CHAPTER 12: HAND - INFECTION, TRAUMA, TRIGGER FINGER, CRPS Flashcards

Question

What are the principles of flexor tendon repair?

Answer 1

- 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.

Answer 2

Bruner's | Midaxial

Answer 3

1. Modified Kessler 2. Strickland – 4-strand - Mod Kessler + Horizontal mattress with epitendinous 3. Tsuge 4. David Evans – 2 Mod Kesslers at 90° to each other 5. Bob Savage – 6-strand 6. Bunnell Callan + Morrison's method of tendon delivery – Pickford’s favourite

Answer 4

``` 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

Answer 5

Belfast regime - controlled active mobilisation Kleinert - early active extension and passive flexion Duran - early passive mobilisation

Answer 6

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)

Answer 7

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.

Answer 8

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).

Answer 9

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

Answer 10

1. Passive flexion → mobilises joints and prevents contraction 2. Passive flexion and hold → produces isometric force on prox muscle belly. Maintains their function. 3. Active flexion → results in tendon glide within the sheath, limits the formation of fibrous attachments, ↑ rate of intrinsic healing. ↑ Strength of repair.

Answer 11

Rupture: 5% Adhesions Joint contractures 17%

Answer 12

- 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

Answer 13

1. Distal Ulna - Caput ulnae - EDM, EDC Little (Vaughn Jackson) 2. Scaphotrapezial spur - Mannerfelts critical corner - FPL, FDP Index 3. Hook of Hamate - FCR 4. Lister’s tubercle - EPL 5. Carpal Tunnel - most common site for flexor rupture

Answer 14

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

Answer 15

1. Full passive ROM 2. Sensate 3. Access to good Hand Therapy 4. Motivation Law of diminishing returns with each subsequent operation

Answer 16

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).

Answer 17

- 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

Answer 18

Distally 1st FDP stump (split in 1/2 n bury graft in middle) Bone (Bunnell) Nailbed (Pulvertaft) Proximal Pulvertaft weave Bunnell cross-cross Kessler

Answer 19

``` PL 13cm Plantaris 31cm (anterior and medial to Achilles) Toe extensors 30cm FDS, EI, EDM Tendon allografts ```

Answer 20

Absent Palmaris – 15% | Absent FDS to little – 15%

Answer 21

Intraop NV injury ``` Early Synovitis, infection Buckling of implant Implant extrusion, migration Pulley breakdown Skin flap necrosis ``` Late Chronic flexion deformity CRPS type 1 Tendon adhesion Rupture of graft Quadriga - tendon too short / tethered - the other FDPs cannot shorten sufficiently to achieve full flexion Lumbrical plus - tendon too long

Answer 22

1. DO NOTHING!! 2. Tenolysis 3. Tendon transfer 4. Primary tendon graft ∘ Scar within sheath, or sheath incompetence, requires two-stage reconstruction. 5. Two-stage tendon graft Zone 2 - DIPJ arthrodesis Zone 3 - Interpositional graft - Tenodese to adjacent FDP - FDS transfer

Answer 23

Preop - all wounds healed - full passive ROM - sensate Intraop - operate in reverse order - prepare recipient site, tunnel before raising muscle - avoid interference with other structures e.g. compress nerve - apply correct tension (EIP→EPL alway loosen, Opponensplasties always tighten so start loose) - tendon transfers must not pass under areas of scar tissue or skin grafts

Answer 24

* Indicated when pulley mechanism is insufficient to prevent bowstringing that limits active joint flexion. * A2 and A4 pulleys minimum. ``` • Materials: ∘ Free tendon graft. ∘ Segment of wrist extensor retinaculum. ∘ Fascia lata. ∘ Slip of FDS. ∘ Dacron, silicone, PTFE. ``` • Method ∘ Wrap around PP + MP in a double loop. ∘ Weaving through remnants of pulleys in a zigzag fashion. ∘ Suturing into holes drilled into phalanx. ∘ Bone anchors.

