Hands & Elbow

Question 1

Flexor tendon nutrition is via?

Answer 1

direct vascular supply (vincula) and synovial diffusion.

Question 2

The carpal tunnel contains?

Answer 2

median nerve and nine flexor tendons (one FPL, four FDS and four FDP). • FPL is most radial, whereas the long and ring FDS tendons are
volar to index and small FDS.

Question 3

Lumbrical muscles originate where?

Answer 3

on the radial aspect of FDP tendons and pass volar to transverse metacarpal ligaments to insert on the radial
aspect of the extensor hood lateral bands.

Question 4

decreased proximal interphalangeal (PIP) flexion with the metacarpophalangeal (MCP)
held in extension, and increased PIP flexion with MCP in flextion =

Answer 4

Intrinsic tightness

Question 5

decreased PIP flexion with MCP in flexion and increased PIP flexion with MCP in extension? =

Answer 5

Extrinsic tightness

Question 6

Radiographic parameters of distal radius?

Answer 6

Radiographic evaluation follows the 11-22-11 guide: • Radial height-11 mm; radial inclination-22 degrees; volar tilt-11
degrees

Question 7

acceptable reduction parameters i distal radius fractures?

Answer 7

• Radial shortening less than 3 mm • Dorsal articular tilt less than 10 degrees
• Intraarticular step-off less than 2 mm

Question 8

The most common complication after distal radius fracture

Answer 8

median nerve dysfunction

Question 9

EPL tendon rupture most commonly occurs when? treatment?

Answer 9

as a late complication following closed treatment due to attritional wear and/or vascular insufficiency near the Lister tubercle. • Treat with EIP-to-EPL tendon transfer, because primary repair is
not possible

Question 10

most common tendon injury after volar plating?

Answer 10

FPL

Question 11

operative indications of scaphoid fracture?

Answer 11

Acute operative indications include more than 1 mm displacement, intrascaphoid angle greater than 35 degrees (humpback deformity), and trans-scaphoid perilunate dislocation.
• Proximal pole fracture is a relative operative indication.

Question 12

Minimally displaced fractures may be treated with …….. fixation, commonly performed by percutaneous or limited open incision methods.
• Formal ORIF is recommended for …….. or those treated in a ………………..
• Guide pin placement should be …………………………………
• Volar approach potentially avoids ………………………………..of the scaphoid.

Answer 12

Minimally displaced fractures may be treated with headless compression screw fixation, commonly performed by percutaneous or limited open incision methods.
• Formal ORIF is recommended for displaced injuries or those treated in a delayed fashion.
• Guide pin placement should be along the central axis of both the proximal and distal fragments.
• Volar approach potentially avoids disruption of the primary dorsal
blood supply of the scaphoid.

Question 13

SNAC wrist sequence?

Answer 13

The radioscaphoid joint is affected first, followed by the scaphocapitate and lunocapitate; the radiolunate joint is spared
the longest.

Question 14

Carpal instability can be broadly classified into four types:

Answer 14

Carpal instability dissociative
Carpal instability nondissociative • Carpal instability adaptive
• Carpal instability complex

Question 15

how does a DISI occur?

Answer 15

DISI is the most common form of carpal instability (increased SL angle). • Scapholunate ligament disruption • Dorsal portion strongest • Untreated chronic instability may result in scapholunate advanced collapse (SLAC) wrist with stages of involvement similar to SNAC
wrist.

Question 16

describe a VISI?

Answer 16

VISI is the second most common (decreased SL angle) • Lunotriquetral ligament disruption • Volar portion strongest
• Natural history less clear

Question 17

Perilunate dislocations are an example of carpal instability complex. • Mayfield described four stages of progressive disruption:

Answer 17

• I—scapholunate
• II—midcarpal
• III—lunotriquetral (perilunate dislocation)
• IV—circumferential (lunate dislocation)

Question 18

describe deforming forces of a Bennett fracture?

Answer 18

fracture-dislocation of the thumb metacarpal base. • APL and thumb extensors cause proximal, dorsal and radial displacement of the metacarpal shaft.
• The “beak” ligament keeps the volar-ulnar base fragment
reduced to the trapezium. Adductor pollicis adduction and supination.

