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Hand Flashcards

1
Q

TFCC components

A
  1. Triangular fibrocartilage proper (articular disc) 2. Ulnocarpal meniscus homologue 3. Dorsal and volar radioulnar ligs 4. Floor of ECU tendon sheath 5. Volar ulnocarpal ligs
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2
Q

Replant order of operations

A

B- bone E- extensors F- flexors A- artery V- vein N- nerve S- skin

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3
Q

Indication for replant

A

Absolutes: Thumb multiple digits amputation at wrist level or proximal any amp in a kid Relative: zone 1 (distal to FDS insertion)

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4
Q

Lumbrical plus finger

A

Paradoxical extension w/ attempted finger flexion

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5
Q

Intersection syndrome

A

At the intersection of compartment 1 (APL and EPB) and compartment 2 (ECRL and ECRB)

Radial sided wrist pain

crepitus

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6
Q

Boutonniere

A

PIP flexion and DIP extension

Pathophys: 1. rupture of central slip

  1. attenuation of triangular ligament- lumbricals become flexors at PIP and extensor at DIP
  2. Palmar migration of collateral bands and lateral bands

Tx: Acute (<4 weeks) injuries- 6 weeks PIP extension splint

1o repair

Lateral band relocation

terminal tendon tenotomy (modified Fowler or Dolphin)

tendon (triangular ligament) reconstruction

PIP fusion- RA or arthritic joints

https://www.orthobullets.com/hand/6012/boutonniere-deformity

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7
Q

Finger extensor mechanism

A
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8
Q

Steps to release PIP flexion contracture

A

Check progress of passive extension prior to proceeding to next step. Extensor tenolysis if there is no active extension

  1. takedown flexor pulley and retract flexor tendon
  2. release check rein ligament
  3. accessory collateral ligament and volar plate
  4. proper collateral ligament released off proximal phalanx
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9
Q

Swan neck

A

PIP hyperextension and DIP flexion

Pathophys- 1o deformity= lax volar plate

2o = extensor force > flexor

Causes= RA (volar MCP subluxation), chronic mallet (DIP extensor force transfers to PIP), FDS laceration (unopposed PIP extension), intrinsic contracture (tethering of lateral bands by transverse retinacular lig)

Tx: double ring splint

Volar plate advancement +/- FDS tenodesis (if ruptured), SORL recon, Fowler tenotomy

https://www.orthobullets.com/hand/6013/swan-neck-deformity

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10
Q

preaxial polydactlyly (Thumb duplication)

A

M> F

White ppl

Tx:

  • Type 1 combination procedure (Bilhaut-Cloquet removing central portions of bone and combining the two thumbs to make one digit)
    • Types 1-3 deformities
    • 20% late deformity
  • Type 2 combo procedure- use soft tissue from lesser digit to augment thumb that you’re keeping
    • radial digit usually sacrificed
    • types 3 & 4
  • Type 3 combo procedure (segmental distal transfer “On-top plasty”)- when one digit has better proximal components and the other has better distal components
    • types 5-7

https://www.orthobullets.com/hand/6079/polydactyly-of-hand

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11
Q

postaxial polydactylyl (duplication of small finger)

A

Blacks > white

Classification

  • Type A- well-formed digit- type 2 recon procedure (using soft tissue of lesser digit to augment primary digit); keep radial digit usually
  • Type B- skin tag- tie-off in nursery or amputate < 1 yo
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12
Q

Central polydactyly

A

associated w/ syndactyly

can cause angular deformity: osteotomy and lig recon early to prevent angular deformity

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13
Q

intrinsic vs extrinsic tightness

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14
Q

PIN syndrome

A

lose of extensor function except ECRL (radial n proper); intact sensation and no pain

Lipoma= most common cause

Sites of compression (LEAFS):

  1. vascular Leash of Henry
  2. ECRB
  3. Arcade of Froshe
  4. Fascial band over radial head
  5. Distal end of supinator

Debridement after 3 mo of non-op

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15
Q

cubital tunnel

A
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16
Q

Claw hand vs ape hand vs sign of benediction

A

https://www.youtube.com/watch?v=0AAligXLJ1A&list=TLPQMDkwNzIwMjHFAjc0h4SsRg&index=2

Claw hand (uln n injury) with loss of hand intrinsic leading to EDC4,5 unable to oppose flexors.

  1. Low uln n injury: Passive position of digs 4 & 5 = MCP, PIP and DIP flexion.
    1. loss of lumbricals and interossei w/ FDS & FDP intact
  2. High uln n injury: Passive position of digs 4& 5= MCP, PIP flexion and DIP loose flexion
    1. Loss of FDP4,5 and loss of intrinsics= balanced loss between extensors and flexors at DIP

Ape hand (med n injury)- unopposed adductor pol pulls the thumb dorsally into the same plane as the rest of the fingers.

Sign of benediction (high med n injury)- happens with attempt to make a fist (active). Digits 4&5 flex, but unable to flex other digits

17
Q

Double Oberlin n transfer

A

Brachial plexus injury

FCU (uln.) + FDS/ FCR( med) = biceps and brachialis to restore elbow flexion

18
Q

High uln n. injury

A

AIN- uln n

Pronator quad (AIN) to uln n. to restore intrinsic function

19
Q

High rad n injury

A

FDS/FCR= PIN/ ECRB

20
Q

Nerve root avulsion treatment

A
  • Neuroma excision & grafting of intercostal n.
  • Transfers
    • Spinal accessory ⇒ Suprascap
    • Oberlin: FCU ⇒ biceps
    • rad branch to triceps ⇒ Ax n. (restore shoulder ER)
  • Tendon transfers- lower 1/3rd traps for shoulder ER
  • Free gracilis transfer
  • Forequarter amputation if complete plexus (C5-T1) avulsed
21
Q

Tendon Transfer principles

A
  • Excursion (amplitude)= fiber length
    • Smith 3-5-7 rule=
      • 3 cm excursion of wrist flexors/ extensors
      • 5 cm MCP extensors
      • 7 cm FDP
  • Line of pull should be same
  • Force (Strength)= proportional to cross-sectional area
  • Functional (no prior reinnervation or tendon repair)
  • Expendable or function less necessary that function that was lost
22
Q

Radial N tendon transfer sets

A
  • High rad n injury
    • Wrist ext = PT ⇒ ECRB
    • Finger ext = FDS, FCR, FCU ⇒ EDC
    • Thumb ext = FDS, FCR, PL ⇒ EPL
23
Q

Med n tendon transfers

A
  • Low (i.e. thenar atrophy from severe CTS)
    • Thumb opposition = Camitz procedure= PL ⇒ OP
    • Huber (for congenital thenar absence in kids) takes Abductor digit minimi and transfers to APB
  • High
    • FDP1-3, FPL
24
Q

Uln n tendon transfers

A
  • Pinch (+ froment sign)
    • ECRB (w/ PL tendon graft augment) ⇒ APB
    • FDS ⇒ APB
  • Claw (loss of intrinsic and lumbricals) (bouvier test)
    • Zancolli (lasso) (FDS looped around A1 pulley) to restore MCP flexion (i.e. Bouvier (-))
25
Q

Bouvier test

A
  • Bouvier (+)= able to extend PIP w/ the wrist held neutral and MCPs held in flexion
    • simple clawing (intact central slip)
    • Tx only needs to restore flexion at MCP (tendon graft inserted to prox phalanx, A1or 2)
  • Bouvier (-) = unable to extend the PIP
    • complex clawing (disrupted central slip)
    • tendon grafts inserted into radial lateral band to restore MCP flexion and PIP ext

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