Hand Bone — FRCS Quiz

38 slides

▸ Slide 702 · Hand - boneHand Bone · 5 questions expand

Question list

Q1-Q55 questions — tap to reveal all answerslist

Which classifications are used for radial head dislocation and distal radius fracture on this slide?
Which eponymous classifications apply to tendon injuries of the hand?
Which eponymous classifications apply to finger joint fracture-dislocations?
Which eponymous classifications apply to carpal and wrist conditions?
What classification is used for CMCJ arthritis and which other hand conditions are listed on this slide?

Answers · Q & A

Q1.Which classifications are used for radial head dislocation and distal radius fracture on this slide?

Radial head dislocation — Mason classification
Distal radius fracture — Melone, Frykman, AO and Fernandez classifications
Lafontaine criteria applied to distal radius fracture instability

Q2.Which eponymous classifications apply to tendon injuries of the hand?

Jersey finger — Leddy & Parker classification
Mallet finger — Doyle classification

Q3.Which eponymous classifications apply to finger joint fracture-dislocations?

PIPJ fracture dislocation — Eaton, Hasting
MCPJ fracture dislocation — simple/complex (Kaplan)

Q4.Which eponymous classifications apply to carpal and wrist conditions?

Scaphoid fracture — Herbert, Russe
Perilunate/lunate dislocation — Mayfield, Tavernier
SNAC/SLAC — Geissler, Watson
Kienbock disease — Litchman, Natress/McMurty/Starhl

Q5.What classification is used for CMCJ arthritis and which other hand conditions are listed on this slide?

CMCJ arthritis — Eaton classification
Skier's thumb — Stener
Bennett fracture and reversed Bennett fracture
Enchondroma

▸ Slide 703 · Describe Xray:Hand Bone · 5 questions expand

Question list

Q1-Q55 questions — tap to reveal all answerslist

Describe the X-ray findings of this hand lesion.
What is the differential diagnosis of a lytic bone lesion?
How do you assess and manage a suspected enchondroma?
What is the epidemiology and pathogenesis of enchondroma?
How do you distinguish enchondroma from chondrosarcoma?

Answers · Q & A

Q1.Describe the X-ray findings of this hand lesion.

Solitary, central, diaphyseal, osteolytic lesion at the 4th metacarpal
Matrix +/- rings and arcs suggestive of calcification
Narrow transitional zone and sclerotic border; mild cortical expansion, no periosteal reaction, cortical breakage
Overall suggestive of a benign tumour

Q2.What is the differential diagnosis of a lytic bone lesion?

Fluid
Fat
Fibrous
Chondral

Q3.How do you assess and manage a suspected enchondroma?

Aim: establish diagnosis, rule out complications
PMHx renal disease, trauma/infection, pain, overlying skin change, joint ROM
X-ray very suggestive of enchondroma; may not need biopsy (+/- MRI)
Ddx: enchondroma (if multiple -> Ollier/Maffucci), infection, brown’s tumour, chondrosarcoma
No pathological fracture: observation or curettage with bone graft; pathological fracture: allow healing then curettage

Q4.What is the epidemiology and pathogenesis of enchondroma?

M:F 1:1; most common 20-50 years; diaphysis/metaphysis
Most common bone tumour in the hand
Benign chondrogenic tumour of hyaline cartilage from abnormal chondroblast function in the physis
Escaped chondrobloast from physis displaced to metaphyseal region and proliferate
Rubin: physeal hyperplasia

Q5.How do you distinguish enchondroma from chondrosarcoma?

Chondrosarcoma: cortical thickening and destruction, endosteal erosion/scalloping >50% of cortical width, larger >5cm
Histology enchondroma: bland mature hyaline cartilage (blue balls) separated by normal marrow
Histology chondrosarcoma: hypercellularity, plump nuclei, binucleate cells, giant cells with chromatin clumps
Solitary malignant transformation 1%

▸ Slide 704 · Describe Xray:Hand Bone · 4 questions expand

Question list

Q1-Q44 questions — tap to reveal all answerslist

What injury is demonstrated and what associated injuries must be excluded?
What is an Essex-Lopresti injury?
What is the management of a radial head fracture with longitudinal radioulnar instability?
What does the JBJS 2022 review (Sheth) advise?

Answers · Q & A

Q1.What injury is demonstrated and what associated injuries must be excluded?

Comminuted radial head and neck fracture, Mason type 3
No elbow dislocation or coronoid fracture
Take X-ray one joint above and below, especially to rule out DRUJ instability (Essex-Lopresti injury)

Q2.What is an Essex-Lopresti injury?

Radial head fracture + dislocation of the distal radioulnar joint + interosseous membrane disruption
Incidence ~1-8%

Q3.What is the management of a radial head fracture with longitudinal radioulnar instability?

Soft tissue: compartment syndrome, PIN palsy
Bony: restore radial alignment to prevent proximal migration and limited rotational range
Radial head + neck fixation or replacement depending on comminution

Q4.What does the JBJS 2022 review (Sheth) advise?

Leads to longitudinal radioulnar instability
Acute: restore radial length and temporary DRUJ immobilisation; indication for acute IOM repair/reconstruction unclear
Chronic: restore radial length, wrist levelling +/- treatment of degenerative changes at RCJ or DRUJ
Central band reconstruction debated but can restore forearm load transfer

▸ Slide 705 · Mason classificationHand Bone · 3 questions expand

Question list

Q1-Q33 questions — tap to reveal all answerslist

What are the defining features of each Mason grade of radial head fracture?
What are the normal radiographic relationships of the forearm?
How is radial bowing measured?

Answers · Q & A

Q1.What are the defining features of each Mason grade of radial head fracture?

1: minimally displaced
2: displaced >2mm or >30% articular
3: comminuted fracture
4: fracture + elbow dislocation

Q2.What are the normal radiographic relationships of the forearm?

US to CP 180 degrees on XR
RS to BT 180 degrees on XR

Q3.How is radial bowing measured?

Max radial bow at 60% of radial length; value <10% of radial length
x/y x 100%, where y = bicep tuberosity to ulnar end of distal radius; x = bicep tuberosity to site of maximum radial bow
Value = vertical distance between the radial bone and the line at maximum radial bow

▸ Slide 706 · RA patient with long term steroidHand Bone · 4 questions expand

Question list

Q1-Q44 questions — tap to reveal all answerslist

Describe the X-ray in this RA patient on long-term steroids.
Which soft tissue structures are at risk in this fracture, and what systemic factor affects management?
What classifications are used for distal radius fractures?
What is the management including instability criteria?

Answers · Q & A

Q1.Describe the X-ray in this RA patient on long-term steroids.

Fracture distal radius with comminution at the volar aspect, intra-articular
Joint volarly subluxed
Ulnar styloid fracture
Soft tissue at risk: SL ligament, TFCC

Q2.Which soft tissue structures are at risk in this fracture, and what systemic factor affects management?

SL ligament and TFCC at risk (intra-articular fracture with volar subluxation)
Ulnar styloid fracture present
Systemic: manage osteoporosis (RA patient on long-term steroid)

Q3.What classifications are used for distal radius fractures?

AO
Fernandez: bending/shearing/compression/avulsion/combined or explosion
Melone 4 components: undisplaced or die-punch/volar spike/separation or rotation/metaphyseal-diaphyseal comminution
Frykman

Q4.What is the management including instability criteria?

Systemic: osteoporosis
Local: CR + slab
Lafontaine criteria 3/5 = unstable: ulnar, intra-articular, dorsal comminution, dorsal angulation >20 degrees, age >60
OT: volar plating, screen TFCC; if not stable splint in supination for 3 weeks

▸ Slide 707 · AP and lateral Xray of wrist with fracture of distal radius and distal ulnarHand Bone · 9 questions expand

Question list

Q1-Q99 questions — tap to reveal all answerslist

What do you assess on the AP and lateral X-ray of a distal radius fracture?
What are the LaFontaine criteria for instability and what alignment is acceptable?
Describe the AO classification of distal radius fractures.
Describe the Frykman, Fernandez and Melone classifications of distal radius fractures.
How is a distal radius fracture acutely managed?
What is the definitive treatment of a 23-C2 distal radius fracture?
Describe the modified volar Henry approach and plating.
What is the Soong classification?
What is the evidence for treating fragility distal radius fractures and why is a chauffeur fracture unstable?

Answers · Q & A

Q1.What do you assess on the AP and lateral X-ray of a distal radius fracture?

AP: intra-articular (RCJ or DRUJ), comminution, radial height, radial inclination, ulnar styloid fracture
Lateral: intra-articular, dorsal/palmar comminution, dorsal/volar tilt
Beware soft tissue injury: TFCC, SL ligament (especially radial styloid fracture)

Q2.What are the LaFontaine criteria for instability and what alignment is acceptable?

LaFontaine (1989): >3/5 predicts displacement; age >60, intra-articular, dorsal comminution, ulnar styloid base fracture, dorsal tilt >20 degrees
AO modification adds osteoporosis, initial displacement >1cm, shortening >5mm, palmar comminution
Acceptable: radial height <3mm loss (normal 12mm), radial inclination <5 degrees loss (normal 23 degrees)
Articular step <2mm; no dorsal tilt (normal 11 degrees volar tilt)

Q3.Describe the AO classification of distal radius fractures.

A: extra-articular (ulnar, radial simple, radial comminution)
B: partial-articular (sagittal, dorsal, volar)
C: complete articular (simple, metaphyseal comminuted, articular comminuted)

Q4.Describe the Frykman, Fernandez and Melone classifications of distal radius fractures.

Frykman: odd numbers for extra-articular (1), RCJ (3), DRUJ (5), both (7); even numbers add ulnar styloid involvement
Fernandez: bending, shearing, compression, avulsion, explosion
Melone: lunate impaction (= Fernandez compression); 4 fragments: shaft, radial, medial volar, medial dorsal

Q5.How is a distal radius fracture acutely managed?

CR under sedation (for pain relief and psychological relaxation) - not haematoma block - + slab
History: need to ask age of menopause
Treatment approach depends on patient and fracture factors
Systemic: treat osteoporosis

Q6.What is the definitive treatment of a 23-C2 distal radius fracture?

Volar locking plate for absolute stability and stable fixation
Screen DRUJ: stable = free mobilisation; unstable = splint for 3 weeks
2.4mm LCP in buttressing mode; modified volar Henry approach between FCR and radial artery; plate proximal to watershed line

Q7.Describe the modified volar Henry approach and plating.

Plane between FCR and radial artery; skin, subcut, FCR sheath and subsheath
Split PQ; reduce fracture; +/- bone substitute
Volar plate proximal to the watershed line
Aim: anatomical reduction, stable fixation for early mobilisation

Q8.What is the Soong classification?

Grade 0: dorsal to the critical line
Grade 1: volar to the critical line but proximal to the volar rim
Grade 2: volar to the critical line and on or distal to the volar rim

Q9.What is the evidence for treating fragility distal radius fractures and why is a chauffeur fracture unstable?

Arora JBJS 2011: cast vs surgery >65, operation better grip strength but no overall clinical difference
DRAFFT 1 (2019): K-wire vs volar locking plate no difference at 5 years; DRAFFT 2 (BMJ 2022): K-wire vs casting no difference at 12 months
Chauffeur fracture: avulsion of the styloid by the RSC ligament, rupture of volar capsule and radiolunate ligament allows radiocarpal subluxation
Brachioradialis insertion 17mm from the styloid tip, so no stabilising force

▸ Slide 708 · 22 yo ulnar sided wrist painHand Bone · 14 questions expand

Question list

Q1-Q1414 questions — tap to reveal all answerslist

What is the clinical presentation on this slide?
How is ulnar variance measured on a wrist X-ray?
What are the consequences of positive ulnar variance?
How are ulnar styloid fractures classified (Fernandez and Jupiter)?
What is the comprehensive classification with Q modification for distal ulna fractures?
List the differential diagnosis of ulnar-sided wrist pain by tissue.
Describe the traumatic types of the Palmer classification of TFCC injury.
Describe the degenerative stages of the Palmer classification of TFCC injury.
How is an acute TFCC tear initially managed?
What are the three aims of treating a chronic TFCC injury?
Chronic TFCC tear, no DRUJ arthritis, ulnar positive variance - what are the options?
Why must a 2mm peripheral rim of TFCC be preserved during debridement?
Chronic TFCC tear with ulnar negative variance - what are the options?
What are the options when there is DRUJ arthritis or instability with a chronic TFCC tear?

