Hand Viva II

 Viva-1 what do you find in Wrist PA view ? 

( We don't have X ray , 

Suppose you saw an undisplaced fracture of Scaphoid ) 

Viva 

 Schapoid View - hand and wrist in ulnar deviation along with 15 degrees of cephalad angulation of X ray tube. 

Indications of Internal Fixation of Scaphoid fractures 

1.Displacememt > 1 mm 

2. SL Angle > 15 degrees 

3. Lunocaoitate angle > 15 degrees

4. Interscaphoid angle >20° (dorsal humpback)

5.Proximal pole # , Periluante dislocation 

6.Delayed union

Operative fixation in acute non displaced fractures 

Non union Scaphoid fractures 

Better early outcome scores in grip strength , ROM with fixation but no difference after 12 to 16 weeks 

Rate of delayed union is less with early fixation .

Complications 

AVN of Proximal Pole 

Non union 

Mx of established non-union

Arthritic changes not present 

Fixation with bone graft 

       ( Distal radius ) 

"Bone graft based on 1, 2 intermateacarpal 

branch of radial artery

Success rate - 70%

Arthritic changes present

-Radial Stylbidectomy

-Proximal row carpectomy

-Scaphoid excision 

- Four Corner Fusion 

- Wrist Arthrodesis

Viva-2

Suppose you saw an X ray / MRI . 

Findings on MRI 

What do you see in MRI ? 

TI MRI

 low signal intensity in the lunate suggestive of kienbeok’s disease

Cause

AVN of lunate bone on wrist

Staging of this condition 

 Lichtmann classification 

 (I) Normal radiographs, praettepossible Stress #

 (II) Sclerosis of Iunate, no colapse

IIIA. fragmentation & early collapse

IIIB. Schapolunate dissociation & fixed rotation 

 of schapoid 

IV. Degenerative changes on lunate .

Other important findings we see in radiographs 

Negative ulnar variance on AP n radiograph taken with forearm in mid-prone position.

Mx.

options

Non-op.

Analgesia

Splintage

operative

Joint levelling -Radial Shortening

Wrist Denervation 

Wrist fusion - Partial/total

Proximal row carpectomy

Choice depends on disease stage, degree of symptoms and partial factors.

Viva 3

You get an X ray of a patient with wrist pain . 

AP. radiograph of wrist - shows ulnar positive Variance. 

Appearance is typical of Ulnar Abutment Syndome.

Which structure is involved in this ? 

 TFCC

Anatomy of this?

Pyramid shaped fibrocartilaginous structure found at distsl aspect of ulna. 

Comprises of disc ( meniscus like structure) and a sling of ligament and acts a s a key stabilizer of DRUJ and ulnocaroal joint . 

Mx option for this condition 

Non operative 

Splints

Analgessia

-Avoid aggravating activities

Operative 

Arthroscopic wafer resection 

Open ulnar Shortening

Osteotomy 

Viva

Dorsal Compartment of Wrist 

I- APL, EPB

II. ECRL , ECRB

III. EPL

IV. EI, EDC

V. EDM

VI. ECU

De Quervaines Syndrome

 painful condition affecting first compartment of wrist joint. Commonin female, espcially post partum. 

Tell clinical Signs of DeQuervan’s syndrome. .

Localized Swelling along radial aspect of wrist 

Tenderness 

Finkelstein test

→

Mx. options 

Non operative 

Splinting

Analgesia

Local Steroid

operative 

- Surgical Release

If non-operative measures fail. 

under GA / regional anaesthetics & arm tourniquet

Release transverse or a longitudinal incision .

→ Adverse effects of local Steroid injection 

- Infection 

Injury of Sup. branch Radial Nerve, Painful Neuroma

- Tendon rupture

→Pitfalls of Surgery

failure to recognize anatomical variation EPB-lies in a separate compartment 

Incomplete Relief of symptoms

Painful Nuroma-injury to superficial branch of Radial Nerve

Kienbock's Disease / Ulnar Abutment Syndrome/ De Quervain's Tenosynovitis /Scaphoid Fracture 

Viva Questions (Hand ) Orthopaedics

 You see a Photograph of a right little finger. MCP jt shows Flexion . 

