Anatomy of Pes anserinus(거위발 건)

• Sartorius(봉공근), Gracilis(박근) & Semitendinosus(반건양근)의 conjoined insertion으로 tibia의 proximal medial aspect에 insertion
• 기능 1) flexor (주기능)
•   2) Internal rotator (이차적 기능)
• 3) 외회전력와 외반력(valgus stress)에 resist

Anatomy of quadriceps mechanism

Anatomy of quadriceps mechanism(대퇴 사두근)

• 4개의 구성요소에 의해서 3층으로 구성된 quadriceps tendon을 형성하여 patella에 insertion한다.
• Superficial layer
• rectus femoris tendon이 patella proximal pole의 ant. Edge에 insertion한다.
• Middle layer
• vastus lateralis와 medialis tendon에 의해 형성
• vastus medialis의 aponeurosis에 의해 형성된 medial retinaculum은 Patella의 side에 insertion하여 슬관절 굴곡 시 patella의 lateral displacement를 막는다.
• 광근 막 전면에 슬개 지대가 있어 이들은 외측이 내측보다 2배 가량 두껍고 4배 가량 두꺼워진 부분이 iliotibial band를 형성한다. 광근 막보다 내부에는 관절막이 두꺼워져 patellofemoral ligament를 형성한다.
• Extensor retinaculum(신전지대)는 광근 막과 내, 외측 광근 등의 섬유에 의해서 형성되며 patella를 지나 proximal tibia에 직접 부착한다.
• Vastus medialis의 상부 섬유는 15~18도 내측을 향하고 있으며 하부 섬유는 50~60도 내측을 향하며 이 두부분을 지배하는 신경 분지도 따로 되어 있기 때문에 상부를 vastus medialis longus, 하부를 vastus medialis obliquus로 부르기도 한다.
• Deep layer – vastus intermdius tendon이 patellar proximal pole의 post. Edge에 insertion한다.
• Patellar tendon – patella의 distal pole에서 origin하여 tibial tuberosity에 insertion한다.

Anatomy of patella

Anatomy of patella

• Proximal pole이 distal pole보다 넓은 삼각형 모양의 sesamoid bone
• Articular surface – vertical ridge에 의해 작은 medial articular facet과 좀 더 큰 lateral articular facet으로 나누어 진다
• ROM에 따른 patellofemoral joint
• 슬관절 완전 신전 시 : 관절을 형성하지 않는다.
• 슬관절 15°굴곡 시 : patella의 lateral patellar facet의 distal portion은 femoral groove의 superior articular margin과 articulation한다. Medial facet은 거의 articulation하지 않고 있다.
• 슬관절 45°굴곡 시 : patella의 mid portion과 articulation하고 medial facet도 어느정도 articulation한다.
• 슬관절 완전 굴곡 시 : patella both facets의 proximal portion은 femur와 articulation한다. 또 medial facet에 좀 더 많은 pressure가 가해진다.
• Patella는 슬관절을 완전 신전에서 완전 굴곡을 시행할 때 femoral condyle에 대해서 약 7~8cm이동한다.

sustained clonus

Video Description

Significant and multiple beats of clonus in the left foot of a patient with cervical myelopathy.

Dimar et al review 104 patients with cervical myelepathy. They found 10 (9.6%) had sustained clonus at presentation. Here is the breakdown of other physical exam findings on presentation: "66 patients (63.5%) reported gait disturbance, 18 (17.3%) had handwriting changes, 33 (31.7%) complained of deterioration of dexterity, 56 (53.8%) had grasp weakness, 7 (6.7%) had bowel and bladder complaints, 27 (26.0%) had a positive Hoffmann sign, 10 (9.6%) had sustained clonus, and 10 (9.6%) had a positive Babinski sign."

Dimar JR 2nd, Bratcher KR, Brock DC, Glassman SD, Campbell MJ, Carreon LY. Instrumented open-door laminoplasty as treatment for cervical myelopathy in 104 patients. Am J Orthop (Belle Mead NJ). 2009 Jul;38(7):E123-8. PubMed PMID: 19714281. Level of Evidence: 2. PMID: 19714281 (Link to Pubmed)

Hoffman's Positive

Video Description

Hoffmann's test is a physical exam maneuver that is sensitive but not very specific for cervical myelopathy.

