Hand and Wrist Surgery - part 8 ppsx

He had a positive midcarpalclunk with ulnar deviation, but his midcarpal instability was not as dramatic ashis symptoms of ulnar abutment.. Ulnar abutment syndromeSubluxation of the dist

often detached from the dorsal aspect of the lunate The proximal wrist and carpal joints are examined through the capsular incisions for any osteochondral orchondral lesions Any free fragments are excised A trial reduction of the scapholu-nate joint is performed manually, and, if there is any difficulty in obtaining the re-duction, 0.062-inch-diameter Kirschner wires (K wires) can be placed dorsally in thescaphoid and in the lunate and used as “joysticks” to assist in the reduction Whilemaintaining the scapholunate reduction, 0.045-inch-diameter K wires are used topercutaneously pin the scapholunate joint both from the radial and from the ulnarsides to maintain the reduction

mid-Once the scapholunate joint has been pinned, radiographs are obtained to firm the reduction in both AP and lateral projections Once the reduction has beenconfirmed radiographically, a 2.0- or 2.5-mm suture anchor is placed in the dorsalrim of the proximal half of the scaphoid in the area where the dorsal segment of thescapholunate interosseous ligament and the DIC ligament have been avulsed An-other suture anchor is placed at the dorsal aspect of the lunate, if the DIC ligamenthas been avulsed off the lunate (Fig 63–2A) The suture attached to the scaphoidsuture anchor is utilized to reattach the dSLIL and the DIC to their origin on thescaphoid The suture attached to the lunate suture anchor is utilized to reattach theDIC to its origin on the lunate If the injury is chronic, and the DIC has contractedand lies distal to its normal location, then the DIC is released distally while main-taining its triquetral attachment and is relocated and attached to the lunate andscaphoid Once these sutures are tied, the same sutures are used to repair the capsu-lar incision with a slight vest-over-pants imbrication (Fig 63–2B)

con-Reattachment of the proximal membranous portion of the scapholunate terosseous ligament has also been described This portion of the ligament, however,

in-is often seen to be din-isrupted or attenuated in several cadaver din-issections cally, it is not as substantial as the dorsal portion of the scapholunate interosseousligament complex or the DIC ligament and is an intraarticular structure bathed insynovial fluid with questionable potential for healing In addition, the degree of fur-

Mechani-dSLIL S

Radius Scaphoid

Figure 63–2 (A) Placement of the scaphoid and lunate suture anchors to repair the dorsal intercarpal (DIC) ligament, which is most commonly avulsed off the lunate and the scaphoid, and the dorsal component of the scapholunate interosseous ligament (dSLIL), which is usually avulsed off the scaphoid (B) Lateral view of a scaphoid illustrating the suture anchor in place The same suture is utilized first to anchor the dSLIL and the DIC ligaments to the scaphoid, then to repair the capsule in a slight vest over pants fashion S, scaphoid; L, lunate; T, triquetrum; R, radius, U, ulna.

S C A P H O L U N A T E I N S T A B I L I T Y

ther dissection of the scaphoid to place the drill holes and sutures for reattachment

of the membranous portion of the scapholunate interosseous ligament is more stantial and of questionable benefit

sub-Postoperative Management

The wrist and forearm are immobilized in a long-arm splint with the forearm inslight pronation for 4 weeks The wrist is then immobilized in a short-arm splintfor an additional 8 weeks Radiographs are obtained postoperatively at 1, 2, and

4 weeks to assess carpal alignment and pin position The skin sutures are removed at

2 weeks Any signs of pin tract inflammation and/or drainage should be treatedwith suppressive antibiotics until pin removal The pins are removed at l2 weeks,the wrist is placed in a removable short-arm volar splint, and gentle active range-of-motion exercises are begun (Fig 63–3)

There is a postimmobilization period of stiffness that either the activities of dailyliving or the addition of formal therapy will resolve over a 3- to 6-month period

Paper presented at: NATO Advanced Research Workshop, Advances in the chanics of the Hand and Wrist; May 22–23, 1992; Brussels, Belgium

Biome-Lavernia CJ, Cohen MS, Taleisnik J Treatment of scapholunate dissociation by

lig-amentous repair and capsulodesis J Hand Surg [Am] 1992;17A:354–359.

Metz VM, Schimmerl SM, Gilula LA, Viegas SF, Saffar P Wide scapholunate joint

space in lunotriquetral coalition: a normal variant? Radiology 1993;188:557–559.

Viegas SF, Patterson RM, Hokanson JA, Davis J Wrist anatomy: incidence,

distri-bution and correlation of anatomy, tears and arthritis J Hand Surg [Am] 1993;18A:

463–475

Viegas SF, Yamaguchi S, Boyd NL, Patterson RM The dorsal ligaments of the

wrist: anatomy, mechanical properties and function J Hand Surg [Am] 1999;24A:

456–468

Watson HK, Ashmead D IV, Makhlouf MV Examination of the scaphoid J Hand

Surg [Am] 1988;13A:657–660.

Whipple TL The role of arthroscopy in the treatment of scapholunate instability

Hand Clin 1995;11:37–40.

L U N O T R I Q U E T R A L I N S T A B I L I T Y

PEARLS

• A standardized PA wrist

radi-ograph yields useful

informa-tion about ulna variance and

impaction

• LT and TFCC pathology often

coexist.

• Dynamic imaging is useful to

confirm the presence of LT

pathology

PITFALLS

• Beware of false-positive and

false-negative arthrograms

Clinical correlation is required

• Viewing the LT articulation

from the midcarpal joint is

important to exclude

nondis-sociative midcarpal instability.

