intrinsic anatomy and dysfunction - teton hand...
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INTRINSIC ANATOMY AND INTRINSIC ANATOMY AND DYSFUNCTIONDYSFUNCTION
PAUL C. DELL, M.D.PAUL C. DELL, M.D.UNIVERSITY OF FLORIDAUNIVERSITY OF FLORIDA
““IF I HAVE SEEN FURTHERIF I HAVE SEEN FURTHER……. IT IS . IT IS BY STANDING UPON THE BY STANDING UPON THE SHOULDERS OF GIANTS.SHOULDERS OF GIANTS.””
SIR ISAAC NEWTON, 1675SIR ISAAC NEWTON, 1675
MENTORINGMENTORING
MOST SUCCESSFUL PEOPLE IN MOST SUCCESSFUL PEOPLE IN DIFFERENT AREAS CAN POINT TO AN DIFFERENT AREAS CAN POINT TO AN INDIVIDUAL(S) OR MENTOR WHO WAS INDIVIDUAL(S) OR MENTOR WHO WAS CRUCIAL TO THEIR CAREER GROWTH CRUCIAL TO THEIR CAREER GROWTH AND SUCCESSAND SUCCESS
MENTORINGMENTORING
TEACHER SUPPLIES INFORMATION IN TEACHER SUPPLIES INFORMATION IN A NEUTRAL FASHIONA NEUTRAL FASHIONMENTORING IMPLIES A BONDING MENTORING IMPLIES A BONDING BETWEEN THE MENTOR AND THE BETWEEN THE MENTOR AND THE MENTEEMENTEERELATIONSHIP IS PERSONAL AND RELATIONSHIP IS PERSONAL AND ALMOST FAMILIAL IN NATUREALMOST FAMILIAL IN NATUREMAY BE SINGULAR OR MULTIPLE MAY BE SINGULAR OR MULTIPLE
WILLIAM F ENNEKINGWILLIAM F ENNEKING
MENTORMENTOR–– RESPECTEDRESPECTED–– TRUSTEDTRUSTED–– ACCOMPLISHEDACCOMPLISHED–– CONFIDENTCONFIDENT–– ACCESSIBLEACCESSIBLE
RICHARD J SMITHRICHARD J SMITHCHIEF OF HAND CHIEF OF HAND SURGERY MASS SURGERY MASS GENERAL HOSP GENERAL HOSP 1972 1972 –– 19871987FORMER FORMER PRESIDENT OF THE PRESIDENT OF THE ASSHASSH1931 1931 –– 19871987THE GREAT THE GREAT COMMUNICATORCOMMUNICATOR
RICHARD J SMITHRICHARD J SMITH
OVER 100 ORIGINAL OVER 100 ORIGINAL CONTRIBUTIONS CONTRIBUTIONS TO HAND TO HAND LITERATURELITERATUREBOSTON 1975 BOSTON 1975 –– 7676KAPLAN, KAPLAN, PULVERTAFT, PULVERTAFT, FLATTFLATT
WILLIAM BURKHALTERWILLIAM BURKHALTER
MENTOR: IMPARTS MENTOR: IMPARTS KNOWLEDGE, KNOWLEDGE, EXPERIENCE, EXPERIENCE, SUPPORTSUPPORTENABLES MENTEE ENABLES MENTEE TO DEVELOP TO DEVELOP SKILLS MUCH SKILLS MUCH MORE RAPIDLY MORE RAPIDLY THAN WHEN THAN WHEN RELATIONSHIP IS RELATIONSHIP IS LACKINGLACKING
WILLIAM BURKHALTERWILLIAM BURKHALTER
