Hand Flashcards
(326 cards)
1
Q
PIP joint OA treatment
A
central fingers with no deformity get arthroplasty; border (index/ring) get fusion - create a cascade with more flexion at pinky PIP 30 to 45 in 5deg increments
2
Q
tx of a flexible swan neck
A
PIP splinting to prevent hyperextension
3
Q
nerve grafting based on trunk
A
upper and middle trunk do better; lower trunk generall better with transfers - this is bc of the distance from nerve to muscle
4
Q
tendon nutrition in watershed area
A
over proximal phalanx via syovial fluid diffusion - called imbibition
5
Q
consequence of exicsion of distal scaphoid pole in carpal instability
A
can lead to non-dissociative carpal instability
6
Q
what is risk of 6U portal
A
high risk of injury to dorsal sensory branch of ulnar nerve
7
Q
tx of coller button interwebspace abscess
A
dorsal and palmar incisions that do NOT cross the webspace
8
Q
if PIP or DIP stays extended with passive wrist flexion then
A
there is a flexor tendon injury/discontinuity
9
Q
bowstringing in thumb caused by
A
incompetent oblique pulley - equivalent to A2 pulley
10
Q
Wasse and Flatt classificaiton applies to
A
PRE-axial (thumb) polydactyly; IV and II are most common
11
Q
ulnar vs radial perfusion to hand
A
ulnar is dominant perfusion in most patients
12
Q
radial digital nerve to thumb course
A
branch of median nerve that crosses the A1 pulley ulnar to radial
13
Q
what is clinodactyly and 2 types
A
radioulnar deviation during development of fingers; usually 5th finger; simple is bony, complex is bony+ soft tissue; uncomplicated 15-45 deg; and complicated > 45deg
14
Q
clinodactyly
A
angular deformity; usually only cosmetic; generally does not respond to splinting; 15-45 is uncomplicated; 45+ rotation is complicated
15
Q
warm ischemia time limit
A
6 hrs if large amounts of muscle; 12 hrs if NO muscle
16
Q
what causes Wartenberg sign
A
overpull of extensor digiti minimi
17
Q
radial artery course at wrist and palm
A
cross over FCR and into thenar compartment to make the superficial palmar arch; deep branch passes DEEP to APL/EPB and splits head of 1st Dorsal interosseous splits into princeps policis and branch to deep arch
18
Q
flexor tenosynovitis w.out improvement
A
if no change in 24-48 hrs repeat the I&D with extensile incision
19
Q
tendon transfer for high radial nerve injury
A
use pronator terres to ERCB; palmaris longus to EPL; variable transfer to EDC
20
Q
high vs low median nerve injury
A
high has insensate to the palm; high knocks out all Flexors except ulnar FDP and FCU; low median n injury only knocks out thumb opposition
21
Q
first step for suspected guyon canal syndrome
A
EMG - not a CT scan or ultrasound to look for pathology. First need to confirm it_s a LOW ulnar nerve problem
22
Q
3 zones of guyon canal - zone 1
A
1 - at proximal edge of volar carpal ligament and ends at nerve burfication (1cm distal to pisiform); ulnar artery bifurcates DISTAL to the ulnar nerve
23
Q
best prognosis of birth plexus injury
A
return of biceps by 2 months; if after 5 months then incomplete recover
24
Q
scapholunate ligament - strongest part
A
C-shaped on sagittal view, DORSAL third is the strongest part
25
structure at risk during peds trigger thumb release
radial digital nerve
26
max distance for nerve conduit
3cm
27
what tendon makes up the palmar aponeurosis
palmaris longus
28
low vs high ulnar injury - which has worse clawing
low has worse clawing bc FDP is preserved to ring and little fingers
29
superifical raidal nerve is how far from styloid
7cm proximal to radial styloid on ulnar side of PIN
30
tendon adhesions risk factors after repair
gap > 3mm, surgery, crush injury, immobilization
31
lumbrical anatomy
lumbrical 1 and 2 are innervated by median nerve an unipennate; 3-4 are bipennate and ulnar nerve
32
PIP arthroplasty criteria
must have good bone stock and sensibility of the joint; normal functioning tendons, if collaterals are out then use silicone; otherwise can use surface
33
lumbrical plius finger is
paradoxical extension of PIP and DIP due to flexor disruption; tx is release of lumbrical tendon. - can be caused by a long FDP graft
34
tx for fifth MC fracture
if comminuted and articular - ORIF
35