64

Lunotriquetral Instability

Loryn P Weinstein and Allen T Bishop

History and Clinical Presentation

A 48-year-old right hand dominant mechanic presented for evaluation of rightulnar-sided wrist pain Two weeks earlier he had slipped in his shop and landed on

a dorsiflexed wrist The primary impact was to the hypothenar eminence quently, he developed intermittent ulnar-sided wrist pain, exacerbated by radial-ulnar deviation Grip strength was diminished, and he felt his wrist give way whentorquing heavy tools These symptoms reduced his work productivity and pre-vented him from participating in his weekly bowling league

Subse-Physical Examination

No wrist swelling or obvious deformity was noted There was point tenderness sally over the triquetrum Range of motion was diminished in all planes A painfulclunk was palpable with radial-ulnar deviation Compression of the triquetrumwith a radially directed force elicited pain Excessive laxity was present with luno-triquetral (LT) ballottement when compared with the contralateral wrist Gripstrength was reduced 20% compared with the contralateral, nondominant side Hewas neurovascularly intact

dor-Diagnostic Studies

Anteroposterior, lateral, and oblique radiographs of the wrist were normal Anarthrogram was obtained (Fig 64–1)

Relative malalignment between the lunate and the triquetrum may be apparent

on lateral radiographs Bisectors of the lunate and triquetrum intersect to form an

LT angle (normal = 14 degrees, range ⫺3 to +31 degrees) Patients with LT ation will exhibit a negative angle (mean value = ⫺16 degrees) A volar intercalatedsegmental instability (VISI) pattern is present in some (chronic) cases

dissoci-Radial deviation and clenched-fist anteroposterior views can be useful Palmarflexion of the scaphoid and lunate without movement of the triquetrum confirmsthe loss of proximal row integrity

Arthrography is a useful imaging tool for LT instability Passage of dye throughthe LT interspace documents the presence of a perforation, tear, or dissociation.Age-related LT perforations and tears have been frequently demonstrated in asymp-tomatic individuals Therefore, arthrogram findings require clinical correlation Avideotaped arthrogram with motion sequences demonstrating abnormal dye pool-ing associated with abnormal proximal row kinetics is useful as a confirmatorystudy

Bone scans, tomograms, and magnetic resonance imaging (MRI) have limitedutility in the setting of LT instability Standards for MRI of LT ligaments are not yetavailable

Extensor carpi ulnaris (ECU) subluxationThe differential diagnosis of ulnar-sided wrist pain is broad (Table 64–1) How-ever, a history of a specific injury with subsequent instability and “clunking” duringradial-ulnar deviation suggests relatively few diagnoses These include LT instabil-

Table 64–1 Differential Diagnosis Diagnosis Differentiating Findings

Triquetrohamate instability Antecedent trauma, hyperextension mechanismTFCC tear Painful radial-ulnar deviation and clunkUlna impaction syndrome Focal tenderness

Pisotriquetral injury Positive LT provocative testsECU instability Positive radiograph findings

Positive arthrogram or arthroscopic exam

L U N O T R I Q U E T R A L I N S T A B I L I T Yity, nondissociative midcarpal instability, TFCC injury, ulnar impaction syndrome,pisotriquetral injury, and ECU subluxation.

Midcarpal instability often produces a painful clunk with ulnar deviation, butantecedent trauma is rarely reported Provocative LT maneuvers are negative A

“catch-up clunk” may be demonstrable during motion of a loaded wrist from a dial to an ulnar deviated position, resulting in a sudden extension of the lunate andscaphoid in this condition as joint contact forces them to “catch up” to the alreadyextended triquetrum Cineradiography is useful to examine the synchronicity ofproximal row kinetics to differentiate midcarpal from LT instability, the latterdemonstrating the “clunk” arising from sudden extension of the scaphoid and lu-nate alone during ulnar deviation, dissociated from the triquetrum

ra-TFCC tears can mimic LT instability with an analogous injury history and tomatic clicking Provocative LT tests are negative, whereas distal radioulnar joint(DRUJ) and TFCC provocative tests are positive In some cases, coincident LT andTFCC pathology is demonstrated by arthrography or arthroscopy Isolated TFCCinjury is best visualized by MRI or arthroscopy

symp-Ulnocarpal impaction syndrome is the result of excessive ulnar positive variance.Pain and weakness with rotational motion are noted A standard neutral postero-anterior (PA) wrist radiograph will demonstrate ulna positive variance and “kissing”degenerative cysts and sclerosis at the lunate and ulna head LT and TFCC tearsare frequently associated findings Arthrography or arthroscopy can assess LT andTFCC integrity prior to undertaking an ulnar shortening procedure

A pisiform fracture may present after acute hypothenar trauma This is best ized with a supination oblique or carpal tunnel view radiograph Radial-ulnar devia-tion may be painful, but specific LT provocative tests are negative Pain and crepitancemay be found by pisiform compression and translation

visual-Subluxation of the extensor carpi ulnaris tendon produces an audible snap asthe forearm is actively supinated and the wrist is slightly flexed and ulnar deviated

LT provocative maneuvers are negative

Diagnosis

Lunotriquetral Instability

Lunotriquetral (LT) instability results from a disruption of the dorsal and palmar

LT interosseous complex A spectrum of pathology is possible, proportional to themagnitude and acuity of ligamentous disruption Degenerative membrane perfora-tion may be asymptomatic Partial tears of the LT membrane may produce dynamicinstability, and complete ligament dissociation may produce a static VISI pattern.Lunotriquetral instability most commonly follows a specific injury Hyperex-tension at the wrist is a common mechanism Weakness and a decreased range ofmotion are usually present Pain is precipitated with radial-ulnar deviation, andsometimes a “clunk” is audible The individual may perceive instability or a giving-way sensation Ulnar paresthesias are occasionally present

Point tenderness is localized to the LT junction A painful clunk may be palpable withradial-ulnar deviation Diminished grip strength and radiocarpal motion are common.Three provocative maneuvers for LT instability have been described: the compres-sion, ballottement, and shear tests Compression of the triquetrum in the ulnar snuffboxusing a radially directed force may elicit pain, suggesting LT or triquetrohamate pathol-ogy Ballottement of the LT ligament is performed by grasping the pisotriquetral unit

Figure 64–2 Demonstration

of shear test, with the iner’s contralateral thumb placed dorsally over the lunate

exam-as the ipsilateral thumb loads the pisotriquetral joint from the palmar side.

between the thumb and index finger of one hand and the lunate between the thumb andindex of the other An anteroposterior translation motion is performed between thesebones Pain and dorsal palmar laxity greater than that on the opposite side signify a pos-itive test The shear test is performed with the elbow supported on the hand table andthe forearm in neutral rotation The examiner’s contralateral thumb is placed dorsallyover the lunate as the ipsilateral thumb loads the pisotriquetral joint from the palmarside (Fig 64–2) The test is positive when pain, crepitance, or abnormal LT mobility iselicited Comparison with the contralateral wrist is important for all provocative tests

A variety of imaging studies can support a diagnosis of LT instability Standardanteroposterior radiographs may be normal in partial tears Findings in completedissociation include disruption of Gilula’s arcs, proximal triquetral translation, and

