust extremity with quinizarin powder - sweating turns powder purple
5. Absence of sweating causes increased resistance to an electric current
• If sweating still present -> nerve damage incomplete
Hoffmann-Tinel Sign (1917)
• Gentle percussion with finger along course of injured nerve will produce transient tingling
sensation in distribution of injured nerve, persisting for several seconds
• Start distally & proceed proximally
• +ve Tinel sign -> evidence of regenerating axonal sprouts which have not completed
myelinisation are progressing
• Distally advancing Tinel sign should be present in Sunderland II & III injuries
• Type I injury (neuropraxia) should not produce any Tinel's sign as no new regeneration should
need to occur
• Type IV & V injuries do not produce advancing Tinel sign unless repaired
• Progressing Tinel's sign is encouraging but does not necessarily mean complete recovery
Reflexes
• Complete severance of either efferent or afferent nerve in a reflex abolishes that reflex
• However, reflex can be lost even in partial injury & not good guide of injury severity
Diagnostic tests
Nerve conduction studies
• Evaluation of peripheral nerves & their sensory & motor responses anywhere along their course
• Stimulation of a peripheral nerve should evoke contraction in muscles it supplies (seen, palpated
or measured electromyographically)
• Latency (t) = time between onset of stimulus & response
• Amplitude = size of response
• Nerve conduction velocity, V = d/t, d = distance between stimulating & recording electrodes
• Motor nerve
• Recording electrode (cathode) placed over a muscle supplied by nerve (over 'motor point'
= region where nerve enters muscle)
• Indifferent electrode placed a few cm away
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• Ground electrode placed over an inactive muscle nearby

• Stimulation site is where nerve is superficial (eg. elbow)
• Stimulator turned on until a clearly defined CMAP (compound motor action potential)
appears = 'threshold'
• Stimulus increased by 50% to 'supramaximal' ensuring complete activation of muscle
• A 2nd stimulator added, distal to 1st stimulator & closer to recording electrode
• Segment velocity between 2 stimulation sites calculated
• V(motor) = [d1-d2]/[t1-t2], where V(motor) = segment velocity in motor fibres; d1 = distance
between 1st (proximal) stimulation site & recording cathode; d2 = distance between 2nd
(distal) stimulation site & recording cathode; t1 = latency between 1st (proximal)
stimulation site & recording cathode; t2 = distance between 2nd (distal) stimulation site &
recording cathode
Motor nerve conduction test for Motor nerve conduction test for
Ulnar nerve above & below Ulnar nerve at wrist using ADM
elbow (from TeleEMG)
• Sensory nerve
• CNAP (compound nerve action potential) measured (lower amplitude than CMAP)
• A uniquely sensory nerve must be chosen for stimulation site
• V(sensory) = d/t, where V(sensory) = segment velocity in sensory fibres; d = distance between
stimulation site & recording cathode; t = average latency between stimulus & CNAP
Sensory nerve conduction test

for Ulnar nerve across the wrist
(from TeleEMG)
• Collision Studies
• Timing of NCS
• Immediately after section of a peripheral nerve, stimulation distally will elicit normal
response for 18-72 hrs until wallerian degeneration occurs
• Absence of distal nerve motor conduction (CMAP) after 3-7/7 excludes neuropraxia type
injury
• Absence of sensory conduction (CNAP) after 7-10/7 excludes neuropraxia type injury
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Orthopaedi UI
• Therefore ideal time for NCS after injury is 10-14/7 after injury to discern neuropraxia
from axonotmesis/neurotmesis
• Neuropraxia will improve (incr. velocity & decr. latency) with repeated tests, while
axonotmesis & neurotmasis will deteriorate
Somatosensory Evoked Potentials (SSEP)
• Stimulate peripheral sensory nerves & measure on scalp

• For study of brachial plexus & spinal cord monitoring
Electromyography
• A needle electrode in muscle is used to record motor unit activity at rest & on attempted
contraction of muscle
• Normal EMG shows no muscle activity at rest & characteristic pattern on voluntary contraction
• Immediately after nerve section, EMG will be normal, although there will be no muscle response
after stimulation of nerve proximal to nerve injury (CMAP)
• Between 5 & 14/7 positive sharp waves consistent with denervation
• At between 15 & 30/7, spontaneous denervation fibrillation potentials present
• If denervation fibrillation potentials not present by end of 2nd week -> good prognostic sign
• Evidence of reinnervation is when highly polyphasic motor unit potentials are detected at attempts
at voluntary activity
• Denervation fibrillations in a muscle only tell you that muscle is not innervated; it does not
determine whether injury is 2nd, 3rd, or 4th degree
• Reinnervation potentials by same token can be restored after regeneration of only a few motor
fibres & does not necessarily mean a good return to voluntary motor control
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Orthopaedi UI
• EMG findings in specific conditions
Insertional Rest Fibrillations Sharp ++

Condition Potentials Interference
Activity * Activity ** *** Waves
Biphasic &
Normal Normal Silent No No Complete
triphasic
Neuropraxia Normal Silent No No No None
Large & longer
Axonotmesis Increased Increased Yes Yes None
polyphasic
Large & longer
Neurotmesis Increased Increased Yes Yes None
polyphasic
Axonal
Increased Increased Yes Yes Incomplete
Neuropathy
Demyelinating
Normal Silent No No Yes Incomplete
Neuropathy
Anterior Horn Large
Increased Increased Yes Yes Incomplete
Disease polyphasic
Small
Myopathy Increased Silent Yes Yes Early
polyphasic
• Insertional Activity = needle inserted into muscle or moved within muscle -> a single burst
of activity that usually lasts 300-500 ms; thought to result from mechanical stimulation or
injury of muscle fibers
• Rest Activity = differentiates neuropathic muscle atrophy from myopathic atrophy
• Fibrillations = action potentials that arise spontaneously from single muscle fibers; usually
occur rhythmically & thought to be due oscillations of resting membrane potential in
denervated muscles. Appears 3-5/52 after nerve lesion. Preceded by Positive Sharp
Waves
• Potentials = number of phases (? action potentials); indicates collateral axonal sprouting;
polyphasic > 4 phases
Early management of nerve injuries
• ABCs as with any injury

• Open injury
• Open wound with nerve injury
• Thorough debridement
• If wound adequately clean & general state of patient allows, then immediate
primary nerve repair preferred
• Open wound but patient's general state in danger
• Clean wound & dress with moist dressing, attempt repair at 3-7/7
• Contaminated wounds
• Thorough debridement
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• Mark ends of nerve with a suture & consider suturing to soft tisssue to avoid
retraction
• Repair nerve when soft tissues have healed at 3-6/52 post injury
• Closed injury
• A closed injury with peripheral nerve damage
• Early active motion of all affected musce groups should be started
• Contractures should be prevented by passive motion
• Specific effects of electrical muscle stimulation unclear
• Dynamic & static splints can be used intermittently
• A closed # a/w nerve injury
• Early exploration usually avoided
• Assess progress of functional return using EMG, NCS & clinical assessment
• However, if ORIF required explore nerve too
• If nerve deficit follows manipulation &/or casting of a closed #
• Early exploration favoured
Nerve repair
• Primary goal - to guide regenerating axons to appropriate end-organs & to restore normal
sensory &/or motor function
Classification
• Primary - within hours of injury

• Delayed primary - 5-7/7 after injury
• Secondary - >7/7 after injury
Criteria for primary nerve repair
• Sharp transection injury

• Minimal contamination
• A bed of viable, well-perfused tissue
• Injured limb should have adequate circulation, skeletal stability, soft tissue coverage
• Microsurgical experience & surgical magnification
• Patient in good overall health
Techniques of nerve repair (neurorrhaphy)
• Before suturing, proximal & distal stumps isolated & all damaged tissue removed & trimmed
• Fascicular pattern & epineurial vascular landmarks for realignment
• 8-0,9-0,10-0 nylon preferred
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Interfascicular
Epineurial Perineurial Epi/perineurial repair
nerve grafting
• Clinical evidence to support one over other type of repair meagre

• Technique selected depends on experience of surgeon
• Sunderland points out that fascicular repair not possible in all cases, but most practical when
• Fascicular groups large enough to take sutures
• Each fascicular group is made up of fibres to a particular branch occupying a constant
position at nerve ends, eg. in median & ulnar nerves above wrist & radial nerve above
elbow
Nerve grafting
• Indications
1. Significant nerve gapping - 2.5 cm or more
2. Excessive tension on nerve repair -> scarring & prohibits regeneration
• Common donor sites
o Sural nerve - up to 40 cm
o Medial & lateral antebrachial cutaneous nerves
o Terminal branch of PIN
o Superficial radial nerve
• Choice depends on
o Location & type of nerve injury
o Size of defect
o Donor site morbidity/deficit
Aftertreatment
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Orthopaedi UI
• Opinions differ as to when joints can be moved

• In upper limb, immobilise in plaster splint or cast for 4/52, then replace in plastic splint, gradually
extending joint over 2-3/52
• In lower limb, immobilise for 6/52
• Rigid splinting not justified if prognosis for nerve function doubtful
• Dynamic splinting of distal joints with passive exercises to maintain motion whilst nerve recovers
Factors influencing regeneration after nerve repair (neurorrhaphy)
• Info from warzone injuries

• Age
• Single most important factor
• Worsening results with increasing age, though numbers at extremes of age small
• Level of injury
• The more proximal the lesion, the more incomplete the recovery
• Boswick et al
• Reviewed 102 peripheral nerve injuries in 81 patients
• 87% of those injuries below elbow regained protective sensation
• 14% regained normal 2 point discrimination
• Condition of nerve ending
• The better the condition the more the improvement
• Gap between nerve ends

• Nicholson, Seddon & Sakellarides noted that upper limit of gap beyond which results will
deteriorate is 2.5 cm
• Methods of closing gaps
1. Nerve mobilisation
2. Nerve transposition
3. Joint flexion
4. Nerve grafts
5. Bone shortening
• Delay between injury & repair
• Delay affects motor recovery more than sensory recovery (due to survival time of striated
muscle)
• Satisfactory reinnervation of muscle can occur after denervation of 12/12
• Little evidence about sensory function return in relation to delay, but sensation can
improve in as late a repair as 2 yrs
• Kleinert et al feel that delayed repair of between 7 & 18 days best for return of satifactory
function
• Reasonable approach: immediate repair if conditions allow & before 6/52 in extensive
soft tissue contusion, contamination, crushing
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Orthopaedi UI
Hand - Tendon Transfers - Principles

Definition
• A procedure in which tendon of insertion or of origin of a functioning muscle is mobilised,

detached or divided, & reinserted into a bony part or onto another tendon, to supplement or
substitute for action of recipient tendon
Indications
• Irreparable nerve damage

• Loss of function of a musculotendinous unit due to trauma or disease
• In some nonprogressive or slowly progressive neurological disorders to restore balance
Basic principles of tendon transfer
• Mobile joints/correction of joint, skin & soft tissue contractures

• If necessary, capsulotomy, or free flap prior to tendon transfer
• Transferred tendon
• Maximal work capacity of transfer = power x amplitude (Kg.M)
• Adequate power of transferred tendon
• Power of a muscle is determined by its cross sectional area
• Only muscles with power of 4+ should be considered donors as they
always lose 1 MRC grade of power
• Sufficient amplitude (excursion/freedom of movement) in transferred tendon
• Amplitude of a muscle is a function of sarcomere length
• It is a fixed value for any muscle, but can be increased by
• Freeing muscle from its fascial attachments
• Changing a muscle from monoarticular to biarticular -> amplitude
is increased by movement of extra joint that tendon crosses
• Amplitude can be limited by scarring & adhesions
• As a guide, amplitudes are as follows
• Wrist motors - 33 mm
• Finger extensors - 50 mm
• Finger flexors - 70 mm
• Transferred tendon should have synergistic action with function of recipient
• Transferred tendon should be of adequate length
• A graft can be used as an extension, but all anastomoses are sources of
adhesions
• A satisfactory line of pull should be achieved
• The less turns or bends through which tendon has to pass, the less friction can
reduce power & amplitude
• An adequate glide of transferred tendon is necessary, through unscarred natural planes
• Functional integrity must be preserved
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Orthopaedi UI
• Transferred musculotendinous unit must be expendable

• If a tendon is split & inserted into different sites only the tighter of the two will function &
the other will not
• Patient
• Realistic expectation
• Cooperative with rehab
Extensive paralysis
• Restore function from proximal to distal

• In general function is restored using following scheme
1. Stabilisation of shoulder
2. Flexion of elbow
3. Extension of wrist
4. Flexion of fingers
5. Reestablishment of thumb grip in opposition or lateral thumb grip
6. Finger extension
7. Restoration of function of interrossei
Surgical considerations in tendon transfers
• Timing
• If no chance of functional recovery, transfers should be performed ASAP
• Following nerve injury repair
• Date of expected recovery can be calculated by measuring distance between
injury to most proximal muscle supplied, assuming a rate of regeneration of 1
mm/day
• If reasonable return of function not present for 3/12 after expected date, consider
tendon transfer
• Early tendon transfers - within 12/52 of injury
• Planning
• Make a list of deficient functions
• Make a list of available donor muscles
• Techniques
• Multiple short transverse incisions rather than long longitudinal incisions
• Careful tendon handling
• Good soft tissue coverage over tendon junctures
• Joining tendons
• End to end anastomoses
• End to side anastomoses
• Side to side anastomoses
• Tendon weave procedures can all be used
• Achieving proper tension
• No general rule
• But reasonable to place limb in position of maximal function of tendon transfer &
suture without tension
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Summary table
Low injury (wrist) High injury (elbow)
MEDIAN NERVE
Thumb opposition (loss of FPB) (note thumb opposition = Index & middle finger flexion
combination of flexion & adduction)
• FDP of index & middle finger
1. Ring finger FDS transfer to APB via a pulley made in sutured side to side to FDP of
FCU tendon at level of pisiform [Picture] ring & little fingers
2. MCP +/or IP joint fusion • +/- ECRL tendon transfer to
FDP for extra strength
Flexion of IP joint of thumb
• BR transfer to FPL
Thumb opposition
• Extensor indices transfer to

abductor pollicis brevis
ULNAR NERVE
Adductor pollicis & FPB (thumb opposition) Loss of FCU
1. Absent FPB = ring finger FDS transfer to APB via a • Use ECRL transfer for power
pulley made in FCU tendon at level of pisiform [Picture]
2. If FPB working & adductor not = extensor indices
transfer through interosseous membrane to adductor
pollicis
Loss of action of interrosei & ulnar 2 lumbricals
1. Split tendon transfers of FDS +/- EIP & EDQ, to radial