STT OA treated with
STT fusion if trapeziometacarpal is NOT involved; if metacarpal is inovlved then CMC arthoplasty or trapeziectomy
36
SSEP and pre-post ganglionic lesions
absent in post or combo pre/post lesions
37
acid vs alkali burns
acid is via liquefaction necrosis; alkali burns more subtle initially but penetrate deeper and saponification of adispose
38
where do the thenar muscles originate
Abductor, Flexor Policis and Opponens policis all start on the transverse carpal ligament - the ADDuctor - starts LONG/middle finger MCP
39
types of nerve transfers
intra and extra plexal; intral includes phrenic and parts of median or ulnar; extra plexal include intercostals, contralateral C7 and hypoglossal
40
long thoracic is made up of which roots
C5-6-7
41
adv of full thickness skin graft
includes sweat, hair, and nerve endings - better sesnation and more durable so less contraction
42
best conditions for tenolysis
local tendon adhesions, no contractures, full PROM; motivated
43
MCP collateral ligaments are most taught at what position
MCP flexion at 90
44
3 zones of guyon canal - zone 2
between palmaris brevis fascia and pisohamate/pisometacarpal ligaments - deep motor branch hooks around the hamate
45
which ligament stays connected in perilunate dislocation
SHORT radiolunate
46
mannerfelt lesion
FPL rupture due to bony prominence of scaphoid rubbing on tendon
47
STAGE 2 SLAC defined by
arthritis of entire radioscaphoid joint - radioLUNATE is spared
48
wassel IV is
doubel proximal and distal thumb phalanx
49
FDS rupture in RhA - tx
observation
50
2 rows of carpal bones
proximal contains the scaphoid, lunate, triquetrum, pisiform; distal is capitate, hammate, trapezoid; trapezium
51
transfers for LOW radial nerve injury
same as brand minus those for ERCB - wrist extension is preserved
52
course of palmar cutaneous branch of median nerve
exits median nerve 5cm proximal to wrist crease; runs in FCR /palmaris longus interval and goes superifical to carpal tunnel to supply sensation to thenar eminence
53
martin gruber connection
connection between median/ulnar nerve proximal to AIN branch or within FDP (15% of people)
54
1st step in scaphoid non-union diagnosis
CT through scaphoid axis
55
froment sign
ulnar nerve injury causing except thumb IP flexion for pinch
56
what is effect of delayed, >6mons nerve repai
decreases number of regenerating axons and their response to growth factors
57
tx of scaphoid non union with humpback
MFC graft and fixation
58
tx of severe wrist-finger contracture
PRC with wrist fusion
59
tx of boutoneiire
splint for 1st step; then 2nd line is recon of extensor/central slip; 3rd line is generally PIP fusion/arthroplasty if rigid
60
SNAP testing in pre-vs post-ganglioninc injury
in PRE ganglionic injury patient may be INSESNATE but show a NORMAL SNAP with absent motot
61
where is 3-4 portal
1cm distal to listers
62
order of innervation for PIN
ECU is FIRST to return, EIP is LAST
63
2nd line tx of swan neck
FDS tenodessis, and fowler central slip tenotomy to reduce PIP hyperextension +/- intrinsic release
64
Dorsal interossei muscle belleies
SUPERFICIAL belly goes UNDER sagittal hood to ABDUCT; DEEP belly goes OVER the sagittal band and helps extend MCP
65
lunula
white portion of proximal nail
66
Riche-cannieu connection
connection between median/ulnar nerve in FPB - 50-77% of people
67
high chance of what with hemidiaphragm paralysis
C5 nerve root avulsion
68
loss of finger extension in RhA Differential
Sagital band rupture, extensori tendon rupture, PIN palsy due to elbow synovitis, or MCP flexion contracture;
69
concern for gout and infection what next
start abx and get Cx as first next step
70
most common pattern fo supraclavicular BPI
all roots avulsed - up to 75-80% of traumatic BPI
71
FCR tendonitiis is a/w
Scaphotrapezial OA
72
stage 3 SLAC tx
Fourc corner fusion; then PRC; total wrist fusion
73
FCR in LRTI resotres which ligament
the intermetacarpal ligament
74
spiral bands relationship to NV bundler
it is DORSAL to NV bundle and inserts on lateral digital sheet
75
denervation changes in EMG are seen when
as early as 10-14 days in proximal musclce; and 4-6 weeks in distal - look for fibrillations and sharp waves
