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Questions pratiques de l'Université Montréal > Main (tendon and nerve injury and transfer) > Flashcards

Main (tendon and nerve injury and transfer) Flashcards

1
Q

Describe Martin-Gruber anastomosis
% population

A

Motor connection from median to ulnar nerve in forearm OR between AIN and ulnar nerve
17% population

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2
Q

Qu’est-ce que la dégénérescence Wallerienne? Nommez 5 événements

A

-Dégénérescence du stump distal d’un nerf coupé
i. Augmentation du calcium cytoplasmique
ii. Macrophages
iii. Phagocytose de la myéline
iv. Prolifération des Schwann
v. Formation des Bandes de Bunger

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3
Q

Que sont les Bandes de Bunger

A

Processus où les cellules de Schwann et les macrophages remplace le tube neural et s’organise en Bande de Bunger

=Un échafaudage pour la régénérescence axonale

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4
Q

Qu’est-ce que la chromatolyse? Nommez un évènement qui surviens dans ce processus.

A

Dégénérescence axonale du stump proximal

Formation du cône de croissance (sprouting axonal) environ 5-24h après le trauma

50% des sprouts font des mauvaises connexions

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5
Q

Définir - Neurotropisme

A

Gradient chemotaxique vers le stump distal propre qui attire le cone de croissance vers le bon target

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6
Q

Definir - Neurotrophisme

A

Support nutritionnel aux axones
Ex: NGF, EGF, IGF-1, IGF-2

ph = f = food

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7
Q

Facteurs qui affectent l’apoptose après une axotomie?

A
  • TFG-B
  • FGF
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8
Q

Discuter la dénervation du muscle proximal et le potentiel de réinnervation

A
  • Dénervation = 1%/semaine
  • Besoin de 25% des plaques motrices pour avoir un potentiel de contraction fonctionnel
  • Si >1an, dégénérescence des plaques motrices
  • Régénération nerveuse = 1mm/jour +30
  • Mauvais pronostique :
    i. AGE
    ii. SOUS UTILISATION
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9
Q

Combien de temps maximal peut prendre la reinnervation fonctionelle des motor endplates?

A

18 mois

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10
Q

What is double crush syndrome

A

Nerve entrapment at one location can predispose to nerve compression more distally due to endoneurial edema

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11
Q

Describe Marinacci anastomosis
% population

A

Motor ulnar to median in forearm

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12
Q

Describe Riche-Cannieu anastomosis
% population

A

Motor connection between medial to ulnar nerve in hand
70% population

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13
Q

Describe Froment-Rauber anastomosis
% population

A

Radial nerve (PIN or superficial radial nerve) to ulnar motor nerve that innervates 1,2 or 3rd interosseous
Very rare

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14
Q

Describe Berrettini Connection

A

Sensory connection between ulnar and median nerve in palm

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15
Q

Classification de Seddon et Sunderland, structures et pronostic?

A

image

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16
Q

Tests Dx pour les dommages nerveux (7)

A

Tinnel
2PD (innervation density)
Seuil de vibration
Semmes-Weinstein Monofilament (Pressure threshold)
Pick up test
Daily living task performance
EMG/NCS

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17
Q

How much time after nerve injury can you do a NCS and EMG and why

A

NCS: 3-6 weeks
before that cannot distinguish neurapraxia from complete nerve injury
EMG: 8-10 weeks
Motor unit potentials cannot be detected before

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18
Q

Valeurs normales pour 2PD statique et dynamique et ce qu’ils testent?

