Hand Everything Flashcards
(35 cards)
What is best technique for operative fixation of phalanx fxs?
SAE question says lagging the fracture with screws is best treatment to chose in order to allow early ROM (better than pinning)
Dorsal PIP dislocations- how to determine stability and treatment.
What is MC block to reduction?
- MC block to reduction is volar plate
- Must address stability following reduction, if fracture -> can usually tell by % of articular surface involved:
- <20%: uniformly stable
- ~40% want to really carefully examine if stable
- > 60%: uniformly unstable
- Treatment:
- Simple dislocation (no fracture) that is stable and very, very small volar plate avulsion fractures of the base of the middle phalanx-> buddy tape and allow motion x 6 weeks
- < 40% Articular surface involved or simple dislocation that is unstable-> dorsal extension block splinting (30 degrees) with weekly incremental increase in extension x 4 wks, followed by 3 months buddy taping during during sports activities
- Dynamic ex-fix
- When involves >40% and there is comminuted, small pieces
- Fixation/Pinning
- Hemi-hamate arthroplasty (graft harvested from dorsal/distal surface). The graft will provide volar buttress to dorsal subluxation of the middle phalanx.
- If too comminuted for fixation
- Preferred for ulnar digits where you want to keep motion for power grip
- Arthrodesis
- Preferred for radial digits which act more as “posts” in their function of key pinch.
- If have to fuse RF -> 40 degrees is optimal to allow some power grip ability
- Acute unstable involvement of > 40% articular surface w/ comminution OR in chronic scenario ->
- Volar plate arthroplasty of PIPJ (-> must excise the collateral ligaments from the volar plate to allow smooth gliding and advancement of the volar plate to the dorsum of the middle phalanx under the extensor mechanism (SAE question)
Volar PIP dislocation - what can be injured, how do you treat?
- Think about central slip injury!!
- Treatment:
- Simple dislocation -> reduction and full time extension splinting x 6 weeks
PIPJ Arthritis treatment in young vs old person
- In a young, active person (typically PTOA or inflammatory dz) - CHOOSE ARTHRODESIS! (Arthroplasty will fail!)
* Fuse in ~40-55 degrees of flexion and as go more ulnar fuse in even more flexion to optimize function- In a older, less active patient WITHOUT rotational deformity with involvement of MF,RF,SF - ARTHROPLASTY (most helpful for pain, doesn’t give great ROM!). In IF consider arthrodesis still bc arthroplasty has higher failure for this digit!
- Look for presence of rotation deformity in question stem - this will tell you that there is insufficiency of the collateral ligaments
- Silicone implant with volar approach has best ROM and lowest revision rate
- In a older, less active patient WITHOUT rotational deformity with involvement of MF,RF,SF - ARTHROPLASTY (most helpful for pain, doesn’t give great ROM!). In IF consider arthrodesis still bc arthroplasty has higher failure for this digit!
DIP ARTHRITIS - what is seen and what is treatment
- Look for Mucoid cysts on dorsum of finger by DIPJ
- Treatment options:
- Surgical excision w/ removal of boney osteophytes
- Can also perform aspiration, drainage and injection of steroid
Shortening of MC fx -> each 2 mm of shortening results in….how much extensor lag? What else is effected?
- each 2 mm of shortening results in 7 degrees of extensor lag
- Will also so decrease in grip strength
5th MC neck treatment
- If no malrotation, and < 70 degree angular deformity: buddy tape and optional follow up
- 5th MC Neck fx (without rotational deformity) can be treated w/ buddy taping vs. splinting and optional follow up (2018 OITE Question!)
Base of 5th MC fx - what is mechanism for injury typically and what is deforming force?
- Injury usually due to punching
* Deforming force ECU
Gamekeepers thumb -
What is injured?
Where does the tear usually occur?
What other “lesion” can be associated with it?
- Due to injury of the PROPER AND ACCESSORY UCL
- Proper UCL is the primary restraint to radial deviation in MCPJ FLEXION
- Accessory UCL is the primary restraint to radial deviation in MCPJ EXTENSION (remember “Extension” and “Axcessory”…they kind of sound alike)
- **Note: the UCL typically tears from its DISTAL insertion (on the proximal phalanx..less common to tear off of the MC)
- STENER lesion - torn UCL w/ adductor aponeurosis interposed
- Factor most a/w re-displacement of DR fracture following closed reduction ->
initial displacement; most specifically loss of radial height!
What XR should be taken to determine if DRUJ injury following a DR fracture
- Must take a post-reduction true lateral XR of the carpus to assess DRUJ alignment
In splinting DR fracture what position should be avoided?
- AVOID THE COTTON-LODER position = extreme flexion/ulnar deviation -> a/w increased risk of acute carpal tunnel syndrome!!!
- Look for inability to actively oppose the thumb (along with the numb/tingles in median n. Distribution!)
After DR fracture, what can be given to avoid CRPS?