76
axonotmesis and wallerian degen
DOES occur on the part NOT connected to the cell body
77
brachial artery and median nerve anatomy
brachial Aa is LATERAL to medial nerve at elbow/antecubital fossa
78
after burn care what position to splint hand
splint in intrinsic plus to AVOID intrinsic minus
79
thoracodorsal comes off which cord
POSTERIOR cord
80
VISI vs DISI
SL is strong dorsally so if its out you get DISI; LT is strong volarly so if its out you get VISI
81
what stimulates tendong fibroblasts
platelet-derived GF stimulates fibroblasts to proliferate and make collagen I
82
pre-axial polydactyly
thumb side; more common in white; generally SPORADIC
83
weakest link at tendon repair is
suture KNOT
84
vascular supply of the hypogastric aa flap
superficial inferior epigastric artery
85
MSC nerve gets contributions from which roots
C5-7
86
nerve action potentials positivs vs negative
negative indicates neuropraxia; positive indicates axonotmesis (good recovery)
87
which is more pain full - pre or post ganglioninc
pre ganglionic is more painful with more dysesthesias etc
88
central cord vs spiral cord in Dupuytrens
central cord does NOT involve NV bundle and causes MCP contracture; spiral cord is PIP contracture and will merge with grayson lig
89
why does raidal nn injury above elbow lead to weak grip
secondary to lost wrist extension
90
tendon transfer for high radial nn injury
pronator terres to ERCB, Palmaris longus to EPL; and FCR to EDC
91
characterisitic of radial longitutidinal deficiency
thumb aplasia or hypoplasia; elbow contracture and radial deviation of hand
92
tx of radial longitudinal deficiency
stretch the radial soft tissue with casting then centralize ulna with ring MC or index MC
93
typical nerve transfers for C5-6 injuries
spinal accessory to suprascapular; triceps branch of radial to axillary and ulner nerve fasical to help biceps
94
most common congential hand difference
syndactyly
95
paronychium
lateral nail fold
96
radial nerve injury timing of tendon transfers
can do early within a week with single extensor to behave as a splint; delayed is generally performed at 6-18months
97
steroid for lateral epicondylitis - outcomes
better relief at 6 weeks; but increased persistent pain at 1 year
98
best case for nerve conduit
sensory nerve with gap < 10mm
99
what transfer for axillary n injury
use triceps branch of radial nn to axillary (leechavengvang transfer)
100
most common extra articular manifestation of RhA
subQ nodules
101
pediatri trigger finger treatment
relase of A1 and partial A2, A3 release AND release of 1 slip of FDS
102
with ulnar drift without MCP disease what is the soft tissue recon
address the extensor subluxation; collateral ligament laxity; synovitis, and volar plate disruption
103
lumbicals start and insert WHERE
start on FDP and insert on RADIAl side of extensor apparatus
104
what is assoc with failure of inject DeQ
EPB subsheaths
105
opponens digit minimi role
supinates litter finger MCP to allow thumb opposition
106
FDP rupture in RhA
fusion of DIP
107
PRC vs 4 Corner
PRC disadvantages - lost wrist ROM and grip strength; AVOID if capitate head has degen; 4 Corner - lunate; capitate; hamate; triquetrum - keeps 60% of motion; 80% grip strength
108
intrinsic vs extrinsinc tendon healing
intrinsic is from within tendon and predominates with early motion; extrinsic is from tendon sheath and predominates with immobilization
109
tx for stage 3b keinboch
PRC; preserves grip strength and motion.
110
in RhA - tx of FPL rupture
if advanced disease just do IP fusion; otherwise FDS transfer or graft with spur resection
111
principles of distal forearm or wrist replant
bone shortening to allow tension free anastomosis; repair ALL cutaneous sensory branches
112
thumb hypoplasia epidemiology
bilateral and M=F incidence
113
median nn route into forearm
through sup, and deep heads of pronator terres
114
max time to mobilize after collagenase for duputrens
up to 7 days; best time is 24-48hrs
115
median ulnar interconnections called
martin-gruber in forearm; riche cannieu in hand. Motor interconnections from median to ulnar
116
thumb hypoplasia classification
