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Hand > Anatomy > Flashcards

Anatomy Flashcards

1
Q

What muscles are spared with a PIN nerve palsy?

A

Brachioradialis and ECRL since they are innervated by the radial nerve preserving wrist extension

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2
Q

What bone links the proximal and distal carpal bones?

A

Scaphoid

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3
Q

What are the sensory branches to the hand

A

Palmar:
Ulnar: palmar cutaneous nerve to the hand small and ring
Median: palmar and digital branches

Dorsal: superficial radial branch, dorsal branch ulnar nerve, digital branches of the median nerve

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4
Q

What prevents bow stringing of the neurovascular bundle for the digits?

A

Clelands dorsal
Graysons volar

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5
Q

What are the present in the extensor compartments of the hand?

A

1: EPB APL
2: ECRB ECRL
3: EPL
4: EIP EDC
5: EDM
6: ECU

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6
Q

How is EPL assessed?

A

Hand flat on table and ask to extend thumb

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7
Q

How is EDC function assessed?

A

Ip joints in flexion and ask to extend mcp

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8
Q

What is the test for dequervains tenosynovitis?

A

Ulnar deviation of the wrist
Stretches the first dorsal compartment with EPB and APL

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9
Q

Where does the dorsal sensory branch of the ulnar nerve arise?

A

7 cm proximal to the ulnar styloid

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10
Q

What is the normal two-point discrimination for fingertip? Static and dynamic.

A

6mm static
2-3mm dynamic

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11
Q

What is pre and post axial for hand classification?

A

Preaxial is Radial
Postaxial is ulnar

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12
Q

What is the role of the zone of polarizing activity and what happens if it is disrupted?

A

Ulnar sided mesenchymal cells

Postaxial to preaxial development, if disrupted then ulnar side such as ulnar longitudinal deficiency

Mirror hand caused by duplication of ZPA

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13
Q

What genes control volar dorsal development?

A

LMX1B gene and WNT7 gene

Disruptions can cause abscence of fingernails, controlled by dorsal ectoderm

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14
Q

What determines proximodistal axial development of the limb?

A

Apical ectodermal ridge
Disruption causes shortened/absent limbs
Loss of FGFR at this region causes hypoplastic thumb

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15
Q

What is camptodactyly?

A

Flexed deformity at the PIP joint

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16
Q

What is considered a congenital hand failure of differentiation?

A

Syndactyly
Camptodactyly
Clinodactyly
Kriner’s deformity

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17
Q

What is clinodactyly?

A

Irregular wedged shaped phalanges

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18
Q

When is the optimal time for treating syndactyly? When to treat earlier? What is the most common web space?

A

1-2 years old unless it involves border digits

3rd web space most common

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19
Q

What is the classification system for thumb duplication, why is the most common subtype and what is it based on?

A

Wassel classification
Most common subtype is IV- complete IP joint duplication, normal metacarpal
Based on skeletal features only

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20
Q

How is camptodactyly treated?

A

Flexion contractures of the PIP joint

Mild forms with physiotherapy
Surgical release with severe cases, high failure rate

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21
Q

How is clinodactyly treated?

A

Radial/ulnar curve to the finger due to a c shaped phalanx

Treat with k wires, z plasty for soft tissue

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22
Q

What type of polydactyly is associated with syndromic cases?

A

Well formed ulnar Postaxial polydactyly- trisomy 13

Radial polydactyly may be associated with Holt Oram or Fanconi anemia

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23
Q

What syndrome is Macrodactyly associated with?

A

Neurofibromatosis

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24
Q

What is associated with radial longitudinal deficiency?

A

TAR syndrome- thrombocytopenia and absent radius

VACTERL syndrome- vertebral, anal, cardiac, te fistulas, renal and lower extremity abnormalities, radial abnormalities

Fanconi anemia- bone marrow failure
Holt Oram

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25
Q

What are the features of cleft hand?

A

Familial usually bilateral
Syndactyly is common
Good hand function, cosmetics is poor
May be associated with cleft lip and palate
Can be associated with Poland syndrome

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26
Q

What is the treatment of a threatened viable digit for constriction band syndrome?

A

Prompt surgical release no more than 50% of the circumference at one time

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27
Q

What is the treatment for pediatric trigger thumb and etiology?

A

From Nottas node, thickening of the FPL tendon

Treated conservatively with stretching and followup in 6-8weeks

Only persistent cases are surgically released

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28
Q

What is the blood supply to the scaphoid bone?

A

Both from radial artery
20 percent distal tip
80 percent dorsal

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29
Q

What is the standard imaging for scaphoid fractures?

A

5 view radiographs, pa lateral oblique clenched fist and scaphoid views

Repeat in 2-3 weeks, bone scan or MRI may be useful if inconclusive

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30
Q

What is the treatment for scaphoid fracture based on location and displacement?

