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0. Anatomy (During Ortho Residency) > Hand & Wrist > Flashcards

Hand & Wrist Flashcards

1
Q

Components of the ULC of the Thumb

A
  1. Proper Collateral Ligaments - resists valgus with thumb in flexion
  2. Acessory Collaeral Ligaments - resists valgus with thumb in extension
  3. Volar Plate - resists valgus with thumb in extension
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2
Q

Indications for Scaphoid Fixation

A
  1. Proximal Pole Fractures
  2. Displacement >1mm
  3. 15 degrees Humpback Deformity
  4. Radiolunate Angle > 15 degrees (DISI)
  5. Interscaphoid Angle >35 degrees
  6. Associated Perilunate
  7. Comminuted #
  8. Unstable vertical or oblique #
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3
Q

Eponymous Name for Idiopathic AVN of the Scaphoid

A

Presier’s Disease

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4
Q

What is a Stener’s Lesion

A

Avulsion of the Ulnar Collateral Ligament of the Thumb gets trapped proximally to Adductor Pollicis Tendon

  • Prevents healing- surgical indication
  • Seen in “Gamekeeper’s Thumb”
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5
Q

Describe Finklestein’s Test

A

Pain over the first dorsal compartment, with thumb clenched in palm and ulnar deviation of the carpus.

  • Sign of DeQuairvain’s Tenosynovitis
  • Inflammation/Tendonitis of the 1st Dorsal Compartment
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6
Q

What is the Location of the Two Tendons in the 1st Dorsal Compartment in Relation to Each Other

A
  • Abductor Pollcis Longus - more radial
  • Extensor Pollicis Brevis - more dorsal
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7
Q

Eaton’s Classification

A

Classification of 1st CMC Joint OA

  1. Normal apperence
  2. Joint space narrowing, osteophytes <2mm
  3. Joint space narrowing, osteophytes >2mm
  4. Pantrapezial arthritis
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8
Q

When is the Distal Radius Shortest Compared to the Ulna?

A

Shortest in pronation.

  • Think: supination is the anatomic position, so the radius has to travel around the ulna to get to pronation.
  • Positive ulnar varience is often seen in pronation films.
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9
Q

Position of Greyson’s and Cleland’s Ligaments in Relation to NV Bundle in Fingers

A
  • Grayson’s (Grip)- volar to the NV bundle
  • Cleland’s (Ceiling)- dorsal to NV bundle
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10
Q

Where does the Superficial Radial Nerve emerge at the wrist?

A

Emerges from beneath the brachioradialis ~7-9cm proximal to the radial styloid (Whartenberg’s Point).

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11
Q

Quadregia Effect

A
  • FDP Tendons of 3rd, 4th and 5th digit have a common muscle belly. The excursion of all of them will be equal to the shortest excusion.
  • If a tendon is repaired short (>1cm short), will affect the posturing of the other fingers
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12
Q

Boundaries of the Thenar Space

A
  • Radial - thenar eminence
  • Ulnar - midpalmar septum
  • Dorsal - Adductor Pollicis
  • Volar- Flexor Tendons
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13
Q

Lumbricals Plus Finger Sign & Causes (4)

A

FDP tendon rupture distal to lunbrical origin causes pull through lumbricals and paradoxical PIP extension with finger flexion when making a fist

  • Causes
    • FDP transection distal to the origin of the lumbrical
    • FDP avulsion
    • Tendon graft too long
    • DIP amputation
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14
Q

Vicker’s Ligament

A

Aka. Short Radiolunate Ligament

  • Implicated in Madelung’s Deformity:
    • Disruption of hte volar ulnar physis resuling int increased raidal inclination and radiopalmar tilt.
  • Associated with Leri-Weil Dyschonostosis:
    • Genetic disorder of SHOX gene
    • Dwarfism and Madelung’s Deformity
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15
Q

Anatomic varients of the “Million Dollar Nerve”

A
  • Recurrent branch of the medial nerve
  • Varients (in relation to flexor retinaculum):
    • Extraligamentous (most common)
    • Subligamentous (next)
    • Intraligamentous (most rare)
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16
Q

What is the most common place for the palmar cutaneous branch of the median nerve to emerge at the wrist?