Answer 25

1. Reduction 2. Immobilisation (+/- Fixation) 3. Rehabilitation

Answer 26

1. Life-threatening injuries. 2. Open wound? 3. Associated NV injury? 4. Associated tendon / ligament injury?

Answer 27

• By closed manipulation • By mechanical traction • By open surgery. – Minimal displacement or displacement of no functional consequence do not need reduction. – Translation is generally better tolerated than angulation or rotation.

Answer 28

* To prevent displacement of fragments. * To prevent movement that might interfere with bone union. * To relieve pain. ``` – Immobilisation can be achieved by: • External splint, e.g. POP or Zimmer splint • Continuous traction • External fixation • Internal fixation. ```

Answer 29

* Irreducible fractures, particularly if malrotated * Intra-articular fractures * Subcapital fractures of phalanges * Open fractures * Segmental bone loss * Polytrauma with hand fractures * Multiple hand or wrist fractures * Fractures with soft tissue injury (vessel, tendon, nerve, skin). ``` Methods of internal fixation: • K wires • Interosseous wires • Intramedullary devices • Screws • Plates. ```

Answer 30

Aims of rehabilitation: 1. Preserve hand function during fracture union. 2. Return hand function to normal once fracture has united. – Immobilise usually no > 3–4 weeks.

Answer 31

Early • NV and other soft tissue injury. • Compartment syndrome. ``` Late • Delayed union • Non-union • Malunion • Joint stiffness and contractures • AVN • CRPS • Osteomyelitis • Growth disturbance or deformity • OA ```

Answer 32

Aims - provide adequate exposure - preserve skin's blood and nerve supply - extendible if necessary - avoid scar contracture. Dorsal, lateral or volar approaches.

Answer 33

Dorsal - skin: H,Y,L over DIPJ, longitudinal over PIPJ + MCPJ - zone III EDC: midline split or Chamay approach: V shaped incision through extensor based distally. Lateral - Midaxial incision (dorsal extremes of IPJ flexion creases) - Midlateral incision (more volar) Volar - very rarely used, e.g. VP avulsion fracture, MCPJ collateral ligament avulsion (lig travels from MC to volar base of PP).

Answer 34

* Check for rotation: make a fist, DIPJ extended (fingers should point to scaphoid tubercle). * 5th MC neck fractures: well tolerated due to mobility of CMCJ, treatment not required unless rotated / angulated >70∘ • Stable fracture: splint for 3–4 weeks. ∘ Buddy strapping ∘ Bedford gaiter ∘ POP, aiming for 3-point fixation, e.g. ulnar gutter, Barton short hand cast, clam-digger cast. • Open fracture: operative. ``` • Fixation can be achieved by: ∘ K wires: transverse, longitudinal, ‘bouquet’ wiring. ∘ Lag screws ∘ Plates – low profile ∘ Interosseous wires ∘ External fixation. ```

Answer 35

DP: splint / Kwire/ Ishiguro 'doorstop' technique for bony mallets. MP/PP: cross Kwire, lateral plate.

Answer 36

Aim: to restore joint congruity and: 1. Prevent deformity 2. Prevent OA 3. Restore early movement. Unicondylar fractures - percutaneous K wire, ORIF + lag screws. Pilon fractures (comminuted) - e.g. axial loading of PIPJ → MP base fracture. - Suzuki frame (K wires and rubber bands dynamic external fixator), Hynes–Giddins device (K wires only). Some fractures may require ORIF and bone graft.

Answer 37

DIPJ • Dislocations and subluxations rare • May be associated with tendon avulsions PIPJ • Volar plate injuries (Eaton): ∘ Type I (hyperextension) – Avulsion of VP without fracture; collateral ligaments split. ∘ Type II (dorsal dislocation) – Complete dorsal dislocation; VP avulsion without fracture. ∘ Type III (fracture subluxation) – Fracture subluxation with a palmar fragment. Treatment - reduction, EAM with dorsal blocking splint or - dynamic ex-fix, ORIF of palmar fragment

