H&W Flashcards
Indications for Hemi-Resection arthroplasty (DRUJ arthrosis)
Painful DRUJ Instability<div>DRUJ contracture<br></br><div>OA DRUJ</div><div>RA DRUJ</div><div>Ulnocarpal Impaction</div></div>
Compression Sites for RTS?
Arcade of Froshe (entrance to sup)<div>Fibrous band at distal supinator</div><div>ECRB border</div><div>RC joint</div><div>Leash of henry (Radial Recurrent artery)</div>
Indications for scaphoid OR
Displacement >1mm<div>Comminution/Bone Loss</div><div>Perilunate</div><div>RL>15 (DISI)</div><div>Lateral interscaphoid >35 deg</div><div>Proximal Pole</div><div><br></br></div>
RFs for Scaphoid Nonunion
Proximal Pole fractures<div>Displacement > 1mm</div><div>Humpback Deformity</div><div>Delay in treatment > 4 weeks</div><div>Height to length ratio > 0.65<br></br></div>
Stages of Mayfield Classification
1- disruption of SL ligament complex<div>2 - disrution of LC complex</div><div>3 - disruption of LT complex (carpus separates from lunate; falls dorsally)</div><div>4 - lunate dislocates from radial fossa (volar extrinsic ligaments intact)</div>
“X-ray Findings in Madelung’s”
narrow physis on ulnar side of DR<div>increased radial inclination, lunate fossa angle</div><div>increased volar tilt</div><div>anterior bowing of distal radius</div><div>dorsal sublux ulnar head</div><div>ulnocarpal impaction signs</div>
DDx Lytic Lesion in the Hand
“infx/non-neo: OM, ABC, UBC, epidermal cyst (intraosseous)<div>benign: enchondroma, GCT, CB, OB</div><div>malignant: chondrosarc, ewing’s, lymphoma, OS</div>”
Non-op Mx of Carpal Tunnel
Brace/Splint - strong recommendation<div>Steroid (inj (strong)>oral (mod)>nothing)</div><div>Ketoprofen phonophoresis - moderate recommendation</div>
Compression sites for Median Nerve?
Supracondylar Ridge<div>Ligament of Struthers</div><div>Lacertus Fibrosus</div><div>PT (humeral head)</div><div>FDS arch</div><div>FPL</div><div>*AIN syndrome: motor weakness, no pain, neuritis</div>
Compression Sites Ulnar Nerve
“Arcade of Str<b><u>u</u></b>thers<div>Medial IM Septum</div><div>Medial Triceps</div><div>Cubital Tunnel (ME, Osbourne Lig)</div><div>FCU heads</div><div>Guyon’s canal</div>”
Principles of Tendon Transfers
<div>LOOSE CAST</div>
Donor<div> Minimize functional Loss</div><div> Normal strength (voluntary control)</div><div> One Tendon, One function</div><div>Together</div><div> Excursion</div><div> Vector of pull in line (only cross 1 joint)</div><div> In-phase tendons (synergistic)</div><div>Stable Soft tissue bed that allows gliding</div><div>Full passive ROM of joints</div><div><br></br></div>
Tendon Transfer for Median n. palsy
thumb IP flex (FPL): BR, ECRL or ECU<div>thumb opp (AbPB): EIP, FDS ring, PL</div><div>D2 DIP flex (FDP): ECRL</div>
Tendon Transfers for Radial n. Palsy
Wrist ext (45 deg): PT to ECRB<div>Finger ext (MCP ext): FCR to EDC</div><div>Thumb Ext: PL to EPL</div>
Order of Neurologic Fxn Return after peripheral nerve injury?
SPTTPM<div>Sympathetic</div><div>Pain</div><div>Temp</div><div>Touch - light</div><div>Proprioception</div><div>Motor</div>
Pathophys of Boutonierre Deformity
“Central slip disruption at PIP (and triangular ligament)<div>->PIP flexion->volar subluxation of lateral bands–> migrate proximally –> tension on terminal tendon –> DIP hyperextension</div><div><img></img><br></br></div><div> <div> <div><img></img><br></br></div> </div></div>”
Etiologies of Swan Neck in RA?
Extrinsic<div> Mallet - disruption of terminal tendon</div><div> Wrist or MP flexion contraction</div><div>Intrinsic</div><div> Instrinsic mm contracture</div><div> Chronic MP volar subluxation</div><div> Tendon adhesion</div><div>Articular</div><div> Volar plat/capsule injury (hyperextension)</div><div> Disruption of FDS</div>
Bunnell Test?
For Intrinsic Tightness; positive if: inability to flex PIP with MCP in extension<div><br></br></div><div>basically - cant CLAW (Which is extrinsic tightness)</div>
Lichtman Classification for Kienbock
“(1) Normal X-ray; MR has changes –> immob/NSAIDS<div>(2) lunate sclerosis; joint leveling surgery</div><div>(3A) lunate collapse</div><div>(3B) lunate collapse + capitate migration and scaphoid rotation (DISI)–> PRC</div><div>(4) Degenerative intercarpal joints -> wrist fusion</div><div><br></br></div><div><img></img><br></br></div>”
Bennet Fracture Reduction?