LT overlap Unlike scapholunate dissociation, a widening of the interosseous val is not visualized Positive ulnar variance should be noted When present, it may

inter-be the cause of an attritional LT tear and require treatment

Arthroscopy has both a diagnostic and therapeutic role Direct inspection andpalpation of the LT ligament, TFCC, capsular structures, and articular surfaces al-lows accurate diagnosis of LT pathology Midcarpal arthroscopy is important for theassessment of LT stability

Nonsurgical Management

Treatment is based on the severity and chronicity of injury Initial management

of acute LT tears (partial membrane injuries) consists of cast immobilization, which

L U N O T R I Q U E T R A L I N S T A B I L I T Yincorporates supplemental padding under the pisiform Partial LT injuries may heal

in this fashion Symptomatic chronic tears and all dissociations (complete brane disruptions), regardless of chronicity, are best managed surgically

mem-Surgical Management

Lunotriquetral stability can be restored by ligament repair, reconstruction, or sis Additional procedures may be necessary if significant ulnar variance or arthrosis ispresent

arthrode-Ligament repair is a technically demanding procedure A dorsal approach tween the fourth and fifth compartments and a transverse capsulotomy distal to theTFCC exposes the LT articulation The remaining LT ligament is typically adherent

be-to the lunate The radial border of the triquetrum is freshened and three or fourparallel drill holes are placed in an ulnar to radial direction Nonabsorbable suture

is passed through the drill holes, anchored to the LT remnant, and passed backthrough the holes The joint is reduced and fixed with Kirschner wires (K wires).Proper alignment is confirmed radiographically before the sutures are tied The su-tures are then tightened The dorsal radiotriquetral ligament may be advanced andtightened during closure for augmentation Eight weeks of cast immobilization and

4 weeks of splint immobilization is recommended postoperatively

Reconstruction can be performed when insufficient LT ligament is available forprimary repair (Fig 64–3) A distally based strip of ECU or flexor carpi ulnaris(FCU) is harvested Static deformity should be reduced and provisionally fixed be-fore preparation for the lunate and triquetrum tunnels A K wire is drilled from thedorsal ulnar corner of the triquetrum to the volar radial corner of the LT joint Asecond K wire is placed in the lunate from its mid-dorsal radial border to exit at thesame place in the LT joint After radiographic confirmation, the holes are seriallyenlarged with awls The tendon graft is then passed through the triquetrum and thelunate The LT joint is percutaneously pinned and again confirmed radiographically

Figure 64–3 Illustration of lunotriquetral (LT) recon- struction.

radi-Controversial point: LT arthrodesis is technically less demanding than ligament

re-pair or reconstruction Reports demonstrate problems with delayed union, union, impaired radiocarpal motion, and ulnocarpal abutment A 20-year seriesfrom our institution recently demonstrated better survivorship with ligament repairand reconstruction methods

non-Suggested Readings

Beckenbaugh RD Accurate evaluation and management of the painful wrist

fol-lowing injury An approach to carpal instability Orthop Clin North Am 1984;15:

289–306

Bishop AT, Reagan DS Lunotriquetral sprains In: Cooney WP, ed The Wrist

Diag-nosis and Operative Treatment Chicago: Mosby; 1998.

Favero KJ, Bishop AT, Lindscheid RL Lunotriquetral ligament disruption: a parative study of methods Presented at the 46th Annual Meeting of the AmericanSociety for Surgery of the Hand, Orlando, FL, 1992

com-Kleinman WB Diagnostic exams for ligamentous injuries American Society for Surgery

of the Hand Correspondence Club Newsletter, No 51, 1985.

Reagan DS, Linscheid RL, Dobyns JH Lunotriquetral sprains J Hand Surg [Am]

1984;9A:502–514

Shin AY, Battaglia MJ, Bishop AT Lunotriquetral instability: diagnosis and

treat-ment J Am Acad Orthop Surg 2000;8:170–179.

Shin AY, Weinstein LP, Berger RA, Bishop AT Treatment of isolated injuries of thelunotriquetral ligament A comparison of arthrodesis, ligament reconstruction and

ligament repair J Bone Joint Surg [Br] 2001;83B:1023–1028.

D O R S A L C A P S U L O D E S I S F O R M I D C A R P A L I N S T A B I L I T Y

PEARLS

• Stability of the DRUJ is essential

• Begin forearm rotation as soon

as possible At minimum,

sup-port forearm in supination

• Carefully analyze degree of

comminution

• Do not expose tendons or

nerves to uneven fixation

William K Feinstein and David M Lichtman

History and Clinical Presentation

A 24-year-old right hand dominant man sustained a dorsiflexion injury to hisright wrist while trying to protect himself from a falling shelf at work He con-tinued to work with pain for about 6 weeks before he presented to an orthopedicsurgeon He was treated nonoperatively for a year and a half, but he continued tocomplain of ulnar-sided wrist pain and clunking He had a positive midcarpalclunk with ulnar deviation, but his midcarpal instability was not as dramatic ashis symptoms of ulnar abutment Radiographs demonstrated ulna positive vari-ance and mild VISI deformity A triple-phase arthrogram revealed tears of theTFCC and lunotriquetral ligament The patient was thus given a diagnosis ofulnar abutment syndrome After failing conservative treatment (nonsteroidal an-tiinflammatory drugs, steroid injections, splinting), he was taken to the oper-ating room for arthroscopic debridement of the torn TFCC and lunotriquetralligaments, and open wafer excision of the right distal ulna He did well postoper-atively and progressed with occupational therapy that included range-of-motionexercises, stretching, and later wrist strengthening exercises However, the clunk-ing sensation remained At 1 year postoperatively, he had minimal complaints

of ulnar abutment; however, the clunking sensation persisted and was associatedwith pain while gripping in palmar flexion A pisiform loading volar splint wasfabricated and was worn for all activities; however, his symptoms did not im-prove over the next 2 months

Physical Examination

Dorsiflexion to 75 degrees, palmar flexion 75 degrees, pronation 50 degrees, andsupination 70 degrees were noted There was decreased grip strength by Jaymar griptesting, and there was a palpable clunk with ulnar deviation of the wrist (midcarpalshift test) This clunk was associated with apprehension and pain

Ulnar abutment syndromeSubluxation of the distal radioulnar jointExtensor carpi ulnaris tendon subluxation

