High Yield MRC Course Flashcards
(154 cards)
1
Q
Mannerfelt Syndrome
A
A/w RA
Rupture of FPL and/or index FDP due to attrition over volar STT osteophyte
2
Q
Vaughn-Jackson Syndrome
A
A/w RA
Rupture of extensor tendons starting with EDM (from attrition over prominent distal ulnar head) -> continues radially
3
Q
Acceptable parameters for DR reduction
A
Radial shortening < 3 mm
Dorsal tilt < 10 degrees
Intra-articular stepoff < 2 mm
4
Q
After DR fx what is the most common intra-articular soft tissue injury?
Most common primary intrinsic ligament injured?
A
TFCC injury (nonop unless DRUJ unstable after DR fixation) SL ligament
5
Q
Order of arthritis in SNAC wrist
A
Counter-clockwise on pronated hand (remember you pronate your hand to grab a SNAC!)
1st: radial styloid, 2nd radioscaphoid jt, 3rd: scaphocapitate & lunocapitate; radiolunate joint is least affected (PRC vs scaphoid excision & 4 corner fusion)
6
Q
Fixation of scaphoid:
W/ humpack only
w/ AVN only
w/ humpback AND AVN
A
Humpback only -> iliac crest bone graft
AVN only -> 1-2 ICSRA
Humpback + AVN -> MFC
7
Q
DISI vs VISI
A
DISI (MC form of carpal instability) -> SL ligament injured (strongest Dorsal); increased SL angle b/c lunate will follow the intact triquetrum which always wants to extend.
VISI -> LT ligament injured (strongest Volar); decreased SL angle/increased LT angle b/c lunate will follow the scaphoid which always want to flex.
8
Q
Mayfield described four stages of progressive disruption in perilunate dislocation
A
I: scapholunate
II: midcarpal
III: lunotriquetral
IV: circumferential
9
Q
PIPJ fx/dislocation - how do you decide treatment?
A
Volar P2 base fragment < 30% involvement -> tx non op with dorsal block splint/pin
Unstable injuries with larger P2 base fragments often require operative intervention, such as dorsal block pinning, ORIF, hemihamate reconstruction, or volar plate arthroplasty
10
Q
In Bennett fx - what are the deforming forces?
What is exam maneuver for reduction?
A
APL** & extensors → proximal, dorsal & radial displacement of shaft
Reduction = “TAPE”
Traction/Abduction/Pronation/Extension
11
Q
What is the rotation of the proximal phalanx in UCL vs RCL injuries?
A
ROTATION OCCURS AROUND INTACT LIGAMENT:
UCL injury -> rotates into supination around the intact RCL
RCL injury -> rotates into pronation around the intact UCL
12
Q
Components of TFCC:
A
dorsal & volar radioulnar ligaments, the articular disc, a meniscus homologue, ECU & ulnolunate & ulnotriquetral ligaments
13
Q
Acute TFCC tear vs Chronic TFCC tear
A
Acute (class I) TFCC tears are most commonly avulsions at the ulnar periphery (type IB) & amenable to repair (periphery=vascularized) - NO DIFFERENCE IN OUTCOME B/T OPEN vs ARTHROCOPIC Degenerative (class II) tears are associated with positive ulnar variance & ulnocarpal impaction syndrome In the absence of DRUJ OA, the most commonly performed procedure is arthroscopic débridement & ulnar shortening osteotomy DRUJ OA may be treated with hemiresection interposition arthroplasty, Darrach resection (low demand), Sauve-Kapandji arthrodesis (e.g. RA) or prosthetic arthroplasty
14
Q
Unexplained dorsal wrist pain in a young adult with negative ulnar variance should prompt what study? And what are we looking for?
A
MRI evaluation -> Kienbock dz (idiopathic osteonecrosis of lunate)
15
Q
What is treatment for stage IIIA Kienbocks (lunate collapse with NORMAL carpal alignment and height)?
A
First-line surgical treatment is:
- a joint-leveling/unloading procedure. In patients with ulnar-negative variance, radial-shortening osteotomy is preferred; if no variance then capitate shortening.
OR
- Revascularization = 4-5 Extensor compartment artery (has the LONGEST pedicle!)
16
Q
What is treatment for stage IIIB Kienbocks
(fixed scaphoid rotation with DECREASED carpal height and proximal migration of capitate)?
A
salvage procedure for associated carpal instability and/or degenerative OA (partial wrist fusion or proximal row carpectomy)
17
Q
What ligaments are NOT involved in Dupuytrens?
What is the prominent cell type and what collagen is increased in this dz?
