Orthopaedic Surgery - Carpal Tunnel Syndrome

Basics

Carpal tunnel syndrome (CTS) is a compressive neuropathy of the median nerve as it passes through the carpal tunnel at the wrist.

The carpal tunnel is a relatively rigid anatomical space. Its floor is formed by the volar radiocarpal and intercarpal ligaments, while the transverse carpal ligament forms the roof.

Within the tunnel pass nine flexor tendons—the four flexor digitorum profundus tendons, four flexor digitorum superficialis tendons, and the flexor pollicis longus tendon—together with the median nerve.

Because there is little room for expansion, any increase in pressure within the tunnel may compress the median nerve.

Functional Effects

Compression of the median nerve may cause numbness, paresthesias, pain, weakness, and impaired fine motor function.

Sensory symptoms usually involve the palmar surface of the thumb, index finger, middle finger, and radial half of the ring finger.

With more advanced compression, weakness or atrophy of the thenar muscles may develop, particularly affecting thumb palmar abduction.

Pregnancy Considerations

Carpal tunnel syndrome occurs more frequently during pregnancy than in the general population.

Symptoms commonly improve or resolve after delivery as pregnancy-related fluid retention decreases.

Initial treatment generally consists of a nighttime wrist splint maintaining the wrist in neutral.

A corticosteroid injection may be considered for persistent symptoms when appropriate, with medication safety reviewed in conjunction with the patient’s obstetric care.

Surgery During Pregnancy

Because pregnancy-related CTS frequently resolves postpartum, surgery is generally deferred when possible.

However, severe cases involving persistent numbness, progressive weakness, or major functional impairment may occasionally require surgical decompression during pregnancy.

When necessary, carpal tunnel release can be performed using local anesthesia.

Epidemiology

Carpal tunnel syndrome affects approximately 4–5% of the population.

It occurs most frequently between approximately 40 and 60 years of age and is more common in women than men.

CTS is the most frequently diagnosed compressive neuropathy of the upper extremity.

Risk Factors

Recognized risk factors include female sex, diabetes mellitus, hypothyroidism and other endocrine abnormalities, smoking, elevated body mass index, pregnancy, perimenopausal status, rheumatoid arthritis, and previous hand or wrist tendinopathy.

Forceful repetitive hand use may also contribute.

The relationship between CTS and routine computer use remains controversial.

Occupational Factors

Work involving forceful gripping, sustained wrist positioning, repetitive hand exertion, or vibration may increase symptoms in susceptible individuals.

In occupational cases, modification of the provoking activity can be an important part of treatment.

Genetics

No specific genetic factor has been definitively established as a direct cause of carpal tunnel syndrome.

However, inherited differences in anatomy, body habitus, and systemic disease susceptibility may indirectly influence risk.

Pathophysiology

CTS develops when increased pressure within the carpal tunnel compromises the median nerve.

Compression and traction can impair the nerve’s microcirculation, producing edema and reduced oxygen delivery.

Repeated or prolonged compression may subsequently produce recurrent demyelination and slower nerve conduction.

Nerve Conduction Changes

As compression becomes more severe, electrical impulses travel more slowly through the median nerve at the wrist.

Prolonged compression may eventually cause axonal injury, resulting in persistent numbness, weakness, and thenar muscle atrophy.

Etiology

Any process that reduces the available space within the carpal tunnel or increases its contents can compress the median nerve.

In many patients, no single structural cause is identified.

Common Causes

Potential causes include flexor tenosynovitis, previous trauma involving the carpal bones, ganglion cysts, fibromas, lipomas, rheumatoid cysts, gout, and diabetic neuropathy.

Inflammatory swelling of the tendon sheaths may be particularly important because all nine flexor tendons pass through the same confined space.

Diagnosis

Carpal tunnel syndrome can often be diagnosed accurately through a careful history and physical examination.

Evaluation should include assessment for sensory disturbance, thenar weakness or atrophy, and reproduction of symptoms with provocative maneuvers.

Electrodiagnostic testing can support the diagnosis and determine severity but is not mandatory in every straightforward case.

Signs and Symptoms

Typical symptoms include numbness and tingling in the median nerve distribution, hand weakness or clumsiness, and pain involving the hand, wrist, or distal forearm.

Symptoms are frequently worse at night.

Many patients wake from sleep because of painful numbness or tingling and may shake the hand to obtain relief.

Sensory Distribution

Paresthesias typically involve the thumb, index finger, middle finger, and radial half of the ring finger.

The little finger is usually spared.

Symptoms may occasionally radiate proximally into the wrist or forearm.

Motor Symptoms

Patients may notice difficulty with tasks requiring fine motor control, such as buttoning clothing, handling coins, writing, or gripping small objects.

More advanced disease may cause weakness of thumb palmar abduction due to involvement of the abductor pollicis brevis.

Nocturnal Symptoms

Nighttime symptoms are particularly characteristic.

Wrist flexion during sleep may increase carpal tunnel pressure and aggravate median nerve compression.

This explains why neutral-position nighttime splinting can be effective.

Tinel Sign

The Tinel sign is elicited by gently tapping over the median nerve at the carpal tunnel while the wrist is held in a neutral position.

A positive test reproduces tingling or electric sensations in the median nerve distribution of the hand.

Phalen Test

The Phalen test is performed by placing the wrist in full flexion, traditionally around 90°, and maintaining the position.

Development of paresthesias in the median nerve distribution within approximately 30–60 seconds supports the diagnosis.

Flexion-Compression Test

For the flexion-compression test, the elbow is extended and the forearm is supinated.

The wrist is flexed to approximately 60°, and direct pressure is applied over the median nerve at the carpal tunnel.

Reproduction of median-distribution paresthesias within about 30 seconds is considered a positive finding.

Physical Examination

The hand should be inspected for thenar muscle wasting.

Strength of thumb palmar abduction should be assessed carefully because weakness may indicate advanced median nerve compression.

Thenar Atrophy

Visible flattening or wasting of the thenar eminence suggests chronic or severe CTS.

Once substantial muscle atrophy has developed, full motor recovery after decompression may be incomplete.

Sensory Examination

Sensation should be tested over the thumb and fingers.

Two-point discrimination can be measured on the radial and ulnar sides of each fingertip.

Normal discrimination is generally less than approximately 5–6 mm, or should be symmetric with the opposite hand when symptoms are unilateral.

Examination for Other Neuropathies

The entire upper extremity should be examined for alternative or additional sites of nerve compression.

Conditions such as cervical radiculopathy, proximal median nerve entrapment, and cubital tunnel syndrome may mimic or coexist with CTS.

Laboratory Tests

Laboratory investigations are not required in every patient but may be useful when a systemic cause is suspected.

Tests may include erythrocyte sedimentation rate, serum glucose, serum uric acid, and thyroid function studies.

These investigations may identify inflammatory, metabolic, endocrine, or crystal-related conditions contributing to nerve compression.

Electrodiagnostic Studies

Electromyography and nerve conduction studies can confirm median nerve compression at the wrist and help determine its severity.

They can also identify additional abnormalities elsewhere along the nerve pathway.

Double-Crush Syndrome

Electrodiagnostic testing may help detect a double-crush syndrome, in which median nerve dysfunction at the wrist coexists with a more proximal lesion, such as cervical radiculopathy or proximal median nerve compression.

This possibility is particularly important when symptoms persist despite apparently adequate carpal tunnel treatment.

Imaging

Plain Radiographs

Routine radiographs are not necessary for uncomplicated CTS.

Wrist radiographs may be useful in patients with a history of trauma, deformity, or longstanding inflammatory arthritis.

They can demonstrate fractures, malalignment, arthritis, or other structural abnormalities affecting the carpal tunnel.

Cervical Spine Imaging

Cervical spine radiographs may be useful when a proximal neurologic cause is suspected.

They can also demonstrate abnormalities such as a cervical rib when thoracic outlet syndrome is being considered, although thoracic outlet symptoms more often resemble ulnar-sided neuropathy.

Differential Diagnosis

Important differential diagnoses include thoracic outlet syndrome, cervical nerve root compression from degenerative disc disease or tumor, proximal median nerve entrapment, and cubital tunnel syndrome.

Clinical distribution of symptoms and electrodiagnostic testing can help distinguish these disorders.

Treatment

General Measures

Initial management is usually nonoperative, particularly in mild or intermittent disease.

The principal conservative measures are nighttime wrist splinting, activity modification, and corticosteroid injection in selected patients.

Nighttime Splinting

A wrist splint should hold the wrist in a neutral position during sleep.

Excessive flexion or extension increases carpal tunnel pressure and can worsen symptoms.

Night splinting is particularly useful for patients with nocturnal paresthesias.

Duration of Splinting

To determine whether conservative treatment is effective, nighttime splinting should generally be used consistently for at least 1 month.

Patients who improve while wearing the splint but experience rapid symptom recurrence after discontinuation may ultimately require surgical treatment.

Activity Modification

When symptoms are associated with work or repetitive activity, modification of the provoking tasks is recommended.

Reducing forceful gripping, repetitive wrist motion, prolonged wrist flexion or extension, and other aggravating activities may reduce symptoms.

Corticosteroid Injection

A corticosteroid injection into the carpal tunnel may provide temporary or sometimes prolonged symptom relief.

Injection should be performed by an experienced clinician because inadvertent injection into or injury of the median nerve can cause significant neurologic damage.

Indications for Corticosteroid Injection

Injection is particularly useful when compression is expected to be temporary, such as during pregnancy, or when modification of the precipitating activity is feasible.

It may also serve as a therapeutic trial in mild to moderate CTS.

Physical Therapy

Formal physical therapy is not routinely required for uncomplicated carpal tunnel syndrome.

Therapy may be useful for workplace modification, ergonomic assessment, or selected hand and nerve-gliding programs, although these are generally adjunctive rather than primary treatment.

Medication

No oral medication has been shown to specifically reverse median nerve compression within the carpal tunnel.

Analgesics may relieve pain temporarily but do not correct the underlying mechanical compression.

Indications for Surgery

Carpal tunnel release is considered when conservative treatment has failed or when there is evidence of constant numbness, motor weakness, thenar atrophy, or significant electrodiagnostic abnormality.

Progressive neurologic deficit is a particularly strong indication for decompression.

Surgical Principle

The goal of surgery is to decompress the median nerve by dividing the transverse carpal ligament.

This increases the volume of the carpal tunnel and reduces pressure on the nerve.

Open Carpal Tunnel Release

Open release is performed through a longitudinal palmar incision.

The incision is typically positioned in line with the ulnar border of the ring finger axis and provides direct visualization of the transverse carpal ligament and median nerve.

The ligament is divided completely to decompress the nerve.

Mini-Open Release

A mini-open technique uses a smaller incision while maintaining direct visualization of the ligament.

Its aim is to reduce soft-tissue disruption while achieving complete decompression.

Endoscopic Carpal Tunnel Release

Endoscopic release divides the transverse carpal ligament through one or more small portals using an endoscopic system.

Long-term results are generally similar to those of open release.

Some patients may return to work more quickly and experience less early scar discomfort.

Open Versus Endoscopic Release

At approximately 6 months and beyond, open and endoscopic procedures generally provide comparable symptom relief.

Endoscopic release may result in faster early functional recovery and less scar tenderness in some patients.

However, the risk of nerve injury may be slightly higher with endoscopic techniques.

Follow-Up

Patients treated conservatively should be reassessed for persistence or progression of numbness, nocturnal symptoms, weakness, and functional impairment.

Failure of a reasonable period of nonoperative management may warrant surgical referral.

Prognosis With Nonoperative Treatment

Many patients with mild or occupationally related CTS improve with a combination of night splinting, corticosteroid injection, and modification of aggravating activities.

If the provoking work activity continues unchanged, conservative measures may provide only temporary relief.

Prognosis After Surgery

Pain often improves very quickly after carpal tunnel release.

Numbness usually recovers more gradually over the following weeks to months because the median nerve requires time to recover from chronic compression.

Severe Compression

Patients with longstanding or severe compression may not regain completely normal sensation or motor strength even after technically successful decompression.

Permanent nerve injury may already have occurred before surgery.

Recovery of Strength

Grip and thenar strength may take 6 months or longer to recover maximally after release.

The speed and completeness of recovery depend partly on the duration and severity of preoperative nerve compression.

Complications

Possible complications include iatrogenic injury to the median nerve or its branches, painful scar formation, pillar pain, incomplete release, infection, and persistent or recurrent symptoms.

Nerve injury can occur with either open or endoscopic surgery but may be slightly more frequent with endoscopic techniques.

Scar Sensitivity

Tenderness or hypersensitivity around the surgical incision can occur, particularly after open release.

This usually improves gradually over several months but may persist in a minority of patients.

Pillar Pain

Pillar pain refers to discomfort on either side of the carpal tunnel after release, often around the thenar or hypothenar regions.

It commonly improves with time but can temporarily interfere with gripping or weight-bearing through the palm.

Persistent Symptoms After Surgery

Persistent symptoms after decompression may result from incomplete division of the transverse carpal ligament, an incorrect initial diagnosis, severe irreversible nerve damage, or an untreated proximal compression site.

A double-crush syndrome or generalized peripheral neuropathy should also be considered.

Patient Monitoring

Patients receiving conservative treatment should be monitored for progression from intermittent symptoms to constant numbness or motor weakness.

Development of thenar atrophy or persistent sensory loss should prompt surgical consideration.

Postoperative Monitoring

After surgery, patients are typically reviewed for wound assessment and suture removal.

Activity can then be increased progressively if wound healing is satisfactory.

Neurologic recovery may continue for several months after the incision itself has healed.

Patient Teaching

Patients should avoid prolonged or repetitive wrist positions that aggravate symptoms.

Workstation or occupational modifications may be useful when symptoms are related to repetitive or forceful hand activity.

Prevention

Reducing prolonged wrist flexion or extension and minimizing repetitive forceful hand use may help decrease symptoms in susceptible individuals.

Maintaining appropriate ergonomic wrist positioning may also be beneficial.

Frequently Asked Question: Should Pregnancy-Related CTS Be Treated Surgically?

CTS arising during pregnancy often improves after delivery.

Initial treatment should therefore consist of nighttime neutral wrist splinting, with corticosteroid injection considered when appropriate.

Surgery is generally deferred until after delivery so that spontaneous resolution can be assessed, although severe cases can be treated surgically under local anesthesia when necessary.

Frequently Asked Question: Can CTS Recur After Surgical Release?

True recurrence after an adequately performed release is uncommon.

