Hand - orthobullets

Wasit > proximal > distal

• Dorsal carpal branch of radial: enters dorsal surface and provides 80% vascularity via retrograde flow
• Superficial palmar arch (branch of volar radial A): enters distal tubercle and supplies 20%

• Anatomic snuffbox tenderness
• Scaphoid tubercle tenderness volarly
• Pain with resisted pronation

• Scaphoid view: 30 degrees wrist extension an d20 degrees ulnar deviation
• MRI

Stable non displaced waist #

No difference in long vs short arm spica

• Distal/waist: 3 months
• mid waist: 4 months
• proxmal third: 5 months

Rate of union 90%

• Proximal pole #
• Displacement > 1mm
• 15% scaphoid humpback deformity
• intrascaphoid angle > 35 degrees
• Associated perilunate dislocation
• Unstable vertical or oblique
• comminuted #

• Decreased tme to union
• Faster return to wor
• Similar cost

• Proximal pole fracture
• Waist and disatal pole as well as presence of humpback: interval FCR and radial artery

• Inlay russe
• Fisk: opening wedge >>restore lenght and angulation
• Vascularized graft from 1-2 intercompartmental supraretinacular artery: branch of radial A

Down the middle of the central axis of scpahoid

Wrist extension

• Night symptoms
• short incisions
• Relief with steroid injections

• Scaphoid tubercle and trapezium radially
• Hook of hamate and pisiform ulnarly
• Transverse carpal ligament: roof
• Proximal carpal row: floor

• Median nerve
• FPL: most radial structure
• 4 FDS
• 4 PDP

Palmar cutaneous branch of median nerve: btw PL and FCR at the level of wrist crease

Recurrent motor branch: 50% extraligamentous with recurrent innervation

• FPL
• Level of hook of the hamate
• Durkans test: pressing thumbs over carpal tunnel and holding pressure for 30seconds..positive if pain or parasthesia within 30 seconds

• Numbness in median nerve distribution
• Positive phalen
• positive tinnes
• Nocturnal numbness
• loss 2 point discrimination
• Weakness or atrophy of thenar musculature

• Inspection shows thenar atrophy
• Durkan test:pressing thumbs over carpal tunnel and holding pressure for 30seconds..positive if pain or parasthesia within 30 seconds
• Phalen test: wrist volar flexion for 60 seconds reproduces symptoms

NSAIDS night spints and activity modifications

Not indicated

Incision is intersection of kaplans line with radial border of fourth ray ending at wrist crease. Dissection to identify transverse carpal ligament

Neutral splinting: if in extension increases CT pressure

• Chronic SL injury and DISI deformity: scaphoid flexed and lunate extended
• >70 degrees

Stage 1: arthritis btw scaphoid and radial styloid >> radial stylectomy or PIN/AIN denervation

Stage 2: Arthritis btw scaphoid and entire scaphoid facet >>> PRC , 4corner fusion

Stage 3: Arthritis btw capitate and lunate >> 4corner fusion or wrist fusion

RADIOLUNATE JOINT IS SPARED

Watson scaphoid shift test: firm pressure over palmar tuberosity >>move wrist from ulnar to radial deviation (positive if feels clunk)

• Incompetent radioscaphocapitate ligament
• Capitolunate arthritis: capitate will articulate with radius

Excise entire proximal row of carpal bones (scaphoid, lunate, triquetrum), preserve radioscaphocapitate ligament

• PRC or 4corner fusion
• Wrist fusion

• Scaphoid no union of >5 year duration or proximal pole necrosis
• Obvious bleeding from bone edges

Stage 1: arthrosis radial side of scaphoid ad radial styloid...Radial stylectomy + scapholunate reduction and stabilization

Stage 2: scaphocapitate arthrosis + stage 1 ....PRC (avoid if capitate arthritis)...or 4 corner fusion

