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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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Hand and Wrist: Bone and Joint


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ANATOMY, EPIDEMIOLOGY, AND CLASSIFICATION

 * Scaphoid links the proximal and distal rows
 * Interacts in five articulations (
   Fig. 23
   )
 * Almost entirely covered in cartilage except dorsal ridge and volar tubercle
 * Tenuous blood flow, mainly retrograde (80%), enters the dorsal ridge (
   Fig. 2
   )
 * 60% of carpal fractures, 43 per 100,000, 82% men62
 * Most common fracture classifications include Herbert, Russe, and Mayo (Table
   1)
   * Not predictive of nonunion19
 * Classification often location-based: Proximal (~10%), Waist (~65%), or Distal
   pole (~25%)62


EVALUATION

 * History
   * Typically, FOOSH injury, extreme wrist hyperextension, or punch injury62
 * Symptoms/findings
   * Radial wrist pain, often mild/tolerable or absent
   * Swelling rare and should alert for more extensive injury33
   * Tenderness in anatomic snuff box and over tubercle, axial compression of
     thumb
     * Sensitivity close to 100%, but poor specificity11


IMAGING

 * X-rays with scaphoid views recommended
   * Wrist PA, PA with ulnar deviation, lateral, pronated oblique
   * False negative rate of 15%–20%
 * CT excellent for fracture characteristics: location, displacement (
   Fig. 24
   ), humpback (
   Fig. 24
   ), comminution (
   Fig. 7
   )
   * Better sensitivity (94%) than X-rays and excellent specificity (96%)11
   * Best for assessing union after treatment44 (
     Fig. 20
     )
 * MRI close to 100% sensitivity13 (
   Fig. 5
   )
   * More costly and time-consuming than CT15
   * Diagnoses AVN in older fractures, but AVN diagnosis of limited prognostic
     value17
 * Advanced imaging overall cost-efficient when question of occult scaphoid
   fracture16
   * Repeated X-rays for occult fracture have poor sensitivity and reliability13


TREATMENT

 * Non-operative
   * Most distal pole fractures and non/minimally-displaced (<2 mm) waist
     fractures24
   * Short forearm cast excluding the thumb,23 6–12 weeks, distal pole heals
     faster than waist46
   * Assess bone bridging/union with serial X-rays or CT (
     Fig. 20
     )
     * Poor agreement on radiographic union on X-rays @ 12 weeks63
     * Union generally accepted when>50% bone bridging on CT, high
       reliability44, 45 (
       Fig. 20
       )
 * Operative
   * Part of larger injury (perilunate fracture-dislocation) (
     Fig. 11
     )
   * Proximal pole
   * Displaced waist fracture >2 mm
   * Humpback and/or DISI (
     Fig. 24
     ,
     Fig. 6
     )
   * Comminution (best assessed with CT) (
     Fig. 7
     )
   * Delayed presentation >4 weeks


APPROACH

 * Dorsal
   * Mini-open10 (
     Fig. 8
     , Video 3)
     * Nondisplaced proximal poles or waist fractures
   * Open33, 34 (
     Fig. 10
     )
     * Displaced proximal poles
     * Perilunate fracture-dislocations/associated injuries (
       Fig. 11
       )
 * Volar
   * Percutaneous37,38 (
     Fig. 14
     ,
     Fig. 15
     , Video 4)
     * Nondisplaced waist fractures
   * Open35 (Video 3)
     * Humpback deformity/DISI (
       Fig. 24
       )
     * Displaced waist and distal pole fractures
 * Arthroscopically assisted39, 40, 41 (Video 5)
   * All fracture types (gross dislocation or humpback technically demanding)
   * Antegrade or retrograde screw fixation


OUTCOMES

 * High union rates (>90%) for distal pole and nondisplaced waist fractures if
   early nonsurgical treatment46
 * High union rates for surgically stabilized proximal poles (>85%) and
   displaced waist fractures (90%–98%)9, 64
 * Missed fractures, comminuted fractures, proximal pole fractures, and
   fractures with displacement and/or humpback deformity have a higher risk of
   delayed and/or nonunion3, 11, 46
 * Possible complications include stiffness, pain, scaphoid nonunion, arthritis,
   and hardware related (use fluoroscopic views39 meticulously regardless of
   approach)




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