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OrthoBullets Study > Hand & Wrist > Flashcards

Hand & Wrist Flashcards

1
Q

What is Vaughn-Jackson syndrome? Treatment?

A

Attritional rupture of extensor tendons due to RA (caput ulnae)

Occurs ulnar –> radial (ie pinky first)

Treatment:

EIP –> EDC transfer + distal ulnar resection

or

Side to side EDC tenodesis (3rd to 4th/5th) + distal ulnar resection

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2
Q

What is the primary lesion in a swan neck deformity?

A

Lax volar plate

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3
Q

What is the ligament associated with madelung’s?

Where does it run?

A

Vicker’s ligament

Goes from radius to lunate (short RL ligament)

Tethers volar ulnar radius

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4
Q

2 most common complications of perilunate injury? Are they going to get back to full function?

A

decreased grip strength

stiffness

No - unlikely to regain full function

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5
Q

4 causes of Swan Neck?

A
  1. MCP joint volar subluxation (rheumatoid arthritis)
  2. mallet finger
  3. FDS laceration
  4. intrinsic contracture
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6
Q

What is the aim of a nerve repair?

A

A tension free repair in a clean wound bed with matched fascicles

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7
Q

1st line treatment in trigger thumb in kids < 2 with no fixed flexion deformity

A

Stretching

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8
Q

Where are the dominant digital arteries found in the fingers?

A

Found on the median (closer to midline) side of the digit

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9
Q

What vessel is dominant in the deep arch?

A

Radial artery

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10
Q

Most common reason for persistent carpal tunnel symptoms after open release?

A

Incomplete release of the transverse carpal ligament

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11
Q

Describe anatomy of Guyon’s canal

A

Zone 1: motor and sensory (prior to bifurcation)

Zone 2: Motor

Zone 3: sensory

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12
Q

In a low radial nerve palsy, why do you get radial deviation with wrist extension?

A

Maintained action of ECRL (attaches base of 2nd MC)

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13
Q

What happens to the relationship between the scaphoid and lunate with SL injury?

A

Scaphoid flexes, lunate extends

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14
Q

In neutral ulnar variance, what percentage of the load of the wrist is taken up by the radius and ulna

A

radius: 80%

Ulna: 20%

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15
Q

What is clinodactyly?

A

Curvature in the radio-ulnar plane of the fingers

Most commonly at middle phalanx of small fingers

Associated with Downs (25%)

Can be normal

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16
Q

Name two hand intrinsics and 3 extrinsics.

A
  1. intrinsics (interosseoi and lumbricals)
  2. extrinsics (FDS, FDP, EDC)
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17
Q

Diagnosis & treatment?

A

Mucous cyst due to OA of DIP

Surgical resection (not aspiration) and debridment of osteophytes

Can watch as some resolve spontaneously

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18
Q

What is the most reliable sign of proximal pole vascularity?

A

intraoperative punctate bleeding

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19
Q

Clinical Diagnostic test for SL injury

A

Watson test

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20
Q

Diagnosis?

A

CIND

Radiocarpal instability

>50% ulnar translation of lunate on lunate facet

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21
Q

What period of a woman’s life is DeQuervain’s most likely to occur?

A

Pregnancy, lactation, post-partum

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22
Q

Dupuytren’s: Spiral cord is _____ & _____ to the neurovascular bundle

A

Deep & lateral

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23
Q

What ligaments retain and position common extensor mechanism during PIP and DIP flexion?

A
  • Retinacular Ligaments
    • Oblique and Transverse bands
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24
Q

Treatment of venous congestion in finger replantation

A

Leech application - used for venous, not arterial!

  • Releases Hirudin
  • Aeromonos hydrophilia infection can occur
  • Prophylax with bactrim or ciprofloxacin

Heparin soaked pledgets if leeches not available

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25
Q

4 important complications of Dupuytrens surgery?

A
  1. Hematoma - can cause flap necrosis
  2. NV injury
  3. Flare reaction (like CRPS)
  4. Recurrence - up to 50%
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26
Q

How do you test proper and accessroy ulnar collateral ligament of the thumb?

A

Proper: Thumb in flexion (resists valgus in MCP flexion)

Accessory: thumb in neutral (resists valgus in extension, along with volar plate)

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27
Q

What are the 3 parts of the scapholunate interosseous ligament? what is the strongest?

A

Dorsal (strongest)

Volar

Proximal

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28
Q

Name & briefly describe classic DRUJ reconstruction technique

A

Adam’s technique

Radioulnar ligament reconstruction with allograft through bone tunnels in radius & ulna

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29
Q

Diagnosis & Treatment?

A

CMC arthritis with MCP subluxation & adduction/webspace contracture

Treat with:

LRTI & MCP Fusion

MCP fusion indicated when MCP hyperextension > 40 degrees

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30
Q

What are the prerequisites for a nerve repair?

A

Clean wound bed

well vascularized

Not a war wound (ie crush or blast)

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31
Q

Risks of poor outcome following replantation

A

Mechanism of injury: most important

Male sex

smoker

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32
Q

Scapholunate ligament is strongest where?

A

Dorsally

(that’s why you get DISI - dorsal is intact)

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33
Q

Chronic paronychia, what must you rule out?

A

Candida

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34
Q

What determines muscle power?

A

Cross-sectional area of the muscle belly

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35
Q

What is the most important pulley in the thumb to prevent bowstringing?

A

Oblique

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36
Q
  1. A patient suffers a laceration to small finger, volar surface 2mm proximal to DIP. Examination reveals the patient can not actively flex small DIP and if the ring and middle fingers held in extension, can’t flex PIP of small. If the ring is allowed to flex, he is still unable to flex the PIP of the short. What is going on?
A

Laceration of FDP

Congenital absence of FDS

20% of population has absent FDS in small finger

If you cut your finger 1 mm proximal to the distal flexion crease and are unable to demonstrate DIP motion, you’ve cut the FDP. However, if you are also unable to demonstrate flexion of PIP with the other fingers held in extension, then you probably have a congenital absence of FDS

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37
Q

CMC arthritis treatment by stage (as per JAAOS 2000)

A

Eaton classification

Nonoperative: always first option

Operative

I: volar beak ligament reconstruction

II - IV: LRTI

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38
Q

In undisplace scaphoid fractures, operative fixation has what effect over nonoperative?

A

Faster time to healing

Faster return to sports and work

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39
Q

What forearm flexors are NOT innervated by the median or AIN nerves?

A

FCU: ulnar

ulnar 2 FDP: ulnar

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40
Q

Causes and effects of hand extrinsic tightness:

A

Think of it as intrinsic weakness

Can also be caused by EDC adherence to MC

Effects

  • MCP extension
  • IP flexion
  • PIP flexion causes MCP extension (b/c extrinsic extensors are tight)
  • MCP flexion causes IP extension (b/c extrinsic extensors are tight)
  • Unable to perform prehensile grasp
  • diminished grip and pinch strength

Yes, you can still passively flex MCP - no block but the above will occur

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41
Q

What are the two indications for closed treatment of an extra-articular base of thumb fracture?

A
  1. less than 30 degrees angulation
  2. stable joint (CMC)
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42
Q

3 Prerequisites for Tendon Transfers

A

Soft tissues must have reached equilibrium

Joints must be supple

Functional recovery must be unlikely

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43
Q

What is a lumbricals plus finger?

What is the main lesion?

A

Paradoxical extension of the IP joint while attempting to flex fingers

Due to disruption of FDP distal to the origin of the lumbricals

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44
Q

What is this and why would you do it?

A

Steindler flexorplasty image

transfer common flexor mass proximally on the humerus for a MSK nerve palsy.

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45
Q

Name 5 etiologies of Swan-neck

A
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46
Q

What deformity do you get by splinting a crushed hand in extension instead of safe position?

A

Intrinsic minus hand

(claw hand)

** This is because splinting in MCP extension causes increased tension of the extrinsic finger flexors

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47
Q

RA trigger finger classification

A

Type 1

  • is similar to nonrheumatoid stenosing tenosynovitis, in which the tendons catch at the first annular pulley during flexion secondary to small, localized hyperproliferation of the synovium.

Type 2

  • the nodules form in the distal palm and cause the finger to lock in flexion. In

Type 3

  • nodules on the flexor digitorum profundus (FDP) tendon near the second annular pulley (over the proximal phalanx) lock the finger in extension.

Type 4

  • trigger finger results from generalized tenosynovitis within the fibroosseous canal. Active motion is more restricted than passive motion, and contracture and stiffness result.
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48
Q

4 general options for fixing SL injury

A

Nonoperative: ineffective

SL Repair (suture anchor vs. joint pinning)

Reconstruction (direct FCR vs. indirect ECRB)

Fusion (STT, SLC)

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49
Q

Diagnosis?

A

Preiser’s disease

Scaphoid AVN

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50
Q

Preferred approach to DIP ORIF?

A

Through nail plate

No increase in nail defomrities

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51
Q

Post-replantation, pulse ox of less than what number indicates potential vascular compromise?

A

Less than 94%

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52
Q

What is the gold standard for diagnosing SL injury? What is the classification?

A

Arthroscopy

Geissler classification

Grade I:

  • Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space
  • No incongruity of carpal alignment in midcarpal space

Grade II:

  • Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space
  • May be a slight gap (less than width of probe) between carpla bones in midcarpal space

Grade III:

  • Incontruity or step-off of carpal alignment as seen from both radiocarpal and midcarpal space
  • Probe may be passed through gap between carpal bones

Grade IV:

  • Incongruity or step-off of carpal alignment as seen from both radiocarpal and midcarpal space
  • There is gross instability with manipulation
  • A 2.7mm arthroscope may be passed through the gap between carpal bones
  • Drive through sign
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53
Q

3 clincal exams for VISI

A

LT shuck test

Kleinman’s shear test

LT compression test

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54
Q

AIN motor weakness with some loss of intrinsic musculature: Diagnosis?

A

Martin-Gruber anastomosis

AIN to Ulnar anastomosis. AIN palsy results in loss of some intrinsic hand muscles

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55
Q

Tendon transfer for chronic EPL rupture

A

EIP –> EPL

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56
Q

3 surgical options for scapholunate injury

A

Repair:

direct repair

Reconstruction:

FCR tendon: Brunelli technique

ECRB tendon via bony tunne in scaphoid

Fusion:

STT fusion

SLC (scaphoid, lunate, capitate) fusion

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57
Q

Which arch, superficial or deep, supplies all of the fingers?

A

Deep arch (radial artery):

supplies all fingers (is complete) in 97% of patients

vs.

Superficial arch (ulnar artery)

supplies all fingers (is complete) in 80% of patients

Is major supply for digits on ulnar side of hand

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58
Q

What is the most common complication of carpal tunnel syndrome after open release?

A

Pillar pain

Pain adjacent to the TCL release site, where subcutaneous pain of the carpal bones

2nd most common is laceration of the palmar cutaneous branch of the median nerve

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59
Q

Main supply of superficial and deep arterial arches of hand?

