Category: Hand and Upper Extremity Review

Hand and upper extremity orthopedic exam prep review questions and answers …

A Review of Distal Radioulnar Joint (DRUJ) Instability and Reconstruction

High-Yield Summary

The distal radioulnar joint (DRUJ) is critical for forearm rotation and load transmission; instability leads to pain, weaknessand functional impairment.
DRUJ instability results from disruption of the triangular fibrocartilage complex (TFCC), distal radioulnar ligamentsor osseous incongruity.
Diagnosis hinges on clinical exam maneuvers (e.g., piano key test, DRUJ ballottement) combined with imaging-CT with contralateral comparison is gold standard for subtle instability.
Non-operative management is reserved for acute, stable injuries without significant subluxation; surgical reconstruction is indicated for chronic instability or irreparable soft tissue damage.
Surgical techniques vary from arthroscopic TFCC repair to open ligament reconstruction; choice depends on injury chronicity, tissue qualityand presence of DRUJ arthritis.

Clinical Fundamentals

Anatomy

The DRUJ is a synovial pivot joint formed by the ulnar head and the sigmoid notch of the distal radius. Stability depends on both osseous congruity and soft tissue constraints.

Key stabilizers:

Triangular fibrocartilage complex (TFCC): Primary soft tissue stabilizer, composed of the articular disc, dorsal and volar radioulnar ligaments, meniscus homologueand sheath of the extensor carpi ulnaris (ECU).
Distal interosseous membrane: Secondary stabilizer transmitting axial load.
Joint capsule and ECU subsheath contribute dynamic stability.

Biomechanics

The DRUJ allows pronation and supination by rotation of the radius around the fixed ulna. Stability is maintained by tension in the radioulnar ligaments, which vary with forearm position:

Volar ligament tightens in supination.
Dorsal ligament tightens in pronation.

Load transmission through the DRUJ accounts for approximately 20% of axial load across the wrist, increasing with ulnar deviation.

Epidemiology

DRUJ instability commonly occurs in conjunction with distal radius fractures, Galeazzi fracturesor isolated TFCC tears. Chronic instability is more frequent in young, active patients and those with ligamentous laxity or prior trauma.

Classification & Diagnosis

Classification System	Description	Clinical Relevance
Palmer Classification	Classifies TFCC lesions into traumatic (Type 1) and degenerative (Type 2)	Guides surgical repair vs. debridement
Mino Classification	Focuses on DRUJ instability patterns: dorsal, volar, bidirectional	Directs surgical approach and ligament reconstruction
Radiographic Grading	Based on ulnar variance and subluxation on CT or MRI	Determines need for ulnar shortening or joint salvage

Diagnostic Pearls

Piano key test: Pressing the distal ulna volarly and dorsally; excessive mobility or pain indicates instability.
Ballottement test: Dorsal-volar translation of the ulna relative to the radius; >5 mm translation suggests instability.
Imaging: Standard wrist radiographs may miss subtle subluxation; CT with contralateral comparison is essential for assessing DRUJ congruity and ulnar variance.
MRI arthrography: Useful for detecting TFCC tears but less reliable for dynamic instability.

Common Pitfalls

Overreliance on static imaging without dynamic clinical assessment.
Failure to compare with contralateral wrist on imaging.
Misdiagnosing chronic instability as simple wrist pain or tendinopathy.

Decision-Making Algorithm

Clinical Scenario	Management	Rationale
Acute DRUJ instability without subluxation or TFCC tear	Non-operative: immobilization in supination 4-6 weeks	Allows ligament healing; avoids surgery in stable injuries
Acute DRUJ instability with displaced TFCC tear or DRUJ subluxation	Arthroscopic or open TFCC repair	Restores ligament tension and joint stability
Chronic DRUJ instability with ligament insufficiency but preserved cartilage	Open ligament reconstruction (e.g., Adams-Berger technique)	Reconstructs stabilizers; prevents progression to arthritis
Chronic DRUJ instability with arthritis or ulnar impaction	Salvage procedures: ulnar head resection (Darrach), Sauvé-Kapandjior prosthetic replacement	Addresses pain and mechanical dysfunction when reconstruction is not feasible

Why specific approaches?

Arthroscopic repair is minimally invasive, preserves anatomyand is preferred in acute tears.
Open reconstruction is necessary when tissue quality is poor or chronic attenuation exists.
Salvage procedures are reserved for end-stage disease or failed reconstructions.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview of Open Ligament Reconstruction (Adams-Berger Technique)

Exposure: Dorsal approach between the ECU and extensor digiti minimi tendons; protect dorsal sensory branches.
Assessment: Evaluate TFCC remnants, joint cartilageand DRUJ congruity.
Graft Harvest: Use palmaris longus or plantaris tendon autograft; prepare for ligament reconstruction.
Tunnel Creation: Drill tunnels in the distal radius sigmoid notch and ulnar fovea to replicate volar and dorsal radioulnar ligaments.
Graft Passage and Fixation: Pass graft through tunnels, tension in neutral forearm rotationand fix with interference screws or suture anchors.
Closure: Repair capsule and ECU subsheath to restore dynamic stability.

Intraoperative Red Flags

Excessive joint gapping after graft fixation suggests inadequate tensioning or tunnel placement.
Injury to dorsal sensory branches can cause chronic neuropathic pain.
Over-tensioning graft leads to restricted forearm rotation and stiffness.

Technical Tips

Use fluoroscopy to confirm tunnel placement and avoid articular penetration.
Maintain forearm in neutral rotation during graft fixation to balance ligament tension.
Repair ECU subsheath meticulously to restore dynamic stabilizer function.

Evidence-Based Synthesis

Recent literature emphasizes the importance of early recognition and tailored surgical intervention for DRUJ instability. High-level studies comparing arthroscopic repair versus open reconstruction demonstrate superior outcomes with arthroscopy in acute TFCC tears but highlight the necessity of open techniques in chronic cases with ligament attenuation.

Biomechanical studies confirm that anatomical reconstruction of both volar and dorsal radioulnar ligaments restores near-normal joint kinematics, reducing the risk of recurrent instability and arthritis.

Controversy remains regarding the optimal management of chronic instability with mild arthritis; some advocate for ligament reconstruction combined with ulnar shortening osteotomy, while others prefer salvage procedures. Long-term comparative data are lacking, underscoring the need for individualized treatment plans.

Emerging evidence supports the use of dynamic ultrasound and 4D CT for improved diagnostic accuracy, though these modalities are not yet standard.

Master Class Pro-Tip

When performing DRUJ ligament reconstruction, prioritize anatomical tunnel placement at the ulnar fovea and sigmoid notch to restore native ligament biomechanics. Avoid over-tensioning grafts by intraoperatively assessing forearm rotation and DRUJ stability under direct visualization. Incorporate meticulous repair of the ECU subsheath to re-establish dynamic stability, which is often overlooked but critical for preventing postoperative subluxation and optimizing functional outcomes. This nuanced balance between static and dynamic stabilizers distinguishes a master surgeon from a competent technician.

August 18, 2026/0 Comments/by OrthoNet AI

Hand and Upper Extremity Review

Current Concepts in the Management of Terrible Triad Injuries of the Elbow

High-Yield Summary

Terrible triad injuries combine elbow dislocation, radial head fractureand coronoid process fracture, resulting in inherent instability requiring surgical intervention in most cases.
Early anatomic restoration of the radial head and coronoid process, combined with lateral collateral ligament (LCL) repair, is critical to restore stability and prevent chronic instability or stiffness.
Non-operative management is rarely indicated except for minimally displaced fractures with a stable joint after reduction.
Surgical approach typically involves a lateral (Kocher or Kaplan) exposure with selective medial exposure for coronoid fixation and medial collateral ligament (MCL) repair if instability persists.
Postoperative rehabilitation balances early motion to prevent stiffness with protection of soft tissue repairs to avoid recurrent instability.

