Dr. Rami Abo Ali

1. ORTHOPEDIC SURGERY
Dr. Rami Abo Ali
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
1

2. INJURIES TO THE UPPER LIMB ( 3 )
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
2

3. 3
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

4. SCAPHOID BONE FRACTURE
 It is caused by fall on out stretched hands ; the most important
point in scaphoid is its blood supply enter the bone from distal to
proximal direction , so the blood supply is decreased from distal
to proximal ; this fact explain why only 1% of the fracture in the
distal third of scaphoid , 20% of the fracture in the middle third
and 40% of the proximal third fracture will develop avascular
necrosis and non union .
 Clinically : there is fullness and tenderness in the anatomical snuff
box ; other diagnostic sign is that, proximal pressure along the axis
of the thumb is painful .
 X-ray :
 a-p , lateral and oblique views are all essentials . Some time recent
fracture show it self only in oblique view .
 scaphoid view : 30 degree wrist extension, 20 degree ulnar deviation ,
waist fractures seen best
 Incidence of fracture by location
 waist -65%
 proximal third - 25%
 distal third - 10%
 CT, MRI
4
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

5. 5
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

6. SCAPHOID BONE FRACTURE
 If union is delayed , cavitation appear on either side of the
fracture .
 In old un-united fracture there will be sclerosis at the edge and
the appearance will be as there is extra carpal bone .
 Sclerosis of the proximal fragment is path gnomonic of avascular
necrosis of the proximal fragment .
 Treatment :
 With negative radiographs and high clinical
suspicion, immobilize and repeat examination and
radiographs in 2 weeks
 After 2 weeks if pain persists and radiographs are still normal,
then further imaging in the form of MRI or CT should be
undertaken
 Undisplaced fracture : conservative treatment 8-10 weeks
 Displaced fracture : treatment by open reduction and fixation by
headless screw .
6
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

7. 7
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

8. SCAPHOID BONE FRACTURE
 Complication
1. avascular necrosis : the proximal fragment may die especially with proximal
pole fracture , it will appear dense on x-ray Treatment : by excision of the
proximal fragment .
2. non union : after 3 months if fracture not united it will be obvious that the
fracture will not unite at all .
Treatment :in old people and in those who are completely asymptomatic ,
non union may be left untreated . In young patients treatment by fixation and
bone grafting .
If the graft fail then do excision of the scaphoid and fusion of the carpel
bones .
3. osteoarthritis : non union and avascular necrosis may lead to secondary
osteoarthritis
8
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
avascular necrosis

9. DISLOCATION OF LUNATE
 High energy injury with poor
functional outcomes
 Occurs when wrist extended and
ulnarly deviated
 Commonly missed (~25%) on initial
presentation
 Classification
 perilunate dislocation
 lunate stays in position while
carpus dislocates
 lunate dislocation
 lunate forced volar or dorsal
while carpus remains aligned
9
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

10. DISLOCATION OF LUNATE
 Treatment
 Nonoperative
 closed reduction and casting : universally poor functional outcomes
with non-operative management
 Operative (mostly indicated )
 emergent closed reduction/splinting followed by open reduction,
ligament repair, fixation, possible carpal tunnel release
 Complications
 Wrist osteoarthritis is a common long-term complication after
perilunate and lunate injuries.
 chronic carpal instability
 rupture of tendons
 median nerve compression
 complex regional pain syndrome
 avascular necrosis of the lunate.
10
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

11. KIENBOCK'S DISEASE
 Avascular necrosis of the lunate leading to
abnormal carpal motion
 most common in males between 20-40 years old
 thought to be caused by multiple factors :
 ulnar negative variance ( leads to increased radial-
lunate contact stress)
 decreased radial inclination
 repetitive trauma
 Symptoms
 dorsal wrist pain (usually activity related , more
often in dominant hand) and decreased range of
motion
11
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

12. KIENBOCK'S DISEASE
 Diagnosis
 X-ray , CT
 MRI (best for diagnosing early disease)
 Treatment
 Treatment options depend upon the
severity and stage of the disease.
 In very early stages, the treatment can be
as simple as observation, activity changes,
and/or immobilization.
 For more advanced stages, surgery is
usually considered
 Complications
 Kienböck disease can lead to scapholunate
dissociation, secondary radiocarpal and
mid-carpal degenerative arthrosis
12
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