A

Superficial:

ulnar

It is distal

Deep:

radial

it is proximal

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60
Q

What do you call the syndrome for proximal median nerve compression? name 5 sites of compression:

A

Pronator syndrome or AIN syndrome (2 entities with the same compression sites)

5 sites of compression:

  • Accessory muscle of Gantzer (accessory head of FPL)
  • Supracondylar process
  • Ligament of struthers
  • Lacertus fibrosis (bicipital aponeurosis)
  • between 2 heads of PT
  • FDS aponeurotic arch

“Sexy Ladies Love Poontang Sauce”

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61
Q

Describe goals of preaxial polydactyly treatment in terms of

size

structures to preserve

staging

A

Make a thumb 80% of contralateral

Preserve medial collateral structures to preserve pinch

1 stage

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62
Q

How do you treat adolescent Kienbock’s disease?

A

Temporary scaphotrapezial pinning

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63
Q

How soon should definitive management with grafting for burns take place?

A

within 5 days

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64
Q

What structures are injured here?

What is the initial treatment?

A

Volar dislocation

Central slip and at least 1 collateral are often ruptured

Full time extension splinting x6 weeks for extensor mechanism to heal

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65
Q

What three muscles provide defroming forces in a Bennetts fracture and what are their innervations?

A
  1. abductor pollicis longus (PIN)
  2. extensor pollicis longus (PIN)
  3. adductor pollicis (Ulnar n.)
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66
Q

2 clinical characteristics of Leri-Weill dyschondrosteosis?

A
  1. Mesomelic dwarfism
  2. Madelungs deformity
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67
Q

Describe tendon transfer for PIN palsy

A

Correction of fingers extension only (wrist extension not required)

FCR –> EDC

PL –> EPL

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68
Q

What is a normal intrascaphoid angle? What does it represent if abnormal?

A

Normal:

If > 35 deg, represents humpback deformity

LISA = lateral intrascaphoid angle

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69
Q

What is torn in volar PIP dislocation?

What is your block to reduction?

A

central slip + 1 collateral ligament

Lateral band is block to reduction

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70
Q

What is quadregia?

What is it caused by?

A

Active flexion lag in fingers adjacent to a digit with a previously injured or repaired FDP

Caused by functional shortening of FDP

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71
Q

5 surgical options (including 2 tendon transfers) for EPL rupture

A

EIP –> EPL

APL –> EPL

Primary repair

Free tendon graft (PL)

IP joint arthrodesis

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72
Q

Name the diagnostic criteria for carpal tunnel syndrome

A

Numbness and tingling in the median nerve distribution

Nocturnal numbness

Weakness and/or atrophy of the thenar musculature

Positive tinel’s sign

Positive phalen’s test

Loss of 2 point discrimination

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73
Q

What direction of PIP dislocation/fracture-dislocations are more common?

A

Dorsal

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74
Q

Congenital clasped thumb - what is the issue?

A

Flexion adduction contracture due to deficient EPL/EPB

Congenital

Risks:

consanguinity

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75
Q

Name the intrinsic hand muscles innervated by the median nerve (or branches of)

A

Lumbricals (radial 2)

Opponens pollicis

Abductor pollicis brevis

Flexor pollicis brevis

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76
Q

Describe three important surgical strategies for syndactyly release.

A
  1. use zig-zag incisions to avoid longitudinal scarring
  2. release length mismatched digits first to avoid growth disturbances
  3. if both sides of a digit involved release in stages to avoid de-vascularizing the digit
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77
Q

What is the normal scaphlunate angle? What does an abnormality imply?

A

Normal: 30-70 deg

Abnormal = VISI/DISI

DISI: SL angle > 60 degrees

VISI: SL <30 deg (they are in line b/c lunate points down in line with scaphoid

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78
Q

What is a Kaplan lesion?

A

Complex dorsal MCP dislocation

Volar plate interposed between base of proximal phalanx and MC head

Most common in index finger

Rare

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79
Q

Most sensitive and specific test for carpal tunnel syndrome

A

Sensitive:

Durkan: most sensitive clinical test

Semmes-Weinstein: most sensitive sensory test

Specific:

Self-administered hand diagram

Of Note:

EMG is helpful as per JAAOS

2 point discrimination (moving & static) are good for looking at return of function post-op

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80
Q

Most common cause of failure in first 12 hours post replantation

A

Arterial thrombus

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81
Q

T/F: Ulnar nerve injuries have good results following repair compared to other peripheral nerves?

A

False.

The deep peroneal nerve, ulnar nerve, and brachial plexus lesions had the worst recovery.

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82
Q

In Dupuytren’s disease, where are the neurovascular structures displaced?

A

Superficially and towards the midline

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83
Q

What is the pathology in congenital trigger thumb?

A

Thickened FPL tendon

aka: Notta’s nodule
(vs. trigger finger: thickened tendon sheath)

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84
Q

Patient has radial clubhand. What 5 tests are mandatory?

A
  1. CBC
  2. Peripheral blood smear
  3. Chromosomal breakage analysis
    • (Top three are to r/o FA which is life threatening)
  4. Renal U/S
  5. Echo
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85
Q

How do you differentiate (clinically) deQuervain’s tenosynovitis and Intersection syndrome?

A

Intersection syndrome (2nd compartment) has pain proximal to the wrist joint

De Quervain’s has pain distal in 1st dorsal compartment

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86
Q

What are 7 factors or techniques that maximize tendon repair?

A

Number of core strands crossing repair site:

  • Linear relationship with 4-6 core strands adequate for early mobilization

Locking loops (Krakow) > grasping (Kessler)

High calibre suture

Core suture placed dorsally

Ideal suture purchase is 7-10mm (1cm) from cut edge

No gapping between sides

Meticulous atraumatic tendon handling minimizes adhesions

Circumferential simple epitendinous suture adds 20% of strength

  • Improves tendon gliding
  • Improves strength
  • Allows less gap formation
  • Simple running suture recommended
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87
Q

Most common complication of thenar flap?

A

Flexion contracture at recipient PIP joint

(THINK: it has to stay bent while stuck on the thenar eminence during healing)

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88
Q

What forearm flexor muscle shares dual innervation?

A

FDP:

median & ulnar

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89
Q

When do pinch and grip strength return to normal post CTS release?

A

Pinch: 6 weeks

Grip: 12 weeks (3 months)

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90
Q

Describe syndactyly vs. acrosyndactyly

A

Syndactyly is fusion of digits due to failure of apoptosis

Acrosyndactyly is where distally the digits are fused but they are open proximally

  • This represents normal apoptosis but something affecting it after (ie constriction band syndrome)
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91
Q

Which part of the LT ligament is the strongest?

A

Volar

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92
Q

In stage 2 Kienbock’s, what is the most sensitive test for staging?

A

CT: once sclerosis is visible on x-rays, CT scan is the most sensitive to detect fragmentation

MRI is only sensitive if there are no early changes (ie stage 1).

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93
Q

Compression sites for AIN (specifically AIN)

A

Lacertus fibrosis

2 heads of PT

FDS

Accessory muscle of Gantzer (FPL)

Accessory muscles from FDS –> FDP

Abberent muscles: FCRB, palmaris profundus

thrombosed ulnar artery

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94
Q

What vessel is dominant in the superficial arch?

A

Ulnar

It is distal

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95
Q

Jersey finger classification

A

Goes from worst to best

Type I: retraction to palm. Disrupted blood supply. Urgent repair

Type II: retracted to PIP. Blood supply intact

Type III: Bony avulsion

Type IV: double disruption (bony avulsion and tendon avulsion from bony fragment)

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96
Q

What is the primary and secondary stabilizers of the extensor tendon of the hand?

A

Primary: sagittal bands

Secondary: juncturae tendinae

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97
Q

In felon, which side of fingers do you incise when using a mid-lateral approach? Why?

A

2, 3, 4th: ulnar

1st, 5th, radial

These are the non-pressure bearing sides of the digit (ie when making pinch - except for 5th, which i don’t get, but that’s what it says)

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98
Q

What are the digitalcutaneous ligaments and what is their function?

A

Clelands and Graysons Ligaments

  1. tether skin to deeper layers of fascia and bone to prevent excessive mobility of skin and improve grip
  2. stabilize the digital neurovascular bundle with finger flexion and extension
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99
Q

3 radiographic signs of VISI

A

Scapholunate less than 30

Radiolunate > 15 volar

capitolunate > 15 degree

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100
Q

In Bennet/Rolando fracture, which fragment is kept reduced to the trapezium? What keeps it there?

A

Volar beak ligament keeps he volar-ulnar base fragment reduced to trapezium

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101
Q

Name 5 differences distinguishing cubital tunnel syndrome and guyon’s canal syndrome

A

Cubital tunnel has:

  • less clawing
  • sensory deficit to dorsum of hand
  • motor deficit to ulnar innervated extrinsic muscles also
  • Tinel’s sign above elbow
  • positive elbow flexion test
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102
Q

Ulnar clubhand associations

A

No systemic/medical associations

Orthopaedic:

  • absent ulnar digits
  • PFFD
  • fibular hemimeila
  • scoliosis
  • Phocomelia
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103
Q

what prevents reduction in distal phalanx fractures?

What do you do?

A

Nail matrix/bed

Nail removal, open reduction, nail replacement

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104
Q

List 3 treatments for Dupuytren’s, from best to worst in terms of recurrence:

A

Open surgery best

Then collaginase

Then needle aponeurotomy

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105
Q

5 dDx of ulnar sided wrist pain

A

DRUJ injury/arhtriits

TFCC tear

LT tear

Pisotriquetral arthritis

ECU tendonitis or instability

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106
Q

What are the 2 most common organisms in a fight bite? What is the other one that everyone talks about?

A

staph and Strep most common

Eikenalla corrodens is the other (gram -)

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107
Q

What deformity will become apparent if a PIP volar dislocation goes untreated?

A

Boutonniere deformity

b/c of concurrent Central slip rupture

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108
Q

What is the difference between radial tunnel syndrome and PIN syndrome

A

PIN syndrome: supinator is usually spared

(according to OB RTS is pain only whereas PIN syndrome is weakness as well)

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109
Q

What is Sauvé-Kapandji procedure and who would you offer it to?

A
  1. DRUJ fusion with creation of pseudoarthrosis proximally in the ulna
  2. Younge Labourers with ulnar abuttment syndrome
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110
Q

Brand Transfer: describe

A

PT –> ECRB

PL –> EPL (or FDS 4 –> EPL)

FCR –> EDC

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111
Q

4 treatment options for mallet finger

A

Nonoperative with extension splinting 6-8 weeks

CRPP vs. ORIF

Arthrodesis

Surgical reconstruction of terminal tendon

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112
Q

In calcium deposits of teh hand and wrist, what helps with quicker resolution?

A

Local anesthetic injection

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113
Q

If no bone is exposed, or if there is adequate volar tissue, what is th epreferred treatment for partial fingertip amputations?

