INTRINSIC ANATOMY AND DYSFUNCTION - Teton Hand …tetonhandconference.com/files/IntrinsicAnatomyAndDysfunction.pdf · intrinsic anatomy and dysfunction paul c. dell, ... wartenberg

INTRINSIC ANATOMY AND INTRINSIC ANATOMY AND DYSFUNCTIONDYSFUNCTION

PAUL C. DELL, M.D.PAUL C. DELL, M.D.UNIVERSITY OF FLORIDAUNIVERSITY OF FLORIDA

““IF I HAVE SEEN FURTHERIF I HAVE SEEN FURTHER……. IT IS . IT IS BY STANDING UPON THE BY STANDING UPON THE SHOULDERS OF GIANTS.SHOULDERS OF GIANTS.””

SIR ISAAC NEWTON, 1675SIR ISAAC NEWTON, 1675

MENTORINGMENTORING

MOST SUCCESSFUL PEOPLE IN MOST SUCCESSFUL PEOPLE IN DIFFERENT AREAS CAN POINT TO AN DIFFERENT AREAS CAN POINT TO AN INDIVIDUAL(S) OR MENTOR WHO WAS INDIVIDUAL(S) OR MENTOR WHO WAS CRUCIAL TO THEIR CAREER GROWTH CRUCIAL TO THEIR CAREER GROWTH AND SUCCESSAND SUCCESS

MENTORINGMENTORING

TEACHER SUPPLIES INFORMATION IN TEACHER SUPPLIES INFORMATION IN A NEUTRAL FASHIONA NEUTRAL FASHIONMENTORING IMPLIES A BONDING MENTORING IMPLIES A BONDING BETWEEN THE MENTOR AND THE BETWEEN THE MENTOR AND THE MENTEEMENTEERELATIONSHIP IS PERSONAL AND RELATIONSHIP IS PERSONAL AND ALMOST FAMILIAL IN NATUREALMOST FAMILIAL IN NATUREMAY BE SINGULAR OR MULTIPLE MAY BE SINGULAR OR MULTIPLE

WILLIAM F ENNEKINGWILLIAM F ENNEKING

MENTORMENTOR–– RESPECTEDRESPECTED–– TRUSTEDTRUSTED–– ACCOMPLISHEDACCOMPLISHED–– CONFIDENTCONFIDENT–– ACCESSIBLEACCESSIBLE

RICHARD J SMITHRICHARD J SMITHCHIEF OF HAND CHIEF OF HAND SURGERY MASS SURGERY MASS GENERAL HOSP GENERAL HOSP 1972 1972 –– 19871987FORMER FORMER PRESIDENT OF THE PRESIDENT OF THE ASSHASSH1931 1931 –– 19871987THE GREAT THE GREAT COMMUNICATORCOMMUNICATOR

RICHARD J SMITHRICHARD J SMITH

OVER 100 ORIGINAL OVER 100 ORIGINAL CONTRIBUTIONS CONTRIBUTIONS TO HAND TO HAND LITERATURELITERATUREBOSTON 1975 BOSTON 1975 –– 7676KAPLAN, KAPLAN, PULVERTAFT, PULVERTAFT, FLATTFLATT

WILLIAM BURKHALTERWILLIAM BURKHALTER

MENTOR: IMPARTS MENTOR: IMPARTS KNOWLEDGE, KNOWLEDGE, EXPERIENCE, EXPERIENCE, SUPPORTSUPPORTENABLES MENTEE ENABLES MENTEE TO DEVELOP TO DEVELOP SKILLS MUCH SKILLS MUCH MORE RAPIDLY MORE RAPIDLY THAN WHEN THAN WHEN RELATIONSHIP IS RELATIONSHIP IS LACKINGLACKING

