{"id":1620,"date":"2024-08-31T11:55:22","date_gmt":"2024-08-31T11:55:22","guid":{"rendered":"https:\/\/suzhouyoubest.com\/?p=1620"},"modified":"2024-08-31T11:55:23","modified_gmt":"2024-08-31T11:55:23","slug":"50-knowledge-points-in-hand-surgery-that-are-easily-misunderstood-by-doctors-2","status":"publish","type":"post","link":"https:\/\/suzhouyoubest.com\/zh\/50-knowledge-points-in-hand-surgery-that-are-easily-misunderstood-by-doctors-2\/","title":{"rendered":"50 knowledge points in hand surgery that are easily misunderstood by doctors"},"content":{"rendered":"

General Concepts\u00a0:<\/strong><\/p>\n\n\n\n

1.\u00a0Epinephrine Use:<\/strong>\u00a0While historically feared due to vasoconstriction risk, epinephrine can be safely used in digital blocks at diluted concentrations (1:200,000 or 1:400,000), with careful aspiration, and potential phentolamine reversal (0.5% solution). Monitor perfusion closely.<\/p>\n\n\n\n

2.\u00a0Betadine and Bone:<\/strong>\u00a0Betadine, while an effective antiseptic, has been shown to be cytotoxic to osteoblasts in vitro. Irrigate exposed bone thoroughly after using Betadine to minimize potential negative impact on healing.<\/p>\n\n\n\n

3.\u00a0Imaging Interpretation:<\/strong>\u00a0Advanced imaging (MRI, CT) offers valuable information, but clinical correlation is paramount. Don’t solely rely on imaging findings; integrate them with history, physical exam, and patient goals.<\/p>\n\n\n\n

4.\u00a0Gilula’s Lines:<\/strong>\u00a0Disruptions in the smooth arcs of carpal bones on PA\/AP views suggest carpal instability. However, minor variations can be normal. Clinical examination is crucial to determine if instability is present.<\/p>\n\n\n\n

5.\u00a0DISI\/VISI:<\/strong>\u00a0Dorsal Intercalated Segment Instability (DISI) and Volar Intercalated Segment Instability (VISI) describe lunate posture on lateral radiographs. While DISI reliably indicates scapholunate ligament disruption, VISI can be a normal variant or indicate lunotriquetral ligament injury or generalized ligamentous laxity.<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

6.\u00a0Scaphoid Views:<\/strong>\u00a0The ulnar deviation view is commonly obtained for suspected scaphoid fractures, but its sensitivity is limited (~64%). MRI or CT are more sensitive for occult fractures.<\/p>\n\n\n\n

7.\u00a0Zero Rotation Views:<\/strong>\u00a0Essential for accurate ulnar variance assessment and evaluating DRUJ congruency. Ensure proper patient positioning for reliable measurements.<\/p>\n\n\n\n

8.\u00a0Tendon Retraction:<\/strong>\u00a0Avoid pulling distally and suturing retracted flexor or extensor tendons to cover bone, as this compromises tendon gliding and function. Cover exposed bone with skin grafts or flaps.<\/p>\n\n\n\n

9.\u00a0Nerve Transection:<\/strong>\u00a0All nerve transections result in neuroma formation. Minimize symptom potential by transecting the nerve sharply under tension to allow retraction into a well-padded area away from the surgical scar and potential mechanical irritation.<\/p>\n\n\n\n

10.\u00a0Zone II Flexor Tendon Repair:<\/strong>\u00a0Modern techniques and early active motion protocols have improved outcomes, but results are still variable. Meticulous surgical technique, appropriate patient selection, and careful postoperative monitoring of therapy are crucial.<\/p>\n\n\n\n

11.\u00a0Flexor Tendon Repair Strength:<\/strong>\u00a0The repair site is weakest in the first 4 weeks after surgery, especially if immobilized. Emphasize protected mobilization with early active motion protocols to maximize healing and minimize adhesion formation.<\/p>\n\n\n\n

12.\u00a0Edema Control:<\/strong>\u00a0Crucial for successful tendon healing and rehabilitation. Implement elevation, compression, and early active motion to minimize edema.<\/p>\n\n\n\n

