Hand and Wrist Surgery - part 4 pptx

Zelouf History and Clinical Presentation A 51 year-old right hand dominant construction supervisor presented with a 2- to3-year history of a progressive right ring finger contracture.. D

Host factors also influence the prognosis of extravasation injuries Advanced age,immune compromise, nutritional deficits, steroid dependency, and preexisting pe-ripheral vascular disease are all common host factors that can greatly amplify thedamage caused by any given extravasation event.

Remember that the mainstay of conservative management is elevation, use of acool compress, and a loosely wrapped splint to protect and rest the injured part Al-though it may seem obvious, make sure that the offending intravenous catheter isremoved so that no more agent can extravasate, and make sure that the affected ex-tremity is not further compromised by tight circumferential items such as jewelry,hospital identification bracelets, or tight bandages Application of heat to the af-fected area often makes the local swelling much worse and should be avoided Markthe affected area of the limb with an ink marker so that improvement or worseningcan be easily noted as time passes Save whatever intravenous equipment and drugbags are present initially so that the offending agent and circumstances of extravasa-tion can be clearly and thoughtfully assessed Injection of antidote material into theaffected area may be occasionally indicated for specific cases (i.e., hydrofluoric acid

or powerful vasoconstrictor extravasations), but in most cases such injectionsshould be avoided because they will only increase local tissue pressures, increase thelikelihood of tissue death or vascular compromise, and inconsistently reach the of-fending agent

Surgical intervention is an immediate requirement if compartment syndrome orcompromise of a major vessel is present Surgical drainage and decompression of anextravasation injury is also helpful if large volumes of agent are involved, or if theoffending agent is a vesicant and the necrosis interval has not yet expired Once thisinterval has passed, surgical intervention may be better delayed until clear demar-cation of dead tissue has occurred After thorough debridement of dead tissue, flapcoverage or other complex reconstructive procedures may be warranted based onthe size of the remaining soft tissue defect

Nonsurgical Management

This patient presented with a severe, acute left forearm compartment syndrome.All circumferential appliances and intravenous lines were removed from the affectedextremity, including the blood pressure cuff, hospital identification bracelet, and20-gauge angiocatheter This situation represented a surgical emergency, and allother immediate care required operative intervention

Surgical Management

The patient was taken to the operating room immediately for emergency ciotomies A dorsal, longitudinal incision was made from the lateral epicondyle tothe mid-carpus, and the dorsal forearm fascia was completely released A palmarincision was then performed, from the antecubital region to the mid-palm in thehand The lacertus fibrosus was released, as well as the entire volar forearm fascia.The deep volar compartment was also explored and the fascia overlying the deepvolar muscle layer was released Distally, a carpal tunnel release was also performed(Figs 26–4 and 26–5)

fas-Upon release of these compartments, ~250 cc of clear fluid was drained from thewounds Laboratory analysis of this fluid suggested it was a mixture of plasma and

Analysis of Case

In the case history presented, the patient suffered a major extravasation injury fromelectrolyte solution intended to replace lost volume from bleeding Several factorsmade this extravasation injury particularly severe First, the patient had epinephrineinfused with the electrolyte solution, which as an extravasant acted as a local vaso-constrictor and greatly worsened local ischemia Second, because the patient wasobtunded, recognition of the injury was significantly delayed and the patient de-veloped a compartment syndrome, probably due both to the amount of fluid ex-travasated as well as to the vasoconstrictive nature of the agent Third, the presence

of constrictive devices around the extremity also contributed in some fashion tothe severity of injury Not only did the patient have a hospital identification bandwrapped tightly around her wrist, the frequent blood pressures that were taken with

an automatic cuff situated at the upper left arm may also have restricted venous flow and added to congestion in the extremity It is also noteworthy that an infusionpump was used, which can produce dramatic extravasation effects by forcing fluidinto the extremity All of these factors can add up and produce a more severe injurythan would have otherwise occurred with intravenous fluid extravasation

out-This case also illustrates that the presence of peripheral pulses does not exclude acompartment syndrome or suggest that severe local soft tissue injury is not present.Furthermore, although it may seem obvious, the infusion should be turned off andthe intravenous catheter removed immediately once a potential extravasation prob-lem has been identified Of note in this case presentation is that the patient may havereceived a significant additional amount of electrolyte and epinephrine solution for

Figure 26–5 The dorsal surface of the left forearm immediately following fasciotomy.

some period of time after abnormality first presented in the left forearm because noone bothered to turn off the intravenous line and move it to another location.

Suggested Readings

Benson LS, Sathy MJ, Port RB Forearm compartment syndrome due to automated

injection of computed tomography contrast material J Orthop Trauma 1996;10:

433–436

Bowers DG, Lynch JB Adriamycin extravasation Plast Reconstr Surg 1978;61:

86–92

Brown AS, Hoelzer DJ, Piercy SA Skin necrosis from extravasation of intravenous

fluids in children Plast Reconstr Surg 1979;64:145–150.

Gault DT Extravasation injuries Br J Plast Surg 1993;46:91–96.

Larson DL What is the appropriate management of tissue extravasation by

anti-tumor agents? Plast Reconstr Surg 1985;75:397–402.

Linder RM, Upton J, Osteen R Management of extensive doxorubicin

hydro-chloride extravasation injuries J Hand Surg 1983;8:32–38.