Stage 3: Periscaphoid arthrosis PRC or 4corner fusion

4CF retains 60% wrist motion and 80% grip strength

Dorsal longitudinal incision btw 3rd and 4th compartment

• Excise scaphoid
• Fuse luate, triquetrum, capitate, hamate: mke sure to correct DISI

Avascular necrosis of the lunate

Ulnar negative variance: leads to increased radio lunate contact strett

Decreased radial inclination

• Repetitive trauma
• Geometry of the lunate

vascular supply to the lunate

stage 1: changes in MRI >>immobilization and NSAID's

Stage 2: Sclerosis of lunate >>Joit leveling procedure/radial wedge osteotomy or STT fusion/distal radius core decompression

Stage 3A: lunate collapse, no scaphoid rotation >>TREAT same as stage 2

Stage 3B: Lunate collapse and fixed scaphoid rotation>>>>>PRC or STT fusion

Stage 4: Degenerated adjacent intercarpal joints: wrist fusion or PRC

Stage 1 or 2 or 3a: with ulnar negative variance..joint levelling = radial shortening or ulnar lenghtening

Stage 1 or 2 or 3a: Ulnar positive or ulnar neutral 

Stage 3a or 3b

STT fusion better results than prv

• Ulnar lenghtening 4mm
• Radial shortening 4mm

• Benign proliferative disorder characterized by fascial nodules and contracture of hand
• Cleland ligament
• Autosomal dominant
• Ring finger> small finger > middle > index
• Myofibroblast: type 3 collagen 
• Spiral cord nodules/bands
• Central cord: disease of pretendinous band
• Retrovascular cord
• Natatory cord

• pretendinous band
• spiral band
• lateral digital sheet
• Grayson's ligament

Proliferative: nodule, very vascular with gap junctions

Involution stage: dense myofibroblast network...fibroblast align along tenion lines

Residual stage: myofibrobalst disappear leaving fibroblasts >>dense collagen rich tissue scar

Hueston tabletop test: ask patient to place palm flat on the table: look for MCP or PIP contracture

• ROM
• Injection Clostridium histolyticum collagenase: early efficacy but associated with lysis ad rupture cords
• Needle aponeurotomy: for mild contractures MCP>PIP

• MCP flexion contracture > 30 degrees
• PIP flexion contractures

• Open palm McCash technique
• Leave skin incision open at distal palmar crease

Spiral cord will be lateral and deep

3-4: distal to lister tubercle btw EPL and EDC >>first portal >>>>EPL and EDC tendons at risk

4-5: In line with ring finger metacarpal btw  EDC and EDM ...portal for TFCC

6R: Radial to ECU ...at risk is dorsal sensory branch of ulnar nerve

6U: Ulnar to ECU ..dorsal sensory branch of ulnar nerve

1-2: btw APL and ECRB ...superficial branch of radial nerve

Dorsal sensory branch ulnar nerve: at risk with 6U and 6R

Superficial branch of radial nerve: at risk with 1-2 compartment

• Disruption of terminal extensor tendon
• Forced flexion of DIP

Volar subluxation of distal phalanx: absolute

• Relative: > 50% articular surface involved
• >2mm articular gap

Extension splinting of DIP x 6-8 weeks: Free movement of PIP

• Avoid hyperextension
• Volar splinting has less complitations

Painful, stiff, arthritic DIP joint

Extensor lag: toleaable if <10 degrees

• Swan neck deformity: from attenuation of volar plate and transverse retinacular ligament at PIP > dorsal subluxation of lateral bands > PIP hyperextension
• Contracture of triangular ligament

Fowler tenotomy

• Mallet finger
• FDS rupture
• Intrinsic contracture
• MCP joint volar subluxation: Rheumatoid arthritis

• Lax volar plate that allows hyperextension of PIP
• Hyperextension PIP + flexion DIP

