HAND SURGERY
From The 6th Bi-Annual Difficult Problems in Hand Surgery, Cleveland Clinic Florida
John A. McAuliffe, MD, Section of Hand Surgery, Department of Orthopaedic Surgery, Cleveland Clinic Florida,
Weston
| PROXIMAL RADIUS: PATTERNS OF INJURY
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| Introduction: remarks focus on identifying complex radial head fractures; Mason classification type I—
nondisplaced; type II—displaced wedge involving >30% of head, angled ≤30° or displaced >3 mm; type III—
comminuted; type IV—associated with elbow dislocation (Johnson); Hotchkiss classification (more helpful) type
I—displaced <2 mm without restriction of motion; no treatment required; type II—2- or 3-part fracture displaced >2
mm; rotation restricted; amenable to open reduction and internal fixation (ORIF); type III—comminuted; ORIF not
feasible; comment—Hotchkiss classification based on exposure of fracture, which makes sense because x-rays often
deceptive about degree of comminution
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| Four major injury patterns: failure to recognize and treat appropriately at outset leads to difficult salvage procedures;
pattern 1—radioulnar disassociation (Essex-Lopresti injury) with disruption of distal radioulnar joint and interosseous
ligament (IOL); radial head must be fixed or replaced; pattern 2—associated medial collateral ligament
injury and/or capitellar fracture; look carefully for capitellar fracture; restoring skeletal anatomy usually adequate;
pattern 3—“terrible triad”; associated with either posterior dislocation of elbow with injury of coronoid (significant
or tiny shear fracture) or anteromedial capsule pulled off without fracture; for coronoid fracture, repair or replace radial
head; need for repair unclear after shear fracture or capsule disruption (assess on individual basis); pattern 4—
posterior Monteggia injuries; associated proximal ulnar fracture; varied degrees of fracture to radial head and neck;
segues into true posterolateral rotatory instability of elbow, with injury to lateral collateral ligament complex; requires
anatomic reduction of ulna with posterior plates; ligament repair may be required; transolecranon fracture-
dislocation—proximal radioulnar joint intact; requires accurate fracture fixation; no impact on stability of elbow or
forearm
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| Evaluation of injury: examine medial elbow for tenderness and ecchymosis; examine wrist and forearm (radioulnar
disassociation often not apparent; palpate joint and forearm for tenderness); suspect capitellar and coronoid fractures;
consider elbow dislocation and spontaneous reduction (look for subtle signs of instability); check radiograph for
proximal radioulnar joint injury; look for associated injury—≈70% of type III (comminuted) fractures associated
with significant ligamentous injury; simple (isolated) comminuted fractures not difficult to treat; in treating complex
fractures, restoration of osseous anatomy (repairing or replacing radial head) solves most ligamentous problems
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| Surgical considerations: long posterior incision allows access to lateral and medial sides of elbow; operate through
zone of injury whenever possible; “lot of the deep dissection is often done for you”; capsular tissues destroyed;
Monteggia injuries may create Boyd exposure of proximal ulna and radius (while this increases risk of heterotopic
ossification, take advantage of dissection); safe zone—with forearm in neutral rotation, 90°-arc on lateral side allows
placement of hardware without risk to proximal radioulnar joint
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| Challenges of ORIF: anatomy (ovoid shape of radial head; angle of neck and head); current smaller hardware inadequate;
radial head must be fixed well or replaced (bone likely to experience greater forces than before injury)
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| Clinical points: significant displacement involves 3 mm of displacement or 30° of angulation; partial excision of radial
head usually tolerated if limited to ≤30% of radial head; ORIF usually unsuccessful if >3 fragments; >3 mm of
proximal displacement of radius indicates IOL rupture
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| Radial head arthroplasty: results successful in short-to-medium term; long-term results unknown; no studies comparing
bipolar or monoblock implants; performing arthroplasty requires attention to detail, eg, restoring length;
hinged fixation—seldom necessary following restoration of skeletal anatomy (may require arthroplasty) and repair
of lateral and medial ligament; required when fixation inadequate (usually when coronoid crushed)
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| Key points: determine whether injury simple (isolated) or complex; x-rays may not reveal comminution; be prepared
to fix or replace radial head; restoring skeletal anatomy important for stability; traditional ligament repair
usually adequate
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| RHEUMATOID HAND SURGERY: WHO KNOWS WHAT WORKS?
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| Introduction: rheumatoid arthritis (RA) not actually arthritis, but systemic rheumatoid disease; affects 1% of population
in United States; ≈33% of patients unable to work 5 yr after diagnosis, ≈50% after 10 yr; surgical treatment—
rates of arthroplasty, arthrodesis, and tenosynovectomy for RA vary 9- to 12-fold from state to state; in evaluating
benefits of orthopaedic procedures for RA of hand, hand surgeons generally optimistic and rheumatologists pessimistic;
current questions before surgeons—what is appropriate rate for surgical treatment? is there sufficient evidence
for determining appropriate treatment? how to determine treatment plans for patients?
