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23 Cards in this Set

  • Front
  • Back
De Quervain disease
—Refers to stenosing tenosynovitis of the first dorsal wrist compartment (abductor pollicis longus [APL] and extensor pollicis brevis [EPB]) and typically occurs in racquet sports and in golfers. Ulnar deviation of the wrist with the thumb in the palm (Finkelstein's test) generally reproduces patient symptoms. Treatment includes activity modification, splinting, local corticosteroid injection, and occasionally surgical release (Fig. 4–57). The APL and EPB may lie in separate subsheaths in the first dorsal compartment, and care must be taken to release both of them.
Flexor carpi radialis/flexor carpi ulnaris tendinitis
—Wrist flexor tendinitis is common and is associated with overuse, especially in golfers and in players of racquet sports. Ulnar deviation and supination lead to dislocation. Activity modification, splinting, and NSAIDs are generally effective. Surgical tenolysis is rarely necessary.
Extensor carpi ulnaris tendinitis
—Tendinitis or subluxation of the sixth dorsal compartment frequently occurs in tennis and hockey players. Patients experience painful snapping with forearm supination (tendon subluxates) and pronation (tendon reduces). This condition must be distinguished from other ulnar wrist disorders. Long-arm cast immobilization in pronation may allow healing. Surgical d?bridement of the sixth dorsal compartment and reconstruction of the fibro-osseous tunnel with a slip of extensor retinaculum are occasionally necessary
Intersection syndrome
—Involves painful crepitus at the dorsal forearm due to irritation and inflammation of the crossing point of the first (APL and EPB) with the second (ECRL and ECRB) dorsal compartments and is typically seen in rowers and weightlifters. Splinting and local injections are typically effective for this self-limiting condition. Surgical decompression of the crossing point is rarely necessary.
“Jersey finger”
—Refers to an avulsion injury of the flexor digitorum profundus tendon from its insertion at the base of the proximal interphalangeal joint (PIP), with the ring finger being the most commonly affected.

The avulsion occurs with sudden hyperextension during finger flexion and may be seen on plain x-ray. The Leddy classification describes three types: type I, retraction of tendon into palm; type II, retraction to PIP; and type III; associated with a large, bony articular fragment, usually without significant retraction due to the A4 pulley. These injuries require retrieval of the retracted tendon and reattachment to the base of the PIP. Type I injuries must be repaired early (within 1 week) because of loss of blood supply to the tendon. Arthrodesis is generally favored over late (>3 months) repair due to finger stiffness after tendon grafting.
Classification of Jersey Fingers
type I, retraction of tendon into palm; type II, retraction to PIP; and type III; associated with a large, bony articular fragment, usually without significant retraction due to the A4 pulley.
“Mallet finger”
—Refers to an avulsion of the terminal extensor tendon. X-ray is used to rule out fracture. These injuries are typically treated with prolonged (>6 weeks) extension splinting. Results are almost uniformly good. Chronic injuries may result in significant swan-neck deformities due to chronic overpull of the extensor tendon at the PIP with flexion of the distal interphalangeal joint (DIP). Chronic deformities in young patients with preserved passive finger motion may be corrected by restoring the balance between extensors and flexors.
Sagittal band rupture
(“boxer's knuckle”)—Typically occurs in pugilists due to forceful subluxation of the extensor tendon. This condition usually involves the index and long fingers in professionals and the ring and small fingers in amateurs. Acute injuries are treated with extension splinting for 4 weeks. Chronic injury will lead to persistent extensor tendon subluxation and should be repaired or reconstructed with a slip of extensor tendon looped around the collateral ligament.
Scapholunate (SL) ligament injury
- Diagnosis
—The most common wrist ligament injury. Patients experience snuffbox tenderness after hyperextension of a pronated wrist, such as that occurring after a fall. Radial deviation of the hand with volar stabilization of the scaphoid (Watson test) may reproduce pain. Radiographic hallmarks include an increased SL interval (>3 mm), a cortical ring sign (proximal and distal poles of scaphoid overlap on posteroanterior projection), and an increased SL angle (>70 degrees) on lateral projection. Persistent SL dissociation with attenuation of extrinsic structures leads to an extended posture of the lunate (dorsal intercalated segment instability [DISI]) (Fig. 4–59) that unloads its articulation with the radius and increases contact forces at the radioscaphoid articulation, leading to progressive arthrosis. Diagnosis may be made with an MR arthrogram, which may help to increase the sensitivity and specificity.
Treatment of Scapholunate (SL) ligament injury
Treatment involves either closed reduction and percutaneous pinning of the SL joint for 8-10 weeks or open reduction and internal fixation of the articulation combined with a capsulodesis. Partial tears can be treated with d?bridement or thermal modulation.
