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Hand > Miller Review Hand Lectures > Flashcards

Miller Review Hand Lectures Flashcards

Orthopaedic Hand Surgery

1
Q

Epineurium

A

Surrounds group of fascicles

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2
Q

Perineurium

A

Extension of blood brain barrier around group of fascicles

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3
Q

Endoneurium

A

On each axon

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4
Q

Function of myelin

A

Increases conduction velocity via saltatory conduction over the nodes of Ranvier

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5
Q

Extrinsic nerve blood supply

A

Vasa nervosum

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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.

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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.

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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.

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9
Q

Timing for nerve repair/reconstruction

A

<18 months before motor endplate degradation

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10
Q

Indications for direct nerve repair

A

Acute laceration with no tension

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11
Q

Indications for conduit nerve repair

A

<2-3cm gap in a sensory only nerve

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12
Q

Indications for nerve allograft repair

A

3-5cm sensory only nerve

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13
Q

Indications for nerve autograft repair

A

>5cm defect or motor nerve

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14
Q

Principles of nerve repair

A

Debride back to healthy vesicles, avoid tension (<10% stretch)

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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

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16
Q

Best prognostic indicator for recovery after nerve injury

A

Better with younger age

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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

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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

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19
Q

What do you see on EMG in severe carpal tunnel and motor endplate degeneration?

A

Positive sharp waves, fibrillations and fasciculations

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20
Q

Most sensitive test to determine sensory deficit in compressive neuropathy

A

2.83 Semes-Weinstein testing

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21
Q

Most sensitive physical exam test for carpal tunnel

A

Durkan’s > Phalen’s > Tinel’s

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22
Q

How far does an injured nerve grow per day

A

1mm/day, 1 inch/month

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23
Q

Nerve conduction changes in compressive neuropathy

A

Distal motor latency >4.5 m/sec and >3.5 m/sec for sensory latency

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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

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25
Q

Carpal tunnel pressure level that decreases nerve conduction

A

30mmHg, 0mmHg with wrist splinted in neutral

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26
Q

Most common variation of median nerve motor branch at carpal tunnel

A

50% extra-ligamentous

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27
Q

Most common complication in carpal tunnel release

A

Incomplete release

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28
Q

Sites of median nerve entrapment

A

Ligament of Struthers, 1% of population has a supracondylar process of the humerus. Lacertus fibrosis. Deep head of pronator teres. FDS arcade.

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29
Q

Pronator syndrome vs carpal tunnel syndrome

A

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.

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30
Q

Nerve syndrome associated with medial epicondylitis

A

Pronator syndrome

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31
Q

AIN syndrome

A

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)

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32
Q

Nerve compression syndrome associated with AIN syndrome

A

Parsonage-Turner syndrome

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33
Q

Ulnar nerve sites of compression

A

Arcade of Struthers, medial septum, medial head of triceps, Osborne’s ligament, FCU aponeurosis, deep flexor-pronator aponeurosis and anconeus epitrochlearis

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34
Q

Difference in exam in cubital tunnel vs. ulnar tunnel syndrome

A

Numbness in dorsal cutaneous branch of ulnar nerve seen in cubital tunnel, not in Guyon’s compression.

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35
Q

Wartenberg sign

A

Loss of adducting interosseous muscle and unopposed small finger drift due to radial nerve innervated EDM in ulnar nerve compression

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36
Q

Jeannes sign

A

MCP hyperextension w/key pinch due to adductor pollicus weakness in ulnar nerve compression

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37
Q

Masse sign

A

Loss of hypothenar musculature in ulnar nerve compression

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38
Q

Zones of ulnar tunnel syndrome

A

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

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39
Q

Anatomy of the ulnar tunnel

A

Floor = transverse carpal ligament. Roof = volar carpal ligament. Radial = hamate. Ulnar = pisiform and ADM.

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40
Q

Treatment of ulnar tunnel syndrome

A

Can do ulnar tunnel release, release of carpal tunnel also provides relief of compression in ulnar tunnel

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41
Q

Sites of radial nerve compression

A

“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.

