Hands & Elbow Flashcards
Flexor tendon nutrition is via?
direct vascular supply (vincula) and synovial diffusion.
The carpal tunnel contains?
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.
Lumbrical muscles originate where?
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.
decreased proximal interphalangeal (PIP) flexion with the metacarpophalangeal (MCP)
held in extension, and increased PIP flexion with MCP in flextion =
Intrinsic tightness
decreased PIP flexion with MCP in flexion and increased PIP flexion with MCP in extension? =
Extrinsic tightness
Radiographic parameters of distal radius?
Radiographic evaluation follows the 11-22-11 guide: • Radial height-11 mm; radial inclination-22 degrees; volar tilt-11
degrees
acceptable reduction parameters i distal radius fractures?
- Radial shortening less than 3 mm • Dorsal articular tilt less than 10 degrees
- Intraarticular step-off less than 2 mm
The most common complication after distal radius fracture
median nerve dysfunction
EPL tendon rupture most commonly occurs when? treatment?
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
most common tendon injury after volar plating?
FPL
operative indications of scaphoid fracture?
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.
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.
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.
SNAC wrist sequence?
The radioscaphoid joint is affected first, followed by the scaphocapitate and lunocapitate; the radiolunate joint is spared
the longest.
Carpal instability can be broadly classified into four types:
Carpal instability dissociative
Carpal instability nondissociative • Carpal instability adaptive
• Carpal instability complex
how does a DISI occur?
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.
describe a VISI?
VISI is the second most common (decreased SL angle) • Lunotriquetral ligament disruption • Volar portion strongest
• Natural history less clear
Perilunate dislocations are an example of carpal instability complex. • Mayfield described four stages of progressive disruption:
- I—scapholunate
- II—midcarpal
- III—lunotriquetral (perilunate dislocation)
- IV—circumferential (lunate dislocation)
describe deforming forces of a Bennett fracture?
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.
Thumb MCP UCL injury Instability in 30 degrees of flexion indicates ?
injury to PROPER ucl (flexion in PALM is PROPER)
what is a stenar lesion?
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.
PIP dislocations most commonly occur
dorsally and result from volar plate and collateral ligament injury.
Volar PIP dislocation requires disruption of what? and treatment ? to prevent?
central slip and must be splinted in full extension following reduction to prevent a
boutonnière deformity
Rotatory PIP dislocation occurs when
one of the phalangeal condyles is buttonholed between the central slip and a lateral
band
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?
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
Irreducible MCP and DIP dislocations are typically due to
interposition of the volar plate; treatment is via open reduction and extraction of
the volar plate
mallet finger treatment?
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.
Dorsal injury over the PIP may disrupt? and consequence of this is?
the central slip insertion. • Lateral bands subluxate volarly. • Acute boutonnière deformity results in a posture of PIP flexion
and DIP hyperextension
If boutonniere deformity flexible ..treatment?
capener splint or
central slip reconstruction
Fundamental principles of flexor tendon repair:?
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%.
flexor tendon rehab protocols?
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.
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?
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.
Adult trigger finger (stenosing flexor tenosynovitis) should be treated how ?
non op - injection steroid
op – A1 pulley release
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).
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).
what is dequervains tenosynovitis?
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.
what is intersection syndrome?
Intersection syndrome is a tendinopathy occurring at the junction between the first and second extensor compartments.
• Commonly affects rowers and generally treated nonoperatively
Components of the triangular fibrocartilage complex (TFCC) include:
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.
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.............................
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.
Posttraumatic DRUJ osteoarthritis may be treated with:
hemiresection interposition arthroplasty, Darrach resection, Sauve-Kapandji
arthrodesis or prosthetic arthroplasty
Nail bed injuries with less than 50% subungual hematoma
may be treated without nail plate removal (nail trephination for pain relief).
Nail bed injuries with greater than 50% subungual hematoma may be treated
with nail plate removal and repair of underlying nail matrix lacerations.
less than 1 cm2 without exposed
bone
secondary intention
larger wound without exposed bone?
skin grafting
Volar oblique injury treated by
cross-finger or thenar flap