• lax volar plate
• Imbalance of muscle forces on PIP: flexion > extension

Non op: double ring splint

Volar plate advancement and PIP balancing with central slip tenotomy

• break in Gilula arc
• Lunate and capitate overlap
• Lunate is triangular: piece of pie sign
• Loss of colinearity of radius lunate and capitate
• SL angle > 70

For perilunate dislocation

• Stage 1: SL dissociation
• Stage 2: SL + lunocapitate disruption
• Stage 3: SL + lunocapitate + lunotriquetral
• Stage 4: lunate dissociated from lunate fossa

• Trans-scaphoid perilunate dislocation
• Periluante
• Transradial-styloid
• Trans-scaphoid-trans-capitate-perilunar

• Associated with fractures
• Purely ligamentous

• Scaphoid
• lunate
• Triquetrum
• Pisiform

• Trapezium
• trapezoid
• Capitate
• Hamate

Chronic: > 8 weeks

Need to do PRC

Traction > extension and push on lunate followed by hyperflexion

• Volar plate
• Volar plate
• Can lead to swan neck defomity

More common direction of dislocation

Type 1: < 30% articular surface > stable > dorsally based extension block splint

Type 2: 30-50% of articular surface > tenuous > if reduces in flexion >>extension block dorsal splint

Type 3: >50% articular surface >> unstable >> ORIF

• Immobilization with dorsal splint in slight flexion x 2 weeks
• Volar plate is interposed

• Central slip
• Can lead to boutonniere deformity
• Extension splinting for 6-8 weeks
• If > 40% joint involvement

• Zone 3 extensor tendon injury
• PIP flexion and DIP extension
• Rupture of central slip > lost extrinsic extensor mechanism from EDC to be lost > prevents extension at PIP > Attenuation of triangular ligament >intrinsics act as felxors of PIP and extend DIP bc there is no balancing force > palmar migration of collateral and lateral bands >leads to unopposed pull from the lumbricals

Elson test: Bend PIP to 9 and ask to extend middle phalanx ...if central slip is ok the dital phalanx will remain floppy...if central slip...DIP will become rigid

• If acute: PIP splinting in full extension x 6 weeks
• If chronic: lateral band relocation (dorsal) or terminal tendon tenotomy like fowler

• central part of extensor hood
• Middle phalanx
• Extension of PIP
• Extrinsic extension mechanism from EDC is lost > boutonniere

• Dorsal/volar interossei
• Base of distal phalanx 
• Extension of DIP

• Prevent volar sublixation: The triangular ligament
• Precent dorsal subuxation: transverse retinacular ligament

• Disruption of the ulnar volar physis of the distal radius
• Vickers ligament: fibrous band that goes from distal radius to lunate (radiolunate ligament)

• Partial deficiency of growth of distal radial physis
• Excessive radial inclination and volar tilt
• Ulno carpal impaction

Release of vickers ligament and epiphysiolysis: controversial, to do in skelletally immature

Radial corrective osteotomy + ulnar shortening: Wrist pain or functional limitations

• Caucasians > African americans
• long finger
• Autosomal dominant with variable penetrance

• Simple: only soft tissue
• Complex: Side to side fusion of adjacent phalanges
• Complete: Extends to fingertips
• Incomplete: does not extend to finger tips
• Complicated: Accesory phalanges involved

• Inflammatory; 0-5 days >> cellular proliferaton
• Fibroblastic 5-28 days: fibroblast with disorganized collagen
• Remodelling: >28 days ok for active motion

At the level of the proximal phalanx where FDP splits FDS

• A1: Metacarpal head
• A2: Proximal  phalanx diaphysis
• A3: Proximal to PIP
• A4: Middle of middle phalanx
• A5: Proximal to DIP

• C1: Distal Proximal phalanx
• C2: Base of Middle phalanx
• C3: Distal middle phalanx

A2 and A4 pulleys prevent bowstringing

• A1: Metacarpal head
• A2: Distal proximal phalanx
• Oblique pulley: most importanr...in between