13.\u00a0Tendon Transfer Strength:<\/strong>\u00a0Expect a loss of approximately one MRC grade of strength in the transferred muscle. Choose a donor muscle with sufficient strength to perform the desired function after transfer.<\/p>\n\n\n\n

14.\u00a0Tendon Transfer Amplitude:<\/strong>\u00a0Match excursion of the donor and recipient tendons. Use the tenodesis effect to augment amplitude if needed.<\/p>\n\n\n\n

15.\u00a0Tendon Transfer Synergy:<\/strong>\u00a0Transfers are more effective when the transferred muscle’s action is synergistic with the function it replaces.<\/p>\n\n\n\n

16.\u00a0Arthrodesis:<\/strong>\u00a0Avoid fusion if possible to preserve joint mobility and the tenodesis effect. Consider the impact of fusion on adjacent joints.<\/p>\n\n\n\n

17.\u00a0Tenosynovitis vs. Tendon Rupture:<\/strong>\u00a0Differentiate by evaluating if the patient can actively maintain joint position once passively placed.<\/p>\n\n\n\n

18.\u00a0Septic Arthritis vs. Crystalline Arthropathy:<\/strong>\u00a0Arthrocentesis is mandatory for diagnosis. Don’t exclude infection based on the presence of crystals alone, as both conditions can coexist.<\/p>\n\n\n\n

19.\u00a0Zone of Injury:<\/strong>\u00a0The zone of injury in acute trauma extends beyond the visible wound due to perivascular inflammation and potential for delayed microvascular thrombosis. Consider this when choosing recipient vessels for free flap anastomosis and prioritize vessel selection outside the zone.<\/p>\n\n\n\n

20.\u00a0Doppler Allen Test:<\/strong>\u00a0A critical component of the vascular examination for suspected arterial injury. Consistently perform a Doppler Allen test to assess radial and ulnar artery patency.<\/p>\n\n\n\n

21.\u00a0Angiography:<\/strong>\u00a0Not routinely indicated for acute, single-level penetrating arterial injuries when the site of injury is known. Consider for complex injuries, suspected embolic events, or potential for thrombolytic intervention.<\/p>\n\n\n\n

Specific Conditions:<\/strong><\/p>\n\n\n\n

Chronic Pain Syndromes:<\/strong><\/p>\n\n\n\n

1.\u00a0CRPS Diagnosis:<\/strong>\u00a0CRPS is a clinical diagnosis. There is no pathognomonic test. The diagnosis requires the presence of disproportionate pain and at least two of the following: stiffness, delayed functional recovery, trophic changes, and autonomic dysfunction.<\/p>\n\n\n\n

2.\u00a0CRPS vs. Neuropathic Pain:<\/strong>\u00a0CRPS is a type of neuropathic pain, but it differs from other neuropathic pain syndromes by the presence of pain spreading beyond the expected nerve distribution and by the presence of autonomic dysfunction.<\/p>\n\n\n\n

3.\u00a0CRPS Treatment:<\/strong>\u00a0Early recognition and aggressive multidisciplinary intervention are key for optimal outcome. Treatment should address sympathetically maintained pain, edema, functional impairment, and any identifiable nociceptive or neuropathic contributions.<\/p>\n\n\n\n

4.\u00a0“Hot” vs. “Cold” CRPS:<\/strong>\u00a0These represent distinct physiological stages of microvascular perfusion associated with CRPS. Treatment should be tailored to each stage. “Hot” CRPS is characterized by edema, increased sweating, and hyperalgesia. “Cold” CRPS is characterized by atrophy, pain with cold intolerance, and diminished sweating.<\/p>\n\n\n\n

Tendon\uff1a<\/strong><\/p>\n\n\n\n

1.\u00a0Trigger Finger Injection:<\/strong>\u00a0While subcutaneous injection of corticosteroid can be effective, intratendinous injection should be avoided due to the risk of tendon rupture.<\/p>\n\n\n\n

2.\u00a0Intersection Syndrome:<\/strong>\u00a0Pain is frequently noted over the first dorsal compartment (APL and EPB) at the wrist, but the tenosynovitis actually affects the second dorsal compartment (ECRL and ECRB) under the extensor retinaculum.<\/p>\n\n\n\n