Clinical Fundamentals

Relevant Anatomy

The elbow joint’s stability depends on bony congruity and ligamentous support. The radial head acts as a secondary stabilizer against valgus and axial loads. The coronoid process prevents posterior translation of the ulna. The lateral collateral ligament complex (LCL) resists varus and posterolateral rotatory instability. The medial collateral ligament (MCL) provides valgus stability.

Biomechanics

The terrible triad disrupts both static and dynamic stabilizers. Radial head fractures compromise valgus and axial load resistance. Coronoid fractures destabilize the ulnohumeral articulation. LCL disruption leads to posterolateral rotatory instability. Restoration of these elements is essential to re-establish the elbow’s kinematic chain.

Epidemiology

Terrible triad injuries typically result from high-energy trauma with axial load and valgus stress on an extended elbow. They are more common in young, active patients and represent a surgical challenge due to the complexity of injury patterns and risk of complications such as stiffness, instabilityand post-traumatic arthritis.

Classification & Diagnosis

Classification System	Description	Impact on Management
Regan-Morrey (Coronoid Fracture)	Type I: Tip fracture <2 mm; Type II: <50% height; Type III: >50% height	Type II and III usually require fixation to restore stability.
Mason (Radial Head Fracture)	Type I: Non-displaced; Type II: Displaced partial; Type III: Comminuted; Type IV: Associated dislocation	Type II-IV often need fixation or replacement; Type III and IV favor arthroplasty if reconstruction is not feasible.
O’Driscoll (Coronoid Fracture Subtypes)	Anteromedial facet involvement critical for varus stability	Anteromedial facet fractures require fixation to prevent varus posteromedial instability.

Diagnostic Pearls

Obtain true AP and lateral radiographs; CT with 3D reconstructions is essential for fracture characterization and surgical planning.
Assess elbow stability after closed reduction; persistent instability indicates need for surgical intervention.
Beware of missed coronoid fractures on plain films; subtle fractures can be overlooked, leading to chronic instability.
MRI is rarely needed acutely but may assist in evaluating ligamentous injuries if instability persists postoperatively.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Fracture Displacement	Minimal displacement (<2 mm coronoid tip, non-displaced radial head)	Displaced fractures, comminutionor instability after reduction
Joint Stability	Stable joint after closed reduction	Persistent instability or subluxation
Patient Factors	Low-demand, medically unfit for surgery	Active patients, young age, high functional demand
Surgical Approach	N/A	Lateral approach for radial head and LCL repair; medial approach for coronoid fixation and MCL repair if needed

Why Specific Approaches and Implants?

Radial head fixation is preferred for reconstructible fractures; arthroplasty is indicated for comminuted fractures not amenable to fixation to restore lateral column support.
Coronoid fixation is essential for restoring anterior buttress; screws or suture anchors are chosen based on fragment size and location.
LCL repair is mandatory to prevent posterolateral rotatory instability; MCL repair is reserved for persistent valgus instability after bony and lateral repairs.
Early motion protocols require stable fixation and soft tissue repair to minimize stiffness without risking instability.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Patient Positioning and Exposure: Supine or lateral decubitus with arm on arm board. Begin with a lateral approach (Kocher interval between anconeus and extensor carpi ulnaris).
Radial Head Management: Assess fracture pattern; attempt anatomic fixation with headless screws or mini-fragment plates. If comminuted, proceed with modular radial head arthroplasty ensuring correct sizing to avoid overstuffing.
Coronoid Fixation: Through lateral or separate medial approach, fix coronoid fragments with screws or suture lasso technique depending on fragment size and location. Anteromedial facet fractures require direct fixation.
LCL Repair: Reattach LCL complex to lateral epicondyle using suture anchors or transosseous sutures. Confirm stability intraoperatively with varus and posterolateral rotatory stress tests.
MCL Repair: Only if valgus instability persists after bony and lateral repairs; typically via medial approach with suture anchors.
Closure and Postoperative Protocol: Close in layers; apply hinged elbow brace allowing controlled early motion.

Intraoperative Red Flags

Overstuffing radial head arthroplasty causing decreased flexion-extension arc and capitellar wear.
Inadequate coronoid fixation leading to persistent instability.
Failure to repair LCL resulting in posterolateral rotatory instability.
Excessive soft tissue stripping increasing risk of stiffness and heterotopic ossification.

Evidence-Based Synthesis

Recent high-impact studies emphasize the importance of restoring all three components of the terrible triad to optimize outcomes. A randomized controlled trial comparing radial head fixation versus arthroplasty demonstrated superior stability and fewer reoperations with arthroplasty in comminuted fractures, shifting the standard toward prosthetic replacement in these cases. Meta-analyses confirm that coronoid fixation reduces recurrent instability and improves functional scores, especially when the anteromedial facet is involved.

Controversy remains regarding the necessity of routine MCL repair; some studies suggest that stable lateral repair and bony fixation suffice in most cases, reserving MCL repair for persistent valgus laxity. Early motion protocols have evolved, with evidence supporting initiation within 1-2 weeks postoperatively to minimize stiffness without compromising repair integrity.

Despite advances, heterotopic ossification and post-traumatic arthritis remain common complications, underscoring the need for meticulous surgical technique and patient-specific rehabilitation.

Master Class Pro-Tip

When performing radial head arthroplasty, intraoperative fluoroscopy combined with direct visualization of the radiocapitellar joint is essential to avoid over-lengthening the radius. Use trial implants to confirm restoration of the lateral column height and elbow congruity before final implantation. Overstuffing is the most common technical error leading to poor outcomes and is often subtle on imaging. Mastery of this nuance differentiates a competent surgeon from a master in terrible triad management.

August 5, 2026/0 Comments/by OrthoNet AI

Hand and Upper Extremity Review

Surgical Techniques for Coronoid Fracture Fixation in Elbow Instability

High-Yield Summary

The coronoid process is critical for anterior elbow stability; fractures compromise varus and posteromedial rotatory stability, often necessitating fixation in unstable elbows.
Regan-Morrey and O’Driscoll classifications guide fixation strategy by fracture size and location, directly influencing surgical approach and implant choice.
Small tip fractures (<10% of coronoid height) may be managed non-operatively if the elbow is stable; larger or anteromedial facet fractures require surgical fixation to restore stability.
Surgical approaches include the anteromedial, medialand lateral windows, selected based on fracture pattern and associated ligamentous injury.
Fixation techniques range from suture lasso constructs for small fragments to buttress plating for anteromedial facet fractures; rigid fixation is essential to allow early motion and prevent stiffness.

Clinical Fundamentals

The coronoid process forms the anterior buttress of the ulnohumeral joint, resisting posterior translation and varus stress. It contributes approximately 50% of the elbow’s bony stability, particularly against posteromedial rotatory forces. The anteromedial facet is a key stabilizer against varus posteromedial rotatory instability (PMRI), while the tip resists posterior subluxation. The elbow’s stability is further supported by the medial collateral ligament (MCL) and lateral collateral ligament (LCL) complexes, which often sustain concomitant injury in coronoid fractures.

