Académique Documents
Professionnel Documents
Culture Documents
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Jules Tinel
1879-1952
During the Second World War he had to leave the Hospital; his family were interned, and one
son executed by the Gestapo because they had helped run an escape route.
Formication in the nerve is a very important sign, for it indicates the presence of young
axis-cylinders in process of regeneration.
This formication is quite distinct from the pain on pressure, which exists in nerve irritations.
Tenderness, indicating irritation of the axis-cylinders and not their regeneration, is almost
always local, perceived at the very spot where the nerve is compressed, or at least magnified at
this spot; it always co-exists with the pain in the muscular bellies under pressure, which are,
very often, more tender than the nerve.
Formication of regeneration, on the other hand, is but little or not at all perceived at the spot
compressed, but is felt almost entirely in the cutaneous distribution of the nerve; the
neighbouring muscles are not tender.
As a rule, it appears only about the fourth or sixth week after the wound. It enables us to
ascertain the existence of this regeneration and to follow its progress.
If it remains fixed and limited to one spot for several consecutive weeks or months, this is
because the regenerating axis-cylinders have encountered an insurmountable obstacle and are
forced together at that place as a more or less bulky neuroma.
The fixity of formication on a level with the lesion, and the complete absence of formication
below the lesion, would almost warrant our affirming the complete interruption of the nerve and
the impossibility of spontaneous regeneration.
If, on the other hand, the regenerated axis-cylinders can overcome the obstacle and make their
way into the peripheral segment of the nerve, we see a progressive migration of the formication
so provoked. Pressure on the nerve below the wound produces this sensation, and from week
to week it may be encountered at a spot farther removed from the nerve lesion. The presence
of formication provoked by pressure below the nerve lesion warrants our affirming that there is
more or less complete regeneration.
The site at which formication can be demonstrated moves along the course of the nerve at the
same pace as the axis-cylinders advance; at the same time that it extends progressively
towards the periphery it disappears at the level of the lesion.
The "formication sign" is thus of supreme importance, since it enables us to see whether the
nerve is interrupted, or is in course of regeneration; whether a nerve suture has succeeded or
failed, or whether regeneration is rapid and satisfactory, or reduced to a few significant fibres.
1 of 2 10/6/2007 12:19 PM
Jules Tinel http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Formication lasts a tolerably long time; appearing about the fourth week, it persists during the
entire regeneration, i.e., for eight,
[ Close Window ]
2 of 2 10/6/2007 12:19 PM
Kienbock's Disease http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer
to the site policies for rules on diseminating site content.
Kienbock's Disease
SUMMARY
Described by Kienbock in 1910, a radiologist in Vienna. (republished article in CORR 1980, Vol 149)
Aetiology:
Uncertain
Theories:
Associated with Negative ulnar variance (of interest, there do not seem to be any reports of Kienbock's
disease after the Darrach's procedure)
Clinical Manifestations:
Young adults
wrist pain that radiates up the forearm
wrist stiffness
tenderness over lunate dorsally
weakness of grip
Radiography:
Lichtman Staging:
Normal architecture & density, may see a linear compression # (Bone scan
Stage 1
& MRI diagnosis)
Stage 2 Increased density, normal architecture & outline; cysts
Stage 3 collapse & fragmentation
Stage 3A No carpal collapse
1 of 3 10/6/2007 12:20 PM
Kienbock's Disease http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Treatment:
Remember:
Surgery only indicated when pain & disability cannot be managed by splintage, analgesia & reassurance.
Surgery:
Stage 1 & 2:
1. Joint Levelling:
1. Radial shortening
2. Ulnar lengthening - high non-union rate.
2. Revascularisation of lunate
Pedicled vascularised graft from distal radius with pronator quadratus
dorsal digital artery placed into drill hole on lunate
2 of 3 10/6/2007 12:20 PM
Kienbock's Disease http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Stage 3:
excision of lunate alone will cause the rest of the carpal bones migrate, leading to joint incongruity, limited
wrist motion and grip strength, and degenerative osteoarthritis
Stage 4:
1. Wrist denervation
2. Total wrist fusion.
[ Close Window ]
3 of 3 10/6/2007 12:20 PM
Nerve Injuries - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies for rules on diseminating site content.
Diagnostic tests Early management of nerve injuries Techniques of nerve repair Aftertreatment
Of spinal nerves
Each segmental spinal nerve is formed by union of the dorsal/sensory root with the ventral/motor root at or before the intervertebral foramen
In the thoracic segments, these mixed spinal nerves maintain their autonomy, providing sensation and motor function to one intercostal segment
In all other areas (cervical, lumbar and sacral regions, plexuses are formed which provide a limb or special body segment without retaining the primitive myomeric pattern
Motor
The cell bodies are in the anterior horn cells and innervate skeletal muscle.
