H&W Flashcards
Indications for Hemi-Resection arthroplasty (DRUJ arthrosis)
Painful DRUJ Instability<div>DRUJ contracture<br></br><div>OA DRUJ</div><div>RA DRUJ</div><div>Ulnocarpal Impaction</div></div>
Compression Sites for RTS?
Arcade of Froshe (entrance to sup)<div>Fibrous band at distal supinator</div><div>ECRB border</div><div>RC joint</div><div>Leash of henry (Radial Recurrent artery)</div>
Indications for scaphoid OR
Displacement >1mm<div>Comminution/Bone Loss</div><div>Perilunate</div><div>RL>15 (DISI)</div><div>Lateral interscaphoid >35 deg</div><div>Proximal Pole</div><div><br></br></div>
RFs for Scaphoid Nonunion
Proximal Pole fractures<div>Displacement > 1mm</div><div>Humpback Deformity</div><div>Delay in treatment > 4 weeks</div><div>Height to length ratio > 0.65<br></br></div>
Stages of Mayfield Classification
1- disruption of SL ligament complex<div>2 - disrution of LC complex</div><div>3 - disruption of LT complex (carpus separates from lunate; falls dorsally)</div><div>4 - lunate dislocates from radial fossa (volar extrinsic ligaments intact)</div>
“X-ray Findings in Madelung’s”
narrow physis on ulnar side of DR<div>increased radial inclination, lunate fossa angle</div><div>increased volar tilt</div><div>anterior bowing of distal radius</div><div>dorsal sublux ulnar head</div><div>ulnocarpal impaction signs</div>
DDx Lytic Lesion in the Hand
“infx/non-neo: OM, ABC, UBC, epidermal cyst (intraosseous)<div>benign: enchondroma, GCT, CB, OB</div><div>malignant: chondrosarc, ewing’s, lymphoma, OS</div>”
Non-op Mx of Carpal Tunnel
Brace/Splint - strong recommendation<div>Steroid (inj (strong)>oral (mod)>nothing)</div><div>Ketoprofen phonophoresis - moderate recommendation</div>
Compression sites for Median Nerve?
Supracondylar Ridge<div>Ligament of Struthers</div><div>Lacertus Fibrosus</div><div>PT (humeral head)</div><div>FDS arch</div><div>FPL</div><div>*AIN syndrome: motor weakness, no pain, neuritis</div>
Compression Sites Ulnar Nerve
“Arcade of Str<b><u>u</u></b>thers<div>Medial IM Septum</div><div>Medial Triceps</div><div>Cubital Tunnel (ME, Osbourne Lig)</div><div>FCU heads</div><div>Guyon’s canal</div>”
Principles of Tendon Transfers
<div>LOOSE CAST</div>
Donor<div> Minimize functional Loss</div><div> Normal strength (voluntary control)</div><div> One Tendon, One function</div><div>Together</div><div> Excursion</div><div> Vector of pull in line (only cross 1 joint)</div><div> In-phase tendons (synergistic)</div><div>Stable Soft tissue bed that allows gliding</div><div>Full passive ROM of joints</div><div><br></br></div>
Tendon Transfer for Median n. palsy
thumb IP flex (FPL): BR, ECRL or ECU<div>thumb opp (AbPB): EIP, FDS ring, PL</div><div>D2 DIP flex (FDP): ECRL</div>
Tendon Transfers for Radial n. Palsy
Wrist ext (45 deg): PT to ECRB<div>Finger ext (MCP ext): FCR to EDC</div><div>Thumb Ext: PL to EPL</div>
Order of Neurologic Fxn Return after peripheral nerve injury?
SPTTPM<div>Sympathetic</div><div>Pain</div><div>Temp</div><div>Touch - light</div><div>Proprioception</div><div>Motor</div>
Pathophys of Boutonierre Deformity
“Central slip disruption at PIP (and triangular ligament)<div>->PIP flexion->volar subluxation of lateral bands–> migrate proximally –> tension on terminal tendon –> DIP hyperextension</div><div><img></img><br></br></div><div> <div> <div><img></img><br></br></div> </div></div>”
Etiologies of Swan Neck in RA?