Loth TS, Eversmann WW Extravasation injuries in the upper extremity Clin Orthop

1991;272:248–254

Loth TS, Eversmann WW Treatment methods for extravasations of

chemothera-peutic agents: a comparative study J Hand Surg 1986;11A:388–396.

Loth TS, Jones DEC Extravasations of radiographic contrast material in the upper

extremity J Hand Surg 1998;13A:407–410.

Luedke DW, Kennedy PS, Rietschel RL Histopathogenesis of skin and

subcuta-neous injury induced by Adriamycin Plast Reconstr Surg 1979;63:463–465.

Mabee JR, Bostwick TL, Burke MK Iatrogenic compartment syndrome from

hyper-tonic saline injection in Bier block J Emerg Med 1993;12:473–476.

Scuderi N, Onesti MG Antitumor agents: extravasation, management, and surgical

treatment Ann Plast Surg 1994;32:39–44.

Seyfer AE Injection and extravasation injuries In: Hand Surgery Update

Rose-mont, IL: American Academy of Orthopaedic Surgeons; 1996:405–411

Seyfer AE Upper extremity injuries due to medications J Hand Surg 1987;12A:

Section VI

Contractures

Jack Abboudi and David S Zelouf

Stiff Joints

Shelly M Sailer

PEARLS

• The tabletop test is positive

when the patient cannot

place his or her open hand

flap onto a table surface due

to flexion contractures This

finding may prompt

considera-tion for surgical treatment

• Counsel patients with early

dis-ease as to your indications for

operative treatment This may

help the patient seek

reevalu-ation at an appropriate point

for surgery before severe

con-tractures form

• MP contracture correction

tends to produce more

satisfy-ing results than PIP correction

• Cleland’s ligaments, the deep

transverse metacarpal

liga-ment, and the flexor tendon

sheath are not involved in the

disease

PITFALLS

• Procedures performed by

“limited exposure” still require

adequate visualization of the

neurovascular structures that

may be displaced from their

normal location

• Neurovascular structures may

be displaced superficially and

toward the midline of the digit

by the spiral cord and should

not be assumed to be in their

anatomic position Generally,

tracing the neurovascular

structures is easier in a

proxi-mal to distal direction starting

just distal to the transverse

carpal ligament

• Neurovascular structures are

displaced more toward the

midline and more superficial

with increasing PIP contracture

27

Dupuytren’s Contracture Jack Abboudi and David S Zelouf

History and Clinical Presentation

A 51 year-old right hand dominant construction supervisor presented with a 2- to3-year history of a progressive right ring finger contracture He denies a history oftrauma He is of Scottish descent, and his father has undergone bilateral Dupuytren’scontracture releases The patient denies a history of diabetes or other medical ill-nesses, and he is taking no medications

Physical Examination

A prominent cord is noted in the palm in line with the ring finger extending to thelevel of the proximal interphalangeal (PIP) flexion crease There was a prominentnodule present over the palmar aspect of the proximal phalanx, with a 60-degreemetacarpophalangeal (MP) contracture and a 10-degree PIP contracture (Fig 27–1).The left hand exhibited early palmar disease with no contracture No knuckle padswere noted, and there was no involvement of the plantar surfaces of the feet

Radiographic Findings

Plain x-rays of the right hand were unremarkable

Differential Diagnosis

Dupuytren’s contractureJoint flexion contractureScar contracture

Flexor tendon bowstringTendon adhesionsTumor (i.e., fibrosarcoma)

Figure 27–1 Preoperative clinical photo.

Dupuytren’s Contracture

Dupuytren’s disease has been attributed to genetic lines of Viking heritage andnorthern European lineage with an autosomal-dominant pattern of inheritance.The condition presents most frequently in males and after the age of 40 Clinicalfeatures include painless palmar pitting, cords, and nodules frequently in line withthe small and ring finger Many structures, described as “ligaments” and “bands” intheir normal state, are referred to as “cords” in the diseased state (Fig 27–2) Thespiral cord is a continuum of the diseased spiral band, lateral digital sheet, andGrayson’s ligament The spiral cord is pulled to the midline with contracture, caus-ing the neurovascular bundle to wrap around the straightening and tightening cord.The natatory cord can be palpated in the web space, and its contracture deviates thedigit from the midline at the MP joint See the suggested readings, later, for morecomprehensive descriptions of the pathoanatomy Disease progression generallyleads to characteristic flexion deformities of the MP and the PIP joint Associatedfindings include dorsal knuckle pads (Garrod’s nodules), thickening of plantar tis-sue in the foot (Lederhose’s disease), and penile fascia (Peyronie’s disease)

Indications for surgical correction of Dupuytren’s contracture depend greatly onthe impact of the deformity on the patient’s ability to perform activities of daily liv-ing and the ability and willingness of the patient to participate in the postoperativerehabilitation Hard-and-fast, objective surgical indications are difficult to define.The “tabletop test” provides the earliest sign of significant flexion contracture, al-though this test alone is not always an indication for surgery The test is positivewhen the patient cannot fully flatten his or her hand against a table surface Gener-ally, flexion deformities of the MP joints are better tolerated by the patient and arerelatively easier to correct, as MP flexion is a relatively “safe” position that maintains

Figure 27–2 Anatomy of normal (A) and contractured (B) digits.