A

Statique : 6mm
Dynamique : 3mm
Test la densité d’innervation des fibres lentes et rapides, respectivement

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19
Q

algorithme/investiguation pour une blessure nerveuse fermée (Blunt)

A

OT/PT, attèle

Contrôle de la douleur
Faire un EMG/NCS de base à 4-6semaines

Revoir à 12 semaines avec un 2e EMG/NCS
i. Si amélioré : Ne pas intervenir, revoir dans 6 semaines
ii. Si pas d’amélioration électrique ou clinique : Intervention chirurgicale

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20
Q

Principes de réparation nerveuse (8)

A
  • Évaluation quantitative pré et post op de la fonction
  • Technique atraumatique microchirurgicale
  • Réparation primaire lorsque possible, 2e PRN
  • Réparation sans tension
  • Éviter le mouvement postural
  • Conduit ou greffe d’interposition PRN
  • Rééducation motrice et sensitive
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21
Q

Indications for secondary repair of nerve laceration

A

Severe contamination
Wide zone of injury
>7jours
Os instables
Compromis vasculaire ++
Sepsis

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22
Q

Techniques (6) for nerve repair other than direct repair

A
  • Nerf autologue non vascularisé
  • Nerf autologue vascularisé
  • Nerf allogène
  • Conduit
  • Veine
  • Fascicule musculaire
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23
Q

Types (3) of nerve repair

A

Perineural/fascicular
Group fascicular
Epineural repair

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24
Q

When can a group fascicular nerve repair be considered? Give 2 examples

A

When nerve transection is at the level where well formed sensory and motor branches are identified

  • Nerf médian >5cm proximal au poignet
  • Nerf ulnaire >8cm proximal au poignet
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25
Q

Solutions (4) for nerve gaps

A

Neurotization (nerve to target muscle)
Mobilization (1-2cm)
Transposition
Bone shortening

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26
Q

Méthodes pour clarifier l’anatomie sensitive et motrice (topographie)?

A

Colorations immunohistochimiques/pathologie
Stimulation nerveuse

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27
Q

Common donor nerve graft options (4) and length of each

A
  • PIN distal branch, 1cm
  • LABC, 5cm
  • MABC branche antérieure, 10cm
  • Sural, 30cm
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28
Q

Caractéristiques d’un donneur nerveux idéal

A
  • Expandable
  • Nombres d’axones similaire (Petit diamètre avec gros fascicules)
  • Facile d’accès
  • Pas de branches
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29
Q

Indication pour un vein graft/conduit/nerf synthétique?

A

</3cm dans une zone NON critique

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30
Q

Advantages of nerve transfer over nerve graft

A

Reduce time for reinnervation
Avoid operating in scared bed

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31
Q

Indication for nerve transfer

A

Brachial plexus with no proximal nerve
Proximal nerve injury requiring long distance for regeneration
Scarred bed in areas with critical neurovascular structures
Makor limb trauma with loss of nerve segment

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32
Q
A
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33
Q

Décrire votre post-op pour une réparation nerveuse

A

Splint pour pas de tension

OT <1semaine pour ROM en flexion

Out of splint à 3 semaine avec AROM précoce puis PROM

Désensibilisation et rééducation

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34
Q

Phases de rééducation sensitive

A
  • Désensibilisation
  • Discrimination
  • Gnosie tactile
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35
Q

Timing pour une excision de névrome

A

3-4mois, pas de retour de fonction et tinnel non progressif

36
Q

Types de névromes et management respectif

A

Névrome latéral -> Résection et réparation des fascicules impliqués
Névrome spindle shape -> Si fascicules continues, neurolyse, sinon résection et réparation

37
Q

Describe MRC muscle scale

A

0: No contraction
1: Flucker or trace of contraction
2: Active movement, with gravity eliminated
3: Active movement, against gravity
4: Active movement, against gravity and resistance
5: Normal power

38
Q

Criterias (3) to consider a tendon trasnfer

A

Supple joint
Stable soft tissue
Appropriate option for donor tendon

39
Q

Criterias of an appropriate donor tendon

A

Expendable (no function loss)
One function (restore only one function)
Adequate excursion
Adequate power
Appropriate vector
Synergy

40
Q

Name 4 tendons with the most excursion

A

1) BR (5.2)
2) ECRL (3.3)
3/4) FDP/FDS (2.8)