Extrinsic<div> Mallet - disruption of terminal tendon</div><div> Wrist or MP flexion contraction</div><div>Intrinsic</div><div> Instrinsic mm contracture</div><div> Chronic MP volar subluxation</div><div> Tendon adhesion</div><div>Articular</div><div> Volar plat/capsule injury (hyperextension)</div><div> Disruption of FDS</div>
Bunnell Test?
For Intrinsic Tightness; positive if: inability to flex PIP with MCP in extension<div><br></br></div><div>basically - cant CLAW (Which is extrinsic tightness)</div>
Lichtman Classification for Kienbock
“(1) Normal X-ray; MR has changes –> immob/NSAIDS<div>(2) lunate sclerosis; joint leveling surgery</div><div>(3A) lunate collapse</div><div>(3B) lunate collapse + capitate migration and scaphoid rotation (DISI)–> PRC</div><div>(4) Degenerative intercarpal joints -> wrist fusion</div><div><br></br></div><div><img></img><br></br></div>”
Bennet Fracture Reduction?
“Traction<div>Abduction (NOT adduction)</div><div>Extension</div><div>Pronation</div><div><br></br></div><div><br></br></div><div>‘peta’</div><div><br></br></div>”
Treatment options for Dorsal PIP dislocation?
“<div><div> <div> <div><img></img></div> </div></div></div>Stable - buddy tapping<div>Tenuous - ie requires 30 deg of flexion post reduction for stability</div><div>Unstable</div><div>-extension block splinting</div><div>-CRPP</div><div>-ORIF</div><div>-dynamic ex fix</div><div>-Volar plate arthroplasty (transosseous fixation)</div><div><b>-hemi-hamate reconstruction arthroplasty (for >50% of articular surface involvement)</b></div>”
Block to reduction of VOLAR PIP dislocation?
Lateral Bands<div>Central Slip</div>
Acceptable reduction parameters for MC #s?
<div><ul><li>NO Malrotation (RC EXAM)</li> <li> <div> <div></div> <div>Shaft (Deg)</div> <div>Neck (deg)</div> <div>Shaft shortening (mm)</div> <div>D2</div> <div>10</div> <div>20</div> <div>3-5</div> <div>D3</div> <div>20</div> <div>30</div> <div>3-5</div> <div>D4</div> <div>30</div> <div>40</div> <div>3-5</div> <div>D5</div> <div>40</div> <div>50</div> <div>3-5</div> </div> </li></ul></div>
“associations with etiology of Dupuytren’s”
Family Hx<div>Northern European descent</div><div>Smoking hx</div><div>EtOH abuse</div><div>Diabetes</div><div>Epileptic medication</div><div>Manual labour <div></div> <div>Less solid answers:</div> Adhesive capsulitis</div><div>Vibration exposure</div><div>?male gender</div><div>hx of peyronies disease<br></br></div>
RA patient unable to extend D4/D5… DDx?
Ext tendon rupture (Vaughan-Jackson)<div>Sagittal band rupture</div><div>Volar MCP dislocation</div><div>PIN Palsy (at RC joint)</div><div>Cervical myelopathy</div>
RFs for failure of non-op DR#s?