Persistent or recurrent symptoms should prompt evaluation for incomplete ligament release, an alternative diagnosis, double-crush syndrome, or an underlying peripheral neuropathy.

Frequently Asked Question: What Are the Typical Symptoms?

Typical symptoms are pain, numbness, and tingling, especially at night.

The sensory symptoms usually involve the thumb, index finger, middle finger, and radial half of the ring finger.

Patients may also experience difficulty with fine motor tasks or hand clumsiness.

When motor weakness develops, the abductor pollicis brevis is commonly affected.

Orthopaedic Surgery - Camptodactyly

Basics

Camptodactyly is a nontraumatic flexion deformity of the proximal interphalangeal (PIP) joint that may gradually progress over time.

It most commonly involves the little finger, although one or more adjacent fingers may occasionally be affected.

The condition may occur in isolation or as part of a recognized congenital or genetic syndrome.

Types of Camptodactyly

Two main clinical patterns are recognized: early-onset and delayed-onset camptodactyly.

The early form develops during the first year of life and is the more common type.

It affects males and females approximately equally.

The delayed or late form usually begins after approximately 10 years of age and occurs predominantly in girls.

Terminology

The two patterns have sometimes been described as congenital and adolescent camptodactyly.

However, some clinicians prefer the terms early and delayed or late camptodactyly because both forms probably represent variations of the same underlying disorder rather than completely separate diseases.

Importance of Age at Treatment

Treatment generally produces the best results when initiated during childhood or adolescence.

Once the deformity becomes longstanding and fixed in adulthood, correction is much more difficult and the results of treatment are generally poor.

Epidemiology

Camptodactyly is uncommon and affects less than 1% of the population.

Risk Factors

A positive family history increases the likelihood of developing the condition.

However, many affected patients have no known relatives with camptodactyly.

Genetics

Many cases occur sporadically.

Familial cases may demonstrate autosomal dominant inheritance, although expression and severity can vary considerably among family members.

Pathophysiology

The precise structural abnormality responsible for camptodactyly is variable.

Almost every soft-tissue structure capable of producing PIP flexion has been implicated.

The final deformity results from an imbalance between the flexor and extensor mechanisms of the PIP joint.

Lumbrical Abnormalities

Abnormalities of the lumbrical muscle may include absence, atrophy, or an abnormal insertion into the lumbrical canal.

These abnormalities can alter the balance of forces across the PIP joint and contribute to progressive flexion.

Flexor Tendon Abnormalities

A fibrous band may arise from the A1 pulley and insert into the flexor digitorum superficialis tendon.

The flexor digitorum superficialis may also have an abnormal origin from the palmar fascia.

Other abnormalities include anomalous tendons and a relatively short flexor digitorum profundus.

Capsular and Ligamentous Abnormalities

Contracture of the collateral ligaments or volar plate may develop as the deformity progresses.

These secondary changes make the PIP joint increasingly stiff and can convert an initially flexible deformity into a fixed contracture.

Etiology

Camptodactyly is thought to result from disturbed balance between the flexor and extensor mechanisms at the PIP joint.

Frequently identified anatomical abnormalities include unusual insertions or relationships of the lumbrical muscle, flexor digitorum superficialis, and retinacular ligamentous structures.

Because the anatomic cause differs among patients, no single treatment is successful in every case.

Associated Conditions

Camptodactyly may occur as part of several syndromes and congenital disorders.

Reported associations include trisomy 13–15, oculodentodigital syndrome, orofaciodigital syndrome, Aarskog syndrome, cerebrohepatorenal syndrome, mucopolysaccharidosis, osteo-onychodysostosis, and Jacob-Downey syndrome.

Diagnosis

Signs and Symptoms

The characteristic finding is a flexion deformity of the PIP joint, most commonly affecting the little finger.

Adjacent fingers may occasionally demonstrate similar involvement.

Pain and swelling are usually absent, even when the contracture is severe.

Bilateral Involvement

Approximately two-thirds of patients have involvement of both hands.

The degree of deformity does not necessarily match from side to side.

When only one hand is affected, the right hand is more commonly involved.

Position of the MCP Joint

The metacarpophalangeal joint is often held in slight hyperextension.

This compensatory posture may partially offset the functional effect of PIP flexion.

For this reason, relatively mild contractures can be well tolerated.

Effect of Wrist Position

In children, the deformity may become less pronounced or temporarily disappear when the wrist is flexed.

This finding reflects the dynamic relationship between the flexor tendons and PIP joint position.

Severe Deformity

In more advanced cases, the finger may also develop a rotational component.

The patient may complain that the digit interferes with gripping, typing, tapping, or other fine hand activities.

Camptodactyly Versus Clinodactyly

Camptodactyly should not be confused with clinodactyly.

Camptodactyly describes a flexion deformity in the sagittal plane at the PIP joint.

Clinodactyly refers to angular deviation of a digit in the radioulnar plane.

Physical Examination

Active and passive motion of the PIP and MCP joints should be carefully measured.

The examination should be performed with the wrist in both flexion and extension.

This helps determine how much of the deformity is dynamic and how much represents a fixed contracture.

Flexible Versus Fixed Deformity

An important part of the examination is determining whether the PIP contracture can be corrected passively.

A flexible deformity is more likely to respond to splinting and stretching.

A fixed contracture suggests established soft-tissue or joint changes and has a less favorable prognosis.

Imaging

Plain Radiographs

Plain radiographs of the involved digit should be obtained, particularly when the deformity is longstanding or severe.

Early in the condition, radiographs may be relatively normal.

Structural changes can develop with growth and prolonged contracture.

Radiographic Changes

Longstanding camptodactyly may produce broadening of the base of the middle phalanx.

The neck of the proximal phalanx may become indented, giving the proximal phalangeal head a characteristic beaked appearance.

Advanced Joint Changes

Other radiographic abnormalities may include narrowing of the PIP joint space, dorsal flattening of the proximal phalangeal condyle, flattening of the palmar surface, and volar subluxation of the middle phalanx.

These structural changes indicate a more established deformity and reduce the likelihood of achieving complete correction.

Differential Diagnosis

Diagnosis is based primarily on a careful history and physical examination.

The differential diagnosis includes clinodactyly, post-traumatic deformity, Dupuytren contracture, arthrogryposis, absence or hypoplasia of an extensor tendon, Marfan syndrome, Beals syndrome or congenital contractural arachnodactyly, pterygium syndrome, symphalangism, and boutonniere deformity.

Treatment

General Principles

There is no single universally successful treatment because camptodactyly can arise from several different anatomical abnormalities.

The goal is to restore or improve the balance between the flexor and extensor mechanisms while maintaining useful joint motion.

Early-Onset Camptodactyly

In early-onset disease, the preferred initial treatment is generally progressive extension splinting.

Because younger patients often have flexible soft tissues and less-established joint deformity, conservative treatment can be particularly effective.

Delayed-Onset Camptodactyly

Delayed or adolescent camptodactyly is also initially treated conservatively.

Surgery may be considered if the deformity is severe, progressive, functionally limiting, or fails to respond to splinting.

Mild Contractures

A PIP flexion contracture of less than approximately 30–40° often causes little functional impairment.

Compensatory hyperextension at the MCP joint allows many patients to use the hand normally.

In such cases, observation and acceptance of the deformity are often preferable to surgery.

Counseling

Patients and families should be informed that operative results can be unpredictable.

For mild deformities, many surgeons recommend accepting the appearance rather than risking increased stiffness or pain from surgery.

Splinting

Splinting is the mainstay of conservative treatment.

Static extension splints, often worn at night, can help maintain or improve PIP extension.

Progressive splinting is especially effective when the deformity remains flexible.

Serial Casting

Serial plaster casting may be used when splinting alone does not provide sufficient correction.

The PIP joint is gradually brought toward extension over a series of casts.

Casting should generally be attempted before operative treatment.

Occupational Therapy

Occupational or hand therapy may be helpful in both early and delayed forms.

The therapist can supervise stretching, splint fabrication, skin care, and progressive range-of-motion exercises.

Night splinting is often recommended to reduce progression.

Indications for Surgery

Surgery is generally reserved for severe and progressive deformity, especially when the flexion contracture exceeds approximately 60° and causes functional limitation or significant unacceptable deformity.

Operative intervention may also be considered to prevent progressive, irreversible articular changes in carefully selected patients.

Patient Selection for Surgery

Surgical candidates should be chosen carefully.

The best candidates are younger patients with deformities that remain at least partially correctable and have a clearly defined anatomical cause.

A treatment plan should be tailored to the clinical examination rather than applying a single operation to every patient.

Surgical Goals

Surgery attempts to correct the abnormal anatomy by releasing, lengthening, or transferring abnormal muscle, tendon, capsular, or ligamentous structures.

Because multiple abnormalities may coexist, procedures are often performed in a stepwise fashion.

Soft-Tissue Release

Severe deformities may require release of contracted skin and soft tissues.

Local flap coverage may occasionally be needed when correction creates a skin deficit.

Flexor Digitorum Superficialis Tenotomy

When the flexor digitorum superficialis contributes significantly to the contracture, tenotomy or lengthening may be performed.

This reduces the abnormal flexion force across the PIP joint.

Volar Plate Release

A contracted volar plate can prevent full PIP extension.

A sliding or formal volar plate release may be incorporated into surgical correction when capsular contracture is present.

Extensor Mechanism Rebalancing

Residual extension lag may require procedures aimed at restoring the balance of the extensor mechanism.

These procedures can include tendon transfers or adjustments of the central slip and lateral bands.

Fowler Tenotomy

In selected severe cases, a Fowler-type tenotomy may be used as part of extensor mechanism rebalancing.

The procedure alters the relationship between the central slip and lateral bands to improve extension forces across the PIP joint.

Tendon Transfer

Tendon transfer may be considered particularly in adolescent camptodactyly when an abnormal tendon or muscular imbalance is a major contributor.

The goal is to redirect force and improve active PIP extension.

Corrective Osteotomy

If radiographs demonstrate established bony deformity or joint remodeling, a procedure aimed solely at increasing joint motion may be ineffective.

In these cases, a corrective extension osteotomy may provide better alignment.

PIP Arthrodesis

When the PIP joint is severely damaged, deformed, painful, or no longer salvageable, PIP joint arthrodesis may be considered.

Fusion sacrifices motion but can provide a stable finger positioned in a more functional alignment.

Surgery in Adults

Corrective surgery initiated in adulthood generally produces poor results.

Adult patients are at greater risk of increased stiffness and pain after intervention.

For this reason, routine reconstructive surgery in adults is generally discouraged unless there is a compelling functional indication.

Follow-Up

Camptodactyly should be monitored throughout growth because progression is common during childhood and adolescence.

The degree of PIP contracture, passive correctability, hand function, and radiographic changes should be followed over time.

Prognosis

Without treatment, approximately 80% of cases may progressively worsen.

Progression is particularly common during periods of rapid skeletal growth.

Growth Spurts

The deformity often becomes more noticeable during growth spurts, when abnormal soft-tissue structures fail to lengthen at the same rate as the skeleton.

This is why periodic reassessment during childhood and adolescence is important.

Natural History After Maturity

Progression usually slows or stops after approximately 18–20 years of age, once skeletal growth is complete.

However, any fixed contracture present at maturity may persist permanently.

Complications

Surgery, particularly in adults or patients with longstanding fixed deformity, can lead to increased PIP stiffness and pain.

Other potential problems include incomplete correction, recurrence, scarring, or reduced active motion.

Patient Monitoring

Because younger patients have the greatest potential for successful treatment, early recognition and continued monitoring are important.

The deformity should be reassessed during periods of growth for increasing contracture or functional limitation.

Patient Teaching

Patients and families should inspect the skin regularly when splints are being used.

Pressure areas, redness, or skin breakdown should prompt adjustment of the splint.

Stretching should continue after completion of casting or intensive splinting to preserve the correction achieved.

Activity

Most patients require no activity restrictions.

Mild deformity usually does not interfere significantly with daily life, sports, or school activities.

Severe contracture may interfere with occupations, sports, or tasks requiring precise fine-motor hand function.

Prevention

There is no established method for preventing camptodactyly.

Early identification and treatment may, however, reduce progression and secondary joint deformity.

Frequently Asked Question: How Often Are Both Hands Involved?

Camptodactyly is bilateral in approximately two-thirds of patients.

The little finger is the most commonly affected digit, although adjacent fingers may also be involved.

Frequently Asked Question: Is Surgery Usually Recommended?

No. Mild contractures of less than approximately 30–40° generally cause little functional impairment and are usually treated nonoperatively.

Because surgical results are variable, surgery is generally reserved for severe, progressive deformities that interfere with function or produce major unacceptable deformity.

Stretching should be continued after the splinting or casting program to maintain the gain achieved  Activity Generally, no limitations are placed on activity

In severe cases, the deformity may pose a problem in sports or occupations requiring fine work with the hands  Prevention No effective means of prevention exists  FAQ Q: How often does camptodactyly affect both hands?

A: It is bilateral in 2/3 of cases; the 5th finger is most commonly involved. Q: Is surgery recommended to correct the deformity?  A: Mild contracture (<30–40°) does not interfere with function and should be treated nonoperatively. Surgical results are not consistent, and surgery usually is reserved for more severe cases that hinder activity.

Orthopaedic Surgery - Calcaneovalgus Foot

Basics

Calcaneovalgus foot is a congenital positional deformity believed to result from abnormal positioning of the fetal foot within the uterus.

The hindfoot is held in valgus, while the entire foot is markedly dorsiflexed.

In pronounced cases, the dorsum of the foot may rest against or nearly touch the anterior surface of the tibia.

Epidemiology

Calcaneovalgus foot is seen in newborn infants.

It occurs more frequently in girls and has an association with breech presentation or delivery.

It is one of the most common congenital foot deformities encountered in the neonatal period.

Prevalence

The condition has been reported in varying degrees in approximately 0.5–30% of births.

The wide range reflects differences in diagnostic criteria and the fact that mild positional deformities may resolve rapidly.

Pathophysiology

Calcaneovalgus foot is primarily a soft-tissue positional deformity rather than a structural bony abnormality.

The Achilles tendon is temporarily stretched because the foot has been held in excessive dorsiflexion.

After birth, the soft tissues gradually regain normal length and balance, and spontaneous correction usually occurs.

Bony Anatomy

There are no primary bony abnormalities in a typical calcaneovalgus foot.

This distinction is important because structural congenital deformities such as vertical talus require different treatment.