Epidemiologically, coronoid fractures are uncommon in isolation and frequently occur with elbow dislocations or complex fracture-dislocations such as the “terrible triad” (radial head fracture, coronoid fractureand LCL injury). Failure to recognize and fix these fractures leads to chronic instability, arthritisand poor functional outcomes.

Classification & Diagnosis

Classification System	Description	Surgical Implication
Regan-Morrey	Type I: Tip <2 mm Type II: <50% height Type III: >50% height	Type I often non-operative if stable Type II/III usually require fixation
O’Driscoll	Type 1: Tip fractures Type 2: Anteromedial facet fractures Type 3: Basal fractures	Type 2 requires buttress plating to restore varus stability
Diagnostic Pearls	Use CT with 3D reconstructions for fracture morphology Assess elbow stability under fluoroscopy post-reduction Beware of missed anteromedial facet fractures on plain films	Misclassification risks inadequate fixation and persistent instability

Decision-Making Algorithm

Non-operative management is reserved for isolated, small tip fractures (<10% coronoid height) with a stable elbow after reduction and no ligamentous disruption. Early mobilization is critical to prevent stiffness.

Operative fixation is indicated when:

Fracture involves >50% of coronoid height (Regan-Morrey Type III).
Anteromedial facet fractures (O’Driscoll Type 2) causing varus instability.
Associated ligamentous injuries (LCL or MCL) causing gross instability.
Elbow remains unstable after closed reduction.

Surgical approach selection depends on fracture location and associated injuries:

Anteromedial approach for anteromedial facet fractures to allow buttress plating.
Medial approach for basal fractures and MCL repair.
Lateral approach for tip fractures and concomitant radial head fixation.

Implant choice balances fragment size and bone quality:

Suture lasso or suture anchors for small tip fragments.
Headless compression screws for larger fragments with sufficient bone stock.
Mini fragment buttress plates for anteromedial facet fractures to resist varus forces.

Surgical Mastery & Pearls

Step 1: Exposure
Position the patient supine or lateral decubitus with the arm on a radiolucent arm board. Use the approach tailored to fracture type: anteromedial for facet fractures, medial for basal fractures, lateral for tip fractures. Protect the ulnar nerve during medial exposures.

Step 2: Fracture Reduction
Achieve anatomic reduction under direct visualization. Use temporary K-wire fixation to maintain reduction. Confirm reduction fluoroscopically in multiple planes.

Step 3: Fixation
For small tip fractures, employ a suture lasso technique through the anterior capsule and coronoid tip, tied over a bone bridge or suture anchor. For larger fragments, insert headless compression screws perpendicular to the fracture plane to maximize compression without hardware prominence.

For anteromedial facet fractures, apply a mini fragment buttress plate along the medial ulna to counteract varus forces. Ensure the plate is contoured to the ulna and does not impinge on the joint.

Step 4: Ligament Repair
Address concomitant LCL or MCL injuries with suture anchors or transosseous repair to restore soft tissue stability.

Intraoperative Red Flags

Persistent instability after fixation suggests missed ligamentous injury or inadequate fixation.

Excessive soft tissue stripping risks stiffness and heterotopic ossification.

Hardware prominence can cause mechanical block or cartilage damage.

Technical Tips

Use intraoperative fluoroscopy to confirm screw length and plate position.

Preserve the anterior capsule to maintain elbow stability.

Early controlled motion postoperatively reduces stiffness without compromising fixation.

Evidence-Based Synthesis

Recent literature emphasizes the importance of restoring the anteromedial facet in PMRI to prevent recurrent instability. Biomechanical studies demonstrate that buttress plating of the anteromedial facet restores varus stability more effectively than screw fixation alone. Clinical series report improved outcomes with combined bony and ligamentous repair in terrible triad injuries, reducing rates of recurrent dislocation and arthrosis.

Randomized controlled trials comparing fixation methods are limited; however, consensus favors rigid fixation with early motion protocols. Controversy remains regarding the necessity of fixing small tip fractures in the presence of ligamentous repair alone. Emerging data suggest that selective non-fixation may be safe in highly stable elbows, but this requires careful intraoperative assessment.

The evolving role of arthroscopic-assisted fixation is promising but currently lacks robust comparative data. Future studies are needed to define indications and long-term outcomes.

Master Class Pro-Tip

Mastery in coronoid fracture fixation hinges on recognizing the fracture’s biomechanical role within the elbow’s stability complex. Prioritize anatomic restoration of the anteromedial facet with buttress plating when indicatedand never underestimate the need for meticulous soft tissue repair. Intraoperative dynamic assessment of stability after fixation guides the necessity for additional ligament reconstruction. This tailored, stability-driven approach-not fragment size alone-defines surgical excellence and optimizes functional recovery.

July 23, 2026/0 Comments/by OrthoNet AI

Hand and Upper Extremity Review

Understanding the Mason Classification of Radial Head Fractures

###

### High-Yield Summary

– The Mason classification stratifies radial head fractures by displacement and comminution, directly guiding management from non-operative care to complex reconstruction or arthroplasty.
– Type I fractures are nondisplaced or minimally displaced and typically managed non-operatively with early motion.
– Type II fractures involve displacement >2 mm or mechanical block and often require open reduction and internal fixation (ORIF).
– Type III fractures are comminuted and unstable, frequently necessitating radial head excision with replacement arthroplasty to restore elbow stability.
– Accurate classification depends on high-quality imaging, including true anteroposterior and lateral radiographs, supplemented by CT for complex or comminuted fractures.

### Clinical Fundamentals

#### Relevant Anatomy
The radial head articulates with the capitellum and the radial notch of the ulna, contributing to elbow stability and forearm rotation. The lateral collateral ligament complex attaches near the radial head, making its integrity critical for varus and posterolateral rotatory stability.

#### Biomechanics
The radial head transmits axial load from the wrist to the humerus, bearing up to 60% of the load in valgus stress. Loss of radial head integrity compromises elbow stability, especially in the presence of ligamentous injury or coronoid fractures.

#### Epidemiology
Radial head fractures account for approximately one-third of all elbow fractures, predominantly occurring in adults aged 30-50 years after a fall on an outstretched hand with the elbow partially flexed.

### Classification & Diagnosis

*Type IV is a modification by Johnston, emphasizing associated dislocation.

#### Diagnostic Pearls
– Obtain true AP and lateral elbow radiographs with the forearm in neutral rotation to avoid underestimating displacement.
– CT scans are essential for assessing comminution and fragment size in Type II and III fractures.
– Beware of subtle mechanical blocks indicating intra-articular fragment displacement, which mandates surgical intervention.

### Decision-Making Algorithm

#### Surgical Approach and Implant Choice
– The Kocher interval (between anconeus and extensor carpi ulnaris) provides safe lateral access.
– Headless compression screws are preferred for large fragments in Type II fractures.
– For comminuted fractures, modular radial head arthroplasty restores stability and load transmission better than excision alone.

### Surgical Mastery & Pearls

#### Step-by-Step Conceptual Overview
1. Position the patient supine or lateral decubitus with the arm on an arm board to allow full elbow flexion and extension intraoperatively.
2. Identify and protect the posterior interosseous nerve during lateral exposure.
3. Use the Kocher approach to access the radial head, avoiding excessive soft tissue stripping to preserve blood supply.
4. For Type II fractures, achieve anatomic reduction with provisional K-wires, then secure with headless screws ensuring subchondral support.
5. In Type III fractures, assess the feasibility of fixation; if not reconstructible, proceed with modular arthroplasty sized to restore radial length and avoid overstuffing.
6. Confirm elbow stability through full range of motion after fixation or arthroplasty.
7. Repair lateral collateral ligament complex if injured to prevent posterolateral rotatory instability.