“Traction<div>Abduction (NOT adduction)</div><div>Extension</div><div>Pronation</div><div><br></br></div><div><br></br></div><div>‘peta’</div><div><br></br></div>”
Treatment options for Dorsal PIP dislocation?
“<div><div> <div> <div><img></img></div> </div></div></div>Stable - buddy tapping<div>Tenuous - ie requires 30 deg of flexion post reduction for stability</div><div>Unstable</div><div>-extension block splinting</div><div>-CRPP</div><div>-ORIF</div><div>-dynamic ex fix</div><div>-Volar plate arthroplasty (transosseous fixation)</div><div><b>-hemi-hamate reconstruction arthroplasty (for >50% of articular surface involvement)</b></div>”
Block to reduction of VOLAR PIP dislocation?
Lateral Bands<div>Central Slip</div>
Acceptable reduction parameters for MC #s?
<div><ul><li>NO Malrotation (RC EXAM)</li> <li> <div> <div></div> <div>Shaft (Deg)</div> <div>Neck (deg)</div> <div>Shaft shortening (mm)</div> <div>D2</div> <div>10</div> <div>20</div> <div>3-5</div> <div>D3</div> <div>20</div> <div>30</div> <div>3-5</div> <div>D4</div> <div>30</div> <div>40</div> <div>3-5</div> <div>D5</div> <div>40</div> <div>50</div> <div>3-5</div> </div> </li></ul></div>
“associations with etiology of Dupuytren’s”
Family Hx<div>Northern European descent</div><div>Smoking hx</div><div>EtOH abuse</div><div>Diabetes</div><div>Epileptic medication</div><div>Manual labour <div></div> <div>Less solid answers:</div> Adhesive capsulitis</div><div>Vibration exposure</div><div>?male gender</div><div>hx of peyronies disease<br></br></div>
RA patient unable to extend D4/D5… DDx?
Ext tendon rupture (Vaughan-Jackson)<div>Sagittal band rupture</div><div>Volar MCP dislocation</div><div>PIN Palsy (at RC joint)</div><div>Cervical myelopathy</div>
- Anatomic Zones:
- Distal to insertion of FDS, injury only to FDP
- FDS insertion to A1 pulley (""no man's land"")
- Carpal tunnel to A1 pulley
- Origin of lumbricals from FDP tendon
- Carpal Tunnel
- Tendinous Portion of Forearm
- Inflammatory (0-5 days)
- Blood clot and granulation, macrophages and fibroblasts remodel ECM
- Strength from sutures
- Proliferative/Collagen (1-6 weeks)
- Proliferation of fibroblasts
- Rapid synthesis of type 1 collage from epitenon
- Repair weakest at 10-15 days
- 40% final strength at 4 weeks
- Improvement in strength of tendon doesn't begin until week 3
- Remodeling (up to 1 year)
- Longitudinal orientation of collagen along tension lines
- Normal tendon fibres by 9 months
- Most reliable maneuver for diagnosis of Boutonierre
- Technique
- Flex PIP to 90°
- Extend PIP against resistance
- If central slip intact the DIP will remain supple
- If ruptured DIP will be rigid
-
- supple skin
- sensate digit
- adequate vascularity
- full PROM
- failed primary repair
- chronic
- often 2 staged
- Stage I
- Hunter rod inserted and sutured distally
- A2 and 4 pulleys often reconstructed
- Stage II
- Performed 3 months later
- Rod removed
- Tendon autograft is passed through sheath
- Extrasynovial grafts
- Palmaris
- Plantaris
- Intrasynovial grafts
- FDS
- Retain gliding surface
- Heal intrinsically
- Complications
- 50% tenolysis
- MC head buttoned holed
- Flexor tendons ulnar
- Lumbricals radial
- Natatory ligaments dorsal
- Superficial transverse metacarpal displaced proximal
- Juxta-epiphyseal injuries to the distal phalanx with nail bed laceration
- Crush injuries
- Technically an open fracture
- Typically the distal phalanx in a flexed posture (disconnected terminal tendon)
- Often mistaken for a mallet finger
- But physis weaker than the bone
- Management:
- Closed injuries -> Closed reduction and splint
- Due to difficulty with compliance often do operative management
- Operative:
- Nail plate removed
- Small oblique incision at junction of paronychial and eponychial folds to expose nail bed laceration
- Remove soft tissue from fracture site
- Can lead to physeal arrest if left
- Extend finger to reduce fracture
- Pin with K-wire across DIP joint
- Repair nail bed laceration with 6-0 or 7-0 sutures
- Re-approximate nail
- Parentral antibiotics x 5-7 days (seems like a lot!)
