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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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Disorders and Diseases


DUPUYTREN DISEASE

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INTRODUCTION

 * Dupuytren disease (DD) is a benign fibrotic systemic disorder that causes
   connective tissue fibrosis in and beyond the palmar fascia
 * Characteristic cord formation contracts along lines of resting tissue laxity
   into palmar cords of the digits or palm, which may limit finger extension in
   a characteristic deformity called Dupuytren contracture
 * Typically presents as a firm subcutaneous palmar nodule; most patients
   describe no pain
 * Risk factors for developing Dupuytren include family history, Caucasian
   ancestry, male gender, and increasing age
 * Treatment goals are to reduce flexion and adduction contractures and improve
   motion
 * Open surgical fasciectomy is the most common current treatment
 * Minimally invasive office-based procedures, including collagenase Clostridium
   histolyticum (CCH) injections and percutaneous needle fasciotomy, have gained
   in popularity
 * Treatment procedures correct contracture but do not cure underlying
   pathobiology
 * There is no cure; regardless of treatment choice recurrence is expected

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EPIDEMIOLOGY

 * Dupuytren disease is the most common inherited disorder to affect connective
   tissue
 * The strongest influences on prevalence are:
   * Ancestry (Caucasian highest risk)
     * Although sometimes referred to as "Viking" disease there is no evidence
       to support ancestry influence other than Caucasian background
     * Genetics generally autosomal dominant with variable penetrance
   * Gender (men higher risk)
   * Age (prevalence increases with age)
     * Dupuytren is uncommon in men and rare in women younger than 40;
       prevalence increases steadily after that
     * Age range of peak incidence is 55–65 for men and 70–80 in women
 * In Caucasians, global incidence is 3% –6%
 * Anatomic location (most frequent to least)
   * Ring and small (50%–60%), long (40%–50%), index and thumb (5%–7%)
 * Dupuytren Diathesis
   * Recurrence risk increases with number of diathesis factors but effect size
     of each remains controversial
   * Family history of DD, especially sibling or parent
   * Age of onset younger than 50
   * Bilateral disease
   * More than 2 digits involved
   * Thumb ray involvement
   * Male gender
   * Caucasian background
   * Knuckle pads (Garrod pads or dorsal Dupuytren nodules)
   * Peyronie disease (fibrous nodules, contracture of tunica albuginea of
     penis)
   * Plantar fibromatosis (Ledderhose disease)

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ETIOLOGY AND HISTOPATHOLOGY

 * The etiology of Dupuytren is not known
   * Biomechanical
     * Geographic patterns of disease in palm suggest role of soft tissue
       mechanical strain in disease initiation
     * Palmar nodule locations usually match areas of grip-related shearing
       forces
     * Regional trauma may provoke a Dupuytren-like response
   * Fibrotic
     * Dupuytren disease is a local fibrosis with biologic similarities to other
       fibrotic diseases including pulmonary fibrosis and cirrhosis
     * T-cell response appears to play a role
     * Diseased fascia histology resembles wound healing with abnormal levels of
       fibronectin, type III collagen, and growth factors
 * Histopathology
   * Normal fascia histology is sparsely cellular, organized parallel fibers
     composed almost entirely of type I collagen
   * Type III collagen more predominant in DD
   * Myofibroblasts are a characteristic cell type; exhibit properties of both
     fibroblasts and smooth muscle, are responsible for progressive cord
     contracture
   * Proliferative stage is hypercellular, with random alignment of
     myofibroblasts and collagen strands, mitotic evidence of cell division, and
     over 35% type III collagen
   * Involutional (fibrocellular) stage is less cellular, aligning
     myofibroblasts along lines of stress
   * Residual (fibrotic) stage hypocellular, densely packed linear collagen,
     less type III collagen, resembles mature scar
   * Type IV collagen is predominant in basement membrane of vasculature and
     epithelial cells
     * Collagenase targets collagen type III and I; avoids type IV