#### Intraoperative Red Flags
– Excessive stripping of soft tissues leading to avascular necrosis risk.
– Overstuffing the radial head prosthesis causing limited motion and capitellar wear.
– Failure to recognize and address associated ligamentous injuries resulting in chronic instability.

### Evidence-Based Synthesis

Recent randomized controlled trials and meta-analyses have refined the management of Mason Type II and III fractures. Evidence supports non-operative treatment for minimally displaced fractures with excellent functional outcomes and low complication rates. For Type II fractures, ORIF improves range of motion and reduces mechanical block compared to conservative care, but fixation failure rates increase with comminution.

In comminuted Type III fractures, radial head arthroplasty has demonstrated superior elbow stability and functional scores compared to excision alone, particularly in the setting of ligamentous injury. However, controversy persists regarding the optimal implant design and long-term outcomes, with some studies reporting polyethylene wear and capitellar erosion.

The literature underscores the importance of restoring radial length and addressing concomitant soft tissue injuries to optimize outcomes. Surgical timing and early mobilization protocols remain areas of ongoing investigation, with emerging data favoring early motion to prevent stiffness without compromising fixation.

### Master Class Pro-Tip

Mastery in managing radial head fractures hinges on appreciating the radial head as a keystone of elbow stability rather than a mere fracture fragment. Prioritize anatomic restoration of the articular surface and radial length while meticulously preserving soft tissue attachments. When arthroplasty is indicated, intraoperative trialing to avoid overlengthening is critical-use fluoroscopy to compare radial height with the contralateral side. Finally, always assess and address lateral collateral ligament integrity intraoperatively; failure to do so is the most common cause of postoperative instability and poor functional outcomes.

July 10, 2026/0 Comments/by OrthoNet AI

Hand and Upper Extremity Review

Management of Acute and Chronic Lateral Epicondylitis

High-Yield Summary

Lateral epicondylitis (LE) is a tendinopathy primarily involving the extensor carpi radialis brevis (ECRB) origin, presenting with lateral elbow pain exacerbated by wrist extension and gripping.
Non-operative management, including activity modification, physical therapyand corticosteroid or biologic injections, remains first-line for both acute and chronic cases.
Surgical intervention is reserved for refractory cases beyond 6 months of optimized conservative care or those with mechanical symptoms; open, arthroscopicand percutaneous techniques each have specific indications.
Precise identification and debridement of pathologic ECRB tissue, preservation of lateral collateral ligament (LCL) complexand restoration of tendon integrity are critical for surgical success.
Recent evidence questions the long-term benefit of corticosteroids and highlights the evolving role of biologics and minimally invasive surgery, emphasizing individualized treatment algorithms.

Clinical Fundamentals

Anatomy:
The lateral epicondyle serves as the common extensor origin, with the ECRB tendon being the primary structure implicated in LE. The ECRB lies deep to the extensor carpi radialis longus (ECRL) and extensor digitorum communis (EDC). The lateral collateral ligament complex, including the radial collateral ligament and the lateral ulnar collateral ligament, is adjacent and must be preserved during surgery.

Biomechanics:
ECRB stabilizes the wrist during extension and resists valgus forces at the elbow. Repetitive microtrauma from wrist extension and forearm supination leads to angiofibroblastic tendinosis rather than inflammatory tendinitis, characterized by collagen disorganization and neovascularization.

Epidemiology:
LE affects 1-3% of the general population, peaking between 35 and 55 years. It is more common in individuals performing repetitive wrist extension or gripping activities, including manual laborers and athletes. Both acute overload and chronic degeneration contribute to symptomatology.

Classification & Diagnosis

Classification System	Description	Clinical Relevance
Nirschl Stages	1-7 scale based on symptom severity and histopathology	Guides prognosis and timing of surgery
Ultrasound Grading	Grades 0-3 based on tendon hypoechogenicity, neovascularityand tears	Assists in diagnosis and monitoring response
MRI Classification	Tendinosis, partial tear, full-thickness tear	Surgical planning, especially for chronic refractory cases

Diagnostic Pearls:

Tenderness localized 1 cm distal to the lateral epicondyle over ECRB origin is pathognomonic.

Pain reproduced by resisted wrist extension with the elbow extended confirms diagnosis.

Differentiate from radial tunnel syndrome by absence of sensory symptoms and pain location.

Beware of concurrent intra-articular pathology or lateral collateral ligament injury in refractory cases.

Decision-Making Algorithm

Management Pathway	Indications	Rationale
Non-Operative	Symptoms < 6 months, no mechanical symptoms, no tendon rupture	Most cases resolve with conservative care; avoids surgical morbidity
Operative	Symptoms > 6 months refractory to non-operative care, partial tendon tear >50%, mechanical symptoms, failed biologics	Surgery removes pathologic tissue, restores tendon functionand addresses structural defects

Surgical Approach Selection:

Open technique preferred for large tears or when direct visualization is necessary.

Arthroscopic approach allows concurrent intra-articular assessment and faster recovery but requires advanced skill.

Percutaneous techniques suitable for tendinosis without significant tearing, with minimal soft tissue disruption.

Surgical Mastery & Pearls

Stepwise Surgical Technique (Open Approach):

Patient positioning supine or lateral decubitus with arm on arm table.

4-5 cm longitudinal incision centered over lateral epicondyle.

Identify and protect the posterior cutaneous nerve of the forearm.

Incise extensor aponeurosis longitudinally to expose ECRB origin.

Debride angiofibroblastic tissue and excise degenerative tendon while preserving healthy fibers.

Avoid injury to lateral collateral ligament complex; confirm stability intraoperatively.

Repair or advance tendon edges with nonabsorbable sutures if necessary.

Close extensor aponeurosis and skin in layers.

Intraoperative Red Flags:

Unexpected instability suggests lateral collateral ligament injury requiring repair.

Extensive tendon loss may necessitate augmentation or reconstruction.

Excessive soft tissue dissection increases risk of postoperative stiffness and hematoma.

Technical Tips:

Use loupe magnification to differentiate pathologic from normal tendon.

Maintain meticulous hemostasis to reduce postoperative swelling.

Early controlled mobilization post-op improves functional outcomes.

Evidence-Based Synthesis

Landmark randomized controlled trials have established that corticosteroid injections provide short-term pain relief but are associated with higher recurrence rates and poorer long-term outcomes compared to physical therapy or placebo. Recent meta-analyses favor eccentric strengthening protocols and shockwave therapy as effective non-operative modalities.

Surgical literature comparing open versus arthroscopic release shows comparable pain relief and functional improvement; however, arthroscopy offers faster recovery and the ability to address concomitant intra-articular pathology. Percutaneous techniques remain investigational with limited high-quality evidence.

Emerging studies on platelet-rich plasma (PRP) and autologous blood injections demonstrate mixed results, with some trials showing improved tendon healing and symptom relief, while others report no significant benefit over placebo. This reflects ongoing uncertainty and the need for standardized protocols.

Current consensus supports a stepwise approach prioritizing non-operative care for at least 6 months, reserving surgery for refractory cases with objective tendon pathology. The choice of surgical technique should be individualized based on surgeon expertise, patient factorsand tendon integrity.