There are two methods to perform. The first is to hold and secure the middle phalanx of the long finger and then "flick" the distal phalanx into an extended position. Involuntary contraction of the thumb IP joint is a positive test.

The second way is to support the distal phalanx (examiners finger under distal phalanx) of the long finger and then "flick" the distal phalanx into an extended position. Involuntary contraction of the thumb IP joint is a positive test.

Malanga et al found the existing literature does not address interexaminer reliability but appears to indicate fair sensitivity and fair to good specificity for the Hoffman's sign.

References:
Malanga GA, Landes P, Nadler SF. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician. 2003 Apr;6(2):199-205. Level of Evidence: 5 - Other. PMID: 16883381 (Link to Pubmed)

Trigger finger

Introduction
Stenosing tenosynovitis caused by inflammation of the flexor tendon sheath Epidemiology more common in diabetics ring finger most commonly involved Mechanism caused by entrapment of the flexor tendons at the level of the A1 pulley fibrocartilaginous metaplasia of tendon and pully found in pathology Associated conditions diabetes mellitus rheumatoid arthritis amyloidosis
Anatomy
Flexor pulleys of finger A1 overlie the MP joints Muscles FDP FDS
Classification
Green Classification Grade I Palm pain and tenderness at A-1 pulley Grade II Catching of digit Grade III Locking of digit, passively correctable Grade IV Fixed, locked digit
Imaging
Radiographs not required in diagnosis and treatment
Presentation
Symptoms finger clicking pain at distal palm near A1 pulley finger becoming "locked in flexed position Physical exam tenderness to palpation over A1 pulley a palpable bump may be present near the same location
Treatment
Nonoperative night splinting, activity modification, NSAIDS indications first line of treatment steroid injections indications best initial treatment for fingers, not for thumb technique give 1 to 3 injections in flexor tendon sheath diabetics do not respond as well as non-diabetics Operative surgical debridement and release of the A-1 pulley indications in cases that fail nonoperative treatment
Techniques
Surgical debridement and release of the A-1 pulley approach longitudinal or transverse incision release technique in children, in addition to A-1 pulley release, may also need to release one or both limbs of the sublimus tendon A-2 pulley A-3 pulley postoperative early passive and active ROM 4 times a day if patient does not have FROM at first post-op visit then send to PT
Complications
Radial digital nerve injury

** 정형외과학 561

수술적 치료: 수술적 치료 방법으로는 전통적 개방술을 통한 감압술, 내시경을 이용한 감압술 및 최소 절개를 통한 감압술이 있다. 전통적 개방술을 통한 감압술은 큰 절개를 통해 수근 관 내외의 해부학적 구조물을 직접 확인할 수 있고 류마토이드 관절염이나 통풍 등의 증식성 건막염(proliferative tenosynovitis)의 경우, 감압술과 동시에 건막 절제술을 용이하게 할 수 있다. 또한 이전에 감압술을 받은 환자의 재수술이나 손목이 고정된 환자의 경우에도 적응증이 된다. 요즈음은 특발성 수근 관 증후군에서 예전에 많이 행해졌던 내부 신경 박리술(internal neurolysis)이나 신경 외막 절개술(epineurotomy) 또는 굴근 건막 절제술(flexor tenosynovectomy)등은 여러 연구에 의해 수술 성적의 통계학적 의의가 없는 것으로 밝혀져 거의 행해지지 않는다. 전통적 개방술의 단점으로는 큰 절개로 인해 정중신경의 수장측 수근 분지(palmar carpal branch)의 종말 분지(terminal cutaneous branch)가 손상되어 반흔 압통(scar tenderness)이 생길 수 있다는 것과 술 후 악력의 회복이 더디다는 것이 있다.

근래에 정형외과 영역에서 내시경적 수술법의 사용이 확대되면서 수근 관 증후군의 수술에도 내시경적 수술법이 도입되었다. Agee, chow 그리고 Okutsu등의 여러 방법이 사용되고 있으며, 손바닥 통증 등 술 후 이환율이 낮고, 강력 파악력과 정밀 파악력의 회복이 빨라 정상 생활이나 일로 빨리 복귀할 수 있다는 장점이 있다. 단점으로는 기술적인 합병증의 빈도가 높은 것이 지적될 수 있으며 술 후 신경 진탕(neuropraxia), 정중 신경 손상, 표재 수장궁(superficial palmar arch)의 손상 등이 있을 수 있다. 또한 횡 수근 인대의 불완전한 절개로 인해 재발률이 높다는 것을 지적하는 연구도 있다.

