The  Day  in  Pictures - PDF Document

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  1. 4/19/12   The  Day  in  Pictures ASSH/AAHS  Specialty  Day   11  February  2012     “Make  My  Day”  in  Hand  Surgery:  Management  of   Upper  Extremity  Trauma   and  Arthritis Selected pictures from hand arthritis and trauma talks Amy L Ladd MD COA Annual Meeting 21 February 2012 Dawn Laporte MD and John Lubahn MD Co-chairs Specialty Day Objectives Today’s  goal •  Update the practicing orthopaedic surgeon on traumatic and arthritic conditions of the upper extremity. •  Distill the current literature surrounding the treatment of these disorders into clinically relevant and useful data. •  Identify recent innovations and emerging concepts in treatment of disorders and injuries of the upper limb. •  Define the principles of acute and chronic treatment of hand and wrist injuries, including tendon and bone. •  Present the principles of evaluation and management of pediatric upper extremity trauma. •  Provide clinical pearls from experienced surgeons which will improve patient outcomes and aid in avoiding complications. Avoid MEGO My Eyes Glaze Over The  goal Fingertip  Injuries:   Classification  and  Treatment  of  Acute   Injuries Provide take home lessons through pictures Geared toward MOC David T. Netscher, MD 1  

  2. 4/19/12   When  do  I  toss  or  keep? Nail Thumb  advancement  flap   “Moberg” 2  

  3. 4/19/12   Fingertip  Injuries   Reconstruction   When  do  I  toss  or  keep? •  Patient age •  Occupation and hobbies •  Urgency to return to work •  Other medical illnesses and tobacco use •  Willingness to comply with treatment •  Mechanism of injury Michael S. Murphy, MD, Lutherville, MD L. Scott Levin, MD, FACS, Philadelphia, PA John Lubahn MD MOC  answer •  Kids – always attempt at reconstruction 3  

  4. 4/19/12   Arm  replants  –  MOC  answer •  Right environment •  Right patient An  oldie  but  a  goodie Groin Flap Groin Flap? 4  

  5. 4/19/12   Hand  allotransplant Groin Flap •  Very fashionable among reconstructive community •  Ethical dilemma •  Time and money will weigh benefit risk ratio Goal of Treatment? Intra-­‐‑Articular  Fractures  and   Dislocations  of  the  DIPJ   •  Fraser J. Leversedge, MD, Durham, NC •  David S. Zelouf, MD, Philadelphia, PA Volar - Jersey Finger Volar - Jersey Finger 5  

  6. 4/19/12   Volar:  Jersey  Finger   Dorsal: Mallet Injury? Cri9cal  Assessment   • ar9cular  involvement   • joint  reduc9on   MC 8 days post op, returned to wrestling 16 y/o wrestler Courtesy of Lawrence H. Schneider, MD MC 3 years later… 6  

  7. 4/19/12   Middle  Phalangeal  Fractures,   Classification  and  Treatment MOC answer (Larry Schneider rules) •  Tamara D. Rozental, MD, Boston, MA •  The distal phalanx base has a remarkable ability to remodel •  Schneider’s rules: 1)  Mallet fractures can be treated in a splint 2)  In cases with displacement see rule 1 3)  If more than 1/3 articular surface see rule 1 4)  In cases with subluxation see rule 1! Treatment algorithm Non-articular: shaft? •  ShaT:    spiral  or  oblique   – CRPP  vs.  ORIF  with  lag  screws   – ORIF  with  plates  for  more  comminuted  injuries     •  Ar9cular   – Dorsal:  CRPP  vs.  lag  screws   – Volar:  ORIF  vs.  hinged  external  fixa9on   •  Closed  Reduc9on  Percutaneous  Pinning  (CRPP)   o  Useful  for  transverse  or  oblique   o  Many  pin  configura9ons   o  Can  go  through  IP  or  PIP  joint   o  Limits  mobiliza9on   Articular: condylar   Articular: dorsal base? •  Detachment  of  central  extensor  tendon   –  Result  of  PIP  disloca9on   •  Treatment   –  Splint  in  extension  if  joint  is  congruent   –  Reduce  if  >2mm  displacement   –  K-­‐wires  vs.  lag  screws  if  large  fragment     7  

