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Orthopaedic Surgery - Thumb Ligament Injuries


Basics

Thumb ligament injuries most commonly involve the:

Ulnar collateral ligament of the metacarpophalangeal joint.

The injury may be:

Partial

or

Complete

and frequently occurs at the ligament’s distal attachment to the:

Base of the proximal phalanx.


Mechanism

The classic mechanism is forceful:

Radial deviation

or

Abduction of the thumb MCP joint.

This places excessive tension on the:

Ulnar collateral ligament.


Radial Collateral Ligament Injury

The:

Radial collateral ligament

of the thumb MCP joint may also be injured.

This usually occurs after excessive:

Adduction

of the thumb.

RCL injuries are less common than:

UCL injuries.


Ligament Tear Versus Avulsion Fracture

The injury may consist of:

Pure ligament rupture

or

Avulsion of a small fragment of bone

from the ligament’s attachment.


Classification

Thumb collateral ligament injuries are generally classified as:

Incomplete tears

or

Complete tears

according to the integrity of the:

Ligament and its bony attachment.


Synonyms

An acute thumb MCP UCL injury is commonly called:

Skier’s thumb.

A chronic UCL injury is historically termed:

Gamekeeper’s thumb.


Skier’s Thumb

Skier’s thumb usually results from an acute:

Hyperabduction injury

such as a fall while the thumb is caught against a:

Ski pole.


Gamekeeper’s Thumb

Gamekeeper’s thumb refers to chronic attenuation or insufficiency of the:

UCL

from repetitive:

Valgus stress.


Interphalangeal Joint Injuries

Collateral ligament injuries of the thumb:

Interphalangeal joint

are less common.

The IP joint is primarily a:

Hinge joint

and injuries may include:

Collateral ligament sprain

or

Dislocation.


Trapeziometacarpal Joint Injuries

Ligament injuries of the:

Trapeziometacarpal joint

are also less common.

They are often associated with:

CMC dislocation or subluxation.


Important TMC Ligaments

TMC dislocation may injure the:

Dorsoradial ligament

and

Anterior oblique ligament.

These structures contribute substantially to:

Thumb CMC stability.


Prevention

Prevention centers on avoiding mechanisms that force the thumb into excessive:

Abduction

or

Adduction.


Sports Prevention

Athletes should avoid situations where the thumb becomes caught during:

Falls

Ball handling

or contact with:

Equipment.


Epidemiology

Thumb ligament injuries occur in:

Men and women

and can affect:

All age groups.


Risk Factors

Common risk factors include:

Skiing accidents

and sports involving:

Ball handling

or sudden:

Thumb impact.


Associated Sports

Examples include:

Baseball

Football

and

Basketball.


Etiology

The classic UCL injury is caused by forceful:

Radial deviation of the thumb.

This produces excessive tension on the ligament and may result in:

Partial tearing

Complete rupture

or

Bony avulsion.


Associated Conditions

A UCL injury may be associated with:

Avulsion fracture

or a:

Stener lesion.


Stener Lesion

A Stener lesion occurs when a completely ruptured:

Ulnar collateral ligament

retracts proximally and becomes displaced superficial to the:

Adductor aponeurosis.


Importance of a Stener Lesion

The interposed adductor aponeurosis prevents the torn ligament from returning to its normal:

Anatomic insertion.

As a result, spontaneous healing is unlikely.


Clinical Clues to a Stener Lesion

Patients may demonstrate:

Marked swelling

Ecchymosis

and sometimes a palpable:

Ulnar-sided mass

at the MCP joint.


Diagnosis

Diagnosis is based on:

History

Physical examination

and

Imaging.


Signs and Symptoms

Typical symptoms include:

Pain

Swelling

and

Bruising

along the:

Ulnar side of the thumb MCP joint.


Deformity

Some patients have visible deformity near the:

Ulnar base of the thumb.


Functional Loss

Patients frequently report difficulty with:

Pinching

Gripping

and

Opening containers.

Loss of stable pinch is especially characteristic of significant:

UCL insufficiency.


Physical Examination

Examine the thumb for:

Swelling

Ecchymosis

Tenderness

and palpable:

Abnormality.


Palpable Mass

A local ulnar-sided mass may represent:

Retracted ligament

Stener lesion

or

Avulsed bone fragment.


Stability Testing

The MCP joint should be stressed in:

Extension

and at approximately:

30° of flexion.


Testing in Extension

Valgus stress in full or near-full extension assesses both:

Accessory collateral ligament structures

and overall:

MCP stability.


Testing in Flexion

Testing at approximately:

30° of MCP flexion

better isolates the:

Proper ulnar collateral ligament.


Comparison With the Opposite Thumb

Stability should be compared with the:

Contralateral uninjured thumb.


Complete Tear

Findings suggesting a complete tear include:

Absence of a firm endpoint

or approximately:

More than 15° greater laxity than the opposite side.

Absolute angular thresholds vary because normal ligament laxity differs between:

Individuals.

The quality of the endpoint is therefore especially important.


Radiographs Before Stress Examination

Plain radiographs should be reviewed before aggressive:

Stress testing.

This is important because an associated fracture may be displaced by:

Forceful examination.


Digital Block

In acute injuries, pain and swelling may prevent reliable examination.

A:

Digital nerve block

may allow more accurate assessment of:

Ligament stability.


TMC Joint Examination

The trapeziometacarpal joint should also be examined when clinically indicated.

The examiner translates the:

First metacarpal

relative to the:

Trapezium.


TMC Instability

Pain and excessive translation suggest:

CMC ligament injury.


Imaging


Plain Radiographs

Acute thumb injuries should undergo plain radiography to assess for:

Fracture

and

Joint alignment.


Avulsion Fracture

Radiographs may demonstrate a small bony fragment at the:

Base of the proximal phalanx

corresponding to:

UCL avulsion.


Chronic Injuries

In chronic ligament insufficiency, radiographs help assess for:

Joint subluxation

and

Degenerative arthritis.


Stress Radiographs

Stress radiographs may occasionally demonstrate:

Abnormal MCP opening

although they are less commonly required when examination and advanced imaging are:

Diagnostic.


MRI

MRI provides detailed information regarding:

Ligament continuity

Retraction

Stener lesion

and associated:

Cartilage or joint damage.


Ultrasound

Ultrasound may also assess:

Ligament integrity

and can identify displacement suggestive of a:

Stener lesion.

Its accuracy depends considerably on:

Operator experience.


Pathological Findings

Pathology may demonstrate:

Attenuation

or

Complete rupture

of the UCL.


Displaced Ligament

In a Stener lesion, the torn ligament lies superficial to the:

Adductor aponeurosis

rather than adjacent to its normal:

Distal insertion.


Differential Diagnosis

Important alternatives include:

First metacarpal fracture

Proximal phalanx fracture

First CMC arthritis

and

Volar plate injury.


Treatment

Treatment depends on:

Ligament involved

Completeness of rupture

Joint stability

Fracture displacement

and whether the injury is:

Acute or chronic.


Incomplete UCL Tear

Partial tears can generally be treated:

Nonoperatively.


Acute Partial Tear

Initial treatment includes:

Rest

Elevation

Ice

Analgesia

and

Thumb-spica immobilization.


Immobilization Duration

A partial ligament tear is commonly immobilized for approximately:

4 weeks.

If an associated stable avulsion fracture is present, immobilization may continue for up to:

6 weeks.


Chronic Partial Injury

Chronic but stable symptoms may be treated with:

Thumb-spica bracing

Activity modification

and rehabilitation.

Persistent instability may require:

Elective repair or reconstruction.


Complete UCL Tear

A complete acute rupture, particularly one associated with:

Instability

or

Stener lesion

generally requires:

Surgical repair.


Avulsion Fracture

Treatment of an avulsion fracture depends on:

Fragment size

Displacement

and

Joint stability.

Options include:

Ligament repair

Fracture fixation

or selected:

Fragment excision.


Stener Lesion

A confirmed Stener lesion requires:

Operative treatment

because the interposed:

Adductor aponeurosis

prevents normal ligament healing.


Chronic Complete Tear

Delayed or chronic complete tears frequently require:

Ligament reconstruction

rather than simple:

Primary repair.


Radial Collateral Ligament Injuries

RCL injuries are managed according to similar principles.


RCL Tear Location

Unlike UCL injuries, RCL injuries more commonly occur at the:

Proximal attachment.


Stener Equivalent

A true:

Stener lesion

does not occur with RCL rupture because the same interposition mechanism is:

Absent.


TMC Joint Injury

A stable TMC ligament injury may be treated with:

Immobilization.


Unstable TMC Joint

An acutely unstable TMC injury may require:

Reduction

and temporary:

Pin fixation.


Chronic TMC Instability

Chronic instability may require:

Ligament reconstruction

such as reconstruction of the:

Anterior oblique ligament

depending on the specific pattern.


Physical Therapy

Therapy is particularly important after:

Surgery.


Rehabilitation Goals

Treatment focuses on restoring:

Range of motion

Pinch strength

Grip strength

and safe progression back to:

Activity.


Internal Brace Rehabilitation

When ligament repair is augmented with a:

Suture-tape internal brace

selected patients may begin protected motion:

Earlier

than with traditional repair alone.


Medication

Pain can generally be managed with:

Acetaminophen

NSAIDs

or other short-term:

Nonopioid analgesia.


Natural Resolution of Pain

Even with appropriate immobilization, swelling and discomfort may persist for:

Several weeks.


Surgery

Acute MCP collateral ligament injuries that require surgery are usually treated with:

Direct suture repair.


Primary Repair

A complete acute tear can often be repaired directly to the:

Proximal phalanx

using:

Suture anchors

or

Bone tunnels.


Internal Brace

A:

Suture-tape internal brace

may be added to reinforce the repair and potentially permit:

Earlier rehabilitation.


Delayed Presentation

When diagnosis is delayed for approximately:

One month or longer

fibrosis and tissue retraction may make primary repair:

Difficult or impossible.


Reconstruction

Chronic injuries may require:

Local tendon advancement

Tendon graft

or

Fascial graft reconstruction.


Late Arthritis

Pain or crepitus during grinding of the MCP joint may indicate development of:

Posttraumatic arthritis.


MCP Arthrodesis

For painful advanced MCP arthritis with chronic instability:

Arthrodesis

may provide reliable:

Pain relief and stability.


TMC Arthritis

Chronic TMC injury complicated by advanced arthritis may be treated with procedures such as:

Arthrodesis

or

Trapeziectomy-based reconstruction

depending on the patient’s:

Age

Functional requirements

and

Arthritic pattern.


Follow-Up

After ligament repair or reconstruction, the thumb is commonly immobilized for approximately:

4–6 weeks.


Removable Splinting

After the initial healing phase, patients may transition to:

Removable splinting

with guided:

Range-of-motion exercises.


Strengthening

Progressive strengthening begins after sufficient:

Ligament healing

and restoration of:

Motion.


Return to Activity

Return to sport or unrestricted use is based on restoration of:

Stability

Strength

Motion

and

Pain-free function.


Prognosis

The prognosis after appropriate acute repair is generally:

Good to excellent.


Acute Injuries

Early recognition and treatment of complete UCL rupture provide the best chance for:

Stable healing

and restoration of:

Pinch strength.


Chronic Injuries

Chronic injuries can also achieve good outcomes after:

Reconstruction

although treatment is usually more technically:

Complex.


Complications

Potential complications include:

Chronic instability

Persistent pain

Nonunion of an avulsion fragment

and

Degenerative joint disease.


Chronic Instability

Untreated complete ligament rupture may result in persistent:

MCP laxity

and weak:

Pinch function.


Avulsion Nonunion

An avulsed bone fragment may fail to unite, leading to:

Pain

or persistent:

Instability.


Posttraumatic Arthritis

Longstanding joint incongruity or instability may cause:

Degenerative arthritis.


Surgical Complications

Other potential complications include:

Stiffness

Sensory nerve irritation

Recurrent instability

and

Repair failure.


Patient Monitoring

Follow-up should be performed by the:

Orthopaedic or hand surgeon

until healing and functional recovery are:

Complete.


Follow-Up Interval

Patients may be reviewed approximately every:

4–8 weeks

during the healing period.


Monitoring Goals

Assessment should include:

Joint stability

Range of motion

Pinch strength

Grip strength

and return to:

Normal activity.


Key Principle

Thumb ligament injuries most commonly involve the ulnar collateral ligament of the MCP joint, usually after forceful:

Thumb abduction.

Acute injury is termed:

Skier’s thumb, whereas chronic UCL insufficiency is historically called:

Gamekeeper’s thumb.

A complete tear is suggested by:

Marked instability and loss of a firm endpoint, while a:

Stener lesion

occurs when the avulsed UCL becomes trapped superficial to the adductor aponeurosis and therefore cannot heal normally.

Partial stable injuries are generally treated with:

Thumb-spica immobilization, whereas complete unstable tears and Stener lesions usually require:

Surgical repair.

Early recognition is important to prevent:

Chronic instability, weak pinch, and posttraumatic arthritis.



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Orthopaedic Surgery - Thumb Arthritis


Basics

Thumb arthritis most commonly affects the:

Carpometacarpal joint of the thumb

also known as the:

Basal joint.

The disorder results primarily from progressive loss of:

Articular cartilage

at the articulation between the:

First metacarpal

and

Trapezium

together with varying degrees of:

Ligamentous insufficiency.


Clinical Presentation

Patients commonly present with:

Pain

Swelling

Stiffness

and reduced:

Thumb function.


Functional Disability

Functional limitation is often prominent because the thumb CMC joint is essential for:

Grip

Pinch

Opposition

and many:

Activities of daily living.

Patients may specifically report difficulty with:

Opening jars

Turning keys

Twisting lids

Gripping objects

or maintaining a firm:

Pinch or grasp.


Primary Osteoarthritis

The most common underlying disorder is:

Primary osteoarthritis.

The thumb CMC joint is one of the hand joints frequently affected by:

Degenerative arthritis.


Other Arthritides

The thumb may also be involved in:

Rheumatoid arthritis

Gout

and

Posttraumatic arthritis.


Anatomy and Biomechanics

The thumb CMC joint is a:

Saddle-shaped joint

that permits a large range of motion.

Its movements include:

Flexion

Extension

Abduction

Adduction

and

Opposition.


Mechanical Stress

Because the CMC joint combines:

High mobility

with substantial:

Pinch and grip forces

it is exposed to significant mechanical loading throughout:

Daily activities.


Ligamentous Support

Ligamentous structures help maintain:

Joint congruity

and

Stability.

Progressive ligamentous laxity can contribute to:

Subluxation

and abnormal loading of the:

Articular cartilage.


Epidemiology

Thumb CMC arthritis occurs most commonly in:

Middle-aged and older adults.


Age

Symptomatic disease commonly becomes apparent from approximately the:

Fifth decade of life onward.


Sex

The supplied source describes involvement of:

Men and women.

In clinical practice, radiographic and symptomatic basal-joint osteoarthritis is commonly encountered in:

Women after midlife.


Risk Factors

No single risk factor is required for the development of:

Primary osteoarthritis.

Potential contributors include:

Age-related cartilage degeneration

Joint laxity

Prior trauma

and repetitive mechanical:

Loading.


Diagnosis

The diagnosis is usually based on:

History

Physical examination

and

Plain radiographs.


Signs and Symptoms

The hallmark symptom is:

Pain at the base of the thumb.


Pain Pattern

Pain is typically aggravated by activities requiring:

Pinch

Grip

or

Twisting.

Examples include:

Opening jars

Turning doorknobs

Writing

and

Using keys.


Swelling

Patients may notice swelling or prominence around the:

Thumb CMC joint.


Stiffness

Progressive arthritis may produce:

Reduced motion

particularly during:

Opposition

and

Abduction.


Weakness

Patients frequently report reduced:

Pinch strength

and

Grip strength.


Physical Examination

Examination should include assessment of:

Thumb alignment

CMC motion

Tenderness

Stability

and

Pinch strength.


CMC Tenderness

Localized tenderness is usually present over the:

Thumb basal joint.


Grind Test

The:

CMC grind test

is commonly used.

The examiner applies axial compression through the first metacarpal while gently:

Rotating the metacarpal

against the:

Trapezium.

Reproduction of:

Pain

or palpable:

Crepitus

supports the diagnosis.


Subluxation

Advanced disease may produce:

Dorsoradial subluxation of the first metacarpal base.

This can create visible prominence at the:

CMC joint.


Thumb Deformity

Progressive CMC collapse may produce:

Adduction contracture of the first metacarpal

with compensatory:

Hyperextension of the MCP joint.

This may reduce the mechanical efficiency of:

Pinch.


Range of Motion

Assess:

Opposition

Palmar abduction

Radial abduction

and

MCP motion.


Laboratory Tests

There are no laboratory studies specific for:

Primary thumb osteoarthritis.


When Laboratory Testing Is Useful

Laboratory investigation may be appropriate when there is suspicion for:

Rheumatoid arthritis

Gout

Infection

or another systemic:

Inflammatory disorder.


Imaging


Plain Radiographs

Plain radiographs are highly useful for confirming:

Thumb CMC arthritis

and estimating its:

Severity.


Standard Findings

Typical osteoarthritic findings include:

Joint-space narrowing

Subchondral sclerosis

Osteophyte formation

and

Subluxation.


Additional Findings

More advanced disease may demonstrate:

Subchondral cysts

Trapezial remodeling

and involvement of the:

Scaphotrapeziotrapezoid joint.


Radiographic Staging

The:

Eaton-Littler classification

is commonly used to describe radiographic severity of:

Thumb CMC osteoarthritis.


Stage I

Stage I generally represents:

Early disease

with minimal structural change and possible:

Joint-space widening from synovitis or laxity.


Stage II

Stage II demonstrates:

Joint-space narrowing

with small:

Osteophytes

and early:

Subluxation.


Stage III

Stage III shows more advanced:

Joint-space loss

Larger osteophytes

and significant:

CMC degeneration.


Stage IV

Stage IV includes thumb CMC arthritis together with degenerative involvement of the:

Scaphotrapeziotrapezoid articulation.


Pathological Findings

Typical osteoarthritic changes include:

Loss and fibrillation of articular cartilage

Subchondral sclerosis

Osteophyte formation

and

Hypertrophic bone remodeling.


Ligamentous Changes

Chronic degeneration may also result in progressive:

Ligamentous attenuation

and

Joint instability.


Differential Diagnosis

Important alternative causes of pain around the thumb and radial wrist include:

de Quervain tenosynovitis

Scaphoid fracture

Scaphoid nonunion

Scapholunate advanced collapse

and other forms of:

Posttraumatic wrist arthritis.


de Quervain Tenosynovitis

de Quervain disease causes pain over the:

First dorsal extensor compartment

near the:

Radial styloid.

Pain is typically aggravated by:

Thumb motion

and

Ulnar deviation of the wrist.


Distinguishing de Quervain Disease

Tenderness is usually located over the:

Abductor pollicis longus

and

Extensor pollicis brevis tendons

rather than directly over the:

CMC joint.


