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CONGENITAL

 * Absent and Hypoplastic Disorders
 * Brachial Plexus Birth Injury
 * Cerebral Palsy
 * Embryology and Classification
 * Finger and Thumb Anomalies
 * Hand and Wrist Fractures and Dislocations
 * Physeal Injury (Traumatic and Acquired)
 * Polydactyly
 * Syndactyly and Symbrachydactyly
 * Wrist and Upper Limb Anomalies


GENERAL PRINCIPLES

 * Anesthesia (including WALANT)
 * Compartment Syndrome
 * Imaging
 * Infections
 * Medical Conditions
 * Principles of Hand and Wrist Arthroscopy


HAND AND WRIST: BONE AND JOINT

 * Carpal Fractures (including Malunion and Nonunion)
 * Distal Radius and Ulna Fractures (including Malunion and Nonunion)
 * DRUJ Arthritis
 * DRUJ Injury and Reconstruction
 * Intercarpal and Radiocarpal Arthritis
 * Metacarpal Injuries (including Malunion and Nonunion)
 * Osteoarthritis of Fingers (including Arthroplasty)
 * Osteoarthritis of the Thumb (including Arthroplasty)
 * Phalangeal Injuries (including Malunion and Nonunion)
 * PIP Dislocations and Fracture Dislocations
 * Scaphoid Fractures
 * Scaphoid Fractures (Nonunion)
 * Scapholunate Ligament Injuries and Reconstruction
 * Thumb Fractures and Ligament Injuries
 * Wrist Dislocations and Instability (not including SL)


HAND AND WRIST: SOFT TISSUE

 * Acute Flexor Tendon Injuries
 * Burns
 * Extensor Tendon Injury
 * Fingertip and Nail Bed Injuries
 * Flexor Tendon Reconstruction
 * Free Tissue Transfer
 * Local and Regional Flaps for Hand Reconstruction
 * Replantation
 * Tendinopathies
 * The Mangled Hand and Amputation


NERVE

 * Adult Brachial Plexus Injuries (Reconstruction, Nerve Transfers, Late
   Reconstruction)
 * Median Nerve Compression
 * Median Nerve Injury, Repair and Tendon Transfers
 * Nerve Injury and Repair
 * Radial Nerve Compression
 * Radial Nerve Injury, Repair and Tendon Transfers
 * Ulnar Nerve Compression
 * Ulnar Nerve Injury, Repair and Tendon Transfers


DISORDERS AND DISEASES

 * AVN of Hand and Wrist
 * Complex Regional Pain Syndrome (CRPS)
 * Dupuytren Disease
 * Primary Bone Tumors
 * Psychological Aspects of Arm Illness
 * Rheumatoid and Inflammatory Arthropathies
 * Soft Tissue Tumors
 * Tetraplegia and Stroke
 * Upper Limb Amputation, TMR, Prosthetics
 * Vascular Disorders

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Congenital


WRIST AND UPPER LIMB ANOMALIES

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MADELUNGS DEFORMITY

SUMMARY

 * A wrist deformity more commonly seen in females and often associated with
   Leri Weill dyschondrosteosis
 * Vickers ligament tethers the volar ulnar radial physis leading to increased
   radial inclination, increased volar title, lunate subsidence, and ulnar
   positive variance or overgrowth
 * Many patients are asymptomatic and do not require treatment but those that
   have pain may warrant surgical intervention in the form of Vickers ligament
   resection and radial physiolysis, ulnar epiphysiodesis, ulnar shortening,
   and/or radial osteotomy

EPIDEMIOLOGY

 * Four times more common in woman than men
 * Leri-Weill dyschondrosteosis—short stature, mesomelia, and Madelungs
   deformity
 * Abnormality in SHOX gene that leads to SHOX haploinsufficiency

ETIOLOGY

 * Madelung’s like deformity can result from trauma, infection, Ollier’s
   disease, MHE, Turner’s syndrome, and Langer-Giedion syndrome
   * True Madelung’s deformity is most commonly idiopathic

ANATOMY

 * Vickers ligament—abnormal short volar radioulnar ligament that originates
   from metaphysis of distal radius, tethering the ulnar aspect of radius and
   portions of carpus
   * Remaining physis grows and the tethered physis results in increased volar
     tilt and radial inclination
   * Ulna elongates and subluxates dorsally

PRESENTATION

 * Presents clinically during periods of rapid growth
   * Often identified during adolescence
 * Can present due to deformity or pain or both
 * Fenerally patients are bothered by the prominence of the ulna head dorsally
   (unaware of radial deformity) (
   Fig. 1B
   )

