CHAPTER 12: HAND - INFECTION, TRAUMA, TRIGGER FINGER, CRPS Flashcards
Hand infections - organisms
Usually Staphylococcus aureus
Human Bites → mixed aerobe and anaerobes
Cat and Dog bites → Pasteurella multocida
Leeches → Aeromonas hydrophilia - Ciprofloxacin
Aerobic
- Staph aureus
- Staph epidermidis
- Strep
Anaerobic
- Peptostreptococcus
- Peptococcus
- Bacteroides
- Eikenella corrodens
What are the different types of infections of the fingertip?
Acute paronychia
- infection of tissue proximal to nail fold, b/t germinal matrix and skin
- drain by separating nail plate from eponychial fold or incising over collection
Chronic paronychia
- Chronic inflammation → thickening of the cuticle and grooving of the nail
- Candida albicans
Felon
- infection of pulp, abscess
- drain over maximum fluctuance
- If untreated → osteomyelitis, septic arthritis, flexor sheath infection, tender pulp scar
Herpetic whitlow
- HSV → superficial fingertip infection
- small clear vesicles at early stages
- DO NOT I&D → bacterial superinfection
- acyclovir
What are the signs of flexor sheath infection?
Kanavel’s signs
- fusiform swelling
- flexed posture
- sheath tenderness
- pain on passive extension
Treatment of flexor tenosynovitis?
emergency
drain and irrigation of sheath
Where can flexor sheath infections of the thumb and little finger drain through?
- can drain through the radial and ulnar bursae → space of Parona = horseshoe abscess.
Lies immediately superficial to PQ at the wrist.
What are the 3 potential spaces in palmar infections?
- Thenar space
→ radial to oblique septum (from palmar fascia to 3rd MC). Index infections spread here - Mid-palmar space
→ ulnar to oblique septum. Middle and Ring infections spread here - Hypothenar space → rare
Distinguish from radial and ulnar bursae
→ synovial sheaths which enclose flexor tendons of thumb and little finger
Communicates proximally with space of Parona
Where else can infections in the hand occur?
Web space infections = collar stud abscess
divided by palmar fascia
Treatment - I&D via volar zig-zag and dorsal longitudinal incisions
What are the 2 potential spaces of the dorsum?
- Dorsal subcutaneous space
→ large potential space overlying entire dorsum of hand.
- Communicates in the finger webs with potential space immediately beneath palmar fascia. - Dorsal subaponeurotic space
→ just below extensor retinaculum
- Drainage by incisions over 2nd MC and b/t 4th and 5th MCs
Hand trauma history.
- Hand dominance, occupation, hand-critical hobbies, smoking.
- Mechanism of injury and forces involved.
- Time of injury, ischaemia time.
- Machinery: type etc.
- Direction of laceration.
- Position of the hand at time of injury.
- Contamination.
- Immunisation (tetanus).
Hand trauma examination.
- Is injured hand or finger viable?
- Vascular injury or compartment syndrome?
- Tendon, nerve or bony injury?
- Skin loss?
- X-rays.
- Fractures and dislocations
- Tendons (posture of hand, tenodesis test, pain on resisted flexion / extension suggests partial damage)
• Composite motion produces the following grip types: 1. Power grip 2. Pinch grip – Pure (tip) pinch – Tripod pinch – Key (lateral) pinch.
• Nerve injuries
1. Sensory:
– Sweating - tactile adherence test.
– Static and dynamic 2PD.
- Motor
– APB = median.
– FDM = ulnar.
What are the extensor compartments of the hand?
- EPB & APL
- ECRB & ECRL
- EPL
- EDC & EIP
- EDM
- ECU
What is De Quervains tenosynovitis?
What is Intersection syndrome?
DQ
- Middle aged women
- ‘Normal’ anatomy in fewer than 20%
- EPB and APL entrapment – sit in 1st dorsal compartment of wrist
- Management – Splints, steroids (but can get skin / subcut / fat atrophy, use dilute preps)
- In pregnancy/lactation - resolves
IS
- Entrapment of 2nd dorsal comp
- Management - Non-op - Steroid/Splint, unusual to need op
What are the extensor tendon zones?
Kleinert and Verdan 1983 Zone I → DIPJ Zone III → PIPJ Zone V→ MCPJ Zone VI → dorsum Zone VII → Extensor Retinaculum Zone VIII → Distal forearm tendons Added later Zone IX → Muscle bellies
What are the actions of extrinsic and intrinsic extensors?
Extrinsics → EIP EDC EDM
- primary MCPJ extensors
- extend IPJs when MPJ is prevented from hyperextension by intrinsics
Intrinsics → Interossei, Lumbricals, thenar and hypothenar muscles
- flex MCPJ and extend PIPJ and DIPJ
- contribute to IPJ extension by 3 mechanisms
Wrist extensors → ECRL, ECRB, ECU
Describe and draw the extensor mechanism
EDC
Sagittal band
Central slip
Lateral bands
Conjoined tendon
Triangular ligament
Transverse retinacular ligament - edge of flexor tendon sheath at PIP to lat band, prevents dorsal shift of lat bands, attenuation of TRL causes Swan neck, tightening of TRL and attenuation of triangular lig causes Boutonnière’s
Oblique retinacular ligament (Landsmeer) - volar lat crest of PIPJ to lateral terminal extensor tendon
Lumbricals insert into radial lateral band
Interosseii insert into both lateral bands and central slip
How is mallet injury classified?
