Transcript Figure 1

Anatomy of the Hand and
Wrist
 Arthritides of the Hand
and Wrist
 Bone and Soft-Tissue
Tumors of the Hand and
Forearm
 Traumatic Brachial Plexus
Injuries
 Dupuytren Contracture
 Flexor and Extensor
Tendon Injuries








Frostbite
Infections of the Hand
Nerve Compression
Syndromes
Replantations in the
Upper Extremities
Soft-Tissue Coverage
Vascular Disorders
Wrist Arhtoscopy
A.
B.
C.
D.
E.
The Nail bed
The Skin/Fascia
Compartments of the
Forearm and Hand
Palmar Spaces of the
Hand
The Digits
F.
G.
H.
I.
J.
The Hand
The Wrist
The Forearm
Vascular Anatomy of
the Hand, Wrist, and
Forearm
Nerves of the Hand,
Wrist, and Forearm
Figure 1:
Illustrations of the cross-sectional anatomy of the compartments of the forearm
(A) and hand (B). (Copyright Fraser J. Leversedge, MD; Martin Boyer, MD, MSc, FRCSC;
(B) and Charles A. Goldfarb, MD.
Table 1
Contributions of Interosseous and Lumbrical Muscles to the Extensor
Apparatus
Muscles
Dorsal interosseous
Lumbrical
Location and Action
4 dorsal interossei
Bipennate; arise from both metacarpals of intermetacarpal space
Each dorsal interosseous has 2 muscle bellies:
Superficial
•passes under sagittal hood to become medial tendon
•insertion: lateral tubercle of proximal phalanx
•action: abductor of digit
Deep
•passes over sagittal hood to become lateral tendon
•insertion: transverse fibers of extensor apparatus
•action: flexor of MCP joint
Originate from FDP tendon
Passes volar to the deep transverse intermetacarpal ligament
Located on the radial side of each digit
Insertion: radial lateral band (of extensor apparatus) via oblique fibers
Action: extend PIP and DIP joints
Only muscle able to “relax” its antagonist (origin on FDP)
Innervation:
1st and 2nd lumbricals (unipennate): median nerve
2nd and 3rd lumbricals (bipennate): ulnar nerve
MCP = metacarpophalangeal, PIP = proximal interphalangeal, DIP = distal interphalangeal (Copyright Fraser J. Leversedge, MD; Martin Boyer,
MD, MSc, FRCSC, and Charles A. Goldfarb, MD.)
Figure 2:
Anatomic zones for the characterization of
flexor tendon injuries. (Copyright Fraser J.
Leversedge, MD; Martin Boyer, MD, MSc, FRCSC;
and Charles A. Goldfarb, MD.)
Figure 3:
Commonly accepted flexor pulley
nomenclature (A1-A5 and C1-C3). Note ulnar
bursa (UB) and radial bursa (RB). (Copyright
Fraser J. Leversedge, MD; Martin Boyer, MD,
MSc, FRCSC; and Charles A. Goldfarb, MD.)
Table 2
The Interosseous Muscles
Muscle
Insertion
Action
Characteristics
Superficial muscle belly
Lateral tubercle of proximal
phalanx
Abduct digit
Bipennate
Deep muscle belly
Transverse fibers of extensor
apparatus
Flex MCP joint
Bipennate
Volar
Extensor apparatus; no insertion
into the proximal phalanx
Flex MCP joint; adduct
index, ring, and little
Unipennate
fingers
Dorsal
MCP = metacarpophalangeal
Table 3
The Lumbrical Muscles
Muscle
Origin
Insertion
Innervation
Action
Characteristics
First lumbrical
FDP tendon
Radial lateral
band
Median nerve
Extend PIP and
DIP joints
Unipennate
Second
lumbrical
FDP tendon
Radial lateral
band
Median nerve
Extend PIP and
DIP joints
Unipennate
Third lumbrical
FDP tendon
Radial lateral
band
Ulnar nerve
Extend PIP and
DIP joints
Bipennate
Fourth
lumbrical
FDP tendon
Radial lateral
band
Ulnar nerve
Extend PIP and
DIP joints
Bipennate
FDP = flexor digitorum profundus, PIP = proximal interphalangeal, DIP = distal interphalangeal
Table 4
The Thenar Muscles
Muscle
Abductor pollicis
brevis
Origin
Insertion
Innervation
Median nerve, 95%
Transverse carpal
Radial base of P1, MCP
Ulnar nerve, 2.5%
ligament, FCR sheath, joint capsule, radial
Both, 2.5%
trapezium, scaphoid sesamoid
Flexor pollicis brevis
Transverse carpal
ligament
Thumb MCP joint
capsule and radial
sesamoid
Opponens pollicis
Transverse carpal
ligment, trapezium,