Answers · Q & A

Q1.What is the clinical presentation on this slide?

22-year-old with ulnar-sided wrist pain
Ulnar positive variance
Type II ulnar styloid fracture (through the base)

Q2.How is ulnar variance measured on a wrist X-ray?

One line tangential to the distal ulnar articular surface, perpendicular to the shaft
Another line tangential to the lunate fossa, perpendicular to the shaft
The interval between the two lines gives the ulnar variance

Q3.What are the consequences of positive ulnar variance?

Ulnar impaction syndrome
TFCC tear
Ulnocarpal arthritis
SL dissociation

Q4.How are ulnar styloid fractures classified (Fernandez and Jupiter)?

Type 1: distal to base
Type 2: through base
Type 3: proximal to base

Q5.What is the comprehensive classification with Q modification for distal ulna fractures?

Q1 styloid, Q2 simple neck, Q3 comminuted neck
Q4 intra-articular, Q5 head + neck, Q6 meta-diaphyseal

Q6.List the differential diagnosis of ulnar-sided wrist pain by tissue.

Bone: ulnar styloid fracture, hook of hamate fracture
Cartilage: chondral lesions
Joint: pisotriquetral arthritis, wrist ganglion
Tendon: ECU subluxation or tendinitis
Ligaments: LT ligament injury, TFCC
Nerve: ulnar nerve entrapment; artery: ulnar artery thrombosis

Q7.Describe the traumatic types of the Palmer classification of TFCC injury.

Traumatic tears are typed by location
Central, ulnar, distal, radial

Q8.Describe the degenerative stages of the Palmer classification of TFCC injury.

A: TFCC wear/thinning
B: wear/thinning + lunate/ulnar chondromalacia
C: TFCC perforation + lunate/ulnar chondromalacia
D: LT ligament perforation
E: + ulnocarpal arthritis

Q9.How is an acute TFCC tear initially managed?

Conservative with splintage and NSAIDs
Observe for 3 months

Q10.What are the three aims of treating a chronic TFCC injury?

1. Decrease ulnocarpal loading
2. Treat the TFCC tear
3. Treat instability

Q11.Chronic TFCC tear, no DRUJ arthritis, ulnar positive variance - what are the options?

Wafer procedure
Ulnar shortening
TFCC debridement - leave a 2mm peripheral rim intact

Q12.Why must a 2mm peripheral rim of TFCC be preserved during debridement?

To avoid iatrogenic instability

Q13.Chronic TFCC tear with ulnar negative variance - what are the options?

Arthroscopic debridement
Lunotriquetral ligament repair or debridement

Q14.What are the options when there is DRUJ arthritis or instability with a chronic TFCC tear?

Darrach
Sauve-Kapandji (SK)
Bower - TFCC has to be repairable or reconstructable
Ulnar head replacement

▸ Slide 709 · Left: Sauve Kapandji, right: DarrachHand Bone · 9 questions expand

Question list

Q1-Q99 questions — tap to reveal all answerslist

What is the Sauve-Kapandji procedure?
What are the problems of the Sauve-Kapandji procedure?
What is the Darrach procedure?
What are the complications of the Darrach procedure?
How is the distal ulna stabilised to prevent convergence after loss of the DRUJ buttress?
Why is Sauve-Kapandji preferred over Darrach in young patients?
What is the general indication for the Sauve-Kapandji and Darrach procedures?
What are the benefits of the Darrach procedure?
Which muscles contract to cause ulnar convergence after loss of the DRUJ buttress?

Answers · Q & A

Q1.What is the Sauve-Kapandji procedure?

DRUJ fusion with stump pseudoarthrosis 1cm proximal to the fusion
Interposition of pronator quadratus
Maintains ulnocarpal support (less ulnar translocation of carpus), mobile pronation/supination, good strength, better cosmesis than Darrach
Indicated in the young, high demand patient, including RA

Q2.What are the problems of the Sauve-Kapandji procedure?

Proximal ulnar impingement
Failed fusion, or fusion of pseudoarthrosis
Heterotopic ossification
Ulnar sensory branch neuritis
Screw impingement over the far cortex causing iatrogenic DQV

Q3.What is the Darrach procedure?

Excisional arthroplasty from ulnar styloid to the level of the sigmoid notch
Retain the ulnar styloid and its attached ligament
Ulnar stump stabilised by interposed PQ, FCU/ ECU

Q4.What are the complications of the Darrach procedure?

Loss of ulnar carpal support leading to ulnar translocation of the carpus
Grip weakness
Ulnar convergence impingement

Q5.How is the distal ulna stabilised to prevent convergence after loss of the DRUJ buttress?

Pronator quadratus interposition
Volar capsular flap
ECU tenodesis - old distally based (tension depends on wrist position), new proximally based
Alternative solution: ulnar head prosthesis

Q6.Why is Sauve-Kapandji preferred over Darrach in young patients?

Maintains ulnocarpal support -> less ulnar translocation of the carpus
Mobile in pronation and supination
Good strength
Better cosmesis

Q7.What is the general indication for the Sauve-Kapandji and Darrach procedures?

Salvage procedures for DRUJ instability with arthritis
Alternative is ulnar head replacement

Q8.What are the benefits of the Darrach procedure?

Improves ROM
Relieves pain
Good cosmesis
Suited to the old, low demand patient

Q9.Which muscles contract to cause ulnar convergence after loss of the DRUJ buttress?

APL, EPB and PQ
EPB arises from the radius, some APL from the ulna
Convergence: 100% happen, 50% sx

▸ Slide 710 · Clinical photo:Hand Bone · 15 questions expand

Question list

Q1-Q1515 questions — tap to reveal all answerslist

Describe the Leddy and Packer classification of FDP avulsion.
How is an acute FDP avulsion managed?
What factors decide one- versus two-stage reconstruction in chronic FDP avulsion?
Describe the two-stage reconstruction of FDP avulsion (Hunter and Salisbury).
What are the options for pulley reconstruction?
Why is the ring finger most commonly affected in FDP avulsion?
What is the clinical presentation and X-ray finding in this FDP avulsion?
What history is important in FDP avulsion?
What examination findings are sought in FDP avulsion?
What imaging is used in FDP avulsion?
What are the complications of FDP avulsion surgery?
What is the salvage procedure for a failed FDP avulsion reconstruction?
When is a tension transfer performed in FDP avulsion?
Describe the Paneva Holovich two-stage reconstruction.
What are the advantages and disadvantages of the Paneva Holovich technique?

Answers · Q & A

Q1.Describe the Leddy and Packer classification of FDP avulsion.

Type 1: retracts to the palm, both vinculae disrupted, will not retract beyond the wrist due to the lumbrical
Type 2: retracts to the PIPJ, distal to A2 pulley, short vinculae disrupted
Type 3: minimal retraction, distal to A4 pulley
Type 4: double avulsion
Type 5: DP base comminution

Q2.How is an acute FDP avulsion managed?

Large fragment: screw fixation
Small fragment: pull-out wire

Q3.What factors decide one- versus two-stage reconstruction in chronic FDP avulsion?

Soft tissue envelope status
Joint contracture
Pulley status
Also guided by chronicity and Leddy and Packer stage

Q4.Describe the two-stage reconstruction of FDP avulsion (Hunter and Salisbury).

Stage 1: silicon rod placed to create a favourable tendon bed, rod sutured to FDS/FDP as donor; physio for ROM
Stage 2 (3-4 months): rod retrieved, tendon graft passed through the mesothelium-lined psuedosheath
Suture to distal first with pull-out wire technique (allows excursion adjustment)
Suture to proximal at zone 5 with Pulvertaft technique (zone 3 if graft is soft)

Q5.What are the options for pulley reconstruction?

Non-encircling: Kleinert ever-present rim, Karev belt-loop, Lister extensor retinaculum, Doyle and Blythe palmaris longus
Encircling: Bunnell single-loop, Okutsu triple-loop
Need at least 3 loops: one A2 loop and two A4 loops
A2 loops pass deep to the extensor mechanism; A4 loops (around the bone) pass superficial to the extensors

Q6.Why is the ring finger most commonly affected in FDP avulsion?

The RF tip is 5mm more prominent in grip in 90% of patients, exposing it to greater forces
The ring finger cannot be fully extended when the middle and small finger MCPJ are flexed to 90deg, due to intertendinous connections

Q7.What is the clinical presentation and X-ray finding in this FDP avulsion?

Clinical photo: DIPJ failed flexion, no open wound
XR: volar DP base fracture
Articular surface involvement, comminution, +/- DIPJ dislocation/subluxation

Q8.What history is important in FDP avulsion?

Mechanism of injury
Chronicity
Function demands, occupation, smoking

Q9.What examination findings are sought in FDP avulsion?

Scar
ROM, active and passive
Palpate the tendon along its sheath to the level of the palm

Q10.What imaging is used in FDP avulsion?

USG

Q11.What are the complications of FDP avulsion surgery?

Fracture
Stiffness
Persistent bowstring

Q12.What is the salvage procedure for a failed FDP avulsion reconstruction?

DIPJ fusion

Q13.When is a tension transfer performed in FDP avulsion?

If there is a non-functional motor unit

Q14.Describe the Paneva Holovich two-stage reconstruction.

Stage 1: silicon rod in the flexor sheath, pulleys reconstructed; a loop between the proximal FDS and FDP stumps is created in the palm
Stage 2: rod retrieved; FDS is cut proximally and reflexed distally through the pseudosheath
FDS attached directly to FDP or secured with a button

Q15.What are the advantages and disadvantages of the Paneva Holovich technique?

Advantage: FDS graft size known at stage 1, so the correct rod size is chosen
Advantage: FDS is intrasynovial, so fewer adhesions
Advantage: relies on one tenorrhaphy site
Disadvantage: problems with tension at the distal tenorrhaphy site

▸ Slide 711 · Describe Xray:Hand Bone · 9 questions expand

Question list

Q1-Q99 questions — tap to reveal all answerslist

Describe the X-ray findings in this bony mallet finger.
Classify mallet finger injuries using the Doyle classification.
What are the indications and regime for conservative treatment with a mallet splint?
What are the indications for operation in mallet finger and what techniques are used?
What reconstruction options exist for chronic mallet finger?
What are the complications of mallet finger and how is swan neck deformity treated?
What history is important in mallet finger?
What examination findings are important in mallet finger?
What management considerations guide mallet finger treatment?

Answers · Q & A

Q1.Describe the X-ray findings in this bony mallet finger.

Intra-articular fracture at the dorsal base of the distal phalanx with displacement
Size ~50% of the articular surface, no comminution
No subluxation of the DIPJ

Q2.Classify mallet finger injuries using the Doyle classification.

Type 1: Close soft tissue mallet
Type 2: laceration
Type 3: deep laceration with tendon loss
Type 4: fracture
Type 4 subtypes: physeal injury, 20-50% art surface, >50% art surface of the articular surface

Q3.What are the indications and regime for conservative treatment with a mallet splint?

Soft tissue mallet OR small dorsal fragment with no joint subluxation, injury <12 weeks
Immobilise the DIPJ in extension for 6-8 weeks (2 weeks long mallet, 4 weeks short mallet splint)
Warn of residual extension lag that will not affect function, and possible later swan neck deformity

Q4.What are the indications for operation in mallet finger and what techniques are used?

