Free Orthopedics Review | Dr Hutaif General Orthopedics -...

All of these substances have been shown to have efficacy in the treatment of tennis elbow. However, placebo saline injections have also been proven to add some benefit compared to no treatment.

While the ulnar nerve is most at risk during elbow arthroscopy in general, debridement of the lateral capsule posterior to the midpoint of the radiocapitellar joint places the posterior interosseous branch of the radial nerve at risk.

While all of the other answers are intra-articular lesions that have been reported in elbow arthroscopies, medial epicondylitis is an extra-articular condition and must be addressed in an open fashion given the proximity of the ulnar nerve.

Resection posterior to the midpoint of the radiocapitellar joint can result in damage to the lateral collateral ligament and subsequent development of posterolateral rotator instability.

The interphalangeal joint of the thumb is flexed secondary to actions of the flexor pollicis longus (FPL). The FPL is innervated by the anterior interosseous nerve, which is the longest branch of the median nerve. The median nerve is formed by the lateral (roots C 5, C 6, and C 7) and medial (roots C 8 and T1) cords of the brachial plexus.

The AIN, the largest branch of the median nerve, originates 5 cm to 8 cm distal to the medial epicondyle from the posteroradial aspect of the median nerve just distal to the proximal border of the superficial head of the pronator teres.

Approximately 17% of the population has a Martin-Gruber interconnection, and 50% of these patients may show additional denervation of normally ulnar nerve-innervated intrinsic muscles. The Martin-Gruber anomaly is a motor neural connection between the anterior interosseous nerve and ulnar nerves that is located adjacent to the ulnar artery in the proximal forearm.

The arrow in the photograph (Slide) is pointing to the pronator teres â one of the most common sites for compression of the anterior interosseous nerve. The pronator teres is innervated by the median nerve.

Around the elbow, the median nerve may be compressed by the pronator teres (causing either anterior interosseous nerve syndrome or pronator syndrome) or the ligament of Struthers originating from a supracondylar process (causing pronator syndrome). In the wrist, the median nerve may be compressed by the transverse carpal ligament or a mass within the carpal canal. The ulnar nerve, not the median nerve, can be compressed by the pisohamate ligament.

Frykman performed biomechanical studies to evaluate the wrist position in falls that produce scaphoid fractures. The results showed that wrist extension greater than 90° and radial deviation consistently resulted in fracture of the scaphoid.

Gelberman and Menon used injection studies to demonstrate that the majority of scaphoid blood flow stems from branches of the radial artery entering the scaphoid at the distal pole. Of these, the branch entering the dorsal ridge supplies 70% to 80% of the intraosseous vascularity of the scaphoid bone. The proximal pole is completely dependent on the intraosseous blood supply and is vulnerable to avascular necrosis when fracture disrupts this vascular source.

Adamany and colleagues performed a cadaveric study to evaluate the dorsal structures at risk with truly percutaneous headless screw placement for scaphoid fractures. They noted that the posterior interosseous nerve and the extensor digitorum communis to the index finger were an average of 2.2 mm from the guidewire and therefore at greatest risk from this approach.

The dorsal approach is advantageous in obtaining central screw placement. The scapho-trapezial-trapezoid joint is at risk during a volar approach, not a dorsal approach, and infection has not been shown to occur more frequently in one approach over the
other. The LT ligament is not seen in either approach. The risk of the open dorsal approach is compromise of the main blood supply to the scaphoid, entering through the dorsal ridge.

The volar approach to the scaphoid is optimal in distal pole fractures because it allows direct visualization of the fracture line and exact reduction and fixation. A volar approach is not recommended for fractures or avascular necrosis of the proximal pole, where dorsal screw placement is best. Scapholunate ligament tears are generally repaired from a dorsal approach because the ligament is stoutest dorsally.

An FDP avulsion is caused by forceful extension of the distal interphalangeal (DIP) joint, occurring at the same time as a maximum contraction of the FDP tendon. Jersey finger is often seen in athletes, especially football or rugby players, who commonly get their fingers caught in an opposing playerâs jersey, thus the name. In most cases, this injury affects the ring finger.

Type I is the most threatening scenario because the FDP tendon retracts into the palm, and vincular and diffusional blood supply is lost. The sheath may be noncompliant after a few days and may not allow passage of the FDP tendon through the sheath in an attempt to repair the stump to its insertion. Additionally, proximal muscle contracture prevents tendon stump
advancement.

After the index finger is rotated 150º, the index finger will be in the ideal location as it mimics the position of where the thumb would have naturally been. This position allows for the greatest amount of grip and pinch strength possible.