A

Healing by secondary intention

Better outcomes vs. surgical in terms of 2 point discrimination

(JAAOS 2013)

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114
Q

What deformity will be apparent if a dorsal PIP dislocation goes untreated?

A

Swan-Neck

b/c of concurrent volar plate injury

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115
Q

LT ligament is strongest where?

A

Volarly

(that’s why you get a VISI with LT disruption - intact volarly)

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116
Q

What is a Stener lesion? How do you treat it?

A

Complete rupture of ulnar collateral ligament (both proper and accessory parts) and displacement above adductor aponeurosis

Requires surgery

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117
Q

Surgical management of ulnar clubhand

A

Syndactyly release and digital rotational osteotomy

  • Done at 12-18 months of age

Radial head resection and creation of 1 bone forearm

  • Done in Stage II to provide stability at the expense of forearm motion
  • There is no good option for restoring elbow motion
  • Corrective procedures should not be performed until the child is at least 6 months old

Osteotomy of the synosteosis

  • May be required in stage 4 to obtain elbow ROM
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118
Q

Differentiate AIN palsy from pronator syndrome and median nerve compression?

A

AIN: motor only

Median nerve palsy & pronator syndrome (which is median nerve compression specifically at SLLPS) witll both have motor and sensory symptoms

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119
Q

Treatment of Kienbock’s by stage

A

Early Disease: cure

I:

  • nonoperative

I, II, IIIa:

  • temporary scaphotrapezial pinning
  • joint leveling (ulnar lengthening, radial shortening)
  • vascularized bone grafts
  • distal radius core decompression

II, IIIA, IIIB:

  • STT fusion

Late Disease: salvage

IIIB, IV:

  • PRC

IV:

  • wrist fusion
  • total wrist arthroplasty
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120
Q

4 treatments for ulnar positive impingement (Abutment)

A

Ulnar shortenining osteotomy (most common)

wafer procedure (arthroscopic )

Darrach procedure (ulnar head resection)

Sauve-Kapandji procedure

Ulnar hemi-resectoin

Ulnar head replacement

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121
Q

Risk of poor outcome post replantation:

A

Mechanism of injury: most important

Male sex

Smoker

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122
Q

What resists lateral subluxation of extensor mechanism in the distal finger?

A

Triangular Ligament

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123
Q

What is the normal ratio of carpal height to 3rd metacarpal height?

A

0.54

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124
Q

Clinically, what is the most important pathologic structure in Dupuytren’s

A

Spiral cord

It causes contracture of the PIP

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125
Q

2 risks of failure in replantation after ring avuslion

A

repair of

vascular damage up to digital pulp

*smoking has NOT been found to be a factor

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126
Q

What do you do with Notta’s nodule during surgery?

A

Notta’s nodule = thickened FPL in trigger thumb

Leave it after release A1 pulley

Just make sure FPL glides well

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127
Q

Where do most injuries that result in quadregia occur?

A

Zone I

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128
Q

In ulnar neutral variance, what percentage of the load goes to the ulna and radius?

A

80% radius

20% ulna

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129
Q

Name the sequence of peri-lunate dislocation:

A
  • scapholunate ligament disrupted –>
  • disruption of capitolunate articulation –>
  • disruption of lunotriquetral articulation –>
  • failure of dorsal radiocarpal ligament –>
  • lunate rotates and dislocates, usually into carpal tunnel

*volar radiocarpal ligaments usually remain intact

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130
Q

What is the lumbrical plus position and 5 causes?

A

Paradoxical extension of IP joints while attempting to flex fingers.

(FDP is disrupted so when it is activated it still pulls on the lateral bands via the lumbricals, causing MCP flexion with no phalangeal flexion.)

  • FDP transection
  • FDP avulsion
  • DIP amputation
  • amputation through middle phalanx shaft
  • “too long” tendon graft
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131
Q

What is still intact in a axonotemesis that allows for better recovery compared to neurotemesis?

A

Endoneurium

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132
Q

Most common congenital hand difference?

A

Syndactyly

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133
Q

Tendon transfers for what nerve deficit have the most predictable results?

A

Radial nerve

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134
Q

After tendon re-rupture, what is the cutoff for revision primary repair vs. graft?

A

1cm

If

If >1cm of scar present: perform tendon graft

Is the sheath is intact and allows passage of a pediatric urethral catheter or vascular dilator, perform primary tendon grafting

If sheath is collapsed, place Hunter rod and perform staged grafting

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135
Q

3 surgical options for scaphoid nonunion

A

Inlay graft (Russe) if undisplaced

Interposition (Fisk) graft if humpback present (see picture)

Vascularized graft: 1-2 intercopmartmental supraretinacular artery of Zaideberg (branch of radial)

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136
Q

Describe Bunnell test

A

Intrinsic tightness test

Positive if PIP flexion less when MCP is in extension vs. flexion

b/c intrinsics are tight in extension so will not be able to flex PIP

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137
Q

Name the most sensitive and most specific test for CTS

A

Sensitive:

Durkan or Semmes-Weinstein monofilament

Specific

Self-administered hand diagram

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138
Q

Parents complain their infant has reduced forearm ROM and on exam their arm is fixed in pronation. After you tell them to quit their bitching, what diagnosis comes to mind?

A

Congenital radio-ulnar synostosis

Usually fixed pronation.

Observe unless bilateral and functional deficits.

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139
Q

5 Indications for ORIF of MC fractures

List the acceptable reduction criteria for each MC

A
  • Intra-articular fracture
  • Any malrotation
  • displaced fracture
  • failure of non-op (see reduction criteria)
  • Multiple MC fractures

Acceptable criteria

  • All: 2-5mm shortening
  • Index: 10 deg angulation
  • Long: 20 deg angulation
  • Ring: 30 deg angulation
  • Small: 40 deg angulation (50 if neck)
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140
Q

What is another name for the superficial transverse metacarpal ligament and what does it do?

A

natatory ligament

Resists hyper-abduction

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141
Q

What is the most common cause of CIND?

A

Carpal instability non-dissociative.

Most commonly caused by distal radius mal-union

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142
Q

2 approaches for pyogenic flexor tenosynovitis

A

Full open approach using long midaxial or brunner incision

Two small incisions distally at A5 pulley and proximally at A1 pulley and using an angiocatheter

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143
Q

Zone II injury to FDS & FDP

What do you repair?

A

FDP

1 strand of FDS

Improves gliding

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144
Q

What is the floor of Guyon’s canal? Why is it relevant?

A

Floor: transverse carpal ligament

relevant b/c if patient has both Guyon’s canal syndrome and carpal tunnel syndrome, you only have to release carpal tunnel

releasing the TCL will decompress guyon’s canal also

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145
Q

How many slips of FDS should you repair?

A

1

Leads to better gliding

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146
Q

How much can you divide the A2 & A4 pulleys?

A

You can divide the:

A2 pulley: 50%

A4 pulley: completely (100%)

without increasing the amount of the work the tendon needs to do

Advantageous in zone II flexor tendon repairs

(JAAOS 2014)

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147
Q

Treatment of thumb CMC arthritis with Z deformity (see picture)? Indications for your choice?

A

CMC resection arthroplasty/LRTI + MCP fusion

Indications for MCP fusion

  • thumb MCP hyperextension exceeds 40°
  • the deformity is not passively correctable
  • advanced degenerative changes are noted to affect the articulation
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148
Q

Function of volar plate?

A

Prevents hyperextension

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149
Q

Flexor Zone 2: how do tendons get blood supply?

A

Diffusion from synovial sheath

This occurs for any tendon within a sheath

Otherwise, direct vascular supply

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150
Q

Etiology of ulnar tunnel (Guyon’s canal) syndrome

A

Ganglia (most common in zone 2 & overall)

ulnar arterial thrombosis (most common in zone 3 - sensory)

Lipoma

GCT

intraneural cysts

Dupuytren’s

Trauma

Abnormal muscles:

Abnormal palmaris brevis/longus

Abn AbDM

Abn FDM

RA - pannus, edema, bony defomrity

Neuropathies (DM, EtOH, CRF, hypothyroid)

Iatrogenic

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151
Q

In volar approach to PIPJ, what pulleys need to be cut?

A

C1, A3, C2

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152
Q

4 treatment options for VISI/LT instability

A

Nonoperative (1st line)

CRPP + ligament repair + dorsal capsulodesis

LT Fusion (for chronic)

Arthroscopic LT debridement and ulnar shortening

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153
Q

Classification of radial longiduinal deficiency

A

Bayne & Klug

I: absent distal radial epiphysis (short distally)

II: absent distal and proximal radial epiphysis

III: Present proximally (partial aplasia)

IV: complete absence (most common)

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154
Q

In which stage of SLAC is the radiolunate articulation involved?

A

Trick question.

The RL articulation is typically NOT invovled.

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155
Q

Where does the palmar cutaneous branch of median cross the wirst crease?

A

lies between PL and FCR at level of the wrist flexion crease

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156
Q

Name 5 radiographic signs of scaphlunate injury/DISI

A

Terry thomas sign (clenched fist >3mm SL interval)

Signet ring sign

SL angle > 70 deg

Radiolunate angle >15 deg

Intrascaphoid angle > 35 deg

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157
Q

Preaxial polydactyly

Most common

second most common

Most associated with syndromes

A

Pre-axial polydactyly

Most common: IV

2nd most common: II

Most associated with syndromes: VII

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158
Q

What are three xray findings that suggest a dislocated radial head is congenital?

A

Posterior dislocation

Short/Bowed Radius

Large/Convex Radial Head

(also hypoplastic capitellum)

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159
Q

What are the 2 main blood supplies to the scaphoid?

A

Primary: dorsal carpal branch of radial artery (80%)

Secondary: superficial palmar branch of radial artery

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160
Q

Volar hand wound: what skin graft do you use?

A

FTSG

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161
Q

Pt with Symptoms:

Burning pain with morning stiffness

Exam:

Digital clubbing, abnormal deposition of periosteal bone, arthralgia, and synovitis.

X-rays:

Periosteal thickening

Periosteal elevation appears as a continuous sclerotic line of new bone formation.

Dx, Association, Treatment

A

Hypertrophic Pulmonary Osteoarthropathy

Associated with:

Lung Cancer (Bronchogenic Ca > NSCLC)

COPD

Treatment: Treat the underlying pathology (Resp)

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162
Q

First line of treatment in clasped thumb

A

stretching for all types x 3-6 months

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163
Q

What is the innervation of ECRB?

A

ECRB: PIN

vs: ECRL/BR: radial nerve proper

ECRB is shorter so gets innervated by the shorter nerve (PIN)

164
Q

What is an important contra-indication for ulnar shortening osteotomy for treatment of ulnar impaction?

A

DRUJ Arthrosis

165
Q

Patient with lateral elbow pain maximal 4cm distal to lateral epicondyle. Likely diagnosis?