CHIEF OF ORTHO CHIEF OF ORTHO 8585THTH EVAC HOSP EVAC HOSP VIETNAM 1965VIETNAM 1965--6666CHIEF OF HAND CHIEF OF HAND SURGERY UNIV OF SURGERY UNIV OF MIAMI 1974 MIAMI 1974 –– 199119911928 1928 -- 19921992
INTRINSIC MECHANISMINTRINSIC MECHANISM
EXTRINSIC EXTENSOREXTRINSIC EXTENSOR
DORSAL COMPARTMENTSDORSAL COMPARTMENTS–– 1ST EPB, APL1ST EPB, APL–– 2ND ECRL, ECRB2ND ECRL, ECRB–– 3RD EPL3RD EPL–– 4TH EIP, EDC4TH EIP, EDC–– 5TH EDQ5TH EDQ–– 6TH ECU6TH ECU
JUNCTURAEJUNCTURAE
JUNCTURAEJUNCTURAE
STABILIZE THE DORSAL HOOD WHEN STABILIZE THE DORSAL HOOD WHEN THE MCP JOINTS ARE FLEXEDTHE MCP JOINTS ARE FLEXED
INTEROSSEOUS MUSCLESINTEROSSEOUS MUSCLES
4 DORSAL4 DORSAL–– 11STST,2,2NDND,4,4TH TH HAVE TWO MUSCLE BELLIESHAVE TWO MUSCLE BELLIES–– 33RDRD HAS ONLY ONE HAS ONLY ONE 3 VOLAR ONE MUSCULAR ORIGIN3 VOLAR ONE MUSCULAR ORIGIN
INTEROSSEOUS MUSCLESINTEROSSEOUS MUSCLES
4 DORSAL INTEROSSEI4 DORSAL INTEROSSEI–– 11STST ,2,2NDND ,4,4THTH
DEEP BELLYDEEP BELLY–– ORIGIN METACARPAL DIAPHYSISORIGIN METACARPAL DIAPHYSIS–– SPIRALS AROUND THE MORE SUPERFICIAL BELLYSPIRALS AROUND THE MORE SUPERFICIAL BELLY–– PASSES SUPERFICIAL TO SAGITTAL BANDSPASSES SUPERFICIAL TO SAGITTAL BANDS–– INSERTS ON THE DORSAL HOODINSERTS ON THE DORSAL HOOD–– FLEX MCPJ , EXTEND PIPJ FLEX MCPJ , EXTEND PIPJ
INTEROSSEOUS MUSCLESINTEROSSEOUS MUSCLES
4 DORSAL INTEROSSEI4 DORSAL INTEROSSEI–– 11STST,2,2NDND,4,4thth
SUPERFICIAL BELLY SUPERFICIAL BELLY –– ORIGIN: ADJACENT SIDES CONTIGUOUS ORIGIN: ADJACENT SIDES CONTIGUOUS
METACARPALS METACARPALS –– RUNS DEEP TO THE SAGITTAL BANDSRUNS DEEP TO THE SAGITTAL BANDS–– INSERTS ON TUBERCLE P1INSERTS ON TUBERCLE P1–– ACTS ONLY AS ABDUCTOR ACTS ONLY AS ABDUCTOR
INTEROSSEOUS MUSCLESINTEROSSEOUS MUSCLES
4 DORSAL INTEROSSEI4 DORSAL INTEROSSEI–– 33RDRD DORSALDORSAL
ORIGIN: 3ORIGIN: 3RDRD / 4/ 4THTH METACARPALSMETACARPALSSINGLE MUSCLE BELLYSINGLE MUSCLE BELLYINSERTS ON DORSAL HOOD INSERTS ON DORSAL HOOD ---- NO NO INSERTION ON BONEINSERTION ON BONELITTLE MOTION OF MIDDLE TOWARD RINGLITTLE MOTION OF MIDDLE TOWARD RING
INTEROSSEOUS MUSCLESINTEROSSEOUS MUSCLES
INTEROSSEOUS MUSCLESINTEROSSEOUS MUSCLES
3 VOLAR INTEROSSEI3 VOLAR INTEROSSEI–– ORIGIN: CONTIGUOUS METACARPAL ORIGIN: CONTIGUOUS METACARPAL