Master Class Pro-Tip

Mastery in lateral epicondylitis surgery hinges on the nuanced balance between adequate debridement of pathologic tissue and preservation of the lateral collateral ligament complex. Overzealous excision risks iatrogenic instability, while insufficient removal predisposes to persistent symptoms. Employ intraoperative dynamic assessment of elbow stability after debridementand consider adjunctive biologic augmentation selectively in chronic, recalcitrant cases to optimize tendon healing and functional restoration.

June 26, 2026/0 Comments/by OrthoNet AI

Hand and Upper Extremity Review

Surgical Options for Proximal Interphalangeal (PIP) Joint Arthrodesis and Arthroplasty

High-Yield Summary

Proximal interphalangeal (PIP) joint arthrodesis is the gold standard for end-stage arthritis or severe instability when pain relief and stability outweigh motion preservation.
PIP joint arthroplasty is indicated for patients prioritizing motion, typically with less severe joint destruction and intact soft tissues.
Implant choice and surgical approach depend on patient factors, joint pathology, and surgeon expertise; common implants include silicone spacers, pyrocarbon, and surface replacement prostheses.
Complications differ by procedure: arthrodesis risks nonunion and malalignment; arthroplasty risks implant loosening, subsidence, and stiffness.
Surgical success hinges on precise joint preparation, soft tissue balancing, and implant positioning to optimize function and durability.

Clinical Fundamentals

Anatomy:
The PIP joint is a hinge synovial joint formed by the head of the proximal phalanx and the base of the middle phalanx. Stability is provided by collateral ligaments, volar plate, and extensor mechanism. The joint allows approximately 100-110 degrees of flexion-extension, critical for hand dexterity.

Biomechanics:
Load transmission through the PIP joint is significant during grip and pinch. The joint’s congruent articular surfaces and ligamentous constraints maintain stability while permitting motion. Loss of cartilage or ligament integrity leads to pain, deformity, and functional impairment.

Epidemiology:
PIP joint arthritis commonly results from trauma, inflammatory arthritis (e.g., rheumatoid arthritis), or osteoarthritis. It disproportionately affects dominant hands and middle fingers due to mechanical stress.

Classification & Diagnosis

Classification System	Description	Impact on Management
Eaton-Littler Classification	Grades PIP joint arthritis severity based on radiographic joint space narrowing and osteophyte formation	Guides timing of arthroplasty vs. arthrodesis
Wehbé and Schneider Classification	Categorizes PIP joint fracture-dislocations by fracture pattern and stability	Determines need for surgical fixation or arthrodesis
Larsen Score (for RA)	Radiographic scoring of joint destruction severity	Influences decision for joint replacement vs. fusion

Diagnostic Pearls:

Obtain true lateral and oblique radiographs to assess joint space, subluxation, and osteophytes.

Clinical exam should assess stability, range of motion, and deformity.

MRI or ultrasound may be useful to evaluate soft tissue integrity in inflammatory arthritis.

Common Pitfalls:

Underestimating collateral ligament insufficiency leads to poor arthroplasty outcomes.

Failure to recognize malalignment or subluxation can result in implant failure or nonunion.

Decision-Making Algorithm

Non-Operative Management:
Indicated for mild symptoms, preserved joint space, and minimal deformity. Includes splinting, NSAIDs, corticosteroid injections, and hand therapy.

Operative Management Criteria:

Severe pain refractory to conservative care.

Radiographic evidence of joint destruction or instability.

Functional impairment impacting activities of daily living.

Arthrodesis Indications:

Severe joint destruction with instability or deformity.

High-demand patients requiring stable, pain-free digits.

Failed arthroplasty or infection.

Arthroplasty Indications:

Moderate joint destruction with preserved soft tissue envelope.

Patients prioritizing motion over absolute stability.

Rheumatoid arthritis with less severe deformity.

Surgical Approach and Implant Selection:

Dorsal approach is most common for both arthrodesis and arthroplasty, providing excellent exposure.

Arthrodesis implants include compression screws, plates, and intramedullary devices.

Arthroplasty implants vary: silicone spacers for flexibility, pyrocarbon for durability, and surface replacements for anatomic restoration.

Surgical Mastery & Pearls

Arthrodesis Technique Overview:

Expose joint dorsally, preserving extensor mechanism.

Remove cartilage meticulously to expose subchondral bone.

Achieve precise alignment in slight flexion (20-30 degrees) to optimize function.

Use compression fixation to promote union; confirm stability intraoperatively.

Avoid excessive soft tissue stripping to preserve blood supply.

Arthroplasty Technique Overview:

Dorsal approach with careful extensor tendon elevation.

Resect minimal bone to preserve length and ligament attachments.

Balance collateral ligaments to prevent instability.

Trial implants to confirm range of motion and stability before final implantation.

Meticulous soft tissue repair to prevent extensor lag or joint subluxation.

Intraoperative Red Flags:

Excessive bone resection risking joint instability or implant subsidence.

Inadequate collateral ligament balancing causing postoperative deformity.

Poor implant fit leading to early loosening or stiffness.

Failure to achieve compression in arthrodesis risking nonunion.

Evidence-Based Synthesis

Recent randomized controlled trials and cohort studies emphasize the superiority of arthrodesis for pain relief and durability in severe PIP joint arthritis, with union rates exceeding 90% when compression fixation is used. Arthroplasty offers improved range of motion but carries higher revision rates, particularly with silicone implants prone to fracture and pyrocarbon implants susceptible to loosening.

Comparative studies highlight that patient selection is paramount: younger, active patients with less joint destruction benefit from arthroplasty, while older or high-demand patients achieve better long-term outcomes with arthrodesis. Advances in implant design, such as pyrocarbon surface replacements, show promise but require longer-term data to confirm durability.

Soft tissue balancing and surgical technique remain critical determinants of success, often outweighing implant choice. Emerging evidence suggests that early mobilization protocols after arthroplasty improve functional outcomes without increasing complication rates.

Master Class Pro-Tip

Mastery in PIP joint surgery demands an intimate understanding of the joint’s biomechanical axis and soft tissue constraints. When performing arthrodesis, aim for a reproducible flexion angle tailored to the digit’s functional role-typically 20 degrees for the index and middle fingers, 30 degrees for the ring, and 40 degrees for the small finger. For arthroplasty, prioritize ligamentous balancing over aggressive bone resection; subtle collateral tightening or release can mean the difference between a stable, mobile joint and a painful, unstable one. Finally, intraoperative fluoroscopy is invaluable for confirming implant positioning and alignment before closure, preventing costly revisions.

June 13, 2026/0 Comments/by OrthoNet AI

Hand and Upper Extremity Review

Understanding the Kanavel Signs and Management of Pyogenic Flexor Tenosynovitis

High-Yield Summary

Pyogenic flexor tenosynovitis (PFT) is a surgical emergency characterized by infection within the flexor tendon sheath, risking tendon necrosis and functional loss if untreated.
The four Kanavel signs-fusiform swelling, finger held in slight flexion, tenderness along the flexor sheath, and pain on passive extension-are critical for early clinical diagnosis.
Prompt surgical irrigation and debridement combined with targeted intravenous antibiotics remain the gold standard for management.
Delay in treatment correlates with increased risk of tendon rupture, stiffness, and poor functional outcomes.
Differentiation from mimics such as cellulitis or septic arthritis relies on clinical examination and, when needed, adjunct imaging or aspiration.

Clinical Fundamentals

Relevant Anatomy

The flexor tendon sheath is a closed synovial-lined space enveloping the flexor tendons from the distal phalanx to the distal palmar crease. It facilitates smooth tendon gliding and is divided into annular and cruciform pulleys that maintain tendon position. The sheath’s limited vascularity predisposes it to rapid infection spread and poor antibiotic penetration.

