1. Dupuytren’s Contracture

Instructions:

“Please can you show me the palms of your hands and straighten your fingers”

Look:

– Which fingers are affected

– Degree of metacarpo phalangeal joint (MCP) and proximal interphalangeal joint(PIP) flexion

– Cords

– Pits

– Nodules or palpable masses

– Scars of surgery including previous skin graft

– Webspace contractures

– Dorsal hand: Garrod’s pads

– Other sites: feet (Ledderhose Disease) and penile involvement (Peyronie’s)

Feel:

– Cords

– Sensation distal to the diseased region

– Digital Allen’s test

Move:

– Assess range of movement grossly: Hueston’s tabletop test, form a fist

– Measure: using a goniometer. When measuring the metacarpo phalangeal joint (MCPJ), fully flex the proximal inter-phalangeal joint (PIPJ) (as the cords can cross more than one joint) and place the goniometer on the dorsal aspect of the digit. When measuring the proximal inter-phalangeal joint (PIPJ), fully flex the metacarpo phalangeal joint (MCPJ).

Function:

– 5 grips: key/pinch/hook/tripod/door

Discussion

How will you consent the patient?

– The aim of surgery is to excise the diseased tissue, correct the deformity and restore movement and function.

– Risks

– Chance of recurrence with all typesof surgery

– PIPJ not fully correctable, especially if > 45 degrees

– Infection

– Neurovascular deficits (1.5% risk of digital nerve injury in primary cases)

– Re-operation

– Stiffness

– Ugly scar

– CRPS

– Loss of a digit

2. Patient with Extensor Pollicis Longus rupture. Please examine.

Look:

– Often no obvious sign of rupture

– Can present in patients with Rheumatoid Arthritis or distal radius fracture (usually a fracture that has been treated non-operatively)

Feel:

– Palpate the length of the tendon over ulnar side of Lister’s tubercle, then crossing over Extensor carpi radialis longus and brevis, and feel for any discontinuity

Move:

– Table top test: Ask the patient to lay hand flat on the table and ask them to lift only thumb off surface. Patient with EPL rupture loses extension of metacarpo phalangeal joint (MCPJ) as Extensor pollicis brevis not strong enough to extend this joint by itself).

– Occasionally the candidate can be tricked because the intrinsics of the thumb maintain the ability to extend the interphalangeal (IP) joint of the thumb.

Discussion

What is your management and how would perform it?

Direct repair (unlikely)

– Can be difficult due to tendon retraction and degeneration of tendon edges.

– A free tendon graft using palmaris longus may be used to bridge the gap or as augmentation

Tendon transfer

– Using EIP tendon gives a predictable outcome, with similar amplitude and direction of pull.

– Need to test its presence with independent extension of index finger

– Three incisions:

*proximal to extensor hood of index at metacarpo phalangeal joint( MCP) joint level

*over thumb MCP joint, through (tendon delivery)

– Most difficult aspect is the tensioning to allow full extension without significant loss of IP joint flexion

– Tenodesis effect is a good way of judging tension intra operatively

Principles:

– Lower limb before upper limb, proximal to distal. Urgent procedures include tenosynovectomy to prevent rupture of the tendon and nerve decompression.

– As the disease progresses, patients develop varying degrees of pain and loss of function,
summarised as follows:

– Synovitis without deformity

– Synovitis with passively correctible deformity

– The joint architecture is maintained but the deformity is fixed

– Articular destruction

Look:

– Deformities and treatment in the table below

– Scars

– Nodules

Feel:

– Tenosynovitis

Move:

– Functional movements: “make a fist and straighten your fingers”

– Functional grips (as above in Q1.)

Discussion:

Talk about metacarpo phalangeal joint (MCP) replacement.

metacarpo phalangeal joint (MCPJ) arthroplasty

– Aims for pain relief, improvement in ulnar drift and extensor deficit, but increased strength and range of motion is not expected

– Caution must be taken regarding proximal disease at the wrist or extensor/flexor tendon rupture

– Silastic implants are favoured

Technical Considerations:

– Longitudinal or transverse incisions

– Longitudinal capsulotomy radial to the extensors, releasing the capsule and ulnar intrinsics

– Metacarpal bony cuts distal to collaterals prior to reaming and sizing.

