Hand Flashcards
What are the principles of TENDON TRANSFER?
- Supple (J)oints- wiht maximum passive ROM. (Recipient)
- Soft tissue (E)quilibrium- free from infection, inflammation, scar. (Recipient)
- Patient (C)ompliance to post-op rehab. (Recipient)
- Adequate (E)xcursion. (Donor)
- Adequate (S)trenght. (Donor)
- Expandable (D)onor. (Donor)
- Straight (L)ine of pull. (Donor)
- Single (F)unction per transfer.(Donor)
- (S)ynergistic tendons. (Donor)
9 points, divided into recipient and donor factors.
Basilar thumb OA:
- Describe this radiograph.
- What is your diagnosis? What are your differential diagnosis?
- How may this patient present clinically?
- What classification will you use?
- How will you manage this patient?
- What is the pathophysiology underlying this condition?
1. Describe this radiograph.
This is a plain radiograph of the left hand in AP projection.
with joint space narrowing at the 1st CMCJ with sclerosis and osteophytes > 2mm. Mention also no STT arthritis noted (means not end stage).
**Plain radiograph i will order is AP, Lat and Robert’s view of the thumb.
- *2. What is your diagnosis? What are your differential diagnosis?**
- Basilar thumb arthritis = 1st carpo-metacarpal joint arthritis.
DDX: STT arthritis
if clinically with no Xray, DDX:
De Quervain’s disease, non-union scaphoid fracture, FCR tendonitis, STT OA, Referred pain from carpal tunnel.
- *3. How may this patient present clinically?**
- older age >75 years, more common in women
- pain at the base of right thumb (at 1st carpo-metacarpal joint).
- pain aggravated with activities associated with forceful pinch or grasping grip (holding cup/key handle).
- chronic pain with acute exacerbation.
- may have concomitant carpal tunnel syndrome (50%)
- may have history of Bennet’s fracture subluxation or Rolando-type fracture in the past
examination:
may have mild generalised arthritis with Heberden’s (DIP)/ Bouchard nodes (PIP)
swelling and crepitations at 1st CMCJ
squarring of thumb/ shoulder sign thumb
metacarpal adduction, thumb webspace contracture
compensatory 1st MCP fixed hyperextension giving rise of zig zag deformity of thumb especially during pinch motion.
provocative test:
1st: -ve distraction-reduction - traction and reduction of the subluxed CMC joint.
2nd: +ve grinding test - combined axial compression and circumduction, rotating the thumb metacarpal base while applying axial compression (ie, compression along the plane of the metacarpal bone).
3rd: -ve torque test - rotating the thumb metacarpal base while applying gentle axial traction. Positive test is indicative of synovitis associated with milder disease as a result of traction on an inflamed joint capsule.
4. What classification will you use?
Eaton and Littler Classification of Basilar Thumb Arthritis
Stage I to IV: based on degree of degeneration and subluxation of the joint
Stage I- Slight joint space widening (pre-arthritis)
Stage II- Slight narrowing of CMC joint with sclerosis, osteophytes <2mm
Stage III- Marked narrowing of CMC joint with sclerosis, osteophytes >2mm
Stage IV-Pantrapezial arthritis (STT-ScaphoidTrapeziumTrapezoid involved)
** In this case, patient is Stage III
5. How will you manage this patient?
Non-operatively -initially
- 1st line: NSAIDs, Splinting (thumb spica bracing), physiotherapy to strenghten thenar muscles
- 2nd line: steroids injection into the 1st CMCJ possibly under II
Operative - depends on patient’s age, degree of joint degeneration, level of activity
i) CMC arthroscopic debridement - early stages
ii) 1st metacarpal osteotomy
- Inidication: Stage I and II, closing wedge dorsal extension
- Contraindication: hypermobility, fixed subluxation of CMC joint, MCP hyperextension of > 10 degrees.
iii) Trapeziectomy +/- ligament reconstruction
Indication: Stage I-IV disease
Technqiues:
a) trapeziectomy + LRTI (ligament reconstruction and tendon interposition)
- replacing what you taken out is to preserve thumb length
b) hematoma arthroplasty (trapeziectomy without LRTI)
c) trapeziectomy + suture suspension (suture suspension with APL to FCR)
d) volar ligament reconstruction with FCR
e) excision of proximal third of trapezioid
iv) CMC arthrodesis
Allows preservation of grip strength
Indication: Stage II-III disease, young male who are heavy labourers.