Associated Conditions

Infants with calcaneovalgus feet should be examined for other positional abnormalities that may also result from intrauterine positioning.

Important associated conditions include developmental dysplasia of the hip (DDH) and torticollis.

Relationship to Pes Planus

There is no convincing evidence that calcaneovalgus foot predisposes a child to pes planus or flatfoot later in life.

Most affected feet develop normal shape and function.

Diagnosis

Signs and Symptoms

The deformity is present at birth and is generally painless and asymptomatic.

The foot is markedly dorsiflexed, often to the point that its dorsum rests against the anterior tibia.

The hindfoot is positioned in valgus.

Muscle Tightness

Occasionally, there may be temporary contracture or tightness of the anterior compartment muscles and dorsiflexors.

Despite this, the deformity is usually flexible.

Flexibility of the Foot

Most calcaneovalgus feet can be passively brought into plantarflexion without substantial difficulty.

The degree of flexibility is an important diagnostic feature and helps distinguish the condition from fixed structural deformities.

Physical Examination

The appearance of the foot is usually sufficient to establish the diagnosis.

The examiner should assess whether the foot can be passively plantarflexed and supinated.

In some newborns, complete correction may not be achievable immediately, but progressive improvement should occur.

Calcaneal Position

The orientation of the calcaneus is especially important.

In calcaneovalgus foot, the hindfoot is dorsiflexed, and the heel points downward.

This finding helps distinguish the condition from congenital vertical talus.

Imaging

Plain Radiographs

Imaging is not routinely required when the physical examination is typical.

If the diagnosis is uncertain, standard anteroposterior and lateral radiographs of the foot and ankle may be obtained.

Radiographs are primarily used to exclude a structural or bony abnormality.

Differential Diagnosis

The main differential diagnoses include congenital vertical talus, posteromedial bowing of the tibia, and neurologic dorsiflexion deformity caused by L5 weakness.

Careful examination of the hindfoot and tibia usually differentiates these conditions.

Congenital Vertical Talus

Congenital vertical talus, also called convex pes valgus, is a rigid structural foot deformity.

Unlike calcaneovalgus foot, the calcaneus is held in plantarflexion or equinus.

The Achilles tendon is contracted, and the navicular is dorsally dislocated over the talar neck.

Distinguishing Vertical Talus

The direction of the heel is a useful clinical clue.

In congenital vertical talus, the heel is positioned upward because the calcaneus is plantarflexed.

In calcaneovalgus foot, the heel points downward because the calcaneus is dorsiflexed.

Posteromedial Bowing of the Tibia

Posteromedial bowing of the tibia can produce a foot that appears dorsiflexed and everted, similar to calcaneovalgus.

However, the primary abnormality is a bow in the tibia itself, rather than a positional deformity at the foot and ankle.

The bony curvature can usually be palpated on examination.

L5 Paresis

Neurologic weakness involving the L5 nerve root, such as may occur in spina bifida, can produce a fixed dorsiflexed foot because of muscle imbalance.

The presence of neurologic abnormalities and a less flexible deformity helps distinguish this from simple calcaneovalgus.

Treatment

General Measures

The most important aspect of treatment is reassurance of the parents.

Calcaneovalgus foot is a benign positional deformity that usually corrects spontaneously as the infant grows.

Parents may require repeated reassurance because the initial appearance can be dramatic.

Stretching

Gentle stretching exercises may be performed several times each day.

Parents can be taught to gently plantarflex and supinate the foot to encourage correction.

These exercises are optional in mild cases because spontaneous improvement is expected even without treatment.

Serial Casting

Occasionally, when the deformity is more pronounced or correction is slower than expected, serial casting may be used.

Casting can accelerate correction by maintaining the foot in a more neutral position.

Activity

No activity restrictions are necessary.

The deformity usually improves rapidly and does not interfere with normal infant development.

Surgery

Surgical treatment is not required for true calcaneovalgus foot.

The need for surgery should prompt reconsideration of the diagnosis and evaluation for another structural deformity.

Referral

Infants with a marked deformity, an unusually rigid foot, or possible congenital vertical talus should be referred to an orthopaedic specialist.

Referral is also appropriate when the diagnosis is uncertain or expected spontaneous improvement does not occur.

Follow-Up

Most infants require only periodic clinical observation.

Follow-up should document progressive improvement in foot position and confirm that the hindfoot becomes increasingly flexible and normally aligned.

Prognosis

The prognosis is excellent.

The deformity gradually corrects, and affected children generally develop a foot with normal appearance, strength, alignment, and function.

Long-Term Outcome

There is no definite evidence that children with calcaneovalgus foot are more likely to develop flatfoot later in life.

Normal walking and activity are expected.

Complications

Complications are rare.

Occasionally, subluxation of the peroneal tendons may occur.

When present, this problem generally responds to serial casting and resolves without long-term functional impairment.

Patient Monitoring

Parents should observe for progressive spontaneous correction.

Persistent rigidity, failure to improve, worsening deformity, or an abnormal heel position should prompt reassessment to exclude congenital vertical talus or another structural or neurologic disorder.

Orthopaedic Surgery - Burners (Stingers)

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Basics

A burner or stinger is a transient neurologic injury most commonly seen in athletes participating in contact or collision sports.

The injury usually involves compression, traction, or a combination of both affecting the upper trunk of the brachial plexus, particularly the C5 and C6 nerve roots.

Patients typically experience a sudden burning or electric pain radiating from the neck or shoulder into the arm, sometimes accompanied by numbness, tingling, or weakness.

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Mechanism of Compression

Compression can occur when the athlete’s head is forcibly turned or bent toward the injured side.

This narrows the neural foramina and may compress the cervical nerve roots or upper brachial plexus.

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Mechanism of Traction

Traction injury occurs when the shoulder and arm are forced downward while the neck bends or rotates toward the opposite side.

This stretches the upper portion of the brachial plexus and may transiently impair nerve conduction.

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Direct-Blow Mechanism

A direct impact over Erb point, located approximately 2–3 cm above the clavicle where the C5 and C6 nerve roots converge, can also produce a stinger.

This mechanism can directly compress or contuse the upper trunk of the brachial plexus.

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Age-Related Pattern

Burners are more commonly encountered in younger athletes.

Older athletes experiencing a similar mechanism are more likely to have a cervical nerve root injury because degenerative changes and cervical stenosis become more common with age.

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Classification

Stingers can be classified according to the severity of nerve injury.

Grade I represents a neurapraxia, in which nerve conduction is temporarily impaired without permanent structural disruption. Symptoms are generally short-lived and there may be no persistent motor or sensory deficit.

Grade II represents axonotmesis, with disruption of axons but preservation of some supporting nerve structures. Motor weakness is usually present and sensory symptoms may also occur.

Grade III represents neurotmesis, the most severe form, with major disruption of the nerve. Motor or sensory deficits may persist for longer than a year.

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General Prevention

The only complete method of prevention is avoidance of activities involving significant contact or collision.

For athletes who continue participating, prevention should focus on appropriate equipment, correct technique, and conditioning.

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Protective Equipment

In American football, neck collars or similar protective devices may reduce excessive cervical motion and may help decrease the likelihood of recurrent stingers in selected athletes.

Helmets and shoulder pads should be checked to ensure proper fit.

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Sports Technique

Proper tackling and blocking technique is important.

Athletes should avoid leading with the head or placing the cervical spine in positions that produce excessive lateral bending or extension.

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Strengthening

Strengthening the neck, shoulder girdle, and scapular stabilizing muscles may reduce recurrence.

Improved muscular control can help limit excessive neck and shoulder displacement during contact.

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Epidemiology

Burners occur predominantly in young male athletes involved in contact sports, particularly American football and rugby.

Recurrence is common.

Recent studies suggest that approximately one-fifth to one-third of stinger episodes may represent recurrent injuries.

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Incidence

In collegiate American football, an incidence of approximately 2.04 injuries per 10,000 athlete exposures has been reported.

In one rugby cohort, approximately 21% of players experienced a stinger, with a reinjury rate of approximately 37% during the same season.

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Risk Factors

A previous history of a stinger is the strongest predictor of a future episode.

Cervical spinal or foraminal stenosis is another important risk factor because it reduces the space available for the cervical nerve roots.

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Genetics

No specific genetic association has been identified.

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Etiology

Most burners result from compression, traction, or combined compression and traction of the upper brachial plexus.

In American football, the majority occur during tackling or blocking.

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Associated Conditions

Recent evidence suggests an association between recurrent stingers and scapular dyskinesis, particularly in rugby athletes.

Abnormal scapular mechanics may alter shoulder and cervical positioning during contact and increase neural stress.

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Diagnosis

Signs and Symptoms

The classic symptom is an immediate sharp, burning, or electric pain radiating from the shoulder or neck down one arm.

Paresthesias, numbness, or weakness may accompany the pain.

Symptoms usually resolve within several minutes, although some athletes experience weakness or sensory disturbance lasting much longer.

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Delayed Weakness

Strength may initially appear normal immediately after injury.

However, weakness can occasionally develop or become more noticeable over the following hours or days.

For this reason, serial neurologic examination is important.

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Physical Examination

The examination should begin with assessment of the cervical spine and affected upper extremity.

If the athlete has no neck pain or tenderness, cervical range of motion may be evaluated carefully.

A simple stinger usually allows full and painless cervical motion.

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Palpation

There is often no significant tenderness over the cervical spine, clavicle, or shoulder.

Tenderness over these areas should raise suspicion for an associated fracture, dislocation, or structural injury.

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Neurologic Examination

Motor strength and sensation should be compared with the contralateral side.

Transient weakness most commonly follows a C5–C6 distribution.

Affected muscles may include the deltoid, biceps, and shoulder external rotators.

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Spurling Test

The Spurling test may reproduce symptoms when cervical nerve root compression contributes to the injury.

The neck is placed into extension, rotation, and lateral bending toward the symptomatic side, followed by gentle axial compression.

Reproduction of radiating symptoms into the ipsilateral arm is considered a positive test.

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Bilateral Symptoms

Bilateral arm symptoms are not typical of a simple stinger and should raise concern for a cervical spinal cord or major cervical spine injury.

If both arms are involved, the athlete should be treated as having a potentially unstable cervical spine injury.

The neck should be immobilized, and protective equipment should generally remain in place until appropriate transport and evaluation can be completed.

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Imaging

Indications for Cervical Radiographs

Routine imaging is not necessary after every uncomplicated first-time stinger that resolves rapidly.

Cervical radiographs should be considered when the patient has recurrent episodes, neck pain, stiffness, tenderness, or pain with cervical range of motion.

Radiographs can help identify fracture, alignment abnormalities, or cervical stenosis.

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MRI

MRI of the cervical spine is particularly important when symptoms are bilateral, persistent, recurrent, or associated with abnormal neurologic findings.

It can evaluate for cervical stenosis, disc herniation, nerve root compression, or spinal cord pathology.

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Pathological Testing

Histologic or other pathological testing is not routinely required for the diagnosis.

Burners are diagnosed primarily through clinical history, physical examination, and selective imaging or electrodiagnostic testing.

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Differential Diagnosis

Important differential diagnoses include cervical spine fracture, cervical disc herniation, clavicle fracture, shoulder fracture or dislocation, and soft-tissue injuries of the shoulder.

Because these conditions can mimic or accompany a stinger, careful examination is essential before return to play.

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Treatment

Initial Management

The athlete should be removed immediately from play after a stinger.

Return should not be permitted while pain, paresthesias, weakness, sensory loss, or restricted motion remains.

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Return-to-Play Criteria

Accepted criteria for return include full and painless cervical and shoulder range of motion, complete resolution of paresthesias, normal sensation, and full strength.

The athlete should also be able to participate in practice without recurrent symptoms before returning to unrestricted competition.

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Same-Day Return to Play

A player may return during the same event only when symptoms have completely resolved and the examination is normal.

There should be no pain at rest or during provocative testing, and strength and sensation must be equivalent to the opposite side.

Any residual neurologic abnormality is a contraindication to immediate return.

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Persistent Neurologic Deficit

Athletes with incomplete neurologic recovery should undergo repeated examinations.

They should not return to contact sport until strength, sensation, and range of motion have fully normalized.

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Recurrent Stingers

Athletes with repeated episodes should not return to play until an appropriate cervical spine evaluation has been completed.

Imaging should exclude structural conditions such as stenosis or disc herniation that could increase the risk of further neurologic injury.

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Cervical Foraminal Stenosis

Athletes with significant cervical foraminal or spinal canal stenosis require particularly careful counseling.

When clinically significant stenosis is present, avoidance of contact and collision sports may be recommended because of the risk of recurrent or more serious neurologic injury.

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Electromyography and Return to Sport

An abnormal electromyographic study does not automatically prohibit return to sport.

Return-to-play decisions should be individualized according to symptoms, strength, neurologic examination, imaging, and the pattern of electrodiagnostic abnormalities.

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Physical Therapy

Physical therapy can improve neck and shoulder range of motion, flexibility, strength, and neuromuscular control.

Rehabilitation commonly emphasizes cervical strengthening, shoulder girdle conditioning, posture, and scapular stabilization.

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First-Line Management

The athlete should remain out of competition until all symptoms have resolved.

Serial neurologic examinations should document recovery of motor function, sensation, reflexes, and cervical motion.

Athletes with recurring symptoms should undergo imaging before returning to play.

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Electromyography

Electromyography is generally considered when weakness, numbness, or other neurologic symptoms persist beyond approximately 3 weeks.

It can help determine the severity and location of nerve injury and identify evidence of axonal loss.

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Further Imaging After EMG

MRI should be considered when electromyography is abnormal or when symptoms involve both upper extremities.

MRI can identify cervical spinal stenosis, disc disease, or another structural cause of persistent neurologic dysfunction.

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Follow-Up

Patients should undergo repeat examination until symptoms have resolved completely.

Strength, sensation, and range of motion should be compared with the opposite side during follow-up.

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Prognosis

The prognosis after an isolated stinger is generally excellent.

Most athletes recover rapidly, and many miss little or no playing time.

In one rugby cohort, the average return to play was approximately 2.9 days, with the majority of athletes missing no competition.

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Duration of Symptoms

The mean symptom duration in one study was approximately 3.5 days, although most episodes resolved within 24 hours.

Longer-lasting symptoms are more concerning for a higher-grade nerve injury.

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Prognostic Factors

A history of repeated stingers with multiple associated symptoms, particularly motor weakness, is associated with greater injury severity.

Frequent recurrence should prompt investigation for underlying cervical stenosis or other structural abnormalities.

