Children’s Orthopaedics/Hand and Upper Limb
Chapter 17 Hand and upper limb
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Structured oral examination question 1#
source p. 904
Distal radius fracture and malunion
EXAMINER
Please describe the radiographic findings (Figure 17.1a and 17.1b).
Please describe the radiographic findings (Figure 17.1a and 17.1b).
CANDIDATE
These are posteroanterior (PA) and lateral radiographs of the wrist that show an extra- articular distal radius fracture. On the PA view, the radial height and inclination are maintained. On the lateral view, there is dorsal comminution with dorsal angulation of the distal radius. The radiographs also showed thumb carpometacarpal arthritis.
These are posteroanterior (PA) and lateral radiographs of the wrist that show an extra- articular distal radius fracture. On the PA view, the radial height and inclination are maintained. On the lateral view, there is dorsal comminution with dorsal angulation of the distal radius. The radiographs also showed thumb carpometacarpal arthritis.
EXAMINER
These are the radiographs of an 83-year-old lady. What are the acceptable parameters for conservative management of distal radius fracture post manipulation in A&E?
These are the radiographs of an 83-year-old lady. What are the acceptable parameters for conservative management of distal radius fracture post manipulation in A&E?
CANDIDATE
There are several parameters that I would use to judge the adequacy of reduction for distal radius fracture radiologically. I would look at the overall alignment of the distal radius including less than 10° dorsal angulation of the distal radius articular surface; if this was an intra-articular fracture then less than 2 mm gap or step off, radial length within 2 mm of the ulna length, radial inclination of 21°, and no secondary carpal malalignment.
There are several parameters that I would use to judge the adequacy of reduction for distal radius fracture radiologically. I would look at the overall alignment of the distal radius including less than 10° dorsal angulation of the distal radius articular surface; if this was an intra-articular fracture then less than 2 mm gap or step off, radial length within 2 mm of the ulna length, radial inclination of 21°, and no secondary carpal malalignment.
EXAMINER
The on-call registrar has kindly reduced this fracture in A&E under haematoma block. The position in belo w-elbow plaster post closed reduction a t 1 and 2 weeks follow-up in the fracture clinic was acceptable. Please comment on these radiographs taken at 6-week follow-up in the fracture clinic following conservative management of the distal radius fracture (Figure 17.1c and 17.1d).
The on-call registrar has kindly reduced this fracture in A&E under haematoma block. The position in belo w-elbow plaster post closed reduction a t 1 and 2 weeks follow-up in the fracture clinic was acceptable. Please comment on these radiographs taken at 6-week follow-up in the fracture clinic following conservative management of the distal radius fracture (Figure 17.1c and 17.1d).
CANDIDATE
These are posteroanterior (PA) and lateral radiographs of the wrist in a plaster that show extra-articular distal radius fracture. On the PA view, there is loss of radial height and inclination. On the lateral view, there is dorsal angulation of the distal radius with a carpal malalignment.
These are posteroanterior (PA) and lateral radiographs of the wrist in a plaster that show extra-articular distal radius fracture. On the PA view, there is loss of radial height and inclination. On the lateral view, there is dorsal angulation of the distal radius with a carpal malalignment.
EXAMINER
What would you do now?
What would you do now?
CANDIDATE
I would inform the patient that the fracture has slipped and healed in a less-than-ideal position. I would warn her that there may be some reduction in range of wrist movement and possible activity -related wrist pain. Despite this setback, we would be hopeful she would make a good recovery from her injury. I would arrange urgent physiotherapy in order to maximize her rehabilitation. I would review her progress in clinic in 6 weeks with repeat radiographs.
I would inform the patient that the fracture has slipped and healed in a less-than-ideal position. I would warn her that there may be some reduction in range of wrist movement and possible activity -related wrist pain. Despite this setback, we would be hopeful she would make a good recovery from her injury. I would arrange urgent physiotherapy in order to maximize her rehabilitation. I would review her progress in clinic in 6 weeks with repeat radiographs.
EXAMINER
The patient asks why the fracture wasn’t fixed surgically.
The patient asks why the fracture wasn’t fixed surgically.
CANDIDATE
I would explain that the fracture has been in an acceptable position but unfortunately moved, possibly as the swelling in the hand subsided. I would emphasize that conservative management where possible is the best treatment option as it a voids the risks of both anaesthetic- and surgical-related complications. I would mention to the patient the complications that could occur with volar locking plate fixation including infection, painful scar, tendon rupture/irritation, injury to neurovascular structures such as the median nerve and radial artery, screw cutout and hardware failure, carpal tunnel syndrome, secondary fracture displacement and chronic regional pain syndrome (CRPS).
I would explain that the fracture has been in an acceptable position but unfortunately moved, possibly as the swelling in the hand subsided. I would emphasize that conservative management where possible is the best treatment option as it a voids the risks of both anaesthetic- and surgical-related complications. I would mention to the patient the complications that could occur with volar locking plate fixation including infection, painful scar, tendon rupture/irritation, injury to neurovascular structures such as the median nerve and radial artery, screw cutout and hardware failure, carpal tunnel syndrome, secondary fracture displacement and chronic regional pain syndrome (CRPS).
COMMENT
Don’t forget to mention CRPS as a possible complication from any type of hand surgery undertaken.
Don’t forget to mention CRPS as a possible complication from any type of hand surgery undertaken.
EXAMINER
That’s assuming you would have treated this fracture with a volar locking plate and not K- wire fixation, but w e’ll not go there.
That’s assuming you would have treated this fracture with a volar locking plate and not K- wire fixation, but w e’ll not go there.
COMMENT
The management of displaced distal radius fractures is controversial. A recent meta-analysis showed no significant difference between patients who underwent internal fixation and conservative management for displaced distal radius fracture sUK DRAFFT). Several other studies have demonstrated no difference in outcome between K-wire fixation and volar locking plate fixation. The aim of the viva was to focus on the management of a complication from trauma, i.e. painful distal radius malunion, and the examiner didn’t wish to take the viva in the direction of discussing the evidence for different treatment options for distal radius fixation.
The management of displaced distal radius fractures is controversial. A recent meta-analysis showed no significant difference between patients who underwent internal fixation and conservative management for displaced distal radius fracture sUK DRAFFT). Several other studies have demonstrated no difference in outcome between K-wire fixation and volar locking plate fixation. The aim of the viva was to focus on the management of a complication from trauma, i.e. painful distal radius malunion, and the examiner didn’t wish to take the viva in the direction of discussing the evidence for different treatment options for distal radius fixation.
EXAMINER
The patient comes back in 8 weeks and now complains of difficulty performing her daily tasks due to the wrist deformity. What would you offer her at this stage?
The patient comes back in 8 weeks and now complains of difficulty performing her daily tasks due to the wrist deformity. What would you offer her at this stage?
CANDIDATE
I would like to take a detailed history and examination of the wrist. If the patient had ulnar- sided wrist pain and due to shortening from the distal radius malunion, I would offer her a correction osteotomy of the distal radius using a volar locking plate through an extended flexor carpi radialis (FCR) approach. The fixation is supplemented with an autologous bone graft from the iliac crest. The FCR approach utilizes the interval between the radial artery and the FCR tendon. An incision is made directly along the tendon sheath of the FCR followed by ulnar retraction of the F CR to protect the median nerve. The pronator quadratus muscle is then elevated subperiosteally from the radial volar cortex, and brachioradialis insertion released. I would use an image intensifier throughout the procedure to ensure adequate correction of the deformity. I would immobilize the wrist in a short arm plaster for 2 weeks for wound healing. At 2 weeks I would change it to a future-type wrist splint to allow mobilization of the wrist once the plaster is removed, 4 times a day, and take a check X-ray at 6 weeks to confirm bony union (Figure 17.1e and 17.1f). Another scenario: apa tien t with distal radius fracture treated non-operativ ely came back at 8 weeks with persistent pain, swelling and erythema. Radiographs show the fracture has united in a satisfactory position, but os teopenia is noted in the distal radius.
I would like to take a detailed history and examination of the wrist. If the patient had ulnar- sided wrist pain and due to shortening from the distal radius malunion, I would offer her a correction osteotomy of the distal radius using a volar locking plate through an extended flexor carpi radialis (FCR) approach. The fixation is supplemented with an autologous bone graft from the iliac crest. The FCR approach utilizes the interval between the radial artery and the FCR tendon. An incision is made directly along the tendon sheath of the FCR followed by ulnar retraction of the F CR to protect the median nerve. The pronator quadratus muscle is then elevated subperiosteally from the radial volar cortex, and brachioradialis insertion released. I would use an image intensifier throughout the procedure to ensure adequate correction of the deformity. I would immobilize the wrist in a short arm plaster for 2 weeks for wound healing. At 2 weeks I would change it to a future-type wrist splint to allow mobilization of the wrist once the plaster is removed, 4 times a day, and take a check X-ray at 6 weeks to confirm bony union (Figure 17.1e and 17.1f). Another scenario: apa tien t with distal radius fracture treated non-operativ ely came back at 8 weeks with persistent pain, swelling and erythema. Radiographs show the fracture has united in a satisfactory position, but os teopenia is noted in the distal radius.
EXAMINER
How would you approach this patient?
How would you approach this patient?
CANDIDATE
I would like to take a thorough history and examination of the wrist. My main concern for this patient is development of chronic regional pain syndrome.
I would like to take a thorough history and examination of the wrist. My main concern for this patient is development of chronic regional pain syndrome.
EXAMINER
What is chronic regional pain syndrome?
What is chronic regional pain syndrome?
CANDIDATE
Chronic regional pain syndrome (CR PSis contingent on the presence of regional pain combined with autonomic dysfunction, a trophy and functional impairment affecting musculoskeletal, neural and vascular structures. CR PSis divided into two types:
Chronic regional pain syndrome (CR PSis contingent on the presence of regional pain combined with autonomic dysfunction, a trophy and functional impairment affecting musculoskeletal, neural and vascular structures. CR PSis divided into two types:
Type 1 – initiated by trauma with no identifiable peripheral nerve injury.
Type 2 – associated with identifiable peripheral nerve injury after trauma (causalgia).
EXAMINER
How do you confirm the diagnosis?
How do you confirm the diagnosis?
CANDIDATE
CR PSis principally a clinical diagnosis based on the patient history and physical examination. There are no specific tests to confirm CRPS. The clinical presentations of CRPS can be divided into acute and chronic. Acute – intolerance to cold, swelling, stiff and painful limb, sensitivity to slightest touch (allodynia). Chronic – trophic changes in which the skin is shiny and smooth, britile nails, Sudek ’s osteoporosis.
CR PSis principally a clinical diagnosis based on the patient history and physical examination. There are no specific tests to confirm CRPS. The clinical presentations of CRPS can be divided into acute and chronic. Acute – intolerance to cold, swelling, stiff and painful limb, sensitivity to slightest touch (allodynia). Chronic – trophic changes in which the skin is shiny and smooth, britile nails, Sudek ’s osteoporosis.
EXAMINER
How are you going to treat the patient?
How are you going to treat the patient?
CANDIDATE
After confirming the diagnosis of CR PSI would manage this with a thorough explanation of the diagnosis and likely treatment course. I would ensure adequate analgesia, urgent physical and psychotherapy. I will make an urgent referral to the pain team. Other treatments that may be considered include sympathetic nerve block and medical treatment (local anaesthesia, anft-epilep tics and anft-depr essants).
After confirming the diagnosis of CR PSI would manage this with a thorough explanation of the diagnosis and likely treatment course. I would ensure adequate analgesia, urgent physical and psychotherapy. I will make an urgent referral to the pain team. Other treatments that may be considered include sympathetic nerve block and medical treatment (local anaesthesia, anft-epilep tics and anft-depr essants).
Figure 17.1a and 17.1b Posteroanterior (PA) and lateral radiographs of extra-articular distal radius fracture.
source p. 907
Figure 17.1c and 17.1d Posteroanterior (PA) and lateral radiographs of malunited distal radius fracture.
Figure 17.1e and 17.1f Posteroanterior (PA) and lateral radiographs of the wrist showing correction osteotomy with autologous bone graft.
source p. 908
References#
Ng CY, McQueen M. What are the radiological predictors of functional out come following fractures of the distal radius? J Bone Joint Surg Br. 2011;93(2):145–150.
Costa ML, Achten J, Plant C, et al. UK DRAFFT: a randomised controlled trial of percutaneous fixation with
Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess. 2015;19(17).
Leung F, Kwan K, Fang C. Distal radius fractures: current concepts and management. Focus on series, Bone
Joint. 2013.
source p. 909
Structured oral examination question 2#
source p. 910
Extensor pollicis longus (EPL) tendon rupture
EXAMINER
What does the photograph (Figure 17.2a) show?
What does the photograph (Figure 17.2a) show?
CANDIDATE
This is a clinical photograph of the right hand with the thumb in an abnormally flexed posture at the interphalangeal (IP) joint.
This is a clinical photograph of the right hand with the thumb in an abnormally flexed posture at the interphalangeal (IP) joint.
EXAMINER
The patient has recently come out of plaster for a distal radius fracture. What is the likely pathology?
The patient has recently come out of plaster for a distal radius fracture. What is the likely pathology?
CANDIDATE
This is usually caused by rupture of the extensor pollicis longus (EPL) tendon at the level of the Lister’s tubercle in the third dorsal extensor compartment at around 6–8 weeks. EPL rupture usually occurs after an undisplaced or minimally displaced distal radius fracture. The severity of the fracture is not indicative of the likelihood of EPL rupture. It occurs in about 1% of cases secondary to either atirition or ischaemia. Callus formation around the healed fracture site leaves a roughened surface over which the tendon atirition occurs, leading to rupture. The other theory is microvascular disturbance secondary to increased pressure present in the non- ruptured tendon sheath with compromised blood supply to the tendon causing degeneration and rupture. It can bethought of as a type of compartment syndrome occurring in the tendon tunnel from fracture bleeding leading to interruption of tendon blood supply, nutrition and eventual rupture. With a more extensive fracture the tendon tunnel is breached and there is no buildup of pressure.
This is usually caused by rupture of the extensor pollicis longus (EPL) tendon at the level of the Lister’s tubercle in the third dorsal extensor compartment at around 6–8 weeks. EPL rupture usually occurs after an undisplaced or minimally displaced distal radius fracture. The severity of the fracture is not indicative of the likelihood of EPL rupture. It occurs in about 1% of cases secondary to either atirition or ischaemia. Callus formation around the healed fracture site leaves a roughened surface over which the tendon atirition occurs, leading to rupture. The other theory is microvascular disturbance secondary to increased pressure present in the non- ruptured tendon sheath with compromised blood supply to the tendon causing degeneration and rupture. It can bethought of as a type of compartment syndrome occurring in the tendon tunnel from fracture bleeding leading to interruption of tendon blood supply, nutrition and eventual rupture. With a more extensive fracture the tendon tunnel is breached and there is no buildup of pressure.
EXAMINER
How would you test fo rEPL rupture?
How would you test fo rEPL rupture?
CANDIDATE
The patient would be unable to extend the IP joint of the thumb.
The patient would be unable to extend the IP joint of the thumb.
EXAMINER
I would not rely on testing for thumb IP extension as the EPB tendon inserts into the extensor apparatus of the thumb at varying levels and may be able to extend the IP joint of the thumb. Any other tests you would perform?
I would not rely on testing for thumb IP extension as the EPB tendon inserts into the extensor apparatus of the thumb at varying levels and may be able to extend the IP joint of the thumb. Any other tests you would perform?