Older Age<div>Metaphyseal comminution</div><div>Radial Shortening</div><div><b>not dorsal angulation</b></div>
Transfer for Ulnar nerve palsy
Clawing: FDS to lateral bands of ulnar digits<div>Key pinch (thumb adduction): FDS to Add Pollicus</div>
Treatment options for elbow OA
Non-op: PT, NSAIDS, steroids<div>Surgical:</div><div>-open vs arthroscopic debridement and capsular release</div><div> -UH arthroplasty or olecranon fossa debridement (Outerbridge Kashiwagi procedure)</div><div>-synovectomy (RA)</div><div>-UH resection with inter-position</div><div>-Arthrodesis (90-110 for hygiene/dominant, 65 for nondominant)</div><div>-TEA</div><div><br></br></div><div><b>consider Ulnar nerve decompression (Esp if <90 deg flex preop)</b></div>
elbow OA presentation
weakness, tight capsule, hypertrophic OA<div><b>not loss of joint space</b></div><div><b><br></br></b></div><div><i>characterized by preservation of articular cartilage and maintenance of joint space, but hypertrophic osteophyte formation</i></div>
Scaphoid Nonunion Tx algorithm
No humpback deformity –> Inlay bone graft (Russe)<div>Humpback deformity –> interposition bone graft (Fisk)</div><div>Osteonecrosis/proximal/revision–> vascularized bone graft</div><div>-Distal radius (1-2 intercompartmental supraretinacular artery)</div><div>-Distal femur (MFC; descending genicular artery pedicle (from the superficial femoral artery))</div><div><br></br></div><div>If Stage 1 SNAC (ie early RS changes) –> can do styloidectomy as well<br></br></div>
Order of Flexor Pulleys in Hand?
“A1 (MCP) - no useful function<div>A2 - most important</div><div>C1</div><div>A3 (PIP)</div><div>C2</div><div>A4 - most important</div><div>C3</div><div>A5 (DIP)</div><div><br></br></div><div></div><div><img></img><br></br></div>”
Volar ulnar approach to Wrist
“interval: ulnar NVB and flexor tendons<div><br></br></div><div><img></img><br></br></div><div><img></img><br></br></div>”
Avulsion fractures invovled in RC # dislocation?
“<div>Three columns:</div>Radial: RSC off radial styloid<div>Intermediate: Short RL off volar lunate facet</div><div>Ulnar: UL and UTq off ulnar styloid</div><div><img></img><br></br></div><div>not a RC Q yet</div><div><br></br></div><div><br></br></div>”
Dx criteria for RA?
“<img></img>”
zones for flexor tendon injuries?
“<ul> <li>Anatomic Zones:</li> </ul><ol> <li>Distal to insertion of FDS, injury only to FDP</li> <li>FDS insertion to A1 pulley (““no man’s land””)</li> <li>Carpal tunnel to A1 pulley</li> <ol> <li>Origin of lumbricals from FDP tendon</li> </ol> <li>Carpal Tunnel</li> <li>Tendinous Portion of Forearm</li> </ol><li><div> <div> <div><img></img></div> </div></div></li>”
flexor pulley anatomy?
“<img></img>”
phases of tendon healing
“<ul> <li>Inflammatory (0-5 days)</li> <ul> <li>Blood clot and granulation, macrophages and fibroblasts remodel ECM</li> <li>Strength from sutures</li> </ul> <li>Proliferative/Collagen (1-6 weeks)</li> <ul> <li>Proliferation of fibroblasts</li> <li>Rapid synthesis of type 1 collage from epitenon</li> <li>Repair weakest at 10-15 days</li> <li>40% final strength at 4 weeks</li> <ul> <li>Improvement in strength of tendon doesn’t begin until week 3</li> </ul> </ul> <li>Remodeling (up to 1 year)</li> <ul> <li>Longitudinal orientation of collagen along tension lines</li> <li>Normal tendon fibres by 9 months</li> </ul></ul>”
Elson Test?
“<ul> <li>Most reliable maneuver for diagnosis of Boutonierre</li> <li>Technique</li> <ul> <li>Flex PIP to 90°</li> <li>Extend PIP against resistance</li> <ul> <li>If central slip intact the DIP will remain supple</li> <li>If ruptured DIP will be rigid</li> </ul><li><img></img><br></br></li> </ul><li> <div> <div><br></br></div> </div></li></ul>”
Flexor Tendon Reconstruction?