SHAFTSSHAFTS–– SUPERFICIAL TO SAGITTAL BANDSSUPERFICIAL TO SAGITTAL BANDS–– INSERT INTO DORSAL HOOD ON INSERT INTO DORSAL HOOD ON
ULNAR SIDE OF INDEX AND RADIAL ULNAR SIDE OF INDEX AND RADIAL SIDE OF RING AND SMALLSIDE OF RING AND SMALL
INTEROSSEOUS MUSCLESINTEROSSEOUS MUSCLES
INTEROSSEOUS MUSCLES INTEROSSEOUS MUSCLES SUMMARYSUMMARY
11STST 22NDND 44THTH DORSAL INTEROSSEIDORSAL INTEROSSEI–– 2 MUSCLE BELLIES2 MUSCLE BELLIES–– INSERTIONINSERTION
BASE OF P1BASE OF P1DORSAL HOODDORSAL HOOD
33RDRD DORSAL INTEROSSEOUS AND DORSAL INTEROSSEOUS AND ALL 3 VOLAR INTEROSSEIALL 3 VOLAR INTEROSSEI–– SINGLE BELLYSINGLE BELLY–– SINGLE INSERTION DORSAL HOODSINGLE INSERTION DORSAL HOOD
LUMBRICALLUMBRICAL
RADIAL SIDE
LUMBRICALLUMBRICAL
EXTENDS IPJ IRRESPECTIVE OF EXTENDS IPJ IRRESPECTIVE OF MCPJ POSITIONMCPJ POSITIONFACILITATES IPJ EXTENSION BY FACILITATES IPJ EXTENSION BY PULLING PROFUNDUS DISTALLYPULLING PROFUNDUS DISTALLYINITIATES MCPJ FLEXIONINITIATES MCPJ FLEXIONRADIAL DEVIATION OF DIGITRADIAL DEVIATION OF DIGIT
EXTRINSIC EXTENSOREXTRINSIC EXTENSOR
SAGITTAL BANDSSAGITTAL BANDS–– ARISE FROM THE EDC TENDONARISE FROM THE EDC TENDON–– INSERT ON THE VOLAR PLATEINSERT ON THE VOLAR PLATE–– EXTEND THE MCP JOINTEXTEND THE MCP JOINT–– STABILIZE THE EDC TENDON OVER THE STABILIZE THE EDC TENDON OVER THE
JOINTJOINT
SAGITTAL BANDSSAGITTAL BANDS
SAGITTAL BANDSSAGITTAL BANDS
TRANSVERSE FIBERSTRANSVERSE FIBERS
TRANSVERSE FIBERSTRANSVERSE FIBERS
DORSAL HOODDORSAL HOOD
OBLIQUE FIBERSOBLIQUE FIBERS
LATERAL BAND
CENTRAL SLIPCENTRAL SLIP
CONTAINS BOTH INTRINSIC AND EXTRINSIC COMPONENTS
CONJOINED LATERAL BANDCONJOINED LATERAL BAND
BOTH INTRINSIC BOTH INTRINSIC AND EXTRINSIC AND EXTRINSIC COMPONENTSCOMPONENTSAT THE LEVEL OF AT THE LEVEL OF THE PIP JOINTTHE PIP JOINT
TRIANGULAR LIGAMENTTRIANGULAR LIGAMENT
TRANSVERSE THIN TRANSVERSE THIN FASCIA FASCIA CONNECTING CONNECTING CONJOINED CONJOINED LATERAL BANDS LATERAL BANDS JUST DISTAL TO JUST DISTAL TO CENTRAL SLIP CENTRAL SLIP INSERTIONINSERTIONPREVENTS VOLAR PREVENTS VOLAR SUBLUXATION OF SUBLUXATION OF THE LATERAL THE LATERAL BANDSBANDS
TERMINAL TENDONTERMINAL TENDON
CONVERGENCE OF CONVERGENCE OF TWO CONJOINED TWO CONJOINED LATERAL BANDSLATERAL BANDSINSERTION INTO INSERTION INTO DORSAL BASE OF DORSAL BASE OF DISTAL PHALANXDISTAL PHALANX