Figure 55-1

Trigger finger is caused by repetitive microtrauma from repeated clenching of the hand.

Figure 55-2

The catching tendon sign for trigger finger.

(From Waldman SD: Physical diagnosis of pain: an atlas of signs and symptoms, Philadelphia, 2006, Saunders, p 195.)

Figure 55-3

Giant cell tumor of the tendon sheath. A, In this 55-year-old woman with a 2-year history of pain and gradual swelling of the fingers, a soft tissue mass (arrow) can be identified at one distal interphalangeal joint. Underlying inflammatory osteoarthritis of the articulations is evident, and this combination of findings would suggest that the mass is a mucous cyst. However, biopsy of the affected joint demonstrated a giant cell tumor of the tendon sheath. B, Photomicrograph (×86) in a different patient reveals a tendon capsule tumor (arrowhead) associated with moderately vascularized stroma, plump spindle-shaped or ovoid cells, and multinucleated giant cells.

(From Resnick D: Diagnosis of bone and joint disorders, ed 4, Philadelphia, 2002, Saunders, p 4248.)

reference)

Atlas of Common Pain Syndromes , Third Edition Steven D. Waldman, Chapter 55, 178-180

www. orthobullet.com

정형외과학 6판 P 561

DIAL Test

 Dial test

- 앙와위 또는 복와위에서 시행

- 경골의 외회전 정도를 측정

- 75~ 90도 굴곡위에서보다 0~30도의 굴곡위에서 더 큰 후방 불안정성이 있고 외회전 불안정성이 있으면 주로 후외측이 손상되었음을, 75~90도에서 더 큰 후방 불안정성이 있고 외회전 불안정성이 미미하면 후방 십자 인대의 단독 손상을 의심해야함

- 후방 십자 인대의 완전 파열과 이와 동반된 후외방 불안정성이 있으면 모든 각도에서 후방 불안정성, 외회전,내반 불안정성이 크게 증가

- 슬관절의 과신전과 내반 불안정성이 크게 있을 경우 후외측인대 외에도 전방 십자 인대의 동반 파열 또한 의심해봐야 함

ref) 대한정형외과학 P 706

suprascapular nerve

Suprascapular nerve는 transverse scapular ligament 밑에서 suprascapular notch 을 통과하여 Supraspinatus M.을 spinoglenoid notch를 지나 Infraspinatus m.을 지배한다.

Osteopenia & Osteoporosis

Osteopenia & Osteoporosis - Lab findings Osteoporosis Osteomalacia Definition Reduced bone mass, normal mineralization Bone mass variable, reduced mineralization Age Post menopausal (Type I) or elderly (Type II) Any age  Etiology Endocrine abnormality, age, idiopathic, inactivity, alcohol, calcium deficiency Vit D deficiency or abnormal vit D pathway, hypophosphatemia, hypophosphatasia, renal tubular acidosis Symptoms and signs Pain and tenderness at fracture site Generalized bone pain and tenderness Xray Axial fracture predominance Appendicular fracture predominance, symmetric, includes pseudofractures (Looser zones) Serum Ca Normal Low or normal Serum PO4 Normal Low or normal ALP Normal Elevated (except hypophosphatasia) Urinary Ca High or normal Normal or low (high in hypophosphatasia) Bone biopsy Tetracycline labeling normal Tetracycline labeling abnormal ref)http://www.orthobullets.com/basic-science/9032/osteopenia-and-osteoporosis ** 참고사항  골대사의 생화학적 지표(Biochemical marker) 골교체율의 생화학적 지표는 파골 세포나 골 모세포에서 분비되는 효소나, 골흡수나 골형성시 유리되는 골 기질 성분들을 추적하는 것으로 혈액이나 소변에서 측정한다. 골 흡수를 나타내는 생화학적 지표로서 요 하이드록시프롤린이 유용하게 사용되어 왔으나 특이도가 낮고 검사 전 음식물 섭취에 제한을 두는 등의 단덤이 있다. 최근에는 피리디놀린, 데옥시피리디놀린, type I collagen N 혹은 C-telopeptide등이 특이도가 높고 음식을 제한하지 않아도 되는 등 우수한 진단 방법으로 평가되고 있다. 골형성 지표에는 비콜라겐성 단백질인 혈청 오스테오칼신이 가장 널리 사용되는데 유일하게 골에만 존재하는 단백질로서 골모세포의 활동을 나타내는데 가장 민감하고 특이하다고 알려져 있다. 칼슘과 결합하는 비타민 K의존성 gamma-carboxyglutamic acid(gla)를 포함하고 있기 때문에 bone gla protein(BGP)라고도 한다.