“<div> <div> <div> <ul> <div><img></img></div> <div>Flexor Tendon Reconstruction</div> <div>Requirements</div> <ul> <li>supple skin</li> <li>sensate digit</li> <li>adequate vascularity</li> <li>full PROM</li> </ul> <div>Indication</div> <ul> <li>failed primary repair</li> <li>chronic</li> </ul> <div>Technique</div> <ul> <li>often 2 staged</li> <li>Stage I</li> <ul> <li>Hunter rod inserted and sutured distally</li> <li>A2 and 4 pulleys often reconstructed</li> </ul> <li>Stage II</li> <ul> <li>Performed 3 months later </li> <li>Rod removed </li> <li>Tendon autograft is passed through sheath</li> </ul> <li>Extrasynovial grafts</li> <ul> <li>Palmaris</li> <li>Plantaris</li> </ul> <li>Intrasynovial grafts</li> <ul> <li>FDS</li> <ul> <li>Retain gliding surface</li> <li>Heal intrinsically</li> </ul> </ul> <li>Complications</li> <ul> <li>50% tenolysis</li> </ul> </ul> </ul> </div> </div></div>”
MCP dislocation:<div>(1) direction</div><div>(2) closed reduction maneuver</div><div>(3) blocks to reduction</div>
“(1) dorsal - volar plate avulsion, collaterals torn if rotational component<div>(2) MCP extension, PIP flexion with a distal force on proxial phalanx</div><div><img></img><br></br></div><div>(3) incarcerated volar plate</div><ul> <li>MC head buttoned holed</li> <ul> <li>Flexor tendons ulnar</li> <li>Lumbricals radial</li> <li>Natatory ligaments dorsal</li> <li>Superficial transverse metacarpal displaced proximal</li> </ul> </ul> <div></div> <ul> <li><img></img></li></ul><div><br></br></div>”
<div>Mx of Seymour fracture (pediatric physis fracture of distal phalanx)</div>
<ul> <li>Juxta-epiphyseal injuries to the distal phalanx with nail bed laceration</li> <li>Crush injuries </li> <li>Technically an open fracture</li> <li>Typically the distal phalanx in a flexed posture (disconnected terminal tendon)</li> <li>Often mistaken for a mallet finger</li> <ul> <li>But physis weaker than the bone</li></ul></ul>
<div><ul> <li>Management:</li> <ul> <li>Closed injuries -> Closed reduction and splint</li> <ul> <li>Due to difficulty with compliance often do operative management</li> </ul> <li>Operative:</li> <ul> <li>Nail plate removed</li> <li>Small oblique incision at junction of paronychial and eponychial folds to expose nail bed laceration</li> <li>Remove soft tissue from fracture site</li> <ul> <li>Can lead to physeal arrest if left</li> </ul> <li>Extend finger to reduce fracture</li> <li>Pin with K-wire across DIP joint</li> <li>Repair nail bed laceration with 6-0 or 7-0 sutures</li> <li>Re-approximate nail</li> <li>Parentral antibiotics x 5-7 days (seems like a lot!)</li> </ul> </ul></ul></div>
indications/contraindications for replantation?