collateral ligament length On the other hand, PIP deformities interfere more withhand function and are more difficult to correct, as PIP flexion is a relatively “unsafe”position that allows for volar plate contracture Therefore, PIP flexion deformitiesare stronger indications for surgery at earlier stages than are MP deformities

At the microscopic level, Dupuytren tissue demonstrates an abundance of normalfibroblastic and myofibroblastic cells The local abundance of these cells explainssome of the other molecular findings attributed to Dupuytren tissue such as in-creased amount of type III collagen The fibroblastic and myofibroblastic prolifera-tion has been localized around occluded microvessels, and seems to be a cellularresponse to local tissue ischemia This may explain the association of Dupuytren’scontracture with conditions that predispose to tissue ischemia, such as alcohol use,smoking, and age

The myofibroblasts share cellular characteristics between fibroblasts and smoothmuscle cells and are concentrated within the palmar nodules The contractile ele-ments of this cell type produce a progressive pull through the Dupuytren cordsthat leads to the characteristic flexion deformity Residual myofibroblasts withinthe dermis and epidermis after surgical excision of diseased tissue have been impli-cated in the recurrence of the contracture This notion is supported by the lowerrecurrence rate seen with palmar skin excision and full-thickness skin grafting afterfasciectomy

Surgical Management

The patient was treated with a subtotal palmar and digital fasciectomy He wasbrought to the operating room where, under axillary anesthesia, Brunner incisionswere utilized to expose the pretendinous cord (Fig 27–3) An early spiral cord wasencountered at the level of the PIP joint After both neurovascular bundles wereidentified and protected, the involved palmar fascia was excised and sent to thepathology laboratory for gross and histologic analysis At the conclusion of the pro-cedure, complete correction was obtained at both the MP and PIP joints Thetourniquet was deflated prior to closure, and brisk capillary refill was noted imme-diately The wounds were closed with interrupted 5–0 nylon sutures, and a shortarm plaster splint was placed, immobilizing the MP joints in 30 degrees of flexion,with the PIP joints comfortably extended

Figure 27–3 tive photo demonstrating pretendinous cord.

Intraopera-Postoperative Management

A follow-up examination was done on the third postoperative day, at which timethe patient’s dressing was removed Inspection revealed minimal swelling, with well-vascularized flaps A light dressing was applied and occupational therapy was insti-tuted with a certified hand therapist, consisting of active, active assisted, and passiverange-of-motion exercises A resting night splint was fashioned with the ring finger

in full extension, to be worn for 3 months A follow-up visit at 3 months revealed anexcellent early result, with full correction, and full flexion (Fig 27–4)

Alternative Methods of Management

There are no proven nonoperative modalities that can reverse or even halt the opment of cords, nodules, and contractures A significant number of patients developprogression of their flexion contractures and involvement of other digits, although therisk and the rate of progression are variable and difficult to predict There are reports

devel-of rare cases devel-of disease regression Therefore, the unpredictable natural history devel-of thisdisease may present a sense of “efficacy” to some patients who try nonoperativemodalities, and they should at least be counseled accordingly The future may holdpromise for the treatment of Dupuytren’s contracture with collagenase injections intothe diseased cords, and such protocols are currently under investigational study.Historically, radical palmar fasciectomy was performed as an attempt to rid thepatient of all diseased tissue However, recurrences were still noted, and this proce-dure has fallen out of favor due to associated wound complications and patientmorbidity

Segmental fasciectomy has been described as a method of correcting the flexioncontracture with segmental excision of diseased tissue through multiple incisions.Full-thickness skin grafting at these multiple incisions can theoretically prevent recur-rence at those sites and provide “fire breaks” against full-length cord recurrence Skingrafting techniques can also be done in conjunction with standard partial fasciectomy.Fasciotomy can be performed through a limited exposure to release the cords andprovide correction of the contracture This procedure does not attempt removal ofdiseased tissue; however, it does provide a method for contracture correction in thedebilitated patient

Figure 27–4 Three-month clinical follow-up demonstrating full extension (A) and flexion (B).

Severe or recalcitrant deformities can ultimately be treated with amputation orray resection In such cases, all involved palmar skin should be excised and free skingrafting or dorsal skin should be used for flap closure if needed Corrective os-teotomies that change the arc of motion to a more functional zone and joint fusionshave been utilized in problem cases as well

Correction of the contracture changes the lay of the palmar skin and may presentareas not amenable to direct closure of the original incision lines Different incisionsand techniques related to wound closure have been described, and the surgeonshould be familiar with each one and understand how to utilize them as the needarises

Generally, a standard Brunner zigzag incision is used for less severe contractures,and can be closed in V-Y fashion for added coverage The transverse limb of theV-Y closure can be left open to relieve skin tension In more severe contractures, astraight incision in line with the ray of the digit can be divided into multipleZ-plasty angles to provide exposure and to increase palmar skin length at closure.Ultimately, the finger can be flexed to gain direct closure, and small parts of the in-cision over the finger can be left to granulate, provided there is no direct exposure ofbone, tendon, or neurovascular structures

There is extensive literature about an “open palm” technique that leaves the mar part of the incision open to gain length After surgery, the wound is cared forwith daily dressing changes and closes via wound contracture over 3 to 5 weeks.Some have used the “open palm” technique routinely, and report a lower complica-tion rate and better motion with this technique

pal-Complications

Although most of the complications related to Dupuytren’s contractures are related

to the surgical treatment of the disease, prolonged nonsurgical treatment of thiscondition can allow for severe contracture formation that makes salvage of the digitdifficult if not impossible Surgical complications of Dupuytren’s contracture fa-sciectomy are numerous, and many can be avoided or minimized with meticuloussurgical technique

Vascular compromise of the digit is an immediate concern at the time of surgery.

