UPPER EXTREMITY UPDATE
From the University of Toronto Faculty of Medicine’s 23rd Annual Upper Extremity Update
| ASSESSMENT AND TREATMENT OF RADIAL NERVE PALSY —Robin R. Richards, MD, Professor, Division
of Orthopaedic Surgery, University of Toronto Faculty of Medicine, and Head, Department of Surgery, Sunnybrook
Health Sciences Centre, Toronto, ON
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| Anatomy of radial nerve: proximal—from posterior cord of shoulder; along top of latissimus tendon; enters arm
at triangular space below tendon; distal—continues close to humerus; around lateral aspect of arm; above elbow,
divides into terminal branches (sensory branch; posterior osseus nerve into supinator); most easily found—
between brachialis and brachioradialis muscles; identify and protect nerve from injury when metal attached
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| Function of radial nerve 2-fold: sensory—innervates dorsum of thumb-index finger webspace; loss of sensation
usually not severe impediment; motor—extends arm, elbow, wrist, fingers, and thumb; radial nerve palsy impedes
extension of wrist and grip strength; maximum grip at 35° extension
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| Etiology of radial nerve palsy: spontaneous (uncommon); internal injury (ends of broken bone); external (penetrating
trauma); neoplastic lesions; iatrogenic (manipulation of closed fractures, [eg, juxta-articular fracture];
plate fixation; thermal damage during cementing [eg, during elbow arthroplasty])
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| Clinical assessment: diagnosis—usually self-evident; inability to extend wrist, finger, thumb, and sometimes elbow;
examine extensor musculature and grade degree of paresis or paralysis; check sensation over dorsum of
thumb-index finger webspace; minor role for nerve conduction testing, eg, for medicolegal reasons or to document
recovery; during recovery—follow patient carefully (although most recover without intervention); periodically
assess degree of recovery and associated injuries; first sign of recovery at brachioradialis muscle; grip-
strength meter useful for indirect assessment of recovery
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| Prognosis: ≈12% of humeral fractures have associated radial nerve injury; failure to recover requires treatment;
closed injuries—≈85% recover without intervention; reassure patient; open injuries—prognosis variable
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| Initial treatment splinting: splint all patients with outrigger splint or cock-up wrist splint
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| Associated fracture: consider treating fracture and nerve separately; first treat humeral fracture in usual manner
(“sort of ignore the nerve injury, at least initially”)
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 | Goals of treatment: union of fracture; restoration of function; minimization of morbidity
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| Closed treatment: apply sugar-tong plaster splint; convert to Sarmiento brace; patients recover in 6 to 12 mo
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| Open treatment: plate fixation—speaker considers gold standard; compared to intramedullary nailing, plating
results in better healing, less pain, and less need to reoparate; enables early weight bearing; used anywhere in
humerus
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| Exploration of radial nerve: to prevent injury during open treatment; to determine reason nerve palsy fails to improve
over 3 to 4 mo; further delay decreases chance for successful grafting; may order electromyography
(EMG) and refer patient for exploration
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| Approach: anterolateral—extensile to shoulder; may require transposing nerve when grafting; posterior—
good access to radial nerve and elbow; best when patient turned on side
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| Identify nerve: rubber drain enables free manipulation
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| Results of grafting: studies report good results; with interfascicular nerve grafting and sural nerve, good-to-excellent
results in 91%
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| Treatment of irreparable nerve injury: eg, nonfunctional response to reconstruction, or patient referred too late
for grafting; perform tendon transfers to substitute for radial nerve function; preoperative planning—create template
(draw axis for radial and ulnar deviation; add extension and flexion; add muscle-tendon units; position according
to vector; add median and ulnar nerve muscle-tendon units); evaluate patient (determine missing
function, eg, extension of wrist, thumb, and digit; compare with template to plan strategy for tendon transfers)
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| SPORTS-RELATED HAND INJURIES —James L. Mahoney, MD, Professor, Division of Plastic Surgery, University
of Toronto, Faculty of Medicine
|
| Introduction: spectrum of ages involved in sports; weekend athletes may delay presenting with significant injury;
2-wk window for optimal treatment of tendon and after musculoskeletal injuries; secondary adherence to surrounding
structures leads to stiffness; swelling, tenderness, and deformity clues to significant injury; detect subtle
rotational deformity by misalignment of plane of fingernails
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| Investigations: obtain initial anteroposterior (AP) and lateral and postreduction x-rays