“<ul> <li>Indications:</li> <ul> <li>Loss of a thumb</li> <li>Multiple digit amputations</li> <li>Amputations at or proximal to the palm (RC EXAM)</li> <li>Pediatric finger amputations</li> <li>Single digit zone I (Flexor tendon zones)</li></ul></ul> <ul> <li>Relative Contra-indications:</li> <ul> <li>Single digit amputations through zone II</li> <li>Severe crush</li> <li>Mangling</li> <li>Segmental amputation</li> <li>Heavy contamination</li> <li>Prolonged warm ischemia time</li> <li>Medically unsuitable</li> <li>Amputation of single border digit</li> <li>Poor prognosticators:</li> <ul> <li>"”red line sign”” –> red stripe at mid lateral aspect of avulsed digit = hemorrhage along vessel</li> <li>"”Ribbon Sign”” –> tortuous spiraled blood vessels seen = significant intimal injury</li> </ul> </ul> </ul> <div></div> <div><img></img></div><div><br></br></div><div><ul> <li>Warm ischemia time should not exceed 12 hours for digits and 6 hours for amputated parts with substantial muscle</li> <li>Cold ischemia time 24 hours for digits and 10-12 hours for limbs</li></ul></div>”
<div>Ddx for base of thumb pain</div>
<ul> <li>De Quervain tenosynovitis</li> <li>FCR tendinitis</li> <li>Scaphoid pathology</li> <li>STT arthritis</li> <li>RC arthritis</li> <li>Thumb MCP arthritis</li></ul>
approaches for scaphoid and adv/disadv
<div> <div></div> <div>Advantages</div><div><br></br></div> <div>Disadvantages</div> <div>Volar (Russe)</div> <div>Good access to waist & distal pole</div> <div>Preserve Dorsal blood supply</div> <div>Extend wrist for OR</div><div><br></br></div> <div>Difficulty with proximal pole</div> <div>Injury to volar ligaments</div> <div>Radial artery at risk</div> <div>Screw placement may require trapezium rongeur</div> <div>Dorsal</div> <div>Proximal Pole</div> <div>Easier screw placement down access</div> <div>Big hole in scaphoid joint surface</div> <div>Increase risk to dorsal blood supply</div> </div>
NCS in nerve compression - findings?
<ul> <li>Nerve Conduction Studies:</li> <ul> <li>Useful for focal compressive lesions</li> <li>Latency</li><ul> <li>Demyelination --> slower latency, slower velocity, amplitude is the same</li> </ul> <li>Velocity:</li> <ul> <li>Time with respect to the distance</li> </ul> <li>Amplitude:</li> <ul> <li>Strength of response</li> <li>Decreased with axonal loss</li> </ul> </ul></ul>
Instrinsic plus/minus?
“<div>Intrinsic Plus Hand (Plus = + intrinsics)</div> <ul> <li>Imbalance between spastic intrinsics (interossei/lumbricals) and weak extrinsics (RDS, FDP, EDC)</li> <li>Characterized by MCP flexion and DIP/PIP extension</li> <li>Causes</li> <ul> <li>Trauma: compartment syndrome</li> <li>RA: MCP dislocations/ulnar deviation leads to spastic intrinsics</li> <li>Neuro: TBI, CP, CVA, Parkinson’s</li> </ul> <li>Exam</li> <ul> <li>Weak grip</li> <li>+ Bunnell sign: extend MCP and PIP is tight</li> </ul> <li>Tx</li> <ul> <li>Proximal muscle slide: subperiosteal elevation of interossei lengthens muscle unit</li> <li>Distal intrinsic release (distla to MCP)</li> </ul><li><img></img><br></br></li></ul><div><br></br></div><div><div>Intrinsic Minus Hand (Claw Hand) (Minus = intrinsics weak)</div> <ul> <li>Imbalance between strong extrinsics and deficient intrinsics</li> <li>Characterized by: MCP hyperextension and DIP/PIP flexion</li> <li>Causes</li> <ul> <li>Ulnar nerve palsy: cubital tunnel, ulnar tunnel</li> <li>Median Nerve palsy: Volkmann ischemic contracture</li> <li>CMT</li> <li>Hand Compartment Syndrome</li> </ul> <li>Exam</li> <ul> <li>MCP hyperextension and IP joint flexion</li> <li>Bring MCP joint out of hyperextension–> flexion deformity of DIP/PIP will correct (RC EXAM)</li> </ul> <li>Tx</li> <ul> <li>Contracture release and passive tenodesis vs active tendon transfer</li> <ul> <li>Goal is to prevent MCP joint hyperextension</li> </ul> </ul><li><div> <div> <div><img></img></div> </div></div></li></ul></div>”
DDX FOR DORSAL WRIST GANGLION
<ul> <li>Mobile with tendon sheaths:</li> <ul> <li>Ganglion of tendon sheath</li> <li>Giant cell tumor of tendon sheath</li> <li>Tenosynovitis of inflammatory or infectious origin</li> <li>Extensor digitorum brevis manus muscle belly</li> </ul> <li>Firm </li> <ul> <li>proximal pole of scaphoid (dorsal in DISI, volar in VISI)</li> <li>Osteophytes from STT arthritis</li> <li>CMC arthritis</li> <li>Venous aneurysm</li> <li>Lipoma</li> <li>Neuroma</li> <li>Harmatoma</li> <li>Sarcoma</li> </ul></ul>
TFCC Repairability?
