powerpoint presentation · 2021. 3. 1. · napier jr. the prehensile movements of the human hand. j...

3/1/2021

1

The Finger Joints

Learning Objectives

At the completion of the course, the learner will be able to

Describe the detailed anatomy of the MP and IP joints

Interpret imaging studies on a basic level

Describe intra-articular, capsular, and tendinous pathologies affecting the digits

Collect a good history and examination for a wide variety of digital joint problems

Communicate effectively with patients and other health care providers regarding digital conditions and treatments

METHODS

• 15 lectures

• question and answer sessions: The DD Forum• Second Saturday of every month in 2021, 8:00-8:45 am Pacific Time

• Find Zoom links on www.doctorsdemystify.com home page

• some repetition between talks

bad news: unavoidable because of multiple speakers

good news: repetition is a good learning tool

Finger Joint Anatomy

Roy A. Meals, MD

MP Joint:Bony Anatomy

• Metacarpal head• Nearly circular when

viewed from side• Wider anteriorly

when viewed end on• Proximal phalanx base

• nearly elliptical• faintly concave

• No bony stability

MP JointLigament Anatomy

• Dorsally: just capsule and tendon, no ligament

• Volar plate

• Thick distally, securely attached to P1• Thin proximally, attached to metacarpal

Volar plate

extensionflexion


• Volar plate

• Sesamoid bone(s), especially thumb• Mini patellas• Common at 1st MTP jt in foot

• Patients see and think they are pathological

• Location differentiates between simple and complex MCP dislocations

• Rarely fracture, develop arthritis, cause joint locking

http://www.doctorsdemystify.com/

3/1/2021

2



• Volar plate

• Collateral ligaments

• origin on mc neck, insert on P1• tight in flexion, lax in extension



• Volar plate


• Accessory collateral ligaments

• origin on mc neck, insert on volar plate

Video clip: MP joint ligaments

Interphalangeal JointsBony Anatomy

• Head of proximal phalanx: bicondylar

• Base of middle phalanx: oval, faint adaptation to bicondylar nature of proximal phalanx

• No bony stability

• Same at DIP joints

Interphalangeal JointsLigament Anatomy

Identical to MP joint except:

• Volarly

• Less laxity in thin, proximal portion (reduces hyperextensibility)

• Medially and laterally

• Collateral ligaments—some portion is tight in any degree of flexion (no medial/lateral motion)

Video clip, PIP joint ligaments

3/1/2021

3

Extrinsic Flexor Tendons(extrinsic = originates in forearm)

Sole flexors of IP joints, 2o flexors of MP joints

• FDS

• Superficial in forearm and palm• Splits and wraps around FDP to insert on P2

• FDP and FPL

• Analogous deep origins, course and insertions

• Annular pulleys

• Restrain tendonsVideo clip, flexor tendon sheath

Extensor Mechanism: A complex interweave of tendon fibers controlled by 4 or 5 muscles

Terminal

tendon

Central

slipConjoined

tendon

Lateral band

Extrinsic

Extensor (1-2)

Interossei (2)

Lumbrical (1)

MP Joint Extension

• Solely performed by extrinsic extensors

• Thumb: epb and epl• Index: eip and edc• Middle: edc• Ring: edc• Small: edc and edq

PIP and DIP JointExtension

Working in concert:

• Extrinsic extensors• Intrinsic muscles

• Interosseous muscles• Lumbrical muscles

• Landsmeer’s oblique retinacular ligaments

Review each……

Intrinsic Muscles

• Interossei• Insertion #1: P1

bases: flex and abduct/adduct MP joints

• Insertion #2: dorsal mechanism: flex MP joints and extend PIP/DIP joints

3/1/2021

4

Intrinsic Muscles

• Lumbricals

• Insert into dorsal mechanism on radial side: flex MP joints and extend PIP/DIP joints

Landsmeer’sOblique Retinacular Ligament

O.R.L.

Passes volar to center of rotation ( ) at PIP joint and

dorsal to center of rotation at DIP joint, therefore

tightens during PIP joint extension and assists with

DIP joint extension

lateral band

MP joints PIP joints DIP joints

extrinsic

flexors

2o flexor sole flexor sole flexor

extrinsic

extensors

sole extensor 2o extensor 2o extensor

intrinsics 1o flexor 1o extensor 1o extensor

Overview of Finger Joint E/FDorsal Tendon Restraints

• Sagittal bands: centralize extrinsic

• extensors at MP joint

• Transverse retinacular ligament (Landsmeer): control conjoined tendon at PIP joint

Video clip: dorsal mechanism

Reading

Wise, K: The anatomy of the mp joints, with observations on the etiology of ulnar drift. J Bone Joint Surg 1975, 57B:485

Gad, P: The anatomy of the volar part of the capsules of the finger joints. J Bone Joint Surg 1967, 49B:362

Kuzcynski, K: The proximal interphalangeal joint. Anatomy and causes of stiffness in the fingers. J Bone Joint Surg 1968, 50B:656

Gigis, P and Kuczynski, K: The distal interphalangeal joints of the human fingers. J Hand Surg 1982, 7:176

Pang EQ et al: Anatomy and Biomechanics of the Finger Proximal Interphalangeal Joint. Hand Clin. 2018 May;34(2):121-126

3/1/2021

5

Hand Surgeons Providing Excellence in EducationforOccupational and Physical Therapists

www.doctorsdemystify.com

The Finger Joints

Examination and Functional Requirements

Mark Elzik, MD

Mission Viejo, CA

Introduction

- Basic examination:- History, history, history

- Inspection, Palpation, Neurovascular exam, Range of motion

- Normal variants

- Functional requirements

History, History, History

- When you ask the right questions, patient will give the results of his/her exam, for instance:

- “Are you able to fasten buttons?”- Requires median nerve sensibility

- “Is your finger stiff in the morning and does it loosen up under warm water?”

- Check closely for trigger finger

- “Does it hurt when you open jars?”- In patient over 45, suggests basal thumb OA

Inspection

• “Attitude” of the hand:• MCP and IP joints are in

position of slight flexion

• Palm contour

• Fingers parallel

• Compare to other side

Inspection• Number of digits

• Webbing

• Distal palmar crease

• Thenar and hypothenar eminences

• Skin: calluses, grime

• Forearm rotation

3/1/2021

6

Inspection• Quick check of upper extremity motion

• Hands behind head, behind back

Rough check of full shoulder motion

• Elbow E/F, palms up/down

• Congenital R-U synostosis can be missed for yrs

• Wrist E/F

• Hand open/fist

Palpation

• Tenderness, interruptions, prominences

• Distal radius and ulna

• Anatomic snuffbox

• Skin: Dry? Cool?

• Joints: Hot? Puffy? Unstable?

Palpation

• Carpo-metacarpal joints• Stable 2nd and 3rd versus

• Mobile 4th and 5th:

Required for grip

Stable

Mobile

Palpation

• Palmar aponeurosis• Dupuytren’s contracture

• Flexor tendons • Trigger finger

Trapped!Tendon

Tendon

SheathNodule

Motor Exam

ThumbExtension: palm on table surface

Opposition to all fingers

Adduction, abduction, flexion

Motor Exam

Normal Variant

Anomalous connection between FPL and FDP to the index fingerLinburg and Comstock anomaly

Can cause inability to flex IP joint of thumb without flexing DIP of index finger

3/1/2021

7

Motor Exam

• Fingers• Abduction/Adduction

• Measured from middle finger

• Perpendicular to plane of thumb

Motor Exam• Fingers

• Isolate joints in order to isolate muscle function

• Flexor Digitorum Superficialis (FDS): • Flexion at PIP• Hold other DIP’s in

hyperextension in order to isolate

Motor Exam• Normal variations

• 10% no independent FDS to small finger

• While examining small finger with ring DIP in extension, small finger FDS will appear to be ruptured

• Must instead hold middle finger in extension, allowing ring and small finger to flex

Motor Exam

• Flexor Digitorum Profundus (FDP):

• Flexion at DIP• Fix PIP of same finger to

isolate FDP

Motor ExamNerve Function

Median: Abductor pollicis brevis

Ulnar: First dorsal interosseous

Radial: Extensor pollicis longus

Riche-CannieuConnection

◼ First web area of palm

◼ Motor branch of ulnar nerve connecting to portion of median nerve

◼ Function incompletely defined

◼ Probably accounts for dual/cross innervation of flexor pollicis brevis

◼ i.e., weak opposition may be possible with complete MN palsy

3/1/2021

8

Sensory Exam

Median

Ulnar

Radial???, because…

Berettini Connection◼ Sensory branch in

palm between ulnar and median nerves

◼ Present in 80% of hands

◼ Usually: sensory fibers from ulnar nerve passing laterally into classic median distribution

Clemente Atlas

Sensory Exam

Monofilaments: neuropathy

2-point discrimination: nerve injury/recovery

Children/comatose/uncooperative: skin wrinkling in water

Dry skin

Dry skin on thumbNo wrinkling

Wrinkled

Sensory Exam

• Tinel sign:• Tapping over course of nerve….gently!

• Positive in compressive neuropathy• False positive rate of 45%

• Can follow course of regenerating nerve

Vascular Exam

• Pulses: radial and ulnar arteries

• Capillary refill

• Allen test: patency of arteries

• Patient clenches fist• Pressure placed over

both arteries with thumbs • One artery released and capillary

refill assessed• Repeat releasing other artery

Vascular Exam

• Modified Allen for the digital arteries

3/1/2021

9

Special Tests

• Bunnell-Littler test• Limitation of

Flexion• Intrinsic

Tightness (lumbricals and interossei) vs.

• Joint capsule contractures

Special testsBunnell-Littler

• Hold MCP in extension, if cannot flex PIP intrinsic vs capsular tightness exists

Allow flxn at MCP: relaxes intrinsics

If remains tight, capsular contracture is responsible for limitation of flexion

Special Tests

• Elson’s test• Early test for central slip dysfunction, prior to appearance of

boutonniere deformity

• Hold PIP in flexion

• Ask patient to extend DIP: normally cannot; early dysfunction can

Range of Motion

• Normal finger passive ROM, in degrees

Flexion Extension

MCP 90 -30 to -45

PIP 110 0

DIP 80 -20

Range of Motion

• MCP Joints: • “cam” joint

• lateral motion in extension, none in flexion


• Importance of proper immobilization

3/1/2021

10

Range of Motion

• Measurement: degrees of range of motion and contracture

• Objective and reproducible

• Multiple techniques• Total Active Motion, Total Passive Motion (see Addendum)

• Distance of pulp to palm: useful in flexion contractures

FunctionalRequirements

• Grasp: Power gripping

• Hammer, golf club

• Pinch: Fine motor• Shirt buttons, paper clips

Function

• Pinch mechanism• Thumb and index finger, middle finger

• Several muscles involved

• Long flexors and extensors stabilize proximal joints

• Lumbricals and interossei provide fine pinch

Function

• Pinch mechanism• Need adequate index and middle finger

extension for finger pulps to meet thumb pulp

Function

• Grasp• Need adequate ring and

small finger flexion for power grip

• Ring and small carpometacarpal mobility

FunctionalRequirements

• Sensory• Protective sensation: border digits, ulnar aspect of small finger, radial aspect

of index

• Fine motor function: necessitates intact sensation of thumb pulp and radial aspect of index finger

3/1/2021

11

Summary

• Examination includes thorough testing of motor, sensation, and vasculature

• Be aware of normal variations to avoid mistakes in diagnosis

• Understand what functions are most important for optimal hand use

Addendum 1Neurologic Levels

Motor Sensory

C6 Wrist extension Thumb and index, radial forearm

C7 Wrist flexion, finger extension

Middle finger

C8 Finger flexion Ring and small, ulnar forearm

T1 Finger abduction, adduction

Ulnar arm

Addendum 2Range of Motion: Notation system

Active Passive

MCP 10 to 75 0 to 90

PIP 30 to 75 10 to 95

DIP 0 to 55 0 to 60

Total flexion 205 245

- Total lack of extension

-40 -10

= Total motion Active 165 Passive 235

Further StudyModel Z, Liu AY, Kang L, Wolfe SW, Burket JC, Lee SK. Evaluation of Physical Examination Tests for Thumb Basal Joint Osteoarthritis. Hand (N Y). 2016;11(1):108-112.Rodriguez R, Strauch RJ. The middle finger flexion test to locate the thenar motor branch of the median nerve. J Hand Surg Am. 2013 Aug;38(8):1547-50.Valdés-Flores E, García-Álvarez E, García-Pérez MM, Castro-Govea Y, Santos-Ibarra A, Chacón-Martínez H, Betancourt-Espericueta L, Mecott GA. A Test for the Clinical Evaluation of the Flexor Digitorum Superficialis of the Fifth Finger. Ann Plast Surg. 2019 Feb;82(2):166-168.