Contraindication: STT arthritis
- What is the pathophysiology underlying this condition?
Theorised that there is attenuation of the anterior oblique ligament (Beak ligament) leading to instability, subluxation, arthritis of the CMC joint
Sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2599975/
Ulnar nerve compression neuropathy
- Describe this clinical finding.
- Where is the pathology likely to be.
- What is the pathoanatomy of this condition.
- EMG will show
- What other signs that may be present in the hand of this patient upon examination?
Ulnar nerve compression/entrapment neuropathy with severe clawing of 4th and 5th digits (low ulnar nerve lesion)
- Hyperextension of the MCPJ and flexion of the DIPJ and PIPJ of the 4th and 5th digits.
- Guyon’s canal- clawing is more severe.
- Weak intrinsic muscles (that normally keeps MCPJ in flexion and DIPJ and PIPJ in extension), overpowering of the extrinsic muscles of flexors and extensors.
Strong extrinsic EDC- leads to unopposed extension of the MCP
Strong FDP and FDS (ulnar nerve branch that supplies this is higher and therefore not affected at Guyon canal compression neuropthy) - leads to unopposed flexion of the PIP and DIP.
- EMG
- Nerve conduction velocity slowing or a complete conduction block.
- No fibrillation potentials - Look – atrophy of 1st dorsal webspace, interroseous
Feel – loss of sensation at ulnar 1 and half digits (volar side), Tinel sign at Guyon’s canal positive.
Move- Weakened grasp, Froments positive
Jeanne sign
Pollock’s sign –ve because this is affected in higher ulnar nerve lesion.
Boutonnierre deformity
- Describe this clinical finding.
- What clinical scenario is this deformity often found?
- What is the pathoanatomy?
- How will you confirm the diagnosis?
- Options for management.
Rheumatoid Hand:
- Describe features seen on this plain radiograph.
- bilateral and symmetrical involvement
- proximal interphalangeal & metacarpophalangealjoint space narrowing
- metacarpal heads erosions
- metacarpophalangeal joint osteopenia
- pancarpal and radiocarpal involvement with erosions
- carpometacarpal erosion
- distal radioulnar joint loss of space
- distal interphalangeal joints spared
- soft tissue swelling
Finger swelling
68 year old male complaints of swelling in the left thumb, such as the type seen in the picture.
- What is your differential diagnosis?
- What are your priorities in the examination of this swelling?
- Further investigations?
- Management
1.What is your differential diagnosis?
Giant cell tumour of flexor tendon sheath
Gouty tophy
Epidermal inclusion cyst
2.What are your priorities in the examination of this swelling?
- Swelling at the volar radial/ulnar of the left thumb
- Extending from the tip of thumb and across the IPJ, with loss of IPJ flexor skin crease.
- Well-defined but lobulated border and surface
- Firm in consistency
- Skin colour
- Mobility in horizontal/ vertical plane (with tendon)
- Warmth/tender
- Fluctuancy
- Neurovacular compromise - check numbness distally, check CRT distally
- Tinel sign of the swelling
- ROM limitation
3.Further investigations?
Plain radiograph - bones involved, erosion, joint subluxation, predict for tendon function (based on erosion at insertion site)
MRI - soft tissue nature for malignancy, proximity to neurovascular bundle, involvement of other vital structures - joint stability in coronal and sagittal plane, FDP involvement.
4.Management
Brunner incision
Marginal excision, send for HPE analysis.
Explore FDP tendon intergrity, DIPJ joint stability in coronal and sagittal plane.
Reassessment of vascular intergrity post excision.
25 year old female presenting with proggressive inability to extend her fingers as represented in the image.
- What are your DDX.
- What is the pathoanatomy?
- What is the prognosis if left untreated?
- Other clinical findings
- Management?
- What are your DDX.
Rupture of the extensor tendons of RF and LF secondary to caput ulna.
- What is the pathoanatomy?