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42
Q

Nerve compression syndrome associated with lateral epicondylitis

A

Radial tunnel syndrome

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43
Q

Wartenberg syndrome/cheiralgia paresthetica

A

SBRN compression

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44
Q

Adson test

A

Diminished radial artery pulse with inhalation due to sublclavian artery compression in thoracic outlet syndrome

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45
Q

Work-up for thoracic outlet syndrome

A

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

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46
Q

Branches off brachial plexus with contributions from every level

A

Radial and median nerve.

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47
Q

Pre-ganglionic lower C8-T1 root avulsion signs

A

Horner’s syndrome, ptosis, miosis, anhidrosis. Enapthalmos.

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48
Q

Treament of pre-ganglionic brachial plexus injuries

A

Typically reconstruction at 3 months, these do not regrow and are not amenable to repair

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49
Q

Treatment of post-ganglion brachial plexus injuries

A

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.

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50
Q

Nerve transfer options for brachial plexus root avulsions

A

Oberlin (FCU fascicle to musculocutaneous nerve for biceps), CN XI to SSN, branch to triceps to axillary nerve

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51
Q

Tendon transfer options for brachial plexus injury

A

Lower trap tendon transfer for external rotation

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52
Q

Free innervated gracilis muscle transfer

A

Used in late brachial plexus reconstruction

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53
Q

Associations with obstetric brachial plexopathy

A

High birth weight, large head and shoulder dystocia

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54
Q

Prognosis for full vs. incomplete recovery after obstetric brachial plexus palsy

A

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.

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55
Q

Principles of tendon transfer

A

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

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56
Q

Tendon transfer feature that best correlates with amplitude

A

Fiber length, this is why you need good excursion of the tendon

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57
Q

At what point in muscle contraction is the force the greatest?

A

When muscle is at resting length

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58
Q

What is the concept of synergism in tendon transfers

A

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.

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59
Q

What factors do you want to match with tendon/muscle transfer?

A

Force, amplitude and direction

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60
Q

Tendon transfer to restore wrist extension in radial nerve injury

A

PT -> ECRB

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61
Q

Tendon transfer to restore finger extension in radial nerve injury

A

FCR, FCU or FDS to EDC

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62
Q

Tendon transfer to restore thumb extension in radial nerve injury

A

Palmaris, FDS or FCR to EPL

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63
Q

Brand tendon transfer for radial nerve injury

A

FCR -> EDC, PT -> ECRB, PL -> EPL

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64
Q

Tendon transfer for elderly patient with severe carpal tunnel syndrome and loss of opposition

A

Camitz: Palmaris longus to P1 of thumb to restore abduction, less so opposition

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65
Q

Transfer for pediatric patient with congenital absence of the thenars

A

Huber: ADM transfer to P1 of thumb to restore opposition

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66
Q

Size of fingertip injury you can heal by secondary intention

A

1 cm^2

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67
Q

Volar oblique fingertip injury with exposed bone in adult

A

Cross-finger flap, down side is flexion contracture

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68
Q

Volar oblique fingertip injury with exposed bone in child’s index or middle finger

A

Thenar flap, can’t do in adults because they get PIP contracture. Watch for thumb neurovascular bundle.

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69
Q

Volar oblique fingertip injury with exposed bone on thumb <1cm

A

Moberg

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70
Q

Benefit of digital island flap for fingertip injuries

A

Maintains sensory innervation, can be from same finger (homo) or different finger (hetero). May consider in index of thumb.

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71
Q

Treatment of transverse fingertip injury with exposed bone

A

V-Y, lateral V-Y (Kutler) or shortening and volar flap

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72
Q

Treatment for thumb fingertip injury with >1cm tissue loss and/or dorsal loss

A

1st dorsal MC artery kite flap

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73
Q

Age that can tolerate fingertip reattachment without revascularization

A

Up to 6 can tolerate composite graft

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74
Q

How does negative pressure improve wound healing

A

Decreased interstitial edema and bacterial load. Increased cell division and skin graft incorporation.

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75
Q

Benefits of full thickness skin graft

A

More durable, less contraction and better sensation.

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76
Q

How much length can you get from a z-plasty?

