Ebook Essentials of musculoskeletal care (4/E): Part 1

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Part 1 book “Essentials of musculoskeletal care” has contents: Overview of general orthopaedics, anesthesia for orthopaedic surgery, fracture healing, fibromyalgia syndrome, deep vein thrombosis, crystal deposition diseases, compartment syndrome, pain diagram, fracture of the scapula, acromioclavicular injuries, frozen shoulder, impingement syndrome,… and other contents. Essentials 4_front matter.indd 8/25/2010 9:23:05 aM American Academy of Orthopaedic Surgeons American Academy of Pediatrics Essentials of Musculoskeletal Care John F Sarwark, MD Editor E s s E n t i a l s o f M u s c u l o s k E l E ta l c a r E Essentials 4_front matter.indd  © a M E r i c a n a c a d E M y o f o r t h o pa E d i c s u r g E o n s 8/25/2010 9:23:05 aM Board of Directors, 2010-2011 JohnJ Callaghan,MD President DanielJ Berry,MD First Vice-President JohnR Tongue,MD Second Vice-President FrederickM Azar,MD Treasurer JosephD Zuckerman,MD Past-President JeffreyO Anglen,MD RichardJ Barry,MD KevinP Black,MD M BradfordHenley,MD,MBA GregoryA Mencio,MD MichaelL Parks,MD FredC Redfern,MD DavidD Teuscher,MD PaulTornettaIII,MD DanielW White,MD,LTC,MC G ZacharyWilhoit,MS,MBA KarenL Hackett,FACHE,CAE(Ex-Officio) Staff MarkW Wieting Chief Education Officer MarilynL Fox,PhD Director, Department of Publications LaurieBraun Managing Editor StevenKellert Senior Editor MarySteermannBishop Senior Manager, Production and Archives CourtneyAstle Assistant Production Manager SusanMorritzBaim Production Coordinator SuzanneO’Reilly Graphic Designer AnneRaci Database Coordinator KarenDanca Permissions Coordinator AbramFassler Production Database Associate CharlieBaldwin Page Production Assistant HollieBenedik Page Production Assistant MichelleBruno Publications Assistant JaneBaque Senior Manager, Publications Websites KatharineZoëGraham Manager, Website Program Systems and Design ReidStanton Manager, Electronic Media BrianMoore Senior Media Producer E s s E n t i a l s o f M u s c u l o s k E l E ta l c a r E Essentials 4_front matter.indd Published2010bythe AmericanAcademyofOrthopaedicSurgeons 6300NorthRiverRoad Rosemont,IL60018 FourthEdition Copyright2010 bytheAmericanAcademyofOrthopaedicSurgeons ThematerialpresentedinEssentials of Musculoskeletal Care,Fourth Edition,hasbeenmadeavailablebytheAmericanAcademyof OrthopaedicSurgeonsforeducationalpurposesonly Thismaterialisnot intendedtopresenttheonly,ornecessarilybest,methodsorprocedures forthemedicalsituationsdiscussed,butratherisintendedtorepresent anapproach,view,statement,oropinionoftheauthor(s)orproducer(s), whichmaybehelpfultootherswhofacesimilarsituations The recommendationsinthispublicationdonotindicateanexclusivecourse oftreatmentorserveasastandardofmedicalcare Variations,takinginto accountindividualcircumstances,maybeappropriate SomedrugsormedicaldevicesdemonstratedinAcademycoursesor describedinAcademyprintorelectronicpublicationshavenotbeen clearedbytheFoodandDrugAdministration(FDA)orhavebeencleared forspecificusesonly TheFDAhasstatedthatitistheresponsibility ofthephysiciantodeterminetheFDAclearancestatusofeachdrugor deviceheorshewishestouseinclinicalpractice Furthermore,anystatementsaboutcommercialproductsaresolelythe opinion(s)oftheauthor(s)anddonotrepresentanAcademyendorsement orevaluationoftheseproducts Thesestatementsmaynotbeusedin advertisingorforanycommercialpurpose CPT®iscopyright2010AmericanMedicalAssociation Allrights reserved Nofeeschedules,basicunits,relativevalues,orrelatedlistings areincludedinCPT TheAMAassumesnoliabilityforthedatacontained herein Allrightsreserved Nopartofthispublicationmaybereproduced, storedinaretrievalsystem,ortransmitted,inanyform,orbyanymeans, electronic,mechanical,photocopying,recording,orotherwise,without priorwrittenpermissionfromthepublisher ISBN978-0-89203-579-3 PrintedintheUSA Cover art RobertLiberace Anatomic Illustrations ScottThornBarrows,MA,CMI,FAMI  © a M E r i c a n a c a d E M y o f o r t h o pa E d i c s u r g E o n s iii 8/25/2010 9:23:11 aM Essentials of Musculoskeletal Care, 4th Edition Editorial Board John F Sarwark, MD Professor Department of Orthopaedic Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois Michael Huxford, MEd, ATC, CSCS Sports Medicine Coordinator Rehabilitative Services Institute for Sports Medicine Children’s Memorial Hospital Chicago, Illinois April D Armstrong, MD Associate Professor Bone and Joint Institute Penn State Milton S Hershey Medical Center Hershey, Pennsylvania Jerome M Benavides, MD, MBA Orthopaedic Surgeon Foot and Ankle Center of South Texas San Antonio, Texas Jason L Koh, MD Vice-Chairman Department of Orthopaedic Surgery NorthShore University Health System University of Chicago Evanston, Illinois Thomas O Clanton, MD Chief, Foot and Ankle Section The Steadman Clinic – Vail Vail, Colorado John G Seiler III, MD Georgia Hand Shoulder & Elbow Atlanta, Georgia Craig J Della Valle, MD Associate Professor Department of Orthopaedic Surgery Rush