Scaphoid Fracture

Acute or chronic scaphoid fracture may cause:

Radial-sided wrist pain

and should be considered when the history includes:

Trauma

or there is:

Anatomic snuffbox tenderness.


Posttraumatic Arthritis

Chronic carpal instability or scaphoid nonunion may cause degenerative patterns such as:

SLAC wrist

or

SNAC wrist.

These may mimic or coexist with:

Thumb-base arthritis.


Treatment

Treatment depends on:

Pain severity

Functional impairment

Radiographic stage

and the patient’s:

Activity demands.


General Measures

Initial management is generally:

Nonoperative.


Activity Modification

Patients should reduce or modify activities that increase:

Thumb-base loading.

Examples include repetitive:

Pinching

Twisting

and

Heavy gripping.


Adaptive Equipment

Larger handles, jar-opening devices, ergonomic tools, and other adaptations may decrease:

Thumb CMC stress.


Splinting

A:

Thumb CMC or thumb-spica splint

can reduce painful movement and provide:

Joint support.


Effectiveness of Splinting

Splinting is often particularly useful for patients wishing to delay or avoid:

Surgery.

It may be worn during:

Provocative activities

or intermittently according to:

Symptoms.


Medication


NSAIDs

NSAIDs may provide both:

Analgesic

and

Anti-inflammatory effects.

They should be used according to the patient’s:

Gastrointestinal

Renal

and

Cardiovascular risk.


Nonnarcotic Analgesics

Acetaminophen

or other nonopioid pain medication may be appropriate for symptomatic:

Pain control.


Intra-Articular Corticosteroid Injection

Injection of:

Corticosteroid

into the CMC joint may provide:

Temporary symptomatic relief.


Role of Injection

Injection is most useful as a:

Symptom-control measure

rather than a treatment that reverses:

Structural arthritis.

Duration of benefit varies considerably between:

Patients.


Hand Therapy

A therapist experienced in hand disorders can assist with:

Splint fitting

Joint-protection techniques

Activity modification

and

Thenar strengthening.


Surgical Preparation

Hand therapy can also improve postoperative recovery by educating patients regarding:

Splinting

Range of motion

and

Rehabilitation expectations.


Surgery

Surgery is considered when symptoms remain:

Painful and functionally limiting

despite appropriate:

Nonoperative treatment.


Trapeziectomy

One of the most common operative procedures is:

Trapeziectomy

in which the arthritic:

Trapezium

is removed.


Ligament Reconstruction and Tendon Interposition

Trapeziectomy may be combined with:

Ligament reconstruction

and

Tendon interposition.

This is often referred to as:

LRTI.


Goal of Tendon Interposition

A portion of tendon may be used to:

Stabilize the first metacarpal

and occupy the space left after:

Trapeziectomy.


Simple Trapeziectomy

Simple trapeziectomy without formal tendon reconstruction is also an effective option in many:

Patients.


Suspensionplasty

Alternative techniques use:

Tendon

or

Suture-based suspension

to support the first metacarpal after:

Trapezial excision.


Arthrodesis

CMC arthrodesis provides very reliable:

Pain relief

and strong:

Pinch strength.

However, fusion permanently eliminates motion at the:

CMC joint.


Candidates for Arthrodesis

Fusion may be considered in selected:

Younger

High-demand

or heavy-labor patients where stability and strength are prioritized over:

Motion.


Arthroplasty

Implant arthroplasty has also been used, but implant-related complications have limited the routine use of some:

Prosthetic designs.


Silicone Arthroplasty

Traditional silicone implant arthroplasty has largely fallen out of favor because of complications including:

Implant wear

Silicone synovitis

and

Instability.


MCP Hyperextension

If significant compensatory:

MCP hyperextension

is present, an additional procedure may be required to restore:

Thumb-column stability.


Follow-Up

Patients undergoing nonoperative treatment should be monitored for:

Pain

Functional limitation

and progression of:

Deformity.


Postoperative Follow-Up

Following reconstructive surgery, patients usually require:

Immobilization

followed by structured:

Hand therapy.


Rehabilitation

Rehabilitation focuses on restoring:

Thumb motion

Pinch strength

Grip strength

and functional use of the:

Hand.


Prognosis

The overall prognosis is generally:

Good to excellent.


Pain Relief

Most appropriately selected patients experience substantial:

Pain reduction

and improved:

Quality of life.


Arthrodesis Prognosis

Arthrodesis provides reliable:

Pain relief

but at the expense of permanent:

Loss of CMC motion.


Trapeziectomy-Based Procedures

Trapeziectomy with or without ligament reconstruction or suspension remains among the most commonly used and effective surgical strategies for:

Symptomatic CMC arthritis.


Recovery Time

Recovery after reconstructive surgery can be:

Gradual

and meaningful improvement in strength may continue for:

Several months.


Complications

Potential complications include:

Persistent pain

Sensory disturbance

Residual subluxation

Weakness

and

Stiffness.


Radial Sensory Nerve Injury

The superficial radial sensory nerve is at risk during surgical exposure.

Injury may cause:

Numbness

Paresthesia

or

Dysesthesia.


Persistent Subluxation

Some degree of:

First-metacarpal subsidence or subluxation

may remain after reconstructive:

Arthroplasty.

Radiographic subsidence does not always correlate with:

Clinical outcome.


Chronic Pain

A minority of patients may continue to experience:

Persistent thumb-base pain

despite technically successful:

Surgery.


Other Surgical Complications

Additional possible complications include:

Infection

Complex regional pain syndrome

Tendon irritation

and failure of:

Fusion

when arthrodesis is performed.


Patient Monitoring

Patients should be followed by both the:

Surgeon

and, when appropriate,

Hand therapist.


Monitoring Goals

Follow-up should assess:

Pain relief

Thumb alignment

CMC stability

Range of motion

Pinch strength

and return to:

Daily activities.


Key Principle

Thumb arthritis most commonly involves the carpometacarpal joint between the first metacarpal and trapezium, where degeneration of articular cartilage and supporting ligaments produces:

Pain, weakness, stiffness, and difficulty with pinch and grip.

Diagnosis is usually established by:

Clinical examination and plain radiographs, which may show joint-space loss, subchondral sclerosis, osteophytes, and subluxation.

Initial treatment includes:

Activity modification, thumb-spica splinting, nonopioid analgesia, hand therapy, and selected intra-articular corticosteroid injection.

For persistent disabling symptoms, effective surgical options include:

Trapeziectomy with or without ligament reconstruction or suspensionplasty, arthrodesis, and selected arthroplasty procedures.

Most appropriately treated patients obtain:

Meaningful pain relief and improved hand function.



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Orthopaedic Surgery - Thoracolumbar Spine Fracture and Dislocation


Basics

Thoracolumbar fractures are among the most common:

Spinal fractures.

The region most frequently injured is the:

Thoracolumbar junction

particularly:

T11–L1.

This area is vulnerable because it represents a transition between the relatively rigid:

Thoracic spine

and the more mobile:

Lumbar spine.


Associated Spinal Injuries

Additional spinal injuries may occur in up to approximately:

15% of patients.

These may be:

Contiguous

or

Noncontiguous.

For this reason, the:

Entire spinal column

should be considered during trauma assessment.


Associated Abdominal Injuries

Abdominal injuries occur in approximately:

20% of patients

with significant thoracolumbar trauma.

Potential associated injuries include:

Splenic rupture

Liver laceration

Renal injury

and

Bowel injury.


Denis Three-Column Classification

The classic:

Denis three-column system

divides the thoracolumbar spine into:

Anterior

Middle

and

Posterior columns.

Although modern treatment also relies on newer concepts such as mechanical stability and posterior ligamentous complex integrity, this classification remains useful for understanding:

Fracture morphology.


Anterior Column

The anterior column consists of approximately the:

Anterior two-thirds of the vertebral body and intervertebral disc

together with the associated anterior supporting structures.


Middle Column

The middle column includes the:

Posterior one-third of the vertebral body and disc

and the:

Posterior longitudinal ligament.

Disruption of the middle column historically has been considered an important marker of:

Potential instability.


Posterior Column

The posterior column includes the:

Pedicles

Facet joints

Laminae

Transverse processes

and

Spinous processes

together with the posterior ligamentous structures.


Minor Injuries

Minor thoracolumbar injuries include isolated fractures involving structures such as:

Spinous processes

Transverse processes

Pars interarticularis

and

Facets.

These injuries may still be clinically important depending on their:

Mechanism

and associated injuries.


Major Injuries

Major thoracolumbar injuries include:

Compression fractures

Burst fractures

Flexion-distraction injuries

Fracture-dislocations

and

Distraction-extension injuries.


Epidemiology

High-energy thoracolumbar trauma occurs most frequently in:

Young adults

particularly:

Males between approximately 15 and 30 years of age.


Older Adults

Elderly patients with:

Osteopenia

or

Osteoporosis

may sustain vertebral fractures after relatively:

Low-energy trauma.


Risk Factors

Important risk factors include:

Motor vehicle collisions

Falls from height

High-energy trauma

and

Osteoporotic bone.


Associated Conditions

Thoracolumbar fractures may be accompanied by:

Neurologic injury

Spinal shock

Other spinal fractures

and significant:

Abdominal trauma.


Spinal Shock

Following major spinal cord injury, patients may temporarily develop:

Flaccid paralysis

Loss of reflexes

and reduced:

Autonomic function

below the level of injury.

This transient state is known as:

Spinal shock.


Diagnosis

Diagnosis requires careful assessment of:

Mechanism of injury

Spinal tenderness

Neurologic status

and

Imaging.


History

For high-energy trauma, information should be obtained from:

The patient

and

Prehospital personnel

when available.


Mechanism of Injury

Important mechanisms include:

Motor vehicle collision

Fall from height

Crush injury

and

Direct high-energy trauma.


Relevant Medical History

Ask about conditions that may alter spinal biomechanics or bone quality, including:

Ankylosing spondylitis

Osteoporosis

Previous spinal surgery

Diabetes mellitus

and known:

Malignancy.


Physical Examination

Repeated neurologic examination is essential.

Any deterioration may provide the earliest sign of:

Progressive neural compromise

or instability requiring:

Urgent intervention.


Documentation

The initial examination should be documented carefully and compared with:

Prehospital findings

and subsequent:

Serial examinations.


Inspection

Inspect the back and trunk for:

Ecchymosis

Seat-belt marks

Visible deformity

Step-off

or evidence of:

Open injury.


Palpation

Palpate the:

Entire spinal column

for:

Tenderness

Gap

Step-off

or deformity.


Motor Examination

Motor power should be graded using the:

Medical Research Council 0–5 scale.


Grade 0

No visible or palpable muscle contraction.


Grade 1

Flicker or trace contraction without joint movement.


Grade 2

Full joint motion with gravity eliminated.


Grade 3

Full joint motion against gravity.


Grade 4

Movement against gravity and some external resistance.


Grade 5

Normal strength against full resistance.


Sensory Examination

A sensory level should be documented using reproducible:

Dermatomal landmarks.


Thoracic Landmarks

Important landmarks include:

T4 – nipple line

T7 – xiphoid region

T10 – umbilicus

and

T12 – inguinal region.


Lumbar and Sacral Landmarks

Additional landmarks include:

L1 – proximal anterior thigh

L2 – middle anterior thigh

L3 – region above the patella

L4 – medial malleolus

L5 – dorsum of the foot, classically near the third toe

and

S1 – lateral foot or small-toe region.


Reflexes

Important lower-extremity reflexes include:

L4 – patellar reflex

and

S1 – Achilles reflex.

There is no routinely useful isolated:

L5 deep-tendon reflex.


Sacral Examination

When neurologic injury is suspected, evaluate sacral function, including:

Perianal sensation

Voluntary anal contraction

and relevant:

Sacral reflexes.


Rectal Examination

Assessment may include:

Anal tone

Voluntary contraction

and

Perianal light touch or pinprick sensation

in approximately the:

S2–S5 distribution.


Bulbocavernosus Reflex

The:

Bulbocavernosus reflex

may help assess sacral reflex activity and can be useful during evaluation of:

Spinal shock.


Anal Wink

The:

Anal wink reflex

may also provide information about:

Sacral neurologic integrity.


Imaging


Initial Trauma Imaging

In modern trauma care, imaging selection depends on:

Mechanism

Clinical examination

and trauma-system protocols.

CT is frequently used as the primary imaging modality in significant:

Thoracolumbar trauma.


Plain Radiographs

AP and lateral spinal radiographs may demonstrate:

Compression

Loss of vertebral height

Kyphosis

Translation

or

Fracture-dislocation.

They may still be useful in selected:

Lower-energy injuries.


CT

CT provides excellent visualization of:

Fracture morphology

Canal compromise

Posterior element injury

and

Bony retropulsion.

It is also extremely valuable for:

Preoperative planning.


Entire-Spine Assessment

Because noncontiguous fractures can occur, imaging of the entire spine should be considered in patients with:

Major trauma

or one confirmed:

Spinal fracture.


MRI

MRI is particularly useful when there is concern for:

Spinal cord injury

Disc herniation

Epidural hematoma

or

Posterior ligamentous complex injury.

These soft-tissue abnormalities may not be adequately demonstrated by:

CT.


Differential Diagnosis

Not every vertebral deformity represents an:

Acute fracture.


Developmental Wedging

Conditions such as:

Scheuermann kyphosis

or congenital:

Vertebral wedging

may mimic:

Compression fracture.


Osteoporotic and Pathologic Fracture

Patients older than approximately:

50 years

who sustain fractures after relatively minor trauma should be evaluated for:

Osteoporosis.

A:

Pathologic fracture

from malignancy or other bone disease should also be considered when clinically appropriate.


Treatment

Treatment depends on:

Fracture morphology

Mechanical stability

Neurologic status

Posterior ligamentous complex integrity

and overall:

Patient condition.


Initial Stabilization

Patients with suspected unstable spinal injury should be handled with:

Spinal precautions

until the injury has been adequately:

Evaluated and stabilized.


Stable Fractures

Stable injuries may be treated with:

Early mobilization

with or without a:

Thoracolumbosacral orthosis, or TLSO.


Brace Selection

A TLSO may be modified depending on the:

Fracture level

and specific:

Biomechanical needs.


Unstable Fractures

Patients awaiting operative stabilization may require:

Restricted mobilization

until definitive fixation is performed.


Compression Fractures

Simple compression fractures generally involve primarily the:

Anterior column.


Mild Compression Fractures

Neurologically intact patients with mild stable fractures may be treated with:

Analgesia

Early mobilization

and often:

No brace.


TLSO for Compression Fracture

A TLSO may be used when it improves:

Comfort

or provides additional:

External support.


Osteoporotic Compression Fractures

Management should include evaluation and treatment of the underlying:

Osteoporosis

to reduce the risk of:

Future fractures.


Vertebral Augmentation

Procedures such as:

Kyphoplasty

or

Vertebroplasty

may be considered in carefully selected patients with painful:

Osteoporotic

or

Osteolytic vertebral compression fractures.

They are not required for most uncomplicated:

Compression fractures.


Burst Fractures

Burst fractures result from:

Axial compression

and commonly involve the:

Anterior and middle columns.


Retropulsion

Fragments of the posterior vertebral body may be driven into the:

Spinal canal.

The presence of canal compromise alone does not automatically mandate:

Surgery.


Nonoperative Burst-Fracture Treatment

Neurologically intact patients with stable alignment may be treated with:

Early mobilization

with or without a:

TLSO.


Surgical Considerations for Burst Fractures

Surgery is more strongly considered when there is:

Neurologic injury

Progressive deformity

Mechanical instability

or major disruption of the:

Posterior ligamentous complex.


Historical Radiographic Thresholds

Historical factors associated with operative treatment include:

Kyphosis greater than approximately 20°

Facet subluxation

Increased interspinous distance

More than 50% loss of vertebral body height

and

More than 50% canal compromise.

These thresholds should not be interpreted in isolation.

The overall:

Clinical and mechanical context

is more important than any single measurement.


Flexion-Distraction Injury

Flexion-distraction injuries are often called:

Chance fractures

or

Seat-belt injuries.


Mechanism

These injuries involve distraction of the:

Posterior spinal structures

with compression or fracture of the:

Anterior column.


Ligamentous Injury

When the injury is primarily ligamentous, healing may be less reliable and the injury is generally:

Unstable.


Abdominal Injury Association

Flexion-distraction injuries have a strong association with:

Intra-abdominal trauma

particularly:

Bowel injury.

A careful abdominal assessment is therefore essential.


Nonoperative Management

Selected purely bony Chance fractures in neurologically intact patients may occasionally be treated:

Nonoperatively.

However, injuries with substantial:

Ligamentous disruption

more commonly require:

Surgical stabilization.


Fracture-Dislocation

Fracture-dislocations may demonstrate:

Facet fracture-dislocation

Rotation

and

Translation.

These injuries are generally:

Highly unstable.


Neurologic Risk

Because of major displacement, fracture-dislocations carry a high risk of:

Spinal cord

or

Cauda equina injury.


Treatment of Fracture-Dislocation

Nonoperative treatment is rarely appropriate.

Surgery usually begins with:

Reduction

and

Posterior stabilization.


Distraction-Extension Injury

Distraction-extension injuries are:

Uncommon

and often occur in patients with an unusually rigid spine, such as those with:

Ankylosing spondylitis

Diffuse idiopathic skeletal hyperostosis

or other disorders affecting:

Spinal biomechanics.


Stability

These injuries are typically:

Highly unstable

and usually require:

Operative fixation.


Surgical Strategy

Treatment commonly involves:

Posterior instrumentation and fusion

with additional anterior reconstruction when required by:

Fracture morphology.


Activity

Patients treated with stable fixation or a suitable brace may advance toward:

Progressive mobilization and weight bearing

as allowed by:

Fracture stability

and

Neurologic status.


Neurologic Injury

Patients with neurologic deficits require individualized:

Rehabilitation

based on the level and completeness of:

Spinal cord or cauda equina injury.


Nursing Care

Serial assessment should include:

Vital signs

and repeated:

Neurologic examinations.


Change in Neurologic Status

Any deterioration in:

Strength

Sensation

or

Sacral function

requires prompt:

Reassessment.


Counseling

Patients with spinal cord injury may require:

Psychological support

and counseling regarding:

Mobility

Employment

Independence

and long-term:

Lifestyle adaptation.


Physical Therapy

Physical therapy plays an essential role in:

Mobilization

and

Functional recovery.


Benefits of Early Rehabilitation

Appropriate rehabilitation may reduce complications such as:

Pressure injury

Pneumonia

Venous thromboembolism

Contractures

and

Disuse osteoporosis.


Occupational Therapy

Occupational therapy is particularly important for patients with neurologic injury who require adaptation for:

Transfers

Self-care

Mobility

and

Activities of daily living.


Medication

Pain control should be individualized.

There is generally no role for routine:

Long-term maintenance opioid therapy.


First-Line Analgesia

Options may include:

Acetaminophen

and

NSAIDs

when medically appropriate.


