Miller Review Hand Lectures Flashcards
Orthopaedic Hand Surgery (249 cards)
1
Q
Epineurium
A
Surrounds group of fascicles
2
Q
Perineurium
A
Extension of blood brain barrier around group of fascicles
3
Q
Endoneurium
A
On each axon
4
Q
Function of myelin
A
Increases conduction velocity via saltatory conduction over the nodes of Ranvier
5
Q
Extrinsic nerve blood supply
A
Vasa nervosum
6
Q
Timing of nerve repair
A
Immediate for clean/sharp laceration. Open wound with nerve rupture, wait 2-3 weeks for demarcation, then excise scar, then operate. If closed injury, wait 3-6 months to see if it recovers on its own.
7
Q
Neurapraxia, axonotmesis, neurotmesis
A
Neurapraxia = stretch injury with conduction block at the axonal level, architecture still intact, recovers in 3-4 months. Axonotomesis = endoneurial level. Neurotmesis = epineurial level.
8
Q
EMG findings in neurapraxia, axonotmesis and neurotmesis
A
Neurapraxia = no spontaneous activity, normal insertional activity. Axonotmesis/neurotmesis = increased insertional activity, fibrillations and sharp positive waves.
9
Q
Timing for nerve repair/reconstruction
A
<18 months before motor endplate degradation
10
Q
Indications for direct nerve repair
A
Acute laceration with no tension
11
Q
Indications for conduit nerve repair
A
<2-3cm gap in a sensory only nerve
12
Q
Indications for nerve allograft repair
A
3-5cm sensory only nerve
13
Q
Indications for nerve autograft repair
A
>5cm defect or motor nerve
14
Q
Principles of nerve repair
A
Debride back to healthy vesicles, avoid tension (<10% stretch)
15
Q
Indications for grouped fascicular nerve repair
A
None, although you line up the original fascicles well, the risk of scar blocking conduction is too great
16
Q
Best prognostic indicator for recovery after nerve injury
A
Better with younger age
17
Q
Double Oberlin transfer
A
In brachial plexus injury, it could be 12 months before elbow flexion is restored, so transferring ulnar fascicles from FCU and median fascicles from FDS/FCR to motor branches of biceps and brachialis shortens the endplate reinnervation time significantly
18
Q
Nerve transfer for hand intrinsic reanimation
A
AIN as it enters PQ is transferred to the motor branch of the ulnar nerve near the wrist
19
Q
What do you see on EMG in severe carpal tunnel and motor endplate degeneration?
A
Positive sharp waves, fibrillations and fasciculations
20
Q
Most sensitive test to determine sensory deficit in compressive neuropathy
A
2.83 Semes-Weinstein testing
21
Q
Most sensitive physical exam test for carpal tunnel
A
Durkan’s > Phalen’s > Tinel’s
22
Q
How far does an injured nerve grow per day
A
1mm/day, 1 inch/month
23
Q
Nerve conduction changes in compressive neuropathy
A
Distal motor latency >4.5 m/sec and >3.5 m/sec for sensory latency
24
Q
CTS-6
A
Score of 12 or greater has 80% chance of carpal tunnel syndrome, validated test used in lieu of EMG/NCS
25
Carpal tunnel pressure level that decreases nerve conduction
30mmHg, 0mmHg with wrist splinted in neutral
26
Most common variation of median nerve motor branch at carpal tunnel
50% extra-ligamentous
27
Most common complication in carpal tunnel release
Incomplete release
28
Sites of median nerve entrapment
Ligament of Struthers, 1% of population has a supracondylar process of the humerus. Lacertus fibrosis. Deep head of pronator teres. FDS arcade.
29
Pronator syndrome vs carpal tunnel syndrome
The palmar cutaneous branch of the median nerve will be numb in pronator syndrome, but not carpal tunnel syndrome, compression most often between heads of pronator. Tinel’s over proximal forearm, symptoms with resisted elbow flexion, resisted forearm pronation and resisted long finger PIP flexion.