A

Depends on the angle, 50% lengthening at 45 degree angle, 75% lengthening at 60 degree angle and 25% lengthening at 30 degree angle

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77
Q

Percentage of hand with complete palmar arch

A

80% have connection between ulnar supplied deep arch and radial supplied superficial arch

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78
Q

Threshold for digital brachial index when evaluation for hand vascular disorders

A

>0.7 is normal

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79
Q

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?

A

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.

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80
Q

Management of small vessel occlusion in the digits in Buerger’s disease vs. other rheumatologic disorders

A

Buerger’s = tobacco cessation. Rheumatologic disease, calcium channel blocker and/or sympathectomy.

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81
Q

Digit most often affected by embolic disease

A

Ring finger, straight shot from the ulnar artery

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82
Q

Origins of embolic disease to the digits

A

Heart (check for murmur), sublclavian (TOS), ulnar artery aneurysms, IVDU

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83
Q

Raynaud’s disease

A

Not associated with underlying pathology, rarely progressive, often symmetric.

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84
Q

Raynaud’s phenomenon

A

Associated with underlying pathology like Sjogren’s, often one side more involved due to vaso-occlusion. Progressive.

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85
Q

Types of sympathectomy for Raynaud’s

A

Chemical (botox), thorascopic VATS and periarterial stripping of adventitia

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86
Q

Indications for digit replant

A

Thumb, multiple digits, wrist or proximal and children. Relative indication is distal to zone I.

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87
Q

Contraindications for digit replant

A

Zone II, segmental injury, prolonged ischemia, crush/avulsion, advanced age, multiple comorbidities, polytrauma

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88
Q

Digit ischemia time

A

No muscle = 12 hours warm ischemia, <24 hours cold ischemia.

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89
Q

Order of operations in digit replant

A

Bone, extensors, flexors, arteries, nerves, veins, fasciotomies

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90
Q

Causes of digital replant failure

A

1st 12 hours = arterial thrombus, After 12 hours = venous congestion, after 1 week = infection

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91
Q

Leeches excrete

A

Hirudin

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92
Q

Prophylaxis for leech therapy

A

CTX or cipro to cover aeromona hydrophilia

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93
Q

Most common procedure after successful digit replant

A

Tenolysis

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94
Q

Management of ring avulsion injury

A

Repair those with adequate circulation, repair and revascularize those with inadequate circulation with no tendon or bone injury.

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95
Q

Deformity associated with chronic mallet finger

A

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.

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96
Q

Deformity associated with chronic central slip rupture

A

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.

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97
Q

Elson test

A

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.

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98
Q

Treatment for closed volar PIP dislocation with Boutonniere deformity

A

PIP figure 8 extension splint x 6 weeks

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99
Q

Non-op treatment for zone IV and V extensor tendon injury

A

Yoke splint

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100
Q

Which way do sagittal band injuries typically sublux

A

Ulnarly. Radial sagittal band is most commonly injured.

101
Q

Physical exam diagnosis of intrinsic tightness

A

PIP flexion limited with MCP hyperextension, improved with MCP flexion

102
Q

Physical exam diagnosis of extrinsic tightness

A

PIP flexion limited with MCP flexion, improved with MCP hyperextension

103
Q

Pathways for flexor tendon healing

A

Primary) intrinsic healing from fibroblasts within the tendon. Minimal) extrinsic fibroblasts/macrophages repair from the sheath

104
Q

High risk for re-rupture after flexor tendon repair

A

Gap >3mm after repair, minimize this with epitendinous suture

105
Q

Critical pulleys to preserve to prevent bowstringing

A

A2 and A4, oblique in the thumb

106
Q

Repair factors that increase strength of flexor tendon repair

A

4+ core strands, dorsal placement of suture, locking loop configuration, 3-0 or 4-0 braided suture, addition of epitendinous suture

107
Q

Where do flexor tendon repairs typically fail

A

Knots

108
Q

When is flexor tendon repair the weakest?