Buck -Gramcko - 1 is smaller but normal; 2 is skinny phalanx and small with variable thena muscles and CMC instability; III is missing proximal metacarpal and thenars; IV is a floating/thumb nubbin; V is most common - absent thumb
117
tx of raynaud vasospasm
ca channel blocker, then botox A injection
118
what nerve is at risk with 3-4 portal
Sup radial sensory nn about 16mm away
119
extrinsic wrist ligaments whats stronger
VOLAR
120
stennar lesion
thumb ucl tears and flips outside the joint and lays on TOP of the adductor apponeurosis- needs surgery will not heal on its own
121
what is pathologic widening on SL gap
> 3mm; if a NON-stress xray its automaticlally static unstable or DISI
122
tx of lupus in hadn
spinting and MCP soft tissue treatments have HIGH failure rates; generally arthroplasty or fusion for MCP; and fusion of PIP/DIP
123
lowest revision rate for PIP arthroplasty
silicone volar approach is best; surface replacement dorsal is worst
124
minimum nerv graft length
10% longer than the gap to avoid tension
125
surgery for herpetic whitlow
CONTRAindicated due to bacterial superinfection
126
epitendinous repair points
improves tendon contour, enhances repair strength, and reduces gap formation; running stitch has lower tensile strength than crossed stich or locked mattress
127
extensor tendon repairs
if > 50% then repair otherwise observe. Proximal injuries do better
128
x finger vs rev x finger flap
rev is the adipofascial tissue used to cover the DORSAL aspect of adjacent finger. X-finger is for the volar side only
129
most common carpal coalition
lunotriquetral - most common in blacks; usually Asx
130
macrodactyly epidemiology
typically UNIlateral; radial digits
131
if you lose wrist extension you also lose
grip strength
132
main fragment in bennet fracture
volar ulnar fragment attached to ant oblique ligament; APL and Adductor Policis pulls the thumb MC dorsal-radial
133
tx of Stage 2 SLAC
PRC vs 4 Corner Fusion, (other options include radioscapholunate fusion; total wrist fusion, total wrist arthroplasty)
134
where is the parona space
between the FDP and pronantor quadratus fascia - facilitates communication between radial and ulnar fascia
135
kleinert vs duran rehab
both are low force low excursion - Kleiner uses dorsal blocking splint with wrist at 45 flexion and elastic bands from fingers to palm.
136
anconeus innervated by
radial nerve; NOT PIN
137
marjolin ulcer is what type of CA
squamous cell ca
138
contribution to wrist motion radiocarpal vs midcarpal
Wrist flexion - 60% is midcarpal, 40% is radiocarpal; Wrist Extension 33% of motion is midcarpal; 66% is via radiocarpal
139
nerve transfer for shoulder abduction and Ext rot
use spinal acessory and transfer to suprascapular nerve in nerve transfer
140
EIP anatomy
runs MOST distal muscle belly; the tendon of EIP is ULNAR to the EDC tendon for index
141
lumbrical plus deformity
due to excess intrinsic tightness leading to IP joint EXTENSION when attempting to perform IP flexion
142
how to recon a thumb with Wassel duplication
must preserve the radial componetns and ulnar components from either side and conjoin to the better developed digit
143
tx of AVN of capitate
if no collapse or arthritic change consider vascular bone graft; if collapse and capitate OA - the mid carpal fusion
144
post-axial polydactyly
pinky side; Auto Dominant and more common in African americans
145
volar plate anatomy
starts at A2 pully and inserts on P2 - prevents hyperextension
146
what percent of distal radius fractures lead to intercarpal instability
30% of DISPLACED and INTRAARTICULAR DR frx lead to this
147
in phase tendon transfers for hand-wrist
wrist extension, finger flexion and thumb adduction OR wrist flexion finger extension, thumb ABDuction
148
tx of advanced glenohumeral dysplasia from brachial plexus injury
external rotation humerus osteotomy
149
dx and tx of fanconi's
mitomycin C or diepoxybutane chromosome challenge - tx with bone marrow txp
150
pseudogout
ROD shaped, weakly positive birefringent crystals - calcium pyrophosphate
151
what axial flap is for elbow area
anconeus flap supplied by descending branch of profunda brachii
152
what percent of trigger thumb resolves spont.