NSAIDs

Anti-inflammatory medications should be used cautiously in patients with:

Renal disease

Gastrointestinal risk

or other relevant:

Contraindications.


Opioids

Short-term opioid therapy may be appropriate for:

Severe acute fracture pain

particularly during the early:

Post-traumatic period.


Radiotherapy

Radiotherapy may have a role in selected patients with:

Radiosensitive tumors

causing pathological thoracolumbar:

Fractures.

Its purpose is primarily to reduce:

Tumor burden

and improve:

Local disease control.


Surgery

The goals of surgery are to:

Restore alignment

Stabilize the spinal column

and, when necessary,

Decompress neural structures.


Surgical Approach

The optimal approach depends on:

Fracture morphology

Neurologic compression

Bone quality

and surgeon:

Experience.


Posterior Instrumentation

Posterior instrumentation is commonly favored because it provides effective:

Reduction

Fixation

and

Correction of alignment

without the additional morbidity of a major:

Anterior approach.


Neural Decompression

Decompression is indicated when there is clinically significant compression of the:

Spinal cord

Conus medullaris

or

Cauda equina

and when decompression is expected to improve:

Neurologic outcome or mechanical stability.


Anterior Approach

An anterior approach may be useful when substantial:

Vertebral body destruction

or

Anterior canal compression

requires direct:

Decompression and reconstruction.


Retropulsed Fragments

Anterior surgery may be particularly useful for selected cases involving significant:

Retropulsed vertebral-body fragments

compressing the:

Anterior spinal canal.


Fusion

Fusion may accompany fixation when:

Instability

Major ligamentous disruption

or extensive bony injury prevents reliable healing without:

Arthrodesis.


Follow-Up

Patients with major injuries often benefit from coordinated follow-up involving:

Spine surgery

Rehabilitation medicine

Physical therapy

and

Occupational therapy.


Rehabilitation Facility

Patients with severe neurologic injury may recover best initially in a specialized:

Inpatient rehabilitation facility.


Pain Specialist Referral

Persistent chronic pain may warrant referral to:

Pain medicine.


Rehabilitation Medicine

Patients with spinal cord or cauda equina injury should be followed by:

Physical medicine and rehabilitation specialists.


Neurology Consultation

Neurologic consultation may be useful when the pattern of deficit does not correlate with the identified:

Spinal injury.


Prognosis

Outcome depends strongly on:

Fracture severity

and particularly on:

Neurologic status.


Neurologically Intact Patients

Patients with stable low-energy injuries and preserved neurologic function usually have an:

Excellent prognosis.


Neurologic Injury

Patients with significant neurologic deficits may experience long-term effects on:

Mobility

Bladder and bowel function

Employment

and

Independence.


Complications

Potential complications include:

Infection

Neurologic deterioration

Pseudarthrosis

Spinal deformity

Junctional degeneration

Spinal stenosis

Chronic pain

and

Disability.


Brace-Related Complications

TLSO braces can cause:

Skin irritation

Pressure injury

and discomfort over:

Bony prominences.

Regular skin checks are important.


Pseudarthrosis

Failure of an intended fusion to heal may cause:

Persistent pain

Implant failure

or progressive:

Deformity.


Junctional Degeneration

Long spinal fusion constructs may increase mechanical stress at adjacent levels, contributing to:

Junctional degeneration

or

Stenosis.


Chronic Pain

Persistent pain may arise from:

Residual deformity

Neurologic injury

Degenerative change

or

Postoperative complications.


Patient Monitoring

Patients should be monitored for:

Pain resolution

Neurologic recovery

Maintenance of alignment

and

Fracture healing.


Fusion Monitoring

If arthrodesis has been performed, follow-up should also evaluate for:

Solid fusion

and

Implant stability.


Red-Flag Findings

Urgent reassessment is required for:

New or progressive weakness

New sensory loss

Loss of bowel or bladder control

Increasing saddle anesthesia

or

Worsening spinal deformity.


Key Principle

Thoracolumbar spine fractures most commonly involve the:

T11–L1 junction, where the rigid thoracic spine transitions to the more mobile lumbar spine.

Evaluation must include careful assessment for:

Noncontiguous spinal injury, neurologic compromise, and associated abdominal trauma.

CT is the principal imaging study for defining:

Fracture morphology, while MRI is especially useful for evaluating:

Spinal cord, disc, epidural, and posterior ligamentous complex injury.

Stable fractures may often be treated with:

Early mobilization with or without a TLSO, whereas unstable injuries such as:

Fracture-dislocations, major ligamentous flexion-distraction injuries, and distraction-extension injuries

usually require:

Operative stabilization.

The major goals of treatment are to preserve or restore:

Neurologic function, spinal alignment, mechanical stability, and early safe mobilization.



Image description
Published on

Orthopaedic Surgery - Thoracolumbar Spine Fracture and Dislocation


⸻


Basics


Thoracolumbar fractures are among the most common:


Spinal fractures.


The region most frequently injured is the:


Thoracolumbar junction


particularly:


T11–L1.


This area is vulnerable because it represents a transition between the relatively rigid:


Thoracic spine


and the more mobile:


Lumbar spine.


⸻


Associated Spinal Injuries


Additional spinal injuries may occur in up to approximately:


15% of patients.


These may be:


Contiguous


or


Noncontiguous.


For this reason, the:


Entire spinal column


should be considered during trauma assessment.


⸻


Associated Abdominal Injuries


Abdominal injuries occur in approximately:


20% of patients


with significant thoracolumbar trauma.


Potential associated injuries include:


Splenic rupture


Liver laceration


Renal injury


and


Bowel injury.


⸻


Denis Three-Column Classification


The classic:


Denis three-column system


divides the thoracolumbar spine into:


Anterior


Middle


and


Posterior columns.


Although modern treatment also relies on newer concepts such as mechanical stability and posterior ligamentous complex integrity, this classification remains useful for understanding:


Fracture morphology.


⸻


Anterior Column


The anterior column consists of approximately the:


Anterior two-thirds of the vertebral body and intervertebral disc


together with the associated anterior supporting structures.


⸻


Middle Column


The middle column includes the:


Posterior one-third of the vertebral body and disc


and the:


Posterior longitudinal ligament.


Disruption of the middle column historically has been considered an important marker of:


Potential instability.


⸻


Posterior Column


The posterior column includes the:


Pedicles


Facet joints


Laminae


Transverse processes


and


Spinous processes


together with the posterior ligamentous structures.


⸻


Minor Injuries


Minor thoracolumbar injuries include isolated fractures involving structures such as:


Spinous processes


Transverse processes


Pars interarticularis


and


Facets.


These injuries may still be clinically important depending on their:


Mechanism


and associated injuries.


⸻


Major Injuries


Major thoracolumbar injuries include:


Compression fractures


Burst fractures


Flexion-distraction injuries


Fracture-dislocations


and


Distraction-extension injuries.


⸻


Epidemiology


High-energy thoracolumbar trauma occurs most frequently in:


Young adults


particularly:


Males between approximately 15 and 30 years of age.


⸻


Older Adults


Elderly patients with:


Osteopenia


or


Osteoporosis


may sustain vertebral fractures after relatively:


Low-energy trauma.


⸻


Risk Factors


Important risk factors include:


Motor vehicle collisions


Falls from height


High-energy trauma


and


Osteoporotic bone.


⸻


Associated Conditions


Thoracolumbar fractures may be accompanied by:


Neurologic injury


Spinal shock


Other spinal fractures


and significant:


Abdominal trauma.


⸻


Spinal Shock


Following major spinal cord injury, patients may temporarily develop:


Flaccid paralysis


Loss of reflexes


and reduced:


Autonomic function


below the level of injury.


This transient state is known as:


Spinal shock.


⸻


Diagnosis


Diagnosis requires careful assessment of:


Mechanism of injury


Spinal tenderness


Neurologic status


and


Imaging.


⸻


History


For high-energy trauma, information should be obtained from:


The patient


and


Prehospital personnel


when available.


⸻


Mechanism of Injury


Important mechanisms include:


Motor vehicle collision


Fall from height


Crush injury


and


Direct high-energy trauma.


⸻


Relevant Medical History


Ask about conditions that may alter spinal biomechanics or bone quality, including:


Ankylosing spondylitis


Osteoporosis


Previous spinal surgery


Diabetes mellitus


and known:


Malignancy.


⸻


Physical Examination


Repeated neurologic examination is essential.


Any deterioration may provide the earliest sign of:


Progressive neural compromise


or instability requiring:


Urgent intervention.


⸻


Documentation


The initial examination should be documented carefully and compared with:


Prehospital findings


and subsequent:


Serial examinations.


⸻


Inspection


Inspect the back and trunk for:


Ecchymosis


Seat-belt marks


Visible deformity


Step-off


or evidence of:


Open injury.


⸻


Palpation


Palpate the:


Entire spinal column


for:


Tenderness


Gap


Step-off


or deformity.


⸻


Motor Examination


Motor power should be graded using the:


Medical Research Council 0–5 scale.


⸻


Grade 0


No visible or palpable muscle contraction.


⸻


Grade 1


Flicker or trace contraction without joint movement.


⸻


Grade 2


Full joint motion with gravity eliminated.


⸻


Grade 3


Full joint motion against gravity.


⸻


Grade 4


Movement against gravity and some external resistance.


⸻


Grade 5


Normal strength against full resistance.


⸻


Sensory Examination


A sensory level should be documented using reproducible:


Dermatomal landmarks.


⸻


Thoracic Landmarks


Important landmarks include:


T4 – nipple line


T7 – xiphoid region


T10 – umbilicus


and


T12 – inguinal region.


⸻


Lumbar and Sacral Landmarks


Additional landmarks include:


L1 – proximal anterior thigh


L2 – middle anterior thigh


L3 – region above the patella


L4 – medial malleolus


L5 – dorsum of the foot, classically near the third toe


and


S1 – lateral foot or small-toe region.


⸻


Reflexes


Important lower-extremity reflexes include:


L4 – patellar reflex


and


S1 – Achilles reflex.


There is no routinely useful isolated:


L5 deep-tendon reflex.


⸻


Sacral Examination


When neurologic injury is suspected, evaluate sacral function, including:


Perianal sensation


Voluntary anal contraction


and relevant:


Sacral reflexes.


⸻


Rectal Examination


Assessment may include:


Anal tone


Voluntary contraction


and


Perianal light touch or pinprick sensation


in approximately the:


S2–S5 distribution.


⸻


Bulbocavernosus Reflex


The:


Bulbocavernosus reflex


may help assess sacral reflex activity and can be useful during evaluation of:


Spinal shock.


⸻


Anal Wink


The:


Anal wink reflex


may also provide information about:


Sacral neurologic integrity.


⸻


Imaging


⸻


Initial Trauma Imaging


In modern trauma care, imaging selection depends on:


Mechanism


Clinical examination


and trauma-system protocols.


CT is frequently used as the primary imaging modality in significant:


Thoracolumbar trauma.


⸻


Plain Radiographs


AP and lateral spinal radiographs may demonstrate:


Compression


Loss of vertebral height


Kyphosis


Translation


or


Fracture-dislocation.


They may still be useful in selected:


Lower-energy injuries.


⸻


CT


CT provides excellent visualization of:


Fracture morphology


Canal compromise


Posterior element injury


and


Bony retropulsion.


It is also extremely valuable for:


Preoperative planning.


⸻


Entire-Spine Assessment


Because noncontiguous fractures can occur, imaging of the entire spine should be considered in patients with:


Major trauma


or one confirmed:


Spinal fracture.


⸻


MRI


MRI is particularly useful when there is concern for:


Spinal cord injury


Disc herniation


Epidural hematoma


or


Posterior ligamentous complex injury.


These soft-tissue abnormalities may not be adequately demonstrated by:


CT.


⸻


Differential Diagnosis


Not every vertebral deformity represents an:


Acute fracture.


⸻


Developmental Wedging


Conditions such as:


Scheuermann kyphosis


or congenital:


Vertebral wedging


may mimic:


Compression fracture.


⸻


Osteoporotic and Pathologic Fracture


Patients older than approximately:


50 years


who sustain fractures after relatively minor trauma should be evaluated for:


Osteoporosis.


A:


Pathologic fracture


from malignancy or other bone disease should also be considered when clinically appropriate.


⸻


Treatment


Treatment depends on:


Fracture morphology


Mechanical stability


Neurologic status


Posterior ligamentous complex integrity


and overall:


Patient condition.


⸻


Initial Stabilization


Patients with suspected unstable spinal injury should be handled with:


Spinal precautions


until the injury has been adequately:


Evaluated and stabilized.


⸻


Stable Fractures


Stable injuries may be treated with:


Early mobilization


with or without a:


Thoracolumbosacral orthosis, or TLSO.


⸻


Brace Selection


A TLSO may be modified depending on the:


Fracture level


and specific:


Biomechanical needs.


⸻


Unstable Fractures


Patients awaiting operative stabilization may require:


Restricted mobilization


until definitive fixation is performed.


⸻


Compression Fractures


Simple compression fractures generally involve primarily the:


Anterior column.


⸻


Mild Compression Fractures


Neurologically intact patients with mild stable fractures may be treated with:


Analgesia


Early mobilization


and often:


No brace.


⸻


TLSO for Compression Fracture


A TLSO may be used when it improves:


Comfort


or provides additional:


External support.


⸻


Osteoporotic Compression Fractures


Management should include evaluation and treatment of the underlying:


Osteoporosis


to reduce the risk of:


Future fractures.


⸻


Vertebral Augmentation


Procedures such as:


Kyphoplasty


or


Vertebroplasty


may be considered in carefully selected patients with painful:


Osteoporotic


or


Osteolytic vertebral compression fractures.


They are not required for most uncomplicated:


Compression fractures.


⸻


Burst Fractures


Burst fractures result from:


Axial compression


and commonly involve the:


Anterior and middle columns.


⸻


Retropulsion


Fragments of the posterior vertebral body may be driven into the:


Spinal canal.


The presence of canal compromise alone does not automatically mandate:


Surgery.


⸻


Nonoperative Burst-Fracture Treatment


Neurologically intact patients with stable alignment may be treated with:


Early mobilization


with or without a:


TLSO.


⸻


Surgical Considerations for Burst Fractures


Surgery is more strongly considered when there is:


Neurologic injury


Progressive deformity


Mechanical instability


or major disruption of the:


Posterior ligamentous complex.


⸻


Historical Radiographic Thresholds


Historical factors associated with operative treatment include:


Kyphosis greater than approximately 20°


Facet subluxation


Increased interspinous distance


More than 50% loss of vertebral body height


and


More than 50% canal compromise.


These thresholds should not be interpreted in isolation.


The overall:


Clinical and mechanical context


is more important than any single measurement.


⸻


Flexion-Distraction Injury


Flexion-distraction injuries are often called:


Chance fractures


or


Seat-belt injuries.


⸻


Mechanism


These injuries involve distraction of the:


Posterior spinal structures


with compression or fracture of the:


Anterior column.


⸻


Ligamentous Injury


When the injury is primarily ligamentous, healing may be less reliable and the injury is generally:


Unstable.


⸻


Abdominal Injury Association


Flexion-distraction injuries have a strong association with:


Intra-abdominal trauma


particularly:


Bowel injury.


A careful abdominal assessment is therefore essential.


⸻


Nonoperative Management


Selected purely bony Chance fractures in neurologically intact patients may occasionally be treated:


Nonoperatively.


However, injuries with substantial:


Ligamentous disruption


more commonly require:


Surgical stabilization.


⸻


Fracture-Dislocation


Fracture-dislocations may demonstrate:


Facet fracture-dislocation


Rotation


and


Translation.


These injuries are generally:


Highly unstable.


⸻


Neurologic Risk


Because of major displacement, fracture-dislocations carry a high risk of:


Spinal cord


or


Cauda equina injury.


⸻


Treatment of Fracture-Dislocation


Nonoperative treatment is rarely appropriate.


Surgery usually begins with:


Reduction


and


Posterior stabilization.


⸻


Distraction-Extension Injury


Distraction-extension injuries are:


Uncommon


and often occur in patients with an unusually rigid spine, such as those with:


Ankylosing spondylitis


Diffuse idiopathic skeletal hyperostosis


or other disorders affecting:


Spinal biomechanics.


⸻


Stability


These injuries are typically:


Highly unstable


and usually require:


Operative fixation.


⸻


Surgical Strategy


Treatment commonly involves:


Posterior instrumentation and fusion


with additional anterior reconstruction when required by:


Fracture morphology.


⸻


Activity


Patients treated with stable fixation or a suitable brace may advance toward:


Progressive mobilization and weight bearing


as allowed by:


Fracture stability


and


Neurologic status.


⸻


Neurologic Injury


Patients with neurologic deficits require individualized:


Rehabilitation


based on the level and completeness of:


Spinal cord or cauda equina injury.


⸻


Nursing Care


Serial assessment should include:


Vital signs


and repeated:


Neurologic examinations.


⸻


Change in Neurologic Status


Any deterioration in:


Strength


Sensation


or


Sacral function


requires prompt:


Reassessment.


⸻


Counseling


Patients with spinal cord injury may require:


Psychological support


and counseling regarding:


Mobility


Employment


Independence


and long-term:


Lifestyle adaptation.


⸻


Physical Therapy


Physical therapy plays an essential role in:


Mobilization


and


Functional recovery.


⸻


Benefits of Early Rehabilitation


Appropriate rehabilitation may reduce complications such as:


Pressure injury


Pneumonia


Venous thromboembolism


Contractures


and


Disuse osteoporosis.


⸻


Occupational Therapy


Occupational therapy is particularly important for patients with neurologic injury who require adaptation for:


Transfers


Self-care


Mobility


and


Activities of daily living.


⸻


Medication


Pain control should be individualized.


There is generally no role for routine:


Long-term maintenance opioid therapy.


⸻


First-Line Analgesia


Options may include:


Acetaminophen


and


NSAIDs


when medically appropriate.


⸻


NSAIDs


Anti-inflammatory medications should be used cautiously in patients with:


Renal disease


Gastrointestinal risk


or other relevant:


Contraindications.


⸻


Opioids


Short-term opioid therapy may be appropriate for:


Severe acute fracture pain


particularly during the early:


Post-traumatic period.


⸻


Radiotherapy


Radiotherapy may have a role in selected patients with:


Radiosensitive tumors


causing pathological thoracolumbar:


Fractures.


Its purpose is primarily to reduce:


Tumor burden


and improve:


Local disease control.


⸻


Surgery


The goals of surgery are to:


Restore alignment


Stabilize the spinal column


and, when necessary,


Decompress neural structures.


⸻


Surgical Approach


The optimal approach depends on:


Fracture morphology


Neurologic compression


Bone quality


and surgeon:


Experience.


⸻


Posterior Instrumentation


Posterior instrumentation is commonly favored because it provides effective:


Reduction


Fixation


and


Correction of alignment


without the additional morbidity of a major:


Anterior approach.