30
Nerve syndrome associated with medial epicondylitis
Pronator syndrome
31
AIN syndrome
Motor only deficits in AIN and vague forearm pain. Can be compressed by PT, biceps bursa, FDS, FCR or Gantzer’s muscle (accessory FPL head)
32
Nerve compression syndrome associated with AIN syndrome
Parsonage-Turner syndrome
33
Ulnar nerve sites of compression
Arcade of Struthers, medial septum, medial head of triceps, Osborne’s ligament, FCU aponeurosis, deep flexor-pronator aponeurosis and anconeus epitrochlearis
34
Difference in exam in cubital tunnel vs. ulnar tunnel syndrome
Numbness in dorsal cutaneous branch of ulnar nerve seen in cubital tunnel, not in Guyon’s compression.
35
Wartenberg sign
Loss of adducting interosseous muscle and unopposed small finger drift due to radial nerve innervated EDM in ulnar nerve compression
36
Jeannes sign
MCP hyperextension w/key pinch due to adductor pollicus weakness in ulnar nerve compression
37
Masse sign
Loss of hypothenar musculature in ulnar nerve compression
38
Zones of ulnar tunnel syndrome
1) Proximal to nerve bifurcation from ganglion = sensory and motor deficits. 2) Deep motor branch from hamate fracture = motor symptoms only 3) Superficial sensory branch compressed from ulnar artery thrombosis = sensory loss only
39
Anatomy of the ulnar tunnel
Floor = transverse carpal ligament. Roof = volar carpal ligament. Radial = hamate. Ulnar = pisiform and ADM.
40
Treatment of ulnar tunnel syndrome
Can do ulnar tunnel release, release of carpal tunnel also provides relief of compression in ulnar tunnel
41
Sites of radial nerve compression
“FREAS” Fascial band at radial head, recurrent leash of Henry, ECRB leading edge, Arcade of Frohse at proximal supinator (most common) and distal supinator. Same sites of PIN syndrome.
42
Nerve compression syndrome associated with lateral epicondylitis
Radial tunnel syndrome
43
Wartenberg syndrome/cheiralgia paresthetica
SBRN compression
44
Adson test
Diminished radial artery pulse with inhalation due to sublclavian artery compression in thoracic outlet syndrome
45
Work-up for thoracic outlet syndrome
Non-specific paresthesias on exam that include MABC, lower plexus trunk signs with overhead activity, u/s 90% sensitive and specific, evaluate for Pancoast tumor
46
Branches off brachial plexus with contributions from every level
Radial and median nerve.
47
Pre-ganglionic lower C8-T1 root avulsion signs
Horner’s syndrome, ptosis, miosis, anhidrosis. Enapthalmos.
48
Treament of pre-ganglionic brachial plexus injuries
Typically reconstruction at 3 months, these do not regrow and are not amenable to repair
49
Treatment of post-ganglion brachial plexus injuries
If open wound and obvious injury, fix ASAP. If closed of LV GSW, observe 3-6 months, outcomes worse outcoes if later than 6 months and minimal reinnervation if you wait 1 year.
50
Nerve transfer options for brachial plexus root avulsions
Oberlin (FCU fascicle to musculocutaneous nerve for biceps), CN XI to SSN, branch to triceps to axillary nerve
51
Tendon transfer options for brachial plexus injury
Lower trap tendon transfer for external rotation
52
Free innervated gracilis muscle transfer
Used in late brachial plexus reconstruction
53
Associations with obstetric brachial plexopathy
High birth weight, large head and shoulder dystocia
54
Prognosis for full vs. incomplete recovery after obstetric brachial plexus palsy
Biceps/deltoid return by 2 months, expect full recovery. Biceps and deltoid return in 3-6 months, expect incomplete recovery. Surgery if no biceps function by 6 months.
55
Principles of tendon transfer
Adquate strength and excursion, no joint contracture, functional and expendable donors, transfer direction in line with pull, synergysm, one motor tendon unit to have one function
56
Tendon transfer feature that best correlates with amplitude
Fiber length, this is why you need good excursion of the tendon
57
At what point in muscle contraction is the force the greatest?