University Medical Center Chicago, Illinois Dan M Spengler, MD Professor and Chair Department of Orthopaedics and Rehabilitation Vanderbilt Orthopaedic Institute Nashville, Tennessee Leesa M Galatz, MD Associate Professor Shoulder and Elbow Service Department of Orthopaedic Surgery Washington University School of Medicine St Louis, Missouri David A Spiegel, MD Pediatric Orthopaedic Surgeon Children’s Hospital of Philadelphia Assistant Professor of Orthopaedic Surgery University of Pennsylvania School of Medicine Philadelphia, Pennsylvania Letha Y Griffin, MD, PhD Team Physician Georgia State University Department of Sports Medicine Peachtree Orthopaedic Clinic Atlanta, Georgia Kathleen Weber, MD, MS Assistant Professor Department of Orthopaedic and Internal Medicine Rush University Medical Center Chicago, Illinois Review Board Section on Orthopaedics Keith R Gabriel, MD Associate Professor Department of Surgery Southern Illinois University School of Medicine Springfield, Illinois iv E s s E n t i a l s o f M u s c u l o s k E l E ta l c a r E Essentials 4_front matter.indd Council on Sports Medicine and Fitness Blaise A Nemeth, MD, MS Assistant Professor (CHS) Department of Orthopaedics and Rehabilitation Department of Pediatrics American Family Children’s Hospital University of Wisconsin School of Medicine and Public Health Madison, Wisconsin  © a M E r i c a n a c a d E M y o f o r t h o pa E d i c s u r g E o n s 8/25/2010 9:23:14 aM EditorialBoardDisclosures NeitherDr Armstrongnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication NeitherDr Benavidesnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication Dr Clantonoranimmediatefamilymemberservesasan unpaidconsultanttoArthrex Dr DellaValleoranimmediatefamilymemberservesas aboardmember,owner,officer,orcommitteememberof theAmericanAssociationofHipandKneeSurgeonsand theArthritisFoundation;servesasapaidconsultanttoor isanemployeeofBiomet,Kinamed,Smith&Nephew, andZimmer;hasreceivedresearchorinstitutionalsupport fromZimmer;andhasreceivednonincomesupport(suchas equipmentorservices),commerciallyderivedhonoraria,or othernon–research-relatedfunding(suchaspaidtravel)from Stryker Dr Galatzoranimmediatefamilymemberservesasan unpaidconsultanttoTornierandhasreceivedresearch orinstitutionalsupportfromBiomet,Breg,Cerapedics, Medtronic,Smith&Nephew,Stryker,Synthes,Wright MedicalTechnology,Wyeth,AxialBiotech,MidwestStone Institute,andK2M Dr Griffinoranimmediatefamilymemberservesasa boardmember,owner,officer,orcommitteememberofthe PiedmontHospital,GeorgiaStateUniversityAthleticBoard, andtheAmericanOrthopaedicSocietyforSportsMedicine Dr Kohoranimmediatefamilymemberservesasaboard member,owner,officer,orcommitteememberoftheIllinois AssociationofOrthopaedicSurgeons;isamemberofa speakers’bureauorhasmadepaidpresentationsonbehalfof Aesculap/B.BraunandArthrex;servesasapaidconsultantto orisanemployeeofAesculap/B.BraunandArthrex;andhas receivedresearchorinstitutionalsupportfromAesculap/B Braun,Arthrex,andEnturia NeitherDr Sarwarknoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication Dr Seileroranimmediatefamilymemberservesasa boardmember,owner,officer,orcommitteememberof theAmericanBoardofOrthopaedicSurgery;hasreceived royaltiesfromSalumedica;servesasanunpaidconsultantto SynthesandArthrex;hasreceivedresearchorinstitutional supportfromAvance;andownsstockorstockoptionsin Orthovita Dr Spengleroranimmediatefamilymemberservesasa boardmember,owner,officer,orcommitteememberofthe MusculoskeletalTransplantFoundation Dr Spiegeloranimmediatefamilymemberservesasa boardmember,owner,officer,orcommitteememberofthe PediatricOrthopaedicSocietyofNorthAmerica Dr Weberoranimmediatefamilymemberownsstockor stockoptionsinPfizer NeitherMr Huxfordnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication E s s E n t i a l s o f M u s c u l o s k E l E ta l c a r E Essentials 4_front matter.indd  © a M E r i c a n a c a d E M y o f o r t h o pa E d i c s u r g E o n s v 8/25/2010 9:23:17 aM Contributors Albert J Aboulafia, MD, MBA Co-Director of Sarcoma Services Department of Orthopaedic Surgery The Alvin & Lois Lapidus Cancer Institute Baltimore, Maryland Lindsay Andras, MD Orthopaedic Resident Emory Orthopaedics Emory University Atlanta, Georgia Sigurd H Berven, MD Rebecca Carl, MD Professor of Pediatrics Department of Orthopaedic Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois Brian D Dierckman, MD Resident Department of Orthopaedic Surgery Emory University Atlanta, Georgia Julie A Dodds, MD Associate Clinical Professor College of Human Medicine Michigan State University East Lansing, Michigan Robert T Floyd, EdD, ATC Director of Athletic Training and Sports Medicine Chair and Professor of Physical Education and Athletic Training Department of Athletic Training The University of West Alabama Livingston, Alabama Jordyn Griffin, BA Medical Student Medical College of Georgia Augusta, Georgia George N Guild III, MD Orthopaedic Surgeon Department of Orthopaedic Surgery Emory University Atlanta, Georgia vi Stephen C Hamilton, MD