Answer 38

``` usu dorsal (VP avulsion) volar rare (central slip avulsion) ```

Answer 39

VP may rupture and flip into joint Rx: open reduction and repair. CMCJ - thumb → ring fingers: rare (high energy trauma). - 5th CMCJ subluxation: may be associated with MC base fracture (reversed Bennett's) or dorsal avulsion from hamate. Treatment: ∘ Closed reduction and splint ∘ Closed reduction and K wire into adjacent MC or carpus ∘ ORIF. Inadequate reduction → poor grip.

Answer 40

* Fracture–subluxation of 1st CMCJ. * Mechanism of injury = axial loading of flexed CMCJ → - palmar oblique (‘beak’) ligament holds fragment in anatomical position - Remainder of MC is adducted and supinated by adductor pollicis, and pulled proximally by APL. • Reduced by: 1. Longitudinal traction 2. Pronation of metacarpal 3. Pressure at base of MC. • Immobilisation by 1. Thumb spica or 2. Percutaneous K wires: a) Transfixion of MC base to trapezium. b) Transfixion of 1st MC base to 2nd MC. c) a+b. 3. ORIF

Answer 41

* 3-part intra-articular fracture of base of 1st MC. * Non-operative: usually inadequate * ORIF with T-plate (dorsal or radiopalmar approach). * External fixation

Answer 42

Bennett’s Fracture - 2 part # dislocation of 1st MC on trapezium - Forces – APL and Adductor Pollicis - Ulnar-Volar Fragment - MC base subluxed dorsally, radially and proximally due to pull of APL Rolando - ≥3 part # dislocation of 1st MC on trapezium - Comminuted T or Y-shaped fracture at base of 1st MC Reverse Bennett’s - Base of 5th Metacarpal - Forces – ECU and Hypothenar muscles

Answer 43

* Skier's thumb: acute * Gamekeeper’s thumb: chronic attenuation of UCL. • Stener lesion: avulsed ligament displaced dorsal to adductor aponeurosis. Spontaneous bony or ligamentous healing not possible due to interposing adductor aponeurosis. ∘ Radial stress test with MCPJ in 30∘ of flexion. • Treatment: Mitek bone anchor, immobilisation for 4wks.

Answer 44

Acute rupture = skier's thumb Chronic repeated hyperabduction = gamekeeper's thumb ``` Stener lesion (80% of all ruptures) - torn ligament / bony fragment is avulsed from its distal insertion and sits superficial to adductor aponeurosis ``` Radial stress test - accessory collateral ligament - test with thumb extended proper collateral ligament - test with thumb flexed >40 deg instability or >15deg difference to contralateral normal side = tear Partial tear - thumb spica 4wks Complete tear - surgery

Answer 45

Lazy-S incision - ulnar midlateral to dorsum of MP joint. Longitudinal incision in add aponeurosis, 3mm volar to EPL tendon. Remove loose bone if found. - Middle 2/3 tears - suture - Distal (common) or proximal (rare) - pull through or Mini-Mitek. - Large Artic Fragments - ORIF. Repair add aponeurosis Green says consider following 4 steps before closure: 1. Suture distal volar repaired lig to volar plate for added stability. 2. Repair dorsal ulnar capsule. 3. Test repair with radial stress. 4. Consider over ulnar deviation of joint in mild flexion with K-wire.

Answer 46

• Most can be managed non-operatively. • Physis: deformity can be remodelled with growth. • Greatest remodelling potential is seen: ∘ When angulation occurs in plane of adjacent joint motion. ∘ When fracture is in close proximity to physis. ∘ When fracture is in a young child with many years of remaining growth. • Rotational and angular deformity has little remodelling potential. • Physis should be respected during surgery.

Answer 47

Salter Harris Classification of Paediatric Epiphyseal Fractures (1963) I – S = SLIP (separated or straight across). Fracture through the physis II – A = ABOVE. The fracture lies above the physis, or Away from the joint. III – L = LOWER. The fracture is below the physis in the epiphysis. IV – T = THROUGH. The fracture is through the metaphysis, physis, and epiphysis. V – R = RAMMED (crushed). The physis has been crushed

Answer 48

Type I – 6% A transverse fracture through the physis Type II – 75% - through the physis and the metaphysis, sparing the epiphysis Type III – 8% - through physis and epiphysis, sparing metaphysis Type IV – 10% - fracture through all three elements: growth plate, metaphysis, and epiphysis Type V – 1% - compression fracture of the growth plate

Answer 49

* Looks like a mallet deformity, but is transepiphyseal rather than transarticular. * Extensor tendon pulls on proximal fragment and FDP on distal fragment → distraction and volar displacement of fracture. * Usually associated with nail bed lac (open fracture). * Requires debridement, reduction, nail bed repair and replacement of nailplate as a splint +/- axial transarticular K wire if unstable.

Answer 50

• Typically occur following trapping a finger in a door. • Distal fragment is angulated dorsally into extension ∘ Results in incomplete flexion at PIPJ. • Minimally displaced fractures: splint + weekly X-rays. • Displaced fractures: closed reduction and K wire.