⸻


Neural Decompression


Decompression is indicated when there is clinically significant compression of the:


Spinal cord


Conus medullaris


or


Cauda equina


and when decompression is expected to improve:


Neurologic outcome or mechanical stability.


⸻


Anterior Approach


An anterior approach may be useful when substantial:


Vertebral body destruction


or


Anterior canal compression


requires direct:


Decompression and reconstruction.


⸻


Retropulsed Fragments


Anterior surgery may be particularly useful for selected cases involving significant:


Retropulsed vertebral-body fragments


compressing the:


Anterior spinal canal.


⸻


Fusion


Fusion may accompany fixation when:


Instability


Major ligamentous disruption


or extensive bony injury prevents reliable healing without:


Arthrodesis.


⸻


Follow-Up


Patients with major injuries often benefit from coordinated follow-up involving:


Spine surgery


Rehabilitation medicine


Physical therapy


and


Occupational therapy.


⸻


Rehabilitation Facility


Patients with severe neurologic injury may recover best initially in a specialized:


Inpatient rehabilitation facility.


⸻


Pain Specialist Referral


Persistent chronic pain may warrant referral to:


Pain medicine.


⸻


Rehabilitation Medicine


Patients with spinal cord or cauda equina injury should be followed by:


Physical medicine and rehabilitation specialists.


⸻


Neurology Consultation


Neurologic consultation may be useful when the pattern of deficit does not correlate with the identified:


Spinal injury.


⸻


Prognosis


Outcome depends strongly on:


Fracture severity


and particularly on:


Neurologic status.


⸻


Neurologically Intact Patients


Patients with stable low-energy injuries and preserved neurologic function usually have an:


Excellent prognosis.


⸻


Neurologic Injury


Patients with significant neurologic deficits may experience long-term effects on:


Mobility


Bladder and bowel function


Employment


and


Independence.


⸻


Complications


Potential complications include:


Infection


Neurologic deterioration


Pseudarthrosis


Spinal deformity


Junctional degeneration


Spinal stenosis


Chronic pain


and


Disability.


⸻


Brace-Related Complications


TLSO braces can cause:


Skin irritation


Pressure injury


and discomfort over:


Bony prominences.


Regular skin checks are important.


⸻


Pseudarthrosis


Failure of an intended fusion to heal may cause:


Persistent pain


Implant failure


or progressive:


Deformity.


⸻


Junctional Degeneration


Long spinal fusion constructs may increase mechanical stress at adjacent levels, contributing to:


Junctional degeneration


or


Stenosis.


⸻


Chronic Pain


Persistent pain may arise from:


Residual deformity


Neurologic injury


Degenerative change


or


Postoperative complications.


⸻


Patient Monitoring


Patients should be monitored for:


Pain resolution


Neurologic recovery


Maintenance of alignment


and


Fracture healing.


⸻


Fusion Monitoring


If arthrodesis has been performed, follow-up should also evaluate for:


Solid fusion


and


Implant stability.


⸻


Red-Flag Findings


Urgent reassessment is required for:


New or progressive weakness


New sensory loss


Loss of bowel or bladder control


Increasing saddle anesthesia


or


Worsening spinal deformity.


⸻


Key Principle


Thoracolumbar spine fractures most commonly involve the:


T11–L1 junction, where the rigid thoracic spine transitions to the more mobile lumbar spine.


Evaluation must include careful assessment for:


Noncontiguous spinal injury, neurologic compromise, and associated abdominal trauma.


CT is the principal imaging study for defining:


Fracture morphology, while MRI is especially useful for evaluating:


Spinal cord, disc, epidural, and posterior ligamentous complex injury.


Stable fractures may often be treated with:


Early mobilization with or without a TLSO, whereas unstable injuries such as:


Fracture-dislocations, major ligamentous flexion-distraction injuries, and distraction-extension injuries


usually require:


Operative stabilization.


The major goals of treatment are to preserve or restore:


Neurologic function, spinal alignment, mechanical stability, and early safe mobilization.

Image description
Published on

Orthopaedic Surgery - Thoracic Outlet Syndrome


Basics

Thoracic outlet syndrome, or:

TOS

is a clinical disorder caused by compression of:

Neural

or

Vascular structures

supplying the upper extremity as they pass through the:

Thoracic outlet

and adjacent:

Supraclavicular region.


Structures Involved

The principal structures at risk are the:

Brachial plexus

Subclavian artery

and

Subclavian vein.


Synonyms

Historical terms include:

Scalenus anticus syndrome

Costoclavicular syndrome

and

Cervical rib syndrome.


Major Clinical Types

Thoracic outlet syndrome is generally divided into:

Neurogenic TOS

Venous TOS

and

Arterial TOS.

Neurogenic disease is by far the most common form.


Neurogenic Thoracic Outlet Syndrome

Neurogenic TOS results from compression or irritation of the:

Brachial plexus.

Symptoms commonly include:

Pain

Paresthesia

Numbness

and occasionally:

Weakness.


Venous Thoracic Outlet Syndrome

Venous TOS results from compression or thrombosis involving the:

Subclavian or axillary vein.

It may produce:

Arm swelling

Cyanosis

and

Venous congestion.


Arterial Thoracic Outlet Syndrome

Arterial TOS results from compression or injury of the:

Subclavian artery.

It may produce:

Coolness

Fatigue

Ischemic pain

or distal:

Embolic symptoms.


Epidemiology

Thoracic outlet syndrome is relatively:

Uncommon.


Incidence

Historical estimates vary widely, approximately between:

0.03% and 0.8%.

The fully developed syndrome is considerably less common than nonspecific:

Upper-extremity pain or paresthesia.


Age

Thoracic outlet syndrome occurs most commonly in:

Young to middle-aged adults.


Sex

It is reported more frequently in:

Women

than in men.


Risk Factors

Potential predisposing factors include:

Cervical ribs

Congenital fibrous bands

Abnormal first-rib anatomy

and disorders that increase susceptibility to:

Peripheral nerve dysfunction.


Systemic Conditions

Associated systemic conditions include:

Diabetes mellitus

Thyroid disease

and

Alcohol-related neuropathy.

These disorders may make peripheral nerves more vulnerable to:

Compression.


Aggravating Factors

Symptoms may be worsened by:

Obesity

Postural abnormalities

Repetitive overhead activity

and prolonged positions that narrow the:

Thoracic outlet.


Shoulder-Girdle Position

A chronically depressed or forward-positioned shoulder girdle may decrease available space for the:

Brachial plexus

and

Subclavian vessels.


Etiology

Thoracic outlet syndrome is often:

Multifactorial.

Potential contributors include:

Trauma

Repetitive occupational activity

Congenital anatomy

Postural abnormalities

and systemic:

Neuropathic disease.


Overhead Activity

Occupations requiring prolonged:

Overhead arm use

such as ceiling painting may provoke symptoms over a relatively:

Short period.


Repetitive Lower-Elevation Activity

Occupations involving repetitive upper-extremity motion without extreme elevation may also contribute over:

Many years.

Examples include prolonged:

Keyboard use

or

Driving.


Double-Crush Phenomenon

Thoracic outlet syndrome may coexist with more distal nerve-compression disorders such as:

Carpal tunnel syndrome

or

Cubital tunnel syndrome.


Concept of Double Crush

The double-crush concept proposes that a nerve compromised proximally may become more susceptible to compression at another point along its:

Course.

This theory remains clinically relevant but does not explain every patient with multiple:

Entrapment neuropathies.


Associated Conditions

Patients with:

Diabetes mellitus

Thyroid disease

Alcohol-related neuropathy

and systemic arthritis may have increased susceptibility to:

Multiple nerve-compression syndromes.


Diagnosis

The diagnosis is primarily:

Clinical.

No single provocative maneuver or diagnostic test can reliably confirm or exclude:

Thoracic outlet syndrome.


Signs and Symptoms

Symptoms depend on whether the primary compression is:

Neural

Arterial

or

Venous.


Neurogenic Symptoms

Patients may report:

Neck pain

Shoulder pain

Arm pain

Paresthesia

or

Numbness.


Distribution

Symptoms may involve the entire:

Upper extremity

but commonly predominate along the:

Ulnar side of the forearm

and the:

Ring and small fingers.

The middle finger may occasionally also be involved.


Sensory Findings

Objective sensory abnormalities are often:

Subtle.

They may involve the:

Ulnar aspect of the hand

and sometimes the:

Medial forearm.


Nocturnal Symptoms

Night pain and paresthesia may occur.

These symptoms should be distinguished from:

Carpal tunnel syndrome

which more often affects the:

Thumb

Index finger

Middle finger

and radial half of the:

Ring finger.


Overhead Intolerance

A common complaint is difficulty using the arm in an:

Elevated or overhead position.

Symptoms may increase during:

Hair washing

Overhead work

or carrying the arm in prolonged:

Abduction.


Weakness and Dexterity

Some patients report reduced:

Grip strength

or

Hand dexterity

even when obvious muscle atrophy is:

Absent.


Additional Pain

Associated discomfort may occur in the:

Head

Neck

Chest

Shoulder

and

Arm.


Arterial Symptoms

Arterial compression is less common and may produce:

Coolness

Arm fatigue

Diffuse aching

and occasionally:

Raynaud-like symptoms.


Venous Symptoms

Venous compression may be:

Intermittent

or

Persistent.

Typical findings include:

Arm swelling

Heaviness

and varying degrees of:

Cyanosis.


Physical Examination

A complete examination should assess:

Neck

Supraclavicular region

Shoulder girdle

and both:

Upper extremities.


Posture

The affected scapula may sit:

Lower

and

More anteriorly

than the opposite side.


Clavicular Position

The clavicle may appear relatively:

Horizontal

or depressed.


Supraclavicular Examination

Palpate the:

Brachial plexus region

for:

Tenderness

or a palpable:

Mass.


Tinel Sign

Percussion over the brachial plexus may reproduce:

Distal paresthesia

often along the:

Ulnar side of the hand.


Shoulder Examination

Evaluate for:

Glenohumeral instability

Rotator cuff disease

and

Scapular dyskinesis

because these can mimic or contribute to:

Thoracic outlet symptoms.


Neurologic Examination

Perform a bilateral examination of:

Motor strength

Sensation

and

Reflexes.


Intrinsic Hand Strength

Assess:

Finger abduction

Finger adduction

Grip strength

and other intrinsic:

Hand-muscle functions.


Vascular Examination

Document:

Radial pulses

Skin temperature

Color

and

Arm swelling.


Provocative Maneuvers

Several stress tests have historically been used to provoke symptoms.

These tests should be interpreted:

Cautiously.


Important Limitation

Loss of the radial pulse alone during arm positioning is:

Not diagnostic.

Pulse reduction can occur in many:

Asymptomatic individuals.

A maneuver is more meaningful when it reproduces the patient’s:

Typical symptoms.


Adson Maneuver

The Adson maneuver is performed with the arm near the:

Side

while the neck is:

Extended

and the head turned toward the:

Affected side.


Wright Maneuver

The Wright maneuver places the shoulder in:

Abduction

and

External rotation.

The patient may also be asked to take a:

Deep breath.


Elbow Position

Keeping the elbow extended during provocative testing may reduce confounding from:

Ulnar nerve compression at the elbow.


Additional Provocative Testing

Other commonly used maneuvers may include:

Elevated arm stress testing

and

Costoclavicular positioning.

No single test has sufficiently high sensitivity and specificity to establish the diagnosis by itself.


Imaging


Cervical Spine Radiographs

AP and lateral radiographs of the cervical spine may identify:

Cervical ribs

Elongated transverse processes

and

Degenerative cervical disease.


Chest Radiograph

A chest radiograph may help identify:

Cervical rib anatomy

and important alternative diagnoses such as:

Apical lung tumor.

This is particularly relevant in patients with:

Smoking history

or unexplained:

Constitutional symptoms.


MRI

MRI is useful when there is concern for:

Cervical disc disease

or another structural lesion causing:

Neural compression.


Electrodiagnostic Studies

Electrodiagnostic testing may help evaluate for:

Carpal tunnel syndrome

Cubital tunnel syndrome

Cervical radiculopathy

or other:

Peripheral neuropathies.


Role in Neurogenic TOS

Electrodiagnostic studies may be normal in many patients with:

Nonspecific neurogenic symptoms.

They are most useful when an objective neuropathy or alternative diagnosis is:

Suspected.


Vascular Studies

When arterial or venous TOS is suspected, evaluation may include:

Duplex ultrasonography

CT angiography

MR angiography

or other:

Vascular imaging.


Pathological Findings

Thoracic outlet syndrome involves compression of:

Neural

or

Vascular structures

as they pass through the:

Scalene triangle

Costoclavicular space

or

Subcoracoid/pectoralis minor region.


Common Sites of Compression

Important anatomical compression zones include the:

Interscalene triangle

Costoclavicular space

and

Pectoralis minor space.


Differential Diagnosis

The differential diagnosis is broad.


Cervical Spine Disorders

Important cervical causes include:

Cervical spondylosis

Disc herniation

and

Cervical radiculopathy.


Brachial Plexus Lesions

Tumors or other masses involving the:

Brachial plexus

or

Apex of the lung

may produce similar symptoms.


Trauma

Previous trauma involving the:

Neck

Clavicle

First rib

or

Shoulder girdle

may cause chronic pain or neurologic symptoms that resemble:

TOS.


Peripheral Nerve Entrapment

Important alternatives include:

Carpal tunnel syndrome

Cubital tunnel syndrome

Radial nerve compression

and

Suprascapular nerve compression.


Systemic Neuropathy

Neuropathies related to:

Diabetes

Alcohol use

Vitamin deficiency

or

Heavy-metal toxicity

may mimic thoracic outlet syndrome.


Complex Regional Pain Syndrome

Complex regional pain syndrome may cause:

Pain

Swelling

Color change

and

Autonomic abnormalities.


Arterial Differential Diagnosis

Potential arterial disorders include:

Atherosclerotic disease

Aneurysm

Arterial occlusion

Embolism

Raynaud disease

and

Vasculitis.


Venous Differential Diagnosis

Venous alternatives include:

Upper-extremity deep venous thrombosis

Effort thrombosis

and

Thrombophlebitis.


Treatment

Initial management is generally:

Nonoperative

for patients with uncomplicated neurogenic:

Thoracic outlet syndrome.


General Measures

Treatment focuses on:

Postural correction

Muscle strengthening

Activity modification

and elimination of:

Contributing mechanical factors.


Patient Education

Explaining the mechanical basis of symptoms can help patients understand why:

Posture

Work position

and

Repetitive overhead activity

may aggravate the condition.


Occupational Modification

Activities involving prolonged:

Arm elevation

or repetitive shoulder-girdle loading should be modified when possible.


Weight Management

When obesity contributes to postural or mechanical loading, appropriate:

Weight reduction

may improve symptoms.


Physical and Occupational Therapy

A structured rehabilitation program is the cornerstone of treatment for:

Neurogenic TOS.


Postural Reeducation

Therapy should emphasize:

Scapular positioning

Thoracic posture

and avoidance of chronic:

Shoulder depression or protraction.


Muscle Strengthening

Important muscles include:

Trapezius

Rhomboids

Levator scapulae

and other:

Scapular stabilizers.


Resistance Exercises

Strengthening may be performed using:

Elastic bands

or

Light free weights

with the shoulder generally maintained below approximately:

90° of elevation

during early rehabilitation.


Pectoral and Scalene Flexibility

Stretching may address tight:

Pectoralis minor

Scalene

and other anterior shoulder-girdle:

Soft tissues.


Time to Improvement

Symptomatic improvement may require approximately:

Several weeks to 2 months

or longer.


Long-Term Exercise

Exercises should be continued until:

Posture improves

Scapular control is restored

and weakness or deconditioning has been:

Corrected.


Medication

Medication plays a secondary role.

Treatment may include:

NSAIDs

Acetaminophen

or selected medications for:

Neuropathic pain.


Vascular Thoracic Outlet Syndrome

Patients with arterial or venous TOS require:

Specialist vascular evaluation.

Treatment may differ substantially from management of:

Neurogenic TOS.


Venous Thrombosis

Acute venous thrombosis may require:

Anticoagulation

Thrombolysis

and eventual:

Thoracic outlet decompression

depending on severity and timing.


Arterial Disease

Arterial TOS with aneurysm, thrombosis, or embolization may require:

Arterial reconstruction

in addition to:

Surgical decompression.


Surgery

Surgery is considered when:

A carefully supervised conservative program fails

and symptoms remain sufficiently severe to cause:

Major functional limitation.


Surgical Decision-Making

Patients should understand that outcomes are variable and that surgery is generally reserved for those with:

Persistent significant symptoms

or objective:

Neurovascular compromise.


Common Surgical Procedures

Typical operations include:

First-rib resection

Scalenectomy

or a combination of:

Both.


Fibrous Band Release

Congenital or acquired:

Fibrous bands

may also be divided when they contribute to:

Compression.


Vascular Reconstruction

Patients with arterial or venous injury may additionally require:

Vessel repair

Patch angioplasty

Thrombectomy

or

Grafting.


Follow-Up

Patients undergoing nonoperative treatment should be followed for:

Postural improvement

Strength

Symptom reduction

and tolerance of:

Work or activity.


Postoperative Follow-Up

After surgery, monitoring should assess:

Neurologic function

Vascular status

Wound healing

and recurrence of:

Symptoms.


Prognosis

Most patients with uncomplicated neurogenic TOS improve with:

Nonoperative management.


Surgical Prognosis

With appropriate patient selection, many patients undergoing surgery experience:

Symptomatic improvement.

Results are generally more predictable when there is a clearly defined:

Anatomic or vascular lesion.


Complications

Potential surgical complications include:

Pneumothorax

Infection

Vascular injury

Brachial plexus injury

and

Shoulder-girdle dysfunction.


Pneumothorax

Pleural injury during first-rib resection may produce:

Pneumothorax.


Vascular Injury

The proximity of the:

Subclavian vessels

creates a risk of significant:

Hemorrhage.


Brachial Plexus Injury

Manipulation or traction may result in:

Neurologic injury

with postoperative:

Pain

Weakness

or

Sensory loss.


Recurrence

Symptoms may recur after surgery because of:

Scar formation

Persistent muscle weakness

Scapular depression

or

Incomplete decompression.


Patient Monitoring

Long-term monitoring should focus on:

Pain

Paresthesia

Hand strength

Arm swelling

Vascular symptoms

and progression through:

Physical therapy.


Key Principle

Thoracic outlet syndrome is a clinical disorder caused by compression of the brachial plexus or subclavian vessels as they pass from the neck into the upper extremity.

The disorder may be:

Neurogenic, venous, or arterial, with neurogenic disease being the most common.

Diagnosis is primarily:

Clinical, and provocative maneuvers should be interpreted cautiously because pulse changes alone are not:

Diagnostic.

The differential diagnosis includes:

Cervical radiculopathy, carpal and cubital tunnel syndromes, systemic neuropathy, brachial plexus lesions, and vascular disease.

Initial management of uncomplicated neurogenic TOS centers on:

Postural correction, scapular strengthening, activity modification, and occupational rehabilitation.