30-65%
153
what motion is allowed in PIP extension splint
DIP flexion/extension to reduce gap in extensor tendon injury
154
tendon transfer for intrinsics in ulnar nn injury
use slips of FDS and suture to dorsal aspect of lateral bands
155
gout crystals
NEEDLE like; NEGATIVE birefringement monosodium crystals
156
transverse retinacular ligmaent role and location
runs at level of PIP and prevents DORSAL subluxation
157
what is natatory ligament and role
superficial fibers of transverse metacarpal ligament IN the WEBSPACE - prevents digital abduction
158
eponychium
dorsal nail fold - proximal to nail plate - adds shine to the nail
159
rehab protocols for fingers
passive protocols - low force, high excursion, Kleinert and Duran; early AROM - moderate force and high excursion (dorsal block splint); and synergistic motion - low force high excursion - uses acitve wrist extension and passive digit motion
160
DRUJ portal
1cm proximal to 4-5 radiocarpal portal
161
annular pulley of the thumb
A1 and obliqu are most important, A1 is at MCP; A2 is at the IP joint
162
scaphoid non union with humback deformity tx
free vascularized medial femoral condyle graft
163
warm perfused digits with blisters tx
if hand is perfused and warm; no reason for rewarming bath - surgical debridement of blsiters
164
ulnar nerve and FCU anatomy
the nerve is RADIAL to FCU
165
early AROM vs PROM motion protocols
similar rates of rerupture, more motion and less contractures with AROM
166
raynauds like sx but Ulnar only - what is dx
hypothenar hammer syndrome caused by ulnar artery thrombosis
167
what is terminal branch of MSC nerve
Lateral antebrachial cutaneous
168
ulnar ligaments of thumb - proper vs accessory
proper runs from the prox phalax to MCP head; accessory runs from MCP head to volar plate
169
what is oberlin transfer
using two fascicles of ulnar nerve to restore elbow flexion; can also augment with median nerve fasicle
170
CT myelography will show what in nerve root avulsion injury
pseudomyelomeninogcele at 3-4 weeks after injury
171
tendon transfer for low median nn injury
goal is to restore fxn of thumb opposition 4 ways - FDS, EIP, Abd Digit Minimi; or least valuable is a palmaris longus transfer
172
tx of PIP dupuytresn greater than 60
better to fuse
173
borders of guyons canal
hook of hamate radially, pisiform ulnar, sits on the TCL and motor branch dives into hypothenar aponeurosisi made by abductor digit minimi
174
which fingers is PIP silicone arthroplasty not ideal
active patient for index and long finger - high rate of failure
175
deforming forces on bennet frx
AbdPL, AddPB, EPL, EPB - all pull dorsal, radial and proximal
176
what is the course of the pretendinous band of the skin
travels superficial to transverse fibers of palmar aponeurosis - inserts skin at MCP - trifurcates into radial and ulnar spiral cords and a central band
177
cubita tunnel is exacerabted by what position
elbow flexion and shoulder abduction
178
epineural repair vs fascicle repair
neither is superior
179
first step for eval of ulnar vascular AVM
ultrasound doppler - then can proceed with angio
180
scaphoid pole frx tx
even if non-displaced treat with screw fixation - high rate of displacement and nonunion.
181
types of jersey finger
type 1 avulses off and retracts to palm, vascularity is disrupted and needs fixation in 7-10days; type 2 is to PIP and vinculum are intact; 3 is with bone piece - 2and 3 can be fixed in weeks
182
tx of raynauds with ulceration
start with topical nitrates which increase cGMP to vasodilate finger vessels
183
carpal instability timeline chronic
after 6 weeks its chronic
184
recurrent motor branch of median nerve supplies
ABDuctor policis brevis; FPB, and Opponens Policis
185
trigger finger more common in these conditions
RhA, DM, HypoThyroid, Sarcoid, Gout or pseudogout, amyloidosis
186
main stabilizers of thumb CMC joint
dorsal ligamentous complex - dorsoradial ligament and posterior oblique ligament; and the DEEP anterior oblique ligament
187
what must preserved in 4C fusion or PRC
Radioschaphocapitate ligament - otherwise will see ulnar translocation of carpus
188
radial bursa is located
at MCP joint and extends 1-2cm proximal to radial tranverse carpal ligament - continuous with FPL sheath
189
Flexor pollicis BREVIS innervation
dual innervation - superifical is median nerve; deep head is ulnar nerve
190
Dorsal intercarpal ligament is between
triquetrum and scapho/trapezoid/capitate
191
first dorsal wrist compartment
APL and EPB; APL usually has 2 slips
192
compartments of the hand
thenar, Adductor policis, hypothenar compartment, 4 dorsal, 3 volar interosseous compartments, and carpal tunnel
193
replant b/w DIP and PIP
generaly good outcomes
194
tendon transfer for high median nn injury
Brachioradialis to FPL; side to side suturing of FDP of index and long fingers to rest of the digits
195
last muscle innervated by radial nerve