A
Cleland ligaments (“Ceiling” of the NV bundle)
Myofibroblasts
Type III collagen (*Normal palmar tissue is typically Type I)
18
Q
What are surgical/collagenase indications for Dupuytrens?
What is average MCP and PIP correction achieved?
A
Surgical indications include inability to place hand flat on tabletop (Hueston test), MCP flexion contracture greater than 30, or any PIP flexion contracture.
Collagenase results in better MCPJ results than PIPJ results
19
Q
MC soft tissue mass of hand/wrist?
2nd MC?
A
Ganglion
Giant cell tumor of tendon sheath (usually volar aspect of digit)
20
Q
Most common hand malignancy
A
squamous cell carcinoma
21
Q
Most common hand sarcoma
A
Epithelioid and Synovial
22
Q
Most common hand benign bone tumor
A
enchondroma (remember these look more bubbly, expansile in hand instead of arc/whirls seen in prox humerus)
23
Q
Most common malignant bone tumor
A
Metastatic lung ca
24
Q
Most common malignant primary bone tumor:
A
Chondrosarcoma
25
Lateral epicondylitis -> what tendon involved and what does histologic exam show?
What PE finding?
Tx?
ECRB (and some of EDC!)
Angiofibroblastic hyperplasia (LACK of inflammatory cells!)...it's a tendinopathy NOT tendonitis!
PE finding -> grip strength worse w/ elbow extension (muscle is on stretch) than flexion
Tx -> ECCENTRIC PT training
26
Main determinant for maintaining fx alignment after closed reduction and splint of DR fx?
Age! (>60 will lose reduction - LaFontaine criteria)
27
Diff of ORIF vs casting of DR fx?
ORIF gets early improvement BUT at 1 year NO DIFF
28
In pts > 65 difference b/t op vs nonop tx of DR fx?
Op tx: > grip strength, better looking XRs
| FUNCTIONALLY THE PATIENT'S DO THE SAME THOUGH!
29
Is there advantage to repairing PQ at end of DR volar ORIF?
No! Not shown to improve ROM, grip strength, or incidence of flexor tendon injuries!
30
Possible tendon ruptures after volar plate placement?
If place past watershed line -> FPL or FDP index
| Long screws -> EPL
31
What are the complications a/w exfix for treatment of DR fx?
```
#1 = fracture subsidence
Pin tract infection
Digital stiffness -> ESP THINK OF THIS IF CARPUS OVER DISTRACTED or have been in exfix too long
```
32
Where is dorsal bridge plate placed for DR fx distally? Complications?
Who should you consider this in?
Who is it contraindicated in?
Index finger MC
MF MC -> a/w EPL entrapment
Indicated -> Highly comminuted fx, SIGNIFICANT DIAPHYSEAL EXTENSION, polytrauma patient
Contraindicated -> volar/ulnar corner (needs a plate), MC fx, bad dorsal soft tissue
33
Most common complication after fixation of DR fx w/ volar/ulnar corner fx that is fixed well?
Symptomatic hardware - follow these patients!
34
MC nerve injury w/ DR fx? What pressure a/w injury?
Median nerve at the carpal tunnel
| > 40 mmHg
35
After DR fx and patient presents in clinic later with CTS - what do you do? Trial conservative or surgery?
Surgery - CTR....don't trial conservative
36
What makes up DRUJ stability?
```
Bone geometry -> 20%/Soft tissue 80%
Soft tissue = RUPERT
Radioulnar ligaments (foveal attachement of this is impt!)
Ulnocarpal ligaments
PQ
ECU
Radius IOM (this one is a stretch...but go with it!)
TFCC
```
37
What contributes to DRUJ stability in the presence of an ulnar styloid fracture?
What is the importance of an ulnar styloid basal oblique fracture?
What is importance of just the tip ulnar styloid fx?
Foveal attachment of the radioulnar ligament
Watch out for this b/c this is where the foveal attachment of RU ligament inserts -> so likely injured and likely DRUJ instability after DR fx is fixed!
Just the tip ulnar styloid basically NEVER have DRUJ instability!
Treatment always goes -> fix DR and then examine DRUJ for stability after to see if is unstable!
38
When do you fix distal ulnar head/neck fractures (that occur w/ DR fx)?
> 50% displacement
OR
> 10 degrees angulation
39
What wrist position is most associated with injury to scaphoid?
What position loads the SL ligament?
Extension and radial deviation
| Extension and ULNAR deviation (think pencil grip view)
40
What is the most common location of:
Adult scaphoid fx
Ped scaphoid fx
Adult -> waist
| Kids -> distal pole
41
2 main operative indications for scaphoid fx?
| Others?
1.) Proximal pole (b/c can heal on it's own...though difficult and will take long time! Like 6 months!)