Incongruent DIPJ, >25% fracture, >2mm displacement, open injury
Screw fixation for a sizable fragment (>50%)
Extension blocking K wire (Ishiguro technique): dorsal block wire plus a second volar wire holding the DIPJ in extension
Pull out wire

Q5.What reconstruction options exist for chronic mallet finger?

Terminal extensor tendon shortening
Fowler central slip tenotomy
Tenodermodesis (elliptical wound)
Spiral oblique retinacular ligament reconstruction (PL graft from dorsal DP base, radial MP, volar PIPJ, ulnar PP)
Salvage surgery: DIPJ fusion

Q6.What are the complications of mallet finger and how is swan neck deformity treated?

Stiffness
Swan neck deformity from secondary attenuation of the PIPJ volar plate and transverse retinacular ligament
Mild: correct the mallet finger
Severe: lateral band tenodesis / FDS tenodesis

Q7.What history is important in mallet finger?

Mechanism of injury - hyperflexion, reducing by extension and vice versa
Hand dominance, smoker, occupation
Chronicity

Q8.What examination findings are important in mallet finger?

Wounds
Confirm no active DIPJ extension
PROM in chronic cases

Q9.What management considerations guide mallet finger treatment?

Open or closed
Bony or soft tissue
Size of the bony fragment
Subluxation of the joint
Timing of injury

▸ Slide 712 · PIPJ # subluxationHand Bone · 12 questions expand

Question list

Q1-Q1212 questions — tap to reveal all answerslist

Describe the Eaton classification of PIPJ fracture-dislocation.
When does a PIPJ fracture-dislocation require surgery?
How do you perform closed reduction of a PIPJ dislocation?
How is stability assessed after reduction of a PIPJ fracture-dislocation?
What is the definitive management of PIPJ injuries by direction?
What are the surgical options for PIPJ fracture-dislocation?
Describe the anatomy of the PIPJ.
Describe the Eaton classification in terms of ligament disruption.
What history is important in a PIPJ fracture-dislocation?
What examination findings are important in a PIPJ fracture-dislocation?
What are the components of the Suzuki frame for dynamic external fixation?
What are the problems of a chronic PIPJ fracture-dislocation deformity?

Answers · Q & A

Q1.Describe the Eaton classification of PIPJ fracture-dislocation.

Type 1: hyperextension
Type 2: dislocation
Type 3: fracture-dislocation, then graded by Hastings: I <30%, II 30-50%, III >50% articular surface
Fracture fragment typically involves ~50% of the joint surface and is likely an avulsion from the volar plate

Q2.When does a PIPJ fracture-dislocation require surgery?

Eaton III with Hastings II or III
Irreducible dislocation
Aim: stable joint for early mob & prevent stiffness
Also request AP X-ray to check for a rotatory component

Q3.How do you perform closed reduction of a PIPJ dislocation?

Dorsal: flex wrist and MCPJ, gentle hyperextension of the MP followed by palmar force
Volar: reverse of dorsal
Rotatory: traction with MCPJ and PIPJ at 90deg flexion to relax the lateral band
Check NV status and document collateral and volar plate integrity

Q4.How is stability assessed after reduction of a PIPJ fracture-dislocation?

Assess PIPJ stability range - unstable if >30deg flexion is needed to remain reduced
Elson test for volar dislocation
Post-reduction XR: articular fragment size, PIPJ Shenton line and V sign

Q5.What is the definitive management of PIPJ injuries by direction?

Dorsal, stable, no fracture: dorsal block splint allowing active flexion
Dorsal, unstable: operative treatment
Volar: extension splint full time 3 weeks, then 3 weeks nocturnal splint
Lateral: buddy taping

Q6.What are the surgical options for PIPJ fracture-dislocation?

Dynamic external fixation (Suzuki frame) for comminuted/open - maintains length by ligamentotaxis
ORIF with screw for a sizeable fragment
Extension block pinning for a congruent joint
Hemihamate graft for comminuted/chronic cases; volar plate arthroplasty in chronic cases
Chronic <50% surface: volar plate arthroplasty (K wire 2-3 weeks + dorsal block splint, then dynamic splint 6-8 weeks)
Chronic >50%: ORIF + hemihamate autograft (distal dorsal hamate at 4/5 CMCJ) with K wire fixation

Q7.Describe the anatomy of the PIPJ.

Hinged joint, congruent with the intercondylar sulcus
3-sided box
Stability from bone and soft tissue (volar plate + collaterals)
2/3 of soft tissue stabilisers must be injured for dislocation to occur

Q8.Describe the Eaton classification in terms of ligament disruption.

1: partial disruption between the proper and accessory collaterals
2: complete disruption of both collaterals + volar plate
3: fracture - loss of bony stability, collaterals stay with the proximal fragment, unstable++

Q9.What history is important in a PIPJ fracture-dislocation?

Mechanism of injury
Chronicity
Premorbid status

Q10.What examination findings are important in a PIPJ fracture-dislocation?

Skin: wounds or dimple
Deformity: chronic dislocation, dorsal pseudoboutonniere
NV status

Q11.What are the components of the Suzuki frame for dynamic external fixation?

Traction wire, reduction wire and hook wire (1.2mm)
Allows PIPJ movement and maintains length by ligamentotaxis

Q12.What are the problems of a chronic PIPJ fracture-dislocation deformity?

Resorbed bone fragment
Contracted soft tissue
Scar over the fracture site

▸ Slide 713 · Volar plate:Hand Bone · 4 questions expand

Question list

Q1-Q44 questions — tap to reveal all answerslist

What is the function of the volar plate?
Describe the anatomy of the MCP volar plate.
Describe the collateral ligament anatomy.
Why do complex dislocations occur at the MCPJ but not the PIPJ?

Answers · Q & A

Q1.What is the function of the volar plate?

Reinforces the joint capsule
Enhances joint stability
Limits hyperextension
Loose in flexion, tight in extension

Q2.Describe the anatomy of the MCP volar plate.

Thickening of the joint capsule volar to the MP joint
Origin: metacarpal head
Insertion: periarticular surface of the proximal phalanx, via checkrein ligaments

Q3.Describe the collateral ligament anatomy.

Origin from the collateral recess
Proper collateral attached to the metacarpal head (dorsal one)
Accessory collateral attached to the volar plate (volar one)
Tighten in extension

Q4.Why do complex dislocations occur at the MCPJ but not the PIPJ?

PIPJ: checkrein inserts into the distal PP, stronger, so no complex dorsal dislocation
MCPJ: checkrein inserts into the proximal PP, stronger, so complex dislocation happens in dorsal dislocation

▸ Slide 714 · Xray showing fracture of 2nd MC head and subluxation of 2nd MCPJ, no sesamoid trHand Bone · 10 questions expand

Question list

Q1-Q1010 questions — tap to reveal all answerslist

What are the clinical telltale signs of a complex MCPJ dislocation?
Describe the closed reduction technique for an MCPJ dislocation.
What is a Kaplan lesion?
Why is the dorsal approach used for open reduction of an MCPJ dislocation?
How is a simple MCPJ dislocation managed definitively?
What is the difference in volar plate behaviour between MCPJ and PIPJ dislocations?
What does the X-ray show in this MCPJ dislocation?
What is the most common pattern and site of MCPJ dislocation?
How is open reduction of an MCPJ dislocation performed through a dorsal approach?
How do Kaplan lesion tissue relations differ between the index and little finger?

Answers · Q & A

Q1.What are the clinical telltale signs of a complex MCPJ dislocation?

Deformity less striking than expected due to bayonetting
Palpable metacarpal head
Dimple on the volar side
Also rule out open wound and NV deficit, and document flexor function
A sesamoid bone is present in 70% of index finger MCP joints

Q2.Describe the closed reduction technique for an MCPJ dislocation.

Adequate sedation and analgesia
Direct pressure over the PP with wrist in flexion to relax intrinsic and extrinsic flexors
Apply volar and distal directed force, followed by flexion of the MCPJ
NO traction - may cause jamming of the volar plate into the MCPJ and convert to a complex dislocation
Looks complex but still try CR as 50% still able to reduce

Q3.What is a Kaplan lesion?

Metacarpal head buttonholes into the palm
Volar plate ruptured
Radial: lumbricals; ulnar: FDP
Distal/posterior: natatory ligament; proximal/anterior: superficial transverse metacarpal ligament
Index finger: lumbrical radial, flexor tendon ulnar

Q4.Why is the dorsal approach used for open reduction of an MCPJ dislocation?

Less neurovascular injury
Easier retrieval of the intraarticular seasamoid
More direct for fixation of MC head fractures
BUT need to incise the volar plate
Volar approach tackles the pathology directly but puts the radial NV bundle at risk

Q5.How is a simple MCPJ dislocation managed definitively?

Reduction with flexion
Immobilise in 60deg flexion
Simple: immobilise for 2 weeks, then progressive ROM
Complex (interposed volar plate +/- sesamoid): open reduction

Q6.What is the difference in volar plate behaviour between MCPJ and PIPJ dislocations?

MCPJ: volar plate attached to the PP -> will trap (same as thumb), because of the checkrein ligament
PIPJ: volar plate attached to the PP -> will not trap

Q7.What does the X-ray show in this MCPJ dislocation?

Fracture of the 2nd MC head and subluxation of the 2nd MCPJ
No sesamoid trapped inside the joint
A sesamoid bone is present in 70% of index finger MCP joints

Q8.What is the most common pattern and site of MCPJ dislocation?

Most common pattern of injury is hyperextension
More common in the index finger

Q9.How is open reduction of an MCPJ dislocation performed through a dorsal approach?

Midline incision, split the extensor
The fibrocartilaginous volar plate is seen but is difficult to differentiate from articular cartilage (both white)
Make a small incision to confirm the tissue, then complete a longitudinal incision to reduce the MC head

Q10.How do Kaplan lesion tissue relations differ between the index and little finger?

IF: lumbrical radial, flexor tendon ulnar
LF: lumbrical radial, FDB and ADM ulnar

▸ Slide 715Hand Bone · 2 questions expand

Question list

Q1-Q22 questions — tap to reveal all answerslist

What hand bone condition is illustrated on this slide?
What are the key teaching points from this slide?

Answers · Q & A

Q1.What hand bone condition is illustrated on this slide?

Not covered in the speaker notes - the slide image is the only source

Q2.What are the key teaching points from this slide?

Not covered in the speaker notes

▸ Slide 716 · XR showing a short oblique fracture of proximal 1/3 of index finger PP with no iHand Bone · 7 questions expand

Question list

Q1-Q77 questions — tap to reveal all answerslist

What are the deforming forces in a proximal phalanx fracture?
How is malrotation assessed in a phalangeal fracture?
What are the nonoperative indications for a proximal phalanx fracture?
What is the nonoperative regime for a proximal phalanx fracture?
What are the operative indications for a proximal phalanx fracture?
What fixation is used for phalangeal shaft, base and head fractures?
Describe the X-ray findings in this proximal phalanx fracture.

Answers · Q & A

Q1.What are the deforming forces in a proximal phalanx fracture?

Central slip extends the distal fragment
Interossei flex the proximal fragment

Q2.How is malrotation assessed in a phalangeal fracture?

Tenodesis check
Scissoring upon making a fist

Q3.What are the nonoperative indications for a proximal phalanx fracture?

transverse/ short oblique pattern
Stable at >50 degrees ROM
Angulation <20deg
Displacement <2mm
No malrotation

Q4.What is the nonoperative regime for a proximal phalanx fracture?

Dorsal splint with MCPJ at 90deg flexion
Intrinsic forces act through the extensor mechanism -> tension band effect

Q5.What are the operative indications for a proximal phalanx fracture?

Long spiral fracture
Displacement, angulation or rotation
Multiple digits

Q6.What fixation is used for phalangeal shaft, base and head fractures?