Meticulous technique and fine dissection of the neurovascular bundles preventiatrogenic injury to those structures Once the fasciectomy is complete, the tourni-quet should be deflated Vascular refill of the operated digits may lag behind theother digits, but should be normal within a few minutes If, after observation, thefinger is still blanched, flexion of the digit relieves tension from the neurovascularbundles that may have shortened with longstanding Dupuytren’s contracture Insuch a situation, the digits need not be splinted in extension, as MP and PIP exten-sion can be addressed with gradual postoperative therapy Vasospasm may compro-mise vascular flow and can be alleviated by bathing the vessels with warm salinesolution or with plain lidocaine

Hematoma formation can be minimized with meticulous hemostasis once the

tourniquet is deflated after fasciectomy Penrose drains can be placed as wick-typedrains at multiple points along the closure Some have advocated use of suctiondrainage that can be removed in the recovery room prior to discharge or at an earlypostoperative visit The “open palm” technique provides a large surface for drainage,and hematoma formation is minimized with this technique

Skin sloughing is a concern due to the multiple thin flaps developed during the

exposure When designing the initial incision, the surgeon should survey the raphy of the palmar skin for any particularly adherent areas The dissection of theseareas generally renders the skin particularly thin, and should not be planned at thebase of the flaps where they may compromise the vascular supply of the whole flap.Rather, the incision should be planned through these troublesome spots

topog-Loss of flexion can occur after Dupuytren’s contracture release, and can

signifi-cantly restrict maximal grip strength, especially when involving the ring and smallfingers Preoperatively, virtually all patients with Dupuytren’s contractures have fullflexion of the involved digits, barring any other underlying pathology Postopera-tively, the surgeon and patient are both quite focused on restoration of extensionand should also be vigilant regarding maintenance of flexion

Recurrence of disease and extension of the disease to other digits are common after

primary surgical treatment of Dupuytren’s contractures, and patients should becounseled about this preoperatively These patients tend to present at a younger agewith multiple digit and bilateral hand involvement Surgical treatment of this sub-group is plagued with technical difficulties, higher recurrence rates, and prolongedpostoperative recovery

Reflex sympathetic dystrophy has been reported in less than 10% of patients and

re-quires prompt diagnosis and treatment

Boyer MI, Gelberman RH Complications of the operative treatment of Dupuytren’s

disease Hand Clin 1999;15:161–166.

Burge P Genetics of Dupuytren’s disease Hand Clin 1999;15:63–71.

Crowley B, Tonkin MA The proximal interphalangeal joint in Dupuytren’s disease

Hand Clin 1999;15:137–147.

Elliot D The early history of Dupuytren’s disease Hand Clin 1999;15:1–19.

Hurst LC Dupuytren’s fasciectomy: zig-zag plasty technique In: Blair WF, ed

Techniques in Hand Surgery Baltimore: Williams & Wilkins; 1996:519–532.

Hurst LC, Badalamente MA Nonoperative treatment of Dupuytren’s disease

Hand Clin 1999;15:97–107.

Jabaley ME Surgical treatment of Dupuytren’s disease Hand Clin 1999;15:109–126 Lubahn JD Dupuytren’s fasciectomy: open palm technique In: Blair WF, ed Tech-

niques in Hand Surgery Baltimore: Williams & Wilkins; 1996:508–518.

Lubahn JD Open-palm technique and soft-tissue coverage in Dupuytren’s disease

Hand Clin 1999;15:127–136.

Mullins PA Postsurgical rehabilitation of Dupuytren’s disease Hand Clin 1999;15:

167–174

Ross DC Epidemiology of Dupuytren’s disease Hand Clin 1999;15:53–62.

Tomasek JJ, Vaughan MB, Haaksma CJ Cellular structure and biology of Dupuytren’s

disease Hand Clin 1999;15:21–34.

Tubiana R Dupuytren’s disease of the radial side of the hand Hand Clin 1999;

15:149–159

Yi IS, Johnson G, Moneim MS Etiology of Dupuytren’s disease Hand Clin 1999;

15:43–51

• Static-progressive and serial

static splinting are very useful

for resolving contractures with

a “hard” end feel

• Dynamic splinting is most

use-ful in resolving contractures

with a “soft” end feel.

PITFALLS

• Dynamic splinting forces are

difficult to control, leading to

poor splint compliance

• Dynamic splinting can cause

inflammation of tissues when

tension is placed too high

• Static splints do not allow for

active motion while splinted,

possibly contributing to tendon

adhesions

Figure 28–1 Anteroposterior (AP) view of the initial injury demonstrates complete amputations of the index and small fingers and near amputa- tions of the long and ring fingers.