Surgery, typically involving:

First-rib resection and/or scalenectomy, is reserved for selected patients with persistent disabling symptoms or significant vascular or neurologic compromise.



Image description
Published on

Orthopaedic Surgery - Thoracic Disc Herniation


Basics

Thoracic disc herniation is protrusion or extrusion of an intervertebral disc within the:

Thoracic spine

that may compress the:

Spinal cord

or

Thoracic nerve roots.

The condition can be difficult to diagnose because symptoms are often:

Nonspecific

and may resemble disorders involving the:

Chest

Abdomen

Spine

or

Peripheral nervous system.


Incidental Disc Abnormalities

A major diagnostic challenge is the high prevalence of:

Asymptomatic thoracic disc abnormalities.

Disc degeneration or herniation on imaging does not necessarily indicate that the abnormality is responsible for the patient’s:

Symptoms.

Clinical findings must therefore correlate carefully with the:

Anatomic level

and degree of:

Neural compression.


Epidemiology

Symptomatic thoracic disc disease most commonly presents during approximately the:

Fifth decade of life.


Sex

A slight predominance in:

Males

has been reported historically.


Trauma

Up to approximately:

50% of symptomatic patients

report some preceding:

Traumatic event

before symptoms begin.


Incidence

Symptomatic thoracic disc herniation is uncommon, with an estimated incidence of approximately:

1 per 100,000 persons per year.


Prevalence on MRI

Thoracic disc abnormalities are much more common than clinically symptomatic disease.

MRI studies have reported abnormalities in up to approximately:

73% of individuals.


Asymptomatic Herniation

Approximately:

37%

of individuals in some imaging series have demonstrated:

Asymptomatic thoracic disc herniation.


Genetics

There is no recognized specific:

Genetic association

with thoracic disc herniation.


Pathophysiology

Symptoms develop when the herniated disc compresses the:

Spinal cord

or

Thoracic nerve root.


Spinal Cord Compression

Because the thoracic spinal canal contains the:

Spinal cord

rather than the cauda equina, central disc herniation may produce:

Myelopathy.


Thoracic Myelopathy

Thoracic cord compression may cause:

Lower-extremity weakness

Spasticity

Hyperreflexia

Sensory disturbance

Gait dysfunction

and

Bowel or bladder abnormalities.

Unlike cervical myelopathy, upper-extremity findings are generally:

Absent.


Radiculopathy

A lateral or foraminal herniation may compress a:

Thoracic nerve root

and produce band-like pain along the:

Chest wall

or

Abdominal wall.


Associated Conditions

Thoracic disc herniation may occasionally occur in adolescents with:

Scheuermann disease.


Diagnosis

Diagnosis requires careful assessment because of the broad:

Differential diagnosis

and the high frequency of incidental:

Thoracic MRI abnormalities.


Signs and Symptoms

Patients may present with:

Axial thoracic pain

Radicular pain

or

Myelopathy.


Axial Pain

Pain may be localized to the:

Mid-thoracic

or

Lower thoracic spine.

It can be:

Aching

Deep

or

Mechanical.


Radicular Pain

Thoracic radiculopathy often produces:

Band-like pain

around the trunk.

The:

T10 dermatome

is a commonly reported symptomatic distribution.


Bowel and Bladder Dysfunction

Bowel or bladder dysfunction has historically been reported in up to approximately:

20% of symptomatic patients.

These findings suggest significant:

Spinal cord involvement.


Clinical Patterns

Two broad clinical presentations are often described.


Younger Patients

Patients younger than approximately:

40 years

more commonly have:

Soft disc herniations.


Acute Soft Disc Herniation

These cases may follow:

Trauma

and may produce relatively acute:

Cord compression

or

Radiculopathy.

They often respond favorably to appropriately selected:

Nonoperative or operative treatment.


Older Patients

Patients older than approximately:

40 years

more commonly have:

Degenerative

or

Calcified disc herniations.


Chronic Calcified Herniation

These patients may have:

Longstanding symptoms

without a clear history of trauma.

Compression of the cord or nerve root tends to be more:

Chronic.


Physical Examination

A complete neurologic examination should be performed with careful assessment for:

Myelopathy.


Gait

Observe for:

Spastic gait

Balance disturbance

Shortened stride

or difficulty with:

Tandem walking.


Motor Examination

Assess lower-extremity:

Strength

and look for signs of:

Upper motor neuron dysfunction.


Reflexes

Evaluate:

Patellar reflexes

Achilles reflexes

and look for:

Hyperreflexia

Clonus

or abnormal:

Plantar responses.


Sensory Level

A sensory level may help localize the lesion.

Useful landmarks include:

T4 – nipple line

T7 – xiphoid process

T10 – umbilicus

and

T12 – inguinal crease.


Abdominal Muscle Examination

Asymmetric contraction of the:

Rectus abdominis

during a sit-up may suggest segmental:

Thoracic neurologic dysfunction.


Superficial Reflexes

The examination may include:

Superficial abdominal reflexes

and, when appropriate,

Cremasteric reflexes.


Range of Motion

Thoracic and lumbar:

Range of motion

should be assessed, although abnormalities are usually:

Nonspecific.


Laboratory Tests

Routine laboratory tests are not required for straightforward:

Disc herniation.


Infection or Malignancy

If infection or tumor is part of the differential diagnosis, testing may include:

Complete blood count

ESR

and

C-reactive protein.


Imaging


Plain Radiographs

AP and lateral thoracic spine radiographs may demonstrate:

Degenerative changes

Disc-space narrowing

Calcification

Deformity

or

Spondylolisthesis.


Excluding Other Disorders

Radiographs may also identify:

Fracture

Tumor

Infection

or other structural abnormalities.


Level Localization

Precise localization of the involved vertebral level is essential.

Imaging should include adequate landmarks to permit reliable:

Vertebral counting.

Historically, radiographs were obtained to include the:

First rib

Twelfth rib

and

Sacrum

when possible.


MRI

MRI is the preferred imaging study for suspected:

Thoracic disc herniation.


MRI Sequences

Evaluation should include:

Sagittal

and

Axial

T1- and T2-weighted sequences.


MRI Findings

MRI can demonstrate:

Disc morphology

Spinal cord compression

Nerve-root compression

and possible:

Cord signal abnormality.


Correct-Level Confirmation

Because wrong-level surgery is a major concern in the thoracic spine, the abnormal disc level must be:

Confirmed carefully.

A sagittal localizer may be used to count:

Downward from C2

and

Upward from the sacrum.

Correlation with:

Plain radiographs

or

CT

is useful.


CT

CT is particularly useful for identifying:

Calcification

and defining:

Bony anatomy.


CT Myelography

CT myelography can demonstrate:

Neural compression

and may be used when MRI is:

Contraindicated

or limited by:

Artifact.


Limitations of CT Myelography

Because it requires:

Intrathecal contrast injection

CT myelography is invasive.

Potential complications include:

Post-dural puncture headache.


Discography

Discography has historically been used to investigate:

Axial thoracic pain

when multiple disc levels are abnormal or severe pain persists despite relatively limited:

Imaging findings.

Its diagnostic value remains:

Controversial.


Differential Diagnosis

The differential diagnosis is extensive.


Intrathoracic Causes

Potential causes include:

Pulmonary

Pleural

or other:

Thoracic abnormalities.


Intra-Abdominal Causes

Abdominal pathology can occasionally mimic:

Thoracic radicular pain.


Infectious Causes

Important possibilities include:

Discitis

Vertebral osteomyelitis

and

Epidural abscess.


Neoplastic Causes

Primary or metastatic tumors may cause:

Thoracic pain

Radiculopathy

or

Myelopathy.


Degenerative Causes

Other spinal causes include:

Facet arthropathy

Thoracic stenosis

and other forms of:

Degenerative spondylosis.


Metabolic and Deformity Causes

Consider:

Metabolic bone disease

Compression fracture

and spinal:

Deformity.


Neurogenic Causes

Neurologic alternatives include:

Peripheral neuropathy

Herpes zoster

Spinal cord tumor

and other causes of:

Thoracic neuralgia or myelopathy.


Treatment

Treatment depends primarily on the presence or absence of:

Neurologic compromise.


General Measures

Acute thoracic disc herniation without significant neurologic deficit can often be treated initially:

Nonoperatively.


Natural History

Soft acute thoracic disc herniations may behave similarly to:

Lumbar disc herniations

and may improve with:

Time

and

Conservative management.


Activity

Activity may continue:

As tolerated

provided there is no associated:

Fracture

Gross instability

or other structural contraindication.


Relative Rest

Short-term reduction of provoking activities may help control:

Acute pain.

Prolonged bed rest is generally avoided.


Physical Therapy

Physical therapy may be useful for:

Pain control

Mobility

Flexibility

and

Strengthening.


Acute Phase

Passive modalities may include:

Heat

Ice

and selected therapeutic:

Modalities.


Rehabilitation Phase

As symptoms improve, treatment may progress to:

Range-of-motion exercises

Flexibility exercises

and

Strengthening.


Extension Exercises

Some programs include:

Thoracic extension exercises.

These should be individualized and discontinued if they increase:

Radicular pain

or

Myelopathic symptoms.


Medication


First-Line Treatment

Medication may include:

Acetaminophen

or

NSAIDs

when medically appropriate.


NSAIDs

Anti-inflammatory medication may help reduce:

Pain

provided the patient does not have important:

Gastrointestinal

Renal

or other contraindications.


Aspirin

Enteric-coated aspirin has historically been used for:

Pain and inflammation

although other NSAIDs are now more commonly selected.


Chronic Opioids

There is no routine role for:

Long-term maintenance opioid therapy

in uncomplicated thoracic disc disease.


COX-2 Inhibitors

Selected patients may receive:

COX-2 selective anti-inflammatory medication

after considering:

Cardiovascular

Renal

and

Gastrointestinal risks.


Injections

Selected patients with persistent radicular pain may benefit from:

Thoracic epidural steroid injection

or

Intercostal injection.

These treatments may reduce pain but do not correct:

Mechanical spinal cord compression.


Surgery

Surgery is indicated when:

Neurologic compromise progresses

or nonoperative management fails to provide an acceptable:

Quality of life.


Major Surgical Indications

Common indications include:

Progressive myelopathy

Significant motor deficit

Severe spinal cord compression

or persistent disabling:

Pain.


Preoperative Assessment

Because thoracic surgical approaches may involve the chest and carry substantial physiologic stress, selected patients may require preoperative evaluation by:

Internal medicine

Cardiology

or

Anesthesiology.


Surgical Level Confirmation

Intraoperative imaging should be used to verify the:

Correct vertebral level

before disc removal.


Anterior Transthoracic Approach

The:

Anterior transthoracic approach

has traditionally been used for many central thoracic disc herniations because it permits direct access to the:

Anterior spinal canal.


Posterior Approaches

Direct posterior laminectomy alone is generally:

Not recommended

for central thoracic disc removal because manipulation of the spinal cord carries a high risk of:

Neurologic injury.


Pediculofacetectomy

A posterior:

Transpedicular or pediculofacetectomy approach

may be appropriate for selected:

Lateral lesions.


Lateral Approaches

Other options include:

Costotransversectomy

and

Lateral extracavitary approaches.


Thoracoscopic Surgery

Video-assisted thoracoscopic surgery provides a:

Minimally invasive anterior approach

for selected patients.


Fusion

Whether spinal fusion is required remains dependent on:

Extent of bone removal

Pre-existing deformity

and resultant:

Stability.


Rib-Cage Stability

The thoracic spine has inherent stability from the:

Rib cage.

However, substantial resection of:

Facets

Pedicles

or vertebral body structures may produce:

Iatrogenic instability.


Follow-Up

Follow-up should assess:

Pain

Neurologic status

and progression of:

Recovery.


Historical Follow-Up Schedule

A traditional postoperative schedule may include visits at approximately:

6 weeks

3 months

6 months

1 year

and

2 years

with subsequent long-term review as indicated.


Referral

Patients may require evaluation by other specialists when alternative diagnoses remain possible, including:

Thoracic surgeons

General surgeons

Rheumatologists

or other relevant:

Specialists.


Prognosis

Most appropriately selected patients undergoing thoracic disc excision achieve:

Good or excellent long-term outcomes.


Prognostic Factors

Recovery depends on:

Duration of symptoms

Severity of myelopathy

Extent of spinal cord compression

Disc calcification

and

Preoperative neurologic status.


Acute Soft Disc Prognosis

Younger patients with:

Soft acute herniations

and shorter symptom duration generally have greater potential for:

Neurologic recovery.


Chronic Calcified Disc Prognosis

Longstanding compression from:

Calcified disc material

may produce irreversible:

Spinal cord injury.


Complications


Surgical Complication Rate

Historical series have reported an overall complication rate of approximately:

14–15%

after thoracic disc excision.


Neurologic Injury

The most serious complication is:

Spinal cord injury

with:

Paraparesis

or

Paralysis.


Dural Injury

Possible complications include:

Dural tear

and

Cerebrospinal fluid leak.


Pulmonary Complications

Anterior thoracic approaches may be associated with:

Pneumothorax

Hemothorax

Pleural effusion

or other:

Pulmonary problems.


Infection

Potential infectious complications include:

Wound infection

and deeper:

Spinal infection.


Instability and Deformity

Extensive surgical resection may lead to:

Segmental instability

or

Postoperative kyphosis.


Nonoperative Neurologic Progression

Patients treated nonoperatively must be monitored for progression of:

Myelopathy

or other:

Neurologic compromise.


Patient Monitoring

Monitoring should include assessment of:

Pain

Gait

Motor function

Sensation

and

Bowel and bladder function.


After Fusion

If arthrodesis is performed, follow-up should also evaluate:

Fusion maturation

and

Spinal alignment.


Red-Flag Findings

Urgent reassessment is warranted for:

Progressive leg weakness

Increasing gait difficulty

New sensory level

Worsening spasticity

or

New bowel or bladder dysfunction.


Key Principle

Thoracic disc herniation is an uncommon symptomatic disorder despite the frequent finding of incidental thoracic disc abnormalities on MRI.

Clinical presentation may consist of:

Axial thoracic pain, radiculopathy, or spinal cord compression with myelopathy.

MRI is the preferred imaging study for assessing:

Neural compression, while CT is particularly valuable for evaluating:

Calcified disc material and bony anatomy.

Patients without significant neurologic compromise may initially be treated with:

Activity modification, analgesia, and physical therapy.

Surgery is reserved for:

Progressive myelopathy, substantial neurologic deficit, severe cord compression, or persistent disabling symptoms despite appropriate nonoperative care.

Simple posterior laminectomy for central disc excision is generally avoided because of the risk of:

Spinal cord injury.



Image description
Published on

Orthopaedic Surgery - Thoracic Disc Herniation


Basics

Thoracic disc herniation is protrusion or extrusion of an intervertebral disc within the:

Thoracic spine

that may compress the:

Spinal cord

or

Thoracic nerve roots.

The condition can be difficult to diagnose because symptoms are often:

Nonspecific

and may resemble disorders involving the:

Chest

Abdomen

Spine

or

Peripheral nervous system.


Incidental Disc Abnormalities

A major diagnostic challenge is the high prevalence of:

Asymptomatic thoracic disc abnormalities.

Disc degeneration or herniation on imaging does not necessarily indicate that the abnormality is responsible for the patient’s:

Symptoms.

Clinical findings must therefore correlate carefully with the:

Anatomic level

and degree of:

Neural compression.


Epidemiology

Symptomatic thoracic disc disease most commonly presents during approximately the:

Fifth decade of life.


Sex

A slight predominance in:

Males

has been reported historically.


Trauma

Up to approximately:

50% of symptomatic patients

report some preceding:

Traumatic event

before symptoms begin.


Incidence

Symptomatic thoracic disc herniation is uncommon, with an estimated incidence of approximately:

1 per 100,000 persons per year.


Prevalence on MRI

Thoracic disc abnormalities are much more common than clinically symptomatic disease.

MRI studies have reported abnormalities in up to approximately:

73% of individuals.


Asymptomatic Herniation

Approximately:

37%

of individuals in some imaging series have demonstrated:

Asymptomatic thoracic disc herniation.


Genetics

There is no recognized specific:

Genetic association

with thoracic disc herniation.


Pathophysiology

Symptoms develop when the herniated disc compresses the:

Spinal cord

or

Thoracic nerve root.


Spinal Cord Compression

Because the thoracic spinal canal contains the:

Spinal cord

rather than the cauda equina, central disc herniation may produce:

Myelopathy.


Thoracic Myelopathy

Thoracic cord compression may cause:

Lower-extremity weakness

Spasticity

Hyperreflexia

Sensory disturbance

Gait dysfunction

and

Bowel or bladder abnormalities.

Unlike cervical myelopathy, upper-extremity findings are generally:

Absent.


Radiculopathy

A lateral or foraminal herniation may compress a:

Thoracic nerve root

and produce band-like pain along the:

Chest wall

or

Abdominal wall.


Associated Conditions

Thoracic disc herniation may occasionally occur in adolescents with:

Scheuermann disease.


Diagnosis

Diagnosis requires careful assessment because of the broad:

Differential diagnosis

and the high frequency of incidental:

Thoracic MRI abnormalities.


Signs and Symptoms

Patients may present with:

Axial thoracic pain

Radicular pain

or

Myelopathy.


Axial Pain

Pain may be localized to the:

Mid-thoracic

or

Lower thoracic spine.

It can be:

Aching

Deep

or

Mechanical.


Radicular Pain

Thoracic radiculopathy often produces:

Band-like pain

around the trunk.

The:

T10 dermatome

is a commonly reported symptomatic distribution.


Bowel and Bladder Dysfunction

Bowel or bladder dysfunction has historically been reported in up to approximately:

20% of symptomatic patients.

These findings suggest significant:

Spinal cord involvement.


Clinical Patterns

Two broad clinical presentations are often described.


Younger Patients

Patients younger than approximately:

40 years

more commonly have:

Soft disc herniations.


Acute Soft Disc Herniation

These cases may follow:

Trauma

and may produce relatively acute:

Cord compression

or

Radiculopathy.

They often respond favorably to appropriately selected:

Nonoperative or operative treatment.


Older Patients

Patients older than approximately:

40 years

more commonly have:

Degenerative

or

Calcified disc herniations.


Chronic Calcified Herniation

These patients may have:

Longstanding symptoms

without a clear history of trauma.

Compression of the cord or nerve root tends to be more:

Chronic.


Physical Examination

A complete neurologic examination should be performed with careful assessment for:

Myelopathy.


Gait

Observe for:

Spastic gait

Balance disturbance

Shortened stride

or difficulty with:

Tandem walking.


Motor Examination

Assess lower-extremity:

Strength

and look for signs of:

Upper motor neuron dysfunction.


Reflexes

Evaluate:

Patellar reflexes

Achilles reflexes

and look for:

Hyperreflexia

Clonus

or abnormal:

Plantar responses.


Sensory Level

A sensory level may help localize the lesion.