Question 19

Thumb MCP UCL injury Instability in 30 degrees of flexion indicates ?

Answer 19

injury to PROPER ucl (flexion in PALM is PROPER)

Question 20

what is a stenar lesion?

Answer 20

In over 85% of cases, a complete injury is accompanied by a Stener lesion, in which the adductor pollicis aponeurosis is interposed between the avulsed UCL and its insertion site on the
base of the proximal phalanx.

Question 21

PIP dislocations most commonly occur

Answer 21

dorsally and result from volar plate and collateral ligament injury.

Question 22

Volar PIP dislocation requires disruption of what? and treatment ? to prevent?

Answer 22

central slip and must be splinted in full extension following reduction to prevent a
boutonnière deformity

Question 23

Rotatory PIP dislocation occurs when

Answer 23

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

Question 24

PIP fracture-dislocations are classified based on the amount of middle phalanx (P2) articular surface involvement.

define stable fracture and treatment and unstable fracture treatment?

Answer 24

A volar P2 base fragment with less than 30% involvement is usually stable enough for nonoperative management, initially in a dorsal block splint.
• Unstable injuries with larger P2 base fragments often require operative intervention, such as dorsal block pinning, ORIF, hemihamate reconstruction, or volar plate arthroplasty.
• Irreducible MCP and DIP dislocations are typically due to inter

Question 25

Irreducible MCP and DIP dislocations are typically due to

Answer 25

interposition of the volar plate; treatment is via open reduction and extraction of the volar plate

Question 26

mallet finger treatment?

Answer 26

Mallet finger is treated with DIP extension splinting if detected within approximately 12 weeks of injury. • A relative surgical indication is a displaced bony mallet injury with significant volar subluxation of P3.

Question 27

Dorsal injury over the PIP may disrupt? and consequence of this is?

Answer 27

the central slip insertion. • Lateral bands subluxate volarly. • Acute boutonnière deformity results in a posture of PIP flexion and DIP hyperextension

Question 28

If boutonniere deformity flexible ..treatment?

Answer 28

capener splint or | central slip reconstruction

Question 29

Fundamental principles of flexor tendon repair:?

Answer 29

Strength of repair proportional to number of core suture strands that cross repair site • A locking-loop configuration decreases gap formation. • Dorsally placed core sutures are stronger. • Epitendinous repair increases overall repair strength by up to 50%.

Question 30

flexor tendon rehab protocols?

Answer 30

Klienert and duran Early protected ROM is advocated to increase tendon excursion, decrease adhesion formation, and increase repair strength. • Active flexion protocols require a minimum four-strand core repair. • Young children cannot comply with therapy and require cast immobilization for 4 weeks.

Question 31

Closed flexor tendon injury from forced DIP extension during grasping is termed a “jersey” finger (closed FDP avulsion in zone 1 distal to the FDS insertion). • Profundus advancement of 1 cm or more carries a risk of ? why?

Answer 31

DIP joint flexion contracture or quadrigia. • Quadrigia occurs because the middle-ring-small FDP tendons share a common muscle belly, and distal advancement of one tendon will compromise flexion of the adjacent digits, resulting in forearm pain.

Question 32

Adult trigger finger (stenosing flexor tenosynovitis) should be treated how ?

Answer 32

non op - injection steroid op -- A1 pulley release

Question 33

Pediatric trigger thumb is more common than pediatric trigger finger. • May present with ..................deformity of the thumb interphalangeal joint and generally requires release of ..................pulley • Pediatric trigger finger may stem from aberrant anatomy, and A1 pulley release alone may not sufficiently resolve triggering (add ..................... excision).

Answer 33

Pediatric trigger thumb is more common than pediatric trigger finger. • May present with fixed flexion deformity of the thumb interphalangeal joint and generally requires release of the A1 pulley • Pediatric trigger finger may stem from aberrant anatomy, and A1 pulley release alone may not sufficiently resolve triggering (add FDS ulnar slip excision).

Question 34

what is dequervains tenosynovitis?