WILLIAM BURKHALTERWILLIAM BURKHALTER

CHIEF OF ORTHO CHIEF OF ORTHO 8585THTH EVAC HOSP EVAC HOSP VIETNAM 1965VIETNAM 1965--6666CHIEF OF HAND CHIEF OF HAND SURGERY UNIV OF SURGERY UNIV OF MIAMI 1974 MIAMI 1974 –– 199119911928 1928 -- 19921992

INTRINSIC MECHANISMINTRINSIC MECHANISM

EXTRINSIC EXTENSOREXTRINSIC EXTENSOR

DORSAL COMPARTMENTSDORSAL COMPARTMENTS–– 1ST EPB, APL1ST EPB, APL–– 2ND ECRL, ECRB2ND ECRL, ECRB–– 3RD EPL3RD EPL–– 4TH EIP, EDC4TH EIP, EDC–– 5TH EDQ5TH EDQ–– 6TH ECU6TH ECU

JUNCTURAEJUNCTURAE

JUNCTURAEJUNCTURAE

STABILIZE THE DORSAL HOOD WHEN STABILIZE THE DORSAL HOOD WHEN THE MCP JOINTS ARE FLEXEDTHE MCP JOINTS ARE FLEXED

INTEROSSEOUS MUSCLESINTEROSSEOUS MUSCLES

4 DORSAL4 DORSAL–– 11STST,2,2NDND,4,4TH TH HAVE TWO MUSCLE BELLIESHAVE TWO MUSCLE BELLIES–– 33RDRD HAS ONLY ONE HAS ONLY ONE 3 VOLAR ONE MUSCULAR ORIGIN3 VOLAR ONE MUSCULAR ORIGIN


4 DORSAL INTEROSSEI4 DORSAL INTEROSSEI–– 11STST ,2,2NDND ,4,4THTH

DEEP BELLYDEEP BELLY–– ORIGIN METACARPAL DIAPHYSISORIGIN METACARPAL DIAPHYSIS–– SPIRALS AROUND THE MORE SUPERFICIAL BELLYSPIRALS AROUND THE MORE SUPERFICIAL BELLY–– PASSES SUPERFICIAL TO SAGITTAL BANDSPASSES SUPERFICIAL TO SAGITTAL BANDS–– INSERTS ON THE DORSAL HOODINSERTS ON THE DORSAL HOOD–– FLEX MCPJ , EXTEND PIPJ FLEX MCPJ , EXTEND PIPJ


4 DORSAL INTEROSSEI4 DORSAL INTEROSSEI–– 11STST,2,2NDND,4,4thth

SUPERFICIAL BELLY SUPERFICIAL BELLY –– ORIGIN: ADJACENT SIDES CONTIGUOUS ORIGIN: ADJACENT SIDES CONTIGUOUS

METACARPALS METACARPALS –– RUNS DEEP TO THE SAGITTAL BANDSRUNS DEEP TO THE SAGITTAL BANDS–– INSERTS ON TUBERCLE P1INSERTS ON TUBERCLE P1–– ACTS ONLY AS ABDUCTOR ACTS ONLY AS ABDUCTOR


4 DORSAL INTEROSSEI4 DORSAL INTEROSSEI–– 33RDRD DORSALDORSAL

ORIGIN: 3ORIGIN: 3RDRD / 4/ 4THTH METACARPALSMETACARPALSSINGLE MUSCLE BELLYSINGLE MUSCLE BELLYINSERTS ON DORSAL HOOD INSERTS ON DORSAL HOOD ---- NO NO INSERTION ON BONEINSERTION ON BONELITTLE MOTION OF MIDDLE TOWARD RINGLITTLE MOTION OF MIDDLE TOWARD RING



3 VOLAR INTEROSSEI3 VOLAR INTEROSSEI–– ORIGIN: CONTIGUOUS METACARPAL ORIGIN: CONTIGUOUS METACARPAL

SHAFTSSHAFTS–– SUPERFICIAL TO SAGITTAL BANDSSUPERFICIAL TO SAGITTAL BANDS–– INSERT INTO DORSAL HOOD ON INSERT INTO DORSAL HOOD ON