<ul> <li>Repairable tears can be done all inside, inside out, or outside in</li> <li>Must have a bone tunnel or suture anchor</li> <li>Peripheral tears have improved blood supply and are potentially repairable</li> <ul> <li><b>Ulnar tears most amenable to arthroscopic repair</b></li> <li>Central tears, volardistal, and radial often debrided</li> </ul> <li>Safe to debride 2/3 of TFCC without compromising stability</li></ul>
Angles for VISI/DISI?
“<img></img>”
1st CMC Arthritis tx and MCP
<ul> <li>Resection Arthroplasty (Trapeziectomy)+/- LRTI:</li> <ul> <li>Current gold standard</li> <li>Can be combined with ligamentous reconstruction</li> <li>Options for tendon: APL/portion of FCR/PL</li> <li>Gerwin:</li> <ul> <li>20 patients randomized to resection vs interposition</li> <li>No difference at 23 months</li> </ul> <li>Kriegs-Au:</li> <ul> <li>No difference between resection alone and interposition</li> </ul> <li>Wajon Cochrane review:</li> <ul> <li>Simple trapeziectomy had lowest complication rate and best pain relief</li> </ul> </ul> </ul>
<div></div>
<ul> <li>MCP hyperextension deformity</li> <ul> <li>treatment depends on degree of hyperextension</li> <li><10° - no surgical intervention</li> <li>10-20° - percutaneous pinning of MCP in 25-35° flexion x 4wk ± EPB tendon transfer</li> <li>20-40° - volar capsulodesis or sesamoidesis</li> <li>>40° - MCP fusion (20 flex, 20 abd, 20 pro)</li> </ul></ul>
indications for ulnar nerve decompression in stiff elbow cases?
<ul> <li>Pre-existing ulnar nerve symptoms</li> <li>If contracture > 90o then likely needs release</li> <li>if > 50 deg increase in ROM</li></ul>
difference in nerve injuries?
“<div> <div> <div><img></img></div> </div></div>”
<div>JAAOS 2017 - Differences between ulnar syndrome and cubital tunnel syndrome</div>
<ul> <li>ulnar palmer and dorsum of the hand are spared in ulnar syndrome</li> <ul> <li>palmar cutaneous and dorsal cutaneous branches of the ulnar nerve branch off before it enters the ulnar tunnel at the wrist</li> </ul> <li>strength preserved in the FCU and the FDP of the ring and little fingers</li> <li>increased claw hand deformity</li> <ul> <li>FDP preservation increase deformity</li> </ul></ul>
Radial nerve syndromes?
