Flexor Stenosing Tenosynovitis Trigger Finger and Thumb

Plancher History and Clinical Presentation A 45-year-old right hand dominant woman was seen in the office because her right middle finger was stuck in her palm. She reported that her family physician gave her an injection in that finger 6 months ago for her symptoms of clicking and pain over the dorsal aspect of her proximal phalanx of her middle finger. She denies any symptoms of diabetes, rheumatoid arthritis, gout, or connective tissue disorders. On examination the patient actively...

Supporative Flexor Tenosynovitis

Floyd III A 52-year-old insulin-dependent diabetic man presented to his primary care physician 4 days after sustaining a palmar stab wound while sharpening a knife. Due to swelling and erythema about the wound overlying the palmar aspect of the fourth metacarpophalangeal joint, the patient was admitted to the hospital and placed on parenteral cefazolin. Significant medical history included insulin-dependent diabetes mellitus, peripheral vascular disease, and...

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Canal or the cubital tunnel AIN palsy Lower trunk BPN AIN, anterior interosseous nerve BPN, brachial plexus neuropathy. AIN, anterior interosseous nerve BPN, brachial plexus neuropathy. The physical exam should be focused on identifying a dermatomal distribution of radicular complaints and sensory changes. Specific muscle group weakness and reflex changes as compared with the opposite side should also be recorded. Special tests like the previously mentioned Spurling's sign and the Valsalva...

Stellate Ganglion Anatomy

Stellate Ganglion Anatomy

Sympathetic blockade Stellate ganglion Lumbar sympathetic IV regional NSAID, nonsteroidal antiinflammatory drug TCA, tricyclic antidepressant TENS, transcutaneous electrical nerve stimulation SSRI, selective serotonin reuptake inhibitor. NSAID, nonsteroidal antiinflammatory drug TCA, tricyclic antidepressant TENS, transcutaneous electrical nerve stimulation SSRI, selective serotonin reuptake inhibitor. Figure 19 1. Anatomy of the neck and placement of the needle for a stellate ganglion block.

Info

Proximal phalangeal condylar fractures, 250 Management algorithms, frostbite injuries, 11, 11-12 Manske classification, hypoplastic thumb, 506, 506, 511 Martin-Gruber anastomosis, ulnar tunnel syndrome, 90 Medial epicondylectomy, cubital tunnel syndrome, 85-86 carpal tunnel syndrome, 64 65, 64-66 pronator syndrome, 71 73, 71-74 Melone classification system, intraarticular distal radius fracture, 381, 382 Membrane stabilizing medication, complex regional pain syndrome reflex sympathetic...

Complications

Radial styloid fracture management should consider the spectrum of associated injuries, and when surgery is indicated, incisions should be chosen to minimize soft tissue problems. Patient demands, bone quality, and other mitigating circumstances will temper the treatment logic for each individual. Postoperative complications are increased with the degree of invasiveness chosen for a particular injury pattern. Acute carpal tunnel syndrome is not common with radial styloid fractures, and some...

Anterior Interosseous Nerve Palsy

Anterior Interosseus Sendromu

Inaccurate diagnosis can lead to unnecessary surgery. Understanding anatomy in the forearm is crucial to successful recovery. Position of the patient's neck in shoulder surgery should be monitored by the anesthesiologist and surgeon. Figure 14 1. Typical pinch sign with flattening of index pulp and classic palsy of the anterior interosseous nerve with ok sign on left hand. Figure 14 1. Typical pinch sign with flattening of index pulp and classic palsy of the anterior interosseous nerve with ok...

Carpal Tunnel Syndrome

Carpal Tunnel Injection Procedure

Do not use this technique in recurrent carpal tunnel syndrome for a repeat procedure when an open procedure was done previously. Never exert force in passing instruments across the ligament without good visualization to avoid cutting the median nerve. A positive Tinel's sign is present directly over the palmar cutaneous branch of the median nerve, which the patient says simulates her numbness and tingling to the thenar eminence. In addition to this, she has an area of numbness of 3 X 2 cm...

Operative Intervention

Pip Dynamic Skeletal Traction

Dislocations involving large volar fractures or those irreducible, unstable, or incongruous joints, regardless of fracture size, require operative intervention. In large disruptions of the middle phalanx volar surface, without the stabilizing collateral ligaments, the proximal phalangeal condyles sink into the volar plate and the distal inserting flexor digitorum superficialis FDS and flexor digitorum profundus FDP bend the middle phalanx rather than produce gliding palmar rotation of the...

