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2457457745730Capitate and hamate appear in infancyTriquetrum appear 3-4yrsLunate appears 4-5yrsTrapezium, trapezoid appears 5-9yrsScaphoid appears 6-10yrsPisiform appears 10-12yrsProximal row is unstable, others are stableChildren more likely to injure radial epiphysis than carpal bonesNormal 2pt discrimination in fingertips is <6mm00Capitate and hamate appear in infancyTriquetrum appear 3-4yrsLunate appears 4-5yrsTrapezium, trapezoid appears 5-9yrsScaphoid appears 6-10yrsPisiform appears 10-12yrsProximal row is unstable, others are stableChildren more likely to injure radial epiphysis than carpal bonesNormal 2pt discrimination in fingertips is <6mm4015739494157000246380494157037782501174115Median nerve: C5 – T1AbPB, OP, FPB (all in thenar eminence); lateral 2 lumbricals; FDS Motor: flex DIPJ of thumb; touch tip of thumb to LF against resistance; flex thumb and palpate thenar emimence; wrist flexion; A-OK sign; abduct thumb against resistance (recurrent branch)Sensation: volar thumb and radial 2 ? fingersRadial nerve: C5 – T1Motor: extend wrist and fingers (post interosseous nerve); extension of thumbSensation: dorsum radial aspect of hand, thumb and radial 2 ? fingersUlnar nerve: C7 – T1ODM, FDM, AbDM (all in hypothenar eminence); AdPB; interosseous muscles; ulnar 2 lumbricals; deep head of FPLMotor: spread fingers and push together against resistance; thumb adduction Sensation: sensation dorsal and volar ulnar 1 ? fingers00Median nerve: C5 – T1AbPB, OP, FPB (all in thenar eminence); lateral 2 lumbricals; FDS Motor: flex DIPJ of thumb; touch tip of thumb to LF against resistance; flex thumb and palpate thenar emimence; wrist flexion; A-OK sign; abduct thumb against resistance (recurrent branch)Sensation: volar thumb and radial 2 ? fingersRadial nerve: C5 – T1Motor: extend wrist and fingers (post interosseous nerve); extension of thumbSensation: dorsum radial aspect of hand, thumb and radial 2 ? fingersUlnar nerve: C7 – T1ODM, FDM, AbDM (all in hypothenar eminence); AdPB; interosseous muscles; ulnar 2 lumbricals; deep head of FPLMotor: spread fingers and push together against resistance; thumb adduction Sensation: sensation dorsal and volar ulnar 1 ? fingers24638011741150026403301076706000246380539750Hand Injuries00Hand Injuries 00 36296608976995UncommonRisk of avascular necrosis - blood supply enters distallyUsually occurs with fractures of other carpal bonesDue to FOOSH00UncommonRisk of avascular necrosis - blood supply enters distallyUsually occurs with fractures of other carpal bonesDue to FOOSH2463808977630Lunate Fracture 00Lunate Fracture 15957558977630002463807407910Triquetrum Fracture 00Triquetrum Fracture 435356074079102nd most common carpal fractureAvulsion or fracture through bodyTender over dorsum of wrist distal to ulnar styloid002nd most common carpal fractureAvulsion or fracture through bodyTender over dorsum of wrist distal to ulnar styloid15957557407910002463803937635Scaphoid Fracture 00Scaphoid Fracture 15957555419091Examination: ASB tenderness (93% sensitivity, 16% specificity)XR: takes 1-2/12 for XR to show avascular necrosis; XR 70% sensitivity with high false +ive rateCT: 89-97% sensitivity, 91-100% specificity; if suspect but XR normal (risk of # 1-5%), suggest doing early CT to avoid unnecessary immobilisationMRI: nearly 100% sensitivity and good for avascular necrosis, ligament injury, carpal instabilityBone scan: 92-100% sensitivity, 87-98% specificity, can’t be done until 72hrs and has high false +ive rateManagement: scaphoid cast 6/52; ORIF if >1mm displacement, >15° angulationComplications: 0.1-1% long term complication rate; 30% proximal pole #’s get avascular necrosis (incidence increases the more proximal the #; shows up on XR as ? density of bone); 50% avascular necrosis if >1mm displacement; nonunion with waist #’s (50% nonunion if >1mm displacement); complex regional pain syndrome00Examination: ASB tenderness (93% sensitivity, 16% specificity)XR: takes 1-2/12 for XR to show avascular necrosis; XR 70% sensitivity with high false +ive rateCT: 89-97% sensitivity, 91-100% specificity; if suspect but XR normal (risk of # 1-5%), suggest doing early CT to avoid unnecessary immobilisationMRI: nearly 100% sensitivity and good for avascular necrosis, ligament injury, carpal instabilityBone scan: 92-100% sensitivity, 87-98% specificity, can’t be done until 72hrs and has high false +ive rateManagement: scaphoid cast 6/52; ORIF if >1mm