thumb CMC capsule
Volar-radial distal
thumb metacarpal
Adductor pollicis
Long finger
metacarpal
Ulnar sesamoid of
thumb, ulnar base of
P1, dorsal apparatus
Superficial head:
median nerve
Deep head: ulnar
nerve
Action
Abduction and flexion
of the thumb
metacarpal
Ulnar angulation at
the MCP joint
Thumb IP joint
extension
Flexion of thumb
metacarpal and P1
Thumb pronation
Thumb IP joint
extension
Median nerve, 83%
Ulnar nerve, 10%
Both, 7%
Flexion and pronation
of thumb metacarpal
Ulnar nerve
Adduction of thumb
metacarpal
Thumb IP joint
extension
FCR = flexor carpi radialis, MCP = metacarpophalangeal, IP = interphalangeal, CMC = carpometacarpophalangeal
Table 5
The Hypothenar Muscles
Muscle
Origin
Insertion
Abductor digiti minimi
Distal pisiform, FCU
insertion
Ulnar base P1, 90%
Extensor apparatus,
10%
Flexor digiti minimi
Opponens digiti
minimi
Innervation
Action
Ulnar nerve
Strong abductor of
little finger
Mild MCP joint flexion
of little finger
Little finger IP joint
extension
Transverse carpal
ligament, hook of
hamate
Little finger P1 palmar
Ulnar nerve
base
Little finger flexion at
MCP joint
Transverse carpal
ligament, hook of
hamate
Distal three quarters
of the ulnar aspect of
Ulnar nerve
the little finger
metacarpal
Supination of the
little finger
metacarpal
Deepens palm to
complement thumb
opposition
FCU = flexor carpi ulnaris, MCP = metacarpophalangeal, IP = interphalangeal
(Continued)
(Continued)
Figure 4:
Dissections of a right wrist. A, Dorsal view of a right wrist with the ECRL and ECRB reflected distally. The
dorsal extrinsic wrist ligaments are identified. The DRC originates at the dorsal lip of the distal radius,
adjacent to the dorsal radial tubercle (the Lister tubercle, designated by #). It traverses the radiocarpal
joint obliquely to insert into the lunate and triquetrum. The DIC arises from the triquetrum and inserts into
the capitate, the distal scaphoid, and the trapezoid. ERCL = extensor carpi radialis longus, ECRB = extensor
carpi radialis brevis, DRC = dorsal radiocarpal ligament, DIC = dorsal intercarpal ligament. B, Dorsal view of
a right wrist after resection of the extrinsic ligaments. The dorsal aspect of the TFCC, the dorsal radioulnar
ligament, is visualized. The SLIL and LTIL stabilize the proximal carpal row. The capitate and hamate are
identified in the distal carpal row. SLIL = scapholunate interosseous ligament, LTIL = lunotriquetral
interosseous ligament, Cap = capitate, H = hamate. C, Dorsal view of the DRUJ. The distal ulna articulates
with the distal radius at the DRUJ where the distal radial articular surface (sigmoid notch) has a greater
radius of curvature than that of the unlar head. The DRUJ is constrained by the dorsal and volar (not
shown) distal radioulnar ligaments. The distal radioulnar ligaments are components of the TFCC. The Lister
tubercle (designated by #) is identified for reference. UH = ulnar head, US = ulnar styloid, dRUL = dorsal
distal radioulnar ligament. D, End-on view of the articular surface of the right distal radius and the
ulnocarpal joint with the carpus reflected palmarly and ulnarly. The SF and LF of the distal radius are
separated by the scapholunate ridge. The volar extrinsic ligaments originate from the distal radius and
include the RC, RSC, and RL ligaments. Components of the TFCC include the central meniscal homologue
(TFCC), the dorsal and volar radioulnar ligaments (not shown), the UL, the UT, and the floor of the ECU
sheath (not shown). SF = scaphoid facet, LF = lunate facet, RC = radial collateral ligament, RSC =
radioscaphocapitate ligament, RL = radiolunate ligament, UL = ulnolunate ligament, UT = ulnotriquetral
ligament. (Copyright Fraser J. Leversedge, MD; Martin Boyer, MD, MSc, FRCSC; and Charles A. Goldfarb, MD.)