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Recurrence

Recurrence is one of the major clinical problems associated with stingers.

Some older studies reported recurrence rates as high as 87%, although rates vary considerably depending on sport, study population, and diagnostic criteria.

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Complications

The overall risk of permanent nerve damage after a simple isolated stinger is low.

However, recurrent episodes may occasionally lead to chronic neurologic symptoms or persistent weakness.

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Chronic Stinger Syndrome

A minority of athletes with frequent recurrent stingers can develop a more persistent syndrome.

Cervical stenosis has a strong association with chronic or recurrent symptoms in these patients.

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Patient Monitoring

A detailed neurologic examination should be performed at the time of injury and compared with the unaffected side.

The athlete should then be reassessed at regular intervals until pain, paresthesias, weakness, and all neurologic abnormalities have completely resolved.

Return to sport should occur only when the examination is normal and the athlete can perform sport-specific activities without recurrence.

Orthopaedic Surgery - Bunion/Hallux Valgus

Basics

A bunion is a prominent enlargement of the medial aspect of the first metatarsal head, often accompanied by overlying soft-tissue and bursal swelling.

Hallux valgus is a deformity centered mainly at the first metatarsophalangeal (MTP) joint. It consists of lateral deviation of the great toe together with medial deviation of the first metatarsal.

As the deformity progresses, subluxation or incongruity of the first MTP joint may develop.

General Prevention

Avoidance of narrow or constricting footwear may reduce symptoms and potentially limit progression in susceptible individuals.

Shoes with adequate width in the toe box are preferable.

Epidemiology

Hallux valgus occurs most commonly in middle-aged and older women, although adolescents and young adults may also be affected.

Females are affected more frequently than males.

The condition is seen predominantly in populations that routinely wear shoes and is much less common in traditionally unshod populations.

Prevalence

Hallux valgus affects approximately 23% of adults between 18 and 65 years of age.

Among adults older than 65 years, prevalence rises to approximately 35%.

Risk Factors

Important risk factors include heredity and footwear.

A positive family history is common, suggesting an inherited predisposition in many patients.

Narrow shoes and high heels may aggravate the deformity by increasing pressure across the forefoot and first MTP joint.

Genetics

A definite single genetic abnormality has not been identified.

However, approximately two-thirds of affected patients report a positive family history, indicating a substantial hereditary contribution.

Hallux valgus is also frequently associated with generalized ligamentous laxity syndromes, which themselves may have a genetic component.

Etiology

The development of hallux valgus is multifactorial.

Footwear with a narrow toe box or elevated heel is strongly associated with the condition.

Epidemiologic studies demonstrate a greater prevalence in shoe-wearing populations and increasing frequency when previously unshod societies adopt Western-style footwear.

Pes Planus

Pes planus may contribute to hallux valgus in some patients.

A pronated gait can alter mechanical loading through the first MTP joint and may increase stress on the medial column of the foot.

Flatfoot may also occur as part of a generalized ligamentous laxity pattern.

Metatarsus Primus Varus

Metatarsus primus varus, in which the first metatarsal deviates medially relative to the second, is strongly associated with hallux valgus.

As the angle between the first and second metatarsals increases, the risk and severity of hallux valgus also tend to increase.

Acquired Joint Laxity

Acquired ligamentous laxity can also contribute to deformity.

Conditions such as rheumatoid arthritis, gout, and previous trauma may weaken the soft-tissue restraints around the first MTP joint.

This allows progressive displacement of the first metatarsal and great toe.

Other Associated Factors

Other conditions that may contribute include amputation of another toe, severe lesser-toe deformities, and Achilles tendon contracture.

These conditions can alter forefoot biomechanics and increase abnormal pressure through the first ray.

Diagnosis

Signs and Symptoms

The most common symptom is pain over the medial eminence, usually caused by pressure from footwear.

The great toe deviates laterally, while the medial aspect of the first metatarsal becomes increasingly prominent.

The deformity may become more obvious during weight-bearing.

Shoe-Wear Problems

Many patients have difficulty finding comfortable footwear.

Pressure from the shoe over the medial bunion may produce irritation, redness, callus formation, or bursitis.

Cosmetic concern is also common, although appearance alone is not usually an indication for surgery.

Second-Toe Problems

In more advanced deformity, the great toe may impinge on or displace the second toe.

This can result in second-toe pain, hammering, crossover deformity, or other lesser-toe abnormalities.

Transfer Metatarsalgia

Hallux valgus may alter normal load distribution across the forefoot.

Patients can develop painful plantar callosities beneath the second metatarsal head, a condition often described as transfer metatarsalgia.

Pain may also arise directly from the first MTP joint, particularly when arthritis develops.

Physical Examination

The patient should be examined both sitting and standing because weight-bearing can accentuate the deformity.

The examiner should evaluate alignment of the great toe, first metatarsal, lesser toes, longitudinal arch, and hindfoot.

Achilles and Gastrocnemius Contracture

Ankle dorsiflexion should be assessed with the knee both flexed and extended.

Restricted dorsiflexion may indicate gastrocnemius or Achilles tendon contracture.

These contractures can contribute to abnormal forefoot loading.

Joint Motion

Motion should be assessed at the ankle, subtalar joint, midfoot, first tarsometatarsal joint, and MTP joints.

Restriction, crepitus, or pain at the first MTP joint may indicate associated arthrosis.

First-Ray Hypermobility

The first tarsometatarsal joint should be evaluated for excessive mobility or instability.

Vertical shear or manual stress can be used to assess the first ray.

Many patients with hallux valgus demonstrate some degree of first-ray hypermobility.

Flexibility of the Deformity

The examiner should determine whether the hallux valgus deformity can be manually corrected.

A flexible deformity is generally easier to treat than a rigid or fixed deformity.

The reducibility of the MTP joint is an important factor in surgical planning.

Foot Morphology

The overall shape of the foot and the status of the longitudinal arch should be documented.

Pes planus, metatarsus primus varus, lesser-toe deformities, and hindfoot malalignment may influence both symptoms and treatment.

Neurovascular Examination

A complete musculoskeletal and neurovascular examination of the lower extremity should be performed.

Peripheral vascular disease or neuropathy may substantially influence the safety and success of surgery.

Imaging

Weight-Bearing Radiographs

Standard evaluation includes standing anteroposterior, oblique, lateral, and axial sesamoid views of the foot.

Weight-bearing radiographs are essential because the deformity may appear less severe when the foot is unloaded.

Hallux Valgus Angle

The hallux valgus angle is measured between the longitudinal axes of the first metatarsal and proximal phalanx.

A normal value is generally less than 15°.

Increasing values indicate greater lateral deviation of the great toe.

Intermetatarsal Angle

The angle between the first and second metatarsals is used to assess metatarsus primus varus.

A normal first-second intermetatarsal angle is less than approximately 9°.

An increased angle is an important determinant of deformity severity and procedure selection.

Hallux Interphalangeal Angle

The hallux interphalangeal angle assesses alignment within the great toe itself.

A normal value is generally less than approximately 10°.

An increased angle may indicate hallux valgus interphalangeus and can influence the need for proximal phalanx osteotomy.

Distal Metatarsal Articular Angle

The distal metatarsal articular angle evaluates orientation of the first metatarsal head articular surface.

A normal value is approximately less than 10°.

An abnormal lateral slope can be associated with a congruent form of hallux valgus.

Sesamoid Position

Radiographs should assess displacement of the sesamoids relative to the first metatarsal head.

With progressive hallux valgus, the first metatarsal head shifts medially while the sesamoid complex remains relatively fixed.

This produces apparent lateral displacement of the sesamoids beneath the metatarsal head.

Joint Congruity and Arthritis

The first MTP joint should be assessed for congruity, subluxation, cartilage loss, osteophytes, and other degenerative changes.

These findings have a major influence on treatment selection.

Lesser-Toe Alignment

Radiographs should also evaluate the lesser toes for associated deformities.

Second-toe displacement, hammering, crossover deformity, or metatarsalgia may require simultaneous treatment.

Pathoanatomy

Hallux valgus is a three-dimensional deformity involving not only the first MTP joint but also the first tarsometatarsal joint and other components of the first ray.

The deformity can broadly be divided into congruent and incongruent types.

Incongruent Hallux Valgus

In an incongruent deformity, multiple static and dynamic abnormalities are present.

The first metatarsal drifts medially, increasing the intermetatarsal angle.

As the metatarsal head moves medially, the sesamoid complex remains relatively fixed by the transverse metatarsal ligament.

Dynamic Soft-Tissue Imbalance

As deformity progresses, the line of pull of the adductor hallucis, flexor hallucis brevis, extensor hallucis longus, and abductor hallucis becomes increasingly lateralized.

This further pulls the great toe into valgus and reinforces the deformity.

Capsular Changes

The medial capsule and ligaments become stretched and attenuated, while lateral soft tissues become progressively contracted.

These changes make the deformity increasingly difficult to correct manually as it advances.

Congruent Hallux Valgus

In congruent hallux valgus, the MTP joint remains anatomically congruent.

The articular surface may be abnormally sloped laterally, allowing the toe to remain aligned with the joint surface despite valgus orientation.

Because there is no pathologic joint subluxation, progression may be less pronounced than in an incongruent deformity.

Differential Diagnosis

The principal differential diagnosis is gout, which can produce pain, swelling, and prominence around the first MTP joint.

Acute gout usually presents with marked inflammation, redness, and tenderness rather than a gradually progressive structural deformity.

Treatment

General Measures

Hallux valgus should initially be treated with nonoperative measures.

Treatment is directed primarily toward reducing pain and improving shoe tolerance rather than correcting the structural deformity.

Footwear Modification

Proper footwear is one of the most important conservative measures.

Patients should avoid pointed shoes and high heels.

Lace-up shoes and styles with a wide toe box provide more space for the forefoot.

Shoe Adaptation

Soft leather shoes can sometimes be stretched over the medial bunion.

Shoes should ideally have no seam or stitching directly over the medial prominence.

Prescription footwear with additional width and depth may be required in severe cases.

Padding and Splints

Commercial pads, cushions, bunion sleeves, and splinting devices may reduce pressure over the medial eminence.

These devices can improve comfort but generally do not permanently correct the underlying deformity.

Orthotic Support

Patients with associated pes planus may benefit from custom or supportive orthoses.

Heel-cord stretching may be beneficial when Achilles or gastrocnemius tightness contributes to abnormal forefoot loading.

Physical Therapy

Physical therapy is usually of limited value for correcting the structural deformity or providing major long-term symptom relief.

Stretching may still be useful when there is an associated gastrocnemius or Achilles contracture.

Medication

Analgesic medications may be used for symptomatic relief.

NSAIDs or other simple analgesics can help when pain is associated with local inflammation or arthritis.

Goals of Surgery

The goals of operative treatment are pain relief, correction of deformity, restoration of more normal foot biomechanics, and preservation of useful joint motion whenever possible.

Procedure selection must be individualized.

Indications for Surgery

Surgery may be considered when there is persistent pain despite appropriate nonoperative treatment, progressive deformity, reduced function, or inability to tolerate reasonable footwear.

The severity of the deformity should be considered together with the patient’s symptoms.

Contraindications to Surgery

Surgery should generally not be performed for cosmetic concerns alone in an otherwise asymptomatic patient.

Significant vascular insufficiency is also a major contraindication because of the increased risk of poor wound healing and infection.

Surgical Decision-Making

Procedure selection depends on several factors, including patient age, severity of the intermetatarsal and hallux valgus angles, joint congruity, first-ray stability, arthritis, rigidity of the deformity, and associated lesser-toe pathology.

Numerous operative procedures have been developed because no single technique is appropriate for every patient.

Soft-Tissue Procedures

Soft-tissue procedures aim to rebalance the structures around the first MTP joint.

They may include release of contracted lateral tissues and tightening of the attenuated medial capsule.

These procedures are often combined with a metatarsal osteotomy.

Modified McBride Procedure

The modified McBride procedure may be used for selected mild deformities, usually as part of a combined correction.

It involves removal of the medial eminence, release of contracted lateral structures such as the adductor hallucis and lateral capsule, and tightening of the medial capsule.

Its purpose is to improve alignment and restore joint congruity.

Limitations of the Modified McBride Procedure

Soft-tissue correction alone may not adequately correct an increased intermetatarsal angle.

For this reason, the procedure is often combined with a metatarsal osteotomy.

Potential complications include overcorrection into hallux varus and joint stiffness.

Distal Chevron Osteotomy

A distal metatarsal chevron osteotomy involves a V-shaped cut near the metatarsal head.

The distal fragment is translated laterally to reduce the intermetatarsal angle and correct the deformity.

This procedure is most appropriate for mild to moderate hallux valgus.

Complications of Distal Chevron Osteotomy

Potential complications include malunion, osteonecrosis of the metatarsal head, stiffness, and hallux varus from overcorrection.

It generally provides insufficient correction for severe deformity.

Proximal Metatarsal Osteotomy

Proximal metatarsal osteotomy is generally reserved for moderate to severe deformity, particularly when the intermetatarsal angle is significantly increased.

The main purpose is to realign the first metatarsal relative to the second.

Types of Proximal Osteotomy

Several configurations have been described, including crescentic, oblique, opening-wedge, proximal chevron, Ludloff, and Scarf osteotomies.

These procedures may be combined with distal soft-tissue correction at the MTP joint.

Recurrence After Proximal Osteotomy

Recurrence after proximal metatarsal osteotomy has been reported in approximately 4–25% of cases.

Postoperative alignment and the quality of correction influence the risk of recurrent deformity.

Double Osteotomy

A double osteotomy combines proximal and distal correction.

It may be considered for severe hallux valgus when substantial angular correction is required.

One option combines a distal chevron with a proximal opening-wedge osteotomy.

Proximal Phalanx Osteotomy

Osteotomy of the proximal phalanx is used mainly for hallux valgus interphalangeus or as an additional procedure when metatarsal correction alone does not adequately align the great toe.

Akin Osteotomy

The Akin osteotomy is a medial closing-wedge osteotomy of the proximal phalanx.

It corrects valgus alignment within the great toe itself.

It is frequently performed in combination with another hallux valgus procedure.

Minimally Invasive Akin Osteotomy

Percutaneous and minimally invasive techniques have also been developed.

In selected patients, a minimally invasive Akin osteotomy can provide effective correction, sometimes without formal internal fixation.

Lapidus Procedure

The Lapidus procedure consists of fusion of the first tarsometatarsal joint combined with correction of the hallux valgus deformity.