Caput ulna syndrome:
Chronic synovitis at wrist -→ DRUJ instability/surrounding capsular +/- ligametous laxity -→ECU tenosynovitis and subluxation in ulnar and volar direction + carpus supination on radius -→ dorsal subluxation of ulnar head
- → tendon attrition leading to rupture due to promiment caput ulna
3. What is the prognosis if left untreated?
Vaughan-Jackson syndrome - proggressive rupture of the extensor tendons, starting with EDM and continuing radially.
- Other clinical findings
Finger deformities- swan neck, boutonierre
Finger triggering
Ulnar drifting at the MCPJ
Volar subluxation at the MCPJ
Rheumatoid nodules
- Management?
Tendon transfer for 4th and 5th (primary repair with poor prognosis as chronic)
Caput ulnae syndrome
- Darrach distal ulnar resection
- Sauve-Kapandji procedure
- Hemiresection arthroplasty/ resection hemiarthroplasty
- Ulnar head prosthetic replacement
Hand orthosis
- Name the orthosis.
- Name the main function.
- List 2 indications where it is utilised.
- Mention 2 common complications.
- Mention the recommended duration for the above orthosis to be applied.
- Mallet finger splint.
- Function
- to maintain the DIPJ of the finger in passive extension/ slight hyperextension, so that injured tissue can take place.
- whilst allowing functional flexion of the PIPJ
- Clinical utilisation
To immobilise for promotion of healing by limiting flexion at DIPJ.
- Undisplaced bony mallet (avulsion fracture of extensor tendons) of digit at Zone 1 - treated conservatively
- Disruption of terminal slip of extensor tendon in
Zone 1 (treated conservatively)
Zone 2 - repaired surgically
- Complications
DIPJ stiffness
Residual extensor lag < 10 degree
Others:
- dorsal skin maceration
- dorsal skin ulceration
- Tape allergy
- Worn full time in a day for 6-8 weeks
- What is the most likely diagnosis?
- How can you confirm this diagnosis?
- How will you treat?
- Glomus tumours at the subungal, fingertip and dorsum of thumb DIPJ.
Glomus tumour is a perivascular temperature regulating structure.
- Confirmation of Dx
Clinical
Symptoms: paroxysmal pain, exquisite tenderness to touch, cold intolerance.
Signs: bluish discolouration, nail ridging/discolouration
Special test:
- Love test - pin head pressure to area elicits exquisite pain
- Hildreth test - inflate tourniquet will reduce pain/tenderness produced by Love test
Radiologically: may have pressure erosion of underlying bone with deformity of bone cortex.
Histologically: confirms diagnosis - well-defined lesion, lacking cellular atypia/mitotic activity, presence of small round cells with dark nuclei.
- Marginal excision if symptoms affecting quality of life
for subungal glomus tumour - reconstruction of nail bed contour with autologous fat graft, if large defects present after resection.
Advise patient that recurrence is 20%
A swelling is found on volar aspect of the thumb. MRI is performed and as attached.
- What is the likely diagnosis?
- What other DDXs?
- How may this patient present clinically?
- How can you confirm this DX?
- How will you treat this conditon?
- GCT of tendon sheath of thumb flexor tendon
- Differential diagnosis
If with MRI - fibroma/fibrosarcoma/glomangioma
If no MRI- ganglion cyst, epidermal inclusion cyst
- Painful, firm, nodular mass
Pain worsens with activity
Moves with passive flexion of flexor tendons - part of tendon sheath
No transillumination
May affect ROM of adjacent joint
- Confirmation of DX
USG
- demonstrate relation of lesion to adjacent tendon
- homogenous hypoechoic lesion, may have some internal vascularity & heterogeneity
MRI
- focal mass with decreased signal intensity on both T1 and T2 weighted images.
- can be homogenous or hetergenous
5. Marginal excision
Have to inform patient rate of recurrence 5-50% especially it
- tumour is deep within the joints and deep to volar plate
- if tendon is also involved
BPI
- What is nerve transfer?
- Indications of nerve transfer.
- Timing
- Give an example of nerve transfer
- Transfer of a normal or near normal physiologically active fascicle or nerve branch (with low donor morbidity) to a more important sensory or motor nerve that has sustained irreparable proximal damage.
