Surgical Wrist and Hand Flashcards
Fractures and Dislocations - what is usually most important
Soft tissue injury is usually more important - esp. in the hand
Bone injury must be stabilized in order to adequately treat the soft tissue injury
Fracture treatment goals
Obtain and maintain fracture reduction
Early motion
Bone/Joint Injury - stages of healing
- Heal w/o infection (first 2 weeks)
- Fracture healing (up to 6 weeks)
- Regain function/mobility (6-12 wks) – ROM and Strength
Volar Locking Plate - advantage
able to start early ROM
Studies show now advantage over casting though
Most common carpal bone to fracture
Scaphoid and then triquetrum
Fracture of base of thumb metacarpal - what to do
Requires surgery
Predisposes to arthritis
Someone comes in with finger sprain and bruising, what do you do
Refer for x-ray
Bruising may indicate a fracture
Hand dislocations - named by
the direction of the displacement of the distal segment
Complications with hand dislocations
Stiffness, arthritis
Mechanism of injury for hand dislocation
hyperextension with axial load
Jammed finger
Thumb MP joint injury - acute vs. chronic
Acute - can repair for 3 weeks, but after 3 weeks is chronic and needs reconstruction
Finger Fracture Therapy - pins are removed when and what can be done with therapy
3-4 wks
A/AA ROM
Splint for rest
Finger fracture - when discontinue splint
6 wks when fx heals - can do PROM then too
Open Dorsal Fracture/Dislocation PIP joint
Digital block Washout Closed reduction Splint Early protected motion
Types of arthritis -
Post traumatic arthritis (Malalignment - Lose cartilage)
OA (Lose cartilage - malalignment)
RA (Synovitis - malalignment and lose cartilage)
Scaphoid nonunion can lead to what
Post traumatic arthritis
RA typical deformities
Caput Ulnae MP volar subluxation Ulnar drift of fingers Swan neck deformity Thumb boutonniere deformity
Problems in arthritis - what are they complaining of
Pain Stiffness Weakness Functional disability Social and emotional disability
Therapy for arthritis
Modalities Splints Adaptive tools ROM ex. Strengthening
Surgical options for arthritic of wrist
Arthroscopy Excision bone Interposition arthroplasty Limited fusions Total wrist fusion Implant arthroplasty
Soft tissue problems - define by
Tissue group
- nerve
- mm and tendon
- blood vessel
Nerve compression syndromes - what do they all have in common
Pain at compression site Radiation of pain Numbness Grip weakness mm weakness Activity related sx
Carpal tunnel - nerve is compressed by
Small space
Tenosynovitis
Position narrows space
Fracture hematoma
CTS - More common in who
2/3 females
mostly over 40
S/S CTS
Dec/altered sensation in thumb, index, middle, and ring
Pain in wrist that radiates prox
Night pain and numbness
Aggravated by activity, worse in certain positions
Exam findings in CTS
Dec median n. distribution sensation
Weak grip
Thenar atrophy or weakness
Pos Tinels (percussion), Phalens (position), Durkans (pressure)
What other pathologies are common with CTS
Diabetes Mellitus
Hypothyroidism
Positive family hx
Obesity, smoking, poor aerobic fitness
Nonsurgical tx for CTS
Wrist splint - 3 to 6 wks
Relative rest
Cortisone injection
(into carpal tunnel 80% benefit - good for dx)
Thenar atrophy sometimes need
mm transfers to restore function
Abd dig min
Palmaris longus
Ext Indicis proprius
Goal with CTS surgery
Remove pressure from Median nerve
Cut transverse carpal tunnel ligament
DeQuervains Syndrome
Stenosing ext tenosynovitis of 1st dorsal compartment
Stenosing flexor tenosynovitis
Trigger finger, trigger thumb
Common feature of tendon entrapment is what
Tenderness of compartment
Tendon entrapment syndrome - early treatment
Activity modifications
Splints
Anti inflammatory meds
Cortisone injection into tendon sheath
Trigger finger vs. Dupuytrens disease
Trigger finger = clicks, catches, painful to fully extend
Dupuy: No pain, unable to fully extend
Dupuytrens Dx
Palmar Fibromas
Flexion contractures
Loss of ext. even passively
No loss of flexion
Treatment for Dupuy
Collagenase injections
Fasciotomy
Fasceiectomy
Newest nonsurgical tx for Dupuytrens
Xiaflex (collagenase clostridium)
Needle Aponeurotomy - pros and cons
For D. cont
Pro - in office and local anesthetic use
Con - recurrence, nerve injury, skin tear, bumps remain)
Subtotal palmar fasciotomy - therapy
early ROM, night time splinting 6 months
Pros and cons to subtotal palmar fasciotomy
Pro - bumps gone, safer for PIP and DIP
Con - need surgical anesthetic, recurrence, neurovascular injury, healing time
Ganglion cysts can relate to
Intra-articular pathology
SL ligament instability, TFCC tears, arthritis
Complications after infection
STIFFNESS
usually due to - swelling, tendon adhesion, joint contracture
Problems causing dysvascular fingers
Clotted vessels
Raynauds
Pseudoaneurysms
Flexor and Extensor tendon repairs - what is important
zone of injury
Need to protect repair for 12 weeks post op
Problems with flexor and extensor tendon repairs
Adhesions, rupture, contracture
Critcial pulleys
A4
A2
What is essential with extensor tendon repairs
correct length is essential!
Micro-surgery would be to what
Nerve and BVs
Post op microsurgery to nerve and BVs
Immobilize as necessary in safe position
Move joints ASAP
Usually 3 wks post op immob for arterial repairs to prevent vessel spasm
Replantation indications
Any part in a child
Thumb
Multiple digits
Sharp lacerations
Relative contraindications for replantation
Gorss contamination
Aculsion or crush injury
Single digit
Comorbidities that preclude surgery
All thumb amputations should be evaluated for
reconstruction
Single digit replantation is feasible but
not always the best option
Function after replantation is always
less than normal!
cold intolerance, stiffness, numbess are 100% likely