ULNAR SIDE OF INDEX AND RADIAL ULNAR SIDE OF INDEX AND RADIAL SIDE OF RING AND SMALLSIDE OF RING AND SMALL


INTEROSSEOUS MUSCLES INTEROSSEOUS MUSCLES SUMMARYSUMMARY

11STST 22NDND 44THTH DORSAL INTEROSSEIDORSAL INTEROSSEI–– 2 MUSCLE BELLIES2 MUSCLE BELLIES–– INSERTIONINSERTION

BASE OF P1BASE OF P1DORSAL HOODDORSAL HOOD

33RDRD DORSAL INTEROSSEOUS AND DORSAL INTEROSSEOUS AND ALL 3 VOLAR INTEROSSEIALL 3 VOLAR INTEROSSEI–– SINGLE BELLYSINGLE BELLY–– SINGLE INSERTION DORSAL HOODSINGLE INSERTION DORSAL HOOD

LUMBRICALLUMBRICAL

RADIAL SIDE

LUMBRICALLUMBRICAL

EXTENDS IPJ IRRESPECTIVE OF EXTENDS IPJ IRRESPECTIVE OF MCPJ POSITIONMCPJ POSITIONFACILITATES IPJ EXTENSION BY FACILITATES IPJ EXTENSION BY PULLING PROFUNDUS DISTALLYPULLING PROFUNDUS DISTALLYINITIATES MCPJ FLEXIONINITIATES MCPJ FLEXIONRADIAL DEVIATION OF DIGITRADIAL DEVIATION OF DIGIT

EXTRINSIC EXTENSOREXTRINSIC EXTENSOR

SAGITTAL BANDSSAGITTAL BANDS–– ARISE FROM THE EDC TENDONARISE FROM THE EDC TENDON–– INSERT ON THE VOLAR PLATEINSERT ON THE VOLAR PLATE–– EXTEND THE MCP JOINTEXTEND THE MCP JOINT–– STABILIZE THE EDC TENDON OVER THE STABILIZE THE EDC TENDON OVER THE

JOINTJOINT

SAGITTAL BANDSSAGITTAL BANDS

SAGITTAL BANDSSAGITTAL BANDS

TRANSVERSE FIBERSTRANSVERSE FIBERS

TRANSVERSE FIBERSTRANSVERSE FIBERS

DORSAL HOODDORSAL HOOD

OBLIQUE FIBERSOBLIQUE FIBERS

LATERAL BAND

CENTRAL SLIPCENTRAL SLIP

CONTAINS BOTH INTRINSIC AND EXTRINSIC COMPONENTS

CONJOINED LATERAL BANDCONJOINED LATERAL BAND

BOTH INTRINSIC BOTH INTRINSIC AND EXTRINSIC AND EXTRINSIC COMPONENTSCOMPONENTSAT THE LEVEL OF AT THE LEVEL OF THE PIP JOINTTHE PIP JOINT

TRIANGULAR LIGAMENTTRIANGULAR LIGAMENT

TRANSVERSE THIN TRANSVERSE THIN FASCIA FASCIA CONNECTING CONNECTING CONJOINED CONJOINED LATERAL BANDS LATERAL BANDS JUST DISTAL TO JUST DISTAL TO CENTRAL SLIP CENTRAL SLIP INSERTIONINSERTIONPREVENTS VOLAR PREVENTS VOLAR SUBLUXATION OF SUBLUXATION OF THE LATERAL THE LATERAL BANDSBANDS

TERMINAL TENDONTERMINAL TENDON

CONVERGENCE OF CONVERGENCE OF TWO CONJOINED TWO CONJOINED LATERAL BANDSLATERAL BANDSINSERTION INTO INSERTION INTO DORSAL BASE OF DORSAL BASE OF DISTAL PHALANXDISTAL PHALANX