Lunotriquetral (LT) ligament injury
LT ligament injury is less common than SL ligament injury. Patients describe ulnar-sided wrist pain after a fall that is worse with pronation and ulnar deviation (power grip). Examination seeks to distinguish LT injuries from the spectrum of injuries that usually accompany them (chondral lesions, triangular fibrocartilage complex [TFCC] tears). Pain is reproduced with ballottement or shuck of the LT articulation. Radiographic hallmarks include widening of the LT interval, volar flexion of the lunate, an increase in the capitolunate angle, and a decrease in the SL angle. An MR arthrogram may help to confirm the diagnosis. Treatment after failure of conservative care is through d?bridement of the LT ligament with or without ulnar shortening. Arthrodesis is useful for refractory cases.
Digital collateral ligament injury
—Often the result of a “jammed finger.” Simple tears are managed with buddy taping for 3 weeks, whereas complete tears should be buddy taped for 6 weeks. Radial collateral ligament injury of the index finger PIP should be surgically repaired because of the need for pinch stability of this joint.
PIP dislocation
—Typically occurs in a dorsal direction and results in a volar plate injury. Reduction is usually accomplished by the athlete, and incomplete reduction may be due to volar plate interposition. After reduction, the finger is buddy taped to the adjacent digit for 3-6 weeks. ROM should begin early. A flexion contracture of the PIP joint (pseudo-boutonni?re) may develop late but generally resolves with therapy and appropriate splinting. Volar PIP dislocation (central slip injury) is unusual and generally results in a tear of the central slip insertion. Treatment includes 6-8 weeks of immobilization with the PIP joint in extension.
Collateral ligament injury of the thumb
—Includes radial and ulnar collateral ligament injuries; “gamekeeper's or skier's thumb.” Instability should be examined in extension and at 30 degrees. X-rays are helpful to rule out fracture, with stress x-rays and MRI also playing a role in confirming the diagnosis. Nondisplaced, bony avulsions should not undergo stress radiography because of the risk of displacement. Incomplete ulnar injuries may be immobilized. Injuries with greater than 15 degrees of side-to-side difference or greater than 45 degrees of opening require operative intervention because the aponeurosis of the adductor becomes interposed between the ends of the torn ligament (Stener's lesion) (Fig. 4–60). Aponeurotic interposition does not occur on the radial side. These rare injuries are often treated closed.
Scaphoid fracture
—Fractures here occur frequently in contact sports. Because the vascular supply enters distally, proximal fractures have a high rate of nonunion and avascular necrosis. Acute and subacute, nondisplaced fractures less than 8 weeks old may be treated in a thumb-spica cast. Percutaneous fixation of nondisplaced fractures leads to earlier union, ROM, return to work, and possibly return to play. Displaced fractures should be managed operatively with either percutaneous or limited open fixation. Nonunion may be managed with a local vascularized bone graft and internal fixation. A CT scan can be used to assess displacement, while MRI is helpful to rule out occult fracture and assess vascularity.
Hamate fracture
—Hook-of-hamate fractures typically occur in a golfer or baseball batter after repeated direct contact. Diagnosis is confirmed by a carpal tunnel view or CT scan. Treatment is either cast immobilization or excision of the hook. The latter allows more rapid return to play.
Metacarpal and phalanx fractures
—Many of these fractures heal with closed reduction and immobilization. Fourth and fifth metacarpal fractures can accept greater angulation than the index and long finger. Displaced fractures, those involving the joints, and those resulting in rotational malalignment should be treated surgically. Early motion is the key to successful rehabilitation. Fractures involving the base of the thumb carpometacarpal (CMC) joint (Bennett's fracture, Rolando's fracture) often require operative reduction and stabilization.
Ulnocarpal abutment syndrome
—Typically occurs in patients with ulnar-positive variance. Pain is exacerbated with rotation or ulnar loading of the wrist. Sclerotic and cystic changes may be seen in the lunate and distal ulna. If supportive measures fail, ulnar shortening (wafer procedure, ulnar-shortening osteotomy) provides predictable pain relief. Ulnar head resection (Darrach), hemiresection with interpositional arthroplasty, the Suave-Kapandji procedure, and prosthetic ulnar head replacement are useful if significant arthritis is present.
Hypothenar hammer syndrome
—Involves ulnar artery constriction, which can occur in baseball pitchers. Allen's test will show decreased ulnar filling. Doppler evaluation and vascular referral may be necessary.
Guyon's canal syndrome
(handlebar palsy)—This condition is characterized by pain and ulnar paresthesias, with weakness of the intrinsic hand muscles. Treatment includes modification of the cyclist's grip and occasionally ulnar nerve decompression
Scaphoid avascular necrosis
—A common complication due to the tenuous blood supply of this bone. Bone grafting and internal fixation are usually curative. Unrecognized injuries may lead to the development of scaphoid nonunion–advanced collapse (SNAC), which in turn requires radial styloid excision, scaphoid excision and partial wrist arthrodesis (four-corner fusion), proximal row carpectomy, and/or total wrist fusion.
Osteochondrosis of the capitate
—Most often found in gymnasts and may respond to d?bridement or limited wrist fusions.
Kienbock's disease
—Avascular necrosis and collapse of the lunate is probably related to overuse and ulnar negative wrist variance. Early in the disease process, ulnar lengthening or radial shortening may be helpful in arresting progression to collapse. Limited wrist fusions may be necessary for cases of advanced collapse.