Sensory
Cell bodies lie within the dorsal root ganglia. The fibres arise in the pain , thermal, tactile and stretch receptors .
These fibres pass cephalad in the dorsal columns and do not synapse until reaching the cervicomedullary junction.
Pathw ay for pressure and crude touch from extremities and trunk
These fibres enter, synapse and cross and ascend into the contralateral ventral spinothalamic tract.
These fibres synapse in the spnal cord, and cross to ascend in the lateral spinothalamic tract. There is some area of neuronal overlap explained by branches that ascend or descend via the dorsolateral column/fasciculus of Lis
Sympathetic
The sympathetic component of all 31 spinal nerves leaves the spinal cord along only 14 motor roots (from T1 to L2). Between T1 and L2 there are white rami containing sympathetic fibres to the ganglions of the sympathetic chain. S
spinal nerves through grey rami.
Divides into an anterior and posterior primary ramus after leaving the intervertbral foramen.
Posterior primary ramus supplies the paraspinal musculature and the skin along the posterior aspect of the trunk neck and head
Microscopic anatomy
1 of 7 10/6/2007 12:22 PM
Nerve Injuries - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Sensory and motor nerves contain both unmyelinated and myelinated fibres at a ratio of 4:1.
The blood supply to the peripheral nerve enters through the mesoneurium. This blood supply is both extrinsic/segmental and intrinsic/longitudinal within the epineurium, perineurium and endoneurium.
Perineurium
it is a cellular layer with tight junctions between cells enclosing the perineurial space (within the perineurium)
Epineurium
= anything outside the perineurium which is not nerve fibre or blood vessel
mainly collagen
Endoneurium
The arrangement of the fascicles in the proximal aspect of perpheral nerves is more complex than in the distal end of the nerve.
1. Retraction
2. Inflammation
3. Degeneration
Any part of a neuron detached from its nucleus degenerates and is destroyed by phagocytosis.
The fundamental concept of wallerian degeneration is that survival of nerve fibres occurs only if they remain connected to the cell body.
Cell body
swells
chromatolysis (basophilia)
By 7 days the Schwann cells are mitosing & phagocytosing cellular & myelin debris
Schwann cells occupy the empty endoneurial tubes forming the 'bands of von Bungner'
The bands act as sprouts (neurites) of regenerating axons ('pioneering axons') down the endoneurial tubes -> Regeneration.
4. Regeneration
2 of 7 10/6/2007 12:22 PM
Nerve Injuries - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Axonal sprouting can occur within 24 hrs of injury. All sprouts are unmyelinated to begin with.
If the sprouts manage to make distal connections then nerve fibre maturation occurs, with increase in axon & myelin thickness.
Neurites which fail to make distant connections die back & are lost to the regenerative process.
If the perineurium is not disrupted then the axons will be guided along their original pathway (1mm/day)
If the perineurium is disrupted there are neurotrophic substances (NGF - nerve growth factors) which attract the neurites to nerve tissue.
The critical gap over which this does not occur is 2mm.
Neuromas form when neurites migrate aimlessly across a large gap. They can be stump neuromas or neuromas in continuity.
[Back To Top]
Seddon Classification
sensory recovery is better (sensory receptors survive longer than motor units)
Sunderland Classification
Mckinnon & Dellon (1988) added a 6 th degree injury = neuroma-in-continuity , where a nerve has had a disordered self -repair with a lateral neuroma. There is a mixture of injuries, when a nerve is partly severed and the remaining trun
Pain, swelling, discoloration, hyperhydrosis, osteoporosis, resulting from an abnormal and prolonged response from the sympathetic nervous system.
3% of major nerve injuries
Can be due to metabolic, collagen disease, malignancy, toxins, thermal or mechanical injury, but only mechanical causes mentioned here.
Mechanical causes producing primary injury include laceration, fracture, fracture manipulation, gunshot wound
Secondary injury can be due to infection, scarring, callus, vascular complications, eg. AV malformation, aneurysm, ischaemia
6. Clinical diagnosis of nerve injury and assessment post injury [Back To Top]
Motor function
Muscle wasting
Method for assessing the the return of muscle function after nerve injuries (British Research Council)
M 0 No contraction
M 1 Return of perceptible contraction in proximal muscles
M 2 Return of perceptible contraction in both proximal and distal muscles
3 of 7 10/6/2007 12:22 PM
Nerve Injuries - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
M 3 Return of prox. and distal muscle power enough to allow the major muscle groups to act against resistance
M 4 Return of function as in stage 3 but synergistic and independent movements are possible
M 5 Complete recovery
Sensation
Sharp pin to assess pain, cotton wool to assess light touch, tips of a paper clip to assess two point discrimination.
