ic15-l: tips and tricks for common hand problems

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IC15-L: Tips and Tricks for Common Hand Problems

Moderator(s): Gregory A. Merrell, MD

Faculty: David A. Kulber, MD, Nicholas E. Crosby, MD, Eon K. Shin, MD, Brandon S. Smetana, MD and Reed Hoyer, MD

Session Handouts

76th Annual Meeting of the ASSH September 30 – October 2, 2021

822 West Washington Blvd Chicago, IL 60607

Phone: (312) 880-1900 Web: www.assh.org

Email: [email protected]

mailto:[email protected]

9/24/2021

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Treatment Considerations for Trigger Finger

IC15-L: Tips and Tricks for Common Hand Problems (AM21)

David Kulber, MDProfessor of Surgery

Cedars Sinai Medical Center And USC Keck School of Medicine

Outline

• Anatomy

• Work Up

• Non-operative treatment

• Operative intervention

• Complications

• Management of complications

• Alternative surgical techniques

Anatomy

• Annular pulleys

• Cruciate pulleys

• Overlying palmar fascia in palm

Wolfe SW. Tendinopathy. In: Wolfe SW. Green’s Operative Hand Surgery. 7th ed. Philadelphia, PA: Elsevier/Churchill Livingstone; 2017;56:1904-1925. Henry Vandyke Carter and one more author - Henry Gray (1918) Anatomy of the Human

Body (See "Book" section below) Bartleby.com: Gray's Anatomy, Plate 425

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Pulley Anatomy

Hand follows the Fibonacci Sequence and fingers point to A1 pulley in full flexion

0, 1, 1, 2, 3, 5, 8, 13, 21…

2 + 3 = 5, 3 + 5 = 8

A1 Pulley Landmark Using the Fibonacci Sequence and Functional Lengths

P3, P2, P…

P3 + P2 = P

P3 is length from DIP to tip

P2 is length from PIP to DIP

P is length from Proximal A1 Pulley to PIP

Anatomy

• Equidistance from palmar digital crease to PIP crease and proximal A1 pulley

Fiorini HJ, Santos JB, Hirakawa CK, Sato ES, Faloppa F, Albertoni WM. Anatomical study of the A1 pulley: length and location by means of cutaneous landmarks on the palmar surface. J Hand Surg Am. 2011;36(3):464‐468. doi:10.1016/j.jhsa.2010.11.045

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Work up

• Discuss medical history

• DM and amyloidosis

• Rule out sagittal band rupture

• Tenderness over A1 pulley

• Pre‐triggering v. triggering v. fixed

• Ultrasound Reveals fluid in the sheath

Minimal fluid

Fluid

Non-operative Management

• Steroid Injection

• Offer up to 2 injections

• Kenalog 10

• 0.75ml with 0.25ml lidocaine

• Inject into palmar digital crease

• Least painful injection site

Operative Treatment

• Open release directly over A1 pulley

• Well described and familiar

• Not without complications

• Palmar fibromatosis / contracture

• Infection

• Pain/scarring

Wolfe SW. Tendinopathy. In: Wolfe SW. Green’s Operative Hand Surgery. 7th ed. Philadelphia, PA: Elsevier/Churchill Livingstone; 2017;56:1904-1925.

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Open trigger finger complications in literature

• 78 fingers in 43 patients

• 2 major complications

• Synovial fluid fistula, PIP arthrofibrosis

• 27 minor complications

• Scar tenderness, swelling, pain, limited motion, infection, wound dehiscence

Will R, Lubahn J. Complications of open trigger finger release. J Hand Surg Am. 2010;35(4):594‐596

Open Trigger Finger Release Complication:

Deep Infection

Resulted in ray amputation

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Open Trigger Finger Release Complication:

Palmar Fibromatosis

Managing complications

• Example of patient with severe scaring following open trigger release

• Treated with tenolysis followed by fat grafting


• Autologous fat grafting

• Prevents scaring and contracture recurrence

• Creates glide planes

• Adipose‐derived stem cells promote healing

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• Post Fat Grafting Results

• Minimal scaring

• Full ROM

Alternative Surgical Technique:Endoscopic Release

• Incision in palmar digital crease

• Less painful than over palm

• Decreases scaring and contracture

• Palmar fascia is left intact

• FDS slip resection through same incision

• We use the Strattos Endosleeve

Completeness and Safety of Endoscopic Release

• 16 cadaveric digits

• Retrograde endoscopic release

• No neurovascular or tendon injuries

• Complete A1 pulley release in all digits

Brown AM, DellaMaggiora RJ, Tsai EY, Kulber DA. Endoscopic Retrograde Approach for Trigger Finger Release: A Cadaver Study. Plast Reconstr Surg Glob Open. 2020;8(12):e3294. Published 2020 Dec 21.