28

Stiff Joints Shelly M Sailer

History and Clinical Presentation

A 44-year-old right hand dominant cabinet maker presented to the emergencyroom after accidentally cutting the fingers of his right hand with a table saw

Physical Examination

The patient completely amputated his index finger through the middle phalanx justdistal to the proximal interphalangeal (PIP) joint and his small finger through the prox-imal phalanx The long and ring fingers were lacerated from the volar aspect throughthe flexor tendons and distal aspect of the proximal phalanges, but were held on by dor-sal skin bridges They were both avascular and insensate The amputated portions ofthe index and small fingers were retrieved, but they were severely mangled and notamenable to replantation He was taken to the operating room for immediate surgicalmanagement

Diagnostic Studies

Initial radiographs revealed traumatic amputation of the index finger through themiddle phalanx, ring finger at the proximal phalanx, and small finger at the proxi-

anatomi-Radiographs taken 8 weeks postoperatively demonstrate union of the ring fingerfracture and complete closure of the unicortical defect of the middle finger.

Figure 28–3 Postoperative C-arm image demonstrates fixation of the ring finger fracture.

Figure 28–4 A langeal (MP) blocking splint used

metacarpopha-to facilitate active motion at the interphalangeal joints.

Surgical Management

The ring finger proximal phalanx level amputation was stabilized with two inch crossed K-wires placed across the fracture site Distally the pins extendedthrough the PIP joint to provide better fixation of the short remaining distal frag-ment of the proximal phalanx Despite near amputation, the long finger proximalphalanx fracture was found to be stable and did not require fixation On both thering and long fingers, the flexor digitorum profundus (FDP) tendons were repairedand the flexor digitorum superficialis (FDS) tendons were tenodesed to the FDPtendons The radial and ulnar digital arteries and nerves were repaired The extensormechanism was intact in both long and ring fingers Revision amputations of theindex and small fingers were performed

0.045-A second surgery was ultimately required to regain full active range of motion.Five months after the initial injury this patient underwent a flexor tenolysis to themiddle and ring fingers after passive range of motion was restored and the scars weresoft and mature

pro-6 weeks postoperatively

This case was complicated by the development of cellulitis in the ring ger 8 weeks postoperatively, which necessitated removal of the two percutaneousK-wires, and a short course of IV antibiotics followed by oral antibiotics After theK-wires were removed, it was determined that the proximal phalanx fractures werestable enough to tolerate motion at the interphalangeal joints of the long and ringfingers It was at this time that the severely stiff interphalangeal joints, the intrinsictightness, and the lack of active flexor tendon function were brought to the fore-front as a therapy challenge

fin-Only 10 degrees of passive motion at the PIP joints was achieved on the firstday of mobilization and was slow to improve with range-of-motion exercises

Figure 28–5 A progressive finger flexion splint used to impart low- load, long duration stress to lengthen shortened tissues.

static-alone There was no active PIP or distal interphalangeal (DIP) flexion as thepatient was now consistently contracting the lumbricals, which flexed the MPjoints and extended the PIP joints He could not isolate use of the FDS andFDP muscles as he had not used them functionally for weeks and they wereadherent at the digit level An MP blocking splint, which facilitated flexion atthe PIP joints, was fabricated to retrain use of the long flexors (Fig 28–4) Abiofeedback unit was used to assist in training the patient to contract the longflexors and relax the lumbricals Even though the patient had very little activemotion, due to adhesions on the long flexors, it was important to maintain mus-cle strength and preserve independent function in preparation for a flexor tenol-ysis when appropriate

A static-progressive finger flexion splint was fabricated for the long and ringfingers (Fig 28–5) Wearing time was increased slowly, monitoring for any exten-sion lag After 2 weeks, the patient had gained 30 degrees of PIP flexion, and hadmaintained full PIP extension Wearing time was then increased to overnight (up

to 8 hours) and range of motion steadily improved

By 4 months postinjury, the patient had nearly full passive PIP and DIP flexion,but only 30 degrees of active PIP flexion and 0 degrees at the DIP joints A flexortenolysis was required at 5 months postoperatively to restore active flexion Imme-diate active motion was performed, and as postoperative edema decreased and thewounds healed, he was able to actively flex the middle and ring fingers to touch thepalm (Fig 28–6) This amount of flexion was adequate to grasp most objects foractivities of daily living and tools for work

Figure 28–6 Final outcome demonstrating excellent com- posite flexion of fingers.

Figure 28–7 progressive splinting is also used on larger joints such as the wrist.

Static-He returned slowly to his job as a cabinet maker after a course of strengtheningand reconditioning Some of his tool handles were adapted for improved grasp andcustom gloves were required to accommodate the amputated digits

Diagnosis

Passive range-of-motion loss is the result of trauma and subsequent immobilization.Adaptive shortening of tissues and scar formation are the main sources of loss ofjoint flexibility and stiffness All of these concepts apply in this case of near amputa-tion with fractures and tendon lacerations Besides exercises and stretching, severalsplinting techniques are available to provide prolonged stretch of shortened tissues.Splinting maintains the tissue elongation gained during therapy, home exercise pro-grams, and functional use of the hand Brand theorizes that the application of me-chanical stress via splinting signals contracted tissue to “grow” or add cells while thebody absorbs redundant tissue