Resident Department of Orthopaedic Surgery Emory University Atlanta, Georgia Kyle E Hammond, MD Resident Physician Department of Orthopaedic Surgery Emory University Atlanta, Georgia James S Kercher, MD Department of Orthopaedic Surgery Emory University Atlanta, Georgia Yukiko Kimura, MD Chief of Pediatric Rheumatology Joseph M Sanzari Children’s Hospital Hackensack University Medical Center Hackensack, New Jersey L Andrew Koman, MD Chair and Professor Department of Orthopaedic Surgery Wake Forest University School of Medicine Winston-Salem, North Carolina Lindsey Snyder Knowles, DPT, STC Department of Outpatient Orthopaedics and Sports Physical Therapy Atlanta Sport & Spine Physical Therapy Atlanta, Georgia Joseph M Lane, MD Chief Metabolic Bone Service Department of Orthopaedics Hospital for Special Surgery New York, New York Thomas J Moore, MD Associate Professor Department of Orthopaedic Surgery Emory University Atlanta, Georgia E s s E n t i a l s o f M u s c u l o s k E l E ta l c a r E Essentials 4_front matter.indd  Robert Murphy, MS, ATC Assistant Athletic Director for Sports Medicine Department of Intercollegiate Athletics Georgia State University Atlanta, Georgia Shane J Nho, MD, MS Assistant Professor Section of Sports Medicine Department of Orthopaedic Surgery Rush University Medical Center Chicago, Illinois Michael S Pinzur, MD Professor of Orthopaedic Surgery Department of Orthopaedic Surgery Loyola University Health System Maywood, Illinois Michael S Sridhar, MD Resident Department of Orthopaedic Surgery Emory University Atlanta, Georgia Harlan M Starr, MD Resident Physician Department of Orthopaedic Surgery Emory University School of Medicine Atlanta, Georgia Brian L Thomas, MD Chairman Department of Anesthesiology Piedmont Hospital Atlanta, Georgia Lawrence Wells, MD Attending Orthopaedic Surgeon Department of Orthopaedic Surgery The Children’s Hospital of Philadelphia Assistant Professor of Orthopaedic Surgery University of Pennsylvania School of Medicine Philadelphia, Pennsylvania © a M E r i c a n a c a d E M y o f o r t h o pa E d i c s u r g E o n s 8/25/2010 9:23:20 aM Contributors’Disclosures NeitherDr Aboulafianoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication Dr Andrasoranimmediatefamilymemberhasreceived researchorinstitutionalsupportfromOsteotechandowns stockorstockoptionsinEliLilly Dr Bervenoranimmediatefamilymemberservesasa boardmember,owner,officer,orcommitteememberofthe BoneandJointDecade,USA,theNorthAmericanSpine Society,andtheScoliosisResearchSociety;servesasapaid consultanttoorisanemployeeofAlphatecSpine,Biomet, DePuy,MedtronicSofamorDanek,Osteotech,Stryker: Pioneer;andUSSpine;hasreceivedresearchorinstitutional supportfromOREFandtheAOFoundation;andownsstock orstockoptionsinBaxano,Simpirica,Providence,Axis,and AccuLif NeitherDr Carlnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication Dr Dierckmanoranimmediatefamilymemberhasreceived researchorinstitutionalsupportfromSurgicalMonitoring AssociatesandStrykerandhasreceivednonincomesupport (suchasequipmentorservices),commerciallyderived honoraria,orothernon–research-relatedfunding(suchaspaid travel)fromSynthes Dr Doddsoranimmediatefamilymemberservesasa boardmember,owner,officer,orcommitteememberofthe ArthroscopyAssociationofNorthAmericaandtheSaint LawrenceOutpatientSurgeryCenter Mr Floydoranimmediatefamilymemberservesasaboard member,owner,officer,orcommitteememberoftheNational AthleticTrainersAssociationandtheNationalAthletic TrainersAssociationResearchandEducationFoundation Ms Griffinoranimmediatefamilymemberservesasa boardmember,owner,officer,orcommitteememberofthe PiedmontHospital NeitherDr Guildnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication NeitherDr Hamiltonnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication NeitherDr Hammondnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication NeitherDr Kerchernoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication Dr Kimuraoranimmediatefamilymemberservesasa boardmember,owner,officer,orcommitteememberofthe ArthritisFoundation;hasreceivedroyaltiesfromOxford UniversityPressandUpToDate;andhasreceivedresearchor institutionalsupportfromRoche E s s E n t i a l s o f M u s c u l o s k E l E ta l c a r E Essentials 4_front matter.indd  Dr Komanoranimmediatefamilymemberservesasa boardmember,owner,officer,orcommitteememberofDT ScimedandKeranetics;servesasapaidconsultanttooris anemployeeofDTScimedandQRxPharma;hasreceived researchorinstitutionalsupportfromDatatrace,Allergan, Biomet,DTScimed,Johnson&Johnson,Keranetics,Smith& Nephew,Synthes,WrightMedicalTechnology,andZimmer; ownsstockorstockoptionsinWrightMedicalTechnology; andhasreceivednonincomesupport(suchasequipmentor services),commerciallyderivedhonoraria,orothernon– research-relatedfunding(suchaspaidtravel)fromDatatrace, DTScimed,andKeranetics NeitherDr Knowlesnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication Dr Laneoranimmediatefamilymemberisamemberofa speakers’bureauorhasmadepaidpresentationsonbehalf