2.) 1 mm displacement (basically any displacement!)
Others:
If want to get back to work more quickly (like a surgeon)
42
What position should the wrist be in for scaphoid view XR?
Wrist extension (30 degrees)/Ulnar deviation(20 degrees)
43
What imaging should you order when looking at scaphoid and trying to:
1. ) make diagnosis?
2. ) look at displacement and stability?
1. ) MRI
| 2. ) CT
44
If you are going to immobilize for a scaphoid fx - how d you do it?
ANY form of wrist immobilization - no diff in LAC/SAC/w or w/o thumb spica!
45
When do you fix scaphoid from volar vs dorsal?
Volar -> Distal pole, or need to correct humpback deformity
| Dorsal -> Proximal pole (better angle to centralize screw), or if need to use 1,2-ICSRA vascularized bone graft
46
What vascularized bone graft has the longest pedicle?
4th extensor compartment artery....think about using in lunate pathology
47
Treatment of SNAC wrist:
1) Just radial styloid involved
2) Radial styloid+scaphocapitate
1.) Radial styloidectomy (NO more than 4 mm! or can injury RSC ligament and carpus will shift ulnar!)
2.) PRC (since capitate and lunate facet of DR are good) - OLDER pts
OR
Scaphoid excision + 4corner fusion - Younger pts
48
Common treatment for hook of hammate fracture?
| What is main complication of this tx?
Excision
Decreased grip strength as a result of loss of pulley system for 4th and 5th FDP tendons!
(Ulnar nerve injury less common)
49
Other than the scaphoid, what carpal bone also has retrograde blood supply?
Capitate!
| If fractured and nondisplaced -> immobilize, displaced -> ORIF
50
What is an atraumatic/chronic cause of SL ligament injury?
Inflammatory arthropathy = Gout, RA!...can lead to DISI!
51
Gold standard to Dx an SL ligament injury?
Arthroscopy
52
In a lunate dislocation what ligament keeps the lunate tethered to the volar radius?
Short radiolunate ligament
53
Perilunate injury treatment?
Tx: ORIF
| Dorsal to fix the SL ligament +/- volar to fix LT +/- CTR PRN
54
Where does the primary blood supply of the scaphoid enter?
Oblique dorsal ridge
55
Hook of hammate fx can be a/w what other injury?
FDP tendon rupture (to RF/SF)
56
Mc base fracture deforming forces:
2nd (IF) MC:
3rd (MF) MC:
5th (SF) MC:
2nd -> ECRL
3rd -> ECRB (remember B/3)
5th -> ECU
57
4th/5th CMC fx/dislocation -> management and what other injury to look for?
High energy injury
Look for Hammate fx
Fix w/ either CRPP or ORIF
Watch out for dorsal ulnar cutaneous nerve
58
MC Shaft fx:
5 degrees of rotation = X cm overlap
2 mm shortenin = Y degrees extensor lag
```
X = 1.5 cm
Y = 7 degrees
```
59
After phalanx fractures or intra-articular fractures or dislocations; what is the MC complication seen after these injuries?
Stiffness!!
60
Volar PIP dislocation -> what is commonly injured and what sequela can result if not treated appropriately (with extension splinting at PIP)
Central slip!
| Boutinere deformity!
61
Dorsal PIP dislocation treatment....how do you decided stable vs unstable?
< 30% P2 base involved -> stable = dorsal block splint
> 30% P2 base involved -> unstable = ORIF...but often comminnuted so hemi-hammate graft
(if chronic w/ no arthritis = hemi-hammate graft...if arthritis fuse radial digits, arthroplasty ulnar digits)
62
At the thumb CMC joint what ligament is primary restraint to dorsal dislocation?
Dorsoradial ligament
63
What is the acceptable angulation allowed for base of thumb MC fx (extra-articular)?
If over this, what is the reduction maneuver and treatment?
Must be 30 degrees or LESS for nonop.
If > 30 degrees = CRPP
Reduction: "TAPE"
Traction/Abduction/Pronation/Extension
64
In UCL and RCL injuries what side do the ligaments typically rupture from?
Tears on the side the ligament gets more narrow:
UCL - prox phalanx side
RCL - MC side
65
After thumb (dorsal..MC) dislocation that you are able to reduce; what else do you need to check for?
Collateral ligament injury! Don't want to miss!
66
DRUJ dislocation - how do you immobilize if volar vs dorsal to create stability?
Palmar (volar) = Pronation (remember the P's)
dorsal = supination
(*Or remember to point the thumb towards the disolcation)
67
On an MRI, how do you differentiate Kienbocks from ulnar impaction syndrome?