Reconstruction is possible and is therefore the best option for thumb hypoplasia in patients with type I, type II, and type IIIA. These three types of hypoplasia can be corrected because the thumb still has most of the bones and muscles intact. C orrective surgery is necessary to correct weak muscles or a tight web space between the thumb and index finger. When a type IIIB exists, reconstruction is not possible and pollicization must be performed.

It is necessary to create a hand with a natural first web space, shorter tendons that allow for natural movement, a shorter metacarpal that ensures the finger will not grow to an unnatural length, and a hyperextended joint to create the most natural- looking hand possible.

Type IIIA hypoplasia includes web space narrowing, thenar atrophy, MP joint laxity, and extrinsic tendon abnormalities. Type IIIA is distinguished from a type IIIB by the fact that a stable C MC joint exists. Because a stable C MC joint exists, a reconstruction is the treatment of choice. When the C MC joint is unstable, as in type IIIB hypoplasia, a pollicization is necessary to restore thumb stability.

The 3-4 portal is the main viewing portal and is located between the third and fourth compartment. This portal is bordered by the extensor digitorum communis (EDC ) to the index finger, and the extensor pollicis longus (EPL) can be palpated in the âsoft spotâ 1 cm distal to Listers tubercle. This portal is usually the first portal to be made during wrist arthroscopy.

The radioscapholunate ligament, otherwise known as the ligament of Testut, lacks structural intergrity and acts as a neurovascular conduit. This ligament is visible on the volar side of the wrist from the 3-4 portal in between the long radiolunate and short radiolunate ligaments.

The complication rate after routine wrist arthroscopy is between 2% and 5%.

The complication rate after routine wrist arthroscopy is between 2% and 5%.

As an axial load is placed on the thumb tip, it drives the thumb metacarpal (MC ) base in a dorsal-radial direction. As the thumb MC base moves dorsoradially, a fracture is created in the volar, ulnar quadrant of the thumb MC base. Gedda and Moberg describe this as a ligament fracture avulsion. The volar, ulnar quadrant piece usually remains stationary, perhaps migrating a small amount distal the thumb metacarpal base moves dorsoradially, creating a fracture in the volar, ulnar quadrant of the trapezium.

The volar, ulnar quadrant piece usually remains stationary due to the volar beak ligament. The thumb metacarpal base tends to sublux dorsoradially due to unopposed pull of the abductor pollicis longus and adductor pollicis. The intact volar beak ligament is usually the counterforce the to these two muscles in the static situation. The extensor pollis longus, flexor pollicis brevis, and abductor pollis longus do not have significant involvement in the Bennettâs fracture subluxation. Although the dorsal radial ligament is important for carpometacarpal stability, it is not the ligament attached to the fractures fragment.

Studies by Livesley, Kjaer-Petersen, and others have shown that patients with fractures with more than a 1-mm step-off after reduction were more likely to develop arthritis at the thumb carpometacarpal joint. Although some studies have not shown functional outcome correlating with the presence of arthritis, Oosterbos and De Boer found that all their patients with fair and poor overall results had nonanatomic reductions. Although a cadaveric study by C ullen has shown that a 2-mm step-off may be acceptable, this contrasts with the clinical evidence currently available.

Studies by Livesley, Kjaer-Petersen, and others have shown that patients with fractures with more than a 1-mm step-off after reduction were more likely to develop arthritis at the thumb carpometacarpal joint. Pain, decreased range of motion, and decreased pinch strength also correlated with these poor outcomes.

Although this is controversial, conservatively treated patients with angulations less than 70° fared well in two prospective studies. Fourteen percent of patients will have a cosmetic deformity, but operatively treated patients exhibited extensor lag and increased rehabilitation times.

Thirty degrees of angulation is the maximum deformity for acceptable fifth finger grip strength. Ali et al showed that fracture angulation of 30° results in a significant decrease in the distance between the origin and the insertion of the flexor digiti minimi (FDM). This shortening creates more âslackâ in the FDM muscle and more excursion is wasted as muscle shortening prior to the initiation of metacarpophalangeal (MP) flexion.

The small finger carpometacarpal joint is mobile, which allows the small finger metacarpal to tolerate deformity better than the fixed index and middle finger rays. Thus, 41° to 50° of angulation can be accommodated by the mobile carpometacarpal joint.

For each 2 mm of shortening, a 7° extensor lag exists. Thus, with 4 mm of shortening, there will be a 14° extensor lag at the metacarpophalangeal joint.

In a cadaveric study, shortening beyond 5 mm was prevented by the tethering effect of the transverse metacarpal ligaments and adjacent metacarpals.

The collateral ligaments are lax in extension and tight in flexion. The joint volume is highest in extension. The metacarpal head is cam-shaped. The collateral ligaments originate dorsal to the axis of flexion. Due to the tightening of the collateral ligaments over the cam-shaped metacarpal head in flexion, joint stability is maximized.