Radial Tunnel Nerve

Fibrous Arcade Frohse

Nonsurgical management of posterior interosseous syndrome includes rest, splinting, and activity modifications. Oral antiinflammatory agents may be helpful, primarily for pain relief. Corticosteroid injections generally have minimal benefit because the neuropathology is compression, not active synovitis. Job or avocation changes may be of some benefit. Appropriate splintage should be provided if muscle paralysis is present. It is extremely important to emphasize full passive range-of-motion...

Bowed Ringer Finger Due To Pip Fracture

Fracture Distal Phalanx Hand

The tendon must be secured through or around the distal phalanx fixation to the distal tendon remnant or periosteum is not secure. The proximal tendon end must not be debrided or advanced more than 1.5 cm, to prevent tethering of the FDP and the quadrigia effect. For type 1 and type 2 injuries, the PIP joint level must be explored before the palm, to prevent pulling the tendon proximally and converting a type 2 injury to a type 1 injury. This will rupture the long vin-culum and its blood...

Radial Nerve Injury

Radial Nerve Course

The Jones Tsuge Boyd modified transfer for high radial nerve palsy requires the presence of a palmaris longus and two fully functional wrist flexors. The Jones Tsuge Boyd transfer does not provide independent finger extension. The Jones Tsuge Boyd modified transfer may cause mild ulnar deviation of the wrist. the brachioradialis, as well as no response to the extensor digitorum communis, extensor pollicis longus, as well as to the extensor carpi radialis brevis ECRB . Tendon laceration...

Fifth Metacarpal Fracture

Dorsal Angulation Fracture

Fifth Metacarpal Neck Fracture Boxer's Fracture The mechanism of injury, examination, and radiographic findings confirm the diagnosis of a fifth metacarpal neck or boxer's fracture. When applied to the fifth metacarpal, boxer's fracture is a misnomer because professional fighters are more likely to fracture their index and middle metacarpal necks. Breaking the small or PA radiograph of the fifth metacarpal revealing metacarpal neck fracture with 60-degree apex dorsal angulation. ring metacarpal...

Enchondroma

Enchondroma Histology

Plancher and Michael Bothwell A 22-year-old woman with no prior hand injury presents after feeling a snap in her left ring finger while playing volleyball. The patient reports pain and swelling. She also reports pain with motion of the finger. The finger is tender to palpation. Range of motion is limited due to pain. On radiographs a pathologic fracture in the hand or digits is frequently noted. Plain x-rays are diagnostic and reveal a centrally located lesion with marked bone...

A3 Pulley Tendon

Periarticular Erosions Nodules

All digital range of motion measured in degrees with 0 being straight. An H preceding a number indicates hyperextension beyond 0 degrees. Passive range of motion equaled active range of motion. finger's PIP joint had a painful arc of motion from 0 to 85 degrees with crepitation. The metacarpophalangeal MP joints had well-maintained and painless arcs of motion. There was no erythema, nail pitting, trophic changes, or significant soft tissue swelling. All fingers were neurovascularly intact. The...

Ulnar Deviation And Wrist Subluxation

Radial Head Dislocation Ulnar Deformity

Ulna anlage present Forearm pronated Progressive ulnar deviation and bowing common Type II is most common type of ulnar clubhand. Adapted from Dobyns JH, Wood VE, Bayne LG. Congenital hand deformities. In Green DP, ed. Operative Hand Surgery, 3rded. New York Churchill-Livingstone 1993 251 548. Type II is most common type of ulnar clubhand. Adapted from Dobyns JH, Wood VE, Bayne LG. Congenital hand deformities. In Green DP, ed. Operative Hand Surgery, 3rded. New York Churchill-Livingstone 1993...

Mid Axial Incision

Mid Volar Technique Thumb Pad

Best routine incision is controversial In subcutaneous dissection, must avoid approaching the flexor tendon sheath Multitude of complications for neglected felon Anteroposterior and lateral plain film radiographs of the finger were obtained and demonstrated no abnormal findings. Flexor tenosynovitis Herpetic whitlow Metastatic tumor A felon is a bacterial infection of the distal pulp space of the fingers or thumb. As first described by Kanavel, the anatomy of the distal phalanx is unique, with...

Pip Joint Debridement

Metacarpophalangeal Amputation

Assume that joint swelling will resolve with elevation and conservative treatment antibiotics Avoid a small incision under local anesthesia rather than wide debridement and irrigation in an operating room under regional anesthesia. Never assume the type of infection until the labs and culture and sensitivities dictate the correct antibiotic treatment. Psoriatic arthritis flare Systemic lupus erythematosus Synovial fluid analysis includes Gram stain, cultures, and sensitivity testing. In septic...