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| Overview of surgical procedures: inferential evidence confirms benefit of many procedures; few controlled studies
with outcome measures available; meanwhile, new disease-modifying drugs helpful (side effects include risk of infection;
comparison with surgical treatment needed); extensor tenosynovectomy—usually combined with other
procedure; studies show pain relief good, with rare incidence of recurrent tenosynovitis or subsequent tendon rupture;
flexor tenosynovectomy—procedure neglected because symptoms masked; technically challenging; doubles active
range of motion; recurrent tenosynovitis rare; synovectomy of proximal interphalangeal (PIP) joints—slows joint
destruction; extends joint function 3 to 5 yr; performed safely; pain relief good; synovectomy of wrist—combined
with other procedures, making results difficult to judge; needs to be compared to early limited radiolunate fusion;
metacarpophalangeal (MP) arthroplasty—review of studies over 33 yr found improvements in function, pain, activities
of daily living (ADL), and patient satisfaction; study of 52 patients found after 14 yr, only 38% of patients
satisfied (deformities recurred; motion lost; demonstrates that benefits time-limited and gaining 10 yr of function
may be optimal outcome)
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| Preventive vs delayed surgery: no cure for RA, neither medical nor surgical; shown that persistent joint swelling
only measure of disease activity that influences pain and function scores; bad reputation of hand surgery often results
from delaying surgery intended to be preventive
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| Goals of hand surgery for RA: relieving pain; restoring function; improving cosmesis; doing no harm (losing function);
determining patient’s needs
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| Guiding principles: begin with procedures most likely to succeed; remember “rheumatoid arthritis” really rheumatoid
disease (challenge not joint but synovitis in supporting structures in hand); deformity itself not indication for
surgery; be honest with patient (increased strength not expected; range of motion may benefit from more functional
arc, but total arc not improved; dexterity never normal; results deteriorate with time); deformities often causally interrelated
(must control proximal joint before treating more distal joint); try to restore nerve function (may provide
significant benefit, even though patients do not complain about sensory symptoms); limit procedures to what surgeon
can accomplish within single tourniquet time (≤2-hr limit)
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| Specific recommendations: never excise distal ulna in patient with mobile wrist; remember functional status of MP
joint determines appropriate treatment for PIP joint and vice versa; do not perform double-level arthroplasties at
MP and PIP levels; treat swan-neck deformity and be careful treating boutonnière deformity (consider terminal
tenotomy); look for flexor tendon dysfunction and compression neuropathy
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| TENDON TRANSFERS: DECISION MAKING
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| Initial decisions: attempting repair or grafting injured nerves—in multiple nerve injuries, any small return of function
valuable; consider level of injury, number of nerves, critical functions, and time to reinnervation; when to perform
tendon transfers—when motor function fails to return as expected; rather than waiting for sensory recovery,
restoring function can stimulate sensory return; early tendon transfer as “internal splint” (often eliminates need for
external splinting; adds to power of reinnervated muscles; acts as substitute when nerve recovery inadequate; splint
stabilization of wrist increases grip strength 3-5 times); alternatives to tendon transfer—nerve or fascicle transfer;
transfer of distal anterior interosseous nerve to motor branch of median or ulnar nerve
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| Radial nerve injuries: motor power for digital extensors—using flexor carpi radialis (FCR) simplifies operation
(compared to using flexor carpi ulnaris [FCU]); FCR universally applicable and also avoids radial deviation of
wrist, even in posterior interosseous nerve palsy; how to power extensor pollicis longus (EPL) in absence of palmaris
longus (PL)—in posterior interosseous nerve palsy, use brachioradialis instead of sacrificing flexor digitorum
superficialis (FDS); splitting FCR up to bipennate muscle provides 2 distal tendons (smaller for EPL; larger
for digital extensors); abductor pollicis longus (APL) function—zigzag collapse deformity of thumb not common,
but if it occurs, sufficient to tenodese APL to wrist
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| Ulnar nerve palsy: correcting clawing vs restoring power grip—discuss individual needs with patients; women may
want to avoid scarring; to restore balance to hand, use FDS or extensor digiti quinti (EDQ; insert into A2 pulley,
lateral band, or proximal phalanx); to restore strength to hand, use wrist motors (extensor carpi radialis brevis
[ECRB] or FCR) with tendon grafting
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| Anatomy is power: “there is almost no diagnosis that we can’t make with good knowledge of surface anatomy and
index finger that’s willing to touch the patient”
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| Attention to detail: separates good practitioners from not so good (“good ones are really obsessive”); must “check
stuff out”
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| Must examine patient: patients referred for second opinion often say other doctor “basically didn’t touch them” (just
looked x-rays, paper work, nerve conduction studies, and discussed surgery)