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Case Example: Pre-operative Exam

Example of Endoscopic Trigger Set-up

Example of Endoscopic Trigger Set-up

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• Incision in palmar digital crease

• Expose A2

• Release the palmar ligaments

• Spread through ligaments of Legue and Javara

Intra-operative Release

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Intra-operative view of released pulley

Resection of FDS slip through single incision

• Slip resected from FDS through incision at MCP crease

• Resected slip may be sent for pathology

• Congo red stain for amyloidosis

• Be careful of slip resection in musicians

Correlation with Amyloidosis

• We sent the FDS slip excised from our case study to pathology

• (+) congo red stain• Confirmed amyloidosis

• We have a large series of positive amyloid diagnoses

• Send for pathology if multiple trigger digits or significant synovitis

• Amyloidosis was previously difficult to diagnose and sequalae can be fatal

• New developments in treatment

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Full ROM after release/slip resection

Example of post-operative scar on ring finger

Example of ROM just days after release

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Endoscopic Trigger Release Results

• Mark Khorsandi –Houston Texas

• 4,023 endoscopic vs 3,977 open releases over 10 years

• Incision in crease and palm

Results of our Prospective Trial

• 11 open and 10 endoscopic trigger finger releases

• Patient and Observer Scar Assessment Score, and Overall Opinion

• @ 1 week, 1 month, and 6 month

Complications Recurrences

Endoscopic 0 0

Open 1 1

Prospective Trial Results

AVERAGE POSAS (std) [12 best, 120 worst]

AVERAGE OVERALL OPINION (std) [0 best, 10 worst]

1 week 1 month 6 months

Endoscopic 24.4 (5.5) 27.3 (8.0) 16.3 (2.6)

Open 46.0 (21.6) 52.3 (15.7) 17.6 (12)

P-Value 0.01 0.009 0.82

1 week 1 month 6 months

Endoscopic 3.1 (1.1) 2.5 (1.1) 1.3 (0.3)

Open 4.2 (1.9) 4.5 (1.5) 1.6 (1.1)

P-Value 0.15 0.02 0.52

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Conclusions – Endoscopic Release

• Safe and effective

• Indirect and complete visualization

• Single non‐palmar incision, preserving palmar fascia

Questions and Comments?

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This talk will cover several short tips and tricks of cubital tunnel as well as a more detailed focus on a couple specific considerations.

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-EMG: less than 50 m/sec or >10 m/sec drop-MRI for location of nerve in revision or other special cases-Ultrasound eval for subluxation, nerve location, and possibly diagnosis-Image: Surgery of the Hand: Sterling Bunnell M.D., 1944-The Management of Cubital Tunnel Syndrome; Journal of Hand SurgeryVol. 40Issue 9p1897–1904Published online: August 1, 2015; Sean Boone, Richard H. Gelberman, Ryan P. Calfee

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https://www.jhandsurg.org/article/S0363-5023(15)00326-3/fulltext

-Arcade: Present in 75% of population; located approximately 8 cm proximal to epicondyle-Triceps partial excision vs transposition of nerve away from triceps-Controversy of deep bands distally (Deep FCU, leading edge FDS); Do they really pose a threat?-Image: The Hand: Diagnosis and Indications; Graham Lister; 1984

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-More recent research looking into advanced imaging techniques that might identify which patients need transposition vs. simple in-situ decompression-Meta analysis: concerns including weakness of data, bias, lack of homogenous information, applying opposite conclusion when hypothesis is not observed-Image: Difficult Problems in Hand Surgery; Strickland and Steichen; 1982

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-If the nerve is unstable after release, epiconyllectomy or fascial repair over tunnel can be considered as opposed to formal transposition-Image: Difficult Problems in Hand Surgery; Strickland and Steichen; 1982

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-Use of a Pedicled Adipose Flap as a Sling for Anterior Subcutaneous Transposition of the Ulnar Nerve; Journal of Hand SurgeryVol. 39Issue 3p552–555Published online: February 6, 2014; Jonathan R. Danoff, Joseph M. Lombardi, Melvin P. Rosenwasser-Flap stabilizes the nerve-Pedicle vessels from ulnar brand of brachial artery-Cannot be used in patients with limited subcutaneous adipose tissue