Transverse shaft: K wire (antegrade or retrograde), Lister wiring, Bouquet pinning
Spiral/oblique shaft: cross K wires, plate, lag screws
Base: cross K wire or plate
Head: type 1 undisplaced, type 2 unstable displaced unicondylar, type 3 unstable bicondylar/comminuted

Q7.Describe the X-ray findings in this proximal phalanx fracture.

Short oblique fracture of the proximal 1/3 of the index finger PP
No intra-articular extension
Apex volar with minimal coronal malignment
No rotational deformity

▸ Slide 717 · MC fractureHand Bone · 5 questions expand

Question list

Q1-Q55 questions — tap to reveal all answerslist

What must be assessed in a metacarpal shaft or neck fracture?
Describe the Jahss maneuver.
What angulation and shortening are acceptable in metacarpal fractures?
What are the operative indications for metacarpal fractures?
What fixation options are used for metacarpal fractures?

Answers · Q & A

Q1.What must be assessed in a metacarpal shaft or neck fracture?

Site and pattern, stability, angulation/displacement/translation
Associated injury: open wounds, CMCJ dislocation
Rule out compartment syndrome
Assess malrotation

Q2.Describe the Jahss maneuver.

Jahss maneuver (for neck #)
MCPJ and PIPJ flexed 90deg
Dorsal directed force through the proximal phalanx

Q3.What angulation and shortening are acceptable in metacarpal fractures?

No rotation is acceptable
MC 2&3: 15deg; MC 4: 30deg; MC 5: 40deg
Shortening 2-5mm acceptable
Mnemonic: 20/30/40/50

Q4.What are the operative indications for metacarpal fractures?

Multiple or open fractures
Unacceptable alignment

Q5.What fixation options are used for metacarpal fractures?

K wires parallel or crossed
Plate if comminution
External fixator if intra-articular comminution

▸ Slide 718 · PA and scaphoid XR showing patients wrist with scaphoid waist fractureHand Bone · 20 questions expand

Question list

Q1-Q2020 questions — tap to reveal all answerslist

Describe the X-ray findings of this scaphoid waist fracture.
Why are scaphoid fractures prone to nonunion?
Describe the Herbert classification of scaphoid fractures.
What is the blood supply of the scaphoid?
What is the conservative management and union rate for a scaphoid waist fracture?
What is the evidence for cast versus surgery in scaphoid waist fractures?
What is the summary diagnosis and which further views are requested?
What history is taken in a scaphoid fracture?
What examination findings are sought in scaphoid fracture?
What is the acute first aid for a scaphoid fracture?
Which patient and fracture factors guide definitive scaphoid management?
What is the aim and technique of surgical fixation of a scaphoid waist fracture?
How is a grossly displaced scaphoid fracture approached?
Describe the percutaneous approaches to the scaphoid.
Describe the dorsal open approach to the scaphoid.
Describe the volar (Russe) approach to the scaphoid.
What is a good lateral (SPC) view and how is displacement measured?
On PA and AP wrist views, where is the ulnar styloid seen?
If a scaphoid fracture is suspected but not seen on initial X-ray, what is the next step?
Which approach is used for fixation of an undisplaced scaphoid fracture?

Answers · Q & A

Q1.Describe the X-ray findings of this scaphoid waist fracture.

Complete, displaced >1mm, horizontal oblique scaphoid waist fracture
Unstable according to the Herbert classification (Herbert B)
Acute - no cyst, sclerosis or arthritis
Associated SL widening; no carpal collapse or other fracture

Q2.Why are scaphoid fractures prone to nonunion?

Biological: retrograde blood supply, no tendon attachment, 80% covered with cartilage, lacks osteogenic cambium layer, bathed in synovial fluid, small bone contact
Mechanical: connects the two carpal rows, area of high stress; proximal fragment extended/radially deviated by SL and DIC, distal fragment flexed/ulnar deviated around the RSC
Delayed presentation: 25% not seen on initial X-ray

Q3.Describe the Herbert classification of scaphoid fractures.

A: stable - tubercle, horizontal waist, treated conservatively
B: unstable
C: delayed (6 weeks)
D: nonunion
Russe adds orientation: horizontal oblique, transverse, vertical oblique

Q4.What is the blood supply of the scaphoid?

All supply is retrograde
Proximal 80% via the dorsal carpal artery
Distal 20% via the superficial palmar branch
No anastomosis between them

Q5.What is the conservative management and union rate for a scaphoid waist fracture?

Short arm cast with thumb left free, wrist slightly extended, functional cup position
Cast for 8 weeks, union rate 90-95%
Scaphoid cast management is reliable in undisplaced stable waist fracture with union rate up to 90%
Duration by site: 8/10/12 weeks and union 90, 80, 60% for distal/waist/proximal fractures
No consensus on long versus short arm cast or thumb immobilisation
Netherlands meta-analysis (J Trauma 2011, 500 patients): no difference in union, pain, grip, time to union or osteonecrosis

Q6.What is the evidence for cast versus surgery in scaphoid waist fractures?

SWIFT trial (Dias, Lancet 2020): fractures displaced 2mm or less should be treated with cast immobilisation, with early fixation of confirmed nonunion
Surgery gives similar long-term outcomes but more complications
McQueen (JBJS 2008): surgery shortens time to union (9 vs 14 weeks) and earlier return to work, but no difference in union rate, ROM or grip at 2 years

Q7.What is the summary diagnosis and which further views are requested?

Herbert B scaphoid waist fracture, suspicious of SL widening
Better lateral view for displacement and humpback deformity
Stress view for SL dissociation

Q8.What history is taken in a scaphoid fracture?

Age, hand dominance, occupation, functional demand
Mechanism of injury, delayed presentation, symptoms

Q9.What examination findings are sought in scaphoid fracture?

Localised tenderness over the anatomical snuffbox and SL interval
Rule out other injuries

Q10.What is the acute first aid for a scaphoid fracture?

Analgesics, rest, elevate
Short arm thumb spica slab

Q11.Which patient and fracture factors guide definitive scaphoid management?

Timing, orientation, associated injuries
Displacement, site
Patient counselling

Q12.What is the aim and technique of surgical fixation of a scaphoid waist fracture?

Reduce with stable fixation and compression; union rate up to 97%
Percutaneous approach with K wire as a joystick for reduction
Headless compression screw with differential pitch targeting the central longitudinal axis

Q13.How is a grossly displaced scaphoid fracture approached?

Volar approach for ORIF - direct visualisation of the whole scaphoid, correct humpback deformity, preserve dorsal blood supply
Dorsal approach if the fracture is proximal

Q14.Describe the percutaneous approaches to the scaphoid.

Volar: incision distal to STTJ, entry at scaphoid tubercle abutting STT; 12G hypodermic needle as guide; reduce by hyperextension and ulnar deviation; bean view - axis from middle third of scaphoid tubercle to distal half of proximal pole
Dorsal: pronate and flex until the scaphoid is seen as a double ring; guidepin at centre; length 18-24mm (-4mm from measured)

Q15.Describe the dorsal open approach to the scaphoid.

Longitudinal incision over Lister tubercle, between the 3rd and 4th compartments, between EPL and EDC
Incise extensor retinaculum and dorsal capsule up to the DIC; flex the wrist over a bolster to reveal the proximal pole
Danger: superficial branch of radial nerve, dorsal carpal branch of radial artery
Pros: can address SL, also good for perilunate dislocation

Q16.Describe the volar (Russe) approach to the scaphoid.

Incision along FCR then towards the scaphoid tubercle
Incise RSC (preserve the RSC stump to prevent humpback) and long radiolunate ligament
Pros: good exposure, correct humpback, avoids the dorsal carpal branch of the radial artery
Cons: radial artery at risk

Q17.What is a good lateral (SPC) view and how is displacement measured?

SPC view: volar cortex of pisiform should lie between the middle 1/3 of the interval between volar cortex of scaphoid and capitate
Displacement >1mm = displaced
Radiolunate angle >15deg dorsal = DISI; capitolunate >15deg volar = VISI
Intra-scaphoid angle >35deg = humpback deformity

Q18.On PA and AP wrist views, where is the ulnar styloid seen?

PA view: ulnar styloid is peripheral (ulnar)
AP view: ulnar styloid is central

Q19.If a scaphoid fracture is suspected but not seen on initial X-ray, what is the next step?

Scaphoid series: PA, lateral, ulnar deviated (scaphoid view), oblique PA with wrist extension 20deg + ulnar deviation 20deg, 45deg pronation and supination
If still negative: thumb spica cast and repeat scan in 2/52
Consider CT and MRI

Q20.Which approach is used for fixation of an undisplaced scaphoid fracture?

Distal fracture: volar percutaneous
Proximal fracture: dorsal percutaneous

▸ Slide 719 · Herbert screwHand Bone · 2 questions expand

Question list

Q1-Q22 questions — tap to reveal all answerslist

What is a Herbert screw?
How does the Herbert screw achieve interfragmentary compression?

Answers · Q & A

Q1.What is a Herbert screw?

A headless compression screw used for scaphoid fixation
It has a differential pitch

Q2.How does the Herbert screw achieve interfragmentary compression?

The lead of the leading (distal) thread is larger than the trailing (proximal) thread

▸ Slide 720 · Scaphoid nonunionHand Bone · 8 questions 1 check expand

Question list

Q1-Q88 questions — tap to reveal all answerslist

Describe the X-ray findings of scaphoid nonunion.
What investigations are used in scaphoid nonunion and why?
What is the natural history and pathoanatomy of scaphoid nonunion?
What are the principles of scaphoid nonunion surgery?
Which bone graft is chosen in scaphoid nonunion with AVN or deformity?
Which surgical approach is preferred for scaphoid nonunion?
What history is important in scaphoid nonunion?
What is the surgical aim in scaphoid nonunion?

Answers · Q & A

Q1.Describe the X-ray findings of scaphoid nonunion.

Scaphoid fracture with sclerosis and cystic change
Relevant negatives for malalignment/SNAC: no obvious radial styloid arthritis, no carpal collapse, Gilula lines intact

Q2.What investigations are used in scaphoid nonunion and why?

XR lateral and scaphoid series: humpback deformity, displacement, DISI
CT 1mm cuts: cyst, bone stock, deformity
MRI with contrast: proximal pole AVN

Q3.What is the natural history and pathoanatomy of scaphoid nonunion?

Natural history is predictable: 97% arthrosis in 5 years, 90% symptomatic
Distal scaphoid flexes, capitate is pulled proximally, compression on scapholunate -> SC arthritis

Q4.What are the principles of scaphoid nonunion surgery?

Debridement of necrotic bone and exposure of a healthy vascularised bed
Alignment: correction of scaphoid malalignment
Biology: bone grafting
Mechanical stability: stabilisation

Q5.Which bone graft is chosen in scaphoid nonunion with AVN or deformity?

AVN -> vascularised bone graft: dorsal 1,2 ICSRA, volar radial carpal artery
Deformity -> opening wedge interposition graft (Fisk)
No deformity -> cancellous graft (arthroscopic) or modified Russe inlay cortical graft
OA/SNAC at presentation -> non-salvageable

Q6.Which surgical approach is preferred for scaphoid nonunion?

Mostly volar, as it causes less disruption to the dorsal carpal branch of the radial artery

Q7.What history is important in scaphoid nonunion?

Age, hand dominance, functional demand, occupation, smoking
Mode and time of injury, treatment received
Symptoms

Q8.What is the surgical aim in scaphoid nonunion?

Realign the fracture and promote union with bone graft + stable fixation

Fact check

Untreated scaphoid nonunion causes arthrosis in 97% within 5 years — imprecise — The 97% figure (Ruby 1985) applied to nonunions already at least 5 years old in a symptomatic series; a 102-case series found 22% arthritis at <5 years, 75% at 5-9 years and 100% at >=10 years. It is not '97% by 5 years'. — medium confidence — source

▸ Slide 721 · Scaphoid nonunion advanced collapseHand Bone · 6 questions expand

Question list

Q1-Q66 questions — tap to reveal all answerslist

Describe the X-ray findings of a stage III SNAC wrist.
How is SNAC wrist managed by stage?
What is the aim and technique of four corner fusion?
When can PRC be used in SNAC and what are its drawbacks?
What is the aim and what are the means of surgery in SNAC wrist?
Why is the lunate relatively resistant to osteoarthritis?