Aimed at motor reinnervation.
- Indications
a. Irreparable pre-ganglionic injury
b. Selected post ganglionic injury
c. Reinnervation of FFMTs - Timing
- within a golden time period
- within 5 months of injury
- Nerve transfer can be intra-plexus, extra-plexus and close-target nerve transfers
Extra-plexus: (neighbouring nerve from ipsilateral or contralateral neck)
eg.
Phrenic nerve
Spinal accesory nerve
Contralateral C7
Intra-plexus: (taken from within plexus, in cases of non-global root avulsion)
Close target nerve:(direct coaptation at a more distal site, closer to neuromuscular junction, for faster motor recovery)
eg.
- SAN to SSN (Shoulder ABD)
- Partial ulnar nerve transfer to musculocutaneous nerve of biceps (Elbow FLEX)
- Partial medial nerve trasnfer to musculocutaneous nerve of brachialis (Elbow FLEX)
- Long head of triceps branch to anterior branch of axilary nerve (SOMSAK) for deltoid (Shoulder ABD)
- Intercostal nerve to musculocutaneous nerve of biceps (Elbow FLEX)
- AIN to radial or posterior interroseous nerve (Wrist and finger EXTEND)
BPI
- Name and describe two types of lesion seen in BPI.
- Name two types of lesion seen in BPI.
Avulsion - nerve is being torn from its attachment at spinal cord level (proximal avulsion)
Rupture - nerve being incompletely divided
BPI
Shoulder reconstruction options
Aim to get shoulder ABDUCTION
- Aim of treatment
- Management options
a) < 9 months
Recepient nerve
Donor nerve
b) > 9 months
- Aim of treatment
Need to reinnervate recepient nerves< 9 months
- Management
a) < 9 months:
SAN to SSN
Phrenic nerve to SSN
Recepient nerve
- SSN
- Axillary nerve
Donor
for SSN
- SAN
- Phrenic nerve (has superior neural regeneration than others)
- Intercostal nerve
for Axillary
- tricep branch of radial nerve (cannot if C7 involved)
- Intercostal nerve
Expected outcome of SAN to SSN: shoulder function restoration 80% success rate (more or same as MRC 3)
b) 9 months
Tendon/Muscle transfer
Aim- shoulder ABD, ELEVATION, ER
Indication- failed neurotisation, delayed intervention > months
Trapezius transfer -→ restore deltoid
Latissimus dorsi transfer -→ restore supraspinatus
BPI
Elbow reconstruction options
Aim to get elbow FLEXION
- < 9 months
- > 9 months
- < 9 months
Neurotisation
Donor nerves:
Intercostal n.
SAN
Phrenic nerve + nerve graft
Partial ulnar (Not pan plexus)
Partial median (Not pan plexus)
Pectoral nerve
Thoracodorsal nerve
Contralateral C7
Recepient nerve:
Motor branche of musculocutaneous
specifically nerve branches of biceps and brachialis
- > 9 months
Tendon transfer
i) Steindler flexorplasty
- transfer of common flexor mass origin and bony part of medial epicondyle of distal humerus to 1 or more inch proximally of humeral shaft to restore elbow flexion.
- Patient need to make a fist and pronate in order to flex elbow joint to get the Steindler effect.
ii) Latissimus dorsi transfer
* C7 nerve must be intact, as thoracodorsal nerve innervates LC
iii) Gracillis free functioning muscle transfer
BPI
Finger reconstruction options
Aim to restore finger FLEXION > EXTENSION
As this is often the last priority for reconstruction, duration is past golden time for neurotisation, end plate atrophy has occured.
- → FFMT as adjuvant palliative reconstruction to enhance results at a later stage.
- → arthrodesis of wrist and thumb for stability and grip
- Describe hand deformities seen.
- What is your DDX?
- What causes this?
- What other limitations this patient may have?
- This is a claw hand (Instrinsic minus hand).
- Hyperextension at MCPJs
- Flexion at IPJs
- Marked wasting of interrosei muscle (dorsal guttering), thenar and hypothenar eminence
- DDX:
- Brachial plexus injury involving the lower roots (C8, T1- Klumpke’s paralysis) - affect ulnar and median nerve.