EIP is the last muscle BUT; the last testable one is EPL
196
where do first and second dorsal compartments' tendons cross
approximately 7cm proximal to wrist
197
supply of free fibula flap
peroneal artery or branch of ant tib artery
198
holt-oran syndrome
radial longitudinal deficiency with cardiac structure issues - AV septal defects(TBX5 gene)
199
rigid swan neck deformity
if joint disease - fusion; if joint is preserved - dorsal capsule release; mobilize lateral band and release collaterals and extensor tenolysis
200
triagnular ligament role
prevents VOLAR subluxation of lateral bands at middle phalanx
201
common digital nerves of median nerve sit between
flexor tendons and superfiical palmar arch
202
how to identify EIP tendon in 4th compartment
has the most distal muscle belly
203
vascular supply of groin flap
superficial cicrumflex iliac artery, runs along the inguinal ligament
204
distal radius frx redisplacement was related to
initial dorsal angulation exceeding 20 degrees, dorsal comminution, extension into the radiocarpal joint, concomitant ulna fracture, and age older than 60 years
205
vascularity of medial gastroc flap
sural artery
206
what is the tendon transfer for C8-T1 injury
Brachioradialis to FPL; ECR to FDP; and EIP for Thump opposition
207
stages of SLAC
1 is Scapohoid and Radial styloid degenerate, 2 is entire Radioscaphoid; 3 is Radioscaphoid + capitolunate; 4 is pan carpal OA
208
grayson ligament
originates from flexor sheath runs volar to the NV bundle and is perpendicular to digital axis
209
superficial palmar arch and median nerve
its SUPERFICIAl to medial nerve
210
rewarming guidelines for frost bite
40-42 celsius (104-108F) for 30 min
211
6U vs 6R portals
on either sde of the Extensor Ulnar carpi tendon
212
main tendon transfer for HIGH median nn injury
brachioradialis to FPL; restore index FDP by side to side suturing of all finger FDP in distal forearm
213
SLAC wrist leads to limits in what motion
extension and radial deviation
214
Tx of RhA MCP Disease
if just ulnar drift with preserved MCP - soft tissue realignment; if developing disease then MCP arthroplasty; if THUMB MCP - then fusion; if Thumb MCP AND IP - arthroplasty
215
acute vs chronic paronychia
chronic general requires removal of nail plate and skin down to germinal matrix to clear. Routine oral Abx is not sufficient
216
syndactyly - where is most common
3rd web space; then 4 then 5
217
PIP collateral ligaments
tight throughout ROM; proper is from prox phalanx head to middle phalanx; accessory is onto the volar plate again
218
cause of failure for STSG and FTSG
hematoma or seroma
219
Annular pulleys 1- 5
1,3,5 start on the palmar plate of the MCP, PIP, and DIP; A2 and A4 are on the proximal and middle phalanx
220
intial tx of non-hemorrahgic blisters on fingers
LIMITED debridement and unroofing
221
what does apical endodermal ridge control
proximal to distal growth
222
ulnar nerve course in relation to UCL
runs OVER the UCL
223
aphalagia is
absence of phalanx - can use a non-vascular toe transfer before 12 -18 months or a vascularized to transfer
224
nerve grafting for upper trunk - why?
bc shortens the time to reinnverate shoulder before end plate changes
225
parital extensor lac repair
if MORE than 60% but still partial rupture - use a core suture
226
causes of VISI (LT disruption)
can be normal varient of liagmentous laxity; rheumatoid; volar RL ligament injury or also DIC injury
227
distal pole scaphoid excision is for
STT OA; failed STT fusion; scaphoid non-union
228
high vs low ulnar nerve injury- which has worse clawing
LOW has worse clawing
229
FDP muscle bellies of fingers
long, ring and samll have COMMON muscle bellies
230
how to test central slip injury
flex PIP to 90 and perform resisted extension of DIP - should cause DIP hyperextension - ELSON test
231
prioritis of tx for BPI
elbow flexion; shoulder stability; hand sensibility; Wrist extension/finger flexion; wrist flexion/finger extension and lastly intrinsics
232
capitate articulates with
MC 2-3-4 via 3 facets (index, long, ring)
233
TAR vs Fanconi's Anemia
both have radial dysplasia but TAR patients have low platelets at birth which eventually normalize; Fanconis have normal platelets which then become pancytopenic
234
contribution of vincula to motion
at PIP and DIP vincula can contribute 60-90%
235
most important factor for nerve recovery
AGE of patient
236
def of perionychium
area includes the nail, nailbed, and surrounding skin
237
ulnar nerve arrises from WHAT cord
Medial cord - c8-t1; sometimes c7
238
what position to cast DRUJ dislocation
PRONATION
239
1 vs 2 vs 3rd deg burns
1 is epidermis only and no blisters, 2 is dermis with regen potential and blisters nerves are INTACT so it hurts; 3rd deg is below nerves so actually not very painful
240
TFCC tear with ulnar positive
must do a shortening procedure, if < 2mm positive then wafer, if > 2mm positive than diaphysea shortening