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| Football: most injuries overall; hand injuries in 5% of players; falls result in fractured scaphoid
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| Basketball: scaphoid fracture from fall
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| Baseball: direct hits
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| Gymnasts: dorsal impingement at wrist; physeal injuries
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| Water skiing: wrap-around of finger or thumb
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| Acute vs open injuries: acute—closed injuries; sprains; springs; tears; dislocations; fractures; open—cleanse
wound; splint injured digit; administer antibiotics
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| Weight lifting: finger injury from falling barbell
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| Volleyball and basketball: stiff or crooked fingers seen in 28% at competitive level; jamming injury most important;
impacted fractures of distal phalanx and proximal interphalangeal (PIP) joint; angled force causes tendon
ruptures and ligamentous injuries; fracture care—elevation; ring removal; padded dressing; most easily reduced
with closed treatment
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| Fracture management: algorithm—reduction; satisfactory alignment; protected mobilization; other modalities—
nerve block; traction; maintain reduction; assess range of motion and alignment; C-arm used for active assessment;
postreduction x-rays; extension-block splinting
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| Examples: avulsion fracture of volar plate with hyperextension, subluxation of middle phalanx on proximal phalanx
(reduce and maintain in flexed position; mobilization; extension-block splinting;); more complex injuries—
eg, volleyball, basketball, and direct hockey puck injuries to end of finger; fracture classification (unicondylar
or bicondylar; associated subluxation; involving base of middle phalanx); external fixation system provides longitudinal
support across PIP joint; pilon fracture—eg, hockey injury; high-speed direct force initially impacts
longitudinal axis of distal and middle phalanx; skier’s thumb—thumb-metacarpophalangeal joint injury; indications
for surgery (instability [>30° difference]; bump sign [ligament palpable]); if stable, immobilize and reassess
in 3 wk; ulnar collateral ligament repair (slightly volar anchor placement)
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| Jersey finger: in football or rugby, grabbing jersey leads to forced extension injury (slightly flexed finger prone to
hyperextension, directing force along profundus tendon and causing avulsion); presenting sign inability to flex
distal interphalangeal (DIP) joint; classification—based on degree of tendon laceration; type 1 (retraction to
palm); type 2 (retraction to level of PIP joint); type 3 (avulsion of bone fragment visible on x-ray)
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| Other sports injuries: rock climbing—tendonopathies; 30% involve PIP joint region; golf—tendinitis; hamate
hook fracture; prevention (gloves that improve grip); racket sports—tendinitis; neurovascular injuries—direct
trauma (handle bar grip in bicycling; batting in baseball; palm in handball); cyclists—carpal tunnel syndrome;
modify handle bars; bowler’s thumb—compression of ulnar nerve
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| Patient expectations: often underestimate problem; advise patients—swelling persists 3 to 6 mo; joint stiffness
lasts months; with PIP joint ligament disruption or operation on phalanx, permanent deformity possible and
swelling and irregularity certain; with appropriate management, risk of arthritis low
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| ASSESSMENT AND TREATMENT OF ULNAR WRIST PAIN —Herbert von Schroeder, MD, Associate Professor,
Division of Orthopaedic Surgery, University of Toronto, Faculty of Medicine
|
| Introduction: >20 causes of ulnar-sided wrist pain; “it’s not just the triangular-fibrocartilage complex (TFCC)”
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| Overview of approach: pain and provocative tests; points (ulnar head and distal radial ulnar joint [DRUJ]; TFCC
region; triquetrum); problems (inflammation [osteoarthritis; OA; fracture nonunion]; impingement [abutment
between ulnar head and lunate]; instability); treatment (immobilization; corticosteroid injection; repair or removal;
reconstruction; realignment/osteotomy)
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| Examination: arm-wrestling position; palpate; provoke pain (axial and subluxation maneuvers); in experienced
hands, physical examination >90% accurate in diagnosis; bony landmarks—ulnar head (bump); TFCC region
(valley); triquetrum (bump)
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| Subluxation of extensor carpi ulnaris (ECU) tendon: examination (windshield-wiper motion for hands; palpate);
treatment (splinting difficult; strap; surgery)
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| Instability of DRUJ: examination (grasp radial aspect of wrist and neck of ulna; “shock it back and forth”; neutral
position ≈1 cm of motion; compare to other side; as alternative, use hand-shaking position); distal radioulnar
ligaments of TFCC stabilize joint; tearing produces instability; problem and treatment—radius malunion
(osteotomy); ulnar styloid nonunion (repair); TFCC tear (for mild instability, fix TFCC; for major instability,