Personal clinical experience and several studies have supported the use of low-loadprolonged stress to apply load and stress to achieve permanent length changes in tissue,thereby increasing passive range of motion Static-progressive splinting employs staticpositioning of a joint at the end range, at low tension for periods of time adequate to en-act lengthening or growth of shortened tissues (Figs 28–5 and 28–7) Because the com-ponents used in static-progressive tension lack the elasticity of those used in dynamicsplinting, the appropriately set tension of the splint does not continue to stress the tis-sue beyond its current maximum length limit It is well tolerated over long periods oftime–overnight, for example It is especially important with revascularized digits thattension be applied in a controlled fashion so as not to compromise blood flow With thesplint components used in this case, tension could be altered for comfort and vascu-lar status, in minute degrees via the MERIT static-progressive component (UE TECH,Edwards, CO) A comfortable, well-tolerated splint with patient-controlled tension istypically able to produce the necessary elongation of adaptively shortened tissues,thereby regaining passive range of motion lost via trauma, immobilization, and scarring

Alternative Methods of Management

There are alternatives to the splinting program used to overcome stiff PIP joints.Table 28–1 describes the specific features of each and the advantages and disadvan-

Table 28–1 Alternative Methods of Management Type of Management Advantages Disadvantages

Dynamic splinting: uses self-adjusting

resilient components such as rubber

bands, springs or elastic line to create

the mobilizing force

Exerts tension upon one or more joints

moving into ever increasing passive

range of motion

Useful in resolving contractures with

“soft” end feel

Serial static splinting/serial casting:

Statically positions joint near end of its

elastic limit

Useful in resolving contractures with

“hard” end-feel

Static-progressive splinting:

Involves the use of inelastic

components such as Velcro tabs,

progressive hinges, or screws to

statically position joint(s)

Useful in resolving contractures with

“hard” or “soft” end-feel

Maximize adhesion length in eitherdirection as patient can activelymove while in splint; however, thisability to intermittently shortentissue thwarts the purpose of thesplint, which is to hold the joint atend range

Allows active resistive motion in theopposite direction of the dynamicpull

Well tolerated over long periods oftime because it holds tissue near theend of its elastic limit and does notstress beyond it

Provides low-load, end range ing, which facilitates relaxation andlengthening of tissues

position-Pressure is distributed over a large face area, which aids in comfort andvascular flow

sur-Well tolerated over long periods oftime because it holds tissue near theend of its elastic limit and does notstress beyond it

Provides low-load, end-range ing, which facilitates relaxation andlengthening of tissues

position-Patient can make minute adjustments tosplint tension to accommodate range-of-motion changes and for comfort

Forces difficult to control, which canlead to poor splint compliance andinadequate wearing time to achieverange-of-motion gains

Tension of splint continues even whentissue has reached its elastic limit,potentially causing inflammation oftissues

Splint or cast must be remolded or made to accommodate increases inmotion

re-Active motion is unavailable at castedjoints; tendon adhesions may becomedenser as patient cannot remove castfor exercise

Motion may be lost in the oppositedirection

Active motion not possible in the splint.Splint must be well made to distributepressure appropriately to allow longwearing periods

tages to consider when prescribing therapy for stiffness of any joint in the upperextremity

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Light KE, Nuzik S, Personius W, Barstrom A Low-load prolonged stretch versus

high-load brief stretch in treating knee contractures Phys Ther 1984;64:330–333.

Schultz-Johnson KS Splinting: a problem solving approach In: Stanley BG,

Tribuzi SM, eds Concepts in Hand Rehabilitation Philadelphia: FA Davis; 1992.

Section VII

Tendon Injuries

Flexor Stenosing Tenosynovitis: Trigger Finger and Thumb

Mark S Rekant

Delayed Treatment of Flexor Tendons: Staged Tendon Reconstruction

Lawrence H Schneider

Chronic Lacerations of Extensor Tendons

Angela A Wang and Michelle Gerwin Carlson

Avulsions of the Flexor Digitorum Profundus

Donald M Lewis and Randall W Culp

PEARLS

• To avoid recurrence of a

trig-ger fintrig-ger, incise and excise a

part of the annular pulley

• Early treatment and early

motion in patients with RA and

avoid releasing the A1 pulley

• Multiple trigger fingers may be

a sign of flexor tenosynovitis

associated with RA, so avoid

releasing the A1 pulley

PITFALLS

• To avoid nerve injury to the

thumb, utilize loupe dissection

• Avoid releasing the A1 pulley

in patients with RA.

29 Flexor Stenosing Tenosynovitis:

Trigger Finger and Thumb

Kevin D Plancher

History and Clinical Presentation

A 45-year-old right hand dominant woman was seen in the office because her rightmiddle finger was stuck in her palm She reported that her family physician gave her

an injection in that finger 6 months ago for her symptoms of clicking and pain overthe dorsal aspect of her proximal phalanx of her middle finger She denies any symp-toms of diabetes, rheumatoid arthritis, gout, or connective tissue disorders

Physical Examination

On examination the patient actively initiated extension of her middle finger butstopped with a short arc of motion because of pain The patient withdrew her handwhen passive extension was attempted because of pain The hand and all digits have

no signs of vascular compromise The patient’s two-point sensory discrimination, asdetermined by the Weber two-point discrimination test, using a dull pointed eyecaliper applied in the longitudinal axis of the digit without blanching the skin, iswithin normal limits A tender, palpable nodule is noted over the palmar surface ofthe second metacarpophalangeal (MP) joint (Fig 29–1)

Diagnostic Studies

Anteroposterior (AP) and splay lateral radiographs reveal no osteophytes or evidence

of osteoarthritis No soft tissue masses are noted

Figure 29–1 A palpable mass seen

in the thumb pulley.