Further StudyAustin GJ el al: Variations of the FDS of the small finger. J Hand Surg 1989, 14A:262-7.Linburg RM, Comstock BE. Anomalous tendon slips from the flexor pollicis longus to the FDP. J Hand Surg 1979, 4:79-83.Napier JR. The prehensile movements of the human hand. J Bone Joint Surg 1956; 38B:902-13.Kuschner SH et al: Tinel’s sign and Phalen’s test in carpal tunnel syndrome. Orthopedics 15:1297-1302, 1992.Meals RA, Shaner M: Variations in digital sensory patterns: a study of the ulnar nerve-median nerve palmar communicating branch.J Hand Surg 1983 8:411-4.

Imaging of the HandMark Greyson, MD

3/1/2021

12

Objectives:

◼ Historical background

◼ Basic concepts of radiology

◼ Special views of the hand

◼ Fractures

◼ Joints

◼ Bone density

History

• First x-ray in 1895

• Wilhelm Roentgen (1845-1923)

• Wife’s hand

Know the Bones

What are these shadows?

Sesamoid Bones

Pediatric X-rays Basic Views

3/1/2021

13

Basic Views

Posteroanterior (PA) view

Basic Views

Lateral View

Basic Views

Where’s

the

fracture?

Where’s

the

fracture?

Basic Views

Fracture Concepts

• Cortical breaks

• Radiolucent lines

Special Views

“Standard” pronated oblique view

3/1/2021

14

Special Views

Supinated oblique view

Special Views

Supinated oblique view – Arthritis & Fracture

Special Views

PA View

Special Views

Brewerton View

Special Views: BrewertonJoints

Osteoarthritis

Arthritis presents with:

• joint space narrowing

• sclerosis

• cysts

• osteophytes

3/1/2021

15

Joints

Osteoarthritis

Density

UltrasoundCheap and quick

Useful for detecting:• Dynamic changes

Ganglion/Abscess

• Foreign body • May not see XR

• Ligament Tears/Tendinitis

• Guided aspirations

CT Scan• Quick 3D view possible

• Useful for detecting:• Suspected fractures not easily seen on X-ray

• Assess union

• Evaluate cortical integrity with bony tumors

• Study fracture pattern and plan surgery

MRI Scan

• Expensive, timely

• Useful for detecting:• Soft Tissue Anatomy

(mass/swelling)

• Ligament injuries – May use arthrography

• Vascularity (Kienböck’s, Scaphoid Non-union)

Bone Scan

• Technetium-labeled bone scintigraphy• High sensitivity, low specificity.

• Increased uptake indicates increased blood flow (immediate) and bone turnover (delayed phase).

• Useful for detecting:• Osteomyelitis

• CRPS

3/1/2021

16

Summary

• PA and lateral radiographs depict the hand and fingers in three dimensions

• Special oblique views may be obtained to confirm presence of fractures

• Radiographs can visualize the finger joints

• Density of bone may vary in metabolic bone diseases

References

Hand Surgeons Providing Excellence in Education

forOccupational and Physical Therapists


DIGITAL

CONGENITAL DIFFERENCES

PROSPER BENHAIM, MD

UCLA Hand Center

CONGENITAL DEFORMITIESUpper Extremity

• Common

• 1 in 626 live births

• Many are single gene disorders

DIFFERENTIATIONOF THE UPPER LIMB

• Limb buds - ventrolateral wall of embryo

• Limb buds appear 4th week (day 26)

• Limb buds develop from day 26-47

3/1/2021

17

Weeks 5-6• Hand paddle develops

• Nerve ingrowth from spinal

cord rami begins to occur

proximally

d37 d42 d44

Hand Paddle

Weeks 6 - 7

• Fingers begin to separate

• Cartilaginous “bones” form

d48 d51

Weeks 7 — 8

• The UE grows and rotates 90°

• Elbows project posteriorly

• Dorsal mesenchymal stem cells – extensors

• Ventral mesenchymal stem cells - flexors

d53 d55 d58

CONGENITAL HAND ANOMALIESClassification and Examples

I Failure of formation of parts

II Failure of differentiation

III Duplication

IV Overgrowth

V Undergrowth

VI Constriction band syndrome

VII Generalized skeletal abnormalities

FAILURE OF FORMATIONTransverse Deficiency

FAILURE OF FORMATIONLongitudinal Deficiency

Complete

longitudinal failure

phocomelia

Partial

Radial (preaxial)

Central

Ulnar (post-axial)

3/1/2021

18

HYPOPLASTIC THUMB

Grade I

Mild shortening

Grade II

Moderate shortening

Thenar hypoplasia

TYPE III HYPOPLASTIC THUMB

TYPE IV - FLOATING THUMB

TYPE V - ABSENT THUMB

• Lateral pinch grip between index and middle fingers

• Secondary rotation of index finger

• Pollicization improves grasp and tip-to-tip pinch

CLEFT HAND

TYPICAL

Absent middle finger

Usually bilateral

Assoc w/ cleft feet (50%)

Assoc with cleft lip, palate

TYPICAL CLEFT HAND

3/1/2021

19

CLEFT HAND

ATYPICAL

Absence of > 1 central digit

LOBSTER CLAW HAND

Thumb and small finger only

ULNAR APLASIA

CONGENITAL HAND ANOMALIESClassification



Syndactyly

Camptodactyly

Clinodactyly

Kirner deformity

SYNDACTYLY

• 1 in 2000 live birth, sporadic vs. familial (10%)

• 50% bilateral

• Middle-ring finger web - most common

• Classification

• Webbing: “complete” vs “incomplete”

• Bone not involved = “simple”, involved = “complex”

SIMPLE SYNDACTYLY

Incomplete Complete

COMPLEX COMPLETE SYNDACTYLY

SIMPLE

COMPLETE

SYNDACTYLY

RF tethering MF

3/1/2021

20

POLAND’S SYNDROMEsymbrachydactylychest wall deformity

POLAND’S SYNDROMEabsent PIP joints

ACROCEPHALO-SYNDACTYLY

• APERT SYNDROME

• “Spoon-like” hand

• Common nail index, middle &

ring fingers

• Complex bony deformities

Apert

Syndrome

CAMPTODACTYLY

• Flexion contracture PIP

joint

• Small finger - 90%

• ? Abnormal insertion of

lumbrical muscle

• Bilateral - 66%

CAMPTODACTYLY Treatment

• Advise parents to accept the deformity

• Passive stretching, serial splinting

rarely successful

• Consider surgery: Young

child - severe contractureRapid

progression

3/1/2021

21

CLINODACTYLY

• Radial-ulnar curvature

• Usually small finger

• Usually radial deviation

• Delta phalanx

DELTA PHALANX

• Trapezoidal-shaped phalanx

• Abnormal C-shaped epiphysis

• Usually middle phalanx of the

small finger

Delta Phalanx of ThumbKIRNER DEFORMITY

• Palmar-radial curvature, rotation

• Distal phalanx, usually bilateral

• Associated musculoskeletal anomalies

• No functional limitations usually

• Observe

• Splint

• Correctional osteotomy




III Duplication polydactyly

• Pre-axial Thumb

• Central Index, middle, ring

• Post-axial Small finger

POLYDACTYLY

• Small finger is most commonly involved

• More common in African-American infants

(incidence = 1 in 300)

• More common in females

3/1/2021

22

SMALL FINGER POLYDACTYLYType 1 – Rudimentary Soft Tissue

SMALL FINGER POLYDACTYLY

Type II – Bifid Digit, One Metacarpal

SMALL FINGER POLYDACTYLY

Type II

SMALL FINGER POLYDACTYLYType III – Metacarpal Duplicated

INDEX FINGER DUPLICATION THUMB DUPLICATION(Type 1: broad pulp and nail)(Type 2: distal phalanx duplication)

3/1/2021

23

THUMB DUPLICATIONType 3

THUMB DUPLICATIONType 4

TRIPHALANGEAL THUMBType 7




III Duplication

IV Overgrowth

V Undergrowth



MACRODACTYLY

• 90% unilateral

• Multiple digits vs. single digit = 3 : 1

• Affects radial side of hand

• Index finger most frequently affected

• ? Related to neurofibromatosis

MACRODACTYLY

3/1/2021

24

MACRODACTYLY

• Staged debulking of soft tissue

• Wedge osteotomies to correct deviation

• Consider amputation




III Duplication

IV Overgrowth

V Undergrowth (brachydactyly)

• Short digit - normal # of bones, 1 is small

• Short metacarpal (brachymetacarpia)

• Short phalanx (brachyphalangia)

BRACHYMETACARPIA BRACHYPHALANGIA

*

*

**

*

*

*

*




III Duplication

IV Overgrowth

V Undergrowth



CONSTRICTION RING SYNDROME

• Circumferential grooving or transverse

amputation

• Associated anomalies (40-50%)

Club feet; cleft lip and palate

• Associated hand anomalies (80%)

Syndactyly

3/1/2021

25

CONSTRICTION RING SYNDROME

REFERENCES

1: Chung MS. Congenital differences of the

upper extremity. Clin Orthop Surg. 2011

Sep;3(3):172-7.

2: Bates SJ, et al. Reconstruction of congenital

differences of the hand. Plast Reconstr Surg.

2009 Jul;124(1 Suppl):128e-143e.

3: Oberg KC, et al. Developmental biology and

classification of congenital anomalies. J Hand

Surg Am. 2010 Dec;35(12):2066-76.

REFERENCES

4: Sammer DM, et al. Congenital hand

differences: embryology and classification.

Hand Clin. 2009 May;25(2):151-6.

5: Linder JM, et al. Congenital anomalies of

the hand: an overview. J Craniofac Surg. 2009

Jul;20(4):999-1004.

6: Goldfarb CA. Congenital hand surgery:

what's new and what's coming. Hand Clin.

2009 May;25(2):293-9.



Collateral Ligament & Volar Plate Injuries

Nicholas E. Rose, M.D.Newport Beach, CA

No vested interest. No off-label FDA uses.

Anatomy: MCP Joint

• Cam effect

• Ligaments• Tight in flexion

• Lax in extension

• JOINT MUST BE SPLINTED IN FLEXION!

3/1/2021

26

Specialized AnatomyThumb MCP Joint

• Condyloid joint

• Sesamoid bones


• Static stability• Adductor aponeurosis

• Dynamic stability

Anatomy: PIP Joint• Collateral Ligaments

• Cord-like proper lig.

• Anterior: accessory lig.