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https://www.jhandsurg.org/article/S0363-5023(13)01676-6/fulltext

-limiting extensive dissection may maintain nerve stability and reduce the need to transpose as well as protection of perineural blood supply-Visualization can be a concern

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-Depending on technique can provide excellent visualization-Diminished scar tenderness and numbness at elbow-Canula-based techniques can block out the nerve or be transparent for visualization-Hoffman (or similar) techniques maintain visualization of nerve throughout entire length-Added cost without improved reimbursement-Endoscopic Cubital Tunnel Release; Cobb, Tyson K.; Journal of Hand Surgery, Volume 35, Issue 10, 1690 – 1697-Endoscopic Cubital Tunnel Release Using the Hoffmann Technique, Hoffmann, Reimer et al., Journal of Hand Surgery, Volume 38, Issue 6, 1234 - 1239

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-Functional outcomes in young, active duty, military personnel after submuscular ulnar nerve transposition1; Fitzgerald, Brian T et al.; Journal of Hand Surgery, Volume 29, Issue 4, 619 – 624-The Management of Cubital Tunnel Syndrome; Boone, Sean et al.; Journal of Hand Surgery, Volume 40, Issue 9, 1897 - 1904

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Treatment ConsiderationsFor Carpal Tunnel Syndrome

Eon K. Shin, M.D.

Associate Professor in Orthopaedic Surgery

Philadelphia Hand to Shoulder Center

Thomas Jefferson University Hospital

October 1, 2021

San Francisco, CA NON-OPERATIVE TREATMENT

Encourage splint use for mild and

moderate disease. Splint use can

improve EMG/NCS parameters.

TIP #1 Karsidag S et al. Long term and frequent electrophysiological observation in CTS. Eura Medicophys 2007.

14 women (28 hands) prospectively

followed every 12 weeks for 1 year

Night splints for 12 weeks

EMG/NCS completed

• Significant EMG/NCS improvements in

patients with moderate disease

• Surgery required for severe disease

Walker WC et al. Neutral wrist splinting in CTS:Night-only vs full-time. Arch Phys Med Rehabil 2000.

21 patients (30 hands) used neutral wrist

splints either full-time or night-only

Randomized with 6 weeks splinting

• 73% of full-time group used splints less than half of waking hours

• Full-time splint use provided greater improvements in symptoms

and electrophysiologic measures

QUESTIONS

• Should we encourage full-time splint use?

• How long should we recommend splint use?

• Does splinting reduce the likelihood of surgery?

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Use corticosteroid injections

as a temporary measure.

TIP #2

Prospective randomized study comparing

methylprednisolone with placebo

CTS symptom severity score at 10 weeks

Rate of surgery at 1 year

• Significant improvement in symptoms at 10 weeks

with methylprednisolone

• No significant differences at 1 year

• After injection, lower rate of surgery

Atroshi I et al. Methylprednisolone injections for CTS. Ann Intern Med 2013.

QUESTIONS

• What is the optimum dose for corticosteroid injections?

• Can corticosteroid injections actually be curative?

• Are multiple injections safe?

• Should corticosteroid injections and splints be used together?

Use other non-operative treatments

sparingly, if at all. Additional studies

are needed to establish efficacy.

TIP #3

NON-OPERATIVE TREATMENT

• Oral medications

• Hand therapy

• Ultrasound?

• Acupuncture?

• Laser treatment?

• Yoga?

No definitive conclusions can be

made regarding efficacy owing to:

Paucity of trials

Small numbers

Treatment heterogeneity

Short-term follow-up

Add subjective value to your practice

by using an endoscopic approach

for carpal tunnel surgery.

TIP #4

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MY PERSONAL EXPERIENCE

What we currently believe:

• Earlier return to work (slight)

• Earlier return to function (slight)

Endoscopic carpal tunnel surgery driven

by patient demand and expectations

No true consensus on surgical outcomes

COMPLICATIONS

• Major irreversible nerve damage rare

• Increased reversible nerve injuries with eCTR

• Increased wound complications associated with oCTR

Michelotti B et al. Prospective randomized evaluationof eCTR vs oCTR. Ann Plast Surg 2014.

Both eCTR and oCTR are “well tolerated with no differences

in functional outcomes… and complications.”

“Although there were no differences between the two groups,

patients still preferred the eCTR, demonstrated by

significantly higher overall satisfaction scores

at the conclusion of the study.”