– Insert implant and ensure there is no buckling

– An intrinsic transfer can be included

Postoperative care:

– Either static splint at night for 12 weeks (MCPJs in full extension and slight radial deviation or a dorsal splint with a dynamic outrigger

– Avoid key pinch for the first 12 weeks

– Hand strengthening at 6 weeks

Look:

– Thenar wasting, abductor pollicis brevis that atrophies

– Previous scar from decompression

Feel:

– Sensation reduced in the radial three and a half digits (palmar branch divides proximal to tunnel)

– Decreased sweating and increased temperature at the thenar eminence

Move:

– Power reduced in abductor pollicis brevis (with hands supine, the patient pushing their thumb from the palmar surface up towards the ceiling)

Special Tests:

– Tinel’s Sign: tapping over the median nerve at the wrist crease produces parasthesias in the hand. This test is least sensitive but most specific (Stewart and Eisen, 1978)

– Phalen’s Test: performed with the elbows flexed and resting on a table top and allowing the wrists to fall into complete volar flexion for one minute. Positive if it reproduces parasthesias within this time (most sensitive test).

– Wrist flexion provocation test: involves wrist flexion and compression of the median nerve at the wrist. Positive if it reproduces parasthesia within 20 seconds, with a sensitivity of 82% and a specificity of 99% (Tetro et al., 1998)

Important to rule out other causes in the differential diagnosis:

– Ask to examine the rest of the upper limb and cervical spine.

Discussion:

What are the operative treatment options?

Open versus endoscopic

– Randomised controlled trial open versus endoscopic single portal. In comparison with open release, single-portal endoscopic carpal tunnel release has a similar incidence of complications and a similar return of hand function, but is a slightly slower technique to undertake (Systematic review, Ashworth, 2010).

– Pain less is less in the endoscopic group at 3 months but no difference between the groups at 1 year (Atroshi, 2006)

Endoscopic

– Not common in the UK

– Perhaps best for bilateral on same day cases in manual labourers who want to get back to work soon.

Technique:

– Anaesthesia: local injection over proximal and distal incisions

– Positioning: supine with arm on hand table

– One proximal incision just proximal to the wrist crease

– Distal incision just distal to the distal edge of the transverse carpal ligament

– One incision (Agee) or two incision (Chow) techniques.

Neurolysis of the median nerve in conjunction with open carpal tunnel release – No difference in outcome (benefit or complications) in three RCTs between carpal tunnel decompression alone versus carpal tunnel decompression and internal neurolysis (Systematic Review, Ashworth, 2010)

Discussion:

What are the levels of median nerve injury and what is their operative management?

Median nerve injuries are classified as high or low depending upon inclusion or exclusion of AIN innervated muscles.

Low Median Nerve Injury

Sites of injury

– Forearm with fractures or soft tissue injuries

Presents with

– Wrist with lacerations, fractures or carpal tunnel syndrome

– Weakness of thumb abduction (loss of ABP and variably of FPB)

– Weakness of opposition (ABP and opponens).

Tendon transfer for:

– Thumb opposition:

There are four types of opponensplasty depending on personal preference and the strength of adjacent muscles

– Palmaris longus to Abductor pollicis brevis (APB)

– Extensor indicis to APB

– Flexor digitorum superficialis (FDS IV) to APB

– Abductor digiti minimi to APB

High Median Nerve Injury

Sites of injury

– Elbow fractures or dislocations

– Pronator syndrome with entrapment at proximal arch of FDS

– Between the two heads of Pronater teres

– At the bicipital aponeurosis

– At the ligament of Struthers at the supracondylar process of the humerus

Presents with signs of low nerve lesion and involvement of the AIN Branch:

– Loss of thumb flexion at interphalangeal joint (FPL).