Answer 34

de Quervain tenosynovitis of the first extensor compartment often affects middle-aged women, new mothers, and golfers. • Corticosteroid injection is successful in more than 80% of patients. • Intraoperative findings at the time of compartment release often reveal multiple slips of the APL tendon and a separate dorsal compartment for the EPB tendon.

Question 35

what is intersection syndrome?

Answer 35

Intersection syndrome is a tendinopathy occurring at the junction between the first and second extensor compartments. • Commonly affects rowers and generally treated nonoperatively

Question 36

Components of the triangular fibrocartilage complex (TFCC) include:

Answer 36

the dorsal and volar radioulnar ligaments, the articular disc, a meniscus homologue, the extensor carpi ulnaris (ECU) subsheath, and the origins of the ulnolunate and ulnotriquetral ligaments.

Question 37

``` Acute (class I) tears are most commonly ........................ (type IB). • No clear clinical outcome differences between open and arthroscopic repair techniques • ........................... (class II) tears are associated with positive ulnar variance and ulnocarpal impaction syndrome. • In the absence of DRUJ osteoarthrosis, the most commonly performed procedure is arthroscopic débridement and............................. ```

Answer 37

``` Acute (class I) tears are most commonly avulsions at the ulnar periphery (type IB). • No clear clinical outcome differences between open and arthroscopic repair techniques • Degenerative (class II) tears are associated with positive ulnar variance and ulnocarpal impaction syndrome. • In the absence of DRUJ osteoarthrosis, the most commonly performed procedure is arthroscopic débridement and ulnar shortening osteotomy. ```

Question 38

Posttraumatic DRUJ osteoarthritis may be treated with:

Answer 38

hemiresection interposition arthroplasty, Darrach resection, Sauve-Kapandji arthrodesis or prosthetic arthroplasty

Question 39

Nail bed injuries with less than 50% subungual hematoma

Answer 39

may be treated without nail plate removal (nail trephination for pain relief).

Question 40

Nail bed injuries with greater than 50% subungual hematoma may be treated

Answer 40

with nail plate removal and repair of underlying nail matrix lacerations.

Question 41

less than 1 cm2 without exposed | bone

Answer 41

secondary intention

Question 42

larger wound without exposed bone?

Answer 42

skin grafting

Question 43

Volar oblique injury treated by

Answer 43

cross-finger or thenar flap

Question 44

Transverse or dorsal oblique injury treated by

Answer 44

V-Y advancement (digit) or Moberg advancement flap (thumb) to preserve skeletal length; alternative treatment is skeletal shortening and closure at level with available skin

Question 45

Transverse or dorsal oblique injury treated by

Answer 45

V-Y advancement (digit) or Moberg advancement flap (thumb) to preserve skeletal length; alternative treatment is skeletal shortening and closure at level with available skin

Question 46

Dorsal thumb injury may require

Answer 46

kite flap from the index (based on first dorsal metacarpal artery).

Question 47

Shortening and closing an injury that acutely violates the FDP insertion may result in

Answer 47

lumbrical-plus finger.

Question 48

what is lumbrical plus finger?

Answer 48

* FDP tendon retracts and creates tension on the extensor mechanism through its intact lumbrical origin, causing paradoxical PIP joint extension with active finger flexion. * Treat with release of the radial lateral band.

Question 49

Full-thickness skin grafts are preferred for .......hand and ...........wounds, because they are more durable, contract less, and provide better sensibility.

Answer 49

Full-thickness skin grafts are preferred for volar hand and fingertip wounds, because they are more durable, contract less, and provide better sensibility.

Question 50

Primary indications for replantation:

Answer 50

Level of amputation outside of zone II flexor tendon sheath, multiple digits, thumb, proximal amputations and any injury in a child

Question 51

Primary contraindications to replantation:

Answer 51

Level of amputation within zone II flexor tendon sheath, single digit amputation (except thumb), segmental, crush, prolonged ischemia, multisystem injuries

Question 52

Factor most predictive of digit survival after replantation is

Answer 52

mechanism of injury

Question 53

Most frequent cause of early (within 12 hours) replantation failure is? treatment?

Answer 53

arterial thrombosis • Consider releasing constricting bandages, place extremity in dependent position, administer heparin, and perform stellate ganglion block.

Question 54

Failure after 12 hours is typically due to? treatment?