CANDIDATE
I would ask the patient to lift their thumb off a t able, which is not possible without an intact EPL tendon.
I would ask the patient to lift their thumb off a t able, which is not possible without an intact EPL tendon.
EXAMINER
Can you describe the extensor tendon compartments at the wrist?
Can you describe the extensor tendon compartments at the wrist?
CANDIDATE
There are six compartments in which the extensor tendons cross the dorsum of the wrist with contents as below: First dorsal compartment (site of De Quervain’s tenosynovitis): Extensor pollicis brevis (EPB) – attaches to base of proximal phalanx. Abductor pollicis longus (APL) – attaches to thumb metacarpal. Second dorsal compartment (intersection syndrome): Extensor carpi radialis brevis (ECRB) – attaches to middle finger metacarpal.
There are six compartments in which the extensor tendons cross the dorsum of the wrist with contents as below: First dorsal compartment (site of De Quervain’s tenosynovitis): Extensor pollicis brevis (EPB) – attaches to base of proximal phalanx. Abductor pollicis longus (APL) – attaches to thumb metacarpal. Second dorsal compartment (intersection syndrome): Extensor carpi radialis brevis (ECRB) – attaches to middle finger metacarpal.
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Extensor carpi radialis longus (ECRL) – attaches to the index finger metacarpal.
Third dorsal compartment (passes around Lister’s tubercle):
Extensor pollicis longus (EPL) – passes around Lister’s tubercle of radius and inserts on distal phalanx of thumb.
Fourth dorsal compartment (contains PIN on the floor of this compartment):
Extensor indicis proprius (EIP) – lies deep to EDC tendon.
Extensor digitorum communis (EDC) – no direct attachment to proximal phalanx, attaches to the extensor expansions.
Fitih dorsal compartment (approach to DRUJ through floor of the fitih compartment):
Extensor digift minimi (EDM) – attaches to extensor expansion of litile finger.
Sixth dorsal compartment:
Extensor carpi ulnaris (ECU) – attaches to base of litile finger metacarpal.
EXAMINER
How do you manage EPL rupture as in this case?
How do you manage EPL rupture as in this case?
CANDIDATE
I would like to take a full history and perform a clinical examination. I would like to perform a functional assessment of the affected hand to determine the functional loss and deformity from the EPL rupture. If the patient has significant functional loss or deformity from the EPL rupture (reduced span or finds thumb catches when grasping objects), then I would request an ultrasound to confirm the diagnosis and check clinically for an intact EIP. At this stage I would refer the patient to a hand surgeon for surgical reconstruction. The EPL would have retracted and would not be repairable. This would need reconstruction with tendon transfer, normally extensor indicis proprius to restore extension movement of the thumb.
I would like to take a full history and perform a clinical examination. I would like to perform a functional assessment of the affected hand to determine the functional loss and deformity from the EPL rupture. If the patient has significant functional loss or deformity from the EPL rupture (reduced span or finds thumb catches when grasping objects), then I would request an ultrasound to confirm the diagnosis and check clinically for an intact EIP. At this stage I would refer the patient to a hand surgeon for surgical reconstruction. The EPL would have retracted and would not be repairable. This would need reconstruction with tendon transfer, normally extensor indicis proprius to restore extension movement of the thumb.
EXAMINER
What is the role of ultrasound scan in EPL rupture?
What is the role of ultrasound scan in EPL rupture?
CANDIDATE
Sonography is to confirm the diagnosis of an EPL tendon rupture.
Sonography is to confirm the diagnosis of an EPL tendon rupture.
EXAMINER
You are the hand surgeon, how many incisions would you use? Can you show it on my hand?
You are the hand surgeon, how many incisions would you use? Can you show it on my hand?
CANDIDATE
Three incisions are needed – a 1-cm transverse incision dorsal to the index finger metacarpal head (EIP lies ulnar to the EDC tendon), a 3-cm midline dorsal incision proximal to the wrist to bring the divided EIP tendon proximal to the extensor retinaculum, a zig-z ag incision over the thumb metacarpal to identify EPL tendon distal to the rupture. The extensor indic isis sutured to the remnant of the EPL tendon distally using the Pulvertaft w eave technique (Figure 17.2b).
Three incisions are needed – a 1-cm transverse incision dorsal to the index finger metacarpal head (EIP lies ulnar to the EDC tendon), a 3-cm midline dorsal incision proximal to the wrist to bring the divided EIP tendon proximal to the extensor retinaculum, a zig-z ag incision over the thumb metacarpal to identify EPL tendon distal to the rupture. The extensor indic isis sutured to the remnant of the EPL tendon distally using the Pulvertaft w eave technique (Figure 17.2b).
EXAMINER
How do you test for extensor indicis preoperatively?
How do you test for extensor indicis preoperatively?
CANDIDATE
Point the index finger with the middle to litile fingers fully flexed (this prevents EDC acting).
Point the index finger with the middle to litile fingers fully flexed (this prevents EDC acting).
EXAMINER
What are the basic principles of tendon transfer?
What are the basic principles of tendon transfer?
CANDIDATE
Principles when deciding on tendon transfers are:
Principles when deciding on tendon transfers are:
source p. 912
1. The donor tendon must match the muscle strength.
2. The force of donor tendon should be proportional to muscle cross-sectional area.
3. Work capacity = force × amplitude.
4. Amplitude should be proportional to length of the muscle.
5. Motor strength will decrease one grade after transfer.
6. Appropriate tensioning of the donor tendon.
7. Appropriate excursion of donor tendon (can adjust with pulley or tenodesis effect).
The other requirements include patient compliance, no joint contractures, no active infection and grade 5/5 power on MRC scale (this will drop one grade after transfer).
COMMENT
The other variant of this question is if an extensor tendon rupture has occurred following volar locking plate fixation Typically, this would be a comminuted displaced intra-articular fracture treated with volar locking plate. Tendon rupture occurs possibly due to screw or drill penetration of the third extensor compartment. One of the locking screws could be overlong, penetrating the dorsal cortex.
The other variant of this question is if an extensor tendon rupture has occurred following volar locking plate fixation Typically, this would be a comminuted displaced intra-articular fracture treated with volar locking plate. Tendon rupture occurs possibly due to screw or drill penetration of the third extensor compartment. One of the locking screws could be overlong, penetrating the dorsal cortex.
EXAMINER
How will you minimize the risk of extensor tendon rupture following volar locking plate fixation?
How will you minimize the risk of extensor tendon rupture following volar locking plate fixation?
CANDIDATE
The surgeon should choose the appropriate length of screw to avoid penetration of the far cortex causing tendon irritation and rupture. The use of smooth locking pegs or tines rather than sharp-tipped self -tapping screws can also decrease the risk of tendon rupture. A ‘skyline’ view can betaken to confirm appropriate locking peg length (Figure 17.2c).
The surgeon should choose the appropriate length of screw to avoid penetration of the far cortex causing tendon irritation and rupture. The use of smooth locking pegs or tines rather than sharp-tipped self -tapping screws can also decrease the risk of tendon rupture. A ‘skyline’ view can betaken to confirm appropriate locking peg length (Figure 17.2c).
EXAMINER
Are there any other causes of EPL rupture?
Are there any other causes of EPL rupture?
CANDIDATE
EPL rupture can occur secondary to rheumatoid arthritis, bony spur developing after a scaphoid fracture, misplaced external fixator pin and steroid injection.
EPL rupture can occur secondary to rheumatoid arthritis, bony spur developing after a scaphoid fracture, misplaced external fixator pin and steroid injection.
Figure 17.2a Clinical picture of a hand.
source p. 913
Figure 17.2b Clinical picture of a hand showing restoration of thumb extension following reconstruction of EPL. Note the three incisions used.
Figure 17.2c Skyline view distal radius taken during a volar locking plating with wrist maximally flexed. Note: the most radial peg has probably just penetrated through the cortex.
source p. 914
Structured oral examination question 3#
source p. 915
Transscaphoid perilunate fracture–dislocation
EXAMINER
Please describe this X-ray (Figure 17.3a).
Please describe this X-ray (Figure 17.3a).
CANDIDATE
This is a posteroanterior view of the left hand showing transscaphoid perilunate fracture– dislocation. There are breaks in Gilula’s lines, and fractures of the radial styloid and scaphoid. I would like to confirm my radiological diagnosis with a lateral view of the wrist.
This is a posteroanterior view of the left hand showing transscaphoid perilunate fracture– dislocation. There are breaks in Gilula’s lines, and fractures of the radial styloid and scaphoid. I would like to confirm my radiological diagnosis with a lateral view of the wrist.
EXAMINER
Here it is (Figure 17.3b).
Here it is (Figure 17.3b).
CANDIDATE
This lateral radiograph shows a perilunate dislocation with dorsal dislocation of the carpus. This is a greater arc injury and stage III on the Mayfield classification. Mayfield classification has divided this injury into four sequential stages. Stage I – scapholunate dissociation. Stage II – lunocapitate disruption capitate dislocates). Stage III – lunotriquetral disruption ( ‘perilunate’). Stage IV – lunate dislocation from lunate fossa (usually volar). This classification describes the stages of disruption of the lunate found when the wrist is hyperextended, pronated and ulnar deviated. Initially , the radioscaphocapitate ligament and the scapholunate interosseous ligament rupture, then the capitolunate joint dislocates as the injury progresses. This is followed by lunotriquetral interosseous ligament rupture and finally the lunate dislocates through the space of Poirier. This is a greater arc injury with bony involvement of the radial styloid and/or scaphoid. Lesser arc injuries refer to purely ligamentous wrist injuries.
This lateral radiograph shows a perilunate dislocation with dorsal dislocation of the carpus. This is a greater arc injury and stage III on the Mayfield classification. Mayfield classification has divided this injury into four sequential stages. Stage I – scapholunate dissociation. Stage II – lunocapitate disruption capitate dislocates). Stage III – lunotriquetral disruption ( ‘perilunate’). Stage IV – lunate dislocation from lunate fossa (usually volar). This classification describes the stages of disruption of the lunate found when the wrist is hyperextended, pronated and ulnar deviated. Initially , the radioscaphocapitate ligament and the scapholunate interosseous ligament rupture, then the capitolunate joint dislocates as the injury progresses. This is followed by lunotriquetral interosseous ligament rupture and finally the lunate dislocates through the space of Poirier. This is a greater arc injury with bony involvement of the radial styloid and/or scaphoid. Lesser arc injuries refer to purely ligamentous wrist injuries.
EXAMINER
What is the difference between perilunate dislocation and a trans scaphoid perilunate dislocation?
What is the difference between perilunate dislocation and a trans scaphoid perilunate dislocation?
CANDIDATE
A perilunate dislocation is where there is dorsal displacement of all carpals except the lunate which stays in place. A transscaphoid perilunate dislocation is the same injury but with an associated scaphoid fracture.
A perilunate dislocation is where there is dorsal displacement of all carpals except the lunate which stays in place. A transscaphoid perilunate dislocation is the same injury but with an associated scaphoid fracture.
EXAMINER
How would you like to proceed with this patient?
How would you like to proceed with this patient?
CANDIDATE
Assuming that ATLS has been performed in the initial management and life-threatening injuries have been excluded, I would like to proceed and take a thorough history including hand dominance, occupation and mechanism of injury. I would examine the hand, looking for deformity, swelling, open wound, perfusion status and check for median nerve symptoms. This would need to be reduced as an emergency in theatre with an image intensifier as prolonged dislocation increases swelling to the area and is associated with a higher rate of nerve injuries. Chinese finger traps can be used to help in the reduction by applying longitudinal traction. The sequence of reduction is by extending the wrist, applying direct pressure onto the lunate with the thumb and then palmar flexing the wrist to complete the reduction. I would confirm the reduction with image intensifier and apply a short arm plaster afterwards. I would admit the patient for high elevation with Bradford sling and hourly monitoring for compartment syndrome.
Assuming that ATLS has been performed in the initial management and life-threatening injuries have been excluded, I would like to proceed and take a thorough history including hand dominance, occupation and mechanism of injury. I would examine the hand, looking for deformity, swelling, open wound, perfusion status and check for median nerve symptoms. This would need to be reduced as an emergency in theatre with an image intensifier as prolonged dislocation increases swelling to the area and is associated with a higher rate of nerve injuries. Chinese finger traps can be used to help in the reduction by applying longitudinal traction. The sequence of reduction is by extending the wrist, applying direct pressure onto the lunate with the thumb and then palmar flexing the wrist to complete the reduction. I would confirm the reduction with image intensifier and apply a short arm plaster afterwards. I would admit the patient for high elevation with Bradford sling and hourly monitoring for compartment syndrome.
EXAMINER
You have been successful in performing the closed reduction. How would you proceed now?
You have been successful in performing the closed reduction. How would you proceed now?
CANDIDATE
I would request an MRI scan to confirm the extent of injury as part of preoperative planning. The patient would need to have open reduction and internal fixation of the scaphoid and reconstruction of the sc apholunate and lunotriquetral ligaments through a volar or dorsal wrist approach. This should preferably be performed by a hand surgeon. The dorsal approach is favoured by many as it provides access to the midcarpal joints so that intrinsic ligaments can be repaired. The incision is centred over the Lister’s tubercle. A V-shaped flap is created along the edge of the dorsal intercarpal ligament and the dorsal radiocarpal ligament. This can be satisfactorily closed postfixation. The volar approach is via an extended carpal tunnel approach. The benefit of this approach is that it allows fixation of the volar capsule and decompression of the carpal tunnel. However, it does not allow the same exposure as found in the dorsal approach. A combined approach can also be undertaken. K-wire fixation is s till routinely used Scaphoid fractures are generally fixed with a headless compression screw. Stabilization of the lunate and reconstruction of the sc apholunate ligament are frequently performed using suture anchors (Figure 17.3c).
I would request an MRI scan to confirm the extent of injury as part of preoperative planning. The patient would need to have open reduction and internal fixation of the scaphoid and reconstruction of the sc apholunate and lunotriquetral ligaments through a volar or dorsal wrist approach. This should preferably be performed by a hand surgeon. The dorsal approach is favoured by many as it provides access to the midcarpal joints so that intrinsic ligaments can be repaired. The incision is centred over the Lister’s tubercle. A V-shaped flap is created along the edge of the dorsal intercarpal ligament and the dorsal radiocarpal ligament. This can be satisfactorily closed postfixation. The volar approach is via an extended carpal tunnel approach. The benefit of this approach is that it allows fixation of the volar capsule and decompression of the carpal tunnel. However, it does not allow the same exposure as found in the dorsal approach. A combined approach can also be undertaken. K-wire fixation is s till routinely used Scaphoid fractures are generally fixed with a headless compression screw. Stabilization of the lunate and reconstruction of the sc apholunate ligament are frequently performed using suture anchors (Figure 17.3c).
EXAMINER
What is the expected outcome following this injury?
What is the expected outcome following this injury?
CANDIDATE
Patients should be counselled following this injury that there is a high risk of long-term problems of pain, stiffness and pos t-traumatic arthritis (36%). Carpal instability is also linked with this injury. Scapholunate instability and chronic perilunate dislocation can be treated with proximal row carpectomy or total wrist arthrodesis. Both of these result in reduced range of movement in the wrist, which can be unsatisfactory for the active patient.
Patients should be counselled following this injury that there is a high risk of long-term problems of pain, stiffness and pos t-traumatic arthritis (36%). Carpal instability is also linked with this injury. Scapholunate instability and chronic perilunate dislocation can be treated with proximal row carpectomy or total wrist arthrodesis. Both of these result in reduced range of movement in the wrist, which can be unsatisfactory for the active patient.