A

Ulnar to FCR tendon

  • Travels outside of the carpal tunnel
  • Watch out for it when doing a carpal tunnel release
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17
Q

Muscles of the Hypothenar Eminence

A
  1. Abductor Digiti Minimi
  2. Flexor Digiti Minimi
  3. Opponens Digiti Minimi

* all innervated by ulnar n.

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18
Q

Muscles of the Thenar Eminence

A
  1. Flexor Pollicis Brevis
    • Deep head innervated by ulnar n.
    • Superficial head innervated by recurrent branch median n.
  2. Abductor Pollicis Brevis - recurrent branch median n.
  3. Opponens Pollicis - recurrent branch median n.
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19
Q

Which bone does not contribute to carpal motion?

A

Pisiform- it is a sesamoid bone of the FCU tendon

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20
Q

Articulations of the Scaphoid

A
  1. Radius
  2. Lunate
  3. Capitate
  4. Trapezium
  5. Trapezoid
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21
Q

Palmar (9) & Dorsal (5) Intrinsic Carpal Ligaments

A

Palmar

  1. Scapholunate (SL)
  2. Lunotriquetral (LT)
  3. Trequetrohamate
  4. Trequetrocapitate
  5. Capitohamate
  6. Capitotrapezoidal
  7. Trapeziotrapezoidal
  8. Scaphotrapeziotrapezoidal (STT)
  9. Scaphocapitate

Dorsal:

  1. Scapholunate (SL)
  2. Lunotriquetral (LT)
  3. Trapeziotrapezoidal (TT)
  4. Capitotrapezoid
  5. Capitohamate
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22
Q

Movement of the proximal carpal row with radial and ulnar deviation.

A
  • Radial Deviation - proximal capal row flexes
  • Ulnar Deviation - PCR extends
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23
Q

What is the main function of the midcarpal joint?

A

Radial and ulnar deviation.

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24
Q

Describes all planes of midcarpal motion.

A
  • Flexion: normal =65 degrees
    • 60% is midcarpal
    • Can accept 10 degrees functional ROM
  • Extension: normal = 55 degrees
    • 33% is midcarpal
    • Can accept 35 degrees functional ROM
  • Radial Deviation: normal = 15 degrees
    • 90% is midcarpal
    • Can accept 10 degrees functional ROM
  • Ulnar Deviation: normal = 35 degrees
    • 50% is midcarpal
    • Can accept 15 degrees functional ROM
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25
Q

What is the most distal muscle innervated by:

Radial N?

PIN?

Median N?

AIN?

Ulnar N?

A
  • Radial N: ECRL
  • PIN: EI
  • Median N: 2nd lumbrical
  • AIN: PQ
  • Ulnar: Adductor pollicis (1st doral interosseus is the most distal, testable muscle innervated)
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26
Q

Vaughn-Jackson’s Sequence

A
  • Rupture of the digital hand extensors from ulnar to radial.
  • Pathoanatomy:
    • DRUJ instability leads to dosal proninence of the ulnar head which causes attritional ruptures of extensor tendons
    • EDM first then proceeds radially.
  • Treatments:
    • ED4 to EDM, or EIP to EDM
      • The more tendons that are ruptured the more transfers that need to be done
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27
Q

Mannerfelt Lieson. What is it? What are 2 ways to treat it?

A

FPL Tendon Rupture. Either traumatic or attritional

  • Causes:
    • Distal pole of scaphoid and trapezium peice through volar wrist capsule causing traumatic rupture
    • Attritional rupture of FDP to index due to synovitis in carpal tunnel. Seen in rhematoid hand, causes swelling and pressure.
  • Ruptures from radial to ulnar (opposite of Vaughn-Jackson Sequence).
    • FLP, FDP index, FDS index, FDP middle
  • Treatment:
    • FDS from ring transfer - if joint mobile and supple
    • Thumb IP fusion
    • FPL advancement through FCR or PL
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28
Q

Orientation of Digital A. vs Digital N. in the hand.