Answer 54

venous congestion or thrombosis. • Consider leech therapy and provide antibiotic prophylaxis against Aeromonas hydrophila

Question 55

most commonly performed secondary procedure following successful replantation.

Answer 55

tenolysis

Question 56

test to determine completness of arches in hand?

Answer 56

Allen Test

Question 57

the most common posttraumatic vascular occlusive condition of the upper extremity, involving the ulnar artery in the proximal palm? treatment?

Answer 57

Hypothenar hammer syndrome Treatment may include resection of the thrombosed segment and interposition vein graft or arterial conduit (better patency rate).

Question 58

Vasospastic disease with a known underlying cause is termed

Answer 58

Raynaud phenomenon.

Question 59

Vasospastic disease without a known underlying cause is termed

Answer 59

Raynaud disease.

Question 60

compartments in the hand?

Answer 60

There are 10 hand compartments: thenar, hypothenar, adductor pollicis, four dorsal interosseous, and three volar interosseous (carpal tunnel is not a compartment).

Question 61

tendons most vunerable to volkmann ischaemic contracture?

Answer 61

The FDP and FPL muscles are most vulnerable in Volkmann ischemic contracture.

Question 62

Carpal tunnel syndrome is typically idiopathic in adults, but ............................ is the most common association in children.

Answer 62

mucopolysaccharidosis

Question 63

how effective is steroid injection in CTS?

Answer 63

Single corticosteroid injection yields transient relief in approximately 80% after 6 weeks, but only 20% are symptom free by 1 year.

Question 64

Operative techniques vary but common theme is division of ........................; ....................and flexor tenosynovectomy confer no additional benefit • Endoscopic carpal tunnel release may be associated with less early scar tenderness, improved short-term function, and better patient satisfaction scores in some studies; long-term results are largely ............. to traditional open release.

Answer 64

Operative techniques vary but common theme is division of transverse carpal ligament; neurolysis and flexor tenosynovectomy confer no additional benefit • Endoscopic carpal tunnel release may be associated with less early scar tenderness, improved short-term function, and better patient satisfaction scores in some studies; long-term results are largely equivalent to traditional open release.

Question 65

what is pronator syndrome?

Answer 65

a compression of the median nerve in the arm/forearm. • Potential sites of compression: supracondylar process, ligament of Struthers (courses between the supracondylar process and medial epicondyle), lacertus fibrosis, between the two heads of pronator teres muscle, FDS aponeurotic arch

Question 66

how can u differentiate pronator syndrome and CTS?

Answer 66

May be differentiated from carpal tunnel syndrome by presence of more proximal forearm pain and paresthesias that include the distribution of the palmar cutaneous branch of the median nerve

Question 67

what is AIN syndrome

Answer 67

Involves motor loss of FPL, index ± long FDP, and pronator quadratus same sites of compression as pronator syndrome.

Question 68

what is cubital tunnel syndrome?

Answer 68

Cubital tunnel syndrome may manifest as pain, numbness, weakness. • Potential sites of compression: arcade of Struthers, medial head of triceps, medial intermuscular septum, Osborne ligament, anconeus epitrochlearis, between two heads of FCU, aponeurosis of FDS proximal edge • Recent meta-analyses of techniques fail to show statistically significant difference in outcome between simple in situ decompression and transposition.

Question 69

what is Ulnar tunnel syndrome?

Answer 69

(compression in Guyon canal) is usually secondary to an extrinsic mass (e.g., ganglion, lipoma, aneurysm, boundaries? zones? differentiate from cubital tunnel?

Question 70

how to differentiate between radial nerve palsy and PIN p[alsy?

Answer 70

dial Nerve • Proper radial nerve palsy (“Saturday night palsy”) is differentiated from PIN compression by additional weakness of proper radial nerve–innervated muscles, such as triceps, brachioradialis, and ECRL.

Question 71

PIN compression sites?

Answer 71

PIN compression syndrome symptoms include distal muscle weakness. • Potential sites of compression: fascial band at the radial head, recurrent leash of Henry, proximal edge of the ECRB tendon, arcade of Frohse (proximal edge of supinator), distal edge of supinator

Question 72

what is radial tunnel syndrome?