– Loss of index and middle finger flexion (FDS and FDP)

– Unable to do ‘OK’ sign

Tendon transfer for:

– Index and middle finger flexion: FDP of index and middle fingers are tenodesed to functioning ring and little FDP.

– IPJ thumb flexion: Brachioradialis to FPL.

– Thumb opposition: EIP to APB

Look:

– Scars in the neck, axilla, upper limb and hand

– Distribution of the muscle wasting (thenar, hypothenar or intrinsic)

– Fasciculations (especially deltoid, commonest Motor Neurone Disease Site)

– Posture of the upper limb (Lower brachial plexus lesion)

– Horner’s syndrome: T1 root lesion interrupts T1 sympathetic ganglion with meiosis (constriction of the pupil

ptosis (drooping of upper eyelid)

enopthalmos (sinking of the orbit)

anhydrosis (dry eyes)

Feel:

– Sensory loss in a dermatomal (C5-T1) or mononeuropathy (median, radial or ulnar) distribution?

– Thickened ulnar nerve (Leprosy)

– Palpate for cervical rib

– Rule out Pancoast’s tumour – dullness to percussion, Horner’s and hoarse voice

Move:

Tone

Motor:

– Flexion of fingers (C8 via median nerve)

– Abduction of fingers (T1 via ulnar nerve)

Reflexes:

– Including finger jerk

Include:

– Cranial Nerve Examination

– Lower limb peripheral nerve examination

Discussion:

What is your differential and how would you manage the patient?

With any hand muscle wasting, the level of the deficit needs to be determined

If bilateral consider (proximal to distal):

Central

– Multiple sclerosis can affect the sensory and motor systems, presenting with clonus, spasm and intention tremor. It can mimic other conditions with variable signs over time.

Cord lesions

– Syringomyelia with initial pain and temperature impairment, later when anterior horn cells are affected there is motor atrophy in the hands

Anterior horn cell (no sensory loss)

– Motor Neurone Disease with lower motor neuron involvement (Progressive or Spinal Muscular Atrophy) or upper and lower motor neuron involvement (Amyotrophic Lateral Sclerosis) presenting first with wasting of the thenar muscles and then the intrinsics

– Poliomyelitis presents with flaccid paralysis, wasting and absent tendon reflexes

Nerve roots

– Cervical spondylosis

Peripheral nerve lesions

– Bilateral carpal tunnel syndrome

– Hereditary Motor and Sensory Neuropathy can present with median and ulnar involvement, and in particular the intrinsic muscles are affected. Examine the lower limb for pes cavus and a ‘champagne bottle’ appearance to the calf.

– Peripheral motor neuropathy

Distal myopathy:

Myotonic dystrophy may present in the hand as subtle weakness or the inablity to release objects (myotonia)

Rule out

– Causes such as rheumatoid arthritis (disuse atrophy) or other non-neurological generalised wasting

How would you manage the patient?

– History

– Examination

– Investigations:

*Blood investigations related to the causes above

*Imaging to include plain X-rays, CT or MRI of the spine

*Nerve conduction studies (NCS)/electromyography (EMG)

Look:

Expose above elbow

– Scars elbow/hand

– Deformity at elbow: varus, valgus (extend elbow to determine this)

– Wasting of muscles: first dorsal interossei, hypothenar, ulnar border of forearm

– Wartenberg’s sign: little finger abducts

– Claw hand – flexion of the ring and little finger PIPJs and hyperextension of the metacarpo phalangeal joint (MCPJs) of the ring and little fingers. Look for presence or absence of DIPJ flexion in these fingers – an early sign of the level of the ulnar nerve lesion (if flexed, FDP is intact, therefore a low lesion).

Feel:

– Sensation at tip of little finger and the dorsum of the hand (ulnar 1 ½ digits by superficial branch in the palm, the dorsal cutaneous branch divides approximately 5cm proximal to the wrist to supply the dorsal ulnar skin of the hand)

– Palpate the nerve at the elbow, feel for any increased mobility around the medial epicondyle with flexion and extension.

