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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 John J Callaghan, MD President Daniel J Berry, MD First Vice-President John R Tongue, MD Second Vice-President Frederick M Azar, MD Treasurer Joseph D Zuckerman, MD Past-President Jeffrey O Anglen, MD Richard J Barry, MD Kevin P Black, MD M Bradford Henley, MD, MBA Gregory A Mencio, MD Michael L Parks, MD Fred C Redfern, MD David D Teuscher, MD Paul Tornetta III, MD Daniel W White, MD, LTC, MC G Zachary Wilhoit, MS, MBA Karen L Hackett, FACHE, CAE (Ex-Officio) Staff Mark W Wieting Chief Education Officer Marilyn L Fox, PhD Director, Department of Publications Laurie Braun Managing Editor Steven Kellert Senior Editor Mary Steermann Bishop Senior Manager, Production and Archives Courtney Astle Assistant Production Manager Susan Morritz Baim Production Coordinator Suzanne O’Reilly Graphic Designer Anne Raci Database Coordinator Karen Danca Permissions Coordinator Abram Fassler Production Database Associate Charlie Baldwin Page Production Assistant Hollie Benedik Page Production Assistant Michelle Bruno Publications Assistant Jane Baque Senior Manager, Publications Websites Katharine Zoë Graham Manager, Website Program Systems and Design Reid Stanton Manager, Electronic Media Brian Moore 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 Published 2010 by the American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, IL 60018 Fourth Edition Copyright 2010 by the American Academy of Orthopaedic Surgeons The material presented in Essentials of Musculoskeletal Care, Fourth Edition, has been made available by the American Academy of Orthopaedic Surgeons for educational purposes only This material is not intended to present the only, or necessarily best, methods or procedures for the medical situations discussed, but rather is intended to represent an approach, view, statement, or opinion of the author(s) or producer(s), which may be helpful to others who face similar situations The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care Variations, taking into account individual circumstances, may be appropriate Some drugs or medical devices demonstrated in Academy courses or described in Academy print or electronic publications have not been cleared by the Food and Drug Administration (FDA) or have been cleared for specifi c uses only The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice Furthermore, any statements about commercial products are solely the opinion(s) of the author(s) and do not represent an Academy endorsement or evaluation of these products These statements may not be used in advertising or for any commercial purpose CPT® is copyright 2010 American Medical Association All rights reserved No fee schedules, basic units, relative values, or related listings are included in CPT The AMA assumes no liability for the data contained herein All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher ISBN 978-0-89203-579-3 Printed in the USA Cover art Robert Liberace Anatomic Illustrations Scott Thorn Barrows, 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 Editorial Board Disclosures Neither Dr Armstrong nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Neither Dr Benavides nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Dr Clanton or an immediate family member serves as an unpaid consultant to Arthrex Dr Della Valle or an immediate family member serves as a board member, owner, offi cer, or committee member of the American Association of Hip and Knee Surgeons and the Arthritis Foundation; serves as a paid consultant to or is an employee of Biomet, Kinamed, Smith & Nephew, and Zimmer; has received research or institutional support from Zimmer; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel) from Stryker Dr Galatz or an immediate family member serves as an unpaid consultant to Tornier and has received research or institutional support from Biomet, Breg, Cerapedics, Medtronic, Smith & Nephew, Stryker, Synthes, Wright Medical Technology, Wyeth, Axial Biotech, Midwest Stone Institute, and K2M Dr Griffi n or an immediate family member serves as a board member, owner, offi cer, or committee member of the Piedmont Hospital, Georgia State University Athletic Board, and the American Orthopaedic Society for Sports Medicine Dr Koh or an immediate family member serves as a board member, owner, offi cer, or committee member of the Illinois Association of Orthopaedic Surgeons; is a member of a speakers’ bureau or has made paid presentations on behalf of Aesculap/B.Braun and Arthrex; serves as a paid consultant to or is an employee of Aesculap/B.Braun and Arthrex; and has received research or institutional support from Aesculap/B Braun, Arthrex, and Enturia Neither Dr Sarwark nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Dr Seiler or an immediate family member serves as a board member, owner, offi cer, or committee member of the American Board of Orthopaedic Surgery; has received royalties from Salumedica; serves as an unpaid consultant to Synthes and Arthrex; has received research or institutional support from Avance; and owns stock or stock options in Orthovita Dr Spengler or an immediate family member serves as a board member, owner, offi cer, or committee member of the Musculoskeletal Transplant Foundation Dr Spiegel or an immediate family member serves as a board