Answers · Q & A

Q1.Describe the X-ray findings of a stage III SNAC wrist.

Scaphoid nonunion with OA change at the radial styloid and distal scaphoid, scaphocapitate and capitolunate joints
Collapsed carpal height as indicated by Nattrass and Youm indices
Lateral: increased SL angle (may be due to humpback deformity) and increased capitolunate angle -> DISI deformity

Q2.How is SNAC wrist managed by stage?

I: radial styloidectomy + excision of distal scaphoid
II: excision of radial styloid + 4 corner fusion or PRC
III: four corner fusion
Pan arthritis: wrist fusion

Q3.What is the aim and technique of four corner fusion?

Eliminate the arthritic midcarpal joint (usually capitolunate)
Maintain carpal height
Also fuse hamate and triquetrum to increase fusion rate
Fusion rate also depends on smoking status

Q4.When can PRC be used in SNAC and what are its drawbacks?

SNAC 2 with SC joint arthritis and intact midcarpal (LC) joint
Decreased carpal height may cause decreased grip strength and risk of future OA

Q5.What is the aim and what are the means of surgery in SNAC wrist?

Aim: removal of the pain generator +/- maintain carpal height in 4 corner fusion
Means: excisional arthroplasty / limited fusion / wrist fusion

Q6.Why is the lunate relatively resistant to osteoarthritis?

The lunate is spherical; even if orientation is disrupted it is unlikely to develop OA

▸ Slide 722 · Widened SL interval (terry Thomas sign: >3mm)Hand Bone · 7 questions expand

Question list

Q1-Q77 questions — tap to reveal all answerslist

Describe the X-ray findings of scapholunate dissociation.
Describe the Watson (SLAC) classification.
Describe the Geissler classification.
How is Watson's test performed?
How is SL dissociation managed (Garcia-Elias)?
Compare PRC with four corner fusion.
What factors are taken into account when managing SL dissociation?

Answers · Q & A

Q1.Describe the X-ray findings of scapholunate dissociation.

Widened SL interval >3mm (Terry Thomas sign)
Gilula line broken - intercarpal alignment disrupted, DISI, scaphoid flexed
Lateral view: SL angle >60deg (DISI)
OA change between scaphoid and radius; midcarpal joint not involved
Likely SLAC Watson stage 2; mention carpal height

Q2.Describe the Watson (SLAC) classification.

I: radial styloid
II: scaphoid fossa
III: capitolunate
IV: pan-arthritis

Q3.Describe the Geissler classification.

Arthroscopic classification for acute SL dissociation
Grades: hemorrhage, incongruent, probe through, scope through
Stage: pre dynamic/dynamic/static/reducible DISI/irreducible DISI/SLAC

Q4.How is Watson's test performed?

Elbow in 90deg flexion, neutral forearm rotation
Scaphoid flexes on radial deviation and extends on ulnar deviation
Examiner's thumb gives a dorsal directed force to the scaphoid tubercle; wrist deviated from ulnar to radial
Positive if a clunk is felt, with dorsal subluxation of the scaphoid over the dorsal rim of the radius

Q5.How is SL dissociation managed (Garcia-Elias)?

Predynamic/acute dynamic: dorsal repair + K wire fixation
Chronic, no SLAC, reducible DISI: reconstruction - anatomical (BLB/BRB) or non-anatomical with capsulodesis (Blatt DIC, Linscheid ECRL, Brunelli FCR)
Chronic, no SLAC, not reducible DISI: STT fusion + radial styloidectomy
SLAC 1: radial styloidectomy + SL reconstruction/ PIN and AIN neurectomy; 2: scaphoidectomy + 4 corner/PRC; 3: 4 corner or total wrist fusion; 4: total wrist fusion

Q6.Compare PRC with four corner fusion.

Systematic review 2015 J Hand surg Eur Saltzman: 4 corner fusion: better grip strength
PRC: better ROM, fewer complications; no implant, no nonunion problems
PRC cons: reduced grip strength, longer rehab, 100% OA at 10 years
PRC prerequisites: RSC intact, no CL arthritis, stable midcarpal joint

Q7.What factors are taken into account when managing SL dissociation?

Integrity and quality of the dorsal SLL
Posture of the scaphoid (DISI)
Carpal alignment and cartilage status

▸ Slide 723 · Describe Xray:Hand Bone · 10 questions expand

Question list

Q1-Q1010 questions — tap to reveal all answerslist

Describe the X-ray findings of a perilunate dislocation.
Outline the acute management of a perilunate dislocation.
Describe Tavernier's manoeuvre.
Describe the Mayfield circle of perilunate instability.
What is the definitive operative management of a perilunate dislocation?
What is the prognosis after perilunate dislocation?
What are the boundaries of the space of Poirier?
Describe the pathoanatomy of perilunate instability.
Describe the volar extrinsic wrist ligaments.
Describe the intrinsic and dorsal wrist ligaments.

Answers · Q & A

Q1.Describe the X-ray findings of a perilunate dislocation.

AP: displaced scaphoid waist fracture, disrupted Gilula line at the proximal and distal curvatures
Piece of pie sign - overlap of capitate and lunate
+/- scaphoid cortical ring sign, +/- radial styloid fracture
Lateral: loss of colinearity of radius, lunate and capitate = trans-scaphoid perilunate dislocation

Q2.Outline the acute management of a perilunate dislocation.

ATLS, AMPLE history; assess median nerve, wounds, compartments
Closed reduction under sedation; back slab; closely monitor neurovascular status
CT scan
If closed reduction fails: OR with volar approach

Q3.Describe Tavernier's manoeuvre.

Prolonged traction with wrist extension
Stabilise the lunate volarly
Reduce the capitate onto the lunate with wrist flexion

Q4.Describe the Mayfield circle of perilunate instability.

I: SLL / scaphoid fracture
II: capitolunate
III: LT
IV: dorsal radiocarpal ligament, lunate dislocation (unopposed SRL pull)
Intrinsic weakest point: space of Poirier, between lunate and capitate

Q5.What is the definitive operative management of a perilunate dislocation?

Refer hand specialist
Aim: anatomical restoration of carpal alignment and stable fixation for ligaments to heal
Fix scaphoid/styloid, repair ligaments with suture anchors, transfix unstable carpal bones
Pinning: 1. lunate to radius (prevent DISI), 2. transfix SL and LT, 3. CL if capitolunate unstable (CIND)
Pin for 8 weeks, cast for 12 weeks; encourage early finger mobilisation
Dorsal approach: Berger flap (repair intrinsic SL ligament and extrinsic radiotriquetral); volar approach: release carpal tunnel, repair LT and radiocarpal ligaments

Q6.What is the prognosis after perilunate dislocation?

36% posttraumatic arthritis
Residual scapholunate instability
Stiffness - 50% of movement lost
CRPS

Q7.What are the boundaries of the space of Poirier?

Intrinsic weakest point of the space of Poirier without ligament b/w lunate & capitate
Bound by volar deltoid ligament (intrinsic) superiorly, RSC radially
RLT (long radiolunate) inferiorly, UC ligament ulnarly

Q8.Describe the pathoanatomy of perilunate instability.

Disruption follows Mayfield's classification (radial to ulnar)
Greater versus lesser arc injuries
Classical greater arc: radial styloid -> scaphoid fracture -> capitate fracture -> ulnar styloid fracture

Q9.Describe the volar extrinsic wrist ligaments.

Long volar arch = RSC + UCL; short volar arch = RL + UL
RSC is strongest to prevent ulnar translocation
Long RL / short RL (ligament of Testut, located between SRL/LRL)
UT / UL / UC blend with the TFCC

Q10.Describe the intrinsic and dorsal wrist ligaments.

Intrinsic: LT, SL (volar and dorsal)
Dorsal extrinsic: DIC (scaphoid to triquetrum), DRC (radius to triquetrum)
Dorsal intrinsic: SL, LT

▸ Slide 724 · Moneim Classification - based on presence of intercarpal dissociationHand Bone · 4 questions expand

Question list

Q1-Q44 questions — tap to reveal all answerslist

Describe the Moneim classification.
Describe the Dumontier classification.
Which ligaments are involved in perilunate instability?
Describe the three column fixation concept.

Answers · Q & A

Q1.Describe the Moneim classification.

Based on the presence of intercarpal dissociation
Type 1: without associated intercarpal dissociation
Type 2: with associated intercarpal dissociation

Q2.Describe the Dumontier classification.

Based on the presence of radial styloid fracture
Type 1: purely ligamentous or only a small cortical avulsion
Type 2: associated with a large radial styloid fracture

Q3.Which ligaments are involved in perilunate instability?

RSC, LRL, SRL, UC, UT, UL

Q4.Describe the three column fixation concept.

Radial column: radial styloid to scaphoid pinning
Intermediate column (lunate facet): SRL and RSC ligament repairs + radiolunate K wire
Ulnar column: DRUJ pinning
Conservative if stable; otherwise ligament repair/reconstruction

▸ Slide 725 · AP and lateral Xray showing abnormalities over lunate with sclerosis and collapsHand Bone · 9 questions 1 check expand

Question list

Q1-Q99 questions — tap to reveal all answerslist

Describe the X-ray findings of this lunate pathology.
How is carpal collapse quantified?
What are the hypotheses and risk factors for Kienbock disease?
Describe the Lichtman classification of Kienbock disease.
What are the surgical aims in early versus late Kienbock disease?
Why are symptoms rather than radiology the guide to treatment in Kienbock disease?
What examination findings are important in Kienbock disease?
What are the Zapico lunate morphology types and what is the vascular supply prevalence?
Describe the Bain arthroscopic classification of Kienbock disease.

Answers · Q & A

Q1.Describe the X-ray findings of this lunate pathology.

Lunate sclerosis with collapsed height; suspected carpal height collapse
No features of STT arthritis; signet ring sign on AP view
DISI on lateral view with reduced SLA
Ulna minus on PA X-ray, radial inclination within normal limits
Consistent with Lichtman type IIIB Kienbock disease; Ddx infection, trauma

Q2.How is carpal collapse quantified?

Nattrass index (carpal height / capitate) <1.57
Youm index (carpal height / 3rd metacarpal) <0.54
Stahl index (lunate height to width ratio) <0.53
McMurtry (ulnar central axis to capitate / ulnar axis to 3rd MC) 0.27-0.33

Q3.What are the hypotheses and risk factors for Kienbock disease?

Avascular necrosis of the lunate of unknown aetiology; biological, mechanical or mixed cause
Biological: single intraosseous/extraosseous vessel variation; 7-20% have a single palmar vessel
Mechanical: ulnar minus, increased radial inclination, lunate morphology (Zapico 1 trapezoidal worst)
Ask about age, functional demands, occupation; risk factors such as alcohol and steroid intake
CT: coronal split; MRI: vascularity (decrease T1 signal), articular congruency (decreased T1 signal suggests AVN)

Q4.Describe the Lichtman classification of Kienbock disease.

1: X-ray normal
2: sclerosis without collapse
3: collapse - 3A normal scaphoid alignment, 3B fixed scaphoid rotation with ring sign, 3C coronal split
4: pan arthritis
Bain arthroscopic classification looks for articular surface involvement

Q5.What are the surgical aims in early versus late Kienbock disease?

Early (I-IIIA): revascularize + redistribute load
biologically revascularize: 4,5 ECA pedicle graft, vascularised pisiform transfer, 2nd dorsal intermetacarpal artery
Mechanical: UV minus -> radial shortening; UV positive/neutral -> radial wedge osteotomy or capitate shortening
Postop Exfix to protect joint level procedure
Stage 3B: excise lunate + rolled PL graft and STT fusion, more motion preserved, or SC fusion (larger fusion area, better load transfer); or PRC
Late stage: remove pain generator and transfer load to radial column and salvage remaining carpal height
Late/arthritis: PRC or total wrist fusion/replacement

Q6.Why are symptoms rather than radiology the guide to treatment in Kienbock disease?

