Hand Flashcards
(126 cards)
1
Q
1st extensor compartment
A
EPB
APL
(de quervains tenosynovitis)
2
Q
2nd extensor compartment
A
ECRL
ECRB
(intersection syndrome)
3
Q
3rd extensor compartment
A
EPL
4
Q
4th extensor compartment
A
EIP
EDC
PIN*
5
Q
5th extensor compartment
A
EDM
Vaughn-Jackson Syndrome
6
Q
6th extensor compartment
A
ECU
7
Q
Oblique retinacular ligament links…
A
the motion of DIP and PIP. With PIP flexion, the ligament relaxes to allow DIP flexion and with PIP extension, it tightens to facilitate DIP extension.
8
Q
Anatomy of the oblique retinacular ligament
A
from lateral volar aspect of the proximal phalanx to the terminal extensor insertion dorsally
9
Q
Contracture of the oblique retinacular ligament causes…
A
volar displacement of the lateral bands and a Boutonniere deformity.
10
Q
The transverse retinacular band functions to…
A
pull the lateral bands volarly with PIP flexion and prevent dorsal translation of the lateral bands with PIP extension.
11
Q
Anatomy of the transverse retinacular ligament
A
Originates from the flexor tendon sheath at the PIP and inserts on the lateral border of the lateral bands.
12
Q
Attenuation of the transverse retinacular ligament leads to…
A
dorsal translation of lateral bands and resulting swan neck deformity.
13
Q
The digital cutaneous ligaments act to…
A
tether the skin to deeper layers of fascia and bone to prevent excessive mobility of skin and improve grip. They stabilize the NV bundle with finger flexion and extension.
(Clelands ligaments and Grayson’s ligaments)
14
Q
Clelands ligaments
A
Dorsal to the digital nerves
15
Q
Grayson’s ligament
A
volar to digital nerves
16
Q
The extensor hood functions to…
A
extend PIP and DIP joint.
17
Q
The central slip of the extensor hood functions to…
A
extend the PIP. It inserts into the base of the middle phalanx.
18
Q
The lateral band of the extensor hood functions to..
A
extend the DIP. It inserts into the distal phalanx.
19
Q
Components of the MCP collateral ligaments:
A
Radial collateral ligaments and ulnar collateral ligaments which each have proper and accessory components.
20
Q
The accessory collateral ligaments are…
A
- fan shaped
- more volar (tight in extension)
- attach from the MC head to the palmar plate
- test with adduction/abduction stress in extension
21
Q
The proper collateral ligaments are…
A
- cord like
- more dorsal (tight in 30 degrees of flexion)
- attach from the posterior tubercle of MC head to the proximal phalanx base
- test with adduction/abduction stress in 30 degrees of flexion
22
Q
Function of the deep transverse metacarpal ligament
A
prevents MC heads from splaying apart
23
Q
Anatomic components of the deep transverse metacarpal ligaments
A
connects 2nd to 5th MC heads together at the volar plate of the MCP joiint
24
Q
Natatory Ligament function
A
resists abduction
25
Natatory ligament anatomy
- most superficial MP joint ligament
| - originates from distal to the MP joint and inserts proximal phalanx of all 5 fingers
26
Sagittal bands function
keeps extensor mechanism tracking in the midline during flexion of the MP joint
27
Anatomy of sagittal bands
originate on the palmar plate and inserts on the extensor mechanism
28
Triangular ligament function
counteracts the pull of the oblique retinacular ligament, preventing lateral subluxation of the common extensor mechanism
Located on the dorsal side of the extensor mechanism, distal to the PIP joint
29
Function of the volar plate
prevents hyperextension
30
Anatomy of the volar plate
- thickening of the joint capsule volar to the MP joint (in the thumbs, sesamoid bones are located here)
- originates on the metacarpal head and inserts on the surface of the proximal phalanx via checkrein ligaments
31
The volar plate is loose in...
flexion and tight in extension.
32
Steps for volar approach PIP joint flexion contracture release:
1. release check rein ligaments
2. release accessory collateral ligament and volar plate
3. release proper collateral ligament off the proximal phalanx
33
Most critical ligaments to prevent bowstringing
A2 and A4
34
A1, A3, and A5 overlie...
the MP, PIP and DIP joints respectively.
| they originate from the volar plate
35
The cruciate pulleys function to...
prevent sheath collapse and expansion during digital motion.