There is an area of complete sensory loss ' the autonomous zone ', which gets smaller even before fibres can regenerate (? Due to increased function of anastomotic branches from adjacent nerves)
A larger area of reduced sensation surrounds this = ' the intermediate zone '
When a nerve is intact and the surrounding nerves are blocked, an area of sensibility larger than the gross anatomical distribution of the nerve occurs = ' the maximal zone '
Sensation assessment after peripheral nerve injury - British Medical Research Society
The best correlator of eventual function is return of 2 point discrimination (as emphasised by Moberg, 1995)
Autonomic function
There is loss of sweating , the pilomotor response and vasomotor action when a peripheral nerve is disrupted.
Pilomotor - The wrinkle test is a useful objective test - Denervated skin does not wrinkle in water
Vasomotor - Initially there may be vasodilatation in a complete lesion, pinkness for 2-3 weeks. Then coldness paleness, mottled. This may spread to more than the anatomical area of skin supplied by the nerve.
Atrophy of fingers and nails can occur.
Test sweating:
1. by rubbing smooth pen against side of finger (if finger moves with pen = sweating present)
2. Ninhydrin print test - applying nihydrin to sweat turns it purple (Moberg, 1995)
3. Look through the +20 lens of an opthalmoscope to see the beads of sweat
4. Dust the extremity with quinizarin powder. Sweating turns the powder purple
If sweating still present this suggests that the nerve damage is incomplete
Gentle percussion with the finger along the course of the injured nerve will produce a transient tingling sensation in the distribution of the injured nerve, persisting for several seconds.
Start distally and proceed proximally
A positive Tinel sign is evidence of regenerating axonal sprouts which have not completed myelinisation are progressing.
A distally advancing Tinel sign should be present in Sunderland 11 and 111 injuries
A type 1 injury (neuropraxia) should not produce any Tinel's sign as no new regeneration should need to occur
Type 1V and V injuries do not produce an advancing Tinel sign unless repaired
A progressing Tinel's sign is encouraging but does not necessarily mean complete recovery.
Reflexes
Complete severance of either the efferent or afferent nerve in a reflex abolishes that reflex. However, the reflex can be lost even in partial injury and is not a good guide of injury severity
Evaluation of peripheral nerves & their sensory & motor responses anywhere along their course
Stimulation of a peripheral nerve should evoke a contraction in the muscles it supplies (seen, palpated or measured electromyographically)
Latency (t) = time between onset of stimulus & the response
4 of 7 10/6/2007 12:22 PM
Nerve Injuries - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Sensory Nerve:
CNAP (compound nerve action potential) is measured (lower amplitude than CMAP)
a uniquely sensory nerve must be chosen for the stimulation site
V (sensory) = d / t (where V (sensory) is the segment velocity in sensory fibres; d is distance betw. stimulation site & recording cathode; t is the average latency betw. stimulus & CNAP)
Sensory nerve conduction test for Ulnar nerve across the wrist (from TeleEMG )
Collision Studies
Timing of NCS:
Immediately after section of a peripheral nerve, stimulation distally will elicit a normal response for 18-72 hrs until wallerian degeneration occurs.
Absence of distal nerve motor conduction (CMAP) after 3-7 days excludes a neuropraxia type injury.
Absence of sensory conduction (CNAP) after 7-10 days excludes a neuropraxia type injury.
Therefore the ideal time for NCS after injury is 10-14 days after injury to discern neuropraxia from axonotmesis / neurotmesis.
Neuropraxia will improve (incr. velocity & decr. latency) with repeated tests, while axonotmesis & neurotmasis will deteriorate
Somatosensory Evoked Potentials (SSEP) = stimulate peripheral sensory nerves & measure on the scalp. For study of brachial plexus & spinal cord monitoring.
Electromyography
A needle electrode in the muscle is used to record motor unit activity at rest and on attempted contraction of the muscle
Normal EMG shows no muscle activity at rest and a characteristic pattern on voluntary contraction
Normal EMG
Immediately after nerve section, EMG will be normal, although there will be no muscle response after stimulation of the nerve proximal to the nerve injury (CMAP)
Within Between 5 and 14 days positive sharp waves consistent with denervation
5 of 7 10/6/2007 12:22 PM
Nerve Injuries - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
If denervation fibrillation potentials are not present by the end of the 2 nd week this is a good prognostic sign.