displacement, >15° angulationComplications: 0.1-1% long term complication rate; 30% proximal pole #’s get avascular necrosis (incidence increases the more proximal the #; shows up on XR as ? density of bone); 50% avascular necrosis if >1mm displacement; nonunion with waist #’s (50% nonunion if >1mm displacement); complex regional pain syndrome159575539376350031330903937000Epidemiology: most commonly fractured carpal bone (70%); 85% 15-29yrs; 50-60% mid-scaphoid, 15-35% proximal, 10% distal; due to fall on dorsiflexed hand or axial load on thumb; another associated injury in 12%Pathophysiology: blood from radial artery entering from dorsal side at waist to supply proximal pole; vascularity of proximal pole depends on intraosseous blood flow; ASB = bony radial styloid, EPB, EPL; the more proximal / oblique / displaced the #, the greater the risk; unstable if oblique / >1mm displaced / rotation / comminution00Epidemiology: most commonly fractured carpal bone (70%); 85% 15-29yrs; 50-60% mid-scaphoid, 15-35% proximal, 10% distal; due to fall on dorsiflexed hand or axial load on thumb; another associated injury in 12%Pathophysiology: blood from radial artery entering from dorsal side at waist to supply proximal pole; vascularity of proximal pole depends on intraosseous blood flow; ASB = bony radial styloid, EPB, EPL; the more proximal / oblique / displaced the #, the greater the risk; unstable if oblique / >1mm displaced / rotation / comminution246380502920Lunate / perilunate Dislocation00Lunate / perilunate Dislocation55473602245360Trans-scaphoid perilunate dislocation: distal scaphoid fragment displaced posteriorly with rest of carpal bones; maybe # of radius and ulna; reduce via traction; may need OT00Trans-scaphoid perilunate dislocation: distal scaphoid fragment displaced posteriorly with rest of carpal bones; maybe # of radius and ulna; reduce via traction; may need OT15957553065145Usually due to forced dorsiflexion; can cause degenerative arthritits, avascular necrosis, median nerve compressionScaphoid dislocation: proximal pole goes dorsal, distal goes volar00Usually due to forced dorsiflexion; can cause degenerative arthritits, avascular necrosis, median nerve compressionScaphoid dislocation: proximal pole goes dorsal, distal goes volar33381952245360Peri-lunate dislocation: dislocation of capitate dorsally; lunate still attached to radius; reduced by traction00Peri-lunate dislocation: dislocation of capitate dorsally; lunate still attached to radius; reduced by traction15957552245360Lunate dislocation: reduce by compression over lunate, wrist extended and flexed; may need OT00Lunate dislocation: reduce by compression over lunate, wrist extended and flexed; may need OT5547360502920003338195502921001595755502920008531860731520000 15709908825230Give neck fracture a pull if: >10° angulation in AP / lateral (>20° if 1st / 4th MC) >50% displacement then buddy strap or splintUnstable if: rotated spiral / oblique, multifragment, >50% displacedOT if: intra-articular, open, multiple fracturesFracture of metacarpal shaft: rotational deformity and shortening more likelyFracture of metacarpal base: often complex, communitued, associated with carpal bone fracture; 4th and 5th associated with ulnar nerve injury; often need OT00Give neck fracture a pull if: >10° angulation in AP / lateral (>20° if 1st / 4th MC) >50% displacement then buddy strap or splintUnstable if: rotated spiral / oblique, multifragment, >50% displacedOT if: intra-articular, open, multiple fracturesFracture of metacarpal shaft: rotational deformity and shortening more likelyFracture of metacarpal base: often complex, communitued, associated with carpal bone fracture; 4th and 5th associated with ulnar nerve injury; often need OT2444758825230Fracture of Other Metacarpals00Fracture of Other Metacarpals2540006677660Boxer’s Fracture00Boxer’s Fracture29273506677660Fracture of neck of 5th metacarpalCan accept almost any degree of angulation (up to 45° is OK)Rotation important to detect and requires reductionEarly mobilisation00Fracture of neck of 5th metacarpalCan accept almost any degree of angulation (up to 45° is OK)Rotation important to detect and requires reductionEarly mobilisation15709906677660002095521570956159546843952540004763135Rolando’s Fracture00Rolando’s Fracture469646047669453 part fracture of base of thumbIntra-articularUncommonWorse prognosis than Bennett’sAlways needs ORIF003 part fracture of base of thumbIntra-articularUncommonWorse prognosis than Bennett’sAlways needs