36
The oblique pulley originates...
at the proximal half of the proximal phalanx of the thumb.
It is the most important pulley of the thumb.
functions like a cruciate pulley in the finger does
37
The oblique pulley of the thumb facilitates...
excursion of FPL and prevents bowstringing.
38
The A1 pulley in the thumb is...
at the level of the volar plate at the MCP joint. The radial digital nerve is closes (about 2.7 mm).
39
The Av pulley of the thumb (annular variable) is located...
between the A1 and oblique pulley.It functions to prevent bowstringing.
40
Options for grafts for pulley reconstruction
- Extensor retinaculum (synovialized and thus has the least gliding resistance)
- palmaris, plantaris, FDS, allograft
41
Techniques for pulley reconstruction
- around the bone (encircling)
- single loop (Bunnell)
- triple loop (Okutsu)** strongest
- nonencircling
- ever present rim (Kleinert)
- belt loop (Karev)
- extensor retinaculum
- palmaris longus transplant thru volar plate
42
Complications of pulley reconstruction
- phalanx fracture
- stiffness
- persistent bowstringing
43
Repair of either the oblique pulley or the A1 pulley will restore thumb kinematics as long as...
the A2 pulley is intact.
44
A2 and A4 pulleys arise from...
the periosteum of the phalanges.
45
The radial artery runs between...
brachioradialis and FCR. It enters the dorsum of the carpus by passing between FCR and APL/PB tendons. Then gives off superficial palmar branch and finally passes between 2 heads of the 1st dorsal interosseous to form the deep palmar arch.
46
The ulnar artery runs...
under the FCU, enters the hand through guyon's canal and lies on the transverse carpal ligament.
47
The ulnar artery gives off.
the anterior and posterior interosseous arteries.
48
The superficial palmar arch lies...
deep to the palmar fascia and distal to the deep arch. It lies at the level of a line drawn across the thumb, parallel to the distal edge of the fully abducted thumb.
49
The predominant blood supply to the superficial palmar arch is the...
ulnar artery.
50
Branches of the superficial palmar arch:
1: deep branch to the deep palmar arch
2: ulnar digital artery of the small finger
3, 4, 5, 6: common palmar digital arteries
51
In the palm, the digital arteries are located...
volar to the digital nerves and then in the digits, the digital arteries are located dorsal to the digital nerves.
52
The deep palmar arch is located...
at the level fo the base of the metacarpals, about 1 fingerbreadth proximal to a line drawn across the palm parallel to teh distal edge of the fully abducted thubm.
53
Predominant blood supply to the deep palmar arch is...
the radial artery.
54
Branches of the deep palmar arch...
1: principis pollicis: runs between the 1st dorsal interosseous and adductor pollicis
2: branch to the radial side of the index finger
3, 4, 5: branches to the common digital arteries in the 2nd, 34d and 45h webspaces.
55
The common digital arteries arise from...
the superficial palmar arch and divide into proper digital arteries at the web spaces.
56
Dominant arteries of the digits are found on the...
median side of the digit.
57
The dorsal carpal arch is formed from...
the posterior interosseous artery and gives rise to the dorsal metacarpal arteries.
58
The most important intrinsic wrist ligaments are...
the scapholunate interosseous ligament and lunotriquetral interosseous ligament.
59
The space of poirier is...
the center of a double "V" shape convergence of wrist ligaments. THe central weak area of the wrist in the floor of the carpal tunnel at the level of the proximal capitate.
It is located between the volar radioscaphocapitate ligament and the volar long radiolunate ligament.
60
The radioscaphocapitate ligament runs...
from the radial styloid to the capitate, creating a sling to support the waist of the scaphoid.