A

Radial tunnel syndrome

THis has pain down the arm vs. lateral epicondylitis, which has point tenderness to lateral epicondyle

166
Q

Volar thumb fingertip amputation

what if it’s >2cm?

A

>2cm: first dorsal metacarpal artery flap

167
Q

How do you treat multiple syndactylies?

A

Staged, so to avoid vascular compromise

b/c you don’t want to dissect on both sides of a digit, where the NV bundle is

Treat ones with lonest length differences first to avoid growth disturbance

168
Q

What is handlebar syndrome?

Give 5 causes.

A

a) Ulnar nerve compression in Guyons canal (Ulnar Tunnel Syndrome)

b)

  1. ganglion cyst (80% of nontraumatic causes)
  2. lipoma
  3. repetitive trauma
  4. ulnar artery thrombosis or aneurysm
  5. hook of hamate fracture or nonunion
  6. pisiform dislocation
  7. inflammatory arthritis
  8. fibrous band, muscle or bony anomaly
  9. congenital bands
  10. palmaris brevis hypertrophy
  11. idiopathic
169
Q

In PIP fracture dislocation, does articular surface reduction influence outcome?

A

No

It is preferred but may not lead to better clinical outcomes

170
Q

CMC arthritis: 4 operative options (there are 7)

A
  • Volar ligament reconstruction
  • LRTI
  • CMC arthroscopy and debridement
  • Extension osteotomy of 1st MC
  • Trapeziometacarpal arthrodesis and fusion
  • Volar capsulodesis, EPB tendon transfer, sesamoid fusion or MCP fusion
  • Silicone replacement (not recommended)
171
Q

5 options for failed Darrach/Sauve-Kapandji

A

1 bone forearm

ECU tenodesis

Ulnar head arthroplasty (only if SK)

Radioulnar resection

Pronator quadratus transfer

172
Q

What is this deformity?

A

VISI

173
Q

Preferred management of Hamate body fracture

A

ORIF

Most are intra-articular

Vs. Hook of hamate fracture: ORIF does not play a role

174
Q

What joint is spared in scaphoid nonunion/SNAC?

A

radiolunate joint

175
Q

What is blocking an irreducible MCP dislocation?

A

Volar plate

and/or

Sesamoids

176
Q

Name 3 clinical differences between pronator syndrome and carpal tunnel syndrome

A

Pronator teres

  • involves palmar cutaneous branch of median nerve (palmar paresthesia)
  • has aching over proximal volar forearm
  • Lacks night symptoms
177
Q

With what motion does ECU sublux?

A

Supination with wrist in ulnar deviation

Relocates with pronation

178
Q

What is the cutoff between tendon debridement and tendon repair?

A

60%

>60% of the tendon injured: repair

179
Q

Hook of hamate fracture

Preferred x-ray image

Best treatment for acute vs. chronic injuries

A

X-ray: carpal tunnel view

Treatment

  • Acute: immobilization
  • Chronic: surgical excision (ORIF plays no role)
180
Q

4 good prognostic indicators for carpal tunnel

A

night symptoms

short incision

relief with steroid injections

Not improved with incomplete release of transverse carpal ligament

181
Q

Is this worrisome? Why?

If yes, what do you do?

A

Post-axial polydactyly in caucasians is worrisome and suggests need for further genetic workup

In blacks, it is normal

182
Q

3 risk factors for trigger finger

A

RA

DM

Amyloidosis

183
Q

What does the AIN innervate?

A

Deep volar forearm compartment

FPL

FDP (radial 2)

PQ

184
Q

What are the deforming forces after Bennet/Rolando fracture?

A

Abductor pollicis longus

Extensor pollicis longus

Adductor pollicis

Causes

  • the shaft to be pulled into adduction
  • The MC base to be supinated
185
Q

5 surgical options for fracture dislocated PIP joint

A

ORIF

Hamate autograft

Dynamic distraction ex-fix

Volar plate arthroplasty

Arthrodesis

186
Q

How do you transport an amputated digit?

A

Any salvageable tissue should be transported with the patient to the hospital

Modality:

  • Keep amputated tissue wrapped in moist gauze in lactate ringers solution
  • Place in sealed plastic bag and place in ice water
  • Avoid direct ice or dry ice
  • Wrap, cover and compress stump with moistened gauze
187
Q

What is this deformity?

A

DISI

188
Q

Contents of the carpal tunnel

A

FDP

FDS

FPL

Median nerve

189
Q

For multiple digit amputations (ie multiple fingers), what’s the best sequence to repair?

A

Structure by structure is best

Digit by digit takes the most time

190
Q

The recurrnet brach of median nerve is most commonly: (anatomy with respect to TCL)

A

Extraligamentous with recurrnet innervation

191
Q

What approach would you use to I&D an IP joint infection? MCP joint?

A

IP: midaxial incision

MCP: dorsal midline

192
Q

Presentation of AIN Compression

A

painless motor weakness

AIN is a pure motor nerve

193
Q

Rupture of what two ligaments leads to VISI?

A

Lunotriquetrial and Dorsal Radiotriquetrial

194
Q

A man complains that his middle finger extends while he holds a beer can. People find this offensive. He has a history of middle finger DIP traumatic amputation.

What is happening?

A

Lumbrical Plus Finger

He has lost insertion of FDP. When FDP is activated to flex the finger this results in unopposed Lumbrical action beacuse they oriigante on FDP. This paradoxically extends the finger.

Treatemnt is FDP repair versus lumbrical release in the palm.

195
Q

In flexor tendon injuries of the thumb, what are the outcomes of early ROM protocols?

A

No improvement in long term outcomes

vs. other fingers: early ROM exercises are the gold standard

196
Q

Indication for antibiotics in animal bites

A

Cat bites

Presentation >8 hours

Immunocompromised (including diabetics)

Hand bite

Deep bites

197
Q

3 symptoms that differentiate pronator syndrome from CTS?

A

Pronator will have:

  1. aching pain over proximal volar forearm
  2. sensory disturbances over the distribution of palmar cutaneous branch of the median nerve (palm of hand) which arises 4 to 5 cm proximal to carpal tunnel
  3. lack of night symptoms
198
Q

Outcomes of corticosteroid vs saline vs hyaluronic acid injections for CMC arthritis

A

No difference

199
Q

Froment’s Sign. What is it?

A

thumb IP joint flexion in attempted key pinch

ulnar nerve palsy

200
Q

Function of deep transverse metacarpal ligament?

A

Resist hyper-abduction at MCP

201
Q

2 options for SL reconstruction

A

FCR tendon transfer (Brunelli) (direct reconstruction)

ECRB Tenodesis (indirect reconstruction)

+Blatt capsulodesis (adjunct)

202
Q

Dorsal hand wound: what skin graft do you use?

A

STSG

203
Q

Patient with finger replantation and swelling. Treated with leeches. Gets septic. Cause and treatment?

A

Aeromonas hydrophilia infection from leech therapy

Should have been put on gram negative coverage during leech therapy (PO cipro)

204
Q

Name 7 radiographic signs of scapholunate ligament injury:

A

Widening of SL interval > 3mm

DISI

Loss of colinearity of lunate & capitate & 2nd MC

scaphlunate angle >70 degrees

Intrascaphoid angle >35 degrees (humpback)

cortical ring sign

Abnormal carpal height ratio:

  • Carpal height is distance between distal articular surface of capitate to distal radial articular surface
  • carpal height ratio = carpal height/length of 3rd MC
  • Normal is 53%
205
Q

3 indications for ulnar nerve decompression with transposition

A

Failed in situ release

Throwing athlete

patient with poor ulnar nerve bed (from tumour, osteophyte or HO)

206
Q

Describe position of digital nerves and arteries in the palm and digits of the hand:

A

Palm: arteries are volar to nerve

Digits:

  • nerve is volar
  • Entire NV bundle is volar to Cleland’s ligament
207
Q

4 structures that insert on the lateral bands?

A
  1. lumbricals
  2. extensor indicis
  3. dorsal interossei
  4. palmar interossei
208
Q

What syndrome is associated with FGFR2?

(Hint: Various body parts fail to “come apart” during formation)

A

Apert Syndrome

209
Q

Explain when you would use volar versus dorsal approach for scaphoid ORIF?

A

dorsal approach

  • indicated in proximal pole fractures
  • care must be taken to preserve the blood supply when entering the dorsal ridge by limiting exposure to the proximal half of the scaphoid
  • percutaneous has higher risk of unrecognized screw penetration of subchondral bone

volar approach

  • indicated in waist and distal pole fractures and fractures with humpback flexion deformities
  • allows exposure of the entire scaphoid
  • uses the interval between the FCR and the radial artery
210
Q

5 sites of compression of PIN

A

Fibrous bands anterior to radiocapetellar joint

  • Between brachialis and brachioradialis

Aka recurrent radial vessels at level of radial neck

  • Leash of Henry

ECRB edge

Arcade of Frohse

  • Proximal edge of superficial Supinator

Supinator muscle edge

  • Distal edge
211
Q

Diagnosis:

Hypertelorism + this picture

A

Apert Syndrome

Hypertelorism = side set facial features = dysmorphic facies

Hand = rosebud hands

central 3 fingers share a common nail.

212
Q

Guyon Canal zones and implications in compression

A

I: mixed

II: motor only

III: Sensory only

Goes from worst to best

213
Q

What type of collagen forms tendons?

A

Type I

214
Q

If grafting a nerve, how much longer than the gap should the graft be?

A

10%

It will shrink with fibrosis

215
Q

Describe Elson’s test - what is it used for?

A

Tests for Central slip rupture

Bend PIP 90° over edge of a table and extend middle phalanx against resistance. in presence of central slip injury there will be

weak PIP extension

the DIP will go rigid

in the absence of central slip injury DIP remains floppy because the extension force is now placed entirely on maintaining extension of the PIP joint; the lateral bands are not activated

216
Q

In high pressure injuection injuries of the hand, what is the amputation rate with injected oil paints

A

near 50%

217
Q

What are the motor weaknesses associated with radial tunnel syndrome?

A

None

It is PAIN ONLY

218
Q

Which scaphoid approach causes less risk of AVN? Why?

A

Volar

b/c avoids main dorsal supply (dorsal carpal branch of radial artery)

219
Q

What zone does a Fight Bite occur in? What is mandatory treatment?

A

Extensor Zone 5

Must do I&D with exploration of the joint + antibiotics

220
Q

Give 1 operative and 1 non-operative treatment for swan neck deformity.

A

1) operative = volar plate advancement and central slip tenotomy
2) non-operative = double ring splint (keeps PIP in extension

221
Q

Ulnar clubhand classification

A

Bayne Classification

0: deficiencies of the carpus and/or hand only
1: undersized ulna with both growth centers present
2: part of the ulna is missing (Typically distal ulna is absent)
3: absent ulna
4: radiohumeral synostosis

Subtypes based on 1st websace for each type:

A: normal webspace

B: mild deficiency

C: Moderate to severe deficiency of webspace

D: absent webspace

222
Q

What is the normal radiolunate angle? What does an abnormality indicate?