3.\u00a0ECU Tendonitis:<\/strong>\u00a0Painful snapping of the ECU tendon with forearm pronation\/supination suggests ECU instability due to a subsheath tear.<\/p>\n\n\n\n

4.\u00a0FCR Tendonitis:<\/strong>\u00a0A diagnosis of exclusion. Thoroughly rule out other causes of volar radial wrist pain before making this diagnosis.<\/p>\n\n\n\n

5.\u00a0Lateral vs. Medial Epicondylitis:<\/strong>\u00a0Consider radial tunnel syndrome in lateral epicondylitis (pain with resisted middle finger extension) and ulnar neuritis in medial epicondylitis (pain with resisted wrist flexion, pronation, and ulnar deviation).<\/p>\n\n\n\n

6.\u00a0Chronic EPL Rupture:<\/strong>\u00a0Frequently caused by attritional rubbing against Lister’s tubercle. Evaluate for predisposing factors such as rheumatoid arthritis, scapholunate instability, or previous distal radius fracture.<\/p>\n\n\n\n

7.\u00a0Chronic ECU\/EDQ Rupture:<\/strong>\u00a0Rheumatoid arthritis with caput ulnae syndrome (dorsal subluxation of the ulna) is a common cause for these attritional ruptures.<\/p>\n\n\n\n

Arthritis\uff1a<\/strong><\/p>\n\n\n\n

1.\u00a0Seropositive vs. Seronegative Arthritis:<\/strong>\u00a0The presence or absence of rheumatoid factor in the blood distinguishes these two broad categories of inflammatory arthritis. Seropositive arthritis includes rheumatoid arthritis, while seronegative arthritis includes psoriatic arthritis, ankylosing spondylitis, reactive arthritis, and enteropathic arthritis.<\/p>\n\n\n\n

2.\u00a0Psoriatic Arthritis:<\/strong>\u00a0DIP joint involvement, nail changes (pitting, onycholysis), and dactylitis are common. Treatment often requires a combination of medical management and surgical intervention.<\/p>\n\n\n\n

3.\u00a0Systemic Lupus Erythematosus (SLE):<\/strong>\u00a0Hand deformities mimic RA, but joint involvement is due to soft tissue laxity, tendon subluxations, and capsular laxity, rather than articular destruction. Radiographs typically do not show erosions or joint space narrowing.<\/p>\n\n\n\n

4.\u00a0Scleroderma:<\/strong>\u00a0Skin fibrosis, Raynaud phenomenon, and digital ulcerations are prominent features. Surgery should be avoided if possible due to a high risk of wound healing complications.<\/p>\n\n\n\n

5.\u00a0Acute Gout:<\/strong>\u00a0Can mimic septic arthritis, especially in the wrist, with rapid onset of pain, erythema, and swelling. Arthrocentesis is crucial for differentiation.<\/p>\n\n\n\n

6.\u00a0Chronic Gout:<\/strong>\u00a0Tophi (deposits of urate crystals) can cause erosions on both sides of the joint, typically with sclerotic borders and overhanging margins. Late findings include joint space narrowing and destruction.<\/p>\n\n\n\n

7.\u00a0Chronic CPPD:<\/strong>\u00a0Often presents as a SLAC-like wrist collapse with chondrocalcinosis (linear calcifications at the articular surface). Treatment options include those used for SLAC wrist.<\/p>\n\n\n\n

8.\u00a0Septic Arthritis:<\/strong>\u00a0A joint-threatening emergency. Requires urgent arthrotomy, drainage, irrigation, and IV antibiotics. Delayed treatment can result in permanent cartilage damage, joint destruction, and loss of function.<\/p>\n\n\n\n

9.\u00a0Juvenile Idiopathic Arthritis:<\/strong>\u00a0Several subtypes with distinct clinical presentations and treatment considerations. Unlike adult rheumatoid arthritis, growth abnormalities are common and can affect the choice of treatment.<\/p>\n\n\n\n

10.\u00a0Trapeziometacarpal Arthritis:<\/strong>\u00a0Radiographic findings do not always correlate with symptoms. Patients may have severe arthritis on radiographs but be asymptomatic. Conversely, patients with minimal radiographic changes may experience disabling pain.<\/p>\n\n\n\n