Kienbocks -> diffuse edema
| Ulnar impaction syndrome -> edema is localized only to the ulnar side (just in that bottom corner!)
68
What is the tx for ulnar impaction syndrome?
1st -> Trial nonop (wrist widget)
2nd -> surgery:
If only have TFCC wear = TFCC debridement
If have TFCC wear + lunate and/or ulnar chondromalacia =
* Wafer (take proxial 2-4 mm of bone) OR
* Ulnar shortening osteotomy (if person also has LT instability want to choose this option b/c will help tighten these ligaments)...but contraindicated if have DRUJ arthritis
69
If have DRUJ arthritis in a young person what do you want to make sure to preserve?
The ulnar head!! B/c the DRUJ is a WB joint (think about holding a beer...it is loaded like this). Do NOT do a Darrach in a young person - will get ulnar convergence where it knocks into the radius!
70
What is the initial portal placed in wrist arthroscopy?
3/4 portal, which is 1 cm directly distal to Lister tubercle
71
When viewing the wrist from the 3/4 portal what is the correct order of volar extrinsic wrist ligaments from radial to ulnar?
Radioscaphocapitate
Long radiolunate
Short radiolunate
72
Which portal(s) place subcutaneous sensory nerves at most risk?
1/2 portal - sensory branch of radial nerve
| 6U - dorsal ulnar cutaneous nerve
73
Best wrist radiograph for determining ulnar variance?
True AP = 0 degree AP
| you want wrist in neutral...if you pronate/supinated this changes the relationship!
74
What is the operative tx for DIP joint arthritis?
| What about PIP arthritis?
DIP: Fusion ONLY (never arthroplasty!)
PIP: radial digits = fusion; ulnar digits = arthroplasty (need motion for grip!)
75
PIPJ arthroplasy - silicone: what patient population is this good for?
What about non-linked: what is it made out of?
RA - because it is LINKED...so this is good b/c their soft tissues are bad so you want a linked implant.
Nonlinked -> made out of Pyrocarbon (ceramic material) and is good b/c its modulus elaticity is SIMILAR TO BONE, but to use these you need good bone & good soft tissues (since unlinked)...there is also metal w/ PE...but can get PE wear
76
In Dupuytrens which cords are mainly responsible for the following contractures:
1. ) DIP
2. ) PIP
3. ) MCP
4. ) Webspace
5. ) What cord is responsible for displacement of NV bundle?
1. ) Retrovascular cord
2. ) Central cord
3. ) Pretendinous cord
4. ) Nataory cord
5. ) Spiral cord (displaces NV bundle volar and midline)
77
Medial epicondylitis involves which tendons?
PT and FCR
| ALso is angiofibroblastic tendinosis (like lateral epicondylitis)
78
What motion do you need in flex/ ext and pro/sup to have functional elbow motion
RULE OF 100:
30-130 ext/flex
50-50 pro/sup
79
Translation of what can help to restore volar tilt of a dorsally displaced DR fx?
Volar translation of the lunate
80
What is the difference b/t:
1. ) Neurapraxia
2. ) Axonotmesis
3. ) Neurotmesis
1. ) Axon injured/conduction block, but intact (NO Wallerian degen takes place)
2. ) Axon + endoneurium +/- perineurium injuried (epineurium intact) - Wallerian degen distal to injury
3. ) Complete transection - Wallerian degen distal to injury
81
What is the treatment for neurapraxia?
Observe! Recovery expected 3-4 months! (It's just a conduction block and all the architecture is preserved!)
82
What is the expected outcome of axonotmesis?
Since nerve still has a neural tube to grow through (has guidance!) then regeneration expected @ 1 mm/day.
83
What is the treatment for neurotmesis?
Needs repair! Complete transection!!
84
What is the difference b/t neurapraxia, axonotmesis and neurotmesis on EMG?
Axonotmesis and Neurotmesis will have fibrillation/sharp waves. Neurapraxia will be normal (will be silent)
85
What is the window of time to repair a nerve?
< 18 months (after this there is denervation atrophy)
86
What are the 3 main repair methods for neurotmesis?
1. ) Direct repair (neurorrhaphy) - do if can do it w/ NO tension
2. ) Conduit: indicated for < 2-3 cm (mostly for sensory nerves)
3. ) Graft (allo vs autograft): allograft < 5 cm defect (sensory nerve only - like a digital nerve), autograft (usually sural nerve) > 5 cm defect
87
What is the most important predictor of outcome in nerve repair?
Age! (younger does much better!)
88
What nerve transfer is possible if need to regain elbow flexion?