“<ul><ul><li>RTS: Same as PIN compression sites but only causes pain with no motor/sensory dysfunction </li> <li>PIN syndrome: pain in forearm and wrist with WEAKNESS</li> <li>Wartenberg’s syndrome: compression of SRN (between BR and ECRL during forearm pronation) leading to PAIN and NUMBNESS</li> </ul></ul>”
Diagnostic Criteria (1987 Revised Criteria) for RA
- Morning stiffness >/= 1 hour<div>2. Swelling in >/= 3 joints</div><div>3. Rheumatoid nodules</div><div>4. Radiographic changes of the hand including bony erosions and decalcification</div><div>5. Symmetric arthritis</div><div>6. Serum RF</div><div>7. Arthritis of the hand (MCP, PIP) and wrist</div><div><br></br></div><div>>/=4 of 7 for a 6 week period</div>
Indications for ORIF of the scaphoid (Rockwood and Green)
“1. Proximal pole fractures<div>2. Displacement >1mm</div><div>3. Humpback deformity</div><div>- Measurements on sagittal CT scan:</div><div>– Lateral intrascaphoid angle >35o(Normal = 30 +/- 5o)</div><div>– Dorsal cortical angle >160o(Normal = 140o)</div><div>– Height-to-length ratio >0.65 (Normal = 0.6)</div><div>4. DISI</div><div>– Radiolunate angle >15o</div><div>– Capitolunate angle >15<span>o</span></div><div><span>– Scapholunate angle >60o</span></div><div>5. Associated perilunate dislocation</div><div>6. Associated distal radius fracture</div><div>7. Comminuted fracture</div><div>8. Unstable vertical or oblique fractures</div><div>9. Delayed presentation</div>”
What are the radiographic views of the scaphoid? (Tornetta)
- The PA view allows visualization of the proximal pole of the scaphoid<div>2. The semipronated oblique view provides the best visualization of the waist and distal pole regions</div><div>3. The semisupinated oblique view provides the best visualization of the dorsal ridge</div><div>4. The lateral view permits an assessment of fracture angulation, carpal alignment, and carpal instability</div><div>5. PA view with the wrist in ulnar deviation results in scaphoid extension, allowing visualization of the scaphoid in profile</div>
What are the advantages of surgical fixation of non-displaced or minimally displaced scaphoid fractures?
- Earlier union<div>- Surgery 7.1 weeks, Non-op 11.4 weeks</div><div><br></br></div><div>2. Avoid prolonged immobilization</div><div><br></br></div><div>3. Allows earlier return to activity/work</div><div>- Surgery = 6 weeks, non-op = 11 weeks</div><div><br></br></div><div>4. No difference in rate of union</div>
What is the preferred non-operative treatment of scaphoid fractures? (JBJS Reviews 2016)
- Long arm or short arm cast <b>including or not including the thumb, </b>leads to equivalent outcomes in the treatment of scaphoid fractures with immobilization<div>2. Duration ~8-12 weeks</div><div>- Depends on clinical and radiographic union</div><div>- <i>When CT is used to assess union, immobilization is discontinued when >50% union achieved</i></div>
What are the indications and advantages of the volar approach for scaphoid fractures? (JAAOS 2012)
- Distal pole and waist fractures<div>2. Humpback deformity</div><div>3. Preserves dorsal blood supply</div>
Describe the volar approach to the scaphoid
“1. Interval between FCR and radial artery<div>2. Skin incision can be zig-zag, or at the glabrous/non-glabrous border (Wagner)</div><div>a. Proximal parallel to FCR, distally parallel to the radial aspect of the thenar eminence</div><div>b. ““Standard Russe incision in made along the course of the FCR tendon and extending distally along the border of the glabrous skin of the thenar eminence””</div><div><img></img><br></br></div><div>3. The volar FCR sheath is opened and FCR retracted ulnar</div><div>4. Radial artery is retracted radial (superficial palmar artery crosses the surgical field and may need ligating)</div><div>5. Floor of the FCR sheath and capsule are incised inline with the scaphoid to expose the distal 2/3</div><div>–> RSC and long radiolunate ligaments are incised</div><div><br></br></div><div><img></img><img></img><br></br></div>”
What is often required to obtain the start point for the guidewire during volar approach to the scaphoid?
Resecting the proximal palmar portion of the trapezium
What is the appropriate lenght of screw measurement for scaphoid fixation?