Answer 72

Radial tunnel syndrome is marked by lateral proximal forearm pain rather than distal motor weakness of the hand and wrist. • Sites of compression same as PIN syndrome • Outcome of surgical decompression less predictable than for PIN syndrome

Question 73

what is Chieralgia paresthetica?

Answer 73

compressive neuropathy of the superficial sensory branch of the radial nerve.

Question 74

seddon classification?

Answer 74

Seddon classification divides nerve injury into neurapraxia, axonotmesis, and neurotmesis (increasing severity).

Question 75

principles of nerve repair?

Answer 75

Peripheral nerve repairs are best when performed early, free of tension, clean wound bed • No technique deemed superior • Gaps may be addressed with nerve conduit, decellularized nerve allograft, or autograft

Question 76

nerve transfers, no elbow flexion? no shoulder abduction?

Answer 76

Classic nerve transfers for upper brachial plexus injury • Ulnar motor branch to FCU coapted to musculocutaneous nerve (elbow flexion) • Descending branch of spinal accessory nerve coapted to suprascapular nerve (shoulder abduction) • Radial nerve motor branch to triceps coapted to axillary nerve (shoulder abduction)

Question 77

Basic tenets of tendon transfers:

Answer 77

Donor must be expendable. • Donor must be of similar excursion and power. • One transfer should perform one function. • Synergistic transfers are easier to rehabilitate. • A straight line of pull is optimal. • One grade of motor strength will be lost after transfer.

Question 78

Tendon transfers for high radial nerve palsy • Wrist extension...………………. • Finger extension—…………….. • Thumb extension—…………..

Answer 78

—PT to ECRB FCU or FCR to EDC PL to EPL

Question 79

Tendon transfer (opponensplasty) options for low median nerve palsy

Answer 79

FDS of ring, EIP, abductor digiti minimi, PL—all transferred to APB

Question 80

Rheumatoid arthritis is a systemic autoimmune disease that often affects the synovium surrounding small joints of the hand and wrist. • Manifestations include

Answer 80

rheumatoid nodules, tenosynovitis, tendon rupture, ulnar MCP drift, swan neck/ boutonnière deformities, caput ulnae, carpal subluxation, and SLAC wrist.

Question 81

Vaughan-Jackson syndrome?

Answer 81

describes progressive rupture of extensor tendons, starting with EDM and continuing radially, from attrition over a prominent distal ulnar head.

Question 82

Mannerfelt syndrome?

Answer 82

describes rupture of FPL and/or index FDP secondary to attrition over a volar STT osteophyte.

Question 83

Kienböck disease (idiopathic osteonecrosis of the lunate) is most common in,,...…………... and presents with .....................….dorsal wrist pain and .................

Answer 83

Kienböck disease (idiopathic osteonecrosis of the lunate) is most common in young men and presents with nontraumatic dorsal wrist pain and decreased grip strength.

Question 84

Unexplained dorsal wrist pain in a young adult with negative ulnar variance should prompt?

Answer 84

mri

Question 85

Lichtman classification and treatment?

Answer 85

Stage I No visible changes on xray, changes seen on MRI Rx=Immobilization and NSAIDS Stage II Sclerosis of lunate Rx= Joint leveling procedure (ulnar negative patients) Radial wedge osteotomy or STT fusion (ulnar neutral patients) Distal radius core decompression Revascularization procedures Stage IIIA Lunate collapse, no scaphoid rotation Same as Stage II above Stage IIIB Lunate collapse, fixed scaphoid rotation Proximal row carpectomy, STT fusion, or SC fusion Stage IV Degenerated adjacent intercarpal joints Wrist fusion, proximal row carpectomy, or limited intercarpal fusion

Question 86

what is Dupuytrens disease?

Answer 86

Benign fibroproliferative disorder that is sometimes inherited and sometimes sporadic

Question 87

main cell type in dupuytrens?

Answer 87

Myofibroblasts are the predominant cell type found histologically in Dupuytren fascia, and their contractile properties are abnormal and exaggerated.

Question 88

spiral cord leads to ?

Answer 88

PIP contracture and NV structures pushed superficial and central.