Double Oberlin transfer ->
Ulnar n. fascicles from FCU
Median n. fascicles from FDS/FCR
Transfer both to the motor branch of biceps & brachialis
89
What is the diff b/t NCS and EMG?
| What EMG findings are abnormal?
NCS (shock them sending a signal along the nerve) -> conduction velocity/latency, amplitude
*Demyelination - decreases velocity/increases latency
*Axonal loss - decreases amplitue
EMG (put probes in muscles and tell patient to use those muscles) -> measures electrical activity
*Axonotmesis & Neurotmesis will show fibrillations/sharp waves
* Sensory > 3.5 msec
* Motor > 4.5 msec
90
When evaluating CTS -> what sensory tests are used and what is seen
1. ) Semmes-Weinstein monofilament -> inability to detect 2.83 monofilament or less is (+) for neuropathy and more sensitive in early findings
2. ) 2 pt discrimination > 6 mm is abnormal/positive for neuropathy and is LATE finding of compressive neuropathy!
* * SEMMES-WEINSTEIN IS BETTER!**
91
What are best provacative tests for CTS?
1. ) Durkans - compression of CT - positive if have numb/tingles < 30 sec (BEST TEST!)
2. ) Phalens (remember "follow through wrist flexion") - positive if have numbness/tingling in < 60 sec
3. ) Tinels (not actually that good of a test)
92
What is the main difference in endoscopic vs open CTR?
Diff in longterm results?
When do preop pinch strength and grip strength return?
Endoscopic allows for less incision pain and earlier return to work.
Longterm - results are the SAME!
Pinch - 6 wks
Grip - 12 wks
93
What are the sites of Median nerve compression? (Pronator & AIN syndrome)
*What 2 main findings will help you differentiate median n. compression at the carpal tunnel from median nerve compression more proximal?
"SPLAT"
1. ) Ligament of Struthers (medial aspect of distal humerus from supracondylar process to medial epicondyle)
2. ) Pronator Teres (2 heads)
3. ) Lacertus fibrosis (comes of medial side of biceps tendon)
3. ) FDS Arcade
4. ) TCL
* Forearm pain
* Decreased sensation in palm (palmar cutaneous n. branches ~ 6 cm proximal to TCL) will both tell you that is proximal site of compression!
94
What is a/w Pronator Syndrome?
| What is treatment?
```
Medial epicondylitis (if you treat this, pronator syndrome improves)
Tx: Splinting, NSAIDS, modify activities (almost NEVER op!)
```
95
What are the sites for ulnar nerve compression?
1. ) Arcade of Struthers - fascial thickening (8 cm proximal to elbow)
2. ) Medial head of triceps/medial intermuscular septum
3. ) Cubital tunnel/Osborne's Ligament/Anconeus Epitrochlearis (mass effect)
4. ) FCU
5. ) Guyon's canal
96
What are findings seen with Cubital tunnel syndrome?
1. ) Wartenberg's Sign (abducted small finger due to weakness of 3rd PAD interosseious and unopposed radially innervated extensor digiti minimi)
2. ) Froment's Sign
3. ) Intrinsic atrophy, ulnar clawing
97
1. ) What is the treatment for Cubital Tunnel Syndrome?
| 2. ) What is 2nd line tx?
1.) Conservative - extension splinting, avoid flexion of elbow x 3 months
2.) Surgery - release all sites! (starting proximally at Arcade of Struthers -> FCU)
(transposition only indicated if they are having subluxation sx)
**Be careful not to injure medial antebrachial cutaneous nerves (branch from medial cord of brachial plexus)!!
98
In regards to compression around Guyon's canal/Ulnar Tunnel Syndrome -> what are the 3 zones, what are their deficits and what are the common causes?
1. ) Zone 1 - motor & sensory; Ganglion cyst
2. ) Zone 2 - motor only; Hook of Hammate fx
3. ) Zone 3 - volar sensory only; ulnar artery thrombosis
99
What are some findings that would tip you off to tell you that ulnar nerve deficit is proximal to Guyon's canal?
Decreased sensation on the dorsum hand in ulnar distribution (this branches off prior to Guyon's canal!).
Weakness in SF & RF FDP would happen proximal to Guyon's canal
100
What makes up the boundaries of the ulnar tunnel/Guyon's canal?
```
Roof = volar carpal ligament
Floor = TCL (ceiling of carpal tunnel!) - release of TCL releases both!!
Radial
Ulnar = Pisiform
Radial = Hook of hammate
```
101
What are the sites of compression of the Radial n./PIN?
```
"FREAD"
Fascial band at radial head
Recurrent Leash of Henry
ECRB edge
Arcade of Frohse (proximal supinator) MOST COMMON!