A

Non displaced fractures are splinted for a total of 12 weeks (either thumb spica or dorsal extension

Proximal pole fractures have high rates of non union and must be fixated

Displaced or nonunion fractures must be fixated

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31
Q

What’s the result of inadequately treated scaphoid fractures?

A

Chronic osteoarthritis

Instability of the displacing does ally lunate leading to a dorsal intercalated segment instability DISI

Leads to Scaphoid nonunion advanced collapse SNAC wrist

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32
Q

What is associated with 4th or 5th CMC joint dislocations?

A

Hamate body fractures will require fixation

Hamate hook fractures associated with ulnar nerve injuries

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33
Q

What is the least commonly fractured carpal bone?

A

Trapezoid

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34
Q

What is Keinbock’s disease?

A

Avascular necrosis of the lunate

Occurs spontaneously or with nonunion of a lunate fracture

Dorsal hand pain activity related

May be treated with partial wrist fusion, total wrist arthoplasty, vascularized bone grafts

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35
Q

What carpal bone is at risk of fracture during wrist hyperextension? What is the mechanism?

A

Capitate

The anvil mechanism: forced hyperextension against the radius resulting in fragment, proximal segment may rotate 180 degrees

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36
Q

What view is best for hook of hamate fractures?

A

Carpal tunnel view

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37
Q

What tendon is the pisoform bone located?

A

FCU tendon

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38
Q

How many functional columns are in the carpal bones?

A

Two functional columns of carpal bones

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39
Q

What is dissociative instability of the carpal bones?

A

Disruption of support structures or biomechanics in the same row

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40
Q

What ligaments are in the proximal row?

A

Scapholunate
Lunotriquetral

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41
Q

How is predynamic instability diagnosed?

A

On arthroscopy

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42
Q

Explain the mechanism of DISI

A

Normally the lunate is held in place by the scapholunate and lunotriquetral ligaments

When there is a scapholunate injury the lunate is pulled dorsally by the triquetrum

With radial deviation, scaphoid flexes, lunate extends and the scapholunate angle is greater than 60

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43
Q

Explain VISI

A

Normally the lunate is held in place by the scapholunate and lunotriquetral ligaments

When the lunotriquetral ligament is disrupted, the lunate flexes with the scaphoid and is pulled volarly

With radial deviation, scaphoid flexes, lunate flexes and the scapholunate angle is less than 30

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44
Q

What is cortical ring or signet ring sign indicative of on x ray?

A

Scapholunate ligament injury and a hyperflexed scaphoid

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45
Q

What is the spilled teapot sign indicative of?

A

Perilinate injury grade iv

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46
Q

What is Watson’s test correspond to?

A

It tests scaphoid stability by stressing the scapholunate ligament

Clunk is felt over the scaphoid on radial deviation

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47
Q

What are the four stages of perilunate injury?

A

1: scapholunate and radioscaphoid disruption
2: dorsal dislocation of the capitate (lunocapitate ligament)
3: lunotriquetral dissociation
4: volar dislocation of the lunate- can compress median nerve, short radiolunate ligament is the remaining ligament left

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48
Q

What always needs repair in perilunate injuries?

A

Scapholunate ligament

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49
Q

What is used to reconstruct the scapholunate ligament that has been torn over a long period of time?

A

FCR tendon or ECRL tendon

If not an option radiolunate fusion

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50
Q

What is a colles fracture of the distal radius?

A

Dorsal angulated distal radius fracture

Smiths fracture is volar dislocated

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51
Q

What is a way to verify a true lateral view on a wrist?

A

50% overlap of the pisiform and distal pole of the scaphoid

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52
Q

What is the rule of 11s for radius?

A

Volar tilt 11 degrees
Radial height: 11 mm
Average radial incline 11x2= 22 degrees

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53
Q

What is ulnar variance?

A

It describes the ulna in relation to the radius

Normal is zero can be positive or negative

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54
Q

What tendon is possibly injured in distal radius fracture?

A

EPL tendon rupture

Can be attrition rupture or ruptured by bone cutting tendon

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55
Q

What is the indication for operative intervention for distal radius fractures after closed reduction?

A

Dorsal angulation more than 10 degrees and radial shortening more than 3mm

Elderly or inactive patients is 20 and 5mm

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56
Q

What splint is used after orif of distal radius fracture?

A

Sugar tong splints to prevent forearm rotation especially with TFCC injury

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57
Q

What best predicts carpal alignment in distal radius fracture?

A

Restoring cortical continuity

Locking plates can reduce the need for bone grafting

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58
Q

What are the five salter Harris types?

A

Type 1(S): Straight across physis(growth plate)

Type 2 (A): above physis

Type 3 (L): through and beLow physis

Type 4 (T): Two, above and below physis

Type 5 (ER): erasure or crushed growth plate

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59
Q

What is being stretched in intrinsic plus position?