A

Days 1-10, strength increases weeks 3-6

109
Q

Leddy Packer classification

A

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
Q

Risk for quadrigia

A

FDP advancement >1cm

111
Q

Management of chronic FDP avulsion

A

DIP arthrodesis

112
Q

Rate of tenolysis after zone II flexor tendon repair

A

50%

113
Q

Management of pediatric flexor tendon injuries

A

Repair and cast for 4 weeks

114
Q

Indications for tenolysis after flexor tendon repair

A

Conservative treatment x 3-4 months, pull PROM, limited AROM

115
Q

Quadrigia

A

Over advancement of flexor tendon causes adjacent tendons from same muscle belly to stop flexing once the tight tendon has maxed out

116
Q

Lumbrical plus finger

A

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
Q

Lab staining for atypical mycobacterium

A

Ziehl-Neelsen or Lowenstein-Jensen at 28-32 degrees for 6 weeks. Biopsy will show granuloma

118
Q

Lab staining for fungus

A

K-OH

119
Q

Lab staining for HSV

A

Tzank smear and viral culture

120
Q

What creates the thenar and midpalmar deep spaces in the hand?

A

Midpalmar septum creates thenar space, hypothenar septum creates midpalmar space.

121
Q

What makes up Parona’s space?

A

Potential space between PQ, flexor tendons, FCU and FPL. This is where the radial and ulnar bursae connect

122
Q

Most common hand bug in cellulitis

A

Group A beta hemolytic strep

123
Q

Dental hygienist with vesicles on his finger. Diagnosis and treatment?

A

Tzanck smear to diagnose HSV1 herpetic whitlow. Treat with observation and acyclovir. Do not I&D, that makes them worse.

124
Q

Bugs that cause acute vs chronic paronychia

A

Acute = S. aureus. Chronic = start thinking Candida

125
Q

Collar button abscess management

A

Volar and dorsal incisions to get to infection volar and dorsal to the intermetacarpal ligament

126
Q

Most common bug in human fight bites

A

S. aureus, E. corrodens in 33%

127
Q

Most common bug in necrotizing fasciitis

A

Group A beta hemolytic strep

128
Q

Most important variable for outcomes in high pressure injection injuries

A

Material injected (organic solvents and oil-based paint worst). Other factors include time to I&D <10 hours, injection pressure <7000 psi.

129
Q

Where to release A1 pulley in rheumatoid

A

Radial side to provide a buffer against ulnar drift, which they are already prone to

130
Q

Intersection syndrome

A

Palpable crepitus at intersection of 1st and 2nd dorsal compartments.

131
Q

Predisposition to fail non-op management of de Quervain’s

A

Multiple slips of APL and separate EPB compartment

132
Q

Pathophysiology of lateral epicondylitis

A

Angiofibroblastic hyperplasia at ECRB origin

133
Q

Pathophysiology of medial epicondylitis

A

Angiobiroblastic hyperplasia at junction of FCR and pronator teres

134
Q

PLRI test

A

Supine with arm overhead, elbow supinated and extended. Elbow flexes with valgus force and axial load -> rotatory subluxation laterally.

135
Q

Best test for PLRI

A

Chair push up test has better sensitivity than pivot shift sign

136
Q

Most common intrinsic ligament injured in distal radius fractures

A

SLIL

137
Q

Most common intra-articular soft tissue injury in distal radius fractures

A

TFCC

138
Q

Treatment for EPL rupture

A

EIP -> EPL transfer

139
Q

Primary determinant in maintaining distal radius reduction

A

Age > 60 = high risk of loss of reduction

140
Q

AAOS guidelines for distal radius fracture operative indications

A

Intra-articular displacement >2mm, post-reduction shortening >3mm and residual dorsal angulation >10 degrees

141
Q

Indication for dorsal plating of distal radius fractures

A

S-L ligament repair/reconstruction

142
Q

Tendons at risk for rupture after volar plating of distal radius fractures

A

FPL > FDP of index finger

143
Q

1 complication with ex-fix of distal radius fractures

A

Over-distraction and stiffness

144
Q

Indications for bridge plate fixation of distal radius fractures

A

Highly comminuted, diaphyseal extension and polytrauma

145
Q

Contraindications for bridge plate fixation of distal radius fractures

A

Palmar lunate facet fragment, loss of dorsal soft tissue coverage, 2nd and 3rd MC fx

146
Q

Most common complication with fragment specific fixation of distal radius fractures

A

Symptomatic hardware

147
Q

Pressure threshold in carpal tunnel to cause carpal tunnel syndrome

A

40mmHg

148
Q

Should you perform prophylactic carpal tunnel release on asymptomatic patients with distal radius fracture?