ZOne 1: Distal to FDS (Jersey finger) ...if acute direct repair...if # fragment ORIF..if chronic 2 stage grafting

Zone 2: FDS to distal palmar crease....both FDS and FDP within same tendon sheath >>>Direct repair of both tendons followed by early ROM (duran protocol)>>>preserve A2 and A4 pulley

Zone 3: Palm: Often associated with NV injury>>>direct repair

ZOne 4: carpal tunnel >>direct repair and repair transverse carpal ligament in lenghtened fashion

Zone 5: Wrist to forearm>>>direct repair

Early ROM does not improve outcome in thumb and has higher rerupture rate

Using tenodesis effect:  If there is a flexor injury when the wrist goes from flex to extension, the affected finger wont flex

Pulley management: repair A2 and A4 pulleys and oblique pulley to prevent bowstringing

Circumferencial epitendinous suture: improves tendon gliding

Timing: ideally within 2 weeks

Approach: incision cross flexion crease transversely or oblique

# of strands that cross the repair site is more important than grasping loops

Hunter-Salisbury two stage procedure

Stage 1: silicon rod is placed to create favourable tendon bed

Stage 2: after 3-4 months silicon rod removed and a tendon graft is passed (palmaris longus

Duran

• Low force and low excursion
• Active finger extension with patient assisted passive finger flexion

FPL tendon that is Thickened: It becomes wider than A1 pulley > abnormal gliding

Flexion deformity at IP joint

Notta node

30-60% will resolve spontaneously before age 2: treat with splinting and stretching

A1 pulley release: Fixed deformity in pt 12 month or older

• Absolute
• Thumb at any level
• Multiple digits
• Through the palm
• Wrist level or proximal
• Pediatric

Relative

• Individual digits distal to insertion of FDS (zone 1)
• Ring avulsion
• Through or above elbow

• Absolute
• Severe vascular disease
• Mangled limb/crush injury
• Segmental amputation
• Prolonged ischemia with muscle content > 6 hours

• Relative
• SIngle digit proximal to FDS insertion (zone 2)
• Prolonged ischemia > 12 hours with no muscle

• Vascular shunt
• Bone fixation
• Extensor tendon repair
• Artery repair
• Venous anastamosis
• Flexor tendon repair
• Nerve repair
• Skin/fasciotomy

Structure by structure

• Release constricting bandage
• Place in dependent position
• Consider heparin
• Consider stellate ganglion block

• Elevate extremity
• Leech application
• Heparin soaked pledges

• Avulsion injury to FDP at base of distal phalanx
• Finger rests in slight extension compared to rest
• Risk factor is retraction > 1cm

ZOne 1: proximal to bifurcation of nerve > mixed motor and sensory

Zone 2: surround deep motor branch > Motor only

Zone 3: Surrounds superficial sensory branch >>sensory only

• Floor: transverse carpal ligament
• Roof: volar carpal ligamnt
• Ulnar: Pisiform and abductor digiti minimi muscle belly
• Radial : hook of hamate

Cubital tunnel has:

• Less clawing
• Sensory deficit to dorsum of hand
• Motor deficit to ulnar extrinsics
• Tinel sign at elbow
• Positive elbow flexion test

• Arcade of struthers: medial intermuscular septum
• Cubital tunnel: osborne ligament
• Arcuate ligament: btw the 2 heads of FCU
• Guyon canal: 3 zones
• Medial head of triceps
• Anconeus epithrochlearis

• Gamekeepr
• Stener lesion
• Proper UCL injury
• Accssory and proper UCL injury
• < 20 degrees valgus opening

• 30 degree pronated lateral: see 4th/5th CMC#
• 30 degree supinated view: See 2-3 CMC #

• DM
• Ring finger
• A1 pulley
• Splinting, injection (except thumb)
• Release of A1 pulley

• Rupture of extensor tendons from ulnar to radial in RA
• DRUJ instability > dorsal subluxation ulnar head > attrition rupture of tendons
• IEM to EDC and ulnar head resection

