Ankle fracture Maisonneuve Fracture – Everything You Need to Know

Maisonneuve fracture involves fracture of the proximal fibula associated with an occult and unstable injury of the ankle. The problem in these patients occur when the ankle injury is presented without a fracture of the lateral malleolus, or the medial malleolus and the injury is mistakenly diagnosed as an ankle sprain and the proximal fibular fracture is missed. Examine the leg for tenderness in the proximal fibula to diagnose a proximal fibula fracture. The patient could be mistakenly treated for having an isolated proximal fibular fracture alone and the ankle injury is missed.

 High index of suspicion is necessary to diagnose and treat this injury. Maisonneuve fracture equals syndesmotic injury. Syndesmotic Injury equals Syndesmotic Reduction and Fixation. If ankle x-rays show medial or posterior malleolus fracture, or a medial clear space widening with no fracture of the lateral malleolus, then you must obtain a long-leg films to assess possible proximal fibular fracture. Clinical examination of their entire leg for pain and tenderness in addition to long leg films of the entire leg that includes the ankle, and the knee is mandatory in case of the patient with approximate fibular fracture to exclude the presence of an additional ankle injury, or if the patient has an unexplained increase in the medial clear space of the ankle joint. You should be searching for the presence of a high fibular fracture. Look for signs of syndesmotic injury such as an unexplained increase in medial clear space or tibiofibular clear space is widened and it should be less than 5 millimeters.

So how do you explain this injury? It is explained by the presence of rotation force to the ankle with transmission of the force through the interosseous membrane, which exits through a proximal fibular fracture. Maisonneuve fracture occurs from external rotation of the foot, most often with pronation mechanism. This force has to go somewhere! If you don’t see a fracture of the fibula then do the squeeze test or the external rotation stress test (both will show syndesmotic). The injury can involve the deltoid ligament injury or medial malleolar fracture medially and a fibular fracture proximally. Additionally, the tibiofibular ligaments are also involved, which can be the anterior tibiofibular ligament, interosseous ligament, the posterior tibiofibular ligament or posterior malleolar fracture. This looks like a very unstable ankle injury that may not be very obvious at presentation and you have to look out for it.

So how do you treat an Maisonneuve Fracture? This treated by fixation of the tibiofibular syndesmotic injury (key of treatment) or syndesmotic screws. if you have a medial site injury and there is a tear of the deltoid ligament, leave it alone. if there’s a medial malleolus fracture you should fix that of the lateral side if there’s approximate fibular fracture leave it alone. If there is a medial malleolar fracture, it should be fixed. If there is a proximal fibular fracture on the lateral side, leave it alone. As for the Syndesmotic Injury, the fixation has to be stable and adequate. Because of the magnitude of the injury, the Maisonneuve fracture may require more syndesmotic screws than with a routine ankle fracture with syndesmotic injury. After the fixation you will give a short leg non-weight bearing splint for six to eight weeks. Here is a patient taste example: the proximal fibular fracture and you can see increase in the medial clear space and you can see that the syndesmosis is widened. You can see that in the posterior malleolar fracture the patient is fixed with syndesmotic screws.

Nerve Injury Positions of the Hand and Fingers

Written by Alec Bryson with Dr. Nabil Ebraheim

The presentation of a patient’s hand may provide insight to which nerve is damaged and the approximate location of the damage. When presenting with ulnar n. damage, a patient may show a claw hand, Wartenberg’s sign, or Froment’s sign. Claw hand will present with clawing of the fourth and fifth digits due to the inability to extend the fingers specifically at the interphalangeal joints. This presentation is due to the lack of innervation to the intrinsic muscles of the hands, and the unopposed action of the flexor digitorum profundus m. (Moore et al., 2018). This indicates damage near the distal end of the ulnar n., below the elbow, and potentially near the wrist. Wartenberg’s sign will be seen as the inability to adduct the fifth digit when extended as well as an inability to cross the second and third digit. This is due to ulnar n. injury leading to wasting of the fifth interosseous m. This causes the fifth digit to rest in a more abducted position due to the unbalanced action of the extensor digiti minimi m. (Ebraheim, 2021). There will also be loss of function of the lumbrical m. in the fourth and fifth digits. A Froment’s test will detect palsy of the ulnar n. resulting from compression in the cubital tunnel. When asking the patient to pinch a piece of paper between their thumb and second digit, a positive Froment’s Sign will show as the patient flexing their thumb’s interphalangeal joint to grip the paper as the paper is pulled away (Attum, 2021). This will result from a weak adductor pollicis m. due to ulnar n. palsy.