Answer 51

Stenosing tenosynovitis Acquired condition Flexor tendon sheath thickens and narrows canal so flexor tendon cannot glide freely through it Pathology Fibrocartilagenous metaplasia and hypertrophy of A1 pulley Reactive swelling of tendon

Answer 52

pain in palm, intermittent snapping/triggering, locking (in flexion or extension) Typically worse in the morning

Answer 53

Dupuytren’s contracture, post-traumatic joint contracture or locking of the metacarpophalangeal joint (rare).

Answer 54

Lifetime risk 2% Can occur in children (thumb > fingers) and adults Risk factors - diabetes, thyroid disease, RA< renal disease

Answer 55

Wolfe 2005 Mild (“pre-triggering”) - ANALGESIA - History of pain, catching or “click” - Tender A1 pulley; but fully mobile finger o Moderate - STEROID INJECTION - Triggering with: A - Difficulty actively extending finger B - Need for passive finger extension. Loss of complete active flexion o Severe - SURGICAL RELEASE - Fixed contracture

Answer 56

- triamcinolone or dexamethasone (water soluble - decreased risk of tendon rupture) +/- LA, insulin needle, 1ml, inject into palm at level of A1 pulley - 1st injection 49-78% effective - 2nd injection 50%

Answer 57

1. after failed conservative treatment 2. recurrent triggering after 1-2 injections of steroid 3. severe symptoms at presentation 4. in people who are unlikely to benefit from steroid injections (e.g. diabetic with multiple digits affected and severe symptoms)

Answer 58

Acquired presents ~6/12 - 2yrs IPJ locked in flexion palpable 'Notta's node' at MCPJ level Conservative - passive stretching (splinting) steroid inj not advocated 36-78% of cases will resolve spontaneously Different authors advocate surgery if failed conservative management age 3-5

Answer 59

Management Steroid lnjection - in sheath/subcut/both Littler Ratio - Double the distance of central P3 whorl to PIPJ crease = A1 pulley location Thumb - release A1 on radial side to avoid oblique pulley (between A1 and A2) which runs ulnar to radial

Answer 60

Rheum Arthritis - check for FDP entrapment by inflammation at level of FDS decussation - A1 pulley is one preventer of ulnar drift so nice to preserve if possible - tenosynovectomy and nodule excision instead.

Answer 61

Management Steroid lnjection - in sheath/subcut/both Littler Ratio - Double the distance of central P3 whorl to PIPJ crease = A1 pulley location Thumb - release A1 on radial side to avoid oblique pulley (between A1 and A2) which runs ulnar to radial

Answer 62

Rheum Arthritis - check for FDP entrapment by inflammation at level of FDS decussation - A1 pulley is one preventer of ulnar drift so nice to preserve if possible - tenosynovectomy and nodule excision instead.

Answer 63

CRPS (1995) = a variety of painful conditions following injury ... pain exceeding both in magnitude and duration of the expected clinical course of the inciting event RSD and causalgia no longer used

Answer 64

- Most Common - Not involving direct nerve injury - 60-70% - Simple trauma - Female : Male 4:1, 3rd-4th decade - Younger get over it, older don’t - Allodynia – Pain with normal stimulus - Hyperpathia – additive pain with repeated stimuli - Hyperalgesia – exaggerated pain response - Pain in uninvolved joints - Autonomic instability – increased temperature, sweating, swelling (sweating reduces later) - Trophic Changes – Nails, Hair, Skin, Osteoporosis - Weakness – small movements, tremor

Answer 65

- Identifiable primary nerve insult | - causalgia + vasomotor, sudomotor and trophic changes

Answer 66

sensitisation of CNS to a painful stimulus following peripheral nerve injury by cytokine mediated feedback to hypothalamus

Answer 67

- Distal Rad/Uln # - up to 21% - Palmar br. median n. - Sup br. radial n. - Tight dressings/POP - Can be isolated to a single digit

Answer 68

Symptoms - pain - allodynia: pain due to stimulus which doesnt usually provoke pain - hyperalgesia: increased pain to normally painful stimulus - hyperaesthesia: increased sensitivity to a stimulus - hyperpathia: excessive perception of a painful stimulus - dysaesthesia: abnormally perceived unpleasant sensation, spontaneous or provoked - causalgia: burning pain, allodynia and hyperpathia after traumatic nerve injury

Answer 69

Signs - stiffness - swelling - discolouration (dermographia - skin changes with light object dragged across skin) - skin changes: inc hair, shiny skin, hyperhidrosis, osteoporosis

Answer 70

- thermography: temp difference 0.6 degrees - Abnormal bone scan in 60% - Reduced blood flow at later stage (Increased initially) - Phentolamine infusion test - blinded with saline - distinguishes sympathetic dependent from sympathetic independent CRPS.

Answer 71