Diagnosis -

 Dupuytren's Contracture 

Risk Factors 

Family hx, Liver disease,

High Alcohol Intake 

DM , Epilepsy

Two main components in histology

 

 Myofibroblast

 Thick collagen Fibers 

Mx. 

Non operative 

Observation , Night time splintage

Injection - Steroids - reduces local tenderness 

               -colllgenase

Surgery 

Permanent Fasciotomy 

Mild cutaneous contracture at MCP Jt. 

Segmental/Patmar fasciotomy 

 Regional fasciectomy ( Z plasty for closure /skin graft ) 

Dermo fasciectomy and skin grafting

- PIP it arthrodesis - severe /recurrent disease 

Amputation of digits 

Counselling 

Delayed wound healing 

tendon,nerve,vessel injury 

temporary and permanent numbness 

necrosis of digit & amputation.

Incomplete correction 

Recurrence and reoperation 

Jt. stiffness

Reduced flexion and extension 

CRPS

Viva 2

Swelling voler aspect of wrist , radial to midline , cystic and soft in consistency 

Suggestive of 

Ganglion cyst

2/ 3rd - Radio carpal Joint 

1/3rd - Scaphotrapezoid jt. 

Clinical test

-Compressible 

- transillumination test +ve 

Outpatient procedure - aspiration under Local anaesthesia 

Simple Imaging - Ultrasound Scan 

 Histlogical definition- Ganglion cyst is a fluid filled cavity lined by compressed collagen & a fewer cells,

Other sites

Dorsum of wrist arise from S-L ( Scapholinare ) ligaments 

DIP Jt. - Presents as Dorsal distal ganglion , mucoid or mucoid cysts 

A2 pulley rerion in relation to flexer tendon seath.

Intraosseous ganglia - often in lunate 

Mx

Management of any disease starts from history followed by clinical examination , investigations counselling and treatment . 

Counselling - explain benign nature if disease 

       -fluctuates in size periodically and may regress spontaneously 

Treatment 

- 1) l Simple observation 

(2) Aspiration - risk of haematoma, infection artery damage, recurrence 

3) Surgical Excision 

Open or 

Arthroscopic

Anaesthetic risks

Surgical complications - nerve vessels damage

- tendon injury

-haemortma

-Pain, swelling, tenderness,stiffness

 -Recurrence

Risk of recurrence for all three treatment methods. 

.

Viva 3 - 

A photograph of hands with following deformities 

Thumbs- - z shaped 

Right middle finger - Swan neck deformity 

All fingers - Volar deviation of MCP Jts 

Symmetric deformity with Polyarthropathy consistent with Rheumatoid Arthritis 

Grading of thumb conditions radiographically 

stage -

I ) Joint Space widening , normal articular contours 

II- Upto ⅓rd subluxation ( on stress radiographs ,osteophytes < 2 mm 

Scaphotrapzpezio -trapezoidal (STT) normal . 

III) > 1/3rd >rd subluxation , osteophytes > 2 mm 

Jt. Space markedly reduced 

-pan-trapezoidal arthritis.

Why subluxation occurs ? 

Palmar (aka beal lig) ligament -very strong lig extending form trapezium to base of Ist MC. 

Degenerstion attenuation & rupture of this ligament leading to dorsal subluxation of 1st MC,

How to explain hyperextension deformity at MCP Jts ? 

Dosal subluxation at CMC Jt leads to metacarpal adduction , thumb in palm deformity and reduction in thumb span . 

To compensate that , hyperextension at MCP joint leads to increase in thumb span. 

→ Mx options.

Non-operative - activity modification , Splints , PT, Intra-articular steroids - outpatient clinic or under fluoroscopic guidance. 

Oral Analgesics 

Operative -1) Excision of trapezium- pain relief -Pinch up weakness

(2) Suspension procedure & tendon interposition arthroplasty - addition with above , no extra benefit .