When muscle is at resting length
58
What is the concept of synergism in tendon transfers
Use a muscle that already has a similar function, for example, wrist extension and finger flexion are linked actions. Using a wrist extensor to transfer to re-establish finger flexion would be synergistic.
59
What factors do you want to match with tendon/muscle transfer?
Force, amplitude and direction
60
Tendon transfer to restore wrist extension in radial nerve injury
PT -\> ECRB
61
Tendon transfer to restore finger extension in radial nerve injury
FCR, FCU or FDS to EDC
62
Tendon transfer to restore thumb extension in radial nerve injury
Palmaris, FDS or FCR to EPL
63
Brand tendon transfer for radial nerve injury
FCR -\> EDC, PT -\> ECRB, PL -\> EPL
64
Tendon transfer for elderly patient with severe carpal tunnel syndrome and loss of opposition
Camitz: Palmaris longus to P1 of thumb to restore abduction, less so opposition
65
Transfer for pediatric patient with congenital absence of the thenars
Huber: ADM transfer to P1 of thumb to restore opposition
66
Size of fingertip injury you can heal by secondary intention
1 cm^2
67
Volar oblique fingertip injury with exposed bone in adult
Cross-finger flap, down side is flexion contracture
68
Volar oblique fingertip injury with exposed bone in child’s index or middle finger
Thenar flap, can’t do in adults because they get PIP contracture. Watch for thumb neurovascular bundle.
69
Volar oblique fingertip injury with exposed bone on thumb \<1cm
Moberg
70
Benefit of digital island flap for fingertip injuries
Maintains sensory innervation, can be from same finger (homo) or different finger (hetero). May consider in index of thumb.
71
Treatment of transverse fingertip injury with exposed bone
V-Y, lateral V-Y (Kutler) or shortening and volar flap
72
Treatment for thumb fingertip injury with \>1cm tissue loss and/or dorsal loss
1st dorsal MC artery kite flap
73
Age that can tolerate fingertip reattachment without revascularization
Up to 6 can tolerate composite graft
74
How does negative pressure improve wound healing
Decreased interstitial edema and bacterial load. Increased cell division and skin graft incorporation.
75
Benefits of full thickness skin graft
More durable, less contraction and better sensation.
76
How much length can you get from a z-plasty?
Depends on the angle, 50% lengthening at 45 degree angle, 75% lengthening at 60 degree angle and 25% lengthening at 30 degree angle
77
Percentage of hand with complete palmar arch
80% have connection between ulnar supplied deep arch and radial supplied superficial arch
78
Threshold for digital brachial index when evaluation for hand vascular disorders
\>0.7 is normal
79
Baseball catcher presents with isolated numbness, cold intolerance, ischemic pain in the small and ring fingers. What studies do you want and what is the treatment?
He needs an arteriogram to evaluate for ulnar artery thrombosis and hypothenar hammer syndrome. Treatment is ligation if they have a complete arch and DBI \>0.7 to limit showering of emboli. Reconstruct with reversed vein graft if DBI \<0.7.
80
Management of small vessel occlusion in the digits in Buerger’s disease vs. other rheumatologic disorders
Buerger’s = tobacco cessation. Rheumatologic disease, calcium channel blocker and/or sympathectomy.
81
Digit most often affected by embolic disease
Ring finger, straight shot from the ulnar artery
82
Origins of embolic disease to the digits
Heart (check for murmur), sublclavian (TOS), ulnar artery aneurysms, IVDU
83
Raynaud’s disease
Not associated with underlying pathology, rarely progressive, often symmetric.
84
Raynaud’s phenomenon
Associated with underlying pathology like Sjogren’s, often one side more involved due to vaso-occlusion. Progressive.
85
Types of sympathectomy for Raynaud’s
Chemical (botox), thorascopic VATS and periarterial stripping of adventitia
86
Indications for digit replant
Thumb, multiple digits, wrist or proximal and children. Relative indication is distal to zone I.