Table 6
Origins and Insertions of the Extrinsic Wrist Ligaments
Ligament
Origin
Insertion
Radial collateral
Radius (0 mm from RS)
Scaphoid waist and distal palmar
trapezium
Radioscaphocapitate
Radius (4 mm from RS)
Scaphoid waist and midpalmar capitate
Radiolunatotriquetral
Radius (10 mm from RS)
Lunate +/- triquetrum
Radioscapholunate
Mesocapsule with termination of AIN and
Ligament of Testut and Kuenz
AIA
Short radiolunate
Volar-ulnar margin of radius
Lunate
Ulnotriquetral
Volar radioulnar ligament
Triquetrum
Ulnolunate
Volar radioulnar ligament
Lunate
Ulnocapitate
Volar margin of the ulnar head
Capitate
Dorsal radiocarpal
Dorsal radius at the Lister tubercle
Lunate and triquetrum
Dorsal intercarpal
Triquetrum
Scaphoid and trapezoid and capitate
Volar Extrinsic, Radiocarpal
Volar Extrinsic, Ulnocarpal
Dorsal Extrinsic
RS = radial styloid tip, AIN = anterior interosseous nerve, AIA = anterior interosseous artery
Figure 5:
Cross-sectional anatomy of
the proximal third (A), middle
third (B), and distal third (C)
of the forearm. (Copyright
Fraser J. Leversedge, MD;
Martin Boyer, MD, MSc, FRCSC;
and Charles A. Goldfarb, MD.)
Table 7
Musculature of the Dorsal Forearm and Wrist
Muscle
Mobile Wad of Three
Brachioradialis
Origin
Insertion
Innervation
Upper supracondylar ridge
Radial styloid
Base of the index finger
metacarpal
Radial nerve
Extensor carpi radialis longus Lower supracondylar ridge
Extensor carpi radialis brevis
Lateral epicondyle, elbow
capsule annular ligament
Superficial Extensor Muscles
Anconeus
Post-lateral epicondyle
Most medial common
Extensor carpi ulnaris
extensor superior ulnar
border
EDM
Common extensor origin
EDC
Deep Extensor Muscles
Common extensor origin
Supinator
Lateral epicondyle, annular
ligament, lateral ulnar
collateral ligament
APL
Radius
EPB
EPL
EIP
Interosseous membrane +/radius
Ulna
Ulna + interosseous
membrane
Radial nerve
Base of the long finger
metacarpal
SBRN, 25%
PIN, 45%
Radial nerve, 30%
Lateral-dorsal ulna
Radial nerve
Base of the small finger
metacarpal
PIN
Small finger extensor
apparatus
Digital extensor apparatus
Anterior proximal radius
Thumb metacarpal base,
trapezium thenar muscle
(varies)
Thumb proximal phalanx,
extensor hood (varies)
Thumb distal phalanx
Index finger extensor
apparatus
PIN
PIN
PIN
PIN
PIN
PIN
PIN
SBRN = superficial branch of the radial nerve, PIN = posterior interosseous nerve, EDM = extensor digiti minimi, EDC = extensor digitorum
communis, APL = abductor pollicis longus, EPB = extensor pollicis brevis, EPL = extensor pollicis longus, EIP = extensor indicis proprius
Table 8
Musculature of the Volar/Flexor Forearm and Wrist
Muscle
Origin
Insertion
Superficial Layer (all cross the
elbow joint)
Superficial head: distal 1 cm of
supracondylar ridge plus medial
epicondyle
Pronator teres
Midlateral radius
Deep head: Medial coronoid
distal to sublime tubercle†
Base of the index and long
finger metacarpals
Palmar aponeurosis
Innervation*
Median nerve
Flexor carpi radialis
Medial epicondyle
PL‡
Medial epicondyle
Median nerve
Medial epicondyle, sublime
Base of P2 (fingers§)
Median nerve
tubercle, anterior radius
Humeral head: medial
Pisiform, pisohamate ligament,
epicondyle
Ulnar nerve
pisometacarpal ligament
Ulnar head: Posteromedial ulna
FDS
FCU
Median nerve
Deep Layer (none crosses the
elbow joint)
FDP
FPL
Pronator quadratus
Anterior plus medial ulna,
interosseous membrane
Anterior radius, interosseous
membrane
Distal ulna
Base of P3 (fingers)
AIN, ulnar nerve
Base of thumb P2
AIN
Volar radius
AIN
* The median nerve may course distally between the FDS and the FDP; commonly within the FDS epimysium, and occasionally within the FDS
substance.