It is particularly appropriate when there is hypermobility or instability of the first tarsometatarsal joint, significant metatarsus primus varus, or arthritis of the first TMT joint.

Effect of the Lapidus Procedure

By stabilizing and realigning the first ray, the Lapidus procedure can substantially reduce the intermetatarsal angle.

It is commonly used for moderate to severe deformities associated with first-ray instability.

First MTP Arthrodesis

Fusion of the first MTP joint may be appropriate for severe deformity, significant degenerative or inflammatory arthritis, connective tissue disorders, spasticity, or failed previous hallux valgus surgery.

It is also commonly considered in older patients with advanced joint destruction.

Results of MTP Fusion

MTP arthrodesis provides reliable pain relief and high patient satisfaction.

Its main disadvantage is permanent loss of motion at the first MTP joint.

However, many patients tolerate this well when the toe is fused in an appropriate functional position.

Prosthetic Arthroplasty

Joint replacement has been proposed as an alternative to fusion for arthritic first MTP joints.

However, prosthetic implants have historically demonstrated relatively high complication and failure rates.

They are generally used cautiously, particularly in younger or highly active individuals.

Keller Resection Arthroplasty

The Keller procedure involves removal of the medial eminence together with resection of part of the base of the proximal phalanx.

It is generally reserved for older, low-demand, sedentary patients.

Complications of Keller Arthroplasty

Potential problems include recurrent valgus deformity, transfer metatarsalgia, weakness of push-off, and cock-up deformity of the great toe.

Because of these limitations, it is rarely selected for younger or active patients.

Follow-Up

Patients treated nonoperatively should be reassessed if symptoms worsen, shoe tolerance decreases, or the deformity progresses.

Following surgery, clinical and radiographic follow-up is used to monitor wound healing, alignment, bone union, joint motion, and recurrence.

Prognosis

Mild and congruent deformities generally progress more slowly with conservative treatment than severe or incongruent deformities.

Nonoperative treatment can relieve symptoms but usually does not reverse the structural deformity.

Prognosis After Surgery

When surgery is performed for appropriate indications and the procedure is correctly matched to the deformity, most patients experience substantial pain relief and improvement in alignment.

Outcome depends on deformity severity, joint condition, procedure selection, and adherence to postoperative rehabilitation.

Complications

Potential surgical complications include wound breakdown, infection, recurrence of hallux valgus, overcorrection into hallux varus, malunion or nonunion, joint stiffness, neuroma formation, and transfer metatarsalgia.

Recurrence

Recurrent deformity may develop if the underlying metatarsal alignment, first-ray instability, or soft-tissue imbalance is not adequately corrected.

More severe initial deformities generally carry a higher risk of recurrence.

Hallux Varus

Excessive correction may produce hallux varus, in which the great toe deviates medially.

This can be painful and functionally limiting and may require additional treatment.

Transfer Metatarsalgia

Altered first-ray loading after surgery can shift excessive pressure to the lesser metatarsal heads.

This may produce persistent forefoot pain or plantar callosities, particularly beneath the second metatarsal.

Patient Monitoring

Patients should be monitored for progression of pain, changes in shoe tolerance, increasing deformity, development of lesser-toe problems, and signs of first MTP arthritis.

After surgery, follow-up should also assess wound healing, correction of alignment, bone union, joint motion, and recurrence of the deformity.

Orthopaedic Surgery - Brachial Plexus Birth Palsy

Basics

Brachial plexus birth palsy is caused by stretching or disruption of the brachial plexus during delivery, usually from excessive upward or downward traction on the infant’s arm, shoulder, or neck.

The resulting weakness produces muscle imbalance around the upper extremity. Over time, this imbalance can lead to secondary muscle contractures, joint deformity, and altered growth of the affected bones.

Although the nerve injury occurs at birth, mild cases may not become obvious until the infant begins actively using the affected arm.

Classification

Brachial plexus birth palsy can be classified according to the nerve roots involved.

Type I, or Erb palsy, primarily involves the upper plexus, classically the C5–C6 roots, although adjacent root involvement may occur.

Type II, or total brachial plexus palsy, involves essentially the entire plexus from approximately C5 through T1 and may be referred to as an Erb-Duchenne-Klumpke palsy.

Type III, or Klumpke palsy, predominantly affects the lower plexus, especially C8–T1.

Synonyms

Other names include birth palsy, obstetric palsy, Erb palsy, and Klumpke palsy.

General Prevention

Some cases may be reduced by identifying pregnancies at high risk for difficult delivery.

Cesarean delivery may occasionally be considered when there is marked fetal macrosomia or significant cephalopelvic disproportion.

However, not every brachial plexus birth injury can be predicted or prevented.

Epidemiology

The reported incidence is approximately 1.5 cases per 1,000 live births.

The incidence has declined over time, likely because of improvements in obstetric management.

Erb palsy is considerably more common than Klumpke palsy, occurring approximately four times as often.

No major difference in incidence has been recognized between male and female infants.

Shoulder Dislocation

Approximately 8% of affected infants may develop posterior shoulder dislocation before the age of 1 year.

This usually develops as a secondary consequence of persistent muscle imbalance and internal rotation contracture.

Risk Factors

Important risk factors include fetal malposition, shoulder dystocia, cephalopelvic disproportion, high birth weight, maternal diabetes, and forceps-assisted delivery.

Among these, shoulder dystocia represents one of the most important obstetric risk factors.

Pathophysiology

The degree of nerve injury can range from temporary stretching to complete disruption or avulsion.

The lesion may occur close to the cervical spinal cord, where the nerve roots exit the spinal canal, or farther distally within the neck and shoulder.

More proximal injuries, particularly root avulsions, generally carry a worse prognosis.

Secondary Muscle Imbalance

Persistent denervation leads to muscle weakness and atrophy.

Because some muscle groups recover better than others, an imbalance develops across the shoulder, elbow, wrist, or hand.

Over time, this can cause joint contracture, abnormal joint development, deformity, and altered growth of the affected extremity.

Etiology of Erb Palsy

Erb palsy most commonly results from downward traction on the shoulder or arm, or lateral traction on the neck during a difficult delivery.

This mechanism preferentially stretches the upper roots of the brachial plexus.

Etiology of Klumpke Palsy

Klumpke palsy is associated with upward traction on the arm, producing injury to the lower brachial plexus.

Both patterns can occur during difficult extraction at delivery.

Associated Conditions

Brachial plexus birth palsy is associated with high birth weight and gestational diabetes, both of which increase the likelihood of difficult delivery and shoulder dystocia.

Diagnosis

Signs and Symptoms

The most common finding is reduced spontaneous use of the affected upper extremity.

The arm may rest in a characteristic internally rotated position.

Loss of active shoulder abduction and external rotation is common in upper plexus injuries.

Shoulder Position

In Erb palsy, the shoulder is often held in internal rotation and adduction.

The infant may be unable to fully abduct or externally rotate the arm.

Persistent internal rotation may eventually become fixed because of muscle contracture.

Elbow Findings

Elbow flexion may be weak or absent when the biceps is affected.

As the child grows, an elbow flexion contracture may develop because of muscle imbalance and altered use.

Muscle Atrophy

Chronic denervation may result in visible atrophy of affected muscles.

The involved extremity may also become smaller in both length and girth compared with the opposite side.

Sensory Findings

Sensory loss may occur in more extensive plexus injuries.

Complete plexus palsy is more likely to produce significant sensory impairment than an isolated upper plexus lesion.

The condition itself is generally not painful.

Horner Syndrome

A Horner syndrome may occur in lower plexus injuries, particularly Klumpke palsy.

Its presence suggests injury involving the lower cervical or upper thoracic sympathetic pathways and may indicate a more severe lesion.

History

Reduced movement of the affected arm may be apparent immediately after birth.

In milder cases, the problem may not be recognized until the infant begins using the arm and caregivers notice reduced shoulder movement, weakness, or developing contracture.

Physical Examination

Clinical examination is the primary method of diagnosis.

The infant should be assessed systematically for shoulder, elbow, wrist, and hand function.

The examiner should observe spontaneous movement and stimulate individual muscle groups when possible.

Palpation

The clavicle, proximal humerus, and ribs should be palpated for tenderness.

This helps identify fractures that may mimic a brachial plexus palsy by causing painful pseudoparalysis.

Sensory Examination

Sensation can be assessed by observing the infant’s response to light touch or gentle pinch.

The findings should be compared with those of the opposite arm.

Motor Examination

Function of the major muscle groups of the shoulder, elbow, forearm, wrist, and hand should be evaluated through stimulation and observation.

Particular attention should be paid to recovery of the deltoid and biceps, because their return is useful in determining prognosis and the possible need for surgery.

Erb Palsy Examination

In Erb palsy, the shoulder is typically internally rotated and demonstrates limited or absent abduction and external rotation.

Elbow flexion may also be weak.

A developing internal rotation contracture may be the earliest clinical sign of secondary glenohumeral dysplasia.

Klumpke Palsy Examination

Klumpke palsy predominantly affects the lower plexus.

The major deficits involve finger flexion, intrinsic hand muscle function, and fine motor control.

The hand may appear weak or clawed in severe cases.

Imaging

Plain Radiographs

Radiographs are often obtained shortly after birth to exclude other injuries causing decreased arm movement.

These include clavicle fracture and proximal humeral fracture, which can coexist with brachial plexus birth palsy.

Imaging in Older Children

In children with persistent shoulder imbalance who are being considered for late reconstruction, radiographs and CT can help evaluate the shape, congruity, and deformity of the glenohumeral joint.

These studies are particularly useful in children older than approximately 4 years.

Ultrasound

Ultrasound is useful during the first year of life.

It can be used both as a screening study and as a dynamic examination of glenohumeral alignment, humeral head position, and joint congruity.

It is particularly helpful because much of the infant shoulder is not yet ossified.

MRI

MRI provides detailed evaluation of the glenohumeral joint and surrounding soft tissues.

It can demonstrate posterior subluxation, dysplasia, joint deformity, muscle imbalance, and other structural abnormalities.

Electromyography

Electromyography may be considered when there is no meaningful clinical return of deltoid or biceps function by approximately 3–6 months of age.

Evidence of absent or poor reinnervation may support consideration of nerve reconstruction.

However, EMG can sometimes overestimate recovery in proximal muscles and must be interpreted together with the clinical examination.

Cervical Myelography

Cervical myelography may help determine the level and severity of nerve injury.

The presence of meningoceles or pseudomeningoceles at the cervical root level may indicate root avulsion from the spinal cord.

Root avulsion carries a poor prognosis and may require a different surgical strategy.

Motor Nerve Conduction Studies

Comparative motor nerve conduction studies may help select infants who are candidates for brachial plexus surgery.

These studies may be performed during the first several weeks of life, approximately 10–60 days after birth.

An axonal viability index can be calculated by comparing compound muscle action potential amplitudes between the affected and unaffected limbs.

Differential Diagnosis

Clavicle Fracture

A clavicle fracture can cause an infant to stop moving the arm because movement is painful.

Unlike brachial plexus palsy, the clavicle is usually tender to palpation, and some shoulder movement may still be present.

Radiographs usually confirm the diagnosis.

Proximal Humeral Physeal Fracture

A proximal humeral physeal injury can produce similar pseudoparalysis.

Tenderness is localized over the proximal humerus.

Because the proximal humerus is poorly ossified at birth, the injury may not initially be visible on plain radiographs.

Ultrasound or MRI can be diagnostic, and repeat radiographs after 7–10 days may demonstrate healing changes.

Septic Arthritis of the Shoulder

Septic arthritis may also present with reduced arm movement.

The infant may exhibit pseudoparalysis because movement is painful.

Fever can be minimal or absent in newborns, so infection should remain in the differential when there is pain, irritability, swelling, or systemic concern.

Treatment

General Measures

Initial treatment consists primarily of observation and maintenance of passive range of motion.

Parents should be instructed to stretch the infant’s arm several times each day according to guidance from an occupational or physical therapist.

Specialist Referral

Infants with suspected brachial plexus birth palsy should be referred to a pediatric orthopaedic or peripheral nerve specialist experienced in this condition.

Management decisions can be complex and depend heavily on serial assessment of neurologic recovery.

Spontaneous Recovery

Approximately 80% of affected infants recover spontaneously by 1 year of age.

Because of this high rate of natural recovery, immediate surgery is not required in most newborns.

Continued follow-up is essential to identify infants who fail to recover sufficiently.

Splinting

Routine splinting is generally unnecessary during the initial period.

The emphasis is instead placed on maintaining joint flexibility through gentle passive movement and stretching.

Activity

No general activity restrictions are necessary.

Normal spontaneous use of the extremity should be encouraged as function returns.

Parents should continue passive range-of-motion exercises to prevent contracture.

Occupational and Physical Therapy

Therapists play an important role in teaching parents how to perform stretching safely.

They also help identify early contractures, monitor functional progress, and encourage developmentally appropriate use of the affected arm.

Shoulder Stretching

Particular attention should be given to maintaining shoulder external rotation and abduction.

Loss of passive external rotation may signal developing internal rotation contracture and glenohumeral dysplasia.

Botulinum Toxin

Botulinum toxin A may be injected into overactive internal rotator muscles in selected patients.

It can temporarily reduce muscle imbalance and may assist in maintaining shoulder reduction or delaying more invasive surgery.

Nerve Repair and Reconstruction

When meaningful function does not return during the first several months of life, microsurgical nerve reconstruction may be considered.

Procedures may include direct nerve repair, nerve grafting, or nerve transfer, depending on the lesion.

The exact timing remains controversial but is often considered when recovery is inadequate by approximately 3–6 months.

Timing of Nerve Surgery

Nerve reconstruction is generally most useful when performed relatively early.

Very delayed reconstruction becomes less effective because denervated muscles progressively lose their capacity for meaningful reinnervation.

Root Avulsion

When nerve roots have been avulsed from the spinal cord, direct grafting from the injured root may not be possible.

Alternative nerve transfers or reconstructive strategies may therefore be required.

Tendon Transfers

Tendon transfers may be performed later in childhood when neurologic recovery has plateaued but useful muscles remain available for transfer.

These procedures aim to restore muscle balance and improve specific movements.

Shoulder Tendon Transfers

In young children without advanced fixed glenohumeral dysplasia, tendon transfers may be used to improve external rotation and abduction of the shoulder.

The goal is to restore a more balanced shoulder and improve function.

Release of Internal Rotators

Tight internal rotator muscles may require surgical release when contracture limits external rotation.

This may be combined with tendon transfer or other reconstructive procedures.