A
  • Proximal to the MCP:
    • Digital A. Volar, Digital N. Palmar
  • Distal to MCP
    • Digital N. Volar, Digital A. Palmar

*Digital N is the most volar structure in the hand distal to the MCP

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29
Q

Keinbocks

A
  • Idiopathic AVN of the Lunate
  • 7-20% of people have only one major artry supplying lunate

Stages (Litchman Classification):

  1. I - no changes on xray, only MRI findings
  2. II - sclerosis of the lunate
  3. IIIa - lunate collapse, no scaphoid rotation
  4. IIIb - lunate collapse with fixed scaphoid rotation
  5. IV - Degenerative ajacent perilunate joints
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30
Q

Blood Supply to the Lunate

A
  • Dorsal Plexus
    • Branches of:
      • Radial A.
      • Anterior Interosseus A.
  • Volar Plexus
    • Branches of :
      • Radial A.
      • Ulnar A.
      • Anterior Interosseus A.
      • Recurrent vessels of deep palmar arch

Rich blood supply, which is why you don’t often see AVN of the lunate following perilunate dislocations.

  • 7-20% of patients only have one major vessle supplying the lunate, predisposing them to Keinbock’s or posttraumatic AVN
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31
Q

% of Scaphoid Covered in Articular Cartilage

A

75%

32
Q

Swan Neck Deformity (Describe deformity itself and causes).

A

Deformity: DIP Flexion and PIP Hyperextension

Causes:

  • Mallet Finger - central slip rupture, causing DIP flexion, and now uneven pull of lumbricals through lateral bands exasturbating the flexion and extension at PIP
  • Stretching of Transverse Retinacular Ligament (TRL)
    • Dorsomedial transpaltion of the lateral bands causing DIP flexion and PIP extension
  • Rheumatoid Arthritis
    • increased force through PIP leading to volar plate laxity, and TRL laxity
33
Q

Boutonneire Deformity (describe deformity and causes)

A

DIP Extension, PIP Hyperflexion

Causes:

  • Central Slip Rupture:
    • More force going through lateral slip, hyper extending DIP.
    • Volar subluxation of lateral bands causing PIP flexion
      • Chronic attenuation - seen in RA
      • Acute - do Elson’s test
  • Triangular Ligament Rupture:
    • Volar subluxation of lateral bands causing DIP extension and PIP flexion
  • Displaced Oblique Retinacular Ligament
    • DIP hyperextension
34
Q

Camper’s Chiasm

A

At PIP where FDP passess through two slips of FDS.

35
Q

Blood Supply to the Flexor Tendons

A
  • Through vincular system
  • Each tendon has a long and short vinculum
36
Q

Carpal Blood Supply

A

Relevant Arteries:

  • Dorsal:
    • Radial A. - deep palmar arch (proximal)
    • Ulnar A. - superficial palmar arch (distal)
    • Intercarpal Supraretinacular Arteries
      • 1, 2- Artery of Ziedenberg
      • 2,3
  • Volar
    • Radial A.
    • Ulnar A.
    • Anterior Interossesus A.
    • Palmar Carpal A. - Matoulin
      *
37
Q

Where is the Extensor Retinaculum at the Wrist?

A

Centered over Lister’s Tubercle, superficial to the extensor compartments.

38
Q

Parona’s Space

A

Potential space in the volar forearm superficial to PQ, in continuity with thenar and midpalmar space in the hand.

39
Q

Flexor Tendon Sheaths (Volar)

A
  1. Flexor Pollicis Longus
  2. Common Flexor Sheath (midpalmar and 5th digit)
  3. Tendon Sheaths fingers 2-5

Varients:

  • Horseshoe abcess connecting FPL and common flexor sheath.
40
Q

Potential Spaces of the Hand and Forearm

A
  • Hand:
    • Thenar Space
    • Hypothenar Space
    • Midpalmar Space
  • Forearm:
    • Parona’s Space (continguuos with arm, so an abscess here can track proximally)
41
Q

Anatomy Around the MCP Joint

A

See Diagram (be able to label)