Useful landmarks include:

T4 – nipple line

T7 – xiphoid process

T10 – umbilicus

and

T12 – inguinal crease.


Abdominal Muscle Examination

Asymmetric contraction of the:

Rectus abdominis

during a sit-up may suggest segmental:

Thoracic neurologic dysfunction.


Superficial Reflexes

The examination may include:

Superficial abdominal reflexes

and, when appropriate,

Cremasteric reflexes.


Range of Motion

Thoracic and lumbar:

Range of motion

should be assessed, although abnormalities are usually:

Nonspecific.


Laboratory Tests

Routine laboratory tests are not required for straightforward:

Disc herniation.


Infection or Malignancy

If infection or tumor is part of the differential diagnosis, testing may include:

Complete blood count

ESR

and

C-reactive protein.


Imaging


Plain Radiographs

AP and lateral thoracic spine radiographs may demonstrate:

Degenerative changes

Disc-space narrowing

Calcification

Deformity

or

Spondylolisthesis.


Excluding Other Disorders

Radiographs may also identify:

Fracture

Tumor

Infection

or other structural abnormalities.


Level Localization

Precise localization of the involved vertebral level is essential.

Imaging should include adequate landmarks to permit reliable:

Vertebral counting.

Historically, radiographs were obtained to include the:

First rib

Twelfth rib

and

Sacrum

when possible.


MRI

MRI is the preferred imaging study for suspected:

Thoracic disc herniation.


MRI Sequences

Evaluation should include:

Sagittal

and

Axial

T1- and T2-weighted sequences.


MRI Findings

MRI can demonstrate:

Disc morphology

Spinal cord compression

Nerve-root compression

and possible:

Cord signal abnormality.


Correct-Level Confirmation

Because wrong-level surgery is a major concern in the thoracic spine, the abnormal disc level must be:

Confirmed carefully.

A sagittal localizer may be used to count:

Downward from C2

and

Upward from the sacrum.

Correlation with:

Plain radiographs

or

CT

is useful.


CT

CT is particularly useful for identifying:

Calcification

and defining:

Bony anatomy.


CT Myelography

CT myelography can demonstrate:

Neural compression

and may be used when MRI is:

Contraindicated

or limited by:

Artifact.


Limitations of CT Myelography

Because it requires:

Intrathecal contrast injection

CT myelography is invasive.

Potential complications include:

Post-dural puncture headache.


Discography

Discography has historically been used to investigate:

Axial thoracic pain

when multiple disc levels are abnormal or severe pain persists despite relatively limited:

Imaging findings.

Its diagnostic value remains:

Controversial.


Differential Diagnosis

The differential diagnosis is extensive.


Intrathoracic Causes

Potential causes include:

Pulmonary

Pleural

or other:

Thoracic abnormalities.


Intra-Abdominal Causes

Abdominal pathology can occasionally mimic:

Thoracic radicular pain.


Infectious Causes

Important possibilities include:

Discitis

Vertebral osteomyelitis

and

Epidural abscess.


Neoplastic Causes

Primary or metastatic tumors may cause:

Thoracic pain

Radiculopathy

or

Myelopathy.


Degenerative Causes

Other spinal causes include:

Facet arthropathy

Thoracic stenosis

and other forms of:

Degenerative spondylosis.


Metabolic and Deformity Causes

Consider:

Metabolic bone disease

Compression fracture

and spinal:

Deformity.


Neurogenic Causes

Neurologic alternatives include:

Peripheral neuropathy

Herpes zoster

Spinal cord tumor

and other causes of:

Thoracic neuralgia or myelopathy.


Treatment

Treatment depends primarily on the presence or absence of:

Neurologic compromise.


General Measures

Acute thoracic disc herniation without significant neurologic deficit can often be treated initially:

Nonoperatively.


Natural History

Soft acute thoracic disc herniations may behave similarly to:

Lumbar disc herniations

and may improve with:

Time

and

Conservative management.


Activity

Activity may continue:

As tolerated

provided there is no associated:

Fracture

Gross instability

or other structural contraindication.


Relative Rest

Short-term reduction of provoking activities may help control:

Acute pain.

Prolonged bed rest is generally avoided.


Physical Therapy

Physical therapy may be useful for:

Pain control

Mobility

Flexibility

and

Strengthening.


Acute Phase

Passive modalities may include:

Heat

Ice

and selected therapeutic:

Modalities.


Rehabilitation Phase

As symptoms improve, treatment may progress to:

Range-of-motion exercises

Flexibility exercises

and

Strengthening.


Extension Exercises

Some programs include:

Thoracic extension exercises.

These should be individualized and discontinued if they increase:

Radicular pain

or

Myelopathic symptoms.


Medication


First-Line Treatment

Medication may include:

Acetaminophen

or

NSAIDs

when medically appropriate.


NSAIDs

Anti-inflammatory medication may help reduce:

Pain

provided the patient does not have important:

Gastrointestinal

Renal

or other contraindications.


Aspirin

Enteric-coated aspirin has historically been used for:

Pain and inflammation

although other NSAIDs are now more commonly selected.


Chronic Opioids

There is no routine role for:

Long-term maintenance opioid therapy

in uncomplicated thoracic disc disease.


COX-2 Inhibitors

Selected patients may receive:

COX-2 selective anti-inflammatory medication

after considering:

Cardiovascular

Renal

and

Gastrointestinal risks.


Injections

Selected patients with persistent radicular pain may benefit from:

Thoracic epidural steroid injection

or

Intercostal injection.

These treatments may reduce pain but do not correct:

Mechanical spinal cord compression.


Surgery

Surgery is indicated when:

Neurologic compromise progresses

or nonoperative management fails to provide an acceptable:

Quality of life.


Major Surgical Indications

Common indications include:

Progressive myelopathy

Significant motor deficit

Severe spinal cord compression

or persistent disabling:

Pain.


Preoperative Assessment

Because thoracic surgical approaches may involve the chest and carry substantial physiologic stress, selected patients may require preoperative evaluation by:

Internal medicine

Cardiology

or

Anesthesiology.


Surgical Level Confirmation

Intraoperative imaging should be used to verify the:

Correct vertebral level

before disc removal.


Anterior Transthoracic Approach

The:

Anterior transthoracic approach

has traditionally been used for many central thoracic disc herniations because it permits direct access to the:

Anterior spinal canal.


Posterior Approaches

Direct posterior laminectomy alone is generally:

Not recommended

for central thoracic disc removal because manipulation of the spinal cord carries a high risk of:

Neurologic injury.


Pediculofacetectomy

A posterior:

Transpedicular or pediculofacetectomy approach

may be appropriate for selected:

Lateral lesions.


Lateral Approaches

Other options include:

Costotransversectomy

and

Lateral extracavitary approaches.


Thoracoscopic Surgery

Video-assisted thoracoscopic surgery provides a:

Minimally invasive anterior approach

for selected patients.


Fusion

Whether spinal fusion is required remains dependent on:

Extent of bone removal

Pre-existing deformity

and resultant:

Stability.


Rib-Cage Stability

The thoracic spine has inherent stability from the:

Rib cage.

However, substantial resection of:

Facets

Pedicles

or vertebral body structures may produce:

Iatrogenic instability.


Follow-Up

Follow-up should assess:

Pain

Neurologic status

and progression of:

Recovery.


Historical Follow-Up Schedule

A traditional postoperative schedule may include visits at approximately:

6 weeks

3 months

6 months

1 year

and

2 years

with subsequent long-term review as indicated.


Referral

Patients may require evaluation by other specialists when alternative diagnoses remain possible, including:

Thoracic surgeons

General surgeons

Rheumatologists

or other relevant:

Specialists.


Prognosis

Most appropriately selected patients undergoing thoracic disc excision achieve:

Good or excellent long-term outcomes.


Prognostic Factors

Recovery depends on:

Duration of symptoms

Severity of myelopathy

Extent of spinal cord compression

Disc calcification

and

Preoperative neurologic status.


Acute Soft Disc Prognosis

Younger patients with:

Soft acute herniations

and shorter symptom duration generally have greater potential for:

Neurologic recovery.


Chronic Calcified Disc Prognosis

Longstanding compression from:

Calcified disc material

may produce irreversible:

Spinal cord injury.


Complications


Surgical Complication Rate

Historical series have reported an overall complication rate of approximately:

14–15%

after thoracic disc excision.


Neurologic Injury

The most serious complication is:

Spinal cord injury

with:

Paraparesis

or

Paralysis.


Dural Injury

Possible complications include:

Dural tear

and

Cerebrospinal fluid leak.


Pulmonary Complications

Anterior thoracic approaches may be associated with:

Pneumothorax

Hemothorax

Pleural effusion

or other:

Pulmonary problems.


Infection

Potential infectious complications include:

Wound infection

and deeper:

Spinal infection.


Instability and Deformity

Extensive surgical resection may lead to:

Segmental instability

or

Postoperative kyphosis.


Nonoperative Neurologic Progression

Patients treated nonoperatively must be monitored for progression of:

Myelopathy

or other:

Neurologic compromise.


Patient Monitoring

Monitoring should include assessment of:

Pain

Gait

Motor function

Sensation

and

Bowel and bladder function.


After Fusion

If arthrodesis is performed, follow-up should also evaluate:

Fusion maturation

and

Spinal alignment.


Red-Flag Findings

Urgent reassessment is warranted for:

Progressive leg weakness

Increasing gait difficulty

New sensory level

Worsening spasticity

or

New bowel or bladder dysfunction.


Key Principle

Thoracic disc herniation is an uncommon symptomatic disorder despite the frequent finding of incidental thoracic disc abnormalities on MRI.

Clinical presentation may consist of:

Axial thoracic pain, radiculopathy, or spinal cord compression with myelopathy.

MRI is the preferred imaging study for assessing:

Neural compression, while CT is particularly valuable for evaluating:

Calcified disc material and bony anatomy.

Patients without significant neurologic compromise may initially be treated with:

Activity modification, analgesia, and physical therapy.

Surgery is reserved for:

Progressive myelopathy, substantial neurologic deficit, severe cord compression, or persistent disabling symptoms despite appropriate nonoperative care.

Simple posterior laminectomy for central disc excision is generally avoided because of the risk of:

Spinal cord injury.



Image description
Published on

Orthopaedic Surgery - Tenosynovitis


Basics

Tenosynovitis is a painful disorder involving:

Inflammation or irritation of a tendon and its surrounding synovial sheath.

It most often affects long tendons in the:

Fingers

Wrist

or

Ankle.


Causes

Tenosynovitis may result from:

Acute injury

Repetitive mechanical loading

Systemic inflammatory disease

Infection

or, in some patients,

No identifiable cause.


Age

The condition is uncommon in:

Children

and is seen most frequently during:

Early to middle adulthood.


Classification by Duration

Tenosynovitis may be described as:

Acute

or

Chronic.


Acute Tenosynovitis

Acute tenosynovitis generally produces symptoms lasting only:

Several days.

Noninfectious acute cases may improve relatively quickly with:

Activity modification

Rest

and

Anti-inflammatory treatment.


Chronic Tenosynovitis

Symptoms persisting longer than approximately:

2–3 weeks

may be considered chronic.

Chronic disease may be accompanied by greater:

Sheath thickening

Fibrosis

and

Tendon degeneration.

These cases may be more difficult to:

Resolve completely.


Common Locations

Frequent clinical forms include:

Posterior tibial tenosynovitis

Flexor tendon tenosynovitis of the hand

Biceps tenosynovitis

and

de Quervain tenosynovitis.


de Quervain Tenosynovitis

de Quervain disease affects the first dorsal extensor compartment, principally the:

Abductor pollicis longus

and

Extensor pollicis brevis tendons.


Synonym

The term:

Tendinitis

is sometimes used interchangeably, although tendinitis refers primarily to the:

Tendon itself

whereas tenosynovitis specifically involves the:

Synovial tendon sheath.


Prevention

Because many cases arise unpredictably, there is no reliable method for preventing all forms of:

Tenosynovitis.


Activity Modification

In patients whose symptoms are related to repetitive loading, prevention of recurrence may involve:

Ergonomic adjustment

Technique modification

and avoidance of abrupt increases in:

Repetitive activity.


Epidemiology

Tenosynovial disorders are among the more common:

Musculoskeletal complaints.

Many individuals experience at least one episode of tendon or tendon-sheath irritation during:

Their lifetime.


Sex

Women appear to be affected slightly more frequently than:

Men.


Risk Factors

Potential risk factors include:

Rheumatoid arthritis

Other inflammatory arthropathies

Previous tenosynovitis

Pregnancy

and selected repetitive:

Occupational or recreational activities.


Repetitive Motion

The relationship between repetitive motion and every form of tenosynovitis is not absolute.

However, repetitive loading may contribute in susceptible patients, especially when activity is:

New

Unusually intense

or associated with poor:

Biomechanics.


Etiology

Repeated use or mechanical constriction may irritate the:

Tendon sheath

causing thickening and impaired:

Tendon gliding.


Noninfectious Tenosynovitis

Many noninfectious cases occur in adults between approximately:

30 and 50 years of age

who perform repetitive:

Hand

Wrist

or

Lower-extremity activities.


Systemic Inflammatory Disease

Tenosynovitis may be a manifestation of:

Rheumatoid arthritis

Systemic lupus erythematosus

or other:

Inflammatory arthritides.


Infectious Tenosynovitis

Infection usually develops when bacteria gain access to the:

Tendon sheath

through:

Penetrating trauma

Laceration

Puncture wound

or, less commonly,

Hematogenous spread.


Flexor Tendon Sheath Infection

Infectious flexor tenosynovitis of the hand is particularly important because infection can spread rapidly within the:

Closed tendon sheath.

It represents an:

Urgent surgical condition.


Pregnancy Considerations

Pregnancy may precipitate or worsen:

Tenosynovitis

particularly:

de Quervain tenosynovitis.

Fluid retention and hormonal changes may contribute to:

Tendon-sheath swelling.


Associated Conditions

Important associated disorders include:

Rheumatoid arthritis

Lupus

and other:

Inflammatory arthropathies.


Diagnosis

Diagnosis is usually based on:

History

Physical examination

and, when necessary,

Laboratory or imaging studies.


Signs and Symptoms

The most common symptom is:

Pain along the course of the affected tendon.


Onset

Pain may develop:

Suddenly

or

Gradually.

It frequently follows a period of:

New or unusually strenuous activity.


Activity-Related Pain

Symptoms generally worsen with:

Use of the involved tendon

and improve with:

Rest.


Swelling

There may be localized:

Swelling

or fullness along the:

Tendon sheath.


Crepitus

Some patients develop palpable or audible:

Crepitus

as the tendon moves within an inflamed or thickened:

Sheath.


de Quervain Symptoms

de Quervain tenosynovitis typically causes:

Radial-sided wrist pain

near the:

Radial styloid.

Symptoms worsen with:

Thumb motion

Gripping

and

Ulnar deviation of the wrist.


Trigger Finger

Tenosynovial thickening around the flexor tendons may produce:

Trigger finger.


Triggering Mechanism

The tendon catches as it passes through a constricted:

Flexor pulley system.

This may produce:

Clicking

Snapping

or

Locking

during finger flexion or extension.


Physical Examination

The examination should identify the specific:

Tendon or tendon sheath

responsible for symptoms.


Tenderness

Tenderness is typically distributed:

Longitudinally

along the course of the:

Affected tendon.


Severity

Tenderness may be:

Mild

Moderate

or

Severe

depending on the underlying:

Cause and duration.


Swelling

Visible or palpable swelling may follow the:

Tendon sheath.


Crepitus With Motion

Moving the affected tendon may reproduce:

Pain

and occasionally:

Crepitus.


Range of Motion

Assess:

Active

and

Passive range of motion.

Restriction may result from:

Pain

Swelling

or mechanical:

Tendon constriction.


Infectious Flexor Tenosynovitis

When infection is suspected in a finger, look for the classic:

Kanavel signs.

These include:

Fusiform swelling of the digit

Tenderness along the flexor tendon sheath

Finger held in slight flexion

and

Pain with passive extension.

The presence of these findings should prompt:

Urgent surgical evaluation.


Laboratory Tests

Laboratory studies are not always required for uncomplicated noninfectious:

Tenosynovitis.


Suspected Infection

When infection is possible, useful studies may include:

Complete blood count

Erythrocyte sedimentation rate

and

C-reactive protein.


Systemic Disease Evaluation

Additional testing may be appropriate when symptoms suggest:

Rheumatoid arthritis

Lupus

Gout

or another systemic:

Inflammatory disorder.


Imaging


Plain Radiographs

Radiographs may be useful when there is:

Penetrating trauma

Suspected fracture

Adjacent arthritis

or another potential:

Bony cause of symptoms.


Radiographic Role

Plain films generally do not demonstrate the tendon-sheath inflammation directly.

They are primarily used to identify:

Alternative diagnoses

and associated:

Skeletal abnormalities.


Ultrasound

Ultrasound can demonstrate:

Tendon-sheath fluid

Synovial thickening

Tendon abnormalities

and dynamic:

Tendon motion.


MRI

MRI may show:

Fluid surrounding the tendon

Synovial thickening

Tendon degeneration

or associated:

Soft-tissue pathology.


Role of Advanced Imaging

Ultrasound or MRI is most helpful when:

The diagnosis is uncertain

Symptoms persist despite treatment

or a mass, tear, or other structural lesion is:

Suspected.


Pathological Findings

The pathological appearance varies according to the:

Cause.


Acute Inflammatory Disease

Acute inflammatory tenosynovitis may show:

Synovial edema

Hyperemia

and infiltration by:

Inflammatory cells.


Chronic Disease

Chronic cases may demonstrate:

Synovial thickening

Fibrosis

and degenerative changes affecting the:

Tendon.


Infectious Disease

Septic tenosynovitis may contain:

Purulent fluid

with marked:

Synovial inflammation

and potentially:

Tendon damage.


Differential Diagnosis

Important alternatives include:

Tendon strain

Partial tendon tear

Complete tendon rupture

Tendon-sheath infection

Arthritis

and other causes of regional:

Soft-tissue pain.


Treatment

Treatment depends on whether the process is:

Mechanical

Inflammatory

or

Infectious.


General Measures

Most uncomplicated noninfectious cases are initially treated with:

Relative rest

Activity modification

and gentle:

Range-of-motion exercises.


Relative Rest

The provoking activity should be reduced sufficiently to allow symptoms to:

Settle.

Complete inactivity is generally avoided when painless movement is:

Possible.


Immobilization

Short-term use of a:

Splint

or

Brace

may be helpful when symptoms are severe.

Prolonged immobilization should generally be avoided because it may lead to:

Stiffness

and

Weakness.


Physical and Occupational Therapy

Physical and occupational therapists may assist with:

Splinting

Stretching

Strengthening

and

Work or activity modification.


Ergonomic Modification

When occupational activity contributes to symptoms, therapy may focus on:

Tool modification

Workstation adjustment

and changes in:

Repetitive movement patterns.