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

For function of interrossei & lumbricals - to restore flexion of Very difficult problem
MCPJ & extension of IPJ
For function of long flexors &
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Orthopaedi UI
interrossei & lumbricals - to restore

• Brand's ECRB graft with a plantaris graft to increase flexion of MCPJ & extension of IPJ
length, attached to insertion of intrinsics
• Zancolli capsulodesis of MCP
joints
Thumb opposition • ECRL to FDP
• BR to FPL
• FDS (ring finger) via FCU pulley to EPL • ECU (with free graft) to EPL
Thumb adduction (pinch) Thumb fusions
• EIP to adductor pollicis
RADIAL NERVE
Radial wrist extensors functioning
• Wrist extension
• Pronator Teres to ECRB
• MCP joint extension
• FCR/FCU to EDC or FDS to EDC

• Extension & abduction of thumb
• PL rerouted to EPL
• If radial nerve might still recover, keep EPL in
continuity & bring palmaris longus upward
BRACHIAL PLEXUS
Anatomy
• SEQUENCE = Rami, Trunks, Divisions, Cords & Branches
• POSITIONS
• Roots & trunks lie in posterior triangle of neck
• Divisions deep to clavicle
• Cords posterior to pectoralis minor
• Terminal branches begin in axilla
• ROOTS (5)
• Formed by ventral rami of spinal nerves C5-C8 & T1
• TRUNKS (3)
• C5 & C6 roots join to form upper trunk
• C7 root forms middle trunk
• C8 & T1 roots join to form lower trunk
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• DIVISIONS (6)
• Each trunk divides into an anterior & a posterior division
• CORDS (3)
• 3 posterior divisions join to form posterior cord
• Anterior divisions of upper & middle trunk unite to form lateral cord
• Anterior division of lower trunk continues alone as medial cord
• BRANCHES (32355)
• Branches come from rami, trunks & cords; usually no branches from divisions
• Upper trunk carries nerve fibers from C5 & C6
• Middle trunk carries only C7 fibers
• Lower trunk carries both C8 & T1 fibers
• Since posterior divisions of all trunks join to form posterior cord, it carries fibers from C5,
6, 7, 8 & T1
• Lateral cord formed from anterior divisions of upper (C5,6) & middle (C7) trunks, it carries
fibers from C5, 6 & 7
• Medial cord formed from anterior division of only lower trunk, thus it carries fibers from C8
& T1
• Fibers carried in any named branch will be determined by which part of plexus they
originate from & what fibers that particular part is carrying
• Any combination of fibers carried in a part can be carried by a branch from that region
• Branches from roots of plexus
1. Branch to phrenic nerve (C5)
2. Dorsal scapular nerve (C5) innervates rhomboideus major & minor & gives a
branch to levator scapulae
3. Long thoracic nerve (nerve to serratus anterior) (C5,6,7)
• May be involved in supraclavicular & axillary wounds, neck blows or
compression due to carrying excess weight on shoulder
• Paralysis of serratus anterior causes "winging" of scapula when arm is
flexed & pressed against a fixed object
• Also difficulty in abducting shoulder above horizontal position due to
decreased ability to rotate glenoid fossa upward
• Branches from trunks
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1. Nerve to subclavius (C5,6) from upper trunk

2. Suprascapular nerve (C5,6) from upper trunk innervates supraspinatus &
infraspinatus
• Branches from divisions
Usually none
• Branches from cords
Lateral cord (Lily My Love)
1. Lateral pectoral nerve (C5,6,7) innervates pectoralis major (clavicular
head) & pectoralis minor
2. Lateral root of median nerve (C6,7) contributes to median nerve
Posterior cord (UTLRA)
0. Upper subscapular nerve (C5,6) innervates upper part of subscapularis
1. Thoracodorsal nerve or nerve to latissimus dorsi (C5,6,7)
2. Lower subscapular nerve (C5,6) innervates lower part of subscapularis &
teres major
Medial cord (4MU)
0. Medial pectoral nerve (C8,T1) innervates pectoralis major & pectoralis
minor
1. Medial cutaneous nerve to arm (medial brachial cutaneous) (C8,T1)
2. Medial cutaneous nerve to forearm (medial antebrachial cutaneous)
(C8,T1)
3. Medial root of median nerve (C8,T1) contributes to median nerve
• Terminal branches (5)
Musculocutaneous nerve (C5,6,7)
Median nerve (C6,7,8,T1)
Ulnar nerve (C8,T1)
Radial nerve (C5,6,7,8,T1)
Axillary nerve (C5,6)
• Note that
All branches from medial cord carry C8, T1 fibers
Higher spinal segments in brachial plexus (C5-C6) tend to innervate muscles
more proximal on upper extremity whereas lower segments (C8,T1) tend to
innervate more distal muscles eg. those in hand (T1)
Aetiology
• Birth
• Missiles
• Stabbings
• RTA
• Motorbikes most common
• Depression of shoulder combined with lateral flexion of neck to opposite side
• 80% of those with brachial plexus injury have other severe injuries
• Rupture of axillary or subclavian artery in 20% of patients
• # proximal humerus
• Scapula #
• Rib #
• Shoulder dislocation
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Classification (many)
• Upper Erb's & lower Klumpke's

• Leffert's classification
1. Open injuries
2. Closed (traction) injuries
A. Supraclavicular
1. Preganglionic (avulsion of nerve roots)
2. Postganglionic (roots remain intact)
B. Infraclavicular
C. Postanaesthetic palsy
3. Radiation injury
4. Obstetric palsy
A. Erb's
B. Klumpke's
Diagnosis
• Differentiation of preganglionic intraspinal lesions from postganglionic extraspinal lesions

• Cutaneous axon reflexes: histamine scratched into area of skin that nerve supplies
• Normal response - cutaneous vasodilatation, wheal formation, flare response
• Preganglionic disruption - anaesthesia, but normal axonal response
• Postganglionic disruption - anaesthesia, vasodilatation & wheal formation present but
flare absent
• Root injury with avulsion from spinal cord can be diagnosed by
• In upper plexus - additional paralysis of serratus anterior, levator scapulae, rhomboids
• In lower plexus - Horner's syndrome
• Other ways
• EMG: demonstration of denervation potentials in segmental paraspinal muscles
supplied by posterior rami
• Myelogram can demonstrate avulsion of roots (after 6-12/52 once blood clot
gone)
• Injuries to trunks, produce same injury patterns as injuries to roots apart from above
findings
Approach to examination [Further details]
• Ask about area of sensory deficit (feels funny/reduced/numb/dead) & let patient draw distribution
on a diagram
• Look for joint stiffness or contractures -> negate tendon transfers
• Test motor power
• Start proximally to distal in cord
• Upper proximal (preganglionic) lesion
• Long thoracic nerve -> serratus anterior - winging of scapula
• Nerve to rhomboids - retropulse shoulder
• Lower proximal (preganglionic) lesion
• Horner's syndrome - usually shows up 3-4/7 after injury
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Orthopaedi UI
• In obstetric brachial plexus palsy

• Ipsilateral foot may be small due to hemicord injury
• Shoulder may be subluxed due to internal rotation deformity (may require subscapularis
lengthening)
• Upper plexus (Erb's)
• C5 & C6 +/- C7 deficits
• Common football tackling injuries
• Attitude: waiter's tip deformity
• Limb
• Flaccid at side of trunk
• Extended at elbow
• Adducted
• Internally rotated
• Wrist
• Pronated
• Flexed
• Fingers flexed
• Motor
• Abduction of shoulder impossible - due to paralysis of deltoid, supraspinatus
• External rotation of shoulder impossible - due to paralysis of infraspinatus & teres
minor
• Active flexion at elbow impossible - due to paralysis of biceps, brachialis,
brachioradialis
• Supination of forearm impossible - due to paralysis of supinator
• Sensation absent over deltoid, lateral aspect of forearm & hand
• Lower plexus (Klumpke's)
• C8 & T1 +/- C7 deficits
• Often caused by penetrating wounds, difficult births, falls onto outstretched arm, trauma
from crutches
• Wasting of intrinsic muscles including thenar & hypothenar groups
• Claw hand deformity
• Weak intrinsics of hand, paralysis of wrist & finger flexors
• Sensory deficit over medial aspect of arm, forearm & hand
• Cord injuries produce regular patterns according to nerves branching from each cord
Studies
• CXR - elevated hemidiaphragm from phrenic nerve injury

• C-spine X-ray - associated C-spine #, transverse process # -> likely root avulsion
• Arteriogram
• CT myelogram (rarely need to get myelograms)
• May be used to help diagnose preganglionic lesion
• Should be delayed 6-12/52, since clot of blood may occlude opening of
pseudomeningocele
• Finding of a large diverticula or meningocele diagnostic for preganglionic root avulsion
• MRI
• T1 highlights fat content of cervical spinal cord & nerve roots (empty sleeves)
• T2 highlights water content (present in pseudomeningocoele)
• Findings
1. Pseudomeningocoele
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2. Empty root sleeves

3. Cord shift away from midline
• EMG
• Perform at 3-4/52 (look for F wave)
• Preganglionic lesion -> denervating potentials in segmental paraspinal muscles
innervated by posterior primary rami
• Sensory & motor evoked potentials
• More useful than EMG
• Perform at 3-6/52 to allow wallerian degeneration to occur
Treatment
• Even with total clinical plexopathy, <24% have avulsion of all 5 roots -> some function can be
restored
• A reverse relationship between time from injury to operation & outcome
• Open injuries
• Often a/w injuries to vessels, mediastinum or thorax therefore brachial plexus injury
needs to be delayed
• Immediate exploration indicated in penetrating/iatrogenic injuries
• Closed injuries
• Physiotherapy to keep joints mobile
• Perform EMGs at 3-4/52 after injury to determine extent of injury
• Myelography &/or axon reflex tests performed if no return of function at 6-8/52
• Preganglionic injuries will not recover & do not warrant exploration
• Postganglionic injury
• Explore at 3-6/12 after injury
• Total/near-total plexus involvement or high energy trauma
• Early surgical intervention (3/52-3/12)
• Recovery in this situation improved by neurological repair or reconstruction
• Partial upper level palsy &/or low energy trauma
• Delayed surgical intervention (3-6/12)
• Observe for recovery - advancing Tinel's sign
• Surgery if recovery plateaus early
• Presence of causalgic pain indicates poor prognosis
Surgery
• Surgery should be done within 1st 6/12 if possible

• Surgical goals/priorities
1. Restoration of elbow flexion (motor branch of musculocutaneous n.)
2. Restoration of shoulder abduction/stability (suprascapular & axillary n.)
3. Restoration of sensation to lateral border of forearm & hand (C6,7 - median n.)
4. Wrist extension & finger flexion
• Surgical techniques
o Incision as shown, may need to osteotomise clavicle
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Orthopaedi UI
• Use intraop nerve stimulation

• Primary nerve repair (neurorrhaphy) if nerve action potential obtained
• Neurolysis
• Nerve grafting if nerve integrity lost or no nerve action potentials
• Common sources: sural, vascularised ulnar
• Graft reversed so that all regenerated axons from proximal anastomosis will
reach distal anastomosis
• Neurotization (nerve transfer)
• If insufficient number of proximal axon resources
• Common sources: spinal accessory, phrenic, intercostal, motor branches of
cervical plexus, contralateral C7 (loss of sensation over thumb & index finger,
triceps weakness)
• In root avulsions of upper plexus, use intercostal nerve to musculocutaneous
nerve to gain elbow flexion
• Postop
• Splintage of shoulder
• Wait 12-18/12 to determine amount of regeneration
Salvage procedures
• No recovery 2 yrs post-injury

• Tendon transfers
• Shoulder
• Saha
• Trapezius to deltoid for abduction of shoulder
• L'Episcopo
• Teres major to a lateral position -> lateral rotator of shoulder
• Modified L'Episcopo involves additional transfer of latissimus
• Zancolli
• Transfer of only latissimus, passing it around humerus under deltoid
through quadrilateral space
• Elbow flexion
• Latissimus dorsi transfer
• Pectoralis major transfer (Clark)
• Triceps
• Sternocleidomastoid
• Steindler flexorplasty - flexor pronator mass transfer
• Free muscle transfer, eg. gracilis transfer for elbow flexion
• Joint fusions, eg. shoulder fusion useful if scapulothoracic function preserved
104
Orthopaedi UI
• Osteotomy, eg. proximal humeral osteotomy - will bring distal segment out of severe internal
rotation
• Amputation (rare)
Results of treatment
• No blanket statements possible, but

• If no EMG abnormalities at 3/52, prognosis good if treated nonsurgically (Barnes)
• Better results with infraclavicular injuries than supraclavicular injuries
• The fewer the avulsed roots the better
• Results of nerve transfer mixed
Also see
• Current Status of Brachial Plexus Surgery by Robert Boome

• Birth Injuries
SUPRASCAPULAR NERVE
Anatomy
• From upper trunk of brachial plexus

• Posterior triangle of neck
• Passes below transverse scapular ligament
• Supplies supraspinatus & infraspinatus
Causes of damage
• Penetrating trauma
105
Orthopaedi UI
• Cancer surgery
• # scapula
• Anterior dislocations of shoulder
• Entrapment in suprascapular notch
• Space occupying lesions in spinoglenoid notch (ganglia)
Clinical
• Pain in shoulder & weakness of shoulder girdle

• Wasting of infraspinatus +/- supraspinatus
Tests
• EMG
Results of suture
• No conclusive reports
Salvage procedures
• Transfer of latissimus dorsi or teres major or both
LONG THORACIC NERVE

Anatomy
• C5,6,7
• Supplies serratus anterior
Causes of damage
• Sharp or blunt trauma, traction injury when head forced acutely away from shoulder, shoulder
depressed
Clinical
• Inability to fully flex or abduct shoulder

• Winging of scapula
106
Orthopaedi UI
Treatment
• If stretched not severed, immobilise shoulder with arm against chest, resolves 3-12/12
• If severed, or paralysis persists, will need reconstruction
Salvage procedures
• Teres major transfer from humerus to 5th & 6th ribs

• Transfer of coracoid insertion of pectoralis minor to vertebral border of scapula
• Transfer of pectoralis minor to distal 1/3 of scapula
AXILLARY NERVE
Anatomy
• C5,6
• Branch of posterior cord of brachial plexus
• Winds around neck of humerus
• Through quadrilateral space
• Supplies deltoid & teres minor + skin of sergeant stripes area
Causes of injury
• # & #-dislocations of shoulder