- Peripheral nerve injury - Combined ulnar and median nerve.
- Neurological - Charcot Marie Tooth, polio, syringomelia, Amyotrophic lateral sclerosis
- Volkmann’s ischemic contracture
- Pathoanatomy (nerves)
Paralysis of interrossei and lumbricals - hyperextension at MCPJs, flexion at IPJs.
Unaffected finger flexors (so acts unopposed)
Unaffected EDCs (so acts unopposed)
- Unable to perform finger ABD and ADD.
Cannot oppose thumb
Cannot perform prehensile grasp
Diminished grip and pinch strength
- Describe deformities seen.
- What is your DDX?
- What causes this?
- What other limitations this patient may have?
- This is a claw hand (Instrinsic minus hand).
- Hyperextension at MCPJs
- Flexion at IPJs
- Marked wasting of interrosei muscle (dorsal guttering), thenar and hypothenar eminence
- Forearm flexor muscle waisting
- Wrist in flexion contracture
- Volkmann’s ischemic contracture
- Pathoanatomy (muscle)
- There is ischemic contracture of muscles of the flexor compartment of forearm.
- Affected muscles fibrosis occurs and replaced by scar tissue, which contracts and draws the wrist and fingers into flexion.
A 67-year-old woman presents with chronic insidiously progressive right wrist pain. Her history is only significant for a remote fall onto her wrist 25 years prior.
- Describe the plain radiograph.
- What is your DDX?
- How will you manage this case?
- This is an AP radiograph of the right wrist demonstrating SNAC wrist (Scaphoid shape indicating loss of bone stock, reduced radiocarpal joint with osteophytes, arthrosis also noted between scaphoid and capitate) with preservation of the capitolunate joint and lunate facet.
- SNAC- Stage 2 ( arthrosis of radioscaphoid joint & scaphocapitate joint, but preserved capitolunate joint)
DDX: SLAC
- Proximal Row Carpectomy (PRC)
- Salvage, motion-preserving procedure, involves removal of proximal carpal row (scaphoid, lunate, triquetrum), articulation left is between proximal capitate and lunate.
- Requirement for success of PRC
– preserved cartilage of head of capitate.
- intact radioscaphocapitate ligament (RSC) (most volar radial ligament)
- Stability of the carpus after a PRC is dependent on preservation of the RSC ligament.
https: //bmcproc.biomedcentral.com/articles/10.1186/1753-6561-9-S3-A39
52-year-old farmer’s periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. A recent imaging study is seen in Figure A. The patient now reports increasing pain and inability to use his wrist.
- Describe the plain radiograph.
- What is your diagnosis?
- The next best step in management would be:
- What is an alternative treatment and what kind of patients are suitable for this?
- Figure A is an AP radiographic view of a grade III SLAC wrist, demonstrating advanced arthritic changes in the capitolunate joint with a large capitate cyst.
- SLAC of the wrist
- Scaphoid excision with four-corner fusion would be the most appropriate management of the above for stage III SLAC.
- Wrist fusion. For patients who require good grip strenght but less wrist motion in their occupation. It is indicated in a patient who performs heavy manual labour, has a stiff wrist and diffuse joint involvement.
https://www.sciencedirect.com/science/article/pii/S1877056811000685
The choice of treatment mostly depends on the background: patient age (young vs. older), functional demands (manual labour vs. sedentary), and residual mobility of the wrist (mobile vs. stiff).
7-month-old boy has this upper limb deformity. The initial work-up is negative for any cardiac, hematopoetic or renal abnormalities. He has good active elbow flexion and no other deformities.
- What is your diagnosis?
- What classification is used? How will you classify this child’s limb?
- What is the best management for this patient? Why?
- Non-syndromic radial longitunidal deficiency (RLD)/ radial club hand.
- This child is Type 4
Bayne and Klug- 4 types
Type 1- short distal radius
Type 2 – short distal radius with residual growth plates
Type 3 – small proximal radius
Type 4 – absent radius
3.Ulna centralization and possible tendon transfers
He has a viable thumb with good active elbow flexion (elbow joint not stiff, good bicep function),
Therefore the treatment of choice is centralization and tendon transfers to re-establish balance across the wrist.