3) Implant Arthroplasty - no good long term benefit 

4) CMC Athrodesis for Labourers -who require Stable thumb & good pinch,

5) First MC-basal Osteotomy 

→ How to treat this in a labourer ?

Excision of tropezius

Fusion of mcp it Under GA orl regional blck

Advantages / disadvantages of Trapezium Excision 

Good pain relief 

Improves function 

Thumb shortening

Reduce power of pinch 

Disadvantages 

painful scar 

- Nerve damage ( Superficial Radial Nerve )

Blood vessel (Radial Artery ) 

Incomplete relief of Symptoms 

Slow recovery of function 

Instability of carpus

 Fight bite puncture wound over the rt. middle finger MCP jt, that may have been caused by human tooth .

Wound may extend into joint causing cartilage damage and may be associated with joint infection and osteomyelitis. 

How to assess ? 

History - including circumstances of injury 

Past Medical History 

TT

Immunization 

Examination- 

    fever, tachycardia 

  Local examination 

     Cellulitis 

      Tendon Sheath Inflammation 

       Tendon rupture 

        Septic arthritis

Inv. -X-ray -AP / Oblique 

       Fracture foreign body

Baseline Blood Inv. - CBC,ESR, CRP

Treatment 

Tetanus Prophylaxis

- Sterile dressings to cover wound

Abx after tissue c/s 

Urgent debridement under GA with a tourniquet around arm . 

Pus swab and tissue samples - histological examination and microbiological 

Extend wound-look for tendon damage

 tag tendon ends and not to do primary repair 

inspect Jt

- Irrigate

- leave wound open , dressing, splinting

Broad spectrum Antibiotics , then narrow spectrum Abx. 

Further , look after 48 hrs. 

Which organism causes infection ? 

Eikenella Corrodens Peculiar 

Staph Aureus - commonest 

Anaerobic bacteria may also be implicated. 

Which abx is given ? 

Before C/s - Brood speectrim Abs such as Co-amoxiclav, cephalosporin & metronidazole 

Describe X- Ray 

PA and lateral view of a Periluante dislocation

PA view 

Discription of Giulula’s smooth carpal lines

- that join proximal surface of row of carpal bones -at radiocarpal joint .

-that join proximal surface of distal row of carpal bones.

Hyperflexion of scaphoid (scaphoid signet ring sign)

Abnormal triangular appearance of I lunate, lunate in it's fossa. 

overlapping of lunate and triquetrum 

Explain of there is fracture of radial styloid , and other carpal bones. 

Lateral view 

Dorsal dislocation of capitate head from it's articulation with lunate at mid carpal Joint 

and dorsal translation of distal carpal row and metacarpals relative to long axis of radius . 

How to classify ?

Mayfield Sequence of Ligament Injury 

Greater Arc - fracture in one of Radial styloid, schapoid, Triquetrum, capitate, hamate

Lesser Arc - no fractures 

Stage I: failure of Radiocarpal Ligament 

 II : failure of SL lig. 

III : failure of LT lig. 

and dorsal midcarpal dislocation 

IV : Palmar Dislocation of Lunate at R/C jt. 

Periluante dislocation is Mayfield stage III lesser arc injury. 

How to assess Patient’s injury ? 

Detailed history , handedness , occupation, MOI, CO-morbidities , past trauma history and time she took last meal . 

Examination - Abnormal wrist contour , pain and swelling , signs of median nerve compression , document median nerve function , sensory motor function up

Mx

Initial Mx.

1.Exclude other injuries

2.Provide Analgesia 

3. Regular neurovascular observations 

4.Splintages 

5. Elevation (Bradford Sling or Chinese finger traps ? ) 

6. Counselling 

7. Prepare and consent patient for ungent theater

8. Minimum initial intervention 

Close (open reduction and of dislocation ) 

Carpal tunnel decompension

Definitive

CR

assisted with joystick k - wires + buried k-wire stabilization of SL , LT and mid carpal joints

OR

- Open Dorsal Anatomical Carpal reduction Buried K wire stabilization ,Repair SL ,LT, dorsal & Pal

mar RC Ligaments .

