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Flashcards in Hand-Nerve Facts Deck (38):
1

Time to replantation 

proximal to carpus

 

- warm ischemia time < 6 hours
- cold ischemia time < 12 hours

distal to carpus (digit)

 

- warm ischemia time < 12 hours
- cold ischemia time < 24 hours 

2

Finger order for replant

thumb, long, ring, small, index 

3

Replant monitoring (most reliable method and pulse ox number)

skin temperture most reliable
- concerning changes include a > 2° drop in skin temp in less than one hour or a temperture below 30° celcius

pulse oximetry
< 94% indicates potential vascular compromise 

4

What is average motion after replant?

50% total motion

(tenolysis most common secondary surgery)

5

Treatment of reperfusion injury after replant

allopurinol is the best adjunctive therapy agent to decrease xanthine production 

mechanism thought to be related to ischemia-induced hypoxanthine conversion to xanthine
 

6

Most common knuckle and side for sagittal band rupture ("boxers knuckle")

Middle (~50%), radial (9:1)

7

most important flexor pulley in thumb

Oblique pulley

originates at proximal half of proximal phalanx

A image thumb
8

radial tunnel syndrome facts (4)

- pain only (no motor or sensory changes)

- maximal tenderness more distal than tennis elbow (4 cm distal to epicondyle)

- same sites of compression as PIN syndrom

- non-op at least 1 year

9

Which of the following is considered the most common complication of an extensive medial release for resistant medial epicondylitis?

Medial elbow instability

 

Vangsness CT Jr, Jobe FW: Surgical treatment of medial epicondylitis: Results in 35 elbows. J Bone Joint Surg Br 1991;73:409-411

10

To adequately expose the volar plate of the proximal interphalangeal joint of the finger, which of following
pulleys is typically incised? 

Distal portion of C1, entire A3, and the proximal portion of C2

A image thumb
11

intrinsic muscles innervated by the ulnar nerve

palmaris brevis, hypothenar
muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis

A image thumb
12

Which normal structures help compose the spiral cord seen in Dupuytren’s contracture?

pretendinous band, spiral band, lateral digital sheet, and Grayson’s ligament

 

NOT Cleland’s ligament

The transverse ligament of the palmar aponeurosis also not involved.

A image thumb
13

Origin and course of the palmar cutaneous branch of the median nerve (PCBMN)

originates from the radial side of the nerve and travels distally with the median nerve, radial to the palmaris longus, and ulnar to the flexor carpi radialis

A image thumb
14

extensor tendon zones of injury

joints are odd

A image thumb
15

Boutonniere Deformity

Zone III extensor tendon injury

rupture of central slip

open or avusion treat open (

closed treat closed ext PIP splint

reconstruction vs terminal tendon tenotomy (Fowler) if fails

A image thumb
16

Q image thumb

swan neck deformity

Primary lesion is lax volar plate that allows hyperextension of PIP

Secondary lesion is imbalance of forces on the PIP joint:

  • mallet injury
  • FDS rupture
  • intrinsic contracture (triangular = transverse retinacular ligament)
  • MCP joint volar subluxation (RA)

17

five compression sites described in radial tunnel syndrome

distal edge of the supinator; fibrous bands superficial to the radiocapitellar joint; tendinous margin of the extensor carpi radialis brevis (ECRB); radial recurrent artery (leash of Henry); and the most common site of compression, the fibrous edge of the supinator (arcade ofFrohse).

18

steps releasing a PIP joint flexion contracture

release check rein ligaments; then accessory collateral ligament and volar plate; and finally the proper collateral ligament is then released off the proximal phalanx

19

treatment

Q image thumb

Treatment

  • nonoperative

reduce and buddy tape to adjacent finger (3-6 weeks)
indications: dislocation is reducible

 

  • operative

open reduction and extraction of the volar plate
indication: failed reduction or open

20

treatment

Q image thumb

nonoperative
splinting in extension for 6-8 weeks

allows central tendon to heal to avoid boutonneire 

21

structures to go through to approach this injury:

Q image thumb

adequate volar exposure of the volar plate requires resection of:


proximal portion of C2 pulley
entire A3 pulley
distal C1 pulley

A image thumb
22

indication to fix:

Q image thumb

if  > 40% joint involved and unstable

23

Rotatory PIP dislocation treatment. 

open reduction
indications: required in most cases

one of phalangeal condyles is buttonholed between central slip and lateral band

try closed reduction first.  traction to finger with MP and PIP joints in 90 degrees of flexion.  

24

Q image thumb

kleinert protocol 

 

low force and low excursion rehabiliation

25

Q image thumb

Duran protocol

 

 

26

Q image thumb

synergistic motion protocols

low force and high tendon excursion

A image thumb
27

factors affecting success of recovery following nerve  repair
 

age
is single most important factor influencing success of nerve recovery
level of injury
is second most important (the more distal the injury the better the chance of recovery)
sharp transections
have better prognosis than crush injuries

28

nerve fiber types

A image thumb
29

nerve injury

A image thumb
30

nerve cond velocity numbers

A image thumb
31

limb bud development: 3 axes and signalling mechanisms

The proximal-distal axis is controlled by the apical
ectodermal ridge and underlying mesoderm through
fibroblast growth factors.

 

The radial-ulnar axis is controlled by the zone of polarizing activity through sonic hedgehog protein.

 

The dorsal-ventral axis is controlled by wnt-7a
protein located in the dorsal ectoderm. Transcription factor Lmx1 is induced by Wnt-7a protein and is required for dorsalization of the limb. Another transcription factor , En-1, is produced on the ventral aspect of the limb and blocks Wnt-7a expression, thereby allowing ventralization of the
limb. 

32

Which of the following genes is up regulated within
Dupuytren’s disease tissue as compared with the
normal fascia

Tenascin C (TNC)

33

proximal row carpectomy indications for perilunate dislocation


chronic injury  (defined as >8 weeks after initial injury)

34

Dupuytren's anatomy

Spiral cord:

Natatory cord:

Central cord:

Lateral cord:

 

spiral cord: lateral digital sheet, the pretendinous ligament, the spiral band, and the Grayson ligament 

natatory cord: natatory ligament (palm)

Central cords: volar superficial fascia (digits)

Lateral cords: lateral digital sheets (digits)

 

AD with variable penetrance

35

order of repair for replant

(proximal amps extra steps)

BE.FAN.V

First do fasciotomies, shunting (B.AVN.MS)

36

temps to intervene in flap monitoring

< 30 deg

drops 2 deg in 1 hr

37

Nerve end organs

(superficial)

meiSSner's ---- hairleSS skin ---- remember the tip of your fingers they are hairleSS --- you use them for fine touch --- they are fine and quick (adaptation)

merKel's ---- folliKles(of hair) --- hairy skin --- for crude touch --- they are crude and slow(adaptation

 

(deep)

Pacinian ----- Pressure+ vibration ---- they vibrate quickly(adaptation)

 

Ruffini - skin stretch

38

length nerve loss to graft

1 inch (2.5-3cm)

less can use conduit