ofGlaxoSmithKline,EliLilly,Procter&Gamble,SanofiAventis,Novartis,andRoche;servesasapaidconsultanttoor isanemployeeofBiomimetic,Orthovita,Osteotech,Zimmer, InnovativeClinicalSolutions,D’Fine,Biomimetics,Soteria, ZelosThearpeutics,andKuros;andhasreceivednonincome support(suchasequipmentorservices),commercially derivedhonoraria,orothernon–research-relatedfunding (suchaspaidtravel)fromAmgen Dr Mooreoranimmediatefamilymemberisamemberof aspeakers’bureauorhasmadepaidpresentationsonbehalf ofOsteotechandSynthes,servesasanunpaidconsultantto Osteotech,andhasreceivedresearchorinstitutionalsupport fromSynthes Dr Murphyoranimmediatefamilymemberservesasaboard member,owner,officer,orcommitteememberofCollege AthleticTrainers’Societyandownsstockorstockoptionsin Stryker Dr Nhooranimmediatefamilymemberhasreceived researchorinstitutionalsupportfromArthrex,DJ Orthopaedics,Linvatec,Ossur,Smith&Nephew,Athletico, andMiomed Dr Pinzuroranimmediatefamilymemberisamemberof aspeakers’bureauorhasmadepaidpresentationsonbehalf ofSBI,Smith&Nephew,andAscension;servesasapaid consultanttoorisanemployeeofSBIandSmith&Nephew; andhasreceivedresearchorinstitutionalsupportfrom SynthesandBiomimetic NeitherDr Sridharnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofhischapter NeitherDr Starrnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication NeitherDr Thomasnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication NeitherDr Wellsnoranyimmediatefamilymember hasreceivedanythingofvaluefromorownsstockina commercialcompanyorinstitutionrelateddirectlyor indirectlytothecontentofthispublication © a M E r i c a n a c a d E M y o f o r t h o pa E d i c s u r g E o n s vii 8/25/2010 9:23:23 aM Dedication To health care providers everywhere—who devote their careers to the health and well-being of individual patients and families, both young and old Essentials 4_front matter.indd 8/25/2010 9:23:28 aM SECTION HAND AND WRIST SPRAINS AND DISLOCATIONS OF THE HAND Figure Buddy taping Figure 514 Dorsal extension block splint for PIP dislocations Splint allows flexion (A) but blocks the last 20° to 30° of extension (B), preventing excessive motion of the volar plate adductor pollicis tendon between the end of the ulnar collateral ligament and the base of the proximal phalanx prevents adequate repair of the avulsed ligament Nonsurgical treatment for sprains and dislocations focuses on relocation of the joint and protection of the reduction with splinting Reduction of a dorsal dislocation of the PIP joint is usually performed with axial traction and flexion of the proximal phalanx (see below) Buddy taping to an adjacent finger is effective treatment for collateral ligament injuries in the finger joints (Figure 8) Complete rupture of the volar plate, associated with dorsal dislocation, is treated by splinting the joint in 20° to 30° of flexion for to weeks or using buddy taping and early motion Incomplete tears of the ulnar collateral ligament of the thumb MP joint can be treated in a thumb spica cast with the thumb slightly flexed for to weeks The duration of treatment is based on subsequent clinical examination and radiographs Closed reduction of a PIP or distal interphalangeal (DIP) joint dislocation should be performed under a digital block anesthetic (see pages 455-457) To reduce the dislocation, grasp the distal portion of the finger and apply longitudinal traction while stabilizing the finger or hand proximal to the dislocation Apply gentle pressure over the dorsum of the deformity to guide the reduction After reduction, move the finger through a range of motion and then assess collateral ligament stability If the joint seems stable, the finger can be buddy taped If the joint has full range of motion after the reduction but tends to dislocate during the last 20° of extension, apply a dorsal extension block splint to allow healing of the volar plate (Figure 9) This type of splint blocks the last 20° to 30° of extension Use the splint for to weeks; then buddy tape the finger to an adjacent finger for an additional weeks The relocation of MP joint dislocations may require regional nerve blocks If the dislocation cannot be reduced with adequate anesthesia, soft tissue could be interposed, and open reduction may be necessary (Figure 10) DIP dislocations are typically dorsal or dorsolateral With open injuries, suspect an associated tear of the extensor tendon After adequate digital block anesthesia, apply longitudinal traction to reduce the dislocation Open dislocations need appropriate irrigation and débridement but tend to be stable after reduction Next, apply a dorsal aluminum splint over the middle and distal phalanges for to weeks If the fingertip droops after the reduction and the patient cannot actively extend the distal phalanx, treat the injury as a mallet finger (see page 501) Carefully examine the flexor digitorum profundus tendon after relocation for discomfort on DIP flexion Some patients have a significant partial flexor digitorum profundus injury following dorsal dislocation of the DIP joint