87
Contraindications for digit replant
Zone II, segmental injury, prolonged ischemia, crush/avulsion, advanced age, multiple comorbidities, polytrauma
88
Digit ischemia time
No muscle = 12 hours warm ischemia, \<24 hours cold ischemia.
89
Order of operations in digit replant
Bone, extensors, flexors, arteries, nerves, veins, fasciotomies
90
Causes of digital replant failure
1st 12 hours = arterial thrombus, After 12 hours = venous congestion, after 1 week = infection
91
Leeches excrete
Hirudin
92
Prophylaxis for leech therapy
CTX or cipro to cover aeromona hydrophilia
93
Most common procedure after successful digit replant
Tenolysis
94
Management of ring avulsion injury
Repair those with adequate circulation, repair and revascularize those with inadequate circulation with no tendon or bone injury.
95
Deformity associated with chronic mallet finger
Swan neck. Lateral bands migrate dorsally. After terminal extensor tendon is disrupted, more pull occurs through the central slip, extending the PIP and DIP remains flexed due to insufficient terminal tendon.
96
Deformity associated with chronic central slip rupture
Boutonniere. Lateral bands migrate volarly. After centeral slip is disrupted, the triangular ligament attenuates, more pull occurs through the terminal extensor tendon, extending the DIP and flexing the PIP.
97
Elson test
To diagnose a central slip disruption, flex the PIP and push against resistance. If DIP remains supple, no central slip injury, if DIP extends, the central slip is out and the lateral bands are activating.
98
Treatment for closed volar PIP dislocation with Boutonniere deformity
PIP figure 8 extension splint x 6 weeks
99
Non-op treatment for zone IV and V extensor tendon injury
Yoke splint
100
Which way do sagittal band injuries typically sublux
Ulnarly. Radial sagittal band is most commonly injured.
101
Physical exam diagnosis of intrinsic tightness
PIP flexion limited with MCP hyperextension, improved with MCP flexion
102
Physical exam diagnosis of extrinsic tightness
PIP flexion limited with MCP flexion, improved with MCP hyperextension
103
Pathways for flexor tendon healing
Primary) intrinsic healing from fibroblasts within the tendon. Minimal) extrinsic fibroblasts/macrophages repair from the sheath
104
High risk for re-rupture after flexor tendon repair
Gap \>3mm after repair, minimize this with epitendinous suture
105
Critical pulleys to preserve to prevent bowstringing
A2 and A4, oblique in the thumb
106
Repair factors that increase strength of flexor tendon repair
4+ core strands, dorsal placement of suture, locking loop configuration, 3-0 or 4-0 braided suture, addition of epitendinous suture
107
Where do flexor tendon repairs typically fail
Knots
108
When is flexor tendon repair the weakest?
Days 1-10, strength increases weeks 3-6
109
Leddy Packer classification
FDP avulsion, 1) retracted to palm, repair early 2) retracted to A2, repair within 6 weeks 3) bone avulsion caught at A4, repair within 6 weeks 4) FDP avulsed off fracture fragment
110
Risk for quadrigia
FDP advancement \>1cm
111
Management of chronic FDP avulsion
DIP arthrodesis
112
Rate of tenolysis after zone II flexor tendon repair
50%
113
Management of pediatric flexor tendon injuries
Repair and cast for 4 weeks
114
Indications for tenolysis after flexor tendon repair
Conservative treatment x 3-4 months, pull PROM, limited AROM
115
Quadrigia
Over advancement of flexor tendon causes adjacent tendons from same muscle belly to stop flexing once the tight tendon has maxed out
116
Lumbrical plus finger
Finger with FDP not intact, retracted proximally. When the finger flexes, the FDP tendons are attached to the lumbricals. The finger without an intact FDP insertion sees greater force through the lumbrical and that finger extends when the others flex.
117
Lab staining for atypical mycobacterium
Ziehl-Neelsen or Lowenstein-Jensen at 28-32 degrees for 6 weeks. Biopsy will show granuloma
118
Lab staining for fungus
K-OH
119
Lab staining for HSV
Tzank smear and viral culture
120
What creates the thenar and midpalmar deep spaces in the hand?