(Note - as this is Mayfield Type 3 injury all 3 ligaments from stage I to III are injured and we have to repair them all three ) 

Post operative

high elevation and careful NV observation 

 Full Pop- 2 weeks , K-wore removal @ 8 weeks and mobilization . 

Risk of post traumatic carpal instabilly or stiffness 

Keywords :

Ganglion / Periluante Dislocation / Hand involvement in RA / Trepezium Excision / Fight Bite Injury 

Resident's note 

Golden points 

Notes in Orthopaedics w

Inflammatory and Rheumatic Disorders

 Inflamatory and Rheumatoid Disorders 

Rheumatoid Arthritis

Most common cause of chronic inflammatory joint disease 

1-3 % , 4th or 5th decdes

women affected 3 to 4 times more often than men.

Causes

1) Genetic susceptibility

2) Immunologic reaction

in joints and tendons

4) Rheumatoid Factors

5) perpetuation of inflammatory factors

 6) articular cortilage distruction.

Pathology 

1)Joints and Tendons 

      Preclinical inflammation - increased ESR and CRP

     Synovitis 

       Destruction

        De formity

2) Extra articular tissues

      1) Rheumatoid Nodules

       2) Lymphadenopathy

       3) Vasculitis

       4) Visceral disease

       5) Muscle weakness

Clinical features

Insidious onset

Early stage

soft tissue swelling 

 

 stiffness.

muscle pain

Tiredness, loss of weight,

Multiple joints pain 

Morning stiffness more than 30 minutes

Physical Exmaination 

Symmetrical distribution - Swelling

tenderness - MCP Jts

- Tevenosynovitis

-Limited movement

Later Stages 

joint deformity 

Tendon rupture 

Clawed toes

 Valgus Knee and Feet 

Pain & stiffness in spines

Extra-articular features

Nodules in back of elbows, viscera, eye

Muscles wasting , lymphadenopathy,

Skin atrophy or ulceration, Scleritis, Nerve Entrapment 

Peripheral Sensory Neuropathy 

Investigations 

X- Ray

USG/MRI

Normocytic Normochromic Anaemia

        Serological tests for rheumatoid focitor - 80% cases positive 

Synovial Biopsy - Needle Biopsy , or through Arthroscopy

Diagnosis 

   Explain as Bilateral Symmetrical Involvement 

   Involving Proximal Joints of hands and Feet Persisting for more than 6 weeks in my patient aged … , female gender …

 Likely be Rheumatoid Arthritis 

D/ D S

Seronegative Inflammation, Polyarthritis 

Ankylosing Spondylitis 

Pseudogout 

Peter's Disease  

       5) Polyarticular Gout

      6) کے Sarcoidosis

      

      7) Lyme Disease 

       8) Viral Arthritis 

9) Polymyaglia Rheumatica 

Treatment 

Corticosteroid Injection 

DMARD ± sulfasalazines , hydroxy chloroquine 

- Leflunamide

- Gold & Penicillamine / TNF Inhibitors 

B) Physiotherapy 

C) Surgical Management 

Synovectomy / tendon repair as replacement and jt. stabilization . 

Complications 

1)Fixed Deformities

2) Muscles weakness 

3) Joint Rupture 

4)Infection 

5) Spinal cord compression 

6) Systemic Vasculitis

7) Amyloidosis 

Acute and Chronic Osteomyelitis

Acute Osteomyelitis 

Orthopaedic Diagnosis 

History 

2) Past History

3) Family History 

4) Social background

5) Examination 

Look / Feel / Move

Special tests

developmental milestones.

C ) Investigations 

Plain Radiography

   Patient - soft tissue , bones and joints 

     using contact media

2- CT

3) IMRI

5-30, 000, stronger than Earth’s magnetic field

4) Diagnostic ultrasound 

5) Radionuclide imaging - 99 m Tc

B ) Blood tests

CBC, ESR CPP - Non specific 

- Tissue typing

 - Rheumatoid factor 

- Synovial fluid analysis.