Objective outcomes are similar

Subjective impressions are different

Remember that the carpal tunnel

is oriented as a tilted ellipse,

rotating further from proximal to distal.

TIP #5

Pacek CA et al. Morphological analysis of the carpal tunnel. Hand 2010.

• Average tilt angle: 14.8° ± 7.8°

• Changes along length of carpal tunnel, rotating away from radial aspect distally

• Palm width highly correlates with carpal tunnel width

When performing an endoscopic carpal tunnel

release, orient the cannula accordingly

Exercise caution in small hands

Following CTR in a workers comp

population, psychiatric diagnoses are the

most predictive for return-to-work timing.

TIP #6

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Kho JY et al. Prognostic variables for patient return-to-work following CTR in workers comp population. Hand 2016.

p < 0.001

p = 0.003

p = 0.001

p < 0.001

In revision carpal tunnel surgery,

use a vascularized flap

if the nerve is scarred.

TIP #7

Courtesy of Dr. Lee Osterman

FLEXOR TENOSYNOVIAL FLAP

• Flap raised from superficial

flexor tendons deep to

median nerve

• Start over radial aspect of

carpal canal

• Divide transversely

• Drape flap over nerve

• Suture to radial leaflet of

transverse carpal ligament

Numerous procedures have been advocated

• All demonstrate satisfactory results

• No Level 1 data

Remember:

• Extensile incision through same area or ulnar

• Complete release of transverse carpal ligament

• External neurolysis with application of wrap or flap

THE LIMITATIONS CONCLUSION

1. Encourage splint use for mild and moderate disease.

2. Use corticosteroid injections as a temporary measure.

3. Use other non-operative treatments sparingly, if at all.

4. Add subjective value to your practice by offering eCTR.

5. Remember that the carpal tunnel is oriented as a tilted ellipse.

6. Following CTR in a workers comp population, psychiatric diagnoses are the most predictive for return-to-work timing.

7. In revision carpal tunnel surgery, use a vascularized flap if the nerve is scarred.

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THANK YOU

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I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N AI N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A

IC15-L: Tips and Tricks for Common Hand Problems

Treatment Considerations for CMC OABrandon S. Smetana, MD

Indiana Hand to Shoulder Center76th ASSH Annual Meeting San Francisco, CA

Friday October 1st, 2021

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I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A

Outline – Top 10 Tips & Tricks 1. Injection CMC joint2. Patient Expectations3. Alone in the OR4. Radial Sensory nerve5. Radial Artery6. Save Time in the OR7. Bail Outs for Tendon Rupture8. MPJ management9. Capsular Closure/Management10. Be Wary of Zebras

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1. Injection of CMC joint

Traction of thumb during CMC injection• Helpful for entry into joint

Minimize volume

Avoid forcing remainder if sig pressure requiredc/o Dr. Jeffrey A. Greenberg

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2. Manage Patient Expectations

• Protocol – rehab, splinting, restrictions

• Recovery length *• 6-9 months• Meals et al. JHS 2003, 2007

• 17/22 pain free at 6 months with hematoma distraction arthroplasty• Burton and Pellegrini JHS 1986

• “Strength and function continue to improve for 6 – 12 months after surgery”

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3. For when you are alone in the OR• Finger traps: Assistance with exposure

*Remove for capsular repair (pants over vest – more to come later)

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4. Radial Sensory Nerve• Find and isolate the radial sensory nerve

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5. Radial Artery• Find and Isolate the Radial artery – 15 seconds

seconds

Greenberg JA, JHS 2020, In Pressc/o F. Thomas D. Kaplan, MD

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6. How to Save Time in the OR

• Take trapezium out as one piece à saves time vs piecemeal

• McGlamry Elevator

h t t p s : / / w w w . a r t h r e x . c o m / p r o d u c t s / A R - 8 9 4 4 M

https://www.youtube.com/watch?v=t32tkGZo8AM

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6. How to Save Time in the OR à Clinic

• Bits of remnant bone on your f/u xray?

• Patient ?s: Why did you leave bone behind? Source of pain?