``` pain out of proportion abnormal sympathetic function swelling mvmt disorder changes in tissue growth ```

Answer 72

Acute - Traumatic - 1-3mths Subacute - Dystrophic - 3-12mths Chronic - Atrophic - years (Sudeck's atrophy)

Answer 73

Early diagnosis is key - Pain - Function – Don’t rush – gentle passive initially, building up slowly - Psychiatric Support

Answer 74

- Treat primary insult - Physio - TENS - Free Radical Scavengers (Vitamin C 500mg tds for 50 days, DMSO (Dimethylsulphoxide), NAC – N-Acetylcysteine) - Calcitonin - Steroids – for acute inflammatory phase - Simple Analgesia - Opiates - Antineuropathics - NMDA Antagonists – e.g. ketamine infusions - Sympathectomy - Blocks (guanethidine) - Epidurals - Implantable Spinal Cord Stimulator – good for function as well as pain - HBO

Answer 75

It is a test for central slip continuity. Place patients fingers over edge of table and flex fingers at PIPJs Ask patient to extend at PIPJ against resistance. Patient will be unable to do this if central slip is ruptured.

Answer 76

1. Quadriga phenomenon (a Quadriga = an ancient Greek four horse chariot) o Condition in which the flexor tendon excursion in unaffected finger is reduced due to altered FDP excursion in the adjacent injured finger (by stiffness, injury or adhesion) (Verdan 1960). o When testing for FDS, the FDP is defunctioned because the FDP tendons are combined, while the FDS muscles are separate in the forearm. o Following repair or reconstruction of an FDP tendon the tension must be identical to the other FDPs, since the excursion of the combined tendons is equal to the shortest tendon. o Suturing extensor tendon to flexor tendon following amputation will result in Quadriga effect. 2. Lumbrical plus - opposite to Quadriga If FDP is allowed to retract after e.g. DP amputation, during attempted flexion, extension of PIPJ results because retracted FDP causes increase in lumbrical pull. To avoid this, secure FDP stump to A4 pulley or partial / complete excision of lumbrical. 3. Bunnel-Littler Test For intrinsic tightness. 1) With the MCPJ in extension the intrinsics are put on a stretch. Try to flex the PIPJ with MCPJ in extension. If it doesn't flex = tight intrinsics or joint capsule contracture. 2) With MCPJ in flexion the intrinsics are relaxed. Thus if unable to flex PIPJ= tight capsule. NB- prior to test check that passive motion of PIPJ is possible (i.e. normal PIPJ) Tight intrinsics occur in: 'Intrinsic Plus' hands due to ischaemia or fibrosis of intrinsics or RA. 4. Bouvier's Test (BOUtonniere's deformity) • To determine if PIPJ capsule & ext. mech. are working normally. • If PIPJ capsule & ext. mech. are functioning normally then blocking MCPJ hyperextension allows IPJ extension. • Positive test occurs as a result of: attenuation of central slip, adherent central slip at PIPJ or volar subluxation of lateral bands.