Evidence of reinnervation is when highly polyphasic motor unit potentials are detected at attempts at voluntary activity
Denervation fibrillations in a muscle only tell you that the muscle is not innervated. It does not determine whether the injury is 2 nd 3 rd or 4 th degree.
Reinnervation potentials by the same token can be restored after regeneration of only a few motor fibres and does not necessarily mean a good return to voluntary motor control
* Insertional Activity = needle is inserted into muscle or moved within muscle, there is a single burst of activity that usually lasts 300 to 500 ms; thought to result from mechanical stimulation or injury of the muscle fibers
** Rest Activity = differentiates neuropathic muscle atrophy from myopathic atrophy
*** Fibrillations - are action potentials that arise spontaneously from single muscle fibers; usually occur rhythmically and are though to be due oscillations of the resting membrane potential in denervated muscles. Appears 3 - 5 weeks after the n
++
Potentials - number of phases (? action potentials); indicates collateral axonal sprouting; polyphasic = > 4 phases
Clinical evidence to support one over the other type of repair is meagre. The technique selected depends on the experience of the surgeon.
6 of 7 10/6/2007 12:22 PM
Nerve Injuries - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Sunderland points out that fascicular repair is not possible in all cases, but most practical when
11. Factors influencing regeneration after nerve repair (neurorrhaphy) [Back To Top]
1. Age
Worsening results with increasing age, though numbers at extremities of age are small
Nicholson, Seddon and Sakellarides noted that the upper limit of gap beyond which results will deteriorate is 2.5 cm. Methods of closing gaps;
1. nerve mobilisation
2. nerve transposition
3. joint flexion
4. nerve grafts
5. bone shortening
Delay affects motor recovery more than sensory recovery (due to the survival time of striated muscle.
Little evidence about sensory function return in relation to delay, but sensation can improve in as late a repair as 2 years.
Kleinert et al feel that a delayed repair of between 7 and 18 days is best for return of satifactory function. Reasonable approach is immediate repair if conditions allow and before 6 weeks in extensive soft tissue contusion, co
4. Level of injury
The more proximal the lesion, the more incomplete the recovery. Boswick et al reviewed 102 peripheral nerve injuries in 81 patients. 87% of those injuries below the elbow gained protective sensation. 14% regained normal 2 p
5. Condition of nerve ending The better the condition the more improvement
Further Reading:
[ Close Window ]
7 of 7 10/6/2007 12:22 PM
Replantation & Microsurgery http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site
policies for rules on diseminating site content.
Can be guillotine, crush or avulsion (these have the poorest results and prognosis)
Ischaemia time
1. Thumb amputation
2. Multiple digit amputations
3. Metacarpal amputation
4. Almost any body part in a child
5. Wrist or forearm amputation
6. Individual digit distal to FDS insertion, replantation at level distal to insertion of FDS often results in satisfactory
function [Diagram]
Contra-indications
1. Local:
1. Severely crushed or mangled parts (See MESS)
2. Amputations at multiple levels
1 of 5 10/6/2007 12:22 PM
Replantation & Microsurgery http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
3. Distal amputations, amputations distal to the DIP joint are difficult to replant since the digital artery begins to
branch and dorsal veins are hard to find
2. General
1. Amputations in patients with other serious injuries or diseases
2. Arteriosclerotic vessels
3. Mentally unstable patients
Class I circulation adequate: requires standard bone and soft tissue treatment
Complete amputations proximal to the FDS tendon insertion (male pts) should be treated with amputation although may
consider proximal replant in children or females
Single digit replantation proximal to FDS insertion produces a digit with significant functional impairment (avg. PIPJ ROM in
these digits is only 35o although cold intolerance and sensation are comparable to more distally amputated group
2 of 5 10/6/2007 12:22 PM
Replantation & Microsurgery http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Post Op:
Temperature probe
Complications:
Early
1. Arterial insufficiency
1. inspect and loosen dressing
2. change hand position
3. stiletto block (spasm)
4. heparin bolus (3000 to 5000 units)
5. if no improvement in 4-6 hours, return to theatre for re-do anastamosis 50-60% successful
2. Venous insufficiency
Can use medical leeches, but must give antibiotics to cover for aeromonas hydrophilia
3. Infections
More common in upper extremity replantations which develops myonecrosis
Late
1. Functional difficulties
Related to "one wound, one scar" concept with resultant loss of differential gliding between the tissues
Motion of digits significantly affected by overall injury sustained, motion of PIPJ accounts for 85 % of arc of
finger motion
2. Cold intolerance
Thought to improve after 2 years but a recent long-term study (1995 ASSH Meeting abstract) has shown no
improvement.