A

Should be colinear ± 15 deg

ABnormality indicates VISI/DISI

223
Q

How does the immediate pre-operative care for carpal tunnel release differ from virtually every other ortho procedure?

A

prophylactic antibiotics, systemic or local, are not indicated for patients undergoing a clean, elective carpal tunnel release

224
Q

Location of physis disruption in Madelungs

A

Disruption of volar ulnar physis

±Vicker’s ligament

225
Q

Good prognostic factors in peripheral nerve injuries:

A

Children

Stretch injuries

Sharp transections that have been repaired within 14 days

Clean, well-vascularized wound beds

Early, direct surgical repair

226
Q

What approach do you use for open reduction of MCP dislocations?

A

Dorsal

Even when the MC head is volar

Prevents risk of injury to the neurovascular bundle

227
Q

What are some prognostic factors for melanoma?

Which is most important?

A

poor prognostic factors for melanoma

  1. deep lesion
  2. male sex
  3. lesion on neck or scalp
  4. positive lymph nodes and metastases
  5. ulceration

**Depth is most important (> 4 mm has

228
Q

In pre-axial polydactyly, which digit is usually smaller?

A

radial

usually take off the small, radial one

229
Q

Describe the Bunnell test.

A

Bunnell test (intrinsic tightness test)

  • differentiates intrinsic tightness and extrinsic tightness
  • positive test when PIP flexion is less with MCP extension than with MCP flexion
230
Q

Best test for scaphoid fractures, acute and late (>3 days)

A

Acute: MRI

Chronic (after 3 days): Bone scan (98% specific, 100% sensitive)

231
Q

Describe the following syndactylies:

Simple

Complex

Complicated

Complete

A

Simple: only skin involved

Complex: Skin & bone involved (adj. phalanges)

Complicated: abnormal bone or soft tissue involve (ie abn phalanges)

Complete: extends all the way to tip of finger (vs. incomplete)

232
Q

What centralizes the extensor mechanism during flexion of MCP?

A

Saggital bands

233
Q

Indications for operative management of mallet finger injury (3)

A

Absolute:

  • Volar subluxation of distal phalanx

Relative

  • >50% of joint involved
  • >2mm articular gap
234
Q

Indications for fasciotomy

A

Absolute compartment pressure 30-45mmHg

Compartment pressure witin 30mmHg of preoperative diastolic pressure

235
Q

Primary lesion in Boutonniere’s deformity

Briefly (3 stages) describe the pathoanatomy

A

Primary lesion: rupture of central slip

  1. Rupture of central slip
  2. Attenuation of triangular ligaments
  3. Palmar migration of collateral bands and lateral bands

=all flexion going through

236
Q

How do tendons get nutrition?

A

synovial sources > vascular sources

237
Q

Principles of management in high pressure injection injuries of the hand (6)

A

High index of suspicion

Low threshold for surgery

Broad spectrum IV antibiotics

Leave wounds to heal by secondary intention

Early motion

Twice daily hand soaks in poviodine or sterile water

238
Q

Name the deficits with a high median nerve palsy:

A

Loss of thumb IP flexion (FPL)

Loss of index and long DIP flexion (FDP to index & long)

Loss of PIP flexion to index, long, ring, little finger (FDS)

Thumb opposition (opponens pollicis & APB)

239
Q

Initial management of high pressure injureis to the hand

A

elevation of the limb (can cause compartment syndrome)

tetanus prophylaxis if needed

systemic prophylactic antibiotics

analgesia

Leave wounds open

240
Q

Outcomes of in-situ ulnar nerve decompression vs. decompression & transposition

A

same outcomes but higher complications with transposition

Mainstay is in-situ

241
Q

What is Durkan’s test?

A
  1. is the most sensitive test to diagnose carpal tunnels syndrome
  2. performed by pressing thumbs over the carpal tunnel and holding pressure for 30 seconds.
  3. onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result.
242
Q

Name Kanaval’s Cardinal Signs

A

For flexor pyogenic tenosynovitis

4 signs:

  • Flexed posture of the involved digit
  • tenderness to palpation over the tendon sheath
  • pain with passive extension of the digit
  • fusiform swelling of the digit

Will also have increased warmth and erythema, but these are not technically part of Kanaval’s signs

243
Q

Replantation: absolute & relative CONTRAindications (4/5)

A

Absolute

  • Severe vascular disorder
  • Mangled limb or crush injury
  • Segmental amputation
  • Prolonged ischaemia time with large muscle content (>6 hours)

Relative:

  • Single digit proximal to FDS insertion (Zone II)
  • Medically unstable patient
  • Disabling psychiatric illness
  • Tissue contamination
  • Prolonged ischaemia time with no muscle content (>12 hours)
244
Q

How do you clinically differentiate cubital tunnel (or elbow) ulnar nerve compression vs. guyon’s canal compression?

A

Presence of dorsal hand symptoms (numbness) suggest elbow entrapment

b/c

dorsal ulnar cutaneous branch of ulnar nerve branches proximal to Guyon’s canal, therefore Guyon canal entrapment spares dorsal hand

245
Q

4 causes of Swan neck specifically in RA hand

A

MCP subluxation

PIP volar plate attenuation

Triangular ligament rupture

FDS rupture

246
Q

Definition & Treatment for Presier’s disease

A

Scaphoid AVN

Nonoperative

Microfracture, revascularization or allograft

Scaphoid excision + 4CF or PRC

247
Q

What is this transfer?

What is the eponym?

Why would you do it?

A

FDS of ring finger –> APB tendon (use FCU as pulley)

Bunnels Opponensplasty

Low Median Nerve Palsy

(Other option is EIP to APB)

248
Q

General principles in treating tendon injuries if:

Full ROM of joint

Rigid joint

A

Full ROM: Tendon repair/transfer

Rigid: Fusion

249
Q

What is the local vascularized bone graft option for scaphoid non-unions?

A

1-2 intercompartmental supraretinacular artery (branch of radial artery)

250
Q

What is the general rule for early ROM protocols?

(for flexor tendon repair)

Name one of these protocols:

A

Low force, low excursion

Kleinert or Duran

251
Q

Shortening of how much of hte FDP will result in quadregia?

A

1cm

252
Q

What is the excursion of the:

Finger flexors

Finger extensors & EPL

Wrist flexors/extensors

A

Finger flexors: 70mm

Finger extensors & EPL: 50mm

Wrist flexors/extensors: 33mm

253
Q

What are two surgical options for carpal tunnel release?

A

open

endoscopic

Outcomes equivalent

254
Q

Name 3 side effects unique to collaginase treatment for Dupuytren’s

A

Skin tearing

Pruritic rash

Lymphadenopathy

255
Q

Thenar Flaps:

Indications/contraindications

Pros/Cons

A

Indication:

Used for coverage of digital tip injuries where there is exposed bone or extensive pulp loss.

Advantages include:

  • More subcutaneous fat than a cross finger flap
  • Good color and texture match
  • Primary closure of the donor site

Disadvantages include:

  • Limited flap size (2cm wide and should be 1.5x the width of the defect so it can wrap around it)
  • Donor site tenderness

Contraindications include

  • RA
  • Dupuytren’s contracture
  • advanced age with degenerative disease
    • These predispose to joint stiffness.
256
Q

Name 3 signs of ulnar nerve injury:

A

Froment’s sign: recruitment of FPL with loss of adductor pollicis

Wartenberg sign: little finger abduction due to unopposed pull of EDM (radial)

Inability to cross the fingers

Ulnar claw hand (if low ulnar nerve palsy)

Loss of ulnar sensory distribution

257
Q

Stable positions for volar & dorsal DRUJ instability?

A

Volar: stable in pronation

Dorsal: stable in supination

258
Q

5 sites of compression of the ulnar nerve

A

Between 2 heads of FCU (most common)

Arcade of struthers (hiatus in medial intermuscular septum)

Cubital tunnel (btw Osborne’s ligament (roof) & MCL (floor))

Medial epicondyle

Deep flexor/pronator aponeurosis

Anconeus epitrochlearis

Aponeurosis of FDS proximal edge

External sources

  • Fracture and medial epicondyle nonunions
  • osteophytes
  • HO
  • tumours
259
Q

Why do you get 4th/5th finger clawing in low ulnar nerve palsy?

A

Preserved ulnar FDP with loss of hand intrinsics

Leads to unopposed flexion of 4th/5th digits

260
Q

Fingertip amputation and flexor or extensor tendon insertions cannot be preserved. Next move?

A

DIP disarticulation and flap (V-Y flap)

261
Q

Patient has pain around the hamate. What 2 x-rays in addition to AP/Lat can aid in diagnosis?

A

Carpal Tunnel View = r/o hook of hamate

30 degree oblique = assess body of hamate

262
Q

Patient has bilateral AIN motor weakness. In the past week he has bad intense shoulder pain and malaise and fever. Diagnosis?

A

Parsonage-Turner syndrome

Viral Brachial plexus neuritis

Classic story in question stem

263
Q

Classification of clasped thumb

A

Tsuyuguchi

264
Q

What tendon does the pisiform live in?

A

FCU

265
Q

In LRTI, what are you trying to recreate?

A

Anterior oblique (volar beak) ligament

This is the “ligament reconstruction” part of the procedure

266
Q

Compartments of forearm

Descrbe fasciotomy

A

Volar

Dorsal

Mobile wad

Fasciotomy:

Volar: start radial to FCU, curvilinear incision ending at medial epicondyle

Mobile wad: over mobile wad, starting 2cm distal to lateral epicondyle, dissecting between EDC & ECRB

267
Q

What is the only ligament spared in Dupuytren’s disease?

A

Clelands ligament

268
Q

Pathoanatomy of intrinsic minus hand

A

Clawhand

Tight extrinsic extensors

Weak intrinsics

=MCP hyperextension & DIP/PIP flexion

269
Q

How will someone with PIN syndrome present?

A

Wrist extension in radial deviation

b/c ECU and ECRB and EDC are gone

Only extensor left is ECRL (Radial proper)

270
Q

3 surgical options for clasped thumb

A

Tendon transfer

  • EIP –> EPL

Thumb reconstruction with:

  • widening 1st webspace
  • deepening of 1st webspace
  • tendon transfer

Arthrodesis

271
Q

Name some predictors of poor outcomes in peripheral nerve injuries

A

Elderly

Crush/blast injuries

Infected wound beds

Poorly vacularized wound beds

Delayed surgical repair (>14 days)

272
Q

What is a Riche Cannieu Anastomosis?

A

Ulnar to median nerve anastomosis

273
Q

Describe compartments of hand

Describe hand fasciotomy incisions

A

10 compartments of the hand

1x thenar

1x adductor pollicis

1x hypothenar

3x palmar interosseous

4x dorsal interosseous (go dorsal, side with more compartments)

Fasciotomy

4 incision technique

Dorsal over 2nd & 4th MC to decompress volar/dorsal interossei & adductor

Longitudinal midaxial over 1st MC - thenar

Longitudinal midaxial over 5th MC - hypothenar

274
Q

Is claw hand worse in high or low ulnar nerve palsy?