Stretching

Gentle stretching can help maintain:

Tendon excursion

and surrounding:

Joint mobility.


Strengthening

Once acute pain improves, progressive strengthening may restore:

Tendon capacity

and reduce recurrence.


Medication


NSAIDs

NSAIDs may provide short-term relief of:

Pain

and

Inflammatory symptoms.

They are commonly used in:

Noninfectious tenosynovitis.


Corticosteroid Injection

Corticosteroid injection may be effective for selected disorders, particularly:

de Quervain tenosynovitis

and

Trigger finger.


Injection Precautions

Injection should be performed carefully to avoid:

Direct intratendinous injection

which can increase the risk of:

Tendon weakening or rupture.


Systemic Inflammatory Disease

Tenosynovitis caused by rheumatoid arthritis or another inflammatory disease may improve with:

Disease-modifying antirheumatic therapy

and appropriate systemic:

Anti-inflammatory treatment.


Infectious Tenosynovitis

Septic tenosynovitis requires:

Urgent treatment.


Antibiotics

Treatment includes prompt:

Intravenous or appropriately targeted antibiotics

based on the suspected organism and:

Culture results.


Surgery

Surgery may be required when:

Nonoperative treatment fails

or when mechanical compression prevents normal:

Tendon gliding.


Surgical Release

Operative treatment may involve:

Opening or releasing the tendon sheath

to relieve:

Constriction.


Synovectomy

Diseased or hypertrophic synovium may be:

Excised

to improve tendon:

Gliding.


Tendon Débridement

Degenerated tendon tissue may require:

Débridement

in selected chronic cases.


de Quervain Surgery

Persistent de Quervain disease may require complete release of the:

First dorsal extensor compartment.

Both the:

Abductor pollicis longus

and any separate compartment containing the:

Extensor pollicis brevis

must be adequately decompressed.


Postoperative Splinting

Temporary splinting may be used after surgery depending on:

Procedure

and

Tendon condition.


Septic Tenosynovitis Surgery

Infectious tenosynovitis may require urgent:

Tendon-sheath irrigation and decompression

with removal of:

Purulent material

and

Infected synovium.


Timing in Infection

Delay in treatment can lead to:

Tendon necrosis

Adhesions

Loss of motion

or spread of:

Infection.


Referral

Patients with suspected systemic inflammatory disease should be referred for appropriate:

Rheumatologic evaluation.


Rheumatology

Patients with:

Rheumatoid arthritis

Lupus

or another inflammatory arthropathy may require:

Disease-modifying therapy

rather than isolated treatment of the:

Tendon sheath.


Follow-Up

Patients should be reassessed according to:

Severity

Location

and

Treatment response.


Typical Monitoring

Nonoperative cases may be reviewed at approximately:

4–6 week intervals.


Examination During Follow-Up

Follow-up should evaluate:

Pain

Swelling

Range of motion

Tendon function

and return to:

Normal activity.


Prognosis

Most uncomplicated cases respond successfully to:

Nonoperative treatment.


Recurrent Disease

Some tendon regions have a greater tendency toward recurrence, particularly the:

Posterior tibial tendon

and

Achilles tendon.


Chronic Tenosynovitis

Longstanding disease may be more difficult to resolve because of:

Fibrosis

Tendon degeneration

and persistent:

Mechanical irritation.


Infectious Prognosis

Outcome in septic tenosynovitis depends heavily on:

Early recognition

and

Prompt treatment.

Delayed care increases the risk of permanent:

Tendon and joint dysfunction.


Complications

The principal complication of noninfectious disease is:

Persistence or recurrence of symptoms.


Tendon Degeneration

Chronic tenosynovitis may contribute to:

Tendon weakening

and occasionally:

Tendon rupture.


Adhesions

Inflammation or surgery can lead to:

Tendon adhesions

and impaired:

Tendon gliding.


Stiffness

Pain and prolonged immobilization can result in:

Joint stiffness

and reduced:

Range of motion.


Infection Complications

Untreated septic tenosynovitis may cause:

Abscess formation

Tendon necrosis

Joint infection

Osteomyelitis

or permanent:

Functional loss.


Patient Monitoring

Patients should be monitored for:

Resolution of pain

Improved tendon excursion

Restoration of range of motion

and recurrence of:

Swelling or triggering.


Key Principle

Tenosynovitis is a disorder of the synovial tendon sheath that may result from mechanical overuse, systemic inflammatory disease, infection, or an idiopathic process.

Typical findings include:

Pain and tenderness along the tendon, swelling, crepitus, and pain with use.

Most noninfectious cases improve with:

Relative rest, temporary splinting, NSAIDs, activity modification, and therapy.

Selected conditions such as:

de Quervain tenosynovitis and trigger finger

may respond to:

Corticosteroid injection.

Persistent mechanical disease may require:

Surgical sheath release or synovectomy, whereas:

Septic flexor tenosynovitis is an urgent condition requiring antibiotics and often operative irrigation and decompression.



Image description
Published on

Orthopaedic Surgery - Tennis Elbow


Basics

Tennis elbow, also called:

Lateral epicondylitis

is a degenerative tendinopathy involving the origin of the:

Extensor carpi radialis brevis

at the:

Lateral epicondyle of the humerus.

Despite the traditional term “epicondylitis,” the disorder is predominantly:

Degenerative rather than inflammatory.


Synonyms

Other terms include:

Lateral epicondylosis

Lateral epicondylalgia

Wrist extensor tendinosis

and

Tennis elbow.


Anatomy

The lateral epicondyle provides attachment for the:

Common extensor tendon.

Important contributing muscles include:

Extensor carpi radialis longus

Extensor carpi radialis brevis

Extensor digitorum communis

and

Extensor carpi ulnaris.


Extensor Carpi Radialis Brevis

The:

Extensor carpi radialis brevis, or ECRB

is the tendon most commonly involved.

It lies deep to the:

Extensor carpi radialis longus.


Function

The wrist extensors stabilize the wrist during:

Gripping

Lifting

and repetitive:

Forearm and hand activity.

They are also highly active during the:

Backhand stroke in tennis.


Clinical Setting

Although strongly associated with racket sports by name, lateral epicondylosis is actually more commonly encountered in patients performing repetitive:

Occupational

or

Daily-living activities.

It affects both:

Athletes

and

Nonathletes.


Typical Patient

The classic presentation is an adult in the:

Fourth or fifth decade

with overuse of the:

Dominant upper extremity.


Natural History

Lateral epicondylosis is generally:

Self-limited.

Symptoms may nevertheless persist for:

Many months

and occasionally longer before resolving.


Prevention

Prevention focuses on reducing excessive repetitive loading of the:

Wrist extensor origin.


Ergonomics

Patients performing repetitive occupational activity may benefit from:

Ergonomic assessment

and modification of their:

Workstation or tools.

This is particularly relevant for patients with prolonged:

Computer

Manual

or

Repetitive hand use.


Athletic Technique

Tennis players should be assessed for:

Racket grip size

Backhand technique

Racket weight

String tension

and training:

Volume.


Epidemiology

Lateral epicondylosis affects:

Men and women approximately equally.


Incidence

Peak incidence occurs during approximately the:

Fifth decade of life.


Lifetime Occurrence

Approximately:

1–3% of the population

develop lateral epicondylosis at some point.


Risk Factors

The condition is associated with activities involving repetitive:

Forearm pronation

Supination

Wrist extension

and

Gripping.


Elbow Position

Repetitive forearm rotation performed with the elbow near:

Full extension

may increase loading at the:

Common extensor origin.


Sports

Associated athletic activities include:

Tennis

Other racket sports

and

Fencing.


Occupational Activities

Occupations and activities associated with repetitive upper-extremity use include:

Plumbing

Painting

Knitting

Dentistry

and prolonged:

Computer work.


Tennis-Specific Factors

Potential contributing factors include:

Poor stroke mechanics

Incorrect racket grip size

Excessive racket weight

and inappropriate:

String tension.


Playing Surface

Harder court surfaces may increase force transmission through the:

Racket

and upper extremity, potentially increasing stress at the:

Lateral epicondyle.


Etiology

The disorder usually begins as repetitive microscopic injury to the:

ECRB origin.


Microtrauma

Repeated loading may produce:

Microscopic tendon tearing

that exceeds the tendon’s ability to:

Repair itself.


Other Involved Tendons

The:

Extensor carpi radialis longus

and

Extensor digitorum communis

may occasionally also demonstrate:

Degenerative involvement.


Failed Tendon Healing

An inadequate healing response leaves the tendon susceptible to repeated:

Microtrauma

and progressive:

Tendinosis.


Pathophysiology

The process is characterized more by:

Collagen degeneration

than by acute:

Inflammation.

This explains why the term:

Lateral epicondylosis

is often considered more pathologically accurate than “epicondylitis.”


Diagnosis

Diagnosis is usually:

Clinical.

The combination of characteristic:

Lateral elbow tenderness

and pain with resisted:

Wrist extension

is strongly suggestive.


Signs and Symptoms

Patients typically report a history of:

Repetitive upper-extremity activity.


Pain Location

Pain is centered around the:

Lateral epicondyle

and may radiate a short distance distally along the:

Proximal extensor muscle mass.


Activity-Related Pain

Symptoms generally worsen with:

Activity

and improve with:

Rest.


Gripping Pain

Patients commonly report pain while:

Gripping objects

Lifting a cup

Shaking hands

or

Carrying objects.


Resisted Wrist Extension

Pain is reproduced when the patient extends the wrist against:

Resistance.

Symptoms are often more pronounced when the elbow is:

Extended.


Range of Motion

Elbow range of motion is generally:

Preserved.

Loss of motion should raise concern for:

Alternative or additional pathology.


Physical Examination

The most characteristic finding is localized tenderness over the:

Common extensor origin

at or just distal to the:

Lateral epicondyle.


Distal Tenderness

Tenderness may extend several centimeters distally over the:

ECRB region.


Resisted Wrist Extension Test

The examiner stabilizes the forearm while the patient attempts:

Wrist extension against resistance.

Reproduction of lateral elbow pain supports the diagnosis.


Passive Wrist Flexion

Passive flexion of the wrist with the elbow:

Extended

stretches the common extensor origin and may reproduce:

Pain.


Grip Testing

Painful or reduced:

Grip strength

may be present because gripping requires stabilization by the:

Wrist extensors.


Radial Tunnel Examination

The clinician should evaluate for:

Radial tunnel syndrome.


Resisted Middle-Finger Extension

Pain reproduced with resisted:

Middle-finger extension

may suggest involvement of the:

Radial tunnel or posterior interosseous nerve region.

This finding should be interpreted with the remainder of the:

Clinical examination.


Cervical Spine Examination

A cervical spine examination is appropriate, especially when symptoms are:

Bilateral

Atypical

or accompanied by:

Neck pain or neurologic findings.


Imaging


Plain Radiographs

AP and lateral radiographs of the elbow may be obtained to exclude:

Fracture

Arthritis

Loose body

or other:

Bony pathology.


Typical Radiographic Findings

Plain radiographs are usually:

Normal.


Calcification

Historical studies report local soft-tissue calcification near the lateral epicondyle in approximately:

23% of patients.


Cervical Spine Imaging

Cervical radiographs may be considered when symptoms could originate from:

Cervical radiculopathy.


CT

CT is rarely needed for isolated tennis elbow.

It may be useful when evaluating:

Loose bodies

Arthritis

or other complex:

Intra-articular pathology.


MRI

MRI is not routinely required for the diagnosis.


Indications for MRI

MRI may be useful when symptoms are:

Persistent

Atypical

or when there is concern for:

Partial tendon tearing

or another:

Elbow disorder.


MRI Findings

Possible findings include:

Tendon thickening

Increased T1 and T2 signal

and

Partial tearing

at the common extensor origin.


Electrodiagnostic Testing

Electromyography and nerve-conduction studies are not usually required for isolated:

Lateral epicondylosis.

They may help when distinguishing it from:

Radial tunnel syndrome

or another:

Neuropathic disorder.


Pathological Findings

Microscopic examination demonstrates:

Degenerative tearing

within the substance of the:

ECRB tendon.


Histology

Characteristic changes include replacement of normal tendon collagen with:

Fibroblastic tissue

Abnormal vascular proliferation

and disorganized:

Collagen.

This has historically been termed:

Angiofibroblastic or angioblastic proliferation.


Inflammation

Importantly, significant acute inflammatory-cell infiltration is usually:

Absent.

The process therefore represents:

Tendinosis

rather than classic:

Tendinitis.


Differential Diagnosis

Important alternatives include:

Cervical radiculopathy

Radial tunnel syndrome

Olecranon bursitis

Medial epicondylitis

Ulnar collateral ligament injury

and

Intra-articular elbow disease.


Radial Tunnel Syndrome

Radial tunnel syndrome involves compression of the:

Posterior interosseous nerve

or radial nerve around the:

Supinator.


Coexisting Radial Tunnel Syndrome

Historical reports suggest that radial tunnel syndrome may coexist with lateral epicondylosis in approximately:

5% of patients.


Intra-Articular Disorders

Conditions such as:

Elbow arthritis

Capitellar osteochondritis dissecans

or a:

Loose body

may produce lateral elbow pain.


Treatment

Most patients are initially treated:

Nonoperatively.


General Measures

Treatment may include:

Activity modification

Relative rest

Ice or cryotherapy

NSAIDs

Physical therapy

Counterforce bracing

and occasionally:

Wrist splinting.


Activity Modification

Activities that reproduce pain should be:

Reduced or modified.

Complete inactivity is generally unnecessary.


Return to Activity

Normal activity can be resumed:

Gradually

as pain and strength:

Improve.


Ergonomic Correction

Work-related factors should be addressed through:

Tool modification

Workstation adjustment

and reduction of repetitive:

Grip or wrist-extension loading.


Athletic Modification

Athletes should optimize:

Stroke mechanics

Equipment

and

Training volume.


Counterforce Brace

A:

Counterforce strap

placed around the proximal forearm may reduce load transferred to the:

Common extensor origin.


Wrist Splint

Short-term use of a wrist splint, particularly at:

Night

or during aggravating activities, may reduce tension on the:

Extensor tendons.


Physical Therapy

Physical therapy is useful when symptoms persist.


Eccentric Exercise

A major component of rehabilitation is:

Eccentric strengthening of the wrist extensors.


Progressive Loading

Rehabilitation may gradually progress from:

Isometric exercises

to

Eccentric and concentric strengthening

as tolerated.


Stretching

Gentle stretching of the:

Wrist extensor musculature

may be incorporated into the program.


Soft-Tissue Treatment

Adjunctive techniques may include:

Friction massage

Soft-tissue mobilization

and other manual:

Therapies.


Therapeutic Modalities

Historically used modalities include:

Ultrasound

and

Iontophoresis.

Evidence for substantial additional benefit is:

Limited.


NSAIDs

NSAIDs may provide short-term:

Pain relief.

Because the underlying process is largely degenerative rather than inflammatory, they do not directly reverse:

Tendon degeneration.


Corticosteroid Injection

Corticosteroid injection may provide:

Short-term pain relief

in selected patients.


Limitations of Corticosteroid Injection

Benefits often diminish over time, and repeated injections may increase the risk of:

Tendon degeneration

or

Tendon rupture.

Therefore, repeated injections should be used:

Cautiously.


Nitroglycerin

Topical:

Nitroglycerin patches

have been studied as an adjunct to rehabilitation and may improve pain in some patients with:

Chronic tendinopathy.

Their role remains:

Selective rather than routine.


Shock-Wave Therapy

Extracorporeal shock-wave therapy has been investigated for:

Lateral epicondylosis.

Results across studies have been:

Variable

and it has not consistently demonstrated a large advantage over:

Placebo or standard rehabilitation.


Low-Level Laser Therapy

Low-level laser treatment has also been investigated, but evidence for a substantial clinically important benefit remains:

Limited.


Biologic Therapy

Autologous blood and:

Platelet-rich plasma

have been proposed to stimulate tendon healing by increasing local:

Growth factors.


PRP

PRP has shown benefit in some studies, particularly for:

Chronic symptoms.

However, results are inconsistent, and it has not consistently demonstrated superiority over:

Structured exercise-based treatment.


Nonoperative Success

Most patients improve without surgery.

Historical series report successful nonoperative treatment in approximately:

90–95% of patients.


Surgery

Surgery is rarely required.


Indications

Operative treatment may be considered after approximately:

6–12 months

of persistent symptoms despite appropriate:

Nonoperative management.


Surgical Principle

Traditional surgery involves removal of:

Degenerated ECRB tissue

from the:

Lateral epicondyle.


Open Débridement

Open surgery may include:

Débridement of the diseased ECRB origin

with repair or reattachment of:

Healthy tendon.


Radial Tunnel Release

If clinically significant coexisting:

Radial tunnel syndrome

is present, decompression may be considered during the same:

Procedure.


Arthroscopic Treatment

Arthroscopic treatment allows:

Débridement of the ECRB origin

while simultaneously evaluating:

Intra-articular pathology.


Open Versus Arthroscopic Surgery

Both open and arthroscopic procedures can provide:

Good outcomes.

Arthroscopy may allow somewhat faster:

Early recovery

in selected patients.


Follow-Up After Surgery

Postoperative rehabilitation is:

Progressive.


Early Period

A splint may be removed at approximately:

1 week

depending on the:

Procedure and wound.


Range of Motion

Gentle:

Elbow

and

Wrist range-of-motion exercises

are then initiated.


Strengthening

Once the wound has healed and motion is comfortable, progressive:

Strengthening

is added.


Activity

Pain-limited activities may be resumed as healing:

Progresses.


Full Activity

Return to unrestricted activity is often possible by approximately:

3 months

although timing varies according to:

Procedure

Occupation

and

Sport demands.


Prognosis

Lateral epicondylosis generally has a:

Good prognosis.


Chronic Course

Symptoms may fluctuate with periods of:

Exacerbation

and

Improvement.


Natural Resolution

Even without invasive treatment, many cases gradually improve because the disorder is often:

Self-limiting.


Nonoperative Outcome

Approximately:

90–95%

of patients can be managed successfully without:

Surgery.


Complications

Complications from conservative treatment are generally:

Uncommon.


Injection Complications

Potential complications of corticosteroid injection include:

Skin depigmentation

Subcutaneous fat atrophy

and

Tendon weakening or rupture.


Surgical Complications

Potential complications include:

Infection

Persistent pain

Recurrent tendon degeneration

Elbow stiffness

and reduced:

Range of motion.


Tendon Retear

The repaired or débrided extensor origin may rarely develop:

Recurrent tearing.


Patient Monitoring

Patients should be followed according to:

Symptoms

and response to:

Treatment.


Persistent Pain

If pain remains unexplained or persistent after several months, reassessment should consider:

Radial tunnel syndrome

Cervical radiculopathy

Arthritis

Loose body

or another:

Elbow diagnosis.


Repeat Imaging

Repeat radiographs or advanced imaging may be appropriate if symptoms remain persistent after approximately:

Several months

or if the clinical picture changes.