TRANSVERSE RETINACULAR TRANSVERSE RETINACULAR LIGAMENTLIGAMENT

ORIGIN: EDGE OF ORIGIN: EDGE OF FLEXOR TENDON FLEXOR TENDON SHEATH AT PIPJSHEATH AT PIPJINSERTION: INSERTION: LATERAL EDGE OF LATERAL EDGE OF CONJOINED CONJOINED LATERAL BANDSLATERAL BANDSPREVENTS PREVENTS EXCESSIVE EXCESSIVE DORSAL SHIFT OF DORSAL SHIFT OF LATERAL BANDSLATERAL BANDS

OBLIQUE RETINACULAR OBLIQUE RETINACULAR LIGAMENTLIGAMENT

ORIGIN: VOLAR LATERAL CREST OF ORIGIN: VOLAR LATERAL CREST OF PROXIMAL PHALANXPROXIMAL PHALANXINSERTION: LATERAL TERMINAL INSERTION: LATERAL TERMINAL TENDONTENDONVOLAR TO AXIS OF PIPJVOLAR TO AXIS OF PIPJDORSAL TO AXIS OF DIPJDORSAL TO AXIS OF DIPJACTIVE TENODESIS TO INITIATE ACTIVE TENODESIS TO INITIATE DIPJ EXTENSION DIPJ EXTENSION



PIPJ EXTENSION PIPJ FLEXION

INTRINSIC TIGHTNESSINTRINSIC TIGHTNESS

INTRINSIC POSITIVEINTRINSIC POSITIVE

MCPJ EXTENDED MCPJ FLEXION

INTRINSIC TIGHTNESSINTRINSIC TIGHTNESS

CAUSESCAUSES

–– FIBROSISFIBROSIS–– ISCHEMIAISCHEMIA–– SPASMSPASM–– NEUROMUSCULAR (CVA)NEUROMUSCULAR (CVA)–– PARADOXICAL EXTENSIONPARADOXICAL EXTENSION

INITRINSIC TIGHTNESSINITRINSIC TIGHTNESS

INTRINSIC POSITIVEINTRINSIC POSITIVE

TRL

SWAN NECKSWAN NECK

CAUSESCAUSES–– MALLETMALLET–– PIPJ SYNOVITISPIPJ SYNOVITIS–– INTEROSSEOUS MUSCLE CONTRACTUREINTEROSSEOUS MUSCLE CONTRACTURE–– VOLAR SUBLUXATION PROX PHALANXVOLAR SUBLUXATION PROX PHALANX–– EDC SUBLUXATIONEDC SUBLUXATION–– FDS DYSFUNCTIONFDS DYSFUNCTION

BOUTONNIEREBOUTONNIERE

INTRINSIC MINUS ULNAR INTRINSIC MINUS ULNAR NERVE DYSFUNCTIONNERVE DYSFUNCTION

CLAW DEFORMITYCLAW DEFORMITYLOSS OF GRIP STRENGTHLOSS OF GRIP STRENGTHASYNCHRONOUS MOTIONASYNCHRONOUS MOTION–– MCP / IPJ FLEXIONMCP / IPJ FLEXION–– MCPJ FLEXION / IPJ EXTENSIONMCPJ FLEXION / IPJ EXTENSIONLOSS OF ABDUCTION LOSS OF ABDUCTION –– ADDUCTIONADDUCTIONLOSS OF PINCH STRENGTH / LOSS OF PINCH STRENGTH / ADDUCTION ADDUCTION

ULNAR NERVE PALSYULNAR NERVE PALSY

CLAW DEFORMITYCLAW DEFORMITY–– MCPJ HYPEREXTENSIONMCPJ HYPEREXTENSION–– IPJ FLEXIONIPJ FLEXIONINTRINSIC WASTINGINTRINSIC WASTINGWARTENBERGWARTENBERGFLATTENED PALMAR ARCHFLATTENED PALMAR ARCH