Anatomy: PIP Joint

• Cam effect less significant than MCP joint

• Collateral ligaments tight in flex AND ext

Anatomy: Volar Plate

• MCP and PIP Joint• Firm distal attachment

• More flexible proximal attachment

• Separates joint from flexor tendons

• Resists hyperextension

Finger MCP Injuries

• Classification• Collateral ligament injuries• Volar plate injuries• Dislocations• Fracture-dislocations

• Stable vs. unstable

Finger MCP Collateral Ligament Injuries

• Relatively rare compared to PIP injuries

• Diagnosis often missed

• Middle finger most common due to length

• Radial > ulnar collateral injuries

• Index RCL of particular concern

3/1/2021

27

Finger MCP Collateral Ligament Injuries

• Examination• Subtle swelling in valley between metacarpal heads• Pain with lateral stress with MCP in flexion (MCP normally lax in

extension)

• Radiographs• +/- avulsion fragment

• Sonography

TreatmentAcute Finger MCP Collateral Ligament Injuries

• Splint MCP in 50º flexion x 3w

• Buddy taping

• Operative treatment• >3mm displacement of small avulsion fragment• Fragment involves > 20% of articular surface &

is displaced & rotated• Grossly unstable joints

TreatmentAcute Finger MCP Collateral Ligament Injuries

• Operative treatment• Internal brace

• Suture tape augmentation• Immediate stability• Earlier rehab • Earlier return to activity & sports

TreatmentChronic Finger MCP Collateral Ligament Injuries

• Can be symptomatic for 12-18 months

• Steroid injection trial + buddy taping

• Arthroscopic debridement

• Ligament reconstruction +/- free tendon graft

MCP Volar Plate Injuries

• Hyperextension injury

• Volar plate torn from proximalattachment

MCP Volar Plate InjuriesDorsal Dislocation

• Simple

• Subluxation (articular surfaces in contact)

• Proximal phalanx 60 - 90 degrees hyperextension

• Reducible

3/1/2021

28

MCP Volar Plate InjuriesDorsal Dislocation

• Complex

• Complete dislocation• Less dramatic clinical appearance• Irreducible

• volar plate interposition

• DeVonta Smith • Alabama receiver• 2021 CFP National Championship

MCP Volar Plate InjuriesComplex Dorsal Dislocation

Volar plate interposition

Thumb MCPGamekeeper’s Thumb

• Sudden abduction stress

• Rupture of UCL & volar plate

• Stener lesion (adductor aponeurosis interposition)

Thumb MCPGamekeepers Thumb

• Stress testing

• Stress radiographs

Thumb MCPTreatment

• UCL Tear (Gamekeepers)• Partial tear

• Gamekeepers brace• Cast

• Complete tear

• Early repair • +/- internal brace

• Late reconstruction with tendon graft

• RCL Tear

• Surgery rarely indicated (no Stener lesion)

PIP Injuries

• Classification• Collateral ligament injuries• Volar plate injuries• Dislocations• Fracture-dislocations

• Stable vs. unstable

3/1/2021

29

PIPCollateral Ligament Injuries

• Lateral dislocation

• Abduction or adduction force• Usually in extension

• Radial > ulnar collateral

ligament injuries

• Acute (<6 weeks) vs. chronic (>6 weeks)

• Complete vs. incomplete


• Examination• Tenderness

• Central slip• Volar plate• Radial collateral ligament• Ulnar collateral ligament

Phot

Would be great


• Examination• Stability

• Radial & ulnar• Angulation > 20 degrees

indicates loss of collateral ligament integrity

• Sonography

Photos here would be great

PIPVolar Plate Injuries


• Volar plate• Integrity tested

by passive hyperextension



• Radiographic examination / stress testing

• Angulation > 20 degrees indicates loss of collateral ligament integrity


• Examination• Range of motion

• Active• Inability of patient to actively extend PIP joint against

resistance may indicate central slip rupture• Passive• Boutonniere deformity

• Limited passive DIP flexion with PIP held in maximum extension

3/1/2021

30


• Radiographs• PA & Lateral• Oblique view

• Useful for condylar injuries

• Sonography

TreatmentAcute Partial Collateral Ligament Injuries

• Buddy taping

• Taped to normal adjacent digit• Immediate active ROM• Full time for first 3 weeks• During periods of stress for 3 more weeks

• Athlete allowed to continue play during course of treatment

TreatmentAcute Collateral Ligament Injuries

• Surgery

• Rarely indicated• Avulsion of PIP collateral lig w/ buttonholing

of condyle between ligament & central slip

TreatmentAcute Collateral Ligament Injuries

• Surgery (ligament augmentation)

• Internal brace • Suture tape

TreatmentChronic Collateral Ligament Injuries

• Symptoms for 12-18 mo.

• Buddy taping 3-6 weeks

• Cortisone injection

TreatmentChronic Collateral Ligament Injuries

• Repair less satisfactory than in acute injuries

• Ligament shortening (difficult to gauge)• Combined ligament/volar plate reconstruction• Loss of motion• Operative repair for index finger PIP RCL in young

adult (Stability for pinch > full range of motion)

3/1/2021

31

Collateral Ligament InjuriesLong-term Sequelae

• Swelling

• Stiffness

• Flexion contracture

• Pain

• Chronic instability

• Post-traumatic arthritis

PIP Volar Plate Injuries• Hyperextension force

• Volar plate injury without dislocation• Dorsal dislocation

• Volar plate torn from distal attachment

• Most common PIP dislocation

• Usually reduced by patient, trainer or coach

PIP Volar Plate Injuries

• Volar plate almost always detaches distally (+/- bony avulsion)

TreatmentAcute PIP Volar Plate Injuries

• Most patients regain full ROM

• Symptoms will persist 12-18 months

• Permanent stiffness

PIP Volar Plate InjuriesSequelae

• PIP Flexion Contracture

• Scarring of volar plate• Dynamic splinting• Therapy• Occasional operative treatment

References

• Freiberg A, Pollard BA, Macdonald MR, Duncan MJ. Management of proximal interphalangeal joint injuries. Hand Clin. 2006 Aug;22(3):235-42.

• Hogan CJ and Nunley JA. Posttraumatic Proximal Interphalangeal Joint Flexion Contractures. J Am Acad Orthop Surg. 2006;14:524-33

• Leibovic SJ, Bowers WH. Anatomy of the Proximal Interphalangeal Joint. Hand Clinics 10:169-78, 1994.

3/1/2021

32

• Merrell G and Slade JF (2011). Dislocations and Ligament Injuries in the Digits. In Green’s Operative Hand Surgery(6th Ed. pp. 291-332). Philadelphia, PA. Elsevier Churchill Livingstone.

• Abbiati G, et al. The Treatment of Chronic Flexion Contractures of the Proximal Interphalangeal Joint. J Hand Surg 20B:385-9, 1995

• Durham JW et al: Acute and Late Radial Collateral Ligament Injuries of the Thumb MP Joint. J Hand Surg 18A:232-7, 1993.

• Lee SJ et al. Thumb ulnar collateral ligament repair with suture tape augmentation. J Hand Surg Asian Pac 25(1):32-38, Mar 2020.

• Draghi F et al. Injuries to the collateral ligaments of the metacarpophalangeal and interphalangeal joints: sonographic appearance. J Ultrasound Med. 37(9):2117-2133, Sept 2018.



Metacarpal and Phalangeal Intra-articular Fractures

Ali Ghiassi, MDUSC Department of Orthopedic Surgery

Introduction

• Intra-articular fractures are challenging to treat

• Digital joints are predisposed to stiffness• Articular involvement = hemarthrosis =

arthrofibrosis• Predispose to early arthrosis• May present late (10 days)

Principles of Treatment

• Accurate fracture reduction

• Maintenance of motion in uninvolved digits/joints

• Edema control

• Immobilization in safe position

• Early remobilization of the injured finger

3/1/2021

33

Mechanism of Injury

• Mechanism/time of Injury

• Closed vs. Open

• Angular or rotational deformity

• Stability

• Associated injuries

Associated Injuries

Time of Presentation

• Early presentation and treatment important

• Present beyond 2-3 weeks consider late reconstruction

• Get motion in all other joints

CondylarFractures

• Common athletic injuries

• Misdiagnosed as sprains

• Classified

• Stable nondisplaced• Unstable Unicondylar• Unstable Bicondylar

(comminuted)

Condylar Fractures

• Generally unstable

• Will have angular deformity

• Surgical stabilization for acute presentation

• Gutter splinting for delayed presentation or non-displaced fractures

• Needs close follow up in the acute period

3/1/2021

34

Condylar Fractures

• Most are unstable and need surgical stabilization

• Consider non-operative for late presentation 2-3 weeks

• High risk of stiffness

Non-operative Treatment

• Use a gutter splint with 3-point molding

• Need weekly fu

• Always risk of displacement

• Used for late presentation to prevent further displacement

Closed Reduction,Percutaneous Pinning(CRPP)

Condylar Fractures

• ORIF

• Should start early unrestricted motion

• Generally extensor mechanism is split or moved to one side

• CRPP

• May start early motion (surgeon’s decision)

• Need to protect wires for 3-4 weeks

Condylar Fractures

• ORIF (open reduction, internal fixation)

• Early edema control

• Tricks and tips

• CRPP (closed reduction, percutaneous pinning)

• Early edema control

• Tricks and tips

3/1/2021

35

PIP Fracture Dislocations

• Dorsal dislocations are associated with impacted fractures at the base of the middle phalanx

• Stable• Articular fragment < 40%

• Tx: CR and dorsal extension block splinting

• Unstable• Articular fragment > 40%

• Reduction is difficult to achieve and maintain



• Gradually work on extension

• One week rest

• Second week flexion in stable arc (90- full)

• Third week flexion in 1/2 stable arc (45-full)

• Fourth week (20-full)

• Week 5-6 d/c splint

• After week 6 work on residual contracture

PIP Fracture Dislocations

• Unstable injuries require operative treatment

• Goal is a congruous reduction of joint• Volar fragment is usually very comminuted• There is usually articular impaction noted• ORIF or Volar plate arthroplasty is indicated

Open Reduction,Internal Fixation

• Need large articular fragment

• Early motion is preferred within stable arc

• No passive strech for 6 weeks

Volar Plate Arthroplasty

• VPA is resurfacing of the depressed articular fragment with the volar plate

3/1/2021

36

Volar Plate Arthroplasty Volar Plate Arthroplasty

• One week rest

• Second week flexion in stable arc

• Third week divide extension 1/2

• Fourth week divide by 1/2

• Week 5-6 button removed

• Week 6 work on residual contracture

Hemi-Hamate Arthroplasty Hemi-Hamate Arthroplasty

Hemi-Hamate Arthroplasty

• One week rest

• Second week active flexion started with dorsal blocking splint (15-20º)

• Discontinue splint at 6 weeks

• Work on residual contracture

Dynamic Skeletal Traction

• Good for pilon fractures of pip joint

• Unstable volar lip fractures of pip

• Chronic pip dislocations

3/1/2021

37

Unstable Pip Fracture Dislocation Dynamic Skeletal Traction

Metacarpal Head Fractures

• Rare intra-articular fractures

• Usually comminuted or associated MP dislocation

• Brewerton view to asses CL avulsion

• Treatment is individualized depending on pattern and degree of comminution

• If < 20% of joint

• Buddy tape, protected ROM

• If > 20%

• ORIF• With early motion• Edema control• Buddy taping

• Usually protective splinting is not needed

• Stiffness is main issue

Metacarpal Head Fractures

CMC dislocations

3/1/2021

38

CMC Dislocations Reading

• Abzug J et al: Pediatric phalanx fractures. J Am AcadOrtho Surg. 2016; 24(11) – pe174-e183

• Carpenter S, Rohde R: Treatment of phalangeal Fractures. Hand Clinics, 2013; 29 (4):519-534, P519-

• Difficult Fractures of the Hand and Wrist, Hand Clinics May 1994

• Caggiano, N et al: Management of Proximal Interphalangeal Joint Fracture Dislocations. Hand Clinics. 2018 May;34(2):149-165



Wendy Chen, MD, MS

Stiff Fingers, Joint Contractures, and Capsulotomies

Presentation originally prepared by Scott Mitchell, M.D.

“An ever-present menace in hand surgery is the tendency for the hand to stiffen and to stiffen in the position of non-function.”

Sterling Bunnell. Surgery of the Hand, 3rd ed. 1956

• Wrist flexed

• Metacarpal arch flattened

• Intrinsic minus position• MCP joints extended

• Fingers clawed

• Thumb adducted

Position of Non-Function

Proximal (wrist)

Distal (digits)

https://www.hand.theclinics.com/issue/S0749-0712(13)X0004-6

3/1/2021

39

Causes of Hand Stiffness Causes of Hand Stiffness

• Prolonged immobilization or Inadequate immobilization

• Trauma

• Infection

• Arthritis

• Dupuytren’s contracture

• Burns

• Congenital anomalies

• Neurologic dysfunction

Pathophysiology: EDEMA is the FIRST RESPONSE

• Affects both injured AND uninjured structures

• Joint capsules distend with fluid

• Pain and swelling lead to characteristic hand posture

• MP joint extension

• IP joint flexion


• Affects both injured AND uninjured structures

• Joint capsules distend with fluid

• Pain and swelling lead to characteristic hand posture

• MP joint extension



Edema distends JOINT CAPSULE

• MP joint key to swollen hand posture

• Joint assumes position of maximum fluid capacity

• Extended MPJ least stable

• Minimal articular surface contact

• Capsular structures lax

• Fluid drives MP joint into full extension


MP joint drives position of IP joints

• MP EXTENSION leads to:• Increased flexor tension

• Decreased extensor tension


• Capsule and collateral ligaments shorten

• Changes become fixed → joint contractures

Edema → Fibrosis → Shortening

3/1/2021

40


Edema increases stiffness via SKIN TENSION

• Normal digit • Dorsal skin over PIP lengthens for

12mm for 90o of flexion

• Swollen digit• 5mm dorsal swelling

• 19mm lengthening required for 90o of flexionEdema → Fibrosis → Shortening

Soft Tissue Injury

• Extent of soft tissue damage influences motion loss

• Combined injuries (bone, tendon, joint) have worse prognosis.

