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Proximal interphalangeal arthroplasty

Indications Implant arthroplasty is indicated for patients with severe pain, deformity, and loss of motion in the proximal interphalangeal (PIP) joint who have failed nonoperative treatment (splinting, antiinflammatory medication, steroid injection, and/or hand therapy). Silicone implants may be used in patients with inflammatory arthritis, posttraumatic arthritis, or osteoarthritis (OA). Silicone implants act as spacers after joint resection. They are supported by the surrounding ligamentous structures and…

Metacarpophalangeal arthroplasty

Indications Metacarpophalangeal (MCP) arthroplasty is indicated in patients with chronic pain, deformity, or functional loss. Arthrodesis is poorly tolerated at the MCP level because the arc of motion starts at this joint. Implant arthroplasty is the preferred surgical treatment for arthritic MCP joints. There are two common implant options for MCP joints: silicone and pyrocarbon. Silicone implants act as spacers. They are hinged and rely on…

Correction of boutonniere deformity

Indications The boutonniere deformity is characterized by flexion at the proximal interphalangeal (PIP) joint and hyperextension of the distal interphalangeal (DIP) joint. Boutonniere deformities are caused by pathology at the dorsal PIP joint. Disruption of the central slip of the extensor apparatus caused by trauma or synovitis results in flexion ( Fig. 40.1 ). The lateral bands migrate volarly and contract, creating an extension force across…

Correction of swan-neck deformity

Indications The swan-neck deformity is characterized by proximal interphalangeal (PIP) joint hyperextension and distal interphalangeal (DIP) joint flexion. Swan-neck posturing is a result of tendon imbalance; the root cause can be at the wrist or at the metacarpophalangeal (MCP), PIP, or DIP joints. Tendon imbalance may be caused by inflammatory arthritis, trauma, tendon rupture, or general ligamentous laxity. Possible abnormalities in a swan-neck deformity include (…

Stabilization of extensor carpi ulnaris tendon subluxation with extensor retinaculum

Indications The extensor carpi ulnaris (ECU) tendon is stabilized within the ulnar groove by a fibro-osseus subsheath lying deep to the extensor retinaculum ( Fig. 38.1 ). Injury to the subsheath results in volar subluxation of the tendon around the ulna head with forearm rotation. Subsheath injury occurs during hypersupination of the forearm, ulnar deviation and flexion of the wrist, or active contraction of the ECU…

Tendon transfers for rheumatoid tendon attrition rupture

Indications In rheumatoid arthritis patients, tendon rupture is a result of synovitis or attrition over a deformed bone. Common bony pathologies include caput ulnae syndrome (dorsal prominence of the ulna head leading to extensor tendon rupture; Fig. 37.1 ) and Mannerfelt syndrome (flexor pollicis longus [FPL] rupture caused by a volar scaphoid osteophyte. The most ruptured tendon in rheumatoid patients is the extensor digiti minimi (EDM),…

Metacarpophalangeal joint synovectomy, crossed intrinsic tendon transfer, and extensor tendon centralization

Indications Crossed intrinsic tendon transfer is indicated in patients with ulnar subluxation of the extensor tendon and passively correctable ulnar deviation of the digits because of rheumatoid arthritis (RA) or traumatic radial sagittal band rupture. The metacarpophalangeal (MCP) joint must be supple and without significant arthritic changes or subluxation. In RA patients, the index finger ulnar common intrinsic tendon is transferred to the extensor digitorum communis…

Forearm fracture-dislocations (Galeazzi and Monteggia)

Indications Radius and ulna fracture-dislocations require operative treatment in the adult population. The forearm unit consists of the ulna and radius, which are held together proximally at the proximal radioulnar joint (PRUJ), at the interosseous membrane (IOM) along the shaft, and distally at the distal radioulnar joint (DRUJ). Because of their intimate relationship, displaced proximal or midshaft fractures of one bone may result in a dislocation…

Associated ulnar fixation (ulnar styloid and metadiaphyseal fractures)

Indications Ulnar styloid, ulnar metaphyseal, and ulnar metadiaphyseal fractures may be treated after reduction and stabilization of distal radius fractures (DRF). If rigid fixation of a DRF results in a stable distal radioulnar joint (DRUJ), then operative fixation of an associated distal ulnar fracture is not mandatory. The most common causes of instability of the DRUJ after DRF are dorsal angulation and shortening of the DRF…