61
Extrinsic volar ligaments
Radiocarpal:
1. radial collateral
2. radioscaphocapitate
3. long radiolunate
4. radioscapholunate
5. short radiolunate
Ulnocarpal:
1. ulnotriquetral
2. ulnolunate
3. ulnocapitate
62
Dorsal extrinsic ligaments:
1. radiotriquetral
2. Dorsal intercarpal
3. radiolunate
4. radioscaphoid
63
Intrinsic wrist ligaments (proximal row)
1. scapholunate (dorsal portion is strongest, volar portion, proximal portion)
2. lunotriquetral ligament
64
Intrinsic wrist ligaments (distal row)
1. trapeziotrapezoid
2. trapeziocapitate
3. capitohamate
65
The main restraint against ulnar translation of the carpus is...
the radioscaphocapitate ligament.
66
The Watson test
- test for scapholunate instability
- with pressure over the palmar tuberosity of the scaphoid, the wrist is moved from ulnar to radial deviation.
- when pressure removed from the scaphoid, it relocates back into the fossa and snapping/clicking occurs
67
Lunotriquetral ballotment test
- test for lunotriquetral instability u
- grasp lunate between thumb and fingers with one hand and triquetrum with other hand
- give AP translation (piano keys) and see if there is pain/instability
68
How to isolate for FDS
-MCP, PIP and DIP of all fingers held in extension with hand flat and palm up; finger to be tested is then allowed to flex at PIP joint
69
Bunnel's test
examiner passively flexes PIP joint, first with MCP in extension, then with MCP in flexion
- intrinsic tightness if PIP can be flexed when MCP is flexed but NOT when MCP is extended
- extrinsic tightness present if PIP can be flexed when MCP is extended but NOT when MCP is flexed
70
A nerve conduction velocity test is...
performed on peripheral nerves to determine their response to an electrical stimuli.
71
NCV technique
-constant voltage electric simulator evokes a response from muscle (motor study) or along the nerve (sensory study)
72
NCV =
distance divided by latency
73
NCV is determined by....
myelin thickness, internode distance, temperature, age.
74
Amplitude
area under the peak is proportional to the number of muscle fibers depolarized
(provides an estimate of the number of functioning axons/muscles)
75
Demyelination leads to...
increased latencies
76
EMG studies...
the electrical activity of individual muscle fibers and motor units
77
EMG technique
insert needle electrode through the skin into muscle to determine activity
78
Abnormal spontaneous EMG activities
1. sharp waves
2. fibrillations (sponatenous action potentials from single muscle fibers)
3. fasciculations (spontaneous discharge of a group of muscle fibers)
79
Tendon healing occurs via 2 pathways...
Intrinsic: produced by tenocytes within the tendon
Extrinsic: stimulated by surrounding synovial fluid and inflammatory cells
80
3 phases of tendon healing
1. Inflammatory phase: 0-5 days, cell proliferation
2. 5-28 days, fibroblastic proliferation with disorganized collagen
3. > 28 days, linear collagen organization
81
FDP facts
1. shares a common muscle belly in the forearm
| 2. has dual innervation (IF, LF via AIN and RF, SF via ulnar nerve)
82
FCR facts
primary wrist flexor
inserts on base of 2nd MC
closest flexor tendon to the median nerve
83
Blood supply to flexor tendons (2 sources)
1. diffusion through synovial sheaths
| 2. direct vascular perfusion (supplied by vinicular system, osseous bony insertions, etc)
84
Flexor tendon zones
1: distal to FDS
2: FDS insertion to distal palmar crease/A1 pulley
3: palm
4: carpal tunnel
5. carpal tunnel to forearm
85
Zone II of flexor tendons is unique..
in that FDP and FDS are in same tendon sheath
86
Treatment of zone II flexor tendon injury
direct repair of both tendons followed by early ROM
| Poor prognosis historically
87
Zone III flexor tendon injury often associated with...
NV injury
88
Treatment of zone III flexor tendon injury
direct tendon repair
89
Zone IV flexor tendon injury treatment
direct tendon repair, often complicated by adhesions due to close quarters of tunnel/synovial sheaths
90
Thumb flexor tendon injuries have different...
outcomes than fingers. Early motion does not improve results, there is high re-rupture rates.
91
Non-operative treatment of flexor tendon injuries indications
-partial lacerations with < 60% of tendon width
| may be associated with gap formation or triggering
92
Treatment for chronic FPL rupture
-FDS4 transfer to thumb
93
Repair of flexor tendon technique
epitendinous suture is sufficient (no benefit of adding core suture)
94
Ideal suture purchase is...