A

Volar plate and the collateral ligaments of the MCP joint due to the asymmetrical metacarpal head

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60
Q

What is the most common injury in boxers?

A

Sagital band rupture leading to extensor tendon subluxation

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61
Q

What is the Jahss maneuver and what is it used for?

A

Metacarpal neck fractures

Stabilizing the metacarpal shaft, mcp in 90 degrees and applying pressure dorsally

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62
Q

Why do metacarpal fractures point apex dorsal?

A

Because they are being pulled volarly by the interossei

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63
Q

What angulation is found with basal proximal phalanx fractures and why?

A

Apex volar due to the pull of the interosseous muscles on the proximal phalanx

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64
Q

What is acceptable for angulation of metacarpal neck fractures for the small ring and index finger?

A

Small: 50 to70 degrees
Ring: 30-40 degrees
Index: 10-15 degrees

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65
Q

What is a Bennett fracture?

A

Intra articular fracture of the thumb cmc joint

Always a fragment attached to the carpus due to ligamentous attachments

Treat with fixation to the carpus

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66
Q

What is a Rolando fracture?

A

Comminuted intra articular fracture of the first metacarpal

Treated with closed k wire or if large fragment plate fixation

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67
Q

What is a Seymour fracture?

A

Salter Harris type open fracture of the distal phalanx

See in nailbed injuries, must be recognized and reduce to prevent growth disturbances

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68
Q

What are the two forces determining apex dorsal or volar for middle phalanx fractures?

A

Proximal or distal to FDS insertion vs central slip

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69
Q

What is a treatment option for proximal phalanx transverse fracture apex volar?

A

Dorsal blocking splint with closed reduction

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70
Q

How should collateral ligament injury be assessed?

A

PIP: Both in extension and flexion since volar plate can stabilize the joint in full extension

May use a local block to assess

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71
Q

What two structures is the metacarpal head stuck between in dorsal dislocations of the proximal phalanx?

A
  1. Radially lumbrical
  2. Ulnar flexor tendons
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72
Q

What is the treatment for UCL and RCL tears?

A

Grade II injuries are immobilized for 4 weeks

Grade III: due to risk of stenner lesions may need primary repair

Stenner lesion is adductor aponeurosis interposing between the torn ends of the UCL

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73
Q

What is the treatment for gamekeepers thumb with arthritis?

A

Fusion of the MCP joint since delayed repair is not possible

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74
Q

What is the most common dislocation of the PIP joint?

A

Dorsal dislocation since the collateral ligament and volar plate complex is stronger “ligament box”

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75
Q

What are the three types of dorsal dislocations of the PIP joint?

A

Type I: hyperextension injury so volar plate is assumed to be injured however, partial joint congruity is maintained so collateral ligaments are intact

Type II: hyperextension injury complete dorsal dislocation so volar plate and collateral ligaments are injured

Type III: associated fracture in addition to type II

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76
Q

What is the treatment for grade 3 dorsal pip dislocations

A

Boney fragments less than 40 percent of articular surface are usually stable

After reduction if well aligned mobilization with dorsal blocking splint is warranted

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77
Q

What is the Venkatsswami VY advancement flap?

A

Used to reconstruct volar oblique injuries
Based on single neurovsacular pedicle

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78
Q

Why are moberg flaps avoided?

A

Dorsal skin necrosis due to division of dorsal branches of digital vessels

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79
Q

What is the Quaba flap used for and what is the blood supply?

A

First dorsal metacarpal artery perforator
Soft tissue defects up to the PIP joint

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80
Q

What is the Foucher flap what is it used for and what is the blood supply

A

First dorsal metacarpal artery flap
Used for thumb tip reconstruction
Is sensate

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81
Q

What is the growth rate for nails?

A

3-4 mm per month

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82
Q

What is the purpose of replacing the nail after nailbed injury?

A

To prevent nailbed ridging

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83
Q

What is the treatment for hook nail deformity?

A

Elevating the soft tissues including the nailbed off of the distal phalanx

Addressing soft tissue deficiency with cross finger flap

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84
Q

What are the different type classification nailbed injuries?

A

Type I: 25 percent hematoma
Type II: greater than 50% hematoma
Treat with trephination(make a hole in the nail to let it drain)

Type III: nailbed laceration and distal phalanx fracture treat with repair
Type IV and V: extensive damage requiring nailbed grafting from great toe

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85
Q

Where is the germinal matrix?

A
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86
Q

What does the AIN nerve supply?

A
  1. FPL
  2. Radial FDP tendons
  3. Pronator quadratus
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87
Q

Where does the majority of the diffusion of nutrients come from for flexor tendons?