- Give Vit C (500 mg x 50d) to prevent CRPS
Op vs nonop DR fracture outcomes in Pts > 60 yo
- Fixation of DR fx (even unstable fx’s) in older population (>60 yo) vs non-op treatment shows essentially no difference in functional outcome at 1 year (those with fixation have better looking XRs but are roughly doing the same clinically)
- Fixation does provide better grip strength when compared to nonop
MC tendon rupture after DR fx treated with a volar plate ->
- FPL
- Also, possible to have EPL rupture after a volar plate due to having a screw that is too long penetrating dorsal cortex.
- Should use a Flexed Wrist Tangential Axial (Skyline) XR to evaluate screws to make sure they aren’t too long!
- Note: a lateral and oblique XRs can miss this b/c it may just be behind Lister’s tubercle
- Also, possible to have EPL rupture after a volar plate due to having a screw that is too long penetrating dorsal cortex.
- XR Views to Assess Placement of Fixation:
- Flexed Wrist Tangential Axial view (Skyline view) -
- Extended Wrist Tangential view (Sigmoid notch view) -
- PA anatomic tilt view:
- Radial Inclination view:
regular lateral is really only useful for looking at
- Flexed Wrist Tangential Axial view (Skyline view) - best to eval screw length/dorsal penetration
- Extended Wrist Tangential view (Sigmoid notch view) - best to eval screw in DRUJ
- PA anatomic tilt view: 11-degree anatomic tilt view that shows the degree of articular congruity
- Radial Inclination view: 22-degree radially inclined lateral view is best for evaluating intra-articular penetration of screws in radoiocarpal joint.
For comparison a regular lateral without the 23 degree inclination (regular lateral is really only useful for looking at plate placement relative to watershed line):
When patient has weakness in first couple weeks with thumb IP flexion after volar plating of DR fx, think about ->
scar entrapment, hardware irritation, FPL impingement or ruptures, and injury to AIN
When patient has weakness in first couple weeks with thumb IP flexion after volar plating of DR fx, and XR shows:
*well positioned plate
* plate volar to critical line
what is likely cause and how do you manage?
*When the lateral XR shows that the plate sits proximal to watershed line (location of origin of volar carpal ligaments, and bone prominence where flexor tendon is closest) and not volar to critical line (ie plate is optimally positioned) -> then FPL rupture is less likely and patient should just be observed b/c weakness will typically resolve with time.
* If persists for 2-3 months -> nerve conduction study (look for AIN injury); if normal then MRI or US to eval for FPL rupture.
* FOR THE TEST LOOK FOR PLATE BEING VOLAR TO THE CRITICAL LINE ( = more volar than most volar aspect of distal radius
If distal to watershed line (which makes plate volar to critical line) then think about FPL rupture!
- After DR is fixed must test the ????stability. And if unstable how to manage?
- After DR fixation - shuck the DRUJ to test stability!
- This tests the radioulnar ligaments of the TFCC
- Think about injury to DRUJ when you see an ulnar styloid fracture - otherwise an ulnar styloid does not need to be fixed and a nonunion of it doesn’t matter clinically!! It’s really just a canary in the coal mine
- If DRUJ unstable and has ulnar styloid fx of reasonable size to fit a pin in it then do this to help with stability.
- If did this and DRUJ still unstable, or if styloid piece too small, then pin across DRUJ
What part of DR fracture has to be looked out for to prevent carpus dislocation?
- Watch out for volar/ulnar corner!! If don’t fix this piece well the whole wrist can dislocate along with this piece
After performing ORIF of DR fracture you test stability of DRUJ…what other injury should you look for and if injured how to manage?
after DR fx ORIF -> eval for SL widening -> if wide and has injury to SL ligament then after DR ORIF w/ volar plate, use a dorsal incision (dorsal aspect of SL ligament is strongest!) and repair SL ligament + K wire for additional temporary fixation!
What tendon should be watched after casting of a DR fracture?
How to manage if injured?
- EPL rupture after a non-displaced DR fx treated w/ a cast should be watched for!!
- More commonly happens as late finding -> This is thought to be an attritional rupture due to compromised blood flow (can be seen later as well due to callus from healed fx causing restricted blood flow)
- Since this is an attritional rupture treatment is EIP to EPL transfer (a direct repair won’t work b/c it’s crappy tendon!!).
- Also, in order to best re-create tension that allows good extension (and doesn’t limit flexion) should perform surgery awake!
- Since this is an attritional rupture treatment is EIP to EPL transfer (a direct repair won’t work b/c it’s crappy tendon!!).
- If happens earlier (less common) it is thought to be due to impingement b/t dorsal aspect of DR and 3rd MC base during the initial hyperextension event/injury
- More commonly happens as late finding -> This is thought to be an attritional rupture due to compromised blood flow (can be seen later as well due to callus from healed fx causing restricted blood flow)
Formal PT vs self-directed PT after DR ORIF
- Postop after DR ORIF -> formal PT has no added benefit over self-directed!
What is Galeazzi fracture?
What structure is in the way if have difficulty with closed reduction?
- distal 1/3 radial shaft + DRUJ dislocation
* If unable to close reduce DRUJ despite getting distal radius reduced -> ECU interposition is MC cause!!
