Orthopedic Teaching Cases 2023, Jan, 17 | 12:00 am

Hand CASE 32

CASE                               32                               

A 34-year-old, right-hand-dominant man presents with a pinpoint injury to his left index finger. He reports that he was cleaning the nozzle of his paint gun when he accidentally pulled the trigger of the gun. Inspection of the digit reveals a pinpoint skin break at the distal phalanx. He receives tetanus prophylaxis and IV antibiotics in the emergency department.

What is the next appropriate step?

  1. Splinting, elevation, and observation

  2. Early active motion of the digit

  3. Bedside incision and drainage with metacarpal block

  4. Formal debridement in the operating room

  5. Amputation of the digit

 

Discussion

The correct answer is (D). High-pressure injection injury requires formal debridement in the operating room. Removal of necrotic tissue and the offending agent is indicated. A bedside I&D will not be adequate in the setting. Without signs of necrosis and without attempting a formal debridement, amputation is not indicated. Splinting and early motion are not adequate treatment of this injury.

Which of the following factors is associated with an improved prognosis?

  1. Debridement within 12 to 24 hours

  2. Force of injection of 8,000 psi

  3. Injection into the palm versus the finger

  4. Injection of industrial solvent

  5. Injection into the thumb

 

Discussion

The correct answer is (C). Debridement within 6 to 10 hours shows improved

prognosis. Continued contact with caustic materials damages the tissues, and early aggressive debridement on an emergent basis is critical for treatment. Injuries with

>7,000 psi have a 100% amputation rate. Injection of the palm has an improved prognosis over the finger as it is not governed by fascial planes. Injection of industrial solvents is associated with a worse prognosis (see below). Injection of the thumb is not associated with improved prognosis. The injected material can extend into the thenar space, and a poorly functioning thumb has a worse prognosis for the overall function of the hand.

Which of the following injection materials is associated with a worse prognosis and increased risk of amputation?

  1. Air

  2. Latex-based paint

  3. Water-based paint

  4. Oil-based paint

  5. Grease

 

Discussion

The correct answer is (D). Less tissue damage is associated with grease, latex-based paint, water-based paint, air, and veterinary vaccines.

 

Objectives: Did you learn...?

 

 

Describe the prognostic factors for paint injection injury? Manage paint injection injury?

 

CASE                               33                               

A 64-year-old man presents with the complaint of inability to place his hand in his pocket and an awkward handshake. On physical examination, he has a flexion contracture involving the ring and small fingers. Dupuytren’s contracture is diagnosed.

Which of the following is true regarding this disease process?

  1. Ectopic involvement (Ledderhose disease of the feet, Peyronie’s disease of the penis) is associated with a less aggressive clinical course

  2. The disease is associated with increased Collagen type III production and myofibroblast proliferation

  3. Grayson’s ligaments are usually spared in the disease process

  4. Alcohol intake has a protective effect

  5. Bands and cords make up the pathologic anatomy

 

Discussion

The correct answer is (B). The disease is associated with an increased Collagen type III to type I ratio. Myofibroblast proliferation causes contraction of the collagenous palmar fascia. Platelet-derived growth factor and fibroblast growth factor have also been implicated in the pathogenesis. Ectopic involvement is usually associated with a more aggressive disease course. Cleland’s ligaments are usually spared in the disease process; Grayson’s ligaments are often involved. Diabetes, antiseizure medications, and alcohol intake are often associated with Dupuytren’s contracture. It often has an autosomal dominant pattern with variable penetrance. Cords and nodules make up the pathologic anatomy. Bands represent normal anatomic structures, which then thicken to form cords.

Which of the following is true regarding the pathology of the Dupuytren’s disease?