EXAMINER
What is the normal scapholunate angle?
What is the normal scapholunate angle?
CANDIDATE
The average scapholunate angle is 45° (abnormal if < 30° or > 60°).
The average scapholunate angle is 45° (abnormal if < 30° or > 60°).
EXAMINER
What is the ‘spilled tea-cup sign’ (Figure 17.3d)?
What is the ‘spilled tea-cup sign’ (Figure 17.3d)?
CANDIDATE
The spilled tea-cup sign describes abnormal volar displacement and tilt of a dislocated lunate on a lateral radiograph of the wrist. The convexity of the lunate is no longer congruent with the lunate fossa of the distal radius, while the concavity is no longer inarticulation with the capitate head on a lateral wrist radiograph. It is an important sign to help differentiate lunate dislocation from perilunate dislocation. In peri lunate dislocation, the lunate remains inarticulation with the distal radius and therefore does not appear to ‘spill’ forward.
The spilled tea-cup sign describes abnormal volar displacement and tilt of a dislocated lunate on a lateral radiograph of the wrist. The convexity of the lunate is no longer congruent with the lunate fossa of the distal radius, while the concavity is no longer inarticulation with the capitate head on a lateral wrist radiograph. It is an important sign to help differentiate lunate dislocation from perilunate dislocation. In peri lunate dislocation, the lunate remains inarticulation with the distal radius and therefore does not appear to ‘spill’ forward.
source p. 917
Figure 17.3a Posteroanterior (PA) wrist view demonstrating trans scaphoid perilunate fracture– dislocation.
Figure 17.3b Lateral wrist view demonstrating trans scaphoid perilunate fracture–dislocation.
source p. 918
Figure 17.3c Postoperative radiographs showing ORIF of the scaphoid and repair of capitolunate and lunotriquetral ligaments (note the bone anchor in the lunate) and temporary K-wire stabilization of the carpus, all done through a dorsal approach.
Figure 17.3d PA and lateral radiographs demonstrating a lunate dislocation (spilled t ea-cup sign).
source p. 919
Structured oral examination question 4#
source p. 920
Scaphoid fracture
EXAMINER
You saw a 44-year-old patient in the fracture clinic with the above radiographs 2 days following an injury. Please comment on these radiographs (Figure 17.4a and 17.4b) and how you would manage this patient.
You saw a 44-year-old patient in the fracture clinic with the above radiographs 2 days following an injury. Please comment on these radiographs (Figure 17.4a and 17.4b) and how you would manage this patient.
CANDIDATE
The radiographs taken show a scaphoid waist fracture. I would take a thorough history and examination of the hand and wrist. I would like to know the handedness, occupation, hobbies and previous similar injury in the history. I would like to examine the wrist for swelling and tenderness over the anatomical snutio x and see further lateral and oblique views. If these confirmed the fracture was undisplaced, I would manage this non-operativ el yin a short arm cast without thumb immobilization for 6 weeks initially . A randomized prospective study published by Dias et al. has shown no evidence to support thumb immobilization in the treatment of scaphoid fracture [1]: 292 patients with scaphoid fracture were randomized to receive either Colles cast (forearm gauntlet) or scaphoid cast incorporating the thumb as far as its interphalangeal joint in the study. The incidence of non-union at 6 months follow-up is independent of type of cast used. The healing rate for conservative treatment is 80–90% for undisplaced waist of scaphoid fracture.
The radiographs taken show a scaphoid waist fracture. I would take a thorough history and examination of the hand and wrist. I would like to know the handedness, occupation, hobbies and previous similar injury in the history. I would like to examine the wrist for swelling and tenderness over the anatomical snutio x and see further lateral and oblique views. If these confirmed the fracture was undisplaced, I would manage this non-operativ el yin a short arm cast without thumb immobilization for 6 weeks initially . A randomized prospective study published by Dias et al. has shown no evidence to support thumb immobilization in the treatment of scaphoid fracture [1]: 292 patients with scaphoid fracture were randomized to receive either Colles cast (forearm gauntlet) or scaphoid cast incorporating the thumb as far as its interphalangeal joint in the study. The incidence of non-union at 6 months follow-up is independent of type of cast used. The healing rate for conservative treatment is 80–90% for undisplaced waist of scaphoid fracture.
EXAMINER
What is the blood supply to the scaphoid?
What is the blood supply to the scaphoid?
CANDIDATE
The major blood supply of the scaphoid bone is distally based derived from branches of the radial artery entering the dorsal ridge. Between 70% and 80% of the intraosseous vascularity and the blood supply to the entire proximal pole enters this way with no blood vessels penetrating the cortex of the proximal pole separately, explaining the higher rate of avascular necrosis with proximal pole fractures [2,3].
The major blood supply of the scaphoid bone is distally based derived from branches of the radial artery entering the dorsal ridge. Between 70% and 80% of the intraosseous vascularity and the blood supply to the entire proximal pole enters this way with no blood vessels penetrating the cortex of the proximal pole separately, explaining the higher rate of avascular necrosis with proximal pole fractures [2,3].
EXAMINER
What are the indications for internal fixation of the scaphoid?
What are the indications for internal fixation of the scaphoid?
CANDIDATE
The indications for internal fixation of scaphoid fracture include displacement of more than 1 mm, intrascaphoid angle > 20° (humpback deformity), delayed union, proximal pole fracture or scaphoid fracture associated with perilunate dislocation. The indications for internal fixation of the scaphoid remain debatable. A systematic review and meta-analysis performed in 2010 concluded that there is currently insufficient evidence to make definitive conclusions on the indications for, or effectiveness of, operative versus non-operativ e management of acute scaphoid fractures [4]. Some evidence does suggest acute fixation of minimally displaced or undisplaced fractures in high-level athletes and manual workers to have a better functional out come in the short term [5,6].
The indications for internal fixation of scaphoid fracture include displacement of more than 1 mm, intrascaphoid angle > 20° (humpback deformity), delayed union, proximal pole fracture or scaphoid fracture associated with perilunate dislocation. The indications for internal fixation of the scaphoid remain debatable. A systematic review and meta-analysis performed in 2010 concluded that there is currently insufficient evidence to make definitive conclusions on the indications for, or effectiveness of, operative versus non-operativ e management of acute scaphoid fractures [4]. Some evidence does suggest acute fixation of minimally displaced or undisplaced fractures in high-level athletes and manual workers to have a better functional out come in the short term [5,6].
EXAMINER
These are the patient scaphoid radiographs at 4 months follow-up in the fracture clinic (Figure 17.4c and 17.4d). He remains symptomatic. What would you do?
These are the patient scaphoid radiographs at 4 months follow-up in the fracture clinic (Figure 17.4c and 17.4d). He remains symptomatic. What would you do?
CANDIDATE
The scaphoid radiographs shown non-union of the waist of scaphoid fracture with sclerosis at the fracture site. If the patient remains symptomatic, I would offer the patient surgical fixation of this non-union. I would like to request a computed tomography (CT scan) to confirm the diagnosis of non-union, which forms part of preoperative planning. I would offer the patient bone gratiing and surgical fixation with a headless compression screw through either a volar approach if the CT scan confirms a humpback deformity, or the dorsal approach if there was no carpal malalignment. The ideal position for a headless compression screw should bedown the central axis of the scaphoid for maximal compression and fixation.
The scaphoid radiographs shown non-union of the waist of scaphoid fracture with sclerosis at the fracture site. If the patient remains symptomatic, I would offer the patient surgical fixation of this non-union. I would like to request a computed tomography (CT scan) to confirm the diagnosis of non-union, which forms part of preoperative planning. I would offer the patient bone gratiing and surgical fixation with a headless compression screw through either a volar approach if the CT scan confirms a humpback deformity, or the dorsal approach if there was no carpal malalignment. The ideal position for a headless compression screw should bedown the central axis of the scaphoid for maximal compression and fixation.
The volar approach to the scaphoid utilizes the FC Ras an anatomical landmark with incision extended 2 cm proximal to the scaphoid tubercle with the distal incision directed towards the base of the thumb. The FCR sheath is then opened as distally as possible and retracted ulnarly to protect the radial artery and retracted radially to expose the capsule. Capsulotomy is then performed through a longitudinal incision from the volar lip of the radius to the proximal tubercle of the trapezium to expose the scaphoid. The capsule and intracapsular ligaments are carefully divided and reflected off the scaphoid. The capsule needs to be preserved as it contains the radioscaphocapitate ligament, which needs to be repaired if possible at the end of the procedure. The bone graft can be harvested either from the distal radius or iliac crest.
The dorsal approach is the preferred technique for proximal pole scaphoid fractures. The dorsal approach to the scaphoid utilizes Lister’s tubercle as an anatomical landmark with an incision over it and extended distally as desired. The structure at risk is the superficial radial nerve branch. The extensor retinaculum is identified and incised, taking care to protect the EPL. The EP Lis then retracted radially to expose the capsule. Capsulotomy is then performed to expose the scaphoid.
EXAMINER
The patient has heard about percutaneous fixation techniques. What will you say to the patient?
The patient has heard about percutaneous fixation techniques. What will you say to the patient?
CANDIDATE
Percutaneous fixation techniques are suitable for minimally displaced or undisplaced scaphoid fractures that allow earlier mobilization without adverse effects on healing. Haddad reported the results of 15 patients with minimally displaced or non-displaced scaphoid fractures treated percutaneously using a volar approach, traction and a cannulated screw [7]. The early rigid fixation of scaphoid fractures allows early mobilization, patients were allowed movement soon after operation. Union was achieved in all at a mean of 57 days. The range of movement after union was equal to that of the contralateral limb and grip strength was 98% of the contralateral side at 3 months. Patients were able to return to sedentary work within 4 days and manual work within 5 weeks. Results of the study showed percutaneous scaphoid fixation permift ed a rapid functional recovery.
Percutaneous fixation techniques are suitable for minimally displaced or undisplaced scaphoid fractures that allow earlier mobilization without adverse effects on healing. Haddad reported the results of 15 patients with minimally displaced or non-displaced scaphoid fractures treated percutaneously using a volar approach, traction and a cannulated screw [7]. The early rigid fixation of scaphoid fractures allows early mobilization, patients were allowed movement soon after operation. Union was achieved in all at a mean of 57 days. The range of movement after union was equal to that of the contralateral limb and grip strength was 98% of the contralateral side at 3 months. Patients were able to return to sedentary work within 4 days and manual work within 5 weeks. Results of the study showed percutaneous scaphoid fixation permift ed a rapid functional recovery.
EXAMINER
What are the complications of percutaneous fixation techniques?
What are the complications of percutaneous fixation techniques?
CANDIDATE
The complications of percutaneous fixation techniques can be divided according to the approach being used, either the volar or dorsal approach. The complications through the volar approach include damage to the FCR, radial artery and suboptimal position of screw placement (the trapezium tends to block the path of the guide wire). The complications of the dorsal approach include damage to the PIN, EP Land EDC. Possible complications for both approaches include guide wire breakage, prominence of the screw (through the subchondral bone), bleeding, infection and chronic regional pain syndrome.
The complications of percutaneous fixation techniques can be divided according to the approach being used, either the volar or dorsal approach. The complications through the volar approach include damage to the FCR, radial artery and suboptimal position of screw placement (the trapezium tends to block the path of the guide wire). The complications of the dorsal approach include damage to the PIN, EP Land EDC. Possible complications for both approaches include guide wire breakage, prominence of the screw (through the subchondral bone), bleeding, infection and chronic regional pain syndrome.
EXAMINER
If the fracture fails to unite after a period of conservative management and goes into non- union, what are the other surgical options?
If the fracture fails to unite after a period of conservative management and goes into non- union, what are the other surgical options?
CANDIDATE
The surgical options for non-union depend on the blood supply to the proximal pole and the presence or absence of osteoarthritis Magne tic resonance imaging (MR Iof the scaphoid may help in preoperative planning to determine the vascularity and avascular necrosis (AVN) of the scaphoid. Open reduction internal fixation with a headless compression screw using acor tic ocancellous bone graft can be used in the absence of AVN and higher success rates are seen in more distal fractures [8]. Where AVN is present, a vascularized bone graft can be considered. There are various options available for re-vascularizing the proximal pole, including a vascularized pedicled bone graft or potentially a vascularized periosteal patch onlay graft, although this technique has demonstrated disappointing union rates [9].
The surgical options for non-union depend on the blood supply to the proximal pole and the presence or absence of osteoarthritis Magne tic resonance imaging (MR Iof the scaphoid may help in preoperative planning to determine the vascularity and avascular necrosis (AVN) of the scaphoid. Open reduction internal fixation with a headless compression screw using acor tic ocancellous bone graft can be used in the absence of AVN and higher success rates are seen in more distal fractures [8]. Where AVN is present, a vascularized bone graft can be considered. There are various options available for re-vascularizing the proximal pole, including a vascularized pedicled bone graft or potentially a vascularized periosteal patch onlay graft, although this technique has demonstrated disappointing union rates [9].
Figure 17.4a and 17.4b Radiographs demonstrating waist of scaphoid fracture.
source p. 923
Figure 17.4c and 17.4d Radiographs demonstrating non-union scaphoid.
source p. 924
References#
1. Clay NR, Dias JJ, Costig an PS, et al. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg (Br). 1991;73B(5):828–832.
2. Dawson JS, Martel AL, Davis TR. Scaphoid blood flow and acute fracture healing: a dynamic MRI study with enhancement with gadolinium. J Bone Joint Surg (Br). 2001;83B:809–814.
3. Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am. 1980;5:508–513.
4. Suh N, Benson EC, Faber KJ, MacDermid J, Grewal R. Treatment of acute scaphoid fractures: a systematic review and meta-analysis. Hand. 2010;5:345–353.
5. Patel PD, Richard MJ. Scaphoid fracture: open reduction internal fixation . Oper Tech Sports Med. 2010;18:139–145.
6. Modi CS, Nan cooT, Powers D, et al. Operative versus nonoperative treatment of acute undisplaced and minimally displaced scaphoid waist fractures – a systematic review. Injury. 2009;40:268–273.
7. Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation: a pilot study. J Bone Joint Surg (Br).
1998;80:95–99.
8. Ramamurthy C, Cutler L, Nuft all D, et al. The factors affecting out come after nonvascular bone gratiing and internal fixation for non-union of the scaphoid. J Bone Joint Surg (Br). 2007;89B:627–632.
9. Thompson NW, Kapoor A, Thomas J, Hayton MJ. The use of avascular ised periosteal patch onlay graft in the management of non-union of the proximal scaphoid. J Bone Joint Surg (Br). 2008;90B:1597–1601.
source p. 925
Structured oral examination question 5#
source p. 926
Scaphoid fracture (proximal pole)
EXAMINER
An apprentice joiner has fallen on his hand at work. Please describe this radiograph (Figure 17.5a).
An apprentice joiner has fallen on his hand at work. Please describe this radiograph (Figure 17.5a).
CANDIDATE
This posteroanterior (PA) radiograph of the wrist shows an undisplaced proximal pole scaphoid fracture. I would like to confirm this further with other scaphoid views.
This posteroanterior (PA) radiograph of the wrist shows an undisplaced proximal pole scaphoid fracture. I would like to confirm this further with other scaphoid views.
EXAMINER
What is the relevant anatomy?
What is the relevant anatomy?
CANDIDATE
The proximal pole blood supply is from distal to proximal. A proximal 1/5 fracture has a non- union rate of 80–100% when treated non-operativ ely.
The proximal pole blood supply is from distal to proximal. A proximal 1/5 fracture has a non- union rate of 80–100% when treated non-operativ ely.