Diagnosis

Midcarpal Instability

This patient was initially treated for ulnar abutment syndrome with TFCC tearand triquetrolunate tear These disorders create symptoms, which overlap with mid-carpal instability Although the symptoms improved following ulnar shortening, themidcarpal instability clunk continued Distal radioulnar joint and extensor carpi ul-naris tendon subluxation were ruled out by physical exam Although a VISI defor-mity is characteristic of midcarpal instability, this is not an absolute requirement forthe diagnosis

Midcarpal instability is due to congenital laxity, gradual attenuation, or acute ruption of the volar arcuate, and/or dorsal radiotriquetral ligaments Each of thesecomponents couples the distal row of carpal bones to the proximal row, ensuringnormal joint contact In normal wrists with normal midcarpal geometric align-ment, bone and ligament contact forces cause the proximal row to move from flex-ion (VISI) to extension [dorsal intercalated segment instability (DISI)] as the wristmoves from radial to ulnar deviation With midcarpal instability, the proximal rowrests in volar flexion due to ligament laxity, and the distal row is translated volarly.When the wrist moves from neutral into advanced ulnar deviation, the joint geome-try, bony restraints, and axial compression on the ulnar side cause the proximal row

dis-to suddenly rotate back indis-to physiologic dorsiflexion, and the distal row snaps backinto dorsal translation This produces what has been referred to as the “catch-upclunk,” causing pain in patients with midcarpal instability

Patients usually present with painful “clunking” on the ulnar side of the wrist ing activities, which require active ulnar deviation of the wrist with the forearm inpronation A history of repetitive loading of the wrist by vocational tasks or avoca-tional interests is common, and symptoms of pain and clunking tend to occur withthese repetitive activities There may or may not be a history of trauma

dur-On physical examination, there is often a palmar sag on the ulnar side of thewrist, with a prominent appearing ulnar head, although sometimes swelling orlocalized synovitis will be present, making the ulnar sag and prominent ulnarhead less dramatic There usually is tenderness over the ulnar carpus in the re-gion of the triquetrohamate joint Usually the patient can spontaneously repro-duce the “clunk” with active ulnar deviation of the pronated wrist The clunkoccurs at the extreme of ulnar deviation, and it is most often visible, audible, andpalpable to the examiner After the clunk occurs, the volar sag disappears An-other reverse clunk can sometimes be appreciated when the wrist moves backinto neutral In this case, the volar sag reappears The midcarpal shift test is animportant diagnostic tool for identifying the patient with midcarpal instabil-ity, especially patients who cannot spontaneously cause the clunk to occur in theoffice (Fig 65–1)

A lateral radiograph of the wrist in neutral deviation will usually demonstrate aVISI deformity with slight volar translation of the distal carpal row Cineroentgeno-

fore-grams in the posteroanterior and lateral planes are diagnostic Wrist flexion andextension is normal; however, as the patient actively moves his wrist from radial toulnar deviation, one can see the entire proximal row snap suddenly from a flexion orVISI position into an extension or DISI position when the wrist reaches a criticalpoint of extreme ulnar deviation.

Dorsal intercarpal ligament

Radiotriquetral ligament

Surgical Management

Dorsal Capsulodesis

After exsanguination of the extremity and elevation of a tourniquet, a dorsal tudinal incision was made centered over the radiocarpal joint (Fig 65–2A) Carefuldissection through the subcutaneous tissues was performed, and the extensor reti-naculum was identified The extensor pollicis longus was released from its compart-ment, and the dorsal capsule was exposed through a longitudinal incision betweenthe third and fourth compartments The wrist extensors were retracted radially andthe finger extensors ulnarly

longi-At this point in the operation, the wrist was taken through its range of motionand the midcarpal clunk was easily reproduced By grasping the dorsal capsule with

At this point, the tourniquet was deflated and good hemostasis was achieved Thedistal segment of the posterior interosseous nerve was identified and excised, andthe arm was then reexsanguinated and the tourniquet re-inflated The dorsal capsulewas then imbricated using two rows of mattress sutures (Ticron) (Fig 65–2C), andthe wrist was taken again through a range of motion while visualizing the bonystructures through fluoroscopy All of the carpal relationships appeared normal, andthe clunk was eliminated.

The dorsal retinaculum was repaired over the second and fourth compartments,and the third compartment was left open A layered closure of the more superficialtissues was performed, and a bulky physiologic dressing with sugar-tong splint wasapplied to hold the wrist in neutral, leaving the thumb and fingers free to move.During application of the postoperative splint, dorsally directed pressure was ap-plied to the distal carpus and metacarpals to maintain the midcarpal joint in its re-duced position

Postoperative Management

A sugar-tong splint was placed postoperatively to hold the wrist in neutral, and thiswas converted to a short-arm cast at 2 weeks At 10 weeks following surgery, the castwas removed, and the patient was allowed to begin gentle active range-of-motionexercises He began a work hardening program at 3 months postoperatively, and re-sumed all other activities at 4 months following surgery The midcarpal clunk didnot return

Alternative Methods of Management

Most patients respond to conservative treatment This includes nonsteroidal inflammatories, avoidance of aggravating activities such as extreme ulnar deviation

anti-of the wrist with axial loading, special splints that push dorsally on the pisiform ducing the VISI sag, and physical therapy Occasionally, the patient can be taught

re-to activate the hypothenar muscles and/or the extensor carpi ulnaris muscle tendonunit prior to ulnar deviation, thereby pre-reducing the wrist and midcarpal joints

as the wrist begins its movement into ulnar deviation, preventing the painful clunk.Alternative surgical treatment includes reconstruction at the triquetrohamate jointwith interosseous tendon grafts, advancement of the ulnar arm of the volar arcuateligament, and midcarpal (capitate-lunate-triquetrum-hamate) arthrodesis A compar-ison between volar ligament repair and midcarpal arthrodesis demonstrated a higherpatient satisfaction level with arthrodesis

No long-term studies are available that compare dorsal capsulodesis with sis for midcarpal instability In the senior author’s experience, however, dorsal cap-sulodesis is an acceptable alternative for mild to moderate cases failing conservative

stretch-ing recurrence of the clunk Patients may also develop a significant reduction in

wrist range of motion, and the change in biomechanics may theoretically result in greater incidence of ulnocarpal or radiocarpal arthritis.

Brown DE, Lichtman DM Midcarpal instability Hand Clin 1987;3:135–140.

Cooney WP III, Garcia-Elias M, Dobyns JH, et al Anatomy and mechanics of carpal

instability Surg Rounds Orthop 1989;9:15–24.

Feinstein WK, Lichtman DM Recognizing and treating midcarpal instability Sports

Med Arthroscopic Rev 1998;6:270–277.