Nerve recovery
Dependent on the type and level of injury, but overall the results are comparable to isolated nerve injuries
Limb ischaemia
3 of 5 10/6/2007 12:22 PM
Replantation & Microsurgery http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Shock
Hypotensive transiently
1
Persistent hypotension
2
Age (years)
< 30
0
30-50
1
> 50
2
Limb salvage vs. amputation. Preliminary results of the Mangled Extremity Severity Score
In both the prospective and retrospective studies, a MESS score of greater than or equal to 7 had a 100% predictable value
for amputation
Results
Children 70% success - poorer results in children reflects a more aggressive approach
4 of 5 10/6/2007 12:22 PM
Replantation & Microsurgery http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Motor MRC 3
[ Close Window ]
5 of 5 10/6/2007 12:22 PM
Scaphoid Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site
policies for rules on diseminating site content.
Scaphoid Fractures
History
Palmarflexion in 3% of cases
Examination
Special tests
X-ray
1 of 6 10/6/2007 12:23 PM
Scaphoid Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
A- C:
Scaphoid
view 1 - with
forearm
pronated
45deg. to
view profile of
scaphoid &
STT joint; D -
Scaphoid
view 2 (ulnar
oblique view)
showing
radioscaphoid
joint (from
Rockwood &
Green)
Bone Scanning
CT
MR
2 of 6 10/6/2007 12:23 PM
Scaphoid Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Position of wrist
Ulnar deviation will distract the fracture, therefore this must be avoided
Neutral in AP plane
Moulded into the palm
Duration 8 weeks
Re-examine and X-ray at 8 weeks out of plaster
If still tender then treat in cast for a further 4 weeks
At 12 weeks leave free regardless of whether there is tenderness or not
Re-X-ray at 6 months
3 of 6 10/6/2007 12:23 PM
Scaphoid Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Operative treatment
Indications
Approach
Volar
Dorsal
Herbert screw
Herbert-Whipple screw
AO low profile compression screw
Acutrack screw
K-wires
4 of 6 10/6/2007 12:23 PM
Scaphoid Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
1. Delayed union
>4 months
2. Non-union
3. Malunion
5. DISI
Non-union: No OA or AVN
5 of 6 10/6/2007 12:23 PM
Scaphoid Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Salvage procedures
Wrist Denervation
Total wrist fusion
[ Close Window ]
6 of 6 10/6/2007 12:23 PM
Scapholunate Ligament Rupture http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
[ Close Window ]
1 of 1 10/6/2007 12:24 PM
Tendon Injuries http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the
site policies for rules on diseminating site content.
Tendon Injuries
TENDON
Wrist Post-operative Complications
RECONSTRUCTION
1 of 7 10/6/2007 12:25 PM
Tendon Injuries http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
2 of 7 10/6/2007 12:25 PM
Tendon Injuries http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
The position of the hand at the time of injury determines the tendon
retraction:
Contraindications to Repair
[Back To Top]
1. Wounds liable to
infection
2. Inability of patient to
cooperate with
rehabilitation
3 of 7 10/6/2007 12:25 PM
Tendon Injuries http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
4 of 7 10/6/2007 12:25 PM
Tendon Injuries http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Order of Repair:
1. FPL
2. FDP tendons
3. FDS to middle & ring fingers
4. FDS to index & little fingers
5. Ulnar nerve
6. Ulnar artery
7. Median nerve
8. FCU
9. FCR
10. Radial artery - ligated.
5 of 7 10/6/2007 12:25 PM
Tendon Injuries http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Belfast Regimen:
1. Rupture
2. Infection
3. Adhesions - prevented by early passive ROM
4. Joint contractures - too tight repair or from prolonged splintage
5. Bow stringing - from damaged pulleys
Contracture of the muscle-tendon unit has usually occurred & tendon graft often required.
Methods:
Contraindications:
1. Infection
2. Too much damage to support an implant or allow decent tendon gliding
3. Motivated patient
4. Experienced surgeon
5. Experienced Hand Therapist
First Stage:
6 of 7 10/6/2007 12:25 PM
Tendon Injuries http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Aims:
Second Stage:
1. Palmaris Longus
2. Plantaris - best for multiple tendon grafts
3. Long toe extensors - 2nd, 3rd or 4th toes
4. EIP
5. Fascia Lata
[ Close Window ]
7 of 7 10/6/2007 12:25 PM
Tendon Transfer - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies for rules on
diseminating site content.