11.\u00a0Carpal Boss:<\/strong>\u00a0A bony prominence at the base of the second or third metacarpals, often mistaken for a fracture. Use carpal boss views (lateral with supination and flexion) to accurately diagnose.<\/p>\n\n\n\n

Vascular Conditions\u00a0\uff1a<\/strong><\/p>\n\n\n\n

1.\u00a0Hemangioma vs. Venous Malformation:<\/strong>\u00a0Hemangiomas are true tumors with rapid growth in infancy followed by involution. Venous malformations are not true tumors and grow commensurately with the child.<\/p>\n\n\n\n

2.\u00a0Hypothenar Hammer Syndrome:<\/strong>\u00a0Caused by repetitive trauma to the ulnar artery in the hypothenar eminence, leading to thrombosis, aneurysm formation, and distal embolization. Has a strong association with smoking.<\/p>\n\n\n\n

3.\u00a0Arterial Aneurysm:<\/strong>\u00a0A permanent localized dilatation of the artery 50% or greater above normal diameter. Consider the possibility of distal embolization as a presenting sign, especially for ulnar artery aneurysms.<\/p>\n\n\n\n

4.\u00a0Digital Artery Aneurysm:<\/strong>\u00a0Often mistaken for a soft tissue mass, especially in the fingertip. Transverse mobility but lack of longitudinal mobility is a key differentiating sign.<\/p>\n\n\n\n

Other\uff1a<\/strong><\/p>\n\n\n\n

1.\u00a0Mutilating Hand Injuries:<\/strong>\u00a0These are combined injuries involving multiple structures with a poorer prognosis than isolated injuries. Requires a systematic approach to evaluation and treatment.<\/p>\n\n\n\n

2.\u00a0Compartment Syndrome:<\/strong>\u00a0Can occur with open wounds. Pain on passive stretch is the most reliable clinical sign for early diagnosis and is present even before neurological deficits.<\/p>\n\n\n\n

3.\u00a0Informed Consent:<\/strong>\u00a0The informed consent discussion should ideally occur in the office, not immediately before surgery. Document the discussion thoroughly in the office note. Ensure that patients understand the risks and benefits of the proposed procedure, alternative treatment options, and the risks of refusing treatment.<\/p>\n\n\n\n

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Disclaimer:<\/p>\n\n\n\n

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General Concepts\u00a0: 1.\u00a0Epinephrine Use:\u00a0While historically feared due to vasoconstriction risk, epinephrine can be safely used in digital blocks at diluted concentrations (1:200,000 or 1:400,000), with careful aspiration, and potential phentolamine reversal (0.5% solution). Monitor perfusion closely. 2.\u00a0Betadine and Bone:\u00a0Betadine, while an effective antiseptic, has been shown to be cytotoxic to osteoblasts in vitro. Irrigate exposed […]<\/p>","protected":false},"author":1,"featured_media":1623,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_seopress_robots_primary_cat":"none","_seopress_titles_title":"Comprehensive Guide to Orthopedic Conditions: Fractures, Tendon Repair, Arthritis, and More","_seopress_titles_desc":"Explore a detailed guide on orthopedic conditions, including ankle fractures, tendon repair, arthritis types, and vascular issues. Learn about diagnosis, treatment, and management strategies for optimal patient care.","_seopress_robots_index":"","footnotes":""},"categories":[1],"tags":[39,41,40,43,38,42],"class_list":["post-1620","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized","tag-anklefractures","tag-carpalinstability","tag-epinephrineuse","tag-handsurgery","tag-orthopedics","tag-tendonrepair"],"acf":[],"meta_box":[],"_links":{"self":[{"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/posts\/1620"}],"collection":[{"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/comments?post=1620"}],"version-history":[{"count":1,"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/posts\/1620\/revisions"}],"predecessor-version":[{"id":1625,"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/posts\/1620\/revisions\/1625"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/media\/1623"}],"wp:attachment":[{"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/media?parent=1620"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/categories?post=1620"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/suzhouyoubest.com\/zh\/wp-json\/wp\/v2\/tags?post=1620"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}