Lichtman DM Midcarpal instability In: McGinty JB, ed Operative Arthroscopy.

New York: Raven Press; 1991:647–650

Lichtman DM, Bruckner JD, Culp RW, Alexander CE Palmar midcarpal

instabil-ity: results of surgical reconstruction J Hand Surg [Am] 1993;18A:307–315.

Lichtman DM, Gaenslen ES, Pollock GR Midcarpal and proximal carpal

instabili-ties In: Lichtman DM, Alexander AH, eds The Wrist and Its Disorders, 2nd ed.

Philadelphia: WB Saunders; 1997:316–328

Lichtman DM, Schneider J, Swafford A, Mack G Ulnar midcarpal instability—

clinical and laboratory analysis J Hand Surg [Am] 1981;6:515–523.

Linscheid R, Dobyns J, Beabout J, Bryan R Traumatic instability of the wrist

J Bone Joint Surg [Am] 1972;54A:1612–1632.

Palmer A, Dobyns J, Linscheid R Management of posttraumatic instability of the

wrist secondary to ligament rupture J Hand Surg [Am] 1978;3:507–532.

Ruby LK, Cooney WP III, Linscheid RL, Chao EYS Relative motion of selected

carpal bones: a kinematic analysis of the normal wrist J Hand Surg [Am] 1988;13A:

1–10

Sebald J, Dobyns J, Linscheid R The natural history of collapse deformities of the

wrist Clin Orthop 1974;104:140–148.

Taleisnik J Pain on the ulnar side of the wrist Hand Clin 1987;3:51–68.

T E A R S O F T H E T R I A N G U L A R F I B R O C A R T I L A G E C O M P L E X

PEARLS

• Patients with injuries to the

wrist, particularly displaced

distal radius fractures, should

be examined after reduction

for instability of the DRUJ

• The majority of patients

pre-senting with ulnar-sided wrist

pain can be managed

non-operatively and returned to

normal activities

• The central component of the

TPCC can be excised to a

sta-ble rim without compromising

its biomechanical function

PITFALLS

• The differential diagnosis of

ulnar-sided wrist pain is lengthy

A careful examination of the

ulnar side of the wrist will

fre-quently rule in other causes of

patient’s symptoms

• The dorsal branch of the ulnar

nerve crosses from volar to

dorsal in the region of ulnar

(6U) wrist arthroscopy portals

Careful dissection and

protec-tion of this nerve is mandatory

to prevent complications

66

Tears of the Triangular Fibrocartilage Complex

Philip E Blazar and Scott D Mair

History and Clinical Presentation

A 19-year-old right hand dominant college student presented for evaluation of leftwrist pain 5 months after closed treatment for a distal radius fracture The pain wasulnar sided and associated with activities, particularly those involving maximal ex-tension or pronation/supination against resistance (e.g., turning a doorknob on aheavy door) There was no clicking The patient’s injury had been treated in a long-arm cast for 8 weeks Office notes from the referring physician document a diagno-sis of distal radius fracture and distal radioulnar joint (DRUJ) dislocation reducedand treated in a closed manner The patient was referred for persistent ulnar sidedwrist pain

Physical Examination

The hand, wrist, elbow, and shoulder were normal to inspection There was mal atrophy of the forearm musculature Active range of motion of all joints wassymmetric bilaterally There was tenderness to palpation radial to the ulnar styloidwith the arm in neutral rotation and mild discomfort, but no increased translationwith stressing the DRUJ TFCC grind maneuver produced no pain or clicking Theextensor carpi ulnaris (ECU) tendon did not subluxate out of its groove, and wristinstability maneuvers caused minimal discomfort and no clunking Neurologic andvascular examinations were normal

Triangular Fibrocartilage Complex (TFCC) Tear

Ulnar-sided wrist pain is a common complaint The patient’s age, hand dominance,avocations, and occupation are important historical factors, and the nature and date

of injury should be sought Patterns of injury have been associated with particularrecreational activities (e.g., hook of the hamate fractures with sports involving a bat

or club) Neurologic complaints are common and should be sought The tial diagnosis above is limited to the diagnoses likely after a distal radius fracture.Examination of the TFCC is performed in conjunction with a thorough exam

differen-of the wrist, elbow, and hand, including neurovascular structures Direct palpation

of the bony and soft tissue structures of the ulnar side to localize point tenderness isthe most helpful examination maneuver Tenderness radial or ulnar to the ECU ten-don with the wrist in neutral rotation may be consistent with a TFCC lesion TheDRUJ is examined with the patient’s elbow on a table in front of the examiner TheDRUJ is stressed with one of the examiner’s hands grasping the distal ulna andthe other grasping the radius Volar and dorsal translation is assessed in neutral,pronation, and supination A TFCC grind test is performed with the wrist in ulnardeviation and dorsiflexion with an axial load applied to the hand by the examiner asthe carpus is rotated on the fixed forearm Radiographs aid in establishing the diag-nosis of a malunion of the distal radius or a nonunion of the ulnar styloid Fractures

at the base of the ulnar styloid are more likely to be associated with a TFCC injurythat will produce persistent symptoms if untreated Ulnocarpal abutment is morelikely in patients with ulnar positive or ulnar neutral variance

The term triangular fibrocartilage complex was originally used by Palmer and

Werner for the group of structures that stabilize the carpus and distal radius to thefixed distal ulna This complex includes the volar and dorsal radioulnar ligaments,the ulnar collateral and ulnocarpal ligaments, and the articular disk The articular

T E A R S O F T H E T R I A N G U L A R F I B R O C A R T I L A G E C O M P L E X

Table 66–1 Classification of Triangular Fibrocartilage Complex Lesion Main Category Subcategories

Type 1: Traumatic A: Horizontal tear adjacent to the radius

B: Peripheral detachment from the ulnaC: Tear of the ulnocarpal ligamentsD: Avulsion from sigmoid notchType 2: Degenerative A: Partial-thickness thinning of the articular disk

B: A + chondromalacia of lunate and/or ulnar headC: B + full-thickness tear of the articular diskD: C + partial tear of the lunotriquetral ligamentE: D + pull tear of the lunotriquetral ligament and arthrosis

disk separates the carpal bones from the distal radioulnar articulation The complex

is central to three biomechanical functions of the wrist: (1) stability of the DRUJ,(2) axial load transmission from the carpus to the ulna, and (3) ulnar-sided carpalstability

TFCC lesions were classified by Palmer in the Journal of Hand Surgery in 1989.