  1. Involvement of the natatory ligament causes an abduction contracture

  2. A central cord displaced the neurovascular bundles volarly and centrally

  3. Involvement of the abductor digiti quinti (ADQ) causes PIP joint contracture in the small finger

  4. The neurovascular bundle lies lateral and deep to the spiral cord

  5. The DIP joint is not affected by a retrovascular cord

 

Discussion

The correct answer is (C). The ADQ inserts at the middle phalanx most often, and involvement of the ADQ often leads to PIP joint contracture of the small finger. Involvement of the natatory ligament causes an adduction contracture of the palm. It is also involved in the spiral cord so it may contribute to a PIP joint flexion contracture. The central cord lies between the neurovascular bundles and is an extension of the pretendinous cord. The spiral cord lies deep and lateral to the neurovascular bundle and displaces the bundle central and superficially, putting it at

particular risk at the MP flexion crease. It is composed of the natatory band, pretendinous band, spiral band, lateral digital sheath, and Grayson’s ligament. The name spiral cord is a misnomer because it does not spiral, rather the bundle spirals around the cord with progressive disease. DIP joint contracture is often from a retrovascular cord.

Which of the following is an indication for surgery?

  1. DIP joint contracture of 35 degrees

  2. PIP joint contracture of 10 degrees

  3. MP joint contracture of 30 degrees

  4. Painful palmar nodules

  5. Palpable recurrent cord

 

Discussion

The correct answer is (C). DIP joint contracture is usually not an indication for surgery and rarely occurs in isolation. A PIP joint contracture of 20 degrees is generally considered an indication for surgery.

Painful nodules are generally not considered an indication for surgery. A recurrent cord without contracture is not an indication for surgery.

Which of the following treatment options is contraindicated?

  1. Needle aponeurotomy

  2. Collagenase injection followed by manual manipulation

  3. Local fasciectomy

  4. Subtotal fasciectomy

  5. Total fasciectomy

 

Discussion

The correct answer is (E). Needle aponeurotomy is performed in the office setting or operating room setting. A needle is used to puncture the offending cord multiple times to weaken it before manual traction breaks the cord. It is often done under local anesthesia of the skin that does not block the digital nerves to prevent damaging the digital nerves with the needle. The aponeurotomy is done at the level of the palm to avoid injuring the digital nerves. It is often used for infirmed patients and has a high recurrence rate. Collagenase injection (Xiaflex) has gained popularity. The collagenase is injected into the cord followed by manipulation 24 hours later. Nerve damage and tendon rupture are risks. It is more effective at

treating MP joint contractures than PIP joint contractures. A local fasciectomy is an excision of a short segment of diseased tissue. It may be done under local anesthesia, which is of benefit to infirmed patients, but this technique has a high recurrence rate. A subtotal fasciectomy is the most commonly performed procedure for Dupuytren’s contracture in which the involved fascia is excised. A total fasciectomy involves removing all fascia of the palm and is associated with an extremely high morbidity. It is of historical interest only.

Which of the following is a contraindicated approach?

  1. Longitudinal incision along volar surface of digit followed by z-plasties

  2. Transverse palmar incision left open

  3. Midaxial digital incision

  4. Modified Brunner zig–zag incisions with v-y flap advancement

  5. Dermatofasciectomy

 

Discussion

The correct answer is (C). A midaxial incision is unlikely to provide adequate exposure. Longitudinal incisions followed by z-plasties have the benefit of designing the flaps over the highest quality skin and incorporating inadvertent button hole incisions in the skin. It also converts excess skin in the transverse direction to the longitudinal direction where there is often a deficit in skin after a long-term contracture. Leaving the transverse palmar incision open (McCash technique) is useful in longitudinal skin defects and, unlike skin grafting, allows for immediate active motion protocols. Modified Brunner zigzag incisions are a well accepted technique that allows for wide exposure. Adding a v–y advancement decreases tension on the incisions and allows for further digit extension. A dermatofasciectomy is used often with recurrent disease and is often combined with skin grafting.

 

Objectives: Did you learn...?

 

 

Describe the fascial anatomy of Dupuytren’s disease? Pinpoint the indication for surgical intervention?

 

 

Describe the surgical approaches and appropriate techniques? Indicate factors associated with the disease process?