• Penetrating wounds
• Direct blows
107
Orthopaedi UI
Clinical
• Loss of deltoid function

• Usually causes inability to actively abduct shoulder (but full abduction can sometimes be possible
due to action of supraspinatus & rotation of scapula)
• Palpate deltoid during testing
Results after injury
• If closed, signs of return of function may not be present for 3-12/12

• No info on results of suturing
Salvage techniques
• Trapezius transfer (Bateman), acromion attached to humerus

• Followed by immobilisation for 8/52
MUSCULOCUTANEOUS NERVE
Anatomy
• C5,6
• Branch of lateral cord of brachial plexus
• Supplies biceps, coracobrachialis & brachialis & skin (lateral cutaneous nerve of forearm)
Causes of injury
108
Orthopaedi UI
• Most commonly penetrating injury, but occasionally # or dislocation of shoulder
Clinical
• Injury can be overlooked as sensory loss ill-defined & flexion of elbow by brachioradialis may
compensate
• Feel for flexion of biceps
Results after injury
• Good results after repair
Salvage to restore elbow flexion
• Flexorplasty
• Anterior transfer of triceps tendon
• Transfer of pectoralis major
• Transfer of sternocleidomastoid
• Transfer of pectoralis minor
• Transfer of latissimus dorsi
RADIAL NERVE INJURY & TENDON TRANSFERS

Anatomy
• See Nerve Compressions

• Motor to triceps, supinators of forearm, extensors of wrist, fingers & thumb
• Sensation to dorsal aspect of radial 3½ digits
109
Orthopaedi UI
Causes of injury
• # of humeral shaft
• Lacerations, gunshot wounds
• Prolonged local pressure (Saturday night syndrome)
• For entrapment syndromes, see Nerve Compressions
Clinical
• Radial nerve lesions

• Inability to extend elbow, supinate forearm, wristdrop
• Reduced sensation over 1st dorsal interrosseous muscle
• Posterior interrosseous nerve lesions
• As nerve supply to ECRL & brachioradialis are intact, able to supinate & extend wrist
(with radial deviation) but unable to extend MCP joints
• No sensory loss
Management
• Blunt injury
• Observe & splint & passive motion of joints
• Explore & suture if no sign of improvement
• Open injury - explore & suture
Results of suture
• 89% will obtain function of proximal muscles

• 63% will obtain useful function of all muscles supplied
110
Orthopaedi UI
• 36% will obtain fine control of of extensors of fingers & thumb

• Critical limit of delay of suture: motor function not to be expected if suture delayed for >15/12
Salvage procedures
• Tendon transfers (Jones/Brand/Tsuge)
Wrist extension Pronator Teres to ECRB

MCP joint extension FCR/FCU to EDC or FDS to EDC
Extension & abduction of thumb PL rerouted to EPL
• Try to retain FCU which is important as wrist tends to work best in radial dorsiflexion & ulnar
palmar flexion
• Usually done after 6-12/12
• >1 yr - no exploration of nerve; tendon transfer as motor end plates degenerated
111
Orthopaedi UI
MEDIAN NERVE INJURY & TENDON TRANSFERS

Anatomy
Clinical
• Lower median nerve at distal forearm & wrist

• Wasting of thenar eminence +/- ulceration
• Loss of abductor pollicis brevis, & at least some loss of flexor pollicis brevis, causing
weakness of thumb abduction & opposition
• Altered sensation palmar aspect of radial 3½ digits
• May be some sensory sparing if lesion distal to palmar cutaneous branch
• Higher median nerve
• As above plus ...
• Loss of flexion of IP joint of thumb (FPL)
• Loss of flexion of index & middle fingers (FDP & FDS) - Pointing finger sign
• Altered sensation over thenar eminence
Management
• If closed
• Observe, splint & passive movement
• If no improvement, explore after NCS
• If open
• Explore
• If no improvement despite above, consider tendon transfers
112
Orthopaedi UI
Salvage procedures
• Low median nerve

• Thumb opposition (loss of FPB) (note thumb opposition is combination of flexion &
adduction)
• Ring finger FDS transfer to APB via a pulley made in FCU tendon at level of
pisiform
• MCP +/or IP joint fusion
• For decreased sensation
• Neurovascular island graft from ulnar side of ring finger to thumb
• High median nerve
For index & middle FDP of index & middle finger sutured side to side to FDP of ring & little
finger flexion fingers, +/- ECRL tendon transfer to FDP for extra strength
For flexion of IP joint of
Brachioradialis transfer to FPL
thumb
For thumb opposition Extensor indices transfer to abductor pollicis brevis
For decreased
A neurovascular island graft as above
sensation
ULNAR NERVE INJURY & TENDON TRANSFERS

Anatomy
• See Nerve Compressions
113
Orthopaedi UI
Clinical
• Wasting of hypothenar eminence & dorsal interrossei +/- ulceration & ulnar side of forearm if
proximal
• Clawing of hand - hyperextension of MCP joints, flexion of IP joints due to loss of function of
interrossei & lumbricals (remember ulnar paradox - more so in more distal lesion as FDP intact
therefore exacerbating deformity)
• Weakness of abduction & adduction of fingers
• Froment's sign
• Reduced sensation ulnar 1 1/2 digits
Treatment
• Closed injury
• Observe, splint, physio
• If no improvement explore & repair
• Open injury - explore & repair
Salvage treatment
• Low ulnar nerve
114
Orthopaedi UI
If Jeannes sign +ve (hyperextension of MCP joint of thumb on pinch)

indicating involvement of FPB -> Ring finger FDS transfer to APB via a
For adductor pollicis & pulley made in FCU tendon at level of pisiform
FPB (thumb
opposition)
If FPB working & adductor not -> use extensor indices transfer through
interosseous membrane to adductor pollicis
To restore MCP joint flexion & interphalangeal joint extension
For loss of action of • Split tendon transfers of FDS +/- EIP & EDQ, to radial dorsal
interossei & ulnar 2 extensor apparatus (tenodesis procedures), or
lumbricals • Stabilise MCP joint with Zancolli capsulodesis where volar
capsule is tightened to produce slight flexion of MCP joint
• High ulnar nerve

• As above + for loss of FCU - use ECRL transfer for power
COMBINED MEDIAN & ULNAR NERVE LESIONS
• Low
Brands ECRB graft with a plantaris graft to

For function of interossei & lumbricals, to restore
increase length, attached to insertion of
flexion of MCP joint & extension of IP joints
intrinsics
Thumb opposition FDS (ring finger) via FCU pulley to EPL
Thumb adduction Extensor Indices to adductor pollicis
• High
Thumb Arthrodesis of thumb MCP joint (& ? IP joint)

For loss of long flexors & interossei Zancolli Capsulodesis of MCP joints, ECRL to FDP, BR to FPL,
& lumbricals ECU (with free graft) to EPL
DIGITAL NERVE INJURY

Incidence
• Distal to wrist
• Most common nerve injuries
Anatomy
115
Orthopaedi UI
• Most important digital nerves to repair

• Thumb ulnar digital nerve
• Index, middle, ring & little finger radial digital nerves
• Ulnar digital nerve to little finger
Repair technique
• Repair tendons 1st to avoid disruption of nerve repair

• Use 8-0 or 9-0 nylon epineurial repair with 4 sutures
Aftertreatment
• Splint finger in position of minimal tension for 3/52
Tendon transfers - summary table

Low injury (wrist) High injury (elbow)
MEDIAN NERVE
Thumb opposition (loss of FBP) (note thumb opposition = Index & middle finger flexion
combination of flexion & adduction)
• FDP of index & middle finger
1. Ring finger FDS transfer to APB via a pulley made in sutured side to side to FDP of ring
FCU tendon at level of pisiform [Picture] & little fingers
2. MCP +/or IP joint fusion • +/- ECRL tendon transfer to FDP
for extra strength
Flexion of IP joint of thumb
• Brachioradialis transfer to FPL
Thumb opposition
• Extensor indices transfer to

abductor pollicis brevis
ULNAR NERVE
Adductor pollicis & FPB (thumb opposition) Loss of FCU
1. Absent FPB = ring finger FDS transfer to APB via a • Use ECRL transfer for power
pulley made in FCU tendon at level of pisiform
[Picture]
2. If FPB working & adductor not = extensor indices
116
Orthopaedi UI
transfer through interosseous membrane to adductor

pollicis
Loss of action of interrosei & ulnar 2 lumbricals
1. Split tendon transfers of FDS +/- EIP & EDQ, to

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

For function of interrossei & lumbricals - to restore Very difficult problem
flexion of MCPJ & extension of IPJ
For function of long flexors &
• Brands ECRB graft with a plantaris graft to increase interrossei & lumbricals - to restore
length, attached to insertion of intrinsics flexion of MCPJ & extension of IPJ
• Zancolli capsulodesis of MCP

Thumb opposition joints, ECRL to FDP, BR to FPL,
ECU (with free graft) to EPL
• FDS (ring finger) via FCU pulley to EPL
Thumb fusions
Thumb adduction (pinch)
• EIP to adductor pollicis
RADIAL NERVE
Radial wrist extensors functioning
• Wrist extension
• Pronator Teres to ECRB
• MCP joint extension
• FCR/FCU to EDC or FDS to EDC

• Extension & abduction of thumb
• PL rerouted to EPL
• If radial nerve might still recover, keep EP
117
Orthopaedi UI
SHOULDER
Sprengel's shoulder
• Scapulae normally complete decent from C5 to T5 by 3rd month of foetal life
• Arrest of decent may occur due to either fibrous or bony tissue
• Undescended scapula
• Often a/w hypoplasia of affected side
• Usually shaped like an equilateral triangle in a mal-rotated position with glenoid facing
down decreasing range of abduction
• Associated with
• Deformities of cervical spine common
• Klippel-Feil syndrome, kidney disease, scoliosis, & diastematomyelia
• Classification
• Grade 1: (very mild) shoulders are level & deformity is minimal when patient is dressed
• Grade 2: (mild) shoulders are almost level & deformity is a lump in web of neck
• Grade 3: (moderate) shoulders are elevated 2 to 5 cm & deformity is easily visible
• Grade 4: (severe) shoulders are quite elevated, superior angle scapula is near occiput
• Clinical
• Shoulder on affected side is elevated usually between 2 & 10 cm
• Scapula looks & feels abnormally high
• Also smaller than normal & more prominent
• Shoulder movements, especially abduction may be restricted due to loss of scapulo-
o o
thoracic motion (1 of upward rotation of scapula occurs with 2 of abduction of humerus)
• 15% bilateral
• X-rays
• Associated with deformities eg. fusion of cervical vertebrae, kyphosis, scoliosis
• May be a bony bridge between scapula & cervical spine (omovertebral bone)
• Rx
• Only required if shoulder function is impaired or deformity is particularly unsightly
• Surgery
• Involves releasing vertebroscapular muscles from spine, excising supraspinous
part of scapula along with omovertebral bar
• Scapula is then repositioned by tightening lower muscles (Woodward Procedure)
• Best performed before age of 6 yrs
Left Sprengel Shoulder Bilateral Sprengel Shoulders
118
Orthopaedi UI
Madelung’s deformity
• Abnormal growth of distal radial epiphysis with premature fusion of ulnar & volar half
• Articular surface is directed ulnarward & volarward
• 1st described by Madelung, who described a painful wrist deformity in a young woman in 1878
• Can be congenital or post traumatic
• May be a/w dysplasias, Turner syndrome, Langer syndrome
• M:F = 1:4
• Bilateral in 2/3
• Clinical
• Presents in adolescence -> median nerve irritation, wrist pain
• Characterized by insidious onset of pain in one wrist, then in other, & increasing
prominence of dorsal ulnar head & bowing of distal radius
• Worsens with growth
• Pain from radioulnar subluxation or radiolunate impingement usually becomes less
severe at maturity
• Wrist motion, particularly extension & supination, is limited
• Radiographic
• Increased width between distal radius & ulna
• Relatively long ulna compared to radius (+ve ulnar variance)
• Decreased carpal angle
• Triangularization of distal radial epiphysis
• Wedging of carpus between deformed radius & protruding ulna, with lunate at apex of
wedge
• Rx
• Observation is indicated early on, especially if patient is asymptomatic
• Ulnar shortening +/- dorsal radial closing wedge osteotomy for severe cases
• Darrach procedure
• Excellent relief of symptoms, but carries problem of ulnar translation of
carpus
• Closing wedge osteotomy of radius & shortening osteotomy of ulna, with
conservation of DRUJ
• At late follow-up (9.7 yrs) function was considerably improved
• Arthrodesis is considered if carpus subluxates off radius
119
Orthopaedi UI
• See eHand for clinical example
Hand Fractures
Epidemiology
• 10% of all #
• Incidence
• P3 45%
• MC 30%
• P1 15%
• P2 10%
• Border digits most common
General Principles
Initial Evaluation
• Consider injury in relation to patient's needs & lifestyle

• Age
• Hand dominance
• Occupation
• Hobbies
• Financial issues
• Precise details about injury
• Mechanism of injury
• Crushing, tearing, or twisting injury or clean laceration or human bite
• Where
• How much time has elapsed
• What has been done
• Physical exam
• Greatest pitfalls: to focus on obvious # & overlook more subtle but often more significant
damage to soft tissues
• Rotational & angular deformity
• Injury to adjacent tendons, nerves, & blood vessels
• Open wound
• Digital viability
• Neurological status (2-point discrimination & individual muscle testing)
• ROM
• May not be possible without local or regional anesthesia
X-rays
• At least 3 views: PA, lateral, & oblique

• Oblique films helpful in intra-articular #
• For finger injuries, true lateral view of individual digit mandatory
120
Orthopaedi UI
Treatment
• Principles
1. #
• Restoration of articular anatomy & elimination of angular or rotational deformity
• USE LEAST INVASIVE TECHNIQUE CONSISTENT WITH NECESSARY
STABILITY
2. Elevation of entire extremity to limit edema
3. Immobilization in intrinsic plus position
4. Early mobilization
• Extra-articular #
o Undisplaced & stable
• Protection, not immobilization (cast, cast with outrigger, gutter splint, AP splints)
• Active ROM exercises
o Displaced
• CR
• If acceptable alignment & stable -> external immobilization (splint or cast)
• If # can be reduced but unstable -> percutaneous pinning (CRIF)
• If # cannot be reduced by CR -> ORIF
• Intra-articular #
• Undisplaced
• Guarded & protected early ROM exercise
• Immobilization often leads to stiffness due to intra-articular adhesions
• Displaced
• Goal of Rx: anatomic restoration of joint surface by ORIF
• Intra-articular # not requiring anatomic reduction: mallet # & comminuted
#-dislocation of finger CMCJ
• Severe comminution precluding ORIF -> mini external fixation or dynamic traction
• Immobilization
• Wrist in 30° of extension & hand in intrinsic plus position, ie. MCPJ in full flexion & IPJ in
full extension
• Maintains intrinsics in relaxed position