Humeral Osteotomy

In older children with established glenohumeral dysplasia or fixed dislocation, a humeral rotational osteotomy may be used.

This procedure repositions the arm into a more functional externally rotated orientation.

It does not restore the normal joint but can significantly improve hand positioning and function.

Restoration of Elbow Flexion

Several muscle transfer procedures may be used to restore elbow flexion.

One option is transfer of the latissimus dorsi, although the choice depends on available muscle function and the specific pattern of weakness.

Wrist and Finger Reconstruction

Tendon transfers for wrist and finger function are less frequently required.

They may be considered in selected children with persistent lower plexus weakness and functional hand deficits.

Follow-Up

Serial clinical assessment is essential throughout infancy and early childhood.

The child should be evaluated for return of motor function, maintenance of passive range of motion, development of contracture, shoulder alignment, and progression of secondary deformity.

Indications for Referral

Any infant with suspected brachial plexus birth palsy should be evaluated by a specialist familiar with obstetric plexus injuries.

This condition requires expertise in pediatric nerve recovery, shoulder development, therapy, and reconstructive surgery.

Prognosis

Approximately 80% of infants recover spontaneously to a substantial degree.

Many of the remaining patients can gain useful function through nerve reconstruction, tendon transfer, osteotomy, or other reconstructive procedures.

Long-Term Function

Even when children adapt well and participate in most activities, residual functional limitations may persist into adolescence.

These may include weakness, restricted shoulder motion, altered limb position, or difficulty with certain sports and overhead activities.

Complications

Important complications include contracture of the shoulder, elbow, or wrist; persistent muscle weakness; sensory loss; reduced growth of the affected extremity; and shoulder subluxation or dislocation.

Growth Disturbance

The affected arm may become smaller in length and circumference because of chronic denervation, reduced muscle activity, and altered loading.

The degree of discrepancy depends on injury severity and recovery.

Glenohumeral Dysplasia

Persistent internal rotation imbalance can progressively alter development of the glenoid and humeral head.

This may result in posterior subluxation, joint dysplasia, or fixed dislocation if not recognized and treated.

Patient Monitoring

The infant should generally be reassessed approximately every 2–3 months during the early period of recovery.

Follow-up should document return of shoulder and elbow function, passive joint motion, hand function, and signs of secondary deformity.

Serial examination guides the timing of electrodiagnostic testing, imaging, and possible surgical intervention.

Orthopaedic Surgery - Boxer’s Fracture

Basics

A boxer’s fracture refers to a fracture through the neck of the ring or small-finger metacarpal, typically with volar angulation or displacement of the metacarpal head.

It is one of the most frequently encountered hand injuries in the emergency department and usually occurs after striking a hard object, such as a wall or another person, with a closed fist.

When the injury occurs during a physical altercation, the patient should also be evaluated for other traumatic injuries.

Metacarpal Angulation

Some degree of metacarpal neck angulation is normal.

For example, normal metacarpal neck angulation may be approximately 15°, whereas a boxer’s fracture may demonstrate substantially greater volar angulation.

Marked angulation may result in loss of the normal prominence of the knuckle.

Jewelry Removal

All rings and other jewelry should ideally be removed from the injured hand before significant swelling develops and before radiographs are obtained.

If a ring is present on the injured digit and removal is too painful, a digital block or hematoma block may be considered before attempting removal.

Epidemiology

Boxer’s fractures are among the most common hand injuries evaluated in emergency departments.

They occur considerably more often in males than females, with an incidence approximately five times higher in males.

The highest incidence is seen in males aged 10–19 years, followed by males aged 20–29 years.

Incidence

Metacarpal neck fractures of this type account for approximately 10% of all hand fractures.

Risk Factors

Important risk factors include physical altercations, punching a hard surface with a closed fist, recurrent fighting behavior, boxing, and mixed martial arts.

Activities that repeatedly expose the MCP region to direct impact increase the likelihood of injury.

Etiology

The typical mechanism is a direct axial or dorsal force transmitted through the knuckle of a clenched fist.

The fracture usually develops through the metacarpal neck.

The pull of the interosseous muscles contributes to the characteristic apex-dorsal fracture angulation, which corresponds clinically to volar displacement of the metacarpal head.

Effect of Soft-Tissue Forces

The interosseous muscles and surrounding soft tissues influence the position of the fracture fragments.

Shortening of the collateral ligaments may also contribute to an MCP joint flexion posture.

These deforming forces explain why metacarpal neck fractures commonly angulate after injury.

Associated Neurovascular Injury

In severely displaced fractures, the digital neurovascular bundles located on either side of the metacarpal head may be injured.

Neurovascular status should therefore be carefully documented in all significantly displaced injuries.

Fight-Bite Injury

A particularly important associated injury is a fight bite, which occurs when the dorsum of the MCP joint contacts another person’s tooth.

The tooth can create a small laceration that penetrates deeply into the extensor mechanism or MCP joint.

Such injuries require urgent recognition because they can lead to serious infection, including septic arthritis.

Importance of Injury History

Patients injured during a fight may be reluctant to disclose the exact mechanism.

A small wound over the MCP joint should therefore raise concern for a possible human bite even when the initial history is unclear.

Extensor Mechanism Injury

When substantial angulation or displacement is present, the overlying extensor mechanism may also be damaged.

Extensor tendon injury should be considered when there is weakness, abnormal tendon tracking, or difficulty extending the affected finger.

Diagnosis

Signs and Symptoms

Patients typically present with pain and tenderness over the involved metacarpal head or neck.

Swelling and bruising may be present.

The normal knuckle prominence may appear flattened or depressed compared with the opposite hand.

Physical Examination

The dorsal skin should be examined carefully for puncture wounds, abrasions, lacerations, or evidence of an open fracture.

This is particularly important when the injury followed punching another person.

A small dorsal wound should not be assumed to be superficial.

Assessment of Rotational Alignment

Rotational deformity is clinically more important than modest angular deformity.

Rotation is best assessed by flexing the MCP and PIP joints while keeping the DIP joint extended.

The fingers should point toward a common area near the scaphoid tubercle without crossing or overlapping.

Finger Cascade

When the patient flexes the fingers, the digits should form a smooth and symmetric cascade.

Scissoring or overlap of one finger over another suggests malrotation and is an indication for specialist assessment and often operative treatment.

Knuckle Depression

With sufficient volar displacement of the metacarpal head, the normal dorsal prominence of the affected knuckle becomes less visible.

Some residual loss of knuckle contour may remain even after successful healing.

Imaging

Plain Radiographs

Standard radiographic evaluation includes posteroanterior, lateral, and oblique views of the hand.

These views define the fracture location, degree of displacement, angulation, comminution, and possible associated injury.

Measuring Angulation

The degree of volar angulation is most accurately assessed on the lateral radiograph.

The amount of angulation helps guide decisions regarding observation, reduction, or surgery.

MRI

MRI is not routinely required for an uncomplicated boxer’s fracture.

It may be considered if there is concern for significant injury to the extensor mechanism or neurovascular structures that cannot be adequately assessed clinically.

Differential Diagnosis

Conditions that may resemble or accompany a boxer’s fracture include MCP joint dislocation, extensor mechanism injury, fracture of the base of the proximal phalanx, transverse metacarpal shaft fracture, and articular fracture of the metacarpal head.

Careful examination and appropriate radiographs help distinguish these injuries.

Treatment

Open Fracture or Fight Bite

Any associated open fracture or fight-bite injury should be treated as a potentially contaminated wound.

These injuries require intravenous antibiotics and urgent surgical irrigation and debridement.

Failure to recognize a penetrating human bite may lead to deep infection or septic arthritis.

Indications for Hand-Surgery Referral

Referral to a hand surgeon is appropriate when there is malrotation, severe comminution, major angulation, open injury, tendon injury, neurovascular compromise, or significant uncertainty regarding stability.

Nonoperative Treatment

Closed fractures without malrotation can often be treated nonoperatively.

For the ring finger, fractures with less than approximately 30° of volar angulation may often be accepted.

For the small finger, up to approximately 40° of volar angulation may be acceptable in selected patients.

Ulnar Gutter Splint

Stable fractures within acceptable alignment can be immobilized in an ulnar gutter splint or cast.

The hand is generally positioned in the intrinsic-plus position, with MCP flexion and appropriate positioning of the interphalangeal joints.

This helps maintain alignment and reduce stiffness.

Buddy Taping

The injured digit may also be buddy-taped to the adjacent finger beneath the splint or cast.

This helps control rotational alignment during healing.

Indications for Closed Reduction

Closed reduction is considered when volar angulation exceeds acceptable limits.

Reduction may also be required when deformity significantly affects function or finger alignment.

Analgesia for Reduction

Reduction can be performed after appropriate local anesthesia, such as a hematoma block or ulnar nerve block.

Children, highly anxious patients, or patients unable to tolerate manipulation may require procedural sedation.

Jahss Reduction Maneuver

A commonly used reduction technique is the Jahss maneuver.

The MCP and PIP joints of the injured finger are flexed to approximately 90°.

A dorsally directed force is then applied along the proximal phalanx while counterpressure is placed over the metacarpal shaft to correct the angulation.

Contemporary Nonoperative Approaches

More recent evidence suggests that, in many uncomplicated boxer’s fractures without malrotation, formal reduction and rigid casting may not provide superior outcomes compared with functional treatment using a soft wrap or less restrictive support.

Treatment should therefore be individualized according to fracture alignment, stability, symptoms, and patient demands.

Physical Therapy

After approximately 4–6 weeks of immobilization, hand therapy may be started when clinically appropriate.

Both active and passive range-of-motion exercises can be used to restore movement at the MCP and PIP joints.

The goal is to prevent stiffness and regain grip function.

Medication

Pain is usually managed with a combination of acetaminophen and NSAIDs, provided there are no contraindications.

A hematoma block may also be used during acute fracture manipulation in the emergency department or clinic.

Surgical Management

Surgery may be required for significant malrotation, severe comminution, unacceptable angulation, open fractures, or unstable injuries.

Some patients may also request correction of a marked cosmetic loss of knuckle contour, although cosmetic concerns alone should be weighed against operative risks.

Fixation Methods

Operative fixation can be achieved using various combinations of Kirschner wires, screws, or other internal fixation techniques.

Stable fixation may allow earlier controlled motion and reduce the risk of stiffness.

Follow-Up

Most boxer’s fractures heal uneventfully.

Clinical and radiographic follow-up is used to confirm maintenance of alignment and progression toward union.

Prognosis

The prognosis is generally very good.

Most patients experience only temporary loss of motion and hand function.

A mild residual depression of the affected knuckle is common and usually has little effect on hand performance.

Healing Time

Clinical healing usually occurs within approximately 6 weeks.

Strength and full motion may continue to improve after fracture union.

Delayed Presentation

Delayed presentation is relatively common because some patients underestimate the injury or are reluctant to explain the circumstances.

If the fracture is already healing and there is no significant malrotation, functional deficit, or unacceptable deformity, nonoperative treatment may still be appropriate.

Complications

Potential complications include loss of reduction, infection in an open fracture, stiffness, extensor tendon injury, and injury to the digital neurovascular bundles.

Patients undergoing surgical fixation may occasionally require later hardware removal.

Loss of Reduction

Fracture alignment may change during the early healing period.

This is one reason that follow-up examination and radiographs are important, particularly when the initial fracture was substantially displaced.

Infection

Infection is primarily a concern in open fractures and fight-bite injuries.

Deep infection can involve the tendon, MCP joint, or bone and may result in significant long-term hand dysfunction if treatment is delayed.

Patient Monitoring

Repeat radiographs are commonly obtained approximately 1 week after injury to confirm maintenance of alignment.

Further radiographs may be obtained at roughly 2-week intervals until clinical healing, depending on the stability and treatment method.

Clinical monitoring should also assess rotation, motion, tenderness, skin condition, and neurovascular status.

Boxer’s Knuckle

A boxer’s knuckle should not be confused with a boxer’s fracture.

Boxer’s knuckle refers to rupture of the sagittal band over the MCP joint, leading to instability or subluxation of the extensor tendon.

The tendon may displace radially or ulnarly during finger motion.

Clinical Features of Boxer’s Knuckle

Patients may describe painful snapping or popping of the extensor tendon over the knuckle during active or passive motion.

Pain is often reproduced when attempting to extend the MCP joint against resistance while the interphalangeal joints are held extended.

Imaging of Boxer’s Knuckle

Because sagittal band injuries do not usually produce abnormalities on plain radiographs, MRI may be required to confirm the diagnosis and define associated soft-tissue injury.

Management of Boxer’s Knuckle

Suspected sagittal band rupture should be referred to a hand surgeon.

Some injuries can be managed with appropriate splinting, whereas others require operative repair, particularly when extensor tendon instability is persistent or severe.

Orthopaedic Surgery - Boutonniere Deformity

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Basics

Boutonniere deformity is characterized by flexion of the proximal interphalangeal joint (PIPJ) together with hyperextension of the distal interphalangeal joint (DIPJ).

The deformity develops as a consequence of injury or failure of the central slip of the extensor mechanism.

It may occur after acute trauma or develop gradually in association with inflammatory disease such as rheumatoid arthritis.

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General Prevention

The main preventive measure is appropriate medical control of rheumatoid arthritis, which can reduce chronic synovitis and subsequent attrition of the central slip.

Traumatic cases are not always preventable, but early recognition and treatment of a central slip injury can reduce the risk of progression to a fixed deformity.

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Risk Factors

The most important medical risk factor is rheumatoid arthritis.

Chronic inflammation of the PIP joint can weaken and gradually damage the central slip, eventually producing the characteristic deformity.

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Etiology

Boutonniere deformity results from a central slip injury.

The central slip may fail because of direct rupture, gradual attenuation, or avulsion from its bony insertion.

Inflammatory synovitis of the PIP joint, particularly in rheumatoid arthritis, can also cause attritional failure of the central slip.

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Pathophysiology

The central slip normally extends the PIP joint.

When it is disrupted, the PIP joint begins to fall into flexion.

As the deformity progresses, the extensor mechanism migrates proximally and volarly relative to the PIP joint.

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Lateral Band Migration

Stretching or disruption of the triangular ligament allows the lateral bands to move volarly around the sides of the PIP joint.

Once the lateral bands subluxate below the axis of rotation of the PIP joint, they act as flexors rather than extensors at that joint.

This further reinforces the PIP flexion deformity.

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DIP Hyperextension

As the extensor mechanism migrates proximally, increased tension is transmitted distally through the lateral bands and terminal tendon.