VS

K u h n s e t a l . J H S 2 0 0 3 K r i e g s - A u e t a l . J B J S 2 0 0 5

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7. Bail outs FCR rupture• Local TissueAPL ERCB / L

ECRB –palmar to IF metacarpalECRL (below)

Takagi et al. JHS AP 2019

https://musculoskeletalkey.com/surgical-treatment-of-basal-joint-arthritis-of-the-thumb/

Soejima et al. JHS 2006

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7. Bail outs FCR rupture• TechnologyAnchor Suture Button Suspensionplasty

Internal Brace Suture Suspension Arthroplasty

Etc……

Roman et al JHS 2016

D e lS igno re T ech H and U p E x t 2009 Weiss et al. JHS 2019https://www.youtube.com/watch?v=t32tkGZo8AM

C/o Dr. Thomas J. Fischer C/o Dr. Thomas J. Fischer

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8. MPJ Management

• Recommendations but little data• How to measure? Cutoff?

• Does reduction of thumb metacarpal subluxation during CMC arthroplasty obviate the need for MPJ procedure?

• Ligament reconstruction• Capsule (see #9)

• Data to come

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9. Capsular closure

• Makes a difference?• Seems to in my hands• Take traction off, antepose thumb

• Pants over vest closure• Transverse capsulotomy

c/o F. Thomas D. Kaplan, MD

c/o F. Thomas D. Kaplan, MD

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10. Zebras• 66F s/p thumb CMC arthroplasty 2001, no issues x5

yrs, then 8-10 yr h/o pain, swelling, bruising, discoloration of hand

• Rx for UC/Crohns, inflammatory arthropathy – on Humira, MTX

• PE • Holds thumb in abduction, ulnar deviation• SILT, no neuroma• Pain to light touch thumb base/radial forearm• Rad/ulnar pulses intact, Allens test intact arch/flow from RA/UA,

BCR digits• No edema/bogginess• No warmth

Case c/o Dr. Jeffrey A. Greenberg

Greenberg JA , JHS 2020, In Press

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10. Zebras

• 66F s/p thumb CMC arthroplasty 2001, no issues x5 yrs, then 8-10 yr h/o pain, swelling, bruising, discoloration of hand


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10. Zebras


• Difficult Problems Conference

• Dr. Thomas J. Fischer


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10. Zebras



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10. Zebras

• Diagnosis: radial artery pseudoaneurysm

• Treatment: pseudoaneurysm resection with primary repair

• Identify and protect radial artery (see #5) • 15 seconds can make you rest easy


Greenberg JA , JHS 2020, In Press Greenberg JA , JHS 2020, In Press

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Thank You!

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I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N AI N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A

Treatment Considerations for de Quervain’s

Reed Hoyer, MD

Indiana Hand to Shoulder Center


Consideration in diagnosis


Thoughts on Physical Exam

Finkelstein’s test Eichoff’s test: potential for high false +

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Wrist Hyperflexion and Abduction of the Thumb (WHAT) test

Sensitivity: 0.99

Specificity: 0.29

Positive predictive value: 0.95J Hand Surg Eur Vol. 2014 Mar;39(3):286-92. doi: 10.1177/1753193412475043. Epub

2013 Jan 22.


What about radiographs?

Rule out alternative diagnoses?141/200 plain radiographs demonstrated positive findingsCMC OA most common*None of these findings influenced treatment recommendations*

1. J Wrist Surg. 2021 Feb;10(1):48-52. doi: 10.1055/s-0040-1716522. Epub 2020 Oct 16.


Still… radiographs, right?

What about radial styloid changes? No definite impact on outcome 14/39 wrist demonstrated findings

2/14 wit abnormal xrays underwent surgery7/25 with normal xrays underwent surgery

Hand (N Y). 2010 Dec;5(4):374-7. doi: 10.1007/s11552-010-9258-8. Epub 2010 Feb 20

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Ultrasound!

Confirms diagnosisThickened retinaculumTenosynovitis

Confirms presence of septum

Identifies location of SRN

Allows for precision of image guided injection


Ultrasound!

Confirms diagnosisThickened retinaculumTenosynovitis

Confirms presence of septumIdentifies location of SRN

Allows for precision of image

guided injection


Ultrasound

Clin Orthop Relat Res. 2012 Jul;470(7):1925-31. doi: 10.1007/s11999-012-2369-5. Epub 2012 May 3.

30-45% of people have EPB subsheath

~60% of patients with DQ will have a subsheath

Subsheath may be associated with failure of injection

• 14/41patients found to have a septum• 10/41 underwent surgery• Majority of surgical patients had septum on U/S

J Hand Surg Eur Vol. 2016 Feb;41(2):212-9. doi: 10.1177/1753193415611414. Epub 2015 Oct 24

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Considerations in treatment


Non‐surgical treatment

Most surgeons consider cortisone injection/immobilization as first line treatments

Questions remain:1. What type of injection?2. Is U/S guidance really helpful?