Biomechanics

Flexor tendons function under high tensile loads during finger flexion. Infection-induced inflammation increases intra-sheath pressure, compromising tendon nutrition and gliding, leading to adhesions and contracture if untreated.

Epidemiology

PFT most commonly affects adults following penetrating trauma, puncture wounds, or contiguous spread from adjacent infections. Staphylococcus aureus is the predominant pathogen, including MRSA strains. Incidence peaks in manual laborers and intravenous drug users.

Classification & Diagnosis

Classification System	Description	Impact on Management
Michon Classification	Stage 1: Serous exudate; Stage 2: Purulent exudate; Stage 3: Necrosis of tendon and sheath	Guides urgency and extent of surgical debridement
Kanavel Signs	1. Fusiform swelling; 2. Finger held in slight flexion; 3. Tenderness along sheath; 4. Pain on passive extension	Clinical diagnostic criteria; presence of all four highly sensitive for PFT
Differential Diagnosis	Cellulitis, septic arthritis, herpetic whitlow, gout, trauma	Avoid misdiagnosis; guides need for imaging or aspiration

Diagnostic Pearls

Presence of all four Kanavel signs strongly suggests PFT; absence of one or more does not exclude diagnosis.
Early infection may present subtly; high index of suspicion is essential in penetrating injuries.
Plain radiographs exclude foreign bodies and osteomyelitis; ultrasound or MRI can delineate fluid collections but should not delay surgery.
Synovial fluid aspiration is rarely performed due to risk of contamination but may aid diagnosis in equivocal cases.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Clinical Presentation	Early, mild symptoms without systemic signs; minimal swelling or tenderness	Presence of all Kanavel signs, systemic toxicity, purulence, or failure of antibiotics
Imaging Findings	No abscess or tendon sheath distension	Fluid collection within sheath, tendon necrosis, or abscess formation
Microbiology	Low virulence organisms, early infection	MRSA, polymicrobial infections, or delayed presentation
Patient Factors	Immunocompetent, reliable follow-up	Immunocompromised, diabetic, or delayed presentation

Rationale for Surgical Approach

Surgical irrigation and debridement allow direct removal of purulence and necrotic tissue, reducing bacterial load and intra-sheath pressure. Closed sheath anatomy limits antibiotic efficacy alone. Incision choice depends on infection extent; midlateral or Bruner incisions provide exposure while preserving neurovascular bundles.

Surgical Mastery & Pearls

Step-by-Step Surgical Technique

Anesthesia and Positioning: Regional block or general anesthesia; supine with arm on hand table.
Incision Planning: Use midlateral or Bruner zigzag incisions to maximize exposure and minimize contracture risk.
Sheath Exposure: Carefully dissect to expose the flexor sheath without injuring neurovascular bundles.
Irrigation and Debridement: Open sheath longitudinally; copiously irrigate with saline; remove purulent material and necrotic synovium.
Tendon Assessment: Evaluate tendon viability; debride necrotic segments conservatively to preserve function.
Drain Placement: Consider small drains or loose closure to prevent fluid accumulation.
Closure: Close skin loosely to allow drainage; avoid tight suturing.
Postoperative Care: Immobilize in slight flexion; initiate early controlled motion once infection subsides.

Intraoperative Red Flags

Tendon necrosis requiring partial or complete excision.
Neurovascular bundle involvement or injury.
Extensive purulence tracking proximally into the palm or forearm.
Failure to identify purulence despite clinical signs-consider alternative diagnoses.

Evidence-Based Synthesis

Recent literature underscores the critical timing of intervention. A landmark prospective cohort study demonstrated that surgical delay beyond 48 hours significantly increases tendon necrosis and stiffness rates. Antibiotic monotherapy is insufficient due to poor penetration into the closed sheath and high bacterial load. Comparative studies of incision techniques reveal no significant difference in outcomes, but midlateral incisions reduce scar contracture risk.

Emerging data suggest adjunctive use of negative pressure wound therapy post-debridement may improve drainage and reduce hospital stay, though randomized trials are pending. MRSA prevalence has shifted empiric antibiotic protocols toward vancomycin or linezolid coverage. Controversy persists regarding the role of corticosteroids; current consensus advises against their use due to immunosuppression risk.

Master Class Pro-Tip

Mastery in managing pyogenic flexor tenosynovitis hinges on anticipating the infection’s anatomical spread and preserving tendon integrity. During irrigation, avoid aggressive tendon manipulation that can exacerbate damage. Instead, employ gentle sheath distension with saline to flush debris. Recognize that incomplete debridement is the most common cause of treatment failure-meticulously explore proximal and distal sheath extensions. Finally, early postoperative hand therapy tailored to infection severity optimizes functional recovery, balancing tendon rest with prevention of adhesions.

May 31, 2026/0 Comments/by OrthoNet AI

Hand and Upper Extremity Review

A Comprehensive Guide to Mallet Finger Management: Operative vs. Non-operative

High-Yield Summary

Mallet finger results from disruption of the terminal extensor tendon at the distal interphalangeal (DIP) joint, often with or without an avulsion fracture.
Non-operative management with continuous DIP extension splinting achieves excellent outcomes in most closed, non-displaced injuries.
Operative intervention is indicated for large bony fragments involving >30-50% of the articular surface, volar subluxation of the distal phalanx, or open injuries.
Surgical options vary from percutaneous pinning to open reduction and internal fixation (ORIF), chosen based on fragment size, displacement, and soft tissue status.
Early recognition and adherence to treatment algorithms optimize functional outcomes and minimize complications such as chronic extensor lag or DIP joint stiffness.

Clinical Fundamentals

Anatomy: The terminal extensor tendon inserts on the dorsal base of the distal phalanx, stabilizing the DIP joint in extension. The extensor mechanism is a delicate balance of tendinous and capsular structures.

Biomechanics: The DIP joint relies on the terminal tendon for extension; disruption leads to unopposed flexion by the flexor digitorum profundus. Bony avulsions compromise joint congruity and stability.

Epidemiology: Mallet finger is common in sports injuries, especially in young adults. It accounts for approximately 9% of hand injuries presenting to emergency departments.

Classification & Diagnosis

Classification System	Criteria	Management Implication
Wehbé and Schneider	Type I: Tendinous injury without fracture Type II: Small avulsion fracture (<30% articular surface) Type III: Large avulsion fracture (>30% articular surface)	Type I & II: Usually non-operative Type III: Consider surgery
Tubiana Modification	Adds subluxation of distal phalanx as a key factor	Subluxation mandates surgical fixation
Open vs. Closed	Open injuries require operative management due to contamination and soft tissue damage	Open injuries: Surgical debridement and fixation

Diagnostic Pearls:

Lateral radiographs with the DIP joint in neutral and slight extension are essential to assess fragment size and displacement.

Assess for volar subluxation of the distal phalanx, which indicates instability.

Beware of missed open injuries presenting as small skin lacerations over the DIP joint.