A tendon transfer is a procedure in which the tendon of insertion or of origin of the functioning muscle is mobilised, detached or divided
and reinserted into a bony part or onto another tendon, to supplement or substitute for the action of the recipient tendon
Only muscles with power of 4+ should be considered donors as they always lose 1 MRC grade of power
Changing a muscle from monoarticular to biarticular, the amplitude is increased by movement of the extra joint that the tendon crosses
A graft can be used as an extension, but all anastomoses are sources of adhesions
The less turns or bends through which the tendon has to pass, the less friction can reduce power and amplitude
7. An adequate glide of the transferred tendon is necessary, through unscarred natural planes
If a tendon is split and inserted into different sites only the tighter of the two will function and the other will not
In extensive paralysis
1 of 3 10/6/2007 12:26 PM
Tendon Transfer - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
2. Flexion of elbow
3. Extension of wrist
4. Flexion of fingers
6. Finger extension
1. Timing
Following nerve injury repair, the date of expected recovery can be calculated by measuring the distance between the injury to the most
proximal muscle supplied, assuming a rate of regeneration of 1mm/day. If reasonable return of function not present for 3 mnths after the
expected, consider tendon transfer.
2. Planning
3. Techniques
5. Achieving proper tension - No general rule, but reasonable to place limb in the position of maximal function of the tendon transfer and
suture without tension
MEDIAN NERVE:
Thumb Opposition (loss of FBP) (note thumb opposition is For index and middle finger flexion
combination of flexion and adduction)
FDP of index and middle finger sutured side to side to FDP
1. Ring finger FDS transfer to APB via a pulley of ring and little fingers, +/- ECRL tendon transfer to FDP for
made in the FCU tendon at the level of the extra strength
pisiform. [Picture]
2. MCP +/or IP joint fusion For flexion of IP joint of thumb -Brachioradialis transfer to FPL
2 of 3 10/6/2007 12:26 PM
Tendon Transfer - Principles http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
ULNAR NERVE:
For Adductor pollicis and FPB (thumb opposition) +For loss of FCU - Use ECRL transfer for power
RADIAL NERVE:
If radial nerve might still recover keep EPL in continuity and bring
palmaris longus upward
[ Close Window ]
3 of 3 10/6/2007 12:26 PM
Ulnar Nerve Palsy Signs http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies for
rules on diseminating site content.
[ Close Window ]
1 of 1 10/6/2007 12:26 PM
Vascular Disorders http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Vascular Disorders
Aneurysms of the Vascular
Vascular Tumours
Upper Extremity Malformations
Thoracic Outlet Occlusive Vascular
Vasospastic Disorders
Syndrome Disorders
Treatment
Arteriovenous Malformations
Clinical Findings
Possible thrill
Ischaemic ulcers distal to the lesion
Investigation
Treatment
Venous Malformations
Venous malformations, although present at birth, often are not noticed until 1 year of age
They engorge when dependent, decompress when elevated, and enlarge with trauma,
puberty, pregnancy, or use of oral contraceptives
1 of 6 10/6/2007 12:28 PM
Vascular Disorders http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Present at birth
Do not involute
Diff Dx
1. AVM
2. Haemangioma
Investigation
MRI: can distinguish between high flow (AVM) and low flow lesions (venous
malformations);
Closed system venography
Treatment:
Haemangiomas
Most common form of haemangioma has infiltrative margins composed of both large and small
vessels
Pyogenic granuloma
Rx = surgical excision
Glomus Tumour
Clinical features:
Frequently involves nail bed with classic triad of recurrent excruciating pain, tenderness
and cold sensitivity
Placing involved digit in ice water will usually reproduce pain within 60 sec
Nail bed ridging (and possibly a small blue spot at the base of the nail can be seen)
Multiple tumours in 25% of patients
2 of 6 10/6/2007 12:28 PM
Vascular Disorders http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Radiographs:
X-rays for apposition loss: perforating lesion of the phalanx, may also show a shelled
out lesion dorsal lesion
Treatment:
In terms of excision the tumour is usually well encapsulated and can be shelled out
Most often affects subclavian artery, vein, and lower trunk (C8 /T1) of brachial plexus
Both the subclavian artery and the brachial plexus traverse between the anterior and middle
scalene muscles. Most symptoms arise from neural compression
Aetiology :
cervical rib (< 10 % of pts with cervical ribs will have symptoms), fibrous bands, anterior
scalene muscle constriction, 2 o to clavicular # ( xs callus/ hypertrophic non-union),
pancoast tumour
In some cases, thoracic outlet syndrome will be accentuated by recurrent anterior
shoulder instability, and this may be the cause of the "dead arm syndrome"
General Examination:
Provocative tests
1. Adson's test
Axillary vessels and plexus bent 90 o at the junction of the glenoid and humeral head
Place extremity in full abduction, external rotation and reach back as far possible. Turn
head away and check for decrease or loss of radial pulse
Creation of a bruit in the supraclavicular area is further evidence
Investigations:
X-ray - Cervical ribs may be seen but more commonly the cause is a fibrous band
which will not show up on X-rays
CXR to rule out pancoast tumour
MR scan to exclude cervical disc disease
Treatment
3 of 6 10/6/2007 12:28 PM
Vascular Disorders http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Postural re-education
Activity modification
Weight loss
Excision of first rib with fibrous band and anterior scalene muscle via supra- clavicular ,
subclavicular or axillary approach
Tend to be unilateral conditions unlike the vasospastic conditions which tend to be bilateral
Embolic Disease
70% are of cardiac origin with the remainder originating from aneurysms or from Thoracic
Outlet Syndrome.