E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S Figure 10 Entrapment of the metacarpal head between the lumbrical and extrinsic flexor tendons (Reproduced with permission from the American Society for Surgery of the Hand: Hand Surgery Update Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, p 22.) SECTION HAND AND WRIST SPRAINS AND DISLOCATIONS OF THE HAND Adverse Outcomes of Treatment Instability, joint stiffness, persistent hyperextension deformity, and/or residual flexion deformity can develop Arthritis also may develop with an inadequate reduction Referral Decisions/Red Flags Patients with an unstable thumb MP joint (suggestive of complete ulnar collateral ligament injury) require further evaluation for possible surgical stabilization Patients whose dislocations cannot be reduced easily with digital anesthesia are candidates for open reduction In addition, patients with fracturedislocations and open dislocations require further evaluation Open dislocations are best treated surgically to achieve adequate débridement and repair E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S 515 Trigger Finger SECTION HAND AND WRIST ICD-9 Code 727.03 Trigger finger Synonyms Locked finger Stenosing tenosynovitis of the flexor tendons Definition The flexor tendons of the fingers glide back and forth under four annular and three cruciform pulleys that keep the tendons from bowstringing The flexor tendon or first annular pulley may become thickened from chronic inflammation and irritation Any thickening can limit the amount of effective tendon excursion As a result of the limited motion, the finger may snap or lock during flexion (Figure 1) The long and ring fingers are most commonly affected, but any digit may be involved Trigger finger may be idiopathic or associated with rheumatoid arthritis or diabetes mellitus The idiopathic type is more often observed in middle-aged women A higher prevalence of trigger finger is observed in patients with carpal tunnel syndrome and de Quervain stenosing tenosynovitis Trigger finger may occur in young children, usually in the thumb Figure Trigger finger A nodule or thickening in the flexor tendon becomes trapped proximal to the pulley, making finger extension difficult 516 E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S TRIGGER FINGER SECTION HAND AND WRIST Treatment Initial treatment may involve a short course of NSAIDs or injection of corticosteroid into the tendon sheath (see pages 519-520) Care must be exercised to avoid injecting the tendon, as corticosteroid injected into a tendon may predispose it to rupture If symptoms persist, a second injection in to weeks is indicated However, because patients with rheumatoid disease are already at increased risk for tendon rupture, only one injection is indicated for these patients before surgical release should be considered If two injections fail to resolve the trigger finger, surgical release should be considered Adverse Outcomes of Treatment NSAIDs can cause gastric, renal, or hepatic complications Repeated corticosteroid injections might lead to rupture of the flexor tendon and also may injure the digital sensory nerve Infection also is a risk In patients with diabetes mellitus, steroid injections may increase blood glucose levels Rarely, injury to the distal nerve may occur at surgery Referral Decisions/Red Flags Failure of nonsurgical treatment, development of contractures in the PIP joint, and/or a locked finger (in flexion or extension) indicate a need for further evaluation Patients with rheumatoid arthritis in whom the problem does not resolve after a single injection also need additional evaluation Patients with type diabetes mellitus who cannot tolerate steroid injection require specialty evaluation 518 E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S TRIGGER FINGER Patients typically report pain and catching when they flex the finger and may describe the finger as going “out of joint.” They may awaken with the finger locked in the palm, although the finger gradually unlocks during the day The proximal interphalangeal (PIP) joint may be identified as the source of the pain, but the stenosis is at the level of the metacarpophalangeal (MP) joint Some patients have a painful nodule in the distal palm, usually at the level of the distal flexion crease, with no history of triggering In other patients, the only symptoms are swelling and/or stiffness in the fingers, particularly in the morning In patients with rheumatoid arthritis or diabetes mellitus, several fingers may be involved Tests Physical Examination Examination reveals tenderness in the palm at the level of the distal palmar crease, usually at the level of the MP joint A nodule also may be palpable at this site The nodule moves, and the finger may lock when the patient flexes and extends the affected finger This maneuver is almost always painful for the patient Full flexion of the finger may not be possible SECTION HAND AND WRIST Clinical Symptoms Diagnostic Tests This is a clinical diagnosis; radiographs are not