The goal of centralizing the carpus on the ulna is to improve reach and to stabilize tendons and muscle balance across the wrist.
- Describe this clinical finding.
- Name the common classification used.
- What are management considerations & options for this patient.
- What age will you propose these management options
1.Deformity of the hand- absent thumb.
Hand is perpendicular to the forearm.
Radial clubhand (Radial longitudinal deficiency)
- Bayne and Klug- 4 types
Type 1- short distal radius
Type 2 – short distal radius with residual growth plates
Type 3 – small proximal radius
Type 4 – absent radius
Have to use plain radiograph to determine which type patient is in.
3.
Considerations:
- age
- elbow flexion ability (bicep deficiency, supple elbow joint/synostosis of ulnohumeral joint)
- absent/presence of thumb
a) Conservative by passive stretching and observation.
Indication: Absent elbow motion, biceps deficiency.
b) Operative
i) Hand centralization
Aim: to centralize the carpus on the ulna to improve reach and to stabilize tendons and muscle balance across the wrist.
Indication: Good elbow motion and biceps function intact.
Method: Resection of varying amount of carpus, shortening of ECU, angular osteotomy of ulna, distraction external fixator
ii) Tendon transfer
iii) Thumb reconstruction/ pollicization if absent
4. Age 6-12 months
Not too young, when it is not safe for child to undergo anaesthesia
Thumb hypoplasia
- Describe this clinical photo.
- What is your diagnosis?
- What classifications are available for this condition?
- What other abnormality might be present
- How will you manage this child?
- Underdevelopment of the right thumb.
- Right thumb hypoplasia
- Blauth classification; I, II, IIIa, IIIb, IV and V
- Partial or complete absence of radius.
Fanconi’s anaemia - rule out through CBC, peripheral blood smear
VACTERL
Holt-Oram
Thrombocytopenia-absent radius
- Approach to management
Clinical evaluation
a) Thumb feature:
- smaller than normal side, including nails.
- pollex abductus
- thenar muscle hypoplasia
- absence of skin creases (muscle and tendon anomalies)
- webspace tightness
- laxity to UCL at MCPJ
- instability at CMCJ
- no active ROM MCPJ and IPJ
Determine severity of thumb hypoplasia & base on Blauth’s classification
- do plain radiograph - osseous or musculotendinous deficiency
- clinical assessment for carpometacarpal joint instability.
b) evaluate for associated abnormalities
cardiac- auscultate, echo
kidney, abdomen - US
plain radiograph forearm- partial/total absent radius
c) treatment
Non-operative - Type 1, observation
Operative-
Type I - if thumb ABDuction is deficient → opponensplasty
Type II, IIIa - release of 1st webspace, opponensplasty, stabilise MCP
Type IIIb, IV, V - pollicization
Thumb hypoplasia
- What is your diagnosis?
- What is your management?
- How to perform surgery to improve this child’s thumb function?
- Left thumb hypoplasia, Blauth II or IIIA
- Management for Type II or IIA is similar
- Release 1st webspace
- Stabilisation of MCPJ
- Opponensplasty
- Surgical technique
i) Release 1st webspace
via Z-plasty
ii) Stabilisation of MCPJ
- fusion
- reconstruction of UCL with FDS
- reconstruction of UCL with free tendon graft
iii) Opponensplasty
Using
- flexor digitorum superficialis or
- abductor digiti minimi
Thumb hypoplasia
- What is your diagnosis?
- What is your management?
- How to perform surgery to improve this child’s thumb function?
- Thumb hypoplasia, Blauth IIIb
- Amputation and thumb pollicization
- management same for Type IIIb and IV
3. Thumb pollicization - Plan skin incision to avoid skin grafts
- Isolate index finger on its neurovascular bundles
- Detach first dorsal and palmar interosseous muscles
- Shorten digit by removing index finger metacarpal and epiphyseal plate
- Stabilize index MCP joint
- Reattach and balance musculotendinous units
- Reconstruct long extensor tendons
- Rebalance flexor tendons