• Prevent joint contractures
• MCPJ collateral ligaments are stretched to maximum length
• PIPJ more likely to become stiff in flexion
121
Orthopaedi UI
• Sufficient to immobilize only injured finger, but rotational alignment usually easier to
control if an adjacent normal finger incorporated
• Do not immobilize uninvolved joints
• Amputation
• An isolated # virtually never an indication for amputation
• Severe crush injuries with damaged tendons, nerves, & blood vessels in addition to bone
-> may be Rx of choice
Follow-Up Care & Healing Time
• Patients seen periodically to be instructed in specific exercises to minimize joint stiffness & to
regain full active motion
• Immobilization should not be continued until consolidation visible radiographically
• "Roentgenographic" healing: 5/12 (1-17/12)
• "Clinical" healing: 3-4/52
• Except mallet & boutonniere chip #, rarely necessary to immobilize >3/52
• Open # do not heal as rapidly as closed #; however, external immobilization should rarely be
continued >4/52
Results of injuries
• Injury dependent - timing, clean/dirty, skin loss, tendon integrity, skeletal injury, NV zone, crush
• Patient dependent - age, job, hobbies, smoker, drugs (coffee), hand dominance, motivation,
medical condition
• Rx dependent
Complications
• Soft tissue injury

• Most commonly due to crushing injuries -> soft-tissue damage -> massive edema
• Concomitant tendon damage -> adhesions
• Scarring -> intrinsic contracture of hand
• MCPJ & PIPJ stiffness
1. Improper immobilization of MCPJ in extension
2. Prolonged immobilization
3. Intrinsic contracture
4. Extrinsic contracture secondary to extensor tendon adherence
5. Varying degrees of hand dysfunction syndrome (RSD)
• Malunion
• Angulation
Disturb intrinsic & extrinsic muscle balance & cause pseudoclawing or painful
grip
• Rotational
Most common
• Non-union
• Uncommon
• Pin-tract infections
122
Orthopaedi UI
• Pins left in no longer than 4/52

• Avoiding skin tension at time of placement
• Bending pins outside skin to prevent migration
• Windowing cast over pins
• Antiseptic solution
• Posttraumatic arthritis
Open Fractures
Classification of Open Fractures in Hand
• Swanson, Szabo & Anderson

• Type I
• Clean wound without significant contamination
• No delay in Rx
• No significant systemic illness
• Type II (1 or more)
• Contamination with gross dirt/debtis, human or animal bites, warm lake/river
injury, barnyard injury
• Delay in Rx >24 hrs
• Significant systemic illness
• Type I
• Primary internal fixation or immediate wound closure not a/w increased risk of infection
• Type II
• Primary internal fixation not a/w increased risk of infection
Antibiotics
• Controversial
• Suprock. J. Hand Surg 1990, & Peacock. J. Hand Surg 1988
• Routine use of antibiotics not necessary in fingers having intact digital arteries
• Early aggressive local wound care important
• Recommendation
• Type I: no antibiotic
• Type II: cefazolin
• Severe crush or massive soft-tissue injury: add aminoglycoside
• Bite wounds & barnyard injuries: add penicillin
Massive Hand Trauma & Multiple Fractures

• Early skeletal alignment critical
• Provides enough stability to allow early motion & thereby minimize stiffness
• Maintenance of thumb-index web space
123
Orthopaedi UI
• K-wires from base of thumb MC into carpus or base of 2nd MC while thumb held in full
palmar abduction
• Primary wound closure
• High-velocity missile wounds, severe crush injuries, bite wounds, & open wounds
untreated for >24 hrs contraindicated
• Edema
• Soft-tissue damage accompanying # in hand inevitably evokes marked edema
• Tendons, ligaments, & intrinsic muscles become bathed in protein-rich fluid, which rapidly
becomes transformed into tough, unyielding, fibrous tissue
• Bulky compressive dressing minimizes initial edema, & early movement pumps fluid out
of hand
• Risk of infection
• Minimized by careful debridement, copious irrigation, bulky sterile dressings, & 2nd look
2-5/7 later -> delayed primary closure or skin coverage
Distal Phalanx Fractures

Anatomy
• Extensor & flexor tendons that insert on base play no role in displacing #, except for avulsion
injuries
• Fibrous septa, which radiate from bone to insert into skin, probably stabilize #
Classification
• Kaplan: 3 general types

• Longitudinal: rarely show displacement
• Transverse: may show marked degree of angulation
• Comminuted
• Usually involve distal tuft of phalanx
• Most frequent type
• Most commonly a/w soft-tissue damage: laceration &/or avulsion of nail matrix
&/or pulp, subungal hematoma
Treatment
• Nondisplaced #
• Splint to relieve pain & protect tender fingertip
124
Orthopaedi UI
• Dorsal or volar splints, or hairpin splint or fingertip guard -> protection without
compressing soft tissues
• Immobilize only DIPJ & do not block PIP flexion
• Displaced #
• Immobilization not required to hold reduction except transverse angulated # -> external
splint or K-wire
• Displaced fragments of tuft # required no reduction
• Prolonged morbidity, especially with concomitant soft-tissue crush injury -> desensitization
• Nail bed injuries
• Evacuation of subungual hematoma markedly relieves pain
• Hot paper clip effective & relatively painless
• Battery-operated disposable cautery (Accu-Temp, Concept)
• Meticulous repair of nail bed minimizes late nail deformity
• Avulsed nail plate sutured back into place after repair of nail bed -> protective splint &
minimizes local tenderness
• ? Exploration of nail bed if subungual hematoma
• Simon & Wolgin
• Subungual hematoma >1/2 size of nail -> 60% nail bed laceration
• Associated P3 # -> 95%
Mallet Finger of Bony Origin (Mallet Fracture)

• Avulsion # of dorsal base of P3 -> mallet deformity
• Mx
• Controversial
• Splinting of DIPJ
• Regain better ROM (especially flexion) of DIPJ than ORIF
• ORIF
• Difficult
• Difficulty in exposure & reduction
125
Orthopaedi UI
• Fragmentation of small dorsal lip #

• Skin slough
• Loss of fixation
• Only indication: mallet # with marked volar subluxation of distal phalanx
Complications
• Chronic fingertip pain

• Numbness
• Cold sensitivity
• Hyperesthesia
• Loss of DIP motion
• Nail growth abnormalities
Proximal & Middle Phalangeal Fractures

Anatomy
• Unstable # of P1 typically recurvatum-type angulation (apex volar)

• Proximal fragment flexed by insertions of interossei into base of P1
• Distal fragment pulled into hyperextension by central slip acting on base of P2
• P2 # less common
• Central slip inserts into dorsum of base & extends P2
• Superficialis divides into halves, each half turning 90° to allow profundus to pass through
& then completing another 90° rotation to insert in to nearly entire volar surface of P2
• # through neck -> volar angulation because proximal fragment flexed by superficialis
• # through base -> dorsal angulation because of extending force of central slip on
proximal fragment & flexing force on distal fragment by superficialis
• # through middle 2/3 may be angulated in either direction or not at all
• Malrotation most frequent Cx
• Flexed fingers, do not remain parallel as in full extension, but point generally in direction
of scaphoid tubercle
• With fingers only semiflexed, use planes of fingernails as additional guide
126
Orthopaedi UI
Treatment
Extra-articular #
• Undisplaced & impacted transverse # in satisfactory alignment

• Protection using buddy taping
• Follow up after 1/52
• Displaced extra-articular #
• Under regional anesthesia, CR & X-rays
• Acceptable alignment & stable -> external immobilization (splint or cast)
• # reduced but unstable -> percutaneous pin fixation (CRIF)
• # cannot be reduced -> ORIF
• Transverse # at base of P1
• Burkhalter's method of hyperflexion of MCPJ & active motion of PIPJ
• If reduction cannot be held with splint -> closed intramedullary pinning
• Spiral oblique # of P1
• Inherently unstable & usually requires internal fixation
• If satisfactory reduction with CR (longitudinal traction combined with PIP flexion,
taking care to correct rotational alignment) -> closed pinning of #
• If # cannot be reduced satisfactorily by CR -> ORIF
• Transverse # at neck of P1
• Angulation usually 60-90° (apex volar)
• Reduction easy to obtain but difficult to maintain
127
Orthopaedi UI
• CRIF, flexing PIPJ & passing K-wire either across or to side of PIPJ into
medullary canals of distal & proximal fragments
• Pin removed at 2-3/52 & motion at PIPJ begun
• Comminuted # of P1 & P2
• Commonly crushing injuries
• Stable internal fixation desirable to facilitate Rx of soft tissues
• Severely comminuted # best treated with external fixation
• Significant loss of bone -> delayed primary bone grafting
Intra-articular #
• Undisplaced intra-articular #
• Uncommon
• Guarded & protected early ROM exercise, using buddy taping
• Intra-articular adhesions -> early mobilization
• Displaced intra-articular #
• Anatomic restoration of joint surface by ORIF, particularly PIPJ & somewhat less so in
MCPJ
• Condylar #
• # of 1 or both condyles of P1 (ie, at level of PIPJ) always demands internal
fixation if >1 mm displacement
• Similar # at distal joint, involving P2
• CRIF or ORIF with multiple K-wires or AO minifragment screw
• Avulsion # at base of P1
• Small or nondisplaced fragments can be adequately managed by buddy taping
• Small fragments can either be fixed with TBW or excised & collateral ligament
reinserted into bone
• Larger displaced # -> restore congruity of articular surface by ORIF
• Avulsion # at base of P2
• 3 types
• Dorsal chip #, which represents an avulsion of bone by central slip of
extensor tendon -> boutonniere deformity
• Volar lip #
• Lateral chip #, representing avulsion of bone by collateral ligament
128
Orthopaedi UI
• Boutonniere deformity
• Caused by disruption of central slip of extensor tendon combined with
tearing of triangular ligament on dorsum of P2, which allows lateral
bands to slip below axis of PIPJ
• Without # should be treated closed, by splinting PIPJ in full extension for
5-6/52
• With a large displaced avulsion # -> ORIF
• Comminuted intra-articular & "Pilon" #
• Severely comminuted intra-articular # that involve either MCPJ or PIPJ often not
amenable to internal fixation
• If open reduction feasible -> often require combination of internal fixation,
external fixation, & bone grafting
• If comminution precludes ORIF -> mini external fixation or dynamic traction
Metacarpal Fractures
Anatomy
• MC slightly arched in long axis & concave on palmar surface

• Weakest point just behind head
• Proximal ends of 2nd & 3rd MC articulate with distal carpal row in immobile articulations; 4th &
5th limited AP motion
• Collateral ligaments of MCPJ are relaxed in extension, permitting lateral motion, but become taut
when fully flexed
129
Orthopaedi UI
• MCPJ immobilized in extension -> collateral ligaments allowed to shorten -> stiff
• Dorsal & volar interosseous muscles arise from shafts of metacarpals & act as flexors at MCPJ
Classification
• Head, ie. distal to insertion of collateral ligaments

• Neck
• Shaft
• Base
Fractures of Metacarpal Head
• 2nd MC head most frequently fractured

• MCPJ stiffness most common Cx
• If possible, intra-articular # should be reduced anatomically & fixed with small K-wires, AO
minifragment screws or condylar plate
• Severely comminuted intra- & periarticular # -> distraction view
• Improvement in articular surface -> external fixator or traction
• No improvement in articular alignment -> short period of splinting to alleviate pain,
followed by early active motion
Fractures of Metacarpal Neck
• Commonly 5th MC "Boxer's #"

• Typical angulation with apex dorsal
• Inherently unstable because of deforming intrinsic muscle forces & frequent comminution of volar
cortex
• Considerably more mobility in CMCJ of ring & small fingers -> significantly more residual
angulation can be tolerated
130
Orthopaedi UI
• 2nd & 3rd MC: 15

o
• 4th & 5th MC: 45

o
• Rotational malalignment never acceptable

• Rx
• No reduction with minimal immobilization
• Excluding # with rotational deformity, minimal splinting for pain relief & gradual
resumption of use of hand
• Recovery time significantly shorter but cosmetic deformity (loss of knuckle)
• CRIF
• CR & intramedullary fixation
• Passage of pins through extensor mechanism -> scarring of extensor
hood -> joint stiffness & loss of extension
• CR & transverse pinning
• Early motion without external splinting
• External fixation
• To maintain or restore length & alignment in severely comminuted #, especially
segmental bone loss
• ORIF with plate
Fractures of Metacarpal Shaft
• 3 important potential problems

• Shortening
• Dorsal angulation
• Rotational malalignment - usually interferes with normal flexion of adjacent fingers
• Minimal angulation can be accepted in 2nd & 3rd MC because no compensatory motion at CMCJ
compared to 4th & 5th
• 2nd & 3rd: 10
o
• 4th & 5th: 20 o
• Rotational malalignment never acceptable

• 3 types
• Transverse #
• CR & immobilization
• Burkhalter-type volar & dorsal splints
• Rotational alignment more easily maintained by including an adjacent
normal finger
• CRIF
• Transverse or intramedullary pinning or combination
• Transverse pinning to an adjacent metacarpal more applicable to border
MC
• ORIF
• Failed CR (rotational or angular deformity)
• Multiple #
• Concomitant soft-tissue injury
• Spiral oblique #
• At least 5 mm of shortening can be accepted without loss of function if no
angulation or rotational malalignment -> external immobilization
• Greater amounts of shortening, rotational deformity, multiple MC # -> ORIF with
K-wires, AO lag screws, or cerclage wiring
• Comminuted #
• Frequently a/w great deal of soft-tissue damage
131
Orthopaedi UI
• If undisplaced & sufficiently stable to allow early finger motion -> external
splinting
• More commonly, combination of internal & external fixation to facilitate Rx of
concomitant soft-tissue damage & to prevent skeletal collapse
Fractures at Base of Metacarpal
• Usually stable
• However, slightest rotational malalignment is greatly magnified at fingertip
Complications
• Soft tissue injury -> stiffness