13. HOOK OF HAMATE FRACTURE
 Hook of hamate fractures are rare, often missed, injuries generally as
a result of a direct blow to the hamate bone most commonly seen in
athletes (golf baseball hockey)
 hook of hamateforms part of Guyon's canal, which allows passage of
the ulnar artery and ulnar nerve into the hand.
 Treatment is generally patient-specific and depends on chronicity of
injury (Non-operative , ORIF, excision )
 Complications
 Non-union (most common)
 Ulnar nerve neuritis in Guyon's canal
 Closed rupture of the flexor tendons to the small finger
13
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

14. METACARPAL FRACTURES
 divided into fractures of metacarpal head, neck, shaft
 acceptable angulation varies by location
 no degree of malrotation is acceptable
 fifth metacarpal is most commonly injured
 treatment based on which metacarpal is involved and location of
fracture ( non-surgical, surgical )
14
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

15. BOXER’S FRACTURE
 Fifth metacarpal neck fracture (known as boxer’s fractures) is the
most common type of hand bone fractures
 Treatment: The fracture results in a flexion and rotational
deformity. Only rotation need be corrected
 Non-operative
 reduction and casting and this can be done by holding the
little finger lightly against the ring finger with elastic strapping
and encouraging early flexion
 Operative
15
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

16. BENNETTS FRACTURE
 A Bennett fracture is a fracture of
the base of the thumb resulting
from forced abduction of the first
metacarpal. It is defined as an intra-
articular two-part fracture of the
base of the first metacarpal bone.
 Due to this fracture, the first
metacarpal shaft subluxes dorsally,
proximally, and radially due to the
pull of the abductor pollicis longus
 Treatment
 The fracture should be reduced and, if
necessary, held with a percutaneous
pin or screw
 Complications
 Untreated or malreduced fractures
can lead to post-traumatic
osteoarthritis, which can cause
significant pain and functional loss.
16
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

17. ROLANDO FRACTURE
 Rolando fracture is a three-part or comminuted
intra-articular fracture-dislocation of the base of
the thumb (proximal first metacarpal). It can be
thought of as a comminuted Bennett fracture
 Treatment
 This is an unstable injury that requires surgical
reduction and fixation.
17
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

18. GAMEKEEPERS/ SKIERS THUMB
 The gamekeeper's/ skiers thumb injury
may be caused by a valgus stress to the
thumb that cause acute (skier) or chronic
(gamekeeper) injury to the ulnar
collateral ligament (UCL) of the thumb,
most often due to a skiing accident
 Diagnosis relies upon thumb MCP radial-
ulnar stress exam and MRI studies
 Treatment depends on classification but
essentially surgical treatment is offered
to patients with:
 joint instability
 a displaced avulsion fracture
 Complications
 Left untreated the thumb is unstable
and cannot resist the force on the index
finger in a
pinch grip
18
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

19. PHALANGEAL FRACTURES
 The phalanges are fractured most
often by twisting or angular forces
 Majority treated nonoperatively if
less than 10 degrees of angulation
and no rotational deformity
 Irreducible or unstable fracture
patterns may require surgery
19
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

20. PHALANX DISLOCATIONS
 Common traumatic injury of the hand involving
the proximal interphalangeal joint (PIP) or distal
interphalangeal joint (DIP)
 Dorsal dislocation most common
 Dislocations of the distal IP (DIP) joint of the fingers
are often associated with fracture
 Treatment is closed reduction and splinting for 2
weeks
 Irreducible dislocations due to volar plate entrapment
blocks reduction or a concomitant fracture renders
the joint unstable needs open reduction
20
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