The most common example in the upper extremity is the hypothenar hammer syndrome
where local trauma causes thrombosis of the ulna artery at Guyon's canal.
The thrombosis can also embolise where it is most likely to affect the ring finger
Treatment:
Rare condition but suspect in throwing athlete with upper extremity oedema as this may
indicate effort thrombosis of axillary vein
The following should be considered as possible causes of upper limb occlusive disease:
Giant Cell Arteritis : Can affect the subclavian and axillary arteries
Polyarteritis nodosa : Necrotising arteritis that preferentially affects the bifurcations of small
vessels (e.g. the digital arteries)
Connective Tissue diseases (RA, SLE etc) Can cause vascular occlusion through
immune complex deposition
Atherosclerosis
Raynaud's
Raynaud's phenomenon:
4 of 6 10/6/2007 12:28 PM
Vascular Disorders http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Raynauds Syndrome:
o Drugs
o CNS disease
Raynaud's disease:
Intermittent
Bilateral
>2yr history
No associated disease
Investigations:
Treatment:
Protection from the cold/ heated gloves (the most effective treatment overall)
Stop smoking
Digital and/or cervical sympathectomy
Pharmacological
4. Nifedipine
5. Nicardipine
6. T3
5 of 6 10/6/2007 12:28 PM
Vascular Disorders http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
6 of 6 10/6/2007 12:28 PM
Wrist Arthroscopy http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer
to the site policies for rules on diseminating site content.
Wrist Arthroscopy
Positioning &
Indications Complications Portals Images
Preparation
Potential complications:
1. traction related
2. complications incurred during the establishment of portals
3. procedure-specific complications
4. others
1 of 3 10/6/2007 12:28 PM
Wrist Arthroscopy http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
arthroscopic portal: - 3/4 portal: (between ECRL & EPL) - lies 1 cm distal to the Lister's tubercle; -
insert the scope in line with the dorsal radial slope;
Instument portal: 6U portal: placed just ulnar to ECU - note the proximity of the dorsal ulnar cutaneous
branch
mid-carpal portal: MC portal: lies in the scaphocapitate interval; - inserted 1cm ulnarwards & 1cm distal
to 3/4 portal; It is radial to the third ray, distal to the proximal row, just radial to the EDC to the index
finger.
1/2 portal: between the ECRB & APL; - note that the radial artery courses along the volar aspect of this
interval.
2 of 3 10/6/2007 12:28 PM
Wrist Arthroscopy http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Further Reading:
[ Close Window ]
3 of 3 10/6/2007 12:28 PM
Wrist Instability http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Wrist Instability
2 carpal rows:
1. Distal
2. Proximal
Scaphoid, lunate and triquetrum form the proximal row. It has no muscle
attachments and is inherently unstable in compression without its ligamentous
attachments. Acts as a link between the relatively rigid distal row and the radioulnar
articulations.