IMAGING

 * Plain radiographs are usually sufficient for diagnosis
 * Vickers ligament can often be visualized as a flame-shaped radiolucent notch
   at the medial radial metaphysis of the distal radius
 * More severe deformities demonstrate increased radial inclination, increased
   volar tilt (
   Fig. 3A, B
   )
 * Proximal carpal row is drawn into deformity forming a triangle proximally
   with lunate subsidence
 * Can involve entire forearm, including distraction of radial head from
   capitellum

TREATMENT

 * Nonoperative:
   * Mild deformity can be monitored with serial radiographs every 6 months
     until skeletal maturity
   * Initial nonoperative treatment for older children who present with pain
 * Operative:
   * Vickers ligament release and radial physiolysis can be performed in younger
     children with considerable growth remaining (
     Fig. 4
     )
   * Symptomatic deformity in older child/adolescent
     * Radial dome osteotomy to help correct 3-dimensional deformity (
       Fig. 5A–C
       )
       * Can be performed with curved osteotomes or curved sagittal saw, concave
         distally
       * distal fragment is deviated radially, dorsally, and extended
       * Fixation performed with k-wires or plate
     * Ulnar shortening osteotomy ± ulnar epiphysiodesis

COMPLICATIONS

 * Failure of physiolysis or tether release to result in compensatory growth
   with worsening deformity over time
 * Ulnar or radial nonunion after osteotomy
 * Insufficient correction of deformity

--------------------------------------------------------------------------------


PROXIMAL RADIOULNAR SYNOSTOSIS

SUMMARY

 * Failure of segmentation of radius and ulna leading to forearm in a fixed
   position between neutral and full pronation
 * 60%–80% bilateral but asymmetric presentation

EPIDEMIOLOGY

 * More commonly found in males than females (1.5 x more common)
 * Typically sporadic but several cases have reported family history

ETIOLOGY

 * Abnormal signaling during the period of longitudinal segmentation of the
   radius and ulna leads to failure of separation of the radius and ulna
   proximally with the forearm fixed in a position of neutral to pronation
 * Can be associated with many syndromes (Holt-Oram, Cornelia de Lange, Poland)
   or isolated

ANATOMY

 * Failure of separation of proximal radius and ulna without the development of
   proximal radioulnar joint (
   Fig. 6
   )
 * May have aberrant structural formation of lateral collateral ligament complex
 * forearm generally rests in fixed position between neutral and full pronation
   (or over pronated)
 * Patients may develop compensatory laxity of the shoulder or wrist to
   accommodate for the lack of forearm rotation
 * May present with or without radial head dislocation

PRESENTATION

 * 60%–80% present bilaterally with asymmetric involvement of forearms
 * Limitations and presentation are dependent on forearm position and whether
   the condition is unilateral or bilateral
 * Absence of rotation typically noted during activities such as playing sports,
   placing soap in the hand, etc. May have gone unnoticed prior to this.
 * Wrist and shoulder may be hypermobile

IMAGING

 * Plain radiographs (AP and lateral view) are typically sufficient to make a
   diagnosis
 * CT or MRI can be helpful in determining a cartilaginous bridge if osseous
   synostosis not evident on radiographs but clinical presentation is consistent
   with congenital proximal radioulnar synotosis

TREATMENT

 * Nonoperative:
   * Most patients do not require surgical intervention as the shoulder and
     wrist can compensate well for mild positional deformities, especially in
     unilateral cases
 * Operative:
   * If the condition is bilateral or the forearm is in significant pronation (>
     60°), the patient may benefit from a rotational osteotomy
     * The ideal position is debated – generally considered to be neutral to
       slight pronation
     * May vary based on cultural differences and need for supination activities
   * Techniques for osteotomy include via the synostosis, distal through one
     bone, distal through bone bones, use of an Ilizarov external fixator (
     Figs. 7
     8A, B
     )
   * Procedures which attempt to obtain active motion by separating the
     syndesmosis and interpose soft tissue between the forearm bones has not
     gained favor. Rotational osteotomies are still the most common surgical
     treatment

COMPLICATIONS

 * Complications increase with larger rotational corrections
 * Recommended to perform > 85° correction in two stages
 * Complications include compartment syndrome, neurovascular compromise, nerve
   palsy (typically transient), loss of correction, nonunion

--------------------------------------------------------------------------------


MULTIPLE HEREDITARY EXOSTOSES

SUMMARY

 * Autosomal dominant disorder characterized by the development of multiple
   osteochondromas originating from the physis/metaphysis of long bones
 * Forearm is involved in 30%–60% of patients with MHE
 * Most commonly seen deformities of forearm are shorted ulna, radial bow, ulnar
   deviation of the wrist, and radial head dislocation (
   Fig. 9
   )
 * Malignant transformation reported in up to 2% of patients with MHE

EPIDEMIOLOGY

 * Affects approximately 1 in 50,000 persons
 * Affects males more commonly than females