21. DE QUERVAIN’S TENOSYNOVITIS
 A stenosing tenosynovial inflammation of the 1st
dorsal compartment which includes abductor
pollicis longus (APL) and extensor pollicis brevis
(EPB)
 Commonly affects middle-aged women
 Other high-risk groups: new mothers, golfers, and
racquet-sport athletes
 Dorsoradial wrist tenderness, swelling, crepitus
 Finkelstein test places first extensor compartment
tendons under maximum tension and exacerbates
symptoms.
 Nonoperative management includes rest, activity
modification, thumb spica splinting/bracing,
nonsteroidal antiinflammatory drugs (NSAIDs), and
corticosteroid injections into the first dorsal
extensor compartment.
 Corticosteroid injections successful in more than
80% of patients
 When these measures fail, surgical release of the
first extensor compartment may be performed.
21
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

22. TRIGGER FINGER (STENOSING TENOSYNOVITIS)
 Most common in women older than age 50
 Commonly associated with diabetes and inflammatory arthropathy
 May otherwise result from repetitive grasping activities
 Initially characterized by pain/tenderness in the distal palm, progresses to
mechanical catching/locking , and may become “fixed”
 Pain and tenderness at the A1 pulley
 Middle and ring finger involvement most common in adults
 Many respond to corticosteroid injection into flexor tendon sheath.
 Failure of nonoperative management treated by surgical release of A1 pulley
22
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

23. GANGLION CYST
 a ganglion cyst is a mucin-filled synovial cyst caused by
either trauma or mucoid degeneration or synovial
herniation
 It is the most common hand mass (60-70%)
 Mostly dorsal carpal , originate from scapholunate
articulation
 Usually asymptomatic ,may cause cosmetic issues.
 Treatment
 Nonoperative
 Observation (first line of treatment in adults)
 Aspiration
 Operative
 surgical resection
23
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

24. TENDON HEALING
 Three phases:
 inflammatory (48 to 72 hours),
 fibroblastic (5 days to 4 weeks), and
 remodeling (4 weeks to about 8 months)
 Tendon Surgical Repair
 Strength following repair
 tendon repairs are weakest at 7-10 days
 most of strength by 21-28 days
 maximum strength at 6 months
 final strength only reaches 2/3 of normal even years after repair
 Early mobilization
 allows earlier ROM but decreased tendon repair strength
 beneficial for flexor tendon healing to prevent adhesion formation
24
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

25. FLEXOR TENDONS
 The flexor tendons run part of their course
through synovial and fibrous sheaths.
 The fibrous sheaths, which are lined with
synovium, run from the distal interphalangeal
(d.i.p.) joints to the distal palmar skin crease
and prevent the tendon ‘bowstringing’ when
the finger is flexed.
 The synovial sheaths of the thumb and little
finger extend proximally through the carpal
tunnel.
 The three central digits (index, middle and
ring) have a separate flexor sheath in the
fingers.
 There is also a sheath in the palm which
extends proximal to the wrist
25
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

26. FLEXOR TENDONS INJURY
 Sites of flexor tendon injury
Zone I : distal to d.i.p. joint.
Zone II : in the fingers (No man’s land )
Zone III : in the palm.
Zone IV: in the carpal tunnel.
Zone V : in the forearm.
26
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

27. FLEXOR TENDONS INJURY
 Zone I: Lesions distal to the tendon sheath
 Injuries distal to the d.i.p. joint lie outside
the sheath.
 Treatment
 Zone I lesions can be treated by
 (1) tendon advancement,
 (2) arthrodesis of the d.i.p. joint
 The cut end of the tendon can be advanced
and reinserted on the distal phalanx. This
may cause a slight flexion deformity.
 In the thumb the advancement can be done
in the forearm because the flexor pollicis
longus has no connection with other flexors
and its tendon can be separated from the
muscle belly in the forearm and moved
distally.
 The results of surgery are better in the
thumb than the fingers.
 Early movement, active or passive, is
important after any tendon repair and
several devices are available to encourage
this.
27
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

28. FLEXOR TENDONS INJURY
 Zone II: Injuries in the fingers (No man’s land )
 Management of flexor injuries in the fingers depends on the tendons
involved and the site of injury .
 The first step is to decide which tendon has been damaged.
 Profundus and superficialis action can be distinguished by asking the
patient to flex the distal phalanx with the middle phalanx held still .
 Only flexor profundus will do this because superficialis does not extend
beyond the middle phalanx
 To assess superficialis, hold all the fingers down except the one that is
to be tested and ask the patient to flex that finger.
 If the finger flexes at the proximal interphalangeal (p.i.p.) joint,
superficialis is intact.
28
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