Question 89

Surgical indications include

Answer 89

inability to place hand flat on tabletop (Hueston test), MCP flexion contracture greater than 30 degrees, or any PIP flexion contracture

Question 90

what do you know about collagenase injections?

Answer 90

Emerging nonoperative treatment: collagenase injection and cord manipulation • Pooled studies show average MCP correction up to 85% and PIP correction up to 60%. • Pain, swelling, and bruising are likely temporary adverse effects of injection. • Skin tears are more common complications than flexor tendon rupture. Cordless studies have demonstrated it works IS approved by NICE

Question 91

dorsal wrist ganglion ??

Answer 91

scapholunate articulation

Question 92

volar wrist ganglion?

Answer 92

—radioscaphoid or STT joint

Question 93

IP ganglion?

Answer 93

osteophyte

Question 94

distal palm ganglion?

Answer 94

flexor tendon sheath

Question 95

Giant cell tumor of tendon sheath is the second most common soft tissue tumor and presents as a slow-growing firm mass often on the volar aspect of a digit. treatment?

Answer 95

marginal excision but recurrence is high.

Question 96

Other soft tissue tumors for differential diagnosis include

Answer 96

epidermal inclusion cyst, lipoma, schwannoma, glomus, hemangioma, pyogenic granuloma

Question 97

``` Must-know hand tumors: • Most common malignancy? • Most common sarcomas—?] • Most common benign bone tumor—? • Most common malignant bone tumor—? • Most common malignant primary bone tumor? ```

Answer 97

Must-know hand tumors: • Most common malignancy—squamous cell carcinoma • Most common sarcomas—epithelioid and synovial • Most common benign bone tumor—enchondroma • Most common malignant bone tumor—metastatic lung carcinoma • Most common malignant primary bone tumor—chondrosarcoma

Question 98

most common pathogen for hand infections?

Answer 98

s.aureus

Question 99

Human bites are a potentially serious infection treated promptly with incision and drainage, especially if joint or tendon sheath is violated. • Most frequently isolated organisms are

Answer 99

group A streptococci, S. aureus, Eikenella corrodens, and Bacteroides spp.

Question 100

Dog bites occur more frequently than cat bites, but cat bites more commonly result in serious infections that require surgical intervention.

Answer 100

Pasteurella multocida, Staphylococcus, and Streptococcus

Question 101

Kanavel signs:

Answer 101

flexed resting posture of digit, fusiform swelling of the digit, tenderness of flexor tendon sheath, pain with passive digit extension

Question 102

name the 3 centres of limb development?

Answer 102

The apical ectodermal ridge controls proximal-to-distal growth. The zone of polarizing activity formation controls radial-to-ulnar growth. • Wingless-type controls dorsal-to-volar growth

Question 103

Radial clubhand is associated with a variety of systemic problems, including. treatment?

Answer 103

TAR syndrome, Holt-Oram syndrome, VACTERL syndrome, and life-threatening Fanconi anemia. Wrist centralization if elbow ROM adequate

Question 104

Radioulnar synostosis is associated with

Answer 104

duplication of sex chromosomes

Question 105

wassel classification?

Answer 105

1-7 distal to proximal bifid-duplication 7 = triphalangism.

Question 106

Poland syndrome

Answer 106

(absent pectoralis major and chest wall abnormalities) and syndactyly

Question 107

apert syndrome

Answer 107

Apert syndrome (acrosyndactyly and mental retardation) are commonly associated with syndactyly.

Question 108

Blauth classification

Answer 108

Type I Minor hypoplasia All musculoskeletal and neurovascular components of the digit are present, just small in size No surgical treatment required Type II All of the osseous structures are present (may be small) MCP joint ulnar collateral ligament instability Thenar hypoplasia Stabilization of MCP joint Release of first web space Opponensplasty Type IIIA Musculotendinous and osseous deficiencies CMC joint intact Absence of active motion at the MCP or IP joint Type IIIB Musculotendinous and osseous deficiencies. Basal metacarpal aplasia with deficient CMC joint q Absence of active motion at the MCP or IP joint. Thumb amputation & pollicization Type IV Floating thumb Attachment to the hand by the skin and digital neurovascular structures Type V Complete absence of the thumb