• EIP to EPL
• Nothing
• EIP to EDC5

MOtor deficit only

• Tendinous edge of PT: most common casue
• FDS arcade
• Edge of lacertus fibrosus
• Thrombosed ulnar or radial artery

• FDP: middle and index
• FPL
• PQ: test with pronation with elbow flexed at 90

• Arises from the median nerve 4-6 cm distal to medial epicondyle
• Goes btw FDS and FDP
• Then btw FPL and FDP
• Then on IOM

Median nerve

• Ligament of struthers
• Lacertus fibrosus
• BTW ulnar and humeral heads of PT
• FDS aponeurotic arch

• Leash of henry: recurrent radial vessels that fan out across pin at level of radial neck
• ECRB edge
• Arcade of frohse: proximal edge of superficial supinator
• SUpinator distal edge

• ECRB
• EDC
• EDM
• ECU
• Supinator
• APL
• EPB
• EPL
• EIP

• DRUj instability or OA
• TFCC tear
• LT tear
• Pisotriqutral OA
• ECU tendinitis or instability

• 20%
• 40%

Ulnar shortening osteotomy

Wafer procedure: 2-4 mm ulna removed arthroscopically from under TFCC

Darrach: Ulnar head resection

Sauve kapandji: DRUJ synostosis and pseudarthoris proximal to it

• Bennett
• Rolando: comminuted
• Hyper pronated thumb view
• Anterior/volar oblique ligament
• APL, adductor pollicis: shaft adducted, shortened and base is supinated

• Deficiency or attenuation of EPB or EPL or both
• Clubfoot and CVT, arthrogryposis

• Splinting and stretching: good results when not rigid and at least one tendon present
• EIP to EPL transfer: Residual extensor deficiency

• Expandable donor
• Straight line of pull 
• Synergistic muscles
• Appropriate excursion
• Supple joint
• Strength 4+: will lose one
• One tendon performs one function

Radial: PT to ECRB, FCU to EDC, PL/FDS to EPL

Low median: FDS (ring) to APB (use FCU as pulley = bunnell opponensplasty)

High median: BR to FPL, FDP of ring and small finger (ulnar ) to FDP of index and middle

Ulnar nerve: FDS or ECRB to adductor pollicis, APL to 1st dorsal interosseus (for index), FDS to lateral bands of ulnar digits (prevent clawing)

Strong extrinsics and weak intrinsics

Loss intrinsics > loss baseline MCP flexion and loss IP extension > Strong extrinsics > unopposed extension of MCO + Strong FDP/FDS leads to unopposed flexion of PIP and DIP

• Dorsal radioulnar ligament
• Volar radioulnar ligament
• Central articular disc
• Meniscus homolog
• ECU subsheath
• Origin of Ulno lunate and ulno triquetral ligamnts

Dorsal and volar RU ligaments: origin signoid notch insert at base of ulnar styloid

Fovea sign: pain with pressure btw ulnar styloid and ECU

• VACTRL
• Holt Oram
• TAR
• Fanconi Anemia

Type 1: minor hypoplasia...normal components...no treatment

Type 2: All osseous structure present + MCP UCL intability + thenar hypoplasia>>>>>Stabilization of MCP joint, opponensplasty and release of first webspace


Type 3A: Musculotendinous and osseous deficiencies + CMC intact + no active motion MCP or IP >>>>>Stabilization of MCP joint, opponensplasty and release of first webspace

Type 3B: Same as 3A but deficient CMC joint >>>>Thumb amputation and pollicization

Type 4: FLoating thumb >>>>Thumb amputation and pollicization

Type 5: Complete absence of thumb >>>Pollicization

• Weak extrinsics
• Spastic intrinsics: interossoi and lumbricals
• MCP flexion and DIP/PIP extension
• Bunnell test: intrinsic tightness diagnosesd when PIP flexion is less with MCP extension that MCP flexion