A

Low palsy.

This is because in a low palsy the extrinsic flexors are spared so there is a larger imbalance between extrinsics and intrinsics.

275
Q

What are the primary and secondary stabilizers of the extensor tendon at the MCP joint ?

A

Primary: Sagittal band

Secondary: Juncturae tendinum

276
Q

What blocks reduction of a dorsal PIP & DIP dislocation?

A

Volar plate

277
Q

Dorsal dislocation of PIP or DIP: what are the common blocks to reduction for a closed vs. open injury

A

Closed: volar plate

Open: FDP tendon

278
Q

2 options for treatment of sagittal band ruptures:

A

Acute:

  • extension splinting x 4-6 weeks

Chronic:

  • Direct repair
  • centralization procedure
279
Q

Options for MCP hyperextension deformity (ie with CMC arthritis)

A

0° to 10°

  • Surgical intervention is not necessary when MCP hyperextension is less than 10°.

10° to 20°

  • Percutaneous pinning of the MCP joint in 25° to 35° of flexion for 3-4 weeks may be performed independently or as an adjunct to EPB transfer.

20° to 40°

  • Capsulodesis of the volar aspect of the MCP joint is recommened to provide a check rein for hyperextension and Sesamoidesis has also been investigated as an adjunctive procedure.
280
Q

What’s the most common tendon used in LRTI? What is an alternative?

A

FCR most common

can use APL or PL

281
Q

What is the first muscle innervated by the radial nerve in the forearm? The last? What is the last testable nerve innervated by the radial nerve?

A

1st: brachioradialis
last: extensor indicus proprius (EIP)

Last testable muscle: EPL

282
Q

4 risk factors for Kienbock’s

A

History of trauma/repetitive trauma

Vascular supply pattern (I > Y > X)

Ulnar negative variance

Abnormal lunate geometry

283
Q

Acceptable time to replantation

A

Proximal to carpus:

  • Warm ischaemia time less than 6 hours
  • Cold ischaemia time less than 12 hours

Distal to carpus (digit)

  • Warm ischaemia time less than 12 hours
  • Cold ischaemia time less than 24 hours
284
Q

What is an Elson test used to diagnose?

A

Central slip injury prior to development of Boutienniers deformity.

  • bend PIP 90° over edge of a table and extend middle phalanx against resistance.
    • in presence of central slip injury there will be
      • weak PIP extension
      • the DIP will go rigid
285
Q

5 risk factors for carpal tunnel syndrome

A

Female

obesity

pregnancy

hypothyroidism

RA

Diabetes

Amyloidosis

Age

smoking

EtOH

repetitive motion activities

Mucopolysaccharidoses

Mucoliposis

286
Q

3 surgical options of ulnar nerve compression

A

In situ release

release with transposition

medial epicondylectomy

287
Q

What is congenital clasp thumb?

A

Absence of EPL ± EPB
1st web space contracture
Associated with Arthrogyposis

Not the same as trigger thumb

288
Q

Describe the Mayfield classification for perilunate dissociation.

A

Stage 1: scapholunate dissociation

Stage 2: +lunocapitate disruption

Stage 3: +lunotriquetral disruption = perilunate

Stage 4: Lunate dislocated from lunate fossa

289
Q

What scapholunate angle is diagnostic of VISI deformity?

A

SL less than 30 degrees

They are colinear b/c the scaphoid is flexed so they are both pointing down

290
Q

Order of repair in finger amputation (structures)

A

Bone fixation ± shortening

Extensor tendon repair

Artery repair

Repair second after bone if ischaemic time is >3-4 hours

Venous anastomoses

Flexor tendon repair

Nerve repair

Skin ± fasciotomy

(beavfns)

291
Q

What is the purpose of moving CTS incision ulnarly in line with the 4th MC?

A

Avoid damage to the recurrent branch of median nerve

292
Q

Classification of ring avulsion injuries

A

Urbaniak

I: circulation adequate

  • treat with standard bone and soft tissue care

II: circulation inadequate

  • treat with vessel repair

III: complete degloving

  • treat with amputation
  • Note that inadequate circulation with bone, tendon or nerve injury is a type III
293
Q

Name the sites of entrapment for AIN palsy

A

Tendinous edge of deep head of PT (most common)

FDS arcade

Lacertus fibrosis

Accessory head of FPL (Gantzer’s muscle)

Accessory muscle from FDS to FDP

Abberant muscles (FCRB, palmaris profundus)

Thrombosed ulnar radial or ulnar artery

294
Q

What is the fatal association with radial longitudinal deficiency?

A

Fanconi anemia

CBC, blood smear, chromosomal analysis

295
Q

Can DISI be seen in uninjured wrists? WHat about VISI?

A

DISI = no, it is always traumatic

VISI = yes, can be seen in hyperlax people without injury

296
Q

Patient comes in with pain over the MCP and snapping of their Extensor tendon. What injury does he have? What sided injury does he have?

A

Likely radial sagittal band rupture

radial > ulnar

297
Q

What is the treatment for impending rupture of a DIP mucust cyst secondary to OA?

A
  1. cyst excision and osteophyte resection
  2. may need to do local rotational flap for skin coverage
298
Q

Name 4 types of opponensplasties

A

Helps recreate opposition

FDS opponensplasty: FDS 4 –> APB

EIP opponensplasty: EIP –> APB

abductor digiti minimi (Huber) transfer: ADM –> APB

PL (Camitz) transfer: PL –> APB

299
Q

3 options for Stage IV lunate AVN

A

Stage IV: adjacent intercarpal arthritis

  • Proximal row carpectomy
  • wrist fusion
  • total wrist arthroplasty
300
Q

In Dupuytren’s, what do the central and lateral cords do?

A

Central cord: PIP contracture

Lateral cord: PIP & DIP contracture

Cords are just pathologic bands/ligaments

ie lateral bands normall affect PIP and DIP

301
Q

What is Wartenberg syndrome?

A

Neuritis of superficial sensory branch of radial nerve

between ECRL & BR (memory tool: the two that are innervated by radial nerve)

302
Q

In flexor zone 2 of the hand, the FDS and FDP run in __________ tendon sheath(s)

A

The same

303
Q

Most high pressure injection injuries are on which hand?

A

Non-dominant

(As it’s holding stuff)

304
Q

Radial clubhand Surgial management and indications/criteria

A

Ulnar centralization ± tendon transfers

Done at 6-12 months if:

  • Good elbow ROM & biceps intact

Contraindicated in:

  • older patient with good function
  • Patient with elbow extension contracture who relies on radial deviation
  • Proximate terminal condition
305
Q

What is the imbalance in a claw hand?

A

AKA intrinsic minus hand

Extrinsics overpower intrinsics.

Either from ulnar or median nerve injury.

EDC, FDP and FDC >> Intrinsics

Leads to MCP extension and DIp,PIP flexion.

306
Q

What is Mannerfeldt’s syndrome? It’s treatment?

A

FPL rupture

Treatment: FDS –> FPL transfer

307
Q

Name 4 features of carpal synostosis

A

More common in females

More common blacks

Lunotriquetral most common

Often bilateral

Due to delay in the natural programmed cell death leading to joint cavitation

308
Q

Preferred treatment for severe MCP RA of fingers?

A

MCP arthroplasty

Thumb only if there is IP joint involvement

309
Q

Pathophysiology and treatment of trigger thumb

A

Enlarged FPL tendon

Treatment is release of A1 pulley

No need to resect nodule

Vs. trigger finger: caused by inflammation of tendon sheath

310
Q

In Dupuytren’s, what displaces the NV bundle?

which way is the NV Bundle displaced?

A

Spiral cord

Displaces NV bundle central and superficial

311
Q

Name the pathologic structure in Dupytren’s causing webspcae contraction:

A

Natatory cords

312
Q

What are the types of carpal instaibility non-dissociative (CIND)

A

Volar CIND (volar carpal ligament insuffiency)

Dorsal CIND (dorsal carpal ligament insufficiency)

Combined CIND (volar & dorsal carpal ligament insufficiency)

Adaptive CIND (secondary to fracture malunion (often distal radius))

313
Q

Diagnosis

Associated syndrome

A

Symbrachydactyly

COmbination of syndactyly and brachydactyly

Associated with Polands syndrome

314
Q

Sectioning of which sagittal band produces dislocation of extensor tendon?

A

Radial

specifically proximal radial

315
Q

5 specific signs of Ulnar nerve palsy:

A
  1. weakened grasp
    * from loss of MP joint flexion power
  2. weak pinch
    * from loss of thumb adduction (as much as 70% of pinch strength is lost)
  3. Froment sign
  • compensatory thumb IP flexion by FPL (AIN) during key pinchcompensates for the loss of MCP flexion by adductor pollicis (ulna n.)
  • adductor pollicis muscle normally acts as a MCP flexor, first metacarpal adductor, and IP extensor
  1. Jeanne sign
  • compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch
  • compensates for loss of IP extension and thumb adduction by adductor pollicis (ulna n.)
  1. Wartenberg sign
    * persistent small finger abduction and extension during attempted adduction secondary to weak 3rd palmar interosseous and small finger lumbrical
  2. Masse sign
    * palmar arch flattening and loss of ulnar hand elevation secondary to weak opponens digiti quinti and decreased small finger MCP flexion
316
Q

Classifiation of Perilunate injury

A

Mayfeld classifation

I: SL dissociation or scaphoid fracture

II: I + lunocapitate dislocation

III: II + lunotriquetral injury or triquetral fracture

IV: Frank dislocation

317
Q

Finger amputation order of repair (in multiple)

A

Thumb (most important)

Long

Ring

Small

Index

318
Q

Replantation: Absolute &relative indiations (5/3)

A

Absolute:

  • Thumb at any level
  • Multiple digits
  • Through the palm
  • Wrist level or proximal to wrist
  • Almost all parts in children

Relative:

  • Individual digits distal to the insertion of FDS (Zone I)
  • Ring avulsion
  • Through or above elbow
319
Q

What is the Jeanne Sign?

A

Compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch

Compensates for loss of Adductor Policis in

Ulnar nerve palsy

320
Q

Most common direction of MCP dislocation?

A

Dorsal

321
Q

Name 4 provocative tests for pronator syndrome

A

+ Tinel’s sign in anterior forearm

Resisted elbow flexion with forearm in supination (bicipital aponeurosis)

Resisted forearm pronation with elbow extended (PT)

isolated long finger PIP joint extension (FDS)

322
Q

What is intersection Syndrome?

A

Inflammation at the intersection of the 1st/2nd dorsal extensor compartments

Pain 6cm proximal to radial styloid

323
Q

What is the name of this phenomena and which finger is the pathologic one?

A

Quadrigia effect.