Distal supinator
```
102
In all of the nerve compression syndromes - what is treatment?
Activity modification, splinting x 3 months -> if no improvement surgical decompression at ALL compression pts!
103
What is the difference b/t PIN compression syndrome and Radial Tunnel Syndrome?
What is MC site of compression?
PIN syndrome -> MOTOR only deficit
Radial Tunnel Syndrome -> PAIN only (no motor or sensory deficits)
For both of them -> Arcade of Frohse (proximal supinator)
104
What is the presentation of radial sensory nerve compression?
Wartenberg Syndrome/Cheiralgia Paresthetica
Compression of nerve b/t the brachioradialis and ECRL
Findings = Tinels over nerve in distal forearm (hx of tight watch, handcuffs, repetitive activity)
105
In obstetric brachial plexopathy, what finding will lead you to expect a full recovery?
Biceps and deltoid fxn retrun by 2 months!
106
When considering tendon transfers -
1. ) What is related to excursion of tenon/amplitude?
2. ) What is related to the force the muscle can generate/strength?
* How do you set the tension?
1. ) Fiber length best correlates to amplitude
2. ) Cross sectional area
* Resting tension!
107
Radial Nerve Injury - consideration of tendon transfers by function needed:
1. ) Wrist extension
2. ) Finger extension
3. ) Thumb extension
1. ) PT -> ECRB (more central line of pull!)
2. ) FCR (choose 1st), FDS or FCU -> EDC
3. ) PL (choose 1st), FCR, or FDS -> EPL
108
In patient with a viral syndrome and then nerve irritation what is the called and what nerve usually effected?
Parsonage Turner
AIN
(Observation!)
109
In a low median neuropathy, what function do you primarily need to get back?
What are the 4 most common transfers for this?
Opposition of thumb!
1. ) Camitz (PL to thumb prox phalanx) - MOST COMMONLY USED! Provides more abduction than opposition. Also, good for elderly w/ CTS and thenar atrophy w/ loss of opposition
2. ) Huber transfer (AbDM) - used in congenital thenar absence
3. ) FDS transfer (these last 2 are less common!)
4. ) EIP oppnensplasty
110
Ulnar nerve injury - by function needed: mainly Pinch!
2 options:
* ECRB -> adductor pollicis (NEED PL tendon graft to make long enough!!)
* FDS -> adductor pollicis (DON'T need graft!)
111
1. ) What causes Claw Hand?
2. ) What test do you use to evaluate?
3. ) What transfer used?
1. ) Ulnar nerve loss -> get intrinsic minus position (ext of MCP, flex PIP) due to loss of the lumbricles
2. ) Bouvier's Test -> flex MCP and ask pt to extend PIP (if can't then you need to address PIP motion in addition to providing MCP flexion)
3. ) FDS transfer DEEP to intermetacarpal ligament (to recreate moment arm of lumbrical)
112
What is synergism in regards to tendon transfer?
Motions that go together (no necessarily the same motion!!)
Ie -> think about grabbing something:
Want wrist flexion and finger extension; wrist extension and finger flexion
113
In finger tip injuries in which there is just pulp loss - what is best treatment?
Nonop!
| Body can heal up to 1 cm2 area!
114
With a volar oblique injury w/ exposed bone what are soft tissue coverage options?
* Thumb -> Moberg advancement FLAP (1-1.5 cm)
* IF, MF in child/young (w/o PIP arthritis) -> Thenar FLAP
* Cross Finger FLAP (dorsal P2)
115
What is important about digital island FLAPs and which digits can they be used for?
Maintains its own sensory innervation
| Thumb or IF
116
What are FLAP options for dorsal oblique or transverse soft tissue digital injury w/ exposed bone?
VY advancement vs shortening and using a volar-based FLAP
117
1. ) What is FLAP for volar thumb injury?
| 2. ) What is FLAP for dorsal thumb injury?
1. ) Moberg advancement (1 -1.5 cm)
| 2. ) 1st dorsal metacarpal artery (FDMA) Kite FLAP (>1.5 cm...can also use for large volar thumb problem)
118
What happens if you close tip of finger skin too tightly?
Hook nail deformity
119
What is Lumbrical Plus finger and what is the cause?
| What is treatment?
Paradoxical finger extension with attempt at finger flexion.
Happens due to FDP tendon injury/retraction or shortening/closing a distal fingertip injury which puts tension on the lumbricals which originate off of FDP tendon - so attempted flexion results in firing of lumbrical which extends IP joints.
Tx: lumbrical release off of distal radial lateral band
120
What are the 3 steps in the process of a skin graft taking?