• Internal wounds may be extensive, even with closed fractures.

Soft Tissue Injury• Extent of soft tissue damage influences

motion loss

• Combined injuries (bone, tendon, joint) have worse prognosis.

• Internal wounds may be extensive, even with closed fractures.

The Anatomy of FLEXION Contractures

• Volar scar contracture

• Superficial fascia (Dupuytren’s contracture)

• Flexor tendon sheath

• Flexor tendon adhesions

• Volar plate


• Bony block/exostosis

• Articular incongruity

Superficial (Skin)

Deep (Bone)

Anatomy






• Volar plate









• Volar plate




3/1/2021

41



• Superficial fascia (Dupuytren’scontracture)



• Volar plate




The Anatomy of EXTENSION Contractures

• Dorsal scar contracture

• Extensor tendon adhesions

• Joint capsule

• Collateral ligament



Superficial (Skin)

Deep (Bone)

The Anatomy of EXTENSION Contractures

• Dorsal scar contracture

• Extensor tendon adhesions

• Joint capsule

• Collateral ligament



Physical Exam: Active versus Passive Motion

• Passive > active ROM• Extra-articular causes limit

motion• Tendon adhesions

• Passive = active ROM• Intra-articular causes

• Capsular contracture• Tendon adhesions on opposite

side of joint

Physical Exam

Physical Exam: Fixed versus positional motion loss

• Motion varies in response to position of adjacent joints

• Tenodesis effect: • Non-articular contracting structure

spanning > 1 joint

• Intrinsic or extrinsic musculotendinous tightness

Physical Exam: Intrinsic Tightness

• Intrinsic tendons • Flex MP joints• Extend PIP and DIP joints

Credit: Martin PosnerHand 50 Lecture on Extensor Tendons

3/1/2021

42


• Intrinsic tendons • Flex MP joints

• Extend PIP and DIP joints

• Tight intrinsics limit composite digital flexion (IP joint flexion)

Credit: Martin PosnerHand 50 Lecture on Extensor Tendons


• Intrinsic tendons • Flex MP joints

• Extend PIP and DIP joints

• Tight intrinsics limit composite digital flexion (IP joint flexion)

• Motion loss more severe if MP joint is extended


Bunnell Test for Intrinsic Tightness• Tests passive PIP flexion with the MP joint flexed then

extended.

• MP flexion

• relaxes intrinsics

• PIP easily flexes

Physical Exam: EXTRINSIC Tightness

• Long flexor tightness• Wrist and MP joints extended• Test passive IP extension

•Extrinsic extensor tightness•Wrist and MP joints flexed•Test passive IP flexion

Capsular Contracture•Loss of both active and passive motion

•Not affected by adjacent joint position

•Exceptions:

•Tendon adhesions on both sides of joint

•Bony blocks to motion

•Joint incongruity

•Disclaimer:

•Capsular contractures may *mask* extra-articular causes of motion loss

Is it the collateral ligaments?

If collateral ligaments are the only limitation, it won’t matter whether the MCPJs are flexed or extended—

the PIPJ will be the same degree of stiff.

3/1/2021

43

Treatment of Stiff Fingers•Prevention

•Judicious immobilization

•Reduce edema

•Pain control

•Early active and passive motion

•Splinting

•Art of therapy

Treatment of Stiff Fingers•Prevention

•Judicious immobilization

•Reduce edema

•Pain control

•Early active and passive motion

•Splinting•Art of therapy

Treatment of Stiff FingersSplinting: Counteract tendency to assume intrinsic minus posture

•Intrinsic plus position

•MCP joints flexed•Stretches capsule and collaterals •Balances flexor/extensor tone

•IP joints extended

•Prevents volar plate contracture

•Thumb abducted

Treatment of Stiff FingersSplinting:•Intrinsic plus position

•MCP joints flexed

•Stretches capsule and collaterals

•Balances flexor/extensor tone

•IP joints extended

•Prevents volar plate contracture

•Thumb abducted

Treatment of Stiff FingersTherapy to Restore Motion•Loss of active motion

•Active and active-assisted motion

•Tendon gliding

•Blocking exercises

•Resisted motion

Treatment of Stiff FingersSplinting: 87% of MPJ and PIPJ contractures can be managed conservatively•Static splint

•Dynamic splint

•Static progressive splint

•Serial cast/splint

Combine daytime dynamic splint or static progressive splint + nighttime static splint.

3/1/2021

44

Treatment of Stiff Fingers: PIP EXTENSION Splints Splinting: PIP EXTENSION Splints

Treatment of Stiff Fingers: PIP FLEXION Splints Splinting: PIP FLEXION Splints

Treatment of Stiff Fingers: EXPECTATIONS

•Nonoperative treatment of fixed flexion deformity of the PIPJ. Hunter et al. JHS Br 1999.

•Average PIP motion arc improved from 24-67 to 8-98o

Treatment of Stiff Fingers: EXPECTATIONS

•Dynamic splinting for the stiff hand after trauma. Glasgow C. J Hand Ther2011

•Time spent in splint is key

•Better outcomes with:

•Less pretreatment stiffness•Shorter time since injury (<12 weeks)•Flexion rather than extension deficits

Surgery

Indications

• No absolutes

• Motion loss > 30 degrees

• Plateau in therapy

•Firm vs soft end point

•May require 5-6 months of non-op treatment

• Tissue equilibrium

• Final benefit anticipated

Contraindications

• Neurovascular compromise

• Arthritis

• Incongruent joint surfaces

• Deficient motors

• Chronic, severe flexion deformities

MP extension contracture release

• Dorsal approach

• Extensor tendon split

• Extensor tenolysis

• Dorsal capsulectomy

• Collateral ligament release

• Splint in flexion

• Final motion 50% of operative ROM

3/1/2021

45


• Dorsal approach








• Dorsal approach







PIP extension contracture release

• Dorsal approach


• Hardware removal

• Dorsal capsulotomy

• Dorsal collateral ligament release

• Distal intrinsic release

• Check active flexion


• Dorsal approach


• Hardware removal

• Dorsal capsulotomy

• Dorsal collateral ligament release

• Distal intrinsic release

• Check active flexion


• Dorsal contractures may mask flexor adhesions

• Traction test to evaluate flexor system following dorsal release

• Confine surgery to one side of joint if flexion limited

• Therapy to maximize passive ROM

• Staged flexor tenolysis

3/1/2021

46

PIP FLEXION contracture release

• Sequential approach• Flexor tenolysis

• Proximal volar plate

• Accessory collateral

• Excision of collateral ligaments

• Check active extension

• Watch for vasospasm

• Outcomes worse with more structures requiring release

PIP FLEXION contracture release• Sequential approach

• Flexor tenolysis























Digit Widget•Dynamic external

fixator

•Extension torque transmitted through pins in the middle phalanx

•Avoids skin pressure

•Accommodates additional soft tissue procedures

•Allows active motion

3/1/2021

47

Summary

•Traumatized hand tends toward a stiff, poorly functional position

•Prevent contractures with appropriate immobilization and early motion

•Physical exam to identify causes of stiffness

•Early therapy, splint for motion

•Surgery offers modest ROM gains, may improve function

ReferencesWang ED, Rahgozar P. The Pathogenesis and Treatment of the Stiff Finger. Clin Plast Surg. 2019 Jul;46(3):339-345. doi: 10.1016/j.cps.2019.02.007. Epub 2019 Apr 19. PMID: 31103078.

Yang G, McGlinn EP, Chung KC. Management of the stiff finger: evidence and outcomes. Clin Plast Surg. 2014 Jul;41(3):501-12. doi: 10.1016/j.cps.2014.03.011. PMID: 24996467; PMCID: PMC4124823.

Catalano LW 3rd, Barron OA, Glickel SZ, Minhas SV. Etiology, Evaluation, and Management Options for the Stiff Digit. J Am Acad Orthop Surg. 2019 Aug 1;27(15):e676-e684. doi: 10.5435/JAAOS-D-18-00310. PMID: 30475280.

Tuffaha SH, Lee WPA. Treatment of Proximal Interphalangeal Joint Contracture. Hand Clin. 2018 May;34(2):229-235. doi: 10.1016/j.hcl.2017.12.012. PMID: 29625642.

References

Hogan CJ, Nunley JA. Post-traumatic proximal interphalangeal joint flexion contractures. Journal of the American Academy of Orthopaedic Surgeons 2008;14(9), 524-33

Curtis RM. Capsulectomy of the interphalangeal joints of the fingers. J Bone Joint Surg Am 1954;36:1219-1232.

Prosser R. Splinting in the management of PIP joint flexion contracture. J Hand Ther 1996 9:378-86.

Hunter et al. Nonoperative treatment of fixed flexion deformity of the PIP joint. J Hand Surg Br 1999 Jun;24(3):281-3.

Houshian S. Chronic flexion contractures of the PIP joint treated with the compass hinge external fixator. J Hand Surg Br 2002;27B(4)356

Soft-tissue distraction vs checkrein ligament release for Dupuytren PIP joint contractures. Plast Reconstr Surg. 2011 128:1107-13

Hand Surgeons Providing Excellence in Education

forOccupational and Physical Therapists


Finger InfectionsClifton Meals, M.D.

Introduction

• 35% of admissions to hand surgeons

• Most result from neglected minor trauma

• ~2/3 of infections caused by Staph aureus

• Prompt evaluation and treatment

• Antibiotics for uncomplicated cellulitis

• Pus requires surgical drainage

• A few zebras

3/1/2021

48

Bacteria

• Staphylococcus Aureus • Gram + cocci in clusters• cellulitis (no pus)• abscesses (pus)

• MRSA (methicillin-resistant S. aureus)

• More difficult to treat• More soft tissue damage

Bacteria

• Polymicrobial infections• Often include Gram neg. • Intravenous drug use• Bite wounds• Farm injuries• Diabetes mellitus

Viruses Fungi

History

• Injury?

• Timing

• Occupation / Exposures

• Health status (DM, HIV, RA, Gout?)

• Tetanus status

• Other infections?

• Medication allergies

Physical Exam

• Rule out threats to life, limb

• Rule out threats to • Joint, tendon

• Cellulitis?

• Abscess?

3/1/2021

49

Cellulitis

• No pus

• Infection of sub-q fat

• Less destructive

• Lymphatic streaking

Abscess

• Pus under pressure

• Locally destructive

• Difficult for antibiotic to penetrate

Treatment

• Antibiotics• Should cover Staph A.

• Rest • Minimizes spread

• Heat• Vasodilation / immune response

• Elevation• Reduces swelling

• Surgery?