Corrective osteotomy of radius malunion

Indications Pain or functional impairment in the setting of radiocarpal or distal radioulnar joint (DRUJ) malalignment There are no fixed radiographic criteria for correction, although symptoms often present with radial inclination of less than 10 degrees, volar or dorsal tilt greater than 20 degrees, ulnar variance greater than or equal to 2 mm, and articular incongruity greater than 2 mm. Contraindications Correction of malunion is not…

Operative treatment of distal radius fractures

Indications Operative management is indicated for distal radius fractures that have a dorsal tilt greater than 10 degrees, radial inclination angle of less than 15 degrees, radial shortening greater than 5 mm, positive ulnar variance greater than 3 mm, and/or an intraarticular step-off greater than or equal to 2 mm. Clinical examination The wrist should be assessed for deformity and any open wounds. Open fractures require…

Procedures for avascular necrosis of the lunate (Kienböck disease)

Introduction Kienböck disease describes the avascular necrosis of the lunate. Although its cause and natural history are uncertain, it is thought to progress through four stages: necrosis and subsequent collapse of the lunate, leading to changes in biomechanics of the other carpal bones and finally to the development of arthritis. Nonoperative management of Kienböck disease is controversial and is usually indicated only in stage I disease.…

Distal radioulnar joint reconstruction using palmaris longus graft

Indications Indications for this procedure include: Chronic, symptomatic distal radioulnar joint (DRUJ) instability that is generally associated with irreparable triangular fibrocartilage complex (TFCC) injury No evidence of distal radioulnar joint arthritis. No evidence of a malunited distal radius fracture with resulting DRUJ dysfunction. Contraindications Although not a true contraindication, a relatively flat DRUJ may risk failure of the reconstruction because of inadequate added support and stability…

Ulnar shortening osteotomy for ulnar impaction syndrome

Indications Indications for the procedure include: Inherited or acquired ulnocarpal abutment (ulnar impaction syndrome) Posttraumatic incongruency of the distal radioulnar joint (DRUJ) Loss of radial height associated with distal radius fracture malunion Madelung deformity or premature physeal closure of the distal radius Contraindications There are also several contraindications: DRUJ arthritis Dorsal DRUJ dislocation or other notable DRUJ instability Caution use (relative contraindication) in patients with DRUJ…

Open reduction and fixation of acute lunate or perilunate dislocation, with or without fracture

Indications Acute and subacute perilunate dislocation or fracture-dislocation (<6 weeks). Patients who present more than 6 weeks after the injury may be better served by a salvage procedure, such as a proximal row carpectomy or partial wrist fusion. Although urgent reduction of a perilunate dislocation can often be accomplished by closed means, operative fixation and consideration of open ligamentous repair are generally indicated. Perilunate injury can…

Salvage procedures for scaphoid nonunion

Scaphoidectomy and four-corner fusion Indications Proximal row carpectomy (PRC) and scaphoidectomy with four-corner fusion (4CF) are motion-preserving salvage operations for patients with proximal wrist degeneration or advanced ligamentous injury. There are variations on the 4CF involving different intercarpal (two bone, three bone) fusions; however, the only “partial wrist fusion” technique we will discuss in this chapter is the traditional 4CF. Examples of pathology or surgical diagnoses…

Treatment of scaphoid nonunion

Treatment of scaphoid nonunion Indications Operative treatment of scaphoid nonunion varies based on the timing of the injury, bone loss at the fracture site, location of the fracture, presence of humpback deformity or an increased intrascaphoid angle, and the vascularity of the proximal pole. Humpback deformity results from collapse of the distal pole of the scaphoid. Normal intrascaphoid angle is 30 degrees plus or minus 5…

Open reduction and internal fixation of acute scaphoid fracture

Indications A scaphoid fracture is considered acute when presenting within 6 weeks of injury. Fractures in which presentation is delayed have poorer healing potential and a higher likelihood of progressing to nonunion with or without surgical intervention. The decision to pursue operative or nonoperative intervention depends on a number of factors, including fracture location and pattern within the scaphoid, displacement or deformity, associated ligamentous injury, and…

Scapholunate and lunotriquetral ligament reconstruction with internal brace and tendon grafting

Indications In young individuals without arthritis, attempts at reconstruction rather than salvage should be pursued to recreate the scapholunate and lunotriquetral ligaments. Internal brace and tendon grafting is an option to reconstruct various stages of scapholunate (SL) ligament injury without articular wear, in particular in association with lunotriquetral (LT) ligament dissociation. In cases with both SL and LT ligament tears, proximal row carpectomy is a suitable…