Midpalmar septum creates thenar space, hypothenar septum creates midpalmar space.
121
What makes up Parona’s space?
Potential space between PQ, flexor tendons, FCU and FPL. This is where the radial and ulnar bursae connect
122
Most common hand bug in cellulitis
Group A beta hemolytic strep
123
Dental hygienist with vesicles on his finger. Diagnosis and treatment?
Tzanck smear to diagnose HSV1 herpetic whitlow. Treat with observation and acyclovir. Do not I&D, that makes them worse.
124
Bugs that cause acute vs chronic paronychia
Acute = S. aureus. Chronic = start thinking Candida
125
Collar button abscess management
Volar and dorsal incisions to get to infection volar and dorsal to the intermetacarpal ligament
126
Most common bug in human fight bites
S. aureus, E. corrodens in 33%
127
Most common bug in necrotizing fasciitis
Group A beta hemolytic strep
128
Most important variable for outcomes in high pressure injection injuries
Material injected (organic solvents and oil-based paint worst). Other factors include time to I&D \<10 hours, injection pressure \<7000 psi.
129
Where to release A1 pulley in rheumatoid
Radial side to provide a buffer against ulnar drift, which they are already prone to
130
Intersection syndrome
Palpable crepitus at intersection of 1st and 2nd dorsal compartments.
131
Predisposition to fail non-op management of de Quervain’s
Multiple slips of APL and separate EPB compartment
132
Pathophysiology of lateral epicondylitis
Angiofibroblastic hyperplasia at ECRB origin
133
Pathophysiology of medial epicondylitis
Angiobiroblastic hyperplasia at junction of FCR and pronator teres
134
PLRI test
Supine with arm overhead, elbow supinated and extended. Elbow flexes with valgus force and axial load -\> rotatory subluxation laterally.
135
Best test for PLRI
Chair push up test has better sensitivity than pivot shift sign
136
Most common intrinsic ligament injured in distal radius fractures
SLIL
137
Most common intra-articular soft tissue injury in distal radius fractures
TFCC
138
Treatment for EPL rupture
EIP -\> EPL transfer
139
Primary determinant in maintaining distal radius reduction
Age \> 60 = high risk of loss of reduction
140
AAOS guidelines for distal radius fracture operative indications
Intra-articular displacement \>2mm, post-reduction shortening \>3mm and residual dorsal angulation \>10 degrees
141
Indication for dorsal plating of distal radius fractures
S-L ligament repair/reconstruction
142
Tendons at risk for rupture after volar plating of distal radius fractures
FPL \> FDP of index finger
143
#1 complication with ex-fix of distal radius fractures
Over-distraction and stiffness
144
Indications for bridge plate fixation of distal radius fractures
Highly comminuted, diaphyseal extension and polytrauma
145
Contraindications for bridge plate fixation of distal radius fractures
Palmar lunate facet fragment, loss of dorsal soft tissue coverage, 2nd and 3rd MC fx
146
Most common complication with fragment specific fixation of distal radius fractures
Symptomatic hardware
147
Pressure threshold in carpal tunnel to cause carpal tunnel syndrome
40mmHg
148
Should you perform prophylactic carpal tunnel release on asymptomatic patients with distal radius fracture?
No, there’s a high rade of persistent median neuropathy, only do it if they have persistent worsening symptoms
149
Next step if patient develops carpal tunnel syndrome 7-10 days after distal radius ORIF
CTR
150
Vitamin C dosing after distal radius fracture
500mg x 50 days, half the dose if renal disease or history of renal calculi
151
What are the soft tissue stabilizers on the ulnar side of the wrist?
RUPERT
152
When do you fix the distal ulna in distal radius fractures?
Ulnar head w/\>50% displacement and 10 deg angulation
153
Most common complication after distal radius fracture
Median nerve dysfunction
154
Wrist position in scaphoid fractures vs SL ligament injury
Scaphoid = extension radial deviation
155
Scaphoid operative indications
\>1mm displacement, proximal pole fracture, greater arc perilunate injury, fracture comminution, high demand occupation.