D3 FDP tendon is relatively short, which limits the excursion of D2 and D4 FDP meaning they cant flex all the way. Could also happen at D4 or D5.

324
Q

Name 3 associated conditions of clasped thumb

A

Lower limb:

  • Contenital vertical talus
  • Congenital talipes equinovarus (bilateral)

Upper extremity

  • Flexion defomrities of the 4 fingers

Syndromes

  • Arthrogryposis
  • Digitotalar dysmorphism
  • Freeman-Sheldon syndrome
  • X-linked MASA syndrome
325
Q

Name 3 indications for operative management of acute scaphoid fracture:

A

>1mm displacemenet

intrascaphoid angle >35 degrees (humpback deformity)

trans-scaphoid perilunate dislocation

Proximal pole fracture (relative)

326
Q

List the components of the TFCC.

A
  1. dorsal and volar radioulnar ligaments
    • deep ligaments known as ligamentum subcruentum
  2. central articular disc
  3. meniscus homolog
  4. ulnar collateral ligament
  5. ECU subsheath
  6. origin of ulnolunate and ulnotriquetral ligaments
327
Q

What is Wartenberg’s SIGN

A

abduction of little finger due to ulnar nerve injury

Due to loss of intrinsics and unopposed pull of EDM (radial nerve)

328
Q

There are mnay risk factors for carpel tunnel.

Name 5.

A
  • female sex
  • obesity
  • pregnancy
  • hypothyroidism
  • rheumatoid arthritis
  • advanced age
  • chronic renal failure
  • smoking
  • alcoholism
  • repetitive motion activities
  • mucopolysaccharidosis
  • mucolipidosis
329
Q

Most common direction of DRUJ dislocation/instability?

A

Dorsal

330
Q

3 conditions associated with Dupuytren’s disease

(i.e. conditions that they get, not causes of dupytrens)

A

Ledderhose disease (plantar fascia)

Peyronie’s disease (dartos fascia of penis)

Garrod disease (Knuckle pads)

I.E. Adrians Fetish Triad

331
Q

What percentage of ganglions spontaneously resolve in 1 year in pediatric patients?

A

76 %

332
Q

Zone of injury for Mallet Finger

A

Extensor zone 1

333
Q

Name the extensor zones of the hand

A
334
Q

What are the principles of tendon transfer?

A

Joint to be corrected/must be supple

Donor must be expendable

Donor must be of similar excursion and power

  • Finger flexors: 70mm
  • Finger extensors and EPL: 50mm
  • Wrist flexors & extensors: 33mm

A muscle should not be used for transfer unless it is 85% of normal strength

  • Ie in the case of muscle reinnervation

One transfer should perform 1 function

Synergistic transfers if possible (easier to rehab)

Maintain a straight line of pull

One grade of motor strength will be lost after transfer

Attach end-to-end if no recovery of native muscle expected & end-to-side if recovery expected

335
Q

Name the pathologic strucutures in Dupuytren’s causing contraction of MCP, PIPs, DIPs, respectively,

A

MCP: Central cord

PIP: Spiral cord

DIP: Retrovascular cord

336
Q

Blocks to reduction for volar PIP dislocation/fracture-dislocation

A

Lateral bands?

Can’t find reference but it says so on an old exam

337
Q

Radiolunate and scapholunate angles in VISI?

A

Radiolunate: greater than 15

Scapholunate less than 35

338
Q

Radiolunate and scapholunate angles in DISI?

A

Radiolunate less than 15 degrees

Scapholunate less than 60 degrees

339
Q

1 contraindication to ulnar shortening ostoetomy

A

DRUJ arthritis

340
Q

What is a Martin-Gruber anastomosis?

A

Anstomosis where median crosses to innervate muscles normally innervated by ulnar nerve

So Median to Ulnar anastomosis

341
Q

Best medical agent to prevent reperfusion injury?

A

Allopurinol

Due to mechanism being the creation of Xanthine. Allopurinol decreases xanthine production

342
Q

What are the 3 parts of the SL ligament?

Which is the strongest?

A

Dorsal, volar, proximal

Dorsal is the strongest

343
Q

4 conditions assocated with positive ulnar variance

A

Scapholunate dissociation

TFCC tears

LT ligament tears

Radial shortening from previous Colles fractures

344
Q

What does a + Elson’s test imply?

A

Zone 3 injury with disruption of the central slip

345
Q

Name the reduction maneuver for MC neck fractures

A

Jahss

MCP flexion to 90 deg

Reduction of neck by dorsal pressure through PIP while stabilizing MC

346
Q

What are the two Collateral MCP Ligaments?

A

Accessory Ligament (stabilizes in extension)

Proper Ligament (stabilizes in flexion)

347
Q

Characteristics and sensitivieis of Eikenella Corrodens

A

Facultative anaerobe

Gram negative

Sensitivies:

Penicillin (answer to most test questions)

2nd generation cephalosporins

tetracycline

ampicillin

carbenicillin

Resistance:

Methicillin (naficillin)

clinda

gent

erythromycin

chloramphenicol

348
Q

Classification for PIP fracture dislocation:

A

Hasting’s classification

Based on amount of P2 articular surface involvement

Type I: stable

Type II: Tenuous

  • 30-50%: treat as type I if reducible

Type III: Unstable

  • >50%:
  • ORIF
  • Hamate autograft

volar plate arthroplasty

349
Q

Poor prognostic indicators for high-pressure injection injuries to the hand (5)

A

Greater injection pressure >1000PSI

Presence of secondary infection

More distal injection

Material injected: industrial solvents and oil based paints cause more necrosis

Time to surgery >10 hours

350
Q

Name 6 things associated with DRUJ injuries:

A

Distal radius fractures (common)

Ulnar styloid and distal ulna fractures

TFCC tears

Ulnar impaction syndrome

Essex-Lopresti injuries

Galeazzi fractures

351
Q

Gold standard for Dupuytren’s disase?

A

Regional subtotal fasciectomy

352
Q

In I&D of felon why do you keep distal to DIP joint crease? 2 reasons

A
  1. prevent contracture of DIPJ
  2. Prevent violation & extension of infection in flexor sheath
353
Q

4 Requirements for tendon reconstruction

A

supple skin

sensate digit

adequate vascularity

full passive range of motion of adjacent joints

354
Q

What are the causes of swan-neck deformity?

A

Extrinsic:

Lead to increased extension force on P2.

Causes:

Disruption of terminal extensor tendon

Wrist of MP joint flexion contracture

Intrinsic

Related to tightness of intrinsics or intrinsic plus finger

Causes:

Chronic MP volar subluxation

Ischaemic contracture

Tendon adhesion

Articular

Include injury to, or degeneration of, the volar structures of the PIP

Volar plate/capsule hyperextension injury

Disruption of FDS (stabilizer of PIP)

355
Q

4 named signs associated with ulnar nerve neuropathy: Describe each

A

Froment’s sign:

  • Thumb IP flexion during thumb adduction (FDP - AIN)

Jeanne sign:

  • Thumb MCP extension in thumb adduction (EPL - radial)

Wartenburg sign:

  • small finger abduction and extension in attemped adduction (EDM - radial)

Masse sign:

  • palmar flattening and loss of ulnar had elevation (weak opponens digiti minimi)
356
Q

5 dDx for dorsolateral wrist/forearm pain and 1 characteristic for each

A

Wartenberg’s: (SRN) tight wristwatches and exacerbated with wrist flex/ex

Lateral antebrachial cuntaoues nerve: Tinel’s over it

De Quervain’s: Finklestein positive (may also be positive with Wartenburgs)

Radial tunnel: (PIN) Pain distal to lateral epicondylitis. Pain only

PIN Compression: Radial tunnel + weakness in radial nerve distribution

357
Q

Classification for basilar thumb (CMC) Arthritis

A

Eaton & Littler Classification

I: slight joint space widening (pre-arthritis)

II: slight CMC narrowing with sclerosis & osteophyte

III: Marked CMC narrowing with osteophytes >2mm

IV: pantrapezial arthritis (STT involved)

358
Q

Preferred treatment for pisiform fracture?

A

pisiformectomy

reliable pain relief without impairment of function

359
Q

Treatment for volar dislocated/fracture dislocated PIP joint

A

If reducble: immobilize in extension 6-8 weeks

to allow for extensor mechanism (central slip) to heal

360
Q

Describe flexor zones of the hand? (fingers and thumb)

A

I: Distal to FDS insertion (only FDP runs in this zone)

II: FDS to A1 pulley

III: A1 pulley to distal carpal tunnel

IV: carpal tunnel

V: Wrist

T1: Distal to IP

T2: Distal to CMC

T3: Base of thumb MC

361
Q

Options for stage III a/b lunate AVN (5/2)

A

IIIA: lunate collapse, no scaphoid rotation

  • joint levelling procedure (ulnar legnthening or radial shortening)
  • radial wedge osteotomy
  • vascularized bone graft
  • distal radius core decompression
  • STT fusion

IIIB: lunate collapse with fixed scaphoid rotation

  • STT fusion
  • proximal row carpectomy
362
Q

NAME THESE LIGAMENTS!

A
363
Q

How much pressure is needed to completely block nerve transmission?

A

60 mmHg

364
Q

Most common complication with syndactyly release

A

Webspace contracture

treat with flap/graft

365
Q

Function of extensor hood and what are it’s two primary components?

A

Extends PIP and DIP

Central slip and Lateral bands

366
Q

Intrinsic plus hand deformities?

A

Tight intrinsics

(lumbricals, interossei)

Weak extrinsics

(FDS, FDP, EDC)

367
Q

Best treatment in fingertip amputations in paeds if:

Soft tissue only

Exposed bone

A

Healing by secondary intention in both cases

368
Q

Indications for formal I&D in hand injury

A

Crushed or devitalized tissue

Foreign body

Bites to digital pulp space, nail beds, flexor tendon sheaths, deep spaces of palm ,joint spaces

Tenosynovitis

Septic arthritis

Abscess formation

369
Q

SNAC classification & treatment

A

Stage I: arthrosis in radial styloid & radial side of scaphoid with sharpening of radial styloid

Stage II: Scaphocapitate arthrosis, in addition to stage I

Stage III: Periscaphoid arthrosis

Treatment:

Stage I: Radial styloidectomy + scapholunate reduction & stabilization + scaphoid nonunion fixation

Stage II/III: PRC vs 4-corner fusion vs. Wrist arthrodesis vs. Wrist arthroplasty

Treatment is generally same as SLAC

370
Q

What are the options for approach to operative fixation of MCP dislocations?

A

Can go dorsal or volar

Volar more direct but places neurovascular structures at risk

371
Q

Small, transverse or jagged wound over dorsal aspect of MCP. What is it?

A

Fight Bite

372
Q

What are three documented outcomes/complications of STT fusion?