There are two main categories: traumatic and degenerative (Table 66–1)

Nonsurgical Management

Recommended initial management of traumatic TFCC injuries based on historyand physical examination is 4 weeks of immobilization The intimate relationship

of the articular disk and the DRUJ typically requires the use of an above-elbow cast

At 4 weeks, patients are begun on range-of-motion and strengthening exercises andprogress as tolerated Surgical management is indicated for failure of conservativetreatment

Degenerative lesions are more common in patients with ulnar positive variance.Recommended initial treatment includes activity modification, splinting, and non-steroidal medications The author’s experience has been that patients with negative

or neutral ulnar variance are more likely to respond to conservative treatment gical intervention is indicated for failure of conservative treatment

Sur-Surgical Management

Surgical treatment of lesions of the TFCC continues to evolve Traumatic lesionsare typically classified at the time of diagnostic arthroscopy Wrist arthroscopy isperformed with the wrist in 10 pounds of traction to facilitate visualization of theTFCC The portals for visualization and manipulation of the TFCC include 3–4,4–5, and 6R Type 1A or central lesions are the most common traumatic injuryseen Arthroscopic debridement of the unstable edges of the tear is typically recom-mended Cadaveric studies have demonstrated that excising the central two thirds

of the articular disk does not alter the biomechanical functions of the TFCC operatively, patients are encouraged in immediate mobilization Return to work orathletics usually is within 6 to 12 weeks Diagnostic arthroscopy of this case demon-strated a type 1B lesion

Post-The finding of a peripheral detachment of the TFCC is not always as obvious

at arthroscopy as one might anticipate A helpful diagnostic maneuver is the poline sign that is elicited with a probe in the 4–5 portal and the arthroscope in the

Two or three sutures are placed and tied over the capsule (Fig 66–2) tively the patient is immobilized for 4 to 6 weeks in a Munster cast to eliminate ro-tation of the forearm, and an additional 2 to 4 weeks in a wrist splint Return to fullactivity is allowed at 3 months.

Postopera-Controversial point: Treatment of type 1C and 1D TFCC injuries has not received

as much attention as the more common injury patterns Classically it was believedthat radial detachments would not heal and were debrided to stable edges, if therewas not a bony fragment attached to the articular disk Recently, open and arthro-scopically assisted repair of avulsion of the TFCC from the sigmoid notch (1D le-sions) has been described but outcome data are limited Distal avulsions (1C) arethe least common injury pattern described in most series Whether debridement orrepair of 1C or 1D lesions is superior is unclear at present

Treatment of degenerative lesions of the TFCC depends on the Palmer tion stage Lesions classified as 2A or 2B are typically treated nonoperatively withantiinflammatories, splinting, and activity modification An extraarticular ulnarshortening or an intraarticular “wafer” procedure (with removal of 2 to 4 mm ofdistal ulna) can be considered in the unusual case of symptoms refractory to thesemeasures If the lesion has progressed to stage 2C, a TFCC debridement is per-formed If the patient is ulnar positive, this may be combined with a “wafer” proce-dure Treatment of stage 2D lesions includes an ulnar shortening and treatment ofthe wrist instability if it is substantial Stage 2E lesions may present with substantialdegeneration of the ulnar carpus and typically require a salvage procedure

classifica-Figure 66–2 Peripheral TFCC repair using two 18-gauge spinal needles or Tuohy needles.

mat-T E A R S O F mat-T H E mat-T R I A N G U L A R F I B R O C A R mat-T I L A G E C O M P L E X

Suggested Readings

Botte MJ, Cooney WP, Linscheid RL Arthroscopy of the wrist: anatomy and

tech-nique J Hand Surg [Am] 1989;14A:313–316.

Fulcher SM, Poehling GG The role of operative arthroscopy for the diagnosis and

treatment of lesions about the distal ulna Hand Clin 1998;14:285–296.

Graham TJ, ed Problems about the distal end of the ulna Hand Clin 1998.

Kleinman WB, Graham TJ Distal ulnar injury and dysfunction In: Peimer C, ed

Surgery of the Hand and Upper Extremity New York: McGraw-Hill; 1996.

Palmer AK Triangular fibrocartilage complex lesions: A classification J Hand Surg

[Am] 1989;14A:594–605.

Palmer AK, Werner FW The triangular fibrocartilage complex of the wrist—anatomy

and function J Hand Surg [Am] 1981;6A:151–162.

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Section XI

Arthritis of the

Hand and Wrist

Osteoarthritis: Proximal Interphalangeal Joint (Silastic Implants)

Thomas Bienz and A Lee Osterman

Osteoarthritis: Carpometacarpal Joint (Ligament Reconstruction with Tendon Interposition)

Vincent Ruggiero and Andrew K Palmer

Scapholunate Advanced Collapse

Andrew H Borom and David B Siegel

Triscaphe Degenerative Arthritis

Andrew E Caputo and H Kirk Watson

B Rheumatoid Arthritis Rheumatoid Arthritis: Distal Interphalangeal Joint Arthrodesis

R John Naranja, Jr and Kevin D Plancher

Rheumatoid Arthritis: Proximal Interphalangeal Joint Arthrodesis

R John Naranja, Jr and Kevin D Plancher

Rheumatoid Arthritis: Metacarpophalangeal

Joint Reconstruction Arthroplasty

R John Naranja, Jr and Kevin D Plancher

Osteoarthritis: Proximal Interphalangeal Joint (Silastic Implants)

Thomas Bienz and A Lee Osterman

History and Clinical Presentation

This 66-year-old right hand dominant woman had a long history of osteoarthritis volving multiple joints of the hand, and knees She initially presented in 1989 at age 51with atraumatic, spontaneous onset of painless distal interphalangeal (DIP) joint arthri-tis and painful degeneration in the dominant hand’s basal joint requiring ligamentreconstruction and tendon interposition (LRTI) arthroplasty This was followed by sim-ilar basal joint symptoms in the nondominant hand requiring arthroplasty 2 years later.Over the next 6 years, she developed progressive degeneration of the left knee as well

in-as the proximal interphalangeal (PIP) and DIP joints of both hands The left knee quired arthroplasty in 1996, but activity modification and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) allowed her to avoid further hand surgery until 1999

re-At that time, the right long finger PIP joint degeneration compounded by ing flexor tenosynovitis of the index and long fingers became sufficiently painful towarrant surgical intervention The past medical history was additionally significantfor hypertension, mild depression, bilateral carpal tunnel syndrome responsive toconservative management and prior cholecystectomy Medications included Verelan,Lozol, Voltaren, and Prozac

stenos-Physical Examination

The patient had significant degeneration of the PIP joints with osteophyte mation (Bouchard’s nodes), and similar findings in the DIP joints (Heberden’snodes) Range of motion (ROM) was most limited in the DIP joints; howeverthese joints did not cause her a great deal of pain (Table 67–1) The right long

for-O S T E for-O A R T H R I T I S : P R for-O X I M A L I N T E R P H A L A N G E A L J for-O I N T ( S I L A S T I C I M P L A N T S )