  • Lumbricals (volar to deep transverse metacarpal ligament)
  • Interossei (dorsal to deep transverse metacarpal ligaments)
  • Deep Transverse Metacarpal Ligament
  • A1 Pulley
  • Flexor Tendon
  • Accessory Collateral Ligaments
  • Sagittal Band
  • Volar Plate
42
Q

Anatomy of the Palmar Fascia

A

See Diagram

Components:

  • Skin
  • Transverse Fibres
  • Deep Transverse Ligament
  • Longitudinal Fibres
  • Septa of Fibres of Legueu & Juvara
43
Q

Components of the Volar Retinaculum

A
  • Superficial:
    • Superficial Carpal Ligament
    • Superficial Palmar Ligament
  • Deep:
    • Proximal: continuation of Antebrachial Fascia
    • Middle: Transverse Carpal Ligament
    • Distal: Aponeurosis between thenar and hypothenar eminence
44
Q

Components of the Scapholunate Ligament

A
  1. Dorsal: Strongest
  2. Palmar
  3. Proximal (thin & membranous)
45
Q

Greater vs Lesser Arc Perilunate Injuries

A
  • Lesser Arc - purely ligamentous perilunate disruption (ie SL ligament, LC ligament, LT ligament)
  • Greater Arc - bony fracture associated with perilunate injury (ie transscaphoid, transcapitate, transtriquetral)
46
Q

Name the 10 Compartments of the Hand and Describe How to Release Them

A

Comparments:

  • Thenar
  • Hypothenar
  • Abductor Pollicis
  • Dorsal Interossei (x4)
  • Palmar Interossei (x3)

How to Release:

  • Two dorsal incisions line with 2nd & 4th metacarpals
  • Two volar incisions one radial side of thenar eminence and one volar over hypothenar eminence
  • +/- Carpal Tunnel & Guyons Canal Release
47
Q

Which Volar Extrinsic Wrist Ligament is Acutally a Neurovascular Bundle? What are it’s components?

A

Radioscapholunate Ligament (aka Ligament of Testut)

  • No contribution to wrist stability
  • Components:
    • Vascular branch AIN
    • Vascular branch Radial A.
    • Branch of AIN nerve
48
Q

Mayfield Stages of Perilunate Instability

A
  1. Scapholunate Failure
  2. Capitolunate Failure
  3. Lunotriquetral Failure - perilunate dislocation, capitate not in line with carpus
  4. Dorsal Radiocarpal Ligament Failure- volar dislocation of the lunate into the carpal tunnel, capitate realignes with the carpus
    • “Tipped Teacup Sign”
49
Q

Space of Porier

A
  • Weakest point in the volar wrist
  • Boareded by:
    • Radiocapitate ligament
    • Radiotriquetral ligament
  • Lunate often displaces through this space
50
Q

Order of Ossification of the Carpal Bones

A

​Capitate first, then clockwise:

  1. Capitate
  2. Hamate
  3. Trequetrum
  4. Pisiform
  5. Lunate
  6. Scaphoid
  7. Trapezium
  8. Trapezoid
51
Q

Aligment of the Distal Carpal Row

A
  • Trapezium aligns with 1st metacarpal
  • Trapezoid aligns with 2nd metacarpal
  • Capitate aligns with 3rd metacarpal
  • Hamate aligns with 4th and 5th metacarpal
52
Q

DRUJ Stability

A

*CONTROVERTIAL* there is evidence supporting both the below and the opposite.

  • Supination: deep dorsal radioulnar ligament restrains dorsal subluxation of the radius
  • Pronation: deep volar radioulnar ligament main restrain to volar subluxation
53
Q

Angular Measurements of the Distal Radius

A
  • Radial Length - 11mm
  • Radial Inclination- 22 degrees
  • Palmar Tilt - 11 degrees
  • Ulnar Varience- 0 to -2mm
54
Q

Extensor Tendon Zones

A

Joints = Odd #

Between Joints = Even #

  • I - DIP
  • II - Middle Phalanx
  • III - PIP
  • IV- Prox Phalanx
  • V - MCP
  • VI - Metacarpal
  • VII - Carpus
  • VIII- Distal Radius (Tendinous)
  • IX- Muscular bellies of tendons in forearm
55
Q