member, owner, offi cer, or committee member of the Pediatric Orthopaedic Society of North America Dr Weber or an immediate family member owns stock or stock options in Pfi zer Neither Mr Huxford nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication 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 Neither Dr Aboulafi a nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Dr Andras or an immediate family member has received research or institutional support from Osteotech and owns stock or stock options in Eli Lilly Dr Berven or an immediate family member serves as a board member, owner, offi cer, or committee member of the Bone and Joint Decade, USA, the North American Spine Society, and the Scoliosis Research Society; serves as a paid consultant to or is an employee of Alphatec Spine, Biomet, DePuy, Medtronic Sofamor Danek, Osteotech, Stryker: Pioneer; and US Spine; has received research or institutional support from OREF and the AO Foundation; and owns stock or stock options in Baxano, Simpirica, Providence, Axis, and AccuLif Neither Dr Carl nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Dr Dierckman or an immediate family member has received research or institutional support from Surgical Monitoring Associates and Stryker and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel) from Synthes Dr Dodds or an immediate family member serves as a board member, owner, offi cer, or committee member of the Arthroscopy Association of North America and the Saint Lawrence Outpatient Surgery Center Mr Floyd or an immediate family member serves as a board member, owner, offi cer, or committee member of the National Athletic Trainers Association and the National Athletic Trainers Association Research and Education Foundation Ms Griffi n or an immediate family member serves as a board member, owner, offi cer, or committee member of the Piedmont Hospital Neither Dr Guild nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Neither Dr Hamilton nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Neither Dr Hammond nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Neither Dr Kercher nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Dr Kimura or an immediate family member serves as a board member, owner, offi cer, or committee member of the Arthritis Foundation; has received royalties from Oxford University Press and UpToDate; and has received research or institutional support from Roche 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 Koman or an immediate family member serves as a board member, owner, offi cer, or committee member of DT Scimed and Keranetics; serves as a paid consultant to or is an employee of DT Scimed and QRxPharma; has received research or institutional support from Datatrace, Allergan, Biomet, DT Scimed, Johnson & Johnson, Keranetics, Smith & Nephew, Synthes, Wright Medical Technology, and Zimmer; owns stock or stock options in Wright Medical Technology; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non– research-related funding (such as paid travel) from Datatrace, DT Scimed, and Keranetics Neither Dr Knowles nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Dr Lane or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of GlaxoSmithKline, Eli Lilly, Procter & Gamble, Sanofi Aventis, Novartis, and Roche; serves as a paid consultant to or is an employee of Biomimetic, Orthovita, Osteotech, Zimmer, Innovative Clinical Solutions, D’Fine, Biomimetics, Soteria, Zelos Thearpeutics, and Kuros; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel) from Amgen Dr Moore or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Osteotech and Synthes, serves as an unpaid consultant to Osteotech, and has received research or institutional support from Synthes Dr Murphy or an immediate family member serves as a board member, owner, offi cer, or committee member of College Athletic Trainers’ Society and owns stock or stock options in Stryker Dr Nho or an immediate family member has received research or institutional support from Arthrex, DJ Orthopaedics, Linvatec, Ossur, Smith & Nephew, Athletico, and Miomed Dr Pinzur or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of SBI, Smith & Nephew, and Ascension; serves as a paid consultant to or is an employee of SBI and Smith & Nephew; and has received research or institutional support from Synthes and Biomimetic Neither Dr Sridhar nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of his chapter Neither Dr Starr nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Neither Dr Thomas nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication Neither Dr Wells nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the content of this publication © 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 ... the Upper Extremity 11 01 Genu Varum 10 40 C ongenital Deformities of the Lower Extremity 11 12 Juvenile Idiopathic Arthritis 10 46 C ongenital Deformities of the Upper Extremity 11 18 Kyphosis 11 91 Toe Walking 11 22... Fractures of the Distal Forearm 10 89 Fractures of the Proximal and Middle Forearm 11 47 Osteomyelitis 11 55 Preparticipation Physical Evaluation 11 64 Scoliosis 11 70 Septic Arthritis 10 91 Fractures of the Femur... 10 06 Foot and Ankle Pain 10 73 F ractures of the Growth Plate 10 11 Growing Pain 10 76 Fractures About the Elbow 10 13 Accessory Navicular 10 82 Fractures of the Clavicle and Proximal Humerus 11 51