1. ) Plasma imbibition (need graft to stick down...so shear stress and hematoma are bad b/c can disrupt this)
2. ) Inosculation
3. ) Revascularization
121
What is a composite FLAP and who should you use them in?
Reattaching finger tip - only do in kids up to age 6 and make sure to tell the parents that the tip will turn black and die and the living new skin will develop underneath.
122
What is the main deciding factor b/t using a Split Thickness Skin Graft vs a Full thickness skin graft?
Need for sensibility.
If don't really need sensibility -> STSG (ie dorsal forearm)
If need sensibility -> FTSG (volar hand!)
123
For local tissue rearrangements how much lengthening do you get out of:
1. ) 60 degree Zplasty
2. ) 45 degree Zplasty
3. ) 30 degree Zplasty
1. ) 60 degree Zplasty - 75%
2. ) 45 degree Zplasty - 50%
3. ) 30 degree Zplasty - 25%
124
What FLAPs are used for tibia coverage:
1. ) Proximal 1/3
2. ) Middle 1/3
3. ) Distal 1/3
1. ) Proximal 1/3 - Gastroc
2. ) Middle 1/3 - Soleus
3. ) Distal 1/3 - Free FLAP
125
What is the main blood supply to the hand?
| What % of people have a complete arch? How can you tell?
Ulnar artery via the superficial palmar branch
80% have complete arch (so injury to either the radial or ulnar artery will not effect distal perfusion). Check via Allen's test
126
What is an abnormal digital brachial index?
< 0.7 (*remember b/c the vascular arch in the hand looks kind of like a 7?!)
127
What is the treatment for hypothenar hammer syndrome?
Depends on digital brachial index:
If < 0.7 -> reconstruct w/ reversed vein graft
If > 0.7 (so digits are well perfused AND person has complete arch) -> cut out/ligate portion = Leriche sympathectomy
128
When have/suspect vaso-occlusive dz as reason for poor blood flow to RF (+/- SF) - what is typical cause?
Embolic dz b/c this is straight shot to this digit - usually see occlusion from PIP and distal b/c this is where vessels get much smaller
129
What is the difference b/t Raynaud Dz vs Raynaud Phenomenon
Dz - this is the primary dz w/o other underlying cause
| Phenomenon -> part of an underlying vaso-occlusive dz
130
What are the absolute indications for replant?
What are the relative indications?
What are the contraindications?
Indications:
1. ) Thumb
2. ) Multiple digits
3. ) Wrist or proximal
4. ) Child
Relative: Single digit distal to FDS (Zone I)
Contraindications:
1. ) Single digit in Zone II
2. ) Segmental
3. ) Crush/avulsion
4. ) Prolonged ischemia (Digits 12/24; Proximal to wrist 6/12)
5. ) Advanced age
6. ) Multiple co-morbidities
7. ) Polytrauma
131
What is the most common cause of replant failure:
1. ) < 12 hrs postop
2. ) > 12 hrs postop
3. ) After 1 week
What is the MC secondary procedure needed after a replant?
1. ) Arterial thrombosis
2. ) Venous congestion
3. ) Infection
Tenolysis!
132
What is the treatment for venous congestion after a digital replant?
What other important info do you need to know about that treatment?
Leeches -> excrete anticoagulant Hirudin
Also carry Aeromonas Hydrophila -> ppx w/ Ciprofloxacin, Ceftriaxone, Bactrim
133
How much of tendon should be injured to indicate repairing it?
> 50%
134
What is the tx for a mallet finger?
| What if caused by sharp object/knife?
DIP (ONLY..PIP free) extension splinting x 6-8 weeks (bony or ligamentous). Can still do this even if present up to 3 months late!
If has subluxation -> DIP pinning.
If sharp object -> tenodermadesis
135
1. ) What deformity do you get if have untreated Mallet finger?
2. ) What deformity do you get if have untreated Central slip rupture? What causes this deformity?
1. ) Swan-neck deformity
2. ) Boutonniere (can get as early as 10-21 d after injury) - happens due to triangular ligament attenuates (stretches) -> lateral bands migrate volar
136
What is the treatment for acute central slip rupture?
PIP extension splinting x 6 weeks
| ***FOR all extensor tendon injuries -> first line is extension splinting!!
137
What splint should be used for extensor tendon injuries to zones IV - VII?
Relative motioin splint = yoke splint
138
What is the treatment for a Boutonniere finger?
If cannot passively correct -> PT until can
If can passively correct -> release terminal extensor tendon -> you don't get droopy DIP b/c still have intact capsule and Oblique Retinacular Ligament
139
How do you tell extrinsic vs intrinsic tightness?
