Orthopaedic Surgery Teaching for Phase V 2016. This OSSE is one of the formal teaching sessions in the 4 week SIP rotation.

1. OSSE Teaching – Hand
Alphonsus Chong
Assistant Professor, Department of Orthopaedic
Surgery, YLL SOM, NUS
Hand Surgeon, Department of Hand &
Reconstructive Microsurgery, NUH

2. Learning Goals
• For common hand and wrist injuries and
conditions, know:
– Clinical assessment and diagnosis
– Treatment principles
– Important complications
• Assumptions
– Review and revision: you already know the
material
• Caveat: info not comprehensive

4. Key Points
• Identify wrist x-ray
• Diagnosis: Distal radius fracture
• Recognise deformities:
– Dorsal angulation; shortening; loss of radial height
• Know complications
• Treatment options

6. Key point – recognition of injury
“Spilled teacup” sign
Lunate Dislocation Dorsal perilunate
dislocation

8. Key Points
• Boxer’s fracture:4/5th
metacarpal neck
fracture
• Common injury
• Examine for malrotation
• Treatment
– Surgical fixation if
malrotation or > 40
degrees angulation

10. Key Features
• Recognise injury
• Realize it is a fracture-
dislocation/fracture-subluxation
• Unstable
– Needs surgical fixation

12. FDS
• Recognize possible
injured structures
• How to examine the
structures

14. Mallet injuries
• Open and Closed
• Forced flexion on DIPJ
• Closed injuries
– Tendinous injuries / avulsion
fractures
– Loss of active extension of DIP -
mallet injury
– Loss of passive extension -chronicity
• Acute - in the absence of a fracture =>6
weeks splinting DIPJ + 6 weeks night
splinting

17. Key points
• Recognize deformities in DIPJ
– Deviation, Herbeden’s nodes, mucus cyst
• Look for other deformities
– PIPJ – Bouchard’s nodes
– Thumb CMCJ
• Diagnosis
– Osteoarthritis
– Others
• RA
• Psoriasis

20. Key Points
• Recognise x-ray findings of osteoarthritis
• Treatment options
– Conservative treatment
• Splinting and analgesia in flares, activity modification
– Surgical
• Excision arthroplasty – trapeziectomy
• Fusion of the 1st CMCJ (younger patients)

22. Key Points
• Recognise the deformity
– Boutonniere – Hyperextension DIPJ, Flexion of PIPJ
– Swan Neck – Hyperextension PIPJ, Flexion deformity
of DIPJ
• Understand pathomechanism for each
• In what conditions are they seen?
– RA
– Traumatic central slip avulsion (Boutonniere)
– Laxity/ Mallet finger (Swan neck)

24. Ganglion
• Most common wrist lump
• Also found in the hand:
– Mucus cyst – DIPJ
– Flexor tendon sheath – A1
pulley
• Treatment options
• Recurrence as a
complication after
excision

26. Dermoid cyst
• Skin lump
• Exposed areas
• No punctum
• Previous injury/
penetration

28. Key Points
• PVNS/ GCTTS
• Most common true
neoplasm in the hand
• Firm tumor, often
multi-lobulated

31. • 45 year old female with DM presents with
history of numbness right thumb, index,
middle fingers x 2 months

32. Key Points in clinical assessment
• Handedness
• How long symptoms
• Progress – better/
worse
• Night symptoms
• Neck symptoms
• Weakness
• Inspection
– Wasting
• Tinel’s
• Phalen’s
• APB testing
• Sensory testing
• Neck – ask to
examine

34. Key Points
• Key features of radial nerve palsy
– Motor
– Sensory
• Common causes
• Recovery patterns

36. Key Points
• Signs of ulnar nerve palsy
• Common causes
• Ulnar paradox

37. Froment’s sign

38. Summary
• Common & Important injuries:
– Wrist fractures/ dislocations, hand fractures
• Lumps and Bumps
• Deformity
– Isolated: Swan neck and Boutonniere
– Osteoarthritis
• Peripheral nerve conditions

39. Questions?

42. Diagnosis?

43. Key points
• Mostly Staph aureus (50-
80%) - clox will cover
• But think of others and
polymicrobial
– Animal/ human bite
– Aquarium/ water injuries
– Diabetics
– Hematogenous

44. 4 days post H&L for trigger

45. Key Points
• Kanavel’s signs - Flexor tenosynovitis
• Risk of flexor tenosynovitis following
penetrating injury