EXAMINER
How do you manage this injury?
How do you manage this injury?
CANDIDATE
Open reduction and internal fixation with a screw placed from a proximal entry point through a dorsal incision.
Open reduction and internal fixation with a screw placed from a proximal entry point through a dorsal incision.
EXAMINER
In this case, the fracture was treated non-operativ ely. This is an X-ray at 4 weeks after immobilization in ap laster cast (Figure 17.5b). Please comment.
In this case, the fracture was treated non-operativ ely. This is an X-ray at 4 weeks after immobilization in ap laster cast (Figure 17.5b). Please comment.
CANDIDATE
The fracture ends appear sclerosed with some cyst formation around the edges, suggesting this is progressing to a non-union. At this stage, the proximal segment appears normal density, suggesting noloss of vascularity.
The fracture ends appear sclerosed with some cyst formation around the edges, suggesting this is progressing to a non-union. At this stage, the proximal segment appears normal density, suggesting noloss of vascularity.
EXAMINER
How would you manage the patient now?
How would you manage the patient now?
CANDIDATE
I would offer the patient open reduction and internal fixation through a dorsal approach with a vascularized bone graft using a 1, 2-in tercompartmental supraretinacular artery (1, 2-ICSRA) pedicle [1] (Figure 17.5c and 17.5d).
I would offer the patient open reduction and internal fixation through a dorsal approach with a vascularized bone graft using a 1, 2-in tercompartmental supraretinacular artery (1, 2-ICSRA) pedicle [1] (Figure 17.5c and 17.5d).
EXAMINER
What is the natural history of a scaphoid non-union?
What is the natural history of a scaphoid non-union?
CANDIDATE
This will progress to a scaphoid non-union advanced collapse (SNAC wrist). The stages of SNAC wrist: Stage I – arthritis between radial styloid and distal scaphoid. Stage II – radioscaphoid fossa involvement. Stage III – capitolunate arthritis. Stage IV – generalized wrist arthritis.
This will progress to a scaphoid non-union advanced collapse (SNAC wrist). The stages of SNAC wrist: Stage I – arthritis between radial styloid and distal scaphoid. Stage II – radioscaphoid fossa involvement. Stage III – capitolunate arthritis. Stage IV – generalized wrist arthritis.
EXAMINER
Why does the arthritis affect the radial styloid and distal scaphoid initially?
Why does the arthritis affect the radial styloid and distal scaphoid initially?
CANDIDATE
With a non-union, the distal scaphoid typically flexes, leading to incongruity between the distal scaphoid and radial styloid, whereas the proximal pole of the scaphoid behaves as a ball and socket joint and is not affected by being extended.
With a non-union, the distal scaphoid typically flexes, leading to incongruity between the distal scaphoid and radial styloid, whereas the proximal pole of the scaphoid behaves as a ball and socket joint and is not affected by being extended.
source p. 927
Figure 17.5a Posteroanterior (PA) radiograph of the wrist showing an undisplaced proximal pole scaphoid.
Figure 17.5b Posteroanterior (PA) radiograph of the same wrist at 4 weeks showing an undisplaced proximal pole scaphoid.
source p. 928
Figure 17.5c and 17.5d Anteroposterior (AP) and oblique radiographs showing union at 8 weeks postoperatively (note the lucency in the distal radius where the graft has been taken from).
source p. 929
Reference#
1. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand
Surg Am. 1991;16(3):474–478.
source p. 930
Structured oral examination question 6#
source p. 931
Rheumatoid hand
EXAMINER
Please describe the X-ray of a 52-year-old lady that was seen in your hand clinic (Figure 17.6).
Please describe the X-ray of a 52-year-old lady that was seen in your hand clinic (Figure 17.6).
CANDIDATE
This is a posteroanterior X-ray of both hands showing a symmetrical polyarthropathy typical of a rheumatoid hand and characterized by radial deviation of the wrist ulnar drift and subluxation of the metacarpophalangeal joints (MCP).
This is a posteroanterior X-ray of both hands showing a symmetrical polyarthropathy typical of a rheumatoid hand and characterized by radial deviation of the wrist ulnar drift and subluxation of the metacarpophalangeal joints (MCP).
EXAMINER
What other features are associated with rheumatoid hand?
What other features are associated with rheumatoid hand?
CANDIDATE
Other hand features include Swan-neck and Boutonnière’s deformities, Z -thumb deformity, swelling of the joints secondary to synovitis, muscle wasting and surgical scars.
Other hand features include Swan-neck and Boutonnière’s deformities, Z -thumb deformity, swelling of the joints secondary to synovitis, muscle wasting and surgical scars.
EXAMINER
What do you mean by a Swan-neck and Boutonnière’s deformity? [This is more likely to be a quick question in the clinicals rather than a detailed viva question.]
What do you mean by a Swan-neck and Boutonnière’s deformity? [This is more likely to be a quick question in the clinicals rather than a detailed viva question.]
CANDIDATE
Hyperextension of the PIP joints with flexion of the DIP joints (Swan-neck deformity). Flexion of the PIP joints and hyperextension of the DIP joints (Boutounnière deformity). The viva scenario may then lead into a detailed classification of each deformity. If ‘thought block’ mention the y can be classified as a flexible or fixed deformity. Factual rote-learned classification systems that do not necessarily help in planning management have fallen out of favour as viva questions. It is more important to understand and apply general management principles.
Hyperextension of the PIP joints with flexion of the DIP joints (Swan-neck deformity). Flexion of the PIP joints and hyperextension of the DIP joints (Boutounnière deformity). The viva scenario may then lead into a detailed classification of each deformity. If ‘thought block’ mention the y can be classified as a flexible or fixed deformity. Factual rote-learned classification systems that do not necessarily help in planning management have fallen out of favour as viva questions. It is more important to understand and apply general management principles.
EXAMINER
What would be your management options in this patient?
What would be your management options in this patient?
CANDIDATE
I would like to take a thorough history and examine both hands. I would be particularly interested in hand dominance, pain and any functional loss, asking specifically about ADLs such as doing up buft ons, writing , handling coins, etc. I would also perform a functional assessment of the hand in the clinic. The patient may also be concerned about cosmesis of both hands. I would also address the realistic expectations from operative intervention of the hands. If the patient is struggling with pain I would offer her MCP joint replacements using silastic implants. I would explain surgery aims to correct the ulnar deviation of the fingers improve any pain from those joints and the appearance of the hand, and possibly the ability to pinch (the range of movement and grip strength are unlikely to improve).
I would like to take a thorough history and examine both hands. I would be particularly interested in hand dominance, pain and any functional loss, asking specifically about ADLs such as doing up buft ons, writing , handling coins, etc. I would also perform a functional assessment of the hand in the clinic. The patient may also be concerned about cosmesis of both hands. I would also address the realistic expectations from operative intervention of the hands. If the patient is struggling with pain I would offer her MCP joint replacements using silastic implants. I would explain surgery aims to correct the ulnar deviation of the fingers improve any pain from those joints and the appearance of the hand, and possibly the ability to pinch (the range of movement and grip strength are unlikely to improve).
EXAMINER
You have decided to put the patient on the waiting list for MCP joint replacement. Any challenges you could foresee in this case?
You have decided to put the patient on the waiting list for MCP joint replacement. Any challenges you could foresee in this case?
CANDIDATE
Rheumatoid arthritis is a systemic autoimmune disease, which involves cell-mediated immune response against soft tissues, cartilage and bone. The challenges can be divided into pre-, intra- and postoperative. Preoperatively the patient would need to beseen in high-risk anaesthetic preassessment with close involvement of a rheumatologist regarding medications and biological agents. The challenges intra operatively include skin condition, soft -tissue release and correct balancing and osteopenic bone. The challenges postoperatively include wound healing, risk of infection and postoperative splinting and hand therapy.
Rheumatoid arthritis is a systemic autoimmune disease, which involves cell-mediated immune response against soft tissues, cartilage and bone. The challenges can be divided into pre-, intra- and postoperative. Preoperatively the patient would need to beseen in high-risk anaesthetic preassessment with close involvement of a rheumatologist regarding medications and biological agents. The challenges intra operatively include skin condition, soft -tissue release and correct balancing and osteopenic bone. The challenges postoperatively include wound healing, risk of infection and postoperative splinting and hand therapy.
EXAMINER
What about medications in the rheumatoid arthritis patient?
What about medications in the rheumatoid arthritis patient?
CANDIDATE
I would enquire about steroid usage that would need covering peri operatively. Methotrexate can be continued ast here is no evidence to suggest increase in infection risk [ 1]. However, newer biological factors such as etanercept and infliximab should be discontinued for 1 week and 6 weeks respectively, to reduce risk of infection postoperatively [2].
I would enquire about steroid usage that would need covering peri operatively. Methotrexate can be continued ast here is no evidence to suggest increase in infection risk [ 1]. However, newer biological factors such as etanercept and infliximab should be discontinued for 1 week and 6 weeks respectively, to reduce risk of infection postoperatively [2].
EXAMINER
What are the complications of MCP joint replacement?
What are the complications of MCP joint replacement?
CANDIDATE
I would divide the complications in to early and late complications Early complications include joint infection stiffness, implant dislocation and incomplete correction of deformity. Late complications include recurrence of ulnar drift prosthesis wear and breakage, loosening, implant subsidence and silicone synovitis [ 3].
I would divide the complications in to early and late complications Early complications include joint infection stiffness, implant dislocation and incomplete correction of deformity. Late complications include recurrence of ulnar drift prosthesis wear and breakage, loosening, implant subsidence and silicone synovitis [ 3].
Figure 17.6 Radiographs of hand demonstrating features of rheumatoid arthritis Erosions MC Pand PIP joints. Bilateral symmetrical involvement. Never the DIP joint. Destructive changes at the wrist. Look for periarticular os teopenia, uniform joint space loss, bone erosions and soft -tissues welling. Joint subluxation and subchondral cysts, ulnar deviation MCP joints.
source p. 933
References#
1. Grennan DM, Gray J, Loudon J, FearS. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis. 2001;60:214–217.
2. Scanzello CR, Figgie MP, Nestor BJ, Goodman SM. Peri operative management of medications used in the treatment of rheumatoid arthritis . HSS J. 2006;2(2):141–147.
3. MP joint arthroplasty. www.wheelessonline.com/ortho/mp_joint_arthroplasty
source p. 934
Structured oral examination question 7#
source p. 935
Thumb carpometacarpal (CMC) joint arthritis
EXAMINER
Please describe the X-ray findings (Figure 17.7a).
Please describe the X-ray findings (Figure 17.7a).
CANDIDATE
This is a posteroanterior (PA) view of the right hand showing joint space narrowing over the thumb carpometacarpal (CMC) joint with subchondral sclerosis. I would like to have true AP and lateral views of the thumb to further confirm this. A Robert’s view, which is a true AP view of the thumb CMC joint, is taken with the elbow extended, the forearm fully pronated and the thumb abducted. This is shown in the X-ray below (Figure 17.7b).
This is a posteroanterior (PA) view of the right hand showing joint space narrowing over the thumb carpometacarpal (CMC) joint with subchondral sclerosis. I would like to have true AP and lateral views of the thumb to further confirm this. A Robert’s view, which is a true AP view of the thumb CMC joint, is taken with the elbow extended, the forearm fully pronated and the thumb abducted. This is shown in the X-ray below (Figure 17.7b).
EXAMINER
Do you know any classification system for thumb CMC joint arthritis?
Do you know any classification system for thumb CMC joint arthritis?
CANDIDATE
I would classify thumb CMC joint arthritis using the Ea ton and Litiler classification. This is a radiological classification. Stage I: slight widening of the joint (2° effusion or ligament laxity). Pre-arthritic joint. Normal articular contours. Stage II: slight joint space narrowing with sclerosis osteophytes < 2 mm, < 1/3 metacarpal base subluxation. Stage III: complete loss of CMC joint space with osteophytes > 2 mm, cystic changes, increased sclerosis. Stage IV: pan-trapezial arthritis.
I would classify thumb CMC joint arthritis using the Ea ton and Litiler classification. This is a radiological classification. Stage I: slight widening of the joint (2° effusion or ligament laxity). Pre-arthritic joint. Normal articular contours. Stage II: slight joint space narrowing with sclerosis osteophytes < 2 mm, < 1/3 metacarpal base subluxation. Stage III: complete loss of CMC joint space with osteophytes > 2 mm, cystic changes, increased sclerosis. Stage IV: pan-trapezial arthritis.
EXAMINER
These X-rays belong to a 65-year-old lady with a painful thumb for the past 2 years. How would you proceed?
These X-rays belong to a 65-year-old lady with a painful thumb for the past 2 years. How would you proceed?
CANDIDATE
I would like to take a thorough history and examination. I would ask about hand dominance, night pain, effect on ADLs and treatment to date. I would ask her where the pain is. Pain can be either diffuse or radial wrist pain up to the thumb MCP joint. I would also examine the thumb, looking for squaring-off at the base of thumb and performing a grind test to confirm pain is localized at the base of thumb CMC joint. I would consider and exclude other differential diagnoses such as: De Quervains (more radial styloid). Intersection syndrome (tender proximal to the styloid). STT arthritis (X -ray). SLAC/SNAC wrist (X-ray). Trigger thumb (clicking, volar pain and swelling). Concomitant CTS (high volume of patient sin hand clinics have both CTS and basal thumb OA). The management of thumb CMC arthritis includes non-oper at ive and operative. Non-operativ e includes analgesia, activity modification, thumb splint and therapeutic injection of local anaesthesia into thumb CMC joint (as per NICE guidelines on osteoarthritis).
I would like to take a thorough history and examination. I would ask about hand dominance, night pain, effect on ADLs and treatment to date. I would ask her where the pain is. Pain can be either diffuse or radial wrist pain up to the thumb MCP joint. I would also examine the thumb, looking for squaring-off at the base of thumb and performing a grind test to confirm pain is localized at the base of thumb CMC joint. I would consider and exclude other differential diagnoses such as: De Quervains (more radial styloid). Intersection syndrome (tender proximal to the styloid). STT arthritis (X -ray). SLAC/SNAC wrist (X-ray). Trigger thumb (clicking, volar pain and swelling). Concomitant CTS (high volume of patient sin hand clinics have both CTS and basal thumb OA). The management of thumb CMC arthritis includes non-oper at ive and operative. Non-operativ e includes analgesia, activity modification, thumb splint and therapeutic injection of local anaesthesia into thumb CMC joint (as per NICE guidelines on osteoarthritis).
COMMENT
Candidates can apply the general NICE guidelines on managing osteoarthritis to different clinical situations. This quality standard covers diagnosing, assessing and managing osteoarthritis in adults. It includes treatment and support, and referral for joint surgery.
Candidates can apply the general NICE guidelines on managing osteoarthritis to different clinical situations. This quality standard covers diagnosing, assessing and managing osteoarthritis in adults. It includes treatment and support, and referral for joint surgery.
EXAMINER
What would YOU perform?
What would YOU perform?
CANDIDATE
I would offer the patient simple trapeziectomy if all non-operativ e management has failed [1]. Prof. Davis et al. published their study in 2012 with a minimum 5 years follow-up of 153 thumbs with trapeziometacarpal osteoarthritis randomized into three groups to undergo either simple trapeziectomy, trapeziectomy with palmaris longus interposition or tr apeziectomy with ligament reconstruction and tendon interposition (LR TI) using 50% of the flexor carpi radialis tendon [2]. The study showed no benefit to tendon interposition or ligament reconstruction in the longer term compared to trapeziectomy alone in regard to thumb pain, function and strength. A Cochrane review in 2015 reported low-quality evidence to guide management, with insufficient evidence to suggest LRTI had additional benefit. LRTI patients experienced more adverse events.