Brachydactyly Cosmetic Surgery

Polish Syndrome Hand Size

Avoid surgery on mild brachy-dactyly. Avoid distraction osteogenesis at the phalangeal level in brachydactyly. Radiographs of the chest and shoulder were normal. Several views of the hands revealed mild webbing of the second and third web spaces and shortened digits on the right hand, primarily at the middle phalangeal level Fig. 78-2 . Brachydactyly associated with Poland's syndrome Clinodactyly Figure 78 1. A 5-year-old child with small right hand and mild syndactyly of the second and third...

Wartenberg S Sign

Wartenberg Sign Ulnar Nerve

Failure to release potential sites of compression proximally i.e., the medial intermuscular septum and arcade of Struthers may result in recurrence of symptoms despite adequate decompression of the cubital tunnel. Avoid injury to the MABC nerve to allow for normal sensation on posterior and inside ' 2 of elbow. There was no apparent forearm or hypothenar wasting of the left upper extremity. Range of motion of the elbow was measured as 0 to 125 degrees bilaterally. Areas were then examined for...

Lunate Capitate Injury

Ray Wrist Dislocation

Perilunate and lunate dislocations often result from a fall on an outstretched hand Fig. 62-5 . Carpal dislocations result from hyperdorsiflexion. The proximal rows of carpal bones are held tightly in position by a group of ligaments between the ra- Figure 62 3. X-ray of triangular appearing lunate normally appears trapezoidal with overlap noted with the distal andproximal carpal row. Figure 62 3. X-ray of triangular appearing lunate normally appears trapezoidal with overlap noted with the...

Radial Deviation Distal Phlanx Pediatric Radial Deviation Distal Phlanx Syndrome

Amniotic Bands Radiograph

Digital lengthening is difficult and requires frequent monitoring to avoid potential complications. On-top plasty requires extensive neurovascular dissection to prevent vascular compromise of digit. Toe-to-hand transfer in the congenitally anomalous hand is difficult. Figure 79 2. Radiographs of both hands with aphalan-gia long and ring fingers, absent middle index, and radial deviation small distal interphalangeal joint. Figure 79 2. Radiographs of both hands with aphalan-gia long and ring...

Lymph Node In Hands

Lymph Nodes Hands

Be aware of possibility of intraarticular injection of Marcaine into radial artery Rupture of the FCR tendon is possible with an injection. It can be avoided by using an orthoplast splint for 10 days postinjection. Figure 31 1. Clinical hand that demonstrates location of tenderness over the flexor carpi radialis FCR . Figure 31 1. Clinical hand that demonstrates location of tenderness over the flexor carpi radialis FCR . Figure 31 2. Robert's view of the carpometacarpal CMC joint demonstrating...

Nonsurgical Management

Metacarpal Neck Fractures Reduction

In discussing the degree of metacarpal neck angulation that can be accepted after fracture, the index and middle fingers, with their relatively immobile carpometacarpal CMC joints, must be considered separately from the ring and small digits. Most surgeons agree that the index and middle fingers should not be left with more than 10 to 15 degrees of residual angulation. The CMC joints of the small and ring fingers travel through a 35-degree flexion arc, which allows patients to tolerate larger...

Differential Diagnosis Tfcc Ulnar Nerve

Ulnocarpal Abutment

The differential diagnosis of ulnar-sided wrist pain is lengthy. A careful examination of the ulnar side of the wrist will frequently rule in other causes of patient's symptoms. The dorsal branch of the ulnar nerve crosses from volar to dorsal in the region of ulnar 6U wrist arthroscopy portals. Careful dissection and protection of this nerve is mandatory to prevent complications. Anteroposterior, lateral, and oblique radiographs of the wrist were obtained Fig. 66-1 . Ulnar styloid nonunion...

Chemotherapy Extravasation

Chemotherapy Extravasation

Intravenous infusion pumps can be particularly dangerous because they can inadvertently force fluid into an extravascu-lar space, producing a compartment syndrome. Pediatric patients can be especially at risk for pump-related problems since the automatic shut off pressure of the pump may be gauged for adult physiology. A specific protocol for administration of doxorubicin hydrochloride Adriamycin should be followed. Preventable problems have been identified as producing extravasation events,...

Carpal Ganglion

Receptors Two Point Discrimination

Retinaculum over the ganglion is excised, and the extensor carpi radialis longus and brevis are isolated and retracted radialward. The extensor digitorum communis to the index finger is then retracted with the remaining extensor tendons ulnarward. The mass is identified and mobilized in a circumferential fashion. Surgical treatment should focus on removing the ganglion cyst and all material between the radiotriquetral ligament and dorsal intercarpal ligament. The ganglion is excised with all of...