10 mm from cut edge
95
The most important part about core sutures is...
the number of sutures strands that cross the repair site (4-6 strands is good).
96
A circumferential epitendinous suture allows for...
improved tendon gliding, strength (20%), less gap formation.
Simple running suture produces less gliding resistance than other techniques.
97
Pulley management with flexor tendon repair
-25% of A2 and 100% of A4 can be incised with little resulting deficit
98
With zone 2 injuries, repair of FDS
only repairing one slip improves gliding
99
Tendon repairs are weakest between...
post op days 6 and 12
100
Repair site gaps > than...
3 mm are associated with increased risk of failure.
101
Advantages of wide awake tendon repair
1. allows for intra-op assessment of gaps
2. reduces need for post-op tenolysis by allowing assessment of whether tendon repair fits through pulleys
3. allows repair of tendons inside tendon sheaths
4. facilitates post-op early active motion
102
Early postop active motion after flexor tendon repair
form a partial fist with 45 degrees of flexion at MP, PIP and DIP joints after 3 days
103
Timing of tenolysis after flexor tendon reconstruction/repair
-wait for soft tissue stabilization (> 3 months) and full passive motion of all joints
104
Immobilization for flexor tendon repair
-wrist and MCP in flexion, IP joints extended
105
Most common complication following flexor tendon repair
-tendon adhesions
| high risk with zone 2 injuries
106
Jersey finger refers to...
an avulsion injury of FDP from insertion at the base of the distal phalanx. (Zone 1 flexor tendon injury)
Most commonly the ring finger (more prominent during grip).
107
With direct tendon repair for jersey finger, advancement of > 1 cm leads to increased risk for...
DIP flexion contracture or quadrigia.
108
Indications for two stage flexor tendon grafting for jersey finger
-chronic injury (>3 months) with full PROM
109
In jersey finger, a FDP tendon retracted into the palm will..
shear the vincula (blood supply) and urgent surgical repair is indicated.
110
Most common extensor tendon injury is...
the long finger and most common zone is VI.
111
Zone I Extensor tendon injury
-disruption of the terminal extensor tendon distal to or at the DIP joint of the fingers and IP joint of the thumb (EPL)
(mallet finger)
112
Zone II extensor tendon injury
disruption of the tendon over the middle phalanx or proximal phalanx of the thumb (EPL)
113
zone III extensor tendon injury
-disruption of the PIP joint of digit (central slip) or MCP joint of the thumb (EPL)
(boutonniere deformity)
114
zone IV extensor tendon injury
disruption over the proximal phalanx of the digit or metacarpal of the thumb
115
zone V extensor tendon injury
-disruption over the mcp joint of the digit or cmc joint of the thumb
(fight bite)
(sagittal band rupture)
116
zone VI extensor tendon injury
-disruption over the MC
| nerve and vessel injury are likely
117
zone VII extensor tendon injury
- disruption at the wrist joint
| - must repair retinaculum to prevent bowstringing
118
zone VIII extensor tendon injury
disruption at the distal forearm
119
zone IX extensor tendon injury
extensor muscle belly injury
120
Presentation of zone III extensor tendon injury
Positive elson test
(flex patient's PIP over a table and ask them to extend against resistance. if central slip is intact, DIP will remain supple. If central slip is disrupted, DIP will be rigid).
121
Indications for non-operative treatment of extensor tendon injury
-lacerations < 50% of tendon in all zones if patient can extend digit against resistance
(treat with immobilization with early protected motion)
122
Indications for DIP extension splinting for extensor tendon injuries
- acute zone 1 injury (< 12 weeks)
- nondisplaced bony mallet finger
- chronic mallet finger if joint supple
123
Indications for PIP splinting in extensor tendon injury
-closed central slip injury
124
Indications for MCP extension splinting
-closed zone V sagittal band rupture
125
Suture technique for extensor tendon injury
1. # of suture strands that cross the repair site is more important that number of grasping loops
2. 4-6 strands provide adequate strength for early active motion
126
Extensor tendon repairs are weakest between...
postoperative day 6 and 12. Usually will fail at the knots.