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ANATOMY AND PATHOANATOMY

 * Nodules, skin pits, and bunching are often the first evidence of Dupuytren
   disease (
   Fig. 2
   ).
 * Cords are linear structures resulting from fibrosis and contracture (
   Fig. 3
   ).
   * Longitudinal pretendinous cords arise in the pretendinous fascia in the
     palm.
   * Central cords arise from disease involvement of the pretendinous bands in
     the palm
 * Central and pretendinous cords do not affect the neurovascular anatomy.
 * Contrary to earlier teachings53 digital cords may involve Grayson's or
   Cleland's ligaments,54 although Grayson's remain more heavily involved
 * Although exceptions occur, in general:
   * Central cords lead to MCP joint contracture
   * Spiral cords lead to PIP contracture (and displace the neurovascular bundle
     centrally and superficially) (
     Fig. 4
     )
   * Retrovascular cords result in DIP contracture
     * Lie deep into the neurovascular bundle
   * Natatory cords result in webspace contracture

SECONDARY PATHOANATOMY

 * Secondary boutonniere deformity
 * Secondary swan neck deformity
 * Secondary sagittal band rupture
 * Secondary PIP ligament contracture

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DIAGNOSIS

 * DD is a clinical diagnosis. Patients commonly present with either a
   nodule/mass or a palpable cord and contracture
 * Prior to any procedure detailed neurologic and vascular exam should be
   documented
   * Check each digit using a digital Allen test; especially important in
     previously treated tissue

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INDICATIONS FOR TREATMENT

 * Therapy, splinting, or medications alone have not been shown to provide
   long-term preventive benefits in the treatment of DD
 * Isolated nodules. Simple nodule excision is not recommended as it may trigger
   prolonged inflammation, recurrence, and disease progression
   * Nodule size, tenderness, or itching often diminish in response to nodule
     corticosteroid injections.60
 * Contractures
   * Indications for treatment depend on preferences of both surgeon and patient
   * Hueston table-top test failure (patient cannot lay their palm flat on a
     table)
   * MCP joint contractures of 30° or greater
   * PIP contractures greater than 15°
   * Significant adduction contractures
 * Current treatment is limited to procedures for deformity–-most common are
   open (fasciectomy, dermofasciectomy) and minimally invasive (collagenase
   injections, percutaneous fasciotomy, open fasciotomy)

FASCIECTOMY

 * Most common procedure performed for Dupuytren contracture
   * Primary wound closure may be obtained by direct closure, local flaps,
     regional flaps, skin grafts, or combinations of these.
   * Open technique (McCash open palm) refers to leaving some or all incisions
     unclosed to heal by secondary intent, typically used in conjunction with
     transverse incisions
 * Fasciectomy technique
   * Incision choices include Bruner-type zigzag incisions,68 Watson multiple
     V-Y advancement flaps,69 Wakefield technique of midline longitudinal
     incision closed via z-plasties,70 and transverse incisions, either left
     open to heal by secondary intention (McCash67 technique) or closed with
     z-plasty
 * Surgical decision-making becomes more challenging with complex patterns of
   disease and involvement of multiple digits
 * Various designs of incisions are demonstrated in
   Figure 8
 * Fasciectomy Technical Tips
   * Re-study the pathoanatomy of the disease.
   * Choose an incision that directly exposes the diseased fascia.
   * Use magnification.
   * Proceed from known to unknown.
   * Do not skeletonize the neurovascular bundle.
   * Minimize tension on skin closure.
   * Initiate early motion and therapy.

NEEDLE FASCIOTOMY

 * Percutaneous needle fasciotomy (PNF) or needle aponeurotomy (NA) requires a
   contracture due to a palpable cord lying beneath redundant skin in a
   cooperative patient.85
 * PNF is an attractive alternative to surgery for many patients
 * Procedure involves sectioning the cord by feel, using the cutting bevel of
   the tip of a standard hypodermic needle passed through intact skin under
   local anesthesia.
 * Needle Fasciotomy Technical Tips
   * Before the procedure:
     * Make sure the patient knows that paresthesias can occur and to report
       them.
     * Caution the patient to avoid any sudden movement of the hand during the
       procedure.
     * Have the patient demonstrate short excursion fingertip flexion/extension.
     * Search for potential spiral cords.
   * During the procedure:
     * Tension the cord, not the tendon.
     * Needles dull quickly; replace often.
     * Prep first and cover any potential skin tear sites with gauze before
       manipulating.
     * Manipulate finger into extension, adduction, adduction, pronation, and
       supination.
     * Manipulate adjacent fingers into extension.
   * Initiate early motion but delay heavy use for at least 1 week.