I would offer the patient simple trapeziectomy if all non-operativ e management has failed [1]. Prof. Davis et al. published their study in 2012 with a minimum 5 years follow-up of 153 thumbs with trapeziometacarpal osteoarthritis randomized into three groups to undergo either simple trapeziectomy, trapeziectomy with palmaris longus interposition or tr apeziectomy with ligament reconstruction and tendon interposition (LR TI) using 50% of the flexor carpi radialis tendon [2]. The study showed no benefit to tendon interposition or ligament reconstruction in the longer term compared to trapeziectomy alone in regard to thumb pain, function and strength. A Cochrane review in 2015 reported low-quality evidence to guide management, with insufficient evidence to suggest LRTI had additional benefit. LRTI patients experienced more adverse events.
EXAMINER
Which ones?
Which ones?
CANDIDATE
Sorry, my mind has gone blank. I would explain preoperatively this is mainly a pain-relieving procedure, she would require hand splinting for 5–6 weeks postoperatively and is likely to have some loss of grip strength on a permanent basis.
Sorry, my mind has gone blank. I would explain preoperatively this is mainly a pain-relieving procedure, she would require hand splinting for 5–6 weeks postoperatively and is likely to have some loss of grip strength on a permanent basis.
EXAMINER
What are the complications of tr apeziectomy?
What are the complications of tr apeziectomy?
CANDIDATE
Complications of tr apeziectomy can be divided into early and late complications. Early – infection, haematoma formation, and injury to the superficial sensory nerves. Late – pain, collapse of trapezial space with pain and instability, tender scar and chronic regional pain syndrome.
Complications of tr apeziectomy can be divided into early and late complications. Early – infection, haematoma formation, and injury to the superficial sensory nerves. Late – pain, collapse of trapezial space with pain and instability, tender scar and chronic regional pain syndrome.
EXAMINER
What would you offer if this is a 34-year-old male manual worker?
What would you offer if this is a 34-year-old male manual worker?
CANDIDATE
I would offer the patient thumb CMC joint fusion if he is a young manual worker. A fusion may allow improved grip strength in a manual worker. However, I would also counsel the patient that fusion has a higher incidence of complication such as non-union ( Figure 17.7c).
I would offer the patient thumb CMC joint fusion if he is a young manual worker. A fusion may allow improved grip strength in a manual worker. However, I would also counsel the patient that fusion has a higher incidence of complication such as non-union ( Figure 17.7c).
EXAMINER
You mentioned the grind t est. Show me how you do it on my hand.
You mentioned the grind t est. Show me how you do it on my hand.
CANDIDATE
I would stabilize your wrist with my left hand then hold your thumb metacarpal with my right hand, and compress and rotate the metacarpal base at the CMC joint. The testis positive if this causes pain and then the pain goes with rotation and distraction.
I would stabilize your wrist with my left hand then hold your thumb metacarpal with my right hand, and compress and rotate the metacarpal base at the CMC joint. The testis positive if this causes pain and then the pain goes with rotation and distraction.
EXAMINER
How would you try to address the adduction deformity of the thumb?
How would you try to address the adduction deformity of the thumb?
source p. 937
CANDIDATE
The adduction of the thumb is related to the radial subluxation of the metacarpal base and may be associated with soft -tissue contracture. A complete excision of the trapezium will shorten the radial column and may improve the deformity. However, if there is ongoing deformity and unacceptable reduction in handspan following trapeziectomy, then I would consider an extension osteotomy of the thumb metacarpal.
The adduction of the thumb is related to the radial subluxation of the metacarpal base and may be associated with soft -tissue contracture. A complete excision of the trapezium will shorten the radial column and may improve the deformity. However, if there is ongoing deformity and unacceptable reduction in handspan following trapeziectomy, then I would consider an extension osteotomy of the thumb metacarpal.
EXAMINER
How would you try to address the hyperextension at the MCP joint?
How would you try to address the hyperextension at the MCP joint?
CANDIDATE
The hyperextension is greater than 30° and therefore if left untreated may cause a secondary swan-neck deformity of the thumb. The options for treatment are either soft -tissue procedures such as volar capsulodesis or EPB tendon transferor a fusion of the MCPJ. I would treat this with a volar capsulodesis using a suture anchor.
The hyperextension is greater than 30° and therefore if left untreated may cause a secondary swan-neck deformity of the thumb. The options for treatment are either soft -tissue procedures such as volar capsulodesis or EPB tendon transferor a fusion of the MCPJ. I would treat this with a volar capsulodesis using a suture anchor.
Figure 17.7a Posteroanterior (PA) radiograph, wrist.
source p. 938
Figure 17.7b Robert’s view (true AP view of the thumb CMC joint).
Figure 17.7c Radiographs demonstrating fusion CMC joint, as this possibly allows improved grip strength in a manual worker, but has a higher incidence of complications such as non-union.
source p. 939
References#
1. Davis TR, Brady O, Barton NJ, Lunn PG, Burke FD. Trapeziectomy alone, with tendon interposition or with ligament reconstruction? J Hand Surg Br. 1997;22(6):689–694.
2. Gangopadhyay S, McKenna H, Burke FD, Davis TR. Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition . J Hand Surg Am. 2012;37(3):411–417.
source p. 940
Structured oral examination question 8#
source p. 941
Flexor tendon sheath infections
EXAMINER
Please describe the clinical picture (Figure 17.8).
Please describe the clinical picture (Figure 17.8).
CANDIDATE
This clinical picture shows diffusely swollen and erythematous fingers, right hand. The fingers are held inflexion.
This clinical picture shows diffusely swollen and erythematous fingers, right hand. The fingers are held inflexion.
EXAMINER
What’s your main concern and how would you approach this patient?
What’s your main concern and how would you approach this patient?
CANDIDATE
My main concern is flexor sheath tenosynovitis. I would like to take a thorough history and examine the hand. In the history, I would like to know the hand dominance, duration of swelling, pain and other associated systemic symptoms. I would examine the hand to look for any other wounds, collection and tenderness along the flexor sheath on palpation. I would then request white cell count, CR Pand ESR to look for raised inflammatory markers. I would also request a plain X-ray of the digit involved to exclude the presence of foreign bodies.
My main concern is flexor sheath tenosynovitis. I would like to take a thorough history and examine the hand. In the history, I would like to know the hand dominance, duration of swelling, pain and other associated systemic symptoms. I would examine the hand to look for any other wounds, collection and tenderness along the flexor sheath on palpation. I would then request white cell count, CR Pand ESR to look for raised inflammatory markers. I would also request a plain X-ray of the digit involved to exclude the presence of foreign bodies.
EXAMINER
Who and how is this underlying condition classically described?
Who and how is this underlying condition classically described?
CANDIDATE
The classic description of flexor sheath tenosynovitis is by Kanavel [1]. He was credited with describing four cardinal signs of flexor sheath tenosynovitis, although his original paper described three – fusiform swelling, tenderness along the flexor sheath and flexed position of the digit. P ain on passive extension of the digit was discussed in subsequent reports. Pain with passive stretching of the involved digit is perhaps the most sensitive test.
The classic description of flexor sheath tenosynovitis is by Kanavel [1]. He was credited with describing four cardinal signs of flexor sheath tenosynovitis, although his original paper described three – fusiform swelling, tenderness along the flexor sheath and flexed position of the digit. P ain on passive extension of the digit was discussed in subsequent reports. Pain with passive stretching of the involved digit is perhaps the most sensitive test.
EXAMINER
You have made the diagnosis of flexor sheath tenosynovitis. How would you manage this patient?
You have made the diagnosis of flexor sheath tenosynovitis. How would you manage this patient?
CANDIDATE
This is an orthopaedic emergency. I would like to counsel and consent the patient for incision and drainage of the flexor sheath. I would speak to the anaesthetist and take the patient to theatre on an emergency basis. Once in theatre, I would position the patient supine with a tourniquet over the arm with the hand lying on an arm board. I would use a two-incision technique for incision and drainage of flexor. I would place my proximal incision over the A1 pulley at the distal palmar crease with complete release of this structure to gain access to the flexor sheath. A second oblique incision is made over the region of the A5 pulley, taking care to avoid injury to the neurovascular bundle. The flexor sheath is then opened up proximally and distally. Cultures are obtained and a small rigid catheter (use aven flon with the metal trochar removed) is passed into the flexor sheath for irrigation. The sheath is copiously irrigated with a minimum of 500 ml normal saline but avoiding excessive fluid extravasation in to the digit because this can result in necrosis of the digit. Wounds should be left open. Postoperatively, the hand should be splinted, elevated, discussion with the microbiologist regarding appropriate intravenous antibiotics continued for 5–7 days until the redness and inflammation has subsided. Early hand therapist input plays an important role in the recovery of the patient.
This is an orthopaedic emergency. I would like to counsel and consent the patient for incision and drainage of the flexor sheath. I would speak to the anaesthetist and take the patient to theatre on an emergency basis. Once in theatre, I would position the patient supine with a tourniquet over the arm with the hand lying on an arm board. I would use a two-incision technique for incision and drainage of flexor. I would place my proximal incision over the A1 pulley at the distal palmar crease with complete release of this structure to gain access to the flexor sheath. A second oblique incision is made over the region of the A5 pulley, taking care to avoid injury to the neurovascular bundle. The flexor sheath is then opened up proximally and distally. Cultures are obtained and a small rigid catheter (use aven flon with the metal trochar removed) is passed into the flexor sheath for irrigation. The sheath is copiously irrigated with a minimum of 500 ml normal saline but avoiding excessive fluid extravasation in to the digit because this can result in necrosis of the digit. Wounds should be left open. Postoperatively, the hand should be splinted, elevated, discussion with the microbiologist regarding appropriate intravenous antibiotics continued for 5–7 days until the redness and inflammation has subsided. Early hand therapist input plays an important role in the recovery of the patient.
EXAMINER
Is there any role incontinuous catheter irrigation postoperatively?
Is there any role incontinuous catheter irrigation postoperatively?
source p. 942
CANDIDATE
A retrospective review comparing the intraoperative incision, drainage and irrigation with or without postoperative continuous catheter irrigation demonstrated no difference in outcomes between the two groups [2].
A retrospective review comparing the intraoperative incision, drainage and irrigation with or without postoperative continuous catheter irrigation demonstrated no difference in outcomes between the two groups [2].
EXAMINER
What are the complications if this condition is not treated promptly?
What are the complications if this condition is not treated promptly?
CANDIDATE
The complications include early skin loss tendon necrosis and rupture, tendon adhesions, deep palmar space infection, septic arthritis, osteomyelitis and hand stiffness. The need for amputation is a known complication, especially in patients with diabetes, peripheral vascular disease and chronic renal disease.
The complications include early skin loss tendon necrosis and rupture, tendon adhesions, deep palmar space infection, septic arthritis, osteomyelitis and hand stiffness. The need for amputation is a known complication, especially in patients with diabetes, peripheral vascular disease and chronic renal disease.
EXAMINER
What about an open approach for flexor sheath irrigation for acute pyogenic flexor tenosynovitis?
What about an open approach for flexor sheath irrigation for acute pyogenic flexor tenosynovitis?
CANDIDATE
The approach uses longitudinal midaxial or a volar zig-zag Brunner’s incision with direct drainage of any purulent material. The midaxial approach is possibly preferable as there isless concern about skin coverage postoperatively. The thumb and small finger are approached from the radial side; the other digits are approached from the ulnar side. The incision begins just distal to the distal flexion crease and is extended proximally to the web space. The incision is kept dorsal to the neurovascular bundle. There is an increased risk of tendon necrosis, increased scarring and stiffness and significant morbidity. The procedure usually requires secondary procedures and prolonged rehabilitation.
The approach uses longitudinal midaxial or a volar zig-zag Brunner’s incision with direct drainage of any purulent material. The midaxial approach is possibly preferable as there isless concern about skin coverage postoperatively. The thumb and small finger are approached from the radial side; the other digits are approached from the ulnar side. The incision begins just distal to the distal flexion crease and is extended proximally to the web space. The incision is kept dorsal to the neurovascular bundle. There is an increased risk of tendon necrosis, increased scarring and stiffness and significant morbidity. The procedure usually requires secondary procedures and prolonged rehabilitation.
EXAMINER
When would you use an open approach?
When would you use an open approach?
CANDIDATE
Some surgeons would prefer to use an open approach with an atypical mycobacterium infection orf or chronic infections. The reis some evidence to recommend open treatment of stage III infections necrosis of the tendon, pulleys or tendon sheath).
Some surgeons would prefer to use an open approach with an atypical mycobacterium infection orf or chronic infections. The reis some evidence to recommend open treatment of stage III infections necrosis of the tendon, pulleys or tendon sheath).
EXAMINER
You have mentioned stage 3 infection.
You have mentioned stage 3 infection.
CANDIDATE
The extent of infection can be graded by theMi chon classification scheme. Stage 1: serous exudate. Stage 2: purulent fluid, granulomatous synovium. Stage 3: necrosis of the tendon, pulleys or tendon sheath.
The extent of infection can be graded by theMi chon classification scheme. Stage 1: serous exudate. Stage 2: purulent fluid, granulomatous synovium. Stage 3: necrosis of the tendon, pulleys or tendon sheath.
source p. 943
Figure 17.8 Flexor sheath tenosynovitis. The reis diffuse swelling of the fingers. The fingers are flexed.
source p. 944
References#
1. Kana velA. Infections of the Hand: A Guide to the Surgical Treatment of Acute and Chronic Suppurative
Processes in the Fingers. London: Balliere, Tindal land Cox; 1939.
2. Lille S, Hayakawa T, Neumeister MW, et al. Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative flexor tenosynovitis . J Hand Surg (Br). 2000;25(3):304–307.
source p. 945
Structured oral examination question 9#
source p. 946
Flexor tendon injury
EXAMINER
Can you describe this clinical photograph and what it represents (Figure 17.9)?
Can you describe this clinical photograph and what it represents (Figure 17.9)?
CANDIDATE
This is a clinical photograph of the right palm showing the five zones of flexor tendon injury. Zone 1 – flexor digitorum profundus distal to insertion of flexor digitorum superficialis. Zone 2 – insertion of flexor digitorum superficialis to proximal edge of A1 pulley (no man’s land). Zone 3 – proximal edge of A1 pulley to distal edge of carpal tunnel. Zone 4 – within the carpal tunnel. Zone 5 – proximal to the carpal tunnel.
This is a clinical photograph of the right palm showing the five zones of flexor tendon injury. Zone 1 – flexor digitorum profundus distal to insertion of flexor digitorum superficialis. Zone 2 – insertion of flexor digitorum superficialis to proximal edge of A1 pulley (no man’s land). Zone 3 – proximal edge of A1 pulley to distal edge of carpal tunnel. Zone 4 – within the carpal tunnel. Zone 5 – proximal to the carpal tunnel.
EXAMINER
When would you consider repairing a lacerated tendon?
When would you consider repairing a lacerated tendon?
CANDIDATE
I would consider repairing a lacerated tendon if involving more than 60% of cross-sectional area. Studies have shown that a lacerated tendon with less than 60% cross-sectional area involvement can be managed without repair, but with debridement and early mobilization. This has resulted in better tendon excursion as well as increased tendon strength compared to tendons that were repaired or immobilized [1].