156
Most common location of scaphoid fracture in adults vs kids
Adults = waist, kids = distal pole
157
Operative management of nondisplaced scaphoid waist fractures
Qucker return to work and better grip strength, higher complication rate with surgery
158
Indication for dorsal vs volar approach for scaphoid ORIF
Dorsal = proximal pole, using 1-2 ICSRA for vascularized graft
159
How do you determine vascularity of the proximal pole of the scaphoid
Intra-op punctate bleeding is the gold standard
160
Treatment addition for scaphoid with AVN
Add vascularized bone graft
161
Vascularized bone graft pedicle used for scaphoid fractures on the dorsum
1-2 intercompartmental supraretinacular artery
162
Vascularized bone graft pedicle used for Keinboch’s disease
4th extensor compartment artery (longest pedicle)
163
Vascularized bone graft pedicle used on the volar side
Volar carpal branch VBG
164
Staging and treatment of SNAC wrist
1) Radial styloid – radial styloidectomy
165
How much of the distal radial styloid can you take off in a radial styloidectomy?
4mm, otherwise you violate the RSC and the carpus subluxes ulnar
166
Why do patients sometimes fail to recover after dorsal triquetral avulsion?
Secondary injury to DIC/DRC ligaments and/or LTIL injury
167
Injuries associated with hook of hamate fracture
Rupture of 4 or 5th FDP \> FDS (up to 14%), ulnar nerve paresthesias from irritation in Guyon’s canal
168
Treatment of hook of hamate fractures? Complications of treatment?
Cast if acute, excise if chronic non-union, excision complications include ulnar nerve injury and 15% loss of grip strength because FDP looses its pulley (hook of hamate) for the 4th and 5th digits
169
Most common nerve injury associated with hamate body fractures
Dorsal sensory branch of the ulnar nerve
170
Wrist bones with retrograde blood supply
Scaphoid and capitate
171
Treatment of midcarpal instability non-dissociative
Non-op. If they fail then they progress to a midcarpal fusion. Can be seen in Ehler’s Danlos patient with clunking wrist.
172
Treatment of large radial styloid fracture with carpal instability non-dissociative
ORIF the radial styloid is usually enough, may need to repair extrinsic volar ligaments if there is still volar translation of the carpus
173
Most common causes of carpal instability dissociative
SLIL and LTIL injury
174
What is carpal instability adaptive?
Carpal instability secondary to extra-articular pathology such as distal radius malunion. Treatment for this is fixing the malunion, not reconstructing ligaments.
175
Example of carpal instability complex?
Combination of carpal instability dissociative (instability within carpal rows, SLIL/LTIL) and carpal instability nondissociative (instability between carpal rows, radial styloid).
176
Strongest part of SLIL? LTIL?
SLIL = dorsal. LTIL = volar.
177
Gold standard for diagnosing carpal ligament instability
Arthroscopy
178
Treatment for LTIL injury
Repair if acute. If chronic can perform ECU reconstruction, fusion or ulnar shortening osteotomy
179
Mayfield classification
Perilunate injuries
180
Lesser arc vs greater arc injuries
Lesser arc = ligament injuries
181
Treatment of perilunate injuries
Early ORIF, CTR if carpal tunnel syndrome present
182
Intrascaphoid angle for humpback deformity
35 degrees
183
SLAC stages and treatment
I) Scaphoid and radial styloid - styloidectomy
184
How much shortening of the metacarpal creates a 7 deg extensor lag?
2mm shortening, 5 degrees of rotation
185
Indication for lag screw fixation of an oblique metacarpal shaft fracture
Fracture length 2x bone diameter, need 3 screws in different planes
186
Biggest risk factor after ORIF of small metacarpal head fracture
AVN
187
Management of simple MCP joint dislocation
Gentle reduction, but don’t pull traction or you could pull the volar plate and sesamoids into the joint, making it operative
188
Management of complex MCP joint dislocation? Most common complication?
Typically need volar approach because sesamoid and/or volar plate are entrapped in the joint. Most common complication is digital nerve injury.