Kaplan’s Cardinal Lines

A
  1. Line from 1st webspace to hook of hamate
  2. Line from radial side proximal crease to ulnar side distal crease
  3. In line with radial D3
  4. In lien with ulnar D4
56
Q

Fascial Layers Invovled in Duypetryns

A
  • Not Involved:
    • Transverse Fibres
    • Cleland’s Ligaments
  • Involved:
    • Pretendinous Bands
    • Spiral Ligaments
    • Natatory Ligaments
    • Lateral Digital Sheath
    • Greyson’s Ligaments
57
Q

Blood Supply to the Scaphoid

A
  • Branches of the Radial A.
    • Superficial Palmar Branch- most of the blood supply, comes in from distal to proximal over dorsal ridge
    • Dorsal carpal branch - waist and proximally
58
Q

Flexor Pulley System

A

A2 & A4 most important in preventing bowstringing

  • A1 over MCP
  • A2 prox phalanx
  • A3 PIP
  • A4 midle phalanx
  • A5 DIP

Thumb:

  • A1 MCP
  • A2 IP

Cruciate Pulleys:

  • C1 distal part of proximal phalanx
  • C2 middle phalanx

C3 distal end of middle phalanx

59
Q

Elson’s Test

A

Test the integrity of the central slip:

  • With PIP in flexion, assess the DIP
  • If DIP floppy - central slip is intact
  • If DIP rigid - means that central slip has ruptured and all the force is going through the lateral bands, which is forcing the DIP into extension via the lumbricals
60
Q

Components of the Extensor Hood

A
  1. EDC Tendon
  2. Dorsal and Palmar Interossei
  3. Lumbricals
  4. Central Slip
  5. Oblique Retinacular Ligaments
  6. Transverse Retinacular Ligaments
  7. Sagittal Bands
  8. Triangular Ligaments
61
Q

Intrinsic Plus (Saftey) Position

A

Wrist - 30 degrees Extended

MCP - 70 degrees Flexion

IP - 0 degrees flexion

62
Q

Transverse Carpal Ligament & Contents of the Carpal Tunnel

A
  • Transverse Carpal Ligament Runs:
    • From Hook of Hamate & Pisiform
    • To Scaphoid Tubercle and Trapeziodal Tuberosity
  • Contents of the Carpal Tunnel:
    • FDS Tendons (4) - arranged in “spiderman” formation
    • FDP Tendons (4)
    • Median N.
    • FPL Tendon
63
Q

Components of the TFCC

A
  1. Articular Disc
  2. Meniscus Homolog
  3. ECU Tendon & Subsheath
  4. Palmar and Dorsal Deep & Superficial Radiocarpal Ligaments
  5. Volar Ulnocarpal Ligaments
    • Ulnotrequetral
    • Ulnocapitate
    • Ulnolunate
64
Q

DRUJ Stabilizers

A

Extrinsic

  1. TFCC
  2. Joint Capsule
  3. IO Membrane
  4. Pronator Quadratus
  5. ECU Tendon & Sheath

Intrinsic:

  1. Bony Contact
  2. Superficial radioulnar ligament
  3. Deep radioulnar ligament
65
Q

Flexor Tendon Injury Zones

A

Digits:

  1. FDP to FDS insertion
  2. FDS to A1 Pulley
  3. A1 pulley to carpal tunnel
  4. Carpal Tunnel
  5. Tendons in Forearm
  6. Muscle Bellies in Forearm

Thumb:

  1. Distal to IP
  2. IP to A1 Pulley
  3. Thenar Eminence
  4. Carpal Tunnel
  5. Tendons in Forearm
  6. Muscle Bellies in Forearm
66
Q

Name the Extensor Compartments of the Hand, Contents and Pathology Associated with Each Compartment

A
  1. APL & EBP- DeQuarvain’s Tenosynovitis
  2. ECRL & ECRB - Intersection Syndrome
  3. EPL - Drummers Wrist, Traumatic Rupture
  4. EI, EDC (4), PIN - Extensor Tenosynovitis
  5. EDM - Vaughn Jackson Sequence
  6. ECU - Snapping ECU
67
Q