TRANSVERSE RETINACULAR TRANSVERSE RETINACULAR LIGAMENTLIGAMENT
ORIGIN: EDGE OF ORIGIN: EDGE OF FLEXOR TENDON FLEXOR TENDON SHEATH AT PIPJSHEATH AT PIPJINSERTION: INSERTION: LATERAL EDGE OF LATERAL EDGE OF CONJOINED CONJOINED LATERAL BANDSLATERAL BANDSPREVENTS PREVENTS EXCESSIVE EXCESSIVE DORSAL SHIFT OF DORSAL SHIFT OF LATERAL BANDSLATERAL BANDS
OBLIQUE RETINACULAR OBLIQUE RETINACULAR LIGAMENTLIGAMENT
ORIGIN: VOLAR LATERAL CREST OF ORIGIN: VOLAR LATERAL CREST OF PROXIMAL PHALANXPROXIMAL PHALANXINSERTION: LATERAL TERMINAL INSERTION: LATERAL TERMINAL TENDONTENDONVOLAR TO AXIS OF PIPJVOLAR TO AXIS OF PIPJDORSAL TO AXIS OF DIPJDORSAL TO AXIS OF DIPJACTIVE TENODESIS TO INITIATE ACTIVE TENODESIS TO INITIATE DIPJ EXTENSION DIPJ EXTENSION
OBLIQUE RETINACULAR OBLIQUE RETINACULAR LIGAMENTLIGAMENT
OBLIQUE RETINACULAR OBLIQUE RETINACULAR LIGAMENTLIGAMENT
PIPJ EXTENSION PIPJ FLEXION
INTRINSIC TIGHTNESSINTRINSIC TIGHTNESS
INTRINSIC POSITIVEINTRINSIC POSITIVE
MCPJ EXTENDED MCPJ FLEXION
INTRINSIC TIGHTNESSINTRINSIC TIGHTNESS
CAUSESCAUSES
–– FIBROSISFIBROSIS–– ISCHEMIAISCHEMIA–– SPASMSPASM–– NEUROMUSCULAR (CVA)NEUROMUSCULAR (CVA)–– PARADOXICAL EXTENSIONPARADOXICAL EXTENSION
INITRINSIC TIGHTNESSINITRINSIC TIGHTNESS
INTRINSIC POSITIVEINTRINSIC POSITIVE
TRL
SWAN NECKSWAN NECK
CAUSESCAUSES–– MALLETMALLET–– PIPJ SYNOVITISPIPJ SYNOVITIS–– INTEROSSEOUS MUSCLE CONTRACTUREINTEROSSEOUS MUSCLE CONTRACTURE–– VOLAR SUBLUXATION PROX PHALANXVOLAR SUBLUXATION PROX PHALANX–– EDC SUBLUXATIONEDC SUBLUXATION–– FDS DYSFUNCTIONFDS DYSFUNCTION
BOUTONNIEREBOUTONNIERE
INTRINSIC MINUS ULNAR INTRINSIC MINUS ULNAR NERVE DYSFUNCTIONNERVE DYSFUNCTION
CLAW DEFORMITYCLAW DEFORMITYLOSS OF GRIP STRENGTHLOSS OF GRIP STRENGTHASYNCHRONOUS MOTIONASYNCHRONOUS MOTION–– MCP / IPJ FLEXIONMCP / IPJ FLEXION–– MCPJ FLEXION / IPJ EXTENSIONMCPJ FLEXION / IPJ EXTENSIONLOSS OF ABDUCTION LOSS OF ABDUCTION –– ADDUCTIONADDUCTIONLOSS OF PINCH STRENGTH / LOSS OF PINCH STRENGTH / ADDUCTION ADDUCTION
ULNAR NERVE PALSYULNAR NERVE PALSY
CLAW DEFORMITYCLAW DEFORMITY–– MCPJ HYPEREXTENSIONMCPJ HYPEREXTENSION–– IPJ FLEXIONIPJ FLEXIONINTRINSIC WASTINGINTRINSIC WASTINGWARTENBERGWARTENBERGFLATTENED PALMAR ARCHFLATTENED PALMAR ARCH