Place MCP in extension:
1.) If PIP motion worse/limited flexion -> Intrinsic (b/c intrinsics/lumbricals are stretched)
Tx: stretching -> if not improved, surgical release of radial lateral bands (insertion of lumbricals!)
2.) If PIP motion better -> Extrinsic (b/c extrinsic extensors are more relaxed!)
Tx: tenolysis (perform if failure of therapy x 3 months!)
140
1. ) How are the extensor zones labeled?
| 2. ) How are flexor zones labeled?
1.) Odds over joints (1 starting distally)
2.)
Zone I -> distal to FDS
Zone II -> FDS intertion to proximal to A1 pulley (NO MANS land! = poor results after flexor tendon repair)
Zone III -> Prox to pulleys to TCL
Zone IV -> Carpal tunnel
Zone V -> Proximal to carpal tunnel (proximal to wrist crease)
141
1. ) What is the appropriate repair of flexor tendons needed so that may start early ROM therapy?
2. ) What suture placement is stronger?
3. ) What pulley's MUST be preserved during repair?
4. ) What is an important risk factor for flexor tendon rupture after repair?
5. ) Where do repairs typically rupture?
1. ) Need 4-8 core strands and epitendinous repair (Epitendinous suture decreases gap formation and increases strength up to 50%!!)
2. ) DORSAL suture placement is stronger
3. ) Pulley's 2 and 4! (others can be opened to access PRN w/o need for repair!)
4. ) Gap > 3 mm!!
5. ) At the knots!!
142
For FDP tendon avulsion/ruptures (ie Jersey finger)- what determines timing of treatment?
Depends on if tendon has retracted to palm or not.
* If retracted to palm (all blood supply/vincula are ruptured) -> repair in 7-10 days
* Otherwise, have up to 6 weeks
143
What are possible complications unique to FDP repair?
1. ) Quadrigia due to common muscle belly of MF, RF, SF! Happens if shorten tendon > 1 cm (other digits won't be able to be fully brought into palm and will get forearm pain)
2. ) Lumbrical plus -> may see with orginal injury b/c FDP retracted so lumbricals tight; but also if use a tendon graft that is too long (to help understand remember/this is functionally still a cut/retracted tendon!)
144
What is the main difference in postop plan for kids compared to adults after flexor tendon injuries?
Adults -> extension block splinting w/ wrist and MCPs flexed
| Kids -> CAST x 4 weeks!! -> can't trust them!!
145
1. ) What is most common organism in all hand infections?
2. ) What organism is specific to human bites?
3. ) What organism is specific to dog/cat bites?
1.) Staph
2.) Eikenella corrodens (Always treat human bites w/ surgery!!) -> if fails tx w/ cephalosporin its b/c of E. corrodens - need PCN
3.) Pasteurella multocida
(Both dog and human bites can be treated w/ Ampicillin/Sulbactam IV followed by amoxicillin + clavulanic acid = Augmentin)
* Cat bites have higher rate of failure of abx treatment and may also require surgical debridement.
146
What special stain and media is needed for mycobacterium?
| What group at risk for this infection?
Stain -> Ziehl-Neelsen
Media -> Lowenstein-Jensen. Culture x 42 days!!!
Fisherman!
147
What allows distal infections to spread proximally into the forearm?
Parona's space (overlays the PQ). Can also allow for acute carpal tunnel
148
What is the most common organism a/w cellulits?
| What else can it cause?
Group A beta-hemolytic Strep
| Necrotizing Fasciitis!!! (can also be caused by Clostridia)
149
What does Herpetic Whitlow look like?
Who is at risk?
What is tx?
Vesicles on erythematous base
Hands in mouth -> toddlers, dental hygienists, pulmonary therapists
Tx: observe, acyclovir (will help quicken course...dz is self limited) - DON'T I&D!
150
In regards to high pressure injection injuries - what is the MOST IMPORTANT VARIABLE FOR OUTCOME?
Material injected! oil-based paint/organic solvents are the WORST -> high amputation rate!
151
What are the contents of the 1st extensor compartment? What aberrant anatomy can be present?
APL -> L for Lots of slips
EPB -> B for By itself (also is more dorsal)
*90% of people who fail nonop tx (splint, steroid injection) have aberrant anatomy!!
152
What does acute calcific tendonitis look like? What is treatment?
Dramatic onset of excruciating pain w/o hx of trauma (mimics septic wrist) -> but then XR shows fluffy calcific deposits -> Tx = immobilization, NSAIDS
153
What is involved in lateral epicondylitis?
ECRB tendon -> angiofibroblastic hyperplasia (NOT a tendonitis - no inflammatory cell! A tendonosis!)
154
What is involved in medial epicondylitis?
FCR/PT