I would consider repairing a lacerated tendon if involving more than 60% of cross-sectional area. Studies have shown that a lacerated tendon with less than 60% cross-sectional area involvement can be managed without repair, but with debridement and early mobilization. This has resulted in better tendon excursion as well as increased tendon strength compared to tendons that were repaired or immobilized [1].
EXAMINER
What is the goal of tendon repair and how would you perform it?
What is the goal of tendon repair and how would you perform it?
CANDIDATE
The goal of tendon repair is to maintain sufficient strength to avoid rupture with either passive or active movement during mobilization. I would repair the tendon using a modified Kessler technique with epitenon reinforcement to decrease gap formation across the repair site and reduce friction. I would aim for a minimum of fourstrands as core sutures as the strength of tendon repair is directly proportional to the number of core sutures across the tendon repair site. Circumferential epitenon suture has also been shown to significantly increase the resistance of the tendon repair to gap formation aswell as adding 20% to the ultimate tensile strength of the repair [2].
The goal of tendon repair is to maintain sufficient strength to avoid rupture with either passive or active movement during mobilization. I would repair the tendon using a modified Kessler technique with epitenon reinforcement to decrease gap formation across the repair site and reduce friction. I would aim for a minimum of fourstrands as core sutures as the strength of tendon repair is directly proportional to the number of core sutures across the tendon repair site. Circumferential epitenon suture has also been shown to significantly increase the resistance of the tendon repair to gap formation aswell as adding 20% to the ultimate tensile strength of the repair [2].
EXAMINER
What is the significance of Zone 2 flexor tendon injury?
What is the significance of Zone 2 flexor tendon injury?
CANDIDATE
Bunnell referred to this area as no man’s land because the initial results of the tendon here were so poor. This zone has the highest probability of developing adhesions and the poorest prognosis. There are two flexor tendons, FDP and FDS, within the flexor tendon sheath and compounded by the fact that FDP travels through the FDS tendon at Champer’s chiasm, creating another adhesion surface. The advances in suture techniques, better understanding of the tendon morphology and its biomechanics as well as early active mobilization rehabilitation protocols have resulted in better outcomes in Zone 2 flexor tendon repair.
Bunnell referred to this area as no man’s land because the initial results of the tendon here were so poor. This zone has the highest probability of developing adhesions and the poorest prognosis. There are two flexor tendons, FDP and FDS, within the flexor tendon sheath and compounded by the fact that FDP travels through the FDS tendon at Champer’s chiasm, creating another adhesion surface. The advances in suture techniques, better understanding of the tendon morphology and its biomechanics as well as early active mobilization rehabilitation protocols have resulted in better outcomes in Zone 2 flexor tendon repair.
EXAMINER
What is the postoperative rehabilitation following flexor tendon repair?
What is the postoperative rehabilitation following flexor tendon repair?
CANDIDATE
Postoperative rehabilitation aims to mobilize early (48 hours postoperatively) to prevent adhesions. Most patients will be put into an active place and hold’ regimen rather than traditional passive range of motion regimen. This was supported by a randomized controlled trial by Trumble et al. in 2010 which showed that active motion had significantly fewer flexion contractures, better satisfaction scores and improved range of motion than passively rehabilitated patients Importantly, there was no difference in the tendon re-rupture rate [3].
Postoperative rehabilitation aims to mobilize early (48 hours postoperatively) to prevent adhesions. Most patients will be put into an active place and hold’ regimen rather than traditional passive range of motion regimen. This was supported by a randomized controlled trial by Trumble et al. in 2010 which showed that active motion had significantly fewer flexion contractures, better satisfaction scores and improved range of motion than passively rehabilitated patients Importantly, there was no difference in the tendon re-rupture rate [3].
Figure 17.9 Flexor tendon injury zones.
source p. 948
References#
1. Bishop AT, Cooney WP 3rd, Wood MB. Treatment of partial flexor tendon lacerations: the effect of tenorrhaphy and early protected mobilisation . J Trauma. 1986;26(4):301–312.
2. Pruift DL, Manske PR, Fink B. Cyclic stress analysis of flexor tendon repair. J Hand Surg (Am).
1991;16(4):701–707.
3. Trumble TE, Vedder NB, Seiler JG 3rd, et al. Zone-II flexor tendon repair: a randomised prospective trial of active place-and-hold therapy compared with passive motion therapy. J Bone Joint Surg (Am).
2013;38:1800–1802.
source p. 949
Structured oral examination question 10#
source p. 950
Enchondroma
EXAMINER
Please describe the clinical picture of a 10-year-old girl who fell onto her left hand a few hours ago (Figure 17.10a).
Please describe the clinical picture of a 10-year-old girl who fell onto her left hand a few hours ago (Figure 17.10a).
CANDIDATE
I noticeds welling over the proximal phalanx left middle finger with no associated bruising or rotational deformity. There is widening of the interspace between the index and middle fingers.
I noticeds welling over the proximal phalanx left middle finger with no associated bruising or rotational deformity. There is widening of the interspace between the index and middle fingers.
EXAMINER
How would you manage this patient?
How would you manage this patient?
CANDIDATE
I would take a detailed history and examination of the affected hand and finger. I would look for any swelling, bruising or rotational deformity of the middle finger on clinical examination. I would provide adequate analgesia for the patient and arrange an X-ray of the middle finger to exclude fracture.
I would take a detailed history and examination of the affected hand and finger. I would look for any swelling, bruising or rotational deformity of the middle finger on clinical examination. I would provide adequate analgesia for the patient and arrange an X-ray of the middle finger to exclude fracture.
EXAMINER
Please describe the X-ray of the left middle finger of this patient Figure 17.10b).
Please describe the X-ray of the left middle finger of this patient Figure 17.10b).
CANDIDATE
This is a posteroanterior (PA) view of the left hand of a skeletally immature patient The radiograph shows a pathological fracture through the cystic lesion affecting the proximal phalanx of the middle finger. The proximal radial cortex is markedly thinned and expanded to the radial side, causing widening between the middle and index fingers. The X-ray finding is highly suggestive of enchondroma (benign cartilage tumour of bone). I would confirm this further with lateral and oblique views of the middle finger.
This is a posteroanterior (PA) view of the left hand of a skeletally immature patient The radiograph shows a pathological fracture through the cystic lesion affecting the proximal phalanx of the middle finger. The proximal radial cortex is markedly thinned and expanded to the radial side, causing widening between the middle and index fingers. The X-ray finding is highly suggestive of enchondroma (benign cartilage tumour of bone). I would confirm this further with lateral and oblique views of the middle finger.
EXAMINER
How would you manage this fracture?
How would you manage this fracture?
CANDIDATE
As discussed earlier, I would take a detailed history and examination of the affected finger. History includes rapid increase in size or pain over the middle finger. I would also look for swelling elsewhere in the contralateral hand and body. Enchondroma has been associated with multiple enchondromatosis (Ollier’s disease) and haemangiomas (Mafucci’s disease). I would explain this is a benign tumour that has been present prior to the injury. I would manage this fracture conservatively with buddy strapping for 2 weeks provided there is no rotational deformity. I would also arrange a contralateral hand X-ray to look for associated enchondroma. I would review them at 6 weeks and then annually. If it continued to increase in size, I would refer to a hand surgeon for partial excision and bone gratiing [ 1].
As discussed earlier, I would take a detailed history and examination of the affected finger. History includes rapid increase in size or pain over the middle finger. I would also look for swelling elsewhere in the contralateral hand and body. Enchondroma has been associated with multiple enchondromatosis (Ollier’s disease) and haemangiomas (Mafucci’s disease). I would explain this is a benign tumour that has been present prior to the injury. I would manage this fracture conservatively with buddy strapping for 2 weeks provided there is no rotational deformity. I would also arrange a contralateral hand X-ray to look for associated enchondroma. I would review them at 6 weeks and then annually. If it continued to increase in size, I would refer to a hand surgeon for partial excision and bone gratiing [ 1].
EXAMINER
What are you going to tell the parent who is concerned regarding this lesion?
What are you going to tell the parent who is concerned regarding this lesion?
CANDIDATE
I would discuss and reassure the patient and parent that this is a benign cartilage tumour of bone that is mostly asymptomatic. Most patients present with incidental findings on X-ray after trauma. Most enchondromas do not require any surgical intervention unless symptomatic. The malignant risk with a single lesion is low but the risk increases to 20–30% for Ollier’s disease and near 100% for Mafucci’s disease. I would reassure the parent that this lesion simply requires further follow-up to make sure it doesn’t increase in size.
I would discuss and reassure the patient and parent that this is a benign cartilage tumour of bone that is mostly asymptomatic. Most patients present with incidental findings on X-ray after trauma. Most enchondromas do not require any surgical intervention unless symptomatic. The malignant risk with a single lesion is low but the risk increases to 20–30% for Ollier’s disease and near 100% for Mafucci’s disease. I would reassure the parent that this lesion simply requires further follow-up to make sure it doesn’t increase in size.
source p. 951
Figure 17.10a Clinical picture of an 11-year-old’s hand.
Figure 17.10b Radiograph of the child’s hand.
source p. 952
References#
1. O’Connor MI, Bancroft LW. Benign and malignant cartilage tumours of the hand. Hand Clin.
2004;20(3):317–323.
2. Athanasian EA. Bone and soft tissue tumours. In DP Green, RN Hotchkiss, WC Pederson et al. (Eds.),
Green’s Operative Hand Surgery, 5th ed. Philadelphia: Churchill Livingstone; 2005: pp. 2211–2263.
source p. 953
Structured oral examination question 11#
source p. 954
Wrist ganglion
EXAMINER
Please describe this clinical picture (Figure 17.11a).
Please describe this clinical picture (Figure 17.11a).
CANDIDATE
This clinical picture of a clenched right fist shows a swelling over the dorsoradial aspect of the wrist, suggestive of ganglion.
This clinical picture of a clenched right fist shows a swelling over the dorsoradial aspect of the wrist, suggestive of ganglion.
EXAMINER
How would you confirm your diagnosis?
How would you confirm your diagnosis?
CANDIDATE
I would take history from the patient specifically asking about any fluctuation in size. Clinically this would be a firm smooth swelling attached to deep structures that classically transilluminates. I would request radiological investigations such as ultrasound or magnetic resonance imaging (MR Ito confirm my diagnosis.
I would take history from the patient specifically asking about any fluctuation in size. Clinically this would be a firm smooth swelling attached to deep structures that classically transilluminates. I would request radiological investigations such as ultrasound or magnetic resonance imaging (MR Ito confirm my diagnosis.
EXAMINER
This is the investigation that has been performed. Please comment (Figure 17.11b).
This is the investigation that has been performed. Please comment (Figure 17.11b).
CANDIDATE
This is a T2-weighted MR scan showing a well-circumscribed, focal, multiloculated lesion overlying the lunate and capitate dorsally on the sagift al view of the wrist. The MR scan confirms the diagnosis of ganglion that is likely to have arisen from the scapholunate ligament.
This is a T2-weighted MR scan showing a well-circumscribed, focal, multiloculated lesion overlying the lunate and capitate dorsally on the sagift al view of the wrist. The MR scan confirms the diagnosis of ganglion that is likely to have arisen from the scapholunate ligament.
EXAMINER
What is the aetiology of this condition?
What is the aetiology of this condition?
CANDIDATE
Ganglion is a mucin-filled synovial cyst with no true epithelial lining that arises from the tendon sheath or joint capsule.
Ganglion is a mucin-filled synovial cyst with no true epithelial lining that arises from the tendon sheath or joint capsule.
EXAMINER
How would you manage this?
How would you manage this?
CANDIDATE
I would counsel the patient that this is a benign condition. As longas the reis no history of increasing size or pain, this can be treated with observation only . If there is pain affecting function, especially with forced wrist extension, then aspiration or surgical excision may be offered.
I would counsel the patient that this is a benign condition. As longas the reis no history of increasing size or pain, this can be treated with observation only . If there is pain affecting function, especially with forced wrist extension, then aspiration or surgical excision may be offered.
EXAMINER
What complications can occur with aspiration?
What complications can occur with aspiration?
CANDIDATE
Haematoma, bruising, infection and reoccurrence.
Haematoma, bruising, infection and reoccurrence.
EXAMINER
What is the incidence of reoccurrence following aspiration?
What is the incidence of reoccurrence following aspiration?
CANDIDATE
The reoccurrence rate following aspiration is 50%.
The reoccurrence rate following aspiration is 50%.
EXAMINER
What would you do if the ganglion reoccurs after aspiration?
What would you do if the ganglion reoccurs after aspiration?
CANDIDATE
If the ganglion reoccurs after aspiration and the patient remains symptomatic, I would offer the patient surgical excision, taking into consideration the reoccurrence rate of 5%. I would perform surgical excision through a transverse incision, taking into consideration the location of the ganglion and structures at risk.
If the ganglion reoccurs after aspiration and the patient remains symptomatic, I would offer the patient surgical excision, taking into consideration the reoccurrence rate of 5%. I would perform surgical excision through a transverse incision, taking into consideration the location of the ganglion and structures at risk.
EXAMINER
What complications can occur with surgical excision?
What complications can occur with surgical excision?
CANDIDATE
Haematoma, bruising, infection neurovascular damage and reoccurrence.
Haematoma, bruising, infection neurovascular damage and reoccurrence.
EXAMINER
What is the second most common hand swelling?
What is the second most common hand swelling?
source p. 955
CANDIDATE
A giant cell tumour or xanthelasma.
A giant cell tumour or xanthelasma.
EXAMINER
Correct.
Correct.
Figure 17.11a Clinical picture of wrist.
Figure 17.11b Imaging of the same wrist.
source p. 956
Structured oral examination question 12#
source p. 957
Dupuytren’s disease
EXAMINER
Please describe the clinical photograph of a 45-year-old with this problem in the non- dominant hand (Figure 17.12a).
Please describe the clinical photograph of a 45-year-old with this problem in the non- dominant hand (Figure 17.12a).
CANDIDATE
The clinical picture shows a thick cord crossing the first webspace of the left hand causing a web space contracture, and fixed flexion at the metacarpophalangeal (MC Pand proximal interphalangeal (PIP) joint of index finger. The appearance is very suggestive of Dupuytren’s disease. The cord seen is known as the commissural band, usually associated with Dupuytren’s diathesis. Dupuytren’s diathesis is the aggressive form of the disease related to features such as bilateral multiple digits involvement; young age < 50 years old, male and positive family history. Other features include ectopic lesion such as Garrod’s pad, Peyronie disease, Ledderhose disease and frozen shoulder. The degree of diathesis is considered important in predicting recurrence and extension of Dupuytren’s disease after surgical management [1].
The clinical picture shows a thick cord crossing the first webspace of the left hand causing a web space contracture, and fixed flexion at the metacarpophalangeal (MC Pand proximal interphalangeal (PIP) joint of index finger. The appearance is very suggestive of Dupuytren’s disease. The cord seen is known as the commissural band, usually associated with Dupuytren’s diathesis. Dupuytren’s diathesis is the aggressive form of the disease related to features such as bilateral multiple digits involvement; young age < 50 years old, male and positive family history. Other features include ectopic lesion such as Garrod’s pad, Peyronie disease, Ledderhose disease and frozen shoulder. The degree of diathesis is considered important in predicting recurrence and extension of Dupuytren’s disease after surgical management [1].
EXAMINER
What is the primary cell involved?
What is the primary cell involved?
CANDIDATE
The primary cell involved in Dupuytren’s disease is the myofibroblast. They are probably derived from fibroblasts and contain smooth muscle actin which leads to contracture of the cord.
The primary cell involved in Dupuytren’s disease is the myofibroblast. They are probably derived from fibroblasts and contain smooth muscle actin which leads to contracture of the cord.