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| Order only studies that affect treatment: unnecessary arthrography and magnetic resonance imaging common;
avoid ordering studies for confirmatory purposes
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| Do not treat test: eg, carpal tunnel syndrome diagnosed by history and physical examination, not abnormal nerve
conduction study; most procedures elective; use clinical judgment
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| Newer not always better: orthopaedics tends to be driven by technology, especially hand surgery; “never be the first
to adopt a new technique nor the last”
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| Choose right tool for job: eg, liking to treat proximal phalanx with plate does not justify treating every phalanx with
plate; be flexible, with skills and capabilities to match need
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| Know when not to operate: surgery may be performed later if necessary; consider other options before deciding to
operate
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| Learn not to chase pain: orthopaedists good at treating mechanical problems; impossible to see pain in joint or
nerve; after eliminating mechanical problem to best of your ability, further surgery unlikely to help patient
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| “Two kind of people in the world— nurses and invalids”: some can care for others and themselves, and some cannot
care for themselves and blame those around them for problems (injuries difficult to treat); recognize problems
and “try to get them through your part of their life as best you can and move on”
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| Health care experience “not about us”: about patients; try to envision situation from patient’s perspective (many
scared, undergoing “weird” experience)
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| Cannot expect perfection: after surgery, “it always aches a little bit when the weather changes and it’s never quite
right”; important to convey to patients at outset and remind them later
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Educational Objectives
| The goal of this program is to provide orthopaedists with instruction on hand surgery. After hearing and assimilating
this program, the orthopaedic surgeon will be better able to:
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 | 1. Recognize patterns of injury in the proximal radius.
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| 2. Repair comminuted radial head fractures.
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| 3. Select effective surgical procedures for managing rheumatoid disease of the hand.
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| 4. Perform tendon transfers required in patients with nerve injuries affecting the hand.
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| 5. Confront the challenges of hand surgery.
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Suggested Reading
Alderman AK et al: Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists.
J Hand Surg [Am] 28:3, 2003; Alderman AK et al: The rheumatoid hand: a predictable disease with unpredictable
surgical practice patterns. Arthritis Rheum 47:537, 2002; Brandsma JW et al: Flexor digitorum
superficialis tendon transfer for intrinsic replacement. Long-term results and the effect on donor fingers. J Hand Surg
Br 17:625, 1992; Burkhalter W et al: Extensor indicis proprius opponensplasty. J Bone Joint Surg Am 55:725, 1973;
Burkhalter WE: Tendon transfer in median nerve palsy. Orthop Clin North Am 5:271, 1974; Doornberg J et al: Effective
treatment of fracture-dislocations of the olecranon requires a stable trochlear notch. Clin Orthop Relat
Res:292, 2004; Dvali L et al: Nerve repair, grafting, and nerve transfers. Clin Plast Surg 30:203, 2003; Friden J et
al: Tendon transfer surgery: clinical implications of experimental studies. Clin Orthop Relat Res:S163, 2002; King
GJ: Management of comminuted radial head fractures with replacement arthroplasty. Hand Clin 20:429, 2004;
McAuliffe JA. General clinical considerations in rheumatoid surgery. In: Weiss A-PC, Hastings H, eds. Surgery of
the Arthritic Hand and Wrist. Philadelphia: Lippincott Williams and Wilkins, 2002; McAuliffe JA: Combined internal
and external fixation of distal radius fractures. Hand Clin 21:395, 2005; McAuliffe JA: Flexor tendon repair,
healing and rehabilitation: a brief commentary. Hand Surg 7:29, 2002; McAuliffe JA: Hand commandments. J Hand
Ther 16:251, 2003; McAuliffe JA: Outcome research: definitions and directions. J Hand Ther 11:164, 1998; Morrey
BF: Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. Instr Course
Lect44:175, 1995; Nicolle FV et al: Prophylactic synovectomy of the joints of the rheumatoid hand. Clinical trial
with 4 to 8-year follow-up. Ann Rheum Dis 30:476, 1971; Ring D et al: Open reduction and internal fixation of fractures
of the radial head. J Bone Joint Surg Am 84-A:1811, 2002; Ring D: Open reduction and internal fixation of fractures
of the radial head. Hand Clin 20:415, 2004; Ring D: Treatment of the neglected distal radius fracture. Clin
Orthop Relat Res:85, 2005; Souter WA: Planning treatment of the rheumatoid hand. Hand 11:3, 1979; Stanley JK:
Conservative surgery in the management of rheumatoid disease of the hand and wrist. J Hand Surg [Br] 17:339,
1992.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the speaker reported nothing to disclose.
Dr. McAuliffe was recorded at The 6th Bi-Annual Difficult Problems in Hand Surgery, sponsored by Cleveland Clinic
Florida, April 29-30, 2005, in Naples. Florida. The Audio-Digest Foundation thanks Dr. McAuliffe and Cleveland
Clinic Florida for their cooperation in the production of this program.
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