†The deep (ulnar) head of pronator teres separates the ulnar artery (deep) from the median nerve (superficial). It is absent in approximately 6% of
wrists.
‡The palmaris longus is absent unilaterally in ~15% of wrists and bilaterally in 7%.
§There is variable presence of the FDS to the small finger.
PL = palmaris longus, FDS = flexor digitorum superficialis, FCU = flexor carpi ulnaris, FDP = flexor digitorum palmaris, AIN = anterior interosseous
nerve, FPL = flexor pollicis longus
Figure 6:
Illustrations of the primary arterial anatomy of the upper extremity. A, Volar forearm, wrist, and
hand. B, Dorsal forearm, wrist, and hand. (Copyright Fraser J. Leversedge, MD; Martin Boyer, MD,
MSc, FRCSC; and Charles A. Goldfarb, MD.)
Figure 7:
Illustration of the brachial plexus (right). (Copyright Fraser J. Leversedge, MD; Martin
Boyer, MD, MSc, FRCSC; and Charles A. Goldfarb, MD.)
Figure 8:
Illustration of the anatomic course and
branches of the radial nerve in the right
upper extremity. BR = brachioradialis,
ECRL = extensor carpi radialis longus,
ECRB = extensor carpi radialis brevis, ECU
= extensor carpi ulnaris, EDC = extensor
digitorum communis, EDM = extensor
digitorum communis, APL = abductor
pollicis longus, EPL = extensor pollicis
longus, EPB = extensor pollicis brevis, EIP
= extensor indicis proprius, PIN = posterior
interosseous nerve. (Copyright Fraser J.
Leversedge, MD; Martin Boyer, MD, MSc,
FRCSC; and Charles A. Goldfarb, MD.)
Figure 9:
Illustration of the anatomic course and
branches of the ulnar nerve in the right
upper extremity. FCU = flexor carpi
ulnaris, FDP = flexor digitorum
profundus, FPB = flexor pollicis brevis,
ADM = abductor digiti minimi, AdP =
adductor pollicis, FDM = flexor digiti
minimi, ODM = opponens digiti minimi.
(Copyright Fraser J. Leversedge, MD;
Martin Boyer, MD, MSc, FRCSC; and
Charles A. Goldfarb, MD.)
Figure 10:
Illustration of the anatomic course and
branches of the median nerve in the right
upper extremity. PT = pronator teres, FDS =
flexor digitorum superficialis, FCR = flexor
carpi radialis, FDP = flexor digitorum
profundus, AIN = anterior interosseous
nerve, PQ = pronator quadratus, FPB =
flexor pollicis brevis, APB = abductor
pollicis brevis, OP = opponens pollicis.
(Copyright Fraser J. Leversedge, MD; Martin
Boyer, MD, MSc, FRCSC; and Charles A.
Goldfarb, MD.)
A.
B.
C.
D.
E.
Primary Osteoarthritis
Erosive Osteoarthritis
Pulmonary
Hypertrophic
Osteoarthropathy
Posttraumatic Arthritis
Rheumatoid Arthritis
F.
G.
H.
I.
Systemic Lupus
Erythematosus
Psoriatic Arthritis
Gout
Calcium
Pyrophosphate
Deposition Disease
(Pseudogout)
Figure 1:
Drawing showing positioning of the hand on
the radiographic cassette for the
hyperpronated view
Table 1
Radiographic Staging* and Treatment of Thumb CMC Arthritis
Stage
1
2
3
4
CMC Articular CMC Articular CMC Joint (Type
Contour
Space
of Changes)
Normal
Normal
Abnormal
Abnormal
Widened
Mild subluxation
CMC
Scaphotrapezial
Surgical Treatment†
Osteophytes Joint
None
CMC synovectomy and
débridement (arthroscopic)
With joint laxity, ligament
reconstruction (FCR tendon)
None
Arthroscopic débridement
and tendon interposition
Partial trapeziectomy with
tendon interposition
Complete trapeziectomy with
ligament reconstruction and
tendon interposition
Trapeziometacarpal
arthrodesis
> 2 mm
None
Partial trapeziectomy with
tendon interposition.