• Malunion
• Angulation
• Always occurs with apex dorsal
• Disturb intrinsic & extrinsic muscle balance & cause pseudoclawing or painful
grip
• Rotational
• Likely to occur with # of border metacarpals
• More difficult to control when >1 metacarpal fractured
• Pin-tract Infections
First Metacarpal Fractures

Classification
• Type I: Bennett's #
• Type II: Rolando's #
• Type III: transverse or oblique #
• Type IV: epiphyseal injury in children
132
Orthopaedi UI
• Important to distinguish intra-articular from extra-articular #, as extra-articular # can be managed

adequately non-operatively
• Up to 30° of angulation of 1st MC base can be accommodated due large ROM at trapezio-
metacarpal joint
Bennett's Fracture
• A #-dislocation, 1st described by Bennett in 1882

• Mechanism of injury: axial blow directed against partially flexed metacarpal
• # line separates major part of metacarpal from a small volar lip fragment, which remains in
anatomical position because of strength of anterior oblique ligament (AOL)
• Remaining MC subluxates proximally, radially, & dorsally
• Displacement forces
• Distal MC fragment displaced proximally, radially, & dorsally by APL
• Displaced MC also rotated in supination by APL
• MC head displaced into palm by pull of Adductor Pollicis
• Volar # fragment remains attached to CMC by volar AOL; AOL anchors volar lip of MC to
tubercle of trapezium
• Pure dislocations very rare & need CRIF

133
Orthopaedi UI
• Concomitant # of trapezium seen with Bennett's # -> ORIF recommended

• Concomitant rupture of MCPJ collateral ligaments has been reported (& easily overlooked)
• Rx
• At least 20 methods have been advocated
• CRIF
• Apply gentle traction to 1st MC longitudinally with thumb adducted & then reduce
# by pushing base of 1st MC in palmar direction
• If thumb abducted -> gap at # site
• 2 percutaneous K-wires through base of 1st MC into either trapezium, trapezoid
or 2nd MC
• Hand then immobilised in POP cast for 4/52 followed by wire removal &
immobilisation
• Aim to reduce joint surface to <2 mm of displacement
• ORIF
• AO mini-screws, Herbert screws or K-wires
• Important technical point: screw diameter must not exceed 30% of cortical
surface of volar lip fragment
• Studies -> correlation between quality of reduction & likelihood of subsequent
arthritis, but no good correlation between radiographic evidence of arthritis &
significant symptoms
Rolando's Fracture
• In 1910, described by Rolando

• In addition to volar lip fragment, a large dorsal fragment present -> Y- or T-shaped intra-articular
#
• Rx depends on degree of comminution
• ORIF only if volar & dorsal fragments large enough
• ORIF alone may not be sufficient, experienced AO hand surgeons -> good results with
ORIEF (combination of ORIF, external fixation, & bone grafting)
• CRIF with K-wire fixation to 2nd MC
• Severely comminuted # in which joint surface is not significantly improved on X-ray taken
in traction, immobilise thumb for a minimal period to relieve pain & then begin early active
motion
• Significant comminution is a definite contraindication to operative Rx of this injury
134
Orthopaedi UI
Extra-articular Fractures
• 2 basic pattern: transverse # & less common oblique #

• Rx
• Anatomic reduction can usually be achieved readily by CR
• Even with 20-30° of residual angulation, usually n o detectable limitation of motion
• Thumb immobilized in short-arm thumb spica cast for 4/52
• Avoid hyperextension of MCPJ in plaster
• Occasionally, oblique type somewhat unstable -> percutaneous pinning
Acute Wrist Trauma

'Sprained wrist does not exist'
• It is a diagnosis made in retrospect, after 2 sets of X-rays 2/52 apart (& bone scan if still
symptomatic)
• Always examine carefully for carpal instability & look for occult #
CARPAL INJURIES
135
Orthopaedi UI
GREATER ARC INJURIES
• A perilunate injury that involves # of 1 or more carpal bones

1. Trans-scaphoid perilunate dislocation (De Quervain's injury)
2. Trans-capitate perilunate dislocation
3. Other # combinations involving scaphoid, capitate, triquetrum
• Scaphoid waist # is a definite indication for ORIF
o Because there may be torn ligament or capsule within # gap
o = 50% non-union
•
o
# of neck of capitate can rotate head 180 - often overlooked & needs ORIF
LESSER ARC INJURIES
• Lesser arc injury involves only intercarpal & extrinsic ligaments without an associated #
1. Perilunate dislocation
2. Lunate dislocation
• Perilunate & lunate dislocations are thought to be 2 stages of same process
• Displaced lunate does not always cause compression of median nerve or lead to AVN of lunate
(a flap of capsule remains attached)
• Rx
• Aim: to reduce dislocation & avoid late carpal instability (very common)
• Exact reduction
• Open reduction usually required
• Often need dorsal + volar approach
• Reduce lunate
• Reduce scaphoid & lunate with wire joysticks
• Fix with K-wires across scapho-lunate joint
• Repair ligaments as best as possible
• Note - no good literature to show that this is better than closed reduction & plaster!
INFERIOR ARC INJURIES
• Propagates through radiocarpal joint, instead of traversing carpus

• Volar or dorsal extrinsic radiocarpal ligaments may be disrupted, or radial styloid # may occur
• Potentially unstable
DRUJ
• Articulation between sigmoid notch of radius & ulnar head

• Separated from radiocarpal joint by TFCC
136
Orthopaedi UI
• Stability depends on
• TFCC mainly
• ECU sheath
• Interosseous membrane
• Pronator quadratus
• Bone shapes
• Compressive load across wrist
• 80% through radiocarpal joint, 20% ulnocarpal
• With change in ulnar variance, force distribution may vary
• Supination/pronation occurs by rotation of radius about fixed ulna through DRUJ
• Ulnar variance
• Relative lengths of ulna & radius
• More +ve with forearm pronation & power grip
TRIANGULAR FIBROCARTILAGE COMPLEX TEARS
• Anatomy
• Arises from ulnar edge of lunate fossa of distal radius & attaches to fovea at base of ulnar
styloid
• Triangular fibrocartilage complex comprises
1. Triangular fibrocartilage disc
2. Volar & dorsal radioulnar lig.
3. Ulnar collateral lig.
4. Ulnolunate lig.
5. Ulnotriquetral lig.
6. Meniscus homologue
• Volar & dorsal radioulnar ligaments form periphery of TFCC & well vascularised
• Central articular disc portion avascular
• Classification
• Class 1 - traumatic TFCC tears
• Class 2 - degenerative TFCC tears (ulnocarpal impaction syndrome)
• Peripheral tears
• Usually post-traumatic
• Acute axial loading injury combined with forced forearm rotation
• Occur at
1. Insertion of TFCC into sigmoid notch of radius
2. Insertion into base of ulnar styloid process
3. Dorsal & volar radioulnar ligaments (palmar & dorsal edges of TFCC)
137
Orthopaedi UI
• Central tears
• = degenerative
• Due to chronic ulnocarpal abutment or impaction
• Found with ulnar +ve variance TFCC tear
• Also known as 'Ulnar Impaction'
• Clinical
• Ulnar wrist pain & tenderness
• Pain with rotation in ulnar deviation
• Forced ulnar deviation causes pain
• Ix
• X-ray - ulnar +ve variance
• Arthroscopy - Trampoline & Syringe tests
Arthrography - dye leaks between radiocarpal & radioulnar joints
• MRI - high accuracy

• Rx
• Traumatic tears
• Immobilisation & NSAIDs initially
• Central: arthroscopic debridement
• Periphery detachment: arthroscopic or open repair (difficult)
• Chronic
• Splintage, NSAIDs & steroid injections initially
• Ulnar shortening for ulnar impaction syndrome
• Wafer procedure - trim distal end of ulna below TFCC (2-4 mm)
• Diaphyseal ulnar shortening with osteotomy of ulna shaft
• Suave-Kapandji if DRUJ arthritis
DRUJ INSTABILITY
• ROM of pronation-supination is compromised by pain due to DRUJ instability so that hand is
unable to work with its normal function & strength
• Injury to TFCC is a necessary part of this injury
• Causes
• Acute
• Isolated TFCC injury
• Associated with #
• Galeazzi #
• Colles #
• Radial head # (as a part of an Essex Lopresti injury)
• Chronic
• RA
• Malunion distal radius #
• Mechanism of injury
• Dorsal subluxation
• Most common
138
Orthopaedi UI
• Results from fall on pronated hand

• Manifested by prominece of ulnar head & loss of supination
• DRUJ which cannot be closed reduced may have entrapment of extensor
tendons (ECU)
• Volar subluxation
• Results from forced supination
• Clinical
• Differentiate from generalized laxity by examing contralateral wrist
• Limited & painful rotation
• Supination is blocked by dorsal dislocation
• Pronation is blocked by palmar dislocation
• Instability - piano key sign
• ECU subluxation elicited when wrist is held in ulnar deviation & wrist is supinated
• Radiographic diagnosis
• X-rays features suggestive of instability
• Widening of DRUJ on AP view
• # (or nonunion) at base of ulnar styloid
• Significant shortening of radius
• Obvious dislocation on lateral view
• CT scan
• Study of choice for instability
• Will also reveal joint incongruity
• Rx of dorsal instability
• Acute instability
• Reduction with supination & direct pressure
• Percutaneous pin fixation if unstable
• Above elbow cast for 4-6/52
• Chronic instability
• Non operative - forearm & elbow immobilization which limits pronation &
supination
• Dorsal capsulodesis with either local tissue or tendon graft (palmaris longus)
• A radio-ulnar sling using a tendon graft also effective
• Consider use of a distally based FCU strip or a proximally based ECU strip
• Ulnar shortening
• Ulnar head excision - Bower's, Darrach
• Fusion - Suave-Kapandj
Carpal Instability
Definition
• Situation where normal alignment of carpal bones is lost

• Carpal instabilities lead to abnormal positioning or alignment of carpal bones by #, ligament
injury, or both
Carpal Anatomy
139
Orthopaedi UI
• 2 carpal rows
1. Distal
• Trapezium, trapezoid, capitate, hamate bound together by strong interosseous
(intrinsic) ligaments to form distal row, which moves together as a single unit
2. Proximal
• Scaphoid, lunate & triquetrum form proximal row
• It has no muscle attachments & is inherently unstable in compression without its
ligamentous attachments
• Acts as a link between relatively rigid distal row & radioulnar articulations
• Intrinsic ligaments
o Origin & insertion within same carpal row
o Distal row
• Bind all distal carpal bones together
o Proximal row
• 2 ligaments dorsally
1. Scapholunate ligament
2. Lunotriquetral ligament
• Extrinsic ligaments
o Volar
• Stronger
• Arranged in 2 distinct "V" shapes centred on lunate & capitate
• Weak area at capitolunate articulation: space of Poirier -> lunate/perilunate
dislocation
• Radioscapholunate ligament is now known to be a vascular pedicle rather than a
true ligament
• Dorsal
• Weaker & centred on triquetrum
• 2 ligaments
1. Dorsal radiocarpal ligament
2. Dorsal intercarpal (trapezoidal-triquetral) ligament
140
Orthopaedi UI
Kinematics
• 3 axes of motion
• FE: 90-70 (flex/ext split between radiocarpal & midcarpal)
o
• RUD: 20-50
o
• PS: 90-90
o
• Theories
• Rows
• Proximal & distal with scaphoid as a bridge
• Motion within & between rows
• Columns (Navarro)
• Central (flex/ext): lunate, capitate, hamate
• Lateral (mobile): scaphoid, trapezoid, trapezium
• Medial (rotation): triquetrum
• Oval ring
• Longitudinal columns (Weber)
• “Link Joint”
141
Orthopaedi UI
• Radial deviation: scaphoid flexes -> proximal pole goes dorsal “pulling” lunate into palmar flexion
• Ulnar deviation: scaphoid extends -> proximal pole goes volar "pulling" lunate into dorsiflexion
• Force transmission
• Principal force transmission through capitate, lunate & proximal pole of scaphoid
• 80% through radiocarpal joint, 25% ulnocarpal
• With change in ulnar variance, force distribution may vary
Clinical Features
• History
• Fall on outstretched hand
• Often presents late as sprained wrist which fails to resolve
• Examination
• Detailed palpation of all landmarks
• Grip strength often diminished
• Special tests
• Scapholunate ballotment
• Kirk-Watson’s test
• Lunotriquetral ballotment
• Reagan’s with 2 hands
• Kleinman’s with 1 hand (thought to be more sensitive)
Investigations
• X-ray
• Views
• PA & lateral (wrist must be neutral)
• Clenched fist PA & lateral
• Ulnar deviation
142
Orthopaedi UI
• Radial deviation
• Oblique
• Opposite extremity
• What to look for?
• PA
• Carpal bones
• Loss of relationship: Gilula's arc
• Loss of carpal height
• SL gap: normal <3 mm
• Cortical ring sign
• V sign of Taleisnik
• # or nonunion
• Distal radius anatomy

• Ulnar variance
• Lateral: carpal angles
• Static instability, if present, will show up on X-ray
• Dynamic instability may not be seen even on clenched fist view
• MR/CT/dynamic fluoroscopy/arthrography may be of value in limited circumstances
• Arthroscopy
• Direct visualisation of radiocarpal & midcarpal joints gives a good picture of instability as
ballotment tests can be performed whilst watching carpal bones but carpus is not under
physiological loads
• Detects ligament tears, TFCC, articular cartilage injuries
143
Orthopaedi UI
Carpal Angles
• With wrist in neutral position, longitudinal axes of long finger metacarpal, capitate, lunate, &
radius in normal wrist all fall on same line - a line drawn through center of head of 3rd MC, center
of head of capitate, midpoints of convex proximal & concave distal joint surfaces of lunate, &
midpoint of distal articular surface of radius
• Longitudinal axis of scaphoid is drawn through midpoints of its proximal & distal poles
Volar Intercalated Segment Instability (VISI)
• When lunate flexed & scapholunate angle <30º

• Much less common than DISI
• Most commonly caused by LTL injury
Dorsal Intercalated Segment Instability (DISI)

• When lunate rotated dorsally & scapholunate angle >70º
• Description of deformity but does not describe pathological process
• Causes: SLL injury, unstable scaphoid #, Keinbock’s & perilunate injury
144
Orthopaedi UI
Classification
Perilunate instability
• Basis: lunate is "carpal keystone" & its relationship with distal radius critical
• All carpal bones of proximal carpal row linked together by strong interosseous ligaments
• Reduction of triquetrum, capitate, & scaphoid back to lunate essential to restore integrity of
proximal carpal row & its alignment with distal carpal bones
• Perilunate dislocation pattern provides a whole spectrum of wrist sprains, #, dislocations, &
instabilities
Radial-sided, central, & ulnar-side instabilities
• Radial side of wrist provides longitudinal stability; central segment, flexion-extension capability; &
ulnar side, rotational stability
• Carpal instability can result from # & dislocations of wrist that affect one or more of these carpal
columns
Mayo Classification
• Instability may be static or dynamic
145
Orthopaedi UI
Carpal Instability Dissociative (CID)
• Relates to instability between individual carpal bones of same row