29. FLEXOR TENDONS INJURY
 Zone II: Injuries in the fingers
 Division of superficialis alone. If superficialis is divided
alone it is best to excise the redundant portion of its
tendon and rely on flexor profundus for finger flexion,
thus avoiding the problems of adhesions and stiffness
 Division of superficialis and profundus. If the tendons
are cut opposite the proximal or middle phalanx they can
be treated either by meticulous primary repair by an
experienced surgeon or by replacing the tendon with an
autograft of another tendon, such as palmaris longus or
plantaris. If both tendons are cut, both should be
repaired
 Division of profundus alone. If the tendon is divided
within 1 cm of its insertion the tendon can be pulled up,
or ‘advanced’, and the cut end attached to the distal
phalanx
29
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

30. FLEXOR TENDONS INJURY
 Zone III: Injuries in the palm
 Division of the flexor tendons in the palm is less serious
than division in the fingers because the repair can be
done outside the fibrous or synovial sheaths.
 Treatment
 The tendons should be repaired meticulously by an
experienced hand surgeon and early mobilization
instituted
30
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

31. FLEXOR TENDONS INJURY
 Zone IV: Injuries in the carpal tunnel
 Eleven flexor tendons (flexor digitorum superficialis (4),
flexor digitorum profundus (4), flexor pollicis longus, flexor
carpi ulnaris and flexor carpi radialis) cross the volar aspect of
the wrist
 If all these are divided, there will be 22 cut tendon ends.
 If the median nerve is divided as well, there will be 24
structures, which must be carefully identified, and if each pair
is joined there will be 12 suture lines very close together.
 However carefully repaired, the tendons and nerves may stick
together and form a solid mass which restricts movement at
the wrist.
31
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

32. FLEXOR TENDONS INJURY
 Zone IV: Injuries in the carpal tunnel
 Treatment
 The problem can be simplified by discarding those
tendons that are not absolutely necessary.
 The flexor superficialis, for example, can be sacrificed if
flexor profundus is working.
 Finger flexion will still be full and the risk of adhesions
between superficialis and profundus outweigh the
improvement of function that might be obtained by
repairing both.
32
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

33. FLEXOR TENDONS INJURY
 Zone V: Injuries in the forearm
 Injuries in the forearm lie outside any sheath and can be
accurately repaired more easily than elsewhere.
 Treatment
 The tendon ends are accurately identified and repaired,
and early mobilization begun
33
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

34. FLEXOR TENDONS INJURY
 Postoperative Rehabilitation
 Postoperative controlled mobilization has been
the major reason for improved results with
tendon repair
 especially in zone II
 leads to improved tendon healing biology
 limits restrictive adhesions and leads to increased
tendon excursion
 Immobilization
 indicated for children and non-compliant patients
 casts/splints are applied with the wrist and MCP
joints positioned in flexion and the IP joints in
extension
34
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

35. FLEXOR TENDONS INJURY
 Complications
 Tendon adhesions
 most common complication following flexor tendon
repair
 higher risk with zone 2 injuries
 Re-rupture
 Joint contracture
 Swan-neck deformity
 Trigger finger
35
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

36. EXTENSOR TENDONS INJURY
 Because the extensor tendons only have a synovial sheath where they
cross the wrist, the problems encountered in repairing flexor tendons
in the fingers do not arise.
 The tendons are easily identified, repair is straightforward and the
fingers can be mobilized after 3 weeks.
 If the tendons are divided on the dorsum of the hand they cannot
contract for more than a few millimetres because they are restricted
by linking fibrous bands.
36
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

37. EXTENSOR TENDONS INJURY
 Treatment
 Tendons divided on the dorsum of the
hand should be repaired and the fingers
splinted in extension for 3 weeks.
 Complications
 Adhesion formation
 Tendon rupture
 Swan neck deformity
 Boutonniere deformity (DIP
hyperextension)
 caused by central slip disruption and lateral
band volar subluxation
37
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