COLLAGENASE INJECTION

 * Clostridial collagenase enzymatic fasciotomy was first reported in 199687 and
   after extensive safety and efficacy testing88,89 was FDA approved in 2010
 * Commercially available collagenase is a mixture of two types of collagenase
   Clostridium histolyticum (CCH), which rapidly degrades collagen types I
   (dermis, tendon, fascia, bone), type III (scar tissue, elastic connective
   tissues, bone, cartilage, tendon), and weakly degrades collagen type IV
   (vascular and epithelial basement membrane)
 * CCH is injected directly into Dupuytren cords at one or more levels
 * After the injection is allowed time to weaken the cord, the cord is ruptured
   with forceful extension by the surgeon (
   Fig. 12
   )
 * CCH Technical Tips
    * Carefully explain common side effects before injection.
    * Use anesthesia for both injection and manipulation.
    * Divide injection into more than 3 aliquots.
    * Prep first and cover any potential skin tear sites with gauze before
      manipulating.
    * Manipulate finger into extension, adduction, adduction, pronation, and
      supination.
    * Manipulate adjacent fingers into extension.
    * Initiate early motion and therapy.

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


DIFFICULT ISSUES ASSOCIATED WITH SEVERE CONTRACTURES

 * Severe or Recurrent PIP Joint Contracture
   * Dupuytren-related PIP joint contractures (
     Fig. 13A
     ) develop secondary issues related to skin, joint capsule, flexor sheath,
     extensor mechanism, and joint surface94 that may prevent correction or lead
     to early recontracture
   * Two-stage approach should be considered for severe or recurrent PIP
     contractures
     * First stage is progressive soft tissue lengthening with an external
       fixator. The second stage is fasciectomy shortly after fixation removal (
       Fig. 13B, 13C
       ).
   * All salvage options for severe recurrent PIP contractures involve
     shortening the finger: amputation, arthrodesis, and middle phalangectomy
   * Patient discussion should include benefits versus potential for
     neurovascular injury, permanent stiffness, and unplanned amputation.

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


OUTCOMES OF TREATMENT

 * Dupuytren treatment outcomes are assessed by initial contracture correction,
   recovery time, and recurrence
 * Most common current shorthand for contracture correction is success, defined
   as correction to less than 5° of full extension for a single joint
 * Success is less likely for greater degrees of contracture, regardless of the
   type of corrective procedure99-104
   * Likelihood of success with CCH drops from 80% for MCP contractures less
     than or equal to 50° to 40% for MCP joint contractures greater than 50°102
   * Success with CCH drops from 50% for PIP contractures less than or equal to
     40° to 20%–25% for PIP joint contractures greater than 50°102,103
 * Failure to achieve full correction is more likely with PIP contractures than
   MCP contractures and is less with small finger contractures
 * Fasciectomy for multiple ray involvement is also less likely to achieve full
   correction
 * Correction of overall contracture is more likely for fasciectomy than for
   either PNF or CCH, particularly for greater degrees of contracture
 * MCP contracture correction appears comparable for fasciectomy, CCH, and PNF
   with an overall 80%–90% chance of success
 * Similar is found for PIP contracture with an overall 25%–50% chance of
   success
 * Fasciectomy. Reported rates of recurrence following limited fasciectomy at
   various follow-up intervals have ranged from 0% to 71%
   * Overall recurrence rate projects to about 5% per year
 * Collagenase and needle fasciotomy. Three-year recurrence of CCH and PNF are
   comparable and project to an overall recurrence rate of about 10% per year
   for MCP contractures and 20% per year for PIP contractures
   * Even with greater recurrence rates than fasciectomy, rapid recovery, and
     low complication risk have led some to recommend minimally invasive
     treatment as the first intervention135 to delay the need for fasciectomy108




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