Reflex

Reflex

• Biceps reflex - C5, C6
• Brachioradialis reflex - C5, C6
• Triceps relfex - C6, C7
• Patellar tendon reflex - L2, L3, L4
• Medial hanstring reflex - L5, S1
• Ankle jerk reflex(Achilles tnedon) - S1 

De Quervain's Tenosynovitis

De Quervain's Tenosynovitis

Definition

- 드 꾀르벵병은 신전 지대의 제 1구획의 APL 및 EPB의 협착성 건막염

  : De Quervain's tenosynovitis refers to a painful inflammatory process of the first dorsal retinacular compartment containing the tendons of the abductor pollicis longus and extensor pollicis brevis.

Synonyms

• Stenosing tenosynovitis of the radial styloid process
• Stenosing tenovaginitis of the first dorsal compartment
• De Quervain's disease
• De Quervain's tendonitis
• De Quervain's stenosinig tenosynovitis
• Tendinosis

ICD-9CM CODES

727.04 Radial styloid tenosynovitis, de Quervain disease727.0 Synovitis and tenosynovitis727.05 Other tenosynovitis of hand and wrist

Epidemiology & Demographics

- 30~50대 사이의 여성에서 호발, 특히 임신 말기나 수유기에 흔함.

• More common in women than in men (10:1)
• Usually occurs between the ages of 30 and 50
• Associated with rheumatoid arthritis (RA)
• Can be seen in new mothers or daycare providers due to holding the babies with an outstretched thumb
• Seen more frequently in certain occupations involving repetitive wrist motion (e.g., clerical, assembly, and manual labor)

Physical Findings & Clinical Presentation

• Pain over the styloid process of the radius with grasping and isometric thumb abduction
• Swelling on the radial styloid
• Tenderness in the anatomic snuffbox
• Positive Finkelstein's test ( Fig. 1-271 )

FIGURE 1-271  : Finkelstein's test is positive in de Quervain's stenosing synovitis.  Ulnar flexion of the wrist produces pain over the dorsal compartment containing the extensor pollicis brevis and abductor pollicis longus. (From Noble J [ed]: Textbook of primary care medicine, ed 2, St Louis, 1996, Mosby.)

• Crepitance
• Numbness of the dorsum of the thumb is rarely noticed.
• Absence of local heat on examination

Etiology

- 대개 수부나 수근 관절을 과도하게 사용하는 반복적인 활동에 의해 발생

- 2차적으로 신전 지대의 섬유화가 진행

- 해부학적 변이(APL의 이상 분지, 이상 건 부착, 비정상적인 중격)

• The cause is usually repetitive use or overuse of the hand and thumb involving pinching with the thumb while moving wrist in radial and ulnar directions causing thickening of the fibrous tendon sheath (e.g., typing, writing, nailing, golfing, fly-fishing, etc.).
• Acute trauma to the first extensor dorsal compartment can also lead to tenosynovitis.
• It can also occur in inflammatory joint conditions like RA and conditions causing calcium apatite deposition.

Diagnosis

• The diagnosis of de Quervain's tenosynovitis is based on the clinical triad of:

1. Tenderness over the radial styloid

               2. Swelling over the first dorsal retinacular compartment

3. Pain on ulnar movement of the wrist with the thumb adducted and flexed (Finkelstein's test; see Fig. 1-271).

• Consideration can be given to injecting 1.5 ml of 1% Xylocaine into the tenosynovial sac, and if all three physical signs resolve, the diagnosis is confirmed, allowing for differentiation from carpometacarpal (CMC) osteoarthritis (OA).
• Finkelstein maneuver can also be present in first CMC joint OA; therefore it should also be evaluated if this test is positive.