189
Reduction maneuver for this fracture?
Hyperextension and volar translation. Do not apply traction or you turn a simple dislocation into a complex one with the volar plate blocking the reduction
190
How to treat this dislocation?
Volar PIP dislocations are associated with central slip disruption. Do not do early ROM, the PIP needs to stay extended to allow it to heal and avoid boutonniere. Get DIP moving early to keep lateral bands from migrating.
191
Most common complication after volar PIP plate avulsion fracture?
Stiffness
192
Algorithm for PIP dorsal fracture dislocations
Non-op if \<30% articular surface
193
Most important thumb ligament preventing CMC instability
Dorsoradial ligament
194
Thumb ligament involved in Bennet fracture deformity
Anterior ligament (volar, oblique, beak ligament)
195
Management of extra-articular thumb metacarpal base fractures?
Non-op if \<30 degrees angulated, reduce with traction, abduction, pronation and extension
196
Bennett fracture deforming forces
APL, adductor and thumb extensors
197
Most common nerve injury when performing ORIF of Bennet fracture via Wagner approach
Dorsal sensory branch of radial nerve
198
Primary dynamic stabilizer of the thumb MCPJ
Adductor pollicis, inserts on proximal phalanx and ulnar sesamoid
199
Collateral ligament assessment for thumb UCL injury
Flexed 30 deg = proper and dorsal capsule. Extended = accessory and volar plate
200
Proximal phalanx displacement in skiier’s thumb
Thumb UCL injury is typically off the proximal phalanx (80%). The proximal phalanx then supinates around the radial collateral ligament
201
Where do RCL injuries avulse from
Metacarpal side, UCL is opposite and avulses from proximal phalanx side
202
Operative indications for thumb UCL injuries
\>15% articular surface, 2mm displaced, Stener lesion or stage III tear with no endpoint.
203
In the thumb, how does the proximal phalanx rotate around an intact UCL?
It pronates
204
Operative indications for thumb RCL injury
Grade III injury
205
What is the next step?
Sesamoids are in the joint so it needs an open reduction.
206
In dorsal PIP dislocation, which soft tissue structures are injured? Volar?
Dorsal = volar plate and collaterals
207
Muscle that causes MCP instability after RCL injury
Adductor and EPL overpull
208
% of Stener lesions in complete UCL injury
\>85%
209
Force seen at thumb CMC joint during pinch?
12 fold
210
Change in ulnocarpal contact pressure with an increase of 2mm positive ulnar variance
Transmission force increases from 20% to 40%
211
Treatment of type I TFCC injuries
iA) central perforation = debridement
212
Proximity of distal radius fracture to joint to be a Galeazzi fracture
Within 7.5cm of articular surface
213
Treatment of dorsal DRUJ dislocation? Volar?
Dorsal = supination
214
Treatment of chronic DRUJ instability after old distal radius fracture
1) Correct distal radius malunion if present. 2) ligament repair if acute injury 3) ligament reconstruction if chronic
215
Diagnosis?
Ulnar impaction syndrome. Note that Keinboch’s will have edema throughout the entire lunate body.
216
Treatment of type II TFCC injuries
These are degenerative from ulnar impaction syndrome
217
Surgical management of end stage DRUJ arthritis? Main complication?
Darrach = ulnar head resection. Sauve-Kapandji = DRUJ fusion and distal ulna metaphysis resection. Ulnar head arthroplasty. Main complication with all is ulnar instability.
218
Structures at risk with wrist arthroscopy making 1,2 portal? 6U?
1,2 = dorsal sensory branch of radial nerve, radial artery
219
Best x-ray to determine true ulnar variance
0-degree rotation PA x-ray with shoulder and elbow abducted and flexed to 90 degrees
220
Treatment of thumb CMC arthritis by stage
Stages progress as volar beak ligament fails
221
Treatment of PIP joint arthritis in border vs central digits?