– Tinel’s test over ulnar nerve behind medial epicondyle

Move:

– Quick screening test: elevate arm, range of movement of the cervical spine

Motor

– Dorsal interossei: resisted abduction of fingers

– First dorsal interosseous: resisted abduction of index finger whilst palpating the muscle for contraction

– Abductor digiti minimi: same as above

– Palmar interossei: card test of adductor power

– Adductor pollicis: Froment’s test. Positive if FPL flexes interphalangeal joint (IPJ) of the thumb

– Flexor digitorum profundus(FDP) little finger (Pollock’s test): if FDP is weak then the lesion is a high lesion

– Flexor carpi ulnaris (FCU): resisted flexion of the wrist in flexed and ulnar deviated position

Discussion

Is there a high or low lesion and explain the ulnar paradox.

Motor branches of the ulnar nerve

– FCU supplied as it passes between its two heads

– FDP supplied as nerve passes on FDP on medial aspect of forearm

– All the small muscles of the hand except LOAF (median nerve)

The lesion is high if the site is above the level of the motor branch to FCU and FDP

– Sensation absent dorsum of hand ulnar side

– FCU test weak

– FDP little finger test weak (Pollock test)

The ulnar paradox states there is less clawing of the hand with high lesions. This relates to the power of FDP, reduced in a high lesion, leading to less flexion of the ring and little IPJs.

Discussion

What are the causes of ulnar nerve palsy, and what is the differential diagnosis?

Causes of ulnar nerve palsy (proximal to distal):

Cubital tunnel: Osborne’s ligament formed by fascia from the medial epicondyle to the olecranon

– Brachial plexus pathology

– Arcade of Struthers (hiatus of the medial intermuscular septum)

– Elbow: Tumours, ganglia, trauma – acute laceration or old malunited fractures, bony spurs

– Cubitus Valgus

– Fascia of FCU: fascial bands within FCU

– Wrist lacerations

– Wrist ganglion

– Ulnar tunnel syndrome: compression in Guyon’s canal between hook of hamate and pisiform

Differential Diagnosis (proximal to distal):

– Cervical radiculopathy

– Pancoast’s Tumour

– Cervical rib

– Thoracic outlet syndrome

Look:

– Swelling and bruising on the volar aspect at the base of the distal phalanx

Feel:

– Attempt to feel the retracted tendon in the palm.

– Tender at base of distal phalanx

Move:

– With metacarpo phalangeal joint (MCPJ) and PIPJ held by examiner in extension, test power of DIPJ flexion.

– To differentiate from anterior interossous nerve (AIN) palsy, test FPL and index FDP power: pinch test. (AIN supplies FPL, pronater quadratus and the radial half of FDP, arising from the median nerve five cm above the medial epicondyle)

Depending on the force of the avulsion, the tendon retracts. The vinculum prevents excessive retraction.

Discussion

How would you manage this injury?

Leddy Packer Classification, 1977 (modified to I-IV)

Operative management

– Early if possible as between 7-14 days the soft tissue swelling prevents passing of the tendon, becoming very difficult >14 days.

– Goal of procedure is to reattach tendon to site of avulsion

– Isolate the tendon proximally and phalanx distally, rethread the tendon, with care to avoid damage to A4 pulley

Look:

– Radial angulation of the wrist and short forearm

– Varying degrees of thumb hypoplasia/absence

– Extremity shortening

Move:

– Range of motion of wrist and elbow

– Patients with a stiff elbow may keep the wrist in radially deviated position to allow feeding

Test:

– Grip strength decreased

– Grasping of small and large objects especially – may develop side to side pinch between adjacent digits

Discussion

What are the associations and what is the treatment? What are the principles of pollicisation?