Boarders & Contents of the Anatomic Snuffbox

A
  • Boarders:
    • Radial- APL& EPB
    • Ulnar- EPL
    • Proximal - proximal boarder of distal radius
    • Distal: Base of 1st & 2nd metacarpals
  • Contents:
    • Branch of Superficial Radial N.
    • Radial A.
    • Wrist Capsule
68
Q

Volar Extrinsic Ligaments of the Wrist

A

Radial to Ulnar:

  1. Radial Collateral
  2. Radioscaphocapitate - strongest
  3. Long Radiolunate- resists volar displacement of lunate
  4. Radioscapholunate - ligament of testut
  5. Short Radiolunate - Vicker’s Ligament
  6. Ulnolunate
  7. Ulnocapitate
  8. Ulnotrequetral
  9. Ulnar Collateral
69
Q

Dorsal Extrinsic Ligaments of the Wrist

A
  1. Dorsal Intercarpal Ligament
  2. Dorsal Radiocarpal Ligament
  • Excise along these tendons in Mayo ligament sparing capsulotomy in dorsal approach to the wrist.
  • These two ligaments meet at trequetrum
70
Q

Makeup of the Lateral Bands

A
  • Lateral Bands: confluence of lumbricals and interossei
    • Lumbricals on radial side only
    • Interossei has radial and ulnar bands. Lay dorsal to the Deep Transverse Metacarpal Ligament
  • Lateral bands divide into medial and lateral intosseus bands:
    • MIB - joints central slip at PIP
    • LIB - joints lateral slips at DIP
71
Q

Guyons Canal: Conents, Boarders & Zones

A
  • Boarders:
    • Radial- hamate
    • Ulnar- pisiform
    • Roof - superficial volar carpal ligament
    • Floor - Deep Flexor Retinaculum
  • Contents:
    • Ulnar A.
    • Ulnar N.
  • Zones:
      1. Proximal to ulnar nerve bifurcation (motor and sensory)
      1. 1st motor branch (motor)
      1. Sensory branch (sensory)
72
Q

Boarders of the Thenar Space

A
  • Radial: Thenar Eminence
  • Ulnar: Middle Metacarpal & Ulnar Bursa
  • Deep: Adductor Pollicis
  • Superficial: Carpal Tunnel
73
Q

Radial Tunnel (Boarders & Significance)

A

From radiocapitellar joint to proximal edge of supinator

  • Boundaries:
    • Lateral: Brachioradialis, ECRL, ECRB (mobile wad)
    • Medial: Biceps & Brachialis
    • Floor: Capsule of Radiocapitellar Joint
  • Significance: Point of compression of PIN.
74
Q

Label the Diagram Below

A

Palmar Superficial Ligaments

  1. Radioscaphoid Ligament
  2. Radiocapitate Ligament
  3. Long Radiolunate Ligament
  4. Lunocapitate Ligament
  5. Scaphocapitate Ligament
  6. Pisohamate
  7. Flexor Retinaculum or Transverse Carpal Ligament

Palmar Deep Ligaments

  1. Short Radiolunate
  2. Ulnolunate
  3. Ulnotriquetral
  4. Palmar scapholunate
  5. Palmar lunotriquetral
  6. Triquetral-hamate-capitate
  7. Dorsolateral scaphotrapezial
  8. Palmar transverse interosseus ligaments of the distal row

Dorsal Ligaments

  1. Dorsal Radiocarpal
  2. Dorsal Intercarpal Ligament
  3. Dorsal Scapholunate
  4. Dorsal Lunotriquetral
  5. Dorsal Transverse Interosseus Ligaments of the Distal Row
75
Q

Label the Diagram Below

A

EDC - extensor tendon

SB - sagital band

MC - metacarpal

ACL - Acessory Collateral Ligaments

IT - Interosseus Tendon

DTML - Deep Transverse Metacarpal Ligament

LT - Lumbrical Tendon

FT - Flexor Tendon

PS - A1 Pully

VP - Volar Plate

76
Q

Label the Diagram Below

A

0. Anatomy (During Ortho Residency) (10 decks)

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