EXAMINER
What other risk factors are associated with this disease?
What other risk factors are associated with this disease?
CANDIDATE
Other risk factors for Dupuytren’s disease include diabetes, epilepsy, high alcohol intake, smoking, COPD, liver disease, positive family history, tuberculosis and HIV/AIDS.
Other risk factors for Dupuytren’s disease include diabetes, epilepsy, high alcohol intake, smoking, COPD, liver disease, positive family history, tuberculosis and HIV/AIDS.
EXAMINER
What structures make up a spiral cord and how does it affect the neurovascular bundle?
What structures make up a spiral cord and how does it affect the neurovascular bundle?
CANDIDATE
The pretendinous, lateral and spiral bands and Grayson’s ligament make up the spiral cord. A spiral cord displaces the neurovascular bundle centrally and superficially and places it at risk during cord excision.
The pretendinous, lateral and spiral bands and Grayson’s ligament make up the spiral cord. A spiral cord displaces the neurovascular bundle centrally and superficially and places it at risk during cord excision.
EXAMINER
How do you classify the disease?
How do you classify the disease?
CANDIDATE
The British Society for Surgery of the Hand (BSSH) classifies Dupuytren’s disease as: Mild – no functional problems, no contracture or metacarpophalangeal joint contracture of less than 30°. Moderate – functional problems, metacarpophalangeal joint contracture of 30–60°, proximal interphalangeal joint contracture of less than 30°, or first web contracture. Severe – severe contracture of both metacarpophalangeal joint (greater than 60°) and proximal interphalangeal joint (greater than 30°).
The British Society for Surgery of the Hand (BSSH) classifies Dupuytren’s disease as: Mild – no functional problems, no contracture or metacarpophalangeal joint contracture of less than 30°. Moderate – functional problems, metacarpophalangeal joint contracture of 30–60°, proximal interphalangeal joint contracture of less than 30°, or first web contracture. Severe – severe contracture of both metacarpophalangeal joint (greater than 60°) and proximal interphalangeal joint (greater than 30°).
EXAMINER
What are the management options?
What are the management options?
CANDIDATE
Management can be divided into non-operativ e and operative. Non-operativ e management includes observation ± night splintage, and collagenase injections.
Management can be divided into non-operativ e and operative. Non-operativ e management includes observation ± night splintage, and collagenase injections.
source p. 958
Operative intervention includes fasciotomy (division of the cord), fasciectomy (excision of the cord)
and dermofasciectomy (cord and overlying skin excised) and skin gratiing. Occasionally amputation would be indicated in a multiply operated digit.
EXAMINER
What is a Z-plasty? Can you draw it?
What is a Z-plasty? Can you draw it?
CANDIDATE
It is a technique to manage skin deficiency. Angles should be made at 60° to the incision to achieve a 75% increase in length (Figure 17.12b).
It is a technique to manage skin deficiency. Angles should be made at 60° to the incision to achieve a 75% increase in length (Figure 17.12b).
EXAMINER
How would you consent for a fasciectomy?
How would you consent for a fasciectomy?
CANDIDATE
The operation will be carried out undergeneral anaesthetic you will be put to sleep) or an axillary bock (nerves to your arm are numbed by an injection in your armpit), and as a day case procedure. The aim is to restore lost movement. You will wakeup with your hand in a heavy bandage and allowed home once you are comfortable. You will beseen at 10 days for removal of your sutures. You will then have physiotherapy to help with scar management and regaining finger movement and may need a splint. Complications include the following [2]: Early infection, bleeding and haematoma formation, arterial or nerve injury, necrosis of digit leading to amputation tendon injury and delayed wound healing. Late joint stiffness recurrence (50% recur but most do not require further surgery) and reoperation incomplete correction of deformity and complex regional pain syndrome.
The operation will be carried out undergeneral anaesthetic you will be put to sleep) or an axillary bock (nerves to your arm are numbed by an injection in your armpit), and as a day case procedure. The aim is to restore lost movement. You will wakeup with your hand in a heavy bandage and allowed home once you are comfortable. You will beseen at 10 days for removal of your sutures. You will then have physiotherapy to help with scar management and regaining finger movement and may need a splint. Complications include the following [2]: Early infection, bleeding and haematoma formation, arterial or nerve injury, necrosis of digit leading to amputation tendon injury and delayed wound healing. Late joint stiffness recurrence (50% recur but most do not require further surgery) and reoperation incomplete correction of deformity and complex regional pain syndrome.
EXAMINER
Do you know any new treatments for Dupuytren’s contracture?
Do you know any new treatments for Dupuytren’s contracture?
CANDIDATE
Collagenase (Xiapex®) injections are now licensed in Europe for a Dupuytren’s contracture. Two randomized controlled studies of 374 patients comparing Xiapex to placebo have shown benefit with 60% showing correction to 5° of full extension [3]. The patient has an injection a t three points along the cord and returns the next day for a finger extension procedure. The technique is appropriate treatment for apa tien t with single-digit involvement and contractures limited to the palm and MCP joint. The patient can receive up to a maximum of three injections per c ord, limited to two digits (one at a time) a t 4-week intervals. The usage of collagenase is of limited benefit in patients with multiple digit involvement. The complications of this treatment include swollen lymph nodes, itching, pain, swelling, injection site bleeding, tenderness and bruising.
Collagenase (Xiapex®) injections are now licensed in Europe for a Dupuytren’s contracture. Two randomized controlled studies of 374 patients comparing Xiapex to placebo have shown benefit with 60% showing correction to 5° of full extension [3]. The patient has an injection a t three points along the cord and returns the next day for a finger extension procedure. The technique is appropriate treatment for apa tien t with single-digit involvement and contractures limited to the palm and MCP joint. The patient can receive up to a maximum of three injections per c ord, limited to two digits (one at a time) a t 4-week intervals. The usage of collagenase is of limited benefit in patients with multiple digit involvement. The complications of this treatment include swollen lymph nodes, itching, pain, swelling, injection site bleeding, tenderness and bruising.
source p. 959
Figure 17.12a Clinical picture of a hand.
Figure 17.12b How to draw a Z-plasty. 1. Draw perpendicular (whited oft ed line) to longitudinal incision. 2. Mark flaps (white and black angles are at 60°). 3. Crossover flaps as shown.
source p. 960
References#
1. Hindocha S, Stanley JK, WatsonS Bay atA. Dupuytren’s diathesis revisited: evaluation of prognostic indicators for risk of disease recurrence. J Hand Surg Am. 2006;31(10):1626–1634.
2. Hayton MJ, Gray ICM. Dupuytren’s contracture: a review. Curr Orthop. 2003;17:1–7.
3. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase Clostridium histolyticum for
Dupuytren’s contracture. N Engl J Med. 2009;361(10):968–979.
source p. 961
Structured oral examination question 13#
source p. 962
Kienbock’s disease
EXAMINER
Please describe this X-ray (Figure 17.13a).
Please describe this X-ray (Figure 17.13a).
CANDIDATE
This is a posteroanterior radiograph of a left hand showing sclerosis of the lunate with some cyst formation and partial collapse. There are no radiological arthritic changes to the surrounding joints. The radiograph is suggestive of Kienbock’s disease (avascular necrosis of the lunate).
This is a posteroanterior radiograph of a left hand showing sclerosis of the lunate with some cyst formation and partial collapse. There are no radiological arthritic changes to the surrounding joints. The radiograph is suggestive of Kienbock’s disease (avascular necrosis of the lunate).
EXAMINER
What are the predisposing factors for Kienbock’s disease?
What are the predisposing factors for Kienbock’s disease?
CANDIDATE
Predisposing factors include ulnar minus variant – this is thought to lead to increased loading on the lunate, poor intraosseous anastomosis and a single extraosseous nutrient vessel.
Predisposing factors include ulnar minus variant – this is thought to lead to increased loading on the lunate, poor intraosseous anastomosis and a single extraosseous nutrient vessel.
EXAMINER
What are the patterns of intraosseous blood supply for lunate?
What are the patterns of intraosseous blood supply for lunate?
CANDIDATE
Gelbermann described the various patterns of intraosseous blood supply for lunate – Y pattern (60%), I pattern (30%) and an X pattern (10%) – in his paper in 1980. Single or repetiv e microfractures can result in disruption of the blood supply to the lunate. Recurrent compression of the lunate between the capitate and distal radius can also disrupt the intraosseous structures. The I- pattern as described by Gelbermann is a single blood supply to the lunate and is most susceptible to AVN from repetiv e microfractures as compared toX andY patterns. As such, apa tien t with I-pattern lunate blood supply is more susceptible to AVN.
Gelbermann described the various patterns of intraosseous blood supply for lunate – Y pattern (60%), I pattern (30%) and an X pattern (10%) – in his paper in 1980. Single or repetiv e microfractures can result in disruption of the blood supply to the lunate. Recurrent compression of the lunate between the capitate and distal radius can also disrupt the intraosseous structures. The I- pattern as described by Gelbermann is a single blood supply to the lunate and is most susceptible to AVN from repetiv e microfractures as compared toX andY patterns. As such, apa tien t with I-pattern lunate blood supply is more susceptible to AVN.
EXAMINER
What classification do you know for Kienbock’s disease?
What classification do you know for Kienbock’s disease?
CANDIDATE
Lichtman, which is a radiological classification. The stages as described by Lichtman are as follows: Stage I – plain radiographs normal (changes seen on MRI). Clinical findings are similar to a wrist sprain. Stage II – lunate sclerosis seen on plain radiographs. The overall size, shape and relationship to the carpal bones are not altered. Clinically the patient complains of recurrent pain, swelling and wrist tenderness. Stage IIIA – fragmentation and collapse of lunate without fixed scaphoid rotation derangements or instability). Stage IIIB – fragmentation and collapse of lunate with fixed scaphoid rotation, decreased carpal height and ulnar migration of the trique trium. Clinically the patient will complain of progressive wrist weakness, stiffness, pain along with clicking and clunking. Stage IV – radiocarpal and midcarpal arthritis, degenerative wrist changes. Clinically the patient has degenerative arthrosis of the wrist.
Lichtman, which is a radiological classification. The stages as described by Lichtman are as follows: Stage I – plain radiographs normal (changes seen on MRI). Clinical findings are similar to a wrist sprain. Stage II – lunate sclerosis seen on plain radiographs. The overall size, shape and relationship to the carpal bones are not altered. Clinically the patient complains of recurrent pain, swelling and wrist tenderness. Stage IIIA – fragmentation and collapse of lunate without fixed scaphoid rotation derangements or instability). Stage IIIB – fragmentation and collapse of lunate with fixed scaphoid rotation, decreased carpal height and ulnar migration of the trique trium. Clinically the patient will complain of progressive wrist weakness, stiffness, pain along with clicking and clunking. Stage IV – radiocarpal and midcarpal arthritis, degenerative wrist changes. Clinically the patient has degenerative arthrosis of the wrist.
EXAMINER
What is the role of MRI in Kienbock’s disease?
What is the role of MRI in Kienbock’s disease?
CANDIDATE
MRI is particularly useful in the early stages of the disease when clinical findings are suggestive of the disease, but radiographs are normal. MRI will show decreased signals on T1- and
MRI is particularly useful in the early stages of the disease when clinical findings are suggestive of the disease, but radiographs are normal. MRI will show decreased signals on T1- and
source p. 963
T2-weighted images.
EIXAMINER : What’s the differential diagnosis?
CAINDIDATE : The differential diagnosis includes pos t-traumatic arthritis, rheumatoid arthritiss ynovial-based inflammatory diseases, ulnar abutment syndrome, fracture and carpal instability.
EXAMINER
What are the management options for Kienbock’s disease?
What are the management options for Kienbock’s disease?
CANDIDATE
This depends on the patient symptoms, functional demands stage of the disease and patient factors. Conservative treatment with a period of time in splintage can be discussed. However, in symptomatic patients with Stage I/II/IIIA disease and if ulnar minus, I would offer a joint levelling procedure, either a radial shortening orless commonly an ulnar lengthening. I would prefer a shortening osteotomy because the incidence of non-/delayed union isless. If ulnar neutral or plus, I would consider a procedure aiming to reduce loading on the lunate – either a partial carpal arthrodesis (scaphotrapezium-trapezoid or scaphocapitate) or a capitate shortening. Other options are a vascularized bone graft with 4, 5-ICSRA , core decompression of the distal radius or a distal radial osteotomy. Surgical options for Stage IIIB/IV disease include a neurectomy, or salvage procedures such as a proximal row carpectomy or a wrist arthrodesis.
This depends on the patient symptoms, functional demands stage of the disease and patient factors. Conservative treatment with a period of time in splintage can be discussed. However, in symptomatic patients with Stage I/II/IIIA disease and if ulnar minus, I would offer a joint levelling procedure, either a radial shortening orless commonly an ulnar lengthening. I would prefer a shortening osteotomy because the incidence of non-/delayed union isless. If ulnar neutral or plus, I would consider a procedure aiming to reduce loading on the lunate – either a partial carpal arthrodesis (scaphotrapezium-trapezoid or scaphocapitate) or a capitate shortening. Other options are a vascularized bone graft with 4, 5-ICSRA , core decompression of the distal radius or a distal radial osteotomy. Surgical options for Stage IIIB/IV disease include a neurectomy, or salvage procedures such as a proximal row carpectomy or a wrist arthrodesis.
EXAMINER
How would you manage this case?
How would you manage this case?
CANDIDATE
I would confirm these were true length films for ulna variance – i.e. a wrist PA view with the shoulder forward flexed 90°, elbow 90° and forearm midprone. If these were, the wrist appears to be ulnar minus and I would offer a joint levelling procedure with a radial shortening using a volar locking plate (Figure 17.13b).
I would confirm these were true length films for ulna variance – i.e. a wrist PA view with the shoulder forward flexed 90°, elbow 90° and forearm midprone. If these were, the wrist appears to be ulnar minus and I would offer a joint levelling procedure with a radial shortening using a volar locking plate (Figure 17.13b).
source p. 964
Figure 17.13a Posteroanterior (PA) radiograph of left hand.
source p. 965
Figure 17.13b Posteroanterior (PA) radiograph demonstrating a joint levelling procedure (radial shortening).
source p. 966
Reference#
1. Gelberman RH, Bauman TD, Menon JAke son WH. The vascularity of the lunate bone and Kienbock’s disease. J Hand Surg Am. 1980;5(3):272–278.
source p. 967
Structured oral examination question 14#
source p. 968
Ulnar collateral ligament (UCL) injury of thumb
EXAMINER
What testis being done here (Figure 17.14a)?
What testis being done here (Figure 17.14a)?
CANDIDATE
This is a stress test being performed for ulnar collateral ligament (UCL) injury of the thumb. The testis done by stabilizing the thumb metacarpal and applying a valgus stress to the thumb MCP joint with the thumb flexed at 30°. The testis positive when the metacarpophalangeal (MCP) joint opens up 20° or more compared to the contralateral side.
This is a stress test being performed for ulnar collateral ligament (UCL) injury of the thumb. The testis done by stabilizing the thumb metacarpal and applying a valgus stress to the thumb MCP joint with the thumb flexed at 30°. The testis positive when the metacarpophalangeal (MCP) joint opens up 20° or more compared to the contralateral side.
EXAMINER
Tell me about ulnar collateral ligament injury. What is a Stener lesion and its significance?
Tell me about ulnar collateral ligament injury. What is a Stener lesion and its significance?
