Bursa, Wrist & Hand Surgery & Rehab

Question 1

What are bursae?

Answer 1

Flattened sacs of synovial membrane supported by dense, irregular connective tissue

Question 2

Where do bursae occur?

Answer 2

Between tissue planes

• Subcutaneous (skin & bone)
• Submuscular (muscle planes)
• Subtendinous (tendon & muscle/muscle & bone/tendon & bony pulley/tendon & ligaments)
• May communicate with the joint

Question 3

What are bursa problems often linked to?

Answer 3

Tendinopathy

Question 4

What pathology is associated with bursae?

Answer 4

Acute inflammation/infection

Chronic

• Pathology in the stroma (supporting tissue)
• Biochemical (cytokines etc)
• Histo-anatomy (increased synovial hypertrophy, vascularisation, inter adipose septa)

Question 5

What areas commonly get bursitis?

Answer 5

• Trochanteric
• Knee
• Iliopsoas
• Ischium
• Ankle
• Subacromial
• Cubital
• Olecranon
• Radio-humeral

Question 6

What is the treatment for acute bursitis?

Answer 6

• Infective: Antibiotics

- Non-infective: NSAIDs, corticosteroid injection, ice, rest, treat underlying problem, behaviour modification

Question 7

What is the treatment for chronic bursitis?

Answer 7

• Bursectomy

- Synovectomy

Question 8

What does periodisation of the rehab program involve?

Answer 8

• Balancing protection of healing tissue with ROM and strength

Question 9

What is associated with increase immobilisation period in the elbow and hand?

Answer 9

Increased risk of flexion contracture

Question 10

Why is orthopaedic management required for hands?

Answer 10

Education

• Oedema management (elevation, compression, fist squeezing)
• Prevention of adhesions
• Maintenance of other joints

Question 11

What is involved in a flexor tendon repair?

Answer 11

• Tendon ends located by extended incision to find where they have retracted
• Threaded back through the sheath/pulleys
• Repaired through window between the pulleys
• Maintaining relationship of FDP/FDS tendons

Question 12

What must a flexor tendon repair ensure to allow early-active flexion rehab protocols?

Answer 12

• Secure knots
• Smooth junction of tendon ends at repair site
• Suture knots to minimise impingement
• Prevent gapping
• Maintain tendon vascularity

Question 13

What are the 4 types of flexor tendon repair?

Answer 13

• Modified Kessler (2 strand)
• Double Kessler (4 strand)
• Savage (6 strand)
• Indiana (4 strand)

Question 14

Approximately how long does it take a flexor tendon to regain enough tensile strength to avoid rupture with normal strong use of hand?

Answer 14

12 weeks after repair

Question 15

What factors can affect rate of healing of flexor tendon repairs?

Answer 15

• Type of injury
• Status of tendon/sheath/vessels at time of repair
• Injury to surrounding structures
• Co-morbiditis
• Lifestyle factors
• Age
• Gender
• Long term steroid use
• Ability to comply with rehab program

Question 16

Why is elevation used in the early phase after repair?

Answer 16

Other forms of oedema control are limited by continuous splinting

Question 17

What does adhesion control involve?

Answer 17

• Passive flexion
• Active extension toa blocked point (splint)
• Passive localised full extension for single joints

Question 18

Why can passive localised full extension not be used for composite joints (i.e. all 3 finger joints)?

Answer 18

It places an adverse stretch effect on the flexor tendon repair (can be tolerated at 4 weeks with wrist in flexion)

Question 19

What does immediate passive flexion involve?

Answer 19

• MCP/PIP joints flexed, passively extending DIP

- DIP/MCP joints flexed, passively extending PIP

Question 20

What are the indications for hand immobilisation?

Answer 20

• Young children for first 3-4 weeks
• Cognitive limitations
• Cast may be needed instead of removable splint
• Fracture/significant loss of skin graft