38. DUPUYTREN’S CONTRACTURE
 This is a condition affecting the collagenous tissue of the
palmar fascia.
 There is frequently a family history.
 It is occasionally related to cirrhosis of the liver, diabetes
and rarely to drugs used to treat epilepsy.
 It affects middle-aged men much more commonly than
women.
 Clinical f eatures
 The characteristic feature is a very slowly progressing
flexion contracture of the fingers and thumb. It is usually
bilateral but may be more severe on one side.
 The palmar fascia feels thickened and nodular and tends
to pucker the overlying skin.
 Definite bands can be felt running along the sides of the
fingers due to thickening of the lateral extensions of the
fascia.
 The proximal interphalangeal joint is usually most
affected, together with the MCPJ.
38
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

39. DUPUYTREN’S CONTRACTURE
 Treatment
 Usually, surgery is necessary for the established contracture with
symptoms and this involves careful dissection of the whole of the
affected area of fascia.
 Skin closure can be difficult but the skin usually heals well.
 Occasionally, the fascia is removed with the overlying skin and
subsequently the area is covered with a free skin flap.
 Occasionally, a finger may be better amputated if deformity is very
severe.
39
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

40. MALLET FINGER
 Violent flexion injuries to, or lacerations across the back of, the d.i.p.
joint can avulse or divide the insertion of the extensor digitorum
longus at the base of the distal phalanx
 Untreated, the lesion causes the distal phalanx to droop and leaves a
‘mallet’ finger deformity.
 Treatment
 Nonoperative
 extension splinting of DIP joint for 6-8 weeks for 24 hours daily
 Operative
 CRPP vs ORIF
40
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

41. JERSEY FINGER
 Refers to an avulsion injury of flexor digitorum profundus
(FDP) from insertion at base of distal phalanx
 The ring finger is most commonly affected
 FDP muscle belly in maximal contraction during forceful DIP
extension
 Treatment
 Operative
 direct tendon repair or tendon reinsertion with dorsal button
41
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

42. BOUTONNIERE DEFORMITY
 The central slip of the extensor expansion can be detached from its
insertion at the base of the middle phalanx by a cut or by violent
muscle contraction.
 This allows the two lateral slips to fall sideways and the p.i.p. joint to
protrude between the two
 Flexion of PIP , hyper extension of DIP
 Treatment
 The lesion should be splinted with the finger straight, but the results
are imperfect.
 Operative (primary central band repair)
42
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

43. SWAN NECK DEFORMITY
 The most common cause of
swan-neck deformity is
rheumatoid arthritis.
 Other causes include
untreated mallet finger,
intrinsic contracture, FDS
rupture..
 Characterized by :
hyperextension of PIP and
flexion of DIP
 Treatment
 Nonoperative
 double ring splint
 Operative
43
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

44. SUBUNGUAL HEMATOMA
 Most commonly caused by a crushing-type injury that
causes bleeding beneath nail
 Treatment
 drainage of hematoma by perforation
 nail removal, D&I, nail bed repair
44
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

45. PARONYCHIA
 A soft tissue infection of the proximal or lateral nail fold
 The most common hand infection (one third of all hand
infections)
 more common in women , most commonly involve the thumb
 Organism:
 acute infection :usually caused by Staphylococcus aureus
 chronic infection :Candida albicans (more common in diabetics)
 Symptoms
 acute paronychia :pain and nail fold tenderness ,erythema, swelling
 chronic paronychia : recurrent bouts of low-grade inflammation (less
severe than acute paronychia)
 Treatment :
 Acute paronychia
Nonoperative: warm soaks, oral antibiotics and avoidance of nail biting
Operative : Incision and drainage with partial or total nail bed removal
followed by oral antibiotics
 Chronic paronychia
Nonoperative : warm soaks, avoidance of finger sucking, topical
antifungals
Operative : marsupialization (excision of dorsal eponychium down to
level of germinal matrix)
45
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

46. FELON
 Felon is a subcutaneous abscess of the fingertip pulp
 Most commonly occurs in the thumb or index finger
 mechanism of injury
 penetrating injury
 local spread (may spread from paronychia )
 no history of injury in 50% of patients
 Treatment is usually incision and drainage and IV antibiotics
46
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali

47. 47
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali