Which of the following is the most appropriate management?

(A) Intratendinous lengthening
(B) Release of the central slips
(C) Release of the check rein ligaments
(D) Release of the lateral bands
(E) Split-thickness skin grafting

The correct response is Option B.

The most appropriate management of the extensor tendon tightness seen in this patient is release of the central slips. Central slip releases can be performed under local anesthesia to immediately improve flexion of the proximal interphalangeal (PIP) joint. This simple maneuver may eliminate the need for extensive soft-tissue reconstruction as long as the scar and tendon contractures are located on the dorsal aspect of the hand and the lateral bands, which supply extensor power to the PIP and distal interphalangeal (DIP) joints, are intact. The risk for subluxation of the intact lateral bands and subsequent development of a boutonierre deformity is minimal.

Intratendinous lengthening is performed in patients who have contractures of the extrinsic flexor tendons resulting from cerebral palsy or stroke. Because the metacarpophalangeal (MP), PIP, and DIP joints can all be affected, this technique is primarily recommended to improve the appearance of the hand.
Patients who have intrinsic tendon tightness that does not improve with therapy may be considered for release of the lateral bands. In this condition, which is often a sequela of compartment syndrome, the intrinsic tendons of the hand are foreshortened, and flexion of the PIP joint is inhibited when the MP joints are fully extended.

Although the scar contractures can be released to relieve some of the stiffness in the PIP joints, the affected area should be covered with full-thickness skin grafts (instead of split-thickness grafts) because they provide superior skin quality and decrease the risk for secondary contractures.

References
1. Burton RI, Melchiar JA. Extensor tendons Ð late reconstruction. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1999-2001.
2. Gerwin M. Cerebral palsy. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:259-285.
3. Smith RJ. Intrinsic contracture. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:604-618.
4. Watson KH, Weinzweig J. Stiff joints. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:552-561.

Three months after sustaining an amputation of the index finger at the level of the distal interphalangeal joint, a 37-year-old man has extension of the proximal interphalangeal (PIP) joint on attempted flexion of the finger. Which of the following is the most appropriate management at this time?

(A) Division of the central slip of the extensor tendon
(B) Division of the lumbrical tendon
(C) Division of the superficialis tendon insertion
(D) Release of the A1 pulley
(E) Amputation at the level of the PIP joint

The correct response is Option B.

The most appropriate management at this time is division of the lumbrical tendon. This patient has a lumbrical-plus deformity, which occurs following sectioning of the flexor digitorum profundus (FDP) tendon. In patients with this deformity, the independent FDP tendon and lumbrical muscle migrate proximally. With flexion, tension is exerted by the lumbrical via the radial lateral band. During attempted flexion of the digit, this tension transmitted through the radial lateral band results in paradoxical extension of the proximal interphalangeal (PIP) joint. Division of the lumbrical insertion or resection of the lumbrical tendon will restore balanced finger flexion. Therefore, in a patient who has the acute onset of significant intrinsic tightness, the radial lateral band should be released or the lumbrical tendon should be resected.

The lumbrical tendons originate from the FDP tendon and insert into the radial lateral band. These tendons pass palmar to the deep transverse intermetacarpal ligament.

Division of the central slip of the extensor tendon will result in a permanent flexion deformity of the PIP joint. Division of the superficialis tendon will further weaken index finger flexion. Release of the A1 pulley is appropriate for management of flexor tenosynovitis or trigger finger in a patient who does not have rheumatoid arthritis. Although amputation at the level of the PIP joint would preclude joint hyperextension, this is an extreme measure that does not address the insertion of the lumbrical tendon.

References
1. Parkes A. The "lumbrical plus" finger. Hand. 1970;2:164-165.
2. Sotereanos DG, Schmidt CC. Hand and digital amputations. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;2:1000-1001.

A 20-year-old woman has pain, swelling, and tenderness of the right wrist after washing cars for eight hours. There is no history of trauma. On physical examination, tenderness and crepitus are noted 4 cm proximal to the wrist, over the distal radial forearm. Which of the following is the most likely diagnosis?

(A) Carpometacarpal joint arthritis
(B) de Quervain tenosynovitis
(C) Intersection syndrome
(D) Scapholunate ligament injury
(E) Wartenberg syndrome
The correct response is Option C.

This patient has findings consistent with intersection syndrome, or tenosynovitis of the second dorsal compartment that involves the extensor carpi radialis longus and brevis tendons at their intersection near the first extensor compartment. Patients have pain and swelling approximately 4 cm proximal to the wrist, at the point where the extensor pollicis brevis and abductor pollicis longus tendons cross the common radial wrist extensors. Erythema and crepitus are also associated. Symptoms are exacerbated with prolonged wrist motion. Appropriate management includes splinting of the wrist in extension and injection of a corticosteroid. Surgical procedures, such as release of the second dorsal compartment and/or synovectomy at the intersection point, may be required in those patients whose symptoms do not improve with conservative measures.

Patients with carpometacarpal joint arthritis have pain at the base of the metacarpal of the thumb. Pain is reproduced on a carpometacarpal grind test or axial compression test.

De Quervain tenosynovitis is stenosing tenosynovitis of the first dorsal compartment; the extensor pollicis brevis and abductor pollicis longus tendons are affected. This condition is characterized by localized pain, swelling, and tenderness 1 to 2 cm proximal to the radial styloid. Affected patients have pain on ulnar deviation of the wrist with the thumb clasped in the palm (Finkelstein test).

Scapholunate ligament injuries are rare in patients who have no history of trauma. In these patients, pain is commonly elicited over the scapholunate interval. Scapholunate instability may also be present. Radiographs may show an increased scapholunate interval.

In Wartenberg syndrome, the superficial sensory branch of the radial nerve is entrapped between the brachioradialis and extensor carpi radialis longus tendons. Pain, numbness, and tingling at the dorsoradial aspect of the wrist are characteristic, and symptoms are often exacerbated when the patient wears compressive jewelry, such as a wristwatch.

References
1. Posner MA. Differential diagnosis of wrist pain: tendinitis, ganglia, and other syndromes. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw Hill, Inc; 1996;1:837-851.
2. Wolfe SW. Tenosynovitis. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:2022-2044.

Five weeks after undergoing primary repair of an injury to the flexor digitorum profundus tendon of the ring finger in zone II, a 33-year-old man suddenly loses the ability to flex the distal interphalangeal joint of the ring finger. A controlled trial of early motion was initiated following surgery.

Which of the following is the most appropriate next step in management?

(A) Continued occupational therapy
(B) Repeat operative exploration and repair
(C) Insertion of a silicone rod
(D) Tenolysis
(E) Arthrodesis

The correct response is Option B.

The most appropriate next step in management is repeat operative exploration and repair. This patient has most likely ruptured the flexor tendon. This typically occurs four to six weeks after initial repair and is most commonly caused by excessive grip force or significant devascularization of the tendon.

Further occupational therapy is not necessary in a patient who has good passive range of motion following rupture.
Staged reconstruction with insertion of a silicone rod and/or delayed tendon grafting is appropriate following tendon rupture if passive range of motion of the finger is significantly limited or there is an insufficient quantity of flexor tendon sheath.

Tenolysis is indicated in patients who have tendon adherence or scarring following tendon repair. This procedure is typically delayed for four to six months following the initial repair, and is most effect if the repair is intact and full passive range of motion is maintained.

Arthrodesis may be considered if the flexor tendons and flexor sheath cannot be repaired or reconstructed. This procedure provides stability but results in slightly flexed positioning of the finger.

References
1. Britton EN, Kleinert JM. Acute flexor tendon injury: repair and rehabilitation. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;1:1113-1132.
2. Strickland JW. Flexor tendons Ð acute injuries. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1851-1897.

A 3-year-old girl is brought by her parents for evaluation because she cannot straighten her left thumb. Her parents have observed intermittent episodes of catching or locking of the thumb since her birth. On physical examination, the thumb cannot be passively extended. A nodule is palpable over the flexor pollicis longus tendon.

Which of the following is the most appropriate management?

(A) Observation for one year
(B) Extension splinting for six months
(C) Injection of a corticosteroid into the tendon sheath
(D) Operative release of the A1 pulley
(E) Reconstruction of the extensor pollicis longus tendon
The correct response is Option D.

In this child who has a fixed flexion deformity of the thumb, most likely resulting from congenital triggering, the most appropriate management is operative release of the A1 pulley. Trigger thumb is an isolated congenital deformity that is thought to occur in 0.05% of live births; 25% to 33% of patients have bilateral findings. This condition is caused by a proliferation of synovial fluid within the tendon. Because the thumb is often minimally flexed in infants, the deformity is not typically diagnosed until age 6 months.

Studies have shown that approximately 30% of children with congenital trigger thumb will experience spontaneous resolution of the deformity by age 3 years. However, because there have been no signs of improvement of the deformity in this 3-year-old girl, simple release of the A1 pulley is indicated.

Congenital clasp thumb can produce findings similar to congenital triggering. In children with the clasp thumb deformity, there is absence of the extensor pollicis brevis and/or extensor pollicis longus tendons. This deformity is characterized by extreme flexion of the metacarpophalangeal joint and adduction of the thumb into the palm.

Conservative treatment can be ineffective in children younger than 3 years. Splinting is often impractical for compliance reasons, and injection of a corticosteroid is difficult in a 3-year-old child. Excision of a tendon nodule is recommended only to improve recurrent triggering.

References
1. Flatt AE. The Care of Congenital Hand Anomalies. 2nd ed. Saint Louis, Mo: Quality Medical Publishing, Inc; 1994:90-92.
2. Ger E, Kupcha P, Ger D. The management of trigger thumb in children. J Hand Surg. 1991;16A:944-947.

A 27-year-old man has a palpable mass on the ulnar aspect of the metacarpal head after falling on his outstretched left thumb. Physical examination shows an additional 45 degrees of laxity of the ulnar collateral ligament of the left thumb when compared with the right thumb.

Operative exploration is most likely to show interposition of which of the following structures between the ends of the collateral ligament?

(A) Abductor pollicis brevis
(B) Abductor pollicis longus
(C) Adductor pollicis
(D) Flexor pollicis brevis
(E) Opponens pollicis

The correct response is Option C.

The palpable mass on the ulnar aspect of the metacarpal head is a Stener lesion, which is formed by interposition of the fascia of the adductor pollicis between the torn ulnar collateral ligament and the metacarpophalangeal (MP) joint. The proximal stump of the ulnar collateral ligament lies superficial and proximal to the fascia of the adductor pollicis. Interposition of the adductor pollicis prevents healing of the ligament. Operative repair is indicated in patients with Stener lesions.

The abductor pollicis brevis and flexor pollicis brevis insert into the radial side of the MP joint, and the opponens pollicis inserts into the radial side of the metacarpal shaft. The abductor pollicis longus is not involved with the MP joint.

References
1. Glickel SZ, Barron OA, Eaton RG. Dislocations and ligament injuries in the digits. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:772-808.
2. Glickel SZ. Metacarpophalangeal and interphalangeal joint injuries and instabilities. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, Inc; 1996;1:1043-1067.