CLAW DEFORMITYCLAW DEFORMITY
+ _
_+
CLAW DEFORMITYCLAW DEFORMITY
CLAW DEFORMITYCLAW DEFORMITY
WITH INTRINSIC PARALYSIS, FULL PIP WITH INTRINSIC PARALYSIS, FULL PIP JOINT EXTENSION CAN BE ACHIEVED JOINT EXTENSION CAN BE ACHIEVED IF MCP JOINT HYPEREXTENSION IS IF MCP JOINT HYPEREXTENSION IS PREVENTEDPREVENTEDLONGSTANDING PIPJ FLEXION MAY LONGSTANDING PIPJ FLEXION MAY LEAD TO ATTENUATION OF THE LEAD TO ATTENUATION OF THE CENTRAL SLIPCENTRAL SLIPBOUVIER BOUVIER
BOUVIER MANEUVERBOUVIER MANEUVER
WARTENBERGWARTENBERG
ECCENTRIC INSERTION EDQ
ULNAR NERVE PALSYULNAR NERVE PALSY
WASTING LOSS OF ARCH
THOMAS SIGNTHOMAS SIGN
SUBCONSCIOUS SUBCONSCIOUS ATTEMPT TO GAIN ATTEMPT TO GAIN GREATER POWER GREATER POWER AND EXCURSION AND EXCURSION OF EDCOF EDC’’SSEXAGGERATES EXAGGERATES MCPJ MCPJ HYPEREXTENSIONHYPEREXTENSION
FROMENTFROMENT’’S SIGNS SIGN
FROMENTFROMENT’’S SIGNS SIGN
JULES FROMENT (1878JULES FROMENT (1878--1946)1946)–– NEUROLOGIST, LYONNEUROLOGIST, LYON–– WW I WW I –– LARGE NUMBER NERVE INJURIESLARGE NUMBER NERVE INJURIES–– THE SIGN OF THE THUMBTHE SIGN OF THE THUMBMANNERFELTMANNERFELT–– HYPERFLEXION OF THE THUMB IPJ DUE HYPERFLEXION OF THE THUMB IPJ DUE
TO SUBSTITUTION OF THE SECONDARY TO SUBSTITUTION OF THE SECONDARY ADDUCTOR OF THE THUMB ADDUCTOR OF THE THUMB ---- THE EPLTHE EPL
IDEAL TREATMENTIDEAL TREATMENT
PREVENT MCPJ HYPEREXTENSIONPREVENT MCPJ HYPEREXTENSION
PROVIDE IPJ EXTENSIONPROVIDE IPJ EXTENSION
PROVIDE ACTIVE MCPJ FLEXIONPROVIDE ACTIVE MCPJ FLEXION
RESTORE ABDUCTION OF INDEX RESTORE ABDUCTION OF INDEX
TREATMENTTREATMENT
FULL PASSIVE ROM JOINTSFULL PASSIVE ROM JOINTS
–– SPLINTSSPLINTS
–– SERIAL CASTSSERIAL CASTS
–– CAPSULECTOMYCAPSULECTOMY
TREATMENTTREATMENT
PREVENT MCPJ HYPEREXTENSIONPREVENT MCPJ HYPEREXTENSION
–– LUMBRICAL BARLUMBRICAL BAR–– DERMODESISDERMODESIS–– VOLAR CAPSULORRHAPHY (ZANCOLLI)VOLAR CAPSULORRHAPHY (ZANCOLLI)–– TENODESISTENODESIS
PARKESPARKESRIORDANRIORDAN
TREATMENTTREATMENT
PROCEDURES FOR ACTIVE MCPJ PROCEDURES FOR ACTIVE MCPJ FLEXIONFLEXION
–– TENDON TRANSFERSTENDON TRANSFERS–– ACTIVE TENODESISACTIVE TENODESIS
ALL MUST PASS VOLAR TO ALL MUST PASS VOLAR TO INTERMETACARPAL LIGAMENTINTERMETACARPAL LIGAMENT
ACTIVE MCPJ FLEXIONACTIVE MCPJ FLEXION
TRANSFER TENDON INTO LATERAL TRANSFER TENDON INTO LATERAL BANDS OR BURKHALTER INSERTION BANDS OR BURKHALTER INSERTION PROX PHALANXPROX PHALANX
–– EIP, EDQ TRANSFER (BUNNELL, EIP, EDQ TRANSFER (BUNNELL, FOWLERFOWLER
–– ECRB + PLANTARIS (BRAND)ECRB + PLANTARIS (BRAND)–– FDS (STILESFDS (STILES--BUNNELL)BUNNELL)
BRAND TRANSFERBRAND TRANSFER
BRAND TRANSFERBRAND TRANSFER
PERSONALPERSONAL
MODIFIED STILESMODIFIED STILES--BUNNELL TO BUNNELL TO PROXIMAL PHALANXPROXIMAL PHALANX–– CORRECTS CLAWCORRECTS CLAW–– PROVIDES MCPJ FLEXION PROVIDES MCPJ FLEXION –– IPJ IPJ
EXTENSIONEXTENSION–– DOES NOT IMPROVE STRENGTHDOES NOT IMPROVE STRENGTH–– NOT INDICATED IN HIGH ULNAR/MEDIAN NOT INDICATED IN HIGH ULNAR/MEDIAN
PALSY OR POSITIVE BOUVIER SIGNPALSY OR POSITIVE BOUVIER SIGN
““IF YOU BECOME A TEACHER, BY IF YOU BECOME A TEACHER, BY YOUR PUPILS YOUYOUR PUPILS YOU’’LL BE TAUGHTLL BE TAUGHT””
OSCAR HAMMERSTEIN II OSCAR HAMMERSTEIN II ---- THE THE KING AND IKING AND I
ESTABLISH A ESTABLISH A CLOSE WORKING CLOSE WORKING RELATIONSHIP RELATIONSHIP WITH YOUR WITH YOUR SURGEONSSURGEONSENHANCE ENHANCE COMMUNICATIONCOMMUNICATIONPOSTOP PLANNINGPOSTOP PLANNING
WE ARE ALL WE ARE ALL TEACHERSTEACHERSWE ARE ALL WE ARE ALL STUDENTSSTUDENTSPATIENTS LOOK PATIENTS LOOK TO YOU FOR TO YOU FOR EDUCATION AND EDUCATION AND GUIDANCEGUIDANCE
““GOOD,BETTER, GOOD,BETTER, BEST, NEVER LET BEST, NEVER LET THEM REST, UNTIL THEM REST, UNTIL THEIR GOOD IS THEIR GOOD IS BETTER, AND BETTER, AND THEIR BETTER THEIR BETTER BESTBEST””ROBERT CARROLLROBERT CARROLL
STIMULATE YOUR STIMULATE YOUR PATIENTS PATIENTS THROUGH THROUGH EDUCATIONEDUCATIONTREAT ALL TREAT ALL PATIENTS WITH PATIENTS WITH DIGNITYDIGNITY
LEARN PRINCIPLES LEARN PRINCIPLES RATHER THAN RATHER THAN COOKBOOKCOOKBOOKA MIND THAT A MIND THAT GRASPS GRASPS PRINCIPLES WILL PRINCIPLES WILL DEVISE ITS OWN DEVISE ITS OWN TREATMENT PLANTREATMENT PLAN
TRANSCEND TRANSCEND BOREDOM WITH BOREDOM WITH ENTHUSIASMENTHUSIASMDO WHAT YOU DO WHAT YOU LOVE AND LOVE LOVE AND LOVE WHAT YOU DO WHAT YOU DO
THANK YOU
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