ETIOLOGY

 * Caused by loss-of-function mutation in EXT1 or EXT2 gene that codes for
   Golgi-resident glycosyltransferases
   * Responsible for synthesis of heparin sulfate chains
     * Requires a second genetic event to have a heparin sulfate deficiency of >
       50% to develop MHE
 * Majority demonstrate mutations in EXT1 sequence

ANATOMY

 * 30%–60% present with forearm deformities
 * Ostechondomas usually located in metaphysis of radius and/or ulna
 * Osteochondroma in distal ulna can lead to growth arrest of distal ulna
 * Tethers growth of distal radius
 * Leads to increased radial inclination, radial bowing, radial head
   dislocation, ulnar deviation of wrist, increased carpal slip

PRESENTATION

 * May present when lesion is palpable or visible
 * If family history, may present earlier for skeletal survey
 * Forearm rotation may be limited but sagittal motion of wrist and elbow
   typically preserved
 * Plain radiographs typically sufficient for diagnosis of location and effect
   of osteochondroma on surrounding bones
 * CT or MRI for lesions with rapid growth to evaluate for possible malignant
   transformation

TREATMENT

 * Nonoperative
   * Surveillance radiographs for patients with osteochondromas present that do
     not cause pain or impending growth disturbance
 * Operative
   * Indications: pain, prophylactic to avoid growth disturbance or loss of
     motion, radial head subluxation/dislocation
   * Simple excision of ostechondroma
     * Approach depends on location of osteochondroma
       * Volar henry approach for distal radius, subcutaneous border of ulna for
         majority of distal ulnar ostechondromas
       * Release of tether radioulnar tether (
         Fig. 12
         )
   * Closing wedge osteotomy can improve radial inclination and carpal slip
   * Ulnar lengthening (acute or via distraction osteogenesis) can be utilized
     for patients with limited growth remaining in order to rebalance the wrist

COMPLICATIONS

 * Loss of motion with radial head dislocation and progressive bowing of radius
 * Typically related to surgical treatment
   * Nonunion, recurrence of deformity, premature growth arrest

--------------------------------------------------------------------------------


ARTHROGRYPOSIS

SUMMARY

 * Characterized by congenital contractures of two or more joints
 * Includes syndromic arthrogryposis, distal arthrogryposis, and amyoplasia
 * Amyoplasia has typical symmetric positioning of limbs in IR, elbow extension,
   wrist flexion and ulnar deviation, wrist flexed, thumb and fingers in palm (
   Fig. 15
   )

EPIDEMIOLOGY

 * Amyoplasia occurs approximately 1 in 10, 000 live births

ETIOLOGY

 * No genetic basis, sporadic

ANATOMY

 * Weak underdeveloped muscles
 * Stiff underdeveloped joints due to lack of motion and contractures
 * Absent girdle muscles, weak or absent brachialis and biceps function

PRESENTATION

 * Classic upper extremity positioning includes shoulder internal rotation,
   elbow extension, wrist flexion and ulnar deviation, rigid finger flexion and
   clasped thumb
 * Careful evaluation of passive and active motion of each joint should be
   performed

IMAGING

 * Radiographs are not typically necessary to confirm the diagnosis but may be
   helpful prior to consideration of an elbow release in an older child with no
   passive motion to confirm the morphology of the joint
 * Plain films (AP and lateral) of wrist can demonstrate carpal coalitions

TREATMENT

 * Nonoperative
   * Stretching and splinting is the primary treatment and should be initiated
     as soon as possible
     * Imperative to have experienced therapist involved as it can be difficult
       to even orient the limb
 * Operative
   * All operative intervention has primary goal of increasing functional
     independence
   * Try to combine procedures to minimize exposure to anesthesia (either within
     the limb or between upper and lower extremity surgery) (
     Fig. 16
     )
   * If 90° of passive elbow flexion has not been achieved by approximately
     1–1.5 years of age, consider posterior capsular release with triceps
     lengthening
     * Curvilinear posterior incision, protect and transpose ulnar nerve, V-Y
       lengthening of triceps, posterior capsular release, gentle manipulation
       of elbow > 90° of passive motion
   * Dorsal Carpal Wedge Osteotomy—addresses wrist flexion and ulnar deviation
     position
     * Maintains arc of motion through radiocarpal joint and resets arc but does
       not increase overall range of motion (
       Fig. 17
       )
   * Thumb-in-Palm:
     * Release 1st web with flap that addresses taut tissue between thumb/index
       finger and palmar aspect of thumb
     * Release thenar contracture, address MCP instability if needed, FPL
       tightness and lack of active extension if needed

COMPLICATIONS

 * Flexion contracture can develop following posterior capsular release
 * Can interfere with functionality—elbow flexion allows hand to mouth but need
   elbow extension for perineal care, etc.
 * Significant flexion contractures reported after active muscle transfers for
   elbow flexion




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