A

No, there’s a high rade of persistent median neuropathy, only do it if they have persistent worsening symptoms

149
Q

Next step if patient develops carpal tunnel syndrome 7-10 days after distal radius ORIF

A

CTR

150
Q

Vitamin C dosing after distal radius fracture

A

500mg x 50 days, half the dose if renal disease or history of renal calculi

151
Q

What are the soft tissue stabilizers on the ulnar side of the wrist?

A

RUPERT

152
Q

When do you fix the distal ulna in distal radius fractures?

A

Ulnar head w/>50% displacement and 10 deg angulation

153
Q

Most common complication after distal radius fracture

A

Median nerve dysfunction

154
Q

Wrist position in scaphoid fractures vs SL ligament injury

A

Scaphoid = extension radial deviation

155
Q

Scaphoid operative indications

A

>1mm displacement, proximal pole fracture, greater arc perilunate injury, fracture comminution, high demand occupation.

156
Q

Most common location of scaphoid fracture in adults vs kids

A

Adults = waist, kids = distal pole

157
Q

Operative management of nondisplaced scaphoid waist fractures

A

Qucker return to work and better grip strength, higher complication rate with surgery

158
Q

Indication for dorsal vs volar approach for scaphoid ORIF

A

Dorsal = proximal pole, using 1-2 ICSRA for vascularized graft

159
Q

How do you determine vascularity of the proximal pole of the scaphoid

A

Intra-op punctate bleeding is the gold standard

160
Q

Treatment addition for scaphoid with AVN

A

Add vascularized bone graft

161
Q

Vascularized bone graft pedicle used for scaphoid fractures on the dorsum

A

1-2 intercompartmental supraretinacular artery

162
Q

Vascularized bone graft pedicle used for Keinboch’s disease

A

4th extensor compartment artery (longest pedicle)

163
Q

Vascularized bone graft pedicle used on the volar side

A

Volar carpal branch VBG

164
Q

Staging and treatment of SNAC wrist

A

1) Radial styloid – radial styloidectomy

165
Q

How much of the distal radial styloid can you take off in a radial styloidectomy?

A

4mm, otherwise you violate the RSC and the carpus subluxes ulnar

166
Q

Why do patients sometimes fail to recover after dorsal triquetral avulsion?

A

Secondary injury to DIC/DRC ligaments and/or LTIL injury

167
Q

Injuries associated with hook of hamate fracture

A

Rupture of 4 or 5th FDP > FDS (up to 14%), ulnar nerve paresthesias from irritation in Guyon’s canal

168
Q

Treatment of hook of hamate fractures? Complications of treatment?

A

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
Q

Most common nerve injury associated with hamate body fractures

A

Dorsal sensory branch of the ulnar nerve

170
Q

Wrist bones with retrograde blood supply

A

Scaphoid and capitate

171
Q

Treatment of midcarpal instability non-dissociative

A

Non-op. If they fail then they progress to a midcarpal fusion. Can be seen in Ehler’s Danlos patient with clunking wrist.

172
Q

Treatment of large radial styloid fracture with carpal instability non-dissociative

A

ORIF the radial styloid is usually enough, may need to repair extrinsic volar ligaments if there is still volar translation of the carpus

173
Q

Most common causes of carpal instability dissociative

A

SLIL and LTIL injury

174
Q

What is carpal instability adaptive?

A

Carpal instability secondary to extra-articular pathology such as distal radius malunion. Treatment for this is fixing the malunion, not reconstructing ligaments.

175
Q

Example of carpal instability complex?

A

Combination of carpal instability dissociative (instability within carpal rows, SLIL/LTIL) and carpal instability nondissociative (instability between carpal rows, radial styloid).

176
Q

Strongest part of SLIL? LTIL?

A

SLIL = dorsal. LTIL = volar.

177
Q

Gold standard for diagnosing carpal ligament instability

A

Arthroscopy

178
Q

Treatment for LTIL injury

A

Repair if acute. If chronic can perform ECU reconstruction, fusion or ulnar shortening osteotomy

179
Q

Mayfield classification

A

Perilunate injuries

180
Q

Lesser arc vs greater arc injuries

A

Lesser arc = ligament injuries

181
Q

Treatment of perilunate injuries

A

Early ORIF, CTR if carpal tunnel syndrome present

182
Q

Intrascaphoid angle for humpback deformity

A

35 degrees

183
Q

SLAC stages and treatment

A

I) Scaphoid and radial styloid - styloidectomy

184
Q

How much shortening of the metacarpal creates a 7 deg extensor lag?