Complete trapeziectomy
with LRTI
Trapeziometacarpal
arthrodesis
> 2 mm
Pantrapezial
arthrosis
Arthroplasty
Complete trapeziectomy
with LRTI
None
Narrowing
Mild subchondral
< 2 mm
sclerosis
Narrowing
Sclerotic or
cystic changes in
subchondral
bone
Narrowing
Sclerotic or
cystic changes in
subchondral
bone
LRTI = ligament reconstruction and tendon interposition
*As described by Eaton and Littler.
†All stages are initially treated nonsurgically.
Figure 2:
AP radiograph of a stage II SLAC wrist. The
capitate has migrated proximally, and joint space
narrowing is seen between the radial styloid and
the scaphoid as well as between the proximal pole
of the scaphoid and the scaphoid fossa of the
distal radius.
Figure 3:
AP radiograph of a SNAC wrist. Joint space
narrowing is seen between the distal pole of the
scaphoid and the radial styloid as well as between
the distal pole of the scaphoid and the trapezium and
trapezoid. Minimal joint space narrowing is seen
between the proximal pole of the scaphoid and the
scaphoid fossa of the distal radius.
Table 2
Radiographic Staging of SLAC Wrist
Stage
Radiographic Signs
Treatment
I
Arthrosis localized to the radial side of the
Radial styloidectomy plus scapholunate reduction and
scaphoid and the radial styloid. Sharpening
stabilization
of the radial styloid
Elimination of radioscaphoid joint by:
1. Proximal row carpectomy; disadvantages: reduction of wrist
motion and grip strength; should be avoided if there are
capitate head degenerative changes
2. 2. Four corner (lunate, capitate, hamate, triquetrum) fusion
(SLAC procedure). Retains 60% of wrist motion and 80% of
grip strength
3. 3. Other: Radioscapholunate fusion, total wrist arthrodesis,
total wrist arthroplasty
II
Arthrosis of the entire radioscaphoid joint.
(The radiolunate joint is usually spared.)
III
Arthrodesis progressing to the capitolunate 1. SLAC procedure, PRC
joint due to proximal migration of the
2. Total wrist arthrodesis (ideal position is 10° of extension and
capitate
slight ulnar deviation)
PRC = proximal row carpectomy
Table 3
Radiographic Staging of SNAC Wrist
Stage
I
II
III
Radiographic Signs
Treatment
Arthrosis between the distal scaphoid and
radial styloid.
Radial styloidectomy plus fixation of scaphoid nonunion
with bone graft
SLAC procedure
Scaphocapitate arthrosis in addition to stage Proximal row carpectomy
I (proximal scaphoid and corresponding
Total wrist arthrodesis
radial articular surface spared)
Total wrist arthroplasty
SLAC procedure
Periscaphoid arthrosis (proximal lunate and
Total wrist arthrodesis
captiate may be preserved)
Total wrist arthroplasty
Table 4
Ulnar Variance and Load Sharing Across Wrist
Ulnar Variance
Load Sharing
+ 2 mm
60% radius, 40% ulna
+ 1 mm
70% radius, 30% ulna
Neutral
80% radius, 20% ulna
− 1 mm
90% radius, 10% ulna
− 2 mm
95% radius, 5% ulna
Table 5
Table 6
Treatment of RA Affecting the Extensor
Tendons
Treatment of RA Affecting the Flexor
Tendons
Condition
Treatment
Condition/Symptoms
Treatment
Radial deviation and
supination of the carpus only
ECRL to ECU transfer
Nerve compression symptoms
Synovectomy with carpal
tunnel release
Triggering
Distal radioulnar joint arthrosis
Distal ulna resection (Darrach
procedure, hemiresection, or
Sauvé-Kapandji procedure)
Synovectomy with resection
of FDS slip
FPL rupture
FDS transfer or tendon graft
with spur excision
FPL rupture with advanced
disease
Thumb IP joint arthrodesis
FDS ruptures in digits
Observation
FDP ruptures in digits
Synovectomy and DIP joint
arthrodesis
Caput ulna syndrome
EIP to EDQ transfer or EDQ to
EDC piggyback transfer
Multiple tendon ruptures
FDS transfer or palmaris graft
ECRL = extensor carpi radialis longus, ECU = extensor carpi ulnaris, EIP =
extensor indicis proprius, EDQ = extensor digitorum quinti, FDS = flexor
digitorum sublimis.