This produces the characteristic hyperextension deformity of the DIP joint.

The combined pattern of PIP flexion and DIP hyperextension creates the classic boutonniere appearance.

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Diagnosis

History

The history may reveal either a chronic inflammatory process or an acute traumatic injury.

Patients with rheumatoid arthritis may describe a slowly progressive deformity.

In traumatic cases, there is often a history of sudden hyperflexion or direct injury to the PIP joint, followed by immediate difficulty actively extending the joint.

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Signs and Symptoms

The classic clinical appearance consists of PIP joint flexion with DIP joint hyperextension.

In early central slip injury, the deformity may not yet be fully developed.

Patients may initially present only with swelling, pain, and an extensor lag at the PIP joint.

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Physical Examination

Examination should determine whether the deformity is flexible or fixed.

Active and passive motion of both the PIP and DIP joints should be assessed.

The integrity of the central slip and lateral bands can be further evaluated using specialized clinical tests.

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Elson Test

The Elson test is commonly used to confirm a central slip injury.

The PIP joint is flexed to approximately 90°, and the patient is asked to extend the PIP joint against resistance.

The examiner simultaneously assesses the behavior of the DIP joint.

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Elson Test Interpretation

If the central slip remains intact, the DIP joint remains relatively supple or lax during resisted PIP extension.

If the central slip is ruptured, the extensor force is redirected through the lateral bands and terminal tendon.

As a result, the DIP joint becomes rigid or stiff in extension during the maneuver.

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Boyes Test

The Boyes test evaluates whether the lateral bands have become shortened or contracted.

The PIP joint is held in full extension while the patient is asked to actively flex the DIP joint.

If the DIP joint flexes fully, the extensor mechanism remains relatively supple.

If active DIP flexion is limited, contracted lateral bands are likely present.

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Limitations of the Boyes Test

The Boyes test may be negative during the acute phase because significant lateral band contracture has not yet developed.

It becomes more useful in chronic deformity when soft-tissue shortening is established.

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Laboratory Tests

No laboratory study is required to diagnose an isolated boutonniere deformity.

Laboratory investigations may be appropriate only when an underlying systemic inflammatory disorder, such as rheumatoid arthritis, is suspected or already known.

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Imaging

Plain Radiographs

Radiographs are useful for identifying associated structural abnormalities.

They can help exclude a bony avulsion fracture, joint dislocation, or degenerative or inflammatory arthritis.

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Radiographic Technique

Imaging should include the entire involved ray so that the metacarpophalangeal joint, PIP joint, and DIP joint can all be evaluated.

This is especially useful when there is concern for more extensive trauma or underlying arthropathy.

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Differential Diagnosis

The main differential diagnosis is pseudoboutonniere deformity.

This condition also produces inability to fully extend the PIP joint, but the mechanism is different.

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Pseudoboutonniere Deformity

Pseudoboutonniere deformity usually follows a hyperextension injury of the PIP joint.

The problem results from scarring or adhesions involving the volar plate and flexor structures rather than central slip disruption.

Unlike true boutonniere deformity, the DIP joint remains functionally normal and does not develop the characteristic hyperextension pattern.

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Treatment

Acute Injuries

Acute central slip injuries are generally treated with the PIP joint held continuously in full extension for approximately 6 weeks.

During this period, the DIP joint should remain free so that active motion can be performed.

This allows the central slip to heal while minimizing stiffness of the distal joint.

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DIP Motion During Splinting

Active DIP flexion and extension exercises are important while the PIP joint remains immobilized.

These exercises help maintain mobility of the lateral bands and reduce the risk of adhesions or contracture.

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Transition After Initial Immobilization

After approximately 6 weeks of continuous PIP extension splinting, patients typically transition to night splinting.

Progressive PIP joint motion is then introduced.

The amount and pace of motion should be advanced gradually to avoid recurrent deformity.

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Chronic Injuries

Chronic boutonniere deformity should first be assessed for passive correctability.

If full passive PIP extension can still be achieved with stretching or progressive splinting, treatment can often proceed similarly to that used for an acute injury.

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Fixed Chronic Deformity

If the deformity is fixed, serial splinting or casting may be required to gradually restore passive PIP extension before definitive treatment.

Surgery is generally reserved for patients in whom splinting fails or who have a meaningful functional deficit.

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Surgical Expectations

Surgical treatment of chronic boutonniere deformity has guarded results.

Complete correction of the extensor lag should not always be expected.

Because of this, surgery is usually considered only when the deformity produces substantial functional impairment.

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Activity

Heavy lifting and sports activities should be avoided until healing is adequate.

Premature loading or repeated flexion stress may disrupt healing of the central slip and lead to recurrent deformity.

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Occupational Therapy

Occupational or hand therapy plays an important role in management.

Treatment may include custom splinting, stretching, edema control, and progressive motion exercises.

Therapy is particularly important in chronic cases and after surgery.

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Acute Central Slip Injury With Bony Avulsion

When the central slip injury includes a bony avulsion fragment, treatment may involve fracture fixation, splinting, or temporary joint pinning in full extension.

Immobilization is generally maintained for approximately 6 weeks.

The exact approach depends on the size and displacement of the fragment and the stability of the joint.

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Acute Central Slip Injury Without Bony Avulsion

When no fracture is present, many injuries can be treated with extension splinting alone.

In selected cases, temporary joint pinning may be used.

Direct repair of the central slip, including fixation with a suture anchor, may be considered when the tendon has been clearly disrupted and operative treatment is appropriate.

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Open Injuries

Open central slip injuries require irrigation and debridement because of the risk of contamination.

Definitive repair or fixation is then performed as indicated.

Temporary pinning of the PIP joint in extension may be used to protect the repair.

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Chronic Passively Correctable Deformity

A chronic deformity that can still be fully corrected passively may be treated in a manner similar to an acute injury.

Approximately 6 weeks of extension splinting or joint pinning may allow soft-tissue rebalancing.

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Terminal Tendon Tenotomy

In selected chronic cases, a terminal tendon tenotomy may be performed.

The purpose is to reduce excessive extension force at the DIP joint and redirect more of the extensor force toward the PIP joint.

This can improve the balance of the extensor mechanism.

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Fixed Contracture With Tight Lateral Bands

When a fixed PIP flexion contracture is accompanied by shortened lateral bands, treatment often begins with serial casting or progressive splinting.

The goal is to restore passive PIP extension.

Once full extension is achieved, treatment can then proceed using principles similar to those for an acute boutonniere injury.

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Fixed Contracture With Volar Plate or Collateral Tightness

If the deformity includes contracture of the volar plate or collateral ligaments, surgical release of the joint contracture may be required.

Soft-tissue rebalancing may then be performed, sometimes in a staged fashion.

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Boutonniere Deformity With PIP Arthrosis

When a fixed boutonniere deformity is associated with substantial PIP joint arthritis, reconstruction of the extensor mechanism alone may not provide adequate pain relief or function.

In such cases, treatment may require PIP joint arthrodesis or arthroplasty.

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Follow-Up

Conservative treatment generally requires at least 12 weeks of follow-up to ensure that splinting and rehabilitation are completed appropriately.

Patients treated surgically require regular postoperative review to monitor healing, alignment, motion, and recurrence.

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Indications for Referral

Referral to a hand or orthopaedic specialist is appropriate for an acute central slip rupture, especially when the diagnosis is uncertain or a bony avulsion is present.

Referral is also appropriate for a chronic boutonniere deformity that produces significant functional impairment.

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Prognosis

The prognosis is generally better when the injury is recognized and treated early.

Chronic fixed deformities have a more guarded outcome.

Even after surgery, some degree of residual PIP extensor lag may persist.

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Complications

Potential complications include recurrent boutonniere deformity, loss of PIP flexion, and development of a mallet-type deformity at the DIP joint.

Stiffness may also result from prolonged immobilization or chronic joint contracture.

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Recurrent Deformity

Recurrence can occur if the central slip fails to heal adequately or if the PIP joint is mobilized too aggressively.

Continued nighttime splinting and gradual rehabilitation may help reduce this risk.

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Limited PIP Flexion

Prolonged extension splinting or surgical scarring may lead to reduced PIP flexion.

Therapy should therefore balance protection of the central slip with preservation of joint mobility.

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DIP Complications

Alteration of the extensor mechanism can occasionally produce a mallet-type deformity at the DIP joint.

This may occur particularly after certain reconstructive procedures or if distal extensor balance becomes abnormal.

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Patient Monitoring

Patients should be monitored closely for recurrent PIP flexion, increasing DIP hyperextension, loss of motion, or persistent extensor lag.

Early detection of recurrent deformity allows adjustment of splinting or rehabilitation before the deformity becomes fixed.

Orthopaedic Surgery - Bite to the Hand

Basics

Bite injuries to the hand are common and potentially serious. They may occur directly, such as from a dog, cat, or intentional human bite, or indirectly through a clenched-fist injury.

If these wounds are not recognized and treated appropriately, they can lead to significant morbidity involving the soft tissues, tendons, joints, and bones of the hand.

Clenched-Fist Injury

The classic indirect human bite injury, commonly called a “fight bite” or “clenched-fist injury,” occurs when a closed fist strikes another person’s teeth.

The injury most commonly affects the skin over a metacarpophalangeal (MCP) joint.

Although the external wound may appear small and harmless, the underlying damage may be extensive.

Deep Structural Injury

A tooth can penetrate the skin and injure the extensor tendon, joint capsule, or MCP joint itself.

Deep structural involvement has been reported in a substantial proportion of clenched-fist injuries.

Because the fist is flexed at the time of impact, the skin wound and deeper injury may not remain aligned when the fingers are subsequently extended.

Hidden Nature of Fight-Bite Wounds

When the injured finger is returned to an extended position, the skin shifts relative to the underlying tendon and joint.

As a result, the deeper injury may lie proximal to the visible skin laceration.

This can make the wound appear more superficial than it actually is and contributes to delayed diagnosis.

Synonyms

Common synonyms include clenched-fist injury and fight bite.

General Prevention

Patients should be advised to avoid unnecessary contact with unfamiliar or potentially aggressive animals and to avoid fistfighting.

The complications of clenched-fist injuries can be reduced by recognizing them early as serious wounds and initiating prompt irrigation, debridement, and appropriate antibiotic therapy.

Epidemiology

Bite injuries to the hand account for a large number of emergency department visits.

Approximately 330,000 emergency visits annually in the United States have been attributed to hand bites.

More than half of the population is estimated to experience an animal bite at some point in life, with many occurring during childhood.

Dog Bites

Approximately 4.5 million dog bites occur annually in the United States.

Dog bites may produce crushing injury, puncture wounds, lacerations, fractures, or tendon damage.

Although infection is possible, the infection rate is generally lower than that associated with cat bites.

Human Bites

Human bite injuries are less common than animal bites, and their true incidence is difficult to determine.

Some patients with fight bites do not initially disclose that the injury occurred during an altercation, which can delay diagnosis and appropriate treatment.

Risk Factors

Risk factors include alcohol misuse, fighting, exposure to unfamiliar animals, and delayed presentation for treatment.

Cat bites have a particularly high risk of infection because their sharp, narrow teeth can penetrate deeply into tissue.

Approximately 30–50% of cat bites may become infected, whereas dog bites have a lower infection rate.

Etiology

Common mechanisms include fistfights, dog bites, cat bites, and bites from other mammals.

The mechanism is important because different bite types cause different patterns of tissue damage and expose the patient to different organisms.

Associated Injuries

Hand bites may be associated with fractures, extensor tendon lacerations, joint capsule penetration, and retained foreign material such as tooth fragments.

Infectious complications may include cellulitis, abscess formation, septic tenosynovitis, septic arthritis, osteomyelitis, and systemic sepsis.

Diagnosis

Signs and Symptoms

The most obvious finding is usually a puncture wound or laceration of the hand.

Swelling and erythema may develop around the injury.

If infection occurs, cellulitis or lymphangitis may spread beyond the original wound.

Tendon Injury

If the extensor tendon has been injured, the patient may have difficulty extending the affected finger.

However, apparent finger extension does not completely exclude extensor injury because the intrinsic muscles can sometimes extend the proximal interphalangeal joint even when part of the extensor mechanism has been disrupted.

Symptoms

Patients may report pain at the wound, along the affected digit or ray, or around the adjacent MCP joint.

Hand function may be reduced, with difficulty gripping objects or moving an individual finger.

Pain and swelling that progressively worsen after the initial injury suggest developing infection.

History

The history should identify whether the wound resulted from a human bite, animal bite, or clenched-fist impact against another person’s mouth.

The clinician should ask about increasing erythema, swelling, pain, drainage, fever, and reduced hand function.

Immunocompromising conditions should also be identified because they increase the risk and severity of infection.

Delayed Presentation

Patients with clenched-fist injuries may minimize or conceal how the injury occurred.

Some may also fail to appreciate the seriousness of a small dorsal hand wound.

Delayed presentation is associated with a higher rate of infection, tissue destruction, joint damage, and poor functional outcome.

Physical Examination

The hand should be examined carefully for every puncture or laceration.

Special attention should be paid to wounds over the third and fourth MCP joints, which are common locations for clenched-fist injuries.

Even a small wound in this area should be considered potentially deep until proven otherwise.

Neurovascular Examination

Motor, sensory, and vascular function should be assessed in the entire hand and in each individual digit.

Capillary refill, pulse examination when appropriate, sensation, and active movement should be documented before treatment.

Examination in the Injured Position

When a clenched-fist injury is suspected, the patient should be asked to make a fist if tolerated.

Flexing the MCP joint may realign the superficial wound with the underlying tendon or joint injury and improve visualization of the true depth of penetration.

Extensor Mechanism Assessment

The extensor tendons should be examined carefully.

Because the intrinsic muscles can contribute to extension of the proximal interphalangeal joint, a patient may appear to have preserved extension despite injury to the central slip or more proximal extensor tendon.

Individual tendon function should therefore be tested systematically.

Laboratory Tests

Laboratory evaluation may include a white blood cell count, erythrocyte sedimentation rate, and C-reactive protein when infection is suspected.

These tests can assist in assessing and monitoring inflammatory activity but do not replace clinical examination.

Wound Cultures

When operative debridement is required, cultures should preferably be obtained from deep tissue specimens rather than superficial swabs.

Tissue cultures generally provide more meaningful information regarding the causative organisms.

Imaging

Plain Radiographs

Radiographs of the hand should be obtained when a significant bite injury is suspected.

