Rotational deformity in the finger can be picked up if gross, but occasionally they are difficult to spot.

Here are 2 ways👇to identify them when they are subtle to:

- Diagnosing instability,
- Intraoperative correction, &
- Preventing late deformities. Step 1: Palpate the scaphoid tuberosity on the wrist crease of the patient. Normally all non rotated (normal) fingers point towards it.

Suspect finger rotation if it is deviating from it.

Antegrade cross K wire is the technique of choice for a proximal phalanx #.

However reduction with traction & K wire placement is difficult

Here are 6 tricks👇 for proximal phalanx # reduction + K wiring by:

- Using 1 assistant,
- Avoiding extensors &
- Immediate mobilisation. Trick #1: Use Jahss manoeuvre to reduce the fracture.

Intrinsic muscles pull the distal fragment, resulting in a volar angulation.

MCP flexion:

1. Relaxes the intrinsics help relax & reduce the distal fragment,

2. Make collateral lig taut to stabilise the proximal part.

PIPJ fracture dislocation stability depends upon the % articular surface involvement.

< 30% = stable, >50% = unstable

Here is a 4 part questionnaire for borderline (30-50%) cases 👇would help you:

- Determine stability,
- Guide management,
- Prevent joint related complications Q #1: Without anesthesia is there >60-70 degree active ROM in the PIP joint?

A. Yes = stable

B. No = might be unstable

Either ways go to Q #2

Inorder to achieve hemostasis in hand surgery, a bipolar electrocautery is preferred over a monopolar.

Here are 2 reasons why one should use a bipolar👇 to achieve:

- Hemostasis with precision,
- Controlled dissection,
- Minimise surrounding tissue damage. Reason #1: Minimise dispersion of energy in surrounding tissue.

Monopolar unit consists of a hand piece pencil & dispersive pad as 2 electrodes of a circuit. This causes lateral spread to other tissues.

However, in a bipolar unit both electrodes are in prongs of hand piece.

Mastering subtle radiological signs in wrist trauma help in diagnosing Carpal injuries

Unfortunately, we don’t get taught how to do this

Here are 6 important typical signs👇while assessing wrist injury Xrays to:

- Diagnose carpal injuries
- Counsel patient
- Avoid missing them Sign #1: Gilula’s lines: 3 lines marking the arcs formed by the proximal and distal carpal rows

A carpal fracture (greater arc injury) or a carpal dislocation (lesser arc injury) leading to a ligament injury & disruption of arcs

Injuries are represented by arcs of vulnerability

Compartment syndrome of the hand involves difficult decision making & surgery for 4 reasons:

1. Happening at odd hours
2. Primary setup not be equipped for emergencies
3. Tendency to apply a slab & wait
4. Lack of knowledge

Here’s how to overcome this situation step-by-step👇: Step #1: One should be oriented to the compartments of the hand:

There are 10 compartments in the hand as 4 divisions:

1. Adductor,
2. Interosseous,
3. Thenar,
4. Hypothenar.

Conventional Orthopedic training is to stand while operating.

Hand surgery requires you to adopt sitting posture for surgeon as well as an assistant.

Here are 3 tips while SITTING👇to

- Aid visualising the operative field
- Being comfortable while operating
- Avoiding fatigue Tip #1: Decide your base posture of sitting comfortably while operating.

It should hold your head and upper body still.

It matters because by choosing a consistent posture it would SAVE TIME and get you geared up every time you would be operating on a hand.

In 2015, my concept of Rheumatoid arthritis was it’s a joints problem.

7 years later I understand that it is equally a tendon pathology too.

Here’s how I came to understand what is really happening, which subsequently changed my management👇: It starts with PANNUS, an inflammatory tissue that is formed on a rheumatoid affected joint.

Inside the pannus, FIBROblasts proliferate & differentiate into →

1. MacroPHAGES consume the tendon
2. OsteoCLASTS erode the bone.

This affects movement at the bone-tendon junction

Identifying flexor tenosynovitis with carpal tunnel syndrome & a tenosynovectomy rapidly RELIEVES PAIN

Unfortunately, we don’t get taught how to think in those terms

For the past 5 years, here’s how I
do it👇:

- To relieve pain
- Reduce disease load
- Rehabilitate them early An incision is planned primarily as a proximal ulnar extension of the carpal tunnel approach or extended later as required.

Brunner’s incision may be planned in the finger.

Since 2010, DMARDs are been used for Rheumatoid hand dorsal tenosynovitis.

Occasionally, it needs tenosynovectomy depending upon the size.

Here is how to OPERATE it👇to:

- Control of the disease progression.
- Prevent psuedo tendon formation.
- Prevent late tendon attrition. Plan a dorsal straight midline incision

One will encounter the bulging tenosynovium with the extensor retinaculum.

95% fractures in the hand and wrist can be diagnosed by plain X-RAYS.

In 2018, I MISSED couple of hand injuries for INCORRECT views.

Here are 6 X-ray views done in trauma situations:

- Help you DIAGNOSE the injury
- AVOID the embarrassment missing them.

🧵👇 View #1: WRIST PA view with extension and ulnar deviation

Scaphoid fractures should to be ruled out in all FOOSH injuries.

Screening of scaphoid bone in full length along with distal end radius fractures.

Diagnose OCCULT scaphoid fractures that would be apparent on CT scans.

How to determine a PIP joint fracture dislocation (involving 30-50% surface) INSTABILITY?

Instability = SURGERY.

(Ans: Dorsal “V sign” on X-ray). LATERAL view is taken in FLEXION and EXTENSION.

Flexion occurs as a HINGE from volar defect causing CONVERGING joint surfaces on the dorsum.

Jahss manoeuvre is a REDUCTION technique for METACARPAL NECK fracture. Step 1: The metacarpo phalngeal and the proximal inter phalangeal joint of the affected finger is flexed to 90 degrees.