Subtract 4mm
Indications for dorsal approach to the scaphoid?<div>Describe the dorsal approach.</div>
“Proximal pole fracture<div>Complete SL rupture</div><div><br></br></div><div>1. 2-3cm straight dorsal incision starting over Lister’s tubercle, extending distal in line with 3rd MC</div><div>2. Skin flaps raised over the extensor retinaculum</div><div>3. Extensor retinaculum is incised longitudinally distal to Lister’s tubercle along with the dorsal hand fascia</div><div>4. EPL, ECRB and ECRL are retracted radially, EDC retracted ulnarly</div><div>5. Radiocarpal T-capsulotomy performed</div><div>- Transverse limb parallel to the distal radius proximally, longitudinal limb extending directly over the SL ligament</div><div>- Capsular flaps are elevated off SL ligament and scaphoid - avoid disruption of the SL ligament and dorsal scaphoid ridge</div><div><br></br></div><div>Guidewire startpoint: membranous portion of the SL ligament origin</div><div><br></br></div><div>Protect the SRn<img></img></div><div><img></img><img></img><br></br></div><div><br></br></div>”
What are the indications for vascularized bone grafting (scaphoid)
Scaphoid non-union with proximal pole osteonecrosis and/or failure of previous grafting
What are the graft options for scaphoid non-union based on location of fracture and presence of deformity?
“<div><ul> <li>Proximal 1/3 non-union without significant humpback</li> <ul> <li>1,2 ICSRA (intercompartmental supraretinacular artery)</li> <ul> <li>Origin: radial artery, 5cm proximal to RC joint</li> <li>Advantages: single approach</li> <li>Disadvantages: unable to correct humpback, vulnerable to kinking</li> <li><img></img></li> </ul> </ul> </ul> <div></div> <ul> <li>Capsule based (4th extensor compartmental artery)</li> <ul> <li>Advantages: simple harvesting technique, short arc of rotation and low risk of kinking</li> <li>Disadvantage: cannot correct humpback, violates dorsal RC and intercarpal ligaments</li> </ul> <li>Alternatives: 2,3 ICRSA, MFC or iliac crest</li> </ul> <ul> <li>With humpback</li> <ul> <li>Volar radius VBG</li> <ul> <li>Origin: radial carpal artery</li> <li>Single incision, preserves dorsal blood supply, simultaneous correction of humpback deformity, may preserve wrist flexion</li> <li><img></img></li> </ul> <li>Alternative: free VBG</li> </ul></ul></div>”
What are the indications for re-operation following prior surgical fixation of scphoid fracture? (JAAOS 2013)
At <b>3 months</b>if there is inadequate union, and evidence of one of the following<div>1. Improper screw placement (at least 3-4 screw threads in each fragment)</div><div>2. Insufficient compression across fracture sit (presence of gapping)</div><div>3. Inadequate fixation</div><div>4. Lack of appropriate bone grafting (based on OR report or report from surgeon)</div>
What is the treatment algorithm for scaphoid non-union based on specific fracture characteristics?
- Delayed union (< 6 months)<div>- ORIF with headless compression screw</div><div><br></br></div><div>2. Established non-union without humpback</div><div>- ORIF with headless compression screw + bone graft (cancellous ICBG or distal radius)</div><div><br></br></div><div>3. Non-union with humpback deformity; no AVN</div><div>- ORIF via volar approach + corticocancellous bone graft</div><div><br></br></div><div>4. AVN without humpback deformity</div><div>- Vascularized bone graft via volar or dorsal approach</div><div><br></br></div><div>5. AVN with humpback deformity</div><div>- Vascularized MFC via volar approach</div>
What are the fundamentals of tendon repair in flexor tendon injuries? (JAAOS 2018)
- Easy placement of sutures in the tendon<div>2. Secure knots</div><div>3. Smooth juncture of the tendon ends</div><div>4. Minimal gapping</div><div>5. Minimal interference with tendon vascularity</div><div>6. Sufficient strength</div>