FPL = flexor pollicis longus, FDS = flexor digitorum sublimis, FDP = flexor
digitorum profundis.
Figure 4:
The pathoetiology of rheumatoid carpal
deform-ity: scaphoid flexion,
scapholunate widening, lunate
translocation, and secondary
radioscaphoid arthrosis combined with
ulnar drift of the digital MCP joints.
(Courtesy of the Indiana Hand Center, ©
Gary Schnitz, 2007.)
Table 7
Table 8
Treatment of RA Affecting the Wrist
Treatment of RA Affecting the MCP
Joint
Severity of Disease/Patient
Characteristics
Treatment
Midcarpal joint well
preserved
Partial arthrodesis
(radiolunate or
scaphoradiolunate)
Advanced disease
Total wrist arthrodesis
Sedentary patient with
good bone stock
Total wrist
arthroplasty
Severity of Disease
Treatment
Early stages
Medical
Ulnar drift with preservation of
articular surface
Soft-tissue realignment
procedures (extensor
relocation, intrinsic release,
collateral ligament reefing)
Severe joint involvement, fixed
deformities, or arthritis—
cartilage loss
MCP joint arthroplasty
Thumb MCP joint involvement
Arthrodesis
Thumb MCP joint involvement
with IP joint involvement
Arthroplasty
Figure 5:
Swan-neck deformity. A, Terminal tendon rupture may be associated with synovitis of the DIP joint, leading
to DIP joint flexion and subsequent PIP joint hyperextension (a). Rupture of the flexor digitorum
superficialis tendon may occur due to infiltrative synovitis which may lead to decreased volar support of the
PIP joint and subsequent hyperextension deformity (b). B, Lateral-band subluxation dorsal to the axis of
rotation of the PIP joint (c), contraction of the triangular ligament (d), and attenuation of the transverse
retinacular ligament (e) are depicted. (Reproduced from Boyer MI, Gelberman RH: Operative correction of
swan-neck and boutonniere deformities in the rheumatoid hand. J Am Acad Orthop Surg 1999;7:95.)
Figure 6:
Boutonniere deformity. Primary synovitis of the PIP joint (a) may lead to attenuation of the
overlying central slip (b) and dorsal capsule and increased flexion at the PIP joint. Lateral-band
subluxation volar to the axis of rotation of the PIP joint (c) may lead in time to hyperextension.
Contraction of the oblique retinacular ligament (d), which originates from the flexor sheath and
inserts into the dorsal base of the distal phalanx, may lead to extension contracture of the DIP
joint. (Reproduced from Boyer MI, Gelberman RH: Operative correction of swan-neck and
boutonniere deformities in the rheumatoid hand. J Am Acad Orthop Surg 1999;7:98.)
Table 9
Treatment of Boutonniere Deformity
Type of Deformity
Treatment
Passively correctable
Splinting
Moderate
Extensor reconstruction (central slip
imbrication, Fowler distal tenotomy)
Stiff contracture
PIP joint arthrodesis or arthroplasty
Table 10
Treatment of Gout
Condition
Treatment
Acute disease
Colchicine or indomethacin
Large gouty tophi are surgically excised.
Severely involved joints treated with
arthrodesis
Chronic disease
Allopurinol
Large gouty tophi
Surgical excision
Severely involved joints
Arthrodesis
Benign Soft-Tissue Tumors
B. Benign Bone Tumors
C. Malignant Soft-Tissue Tumors
D. Malignant Bone Tumors
A.
Figure 1:
A, Axial T1-weighted MRI scan of the hand of an elderly man shows a large, multilobulated, soft-tissue
mass involving the thenar space, as well as both the flexor and extensor compartments with
communication through the interosseous ligaments between the third and fourth metacarpals. The areas
of high signal intensity (arrows) are diagnostic for lipoma. B, Diagram of same cross section shown in A
with structures labeled. (Reproduced from Johnson TR, Steinbach LS [eds]: Essentials of Musculoskeletal
Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, p 159.)