ORIF15716244766945002540002258060Bennett’s Fracture 00Bennett’s Fracture 46951902257425Intra-articular fracture-dislocation of carpo-metacarpal joint of thumbSmall medial fragment maintains contact with trapezium; distal fragment displaced proximally, radially and dorsally by pull of APLFrom axial blow to partially flexed thumb Management: traction, abduction and pressure over base of thumb; usually needs K wire fixation00Intra-articular fracture-dislocation of carpo-metacarpal joint of thumbSmall medial fragment maintains contact with trapezium; distal fragment displaced proximally, radially and dorsally by pull of APLFrom axial blow to partially flexed thumb Management: traction, abduction and pressure over base of thumb; usually needs K wire fixation1571625225933000254000502920Hamate Fracture 00Hamate Fracture 26873206858000046951905029202% of carpal fracturesDue to racket sportsMost fractures involve hook of hamateRisk of ulnar nerve injury002% of carpal fracturesDue to racket sportsMost fractures involve hook of hamateRisk of ulnar nerve injury15716255029200037782507248525Flexor Tendons:I Insertion of FDS to FDP tendon; lose DIPJ flexion FDP = flexes DIPJ; if broken, can still flex PIPJ II Both FDS and FDP involved FDS = flexes PIPJIII Distal edge of carpal tunnel to proximal edge of flexor sheath; good outcomeIV Carpal tunnelV Proximal to carpal tunnel; injuries tend to be severeTendon sheath function important – making more prone to deep space infections<25% division can be treated conservatively00Flexor Tendons:I Insertion of FDS to FDP tendon; lose DIPJ flexion FDP = flexes DIPJ; if broken, can still flex PIPJ II Both FDS and FDP involved FDS = flexes PIPJIII Distal edge of carpal tunnel to proximal edge of flexor sheath; good outcomeIV Carpal tunnelV Proximal to carpal tunnel; injuries tend to be severeTendon sheath function important – making more prone to deep space infections<25% division can be treated conservatively2444753279140Tendon Injuries00Tendon Injuries157099071564505257165477710500157099032791402444752284730Phalanx Fracture00Phalanx Fracture15709902284095Middle phalanx fractures are unstable and require OTK wire if fragment >5mm or involves >1/4 joint surfaceIf undisplaced shaft fracture = splint 2/52If DP fracture = symptomatic onlyPP has no tendor attachments so fractures often cause volar angulation00Middle phalanx fractures are unstable and require OTK wire if fragment >5mm or involves >1/4 joint surfaceIf undisplaced shaft fracture = splint 2/52If DP fracture = symptomatic onlyPP has no tendor attachments so fractures often cause volar angulation15709901351915Usually dorsal; may be irreducible if entrapment of avulsion #, profundus tendon or volar plate; radial collateral ligament 6x more likely than ulnar collateral ligament to ruptureManagement: reduce by traction and mild hyperextension buddy strap or splint in flexionIf of thumb, usually open00Usually dorsal; may be irreducible if entrapment of avulsion #, profundus tendon or volar plate; radial collateral ligament 6x more likely than ulnar collateral ligament to ruptureManagement: reduce by traction and mild hyperextension buddy strap or splint in flexionIf of thumb, usually open2444751351915PIP/DIPJ Dislocations00PIP/DIPJ Dislocations244475429260MCP Dislocations00MCP Dislocations1570990429261Hyperextension dorsal dislocation; volar plate may be trapped in joint (complex)Management: relocate by flexing wrist pushing phalanx distal and volarly onto MCPJ (avoid pure traction and hyperextension as may make simple complex) splint in flexion; if complex may need OT; closed reduction hard if metacarpal head button-holes through capsule00Hyperextension dorsal dislocation; volar plate may be trapped in joint (complex)Management: relocate by flexing wrist pushing phalanx distal and volarly onto MCPJ (avoid pure traction and hyperextension as may make simple complex) splint in flexion; if complex may need OT; closed reduction hard if metacarpal head button-holes through capsule2730507980680Nail Injury00Nail Injury1599565797941150% nail bed injuries have associated fracture of DPManagement: place drainage hole in nail before replacing; suture nail in place for 3/52 If subungal haematoma – trephination OK if DP fracture, but need to give prophylactic antibiotics; remove nail if trephination doesn’t relieve symptoms0050% nail bed injuries have associated fracture of DPManagement: place drainage hole in nail before replacing; suture nail in place for 3/52 