CLAW DEFORMITYCLAW DEFORMITY

+ _

_+



WITH INTRINSIC PARALYSIS, FULL PIP WITH INTRINSIC PARALYSIS, FULL PIP JOINT EXTENSION CAN BE ACHIEVED JOINT EXTENSION CAN BE ACHIEVED IF MCP JOINT HYPEREXTENSION IS IF MCP JOINT HYPEREXTENSION IS PREVENTEDPREVENTEDLONGSTANDING PIPJ FLEXION MAY LONGSTANDING PIPJ FLEXION MAY LEAD TO ATTENUATION OF THE LEAD TO ATTENUATION OF THE CENTRAL SLIPCENTRAL SLIPBOUVIER BOUVIER

BOUVIER MANEUVERBOUVIER MANEUVER

WARTENBERGWARTENBERG

ECCENTRIC INSERTION EDQ

ULNAR NERVE PALSYULNAR NERVE PALSY

WASTING LOSS OF ARCH

THOMAS SIGNTHOMAS SIGN

SUBCONSCIOUS SUBCONSCIOUS ATTEMPT TO GAIN ATTEMPT TO GAIN GREATER POWER GREATER POWER AND EXCURSION AND EXCURSION OF EDCOF EDC’’SSEXAGGERATES EXAGGERATES MCPJ MCPJ HYPEREXTENSIONHYPEREXTENSION

FROMENTFROMENT’’S SIGNS SIGN

FROMENTFROMENT’’S SIGNS SIGN

JULES FROMENT (1878JULES FROMENT (1878--1946)1946)–– NEUROLOGIST, LYONNEUROLOGIST, LYON–– WW I WW I –– LARGE NUMBER NERVE INJURIESLARGE NUMBER NERVE INJURIES–– THE SIGN OF THE THUMBTHE SIGN OF THE THUMBMANNERFELTMANNERFELT–– HYPERFLEXION OF THE THUMB IPJ DUE HYPERFLEXION OF THE THUMB IPJ DUE

TO SUBSTITUTION OF THE SECONDARY TO SUBSTITUTION OF THE SECONDARY ADDUCTOR OF THE THUMB ADDUCTOR OF THE THUMB ---- THE EPLTHE EPL

IDEAL TREATMENTIDEAL TREATMENT

PREVENT MCPJ HYPEREXTENSIONPREVENT MCPJ HYPEREXTENSION

PROVIDE IPJ EXTENSIONPROVIDE IPJ EXTENSION

PROVIDE ACTIVE MCPJ FLEXIONPROVIDE ACTIVE MCPJ FLEXION

RESTORE ABDUCTION OF INDEX RESTORE ABDUCTION OF INDEX

TREATMENTTREATMENT

FULL PASSIVE ROM JOINTSFULL PASSIVE ROM JOINTS

–– SPLINTSSPLINTS

–– SERIAL CASTSSERIAL CASTS

–– CAPSULECTOMYCAPSULECTOMY

TREATMENTTREATMENT

PREVENT MCPJ HYPEREXTENSIONPREVENT MCPJ HYPEREXTENSION

–– LUMBRICAL BARLUMBRICAL BAR–– DERMODESISDERMODESIS–– VOLAR CAPSULORRHAPHY (ZANCOLLI)VOLAR CAPSULORRHAPHY (ZANCOLLI)–– TENODESISTENODESIS

PARKESPARKESRIORDANRIORDAN

TREATMENTTREATMENT

PROCEDURES FOR ACTIVE MCPJ PROCEDURES FOR ACTIVE MCPJ FLEXIONFLEXION

–– TENDON TRANSFERSTENDON TRANSFERS–– ACTIVE TENODESISACTIVE TENODESIS

ALL MUST PASS VOLAR TO ALL MUST PASS VOLAR TO INTERMETACARPAL LIGAMENTINTERMETACARPAL LIGAMENT

ACTIVE MCPJ FLEXIONACTIVE MCPJ FLEXION

TRANSFER TENDON INTO LATERAL TRANSFER TENDON INTO LATERAL BANDS OR BURKHALTER INSERTION BANDS OR BURKHALTER INSERTION PROX PHALANXPROX PHALANX