- Indications:
- Loss of a thumb
- Multiple digit amputations
- Amputations at or proximal to the palm (RC EXAM)
- Pediatric finger amputations
- Single digit zone I (Flexor tendon zones)
- Relative Contra-indications:
- Single digit amputations through zone II
- Severe crush
- Mangling
- Segmental amputation
- Heavy contamination
- Prolonged warm ischemia time
- Medically unsuitable
- Amputation of single border digit
- Poor prognosticators:
- ""red line sign"" --> red stripe at mid lateral aspect of avulsed digit = hemorrhage along vessel
- ""Ribbon Sign"" --> tortuous spiraled blood vessels seen = significant intimal injury
- Warm ischemia time should not exceed 12 hours for digits and 6 hours for amputated parts with substantial muscle
- Cold ischemia time 24 hours for digits and 10-12 hours for limbs
- De Quervain tenosynovitis
- FCR tendinitis
- Scaphoid pathology
- STT arthritis
- RC arthritis
- Thumb MCP arthritis
- Nerve Conduction Studies:
- Useful for focal compressive lesions
- Latency
- Demyelination --> slower latency, slower velocity, amplitude is the same
- Velocity:
- Time with respect to the distance
- Amplitude:
- Strength of response
- Decreased with axonal loss
- Imbalance between spastic intrinsics (interossei/lumbricals) and weak extrinsics (RDS, FDP, EDC)
- Characterized by MCP flexion and DIP/PIP extension
- Causes
- Trauma: compartment syndrome
- RA: MCP dislocations/ulnar deviation leads to spastic intrinsics
- Neuro: TBI, CP, CVA, Parkinson's
- Exam
- Weak grip
- + Bunnell sign: extend MCP and PIP is tight
- Tx
- Proximal muscle slide: subperiosteal elevation of interossei lengthens muscle unit
- Distal intrinsic release (distla to MCP)
- Imbalance between strong extrinsics and deficient intrinsics
- Characterized by: MCP hyperextension and DIP/PIP flexion
- Causes
- Ulnar nerve palsy: cubital tunnel, ulnar tunnel
- Median Nerve palsy: Volkmann ischemic contracture
- CMT
- Hand Compartment Syndrome
- Exam
- MCP hyperextension and IP joint flexion
- Bring MCP joint out of hyperextension--> flexion deformity of DIP/PIP will correct (RC EXAM)
- Tx
- Contracture release and passive tenodesis vs active tendon transfer
- Goal is to prevent MCP joint hyperextension
- Mobile with tendon sheaths:
- Ganglion of tendon sheath
- Giant cell tumor of tendon sheath
- Tenosynovitis of inflammatory or infectious origin
- Extensor digitorum brevis manus muscle belly
- Firm
- proximal pole of scaphoid (dorsal in DISI, volar in VISI)
- Osteophytes from STT arthritis
- CMC arthritis
- Venous aneurysm
- Lipoma
- Neuroma
- Harmatoma
- Sarcoma
- Repairable tears can be done all inside, inside out, or outside in
- Must have a bone tunnel or suture anchor
- Peripheral tears have improved blood supply and are potentially repairable
- Ulnar tears most amenable to arthroscopic repair
- Central tears, volardistal, and radial often debrided
- Safe to debride 2/3 of TFCC without compromising stability
- Resection Arthroplasty (Trapeziectomy)+/- LRTI:
- Current gold standard
- Can be combined with ligamentous reconstruction
- Options for tendon: APL/portion of FCR/PL
- Gerwin:
- 20 patients randomized to resection vs interposition
- No difference at 23 months
- Kriegs-Au:
- No difference between resection alone and interposition
- Wajon Cochrane review:
- Simple trapeziectomy had lowest complication rate and best pain relief
- MCP hyperextension deformity
- treatment depends on degree of hyperextension
- <10° - no surgical intervention
- 10-20° - percutaneous pinning of MCP in 25-35° flexion x 4wk ± EPB tendon transfer
- 20-40° - volar capsulodesis or sesamoidesis
- >40° - MCP fusion (20 flex, 20 abd, 20 pro)
- Pre-existing ulnar nerve symptoms
- If contracture > 90o then likely needs release
- if > 50 deg increase in ROM
- ulnar palmer and dorsum of the hand are spared in ulnar syndrome
- palmar cutaneous and dorsal cutaneous branches of the ulnar nerve branch off before it enters the ulnar tunnel at the wrist
- strength preserved in the FCU and the FDP of the ring and little fingers
- increased claw hand deformity
- FDP preservation increase deformity
- RTS: Same as PIN compression sites but only causes pain with no motor/sensory dysfunction
- PIN syndrome: pain in forearm and wrist with WEAKNESS
- Wartenberg's syndrome: compression of SRN (between BR and ECRL during forearm pronation) leading to PAIN and NUMBNESS
- Proximal 1/3 non-union without significant humpback
- 1,2 ICSRA (intercompartmental supraretinacular artery)
- Origin: radial artery, 5cm proximal to RC joint
- Advantages: single approach
- Disadvantages: unable to correct humpback, vulnerable to kinking
- Capsule based (4th extensor compartmental artery)
- Advantages: simple harvesting technique, short arc of rotation and low risk of kinking
- Disadvantage: cannot correct humpback, violates dorsal RC and intercarpal ligaments
- Alternatives: 2,3 ICRSA, MFC or iliac crest
- With humpback
- Volar radius VBG
- Origin: radial carpal artery
- Single incision, preserves dorsal blood supply, simultaneous correction of humpback deformity, may preserve wrist flexion
- Alternative: free VBG