Depending on the location of a lesion to the median n., the patient will present with one of three signs. A positive Benedictine sign will be caused by proximal median n. damage. It will be seen as paralysis of the first and second digit, with weakness to the third digit. A proximal lesion would lead to paralysis of several muscles (FDS, FPL, FPB, and the radial half of FDP), leaving the ulnar half of the flexor digitorum profundus m. as the only remaining flexor (Ebraheim, 2021). When the patient is asked to make a fist, the hand will resemble the similar position taken during a blessing. A positive Benedict sign will also resemble the ulnar claw hand. However, the Benedict sign will present when the patient is flexing, not extending the fingers (Ebraheim, 2021). A median n. injury affecting the anterior interosseous n. branch will present as an inability to do the OK sign. This occurs due to paralysis of the flexor pollicus longus m. and the lateral part of the flexor digitorum m. (Moore et al., 2018). A positive Ape hand (Simian hand) is caused by paralysis of only the thenar m. from damage to the recurrent branch of the median n. to the thenar m. The thumb will be seen in the same plane as the other digits due the thumb being pulled more dorsal by the action of the adductor pollicis m., which is innervated by the ulnar n. (Moore et al., 2018).

Finally, proximal radial n. damage will be seen as wrist drop. This is usually caused by fractures of the distal third of the humeral shaft (Holstein-Lewis Fracture) and caused paralysis of the wrist and fingers extensors (Ebraheim, 2010). Lower radial n. injury will present in the patient as the ability to extend the wrist, but the loss of finger extension. There will be no wrist drop, but the patient would not be able to make a hitchhiking sign.

Reference List

Attum B. Physical exam of the hand [Internet]. Orthobullets. Lineage Medical, Inc.; 2021 [cited 2021Oct21]. Available from: https://www.orthobullets.com/hand/6008/physical-exam-of-the-hand

Ebraheim N. Anterior Interosseous Nerve Injury – Everything You Need To Know – Dr. Nabil Ebraheim [Internet]. YouTube. 2021 [cited 2021Oct21]. Available from: https://www.youtube.com/watch?v=M9y-iDKLDPE

Ebraheim N. Claw Hand, Ulnar Claw Hand – Everything You Need To Know – Dr. Nabil Ebraheim [Internet]. YouTube. 2017 [cited 2021Oct21]. Available from: https://www.youtube.com/watch?v=GyqaKGg3HmM

Ebraheim N. Nerve Injury Position of the Hand & Fingers – Everything You Need To Know – Dr. Nabil Ebraheim [Internet]. YouTube. 2021 [cited 2021Oct21]. Available from: https://www.youtube.com/watch?v=nwd1h0Dfo5o

Ebraheim N. Radial Nerve Palsy, injury – WRIST DROP . Everything You Need To Know – Dr. Nabil Ebraheim [Internet]. YouTube. 2010 [cited 2021Oct21]. Available from: https://www.youtube.com/watch?v=_Cu6ttAhe8Y

Moore KL, Dalley AF, Agur A. Clinically Oriented Anatomy. 8th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2018.

Bursitis of the Knee, Hip, Elbow and Shoulder — Everything You Need to Know

Written by Andrew Kelley with Dr. Nabil Ebraheim

Prepatellar Bursitis of the Knee

Prepatellar bursitis, also known as housemaid’s, carpet layer’s, and carpenter’s knee, is a superficial bursitis caused by inflammation of the bursa separating the patellar bone and the skin (1). Patients with prepatellar bursitis will normally present with knee pain and swelling (2). Prepatellar bursitis is mostly caused by long-term repetitive mini trauma from kneeling and crawling on hard surfaces. Other causes include acute injury, infection, gout, and rheumatoid arthritis (2). Its annual incidence is 10/100,000 per year with 80% of those affected being males age 40-60 (1). In cases of non-traumatic prepatellar bursitis, treatment is dependent on resolution of the underlying condition. Early differentiation between septic and non-septic bursitis is important in the early presentation in order to improve patient outcomes. Acute bursitis normally responds well to conservative treatment such as rest, ice, activity modification, NSAIDs, and fluid aspiration. Chronic bursitis due to mini traumas is treated similarly but may require additional corticosteroid therapy (1).

Olecranon Bursitis of the Elbow

Olecranon Bursitis, also known as student’s elbow and plumber’s elbow, is caused by inflammation of the bursa overlaying the olecranon process of the ulnar bone at the tip of the elbow. This bursa allows for smooth motion of the olecranon process against the superficial tissue at the tip of the elbow. Affected patients normally present with swelling at the bend of the elbow. A characteristic “golf ball” shape of swelling can be seen, and a fully intact range of motion of the elbow can differentiate it from elbow joint injuries (3). Olecranon Bursitis most commonly affects men age 30-60. Most cases are due to repeated minor trauma and sports (4). Treatment is focused on resolving the underlying cause of inflammation. Conservative treatment includes ice and rest along with NSAIDs for symptomatic relief are indicated. While aspiration and corticosteroid injection are proven relief interventions, they carry an increased risk for infection (4).

Greater Trochanteric Bursitis of the Hip

Greater trochanteric bursitis, or greater trochanteric pain syndrome (GTPS), is caused by inflammation of the bursa laying deep to the iliotibial band and superficial to the greater trochanter of the femur. It acts as a lubricant for the gluteal tendons. Patients with hip bursitis normally present with chronic intermittent pain of the lateral hip, thigh, and buttock (6). This bursitis normally affects women age 40-60. The increased pelvic width of women relative to their body may predispose them to increased iliotibial band tension on the bursa (6). The cause of hip bursitis can be repetitive microtrauma, blunt trauma, or idiopathic. Movements requiring repetitive hip abduction like stair climbing and bicycling, direct traumatic falls, and sedentary lifestyles are common causes of this condition (5).  Common treatments for this bursitis include NSAIDs, physical therapy, and corticosteroid injection. Surgery is a rare treatment option for bursitis resistant to conservative treatment options (5).