Border = arthrodesis, central = arthroplasty (linked in RA, unlinked in OA because of collateral stability)
222
Highest complication with PIP arthroplasty
Implant fracture
223
Indications for MCP joint arthrodesis
Spasticity and high risk of dislocation after arthroplasty (CP, TBI, arthrogryposis). Typically MCP fusions are limited because hand function and ability to perform hygiene decreases as you fuse more and can’t abduct/adduct digits
224
Implants used and complications associated with PIP and MCP arthroplasty
Silicone = implant fracture. Pyrocarobon = loosening. CoCr on PE = poly wear.
225
Conditions seen in the rheumatoid hand
Bony erosions, scapholunate dissociation, volar/ulnar carpal subluxation, caput ulna syndrome (ulna sits dorsally subluxation resulting in ulnar impaction and EDM/EDC rupture), Mannerflet lesion (volar scaphoid osteophyte -\> FPL, FDP FCR rupture)
226
What deformity happens with injury to the transverse retinacular ligament?
Swan neck deformity. The TRL keeps the lateral bands from subluxating dorsally when it is intact.
227
What deformity happens with injury to the triangular ligament?
Boutonniere. The triangular ligament keeps the lateral bands from subluxating palmarly when it is intact.
228
Tendon transfer option in the ulnar deviated rheumatoid wrist
ECRL -\> ECU transfer
229
Management of bilateral end stage wrist rheumatoid arthritis
Fuse on wrist in flexion and the other in extension. May also consider arthrodesis in one and arthroplasty in the other (arthroplasty must have good disease control, ligament/tendon stability and minimal deformity to limit loosening)
230
Operative management of caput ulna in RA
Side to side tendon repairs or EIP and/or FDS tendon transfers + Darrach vs Sauve-Kapandji procedure. Don’t pick DRUJ arthroplasty due to high risk of instability.
231
Vaughan-Jackson syndrome
Prominent distal ulnar head in RA causes rupture of extensor tendons from ulnar to radial starting with EDM
232
Mannerfelt syndrome
FPL and/or index FDP rupture secondary to volar STT osteophyte abrasions in RA
233
Most common wrist ligament injury associated with gout
SLIL rupture is commonly associated with inflammatory arthropathy
234
Type of lunate associated with Keinbochs disease
In addition to articulations with the capitate and distal radius, it has an articulation with the hamate
235
Blood supply to lunate
Enters palmar and dorsal
236
Anatomic risk factors for Keinboch’s
Negative ulnar variance, decreased radial inclination and type II lunate (hamate articulation)
237
What determines treatment in Keinboch’s disease
Normal carpal alignment (radial shortening if negative variance, capitate shortening if normal variance, revascularize w/4th/5th extensor compartment artery) vs. carpal collapse (PRC or scaphocapitate arthrodesis, total wrist arthrodes for more severe disease)
238
Preiser’s disease treatment
Scaphoid AVN. 1-2 ICSRA VBG if early. If late PRC, 4 corner or total wrist
239
Other body parts affected in Dupuytren’s
Lederhosen’s = plantar fascia, Garrod’s knuckle, Peyronie’s
240
Key pathologic cell in Dupuytren’s
Myofibroblast, stimulated by prostaglandins and lysophosphatic acid and produces alpha-smooth muscle actin and pathologic production of type III collagen
241
Digital ligament not involved in Dupuytren’s
Cleland’s (dorsal to neurovascular bundle).
242
Dupuytren’s cord that causes MP contracture
Preteindinous cord, note that this does not alter the course of the neurovacular bundle
243
Dupuytren’s cord that causes PIP contracture
Central cord
244
Dupuytren’s cord that displaces the neurovascular bundle volar and central
Spiral cord
245
Indications for treatment in Dupuytren’s
MCP contracture \> 30 and any PIP joint contracture
246
Collagenase is best indicated for which patients in Dupuytren’s
MP contracture. ROM improvement not as great in PIP contracture and higher risk of tendon rupture in PIP contracture (especially small finger)
247
Most common complication in palmar fasciectomy for Dupuytren’s?
Nerve injury (10x greater if revision case)
248
Most common complication with collagenase use?
Skin tear
249
Cord that causes DIP contracture in Dupuytren’s
Retrovascular cord