A

Adjacent DJD,

70% normal motion

80% grip power

373
Q

3 surgical options in Madelungs

A

Physiolysis + release of Vicker’s ligament

Radial corrective DOME osteotomy + resection of Vickers + distal ulnar shortening osteotomy

DRUJ arthroplasty (controversial)

374
Q

6 risk factors for Dupuytren’s Disease

A

SLEDGE Hammer

Seizures (Epilepsy/Anti-seizure medication)

Liver disease

EtOH

Diabetes

Genetics

HIV

375
Q

What is the normal ratio for ulnar styloid length and variance?

A

Less than 0.22 is normal

(ulnar styloid length - ulnar variance) / width of ulnar head

376
Q

What is the most important pulley in the thumb?

A
  • Oblique Pulley
  • Facilitates full excursion of flexor pollicis longus
377
Q

Outcomes of FCU –> ECRB transfer in CP

A

Improved cosmesis in 16/16 patients (most reliable)

Improved function in 14/16 patients

Improved grip strength

378
Q

Name 4 causes of VISI

what is the most common?

A

LT instability (most common)

Dorsal radiocarpal ligament injury

Volar radiolunate ligament injury

May be a normal variant in a patient with ligamentous laxity

Associated with TFCC tear

379
Q

1 nonoperative and 1 operative treatment for AIN compression

A

Nonop: splint with elbow in 90 degrees 8-12 weeks (successful in majority and should be cornerstone of treatment (as per JAAOS))

Op: surgical decompression (75% success)

consider early OR if definite space occupying lesion

380
Q

Seddon Classifcation of peripheral nerve injury:

A

Neurapraxia:

  • mild nerve stretch or contusion
  • myelin sheath disruption but no Wallerian degeneration
  • Good prognosis

Axonotmesis:

  • Severe but incomplete nerve injury
  • Focal conduction block exists
  • Wallerian degenration occurs
  • guarded prognosis

Neurontmesis:

  • Complete nerve injury
  • Wallerian degeneration occurs
  • All layers of nerve damaged
  • Worst prognosis
381
Q

Name 4 options for treatment of this patient’s wrist pain:

A

Stage 2 Kienbock’s

Joint leveling procedure (ulnar negative patients)
Radial wedge osteotomy or STT fusion (ulnar neutral patients)

Radial decompression

vascularized grafting (4,5 ECA)

382
Q

Positioning of limb in volkman’s ischaemic contracture

A

Elbow flexion

Forearm pronation

Wrist flexion

Thumb adduction

MCP joints in extension

IP joints in flexion

Pretty much like every other contracture (CP)

383
Q

What are Kanaval’s Signs?

A

Signs of flexor tenosynovitis:

  • finger held in flexion
  • fusiform swelling
  • tenderness along the flexor tendon sheath
  • pain with passive extension
384
Q

Jersey finger is a rupture of the _________ tendon in flexor zone _____ of the hand

A

FDP

Zone 1

385
Q

Treatment of arterial insufficiency with finger replantation

A

Release constricting bandages

Place in dependent position

Consider heparinize

Consider stellate ganglion block

Early surgical exploration if previous measure unsuccessful

386
Q

Diagnosis?

Indication for treatment and general principles

What do you have to tell family?

A

Cleft hand

Operate if abnormal thumb webspace

Surgical thumb, thumb webspace reconstruction takes precedence (ie over correction of central cleft)

Must counsel family of inheritance (AD, with 70% penetrance) and that each subsequent generation gets worse

387
Q

Describe the Bunnel Test

A

Tests for intrinsic tightness

Decreased PIP flexion with MPs held extended is a sign of intrinsic tightness

Works b/c intrinsics pass volar to MP joint and dorssl to PIP joint.

With the MP extended, they are taught at MP joint, so if they are tight, you won’t be able to flex PIP b/c that will tigthen them even more and they wont’ have the excursion to do that

388
Q

What do you call a congenital PIP flexion contracture?

A

Camptodactyly

389
Q

What are these two ligaments?

A

Dorsal Extrinsic Ligaments

Big arrow = Dorsal Intercarpal

SMall arrow = Radiotriquetrial

390
Q

Complications with Collagenase

A

edema

contusion

pain (from injection & manipulation)

Skin laceration

lymphadenopathy

CRPS (rare)

Flexor tendon rupture (Rare)

391
Q

What is the indication for releaseing a slip of FDS in trigger finger?

A

Pediatric Trigger Finger

usually the Ulnar slip

May need to release the second slip as well as A3 pulley

392
Q

In neurontmesis, what do the proximal and distal stumps form?

A

Proximal: neuroma

Distal: glioma

393
Q

List 3 causes of lumbricals plus finger position

A

Any disruption of FDP distal to the origin of the lumbricals

FDP Transection

FDP avulsion

DIP amputation

Amputation through middle phalanx shaft

Too long tendon graft

394
Q

What are three indications for grouped fascicular repair?

(Hint: they are specific nerve injuries)

A
  • median nerve in distal third of forearm
  • ulnar nerve in distal third of forearm
  • sciatic nerve in thigh
395
Q

What pulleys do you have to incise for a volar shot-gun type approach to PIP?

What is an indication for this approach?

A
  1. C1, A3, C2 Pulleys
  2. PIP fracture dislocations - for ORIF or hamate autograft
396
Q

What is the maximal injury + nerve regeneration time to prevent irreversible muscle damage?

A

18 months

397
Q

What are 3 options for closure of palmar fasciectomy for Dupuytren’s?

A
  • direct closure after fascial excision
  • skin excision followed by full-thickness skin grafting (NOT STSG)
  • open technique in which a portion of the volar skin is left open to close subsequently by wound contraction.
398
Q

Principles of Tendon Transfer. Name them

A

Joint to be corrected/moved must be supple

Donor must be expendable

Donor must be of similar excursion and power

  • Smith’s 3-5-7 rule
  • Finger flexors: 70mm
  • Finger extensors and EPL: 50mm
  • Wrist flexors & extensors: 33mm

Appropriate tensioning

A muscle should not be used for transfer unless it is 85% of normal strength

  • Ie in the case of muscle reinnervation

One transfer should perform 1 function

Synergistic transfers if possible (easier to rehab)

  • Wrist extension ↔ finger flexion ↔ thumb adduction
  • Wrist flexion ↔ finger extension ↔ thumb abduction

Maintain a straight line of pull

One grade of motor strength will be lost after transfer

Usually attach transferred muscle to the tendon of the motor end to end if no native recovery anticipated; end to side if recovery anticipated.

399
Q

How do you classify lunate AVN?

A

Lichtman Classification

I: No xray changes - only MRI changes

II: sclerosis of lunate

IIIa: lunate collapsed, no scaphoid rotation

IIIb: lunate collapsed, fixed scaphoid rotation

IV: degenerated adjacent intercarpal joints

400
Q

SLAC Classification & Treatment

A

Watson Classification

Stage I: arthrosis in radial styloid & radial side of scaphoid with sharpening of radial styloid

Stage II: Arthrosis of entire radioscphoid joint. Sparing of the radiolunate joint

Stage III: Arthrodesis progressing to the capitolunate joint due to proximal migration of capitate

Treatment

Stage I: radial styloidectomy & scaphoid stabilization

Stage II: PRC, scaphoid excision & 4CF

  • contraindicated if incompetent radioscaphocapitate ligament & stage 3

Stage III: Scaphoid excision & 4CF, wrist arthrodesis

Treatment generally same as SNAC

±PIN & AIN denervation at any stage (they only provide sensation and proprioception to wrist capsule)

401
Q

What is intersection syndrome? What population is it most common in?

A

inflammation of 2nd extensor compartment as it crosses under 1st

Occurs 6cm proximal to radial styloid

Common in repetitive wrist extension athletes (rowers, weight lifters)

402
Q

What must you do when performing surgical decompression of DeQuervain’s tenosynovitis?

A

Release both APL and EPB from their subsheaths within the 1st dorsal compartment

If you don’t, you will have recurrence

403
Q

Opponensplasty: describe 4 ways

What does it do?

A

Restores pinch

FDS opponensplasty: FDS 4 –> APB

  • Cannot do if high median nerve palsy b/c FDS will also be knocked out

EIP opponensplasty: EIP –> APB

abductor digiti minimi (Huber) transfer: ADM –> APB

PL (Camitz) transfer: PL –> APB

  • Cannot do if high median nerve palsy b/c PL will also be knocked out
404
Q

What is Wartenburg’s sign

A

Ulnar nerve palsy

Little pinky abduction due to unopposed pull of EDM

405
Q

What movement causes scaphoid flexion and what causes scaphoid extension?

A

Flexion = radial deviation

Extension = ulnar deviation

406
Q

Does the acute management of paronychia include steroids?

What about chronic?

A

Yes for aucte and chronic

Topical antibiotics + steorids if mild-mod case (no abscess) (acute)

Topical antifungal/antibiotics + steroids in chronic

This was just as good as gent alone in acute

Can also use abx + soaks if no abscess

407
Q

What is Campylodactyly?

What is Symphalangism?

A

Camptodactyly - bent

Symphalangism - stiff

Camptodactyly involves fixed flexion deformity of the proximal interphalangeal joints. The fifth finger is always affected.

Camptodactyly can be caused by a genetic disorder. In that case, it is an autosomal dominant trait that is known for its incomplete genetic expressivity.

Pathophysiology:

typically caused by either

  • abnormal lumbrical insertion/origin
  • abnormal (adherent, hypoplastic) FDS insertion
  • other less common causes include
  • abnormal central slip
  • abnormal extensor hood
  • abnormal volar plate
  • skin, subcutaneous tissue, or dermis contracture

•If full PIP extension can be achieved actively with MCP held in flexion, digit can be explored and abnormal tendon transferred to radial lateral band

  • Type I
    • Isolated anomaly of little finger, presents in infancy and affects males and females equally
    • Most common form
    • Stretching/splinting
  • ​​Type II
    • Same clinical features as Type I, presents in adolescence
    • • Affects girls more often than boys
    • From abnormal lumbrical insertion, abnormal FDS origin or insertion
    • If full PIP extension can be achieved actively with MCP held in flexion, digit can be explored and abnormal FDS tendon transferred to radial lateral band
  • Type III
    • Severe contractures, multiple digits involved, presents at birth
    • Usually associated with a syndrome
    • Non-operative (unless functional deficit exists after skeletal maturity), then consider corrective osteotomy/fusion
  • Kirner’s Deformity
    • Specific deformity of small finger distal phalanx with volar-radial curvature (apex dorsal-ulnar)
    • Often affects preadolescent girls
    • Often bilateral
    • Usually no functional deficits

Symphalangism

Congenital digital stiffness that comes in two forms

  • hereditary symphalangism
  • nonherediatry symphalangism

Epidemiology location

  • more common in ulnar digits

Pathophysiology

  • failure of IP joint to differentiate during development
  • Genetic inheritance pattern (hereditary type)
  • autosomal dominant

Associated conditions

  • syndactyly (nonhereditary type)
  • Apert’s syndrome (nonhereditary type)
  • Poland’s syndrome (nonhereditary type)
  • correctable hearing loss (hereditary type)

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