Intrinsic ligaments
These have their origin and insertion within the same carpal row
Distal row
To bind all the distal carpal bones together
Proximal row
Scapholunate ligament
Lunotriquetral ligament
Extrinsic ligaments
Volar
Stronger, and arranged in 2 distinct "V" shapes centred on the lunate and the capitate
The radioscapholunate ligament is now known to be a vascular pedicle rather than a
true ligament
1 of 6 10/6/2007 12:29 PM
Wrist Instability http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Dorsal
2 of 6 10/6/2007 12:29 PM
Wrist Instability http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Relates to instability between carpal rows or transverse osseous segments, and can be
caused by ligament injury or bony fracture (or both)
Several patterns exist which are a combination of CID and CIND lesion
It is better to describe the individual components of these injuries as it is a guide to
treatment
Most frequently represented by perilunate injury
3 of 6 10/6/2007 12:29 PM
Wrist Instability http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Secondary changes in the carpus, which results from a non-union or malunion of the
distal radius or carpal bones
History
Examination
Special tests
Scapholunate ballotment
Kirk-Watson's test
Lunotriquetral ballotment
Reagan's with 2 hands
Kleinman's with one hand (thought to be more sensitive)
X-ray
Arthroscopy
Direct visualisation of the radiocarpal and midcarpal joints gives a good picture of
instability as the ballotment tests can be performed whilst watching the carpal bones
but the carpus is not under physiological loads
When the lunate is rotated dorsally and the scapholunate angle is greater than 70 o
This is a description of the deformity but does not describe the pathological process
4 of 6 10/6/2007 12:29 PM
Wrist Instability http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
When the lunate is flexed and the scapholunate angle is less than 30 o
CID
treat # or malunion
Acute
Early open repair + K-wire stabilisation up to 3 weeks
Delayed open repair can be performed up to 6 months
Repair is by either direct suture, pull through sutures or suture anchors
Chronic
Bony procedures - scapho-trapezio-trapezoid fusion (STT)
Soft tissue - dorsal capsulodesis (Blatt procedure) or FCR tenodesis
(Brunelli Procedure)
Rarely recognised acutely but if so then acute open repair of the ligament
Lunotriquetral fusion
FCU tenodesis
5 of 6 10/6/2007 12:29 PM
Wrist Instability http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Immediate closed reduction followed by open repair of the ligaments via dorsal
approach
CIND
CIC
CIA
[ Close Window ]
6 of 6 10/6/2007 12:29 PM
Wrist Osteoarthritis http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Wrist Osteoarthritis
From: JK Stanley. Current Orthopaedics. 13:290-6.1999.
1. Idiopathic
fuse scaphoid & lunate to
distal radius; radio-lunate
Malunion distal die punch injury of scaphoid or
fusion; involvement of
radius lunate fossa; 4 part #; pilon injury
midcarpal jt. = proximal row
carpectomy
limited wrist fusion = excise
distal pole of scaphoid & fuse
Scaphoid
SNAC wrist prox. pole to lunate to
nonunion
capitate (or ? radial
styloidectomy?)
'hump back' deformity = scaphoid
united in flexed position; may be
Scaphoid rotational malunion also;
osteotomy risky
malunion scaphoid does not support lat.
column thus incr. load central &
medial columns
medial column injuries ->
Carpal bone
capito-hamate & hamo-lunate
#'s
impaction
Kienbock's prox. row carpectomy or wrist
Arthrosis = Lichtman stage 4
2. disease arthrodesis
Mechanical Preiser's
AVN of scaphoid
disease
AVN Capitate
70% of people have a facet on
the medial aspect of the lunate
Hamo-lunate Hamate head excision
which can impinge on the head
Impaction (arthroscopic)
of hamate in full ulnar deviation;
diagnosed arthroscopically
STT OA ass. with chondrocalcinosis; pain
STT arthrodesis
[Radiograph] on radial deviation of wrist;
from malunion distal radius #s; Sauve-Kapandji procedure
DRUJ OA
injury to sigmoid notch [Picture]
scaphoid excision & 4 corner
Carpal
SLAC fusion
instability
(capito-hamo-triquetro-lunate)
from scapho-lunate interosseous
Dorsal rim
lig. incompetence; diagnosed
impaction
arthroscopically; precursor of
syndrome
SLAC & SNAC
Piso-triquetral
causes loose bodies in wrist joint
OA
3. Metabolic Gout
Pseudogout
4. RA
Inflammatory
Psoriasis
common pattern of OA
may be end-stage of scapho-lunate dissociation
The structures maintaining scapho-lunate alignment fail from trauma or degeneration.
1 of 3 10/6/2007 12:33 PM
Wrist Osteoarthritis http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Neurectomy:
Arthroplasty:
DRUJ Procedures:
1. Darrach
Procedure
Darrach's
original
procedure
was
to
resect
the
distal
ulna
but
retain
a
strip
of
bone
2 of 3 10/6/2007 12:33 PM
Wrist Osteoarthritis http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
on the ulnar side with the styloid & the ligaments joining this to the carpus.
(forerunner of Bower's hemiresection & soft tissue interposition)
Theoretically get subluxation of the carpus to the ulnar side.
Get instability of the stump causing discomfort in young active people.
2. Sauve-Kapandji Procedure:
Preferred option
Prevents 'ulnar subluxation' of carpus (radiocarpal joint)
Good forearm function in 80%
20% complain of troublesome clicking in forearm rotation.
may be ECU slipping over prox. ulnar stump.
may be ulnar stump abutting on distal radius
Can try tendon sling procedures
[ Close Window ]
3 of 3 10/6/2007 12:33 PM