Elective Upper Limb Surgery

Question 1

Outline the anterior (deltopectoral) approach to the shoulder

Answer 1

• 10-15cm incision over deltopectoral groove
• Split deltoid and pec major (retracting cephalic vein)
• Retract short head of biceps medially
• Divide subscapularis between stay sutures with arm externally rotated
• Longitudinal capsulotomy

Question 2

Applications of anterior approach to the shoulder

Answer 2

• Anterior stabilisation
• Joint replacement
• Fracture fixation

Question 3

What are the 2 x-ray views required to image the shoulder

Answer 3

1. AP
2. Lateral
3. Axillary

Question 4

Which rotator cuff is most commonly torn

Answer 4

Supraspinatus

Question 5

What is involved in supraspinatus repair

Answer 5

1. Coracoacromial ligament excision to decompress rotator cuff
2. Tendon repair if <65

Question 6

Surgical intervention for ACJ arthritis

Answer 6

Distal clavicle osteotomy in severe cases

Question 7

What is the first movement to be restricted in frozen shoulder

Answer 7

External rotation

Question 8

How long does frozen shoulder take to completely resolve

Answer 8

Up to 2 years

Question 9

What are the 3 phases of frozen shoulder

Answer 9

1. Painful
2. Frozen
3. Thawing

Question 10

Neurovascular relationships of the surgical neck of the humerus

Answer 10

1. Axillary nerve

2. Circumflex humeral vessels

Question 11

Neurovascular relationships of the spiral groove

Answer 11

1. Radial nerve

2. Profunda brachii vessels

Question 12

Neurovascular relationships of the posterior aspect of he medial epicondyle

Answer 12

Ulnar nerve

Question 13

List the 3 joints forming the elbow

Answer 13

1. Ulnohumeral
2. Radiohumeral
3. Proximal radioulnar

Question 14

List the 6 ossification centres of the elbow in order

Answer 14

1. Capitulum (3 months)
2. Radial head (5 years)
3. Internal (medial) epicondule (7 years)
4. Trochlea (9 years)
5. Olecranon (11 years)
6. Lateral epicondyle (13 years)

Question 15

Describe the relationship of the median nerve and brachial artery to the biceps tendon at the elbow joint

Answer 15

Median nerve and brachial artery lie medial to the biceps tendon and superficial to brachialis

Question 16

Which approach to the humerus is most commonly used for ORIF (especially if radial nerve already injured)

Answer 16

Posterior approach

Question 17

Outline the posterior approach to the humerus

Answer 17

1. Extensile incision
2. Split triceps (lateral and long heads superficially, medial head deep)
3. Identify radial nerve

Question 18

Define tennis elbow

Answer 18

Common extensor tendinopathy

Question 19

What causes cubitus varus

Answer 19

Supracondylar fracture or other elbow fracture in childhood

Question 20

List the 3 sites of potential ulnar compression

Answer 20

1. Medial epicondyle
2. Between the two heads of flexor carpi ulnaris
3. Ulnar tunnel of the hand

Question 21

How does a ‘pulled elbow’ present

Answer 21

• Child aged 2-5
• Limited supination
• Tenderness over the radial head

Question 22

Describe Verden flexor tendon zone 1

Answer 22

• Between DIP and PIP joint creases distal to the insertion of FDS
• Contains FDP tendon within the distal flexor sheath

Question 23

Describe Verden flexor tendon zone 2

Answer 23

• Between distal palmar crease and midpoint of middle phalanx
• Corresponds to proximal part of flexor tendon sheath

Question 24

Describe Verden flexor tendon zone 3

Answer 24

• Between distal margin of carpal tunnel and distal palmar crease
• Contains both FDS and FDP tendons but are unsheathed

Question 25

Describe Verden flexor tendon zone 4

Answer 25

- Area of the carpal tunnel | - Contains both FDP and FDS tendons

Question 26

Describe Verden flexor tendon zone 5

Answer 26

Area of wrist and forearm up to carpal tunnel

Question 27

Outline the anterior (Henry's) approach to the radius

Answer 27

1. Extensile approach incision in line of lateral epicondyle to styloid process 2. Develop plane between brachioradialis (overlying superficial branch of radial nerve) and FCR 3. Elevate insertion of supinator to protect posterior interosseous nerve (exposes proximal 1/3rd) 4. Elevate insertion of pronator teres and origin of FDS (exposes middle 1/3rd) 5. Elevate radial border of pronator quadratus (exposes distal 1/3rd)

Question 28

Outline the approach to the ulnar shaft

Answer 28

- Subcutaneous border of the ulna is palpable along its entire length - Exposed by reflecting ECU and FCU

Question 29

Describe the management of extensor tendon injuries of the hand

Answer 29

- Primary suture - Splintage in extension for 6 weeks - Hand physiotherapy

Question 30

What causes mallet finger

Answer 30

Disruption of the extensor tendon of the distal phalanx from forced flexion of an extended finger

Question 31

Treatment of mallet finger

Answer 31

6 weeks of splintage with DIP hyperextension and PIP flexion

Question 32

What causes mallet thumb

Answer 32

Delayed rupture of EPL following Colles' fracture or in RA

Question 33

How is mallet thumb managed

Answer 33

Tendon transfer of extensor indices

Question 34

Describe Boutonniere deformity

Answer 34

Lateral bands of the extensor expansion sublux volarly

Question 35

Describe Paronychia

Answer 35

Infection between the side of the nail and the lateral pulp of the finger

Question 36

What is the most common cause of Paronychia

Answer 36

Staphylococcus aureus

Question 37

Define a felon

Answer 37

Abscess in the pulp of the finger

Question 38

What are the risks of pulp infections

Answer 38

Distal phalanx destruction