PEARLS

• Grommets are not indicated

for use with Silastic implants in

the PIP joints

• Using the volar approach to

the PIP (when indicated)

mini-mizes the risk of damage to the

central slip insertion and can

be performed simultaneously

with a tenolysis to break up

ad-hesions between the FDP and

FDS as is commonly seen in

long-standing arthritic fingers

• The implant stems should slide

freely in the medullary canal

without buckling If the

appro-priate size necessary has a

stem length that prevents this,

the stem should be shortened

up to 5 mm to prevent such

buckling

• The largest size implant that

fits the space is generally

pre-ferred Implants smaller than

size 1 may allow bony

over-growth to bridge and ankylose

the joint

PITFALLS

• In a severely degenerated

phalanx, locating the

intra-medullary canal can be quite

challenging.

• Even the blunt leader-tip bur

can perforate the cortex, and

such perforation will result in a

malaligned implant,

compro-mising results Biplanar

fluo-roscopy should be used during

burring if the surgeon is not

absolutely certain of the bur’s

path within the phalanx

Table 67–1 Patient Range of Motion

hyperex-finger’s PIP joint had a painful arc of motion from 0 to 85 degrees with tion The metacarpophalangeal (MP) joints had well-maintained and painless arcs

crepita-of motion There was no erythema, nail pitting, trophic changes, or significantsoft tissue swelling All fingers were neurovascularly intact The patient reportedoccasional “triggering” in the index and long fingers when extending from a fullyflexed position

This was associated with pain along the palmar base of the digits and tendernesswith a palpable nodule in the flexor tendons at the first annular (A1) pulley

Diagnostic Studies

The radiographs demonstrated PIP and DIP loss of joint space, subchondral sis, cyst formation, and osteophytic joint surface widening in both the sagittal andcoronal planes (Fig 67–1) There was a 15-degree ulnar deviation of the indexDIP, as well as the long and ring finger PIP joints The ring finger DIP joint had a15-degree radial deviation The MP joints showed a mildly decreased joint space,particularly in the ring and small fingers, and only minimal osteophyte forma-tion There was evidence of the prior trapeziectomy and LRTI with well-preserved

sclero-426

Figure 67–1 (A,B) Radiographs showing loss of joint space, sclerosis, cyst formation, and osteophytic joint surface widening in the sagittal plane and the coronal plane.

suspension of the first metacarpal maintaining the scaphometacarpal interval Theradiocarpal and distal radioulnar joints were well maintained There was no signifi-cant osteopenia or periarticular erosions.

Stenosing flexor tenosynovitis (trigger finger) in the index and long fingers.

Osteoarthritis (OA) is the most common type of arthritis and often affectsthe hands The most commonly affected joint is the DIP joint followed by thebasal joint, PIP, and MP, in descending order of incidence As with the treatment

of larger joints affected by OA, surgical intervention should be postponed aslong as possible using adaptive devices, activity modification, and medical ther-apy (NSAIDs or steroid injection) When the decreased ROM and pain no longerrespond adequately to conservative management, surgical options should be con-sidered Before proceeding with arthroplasty, the primary contraindications (priorinfection and loss of adequate motors) as well as alternative treatments must bereviewed

Because the index finger is more often used as a “post” against which thethumb pinches than for grasping, index PIP joint stability is more critical thanabsolute motion If OA progresses to the point of debilitating pain and/or de-formity at this joint, we prefer PIP joint arthrodesis, as an arthroplasty has dif-ficulty resisting the lateral shear of pinch and is likely to collapse into ulnardeviation over time In contradistinction, the more ulnar digits are used pri-marily in grasping, and ROM is of paramount importance In the PIP joints ofthe ring and small fingers, OA is best treated by procedures that maintain ROM,such as Silastic arthroplasty

The functional demands of the patient determine the course of treatment for thelong finger In high-demand patients, the long finger PIP joint should be fused forthe same reasons listed previously for the index finger In the low-demand patientwho would benefit more from ROM than rigid stability, arthroplasty is the bet-ter option In this patient, the index PIP joint was well maintained, and althoughall her DIP joints and the three other PIP joints were significantly degenerated, shehad pain only in the long finger PIP joint In the event that other joints had beensymptomatic, the DIP joints could have been fused or additional PIP arthroplastiesperformed

O S T E O A R T H R I T I S : P R O X I M A L I N T E R P H A L A N G E A L J O I N T ( S I L A S T I C I M P L A N T S )

Surgical Management

Following the induction of general anesthesia and prophylactic administration of

1 g of IV cefazolin, a well-padded tourniquet was applied to the right upper arm.The arm and hand were then prepped with a Betadine scrub solution followed byBetadine paint An impervious stockinet followed by an extremity drape was thenplaced An exam under general anesthesia was undertaken confirming decreasedpassive ROM in the PIP joint with crepitus and firm end points An Esmarch ban-dage was used to exsanguinate the limb, after which the tourniquet was inflated to

250 mm Hg; 3.5x loupe magnification was used for all dissection

After standard release of the index and long finger A1 pulley with tomy, attention was directed to the PIP joint Silastic arthroplasty A radially basedvolar V-shaped flap was created with its apex along the midaxial line at the long fin-ger’s PIP flexion crease (Fig 67–2) This flap was bluntly elevated off the underlyingflexor sheath Care was taken to avoid damage to the neurovascular bundles; crossingvessels were coagulated with bipolar cautery A transverse flexor sheath incision wasmade at the distal end of the second annular (A2) pulley A similar incision was made

tenosynovec-at the proximal edge of the A4 pulley These transverse incisions were then converted

to an ulnar-based rectangular flap by incising the radial border of the A3 pulley andsheath The flexor digitorum superficialis (FDS) and flexor digitorum profundus(FDP) tendons were retracted radially through this window in their sheath, exposingthe volar plate The volar plate was incised along its radial, ulnar, and distal borders,freeing it from the middle phalanx (P2) and reflecting it proximally The collateralligaments were recessed by inserting a No 15 scalpel blade between the ligament and

428

Skin incision Incise flexor sheath

between A-2 & A-4

Retract flexor tendons

& tendon sheath.