C) Bone-Biopsy 

D) Diagnostic arthroscopy 

Infection 

Direct Introduction 

(2) from contiguous infection 

(3) indirect spread from blood stream

Factors predisposing to bone infection 

- Malnutrition & general debility"

- DM

- Corticosteroid administration

- Immune deficiency

-immunosuppressive drugs.

- Venous stasis in limbs

- Peripheral l vascular diseases

 - loss of sensibility

- intrinsic invasive measures

- Trauma

Principles of treatment 

1 ) Analgesia

2) rest the affected part

3) indentify infecting organism, administer effective abx tr

4) release pus as soon as it’s detected 

5) Stabilize bone if it's fractured

6) eradicate avascular & necrotic bone

7) maintain soft tissue and skin colour 

Acute Haematogenous Osteomyelitis

Adults & Children - S. Aureus - 70%

                 -less often GABS (Str. Pyogenes) or 

                             -alpha -haemolytic Diplococus , S. Pneumoniae

1-4. children - H. Influenzae. 

                       - Kingalla kingne

Metophysis - involvement

1) Non-anastomosing losine terminal antony branches of nutrient artery

2) relative vascular stasis

3) lower oxygen tension

4) fire vessels in hypertrophic zone-bacteria pass through them and adhere to type I collagen

Pathology - 

Inflammation, suppuration, bone necrosis reactive new bone formation, resolution & healing or chronicity

Metaphysis

-Intracapsular - SHE( SHOULDER , HIP and ELBOW JOINTS ) and spreads to it.

2) Periosteum looseliy attached in children spreads along shaft.

(3) physis is barrier to spread to joint 

4) In infants ,bacteria spreads to joints 

its through physis

Clinical features 

(1) child over 4

(2) Pain, swelling , refused to move 

(3) high grade fever 

 4) Infants - symptoms are mild 

(5) Bony tenderness 

(6) TL vertebrae are comon sites 

Diagnostic Smaging

1)Plain xray

2) USG

3) 99m Tc - HDP : Increase activity in both perfusion and bone phase 

4) MRI

B) Laboratory Tests 

18 G needle.

Aspiration.

tissue aspiration 60% positive

CRP-12-24 hrs., ESP-24-48 hrs

D/P

4) Cellulitis

B) Acute suppurative Arthritis

2) Acute P

3) Rheumatism

4) Sickle cell crisis

D) Gaucher’s Disease

Treatment 

 Analgesia 

Support affected part

Abx

Pus drainage

Fix facturas

Cover wound , remove dead bone 

Choice of Abx. 

 Upto. 06 months - 3rd gen. cephalosp

                                     Covers Aureus

  6 months to 6 years - H. Influenza

Fluclox + 3rd gen ceohalosporin

Older chibaren & previously fit 

flucloxacillin & Fusidic 

 acid

Elderly previously unfit patients 

Like in 

6 months children - G ‘-’ve organisms from GI Tract , respiratory system . 

Pts. with Sickle Cell dis-

3rd gen ceohalosporins or fluoroquinolones 

MArSA-

IV Vancomycin + 3rd Gen Cephalosporin

- Garre’s Sclerosing Osteomyelitis 

Marked Sclerosis and Cortical thickening .

-Long history of bone pain and Swelling over bone 

Treatment - Curettage 

Acute suppurative Arthritis

S. Aureus

Involvement

I/A injections 

Adjacent bone abscess

Blood spread from distant site

Clinical features

1 ) Pain / swelling ) refusal to move the part, fever

2)septiceamia in infants 

3) rapid pulse, erythema over involved bone and swelling 

4 ) restricted movement 

Imaging

 

USG

X - Ray

MRI

G-stain

WBC-300/ ml is normal 

- 1000/-non infective 

> 50,000/ml - infective

D/D of Acute Osteomyelitis 

Trauma 

Irritable Joint 

4) Haemophiliac Bleed 

5) Rheumatic fever 

6) Juvenile Rheumatoid Arthritis

7) Sickles cell Disease

10) Gaucher's Disease 

11) Gout and Pseudogout

Complications 

Subluxation

Damage to cartilage

Articular cartilage erosion 

Gonococcal Arthritis

Neisseria Gonorrhoea.