Radiological findings do not correlate well with patient symptoms
Treat if symptomatic: start conservative with activity modification, splint, NSAID for 3-6 months

Q7.What examination findings are important in Kienbock disease?

ROM
Swelling
Tenderness just distal to Lister tubercle

Q8.What are the Zapico lunate morphology types and what is the vascular supply prevalence?

Zapico: 1 trapezoidal (worst), 2 rectangular, 3 double facet
Majority of lunates have both dorsal and palmar vessels with rich anastomoses
7-20% have a single palmar vessel supplying the whole lunate
Intraosseous prevalence: Y > I > X

Q9.Describe the Bain arthroscopic classification of Kienbock disease.

0: 0 (no involvement)
1: proximal lunate
2a: proximal lunate + radius articular surface
2b: split of both distal and proximal lunate surfaces
3: both lunate + radius
4: 3 + proximal capitate

Fact check

Youm index <0.54 and Nattrass index <1.57 indicate carpal collapse — imprecise — These are the normal population means, not fixed cut-offs: Youm carpal height ratio is 0.54 +/- 0.03 (normal range about 0.51-0.57) and Nattrass index is 1.57 +/- 0.05 (range about 1.52-1.62). Compare with the contralateral wrist rather than a single threshold. — medium confidence — source

▸ Slide 726 · Wrist fusionHand Bone · 3 questions expand

Question list

Q1-Q33 questions — tap to reveal all answerslist

What position is the wrist fused in and why?
What are the functional movements of the wrist?
How much of wrist ROM comes from each joint?

Answers · Q & A

Q1.What position is the wrist fused in and why?

Extension 20deg for grip strength
Neutral or 10deg ulnar deviation

Q2.What are the functional movements of the wrist?

40deg flexion/extension
10deg radial deviation
30deg ulnar deviation

Q3.How much of wrist ROM comes from each joint?

60% radiocarpal joint
30% intercarpal
10% intracarpal

▸ Slide 727 · 1st CMCJ OA narrowing of joint space, subchondral sclerosis, dorsal and radialHand Bone · 12 questions expand

Question list

Q1-Q1212 questions — tap to reveal all answerslist

Describe the X-ray findings of first CMCJ osteoarthritis.
Describe the Eaton and Littler classification.
What are the key examination findings and tests in first CMCJ OA?
What is the conservative management of first CMCJ OA?
What are the operative options for first CMCJ OA by stage?
Describe the pathoanatomy of first CMCJ osteoarthritis.
What history is important in first CMCJ OA?
What is the aim of treatment in first CMCJ OA?
Describe the Wagner approach to trapeziectomy.
What are the advantages and disadvantages of trapeziectomy?
What is the functional position for first CMCJ fusion and when is it contraindicated?
Which nerves are targeted in first CMCJ denervation?

Answers · Q & A

Q1.Describe the X-ray findings of first CMCJ osteoarthritis.

Joint space narrowing, subchondral sclerosis
Dorsal and radial subluxation >1/3, osteophytes
Also arthritis in the STTJ
MCPJ hyperextension deformity; narrowing of the 1st webspace
Eaton stage IV; request a Robert's view (hyperpronation, thumb flat on cassette)

Q2.Describe the Eaton and Littler classification.

I: increased joint space
II: <1/3 subluxation, osteophyte <2mm
III: >1/3 subluxation, osteophyte >2mm
IV: pantrapezial arthritis

Q3.What are the key examination findings and tests in first CMCJ OA?

Look: square off sign (dorsoradial prominence), MCPJ hyperextension, adducted and flexed 1st MC
Feel: tenderness, grind, crank, torque and retropulsion tests
Move: ROM, 1st webspace (45-55deg between 1st and 2nd MC), STT radiocarpal grinding test
Rule out Finkelstein, Eichhoff and RCJ grind; associations include carpal tunnel (50%) and trigger finger

Q4.What is the conservative management of first CMCJ OA?

Lifestyle modification, splint, NSAIDs
Steroid injection: 80% pain relief in Eaton 1
Physio: 1st webspace stretching and 1st dorsal interosseous strengthening

Q5.What are the operative options for first CMCJ OA by stage?

Early (stage 1-3): arthroscopic debridement + thermal shrinkage; first MC basal osteotomy
Later (stage III/IV): trapeziectomy +/- webspace contracture release, or Eaton's procedure (trapeziectomy + LRTI)
Newer: suspensionplasty with suture button, APL (Weilby) or ECRL; less commonly 1st CMCJ arthroplasty or fusion
Fusion contraindicated in stage IV (exacerbates STTJ arthritis); unable to put hand flat
Davis 2012 RCT and Cochrane 2015: no long-term benefit of LRTI over trapeziectomy alone; LRTI had more adverse events
MCPJ hyperextension: EPB transfer to PP base, volar capsulodesis, or MCPJ fusion

Q6.Describe the pathoanatomy of first CMCJ osteoarthritis.

Biconcave saddle joint
Beak ligament (trapezium volar tubercle to ulnar 1st MC base) prevents dorsal subluxation on key pinch
Weakened beak ligament -> dorsal subluxation on pinch -> see-saw movement -> cartilage degeneration -> further instability
Recent evidence: dorso-radial ligament more important than beak ligament, maintaining the relationship between 1st and 2nd MC

Q7.What history is important in first CMCJ OA?

Risk factors: occupation
Pain
Functional limitations

Q8.What is the aim of treatment in first CMCJ OA?

Stable, painless thumb
Restore thumb function of opposition

Q9.Describe the Wagner approach to trapeziectomy.

Incision between dorsal and volar glabrous skin
Interval between APL and thenar muscles (or scope)

Q10.What are the advantages and disadvantages of trapeziectomy?

Advantages: simple procedure, good pain relief, preserves ROM
Disadvantages: splintage 4-6 weeks
Loss of thumb length and pinch strength (50-60%)
Metacarpal subsidence and instability

Q11.What is the functional position for first CMCJ fusion and when is it contraindicated?

Radial and palmar abduction 30deg, 15deg pronation
Cons: unable to put the hand flat on the table
Contraindicated in stage IV - exacerbates STTJ arthritis

Q12.Which nerves are targeted in first CMCJ denervation?

Thenar branch of the median nerve
Superficial branch of the radial nerve entering the CMCJ
Articular branches of the palmar cutaneous branch
Nerve of Cruveilhier
Dorsal articular nerve of the first dorsal interosseous space

▸ Slide 728 · Gamekeepers thumb (6 week) / Skiers thumb (acute)Hand Bone · 8 questions expand

Question list

Q1-Q88 questions — tap to reveal all answerslist

What is injured in gamekeeper's/skier's thumb and where do the avulsions occur?
How do you differentiate partial from complete UCL injury?
What is a Stener lesion and what is its mechanism?
What investigations are used for UCL injury?
How is incomplete versus complete UCL injury managed?
What is the outcome after UCL injury treatment?
What is the difference between gamekeeper's and skier's thumb?
Where does the adductor pollicis attach?

Answers · Q & A

Q1.What is injured in gamekeeper's/skier's thumb and where do the avulsions occur?

Injury to the ulnar collateral ligament, important for lateral pinch
Avulsion distally 50%, proximally 40%, midsubstance 10%

Q2.How do you differentiate partial from complete UCL injury?

Radial stress test at neutral and 30deg (neutral tests accessory + proper, 30deg tests proper)
Complete: 15deg more laxity compared with normal; at 30deg, no endpoint
Grade 1: pain, no laxity; grade 2: soft endpoint; grade 3: no endpoint
Also rule out a Stener lesion

Q3.What is a Stener lesion and what is its mechanism?

Complete UCL rupture trapped superficial to the adductor pollicis aponeurosis
Prevents healing or causes unpredictable healing; fibrotic mass -> needs operative treatment
Mechanism: forced hyperabduction of the thumb

Q4.What investigations are used for UCL injury?

XR: avulsion fracture
USG/MRI: Stener lesion

Q5.How is incomplete versus complete UCL injury managed?

Incomplete: thumb spica cast 4 weeks, then splint 2 weeks, then gentle ROM; no strenuous exercise for 3 months
Complete acute: repair UCL +/- suture anchor or pullout wire, then repair aponeurosis to extensor tendon sheath, K wire with MCPJ at 20deg flexion, thumb spica
Chronic/Stener: static reconstruction with PL graft; dynamic reconstruction with EIP, EPB or adductor pollicis

Q6.What is the outcome after UCL injury treatment?

Samora (CJSM 2013): >90% excellent outcome
Acute and chronic injuries achieved comparable results (acute = chronic)

Q7.What is the difference between gamekeeper's and skier's thumb?

Gamekeeper's thumb = chronic injury (6 weeks)
Skier's thumb = acute injury

Q8.Where does the adductor pollicis attach?

Ulnar base of the proximal phalanx of the thumb

▸ Slide 729 · Xray hand showing 1st MC base intra-articular fracture suluxation with CMCJ radiHand Bone · 13 questions expand

Question list

Q1-Q1313 questions — tap to reveal all answerslist

What are the key facts about 1st metacarpal fractures?
Describe the X-ray findings in this hand injury.
How does the 1st metacarpal displace in a Bennett fracture?
What is a Bennett fracture and which X-ray view best shows displacement?
Why is surgery usually needed for a Bennett fracture?
What is the PAET reduction manoeuvre?
Is it necessary to fix the ulno-volar fragment in a Bennett fracture?
How is CRPP performed for a Bennett fracture?
When is ORIF used for 1st MC base fractures and what implants are used?
Describe the Wagner approach for ORIF of the 1st MC base.
How is a Rolando fracture treated and what is its prognosis?
What is opposition of the thumb?
What is a reverse Bennett fracture and what must you look for?

Answers · Q & A

Q1.What are the key facts about 1st metacarpal fractures?

80% involve the MC base, most common is Bennett (partial intra-articular)
Others: Rolando (complete intra-articular +/- comminuted) and extra-articular
Mechanism is typically axial force to the thumb
CMCJ allows large sagittal movement; up to 30deg angulation is accepted

Q2.Describe the X-ray findings in this hand injury.

1st MC base intra-articular fracture-subluxation
CMCJ radial and dorsal subluxation
1st MC is supinated, shortened, adducted and flexed

Q3.How does the 1st metacarpal displace in a Bennett fracture?

Shortened with radial and dorsal subluxation by APL
Supination by EPL and adductor pollicis
Adduction by adductor pollicis

Q4.What is a Bennett fracture and which X-ray view best shows displacement?

2-part volar ulnar intra-articular fracture of the 1st MC base
Known to be easy to reduce but difficult to hold
Hyperpronated thumb (Robert's) view best assesses displacement

Q5.Why is surgery usually needed for a Bennett fracture?

Fracture is intra-articular, displaced with joint subluxation
Conservative treatment only for undisplaced fractures ie 1mm
Distal fragment is subjected to multiple tendon pull and prone to displacement

Q6.What is the PAET reduction manoeuvre?

(1) Traction
(2) Extension with pressure over dorsal apex
(3) Abduction
(4) Pronation of the MC

Q7.Is it necessary to fix the ulno-volar fragment in a Bennett fracture?

No - fixation is not necessary to catch the ulno-volar fragment

Q8.How is CRPP performed for a Bennett fracture?

Indicated if small fragment and reducible
1st pin: distal fragment to trapezium
2nd pin: 1st to 2nd MC to maintain length
Followed by thumb spica cast immobilisation

Q9.When is ORIF used for 1st MC base fractures and what implants are used?