Incise volar plate

Retract volar plate.

Release collateral ligaments

"Shotgun" exposure of arthritic PIP joint

Figure 67–2 Volar approach

to the proximal langeal joint.

interpha-articular surface The blade was then worked proximally to release the ligament’s gin of the head of the proximal phalanx This allowed hyperextension of the PIPjoint to 180 degrees (“shotgun” exposure of the PIP joint) such that the dorsal aspect

ori-of P2 was lying against the dorsal aspect ori-of the proximal phalanx (P1)

With the PIP joint fully exposed, it became evident that there was virtually noarticular cartilage remaining intact The excess osteophytes at the proximal P2 wereresected with the exception of the dorsal border, where aggressive resection wouldrisk iatrogenic detachment of the central slip The head of P1 was then transverselyresected using a microsagittal saw just distal to the collateral ligament origin Theblunt leader-tip burs provided with the Swanson Silastic implant set were then used

to find and broaden the passage into the intramedullary canal of both P1 and P2.Great care was taken to ensure that perforation of the phalanx shaft did not occur.Progressively larger sizing rasps were then used to enlarge and square-off the boneends first of P1 and then of P2 After attaining good “fit and fill” with the No 2rasp, a No 2 trial implant was inserted as a spacer between the bone ends The PIPjoint was then passively flexed to 100 degrees A similar trial was then undertaken

by atraumatically pulling on the FDP (through the previously made A1 pulley sion), demonstrating that the long finger flexed fully to the distal palmar crease.There was a tendency for ulnar deviation requiring further release of the ulnar col-lateral ligament (UCL) A No 15 scalpel was inserted between the UCL and the P1,then gently worked proximally, freeing-up the more distal aspect of its origin untilany soft tissue restraint to axial alignment was corrected

inci-After removal of the trial implant, two drill holes were placed in the volar aspect

of P2 for later volar plate repair The wound and bone ends were copiously irrigatedwith normal saline solution A No 2 Swanson Silastic implant was then opened anddipped in saline Care was taken to avoid handling the implant with anything otherthan blunt-tipped forceps The proximal stem was placed into P1 first while holdingthe joint in hyperextension With the proximal end firmly seated, the distal stemwas gently held and bent up into P2 while bringing the PIP joint back to a neutralposition The joint was again put through a full arc of motion using fluoroscopic ex-amination to confirm that the prosthesis did not buckle and that the finger trackednormally No grommets were used

The wounds were again irrigated The volar plate was repaired to the two previouslyplaced drill holes in P2 using 4–0 Ethibond suture The FDS and FDP tendons werethen allowed to fall back into their bed, and a partial closure of the sheath and A3pulley was undertaken using 6–0 nylon suture The tourniquet was deflated at 90 min-utes and hemostasis was attained using bipolar electrocautery at all three incisions Theskin was then closed with 4–0 nylon suture in simple, interrupted fashion After place-ment of Bacitracin ointment and an Adaptic dressing, a dry gauze dressing and volarplaster splint were placed, holding the wrist in 30 degrees of extension, the MPs flexed

70 degrees, and the IP joints fully extended and adjacent to one another, ing axial, angular, and rotational alignment Micropore tape (three-fourths circumfer-ential) placed between the index and long finger further aided positional control

maintain-Postoperative Management

The patient returned to the office on postoperative day 2 with only moderate pain Shewas fitted with a removable thermoplastic resting splint and started on light mobiliza-tion under the guidance of a certified hand therapist three times per week On postop-erative day 9 she was reevaluated Her wound was benign but her finger was still quite

O S T E O A R T H R I T I S : P R O X I M A L I N T E R P H A L A N G E A L J O I N T ( S I L A S T I C I M P L A N T S )

swollen ROM of the long finger PIP joint was 20 to 30 degrees active and 20 to 60degrees passive Sutures were removed and Steri-strips applied She was started on aCoban wrapping protocol for edema control and was fitted with additional “blockingsplints,” which allow for DIP motion while preventing PIP motion and vice versa.Physical therapy was discontinued at 9 weeks postoperation and she was in-structed in a home exercise program She was seen again in the office at 2.5 monthsand had a painless active arc of motion at the long finger PIP from 20 to 60 degreeswith passive arc from 0 to 90 degrees She demonstrated composite active flexion towithin 3 cm of the distal palmar crease.

Alternative Methods of Management

Alternative methods of managing OA of the PIP joint apply to three areas: alternativesurgical approaches to the PIP joint for Silastic arthroplasty, alternative implants, andalternative reconstructive procedures (Table 67–2) The approach to the PIP joint may

Allows visualization and pulation of central slip with-out requiring its release

mani-Predictable results; adequate,pain-free motion in mostcases

Stable construct with ble results; may be used inheavy labor

predicta-Provides an intact, stable jointwith the potential forfurther growth in childrenReplaces joint surface withbiologic material withtheoretic long-termadvantages

Allows reconstruction of largebony defects with biologictissue

Interposition procedures arerelatively simple comparedwith other biologicarthroplasties

Can’t be used if central slip islax, avulsed, or covered inosteophyte

Requires central slip release andrepair; delays postoperativemobilization

Requires release of at least one

or both collateral ligaments;

more complex approach

Relative radial/ulnar ity; risk of particulate weardebris

instabil-Significant decrease in finger’sROM, preventing firm grasp

Difficult procedure, lesspredictable results; signifi-cant donor site morbidityLess predictable results; can’tresurface both sides of jointwith good results; slightdonor site morbidityTechnically demanding; ad-dresses only one side of thejoint; unpredictable resultsExternal fixator applicationcan be technically demand-ing; ROM and pain reliefnot as predictable as in sili-cone arthroplasty

Our approach of choice

Used in boutonniere deformity

Used when the condition ofthe central slip is uncertain

Not indicated after infection

May be used after or duringinfection; less ideal in thelong, ring, and small fingersOccasionally indicated inchildren with posttraumaticarthritis

Not indicated after infection;works best in patients <30years old

Best reserved for young patientswith large bony defects

Consideration in young patientswith both sides of jointinvolved and with minimalbone loss