This is a preaxial/radial deficiency. The main findings are hand and forearm abnormalities but there can be upper arm and shoulder girdle abnormalities (short clavicle and humerus, small scapula, elbow abnormalities). The forearm is foreshortened and the wrist is in radial deviation. The right- angled position further shortens the arm and limits movements. The position places the extrinsic flexors and extensors at a mechanical disadvantage with the tendons having to traverse the angle to elicit finger movements, limiting the ability to move the fingers.

The muscles usually originating and inserting on the radius are abnormal. Flexor and extensor carpi ulnaris, interossei, lumbricals and hypothenar muscles are often normal. The radial nerve usually ends at the elbow. The median nerve is usually enlarged and supplies a dorsal branch for dorsoradial sensation. This branch must be protected during surgery. The radial artery is often absent.

4 types:

I: mild radial shortening without considerable bowing. Minor radial deviation of the hand. Considerable thumb hypoplasia may be present.

II: miniature radius with distal and proximal physeal abnormalities and moderate deviation of the wrist.

III: partial absence of the radius (most commonly the distal portion) and severe wrist radial deviation.

IV: complete absence of the radius. The hands tends to develop a perpendicular relationship to the forearm – most common type.

Associations

– Cardiac anomalies (ASD and absent radius – Holt-Oram syndrome)

– Pancytopaenia and thrombocytopaenia with absent radius – TAR syndrome

Treatment

Non-operative

– Initially in infancy, splints are difficult to apply, so passive exercises are the mainstay.

– Serial casting can be used to achieve longitudinal alignment through stretching the radial side.

Children require an intensive preoperative workup including echocardiography, kidney ultrasound and platelet status.

The parents/carers are instructed to do stretching exercises at the first visit. Splinting is started when the forearm is long enough.

Operative

– Traditionally avoided in patients with elbow stiffness.

– Can be preceded by an external fixator to correct soft tissue deformity.

– Centralisation between ages 6-12 months involving some or all of: resection of varying amounts of carpus (effecting a closing wedge osteotomy), shortening of ECU, radial soft tissue release, ulnar osteotomy for bowing of ulnar.

– Thumb reconstruction is carried out at 18 months if absent thumbs. (Pollicisation)

– Contraindications: major organ defect that make the anaesthetic risk unacceptable, firmly established adult pattern, and inability to flex elbow to allow hand to mouth postoperatively.

The aims of reconstruction are correction of the radius, wrist balancing on the forearm, maintaining wrist and finger movements, promotion of forearm growth, improvement of overall limb function and enhancement of limb appearance.

Centralization of the carpus on the distal ulna is the preferred surgical procedure.

More than 30° of ulnar angulation requires a corrective osteotomy at the time of centralization. This is done at about 1 year of age. A zigzag incision is performed on the radial side of the forearm. The dorsal branch of the median nerve must be identified in the skin fold at the wrist. Aberrant tissue and contracted fibrous bands are released. A second incision is made at the dorsum of the midline of the wrist running ulnarly in a transverse and elliptical fashion to the volar midline. The carpus is exposed by a transverse arthrotomy. Redundant soft tissue is excised. The carpus is then reduced onto the distal ulna. If adequate reduction cannot be achieved, a carpectomy, limited shaving of the distal ulna epiphysis or shortening ulna osteotomy might be necessary or distraction with an external fixator can be performed.

Dorsal capsular reefing, distal advancement or reefing of extensor carpi ulnaris insertion and transfer of flexor carpi ulnaris to the dorsum are performed.

Thumb hypoplasia requires reconstruction or pollicisation. This is usually done after forearm reconstruction.

Multiple techniques have been described without there being one single technique which reliably and permanently corrects the radial deviation, balances the wrist and allows continued growth of the forearm.

Immediate active and passive mobilisation are initiated. K-wires are removed between 8 weeks and 6 months depending on the severity and surgeons preference. A day and night time splint are used for 4-6 weeks after wire removal and a night time splint until skeletal maturity.

Danmore E, Kozin SH, Thoder JJ. The recurrence of deformity after surgical centralization for radial clubhand. J Hand Surg Am 2000;25(4):745-51.