Subacromial Bursitis of the Shoulder

Subacromial bursitis is caused by inflammation to the bursa just below the acromion process. The subacromial bursa acts as a lubricating medium between the acromion process superiorly and the muscles of the rotator cup inferiorly.  Subacromial bursitis normally presents as anterolateral shoulder pain, especially during overhead activities. This chronic inflammation of the shoulder bursa can eventually lead to weakness and rupture of the surrounding ligaments and tendons (7). Older individuals are more likely to experience shoulder bursitis due to years of overuse. Most patients present due to direct trauma to the shoulder or repetitive overhead activities (7). Treatment includes rest, NSAIDs, physical therapy, and corticosteroid injections. Surgical therapy is reserved for cases unresponsive to conservative therapy (7).

References:

  1. Rishor-Olney CR, Pozun A. Prepatellar Bursitis. [Updated 2021 Sep 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
  2. J. Dean Cole MD. Causes of knee bursitis (prepatellar bursitis) [Internet]. Arthritis. Arthritis-health; [cited 2021Oct28]. Available from: https://www.arthritis-health.com/types/bursitis/causes-knee-bursitis-prepatellar-bursitis
  3. Pangia J. Olecranon bursitis [Internet]. StatPearls [Internet]. U.S. National Library of Medicine; 2021 [cited 2021Oct28]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470291/
  4. Blackwell JR, Hay BA, Bolt AM, Hay SM. Olecranon bursitis: a systematic overview. Shoulder Elbow. 2014 Jul;6(3):182-90. doi: 10.1177/1758573214532787. Epub 2014 May 6. PMID: 27582935; PMCID: PMC4935058.
  5. Seidman AJ. Trochanteric bursitis [Internet]. StatPearls [Internet]. U.S. National Library of Medicine; 2021 [cited 2021Oct28]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538503/
  6. Reid D. The management of Greater Trochanteric pain syndrome: A systematic literature review [Internet]. Journal of orthopaedics. Elsevier; 2016 [cited 2021Oct28]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4761624/
  7. Faruqi T. Subacromial bursitis [Internet]. StatPearls [Internet]. U.S. National Library of Medicine; 2021 [cited 2021Oct29]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541096/

Motions of the Thumb

Motions of the Thumb

The motions of the thumb are complex and are often difficult to visualize, as multiple joints and planes are involved. The motions are crucial to the overall function of the hand, with amputation of the thumb resulting in 40% impairment. Amputation has also been cited as causing 22% disability of the whole person. In cases of thumb hypoplasia and carpometacarpal joint instability, thumb amputation and index finger pollicization is recommended. tBecause of the value of the thumb, reimplantation of the amputated thumb at any level is recommended. The main motions of the thumb include flexion, extension, abduction, adduction, and opposition. Valued as 50-60 percent of overall thumb function, opposition is one of the most critical motions. Abduction and adduction of the thumb occur mainly at the carpometacarpal (CMC) joint. Abduction is described as the motion of the thumb away from the second metacarpal, whereas adduction is the opposite of the motion. These motions are defined in two planes: palmar and dorsal. In radial abduction-adduction, the thumb moves parallel to the radius and the palm of the hand. A smaller range of motion is generally seen in the radial plane. Alternatively, in palmar abduction-adduction the thumb follows a plane perpendicular to the palm of the hand. Clinically, these motions are not typically measured directly but are assessed in the motion of opposition. Flexion and extension can occur at all three joints of the thumb, including the CMC, MCP, and IP joints. These motions at the CMC joint are often not measured, as they are challenging to quantify. The average flexion observed at the MCP joint is approximately 50 degrees, although this may be limited in some individuals to less than 30 degrees. Extension is not usually seen at the MCP joint. Flexion at the IP joint approaches 80 degrees on average. Typically, the IP joint is capable of approximately five degrees of extension. Opposition is a very important motion and, as mentioned, 50-60% of overall thumb function. It is comprised of several integrated motions: palmar abduction that transitions to adduction at the CMC joint, rotation at the CMC joint, and flexion at the CMC, MCP, and IP joints. thThe composite motion involves crossing the thumb over the thumb of the hand toward the base of the little finger. Complete opposition of the thumb may be defined in two ways: by the tip of the thumb touching the base of the fifth digit and by the tip of the thumb touching the tip of the little finger. Therefore, deficiencies in opposition can be quantified by measuring the distance from the tip of the thumb to the base of the little finger or from the tip of the thumb to the tip of the little finger. Alternatively, the degree of opposition may be determined by measuring from the flexor crease of the IP joint to the distal palmar crease over the third metacarpal. A normal span is at least 8 cm. opposition may also be assessed by systematically touching the tip of the thumb to various parts of the hand, a clinical test outlined by Kapandji.