case presentations - slocum foundation
TRANSCRIPT
![Page 1: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/1.jpg)
Case Presentations
David Bear, MD
Hand and Upper Extremity SurgeonSlocum Center for Orthopedics and Sports Medicine
![Page 2: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/2.jpg)
Disclosure I have nothing to disclose
![Page 3: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/3.jpg)
Case #1 20 year old female presents with chief complaint of
inability to straighten her right ring and pinky fingers Referred for treatment of trigger fingers Denies any trauma or known cause Worsened over 6 months Negative PMH
![Page 4: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/4.jpg)
Case #1: Differential diagnosis? Trigger fingers? Dupuytren’s contracture? Extensor tendon injury? Neurologic cause?
Peripheral nerve compression? Central nervous system?
![Page 5: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/5.jpg)
Case #1: Physical Exam
![Page 6: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/6.jpg)
Case #1: Physical Exam? Visual inspection Flexed posture of ring and small fingers No visible atrophy Hand appears well perfused
![Page 7: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/7.jpg)
Case #1: Physical Exam? Palpation: No tenderness in hand/wrist/elbow No palpable masses No A1 pulley tenderness No Dupuytren’s cord/nodules
![Page 8: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/8.jpg)
Case #1: Physical Exam? Vascular exam: 2+ radial pulse Brisk capillary refill in finger tips
![Page 9: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/9.jpg)
Case #1: Physical Exam? Sensory exam: Decreased sensation in small finger and ulnar side of
ring fingers
Motor exam: Full passive motion in fingers No signs of triggering or tendon subluxation Weakness in the intrinsics Decreased pinch and grip strength
![Page 10: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/10.jpg)
Case #1: Physical Exam? Special tests: Positive tinels over ulnar nerve at elbow Increased ulnar nerve numbness with elbow flexion No ulnar nerve subluxation at elbow Positive Froment sign
![Page 11: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/11.jpg)
Case #1: Differential diagnosis? Trigger fingers? Dupuytren’s contracture? Extensor tendon injury? Neurologic cause?
Peripheral nerve compression? Central nervous system?
NEXT STEP??
![Page 12: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/12.jpg)
Case #1: EMG/NCS NCS shows moderately severe compression of ulnar
nerve at level of the elbow No other signs of compression Could consider imaging
Diagnosis: Cubital tunnel syndrome
Plan: ?
![Page 13: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/13.jpg)
Case #1
![Page 14: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/14.jpg)
Case #1 Rare cause of compression found during surgery
Outcome: Patient improved and had normal function and sensation at 3 months postop. Claw deformity resolved.
![Page 15: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/15.jpg)
Case #2 80 year old active RHD female presents with a 1 week
history of inability to extend her right middle and ring fingers.
Denies any trauma or known cause Denies pain Unable to get fingers open enough to pick things up
and complete ADLs. Enjoys sewing and now unable. PMH: HTN, hyperlipidemia
![Page 16: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/16.jpg)
Case #2: Differential diagnosis? Trigger fingers? Dupuytren’s contracture? Extensor tendon injury? Neurologic cause?
Peripheral nerve compression? Central nervous system?
![Page 17: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/17.jpg)
Case #2: Physical Exam Visual inspection Flexed posture of middle and ring fingers No visible atrophy Hand appears well perfused
![Page 18: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/18.jpg)
Case #2: Physical Exam? Palpation: No tenderness in hand/wrist/elbow No palpable masses No Dupuytren’s cord
![Page 19: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/19.jpg)
Case #2: Physical Exam Vascular exam: 2+ radial pulse Brisk capillary refill in finger tips
![Page 20: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/20.jpg)
Case #2: Physical Exam Sensory exam: Sensation intact median/radial/ulnar nerves
Motor exam: Full passive motion in middle and ring fingers Minimal active extension in middle and ring fingers No signs of extensor tendon subluxation No triggering Normal strength otherwise in median/radial/ulnar n.
![Page 21: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/21.jpg)
Case #2: Physical Exam
![Page 22: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/22.jpg)
Case #2: Differential diagnosis? Trigger fingers? Dupuytren’s contracture? Extensor tendon injury? Neurologic cause?
Peripheral nerve compression? Central nervous system?
Special exam tests to help?
![Page 23: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/23.jpg)
Case #2: Physical Exam Special tests:
Check tenodesis effect to determine nerve vs tendon rupture etiology.
No significant extension of middle/ring finger with tenodesis
![Page 24: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/24.jpg)
Case #2: Diagnosis Diagnosis: Likely extensor tendon rupture
Ultrasound ordered and patient was found to have evidence of attritional tendon rupture of middle and ring finger extensor in her dorsal forearm.
![Page 25: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/25.jpg)
Case #2: Plan Discussed conservative treatment vs operative
intervention. Based on difficulty with patient performing ADLs and
hobbies, decided to proceed with tendon transfer under local anesthesia.
![Page 26: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/26.jpg)
Case #2: Local anesthesia
![Page 27: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/27.jpg)
Case #2: OR findings
![Page 28: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/28.jpg)
Case #2: OR after repair
![Page 29: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/29.jpg)
Case #2: Post-op Patient tolerated surgery well Obtained about 90% improvement in function Able to successfully resume ADLs and sewing by 2
months from surgery
![Page 30: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/30.jpg)
Thank you!
![Page 31: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/31.jpg)
Case #3 16 year old competitive male high school baseball
player presents 2 weeks after injury during practice where he collided with another player.
Complains of ulnar sided hand pain. Initially diagnosed with a hand sprain Has been able to continue playing with some pain.
Extra Case for Home Study. Will be discusses if time allows.
![Page 32: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/32.jpg)
Case #3 Physical exam:
Swelling over ulnar hand Tenderness over ulnar metacarpals Weak finger flexion and extension Sensation intact Any other physical exam tests?
![Page 33: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/33.jpg)
Case #3 Obvious malrotation noted on finger flexion
![Page 34: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/34.jpg)
Case #3
![Page 35: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/35.jpg)
Case #3 Plan:
Elected to proceed with surgery. Discussed pins/plate and screw fixation/nail
fixation. Decided to proceed with nail fixation to allow
earlier return to baseball.
![Page 36: Case Presentations - Slocum Foundation](https://reader033.vdocuments.mx/reader033/viewer/2022052601/628ccc0d3358ae60a5537897/html5/thumbnails/36.jpg)
Case #3 Healed well and returned to baseball 6 weeks postop