• Most common types occur between bones of proximal row
• DISI
• = a dorsiflexed static posture of lunate on true lateral X-ray of wrist
• Most common carpal instability pattern
• Unstable scaphoid #
• Radial column of wrist becomes unstable
146
Orthopaedi UI
• Distal scaphoid continues to follow palmar flexion tendency, while proximal

fragment follows lunate into extension -> DISI
• Scapholunate instability
• Also radial-side carpal instability
• Involves substantial disruption of SL ligament
• Scaphoid, devoid of proximal ligament attachments, rotates around palmar
radiocapitate ligament -> dorsal rotatory subluxation of proximal pole
• Lunate follows triquetrum into extension -> DISI
• Classification
• Type 1: dynamic
• -ve X-ray
• +ve Watson
• +ve cine
• Type 2: static
• +ve plain films
• Type 3: degenerative
• Type 4: secondary
• Kienbock’s; SNAC
• X-rays
• SL gap >3 mm (Terry Thomas sign) on clenched fist PA view
• SL angle >70
o
• RL angle >15
o
• Foreshortened scaphoid
• Cortical ring sign
• Taleisnik's “V” sign
• Keinbock’s disease
• Transscaphoid perilunate or pure perilunate dislocations
• Highest degree of CID
• VISI
• = a volarflexed static posture of lunate on true lateral X-ray of wrist
• Lunatotriquetral dissociation
• Ulnar-side carpal instability
• Involves substantial disruption of lunatotriquetral & volar radiolunotriquetral
ligaments & attenuation or rupture of dorsal radiotriquetral attachments
• X-rays
• RL & CL angle >15
o
• SL angle <30
o
• Axial Carpal Instability

• Involves a longitudinal force of disruption resulting in either dislocation or # dislocation
• Trans - if pathway of force is through a bone
• Peri - if pathway of force is around a bone
147
Orthopaedi UI
Carpal Instability Non-Dissociative (CIND)
• Relates to instability between carpal rows

• Can be classified into 3 groups based on level of involvement
1. Radiocarpal
2. Midcarpal
3. Combined radiomidcarpal
• Radiocarpal instabilities commonly a/w complete or partial radiocarpal dislocation or Barton's
volar-dorsal #-dislocations, malunion of distal radius, ulnar translation
• Midcarpal instabilities relate to loss of ligament support from extrinsic scaphotrapezial,
scaphocapitate, & triquetrocapitate ligaments
• Clinically, subluxations
o Painful or painless
o Giving way
o Unreliable clunking wrist
Carpal Instability Combined (CIC)

• Ligamentous disruption both within & between rows
• Several patterns exist which are a combination of CID & CIND lesions
• Better to describe individual components of these injuries as it is a guide to Rx
• Most frequently represented by perilunate injury
• Perilunate dislocations
• Arc of injury can course through
• Bone - greater arc injuries, ie. trans-scaphoid or trans-radial styloid perilunate
dislocation
• Ligaments around lunate - lesser arc injuries, ie. perilunate dislocation, lunate
dislocation
• Combination of both
148
Orthopaedi UI
• X-rays
• Breaks in Gilula's arcs
• Signs of instability in involved intervals
• Mayfield classified 4 stages of perilunate instability proceeding from radial to ulnar
around lunate
• I - scapholunate ligament injury
• II - scapholunate & capitolunate ligaments injury
• III - scapholunate, capitolunate & lunotriquetral ligaments injury
• IV - dislocation of lunate from radiocarpal joint, usually in a volar direction
• Scaphocapitate Syndrome
• Uncommon variant of perilunate dissociation
• Arc of injury through neck of capitate & proximal fragment rotates 90-180
o
• Can cause midcarpal arthritis
Carpal Injury Adaptive (CIA)
• Secondary changes in carpus, which results from non-union or malunion of distal radius or carpal
bones
149
Orthopaedi UI
Treatment
CID
• Scaphoid # or non-union (can lead to SNAC)

• Treat # or malunion
• Scapholunate ligament injury (can lead to SLAC)
• Acute
• Early open repair + K-wire stabilisation up to 3/52
• Delayed open repair can be performed up to 6/12 (17/12 in one study)
• Repair by either direct suture, pull through sutures or suture anchors
• Chronic
• Bony procedures - scapho-trapezio-trapezoid fusion (STT) if ligament not
repairable or deformity not supple
• Soft tissue
• Dorsal capsulodesis (Blatt procedure)
150
Orthopaedi UI
• FCR tenodesis (Brunelli procedure)
• Established Scapholunate Advanced Collapse (SLAC)

• Scaphoid excision & 4-corner fusion (capitate, hamate, lunate, triquetrum)
• Proximal row carpectomy
• Radial styloidectomy
• Wrist denervation (division of anterior & posterior interosseous nerves at wrist)
• Lunotriquetral ligament injury
• Rarely recognised acutely but if so then acute open repair of ligament
• Lunotriquetral fusion
• FCU tenodesis
• Ligament reconstruction not favored due to recurrent late instability
• Acute perilunate dislocation
• Immediate closed reduction followed by open repair of ligaments via dorsal approach
CIND
• Acute direct repair of ligaments

• Immobilisation with splints - midcarpal instability most amendable to splinting
• Fusion across midcarpal joint
• Ligament reconstruction does not yield lasting results in most series
CIC
• Treat individual components of injury

• Perilunate dislocation
• Open reduction & pin fixation & casting of 4-8/52
• Direct repair of disrupted volar ligaments not beneficial
• Poor outcomes correlates most closely with a persistently elevated SL gap
CIA
151
Orthopaedi UI
• Normally related to radial malunion therefore perform corrective dist
Fractures of Scaphoid
Surgical Anatomy
• Irregularly shaped, resembling a deformed peanut

• Rests in a plane at 45° to longitudinal axis of wrist
• Articular cartilage covers 80% of surface
• Firmly attached at both ends to strong ligament systems that limit & control its motion (see
pictures)
• Proximal pole constrained to lunate by interosseous ligament
• Distal pole has V-shaped scaphotrapezial ligament, scaphocapitate ligament, & dorsal
capsule
• Rests on & can be attached along ulnar aspect of waist to radioscaphocapitate ligament
• Dorsal intercarpal ligament inserts obliquely on a roughened ridge & brings primary blood
supply that enters scaphoid
• Blood supply
• Major blood supply comes from scaphoid branches of radial artery, entering dorsal ridge
& supplying 70-80% of bone, including proximal pole
• 2nd major group of vessels from superficial palmar arch of radial artery enters scaphoid
tubercle, perfusing only distal 30% of bone
• With # through waist & proximal 1/3, revascularization will occur only with # healing
• With proper Rx
• Nearly 100% of tuberosity & distal 1/3 scaphoid # will heal
• 80-90% of # at waist will heal
• Only 60-70% of proximal pole # will heal
Biomechanics
• Mechanically links proximal & distal carpal rows

• Controls wrist stability
152
Orthopaedi UI
• Principal bony support between proximal & distal carpal rows

• Carries compressive loads from hand across wrist to distal forearm
• Spans both carpal rows & therefore has less mobility than other carpals
• Principal bony block to dorsiflexion of hand & wrist & is susceptible to # during fall on outstretched
hand
• Scaphoid flexes with wrist flexion & extends with wrist extension, also flexes during radial
deviation & extends with ulnar deviation
• Acts with rest of proximal carpal row as "intercalated segments" subjected to forces acting on
them
• Compressive forces, acting across a 3-link structure, cause zig-zag collapse deformity
• With #, distal scaphoid tends to flex & proximal scaphoid extends with proximal carpal row ->
angulation at #, which gaps open dorsally & gradually assumes humpback deformity
Mechanisms of injury
• Most common of carpal # - 75-80%

• Usually in young adult men following falls on outstretched palms with wrist dorsiflexed & radially
deviated
• Incidence of #
• Waist - 65%
• Proximal 1/3 - 25%
• Distal 1/3 - 10%
Clinical
• History
• Forcible dorsiflexion of wrist
• Palmar flexion in 3% of cases
• Examination
• Fullness in ASB -> effusion in wrist
• Careful palpation of all bony landmarks, with tenderness in ASB & scaphoid tubercle
• Pronation followed ulnar deviation will cause pain
• Special tests
• Scaphoid compression test – longitudinal force along 1st metacarpal
• Kirk-Watson’s test
• Resisted pronation
X-rays
• Good quality films required

• Views
153
Orthopaedi UI
• PA in ulnar deviation
• Lateral with wrist in neutral
• Scaphoid view 1 (A-C)
• PA 45° pronation & ulnar deviation
• To view profile of scaphoid & STT joint, also ulnar shortening
• Scaphoid view 2 (D)
• AP with 30° supination & ulnar deviation
• Shows radioscaphoid joint
• Others
o PA with wrist in slight extension (Ziter view)
o AP with clenched fist to detect ligamentous injury/dynamic instability - interosseuos
ligaments tighten on clenching fist
• Motion views of wrist (flexion-extension & radial & ulnar deviation) may demonstrate #
displacement
• False -ve rate

• Leslie & Dickson 1981 - 2%
• Munk et al. 1995 - 6%
• Same X-rays repeated at 2-3/52 if initial films -ve
154
Orthopaedi UI
• Occult #
• Bone scan
• Sensitive but not very specific
• CT
• Can still miss #
• Better for collapsed, angulated, mal- or nonunion
• MR
• Excellent sensitivity & specificity
• # line will be visible on T2 weighted sequence as line of high signal which
represents marrow oedema
• Changes present on MR after 12 hrs
Herbert Classification
• Based on
• Site of # within scaphoid: proximal, middle, & distal 1/3
• Time interval between injury & diagnosis
• Acute if <4/52
• Delayed union
• Nonunion
Treatment
Stable non-displaced #
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Orthopaedi UI
• Long arm-thumb-spica cast

• Position of wrist
• Ulnar deviation will distract #, therefore must be avoided
• Neutral in AP plane
• Moulded into palm
• Re-examine & X-ray at 8/52 out of plaster
• If still tender then treat in cast for further 4/52
• At 12/52 leave free regardless of whether tender or not
• Repeat X-ray at 6/12
Unstable #
• Criteria
• Displacement of >1 mm in any direction
• Capitolunate angle >15
o
• SL angle >60
o
• Proximal pole #
• Vertical oblique #
• Indications for ORIF
• Unstable #
• Trans-scaphoid perilunate dislocations
• Approach
• Volar
• Through bed of FCR
• Good for waist & distal #
• Procedure (Joe Dias)
• Surface: scaphoid tubercle & FCR tendon
• Longitudinal incision, beginning 3-4 cm proximal to wrist flexion crease,
along FCR radial border to scaphoid tubercle, then angle radially along
direction of APB toward scaphotrapezial & trapeziometacarpal joints
• Protect terminal branches of palmar cutaneous branch of median nerve
& superficial radial nerves
• Dissect through bed of FCR tendon sheath
• Incise & reflect capsule in longitudinal axis of scaphoid bone
• With sharp dissection, expose #, & incise radioscaphoid &
radioscapholunate ligaments
• Define scaphotrapezoid joint by reflecting scaphotrapezoid lig. radially
• Reduce # using K-wires as joystick, taking care to avoid rotation or
angulation
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Orthopaedi UI
• Fixation methods
• Herbert screw
• Check Herbert jig: correct side should be showing on jig,
check long drill bit lies in correct position to spike
• Insert jig by putting spike as far dorsally behind proximal
pole as possible
• Jig should lie 45° to surface & 45° to long axis o f forearm
• Check position with I.I.
• Prepare # & bone graft from iliac crest
• Long drill right down-> Short drill-> Tap -> Screw as per
length on jig
• Avoid scapholunate joint!
• If too difficult, use AO cannulated/cancellous screw or K-wires
• Close wrist capsule with nonabsorbable sutures or long-lasting
absorbable sutures
• Close skin & apply a dressing that includes either a sugar-tong splint with
a thumb spica extension or a long arm cast incorporating thumb
• Dorsal
• Between EPL & EDC (extensor compartments III & IV)
• Good for proximal 1/3 #
• Care must be taken to preserve blood supply to scaphoid which enters along
dorsal ridge
• Procedure
• Longitudinal incision over Lister's tubercle
• Protect sensory branches of radial & ulnar nerves
• Incise extensor retinaculum & compartment IV
• Reflect ECRB & EPL radially
• 'L' incision of dorsal ligament reflecting flap to radial side, entering joint
• Flex wrist 90° to expose proximal pole & #
• Prepare # & bone graft
• Reduce # using K-wires as joystick, taking care to avoid rotation or
angulation
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Orthopaedi UI
• Long drill in parallel with dorsal scaphoid ridge (prominent ridge on

dorsum of scaphoid - expose it)
• Check with I.I.
• Short drill... etc
• Types of internal fixation

• Herbert screw
• Herbert-Whipple screw
• AO low profile compression screw
• Acutrack screw
• K-wires
Sequelae
• Delayed union
• >4/12
• Non-union
• Malunion
• May heal in a flexed position
• "Hump back" deformity
• Avascular necrosis - See eHand Images
• DISI
• Scaphoid Non-union Advanced Collapse (SNAC)
• Develops from longstanding scaphoid non-union
• Takes 5-10 yrs to develop in most cases but can take up to 20 yrs
• Loss of carpal height
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Orthopaedi UI
• P
SNAC OA Treatment
r
I Radioscaphoid (RS) • Radial styloidectomy o
OA • Care must be taken to preserve radiocarpal x
ligaments i
m
a
II RS OA + • Partial scaphoid excision (distal pole) l
scaphocapitate (SC) • Proximal row carpectomy
OA • All results are better with larger proximal pole p
fragments o
• Proximal pole excision or prosthetic replacement l
has been universally abandoned because of carpal instability e
o
III RS + SC + • Scaphoidectomy + 4-corner fusion f
lunocapitate OA
s
caphoid acts like lunate
• OA develops between distal scaphoid fragment & radial styloid (not between radius &
proximal fragment)
Non-union
• Incidence
• Leslie & Dickson 5%
• Dias et al 12.3%
• Factors
• Delay in Rx
• Inadequate immobilisation
• Proximal #
• Aims of treating non-union
• Correct carpal kinematics
• Achieve union
• Reduce pain
• Increase function
• Reduce risk of developing secondary degenerative changes
• Non-union: no OA or AVN
• For collapsed, foreshortened nonunion - ORIF with Matti-Russe inlay grafts
• For nonunion not collapsed, foreshortened - ORIF with volar wedge grafting
• Vascularised bone grafts have controversial role
• Zaidenberg graft - radial bone flap between 1st & 2nd extensor compartment with
a septal vessel
• Pedicled bone with pronator quadratus attachment
• Non-union: AVN present but no OA
• Matti-Russe inlay grafts
• ORIF
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Orthopaedi UI
• Vascularised bone grafts