Acute Paronychia

• Cellulitis / abscess of soft tissue around nail

• Most common infection of the hand

Paronychium

Eponychium

Hyponychium

Acute Paronychia

• Cellulitis: warm soaks & oral Abx

• Pus: use scalpel to elevate paronychial fold from nail plate

• Pus underneath nail: remove part of nail

• 7-10 days of oral antibiotics

Chronic Paronychia

• Indurated eponychium• Long duration• Dishwashers• DM, HIV• Candida albicans• Eliminate exposure• Topical / Oral Abx• Occasionally Surgery

3/1/2021

50

Felon

• Abscess of pulp

Felon• Incision & drainage

• Leave open / pack

• Warm soaks BID x ~ 5 days

• Antibiotics ~ 5 days

Flexor Tenosynovitis

• Kanavel Signs• Flexed posture

• Pain w/ passive stretch

• TTP along tendon sheath

• Fusiform swelling

Flexor Tenosynovitis

• Abscess of tendon sheath• Destructive

• May ascend rapidly

• Difficult for immune system

• Difficult for Abx

• Surgical emergency

Treatment Principles

• Minimize soft tissue trauma

• Direct access to tendon sheath

• Permit easy extension

• Avoid high-contact areas

• Loose closure

• + / - drain

• Postop immobilization

Incisions

3/1/2021

51

Incisions Bite Wounds

• Dog > Cat > Human

• Open wounds left open

• Abscesses drained

• Cover gram positive, gram negative, anaerobes

• Augmentin / Unasyn

Septic Arthritis

• Rule out gout, pseudogout, OA

• Often penetrating trauma

• Fist vs. teeth → infected MPJ

• Pain with joint motion

• Rapid destruction of cartilage

• Surgical emergency

• Abx

Osteomyelitis

• Abscess of bone

• Local spread

• Hematogenous seeding

• X-Ray findings often subtle

• Often a diagnosis of exclusion

• + / - biopsy / culture

• IV Abx

• Surgery if necessary

Mycobacterium& Chronic FTS

• Milder, Chronic FTS

• Exposure to salt water

• Rice bodies on exam

• No pus

• Mycobacterium marinum• Granulomas

• Special stains

• Long course IV Abx

• + / - surgery

Herpetic Whitlow

• Virus

• May mimic paronychia / felon

• Think exposure

• Clear vesicles

• Self-limiting (3 weeks)

• Anti viral Rx may help

• Do not operate

3/1/2021

52

Gout

• Crystal arthropathy

• Commoly mimics infection

• Most common in men

• H/o recurrent episodes

• Any joint

• Treatment: NSAIDs, colchicine, allopurinol

• Rarely surgery

Summary

• ~2/3rds of infections caused by Staph A.

• Several emergencies• necrotizing fasciitis


• septic joint

• Antibiotics for uncomplicated cellulitis

• Pus requires surgical drainage

• Mimics: gout, virus, mycobacteria

References

• Koshy JC, Bell B. Hand Infections. J Hand Surg 2019; 44(1): 46-54.

• Stevanovic MV, Sharpe F: Acute infections. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds): Green’s Operative Hand Surgery, Philadelphia, Elsevier, 2017; 17-61.

• Kann SE, Jacquemin J and Stern PJ. Simulators of hand infections. Instr Course Lect, 1997; 46: 69-82.

The Snapping FingerClifton Meals, MD

Always a trigger finger? Always a trigger finger?

3/1/2021

53

Always a trigger finger?

• Trigger finger• Subluxing EDC / sagittal band injury

• Lateral band subluxation at the PIP• MP osteoarthritis with snapping collateral ligament• Sesamoid at thumb IP after IP hyperextension injury

Trigger Finger

Trigger Finger

• Stenosing tenosynovitis

• Nodule in tendon and/or thickening of A1 pulley cause tendon to catch

Symptoms

• Pain and in the palm

• Can’t make a tight fist

• Morning stiffness

• Locking in flexion

Associated Conditions

• Diabetes mellitus

• Gout

• Rheumatoid arthritis

• Amyloid deposition

• Carpal tunnel syndrome

Exam

• Demonstrate triggering

• Palpate nodules

•Palmodigital crease is half way between

the PIP crease and the proximal edge of A1

3/1/2021

54

Treatment

• NSAIDS

• Splinting

• Static MP extension• 3-6 weeks• Approx 50% success


• Cortisone injection• 0.5 ml Kenalog 40

• Success rates• Single injection: 50%

• Second injections: 75-90%

Repeat injections in short

time span may risk tendon

rupture

Surgery Complications

• Digital nerve injury

• Bowstringing

• Stiffness

Subluxing EDC

• Sagittal bands centralize EDC

• Stressed when MP flexed

Subluxing EDC

• Unilaterally injured sagittal band allows EDC to sublux

• Usually, radial sagittal band injured, EDC subluxesulnarly

3/1/2021

55

Mechanism of Injury

• Direct blow – “boxer’s knuckle”

• Flicking injury

• Laceration

• Rheumatoid arthritis

Subluxing EDC

• EDC can stick in subluxed position

• Difficulty initiating extension

• Snapping

Treatment of acute injuries

• Splinting of MP in extension

• hand-based P1 blocker• relative motion splint• 4-6 weeks

Treatment of chronic cases

• Can try splinting – less successful

• Surgical repair of the sagittal band

Post-op Rehab

• Relative motion splint for 4 weeks

• Protected flexion / night splinting for 2 weeks

3/1/2021

56

References

• Kuczmarski AS, Harris AP, Gil JA, Weiss AC. Management of Diabetic Trigger Finger. J Hand Surg Am. 2019 Feb;44(2):150-153.

• Gil JA, Hresko AM, Weiss AC. Current Concepts in the Management of Trigger Finger in Adults. J Am Acad OrthopSurg. 2020 Aug 1;28(15):e642-e650.

• Strauch RJ. Extensor Tendon Injury. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds). Green’s Operative Hand Surgery ed 7, Philadelphia: Elsevier, 2017; 152-82.



Dislocations:MP, PIP, and DIP Joints

Tze C. Ip, M.D.Newport Orthopaedic Institute

Finger Dislocations

• PIP joint most commonly injured joint in the hand

• 2004-2008: over 166,000 ED visits

• Spectrum of injury• “Jammed Finger”

• Irreducible Fracture Dislocation

Finger Dislocations

• Goals• Maintain a congruent joint

• Focus on early stable ROM

• Edema control

Finger Dislocations

• Primary Stabilizers:

Joint surface

Collateral ligaments

• Secondary Stabilizers:

Volar plate

Accessory collateral ligaments

Soft tissues

3/1/2021

57

Evaluation

Clinical:

• Swelling

• Skin Puckering

• Deformity

• Other injuries

Evaluation

Clinical:

• Concentric reduction with motion

• Active stability

• Passive stability

Central Slip Evaluation

Maintenance of full PIP extension

Elson Test:

-PIP is held flexed at 90⁰ and the patient is asked to extend the DIP

-Rigidity at the DIP indicates an injury to the central slip

Evaluation

Three Grades of Injuries:

• Grade I: Microscopic tear (stable injury)

• Grade II: Intact ligament but with laxity (stable injury)

• Grade III: Complete disruption of ligaments

Dislocations

Three Types (point of reference is

the location of the middle phalanx):

• Dorsal

• Lateral

• Volar

Dislocations

Dorsal:• Hyperextension

• Longitudinal compression

• Can result in soft tissue and/or bony injury

• Instability with extension

3/1/2021

58

Dislocations2) Type II (Dorsal dislocation)

• volar plate injury

• bilateral split to the collateral ligaments

• usually results in bayonette apposition

For 2021: better image needed

Dislocations

Treatment:

• Types I and II

• 2-3 days of protection

• begin early range of motion

Dislocations

• Type III (Stable)• Dorsal Blocking splint at 20-30 degrees of flexion

for 7-14 days

• Early active motion

• Buddy taping afterwards

Dislocations

• Type III (Unstable)

• Dynamic skeletal traction

• Extension block splinting

• Open reduction internal

fixation

Dislocations

Lateral Dislocation:

• Clinical Test

• Stress at full extension

• Stress at 30 degrees of flexion

Dislocations

Lateral Dislocation:

• Treatment

• Buddy Taping

• Greater than 20 degrees laxity Repair in an

athlete?

3/1/2021

59

Dislocations

Volar Dislocations:

• Rotatory longitudinal compression

• Semi-flexed middle phalanx

Dislocations

Volar Dislocations:

• Rare

• Unstable in flexion

• Can be unreducible

• Volar plate or collateral ligaments can be

interposed

MCP JointsCapsule

• Extends from the metacarpal neck to the base of the proximal phalanx

Volar Plate

• continuous with the deep transverse metacarpal ligament

Dorsal

• reinforced with common extensors

MCP Joints

Dorsal Dislocation• Uncommon

• Most frequent digits involved are the index and small digit

MCP Joints

Simple: reducible

• Begin early ROM and dorsal blocking splint

MCP Joints

Complete (Complex):

• Treatment

• Open reduction with the release of the A1 pulley

• Retrieve displaced volar plate interposed in the joint

3/1/2021

60

MCP Joints

Volar Dislocations:

• Extremely Uncommon

• Two structure blocking reduction

• dorsal capsule

• volar plate

DIP Joints

Dislocations• Usually dorsal or lateral

• Usually reducible

References

• Miller EA, Friedrich JB. Management of Finger Joint Dislocation and Fracture-Dislocations in Athletes. Clin Sports Med. 2020 Apr;39(2):423-442.

• Saitta BH, Wolf JM. Treating Proximal Interphalangeal Joint Dislocations. Hand Clin. 2018 May;34(2):139-148.

• Prucz RB, Friedrich JB. Finger joint injuries. Clin Sports Med. 2015 Jan;34(1):99-116.

• Glickel and Barron: Proximal interphalangeal joint fracture dislocations. Hand Clin. 2000 Aug;16(3):333-44. Review.

References

• Bindra and Foster: Management of proximal interphalangeal joint dislocations in athletes.

• Hand Clin. 2009 Aug;25(3):423-35. Review• Calfee and Sommerkamp TG. Fracture-dislocation about the

finger joints. J Hand Surg 2009 34A:1140-7. Review.• Dinh et al: Management of proximal interphalangeal joint

injuries. J Am Acad Orthop Surg. 2009: 17(5):318-24. Chinchalkarand Gan: Management of proximal interphalangeal joint fractures and dislocations. J Hand Ther. 2003 Apr-Jun;16(2):117-28. Review.

• Freiberg, et al: Management of proximal interphalangeal joint injuries. Hand Clin. 2006 Aug;22(3):235-42. Review.



Mallet Fingersand

Distal Phalanx Fractures

Roy A. Meals, MD

Disclaimer: RM receives royalties for Mallet Mender Splint

http://www.ncbi.nlm.nih.gov/pubmed/10955207






3/1/2021

61

Mallet Fingeretiology: sudden forced dip joint flexion

• Hand stationary: baseball, volleyball, basketball• Bony or tendinous

• Hand moving: tucking in slip cover or bed spread, pushing off sock, cleaning upholstery

• Tendinous

Mallet deformityExamination

• dip joint • medial/lateral stability• FDP tendon function • neurovascular status• nail

• pip joint• m/l stability• active e/f• hyperextensibility

• x-ray

Mallet FingerDifferential Diagnosis

• fracture or dislocation

• osteoarthritis

• flexor tendon tightness (especially after graft)

• Dupuytren disease can rarely contract DIP joint

Mallet FingerNatural History

• patient intuitively splints it

• The bone always heals

• rarely a functional deficit

• unsightly to some

• may lead to hyperextension at PIP joint (swan neck deformity)

• actual benefits• reduce or correct dip extensor lag

• Prevent/minimize swan neck deformity

• purported benefit of surgery• prevent osteoarthritis (never occurs)

Mallet FingerTreatment

Mallet FingerComplications of TreatmentJHS 1988, 13A:341

• Splinting 38/84 fingers (45%)• Skin maceration, necrosis, nail deformity, pain, tape allergy

• 1/38 complications permanent (nail groove)

• Surgery 24/45 (53%)• Infection, reoperation, nail deformity, joint deformity

• 18/24 complications permanent

3/1/2021

62

So if we can

avoid these

problems,

splinting is best.

DIP Joint Hyperextension

• causes loss of capillary circulation dorsally

• avoid

Methods of Splinting

any rigid material+tape

MethodsofSplinting

aluminum/foam

(closed or open

pore)

plaster

Mallet Mender splint

Stack splint

Videoclip:Mallet Mender Application

• BonyWeeks 1-4: full time

• Tendinous• Weeks 1-6: full time• Week 7: night time• Week 8: if persistent extension lag:

resume full time splinting

• Both injury types at week 9: blocking and passive flexion exercises

Splinting Acute Mallet Injuries

3/1/2021

63

Splint Treatment for Late Presentation

• Effective up to 6 months after tendinous injuries• For each month of delay in starting splinting, splint a week

longer

• e.g., 3 month delay: 6 weeks + 3 weeks

• Not effective for bony injuries

Surgical Treatment for Early Presentation

K-wire holding dip joint in extension, cut off below skin.