A

2mm shortening, 5 degrees of rotation

185
Q

Indication for lag screw fixation of an oblique metacarpal shaft fracture

A

Fracture length 2x bone diameter, need 3 screws in different planes

186
Q

Biggest risk factor after ORIF of small metacarpal head fracture

A

AVN

187
Q

Management of simple MCP joint dislocation

A

Gentle reduction, but don’t pull traction or you could pull the volar plate and sesamoids into the joint, making it operative

188
Q

Management of complex MCP joint dislocation? Most common complication?

A

Typically need volar approach because sesamoid and/or volar plate are entrapped in the joint. Most common complication is digital nerve injury.

189
Q

Reduction maneuver for this fracture?

A

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
Q

How to treat this dislocation?

A

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
Q

Most common complication after volar PIP plate avulsion fracture?

A

Stiffness

192
Q

Algorithm for PIP dorsal fracture dislocations

A

Non-op if <30% articular surface

193
Q

Most important thumb ligament preventing CMC instability

A

Dorsoradial ligament

194
Q

Thumb ligament involved in Bennet fracture deformity

A

Anterior ligament (volar, oblique, beak ligament)

195
Q

Management of extra-articular thumb metacarpal base fractures?

A

Non-op if <30 degrees angulated, reduce with traction, abduction, pronation and extension

196
Q

Bennett fracture deforming forces

A

APL, adductor and thumb extensors

197
Q

Most common nerve injury when performing ORIF of Bennet fracture via Wagner approach

A

Dorsal sensory branch of radial nerve

198
Q

Primary dynamic stabilizer of the thumb MCPJ

A

Adductor pollicis, inserts on proximal phalanx and ulnar sesamoid

199
Q

Collateral ligament assessment for thumb UCL injury

A

Flexed 30 deg = proper and dorsal capsule. Extended = accessory and volar plate

200
Q

Proximal phalanx displacement in skiier’s thumb

A

Thumb UCL injury is typically off the proximal phalanx (80%). The proximal phalanx then supinates around the radial collateral ligament

201
Q

Where do RCL injuries avulse from

A

Metacarpal side, UCL is opposite and avulses from proximal phalanx side

202
Q

Operative indications for thumb UCL injuries

A

>15% articular surface, 2mm displaced, Stener lesion or stage III tear with no endpoint.

203
Q

In the thumb, how does the proximal phalanx rotate around an intact UCL?

A

It pronates

204
Q

Operative indications for thumb RCL injury

A

Grade III injury

205
Q

What is the next step?

A

Sesamoids are in the joint so it needs an open reduction.

206
Q

In dorsal PIP dislocation, which soft tissue structures are injured? Volar?

A

Dorsal = volar plate and collaterals

207
Q

Muscle that causes MCP instability after RCL injury

A

Adductor and EPL overpull

208
Q

% of Stener lesions in complete UCL injury

A

>85%

209
Q

Force seen at thumb CMC joint during pinch?

A

12 fold

210
Q

Change in ulnocarpal contact pressure with an increase of 2mm positive ulnar variance

A

Transmission force increases from 20% to 40%

211
Q

Treatment of type I TFCC injuries

A

iA) central perforation = debridement

212
Q

Proximity of distal radius fracture to joint to be a Galeazzi fracture

A

Within 7.5cm of articular surface

213
Q

Treatment of dorsal DRUJ dislocation? Volar?

A

Dorsal = supination

214
Q

Treatment of chronic DRUJ instability after old distal radius fracture

A

1) Correct distal radius malunion if present. 2) ligament repair if acute injury 3) ligament reconstruction if chronic

215
Q

Diagnosis?

A

Ulnar impaction syndrome. Note that Keinboch’s will have edema throughout the entire lunate body.

216
Q

Treatment of type II TFCC injuries

A

These are degenerative from ulnar impaction syndrome

217
Q

Surgical management of end stage DRUJ arthritis? Main complication?