Key Principle

Tennis elbow is primarily a degenerative tendinopathy of the ECRB origin at the lateral epicondyle rather than a true inflammatory disorder.

Patients characteristically develop:

Lateral elbow pain with gripping and resisted wrist extension, while elbow range of motion is usually:

Normal.

Diagnosis is primarily:

Clinical, with imaging reserved for atypical, persistent, or diagnostically uncertain cases.

Most patients improve with:

Activity modification, ergonomic or technique correction, eccentric extensor strengthening, counterforce bracing, and time.

Injections may provide selective symptomatic relief, but repeated corticosteroid exposure should be used cautiously because of potential:

Tendon weakening.

Surgery is reserved for a small minority of patients with:

Persistent symptoms despite prolonged appropriate nonoperative treatment.



Image description
Published on

Orthopaedic Surgery - Tarsal Tunnel Syndrome


Basics

Tarsal tunnel syndrome is an entrapment neuropathy involving the:

Tibial nerve

or one of its distal branches as the nerve passes through the:

Tarsal tunnel.

The neuropathy may result from:

Compression

or

Traction.


Anatomy

The proximal tarsal tunnel is a:

Fibro-osseous canal

located along the posteromedial aspect of the:

Ankle.

It represents a distal continuation of the:

Deep posterior compartment of the leg.


Contents of the Tarsal Tunnel

From anterior to posterior, the tunnel contains the:

Posterior tibial tendon

Flexor digitorum longus tendon

Posterior tibial artery and vein

Tibial nerve

and

Flexor hallucis longus tendon.


Floor of the Tunnel

The floor is formed by:

The medial talus

The sustentaculum tali

and

The medial wall of the calcaneus.


Roof of the Tunnel

The roof is formed by the:

Flexor retinaculum.

This structure may begin as far as approximately:

10 cm proximal to the medial malleolus.


Fibro-Osseous Compartments

The tendons and neurovascular bundle travel in relatively constrained:

Fibro-osseous compartments

connected to the:

Flexor retinaculum.

Because the tunnel is not easily expandable, even a modest increase in local volume can produce:

Nerve compression.


Tibial Nerve Branches

Within or near the tarsal tunnel, the tibial nerve gives rise to:

Medial calcaneal nerve

Medial plantar nerve

and

Lateral plantar nerve.

The exact branching anatomy is:

Variable.


Medial Calcaneal Nerve

The:

Medial calcaneal nerve

arises directly from the tibial nerve in approximately:

69–90% of individuals.

It may also originate from the:

Lateral plantar nerve.


Number of Calcaneal Branches

A single medial calcaneal branch is present in approximately:

79%

although multiple branches may occur.


Sensory Distribution

The medial calcaneal nerve supplies sensation to the:

Medial heel.

Because it may branch proximal to the site of compression, heel sensation can occasionally be:

Preserved

despite tarsal tunnel syndrome.


Medial and Lateral Plantar Nerves

The tibial nerve terminates as the:

Medial plantar nerve

and

Lateral plantar nerve.

In approximately:

93–96%

of individuals, this bifurcation occurs within the:

Tarsal tunnel.

In the remainder, the division occurs more proximally in the:

Leg.


Medial Plantar Nerve

The medial plantar nerve provides sensation to:

The plantar medial foot

Great toe

Second toe

Third toe

and the:

Medial side of the fourth toe.


Medial Plantar Motor Supply

It provides motor innervation to:

Abductor hallucis

Flexor digitorum brevis

Flexor hallucis brevis

and the:

First lumbrical.


Lateral Plantar Nerve

The lateral plantar nerve supplies sensation to:

The lateral side of the fourth toe

and

The fifth toe.


Lateral Plantar Motor Supply

It provides motor innervation to:

Quadratus plantae

Abductor digiti minimi

Flexor digiti minimi brevis

The lateral three lumbricals

Adductor hallucis

and

The interossei.


Most Commonly Involved Branch

The:

Lateral plantar nerve

is frequently involved in tarsal tunnel syndrome.


Distal Tarsal Tunnel

Distally, the medial and lateral plantar nerves pass through separate:

Fibrous tunnels

deep to the:

Abductor hallucis muscle.

These sites can also become points of:

Entrapment.


Medial Plantar Nerve Entrapment

The medial plantar nerve can become compressed between the:

Navicular

and

Abductor hallucis

or near the:

Knot of Henry.


First Branch of the Lateral Plantar Nerve

The first branch of the lateral plantar nerve may be compressed within the fascia of:

Abductor hallucis

as it courses toward the:

Abductor digiti minimi.

This may produce:

Chronic heel pain.


Pregnancy Considerations

Tarsal tunnel symptoms may develop during:

Pregnancy

because of:

Fluid retention

and increased local:

Tissue volume.

Management is usually:

Supportive

because symptoms often improve after:

Delivery.


Epidemiology

Tarsal tunnel syndrome can occur over a wide:

Age range.

Historical series have reported affected patients between approximately:

14 and 80 years.


Sex

It appears to be slightly more common in:

Women

than in men.

One historical review reported approximately:

56% female patients.


Incidence

The true incidence is:

Unknown.


Risk Factors

No single risk factor has been conclusively established.

Several occupations and repetitive activities have nevertheless been associated with:

Tibial nerve traction or compression.


Jogger’s Foot

Excessive:

Hindfoot valgus

may place traction on the tibial nerve during repetitive:

Running.

This presentation has sometimes been termed:

Jogger’s foot.


Repetitive Squatting

Activities requiring repeated:

Squatting

or

Crouching

may increase pressure within the tarsal tunnel.

Historical examples include:

Race jockeys.


Pathophysiology

Tarsal tunnel syndrome develops when the tibial nerve or one of its branches is subjected to:

Compression

Traction

or both.


Restricted Tunnel Volume

Because the tarsal tunnel has relatively rigid boundaries, increases in local tissue volume may raise:

Intratunnel pressure.


Sensory Dysfunction

Sensory symptoms are thought to result partly from:

Nerve ischemia

and impaired:

Axonal conduction.


Motor Dysfunction

Late motor deficits may result from more prolonged:

Direct nerve compression

and axonal injury.


Chronic Traction

Repetitive traction can lead to:

Epineurial fibrosis

and decreased:

Nerve mobility.

This may make the nerve more susceptible to additional:

Compression or injury.


Etiology

A specific cause can be identified in approximately:

60–80% of patients.

Causes can broadly be grouped into:

Trauma

Space-occupying lesions

and

Foot or hindfoot deformity.


Common Causes

Historical series have reported approximate frequencies of:

Trauma – 17%

Varicosities – 13%

Hindfoot varus – 11%

Fibrosis – 9%

and

Hindfoot valgus – 8%.


Space-Occupying Lesions

Other causes include:

Ganglion cyst

Lipoma

Neurilemmoma

Inflammatory synovitis

Pigmented villonodular synovitis

Tarsal coalition

and

Accessory musculature.


Diagnosis

Tarsal tunnel syndrome is commonly:

Missed or misdiagnosed

because symptoms can be:

Variable

and

Poorly localized.


Signs and Symptoms

The typical presentation is an:

Insidious or intermittent onset

of neuropathic:

Pain

Burning

Paresthesia

or

Numbness.


Distribution of Symptoms

Symptoms depend on which branch of the tibial nerve is:

Affected.

They may involve the:

Plantar foot

Heel

or

Toes.


Valleix Phenomenon

Pain or paresthesia may radiate proximally up the:

Medial leg

along the course of the tibial nerve.

This is known as the:

Valleix phenomenon.

Historical series have reported it in approximately:

One-third of patients with severe compression.


Distal Radiation

Symptoms may also radiate distally along the distribution of the:

Medial or lateral plantar nerves.


Activity-Related Symptoms

Pain typically worsens with:

Prolonged standing

Walking

or

Activity.


Night Pain

Some patients report substantial:

Night pain.

Venous congestion or prolonged nerve irritation may contribute.


Factors That Relieve Symptoms

Symptoms may improve with:

Rest

Loose footwear

and

Elevation.


Physical Examination

A complete examination of the:

Foot and ankle

should be performed.


Foot Alignment

Assess the patient for:

Hindfoot valgus

or

Hindfoot varus.

Alignment abnormalities may increase:

Traction

or

Compression

on the tibial nerve.


Provocative Positioning

Forced:

Dorsiflexion

Inversion

or

Eversion

may reproduce symptoms by stretching or narrowing the:

Tarsal tunnel.


Palpation

Palpate the tarsal tunnel and the course of the tibial nerve for:

Tenderness

Swelling

or evidence of a:

Mass.


Tinel Sign

Percussion over the:

Tibial nerve

may reproduce distal:

Paresthesia.

A positive Tinel sign supports a diagnosis of:

Tibial nerve irritation.


Cuff Test

A pneumatic cuff may be used to produce temporary:

Venous congestion.

Engorgement of varicosities can reproduce symptoms when venous structures are contributing to:

Compression.

This test is used infrequently in modern practice.


Compression Test

Direct pressure over the:

Tarsal tunnel

for approximately:

60 seconds

may reproduce the patient’s:

Neuropathic symptoms.


Sensory Examination

Examine sensation over the territories of the:

Medial calcaneal

Medial plantar

and

Lateral plantar nerves.


Heel Sensation

The medial calcaneal nerve is often:

Spared

because it may branch proximal to the site of:

Compression.


Two-Point Discrimination

Reduced:

Two-point discrimination

may be an early finding of:

Sensory dysfunction.


Motor Examination

Motor deficits are usually:

Late findings.


Intrinsic Weakness

Weakness of the intrinsic muscles can be difficult to:

Detect clinically.


Toe Plantarflexion

Rarely, weakness of:

Toe plantarflexion

may be evident.


Muscle Atrophy

Late disease may produce atrophy of:

Abductor hallucis

or

Abductor digiti minimi.


Laboratory Tests

Routine laboratory tests do not diagnose:

Tarsal tunnel syndrome.

They may help identify systemic causes of:

Peripheral neuropathy.


Diabetes and Systemic Disease

Testing may be appropriate when evaluating for:

Diabetes mellitus

Vitamin deficiency

Thyroid disease

or other systemic:

Neuropathies.


Imaging


Weight-Bearing Radiographs

Routine weight-bearing foot and ankle radiographs help assess:

Alignment

Bony deformity

Exostosis

and

Tarsal coalition.


MRI

MRI is useful when evaluating for:

Space-occupying lesions

or other structural causes of:

Nerve compression.


MRI Findings

MRI can identify:

Ganglion cysts

Tumors

Varicosities

Accessory muscles

and inflammatory:

Soft-tissue abnormalities.


Diagnostic Yield

One historical study identified a potential causative abnormality on MRI in approximately:

88% of symptomatic feet.


Pediatric Considerations

In children, MRI is especially valuable because nerve compression may occasionally result from:

Neoplastic or other mass lesions.


Electrodiagnostic Studies

Electrodiagnostic testing may help evaluate:

Tibial nerve dysfunction

and identify more generalized:

Peripheral neuropathy.


Motor Latency

Isolated motor latency testing has relatively:

Low sensitivity.


Sensory Action Potentials

Sensory action potentials are among the more sensitive:

Electrodiagnostic measurements.

Historical data have reported sensitivity around:

90.5%

but with a modest:

False-positive rate.


Mixed Nerve Conduction Studies

Mixed motor-sensory conduction studies may demonstrate abnormalities with relatively good:

Specificity.

Historical series have reported abnormalities in approximately:

85.7% of cases.


Limitations of Electrodiagnostic Testing

Normal electrodiagnostic studies do not completely exclude:

Tarsal tunnel syndrome.

Findings must be interpreted together with:

History

Physical examination

and

Imaging.


Proximal Nerve Compression

Evaluation should also consider more proximal causes such as:

Lumbar radiculopathy

or a:

Double-crush phenomenon.


Pathological Findings

Surgical exploration may reveal:

Focal nerve swelling

Fibrosis

Scarring

or an identifiable:

Compressive lesion.


Differential Diagnosis

Important differential diagnoses include:

Diabetic peripheral neuropathy

Peripheral neuritis

Peripheral vascular disease

Morton neuroma

Metatarsalgia

Subtalar arthritis

Posterior tibial tendon dysfunction

Plantar fasciitis

Complex regional pain syndrome

Proximal tibial nerve or sciatic nerve compression

and

Lumbar radiculopathy.


Plantar Fasciitis

Plantar fasciitis usually produces:

Mechanical plantar heel pain

rather than burning or paresthetic:

Neuropathic symptoms.


Lumbar Radiculopathy

Lumbar nerve-root compression may mimic distal tibial nerve symptoms.

A complete neurologic examination should therefore include assessment for:

Proximal neurologic disease.


Treatment

Initial treatment is generally:

Nonoperative.

Exceptions include:

Acute severe nerve compression

or an identified:

Space-occupying lesion

that requires removal.


General Measures

Conservative treatment may include:

Activity modification

Rest

Temporary immobilization

Orthotics

Anti-inflammatory medication

Neuropathic pain medication

Physical therapy

Compression stockings

and

Weight reduction when appropriate.


Immobilization

A boot or brace may temporarily decrease:

Nerve irritation

by reducing repetitive:

Ankle and hindfoot motion.


Orthotics

Orthotic devices may help correct:

Hindfoot valgus

or other alignment abnormalities that increase:

Tibial nerve tension.


NSAIDs

NSAIDs may reduce:

Associated inflammatory pain

although they do not directly reverse:

Nerve compression.


Corticosteroid Injection

A carefully placed corticosteroid injection may sometimes reduce local:

Inflammation

or

Synovitis.

Injections should be performed cautiously because of the proximity of the:

Tibial nerve and vascular structures.


Neuropathic Pain Medication

Medications used for neuropathic symptoms may include selected:

Tricyclic antidepressants

or

Antiepileptic agents.


Nerve Blocks

Diagnostic or therapeutic:

Nerve blocks

may occasionally be used in selected patients.


Physical Therapy

Therapy may include:

Neural mobilization

Desensitization

Stretching

and correction of:

Biomechanical abnormalities.


Compression Stockings

When symptoms are related to:

Venous congestion

or

Varicosities

compression stockings may help reduce:

Local swelling.


Weight Management

Weight reduction may decrease repetitive:

Mechanical loading

and pressure around the:

Tarsal tunnel.


Surgery

Surgical decompression may be considered when:

Conservative treatment fails

or when a clear structural cause is identified.


Indications for Surgery

Typical indications include:

Persistent symptoms after approximately 3–6 months of nonoperative treatment

Acute tarsal tunnel syndrome

or

Space-occupying lesion.


Surgical Approach

A curved:

Posteromedial incision

is made along the course of the:

Tibial nerve.


Flexor Retinaculum Release

The entire:

Flexor retinaculum

should be released to decompress the proximal:

Tarsal tunnel.


Distal Decompression

The:

Medial plantar

and

Lateral plantar nerves

should also be released distally as they pass beneath the:

Abductor hallucis.


Space-Occupying Lesions

Any responsible lesion such as a:

Ganglion

Tumor

or other mass should be:

Excised or treated.


Associated Pathology

Underlying abnormalities such as:

Posterior tibial tendon dysfunction

or

Tarsal coalition

may also require treatment.


Scar Prevention

Surgical dissection should be minimized when possible because excessive tissue disruption may increase:

Postoperative scar formation

around the:

Nerve.


Follow-Up

Postoperative care usually begins with:

Protected non-weight-bearing.


Initial Immobilization

A splint is maintained until the incision heals, generally for approximately:

2–3 weeks.


Weight-Bearing Progression

After wound healing, patients gradually begin:

Weight bearing

and

Range-of-motion exercises.


Swelling Control

Elevation, compression, and other swelling-control measures may help reduce postoperative:

Edema.


Prognosis

Outcomes are generally more favorable when:

The patient is younger

Symptoms have been present for a shorter duration

and a specific:

Compressive lesion

can be identified.


Timing of Surgery

Results tend to be better when decompression is performed before development of:

Motor weakness

or

Muscle atrophy.


Surgical Outcomes

Historical reviews have reported improvement or resolution of symptoms in approximately:

90% of selected patients.

However, longer-term studies using stricter outcome criteria have reported:

Less predictable results

and deterioration of benefit in some:

Patients.


Complications

The principal adverse outcome is:

Persistent or recurrent symptoms after decompression.


Failed Tarsal Tunnel Release

Important causes of failed surgery include:

Incorrect initial diagnosis

Incomplete surgical release

Adhesive neuritis

Intraneural damage

and

Untreated proximal or additional nerve compression.


Incorrect Diagnosis

Symptoms may persist when the true problem is:

Lumbar radiculopathy

Peripheral neuropathy

or another:

Foot disorder.


Incomplete Release

Failure to release the full length of the:

Flexor retinaculum

or distal plantar nerve tunnels may leave residual:

Compression.


Adhesive Neuritis

Postoperative scar formation around the nerve may produce:

Adhesive neuritis

with recurrent:

Pain and paresthesia.


Intraneural Damage

Chronic systemic neuropathy or direct nerve injury may produce irreversible:

Intraneural damage.


Double-Crush Phenomenon

Symptoms may persist if both:

Distal tibial nerve compression

and a more proximal lesion such as:

Lumbar radiculopathy

are present.


Evaluation After Failed Release

The surgical scar and extent of the previous incision should be examined carefully because an incision that is too short may suggest:

Incomplete decompression.


Electrodiagnostic Testing After Failed Surgery

Electrodiagnostic studies are generally less useful for determining the cause of:

Failed tarsal tunnel release.


Revision Surgery

Revision decompression may be considered in selected patients with:

Incomplete release

or

Adhesive neuritis.


Barrier Procedures

In cases of extensive scar formation, the nerve may be wrapped with:

Vein

or

Synthetic biologic material

to reduce recurrent:

Adhesion formation.


Revision Prognosis

Outcomes after:

Revision surgery

are generally less favorable than after successful:

Primary decompression.


Patient Monitoring

Patients should be followed for changes in:

Pain

Paresthesia

Sensation

Intrinsic muscle strength

and

Functional walking tolerance.


Key Principle

Tarsal tunnel syndrome is an entrapment neuropathy of the tibial nerve or its distal branches within the fibro-osseous tunnel along the medial ankle.

Symptoms typically include:

Burning pain, paresthesia, numbness, and activity-related plantar foot discomfort, sometimes with a positive:

Tinel sign.

Evaluation should identify potential causes such as:

Trauma, varicosities, hindfoot deformity, fibrosis, ganglion cyst, tumor, tarsal coalition, or accessory muscle.

Initial treatment is usually:

Nonoperative, using activity modification, orthotics, medication, physical therapy, and treatment of contributing deformity or swelling.

Surgical decompression is considered for:

Persistent symptoms, acute compression, or a defined space-occupying lesion, and should include release of the:

Flexor retinaculum and distal medial and lateral plantar nerve tunnels.



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Kembara Xtra 

Facts about medicine and its subtopic such as anatomy, physiology, biochemistry, pharmacology, medicine, pediatrics, psychiatry, obstetrics and gynecology and surgery.