OA HAND
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- DIPJ OA = Herbeden Nodes
- PIPJ OA = Bouchard's Nodes
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- Confirm cyst with transillumination
- Nail ridging - mucous cyst pressing on the germinal matrix ➔ nail ridging
- Need TRO rheumaroid arthritis, psoriatic arhritis
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- Non Op - 20-60% spontaneously resolve
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- impending rupture, infected
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- “Cyst excision, osteophyte resection KIV fusion”
- Considerations - may need rotational flap for skin coverage if doing cyst excision
- Other option is don’t do excision to avoid need for flap.
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- Zitelli Bilobed flap
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- To try to prevent recurrence as increased dorsal joint space leads to one way valve.
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- Headless compression screw best fusion rates
- K-wires risk of pin track infection
Base of thumb OA
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- Saddle joint, and thus it is unstable, stabilized by 16 ligaments, of which main ones are:
- 5 ligaments stabilising base of thumb
- 3 ligaments from MT base to Trapezium
- Anterior Oblique Ligment [Beak's ligament] +
- Posterior Oblique ligament (From base to Trapezium)
- Dorsoradial ligament (from base to trapezium)
- 2 ligaments to 2nd MT base
- Anterior + posterior inter metacarpal ligament (from base to 2MT base)
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- Described by Pellegrini et al.
- Due to attenuation of the AOL (Beak's ligament) ➔ Leads to loss of restraint to dorsal translation when flexing MCPJ ➔ joint incongruency with abnormal palmar forces (thats why destruction starts from palmar to dorsal)
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- History - 3 big - PAIN, STIFFNESS, DEFORMITY
- Shouldering of the CMCJ - seen as prominence at base of thumb due to dorsal subluxation of the MC on the trapezium
- Hyperextension of MPJ
- Grind test
- Assess the first web contractures
- Check for Carpal Tunnel - Florack et al. JHS 1991 - 40% had concomitant CTS! Can release at same setting.
- Check for trigger finger
- Kapandji score for thumb function (out of 10)
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- Robert’s view - place thumb dorsum on the cassette (abducted and hyper-pronated wrist)
- New “Peri-trapezial view” - place palm on special mould
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- Eaton and Littler
- Stage 1 = joint widening due to synovitis
- 2 = narrowing of CMCJ, osteophytes < 2mm, 1/3 subluxation
- 3 = marked narrowing, osteophytes >2mm, > 1/3 subluxation
- 4 = pantrapezial arthritis (STT involvement)
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- Non op
- Splinting
- Steroid injection
- Op - if fail conservative
- Unstable with no OA = Recon of Beck ligament
- OA Options
- Trapeziectomy +/- LRTI +/- interposition +/- suspension
- Fusion
- Arthroplasty
- If presence of thumb MCPJ hyperextension
- Kwire is for some scarring and to allow some stiffening
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- Beak's ligament reconstruction
- MC extension osteotomy - can be done at Eaton Littler 1
- Trapeziectomy alone
- +/- adjuncts
- Ligament Reconstruction Tendon interposition (LRTI) - FCR tendon is woven through base of thumb to reconstruct the Beak ligament
- Suspension with tight rope/ K-wire (most tight rope)
- Purpose is to prevent metatarsal subsidence; however, no evidence that subsidence leads to poor outcomes
- Palmaris longus interposition
- Replacement (rare)
- Fusion (for young manual workers)
- Position 10° radial abduction 30 ° palmar abduction for function
- Need to warn of problem - cannot put hand in pocket
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- Early - SRN injury, confuse trapezium with scaphoid (check II)
- Late - Subsidence of MC (however, studies show no correlation with clinical outcomes)
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- K-wiring at base, remove at 6/52
- bulky dressing
- 6/52 thumb spica splint
- 3/12 back to usual hand function with less pain, 60-70% pinch strength
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- “cup holding position”
- 10° radial abduction 30 ° palmar abduction
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- Trapeziectomy alone - Cochrane review 2009 found trapeziectomy alone was a/w fewer complications than + LRTI with similar functional outcomes
- Davis et al JHS 1997, Belcher JHS 2000 - No difference with interposition
- Overall - Systematic review by Vermeulen 2011 found no surgical procedure is proven to be superior to another
- Fusion not superior but found to have 8-20% non union risks
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- Plane = thenar muscles// APL (first extensor compartment)
- Danger - SRN dorsal sensory nerve
- I = between glaborous and hairy skin following the thenar eminence in a gentle curve
- S = Find APL tendon and nerves, detach thenar muscles
- Deep = Perform longitudinal capsulotomy
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- Plane = Between first and third extensor compartments
- I = straight incision between EPL and EPB
- S = Incise fascia between the 2 tendons
- D = longitudinal capsulotomy