Doyle
I - Closed ± chip fracture of P3
II - Laceration
III - Abrasion with loss of tendon substance (and skin)
IVa - Trans-epiphyseal in children
IVb - Closed + articular surface involving 20-50%
IVc - Closed + articular surface involving >50%
How do you treat a closed mallet injury?
Ishiguro Technique (doorstop technique)
o Flex DIPJ to 90deg – pulls mallet fragment distally
o Thin wire dorsally into head of P2 to skewer extensor and crowbar fragment into reduction, drill K wire in at 45deg to DP
o Straighten DIPJ then axial wire across DIPJ (pic on desktop)
What happens if a mallet finger is left untreated?
Swan neck deformity (immediate / delayed) due to division of zone 1 EDC and increased pull of central slip. Lateral bands displaced dorsally, PIPJ VP becomes lax & hyperextend
Rx - PIPJ volar plate tightening / Fowler procedure (central slip tenotomy)
How do you treat central slip injury?
Open: Repair & Kwire Closed: gutter splint 3/52, then Capener or SAM (Short Arc of Motion)
What is a Boutonnieres deformity?
Nalebuff Classification
o 1 – Mild – 10-15deg lag
o 2 – Mod – 15-30 deg
o 3 – Severe – 40 deg+
Pathology
o Attenuation/split in central slip
o Transverse Retinacular Ligament pulls PIPJ in to flexion
Stages
o 1 – Dynamic imbalance, passively supple
o 2 – Established – joint not involved, but not passively correctable
o 3 – Joint changes
How do you repair extensor tendons?
∘ Zone 1: running / figure of 8 suture that may incorporate the skin (dermotenodesis).
∘ Zone 2: running / figure of 8 suture reinforced with Silfverskiöld cross-stitch.
∘ Zones 3–8: MK core reinforced with Silfverskiöld.
What is the protocol for extensor tendon repair?
Zone 1+2: mallet injury.
• Splint in slight hyperextension of DIPJ for 6–8 wks.
Zone 3:
• Static PIPJ immobilisation in extension for 6 wks (gutter splint).
• DIPJ free to flex to ensure lateral bands do not shorten, leading to boutonnière.
Zones 4–7: ‘Norwich’ regime.
• Volar splint – wrist 45∘ extension, MCPJs flexed >50∘, IPJs extended.
• CAM on day 1.
∘ Wk 1-4:
Exercises: 4 per rep, 4 times/day.
(a) Combined IPJ and MCPJ extension.
(b) MCPJ extension with IPJ flexion (hook grip).
∘ Wk 5: splint at night only; MCPJ flexion commenced.
∘ Wk 6: Full power grip.
What is SAM?
SAM – Short Arc of Motion
- For central slip injury
- Alternative to Capener
- Volar block: initially limiting flexion to 30deg
- Gradually cranked out to allow more flexion
What is the classification for FDP ruptures?
- FDP in palm
- FDP at PIPJ - long (more proximal) vinculum remains intact
- FDP at A4 pulley - large avulsion fragment, both vinculae intact
What are the principles of flexor tendon repair?
- Number and size of incisions in sheath kept to minimum. Step incision.
- A2 and A4 preserved if possible.
- Minimal handling of tendon ends.
- Epitendinous suture of back-wall first to align tendon.
- Core suture → McLarney’s Adelaide cruciate 4 strand (locking) repair (or Modified Kessler).
- Reconstruct sheath if possible but don’t compromise glide.
- In grafts and transfers use Pulvertaft weave.
What skin incisions do you use?
Bruner’s
Midaxial
What types of tendon repairs are there?
- Modified Kessler
- Strickland – 4-strand - Mod Kessler + Horizontal mattress with epitendinous
- Tsuge
- David Evans – 2 Mod Kesslers at 90° to each other
- Bob Savage – 6-strand
- Bunnell
Callan + Morrison’s method of tendon delivery – Pickford’s favourite
Name some different hand therapy regimes
Early Active Mobilisation Accelerated Active Motion – Solomons Allen Belfast and Sheffield Strickland/Cannon Silfverskiold and May Evans and Thompson
Early Passive Mobilisation
Kleinert
Duran and Houser
Variations on early passive mobilization
Immobilisation
Cifaldi Collins, and Schwarze
Summarise the different types of flexor tendon post-op protocols
Belfast regime - controlled active mobilisation
Kleinert - early active extension and passive flexion
Duran - early passive mobilisation
What is the Duran protocol (modified)?