Pisiform Ligaments

Henle Ligament

There was no evidence of abnormal spontaneous activity in the right flexor dig-itorum profundus, abductor digiti minimi, or the abductor pollicis brevis. In the right first dorsal interosseous muscle there was increased insertional activity with 2 present at multiple sites fibrillations and 2 positive sharp waves recruitment frequency was 30 to 40 Hz normal 5 to 15 Hz the interference pattern was decreased and discrete, indicating marked loss of motor units amplitude was decreased with the...

Surgical Management

Kirschner Wire

During the 7 days before surgery, a splint was applied and the upper extremity maximally elevated to reduce swelling. Operative procedures included open reduction and internal fixation of the scaphoid with an antegrade screw and 0.054-inch Kirschner wire, closed reduction and pinning of the distal radial fracture with Kirschner wires, repair of the scapholunate interosseous ligament, intercarpal pin stabilization, and open carpal tunnel release Fig. 59 2 . The scaphoid was exposed through a...

Delayed Treatment of Flexor Tendons Staged Tendon Reconstruction

Flexor Digitorum Superficialis Tendon

Schneider History and Clinical Presentation An 18-year-old student lacerated both flexor tendons in zone 2 of his right dominant index finger on broken glass. His primary treatment was by direct repair of both flexor tendons 3 days postinjury, and he was started on a mobilization program in a hand therapy unit. Unfortunately, this did not result in functional pull-through of his flexor tendons. He then underwent flexor tenolysis in an attempt to salvage function, a procedure that...

Diagnostic Studies

Radial Wrist Pain Differential Diagnosis

Initial radiographs included three standard films of the wrist a posteroanterior PA view of the wrist with the forearm in a neutral position, a lateral projection of the wrist, and an oblique view with the forearm in 35 degrees of supination. These films were negative. Follow-up serial films at 4 weeks demonstrated a fracture of the proximal pole of the scaphoid Fig. 57-1 . Figure 57 1. Posteroranterior view of the hand showing acute proximalpole scaphoid fracture. Figure 57 1. Posteroranterior...

Collar Button Abscess

Collar Button Abscess

Lack of recognition of collar button access Inadequate drainage and dissection Avoid local anesthetic block to ensure deep debridement. Flaps to open wounds should not be shallow to avoid flap necrosis. Kanavel's sign was used to distinguish a deep infectious tenosynovitis from a superficial cellulitis although pain with finger extension was present in this patient Fig. 7-2 . Posteroanterior and lateral radiographs of the hand do not identify any foreign objects and no bone or soft tissue...

Lipoma

Plancher and Michael Bothwell A 40-year-old right hand dominant woman presents with a mass on her right little finger. The mass has grown in size and is now causing functional problems. The patient reports the mass is not painful. She also reports a recent weight gain, corresponding with the enlargement of the mass. The patient has full range of motion of the little finger and exhibits no strength deficits. The patient has a normal vascular examination. Swelling is present over the...

Scapholunate Advanced Collapse

Scaphoid Non Union Advanced Collapse

Siegel History and Clinical Presentation A 54-year-old right hand dominant man who works as a museum director presented with a 3-year history of gradually increasing pain, swelling, and loss of mobility in his right wrist. He also noted the recent onset of nocturnal paresthesias in the sensory distribution of the median nerve. There was no history of trauma, although he had played professional basketball for 12 years. A wrist splint, nonsteroidal antiinflammatory...

Eponychial Marsupialization

Eponychial Marsupialization

Paronychia is the most commonly seen infection of the hand Warm soaks and antibiotics effective if there is no drainage or fluctuance Eponychial marsupialization for chronic paronychia also remove nail if signs of involvement Herpetic whitlow Acute paronychia Chronic paronychia This patient's presentation is typical of acute paronychia, an infection of the soft tissue folds surrounding the fingernail. The clinical presentation initially consists of localized tenderness of the paronychial...

Macrodactyly

Proteus Syndrome

A 5-month-old boy presented with an enlarged left middle finger. He was born at 38 weeks' gestation by normal vaginal delivery, weighing 7 lb, 9 oz. The pregnancy was complicated only by preterm labor at 32 weeks that was successfully managed with bed rest and medication. The diagnosis was made at the time of delivery. The child had no other medical problems. All developmental milestones were achieved normally. Family history was negative. The child has an enlargement of the left middle digit,...

Lumbrical Bar Splint

Splint Claw Deformity

Nerve or possibly the lower cervical nerve roots C8 T1 or inferior brachial plexus. Cervical nerve root compression typically results in neck pain with radicular symptoms down the arm. Weakness and atrophy would be expected in the thenar and hypothenar musculature, which are both innervated by the lower cervical and first thoracic nerve roots. A lesion of the lower brachial plexus e.g., a Pancoast tumor of the lung apex would result in similar findings. The ulnar nerve is most commonly...