needed Differential Diagnosis ■ ■ ■ ■ ■ ■ ■ ■ Anomalous muscle belly in the palm (swelling more proximal in the palm) Diabetes mellitus (single and multiple trigger fingers) Dupuytren disease (palpable cord) Extensor tendon subluxation Ganglion of the tendon sheath (tendon mass at the base of the finger that does not move with flexion) Partial tendon injury PIP joint injury Rheumatoid arthritis (multiple joint involvement) Adverse Outcomes of the Disease Flexion contracture of the PIP joint or stiffness in extension may develop E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S 517 The flexor tendons pass beneath a pulley situated just distal to the distal palmar crease Palpating this area as the patient flexes and extends the finger reveals a click or snapping sensation as the enlarged tendon passes beneath the pulley Note: Opinions differ regarding single- and two-needle injection techniques Proponents of the single-needle technique believe that one needle is less painful for the patient than two Because the corticosteroid preparation is thicker than the local anesthetic, however, a slightly larger gauge needle is required at the outset The DVD shows a two-needle, two-syringe technique CPT Code 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”) Current Procedural Terminology © 2010 American Medical Association All rights reserved SECTION HAND AND WRIST Procedure: Trigger Finger Injection Materials Step • Sterile gloves Wear protective gloves at all times during this procedure and use sterile technique • Bactericidal skin preparation solution Step • to mL of a 1% local anesthetic without epinephrine Cleanse the palm with a bactericidal skin preparation solution • Two 3-mL syringes with a 25-gauge needle Step • mL of a corticosteroid preparation Identify the lump on the tendon Infiltrate the skin at the distal palmar crease, which directly overlies the tendon, and inject the anesthetic at that level • Adhesive dressing Step Inject 0.5 mL of a 1% anesthetic solution into the subcutaneous tissue and then advance the needle into the tendon sheath and inject the rest of the anesthetic (Figure 1) Continue to insert the needle as the patient moves the affected finger through a small arc of flexion and extension When the needle touches the moving tendon, the patient will experience a scratchy sensation If the needle moves, it has penetrated the tendon and should be partially withdrawn until the scratchy sensation occurs At this point, the needle tip is inside the tendon sheath but external to the tendon Step Leave the needle in place, change syringes, and then inject the corticosteroid preparation E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S 519 SECTION HAND AND WRIST PROCEDURE: TRIGGER FINGER INJECTION Figure A, Location for needle insertion for trigger finger injection B, Proper positioning of the needle, through the pulley and into the tendon sheath Step Check the finger for filling of the tendon sheath with the solution Step Dress the puncture site with a sterile adhesive bandage Adverse Outcomes Injection of a corticosteroid into the subcutaneous tissues may lead to depigmentation and/or local fat atrophy, resulting in a tender, unsightly depression beneath the skin Aftercare/Patient Instructions Advise the patient of possible significant discomfort for to days following any injection of a corticosteroid Also, the finger may be numb for to hours until the local anesthetic wears off Instruct the patient to return to your office if swelling, redness, or inordinate pain occurs The patient should be able to use the finger in a normal fashion after the injection 520 E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S Definition ICD-9 Codes Most tumors in the hand and wrist are benign, with primary malignant tumors and skeletal metastases accounting for less than 1% of these neoplasms Ganglia are the most common benign soft-tissue tumors, followed by giant cell tumors and epidermal inclusion cysts Enchondromas are the most common benign neoplasm of the bones of the hand, accounting for 90% of all cases Squamous cell carcinomas are the most common malignant neoplasm of the hand, and chondrosarcomas are the most common primary malignant bone tumor in the hand Malignant melanomas are frequently seen in the upper extremity because of exposure of the arm to the sun 195.4 Malignant neoplasm, upper limb 213.5 Benign neoplasms of short bones of upper limb 229.8 Benign neoplasms of other and unspecified sites SECTION HAND AND WRIST Tumors of the Hand and Wrist Clinical Symptoms Many tumors of the hand are painless The exception is a glomus tumor, which characteristically is extremely painful and sensitive to cold Enchondromas present with pain after a patient sustains a pathologic fracture through the weakened bone Lipomas can cause pain and numbness in the fingers if the lesion is compressing an adjacent nerve Masses located near joints can cause loss of motion Tests Physical Examination Note the position, size, and characteristics of the mass (Figures and 2) These factors help to narrow the diagnostic possibilities A ganglion cyst is characterized as a mass located over the dorsal or volar radial aspect of the wrist, over the flexion crease of the finger at the level of the web space, or over the top of the distal interphalangeal joint of a finger Epidermal inclusion cysts typically occur around the end of a digit or at the end of an amputation stump Pressing a small flashlight against an inclusion cyst will not transilluminate the mass, but this same maneuver will transilluminate a ganglion cyst A giant cell tumor is characterized by a multinodular, firm, nontender mass located around an interphalangeal joint, usually of the thumb or the index or long finger E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S 521 SECTION HAND AND WRIST TUMORS OF THE HAND AND WRIST Figure Typical locations and types of benign hand tumors A blue or red area visible under the fingernail could be a glomus tumor, subungual hematoma, or foreign body However, subungual discoloration in the absence of trauma should raise a suspicion of melanoma Likewise, a mole (nevus) that changes shape or color can indicate a malignant melanoma Lipomas typically are superficial, soft, reasonably well defined, and nontender on palpation A frequent location in the hand is the thenar eminence When lipomas are located on the palmar surface of the wrist, compression of the median or ulnar nerve may occur Recurrent paronychia infections and chronic nail deformities can be caused by underlying squamous cell carcinoma A diagnosis of Kaposi sarcoma should be suspected in a patient with AIDS who develops skin nodules or red-brown plaques A symptomatic enchondroma is characterized by tenderness and swelling over the involved phalanx (usually the proximal) A pathologic fracture may be present A carpal boss is a dorsal prominence at the base of the third metacarpal or second metacarpal These dorsal osteophytes may be confused with a neoplasm A ganglion is sometimes associated with a carpal boss 522 E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S SECTION HAND AND WRIST TUMORS OF THE HAND AND WRIST Figure Clinical appearance of various hand tumors A, Ganglion (mucous) cyst B, Epidermoid cyst C, Giant cell tumor D, Glomus tumor E, Melanoma F, Lipoma G, Squamous cell carcinoma H, Enchondroma (Reproduced from Evers B, Klammer HL: Tumors and tumorlike lesions of the hand Arch Am Acad Orthop Surg 1997;1:37-42.) Diagnostic Tests PA and lateral radiographs of the involved finger or PA, lateral, and oblique views of the hand should be obtained Differential Diagnosis See Table and Figure for a complete listing Adverse Outcomes of the Disease Ganglions can result in limited joint motion Nail changes, skin atrophy, and infection can develop as a result of a mucoid cyst Drainage is a problem associated with epidermal mucoid cysts Patients with giant cell tumors may have limited tendon function because of peritendinous adhesions Nerve compression can develop as a result of lipoma With an enchondroma, fracture can occur Squamous cell carcinomas and malignant melanoma can metastasize and result in death E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S 523 Synonym ICD-9 Code Ulnar tunnel syndrome 354.2 Lesion of ulnar nerve Definition Entrapment of the ulnar nerve at the wrist usually is caused by a space-occupying lesion such as a lipoma, ganglion, ulnar artery aneurysm, or muscle anomaly (Figure 1) Repetitive trauma, such as operating a jackhammer or using the base of the hand as a hammer, also may cause ulnar neuropathy at the wrist Ulnar nerve entrapment at the wrist is less common than ulnar nerve entrapment at the elbow SECTION HAND AND WRIST Ulnar Nerve Entrapment at the Wrist Figure Distal ulnar tunnel showing the three zones of entrapment Lesions in zone cause both motor and sensory symptoms, lesions in zone cause motor deficits, and lesions in zone create sensory deficits E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S 525 TUMORS OF THE HAND AND WRIST Table Common Benign Tumors of the Hand and Wrist Common Location(s) Patient Age and Sex Epidermal inclusion cyst Fingertip or anywhere from penetrating injury Teens to middle age; more common in men Painless, slow growing; does not transilluminate Round soft-tissue mass, also in distal phalanx Giant cell tumor of tendon sheath Digits on palmar surface > 30 years; ratio of men to women, 2:3 Slowly enlarging painless mass 20% show cortical erosion Glomus tumor 50% occur under fingernail 30 to 50 years; ratio of women to men, 2:1 Triad of symptoms: marked pain, cold intolerance, very tender; blue discoloration of nail Some show erosion on lateral view Lipoma Thenar area in palm and first web space 30 to 60 years; slight predominance in women Painless, slow growing; might cause nerve entrapment No bony involvement, soft-tissue mass Enchondroma In proximal phalanges or metacarpals 10 to 60 years; affects men and women equally Might become painful after trauma because of fracture Radiolucent