CANDIDATE
Acute ulnar collateral ligament injury is known as skier’s thumb and chronic injury is known as a gamekeeper’s thumb. A Stener lesion occurs when the UCL avulses from its insertion to the base of the proximal phalanx, folds proximally and the adductor aponeurosis becomes interposed between the torn UC Land the MCP joint preventing its healing. A St ener lesion requires surgical intervention.
Acute ulnar collateral ligament injury is known as skier’s thumb and chronic injury is known as a gamekeeper’s thumb. A Stener lesion occurs when the UCL avulses from its insertion to the base of the proximal phalanx, folds proximally and the adductor aponeurosis becomes interposed between the torn UC Land the MCP joint preventing its healing. A St ener lesion requires surgical intervention.
EXAMINER
How would you differentiate between complete and incomplete tear?
How would you differentiate between complete and incomplete tear?
CANDIDATE
Clinical examination should differentiate between complete and incomplete lesions. Incomplete lesions have a definite endpoint to collateral ligament testing. There are two components to the ulnar collateral ligament, the proper and accessory UCL. Instability of the MCPJ inflexion suggests an isolated proper UCL injury whereas instability inextension suggests the accessory ligament is involved. Plain radiographs would not demonstrate any joint widening on the ulnar border of the MCPJ in an incomplete lesion. Ultrasound scanning is useful.
Clinical examination should differentiate between complete and incomplete lesions. Incomplete lesions have a definite endpoint to collateral ligament testing. There are two components to the ulnar collateral ligament, the proper and accessory UCL. Instability of the MCPJ inflexion suggests an isolated proper UCL injury whereas instability inextension suggests the accessory ligament is involved. Plain radiographs would not demonstrate any joint widening on the ulnar border of the MCPJ in an incomplete lesion. Ultrasound scanning is useful.
EXAMINER
When would you decide to operate on UCL injury?
When would you decide to operate on UCL injury?
CANDIDATE
I would opt to operate if there’s more than 20° of opening on radial stressing of an acute UCL injury or the presence of a Stener lesion. The UCL can be repaired with direct suture repair, suture anchor or small screw fixation if the reis a large avulsed bony fragment (Figure 17.14b).
I would opt to operate if there’s more than 20° of opening on radial stressing of an acute UCL injury or the presence of a Stener lesion. The UCL can be repaired with direct suture repair, suture anchor or small screw fixation if the reis a large avulsed bony fragment (Figure 17.14b).
EXAMINER
How does a chronic UCL injury present?
How does a chronic UCL injury present?
CANDIDATE
Patients will complain of pain mainly on the inner side of the thumb when stressing the thumb with activitie slik e gripping or pinching. In addition, the y complain that the thumb feels weak on pinching.
Patients will complain of pain mainly on the inner side of the thumb when stressing the thumb with activitie slik e gripping or pinching. In addition, the y complain that the thumb feels weak on pinching.
EXAMINER
How would you manage a chronic UCL injury?
How would you manage a chronic UCL injury?
CANDIDATE
In a symptomatic chronic UCL injury, this would need reconstruction using the palmaris longus tendon as a graft. In longstanding cases, patients can develop arthritic changes and, in this situation, MCP fusion would be indicated.
In a symptomatic chronic UCL injury, this would need reconstruction using the palmaris longus tendon as a graft. In longstanding cases, patients can develop arthritic changes and, in this situation, MCP fusion would be indicated.
source p. 969
Figure 17.14a Clinical picture of stress testing ulnar collateral ligament (UCL).
Figure 17.14b Intraoperative picture showing an approach to the medial side of the thumb MCP joint for an ulnar collateral ligament repair. The scissor tips are pointing a t the bare insertion of the ligament to the base of the proximal phalanx. This is a chronic case and the scarred proximal ligament is lying bunched up over the metacarpal head.
source p. 970
Structured oral examination question 15#
source p. 971
Boutonnière deformity
EXAMINER
A rugby player has injured his finger during a game. He has pain and swelling and attends casualty where radiographs are taken. Describe what you see and the likely diagnosis (Figure 17.15a).
A rugby player has injured his finger during a game. He has pain and swelling and attends casualty where radiographs are taken. Describe what you see and the likely diagnosis (Figure 17.15a).
CANDIDATE
The radiographs show flexion at the PIP joint of the litile finger and hyperextension at the DIP.
The radiographs show flexion at the PIP joint of the litile finger and hyperextension at the DIP.
EXAMINER
How would you manage this?
How would you manage this?
CANDIDATE
I would test the central slip of the extensor mechanism by Elson’s test – the PIP joint is flexed to 90° over the edge of a table, and the patient is asked to extend the finger against resistance (the examiner presses on the middle phalanx). A positive test shows weakness of extension of the PIP joint with hyperextension of the DIP joint due to recruitment of the lateral bands. A closed central slip rupture if left may lead to a Boutonnière deformity. I would offer a dynamic splint – a Capener – to keep the PIP joint passively extended but allow active flexion (Figure 17.15b). This needs to beworn for 6 weeks. I would explain that a mild flexion deformity is likely even with treatment.
I would test the central slip of the extensor mechanism by Elson’s test – the PIP joint is flexed to 90° over the edge of a table, and the patient is asked to extend the finger against resistance (the examiner presses on the middle phalanx). A positive test shows weakness of extension of the PIP joint with hyperextension of the DIP joint due to recruitment of the lateral bands. A closed central slip rupture if left may lead to a Boutonnière deformity. I would offer a dynamic splint – a Capener – to keep the PIP joint passively extended but allow active flexion (Figure 17.15b). This needs to beworn for 6 weeks. I would explain that a mild flexion deformity is likely even with treatment.
Figure 17.15a Anteroposterior (AP) and lateral radiographs of alit ile finger.
source p. 972
Figure 17.15b Picture of a splint used to manage a Boutonnière deformity.
source p. 973
Structured oral examination question 16#
source p. 974
Swan-neck deformity
EXAMINER
These are clinical pictures of a 60-year-old lady complaining of difficulty making a full fist with her left hand ( Figure 17.16).
These are clinical pictures of a 60-year-old lady complaining of difficulty making a full fist with her left hand ( Figure 17.16).
CANDIDATE
The photograph shows hyperextension at the proximal interphalangeal joint (PIPJ) and flexion at the distal interphalangeal joints (DIP) of the left middle and ring fingers.
The photograph shows hyperextension at the proximal interphalangeal joint (PIPJ) and flexion at the distal interphalangeal joints (DIP) of the left middle and ring fingers.
EXAMINER
What deformity is this and what is the pathophysiology of it?
What deformity is this and what is the pathophysiology of it?
CANDIDATE
This is swan-neck deformity. These deformities occur duet o volar plate laxity or an imbalance of forces on the PIP joint. Candidate should have followed through and said the picture was highly suggestive of swan- neck deformity in keeping with a picture of a generalized symmetrical polyarthropathy, most likely rheumatoid arthritis. The patient is unable to make a full fist due to the hyperextended posture of the PIP joint.
This is swan-neck deformity. These deformities occur duet o volar plate laxity or an imbalance of forces on the PIP joint. Candidate should have followed through and said the picture was highly suggestive of swan- neck deformity in keeping with a picture of a generalized symmetrical polyarthropathy, most likely rheumatoid arthritis. The patient is unable to make a full fist due to the hyperextended posture of the PIP joint.
EXAMINER
What is the classification system associated with this deformity?
What is the classification system associated with this deformity?
CANDIDATE
Swan-neck deformity in a rheumatoid hand is classified according to PIPJ mobility and radiographic appearances: Type I – PIP joint flexible in all positions. Type II – PIP joint motion limited only by tenodesis effect (tight intrinsics). Type III – fixed PIP joint contracture, X-ray preserved joint space. Type IV – arthritic changes with loss of active and passive motion a t PIPJ.
Swan-neck deformity in a rheumatoid hand is classified according to PIPJ mobility and radiographic appearances: Type I – PIP joint flexible in all positions. Type II – PIP joint motion limited only by tenodesis effect (tight intrinsics). Type III – fixed PIP joint contracture, X-ray preserved joint space. Type IV – arthritic changes with loss of active and passive motion a t PIPJ.
EXAMINER
What are the causes of this deformity?
What are the causes of this deformity?
CANDIDATE
Swan-neck deformity has several different aetiologies. The primary pathology is a lax volar plate; this may be caused by rheumatoid arthritis trauma or generalized ligamentous laxity. The secondary pathology is an imbalance of hand intrinsic muscles. This may occur at different sites such as at MCP, PIP or DIP joints. MCP joint volar subluxation seen in RA causes intrinsic and central tendon tightness leading to volar subluxation and flexion at the MCP joint. PIP joint FDS rupture with unopposed PIPJ extension resulting in intrinsic contracture. There is tethering of the lateral bands by the transverse retinacular ligamentas a result of PIPJ hyperextension. The excursion of the lateral bands is restricted; therefore, the extension force is not transmift ed to the terminal tendon. The extension force is transmift ed to the PIP joint instead. DIP joint Mallet injury. The DIP joint extension force is transferred to the PIPJ central slip.
Swan-neck deformity has several different aetiologies. The primary pathology is a lax volar plate; this may be caused by rheumatoid arthritis trauma or generalized ligamentous laxity. The secondary pathology is an imbalance of hand intrinsic muscles. This may occur at different sites such as at MCP, PIP or DIP joints. MCP joint volar subluxation seen in RA causes intrinsic and central tendon tightness leading to volar subluxation and flexion at the MCP joint. PIP joint FDS rupture with unopposed PIPJ extension resulting in intrinsic contracture. There is tethering of the lateral bands by the transverse retinacular ligamentas a result of PIPJ hyperextension. The excursion of the lateral bands is restricted; therefore, the extension force is not transmift ed to the terminal tendon. The extension force is transmift ed to the PIP joint instead. DIP joint Mallet injury. The DIP joint extension force is transferred to the PIPJ central slip.
EXAMINER
What are the surgical treatments for swan-neck deformity?
What are the surgical treatments for swan-neck deformity?
source p. 975
CANDIDATE
The patient hand function and expectations must be fully assessed. The surgical treatment depends upon the site of the lesion (DIPJ, PIPJ or MCPJ), where the deformity originated from and whether the deformities are fixed or flexible. Flexible deformities can be treated with soft -tissue procedures, whereas fixed deformities require bony procedures such as arthrodesis or arthroplasty. The surgical interventionist ailored in addressing the primary pathology of the swan-neck deformity. I would divide the surgical procedures according to the joints involved such as below: MCP joint problems can be addressed with synovectomy and MCP joint arthroplasty. A lateral tenodesis can be performed using the ulnar lateral band which is mobilized at the MCP joint. The bandis passed volar to Cleland’s ligament and fixed to itself around the A2 pulley attachment (as for FDS tenodesis). PIP joint problems, FDS tenodesis can be performed with a single slip of the FDS being passed around the A2 pulley sewn to itself holding the PIP joint flexed. This position can be maintained with a temporary K-wire. A dorsal release may also be necessary using a curvilinear incision over the PIP joint. The extensor expansion including lateral bands and collateral ligaments is released with removal of osteophytes and with a synovectomy if required, ensuring full PIP joint range of movement. Particular attention should bepaid to the central slip to ensure that it’s not damaged during surgery. DIP joint problems can be addressed with a DIP joint fusion or possibly a dermodesis.
The patient hand function and expectations must be fully assessed. The surgical treatment depends upon the site of the lesion (DIPJ, PIPJ or MCPJ), where the deformity originated from and whether the deformities are fixed or flexible. Flexible deformities can be treated with soft -tissue procedures, whereas fixed deformities require bony procedures such as arthrodesis or arthroplasty. The surgical interventionist ailored in addressing the primary pathology of the swan-neck deformity. I would divide the surgical procedures according to the joints involved such as below: MCP joint problems can be addressed with synovectomy and MCP joint arthroplasty. A lateral tenodesis can be performed using the ulnar lateral band which is mobilized at the MCP joint. The bandis passed volar to Cleland’s ligament and fixed to itself around the A2 pulley attachment (as for FDS tenodesis). PIP joint problems, FDS tenodesis can be performed with a single slip of the FDS being passed around the A2 pulley sewn to itself holding the PIP joint flexed. This position can be maintained with a temporary K-wire. A dorsal release may also be necessary using a curvilinear incision over the PIP joint. The extensor expansion including lateral bands and collateral ligaments is released with removal of osteophytes and with a synovectomy if required, ensuring full PIP joint range of movement. Particular attention should bepaid to the central slip to ensure that it’s not damaged during surgery. DIP joint problems can be addressed with a DIP joint fusion or possibly a dermodesis.
EXAMINER
What are the complications of surgery?
What are the complications of surgery?
CANDIDATE
I would divide the complications of surgery into those related to the actual surgical procedures, those related to the systemic disease of rheumatoid arthritis or those related to anft- rheumatoid medications.
I would divide the complications of surgery into those related to the actual surgical procedures, those related to the systemic disease of rheumatoid arthritis or those related to anft- rheumatoid medications.
Figure 17.16 Swan-neck deformity, fingers.
Complications related to surgery
source p. 976
Soft -tissue procedure infection, wound breakdown, failure to correct deformity, recurrence of deformity, overcorrection of deformity, neurovascular damage, scar pain, stiffness and CRPS.
Arthrodesis procedure non-union, malunion, implant failure or prominence metalwork (additional to the complications of soft -tissue procedure).
Arthroplasty procedure implant failure, fracture, dislocation, loosening, stiffness, osteolysis, tendon/ligament damage, failure to relieve symptoms.
Complications related to medications
Medications should be managed in conjunction with a rheumatologist. Patients taking corticosteroids undergoing surgery may need corticosteroid coverage peri operatively. Coverage should be provided if the patient has been on 10 mg of prednisolone per day for 1 week or more within the last 6 months. This is usually given in the form of hydrocortisone IM or IV. The exact regime depends upon the amount of surgical stress expected.
Aspirin/NSAIDs use affects platelet function and bleeding during and after surgery. NSAIDs can also increase the risk of GI bleeds and renal impairment peri operatively.
Anft-TNF and other biological medications may affect wound healing and increase the risk of infection postoperatively. Speak to a rheumatologist preoperatively. It is considered safe to continue methotrexate during the operative period, with most studies showing no increase in infection rates.
Complications related to systemic diseases
Cervical spine cervical spine disease is common inpatients with RA. This must be fully assessed clinically and radiologically preoperatively. Atlantoaxial subluxation or basal invagination is a possible complication of RA and the C-spine anaesthetist should make a full assessment preoperatively.
Cardiac disease mostly not related toRA, but some cardiac disease can be secondary toRA such as pericarditis, conduction blocks secondary to granulomas or nodules, left-sided heart failure and disease of the myocardium or valves.
Airway disease along with cervical spine pathology, cricoarytenoid RA and laryngeal oedema can make management of airway difficult.
Lung disease: pleurisy, pleural effusion, rheumatoid nodules and mild fibrosing alveolitis. More severe lung disease such as interstial pneumonitis or fibrosis and bronchiolitis can affect operative risk.
These may be secondary to rheumatic drug therapy such as gold, penicillamine or methotrexate.
Bone disease can lead to osteoporosis and care should betaken when handling these patients.
Vasculitis can lead to non-healing ulcers and neuropathy.
Renal disease: the kidneys may be affected by vasculitis or amyloidosis (chronic disease).
Pharmacological treatments may also damage the kidneys.
source p. 977
Haematological RA patient may have anaemia or neutropenia (Felty’s syndrome).
Infection patients with RA may have an increased susceptibility to infection postoperatively. This may be related to the disease processor secondary to medications (an ft-TNF).