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Hand Bone

Tendon transfer and thoracic outlet syndrome

Flexor tendon transfer for lost thumb flexion and neurogenic outlet compression syndrome.

13 questions 2 source pages

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13 questions
Q1What are the causes of failed thumb IPJ flexion?▸
  • FPL rupture (Mannerfelt syndrome)
  • AIN palsy
  • Trigger thumb
Q2What 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
Q3What 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)
Q4How 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
Q5How 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
Q6How 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
Q7What 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)
Q8What 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)
Q9What 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
Q10What 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
Q11What investigations are used in thoracic outlet syndrome?▸
  • XR; CT or MRI
  • NCT for MABCN (medial antebrachial cutaneous nerve)
  • Doppler USG (venous)
  • Angiogram (arterial)
Q12What 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)
Q13What 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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