Possibly useful for surgeons, dentists

Surgical Treatment for Late Presentation

• Fowler procedure (release central slip)

• Spiral oblique retinacular ligament reconstruction

• Fusion


• Intra-articular• Dorsal lip—bony mallet injuries

• Volar lip—FDP avulsion

• Shaft and tuft• Lever arm is short

• Mechanism: crush• Car doors usually do not fracture distal phalanx


• Intra-articular• Volar lip—FDP avulsion, usually with only fleck of distal phalanx

and preservation of joint

Joint surface restored

FDP reattached

Gentle splinting of shaft fx

adequate since it does not

experience deforming

forces from tendons


• Epiphyseal—may retard growth but finger lengths are different anyway

• Shaft and tuft—dramatic but innocuous• Tendons attach more proximally

• Gentle taping or splinting for comfort

• Frequent pulp, nail bed injuries associated with tuft and shaft fxs

3/1/2021

64

References: Mallet Fingers

• Lamaris G, Matthew M: The Diagnosis and Management of Mallet Finger Injuries. Hand (N Y). 2017 May; 12(3): 223–228.

• Grunberg A and Reagan D: Central slip tenotomy for chronic mallet finger deformity. J Hand Surg 1987, 12A:545

• Wehbe, M and Schneider L: Mallet fractures. J Bone Joint Surg 1984, 66A:658

• Chao JD et al: Central slip tenotomy for chronic mallet finger. An anatomic study. J Hand Surg 2004, 29A: 216

• Kleinman W and Peterson D: Oblique retinacular ligament reconstruction for chronic mallet finger deformity. J Hand Surg 1984, 9A:399

• Stern P and Kastrup J: Complications and prognosis of treatment of mallet finger. J Hand Surg 1988, 13A:329

References

Intra-articular Distal Phalanx Fractures

Wieschhoff G et al: Traumatic Finger Injuries: What the Orthopedic

Surgeon Wants to Know. RadioGraphics; 2016;36 (4) Published

Online: Jul 11 2016

Carpenter S, Rohde R: Treatment of Phalangeal Fractures. Hand Clin

29 (2013) 519–534

Bartelmann, U. et al. Handchir Mikrochir Plast Chir 2001 (screws)

Sauerbier M et al. Handchir Mikrochir Plast Chir. 1999 (tension

band)

Lubahn, J. D., Hood, J. M. Clin Orthop 1996

Schneider, L. H. Hand Clinics 1994

Schneider, L. H., Wehbe, M. A., J Bone Joint Surg Am 1988

Stark HH et al. J Bone Joint Surg Am. 1987

Resource

• Mallet mender splint blanks and instruction sheets for application and for patient:

• George Tiemann and Company• 1 800 TIEMANN (843-6266)

• www.georgetiemann.com



Osteoarthritis and Post-traumatic Arthritis of the Digits

Paul A Ghareeb MD

Assistant Professor, Emory Hand Surgery

Osteoarthritis (OA)

• Joint inflammation and destruction due to “wear and tear”

• Most common joint disorder

• Symptoms often wax and wane

• Almost universal in elderly

• Traumatic OA tends to occur in younger patients

• Diagnosis: Clinical exam + Imaging

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5480656/

https://pubs.rsna.org/doi/pdf/10.1148/rg.2016150216

3/1/2021

65

Traumatic Arthritis

• Intra-articular fracture leading to joint incongruity

• Amount of incongruity that leads to arthritis is unknown

• Dislocation

• Subluxation/instability

OA of the Fingers

• DIP, PIP, and thumb CMC joints are most frequently affected

• 50+ y/o -- females > males

• 50% genetically linked

• Estrogen may be protective

• Increased with repetitive forceful use - factory workers, farmers

Symptoms of OA

• “Gelling” after prolonged rest

• Morning stiffness

• Pain following activity, relieved by rest

• Weakness - usually mild and localized

Signs of OA

• Tenderness to palpation of the joint

• Effusion with little synovitis

• Heat and redness not common

• Bone spurs/osteophytes

• +/- crepitus or grinding

DIP Joints• Heberden nodes

• Mucous cysts

• Decreased motion

• +/- instability due to bone erosion

• Angulation at joint due to pinching, i.e. ulna deviation

• Pain

Treatment- OA DIP Joints• Heat, paraffin baths, splinting,

NSAIDS, Therapy

• Fusion in 0-20 degrees with wires, pins, screws

• Takes 6-8 weeks to heal, some get a fibroarthrodesiswith some motion still present

• Splint DIP, mobilize PIP/MCP joints

• Arthroplasty- typically unsuccessful, 10-30 extensor lag, 25-30 motion, lacks stability

3/1/2021

66

OA PIP Joints

• Bouchards nodes• Decreased motion• +/- instability due

to bone erosion• Angulation at joint

due to pinching, i.e. ulna deviation

• Pain

OA PIP Joints

• Heat, paraffin baths, splinting, NSAIDS, Therapy

• Joint de-innervation

• Fusion (plate and screws, interosseous wiring, tension band)

• 40-50 degrees, cascade, takes 6-8 wks to heal, mobilize MCP and DIP joints, maintain strength

• Arthroplasty-silicone

• fibrous encapsulation, get motion, not strength or stability

• older and low demand patients

• not index finger, due to ulna deviation with pinch

Joint Deinnervation

• Jimenez et al JHS 2020• 11 cases

• Improvement in pain from 7.8 to 1.4

• ROM improved from 52 to 79 degrees

• DASH scores significantly improved

Fusion vs Arthroplasty

Silicone PIPJ Arthroplasty -Postop

• Guarded active flexion/extension days 5-20

• Protect collateral ligaments

• Buddy tape to intact radial digit

• Isolate and increase flexion by extension splinting of MCP + DIP joints

• Passive ROM at 3weeks

• Flexion 0-60 degrees

Treatment of OA MCP Joints

• More common in rheumatoid arthritis

• Heat, paraffin baths, cortisone injections, NSAIDS, Therapy

• Fusion- young high demand patients 20-30 degrees

• increased strength

• can not spread finger

• Silicone implants-low demand/elderly patients

3/1/2021

67

Silicone MCP ArthroplastyPost - op

• 3-5 days p/o start ROM

• Daytime dynamic splinting

• Nighttime static splint

• Limit flexion to 45-60 degrees for stability and durability

• Can add flexion outrigger at 3 weeks if stiff in extension

Pyrocarbon Joint Arthroplasty

Pyrocarbon Joint Arthroplasty

• Wagner et al 2018:• No change in PIP joint motion

• Significant improvement in joint pain

• 34% reoperation rate• 21% implant revision rate

• 13% secondary procedure rate

Thumb OA• IP joint- Fuse 5-20 degrees

• MCP joint- Fuse 5-25 degrees• May occur after radial/ulna

ligament injury with instability

• Arthroplasty- low demand/elderly, not often indicated

Thumb CMC OA• Most common location of

symptomatic arthritis in the hand

• Joint laxity may predispose

• Eaton classification to describe severity of XR findings

• Pain with activity (can’t open a jar)

• + CMC Grind test

• Therapy, NSAIDs, short opponens splinting, steroid injection

Thumb CMC Joint

• Fusion

• young, high demand, post Bennett's fx, subluxation

• Place metacarpal in opposition

• May develop OA of Scapho-trapezial joint

• Arthroplasty – Many different techniques

• Trapeziectomy alone

• Ligament Reconstruction with Tendon Interposition (LRTI)

• Suspensionplasty

• Tightrope

3/1/2021

68

CMC

Fusion Excision ArthroplastyKnuckle Cracking!

• Joint subluxes causing decreased intra-articular pressure

• Gas formation and vaporization of joint fluid

• Audible crack

• Takes 30 minutes for gas to resorb- can repeat

When to Treat OA with Therapy Rather Than Surgery

• Mild deformity but good function

• Minimal pain

• Active patients frustrated by normal decline of strength and endurance with ageing

• Patients need to understand normal limitations of OA- need instructions in ergonomics

References

• EW, JW, MH et al. Medium term outcomes with pyrocarbon proximal interphalangeal arthroplasty: A study of 170 consecutive patients. J Hand Surg Am 2018;43:797-805

• Pickrell BB, Eberlin KR. Thumb Basal Joint Arthritis. Clin Plast Surg. 2019 Jul;46(3):407-413

• Yamamoto M, Malay S, Fujihara Y, Zhong L, Chung KC. A Systematic Review of Different Implants and Approaches for Proximal Interphalangeal Joint Arthroplasty. Plast Reconstr Surg. 2017 May;139(5):1139e-1151e

• Jiménez I, Marcos-García A, Muratore G, Caballero-Martel J, Medina J. Denervation for Proximal Interphalangeal Joint Osteoarthritis. J Hand Surg Am. 2020 Apr;45(4):358.e1-358.e5

• Operative Hand Surgery- Green

• Arthritis and Allied Conditions- Koopman

• Kelley’s Textbook of Rheumatology



Rheumatoid Arthritis

in the Finger Joints

Emil Dionysian, M.D.

Kaiser Permanente, Orange County

Slide preparation assisted by Neil Harness, M.D.

3/1/2021

69

Introduction

• Systemic autoimmune disorder

• Chronic, symmetric erosive synovitis of peripheral joints

• Progressive deformity

• Nonarticular manifestations

Initial Evaluation

• Systematic approach

• Document ROM over time

• AROM, PROM, Deformity

• Wrist: synovitis

• Thumb: CMC, MP, IP

• Digits: MP, PIP, DIP

Nodules

Flail IPs both thumbs

Marked Z collapse

thumb

RA Deformities

Stages

• I Synovitis without deformity

• II Synovitis with passively correctible deformity

• III Fixed deformity without joint changes

• IV Articular destruction

Non-operative Rx

• Rest: • Decreases synovitis

• Exercise:• Decreases stiffness

• Increases tendon motion, strength

• Short frequent exercise best

• Therapist

• Joint protection instruction

Lifestyle modification (anti-inflammatory)

Diet. Fasting followed by plant based

Exercise: 30 minutes per day

Sleep. Regularity and duration

Stress Management / coping technique

Connection and support

Avoid smoking and Alcohol

3/1/2021

70

The disease that can cause deformityOpen with left hand

Close with right hand

Diminish stresses that promote ulnar drift

Assistive device for turning knobs

Pamper the joints• A wheeled cart or island in the kitchen

helps move food from cooktop to tabletop..

• Lever-style faucets or tap turners make turning taps easier.

• Larger handle utensils and pots and pans

Non-operative Rx

• Splinting: wrist and thumb

• Steroid Injections: • CTS

• Tenosynovitis

• Joints not responding to medical Rx

• Only inject area 2 to 3 x per year• Risk of tendon rupture

• Steroid induced arthropathies

Non-operative Rx

• Not all patients will require surgery

• Goals: pain relief, preservation of function• NSAIDs

• resting splints

• local steroid injection

• Disease modifying anti-rheumatic drugs

• Tumor necrosis factor inhibitors

• eg Enbrel, Arava, etc.

3/1/2021

71

Indications

• Deformity alone is not an indication

• Loss of function that can be dramatically changed with surgery

• Pain

• Avoid surgery in:• Healthy, active patients with loss of function (ie. sports)

• Older patients with minimal pain who function well

Medical Considerations

• Cervical spine clearance

• Pulmonary involvement

• Felty’s syndrome (low WBC)

• Steroids and Methotrexate• Affect on wound healing

• NSAIDS• Affect platelet aggregation

Surgical Goals

• Alleviation of pain

• Improvement of function

• Retardation of progression of the disease

• Improvement in appearance

• Motion, dexterity and weakness remain problematic

Surgical Treatment

• Categories• Synovectomy

• Tenosynovectomy

• Tendon surgery

• Arthroplasty

• Arthrodesis

• Goals according to stage of disease• Preventative

• Corrective

• Salvage

Preoperative Planning

• Surgical planning• address painful areas first

• reliable/predictable procedures

• address nerve compression

• Complex deformities• proximal to distal

• staged vs. single stage reconstruction

Synovectomy

• Rarely indicated

• Consider in a patient with:• Smoldering, slowly progressing disease

• Responding to med Rx

• Responds to steroids

• Little radiographic joint destruction

3/1/2021

72

MP Joint Deformity

• Synovitis deforms joint capsule/ ligaments

• Radial sagittal band attenuation

• Flexor/Extensor imbalance

• Influence of wrist deformity

• Intrinsic contractures

Treatment

• Splinting

• Synovectomy

• Soft-tissue reconstruction• requires adequate articular

surfaces

• MP arthrodesis

• MP silicone arthroplasty

MP silicone arthroplasty

• Swanson implant commonly used

• Average 45 deg motion

• Good pain relief

• Good ability to realign joint

• Implant fx < 30% & often asymptomatic

• Infection 1-9%

MP Joint Arthroplasty

• Silicone implants• Gained popularity in the 1970’s

• first designed in 1962

• On long term follow-up high implant fracture rate (30%) and osteolysis.