Look:

– Patient may have wrist drop splint.

– Scars over humeral shaft or around the elbow.

– Ask the patient to hold both arms out in front of them to show the wrist drop

– Wasting of forearm muscles, hand held pronated, thumb adducted.

– Look for triceps wasting

Feel:

– Sensation in first dorsal webspace: indicates whether an isolated posterior interossues nerve (PIN) deficit or a radial nerve palsy

Move:

Determine level of compression/ injury:

– At or above midhumerus: triceps weakness (excluding gravity, then against resistance, then reflex)

– Middle third of humerus: brachioradialis (flex elbow in neutral position), supinator (supination in elbow extension)

– Around/below elbow: EPL (retropulsion), ECRB, EDC (extension of wrist and finger extension at metacarpo phalangeal joint)

Differentiate radial nerve and posterior interosseous nerve (PIN) palsy:

– Radial nerve: reduced or loss of elbow and wrist extension and supination, sensation reduced in first dorsal webspace

– PIN: able to supinate and extend wrist with weakness (brachioradialis and ECRL intact), unable to extend fingers, no sensory loss

Discussion

What are the causes of wrist drop and how do you differentiate them from EDC rupture? Discuss tendon transfers.

Causes(Sites of entrapment)

Radial nerve

– Axilla (Saturday night palsy)

– Humerus shaft fracture of middle third, or junction of middle third and distal third (Holstein-Lewis fracture)

Posterior interosseous nerve compression

– Tendinous proximal border of supinator (arcade of Frohse), most common site of radial tunnel syndrome

– Distal edge of supinator

– Tendinous origin of ECRB

– Radial recurrent vessels (leash of Henry)

– Thickened fascia at radiocapitellar joint

– Post-operative complication after radial head/neck fixation

– Tenodesis effect is not present in EDC rupture. If the tendons are in continuity, with passive flexion of the wrist the fingers extend.

Tendon transfers

Many different options available

Principles:

– Consider the synergistic activity of the muscle

– Amplitude and power

– Tendon excursion

FCU transfer:

– PT to ECRB

– FCU to EDC

– PL to reroute EPL

Can also use FCR instead of FCU (Starr)

Technique:

– First incision is directed longitudinally over the FCU in the distal half of the forearm, with its distal extent J shaped so as to reach the PL tendon.

– Second incision begins 5cm below the medial epicondyle over the dorsal aspect of the forearm aiming in towards Lister’s tubercle. This allows proximal dissection of FCU and for it to be delivered through the wound for redirection.

– Third incision begins in the volar-radial aspect of the mid forearm and directs distally and radially around the forearm to the insertion of PT, and then angles back towards Lister’s tubercle. This allows dissection of PT and redirection to ECRB.

Post-operative management:

– In theatre, an above elbow backslab is applied that immobilizes the forearm in 15 to 30 degrees of pronation, the wrist in approximately 45 degrees of extension, the MP joints in slight (10 to 15 degrees) flexion, and the thumb in maximum extension and abduction.

– The PIPJs of the fingers are left free

– Sutures are removed at 2 weeks and a cast is applied in the same position

– The cast is removed at 4 weeks, with a removable short arm splint for a further two weeks, holding the wrist, thumb and fingers in extension, with removal only for exercise.

Look:

– Swelling of the joint

– Hyperextension deformity of the metacarpo phalangeal joint

– Adduction contracture (late)

– Squaring of the hand

– Scars on other side at the base of the thumb

– Signs of osteoarthritis elsewhere in the hand (Heberden’s nodes)

Feel:

– Tenderness, particularly over the volar aspect of the thumb at the base

Move:

– Pain on axial compression of the metacarpal on the trapezium (axial grind test) with crepitus

– Distraction reduction test

– Exclude coexisting trigger thumb/carpal tunnel/De Quervain’s

Functional Assessments:

– Key, pinch and power grip produces weakness and pain

Discussion

Discuss the management

Treatment

– Related to functional impairment, age, level of activity and degree of joint degeneration.