Decision-Making Algorithm

Non-operative Management Criteria:

Closed injury

Tendinous mallet or bony fragment <30% of articular surface

No volar subluxation of distal phalanx

Patient compliance with continuous splinting

Operative Management Criteria:

Bony fragment involving >30-50% of articular surface

Volar subluxation of distal phalanx (joint instability)

Open injuries or soft tissue interposition preventing reduction

Failure of non-operative treatment (persistent extensor lag >20° after 6-8 weeks)

Surgical Approach Selection:

Percutaneous extension block pinning: Preferred for reducible fractures with minimal comminution

Open reduction and internal fixation (ORIF): Indicated for large fragments, comminution, or soft tissue interposition

Tendon repair: Reserved for pure tendinous ruptures with significant extensor lag or chronic injuries

Surgical Mastery & Pearls

Stepwise Surgical Technique for Percutaneous Extension Block Pinning:

Position the finger in slight hyperextension under fluoroscopy.

Insert a Kirschner wire (K-wire) dorsally into the middle phalanx to block extension.

Reduce the avulsed fragment by extending the distal phalanx.

Insert a second K-wire across the DIP joint to maintain reduction and immobilize the joint.

Confirm reduction and hardware placement fluoroscopically.

Immobilize the finger in a splint postoperatively for 6 weeks.

Open Reduction and Internal Fixation (ORIF):

Use a dorsal midline or lateral approach to expose the fragment.

Carefully protect the extensor tendon and neurovascular bundles.

Debride interposed tissue and reduce the fragment anatomically.

Fixation options include mini-screws, tension band wiring, or small plates depending on fragment size.

Repair the extensor tendon if disrupted.

Intraoperative Red Flags:

Inability to achieve anatomic reduction due to soft tissue interposition

Excessive hardware prominence risking skin irritation or tendon attrition

Unrecognized volar plate or collateral ligament injury compromising joint stability

Technical Tips:

Maintain continuous DIP extension during splinting or pinning to prevent extensor lag.

Avoid hyperextension that may cause skin necrosis or joint stiffness.

Early mobilization after hardware removal is critical to restore range of motion.

Evidence-Based Synthesis

Randomized controlled trials and meta-analyses consistently demonstrate that non-operative splinting yields excellent functional outcomes in tendinous mallet injuries and small avulsion fractures without subluxation. The landmark study by Crawford (1984) established the efficacy of continuous extension splinting with a 90% success rate.

Recent literature emphasizes fragment size and joint subluxation as key predictors of failure with conservative treatment. Studies comparing percutaneous pinning to ORIF show similar functional outcomes, but percutaneous techniques have lower complication rates and shorter operative times.

Controversy persists regarding the threshold fragment size for surgery, with some advocating for >30% involvement while others suggest >50%. Additionally, the role of early surgical intervention in tendinous mallet without fracture remains debated, with limited high-quality evidence.

Open injuries uniformly require surgical management due to infection risk and soft tissue damage, supported by consensus guidelines.

Master Class Pro-Tip

Mastery in mallet finger management hinges on meticulous assessment of joint stability and fragment characteristics. When opting for surgery, prioritize achieving anatomic reduction with minimal soft tissue disruption. Employ percutaneous techniques whenever feasible to reduce morbidity. Vigilantly monitor for subtle volar subluxation on imaging-this is the inflection point where non-operative care fails and surgical intervention becomes mandatory. Finally, patient education on strict splint compliance and early supervised mobilization after immobilization are critical to prevent chronic extensor lag and DIP stiffness, distinguishing a competent surgeon from a master.

May 18, 2026/0 Comments/by OrthoNet AI

Hand and Upper Extremity Review

Current Concepts in the Treatment of Dupuytren’s Contracture: Collagenase vs. Fasciectomy

High-Yield Summary

Dupuytren’s contracture is a progressive fibroproliferative disorder of the palmar fascia causing fixed flexion deformities, primarily affecting the MCP and PIP joints.
Collagenase Clostridium histolyticum (CCH) injection offers a minimally invasive option with faster recovery but higher recurrence rates compared to surgical fasciectomy.
Fasciectomy remains the gold standard for severe or recurrent contractures, providing more durable correction at the cost of longer rehabilitation and higher complication risk.
Patient selection hinges on contracture severity, joint involvement, comorbidities, and functional demands.
Mastery of surgical anatomy and technique is critical to minimize neurovascular injury and optimize long-term outcomes.

Clinical Fundamentals

Dupuytren’s contracture involves abnormal proliferation and contraction of the palmar and digital fascia, primarily the pretendinous bands. The disease typically affects men over 50, with a higher prevalence in Northern European descent. The pathophysiology centers on myofibroblast-driven collagen deposition leading to nodules and cords, which tether the skin and underlying structures.

Biomechanically, contractures most commonly impair extension at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, with PIP involvement portending a more challenging prognosis due to joint capsule and ligamentous contracture. The digital neurovascular bundles lie immediately adjacent to diseased cords, demanding meticulous dissection during surgery.

Classification & Diagnosis

Classification System	Description	Clinical Impact
Tubiana Classification	Stages contracture by total extension deficit (MCP + PIP + DIP) in degrees	Guides treatment threshold; >30° often indicates surgery
Iselin Classification	Differentiates cord types (pretendinous, spiral, lateral digital)	Identifies risk to neurovascular bundles during surgery
Clinical Examination	Hueston’s tabletop test: inability to place hand flat indicates contracture	Simple screening tool; positive test suggests intervention

Diagnostic Pearls:

Differentiate Dupuytren’s cords from flexor tendon sheath thickening or trigger finger by palpation and dynamic testing.

Spiral cords displace neurovascular bundles superficially and laterally, increasing risk of iatrogenic injury.

Early PIP contracture (<30°) may respond to non-operative measures or collagenase; >30° often requires fasciectomy.

Decision-Making Algorithm

Criteria	Non-Operative (Collagenase)	Operative (Fasciectomy)
Contracture Severity	MCP contracture <30°, PIP <20°	MCP or PIP contracture >30°, severe deformity
Joint Involvement	Isolated MCP or mild PIP	Multiple joints, severe PIP involvement
Recurrence	Primary disease	Recurrent or refractory contracture
Patient Factors	High surgical risk, preference for minimal downtime	Good surgical candidate, willing to accept longer rehab
Functional Demand	Low to moderate	High functional requirement or manual labor

Rationale: Collagenase enzymatically disrupts collagen cords, allowing minimally invasive correction with rapid recovery but higher recurrence (up to 50% at 5 years). Fasciectomy physically removes diseased fascia, offering more durable correction but with increased risk of nerve injury, wound complications, and longer rehabilitation.

Surgical Mastery & Pearls

Collagenase Injection Technique:

Identify palpable cords and mark injection sites avoiding neurovascular bundles.

Inject collagenase into the cord, wait 24-72 hours, then perform controlled finger extension to rupture the cord.

Post-procedure splinting and hand therapy optimize outcomes.

Fasciectomy Conceptual Steps:

Exposure: Use Bruner or zig-zag incisions to maximize skin preservation and access.

Identification: Carefully dissect and isolate diseased cords, noting spiral cords that displace neurovascular bundles.

Neurovascular Protection: Use loupe magnification; identify and protect digital nerves and arteries before cord excision.

Fascial Excision: Remove diseased fascia en bloc or segmentally, preserving normal tissue.

Joint Release: Address capsular contracture if residual PIP contracture persists after fascial excision.

Closure: Meticulous layered closure with skin grafting if necessary for skin deficits.

Postoperative Care: Early mobilization with splinting to prevent recurrence and stiffness.

Intraoperative Red Flags:

Difficulty identifying neurovascular bundles suggests spiral cord involvement-proceed with extreme caution.

Excessive bleeding may indicate arterial injury; maintain hemostasis to prevent hematoma and skin necrosis.

Persistent PIP contracture after fasciectomy may require capsulotomy or staged procedures.