• 2% failure rate per year

• Newer designs • pre-flexed 15 deg. And volar hinge

• Pyrolytic carbon implants

Therapy

• Post-operative care and rehabilitation

• Early protected motion PIP

• Early immobilization for MP

• MCP dynamic support

• Active and static splinting

• Exercises under the supervision of a hand therapist

• Result of arthroplasty 50% surgery: 50% therapy

Therapy

• Dressings removed 2 days after surgery

• A/AAROM starts POD 3-5

• Therapist• Maintains alignment during motion• 0 to 70 degrees at 2 weeks• Limit IF, MF to 45-60 degrees• Dynamic extension splints w/ digit alignment slings• Resting extension splint at night• Therapy x 3 months

3/1/2021

73

MP Joint ArthroplastyTrail IA et.al, JBJS Br. 2004 Sep. 86(7) 1002-6

17 year survivorship analysis

MP joint silastic replacement

1336 implants

2/3 fracture

63% survivorship

Improved with Soft tissue balancing and wrist realignment

MP Joint Arthroplasty

• Long Term Results (Best study/honest)• Goldfarb & Stern, JBJS 2003

• 36 patients (208 joints) w/ Avg. 14 yr f/u

• Motion improved (30 to 36 deg.)

• Ulnar drift (26 to 16 deg.)

• 63% implants broken

• 38% of patients expressed satisfaction

• 27% pain free

Silicone MCP implants

• Modification of Swanson Design• Bass, Stern, Nairus, JHS 1996

• Sutter silicone MP implants

• Retrospective review

• 42 hands, 168 implants

• 45% fractured if followed >3 yrs

PIP Joints• Swan Neck and Boutonniere

• Motion more important than at DIP joint

• Motion important in the more ulnar digits

• Stability more important in border digits

• Arthrodesis vs. Arthroplasty

General Rules

• Index finger arthrodesis perferred• Lateral stability needs to be maintained for pinch

• PIP arthrodesis preferred in setting of MP arthroplasty, although PIP/MP arthroplasty may give good results when staged

General Rules

• Limited role for arthroplasty in flexion boutonniere deformity

• PIP arthroplasty ok in swan neck if hyperextension deformity corrected (sublimis tenodesis)

• Poor lateral ligamentous support and/or associated flexor tendon ruptures relative indication for fusion.

3/1/2021

74

PIP Arthrodesis

• PIP cascade• 40 deg. Index to 55 deg. Small finger

• Fixation• 90-90 wiring

• Tension band

• Compression screws

• Plate and screws

PIP Arthroplasty

• Traditionally performed w/ Swanson silicone implants

• New pyrocarbon/metal implants gaining popularity for osteoarthritis

• Soft tissue balancing/stability remain difficult in RA

PIP Arthroplasty

• A systemic review of different implants and approaches for PIP joint arthroplasty

• Yamamoto M et. Al Plast Reconstr Surg

• 2017 May; 139(5): 1139e-1151e

• “Silicone implant with volar approach showed the best Active arc of motion with less extension lag and fewer complication”

DIP Joints - Arthrodesis

• Position: 0 to 10 deg flexion

• Relative unimportance of DIP motion

Arthroplasty/ArthrodesisSummary

• DIP/Thumb IP Arthrodesis

• PIP/Thumb MP Arthrodesis/Arthroplasty

• MP Arthroplasty

3/1/2021

75

References

• Feldon, Rheumatoid Arthritis and other connective tissue diseases, in Green’s Operative Hand Surgery, 7th ed. (2017)

• Amadio & Shin, Small joint arthrodesis and arthroplasty , in Green’s Operative Hand surgery, 7th ed. (2017)

• Chung KC, Pushman AG, Current concepts in management of rheumatoid hand. J.Hand Surg. 2011

• Akinson, JH, Chung, KC: “Advances in small joint arthroplasty of the hand” Plast. Reconst. Surg. 2014 dec.134(6): 1260-1268



Boutonniere and Swan Neck Deformities

Brian A. Pinsky, MD

The Long Island Plastic Surgical Group

Anatomy of the extensor mechanism

• Complex system of tendons/ligaments

• Combination of two separate systems

• Extrinsic - radial n. • Intrinsic - median and

ulnar n.

• Coordinates movements btw joints

Anatomy

• Extrinsics function to extend the MCP joint, flex PIP and DIP joints

• Intrinsics flex MCP and extend PIP and DIP

• Pathologic posture is related to imbalance in intrinsic/extrinsic flexor and extensor mechanisms

3/1/2021

76

Boutonniere Deformity

• Definition: Flexed PIP -> hyper-extended DIP -> hyper-extended MCP

• Imbalance between muscle and tendon units across finger joints

• Deformity begins at the PIP, adjacent joint changes are secondary

• Test DIP extension to look @ competence of central slip (Elson’s Test)

Boutonniere Deformity

• Etiology: Dorsal disruption of the extensor mechanism central slip at the PIP

• Laceration (trauma), • Attenuation (RA - synovitis, Dupuytren’s) • Dorsal burn• Attrition • Rupture of the central tendon

Boutonniere

• Lateral bands fall volar to PIP axis; PIP extensor becomes a flexor

• Initially presents w/ PIP flexion

• DIP hyperextension follows in several weeks

Boutonniere DeformityMechanisms

• ACUTE• Traumatic - open vs. closed

• Full active flexion maintained

• Full passive extension

• If PIP passively placed in full extension, can maintain position actively

• CHRONIC• Shortened, scarred lateral bands

• Thickened/shortened oblique retinacular ligament limits active DIP flexion

• Can see secondary joint changes - OA

4 Stages of the Boutonniere

• Dynamic imbalance (muscle and tendon)• Stage I - Mild lag at PIP, min deficit

• Stage II - Mod lag (10-30 deg), Passively correctable PIP

• Static extensor mechanism imbalance• Stage III – Fixed PIP flex contracture

• DIP stiff in extension

• Oblique retinacular ligament tightness

• Fixed joint contractures • Stage IV

• Collateral ligament/volar plate scarring

• Cartilage loss/ arthrosis

Treatment of BoutonniereGoals

• Reduce swelling and pain

• Prevent/minimize PIP flexion contracture

• Prevent lateral band subluxation

• Restore AROM and PROM of MP/PIP/DIP

• Restore hand function

• Patient MUST understand that some degree of extensor lag @ PIP expected even w/ good outcome

3/1/2021

77

Treatment of BoutonniereNon-Surgical

• Most boutonnieres will respond to splinting and therapy

• First-line treatment in closed injury -• Splint 6-8 wks constant extension @ PIP with DIP flxn exercises, 4-6

wks intermittent pm splinting

• The earlier, the better

• Allows central slip to heal

• Most flexible/correctable boutonnieres can be treated non-surgically

Exercise/splinting for the boutonniere

• Key in treatment is full passive ROM at PIP and DIP joints

• PIP Contracture -> Consider dynamic splinting, static-progressive splinting, or serial casting

• Monitor skin integrity

• Expect a small amt of PIP extensor lag and DIP hyperextension even if splinted early, no functional deficit

A multitude of options… Principles of Surgical Treatment

• Differentiate between acute and chronic injury

• Rebalancing of extensor system - divert power from distal joint to prox joint

• Best when joint has full passive mobility• Can be done in 2 stages: 1) release joint

contracture 2) extensor rebalancing

Surgical Principles Continued…

• Done in conjunction with a splinting and exercise program

• If arthritic changes, must combine with arthroplasty or fusion

• Most patients have good function WITH this deformity, careful to not worsen finger function

Surgical TreatmentChronic Boutonniere

• TERMIAL TENDON TENOTOMY• Must have full PROM @ PIP

• Post-op management• DIP extension splintremove for AROM• Splint for 6-8 weeksthen gradual wean

3/1/2021

78

Surgical procedures for boutonniere

• Tendon graft procedures

• Lateral band transfer

• Transfer 1-2 lat bands tocentral slip• Can restrict PIP flexion

Surgical procedures for boutonniere

• Staged Approach • 1) Extensor and transverse ligament tenolysis

• 2) Transverse ligament division• 3) Terminal tenotomy (if mild lag present)• 4) Central slip advancement

Complications after boutonniere surgery

• Recurrent deformity

• Incomplete recovery of flexion after prolonged splinting program and/ or surgery

• Secondary mallet (after terminal tenotomy)

• Surgical results unpredictable

Swan Neck Deformity

• PIPJ is hyperextended and the DIPJ is flexed

• Lack of voluntary DIP extension

• Function loss relative to PIP flexibility

• All swan-neck deformities are NOT the same

Etiology - Variable

1. Disruption of terminal extensor insertion leading to extensor tendon imbalance

2. Disruption or laxity of volar plate, FDS, or retinacular ligament @ PIP resulting in PIP hyperextension and compensatory DIP flexion

3. Intrinsic muscle tightness or spasticity from systemic diseases (RA) or CNS dysfunction

Etiology - Rheumatoid

1. If Mallet –type injury: Ext tendon attrition or rupture @ DIP

2. Synovitis resulting in PIP volar plate laxity or FDS rupture

3. MCP joint subluxation/dislocation causing intrinsic tightness, can decrease PIP ROM in certain positions only

3/1/2021

79

Swan Neck Pathophysiology

• Altered functional dynamics

• If PIP hyperextends, the lateral bands ride dorsally→ decreases distal tendon tension→results in droop of DIP into flexion

• Excess Extensor force @ PIP causes volar plate to stretch over time

• PIP and DIP motion are interdependent, lack or excess motion at one joint will reciprocally affect the other joint

Treatment

• GOAL = PREVENT PIP HYPEREXTENSION

• Treatment depends on the status of the PIP joint

• Important to treat early to avoid PIP stiffness, improves overall function and outcome

• Multiple procedures described

• Deformity tends to be worse at the joint that initiates deformity

Classification

• Type 1 No loss of PIP joint flexion• Tx aimed at preventing or correcting PIP

hyper-extension

• Type 2 Intrinsic Tightness

• Type 3 Limited PIP ROM

• Type 4 PIP arthritis

Non-operative Tx

• Splinting can be definitive depending on patient desires

• DOES NOT USUALLY RESPOND TO A SPLINTING AND EXERCISE PROGRAM

• splinting necessary preop to relieve fixed contractures/ mobilize joint/ relieve intrinsic tightness but volar plate laxity will persist

DIP Arthrodesis

• Use when deformity initiated by mallet injury

• Recommend fusion in neutral position

• Still need to address PIP joint

Flexor tenodesis• Strong internal splint to PIP

hyperextension

• One slip FDS divided proximal to MCP, left in tact distally

• FDS Sutured to itself around A2 pulley

• Suture in 20 deg flexion contracture

• Post-op: Early flexion, extension-block splint for 4-6 wks

3/1/2021

80

Oblique Retinacular Ligament Reconstruction

• Multiple techniques, complicated

• Require passively correctable deformity and preserved joint

• Volar PIP tenodesis - passively pulls the DIP into extension as the PIP actively extends

Type IIIntrinsic Tightness

• PIP flexion limited secondary to MP extension/ radial deviation

• Can be seen in untreated swan-neck or Rheumatoid pt with MP joint pathology

• Correct intrinsic tightness with therapy or surgical release

• Ex: If pathology at MCP => intrinsic release +/- MP arthroplasty, extensor centralization

• Then treat PIP hyperextension

Type IIILimited PIP ROM

• PIP flexion limited in all positions (fixed deformity)

• Usually soft tissue contracture, joint space maintained until late-stage disease

• Passive motion restricted by extensor mechanism, collateral ligaments, skin

• Treatment = Closed manipulation, stretch soft tissue• Can be done at time of MP arthroplasty or

DIP fusion, pin in 90 deg flexion

Type III

• Lateral Band Release – if closed manipulation fails

• Concept – restore PROM, then AROM

• Operation assumes in tact flexor tendon w/o adhesions

Type IVStiff PIP, arthritis

• Arthroplasty vs. arthrodesis

Complications after swan neck surgery

• Stretching/ rupture of tenodesis→ recurrence

• Too tight tenodesis→ excessive PIPJ flexion and potential boutonniere

• Loss of joint flexion

3/1/2021

81

Take home points

• Extensor mechanism is complex

• Deformity at one joint will result in opposite deformity of adjacent joints

• Boutonniere is best treated with splinting and exercise program

• Swan neck can be treated with splinting if pt desires but surgery is only permanent correction

• Reconstruction only possible if deformity is passively correctable!