Answer 77

Quadriga: 1. Adhesion / scarring of FDP tendons 2. Over tightening / distal advancement of FDP after rupture and repair 3. After amputation, if FDP is sutured to EDC Result: weak grasp on remaining fingers, and cannot make full fist because if 1 tendon is shortened the others cannot flex fully. Lumbrical plus: e.g. if FDP allowed to retract after amputation of digit A lax FDP results in tension in the lumbricals. Result: when patient makes a fist, the affected finger extends at the PIPJ due to lumbrical pull.

Answer 78

To test intrinsic or extrinsic finger extension? Intrinsic: extension of PIPJ with MCPJ flexed Extrinsic: extension ofIPJ with MCPJ extended.

Answer 79

Patient Selection - Well motivated - Able to understand nature and limitations of surgery - Able to co-operate with post op physio Recipient site factors - Good soft tissue cover - A stable skeleton - Full range of passive movement - Normal sensation

Answer 80

APOSLE 1. Amplitude of motion→ similar excursion o Wrist flex and ext = 3 cm o Finger extensors = 5cm o Finger flex = 7cm Effective amplitude of donors can be ↑ by use of tenodesis, freeing fascial attachments of the donor muscle unit. 2. Power and control → similar pull o Lose at lease 1 grade after transfer o BR does not adapt well 3. One tendon – one function o effectiveness if try to do 2 functions 4. Synergistic Action o Muscles which normally act together to produce a composite movement should be used to replace each other whenever possible. o Finger flex assoc with synergistic wrist extension o Finger ext assox with wrist flex o A transfer of a wrist flexor to a finger extensor = synergistic → better function 5. Line of Pull o Best if direct from origin to insertion o Deviations around pulleys ↓ effectiveness 6. Expendability o Only transfer expendable tendons o Important that one wrist flexor remains intact when producing wrist and finger extension in radial palsy.

Answer 81

- No need to repair if tendon is >40% intact - Core: 4 strand is better than 2 (less gapping) - Locking is better than grasping - 3/0 stronger than 4/0 by 50% - Longer core suture purchase length is superior (1cm vs 0.4cm). Optimum = 0.7-1.0cm. - Absorbable comparable to non-absorbable sutures (for 4 strand core). (Caulfield et al, 2008 JHS(E)) - Mitek superior to button technique for FDP avulsions (patient satisfaction and lower morbidity). - Flexor sheath repair: results contradictory and mainly animal-based. 1 study on children showed better mvmt with vein graft sheath repair.

Answer 82

Cochrane review (2004) showed good results and trend toward EAM protocols vs immobilisation. Kitis 2009 (Scand) compared Kleinert (controlled active) vs Duran (controlled passive): showed CAM had better TAM and DASH scores.

Answer 83

(a) Digital nerve repairs: mobilise from day 4 vs immobilise for 3wks: no difference in outcome. (2005). (b) Zone 1+2 EAM (233pts, prospective: Elliott JHS 1994). - FDP: 5.8% - FPL: 16.6% Rupture rate review paper (Tang 2005 Hand Clinics). - FDP = 4-10% - FPL = 3-17% Tenolysis rate ~33% (Swiss)

Answer 84

She would likely be best treated with repair of the nerves (Level III Evidence) and the profundus tendon. She should be treated with an early protected active movement protocol (Level II Evidence). She should be allowed to return to work at 8 weeks after repair (Level II Evidence).

Answer 85

- McLarney (JHS (Am) 1999) 1st described non-locking version of this core suture. - Showed it was superior to MKS 2 strand, Strickland and modified Savage 4 strand repairs. - It required twice the force (44N) to produce 2mm gap compared with the others.