Tfcc Compression Test

Ulnar Snuffbox Test

Lunotriquetral LT instability results from a disruption of the dorsal and palmar LT interosseous complex. A spectrum of pathology is possible, proportional to the magnitude and acuity of ligamentous disruption. Degenerative membrane perforation may be asymptomatic. Partial tears of the LT membrane may produce dynamic instability, and complete ligament dissociation may produce a static VISI pattern. Lunotriquetral instability most commonly follows a specific injury. Hyperextension at the wrist...

Complex Regional Pain Syndrome Type 1 Reflex Sympathetic Dystrophy

Agin History and Clinical Presentation A 50-year-old woman was undergoing magnetic resonance imaging MRI with contrast. Intravenous access was started in her right antecubital fossa. As the infusion of gadolinium was started, the patient reported a burning pain in her arm from the antecubital fossa to her fingers. Her forearm and hand swelled. As the swelling increased, she reported numbness and cyanosis. Over the next few days the swelling resolved. Slowly sensation returned to her...

Epicondylectomy Lupus

Medial Epicondylectomy Complications

The trough Fig. 15 7 , and the overlying muscle fascia was loosely reapproximated Fig. 15-7C . The elbow was taken through a range of motion, and no compression of the ulnar nerve was noted. The wound was copiously irrigated with warm normal saline. The tourniquet was deflated and meticulous hemostasis was obtained. The skin was closed and a sterile dressing was applied. The arm was splinted in a position of 45 degrees of elbow extension, full pronation, and 15 degrees of wrist flexion. The...

Wrist Drop Radial Nerve Connective Tissue Disease

Brachial Biceps Lipoma

Beware of cervical radicu-lopathy presenting as posterior interosseous syndrome. No sensory symptoms in posterior interosseous syndrome. Beware tendon rupture in rheumatoid patients presenting as posterior interosseous nerve syndrome. Treatment is entirely different. Revisions usually secondary to incomplete release of nerve through supinator. Compression of posterior interosseous nerve has been reported at distal edge of supinator. The right forearm measured 2 cm larger than the left in...

Adactyly Syndromes

Distraction Osteogenesis

Nonvascularized toe phalan-geal transfer does not result in prolonged growth. Distraction osteogenesis requires frequent monitoring to avoid potential complications. Toe-to-hand transfer is difficult in adactyly and may require multiple toe transfers. Figure 75 1. A 10-month-old with congenital anomaly of the right hand. Figure 75 2. Anomalous right hand with absent thumb, index, long, ring, and small digits. Figure 75 2. Anomalous right hand with absent thumb, index, long, ring, and small...

Kevin D Plancher

A 20-year-old right hand dominant male laborer caught his left hand in a circular saw with the guard off. He has a laceration to his left index finger and can't feel the tip of his finger, and has an open bleeding wound. On physical examination, the patient has an acute open laceration involving the radial side of the right index finger. A careful motor examination was performed. The functioning level of specific muscles is determined to assist with identifying peripheral nerve injuries. A...

Triscaphe Degenerative Arthritis

A 62-year-old right hand dominant woman who works as a polisher presented with right wrist pain progressively worsening over the last 6 months. She noted significant and progressive difficulty with strength and holding onto small objects. She denied any trauma and noted no specific previous treatment. The patient had specific localized tenderness and swelling of the scaphoid-trapezium-trapezoid STT triscaphe joint. This area is located by following the index meta-carpal proximally until a...

Carpometacarpal Joint Dislocation Thumb Imaging

Base The 5th Cmc Dislocation

Clinical suspicion is imperative in making this diagnosis. Patients present with pain and swelling of the hand. A dorsal lump, or in the case of the less frequent volar dislocation, a volar lump or thickening of the palm, is present. However, this may be masked by marked generalized swelling of the hand. In the case of a volar dislocation, careful examination of the median nerve is important due to the possibility of an acute carpal tunnel syndrome. In addition, the function of the motor branch...

Benign Vascular and Malignant Vascular Tumors

Pictures Muscle Tumors Found Mri

Kuschner Case A. A 35-year-old right hand dominant woman complains of a painful mass about the tip of the index finger of 6 months' duration. She states that the pain is aggravated by cold and often radiates proximally after tactile stimulation. She denies any history of trauma, puncture wounds, or fever. Case B. A 55-year-old right hand dominant woman with a history of swelling about the left upper extremity after radical mastectomy and lymph node dissection 10...