tendon weave ligament reconstruction; do not resect distal ulna for instability)
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| OA of DRUJ: steroid injection; Bowers hemiresection (interpose capsule); arthroplasty possible
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| TFCC region: causes of pain—degenerative tears; traumatic tears of TFCC; abutment problems between head of
ulna and proximal carpal row; ulnar styloid nonunion; examination—palpate tenderness at TFCC
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| TFCC tear without instability: examination (palpation; x-rays); treatment (arthroscopy); magnetic resonance imaging
(MRI) unreliable
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| Isolated TFCC tear: peripheral tear (young patient; repair; high healing rate; possible ulnar-shortening osteotomy);
central tear (elderly patient; arthroscopy and debridement; probable ulnar-shortening osteotomy)
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| Ulnocarpal abutment: ulna too long; examination (deviation and pronation to produce pain); associated with
TFCC tear, OA, and cyst (lunate); problem and treatment—minor or no trauma (arthroscopy and debridement;
open repair; ulnar-shortening osteotomy); radius fracture (radial-lengthening osteotomy)
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| Ulnar styloid nonunion: examination (check for instability); treatment—may heal without treatment; inject steroid;
excise bone fragment; repair instability
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| Triquetrum: causes of pain—lunotriquetral (LT) ligament tear; dorsal shear fracture; triquetral impingement ligament
tear (TILT) syndrome; OA of pisotriquetral joint
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| LT ligament tear: examination (grasp pisotriquetral complex and shake; produces pain between bones)
treatment—steroid injection; splinting; fusion
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| Dorsal triquetral shear fracture: examination (tenderness on dorsal bump; pain can last months) treatment—
immobilization; steroid injection; excision
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| TILT syndrome: impingement at cuff of wrist capsule; seen in, eg, tennis players; examination (pain on ulnar aspect
of triquetrum); treatment—activity modification; steroid injection; open incision of exostosis
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| Pisotriquetral joint OA: examination (grind test); treatment—steroid injection; well-padded splint; excision of
pisiform
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Suggested Reading
Ahn AK et al: Triangular fibrocartilage complex tears: a review. Bull NYU Hosp Jt Dis 64:114, 2006; Bae DS et al:
Pediatric distal radius fractures and triangular fibrocartilage complex injuries. Hand Clin 22:43, 2006; Bain GI et al:
Arthroscopic excision of ulnar styloid in stylocarpal impaction. Arthroscopy 22:677, 2006; Bain GI et al: Hemiresection
of the distal ulna by means of pronator quadratus interposition and volar stabilization. Tech Hand Up Extrem
Surg 11:83, 2007; Coggins CA: Imaging of ulnar-sided wrist pain. Clin Sports Med 25:505, 2006; Darlis NA et al:
Arthroscopic triangular fibrocartilage complex debridement using radiofrequency probes. J Hand Surg [Br] 30:638,
2005; Epub 2005 Aug 19. Harley BJ et al: Volar ligament release and distal radius dome osteotomy for correction
of Madelung's deformity. J Hand Surg [Am] 31:1499, 2006; Kitzinger HB et al: Ulnar Shortening Osteotomy With
a Premounted Sliding-Hole Plate. Ann Plast Surg 58:636, 2007; Lauder AJ et al: Oblique ulnar shortening osteotomy
with a new plate and compression system. Tech Hand Up Extrem Surg 11:66, 2007; Petersen K et al: Ulnar
shortening osteotomy after Colles fracture. Scand J Plast Reconstr Surg Hand Surg39:170, 2005; Pomerance J:
Plate removal after ulnar-shortening osteotomy. J Hand Surg [Am] 30:949, 2005; Shin AY et al: Ulnar-sided wrist
pain: diagnosis and treatment. Instr Course Lect54:115, 2005; Slutsky DJ: Arthroscopic dorsal radiocarpal ligament
repair. Arthroscopy 21:1486, 2005; Slutsky DJ: Distal radioulnar joint arthroscopy and the volar ulnar portal. Tech
Hand Up Extrem Surg 11:38, 2007; Tay SC et al: The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of
sensitivity and specificity. J Hand Surg [Am] 32:438, 2007; Zanetti M et al: Role of MR imaging in chronic wrist
pain. Eur Radiol 17:927, 2007.
Educational Objectives
| The goal of this program is to update orthopaedists on managing problems of the upper extremity. After hearing
and assimilating this program, the orthopaedic surgeon will be better able to:
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| 1. Assess radial nerve palsy.
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| 2. Treat radial nerve palsy.
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| 3. Identify hand injuries characteristic of various sports.
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| 4. Provide nonoperative and surgical treatment for sports-related hand injuries.
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| 5. Evaluate and treat ulnar wrist pain.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Richards, Mahoney, and von Schroeder were recorded at the 23rd Annual Upper Extremity Update, held in Toronto,
ON, March 30, 2007, and sponsored by the University of Toronto Faculty of Medicine. The Audio-Digest
Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.
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