If 1. large fragment, 2. irreducible
ORIF with K wire or screw
Lag screw for Bennett, plate for Rolando
Post op casting x 4/52

Q10.Describe the Wagner approach for ORIF of the 1st MC base.

Skin incision between volar and dorsal radial skin, curving volar towards the radial border of FCR (hockey stick incision)
Plane between APL and thenar muscles (in plane radial and medial)
Protect sensory branches of radial nerve
Subperiosteal reflection of thenar muscle

Q11.How is a Rolando fracture treated and what is its prognosis?

Base split into volar and dorsal fragment (Y fracture)
ORIF with plate (T/L plate) or external fixation with Thoren traction (abduction + extension vectors)
Connected in a Bandi outrigger splint for 2 weeks, then cast
Worse prognosis

Q12.What is opposition of the thumb?

Palmar abduction, flexion and pronation

Q13.What is a reverse Bennett fracture and what must you look for?

Reverse Bennett = fracture of the base of the 5th MC
CT to look for concomitant hamate fracture

▸ Slide 730 · 5th and 4th CMCJ dislocationHand Bone · 3 questions expand

Question list

Q1-Q33 questions — tap to reveal all answerslist

What do you assess in a 5th CMCJ fracture dislocation?
Why is closed reduction alone unlikely to be stable in a 5th CMCJ fracture dislocation?
How is a 5th CMCJ fracture dislocation managed operatively?

Answers · Q & A

Q1.What do you assess in a 5th CMCJ fracture dislocation?

Soft tissue cover
NV: motor branch of ulnar nerve near hook of hamate
Compartment status
Rotation deformity
Cascade of MCPJ (draw a curve line on X-ray)

Q2.Why is closed reduction alone unlikely to be stable in a 5th CMCJ fracture dislocation?

The dislocation is pulled by ECU
Close reduction is not likely to be stable

Q3.How is a 5th CMCJ fracture dislocation managed operatively?

CR + KWF (K wire fixation) to carpal bone and other MC bones
Risk: motor branch of ulnar nerve
K wire must not perforate the volar side

▸ Slide 731 · Pisotriquetral arthritisHand Bone · 2 questions expand

Question list

Q1-Q22 questions — tap to reveal all answerslist

What is pisotriquetral arthritis?
What are the clinical features and management of pisotriquetral arthritis?

Answers · Q & A

Q1.What is pisotriquetral arthritis?

Not covered in the speaker notes beyond the slide title

Q2.What are the clinical features and management of pisotriquetral arthritis?

Not covered in the speaker notes

▸ Slide 732 · Rheumatoid handHand Bone · 8 questions expand

Question list

Q1-Q88 questions — tap to reveal all answerslist

What is the pathophysiology of rheumatoid hand involvement?
What happens in the hand in rheumatoid arthritis?
What intrinsic factors in the hand cause MCPJ ulnar drift in RA?
What are the classic deformities seen in the rheumatoid hand?
What are the aims of treatment in the rheumatoid hand?
What are the urgent indications in the rheumatoid hand?
What is the priority in managing the rheumatoid hand?
What are the ACR/EULAR 2010 diagnostic criteria for RA?

Answers · Q & A

Q1.What is the pathophysiology of rheumatoid hand involvement?

RA is a progressive, systemic, cell-mediated (T-cell, MHC class II) autoimmune condition affecting the synovial lining of joints and tendon sheaths
Rheumatoid factor = IgM autoantibodies directed against the Fc portion of IgG, forming immune complexes
Pannus causes destruction of the articular surface through release of activated neutrophils and microvascular ischemia
Stages: Stage 1: synovitis, Stage 2: destruction, Stage 3: deformity; synovial fluid becomes a Newtonian fluid (loss of shear thinning), altering tribology
Genetics: associated with HLA DW4, DR4

Q2.What happens in the hand in rheumatoid arthritis?

UC ligament synovitis causes dorsal subluxation of the ulnar head (caput ulnare)
RC ligament synovitis + ECU subluxation causes ulnar translocation of the carpus
Caput ulnare + ECU subluxation = Vaughan Jackson syndrome, with attrition rupture of extensor tendons (EDM, then EDC, then EI)
MCs deviate radially; flexors and extensors sublux ulnar and volar
Leads to MCPJ ulnar drift with ulnar intrinsic and collateral contracture

Q3.What intrinsic factors in the hand cause MCPJ ulnar drift in RA?

Lateral pinch and power grip exert an ulnar directed force
Small sloping ulnar condyle
Gravity
Attenuation of sagittal band and radial joint capsule

Q4.What are the classic deformities seen in the rheumatoid hand?

Swan neck deformity
Boutonniere deformity
Z thumb
Vaughan Jackson syndrome with ulnar caput
Mannerfelt syndrome
Ulnar drift

Q5.What are the aims of treatment in the rheumatoid hand?

MDT and maximise medical treatment
Treat according to function: painless, good hand function with good ROM, adequate power
Prevent deformity and complication

Q6.What are the urgent indications in the rheumatoid hand?

Acute carpal tunnel syndrome
Locked trigger finger
Impending tendon rupture

Q7.What is the priority in managing the rheumatoid hand?

Aim: MDT, maximise medical treatment, treat according to function (painless, good ROM, adequate power); prevent deformity and complication
Urgent: acute CTS, locked trigger finger, impending tendon rupture
Reconstruction follows Souter's order of predictability: extensor tenosynovectomy + wrist stabilisation + ulnar head resection, then flexor tenosynovectomy, thumb, DIPJ, MCPJ

Q8.What are the ACR/EULAR 2010 diagnostic criteria for RA?

Synovitis in >=1 joint plus no alternative diagnosis
>=6/10 across 4 domains
Joints involved 0-5; RF/anti-CCP 0-3; inflammatory marker 0-1; duration >6 weeks 0-1

▸ Slide 733 · Clinical photo showing patients both handsHand Bone · 7 questions expand

Question list

Q1-Q77 questions — tap to reveal all answerslist

What thumb and finger deformities accompany the MCPJ ulnar drift in this patient?
What are the intrinsic causes of MCPJ dislocation in RA?
What are the extrinsic causes of MCPJ dislocation in RA?
How do you treat MCPJ dislocation in RA?
What are the outcomes of MCPJ arthroplasty in RA?
Why is arthroplasty advocated over fusion at the MCPJ in RA?
What are the operative options for a supple versus a rigid MCPJ in RA?

Answers · Q & A

Q1.What thumb and finger deformities accompany the MCPJ ulnar drift in this patient?

Boutonniere deformities of both thumbs
Swan neck deformity in multiple other digits
Prominent knuckles with radial deviation of the MCs; no scars and no active joint swelling
Overall picture: symmetrical polyarthropathy with typical deformities of RA

Q2.What are the intrinsic causes of MCPJ dislocation in RA?

Anatomical: ulnar condyle smaller and ulnar sloping condyles of IF and MF; radial collaterals weaker; EI and EDM on ulnar side
Biomechanical: grip exerts ulnar directed force from the thumb
Gravity causes ulnar subluxation

Q3.What are the extrinsic causes of MCPJ dislocation in RA?

Carpal ulnar translocation causes radial deviation of MCs; extensor vector pulls MCPJ into ulnar drift
MCPJ synovitis -> sagittal band erosion + volar plate stretching -> extensor tendon ulnar subluxation -> ulnar intrinsic contracture -> PP ulnar deviation
Flexors also ulnar sublux, causing further ulnar drift

Q4.How do you treat MCPJ dislocation in RA?

Splinting and activity modification (eg how to hold a mug)
Supple: extensor tenosynovectomy, extensor realignment (radial sagittal band imbrication, RCL reefing, cross intrinsic transfer, volar plate release + collateral recon)
Rigid: fusion or arthroplasty; advocate arthroplasty as MCPJ is >60% of hand function
Arthroplasty: silicone/pyrocarbon; correct wrist radial deviation + collateral recon same OT
Complications: infection, loosening, recurrence

Q5.What are the outcomes of MCPJ arthroplasty in RA?

70% satisfaction at 1 year, 69% survivorship at 20 years
Silicone implant 63% fracture in 17 years
Decreases ulnar deviation and extension lag

Q6.Why is arthroplasty advocated over fusion at the MCPJ in RA?

MCPJ provides >60% of hand function
Correct wrist radial deviation and collateral recon in the same OT
Implant options: silicone or pyrocarbon

Q7.What are the operative options for a supple versus a rigid MCPJ in RA?

Supple: extensor tenosynovectomy and extensor realignment (radial sagittal band imbrication, RCL reefing, cross intrinsic transfer, volar plate release + collateral recon)
Rigid: fusion or arthroplasty

▸ Slide 734 · Priority: souter principleHand Bone · 7 questions expand

Question list

Q1-Q77 questions — tap to reveal all answerslist

What is the Souter principle / priority in RA hand surgery?
What are the 3 aetiologies of swan neck deformity?
What perpetuates a swan neck deformity and what are the complications?
What is the Nalebuff classification of swan neck deformity?
How do you detect intrinsic tightness and why does it matter?
How is swan neck deformity treated?
How do you choose between FDS tenodesis and SORL reconstruction?

Answers · Q & A

Q1.What is the Souter principle / priority in RA hand surgery?

Urgent: C spine, acute carpal tunnel, impending tendon rupture
LL first: foot, hip, knee, ankle
UL: proximal --> distal

Q2.What are the 3 aetiologies of swan neck deformity?

MCPJ: joint volar subluxation, dorsal subluxation of lateral band
PIPJ: volar plate attenuation / FDS rupture
DIPJ: mallet finger (terminal extensor tendon rupture)

Q3.What perpetuates a swan neck deformity and what are the complications?

Attenuation of transverse retinaculum; tightening of triangular ligament and intrinsics -> further dorsal dislocation of lateral band
Hyperextension of PIPJ functionally lengthens extensor mechanism -> DIPJ in flexion
Complication: intrinsic tightness (Bunnell test) + fixed deformity

Q4.What is the Nalebuff classification of swan neck deformity?

1: flexible and full ROM
2: intrinsic tightness
3: stiff PIPJ
4: arthritis

Q5.How do you detect intrinsic tightness and why does it matter?

Use the Bunnell test
It determines the choice between FDS tenodesis (no tightness) and SORL reconstruction + intrinsic release (intrinsic tightness)

Q6.How is swan neck deformity treated?

Determine if there is intrinsic tightness
Conservative if no complication: double ring splint at PIPJ (Murphy ring)
No intrinsic tightness: FDS tenodesis (ulnar FDS slip cut, loop around A2 and suture back proximally with PIPJ in 40deg flexion)
Intrinsic tightness: SORL reconstruction + intrinsic release
DIPJ/PIPJ arthrosis: fusion

Q7.How do you choose between FDS tenodesis and SORL reconstruction?

Check if DIPJ flexion deformity corrects upon PIPJ flexion; if not corrected, do SORL reconstruction
PL vs lateral band as SORL graft: PL more bulky
Lateral band may not be present when the underlying cause was terminal slip rupture

▸ Slide 735 · What is boutonniere?Hand Bone · 7 questions expand

Question list

Q1-Q77 questions — tap to reveal all answerslist

What is a boutonniere deformity?
What is the pathophysiology of a boutonniere deformity?
How is an acute boutonniere deformity managed?
How is a chronic boutonniere deformity managed according to extension lag?
Summarise the Matev reconstruction for chronic boutonniere deformity.
What is the Burton classification of boutonniere deformity?
What is the differential diagnosis of multiple boutonniere deformities?

Answers · Q & A

Q1.What is a boutonniere deformity?

Button hole: the lateral band is the hole and the PIPJ passes through the hole

Q2.What is the pathophysiology of a boutonniere deformity?

Central slip rupture (traumatic/inflammatory) -> failed extension at PIPJ; central slip transmits extension force to DIPJ via the intact lateral band connection
With time bilateral lateral band volar subluxation with contracted transverse retinacular ligament and ORL
Triangular ligament attenuated; subluxed lateral band becomes a flexor to PIPJ instead of extensor, exacerbating deformity
Does not happen in acute central slip rupture as lateral bands are not yet subluxed

Q3.How is an acute boutonniere deformity managed?