Evidence-Based Synthesis

The landmark CORD I and II randomized controlled trials established collagenase as a safe, effective alternative to surgery for mild to moderate contractures, demonstrating significant improvement in extension with minimal downtime. However, long-term follow-up reveals recurrence rates approaching 50% at 5 years, particularly in PIP joints.

Comparative cohort studies and meta-analyses consistently show fasciectomy achieves superior long-term correction, especially for severe PIP contractures, but at the cost of increased complications such as nerve injury (up to 10%) and wound healing problems. Recent innovations in limited fasciectomy and dermofasciectomy aim to balance efficacy and morbidity.

Clinical consensus favors collagenase for patients prioritizing rapid recovery and with less severe disease, reserving fasciectomy for severe, recurrent, or PIP-dominant contractures. Emerging data on percutaneous needle fasciotomy blur these boundaries but lack long-term durability.

Areas of ongoing debate include optimal timing of intervention, role of adjunctive therapies (e.g., radiation, anti-fibrotics), and strategies to reduce recurrence post-collagenase.

Master Class Pro-Tip

When performing fasciectomy, anticipate spiral cord anatomy by preoperative ultrasound or meticulous intraoperative dissection. Early identification and neurovascular bundle mobilization before cord excision dramatically reduce iatrogenic nerve injury. Combine this with staged capsulotomy for stubborn PIP contractures to maximize functional restoration while minimizing complications. This nuanced approach distinguishes the master surgeon from the competent operator.

May 4, 2026/0 Comments/by OrthoNet AI

Hand and Upper Extremity Review

Management of Traumatic Sagittal Band Injuries and Extensor Tendon Subluxation

High-Yield Summary

Traumatic sagittal band injuries disrupt the centralizing mechanism of the extensor tendon at the metacarpophalangeal (MCP) joint, leading to tendon subluxation or dislocation, most commonly affecting the middle finger.
Diagnosis hinges on clinical examination demonstrating extensor tendon instability during MCP joint flexion, supplemented by dynamic ultrasound or MRI when needed.
Non-operative management is reserved for acute, partial tears without tendon instability; complete ruptures or chronic subluxations require surgical repair or reconstruction.
Surgical approaches focus on restoring the sagittal band’s centralizing function, with direct repair preferred in acute cases and tendon graft or slip reconstruction in chronic or failed repairs.
Early recognition and appropriate surgical technique reduce extensor lag, MCP joint stiffness, and recurrence of subluxation, optimizing functional outcomes.

Clinical Fundamentals

Anatomy: The sagittal band is a fibrous structure originating from the volar plate and deep transverse metacarpal ligament, encircling the extensor tendon at the MCP joint. It stabilizes the extensor tendon centrally over the MCP head during flexion and extension.

Biomechanics: The sagittal band counters the natural ulnar deviation force on the extensor tendon, preventing subluxation. Injury leads to loss of this restraint, allowing the tendon to slip radially or ulnarly, impairing finger extension.

Epidemiology: Traumatic sagittal band injuries predominantly occur in young, active males following blunt trauma or forceful MCP hyperextension. The middle finger is most commonly affected due to its central position and biomechanical stresses.

Classification & Diagnosis

Classification System	Description	Clinical Relevance
Rayan and Murray Classification	Type I: Acute rupture with tendon subluxation; Type II: Chronic rupture with tendon dislocation; Type III: Chronic rupture with MCP joint arthritis	Guides timing and type of surgical intervention
Mallet Finger vs. Sagittal Band Injury	Differentiation based on extensor lag at DIP vs. MCP joint	Prevents misdiagnosis and inappropriate treatment
Dynamic Ultrasound Grading	Grade 1: Intact but lax band; Grade 2: Partial tear with subluxation; Grade 3: Complete tear with dislocation	Assists in surgical planning

Diagnostic Pearls:

Palpate for a tender, swollen MCP joint with extensor tendon displacement during active flexion.

Dynamic ultrasound is superior to static MRI for detecting tendon subluxation.

Beware of missed diagnosis in partial tears presenting with subtle symptoms; early imaging is critical.

Decision-Making Algorithm

Management Pathway	Indications	Rationale
Non-Operative	Acute partial tears without tendon instability; minimal pain and preserved function	Immobilization in MCP extension for 4-6 weeks allows healing of intact fibers
Operative Repair	Complete sagittal band rupture with tendon subluxation; failed conservative treatment; chronic instability without arthritis	Direct repair restores anatomy and tendon centralization, preventing extensor lag
Reconstruction	Chronic injuries with scarred or deficient sagittal band; failed primary repair; MCP joint arthritis absent	Tendon slip or graft reconstruction recreates centralizing mechanism when primary repair is not feasible
Arthroplasty or Arthrodesis	Chronic cases with MCP joint arthritis and persistent instability	Salvage procedures reserved for end-stage disease

Why Specific Approaches:

Acute direct repair is favored due to better tissue quality and healing potential.

Reconstruction techniques address tissue loss and chronic scarring, restoring function when repair is impossible.

Non-operative treatment risks chronic instability if tendon subluxation is present.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview:

Exposure: Dorsal longitudinal or curvilinear incision centered over the MCP joint; careful dissection to preserve paratenon and neurovascular bundles.

Assessment: Identify sagittal band tear and evaluate extensor tendon position; clear scar tissue in chronic cases.

Repair:

Acute: Direct end-to-end repair using nonabsorbable sutures; augment with local tissue advancement if needed.

Chronic: Reconstruction using extensor tendon slip (e.g., juncturae tendinum) or free tendon graft (palmaris longus).

Tendon Centralization: Confirm stable tendon tracking through full MCP flexion-extension arc intraoperatively.

Closure: Meticulous layered closure to avoid adhesions; immobilize MCP joint in extension.

Intraoperative Red Flags:

Persistent tendon subluxation after repair indicates inadequate reconstruction or overlooked secondary stabilizers.

Excessive tension on repair risks suture failure and postoperative stiffness.

Neurovascular injury risk due to proximity of dorsal branches; maintain careful dissection.

Technical Tips:

Use dynamic intraoperative testing to confirm stability.

Avoid overtightening to preserve MCP joint motion.

Early controlled mobilization post-immobilization reduces stiffness.

Evidence-Based Synthesis

Recent literature emphasizes the superiority of early surgical repair over delayed intervention for complete sagittal band ruptures, demonstrating improved extensor function and reduced recurrence rates. Dynamic ultrasound has emerged as a critical diagnostic adjunct, outperforming static MRI in detecting tendon instability. Comparative studies reveal that direct repair yields better outcomes in acute injuries, while reconstruction techniques provide durable stability in chronic cases, though with a higher risk of stiffness.

Controversy persists regarding the optimal reconstruction method; tendon slip transfers offer less donor site morbidity but may be biomechanically inferior to free grafts. Long-term outcome data remain limited, underscoring the need for prospective trials. Non-operative management is effective only in strictly selected partial tears without subluxation, as failure leads to chronic dysfunction.

Master Class Pro-Tip

When performing sagittal band reconstruction, prioritize restoring the native sagittal band vector by anchoring grafts or slips to the volar plate and deep transverse metacarpal ligament rather than solely to periosteum. This biomechanical nuance ensures dynamic centralization of the extensor tendon throughout MCP motion, minimizing recurrence and optimizing finger extension strength. Mastery of this principle distinguishes expert surgeons capable of consistently excellent functional restoration.

April 21, 2026/0 Comments/by OrthoNet AI