Differential Diagnosis

TumorsMassInfectionOsteoarthritis with osteophytesTrigger finger

Diagnosis

Flexor Stenosing Tenosynovitis of the Right Middle Finger—“Trigger Finger”

The digital flexor sheath contains five discrete “annular bands” (A1 through A5 ley) (Fig 29–2) These pulleys prevent bow-stringing of the flexor tendon and alsomaximize its efficiency in relation to digital motion Nutrition of the flexor tendonsheath is dependent on perfusion from the surrounding tenosynovium rather thanthe vincula system, which perfuses the flexor tendon distally through a small net-work of vessels The annular band and the tenosynovium are responsible for thepathophysiology of trigger fingers and thumbs (Fig 29–3)

pul-When the normally thin flexor sheath becomes inflamed and thickened, it duces the space that the tendon has to pass through The tendon no longer glidesfreely and the tendon itself may swell up in a balloon-like mass and prevent passage

re-of the tendon through the sheath Forced movement at this point will drag the larged portion (Fig 29–4) of the tendon through the sheath, producing a snapping

Figure 29–4 The forced movement drags the enlarged portion of the tendon through the sheath, producing a snap- ping sensation This is also what can lead to the locking

of the finger.

sensation and may lead to locking of the finger in flexion The first annular pulleyacts as a fulcrum about which the flexor tendon bends This fulcrum has been pos-tulated as causing focal tendon degeneration with sheath thickening and tendonnodule development

Nonsurgical Management

Conservative treatment includes modification of provocative activities in the place and personal hobbies Oral nonsteroidal antiinflammatory drugs (NSAIDs),including cyclooxygenase (COX-II) inhibitors, and a steroid injection into thearea of primary pathology is indicated Contraindications to injections or NSAIDsinclude sensitivity to any of the materials or the presence of an infection Using

work-a 27-gwork-auge, work-a 11⁄4-inch needle is used to inject 1.5 cc Celestone and 1.5 cc plainMarcaine/lidocaine without epinephrine into the area of the proximal flexor sheathand annular pulley The needle should be placed at a 45-degree angle to the longitu-dinal axis of the metacarpal at the proximal-most extension of the fibro-osseoussheath, which is located just distal to the distal palmar crease (Fig 29–5) The injec-tion should not be forced, and if excessive force is required, then the needle should

be repositioned Patients are encouraged to use their finger in a normal fashion afterthe injection and should anticipate a decrease of triggering over the next 7 days.Gentle manipulation by the surgeon once the digit is anesthetized will ensure thatthe medication has moved proximally and distally throughout the fibro-osseoustunnel A successful injection is always noted when a fluid wave can be palpated

in the distal flexor sheath during the injection or when a “pop” is felt or heard withinjection of the finger The patient attends a supervised occupational therapy pro-gram for 6 weeks and schedules a follow-up appointment If triggering occurs or ifthe finger becomes irreducibly locked, surgical intervention is prescribed

Figure 29–5 The injection with the needle at 45 degrees

to the longitudinal axis of the metacarpal at the proximal- most extension of the fibro- osseous sheath.

(Fig 29–6), A1 pulley, as well as visualization of the radial and ulnar digital rovascular bundles, which lie adjacent to the flexor sheath The first annular pulley

neu-is released through a longitudinal incneu-ision and a small piece of the pulley neu-is excneu-ised

to avoid reformation of this pulley (Fig 29–7) The distal border of the A1 pulleycorrelates with the anatomic landmark of the MP flexion crease Release of thefibro-osseous sheath beyond this landmark jeopardizes the integrity of the secondannular pulley, which can lead to flexor tendon bow-stringing and limitation indigital motion Before wound closure, the patient is asked to actively extend andflex the finger to ensure complete sheath release A dressing is applied to ensurewound protection but maintain digital motion

Multiple trigger fingers may be a sign of flexor tenosynovitis associated with toid arthritis In these patients with secondary trigger fingers who do not respond to cor-tisone injection, flexor tenosynovectomy often is necessary In the rheumatoid arthritis(RA) patient, release of the A1 pulley is not recommended because this enhances thebiomechanical forces that are responsible for the finger deformity of RA, that is, volarsubluxation and ulnar deviation of the digit at the MP joint If flexor tenosynovectomydoes not allow unrestricted gliding within the fibro-osseous sheath, resection of a slip of

rheuma-Figure 29–6 Intraoperative spreading to the sheath with scissors.

Figure 29–7 The first annular pulley is released through a longitudinal inci- sion A small piece of the pul- ley should be excised to avoid reformation of this pulley.

recog-in a trigger thumb release as it lays 0.16 mm under the skrecog-in.

Bow-Stringing of the Flexor Tendon (Loss of Flexion)

Release of the second annular pulley, in addition to the first annular pulley, mayresult in the loss of finger motion (an extensor lag) Taking care to release only theA1 pulley prevents this debilitating complication

Avoid by prescribing supervised hand occupational therapy postoperatively

Fibrous Nodule Formation Beneath the Scar

Avoid by prescribing supervised hand occupational therapy postoperatively

Suggested Readings

Bonnici AV, Spencer JD A survey of ‘trigger finger’ in adults J Hand Surg [Br]

1988;15B:290–293

Freiberg A, Mulholland RS, Levine R Nonoperative treatment of trigger fingers

and thumbs J Hand Surg [Am] 1989;14A:553–558.