  8. 4/19/12   PIPJ  Dislocation  -­‐‑  Diagnosis  and   Treatment •  Dean G. Sotereanos, MD, Pittsburgh, PA Unstable Fracture/Dislocation? •  Forces at rest favor dislocation •  Treatment is Operative Hamate Hamate Hemiarthroplasty fracture site defect Hemiarthroplasty? 4th MC 5th MC H defect Hamate Metacarpal  Fractures  -­‐‑  Closed   vs.  Open  Treatment Hemiarthroplasty •  Thomas J. Fischer, MD, Indianapolis, IN 2m post 1m post 8  

  9. 4/19/12   The Platform? K-wires – not without complication? •  Kirschner Wires Can: •  Alan Freeland, Jackson MS o Penetrate – Gliding tissue structures o Incinerate –Drilling can superheat bone o Irritate – Stick out, impede hand function o Suppurate –infection with all techniques The Window Frame or The Platform of the Hand? •  Doug Campbell, Leeds, UK MOC  alert •  Why I need to stabilize some of the metacarpal arch Anatomy Anatomy? Looser intermetacarpal ligaments Strong basal ligaments Strong basal ligaments 9  

  10. 4/19/12   Whole   width  of   palm  is   stable     -­‐  Powerful   and  stable   base  for   finger   func9on   Border Metacarpals Fracture shaft Metacarpal V SNAP! Fracture shaft Metacarpal V Fracture shaft Metacarpal IV & V Effective width of palm narrows Effective stable width of palm now very narrow SNAP! SNAP! 10  

  11. 4/19/12   Constructs Available ?? Hand Surgery Rehab Timeline? § Plates § Locking § Fixed angle §  Hybrid constructs § External fixators § Screws § Intrafocal wires (Kapandji) § K-wires § Casts § Braces and splints TJF Classification   Russe  Classification Acute  Scaphoid  Fractures:   Classification  and  Treatment Alexander Y. Shin, MD Mayo Clinic Rochester, Minnesota Russe,  JBJS  42A,  1960 Surgical  Fixation Surgical  Fixation •  Proximal pole – both unstable and stable •  All unstable fractures 11  

  12. 4/19/12   Surgical  Fixation •  Stable fractures with compelling nonbiologic factors Surgical  Fixation •  Fractures associated with o  Contralateral extremity fractures o  Lower extremity fractures with need of ambulation aids o  Concomitant wrist injuries (trans- scaphoid perilunate) Distal  Radius  Fractures  that   “Make  My  Day” MOC  answer •  Stable fractures: immobilization is fine •  Unstable, displaced fractures treat with ORIF •  Jesse B. Jupiter, MD, Boston, MA No  prospective  randomized   studies  exist  to  compare  cast  vs   ORIF  of  unstable  scaphoid  fxs Trends? Is there a place for cast treatment any more? ... You Bet it is recommended and reliable for: •  minimally displaced extra- and intra-articular fractures •  displaced fractures, stable after closed reduction •  unstable fractures in elderly (asymptomatic malunion) Koval  et  al,  JBJS  A  2008 12  

  13. 4/19/12   Reality 20  years  ago  the  residents  did  the  closed  reductions and  put  the  casts  on,  while  the  seniors  did  the  surgery... now  the  residents  just  operate  and  the  seniors (residents  20  years  ago)  are  the  only  ones  around   who  know  how  to  make  a  cast  work..!! this  may  explain  (to  a  certain  extent)  why statistics  on  conservative  treatment  have  overall  disapointing  outcomes.... 60 year old self employed dentist Motorcycle enthusiast He needs to work OMG!! 13  

  14. 4/19/12   MOC  answer AAOS guidelines •  Reduce the fracture •  Fix if stable if you have a good reason •  No system or approach currently favored One year Neuropraxia  After  Distal  Radius   Fractures Acute CTS vs Acute Contusion •  Robert M. Szabo, MD, MPH, Sacramento, CA Lack of Available Literature? Median Nerve Symptoms in DRF? •  AAOS Clinical Practice Guideline Workgroup did not conclusively recommend for or against performing CTR for median nerve dysfunction after distal radius fracture Acute Contusion Symptoms are immediate and non-progressive Observation Acute CTS Symptoms ↑ with swelling Sensation is normal at first •  Prophylactic CTR during DRF fixation remains controversial Immediate CTR That’s  the  MOC  answer,  too! 14  

