6/22/2011 PROCEDURES. Wrist and Hand SYNDROME
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1 SURGICAL PROCEDURES Wrist and Hand CARPAL TUNNEL CARPAL TUNNEL SYNDROME 1
2 SURGERY Carpal Tunnel Release Indicated for patients who don t improve with conservative treatment Reported to relieve symptoms in 70-90% of patients Endoscopic or open procedure Involves division of transverse carpal ligament, increasing tunnel volume Post-immobilization May be fitted with splint in slight wrist extension with MCP/IP joints free for 10 days CARPAL TUNNEL SYNDROME SURGERY Insert Carpal tunnel syndrome surgery inside the operating room video here. 2
3 CARPAL TUNNEL ENDOSCOPIC SURGERY Insert Carpal Tunnel Syndrome Endoscopic Release surgery video here CARPAL TUNNEL ENDOSCOPIC SURGERY Insert Guyons canal and carpal tunnel release video here 3
4 TRIGGER FINGER TRIGGER FINGER Insert Trigger finger Surgery inside the operating room 4
5 REPETITIVE TRAUMA SYNDROMES/OVERUSE SYNDROMES Trigger Finger surgical management Transverse incision of A1 pulley 2-3 days post-op: Dressings removed, edema control A/PROM 6 x per day for 10 minutes, emphasizing tendon-gliding and MP extension with IP flexed Consider hand based extension splint for limited MP or IP joint extension (night) days post-op: 48 hrs after suture removal, initiate scar mobilization including scar massage and elastomer putty 3-4 weeks post-op: Progressive strengthening using putty or hand helper DEQUERVAINS SYNDROME 5
6 DEQUERVAIN S SYNDROME Insert DeQuervain s tenosynovitis video here REPETITIVE TRAUMA SYNDROMES/OVERUSE SYNDROMES Surgical treatment: 10 days post-op: Dressings removed, initiate edema control A/PROM 4-6 x per day for 10 minutes, emphasize wrist/thumb ROM and thumb flexion with wrist UD After suture removal, initiate scar mobilization with scar massage and elastomer putty Manual desensitization due to radial nerve superficial branch Dynamic splinting if limited it PROM of thumb 3-4 weeks post-op: Progressive strengthening to wrist and thumb (isometrics, theraband, weights, putty) Musculoskeletal Impairments III ROM and function restored within 3-4 weeks post-op 6
7 GAMEKEEPER S THUMB GAMEKEEPERS THUMB Insert Watch ulnar collateral ligament repair online videosurf video here Musculoskeletal Impairments III 7
8 DUPUYTREN S CONTRACTURE DUPUYTREN S CONTRACTURE Insert dupuytren s contracture release video here 8
9 MALLET FINGER MALLET FINGER Insert Mallet finger screw fixation video here 9
10 WRIST ARTTHROPLASTY WRIST ARTHROPLASTY Arthrodesis Most common for late-stage RA Doesn t limit ADL s as long as other proximal joints unaffected Arthroplasty : Appropriate for patients with proximal joint issues Indications: Severe pain Deformation and marked limitation of wrist Subluxation/dislocation of RC joint Low-demand individuals 10
11 WRIST ARTHROPLASTY Contraindications: Active infection (A) Expected high-demand (A) Inadequate motor control (A) Extensor rupture (A) Limited ROM without pain (A) Severe deformity (R) Multiple extensor rupture (R) Bone stock quality (R) Need for ambulation aids (R) Compromised immune system (R) WRIST ARTHROPLASTY Surgical procedure: Typically involves insertion of 2-piece system that is loosely constrained or nonconstrained Uses bio-ingrowth, cement, and screws for fixation Dorsal, longitudinal incision in line with 3 rd metacarpal Dorsal clearance and retraction of digital extensors Resection of appropriate bone and insertion of implant 11
12 WRIST ARTHROPLASTY Insert total wrist arthroplasty surgery video here MCP ARTHROPLASTY 12
13 MCP ARTHROPLASTY Surgical intervention: Most common procedure used to manage late-stage RA of the hand Patient must have intact extensor digitorum communis tendon Sequenced correctly with other procedures Indications: MCP joint and decreased d function Instability and deformity Stiffness and decreased AROM Poor appearance of hand MCP ARTHROPLASTY Surgical procedure: Different designs and amount of stability 2 types: One-piece prosthesis Has inherent stability built in Re-surfacing prosthesis Rely on external stability Single, transverse incision over dorsal aspect Careful separation of extensor tendons Incision of the extensor hood Soft tissue is retracted including tendons and ligaments Capsulotomy and osteotomy performed and implant placed Soft tissue repaired and incision closed 13
14 MCP ARTHROPLASTY Insert MCP Joint Arthroplasty video here PIP ARTHROPLASTY 14
15 PIP ARTHROPLASTY May be the procedure of choice for more mobile digits (ulnar side) If MCP and PIP joint involved, PIP joint usually corrected by soft tissue reconstruction or arthrodesis Indications: Pain and destruction of articular surfaces Stiffness and decreased ROM PIP ARTHROPLASTY Surgical procedure: 2 categories of implants: One-piece flexible joint spacer Greater inherent stability Two-component surface replacement system Greater joint mobility With RA patient, usually one-piece chosen With OA patient, usually two-component surface replacement system 15
16 PIP ARTHROPLASTY Surgical procedure: Curved, longitudinal incision on dorsal aspect of PIP joint Central-slip Sparing approach Splinting approach Osteotomy performed and bone prepared for implant Soft tissues addressed if contractures present Volar plate released THUMB CMC THUMB CMC ARTHROPLASTY 16
17 THUMB CMC ARTHROPLASTY Surgical procedure: Used when conservative treatment is unsuccessful Indications: Disabling pain at base of thumb Instability Stiffness and limited ROM Decreased pinch and grip strength When arthrodesis is not indicated THUMB CMC ARTHROPLASTY Surgical procedure: 3 broad categories: Ligament reconstruction Pain and instability but no articular damage Trapezial resection/tendon interposition or suspension arthroplasty Widely used Joint replacement arthroplasty Rarely used with RA due to bone stock issues 17
18 THUMB CMC ARTHROPLASTY Surgical procedure: Tendon interposition arthroplasty: Dorsal base of thumb Resection of trapezium and base of 1 st metacarpal Tendon graft used as spacer in trapezial space and tendon repositioned to enhance joint stability Resurfacing arthroplasty Dorsal incision b/t APL and EPB Osteotomy performed and implants inserted CMC JOINT ARTHROPLASTY Please insert CMC arthroplasty with cartilage allograft video here 18
19 CMC JOINT ARTHROPLASTY Please insert CMC arthroplasty with silastic implant video here 19
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