41
Q

Excursion at thee wrist, MCP and fingertip level

A

3-5-7 rule

Wrist level: 3.3cm
MCP level: 5.0 cm
Fingertips: 7.0cm

42
Q

Decribe 2 tendon groups that act together in synergy

A

Supination, wrist flexion, finger extension and adduction

Pronation, wrist extension, finger flexion, abduction

43
Q

Alternatives to tendon transfers

A

Correct root cause with either nerve or tendon repair

Externals static or dynamic splint in functional position

Internal splinting: arthrodesis or tenodesis in functional position

44
Q

Systemic disease that can cause tendon rupture (3)

A

Rheumatoid arthritis
Poliomyelitis
Leprosy/Hansen’s disease

45
Q

Requirements (7) that must be meet before a tendon transfer

A

Skeletal stability
Supply soft tissue coverage
Joint mobility confirmed
Correction of contractures
Adequate protective sensation
Patient motivation/reliability
Control of systemic disease if present

46
Q

Option of tendon transfer to gain thumb opposition (4)

A

EIP
FDS ring finger
Palmaris Longus (Camitz)
Abductor digiiti minimi (Huber)

47
Q

Option of tendon transfer to gain thumb flexion (3) which is most commonly used

Where is the donor tendon weaved to?

A

Donor must be weaved to distal FPL tendon

BR (most common)
ECRL
FDS D4

48
Q

Option of tendon transfer to D2 and D3 DIP flexion (3) which is most commonly used

Where is the donor tendon weaved to?

A

Donor must be weaved to distal FDP tendon

BR
ECRL (most common)
FDS D4

49
Q

Donor tendon options to gain Thumb adduction

Where are the donor tendons inserted

A

Inserted at ulnar base of thumb P1

ECRB (Smith) (will need tendon graft to provide length)
BR (Boyes) (will need tendon graft to provide length)
FDS D3/D4 (Littler)

50
Q

Option of tendon transfer to D4 and D5 DIP flexion (3)

A

Suture both to D3 FDP tendon

51
Q

Imbalances that cause clawing in ulnar nerve injury

A

Lack of MCP flexor from lumbricals and interossei –> causes MCP joint hyperextension and PIP and DIP flexion

52
Q

Describ the Bouvier Test

A

Bloc the MCP joint from hyperextending (in flexion), patient is asked to extend the IP joint.

+ test patient is able to extend, therefore patient can receive a joint positioning procedure/static procedure

  • test patient cannot extend IP, needs a dynamique tendon transfer
53
Q

Describ options for static reconstructive procedures for claw hand deformity

A

Lasso de Zancoly

54
Q

Describ options of dynamic tendon transfer

A

Modified Stiles-Bunnell procedure: from D3 FDS
ECRL
ECRB
FCR
BR

55
Q

Which wrist extensor tendons are generally not reconstructed

A

ECRL and ECU

56
Q

Describe donor tendon options for wrist extension

A

Pronator teres to ECRB

57
Q

Common cause of loss of EDC function other than radial nerve palsy

A

Rhumatoid arthritis leading of rupture of EDC ulnar to radial

58
Q

Option of tendon transfers for MCP extension

A

FCU
FCR
FDS D3

59
Q

Tendon transfers to reconstruct EPL function

A

PL
FDS D4
EIP

60
Q

Tendon transfers to reconstruct EPB or APL

A

FCR

61
Q

Name 4 combinations of tendon transfers for raidal nerve palsy

A

“Brand”
FCR to ECD
PT to ECRB
PL to EPL

“FCU transfer”
FCU to EDC
PT to ECRB
PL to EPL

“Boyes”
Middle FDS to EDC
D4 FDS to EIP and EPL
FCR to APL and EPB

“Merle d’Aubigné”
FCU to EPL and EDC
PT to ERCB
PL to APL and EPB

62
Q

Complications (3) of tendon transfers

A

Tendon adhesions
Tendon rupture
Transfer weakness

63
Q

Expected recovery period for nerve according to distance of injury

A

Distance in mm + 30= of days to recover sensation

64
Q

3 types of nerve coaptation

A

End to end
End to side
Reverse end-to-side/supercharge

65
Q

Characteristic of ideal nerve donor (5)