Conservative first +/- central slip repair

Q4.How is a chronic boutonniere deformity managed according to extension lag?

Mostly conservative as less disabling than swan neck deformity
<15 degrees (flexible/grade I): Capener splint to prevent ORL contracture; Fowler tenotomy (cut lateral band just proximal to DIPJ to let ORL flex the DIPJ)
30-40 degrees (rigid, grades II/III) with TRL/SORL contracture: TRL release + extensor recon (Matev)
Arthritis: fusion

Q5.Summarise the Matev reconstruction for chronic boutonniere deformity.

Cut ulnar slip of lateral band at DIPJ and radial slip at MP
Connect ulnar proximal stump to radial distal to lengthen the terminal extensor
Radial proximal loops around the central slip remnant as reconstruction for the central slip
Put simply: ulnar LB to radial LB to lengthen extensor, radial LB recon CS

Q6.What is the Burton classification of boutonniere deformity?

Stage 1: supple
Stage 2: fixed contracture of lateral band
Stage 3: joint involvement with fibrosis + volar plate
Stage 4: arthritis

Q7.What is the differential diagnosis of multiple boutonniere deformities?

RA
Psoriasis

▸ Slide 736 · RA thumb deformityHand Bone · 6 questions expand

Question list

Q1-Q66 questions — tap to reveal all answerslist

What is the Nalebuff classification of RA thumb deformity?
Describe Nalebuff type I RA thumb deformity and its treatment.
Describe Nalebuff type II RA thumb deformity and its treatment.
Describe Nalebuff type III RA thumb deformity and its treatment.
Describe Nalebuff type IV RA thumb deformity and its treatment.
Describe Nalebuff types V and VI RA thumb deformity.

Answers · Q & A

Q1.What is the Nalebuff classification of RA thumb deformity?

I: boutonniere of thumb (MCPJ disease)
II: boutonniere + CMCJ involvement
III: swan neck of thumb
IV: gamekeeper thumb
V: swan neck without IPJ involvement + MCPJ disease (MCPJ volar plate stretched)
VI: arthritis mutilans

Q2.Describe Nalebuff type I RA thumb deformity and its treatment.

Boutonniere of thumb: primary MCPJ disease with extensor hood synovitis; EPB attenuated, EPL subluxes ulnar and becomes a flexor of MCPJ
Supple: synovectomy + EPL to EPB rerouting + IPJ fusion
MCPJ rigid, IPJ supple: MCPJ fusion + EPL reroute
MCPJ and IPJ rigid: IPJ fusion + MCPJ fusion (if CMCJ normal) or MCPJ arthroplasty (if CMCJ arthritis)

Q3.Describe Nalebuff type II RA thumb deformity and its treatment.

Boutonniere + CMCJ involvement; primary pathology is CMCJ arthritis
Tx: CMCJ fusion / trapeziectomy + soft tissue interposition

Q4.Describe Nalebuff type III RA thumb deformity and its treatment.

Swan neck of thumb: CMCJ arthritis with subluxation, 1st webspace contracture, recruitment of EDB to hyperextend MCPJ to get the thumb out of the palm
Supple: volar plate capsulodesis + FPL tenodesis
Rigid: MCPJ arthrodesis +/- webspace release

Q5.Describe Nalebuff type IV RA thumb deformity and its treatment.

Gamekeeper thumb: attenuation of UCL of MCPJ + contracture of 1st webspace
Supple: UCL reconstruction + webspace release
Rigid: fusion

Q6.Describe Nalebuff types V and VI RA thumb deformity.

V: swan neck without IPJ involvement + MCPJ disease (MCPJ volar plate stretched)
VI: arthritis mutilans - treatment is fusion

▸ Slide 737 · RA wrist deformityHand Bone · 7 questions expand

Question list

Q1-Q77 questions — tap to reveal all answerslist

What features of RA wrist involvement should you look for in this patient?
What is the differential diagnosis of finger drop in RA and how do you differentiate?
What is the pathophysiology of caput ulnare and Vaughan-Jackson syndrome?
What are the priorities in managing RA?
How do you treat Vaughan-Jackson syndrome?
When do you use a tendon graft versus a tendon transfer for ruptured extensor tendons in RA?
How do you prevent further attritional extensor rupture in RA?

Answers · Q & A

Q1.What features of RA wrist involvement should you look for in this patient?

Prominent ulnar styloid with finger drop of MF to LF
+/- prominent knuckles +/- ulnar deviation of MCPJ
Skin thin with loss of cutaneous fat; no scars or other joint swelling/deformity
Assess the DRUJ for instability and check for radiocarpal joint involvement

Q2.What is the differential diagnosis of finger drop in RA and how do you differentiate?

Tendon rupture - test tenodesis
PIN palsy - test EPL and EI function; radial deviation of wrist (intact ECRL)
MCPJ subluxation - try to reduce MCPJ - unable
Sagittal band rupture - reduce MCPJ, able to maintain extension
Intrinsic contracture - Bunnell test

Q3.What is the pathophysiology of caput ulnare and Vaughan-Jackson syndrome?

RA involvement of DRUJ and UC ligament -> ulnar head dorsal subluxation
ECU sheath synovitis -> ECU volar subluxation; with RC ligament erosion the carpus subluxes volarly, translocates ulnarly and supinates
This places the carpal further away from the ulnar head and increase pressure over the extensor compartment -> progressive attrition rupture starting EDM, then EDC, then EI

Q4.What are the priorities in managing RA?

Systemic: medical treatment; locally in the hand follow Souter's principle of predictable success
Systemically: life threatening, patient preference, most symptomatic, sure win
LL first, then UL; UL proximal first, then distal

Q5.How do you treat Vaughan-Jackson syndrome?

First prevent further tendon rupture - give a splint
Treat caput ulnare: Sauve-Kapandji (preferred in RA with ulnar translocation) or Darrach (not in unstable carpus; can do if wrist already fused)
Darrach problems: ulnar impingement on radius (prevent by soft tissue interposition with PQ reattached dorsally), ulnar dorsal/volar instability (prevent by ECU tenodesis), decreased grip strength
Bower not a good option as it requires intact TFCC
Ruptured tendon: graft if good muscle quality with excursion >2cm (likely 2-stage, 2 anastomoses) vs transfer (side to side, EI or R/F FDS)

Q6.When do you use a tendon graft versus a tendon transfer for ruptured extensor tendons in RA?

Tendon graft if good muscle quality with excursion >2cm, but likely needs 2 stages and has 2 anastomosis sites
Tendon transfer (side to side, EI or R/F FDS) has one healing site but the donor unit downgrades one motor power grade

Q7.How do you prevent further attritional extensor rupture in RA?

Extensor retinacular reconstruction
Re-routing of the extensor retinaculum
Tenosynovectomy

▸ Slide 738 · Failed thumb IPJ flexionHand Bone · 6 questions expand

Question list

Q1-Q66 questions — tap to reveal all answerslist

What are the causes of failed thumb IPJ flexion?
What history do you take in a patient with failed thumb IPJ flexion?
What is the differential diagnosis of failed thumb IPJ flexion in RA?
How is FPL rupture in RA managed?
How are ruptures of other digital flexor tendons in RA managed?
How is trigger finger in RA managed?

Answers · Q & A

Q1.What are the causes of failed thumb IPJ flexion?

FPL rupture (Mannerfelt syndrome)
AIN palsy
Trigger thumb

Q2.What history do you take in a patient with failed thumb IPJ flexion?

Age + premorbid status
Current disability: chronicity, decrease gripping power, median neuropathy with thenar muscle wasting and numbness
Hand function

Q3.What is the differential diagnosis of failed thumb IPJ flexion in RA?

Rupture (direct invasion, ischaemic, attrition - STT synovitis)
Triggering (tenosynovitis, MCPJ subluxation, tendon nodule)
AIN palsy (compression at lacertus fibrosus secondary to elbow synovitis)
Advanced CTS (median nerve perineuritis, compression by synovitis)

Q4.How is FPL rupture in RA managed?

Always tenosynovectomy; FPL rupture always needs synovectomy + spur excision
IPJ fusion: stable thumb, good power, but loss of motion
FDS4 transfer / free graft: motion preserved, but unpredictable motion gain and difficult tension adjustment

Q5.How are ruptures of other digital flexor tendons in RA managed?

FDS only - observe
FDP at wrist - suture to adjacent FDP
FDP at finger - DIPJ fusion
FDP + FDS - transfer intact FDS or tendon graft

Q6.How is trigger finger in RA managed?

Tenosynovectomy
3 potential sites: carpal tunnel, A1, just distal to A2/FDS decussation
Preserve A1 - otherwise increase ulnar drifting and MCPJ subluxation
If severe ulnar drift, resect ulnar slip of FDS

▸ Slide 739 · Thoracic outlet syndromeHand Bone · 7 questions expand

Question list

Q1-Q77 questions — tap to reveal all answerslist

What is the presentation and epidemiology of thoracic outlet syndrome?
What risk factors and history suggest thoracic outlet syndrome?
What causes thoracic outlet syndrome?
What clinical tests are used in thoracic outlet syndrome?
What investigations are used in thoracic outlet syndrome?
What is the management of thoracic outlet syndrome?
What are the boundaries of the thoracic outlet and what is Paget-Schroetter syndrome?

Answers · Q & A

Q1.What is the presentation and epidemiology of thoracic outlet syndrome?

Females > males (3:1); neurogenic 95%, venous 4%, arterial 1%
Symptoms worse with overhead activities
Neurogenic: pain at trapezius (96%), intrinsic minus hand, thenar and hypothenar wasting
Vascular: Raynaud phenomenon (pale > red > cyanotic)

Q2.What risk factors and history suggest thoracic outlet syndrome?

Symptoms worse with overhead activities
Previous trauma, body builder, smoker / constitutional symptoms
Look actively for the underlying cause (bone, soft tissue, vascular, neoplastic)

Q3.What causes thoracic outlet syndrome?

Bone 30%: cervical rib, enlarged C7 transverse process, clavicle fracture, ACJ/SCJ dislocation
Soft tissue 70%: muscular, scalene muscle anomaly, fibrous band / variant costoclavicular ligament insertion
Vascular: aneurysm, thromboembolism
Neoplastic: Pancoast tumour, bone met

Q4.What clinical tests are used in thoracic outlet syndrome?

Tinel at Erb's point (upper trunk), 2-3cm above clavicle
Subclavicle bruit
Adson and costoclavicular test
Wright manoeuvre and Roos test

Q5.What investigations are used in thoracic outlet syndrome?

XR; CT or MRI
NCT for MABCN (medial antebrachial cutaneous nerve)
Doppler USG (venous)
Angiogram (arterial)

Q6.What is the management of thoracic outlet syndrome?

1st line non-op / nerve block; OT if failed non-op for 6 months
Address underlying pathology; decompression +/- revascularisation
Decompression: 1st rib excision + anterior/middle scalenectomy +/- neurolysis of medial cord
Complication: pneumothorax (PTx)

Q7.What are the boundaries of the thoracic outlet and what is Paget-Schroetter syndrome?

Proximal interscalene space: anterior anterior scalene, posterior middle scalene, inferior 1st rib; contents trunk + vessel
Middle costoclavicular space: anterior clavicle + subclavius, posterior 1st rib + scalenes, medial costoclavicular ligament, lateral upper scapular border; contents division + vessel
Distal retropectoralis minor (thoraco-coraco-pectoral/subcoracoid) space: superior coracoid, anterior pectoralis minor, posterior ribs 2-4; contents cord + vessel
Paget-Schroetter syndrome: venous TOS in well-developed young athletes; intermittent subclavian vein obstruction by abnormal costoclavicular ligament / scalene hypertrophy -> upper limb DVT

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