A

Darrach = ulnar head resection. Sauve-Kapandji = DRUJ fusion and distal ulna metaphysis resection. Ulnar head arthroplasty. Main complication with all is ulnar instability.

218
Q

Structures at risk with wrist arthroscopy making 1,2 portal? 6U?

A

1,2 = dorsal sensory branch of radial nerve, radial artery

219
Q

Best x-ray to determine true ulnar variance

A

0-degree rotation PA x-ray with shoulder and elbow abducted and flexed to 90 degrees

220
Q

Treatment of thumb CMC arthritis by stage

A

Stages progress as volar beak ligament fails

221
Q

Treatment of PIP joint arthritis in border vs central digits?

A

Border = arthrodesis, central = arthroplasty (linked in RA, unlinked in OA because of collateral stability)

222
Q

Highest complication with PIP arthroplasty

A

Implant fracture

223
Q

Indications for MCP joint arthrodesis

A

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
Q

Implants used and complications associated with PIP and MCP arthroplasty

A

Silicone = implant fracture. Pyrocarobon = loosening. CoCr on PE = poly wear.

225
Q

Conditions seen in the rheumatoid hand

A

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
Q

What deformity happens with injury to the transverse retinacular ligament?

A

Swan neck deformity. The TRL keeps the lateral bands from subluxating dorsally when it is intact.

227
Q

What deformity happens with injury to the triangular ligament?

A

Boutonniere. The triangular ligament keeps the lateral bands from subluxating palmarly when it is intact.

228
Q

Tendon transfer option in the ulnar deviated rheumatoid wrist

A

ECRL -> ECU transfer

229
Q

Management of bilateral end stage wrist rheumatoid arthritis

A

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
Q

Operative management of caput ulna in RA

A

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
Q

Vaughan-Jackson syndrome

A

Prominent distal ulnar head in RA causes rupture of extensor tendons from ulnar to radial starting with EDM

232
Q

Mannerfelt syndrome

A

FPL and/or index FDP rupture secondary to volar STT osteophyte abrasions in RA

233
Q

Most common wrist ligament injury associated with gout

A

SLIL rupture is commonly associated with inflammatory arthropathy

234
Q

Type of lunate associated with Keinbochs disease

A

In addition to articulations with the capitate and distal radius, it has an articulation with the hamate

235
Q

Blood supply to lunate

A

Enters palmar and dorsal

236
Q

Anatomic risk factors for Keinboch’s

A

Negative ulnar variance, decreased radial inclination and type II lunate (hamate articulation)

237
Q

What determines treatment in Keinboch’s disease

A

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
Q

Preiser’s disease treatment

A

Scaphoid AVN. 1-2 ICSRA VBG if early. If late PRC, 4 corner or total wrist

239
Q

Other body parts affected in Dupuytren’s

A

Lederhosen’s = plantar fascia, Garrod’s knuckle, Peyronie’s

240
Q

Key pathologic cell in Dupuytren’s

A

Myofibroblast, stimulated by prostaglandins and lysophosphatic acid and produces alpha-smooth muscle actin and pathologic production of type III collagen

241
Q

Digital ligament not involved in Dupuytren’s

A

Cleland’s (dorsal to neurovascular bundle).

242
Q

Dupuytren’s cord that causes MP contracture

A

Preteindinous cord, note that this does not alter the course of the neurovacular bundle

243
Q

Dupuytren’s cord that causes PIP contracture

A

Central cord

244
Q

Dupuytren’s cord that displaces the neurovascular bundle volar and central

A

Spiral cord

245
Q

Indications for treatment in Dupuytren’s

A

MCP contracture > 30 and any PIP joint contracture

246
Q

Collagenase is best indicated for which patients in Dupuytren’s

A

MP contracture. ROM improvement not as great in PIP contracture and higher risk of tendon rupture in PIP contracture (especially small finger)

247
Q

Most common complication in palmar fasciectomy for Dupuytren’s?

A

Nerve injury (10x greater if revision case)

248
Q

Most common complication with collagenase use?

A

Skin tear

249
Q

Cord that causes DIP contracture in Dupuytren’s

A

Retrovascular cord

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