Modified Duran
- dorsal protective splint (40 to 50 degrees at the MP joints and from 20 degrees of extension to 20 degrees of flexion at the wrist, with the IP joints allowed to extend to neutral in the splint)
- omit rubber band traction and strap IP joints in extension between exercises or at night
- passive individual and composite flexion and extension, active composite extension exercises (manually blocking the MP in greater flexion for more complete active IP extension), and the passive flexion and extension exercises
- In therapy only, splint is removed for careful protected tenodesis exercises (passive or assisted simultaneous wrist flexion and finger extension, alternating with simultaneous wrist extension and finger flexion)
What is the Kleinert regime?
Early active extension with passive flexion.
- Dorsal protective splint. Finger flexion with rubber band traction. Bands attached to fingernails and the volar aspect of the splint i.e. active extension can occur against the elastic recoil of the bands.
- Passive flexion provided by the recoil of the bands.
What flexor tendon protocol do you use?
Original articles
Small J, Brennan M, Colville J: Early active mobilization following flexor tendon repair in zone 2, J Hand Surg 1989; 14B:383-91 and
Cullen K, Tolhurst P, Lang D, Page R: Flexor tendon repair in zone 2 followed by controlled active mobilization, J Hand Surg 1989
Modified 1+2
Gratton P: Early active mobilization after flexor tendon repairs, J Hand Ther 6:285, 1993).
What is the Belfast regime?
Early Active Mobilisation (Belfast)
Early Stage (wk 1-4)
- splint wrist neutral / 20deg flexion, MCPJ 80-90 deg flexion, IPJs extended
- volar fingers free
- 48hrs postop
- full passive flexion, active flexion, and active extension
- 1st wk - 30 degrees at PIPJ and 5 - 10 degrees at DIPJ
- 4th wk - 80-90 degrees at PIPJ and 50-60 degrees at DIPJ
Intermediate Stage (wk 4-6) Splint discontinued at 4wks - if tendon glide poor 5wks - most patients 3 weeks after splinting is discontinued, residual flexion contractures are treated with Capener (finger based dynamic extension) splints, and passive IPJ extension with MCPJ flexed
8wks - progressive resistive exercise and heavier hand use
12wks - full function
Scar management throughout
What does EAM achieve?
- Passive flexion → mobilises joints and prevents contraction
- Passive flexion and hold → produces isometric force on prox muscle belly. Maintains their function.
- Active flexion → results in tendon glide within the sheath, limits the formation of fibrous attachments, ↑ rate of intrinsic healing. ↑ Strength of repair.
What are the specific complications of flexor tendon repair?
Rupture: 5%
Adhesions
Joint contractures 17%
What is tenolysis?
- Release of adhesions to restore Active ROM
- Waste of time in under 12s
- Neuroleptanalgesia - active pt participation intraop
- Not less than 3/12 post-op
- Best at 6-12 months
Name some tendon rupture sites
- Distal Ulna - Caput ulnae - EDM, EDC Little (Vaughn Jackson)
- Scaphotrapezial spur - Mannerfelts critical corner - FPL, FDP Index
- Hook of Hamate - FCR
- Lister’s tubercle - EPL
- Carpal Tunnel - most common site for flexor rupture
What are the indications for 2 stage flexor tendon repair?
Indications
- Primary repair not possible (delayed presentation, attrition rupture, crush injury / segmental loss, infections).
- Failed primary repair
- ?Loss of all pulleys
Wound factors
- Good soft tissue cover, soft and supple scars.
- Joints should be mobile, PROM>AROM.
- Stable joints.
- Sensate.
Patient factors
- realistic expectations (including recurrence)
- patient compliance
What are the requirements of a secondary tendon recon?
- Full passive ROM
- Sensate
- Access to good Hand Therapy
- Motivation
Law of diminishing returns with each subsequent operation
How do you do a 2 stage tendon graft reconstruction?
1st stage
∘ Passive silicone tendon rod (Hunter rod) is placed in flexor sheath.
∘ Pulleys and skin/joint contractures are reconstructed.
Second stage at 3–6 months
∘ Tendon graft is placed into pseudosheath formed around rod (PL, plantaris, long toe extensors/flexors, EIP, EDM or FDS from injured finger).
∘ Distally: Mitek / Sood Elliot technique.
∘ Proximally: Pulvertaft weave: tensioned to recreate natural cascade of fingers (tenodesis test).
How do you do a 2 stage recon?
- Need 4mm of A4, 8mm of A2
- Reconstruct with extensor retinaculum – go around extensor for A4, deep to it for A2 – otherwise lateral bands get tightened
- Nagor silicone rods
- 2nd stage only once soft, supple, with full passive ROM
- At least 3 passes with Pulvertaft weave – each gives about 25% strength
- Palmaris longus
- Elliott/Sood 3-needle technique for distal attachment
- To get tension just right: stretch out to full opposed range of movement and put graft/transfer in as tight as possible
What are the different ways of insetting the tendon graft?
Distally 1st
FDP stump (split in 1/2 n bury graft in middle)
Bone (Bunnell)
Nailbed (Pulvertaft)
Proximal
Pulvertaft weave
Bunnell cross-cross
Kessler
What are the potential donor sites for tendon grafts?
PL 13cm Plantaris 31cm (anterior and medial to Achilles) Toe extensors 30cm FDS, EI, EDM Tendon allografts