–– EIP, EDQ TRANSFER (BUNNELL, EIP, EDQ TRANSFER (BUNNELL, FOWLERFOWLER

–– ECRB + PLANTARIS (BRAND)ECRB + PLANTARIS (BRAND)–– FDS (STILESFDS (STILES--BUNNELL)BUNNELL)

BRAND TRANSFERBRAND TRANSFER

BRAND TRANSFERBRAND TRANSFER

PERSONALPERSONAL

MODIFIED STILESMODIFIED STILES--BUNNELL TO BUNNELL TO PROXIMAL PHALANXPROXIMAL PHALANX–– CORRECTS CLAWCORRECTS CLAW–– PROVIDES MCPJ FLEXION PROVIDES MCPJ FLEXION –– IPJ IPJ

EXTENSIONEXTENSION–– DOES NOT IMPROVE STRENGTHDOES NOT IMPROVE STRENGTH–– NOT INDICATED IN HIGH ULNAR/MEDIAN NOT INDICATED IN HIGH ULNAR/MEDIAN

PALSY OR POSITIVE BOUVIER SIGNPALSY OR POSITIVE BOUVIER SIGN

““IF YOU BECOME A TEACHER, BY IF YOU BECOME A TEACHER, BY YOUR PUPILS YOUYOUR PUPILS YOU’’LL BE TAUGHTLL BE TAUGHT””

OSCAR HAMMERSTEIN II OSCAR HAMMERSTEIN II ---- THE THE KING AND IKING AND I

ESTABLISH A ESTABLISH A CLOSE WORKING CLOSE WORKING RELATIONSHIP RELATIONSHIP WITH YOUR WITH YOUR SURGEONSSURGEONSENHANCE ENHANCE COMMUNICATIONCOMMUNICATIONPOSTOP PLANNINGPOSTOP PLANNING

WE ARE ALL WE ARE ALL TEACHERSTEACHERSWE ARE ALL WE ARE ALL STUDENTSSTUDENTSPATIENTS LOOK PATIENTS LOOK TO YOU FOR TO YOU FOR EDUCATION AND EDUCATION AND GUIDANCEGUIDANCE

““GOOD,BETTER, GOOD,BETTER, BEST, NEVER LET BEST, NEVER LET THEM REST, UNTIL THEM REST, UNTIL THEIR GOOD IS THEIR GOOD IS BETTER, AND BETTER, AND THEIR BETTER THEIR BETTER BESTBEST””ROBERT CARROLLROBERT CARROLL

STIMULATE YOUR STIMULATE YOUR PATIENTS PATIENTS THROUGH THROUGH EDUCATIONEDUCATIONTREAT ALL TREAT ALL PATIENTS WITH PATIENTS WITH DIGNITYDIGNITY

LEARN PRINCIPLES LEARN PRINCIPLES RATHER THAN RATHER THAN COOKBOOKCOOKBOOKA MIND THAT A MIND THAT GRASPS GRASPS PRINCIPLES WILL PRINCIPLES WILL DEVISE ITS OWN DEVISE ITS OWN TREATMENT PLANTREATMENT PLAN

TRANSCEND TRANSCEND BOREDOM WITH BOREDOM WITH ENTHUSIASMENTHUSIASMDO WHAT YOU DO WHAT YOU LOVE AND LOVE LOVE AND LOVE WHAT YOU DO WHAT YOU DO

THANK YOU

Documents

INTRINSIC ANATOMY AND DYSFUNCTION - Teton Hand …tetonhandconference.com/files/IntrinsicAnatomyAndDysfunction.pdf · intrinsic anatomy and dysfunction paul c. dell, ... wartenberg