They can identify fractures, bone impaction, retained tooth fragments, or other foreign bodies.

Delayed Imaging Findings

In patients presenting later, radiographs may demonstrate changes associated with osteomyelitis.

Bone destruction, periosteal reaction, or other abnormalities may indicate progression of infection beyond the soft tissues.

Ultrasound

Ultrasound can be useful for detecting fluid collections or abscesses.

It may also assist in evaluating selected soft-tissue abnormalities when the physical examination is uncertain.

Differential Diagnosis

The differential diagnosis includes a simple superficial laceration and a retained foreign body.

However, apparently minor wounds over the MCP joint after an altercation should always raise concern for deeper bite injury.

Treatment

Tetanus Prophylaxis

Tetanus immunization status should be reviewed in every patient.

If immunization is not up to date, appropriate tetanus-containing vaccination should be administered.

Patients with an incomplete prior vaccination series may also require tetanus immune globulin, depending on the wound and immunization history.

Rabies Considerations

Rabies exposure should be assessed according to the animal involved and the circumstances of the bite.

In the United States, rabies is most commonly associated with animals such as bats, raccoons, skunks, and foxes.

When significant exposure has occurred and the animal cannot immediately be confirmed to be free of rabies, appropriate post-exposure prophylaxis should be considered.

Irrigation and Debridement

The most important early treatment is aggressive irrigation and debridement.

The goal is to remove bacteria, devitalized tissue, contaminated material, and retained foreign bodies.

Copious irrigation with normal saline is commonly performed initially.

Wound Exploration

The wound may need to be extended surgically to determine its true depth.

In clenched-fist injuries, careful exploration is particularly important to assess the extensor tendon, joint capsule, cartilage, and MCP joint.

Failure to identify joint penetration can result in septic arthritis.

Wound Management

After adequate irrigation and debridement, deeper structures may be loosely covered as necessary.

The wound is generally left open rather than primarily sutured, particularly when contamination or infection is present.

Packing and regular dressing changes may be used depending on the wound.

Immobilization and Elevation

The hand should initially be immobilized and elevated.

This decreases soft-tissue stress, swelling, and pain while the acute wound is being monitored.

Prolonged immobilization should be avoided once the infection is controlled because stiffness can develop rapidly.

Antibiotic Prophylaxis

Because hand bites carry a substantial infection risk, prophylactic antibiotics are generally recommended.

Amoxicillin-clavulanate is commonly used as a first-line oral agent when the patient is not allergic.

A typical prophylactic course lasts approximately 5–7 days, depending on the injury and clinical circumstances.

Follow-Up After Initial Treatment

The wound should be reassessed early, commonly within approximately 24 hours.

If packing has been used, it can be removed or changed at this visit.

Warm soaks and local wound care may then be initiated when appropriate.

Management of Established Infection

If infection is present, repeat irrigation and debridement may be necessary.

Patients with significant infection may require hospital admission and intravenous antibiotic therapy.

Septic arthritis, deep-space infection, tendon sheath infection, or systemic illness requires particularly aggressive management.

Physical Therapy

Formal therapy is usually unnecessary during the immediate acute phase.

However, once the wound is stable and infection is controlled, finger range-of-motion exercises should begin relatively early, often within the first week.

Early motion helps prevent stiffness, particularly at the MCP joints.

Common Organisms in Human Bites

The human mouth contains numerous bacterial species.

Common organisms associated with human bite wounds include Eikenella corrodens and streptococcal species, along with staphylococci and anaerobic organisms.

Because the flora are polymicrobial, antibiotic coverage should address both aerobic and anaerobic bacteria.

Common Organisms in Animal Bites

Animal bite infections may involve Pasteurella species, Staphylococcus aureus, streptococci, Bacteroides, and other anaerobic organisms.

Pasteurella is particularly associated with cat and dog bites.

First-Line Oral Antibiotic

Amoxicillin-clavulanate provides broad coverage against many organisms encountered in both human and animal bites.

It is therefore commonly selected as first-line oral therapy in patients who can tolerate penicillin-class antibiotics.

Intravenous Antibiotics

Clinically apparent deep infection may require intravenous therapy.

An agent such as ampicillin-sulbactam may be used empirically before culture results are available.

Treatment should subsequently be adjusted according to culture and sensitivity results.

Blood-Borne Viral Transmission

Although uncommon, human bites involving blood exposure can potentially transmit hepatitis B, hepatitis C, or HIV.

The risk depends on whether blood was present in the mouth or wound and on the infectious status of the individuals involved.

Appropriate exposure assessment should therefore be performed when significant blood contact has occurred.

Hepatitis B Prophylaxis

Hepatitis B vaccination status should be reviewed after a human bite involving blood exposure.

An accelerated vaccination schedule or other post-exposure measures may be considered according to the patient’s immunity and exposure risk.

Surgical Management

Surgical irrigation and debridement involve removing contaminated and nonviable tissue and thoroughly cleaning infected spaces.

All potentially involved structures should be assessed during exploration.

Joint Involvement

If the joint capsule has been penetrated, formal joint irrigation and debridement are required.

This is essential to reduce the risk of septic arthritis and subsequent cartilage destruction.

Cultures During Surgery

Deep cultures should be obtained intraoperatively before definitive antibiotic adjustment whenever possible.

Tissue specimens are preferred because they more accurately represent the organisms responsible for deep infection.

Wound Closure

Bite wounds requiring operative treatment are generally left open and managed with dressing changes rather than closed primarily.

Delayed closure may be considered later when contamination and infection have resolved.

Tendon Reconstruction

Extensor tendon injuries or other structures requiring definitive reconstruction are often not repaired immediately if active infection is present.

The initial priority is controlling infection.

Definitive tendon repair or reconstruction can be addressed after the wound has become clean and infection has resolved.

Follow-Up

Close follow-up is essential.

The wound should be reassessed early to ensure that swelling, erythema, pain, and drainage are improving rather than worsening.

Hand function and neurovascular status should also be monitored.

Prognosis

The prognosis is generally good when bite injuries are recognized and treated early.

Prompt irrigation, debridement, antibiotics, and appropriate follow-up can prevent most serious complications.

Late presentation substantially worsens the prognosis.

Delayed Presentation

Patients presenting very late, particularly after more than approximately 8 days, have a higher risk of severe infection, tissue loss, joint destruction, and even amputation.

This emphasizes the importance of early recognition and treatment.

Complications

The most important complication is infection, which may involve the soft tissues, tendon sheaths, joints, or bone.

Other complications include stiffness, persistent pain, tendon injury, loss of motion, and reduced hand function.

Septic Arthritis

Penetration of a bite wound into the MCP joint may result in septic arthritis.

Without prompt treatment, infection can rapidly damage the articular cartilage and lead to chronic pain, stiffness, and loss of function.

Osteomyelitis

Untreated or delayed infection can spread into bone and produce osteomyelitis.

This complication may require prolonged antibiotic treatment and additional surgical debridement.

Stiffness

Hand stiffness may develop because of pain, edema, infection, prolonged immobilization, or tendon and joint injury.

Early supervised range-of-motion exercises are therefore important once the wound is sufficiently stable.

Patient Monitoring

If packing is used, it should generally be removed or changed at approximately 24 hours.

The patient should continue to be followed until the wound is healing satisfactorily and there is no evidence of progressive infection.

When there is uncertainty regarding wound stability or infection, reassessment at 24–48-hour intervals is appropriate.

Orthopaedic Surgery - Bisphosphonates

Basics

Bisphosphonates are medications that reduce bone resorption by suppressing osteoclast activity.

They are commonly used in the treatment of osteoporosis, metastatic bone disease, Paget disease of bone, and malignancy-associated hypercalcemia.

Bisphosphonates can be administered either orally or intravenously, depending on the clinical indication, patient factors, and specific medication being used.

Oral Bisphosphonates

Commonly used oral bisphosphonates include alendronate, risedronate, and ibandronate.

These agents are frequently prescribed for osteoporosis and other conditions characterized by excessive bone turnover.

Because oral bisphosphonates can irritate the upper gastrointestinal tract, specific administration instructions are important.

Intravenous Bisphosphonates

Frequently used intravenous agents include zoledronate and pamidronate.

Intravenous therapy is particularly useful in patients with metastatic bone disease, multiple myeloma, malignancy-related hypercalcemia, or those who cannot tolerate oral treatment.

Epidemiology and Clinical Use

Patients with metastatic bone disease or multiple myeloma often have increased osteoclast-mediated bone destruction.

As a result, most such patients receive therapy that suppresses osteoclast function, either with a bisphosphonate or another antiresorptive agent such as denosumab, which inhibits osteoclast formation, function, and survival.

High Bone-Turnover Disorders

Bisphosphonates are also commonly used in disorders associated with increased bone turnover.

These include osteoporosis, Paget disease, and selected cases of polyostotic fibrous dysplasia.

By reducing osteoclastic activity, these medications can decrease excessive bone resorption and improve skeletal stability.

Risk Factors and Dental Considerations

One of the most important concerns before starting bisphosphonate therapy is poor dental health.

Patients with significant dental disease may be at greater risk of developing osteonecrosis of the jaw, particularly when potent intravenous bisphosphonates are used for prolonged periods.

Pretreatment Dental Evaluation

Before beginning long-term or high-potency bisphosphonate therapy, patients should undergo appropriate dental evaluation.

Any necessary tooth extractions, treatment of active dental infection, or major reconstructive dental procedures should ideally be addressed before therapy begins.

Good oral hygiene and regular dental follow-up remain important during treatment.

Pathophysiology

Bisphosphonates reduce skeletal resorption by interfering with the normal function and survival of osteoclasts, the cells responsible for breaking down bone.

Their action ultimately decreases the rate at which mineralized bone is removed.

Mevalonate Pathway

Many bisphosphonates act by interfering with enzymes in the mevalonate pathway.

Disruption of this pathway impairs intracellular processes required for normal osteoclast function.

This reduces the ability of osteoclasts to adhere to and resorb bone effectively.

Osteoclast Ruffled Border

Active osteoclasts form a specialized ruffled border against the bone surface.

This structure is essential for creating the acidic environment and releasing enzymes required for bone resorption.

Bisphosphonates interfere with this resorptive apparatus and thereby diminish osteoclastic activity.

Osteoclast Apoptosis

Bisphosphonates can also promote apoptosis, or programmed cell death, of osteoclasts.

The resulting reduction in osteoclast number and activity decreases bone turnover and limits further bone loss.

Complications

The adverse effects of bisphosphonate therapy vary according to whether the medication is administered orally or intravenously and according to treatment duration.

Important complications include gastrointestinal irritation, acute systemic reactions, osteonecrosis of the jaw, and atypical femoral fractures.

Gastrointestinal Adverse Effects

The most common complication of oral bisphosphonate therapy is upper gastrointestinal irritation or gastric upset.

Patients may experience dyspepsia, reflux symptoms, esophageal irritation, or abdominal discomfort.

Proper administration helps reduce these complications.

Administration of Oral Bisphosphonates

Oral bisphosphonates should generally be taken on an empty stomach with a full glass of water.

The patient should remain upright after taking the medication, traditionally for approximately 30–60 minutes depending on the specific preparation, to reduce the risk of esophageal irritation.

Food and other medications may interfere with absorption and should be avoided for the recommended period after dosing.

Intravenous Adverse Effects

The most common early adverse effects of intravenous bisphosphonates include fever, bone pain, and muscle aches.

These acute-phase reactions may occur in approximately one-quarter of patients, particularly after an initial infusion.

Symptoms are usually temporary.

Osteonecrosis of the Jaw

One of the most important long-term complications of bisphosphonate therapy is osteonecrosis of the jaw.

This complication is characterized by impaired healing and exposed or necrotic jaw bone, often after dental extraction or other invasive dental treatment.

The risk is particularly relevant in patients receiving high-dose intravenous therapy for malignancy.

Prevention of Jaw Osteonecrosis

Preventive measures include addressing major dental problems before treatment, maintaining good oral hygiene, and obtaining regular dental care.

Patients should inform their dentist that they are receiving bisphosphonate therapy.

Any invasive dental procedure during treatment should be planned carefully.

Atypical Femoral Fractures

Long-term bisphosphonate use is also associated with atypical stress fractures of the femur.

These fractures commonly involve the subtrochanteric or femoral shaft region and may develop gradually because of prolonged suppression of bone remodeling.

Prodromal Symptoms

Before an atypical femoral fracture becomes complete, patients may experience thigh or groin pain during walking or weight-bearing.

This discomfort may precede fracture by weeks or months.

Patients receiving prolonged bisphosphonate therapy should report new persistent thigh or groin pain promptly.

Radiographic Findings

Early radiographs may be normal.

When abnormalities are present, they may include periosteal reaction, cortical thickening, or localized beaking of the lateral femoral cortex.

These findings can represent an incomplete or impending atypical fracture.

Duration of Therapy

Because the risk of atypical femoral fracture increases with prolonged treatment, the need for continued bisphosphonate therapy should be reassessed periodically.

Long-term treatment should be individualized according to the patient’s fracture risk, response to therapy, and potential complications rather than continued automatically.

Drug Holiday Consideration

In selected patients whose fracture risk has fallen after several years of therapy, a temporary bisphosphonate drug holiday may be considered.

The timing and duration depend on the specific medication, bone density, previous fractures, and overall osteoporosis risk.

Patients at very high fracture risk may require continued therapy or an alternative treatment strategy.

Patient Monitoring

Patients receiving bisphosphonates are commonly monitored with serial dual-energy X-ray absorptiometry (DEXA) scans.

DEXA testing provides an estimate of bone mineral density and helps assess the response to osteoporosis treatment over time.

Additional Monitoring

Follow-up should also include assessment for new fractures, changes in height or posture, medication tolerance, dental problems, and symptoms suggestive of atypical femoral fracture.

Persistent thigh or groin pain should prompt further evaluation even when the initial radiograph is normal.

Patient Education

Patients should understand why bisphosphonate therapy has been prescribed and how to take the medication correctly.

Those receiving oral therapy should follow administration instructions carefully to reduce gastrointestinal complications.

Patients should also maintain good dental care and promptly report jaw symptoms, persistent thigh or groin pain, or other new skeletal complaints.

Prognosis

When used appropriately, bisphosphonates can substantially reduce excessive bone resorption and help lower fracture risk in patients with osteoporosis and other high-turnover skeletal disorders.

The benefits of therapy should be balanced against uncommon but potentially important complications, especially during prolonged treatment.

Regular reassessment allows treatment to be adjusted according to changing fracture risk and patient response.