  15. 4/19/12   Flexor  Tendon  Repair  Zone  II •  Martin I. Boyer, MD, FRCS(C), St. Louis, MO Depart ment of Ortho paedic Surger y, Barne s- Jewish Hospit al at Washi ngton Unive rsity, Saint Louis MO •  Double  Modified  Kessler:  An  8-­‐‑strand  repair  is  accomplished  if  looped   suture  is  used  (Winters,  Gelberman  et  al,  JHS(A)  1998,  23(1)) •  Locking  loops  (Hotokezaka  and  Manske,  JHS(A)  1997,  22(6)) •  One    knot  in  the  repair  site Rehabilitation MOC  answer •  Based  on  the  best   available  experimental   data,    INCREASED   levels  of  intrasynovial   repair  site  excursion   combined  with  LOW   levels  of  repair  site  load   are  recommended  in   2011 1.  In  2011,  repair  both  FDS  and  FDP 2.  At  least  a  4-­‐‑strand  core  suture  repair  using   double  stranded  3-­‐‑0  or  4-­‐‑0  suture  (I  prefer  the   8-­‐‑strand  Gelberman-­‐‑Winters  core  technique  –   Supramid)   3.  Running  6-­‐‑0  prolene  epitendinous  suture 4.  Flexor  tendon  sheath  repair  controversial Seymour’s fracture? Physeal fracture of distal phalanx with nailbed laceration •  “Open fractures” Hand Fractures in Children Donald S. Bae, MD •  Nailbed incarceration Children’s Hospital Boston No financial disclosures. •  High index of suspicion 15  

  16. 4/19/12   Seymour’s fracture Phalangeal neck fracture? Sports-related or “doorjamb” injuries X-rays findings subtle Closed treatment -> little remodeling, poor flexion Surgery recommended for displaced fractures Complications •  Infection •  Physeal arrest •  Nail deformity Phalangeal neck fractures? Rheumatoid  arthritis  –thumb o Amy L. Ladd MD, Palo Alto, CA Technical pearls: •  Minimize passes •  Avoid lateral bands Risk of postoperative stiffness Self-­‐assessment  ques9on   MP  joint   •  What is the most common deformity of the thumb in rheumatoid arthritis? • Most  common  and  rewarding  surgery   a. Hyperextension of the metacarpophalangeal (MP) joint – Swan-neck deformity b. Hyperflexion of the metacarpophalangeal (MP) joint – Boutonnière deformity c. Thumb carpometacarpal (CMC) arthritis and adduction contracture d. Hyperflexion of the metacarpophalangeal (MP) joint – Boutonnière deformity with CMC arthritis e. Arthritis mutilans o  Fusion  (Rizzo)   o  Rare  arthroplasty   •      16  

  17. 4/19/12   Thumb deformity in RA - 2012? MP fusion? Classic presentation unusual unless untreated or unresponsive to treatment •  Presentation (to surgeon) more representative of OA population •  Goldfarb JBJS 2003 courtesy C Eaton IP joint? ? Self-­‐assessment  ques9on   •  What is the most common deformity of the thumb in rheumatoid arthritis? o  Fusion  if  MP  okay;  and  for  arthri9s  mu6lans   o  Manipula9on  and  pinning  in  fixed   boutonnière   a. Hyperextension of the metacarpophalangeal (MP) joint – Swan-neck deformity b. Hyperflexion of the metacarpophalangeal (MP) joint – Boutonnière deformity c. Thumb carpometacarpal (CMC) arthritis and adduction contracture d. Hyperflexion of the metacarpophalangeal (MP) joint – Boutonnière deformity with CMC arthritis e. Arthritis mutilans Courtesy  HJCR  Belcher   Conclusions •  Pictures of hand surgery - what you need to know •  MOC questions in general is conservative 17