Lin JS, Samora JB. Surgical and Non-surgical management of Mallet Finger: a Systematic Review. Journal Hand Surg. Vol 43 (2) Nov 2017

Strickland JW, Boyer MI: Swan-neck Deformity.pp.459-470. In Strickland JW (ed): Master Techniques in OrthopaedicSurgery: The Hand. Lippincott-Raven, Philadelphia, 1998

Nalebuff EA,Millender EH: Surgical Treatment of the Swan-neck Deformity in Rheumatoid Arthritis. Ortho Clinic NA, 6(3), 7/75

Souter WA: The problem of Boutonniere Deformity. Clin Ortho 1974; 104

To P, Watson JT: Boutonniere Deformity. J Hand Surg 2011, 36A (1)

References

Grau L et al: Biomechanics of the Acute Boutonniere Deformity. Journal Hand Surg. Vol 43, issue 1. Sept 2017.

Aulicino PL: Extensor Tendon Injuries.pp.149-158. In Light TR (ed): Hand Surgery Update II. AAOS, Rosemont, IL. 1999.

Burton RI, Melchior JA: Extensor Tendons-Late Reconstruction.pp.1988-2021.In Green DA: Operative Hand Surgery, 4th edition. Churchill Livingstone, Philalphia 1999.

Doyle JR: Boutonniere Deformity.pp.539-554. In Strickland JW (ed): Master Techniques in Orthopaedic Surgery: The Hand. Lippincott-Raven, Philadelphia. 1998.

References



Digital Tumors

Roy A. Meals, M.D.

Finger Tumors

• “tumor” = “swelling”• “neoplasm” = “new growth”

• inflammation

• cysts

• chemical deposits

• foreign bodies tumorsinfections

neoplasms

3/1/2021

82

Questions to Ask the Patient

How long present?

How fast came up?

Wax and wane in size?

Recall injury?

Similar findings elsewhere?

Now or previously?

General health problems?

Family history of similar?

Questions to Ask Yourself

Soft, firm, hard?

Hot, tender?

Pulsatile?

Movable on skin, deep structures?

Shape: spherical, spindle, flat, irregular?

Follow path of nerve? tendon? blood vessel?

Overlying skin changes? redness? ulcer?

Localized or diffuse?

Soft tissue or bone?

Classification of Finger Tumors

• Neoplasm• Soft tissue

• Benign

• Malignant

• Bony• Benign

• Malignant

• Inflammation • Infectious

• Traumatic

• Acellular • Cysts

• Deposits

• Foreign bodies

Neoplasm

or

Inflammation

or

Acellular?

Soft tissue

or

Bony?

Localized

or

Systemic?

Benign

or

Malignant?

Choose 1 characteristic

from each column

Neoplasm, soft tissue, benign, localized

Now ask, which tissue?

• synovium/tenosynovium

• skin

• nerve

• blood vessel

• connective tissue

• fat

Neoplasm, soft tissue, benign, localized

• synovium/tenosynovium• giant cell tumor of tendon sheath

• skin: wart, keratoacanthoma, many others

• nerve: nerilemmoma (Schwann cell tumor)

• blood vessel• arteriovenous malformation• glomus tumor• pyogenic granuloma

• connective tissue: Dupuytren’s

• fat: lipoma

3/1/2021

83

Neoplasm, soft tissue, benign, localized: TENOSYNOVIUM

giant cell tumor of tendon sheath

most common neoplasm in the hand

firm, lobulated, near tendon

Neoplasm, soft tissue, benign, localized: SKIN

wart, keratoacanthoma, many others

Neoplasm, soft tissue, benign, localized: NERVE

nerilemmoma (Schwann cell tumor)spindle-shaped swelling in digital nervemoves more side to side than proximal to distal

Neoplasm, soft tissue, benign, localized: BLOOD VESSEL

1. arteriovenous malformation: nest of vessels2. glomus tumor: overgrown A-V shunt3. pyogenic granuloma: reaction to injury

1

1 2

3

Neoplasm, soft tissue, benign, localized: CONNECTIVE TISSUE

• Dupuytren’s• rare in digit without affecting palm

Neoplasm, soft tissue, benign, systemic

Now ask, which tissue?

• connective tissue

• blood vessel

• nerve• neurofibomas—rare in fingers

• synovium/tenosynovium

3/1/2021

84

Neoplasm, soft tissue, benign, systemic: CONNECTIVE TISSUE

• Dupuytrens: palms, feet, knuckles, penis

• rheumatoid nodules: fingertips and elbow

Neoplasm, soft tissue, benign, systemic: BLOOD VESSEL

• arteriovenous malformations• diffuse; intravascular calcifications

Neoplasm, soft tissue, benign, systemic: SYNOVIUM

• rheumatoid synovitis

• rheumatoid tenosynovitis

Neoplasm, soft tissue, MALIGNANT, LOCALIZED

1 squamous cell carcinoma

2 malignant melanoma

(differentiate from subungual hematoma 3)

1 3 2

Neoplasm, soft tissue, MALIGNANT, SYSTEMIC:• metastatic

• lung; any tissue possible

• finger pulp location can be first indication of disease

Neoplasm, bony, benign, localized

• enchondroma• metaphyseal, expand but doesn’t destroy cortex, calcific stippling

interiorly, often identified because of pathologic fracture

•

3/1/2021

85

Neoplasm, bony, benign, systemic

• enchondromas• multiple: Ollier’s disease

• multiple w/ hemangiomas: Mafucci’s syndrome

• considerable risk of malignant degeneration

Neoplasm, bony, benign, systemic

• osteoarthritis (bone spurs)• DIP joints (Heberden’s nodes) very common

• PIP joints (Bouchard’s notes) less common

Neoplasm, bony, aggressive

• giant cell tumor of bone• high local recurrence rate, esp. in hand

• can metastasize

• treat aggressively• wide, local excision

• amputation

Neoplasm, bony, malignant

• localized • osteosarcoma

• chondrosarcoma

• systemic• multiple myeloma

Inflammation

infection, soft tissueparonychia

felontenosynovitis

infection, boneosteomyelitis

common bacterialtuberculosis

syphilis

Inflammation

• trauma • sprain

• acute

• chronic

3/1/2021

86

Acellular: cysts• ganglion and mucous cysts

• volar midline at proximal flexion crease

• at dip joint off dorsal midline

• other locations--transilluminate

Acellular: cysts

• inclusion cysts• epithelium gets pushed inside, keeps producing keratin

• hard; usually on contact surfaces

• do not transilluminate

Acellular: Chemical Deposits

Calcium: tendon, artery, soft tissue (lupus)

Acellular: Chemical Deposits

• uric acid (gout) • gouty deposits called tophus/tophi

• joint erosions, especially DIP joints

Acellular: Foreign Bodies Estimated Relative Occurrences

• soft tissue• ganglions and mucous cysts 800• giant cell tumors of tendon sheath 30• all other benign, including infections 150• malignant 5

• bone• enchondroma 10• other benign 5• malignant <<1

• total 1000

3/1/2021

87

Reading

Nepal Pet al: Common Soft Tissue Tumors Involving the Hand with Histopathological Correlation. J Clin Imaging Sci. 2019; 9: 15.

Henderson M et al: Hand Tumors I. Skin and Soft-Tissue Tumors of the Hand. Plas Recon Surg 2014; 133(2): 154e-164e

Schultz R and Kearns R: Tumors in the hand. J Hand Surg 1983, 8:803

Johnson J et al: Tumorous lesions of the hand. J Hand Surg 1985, 10A:384

Binu P et al: Malignant tumours of the hand and wrist. Indian J Plast Surg. 2011 May-Aug; 44(2): 337–347.



The Finger Joints

Review the talks as you wish

Zoom with us on 2nd Saturday each month 8:00 – 8:45 am, free-ranging QA session

When ready to complete the course:At the bottom of the “Course” page, click onLessons: DD The Finger Joints, On-Line: Evaluation -> Quiz -> Certificate

Passing score on the quiz is 70%

Questions? [email protected]

Featured Pandemic-Proof Learning Opportunities

• BONES, Inside and Out

• Doctors Demystify Current Science• Video lectures• Model making

• Brachial plexus• Flexor tendon system• Collagen cross-linking

• Self-assessment quizzes • Zoom Q/A sessions

Books

•The Hand Owner’s Manual 10 CE hours

•100 Orthopedic Conditions 8 CE hours

Clinical Conditions (narrated PowerPoint presentations)

•Tendons and Muscles for OTs and PTs 4 CE hours

•Upper Extremity Nerves for OTs and PTs 6 CE hours

•The Aging Boomers, Implications for OTs and PTs 4 CE hours

•Wound Care 4 CE hours

•Conditions Affecting Cartilage/Ligament/Fascia 4 CE hours

•Brachial Plexus 2 CE hours

•Bracing Innovation 1.5 CE hours

•Dupuytren Disease 3 CE hours

•Tenodesis 2 CE hours

•Thumb Basal Joint Arthritis 2 CE hours

Clinical Conditions (PowerPoint slides to read)

•Elbow 3 CE hours

•Finger Joints 3 CE hours

•Muscles and Tendons 3 CE hours

•Shoulder 3 CE hours

•Thumb 3 CE hours

•Upper Extremity Nerves 3 CE hours

•Whys &Hows of Hand Surgery 3 CE hrs

•Wrist 3 CE hours

Anatomy (Narrated PowerPoint presentations)

•Forearm and Hand Anatomy 2 CE hours

•Shoulder and Elbow Anatomy 2 CE hours

•Hip, Thigh, and Knee Anatomy 2 CE hours

Surgeons providing excellence in education for OTs and PTs since 1990

We guarantee your satisfaction or you get your money back


https://journals.lww.com/plasreconsurg/toc/2014/02000


https://www.doctorsdemystify.com/lesson/dd-the-finger-joints-on-line-evaluation-quiz-certificate/

mailto:[email protected]

http://www.doctorsdemystify.com/course/the-hand-owners-manual/

http://www.doctorsdemystify.com/course/the-hand-owners-manual/

http://www.doctorsdemystify.com/course/100-orthopedic-conditions/

https://www.doctorsdemystify.com/live-courses/doctors-demystify-tendons-and-muscles-self-study/

https://www.doctorsdemystify.com/live-courses/doctors-demystify-upper-extremity-nerves-on-line-2/

http://www.doctorsdemystify.com/live-courses/doctors-demystify-the-aging-boomers-on-line/

http://www.doctorsdemystify.com/live-courses/doctors-demystify-wound-care-on-line/

http://www.doctorsdemystify.com/course/doctors-demystify-cartilage-ligaments-fascia-on-line/

http://www.doctorsdemystify.com/course/doctors-demystify-the-brachial-plexus/

http://www.doctorsdemystify.com/course/doctors-demystify-bracing-innovation/

http://www.doctorsdemystify.com/course/doctors-demystify-dupuytren-disease/

http://www.doctorsdemystify.com/course/doctors-demystify-tenodesis/

http://www.doctorsdemystify.com/course/doctors-demystify-thumb-basal-joint-arthritis/

http://www.doctorsdemystify.com/course/dd-the-elbow-on-posters/

http://www.doctorsdemystify.com/course/dd-the-finger-joints/

http://www.doctorsdemystify.com/course/dd-muscles-and-tendons-on-posters/

http://www.doctorsdemystify.com/course/dd-the-shoulder-on-posters/

http://www.doctorsdemystify.com/course/dd-the-thumb-on-posters/

http://www.doctorsdemystify.com/course/dd-upper-extremity-nerves-on-posters/

http://www.doctorsdemystify.com/course/dd-the-whys-and-hows-of-hand-surgery/

http://www.doctorsdemystify.com/course/dd-self-study-course/

http://www.doctorsdemystify.com/course/doctors-demystify-forearm-and-hand-anatomy/

http://www.doctorsdemystify.com/course/doctors-demystify-shoulder-and-arm/

http://www.doctorsdemystify.com/course/doctors-demystify-hip-thigh-and-knee-anatomy/

powerpoint presentation · 2021. 3. 1. · napier jr. the prehensile movements of the human hand. j...

Documents