Biomechanically and clinically, fracture patterns are often associated with certain types of force. Transverse fractures occur with a direct blow, comminuted fractures occur with axial compression and bending, spiral fractures occur in torsion, and oblique fractures occur with torsion and axial load.

Giant cell tumor of tendon sheath is most commonly found in patients in the fourth through sixth decades; therefore, age 30-40 years is the most appropriate answer choice.

Giant cell tumor of tendon sheath is painless. Giant cell tumor of tendon sheath does not transilluminate, as ganglion cyst does. No overlying skin color changes occur. Giant cell tumor of tendon sheath only increases in size and does not fluctuate like a ganglion cyst; it does not present with a rapid increase in size.

Magnetic resonance imaging provides anatomic detail of the soft tissue mass, helps generate a differential diagnosis, and determines if the mass is unifocal or multifocal and where it originates. Giant cell tumor of tendon sheath is a soft-tissue tumor. C omputed tomography is best for bone-based tumors. Ultrasound helps localize lesions but does not provide anatomic detail to help determine the type of mass. Although angiograms are useful for vascular tumors such as renal cell carcinoma or arteriovenous malformations, they are not necessary in the evaluation of a soft tissue mass in the hand with features suggestive of giant cell tumor of tendon sheath. A bone scan is useful when malignant bone tumors are suspected rather than benign soft tissue masses.

Multinucleated giant cells, histiocytes, monocytes, and fibroblasts are commonly found in pathologic giant cell tumor of tendon sheath specimens. Polymorphonuclear lymphocytes are typically associated with bacterial infections.

The Atasoy-Kleinert V-Y advancement flap is the best option for transversely oriented fingertip amputations/defects and also for defects with more dorsal than volar tissue loss. The apex of the V is positioned at, or just distal, to the distal interphalangeal joint crease on the volar side of the digit. After incising the V marking, the flap is advanced distally to cover the defect, and the incisions are closed in a Y pattern.
Local, or chemical, debridement and allowing the resulting defect to heal by secondary intention are a viable option, but the patient stated that he would prefer an aggressive treatment protocol because the appearance of his fingertip is so embarrassing.
The Kutler (lateral) V-Y advancement flap is typically used to cover tip defects that demonstrate more volar than dorsal tissue loss. The procedure involves creating V-Y advancement flaps laterally on either side of the affected digit and advancing them toward each other in the midline thereby covering the defect.
The Moberg flap is typically used for reconstruction of thumb amputations. This procedure involves the creation of volar tissue flap that includes the neurovascular bundles on either side of the digit. Its use is cautioned in very distal amputations because excess stretch on the vascular pedicles may lead to necrosis at the tip of the flap. Its use is also cautioned in the fingers because of the difference in orientation of the blood supply compared to the thumb.
A full-thickness, rather than a split-thickness, skin graft is a viable option to manage this patient. Skin grafts for hand reconstruction should be harvested with the âlike replaces likeâ principle in mind, especially when reconstructing the volar skin. Volar hand skin is much thicker and of unique quality when compared with the rest of the body, and therefore, the most appropriate place to harvest a skin graft is the volar surface of the hand.

Local flaps such as cross finger flaps are good options but require at least two surgeries (inset then division) and can often result in stiffness secondary to the requisite period of immobilization. In addition, local flaps have lesser return of sensibility than the other techniques listed.
Return of tactile sensibility is excellent after healing by secondary intention, but dressing changes for wounds that measure 2 cm 3
2 cm would take months to completely heal.
Skin grafting is the next available option with acceptable sensory return. It can be performed during local anesthesia, requires only one operation, and allows for early motion thereby avoiding stiffness. Studies have shown that full-thickness skin grafts recover sensation better than split-thickness skin grafts.
A radial forearm flap will be excessively bulky, has unacceptable donor site morbidity in this situation, and results in inadequate sensory recovery.

The triangular fibrocartilage complex is made up of the dorsal and palmar radioulnar ligaments, the meniscal homologue, the articular disk, the ulnolunate, and the ulnotriquetral ligaments. The radiolunate ligament is not part of the complex.

The triangular fibrocartilage complex is supplied by both branches of the anterior interosseous artery and the ulnar artery; it is not supplied by the dorsal branch of the radial artery.

C adaveric studies have been performed to determine the amount of load across the wrist with various relationships between the radius and ulna lengths. In wrists with neutral ulnar variance (in which the radius and ulna are equal in length), 20% of the load is transmitted across the ulna and 80% is transmitted across the radius. In wrists with negative ulnar variance (in which the ulnar is shorter than the radius), more load is transmitted across the radius and less is transmitted across the ulna. The opposite is true with positive ulnar variance (the ulna is longer than the radius).