Figure 2:
Oblique (left) and AP (right) views (A) and lateral oblique view (B) of the hand of a 22-year-old woman who
presented with pain in the hand following a punch to an inanimate object. Lucency in the fifth metacarpal is welldefined and is a classic characteristic of an enchondroma. (Reproduced from Bedi A, Beirmann JS: Hand tumors, in
Schwartz HS [ed]: Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2007, p 31.)
A.
B.
C.
D.
E.
Anatomy of the
Brachial Plexus
Classification of Injuries
Mechanism of Injuries
Clinical Examination
Electrodiagnostic
Evaluation
F.
G.
H.
I.
J.
Imaging Evaluation
Determinants of
Treatment
Treatment
Treatment Based on
Type of Injuries
Rehabilitation
Figure 1:
Anatomy of the brachial plexus roots and types of injury. The roots are formed by the coalescence of the
ventral (motor) and dorsal (sensory) roots as they emerge from the spinal cord. The dorsal root ganglion
holds the cell bodies of the sensory nerve fibers conveyed by the dorsal root, whereas the cell bodies for the
ventral nerve fibers lie within the spinal cord. Three types of injury can occur: avulsion (top right) injuries pull
the rootlets out of the spinal cord; stretch injuries (middle right) attenuate the nerve; and ruptures (bottom
right) result in a complete discontinuity of the nerve. (Reproduced with permission from the Mayo Foundation
for Medical Education and Research.)
Figure 2:
Classic form of the brachial
plexus. (Reproduced with
permission from the Mayo
Foundation for Medical
Education and Research.)
Table 1
Frequency of BPI by Anatomic Level
Location of Lesion
Frequency (%)
Supraclavicular
62
Supraclavicular + distal
9
Retroclavicular
7
Retroclavicular + distal
1
Infraclavicular
20
Infraclavicular + distal
1
Figure 3:
Myelography and CT myelography can be instrumental in determining the level of nerve injury.
If a pseudomeningocele is present, there is a greater likelihood of a nerve root avulsion. A, A
myelogram demonstrates multiple root avulsions. The asterisks indicate pseudomeningoceles.
B, CT provides further evaluation of the injury. The arrows point to the nerve roots visible
within the thecal sac on the side opposite the pseudomeningocele. (Reproduced with
permission from the Mayo Foundation for Medical Education and Research.)
Relevant Anatomy and Disease Patterns
B. Pathology
C. Epidemiology
D. Treament
E. Complications
A.
Figure 1:
Normal fascial anatomy of
the palm and digits,
illustrating relationships to
the tendon sheath and
neurovascular bundles.
Figure 2:
Patterns of diseased cords. The spiral cord (derived
from the pretendinous band, spiral band, Grayson
ligament, and lateral digital sheet) displaces the
neurovascular bundle toward the midline. The
Grayson ligment is seen as an isolated thickened
structure. The lateral cord comes off the natatory
cord to merge with the lateral digital sheet along the
midaxial line.
Figure 3:
The retrovascular cord arises from the preaxial
phalanx and courses dorsal to the neurovascular
bundle to insert in the side of the distal phalanx.
It is the usual cause of DIP joint contractures.
A.
B.
C.
D.
Basic Science of Flexor
and Extensor Tendons
Diagnosis of Tendon
Disruption
Primary Repair of
Injured Flexor Tendons
Primary Management
of Extensor Tendon
Injuries
E.
F.
G.
H.
Tendon Repair
Complications
Tendon Reconstruction
Late Complications
After Tendon Injury
and Repair
Conditions Involving
Tendinitis
Figure 1 :
Lateral (A) and dorsal (B)
views of a finger depict the
components of the digital
flexor sheath. The sturdy
annular pulleys (A1, A2, A3, A4,
and A5) keep the tendons
closely applied to the
phalanges. The thin, pliable
cruciate pulleys (C1, C2, and
C3) collapse to allow digital
flexion. The palmar
aponeurosis pulley (PA) adds
to the biomechanical
efficiency of the pulley system.
(Reproduced from Strickland
JW: Flexor tendon injuries: I.