expansive lesion, cortex thin, fracture and areas of calcification possibly visible SECTION HAND AND WRIST Type of Tumor* Signs and Symptoms Radiographic Findings Ganglion cyst (see Ganglia of the Wrist and Hand, p 488) * See Figure Treatment Treatment is based on the diagnosis For some tumors, MRI will add significant additional information regarding the nature of the mass Surgical excision and histologic examination are required for most expanding or symptomatic masses Adverse Outcomes of Treatment Ganglions recur at the same site in 5% to 10% of patients The recurrence rate of giant cell tumors is relatively high after surgical excision Joint stiffness can develop after treatment of pathologic fractures caused by enchondromas Referral Decisions/Red Flags Patients with a painful or expanding mass, one that interferes with function, or one believed to be malignant require further evaluation Pigmented subungual lesions should be referred for evaluation 524 E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S ULNAR NERVE ENTRAPMENT AT THE WRIST Clinical Symptoms SECTION HAND AND WRIST Patients may or may not have pain, but they often report weakness and numbness Tests Physical Examination Figure Intrinsic muscle wasting indicative of ulnar nerve entrapment at the wrist Inspect the hypothenar eminence for atrophy Assess sensory and motor function of the ulnar nerve In some patients, only the motor branch of the ulnar nerve may be affected, sparing the sensory branches; however, with sensory involvement, tapping over the ulnar nerve in the hypothenar region will produce tingling in the ring and little fingers (Tinel sign) Sensation over the dorsal and ulnar aspects of the hand is normal When the ulnar nerve is involved at the elbow, almost all patients will have both sensory and motor involvement, with numbness over the dorsal and ulnar sides of the hand Motor weakness is detected by atrophy of the hypothenar and intrinsic muscles or weakness of the intrinsic muscles (muscles that spread the finger) (Figure 2) Diagnostic Tests Results of electrophysiologic studies may be abnormal and may differentiate ulnar entrapment at the wrist from the more common entrapment at the elbow Differential Diagnosis ■ ■ ■ ■ ■ ■ ■ Carpal tunnel syndrome (usually involves the thumb and the index, long, and ring fingers) Cervical (C7-C8) radiculopathy (more proximal muscle involvement, numbness on the dorsum of the hand) Peripheral neuropathy (from diabetes, alcoholism, or hypothyroidism; more generalized numbness) Thoracic outlet syndrome (symptoms more diffuse) Ulnar artery thrombosis in the hand (positive Allen test, firm cord on the ulnar side of the hand) Ulnar neuropathy at the elbow or cubital tunnel syndrome (sensory changes on the dorsum of the hand) Wrist arthritis (pain, limited motion, evident on radiographs) Adverse Outcomes of the Disease Loss of intrinsic muscle function causes decreased grip strength and pinch Sensory loss, when present, involves the ring and little fingers In advanced disease, clawing of the ring and little fingers can develop 526 E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S ULNAR NERVE ENTRAPMENT AT THE WRIST Because the usual cause of ulnar entrapment at the wrist is extrinsic compression (because of a lipoma, ganglion, or tumor, for example), treatment is usually surgical When the obvious cause is external pressure, such as resting the hypothenar area on a keyboard or desk, then the use of padding or a change in position could help Adverse Outcomes of Treatment Postoperative infection, persistent symptoms, or both are possible Referral Decisions/Red Flags Patients with ulnar weakness and neuropathy need further evaluation E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S SECTION HAND AND WRIST Treatment 527 PAIN DIAGRAM Hip and Thigh snapping hip dislocation of the hip trochanteric bursitis fracture of the pelvis hip fracture (Fracture of the Proximal Femur) hip impingement inflammatory arthritis and other conditions osteoarthritis of the hip osteonecrosis of the hip strains of the hip transient osteoporosis of the hip trochanteric bursitis lateral femoral cutaneous nerve syndrome fracture of the femoral shaft strains of the thigh 528 E s s E n t i a l s o f M u s c u l o s k E l E ta l c a r E  © a M E r i c a n a c a d E M y o f o r t h o pa E d i c s u r g E o n s ... theUpperExtremity 11 01 GenuVarum 10 40 C ongenitalDeformities of theLowerExtremity 11 12 JuvenileIdiopathic Arthritis 10 46 C ongenitalDeformities of theUpperExtremity 11 18 Kyphosis 11 91 ToeWalking 11 22... Fractures of the DistalForearm 10 89 Fractures of theProximal andMiddleForearm 11 47 Osteomyelitis 11 55 PreparticipationPhysical Evaluation 11 64 Scoliosis 11 70 SepticArthritis 10 91 Fractures of theFemur... 10 06 FootandAnklePain 10 73 F ractures of the GrowthPlate 10 11 GrowingPain 10 76 FracturesAbouttheElbow 10 13 AccessoryNavicular 10 82 Fractures of theClavicle andProximalHumerus 11 51
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