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