241
suprascapular nerve comes off which trunk
SUPERIOR
242
spontaneous resolution of peds trigger thumb
30-60%
243
which tendon has separate subsheat in DeQ
EPB - 40% have separate sheath
244
vascular supply of the lat dorsi flap
thoracodorsal A, branch of the Subscapular artery
245
tx of campodactyly < 30 deg
passive stretching and splinting; good prognosis for kids under 3
246
neuropraxia and wallerian degen
DOES NOT OCCUR
247
tx of DRUJ OA
Darrach resection - down side is ulnar instability; distal ulna hemi resection with tendon interposition (Bowers) - preserves TFCC insertion); Ulnar head or DRUJ arthroplasty
248
palmaris longus is absent in
15% of unilateral wrist and 7% of bilateral wrists
249
are gender or diabetes rf for poor outcomes after CTR
NO - severity on Electrodiagnositc studies is however
250
fight bite bacterai
m/c is still staph and strep, but need to cover from GR- Eikinella
251
zone of polarizing activity (ZPA) modulated by
sonic hedgehog and controls radio-ulnar or A/P development
252
perilunate dislocaiton classifcation
mayfield stage 1-4; 1 is SL; 2 Capitolunate; 3 is LT; 4 is capitate pushes the lunate out into volar dislocation -short radiolunate remains intact
253
tx for supination deficit in CP or quadriplegia
prontator terres muscle transfer; if fixed pronation deformity may need to release the pronator quadratus
254
tx of multiple extensor tendon ruptures
use middle FDS as transfer and palmaris graft
255
Elson test
ability to extend PIP at 90 flexion - indicates central slip injury
256
SLAC stages
1 - SL pain, normal xray, positive watson; 2 - dynamic; incompetent or incomplete SL ligament - leads to positive stress xray; 3- - static- instability seen on NON_stress xray; 4 - DISI
257
what is arcade of Frosche
fibrous band of supinator that can pinch the PIN
258
Radioscapholunate fusion - how to reduce non union
excise the distal pole; also helps with flexion arc
259
how does SNAP (Sensonry Axn potential) help localize injury
they are INTACT in preganglioninc injury -but clinically are insensate
260
Lunotriquetral ligament - strongest part
Volar portion is the strongest
261
when to do nerve surgery
before 6months after 12 its better to do tendon transfers
262
order of hand joints OA prevalance
DIP; CMC, PIP, MCP; similar in men and women until menopause then more common in women
263
what position to fuse DIP in OA
10-20 deg of flexion
264
what is BRAND transfer
high radial nerve injury transfer - FCR to EDC, Pron Terres to ERCB, Palmaris to EPL
265
extensor tendon to germinal matrix distance
1.2 to 1.4mm
266
poland syndrome
syndactyly and chest wall abnormalities including absent pec major
267
intrinsic tightness leads to what motion
limited PIP flexion when MCP are extended; but returns to normal in MCP flexion
268
what percent of midde phalanx leads to PIP instability
20% is always stable, 60% is always unstable; in between needs a good exam
269
exensor zone injuries of 3,4,5,6
3 is over central slip; 4 is prox phalanx, 5 Is MCP joint and 6 is MCP shaft, 7 is wrist, 8 is distal forearm
270
in DeQuervains what tendon has extra slips
EPB
271
main stabilizers for pinch THUMB and INDEX
UCL for Thumb and RCL for Index
272
does dupuytrens affect transverse bands
no; they are perpedicular to pretenidnous cords and lie dorsal to this. The vasculartiy is DORSAL (or DEEP) to these transverse bands
273
flexor digiti minimi is absent in what percentage of hands
15-20%
274
cleland ligament
originates from phalanx - runs DORSAL to NV bundle
275
what part of TFCC has blood supply
peripheral volar, dorsal, ULNAR
276
complication of scaphoid pole excision in STT OA
DISI due to short scapohoid level arm
277
attrition of volar beak lig in thumb leads to
degen OA of thumb CMC joint
278
how much tfcc can you debride
up central two-thirds before compromising DRUJ instability
279
caput ulae syndrome
seen in RhA with ulnar disloction of carpus and ultimately radial deviation - tx with ECRL to ECU transfer
280
BEST replant outcomes
mid-distal forearm
281
what is end to side nerve transfer
donor nn is inserted into opened perineurium of receipient to accelerate regeneration
282
best view for dorsal screw penetration in Distal radius orif
flexed wrist tangential view
283
proximal phalanx replants
NO -lots of adhesions - zone 2 - contraindicated
284
scaphoid vascularity
proximal 70% is via dorsal radial artery; distal 30% Is via palmar
285
peds phalangeal NECK frx treatment
generally unstable; try closed reduction with pinning or perc reduction with open fixation
286
what does pseudomeningocele on CT myelo mean
PREganglionic injury- nerve root avulsion
287
common palmar digital arteries come from
supeificial palmar arch which is DISTAL to the deep palmar arch
288
motor supply of ulnar nerve
ring and little FDP, interossei, deep FPB, adductor aponeurosis, hypotenar musc.