• Non-union: OA present but no AVN
• See SNAC (above)
• Salvage procedures if OA & AVN
• Wrist denervation
• Limited intercarpal fusion
• PRC
• Total wrist fusion
Distal Radius Fractures
Anatomy
• Metaphysis primarily cancellous bone

• 80% of axial load supported by distal radius
• Reversal of normal volar tilt -> load transfer onto ulna & triangular fibrocartilage complex
• Ligamentous attachments often remain intact during #, facilitating reduction through
"ligamentotaxis"
• Volar ligaments stronger & confer more stability to radiocarpal articulation
Epidemiology
• Among most common of all orthopaedic injuries accounting for nearly 1/6 of all #
• Bimodal age distribution: 1 peak in early adolescence, 2nd in older age
Mechanism
• FOOSH
• Wrist at 40-90º dorsiflexion usually produces # of distal radius
• Scaphoid # occur at ~97º
• 3 types of forces may operate
1. Bending
2. Axial loading
3. Shearing
• Radius initially fails in tension on volar aspect, with # propagating dorsally where bending forces
induce compression stresses -> dorsal comminution
• Cancellous impaction of metaphysis further compromises dorsal stability
• Shearing forces often -> articular surface involvement
• High energy injuries -> significantly displaced or highly comminuted, unstable #
• Dorsal stability depends on
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Orthopaedi UI
0. Amount of comminution
1. Quality of bone
2. Age
Clinical
• Check for other # in entire upper limb

• Neurovascular assessment, particularly median nerve compression
Imaging
• X-rays
• PA & lateral, KIV oblique views
• Post-reduction X-rays for further # definition
• Normal radiographic relationships
• Radial inclination: 23 (13-30º)
o
• Radial length: 12 mm (8-18 mm)

• Volar tilt: 11 (1-21º)
o
• Check for
• Intra- or extra-articular #
• Loss of radial height (>5 mm)
• Loss of radial inclination (normal 20-25º)
• Dorsal tilt (normal 10º volar)
• Radial width
• Comminution
• Ulna #
• NB axial or rotational malalignment can produce DRUJ problems
• CT best for intra-articular #
Classifications
• 15 different classification systems exist!

• Stable - # do not displace at time of presentation or following CMR
• Unstable - inability of # to resist displacement following anatomical reduction
Frykman Classification
• Based on pattern of intraarticular involvement

• Descriptive only & does not include variables, eg. direction & degree of displacement or
comminution
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Orthopaedi UI
Group # configuration
1&2 Extra-articular # ± distal ulna #
3&4 Intra-articular # involving radiocarpal joint ± distal ulna #
5&6 Intra-articular # involving DRUJ ± distal ulna #
7&8 Intra-articular # involving RC & DRUJ ± distal ulna #
McMurtry & Jupiter Classification
• Based on number of intraarticular parts
Group # configuration
1 2 parts: Barton #, Chauffeur #, Die-punch #
2 3 parts: lunate & scaphoid fossae separate from distal radius
3 4 parts: lunate fossa fractured into dorsal & volar fragments
4 5 parts or more
Melone Classification
• Based on consistent mechanism: lunate impaction injury

• Sub-types of 4-part intra-articular # (shaft, radial styloid, dorsal-medial & volar-medial fragments)
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Orthopaedi UI
Type # configuration
I Minimal or no comminution – stable
II Comminuted - stable, IIA: reducible, IIB: irreducible
III Displacement of medial complex as a unit + anterior spike
IV Wide separation or rotation of dorsal fragment + palmar fragment rotation
V Explosion #; severe comminution with major soft-tissue injury
• Gives some indication to Rx

• Types I & II: MUA + POP cast
• Type III: MUA + K-wire/external fixation
• Type IV: ORIF
Universal Classification
AO classification
163
Orthopaedi UI
• Comprehensive but has poor inter & intraobserver agreement
ASSOCIATED INJURIES
• Distal radioulnar joint

• DRUJ disruption
• Bony constraints cannot control
• Requires soft tissue stabilization
• Repair with sutures/suture anchors
• ORIF larger fragments
• Ulnar styloid #
• Frequent
• Rarely unstable
• Usually partial TFCC tear
• Rarely needs Rx - base # (50%)
• Ulnar head/neck #
• Comminuted - very unstable
• Difficult to securely fix
• Treat with excision/soft tissue reconstruction
• Bone can be used for grafting radius
• Median nerve injury (13-23%)
• Causes
• Contusion
• Hematoma/compression
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Orthopaedi UI
• Traction/neuropraxia
• Reduction process frequently increases intracompartmental pressure in carpal
canal
• Early surgical decompression recommended if significant symptoms
• Late decompression less successful
• Scaphoid #
• Look for it
• Intercarpal ligament injury - total/partial
• Scapholunate - common
• Lunotriquetral - common
• Can see diastasis in traction X-ray
• Treated early with percutaneous pin fixation - usually adequate
Treatment
Goals & Considerations
• 4 principles/goals in Rx of distal radius #

1. Restoration of articular congruity & axial alignment
2. Maintenance of reduction
3. Achievement of bony union
4. Restoration of hand & wrist function
• Other considerations may justify acceptance of less than anatomic results
1. Low functional demand
2. Significant medical illness
3. Inability to comply with postop instructions
4. Previous # & deformity
• It must be emphasised that chronological age does not correlate with functional age & many of
these #, even in older patients, will benefit from aggressive Rx
Undisplaced Cast immobilisation

CR + cast
Stable immobilisation
Extraarticular or 2-part intraarticular with minimal or no
comminution Percutaneous K-wire
Extraarticular & intraarticular with comminution Ext fix
Displaced lunate facet Limited open reduction
Complex intraarticular ORIF
Displaced Unstable Complex intraarticular & extraarticular Combination
Anatomical aims/Indications for Reduction
• To restore radial inclination, length & tilt

• Acceptable angulation of distal radius
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Orthopaedi UI
• <5º loss of radial inclination

• <2 mm shortening
• <10º loss of normal volar angulation (ie. no more than 0º or 20º volar angulation)
• Accurate restoration of articular surface with <2 mm step-off
• Evidence from eRadius
Treatment options
• Cast immobilisation
• For
• Undisplaced #
• Displaced # which is stable after CR
• Cast with wrist in 20 volar flexion & ulnar deviation
o
• Ideal forearm position, duration of immobilization, need for long-arm cast controversial
• Extreme wrist flexion
• Avoided as it increases carpal canal pressure & digital stiffness
• Reductions that require maintenance of extreme wrist flexion may require
operative fixation
• Cast for ~6/52 or until radiographic evidence of union, then molded splint for 2-3/52
• Supervised active-assisted wrist motion exercises
• Percutaneous K-wire
• For extraarticular or 2-part intraarticular unstable # (without bicortical comminution)
• Placement
• Classical styloid + Lister's tubercle wire placement
• Trans-ulnar pin placement
• Intra-focal wiring
• Kapandji technique (Kapandji A. Ann. Chir. Main. Memb. Super. 6:57-63.
1987)
• Most effective if volar comminution absent
• Generally to supplement short-arm casting or ext fix
• Pins removed 3-4/52 postop, with cast maintained as above
• External fixation
• For unstable comminuted extraarticular & intraarticular #
• Types
• Bridging
• Non-bridging
• Dynamic: now thought to be unsuitable as position lost when fixator mobilised
• Ligamentotaxis can restore radial length & inclination but rarely palmar tilt
• Overdistraction avoided
• Frame configuration not critical
• Ext fix may be supplemented with percutaneous pinning of comminuted or articular
fragments
• Pins removed at 3-4/52, although 6-8/52 recommended
• Relatively low Cx rates
• Limited open reduction
• # with persistent intraarticular incongruity (>2 mm) despite CR & traction
• This often involves displaced lunate facet
• Restoration of articular surface -> K-wire fixation & bone graft with ext fix
• ORIF
• Primary indication: articular fragment displacement not amenable to closed or limited
open procedures, especially of shear variety
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Orthopaedi UI
• Some complex articular # with careful preop planning

• Buttress plate with or without K-wires to stabilize articular fragments
• Or combination of any of above techniques
• Also see Jesse Jupiter's Mx Algorithm
Intra-articular fractures
• Barton's #
• #-dislocation or subluxation of wrist in which dorsal or volar rim of distal radius is
displaced with hand & carpus
• Volar more common
• Most are unstable
• Mechanism
• Fall on dorsiflexed wrist
• Forearm fixed in pronation
• Rx
• Volar
• ORIF with buttress plate via anterior approach
• Dorsal
• ORIF via dorsal approach
• Between extensor compartments IV & V
• Remove Lister's tubercle to facilitate plate positioning
• Die-punch #
• Impacted displaced # of lunate fossa of distal radial articular surface
• Mechanism: axial load that drives carpus into distal radius
• May be split into multiple fragments & CR difficult
• Often a/w posttraumatic carpal instability & injury to DRUJ
• Reduction must be within 1-2 mm of articular congruity; even anatomical reduction ->
arthritis due to cartilage damage
• Chauffeur's #
• Avulsion # with extrinsic ligaments remaining attached to styloid fragment
• Mechanism
• Compression of scaphoid against styloid
• Wrist in dorsiflexion & ulnar deviation
• Often a/w intercarpal ligamentous injuries
• Scapholunate dissociation
• Perilunate dislocation
• Rx: MUA + K-wire
Colles' #
• Described by Abraham Colles in 1814, originally described as low energy extraarticular # of distal
radius in elderly individuals
• Typically dorsally displaced & angulated, 2-3 cm proximal to wrist joint
• Mechanism
• FOOSH
• Forced dorsiflexion of wrist
167
Orthopaedi UI
• Dorsal surface undergoes compression while volar surface undergoes tension
Smith's #
• Palmarly displaced distal radius #

• Volar angulation of # is referred to as "Garden Spade" deformity (reversed Colles #)
• Hand & wrist are displaced forward or volarly
• Mechanism
• Backward fall on palm of an outstreched hand -> pronation of upper extremity while hand
is fixed to ground
• Classification
• Type I: extraarticular
• Type II: crosses into dorsal articular surface
• Type III
• Enters radiocarpal joint
• Volar Barton's # = Smith's type III
• Both involve volar dislocation of carpus a/w intraarticular distal radius component
Galleazi #
• Anatomical ORIF of radius ± K-wire stabilisation of DRUJ
Adjuncts to intra-articular # Mx
• Arthroscopically assisted reduction

• Autogenous bone graft
• Carbonated hyproxyapatite cement (Norian plus other companies) which acts to fill hole often
present after # reduction
Prognosis
• Importantly, position of # at union rather than position at time of presentation has greatest
correlation with long-term functional results
• Clinical studies have confirmed laboratory data correlating malunion with poor function, pain,
decreased ROM, decreased grip strength, & poor patient function/satisfaction have been
consistently a/w poor anatomic results after # (McQueen M, Caspers J: Colles' fracture: Does the
anatomical result affect the final function? J Bone Joint Surg 1988;70B:649-651.)
Complications
• Early
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Orthopaedi UI
1. Associated carpal injury: # or ligamentous tear

2. TFCC tear - 50%
3. DRUJ subluxation or dislocation
4. Acute post reduction swelling/compartment syndrome
5. Nerve - median most common - 13-23%
6. Vessel - rare - radial artery commonest
7. Tendon - rare
• Late
1. EPL rupture in 1.5% (Rx: EIP to EPL transfer)
2. RSD 25%
3. Malunion
4. Non-union - rare
5. Adaptive carpal instability (CIA) which can be treated with corrective osteotomy
6. Symptomatic radiocarpal OA - 7%
7. DRUJ OA (Rx: Darrach's/Suave-Kapandji procedure)
Keinbock's Disease
Introduction
• Described by Keinbock in 1910, a radiologist in Vienna (republished article in CORR 1980, Vol
149)
• Collapse of lunate due to vascular insufficiency & avascular necrosis
Anatomy
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Orthopaedi UI
• Keystone in proximal carpal row in lunate fossa of radius

• Anchored by interosseous ligaments to scaphoid & triquetrum with which it articulates
• Distally, convex capitate head fits congruently into concavity of lunate
• Joint reaction force from capitate & radius squeezes lunate ulnarly
• Proximal horn of hamate has a variable articular facet on distal ulnar surface of lunate, & ulnar
deviation increases degree of contact
• Vascular supply
• Primarily through proximal carpal arcade both dorsally & palmarly
• Intralunate anastomoses of 3 main types, characterized as I, Y, & X
• Degree of cross flow between 2 systems probably subject to considerable variation
Aetiology
• Uncertain
• Theories
1. Single forgotten wrist trauma
2. Repetitive microfractures that result in vascular compromise, causing disruption of blood
supply to lunate
3. Recurrent compression of lunate between capitate & distal radius which disrupts
intraosseous structures through shear stress at extreme wrist positions &/or repetitive
compression loading
• Associated with -ve ulnar variance (of interest, there do not seem to be any reports of Kienbock's
disease after Darrach's procedure)
Clinical
• Young adults
• Wrist pain that radiates up forearm
• Wrist stiffness
• Tenderness over lunate dorsally
• Weakness of grip
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Orthopaedi UI
Radiography
• Ulnar variance is measured on PA views with wrist in neutral rotation (ulna is relatively longer in
supination)
• Lichtman Staging
1 Normal architecture & density, may see a linear compression # (bone scan & MRI diagnosis)
2 Increased density (sclerosis), normal architecture & outline
3 Collapse & fragmentation
3A No carpal collapse
3B Carpal collapse (scaphoid rotation, proximal migration of capitate)
4 Advanced collapse, OA
171
Orthopaedi UI
• MRI
• Excellent to assess vascularity & demonstrate revascularization as well as healing
• Shows evidence of diminished vascularity before changes apparent on X-ray (within a
few days of injury)
Treatment
Acute Lunate Fractures
• Simple # can be treated expectantly in cast or splint