Differential Diagnosis

• Carpal tunnel syndrome
• Arthritis (e.g., degenerative OA or RA)
• Gout
• Infiltrative tenosynovitis
• Radiculopathy
• Compression neuropathy (e.g., superficial branch of the radial nerve "bracelet syndrome")
• Ganglia
• Infection (e.g., tuberculosis, bacterial)
• Scaphoid fracture
• Intersection syndrome

Laboratory Tests

• ESR is usually normal in patients with de Quervain's tenosynovitis.
• Arthrocentesis can be used to rule out gout (crystals) and infection (Gram stain and culture of aspirate).

Imaging Studies

• Imaging of the wrist and thumb is not necessary unless a fracture or arthritis is suspected.

Treatment

Nonpharmacologic Therapy

• Rest
• Avoiding repetitive movements of the hand or thumb
• Splinting (thumb spica)
• Icing (4-6 times day for 15 minutes)
• Physiotherapy

Acute General Rx

• Corticosteroid injection using 20 to 40 mg triamcinolone acetonide and 1% Xylocaine is effective in relieving pain.
• NSAIDs (ibuprofen 800 mg tid or naproxen 500 mg bid)
• Topical hydrocortisone on the radial styloid for mild conditions

Chronic Rx

• Once signs of active inflammation have resolved after 3-4 wk, gentle stretching exercises involving abductor and extensor tendons usually help recovery.
• Surgical release is generally reserved for patients not responding to NSAIDs and corticosteroid injection therapy.

Disposition

• ∼90% of patients have relief of symptoms with either single or multiple steroid injections.
• Rarely, steroid injection use can cause infection and tendon rupture.
• If left untreated, can lead to fibrosis and decrease in mobility (stenosing tenosynovitis).
• Surgical control of symptoms achieved in 90% of referred cases
• Complications of surgery include:

                  - 수술 후 합병증으로

                      1. 건의 탈구(신전 지대의 지나친 절제, 건막 절개시에 가능한 배측에서 시행),

                      2. 표재 요골 신경 분지의 손상(신경통)

• Radial nerve damage
• Paresthesia (∼10%)
• Neuroma
• Scarring

                       

                    Campbell P.4300

                         failure to obtain relief after surgery may result from

                          - formation of neuroma in a branch of ther superficial radial nerves

                          - volar subluxation of the tendon when too much of ther sheath is removed

                          - failure to find and release a seperate aberrant tendon within a seoerate compartment

                          - hypertrophy of scar from a longuitudinal skin incision

• Recovery rates are higher with early treatment to ∼80% after 6 wk but >40% after 4 yr.

Pearls & Considerations

• Steroid injection is generally recommended after failure of conservative treatment for 2-6 wk.
• Pain relief is usually noted within 48 hr with patient becoming asymptomatic by the first or second week after corticosteroid injection.
• If there is no improvement by 6 wk post second corticosteroid injection, referral to an orthopedic hand surgeon is recommended.
• Without treatment it will not improve and can get worse.
• Condition can recur if triggering activity continues.

Suggested Readings

available at INTER REF www.expertconsult.com

Related Content

• De Quervain's Tenosynovitis (Patient Information)

AUTHOR: SYEDA M. SAYEED, M.D.

Suggested Readings

Asif et al., 2009Asif M., Ilyas A.M.: Surgical treatment for de Quervain's tenosynovitis. J Hand Surg 2009; 34: 928-929

Bouras et al., 2010Bouras Y.: Surgical treatment in de Quervain's tenosynovitis. Ann Chir Plast Esthet 2010; 55: 42-45

Capasso et al., 2002Capasso G., Testa V., Maffulli N.,

et al

: Surgical release of de Quervain's stenosing tenosynovitis postpartum: can it wait?. Int Orthop 2002; 26: 23

Graham et al., 2007Graham J.B., Hulkower S.D., Bosworth M.,

et al

: Are steroid injections effective for tenosynovitis of the hand?. J Fam Pract 2007; 56: 1045-1047

Ilyas et al., 2007Ilyas A.M.: De Quervain tenosynovitis of the wrist. J Am Acad Orthop Surg 2007; 15: 757-764

Jirarttanphochai et al., 2004Jirarttanphochai K.: Treatment of de Quervain disease with triamcinolone injection with or without nimesulide A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am 2004; 86-A: 2700

Richie and Briner, 2003Richie C.A., Briner W.W.: Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract 2003; 16: 102

Reference

Ferri's Clinical Advisor 2014 Fred F. Ferri , 327-327.e1 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.