A

Pure motor or sensory
Contains adequate axons
Similar diameter
Minimal donor site morbidity
Synergist action

66
Q

Indications for nerve transfer (4)

A

Ver proximal nerve
Primary nerve repair not possible
Nerve gap >7.2cm
Long distance between injury and motor endplates

67
Q

Contraindications to nerve transfer (2)

A

> 18 months since injury
Donor motor strength bellow MRC grade M4

68
Q

Medical Research Council Muscle Scale

A

0: no contraction
1: Flicker or trace of contraction
2: Active movement, with gravity eliminated
3: Active movement, against gravity
4: Active movement, against gravity with resistance
5: Normal power

69
Q

Upper extremity function priority

A
  1. Elbow flexion
  2. Shoulder abduction and external rotation
  3. Scapula stabilization
  4. Elbow extension
  5. Hand function
  6. Upper limb sensation
70
Q

Nerve damage causing scapular winging

A

Long thoracic nerve

71
Q

Nerve transfer for scapular winging

A

Thoracodorsal nerve

72
Q

2 nerve transfer as part of the double nerve transfer to gain shoulder abduction (which to which nerve)

A

Spinal accessory nerve to suprascapular nerve

Radial nerve (branch of long head of triceps) to axillary nerve

73
Q

Name 3 other nerve transfers possible to gain shoulder abduction other than the double nerve transfer

A

Thoracodorsal nerve

Intercostal nerve

Phrenic nerve (last resort)

to suprascapular or axillary nerve

74
Q

4 Nerve transfers to gain elbow flexion, which is gold standard

A

Oberlin: Ulnar nerve to biceps branch (gold standard)

Double fascicular transfer (DFT)

Intercostal nerves (2-3 nerves)

Thoracodorsal nerve

Medial pectoral nerve + nerve graft

75
Q

Describe the Oberlin transfer

A

Motor fascicles of FCU to biceps branch of musculocutaneous nerve

76
Q

Describe the double fascicular transfer (DFT)

A

Oberlin transfer + median nerve fascicles to FCR and FDS to brachialis branch of MCN

77
Q

Contraindications to thoracodorsal nerve transfers

A

Weak shoulder adduction

78
Q

Recipient branch for nerve transfers to gain elbow extension

A

Nerve branch to long head of triceps (radial nerve)

79
Q

6 Donor nerves for transfers to gain elbow extension, which is gold standard

A

Teres minor (gold standard)
Ulnar motor fascicle
Medial pectoral nerve
Thoracodorsal nerve
Phrenic nerve
Intercostal nerve

80
Q

Recipient branch for nerve transfers to gain pronation

A

Pronator teres branch of median nerve

81
Q

3 Donor nerves to gain pronation

A

ECRB branch
FCU branch
FDS branch

82
Q

3 types of nerve transfer for radial nerve palsy to gain wrist and finger extension

A

1) Dual nerve transfer
Two branches FDS to ECRB branches (wrist ext)
FCR and PL branches to PIN (finger ext)

2) PQ branch to PIN

3) Supinator motor branch to PIN

83
Q

3 Donor nerve branches to gain intrinsic hand function/distal ulnar nerve injury, which is gold standard

A

PQ branch of AIN (gold standard)

EDM branches

ECU branches

84
Q

Goals of nerve transfer for medial nerve injury

A

Restore thumb opposition and pinch between thumb and index

85
Q

Potential donor nerve branches for median nerve injury (7)

A

Motor branch of

Brachialis
BR
FDS
FCR
FCU
ECRB
Supinator

86
Q

3 complications of nerve transfers

A

Poor functional recovery
Donor site weakness
Neuroma

Questions pratiques de l'Université Montréal (41 decks)

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