• Close follow-up for 1st several weeks with tomography &, in some instances, MRI
• Separation of lunate fragments by intrusion of capitate -> nonunion
• Distraction with external fixator may allow lunate fragments to coapt
• Ulnar minus variant -> leveling procedure, eg. radial recession or ulnar lengthening can reduce
joint compressive stresses
Kienböck's Disease
• Remember
• Keinbock's often causes little disability
• Radiological findings & symptoms do not correlate well
172
Orthopaedi UI
• No surgical procedure has been conclusively shown to prevent progression

• Surgery only indicated when pain & disability cannot be managed by splintage, analgesia &
reassurance
• Surgery
• Stage 1 & 2
• Aim to prevent lunate collapse
1. Joint levelling
1. Radial shortening
2. Ulnar lengthening - high non-union rate
2. Revascularisation of lunate
Pedicled vascularised graft from distal radius with pronator
quadratus
Dorsal digital artery placed into drill hole on lunate
• All these procedures have 70% success rate in pain relief
• Stage 3
1. Limited carpal fusion without lunate excision
2. Limited carpal fusion with lunate excision (STT or scapho-capitate)
3. Wrist denervation
4. Proximal row carpectomy
5. Total wrist arthrodesis - indicated in persons who use their hands for heavy labor,
have severe degenerative changes, or fail to improve following other surgical
procedures
6. Titanium lunate implants (+/- limited fusion)
Excision of lunate alone will cause rest of carpal bones to migrate -> joint
incongruity, limited wrist motion & grip strength, & OA
• Stage 4
0. Wrist denervation
1. Total wrist fusion
De Quervain's Disease
Anatomy
• 1st extensor compartment

• Transports APL & EPB tendons
• These tendons -> radial border of anatomic snuff box
• Anatomic variants: multiple slips of APL & complete compartmentalization of EPB
• APL
• Origin
• Small facet of ulnar side of radius near its middle
• Lateral side of dorsal surface of ulna just below insertion of anconeus &
interosseous membrane
• Insertion
• APB muscle or radial side of base of 1st MC
• EPL
• Origin: posterior side of both ulna & radius near middle
• Insertion: posterior surface of base of proximal phalanx of thumb
173
Orthopaedi UI
Pathogenesis
• A stenosing tenosynovitis of APL & EPB tendons (1st compartment) at styloid process of radius
• Inflammation -> thickening & stenosis of synovial sheath of 1st compartment & pain with tendon
movement
Clinical
• Most common in women aged 30-50 yrs

• Pain over radial styloid process (& sometimes forearm & thumb)
• Swelling & palpable thickening of fibrous sheath
• Sharp tenderness over styloid process of radius
• Finkelstein's test
• May also be +ve in CMC DJD
• Sharp pain at this site is also produced by active extension & abduction of thumb against
resistance
Differential diagnosis
• DJD of CMC joint

• Grind test +ve in DJD -> typically, pain will be located on volar side of wrist
• STT OA
• Scaphoid non-union
• Ganglion
• Intersection syndrome
• Tendons of 1st compartment may cross over tendons of 2nd compartment (ECRL/B), just
proximal to extensor retinaculum
• Caused by irritation at intersection of outrigger muscles, ie. between (APL, EPB) &
(ECRL/ECRB), ~4 cm proximal to wrist joint
• Resultant tenosynovitis occurs mainly in 2nd compartment
• Wartenberg's syndrome
• Isolated neuritis of superficial radial nerve
• May have +ve Tinel's sign
• May be caused by tight jewelry
Radiographs
• If diagnosis in doubt, consider obtaining Robert's view, to profile CMC joint

174
Orthopaedi UI
Treatment
Nonoperative
• Thumb spica splint

• Steroid injection
• Dexamethasone (clear cortisone preparation) can be used to minimize depigmenation &
subcutaneous fat atrophy
• Injection into sheath from distal to proximal through 1st dorsal compartment
• Injection must be beneath retinaculum & not subcutaneous
• Some advocate repeated steroid injections, noting that results of surgical release can be
unpredictable
Surgical
• May use local anesthesia

• Incision
• Longitudinal - fewer Cx related to iatrogenic radial sensory neuropathy
• Oblique - allows for extended distal exposure, if needed
• Transverse - higher risk of injury to superficial radial nerve
• Superficial branches of radial nerve identified & rerouted away from tendon sheath (if necessary);
otherwise, entrapment in scar tissue postop
• Decompression of 1st dorsal compartment
• Directly visualize distal edge of 1st compartment sheath
• Thickened sheath opened with longitudinal incision through central aspect of
compartment roof, thus freeing involved tendons
• Important to leave equal halves of tendon sheath to avoid postop instability
• Preserving retinacular flaps will help to prevent prolapse with wrist flexion or
extension
• Search for anatomic abnormalities, & release more tendon sheath if necessary
• Must have +ve identification of EPB (5% absent)
• Note possibility of separate fibroosseous canal for EPB tendon
• Multiple slips of APL tendon also common
• Determine if there is any instabilty
• Flex & extend wrist, & note any tendency for subluxation
• If subluxation present, then loosely oppose edges of tendon sheath with horizontal
matress stitch
• Rongeur bony prominences
•
o
Start early ROM of thumb, but with wrist splinted in 10 extension for 2/52 to prevent volar tendon
prolapse
• Cx
• Nerve entrapement &/or neuroma formation
• Ulnar branch of superficial radial nerve parallels 1st compartment tendons &
becomes adherent to opened compartment roof
• +ve Tinel's, hypesthesia
• Inadequate decompression of involved tendons (EPB & APL)
• Tendon instability
• Tendons may subluxate volarly during wrist flexion -> painful snapping sensation
175
Orthopaedi UI
• May be avoided by incising tendon sheath more dorsally, & by splinting wrist in
extension for ~10/7
• Tendon adherence
• Adherence of surgical scar
Complex Regional Pain Syndrome
Definition
• An abnormal reaction to injury characterised by pain, swelling, stiffness, vasomotor changes &
osteoporosis of affected part
• Caused by sustained efferent sympathetic nerve activity perpetuated in a reflex arc
• Also: Reflex Sympathetic Dystrophy (RSD), Sudeck's Atrophy, Causalgia
• 1st clinical description in 1864 by Mitchell
Classification
• CRPS type I (RSD)

• Clinical findings include regional pain, sensory changes, allodynia, abnormalities of
temperature, abnormal sudomotor activity, edema, & abnormal skin color that occur after
a noxious event
• CRPS type II (Causalgia)
• Includes all foregoing features with a peripheral nerve lesion
Old Classification of RSD (Lankford)
• Minor causalgia
• Purely sensory nerve to distal portion of limb
• Minor traumatic dystrophy
• Most common type
• Shoulder hand syndrome
• Proximal trauma or painful visceral lesion (shoulder or neck injury, cervical disc, PU, MI,
Pancost tumour etc)
• Major traumatic dystrophy
• Trauma that produces swelling, redness, dysfunction eg. crush injuries & Colles' #
• Major causalgia
• Partial injury to a major mixed nerve in proximal part of extremity
176
Orthopaedi UI
Diagnosis of RSD/CRPS
• Can be made in following context

• A history of trauma to affected area a/w pain that is disproportionate to inciting event plus
one or more of following
1. Abnormal function of sympathetic nervous system
2. Swelling
3. Movement disorder (stiffness)
4. Changes in tissue growth (dystrophy & atrophy)
Aetiology
• Precipitating factors
• Trauma (often minor) ranks as leading provocative event
• Prolonged immobilization
• Ischemic heart disease & myocardial infarction
• Cervical spine or spinal cord disorders
• Cerebral lesions
• Infections
• Surgery
• Repetitive motion disorder or cumulative trauma, causing conditions eg. carpal tunnel
• However, in some patients a definite precipitating event cannot be identified
Clinical Features
1. Pain
• Hallmark of RSD/CRPS is pain & mobility problems out of proportion to those expected from
initial injury
• 1st & primary complaint: severe, constant, burning &/or deep aching pain
• Allodynia: all tactile stimulation of skin (eg. wearing clothing, light breeze) may be perceived as
painful
• Hyperpathia: repetitive tactile stimulation (eg. tapping on skin) may cause increasing pain with
each tap & when repetitive stimulation stops, there may be prolonged after-sensation of pain
• Myofascial pain syndrome: diffuse tenderness or point-tender spots in muscles of affected region
due to small muscle spasms called muscle trigger points
• Paroxysmal dysesthesias & lancinating pains: spontaneous sharp jabs of pain in affected region
that seem to come from nowhere
2. Swelling
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Orthopaedi UI
• Pitting or hard (brawny) edema is usually diffuse & localized to painful & tender region
• If edema sharply demarcated, it is almost proof that patient has RSD/CRPS
3. Movement Disorder
• Stiffness
• Difficulty moving because they hurt when they move
• In addition, there seems to be a direct inhibitory effect of RSD/CRPS on muscle
contraction
• Patients describe difficulty in initiating movement, as though they have "stiff" joints
• This phenomena of stiffness is most noticeable to some patients after a sympathetic
nerve block when stiffness may disappear
• Decreased mobilization of extremities can lead to wasting of muscles (disuse atrophy)
• Tremors & involuntary severe jerking of extremities may be present
• Sudden onset of muscle cramps (spasms) can be severe & completely incapacitating
• Some patients describe a slow "drawing up of muscles" in extremity due to increased muscle
tone leaving hand-fingers or foot-toes in a fixed position (dystonia)
• Psychological stress may exacerbate these symptoms
4. Skin Changes
• Skin
• May appear shiny (dystrophy-atrophy), dry or scaly
• RSD/CRPS is a/w a variety of skin disorders including rashes, ulcers & pustules
• Hair may initially grow coarse & then thin
• Nails in affected extremity
• May be more brittle, grow faster & then slower
• Faster growing nails is almost proof that patient has RSD/CRPS
• Abnormal sympathetic (vasomotor changes) activity TSC
• Patient may perceive sensations of warmth or coolness in affected limb without even
touching it (vasomotor changes)
• Skin may show increased sweating (sudomotor changes) or increased chilling of skin
with goose flesh (pilomotor changes)
• Changes in skin color can range from a white mottled appearance to a red or blue
appearance
• Changes in skin color (& pain) can be triggered by changes in room temperature,
especially cold environments
• However, many of these changes occur without any apparent provocation
• Patients describe their disease as though it had a mind of its own
5. Spreading Symptoms
• Initially, RSD/CRPS symptoms are generally localized to site of injury

• As time progresses, pain & symptoms tend to become more diffuse
• Typically, disorder starts in an extremity, however, pain may occur in trunk or side of face
• On the other hand, disorder may start in distal extremity & spread to trunk & face
• At this stage, an entire quadrant of body may be involved
• Maleki et al recently described 3 patterns of spreading symptoms in RSD/CRPS
178
Orthopaedi UI
1. A "continuity type" of spread where symptoms spread upward from initial site, eg. from
hand to shoulder
2. A "mirror-image type" where spread was to opposite limb
3. An "independent type" where symptoms spread to a separate, distant region of body;
may be related to a 2nd trauma
6. Bone Changes
• X-rays may show patchy osteoporosis

• Bone scan may show increased or decreased uptake of a certain radioactive substance
(technecium 99m) in bones after intravenous injection
7. Duration of RSD/CRPS
• Duration varies
• In mild cases it may last for weeks followed by remission
• In many cases pain continues for years & in some cases, indefinitely
• Some patients experience periods of remission & exacerbation
• Periods of remission may last for weeks, months, or years
Investigations
• Tch bone scan - segmental diffuse pattern of tracer uptake (sensitive, Triphasic scan = specific)
• Diagnostic sympathetic block (stellate ganglion) -> relief
Treatment
• Treat cause
• Physiotherapy
• Fluidotherapy
• TENS
• Sympathetic blockade
• TCA's, vasodilators, steroids
• Prevention: avoid nerve injury, tight dressings, prolonged immobilization
179
Orthopaedi UI

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Sholahuddin Rhatomy,MD

1. Hand Anatomy & Mechanics…………………………………………………………… 3

Hand Anatomy & Mechanics

DORSAL SURFACE (Extrinsic extensor mechanism)

• Origin - most commonly extensor tendon of ring finger

• Sagittal band/dorsal hood [5]

• Divides into 3 slips

• Adhesion to P1 after lacerations/#

Interosseous aponeurotic expansion

• Transverse Retinacular Ligament [15]

Intrinsic Minus Hand (Claw hand)

Intrinsic Plus Hand

• Palmar subaponeurotic space

• Tendon sheaths to little finger & thumb

• Palmar fascial space

Vessels & Nerves

• Superficial palmar arch

Digital Cutaneous Ligaments

• Grayson's (Ground) & Cleland's (Ceiling) ligaments

Flexor Tendons & Pulleys

• Muscle forces acting on thumb

• Thumb opposition = abduction + rotation mainly at 1st CMCJ

Flexion-Extension / Central Centre of rotation = capitate

• Modeled as a universal joint

Flexor Tendon Injuries of the Hand

• Flexor tendon sheath

• Thickened areas within flexor sheath

• Position of hand at time of injury determines tendon retraction

Only FDP injured

• Failed primary repair worse than no repair!

• Atraumatic handling of tendon ends

• Fishmouth End-to-End Suture (Pulvertaft)

• Running epitenon suture

Multiple Flexor Tendons at Wrist (Zone 5)

• Kleinert Dynamic Splint

• 2/3 up forearm, straps on palmar crease, wrist & forearm

• 3 medications have been shown to decrease adhesions in animal studies

• Rupture - prompt reexploration & repair

• Exact nature controversial

Phase Days Histology Tensile strength

Effects of Time on Tendon Healing

Partial Flexor Tendon Lacerations

• A partially lacerated tendon retains varying amounts of its strength

• Outcomes were similar in both groups

SECONDARY FLEXOR TENDON REPAIR & RECONSTRUCTION

• Defined as delayed primary repair performed >3/52 after injury

Prerequisites for tendon reconstruction

• Delayed direct repair

Two-stage Flexor Tendon Reconstruction

Extensor Tendon Injuries

• Origin: lateral epicondyle of humerus

Extensor mechanism of digit

• Extensor apparatus is a "plexus of tendons with an aponeurotic sheet." Stack, 1962

• Divides into 3 slips

• Left untreated, boutonniere deformity may develop

• Rehab dependent on level of extensor tendon injury

• Loss of flexion can occur due to extensor tendon shortening