289
symphalangism definition
failure to differentiate IP joints - usually ulnar
290
brown streak in nail bed needs
BIOPSY - can result In subungual melonoma
291
cuff surgeries for GH dysplasia from brachial plexus injury
selective release of pec major, subscap and coracobrachialis with lat dorsi and teres major transfers to help External rotation
292
first muscle innervated by radial nerve
brachioradialis in anterior compartment -early return of this can portend a early return to fxn in nerve injury cases
293
which muscles are key to testing for BPI
rhomboids and serratus - dorsal scapular nn and long thoracic - if normal then indicates a POST ganglionic injury
294
hyponychium
skin imemdiate distal and palmar to the nail - at jxn of sterile matrix and fingertip skin
295
downside of volar approach to MCP during dislocation
injury to nerves as they get pushed closer to skin
296
best fusion rate in fingers seen with
headless screws
297
tendon healing stages
first 7 days macrophage and fibroblasts migrate and eat debris; week 1-3 is proliferation of unorganized type 3 collagen and neovascularization and fibroblasts - still week; at week 3-12 strengthening begins
298
consequence of untreated volar dislocation with frx at PIP
Boutonierre - the central slip which attaches to dorsal middle phalanx will become incompetent resulting in volar sublux of lateral bands
299
cervical paraspinal EMG in POST-ganglionic injury
IS NORMAL
300
hand vascular arches
superficial arch is more distal and supplies ulnar digital artery as well as common digital arteries to middle and ring finger; deep arch gives of to thumb and index
301
which tfcc tear to repair
acute ulnar based is best
302
endo, peri, epineureum
endo is around nerve fibger; peri is around the fascicle; peripheral nerve is surrounded by EPIneurium
303
watson test for SL competnece
the wrist is moved to radial deviation and scaphoid should normally FLEX; if its OUT volarpressure from examiner will keep the scaphoid dorsally and painfully displaced - once pressure is discontinued it CLUNKS back in place and releives the pain
304
what part of A2 pulley is most important
distal 50% is most important
305
injury to vessel during Dupuytrens
if vasospasm from traction or extending the contracted digit then flex finger and warm saline + topical lidocaine; phentolamine can be given for prolonged vasospasm; if cut then needs primary repair
306
do ALL dupuyrens nodules become cords
no they appear earlier but do not necessarily progress
307
Bouvier test for PIP fxn
assesement of clawing - neutral wrist, MCP flexion and asses if PIP can actively extend - if they cannot then need to connect tendon to lateral band
308
why is isolated C8-T1 relatively contraindicated for BPI surgery
bc more predictable to do nerve or distal tendon transfers
309
tx of Swan Neck in CP
central slip tenotomy to balance extensor mechanism over PIP and DIP
310
nerve surgery vs tendon transfers
generally after 12 months tendon transfers are recommended; nerve surgery should be within 6 months
311
rate of EPL rupture with distal radius
5% at most
312
DIP arthroplasty vs arthrodesis
similar outcomes with pain and function but higher faiure with arthroplasty
313
causes of DISI or SL disruption
Kienbock, Radiolunate injury, Dorsal intercapral ligament injury; distal radius frx/nonunion
314
triquetrum articulations
distally hammate, radially with lunate, volarly with pisiform
315
what is best prognosis of brachial plexus birth injury
return of antigravity biceps by 2 months
316
3 zones of guyon canal - zone 3
include the sensory branch; remains superficial; innverates palmaris brevis and sensation to little finger and ulnar ring finger
317
visceral vs parietal paratenon
visceral lines the tendon; parietal lines the undersurface of the sheath
318
which tendon has multiple slips in DeQ
APL - has wide variability in insertions and slips
319
Parona's space,
lies bw the fascia of the pronator quadratus muscle and FDP conjoined tendon sheaths. Infection tracking through this space presents as a horseshoe abscess.
320
Wassel II is
Double distal phalanx
321
what collagenasse is used for Dupuytrens
clostridium histolyticum; low activity against collagen IV and has lowere recurrence at MCP vs PIP
322
optimal flexion for ring pIP
40 degrees; in general ulnar digit PIP flexion is important to preserve for power grip
323
hook of hamate is site of origin for
flexor digiti minim and opponens digit minimi
324
traumatic amp proximal toFDS insertion
contraindicated to replant
325
thenar space is separated from mid palm space by
septum at the long finger metacarpal
326
dorsal extrinsic ligaments of wrist
Dorsal radiocarpal (inserts on the lunate and triquetrum); and the dorsal INTERcarpal - triquetrum to scaphoid/trapezoid/capitate