Foundation of treatment. J
Am Acad Orthop Surg
1995;3:44-54.)
Figure 2 :
Finger extensor mechanism anatomy. A, Lateral view. B, Dorsal view. DIP = distal interphalangeal joint,
MCP = metacarpophalangeal joint, ORL = oblique retinacular ligament, PIP = proximal interphalangeal
joint, TRL = transverse retinacular ligament. (Adapted with permission from Coons MS, Green SM:
Boutonniere deformity. Hand Clin 1995;11:387-402.)
Figure 3:
The five zones of flexor tendon injury. Note
the three zones of the thumb. (Copyright
Fraser J. Leversedge, MD, Martin Boyer, MD,
MSc, FRCSC, and Charles A. Goldfarb, MD.)
Figure 4:
The extensor tendon zones of injury.
(Reproduced from Newport ML: Extensor
tendon injuries in the hand. J Am Acad
Orthop Surg 1997;5:59-66.)
Pathophysiology
B. Evaluation
C. Management
D. Late Effects
A.
A.
B.
C.
D.
E.
F.
Fingertip Infections
Septic Flexor
Tenosynovitis
Septic Arthritis
Osteomyelitis
Human Bite Wounds
Animal Bite Wounds
G.
H.
I.
J.
K.
Deep-Space Infections
Uncommon Infections
Conditions Often
Mistaken for Infections
Immunocompromised
Patients
Drug Principles
A.
B.
C.
D.
Peripheral Nerve
Anatomy and
Physiology
Basic Science of Nerve
Compression
Electrophysiology
Common Compression
Neuropathies
E.
F.
G.
Radial Nerve
Compression
Syndromes
Thoracic Outlet
Syndrome
Neuropathies of the
Shoulder
Figure 1 :
Clinical photograph of a patient with anterior
interosseous nerve compression or paralysis. Note
the inability to flex at the interphalangeal joint of the
thumb and the distal interphalangeal joint of the
index finger. (Reproduced from Rizzo M, Cooney WP,
Carlson HL, Mays W: Hand and wrist reconstruction, in
Fischgrund JS [ed]: Orthopaedic Knowledge Update 9.
Rosemont, IL, American Academy of Orthopaedic
Surgeons, 2008, pp 357-376.)
Figure 2 :
Intraoperative photograph showing a ganglion in
the ulnar tunnel causing isolated compression of
the motor branch of the ulnar nerve. (Reproduced
from Rizzo M, Cooney WP, Carlson HL, Mays W: Hand
and wrist reconstruction, in Fischgrund JS [ed]:
Orthopaedic Knowledge Update 9. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 2008,
pp 357-376.)
History
B. Indications and Contraindications
C. Pediatric Replantations
D. Considerations by Level
E. Critical Points in Replantation
A.
Table 1
Kay, Werntz, and Wolff Classification of Ring Avulsion Injuries
Injury Type
Characteristics
Class I
Circulation adequate
Class II
Arterial compromise only
Class III
Inadequate circulation, with bone, tendon, or nerve injury
Class IV
Complete degloving or amputation
Overview
B. Types of Coverage
C. Coverage for Common Defect Sites
D. Muscle Flap of Lower Extremity
E. Soft-Tissue Defects
F. Bone Flaps
G. Tissue expansion
A.
Table 1
The Reconstructive Ladder
Primary closure
Healing by secondary intention
Split-thickness skin grafts
Full-thickness skin grafts
Random pattern local flaps
Axial pattern local flaps
Island pattern local flaps
Distant random pattern flaps
Distant axial pattern flaps
Free tissue transfer
General Information
B. Ulnar Artery Thrombosis
C. Buerger Disease (Thromboangiitis Obliterans)
A.
Figure 1:
Palmar view of the vascular anatomy of
the forearm and hand.
Introduction
B. Conditions Treated With Arthroscopy
C. Patient Setup
D. Portals
E. Complications
A.
Table 1
Palmer Classification of Type 1 (Acute) TFCC Tears
Class
Location
Characteristics
1A
Central
Traumatic tears of articular
disk
1B
Ulnar
Ulnar avulsion
1C
Volar distal
Distal traumatic disruption of
the ulnolunate or
ulnotriquetral ligaments
1D
Radial
Traumatic avulsion from
sigmoid notch of radius
Figure 1:
The standard wrist arthroscopy portals.