Marks MR, Gunter SF Efficacy of cortisone injection in treatment of trigger fingers

and thumbs J Hand Surg [Am] 1989;14A:722–727.

Otto N, Wehbe MA Steroid injections for tenosynovitis in the hand Orthop Rev

1986;15:290–293

Saldana MJ Trigger digits: diagnosis and treatment J Am Acad Orthop Surg 2001;

9:246–252

Turowski GA, Zdankiewicz PD, Thomson JG The results of surgical treatment of

trigger finger J Hand Surg [Am] 1997;22A:145–149.

• Initial management consists of

a custom thumb spica splint

and additional

antiinflamma-tory medication and a possible

corticosteroid injection

• Careful attention to technique

during injecting (needle angle

and placement)

• Longitudinal septum may

di-vide the APL and the EPB in

20 to 30% of patients.

• Necessary to identify and

re-lease both the EPB and APL

before closure during surgery

PITFALLS

• Unresponsiveness to

cortico-steroid injections and recurrent

symptoms can occur because

of the presence of the

longitu-dinal septum

• Injection not placed correctly

will lead to recurrence of

symptoms

• Patient falling to follow

conser-vative treatment regiment with

hand therapy will in 5% of all

patients necessitate surgical

release

Figure 30–1 Physical exam will localize pain and swelling over the region of the radial styloid.

Case 30

De Quervain’s Disease

Kevin D Plancher

History and Clinical Presentation

A 45-year-old right hand dominant woman presents with wrist pain that is ing her from doing activities at home She spends a significant amount of time in hergarden, and she has noticed increased wrist pain, especially when she uses her thumb.She reports that these symptoms do not improve with rest She denies any history oftrauma to her wrist and has not been diagnosed with rheumatoid arthritis

prevent-Physical Examination

Pain and swelling are localized over the region of the radial styloid (Fig 30–1) Thepain radiates down to the thumb and a thickened fibrous sheath is palpable over theradial styloid Maximum tenderness is noted over the radial styloid, and tenderness

is also noted along the long abductor tendon and muscle Pain is increased with tension and abduction of the thumb against resistance A Finkelstein test is positiveand produces significant pain (Fig 30–2)

ex-Diagnostic Studies

Radiographs consisting of a posteroanterior (PA) and lateral view of the wrist as well

as the important hyperpronated view or Robert’s view were within normal limits

No carpometacarpal (CMC) arthritis was evident on the Robert’s view

Differential Diagnosis

Scaphoid fractureArthritis

Flexor carpi radialis tendonitisThumb carpometacarpal arthritisIntersection syndrome

Wartenberg’s syndrome

Figure 30–3 De Quervain’s disease can have swelling or a thickening of the tendons of the first dorsal compartment (A) The relationship

of the compartments (B) A close-up of the first dorsal compartment.

Figure 30–2 (A) Finkelstein test (B) Physical exam on a patient.

Diagnosis

De Quervain’s Tenosynovitis of the Right Wrist

De Quervain’s disease may be caused by any condition that produces a swelling or athickening of the tendons of the first dorsal compartment of the wrist (Fig 30–3A)

It is a stenosing tenosynovitis of the abductor pollicis longus (APL) and sor pollicis brevis (EPB) tendons (Fig 30–3B) This typically occurs in the third,fourth, and fifth decades of life and is 10 times more common in women The cause

exten-is usually related to overuse and may be associated with rheumatoid arthritexten-is.Overuse causes a chronic inflammation of the sheath that covers the long abductorand the short extensor tendons

The tendons of the APL and the EPB pass through a fibro-osseous tunnelformed by a groove in the radial styloid and overlying extensor retinaculum

Figure 30–4 The tendons of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) pass through a fibro-osseous tunnel formed by a groove in the radial styloid and overlying extensor reti- naculum.

(Fig 30–4) The tendons deviate as they pass through the tunnel, and the angleincreases with ulnar deviation of the wrist Anatomic studies of the fibro-osseouscanal have documented that in 94% of specimens the abductor pollicis tendonhas two to four slips Multiple EPB tendons are found in only 2% Multiple sub-compartments were recorded in 47% of patients and 75% of specimens Mul-tiple APL tendon slips and two subcompartments are the rule rather than theexception in normal anatomy

Despite the fact that many anatomy texts still suggest that the tendons of the EPBand APL are contained in a single compartment under the extensor retinaculum,several anatomic and surgical studies have convincingly demonstrated this to betrue in less than 25% of operative cases Accordingly, one should be certain to iden-tify the EPB and APL tendons at the time of operation

Nonoperative Management

Negative radiographs and clinical examination determine conservative treatment,starting with a custom thumb spica splint (Fig 30–5) In addition, antiinflammatorymedications and a corticosteroid injection (Fig 30–6) into the first dorsal compart-ment are important adjuvants These are most successful within the first 6 weeksafter injury Some authors have reported a high rate of success with injections,

Figure 30–5 Conservative treatment starting with a custom thumb

spica splint.

Figure 30–6 Corticosteroid injection into the first dorsal compartment.