If subungal haematoma – trephination OK if DP fracture, but need to give prophylactic antibiotics; remove nail if trephination doesn’t relieve symptoms2730506503035Amputation00Amputation15995656501765Better prognosis if proximal to PIPJ (terminalisation if through DIPJ); otherwise best to reimplant within 6hrs); Bone, tendon, skin lasts 8-12hrs warm ischaemia, 24hrs cold ischaemia; Muscle lasts 6hrs warm ischaemia, 12hrs cold ischaemiaManagement: wrap in saline soaked gauze place in water tight bag put in very cold water >1cm finger tip amputations need grafting Reimplantation contraindicated if: other severe injury, significant chronic illness, severely damaged, >50yrs, avulsion injury, cooling delayed >6hrs00Better prognosis if proximal to PIPJ (terminalisation if through DIPJ); otherwise best to reimplant within 6hrs); Bone, tendon, skin lasts 8-12hrs warm ischaemia, 24hrs cold ischaemia; Muscle lasts 6hrs warm ischaemia, 12hrs cold ischaemiaManagement: wrap in saline soaked gauze place in water tight bag put in very cold water >1cm finger tip amputations need grafting Reimplantation contraindicated if: other severe injury, significant chronic illness, severely damaged, >50yrs, avulsion injury, cooling delayed >6hrs2730505960745Nerve Injuries00Nerve Injuries15995655960111Nerves superficial to digital arteriesSurgery needed if: thumb, ulnar border of little finger, distal index finger, dominant hand00Nerves superficial to digital arteriesSurgery needed if: thumb, ulnar border of little finger, distal index finger, dominant hand273050570865Tendon Injuries00Tendon Injuries15805153640455VI Dorsum of hand; may be proximal to junctura tendinae so extension of MCPJ may be possible Usually need OTVII Over wrist; extensor retinaculum; needs OTVIII Over distal forearm; OT if >25% injury followed by splintTendon sheath function less important (less communication between extensor sheathes); central slip attaches to MP, 2 lateral bands to DP; a complete tendon lac prox to junctura may still have normal extensor function<80% division can be treated conservatively (splint 6/52 if mid-extensor, 8/52 if distal)Infections: most staph aureus; 30% G-ive if diabetes; tender over tendon sheath distant from area of penetration; treat with flucloxacillin00VI Dorsum of hand; may be proximal to junctura tendinae so extension of MCPJ may be possible Usually need OTVII Over wrist; extensor retinaculum; needs OTVIII Over distal forearm; OT if >25% injury followed by splintTendon sheath function less important (less communication between extensor sheathes); central slip attaches to MP, 2 lateral bands to DP; a complete tendon lac prox to junctura may still have normal extensor function<80% division can be treated conservatively (splint 6/52 if mid-extensor, 8/52 if distal)Infections: most staph aureus; 30% G-ive if diabetes; tender over tendon sheath distant from area of penetration; treat with flucloxacillin3204845632460Extensor Tendons:I DP and DIPJMallet finger: damage to distal extensor tendon to distal phalanx via forced flexion (at attachment to bone = type I, with avulsion # = type II, with >20% articular surface avulsed = type III) Treat conservatively: if only chip fracture and <15° movementt lost Otherwise 6/52 splinting, or K wire if >2mm / >1/4 joint surface fragment Swan neck deformity if not appropriately treatedII Over MPIII Over PIPJCentral slip rupture: due to dislocation of PIPJ (maybe delayed); tender over middle of PIPJ, full extension of finger may be possible; if complete laceration, can cause volar displacement of lateral bands causing them to become flexors boutonniere deformityIV Over PPV Over MCPJ; consider human bite00Extensor Tendons:I DP and DIPJMallet finger: damage to distal extensor tendon to distal phalanx via forced flexion (at attachment to bone = type I, with avulsion # = type II, with >20% articular surface avulsed = type III) Treat conservatively: if only chip fracture and <15° movementt lost Otherwise 6/52 splinting, or K wire if >2mm / >1/4 joint surface fragment Swan neck deformity if not appropriately treatedII Over MPIII Over PIPJCentral slip rupture: due to dislocation of PIPJ (maybe delayed); tender over middle of PIPJ, full extension of finger may be possible; if complete laceration, can cause volar displacement of lateral bands causing them to become flexors boutonniere deformityIV Over PPV Over MCPJ; consider human bite158114957086500 ................
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