Should we inject?

Is Cortisone an independent predictor of surgery? Retrospective study; “medicalized” the problem12 years, 2513 patients1.7x increased odds of surgery after injectionArch Bone Jt Surg. 2015 Jul;3(3):198-203.

Or does Cortisone provide significant, lasting relief?Prospective study50 patients82% obtained relief with injection½ remained symptom free at 1 yearJ Hand Surg Am. 2015 Jun;40(6):1161-5. doi: 10.1016/j.jhsa.2014.12.027. Epub 2015 Apr 30.

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Supposing you choose to inject…

Consider a soluble corticosteroid (dexamethasone, betamethasone)Absorbed faster More rapid onset Less risk of soft tissue complications (fatty atrophy, depigmentation)J Hand Surg Am. 2018 Jun;43(6):558-563. doi: 10.1016/j.jhsa.2018.03.004.


Is lidocaine necessary?

Comparison of flexor sheath steroid injection w/ and w/o lidocaine

Prospective, RCT110 fingersVAS with lidocaine: 3.5VAS no lidocaine: 2.0


U/S guidance

Safety and efficacy demonstrated in multiple clinical studies

Mixed data from cadaver studies:

Kutsikovich 2018100% accuracy with blind and U/S guided techniquesBetter isolated EPB subsheath injection with U/S (not statistically significant)No difference in subcutaneous dye infiltration (2/21 each group)

J Hand Surg Am. 2018 Aug;43(8):777.e1-777.e5. doi: 10.1016/j.jhsa.2018.01.020. Epub 2018 Feb 23.

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U/S guidance

Leversedge 2017

50% accuracy of blind needle placement100% accuracy with U/S placement96% accuracy of injection into EPB subsheath when presentSubcutaneous infiltration 6/50J Am Acad Orthop Surg. 2016 Jun;24(6):399-404. doi: 10.5435/JAAOS-D-15-00753.


U/S guidance

No apparent difference in complications/efficacy

• RCT 48 wrists: • No difference in 4 week or 3 month

outcomes• No difference in recurrence rates• No difference in hypopigmentation (70%

and 80%!!! At 3 months; triamcinolone)Orthop Traumatol Surg Res. 2020 Apr;106(2):301-306. doi: 10.1016/j.otsr.2019.11.015. Epub 2019 Dec 31.


Surgery… finally!

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No Subsheath!

~35% of patients undergoing FDC release will not have a septumJ Wrist Surg 2019;8:380–383.

~5% will not have an EPB (all comers)

Tip:Dissect distally

Identify all tendons volar to snuff box Trace them proximally

Confirm release


Tendon Subluxation

1 oz of prevention…

Technical pearls:Dorsal incision in retinaculumAssess for subluxation (passive flexion or WHAT test)Ensure tendons are “located” prior to closureImmobilize for 1 week


Data on Subluxation

RCT “dorsal + immobilization” vs “midline and early ROM”

Conclusions: NO DIFF in subluxation

No affect of subluxation on PROsAnn Plast Surg. 2019 Jun;82(6):628‐635.

But, we KNOW symptomatic tendon subluxation occurs

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Retinacular flap J Wrist Surg 2018;7:31–37.


Failure of Surgical Treatment

Don’t double down on a bad outcome

“Failed” First dorsal compartment release surgery42 patients over 8 years11 patients’ pain unrelated to FDC

7 with Wartenberg’s4 with basal joint arthritis

10 patients had SRN sensitivity, treated with OT19 of remaining 21 underwent revision surgery

ALL found to have unreleased additional compartmenthttps://doi.org/10.1177/1558944716660555gr


Failure?

Rule out alternative diagnosis

Confirm EBP subsheath wasn’t missedPhysical Exam maneuver: thumb MP extension against resistance

1. Handchir Mikrochir Plast Chir. 2017 Aug;49(3):185-187. doi: 10.1055/s-0043-105497. Epub 2017 Aug 14.

U/S evaluation

Surgical treatment – no missed subsheathExcision of slip of APLEPB exision

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Summary• Clinical diagnosis

Consider WHAT test

• Radiographs are not typically needed• U/S is helpful in demonstrating a septum• Injection is a first line treatment

The need for U/S guidance is not clear

• Single compartment present 1/3 of the time in symptomatic patients

• Tendon subluxation can be prevented• In “failed” surgery, consider alternative diagnoses, missed

compartment

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ic15-l: tips and tricks for common hand problems

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