A

Diffusion from flexor sheath
(Vinculum secondary)

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88
Q

What’s are the zones of injury for the flexor tendons?

A

Zone 1: distal to the FDS insertion
Zone 2: from proximal edge of A1 to FDS insertion
Zone 3: distal end of carpal tunnel to proximal A1
Zone 4: within the carpal tunnel
Zone 5: proximal to the carpal tunnel

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89
Q

What percentage is the threshold for repair in partial flexor tendon injuries?

A

Over 50%

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90
Q

What is the left packer classification of flexor tendon avulsion injuries?

A

Type I: FDP retracts to the palm ( both vincula ruptured)
Type II: FDP avulses small fragment of distal phalanx, tendon retracts to the level of the PIP joint A3
Type III: large bone fragment avulsed to the level of the middle phalanx a4 pulley
TypeIV: fragment avulsed and tendon avulsed from fragment with tendon retraction
Type V avulsion of tendon and distal phalanx fracture

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91
Q

What is the strength added from epitendious repair?

A

Adds up to 50% strength to core suture

Also improves gliding

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92
Q

When is immediate tendon repair contraindicated?

A

Bite injuries, first washout and debridement then delayed repair in 48-72 hrs

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93
Q

What percentage of the population has congenital abscence of FDS in the little finger?

A

20%

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94
Q

What is the Limburg comstock anomaly?

A

Attachments between the FPL and index FDP tendons in the carpal tunnel

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95
Q

What is the most frequently ruptured tendon after repair?

A

FPL

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96
Q

What is the only extensor muscle with a true sheath?

A

Extensor carpi ulnaris

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97
Q

What is the anatomy of the extensor mechanism?

A
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98
Q

What is the Doyle classification of extensor tendon injuries?

A
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99
Q

What allows the finger to extend despite a central slip injury?

A

Lateral bands however long term would develop a boutonnière deformity

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100
Q

What is the postop position of repair of extensor tenons placed in?

A

Wrist in 30 degrees extension,
MP joints flexed at 30 degrees

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101
Q

What is the problem in the scenario of able to flex ip joint when MCP joint in extension but unable to flex in when MCP joint in flexion after extensor tendon repair?

A

Due to the extensor tethering needs tenolysis

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102
Q

What is lumbrical plus deformity?

A

Paradoxical joint extension when attempting flexion, due to lumbrical tightening and pulling on the extensor mechanism

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103
Q

What are the six key principles of tendon transfers?

A

SPEEPS
S: single function
P: power (adequate)
E: Expendable excursion
E: excursion (similar)
P: pull (vector)
S: Synergistic

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104
Q

What is the most common indication for tendon transfer?

A

Nerve injury alone

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105
Q

What is a common tendon transfer for wrist extension?

A

PT(median nerve) to ECRB

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106
Q

What is a common tendon transfer for thumb opposition?

A

EIP around the ulnar border of the wrist or

ring finger FDS transfer

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107
Q

What is the tendon transfer for radial nerve palsy to restore thumb extension and abduction

A

FCR to EPB and APL

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108
Q

What tendon tansfer is used to restore finger extension after radial nerve injury?

A

FCR (preferred) or FCU to EDC

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109
Q

What can be used to restore thumb extension in radial nerve injuries?

A

PL or FDS of the ring finger

110
Q

What is a common nerve transfer to restore isolated serratus anterior muscle?

A

Thoracodorsal nerve to serratus anterior

111
Q

What are the three nerves to restore in C5/6 root avulsion? And what nerves are used to restore?

A

Restore Suprascapular nerve for shoulder girdle—> reconstruct with spinal accessory

Musculocutaneous—> reconstruct with ulnar nerve

Axillary—> long head of the triceps radial nerve

112
Q

After brachial plexus injury what is the first priority to restore?

A

1: Elbow flexion
2: shoulder stability
Allows for hand to mouth function

113
Q

What is the gold standard for nerve transfers to restore elbow flexion after C5/C6 avulsion?

A

FCU fascicle from the ULNAR nerveto biceps branch of the musculocutaneous nerve (oberlin procedure)

Can also transfer branch of the MEDIAN nerve to the FCR

If not possible throacodorsal nerve to biceps

114
Q

What are nerve transfers for radial nerve injury?

A
  1. Nerve to FDS to ECRB for wrist extension
  2. Nerve to FCR and PL to PIN
115
Q

What is the gold standard donor nerve transfer to restore intrinsic function following ulnar nerve injury in the proximal forearm?

A

AIN branch to pronator quadratus to be transferred to the motor branch of the ulnar nerve

Done end to end or end to side if recovery is anticipated

116
Q

What determines salvagability in amputations through the middle phalanx?

A

If FDS tendon was transected

If it was transected revision amputation allowing FDS and extensor tendon to retract in

117
Q

What is the benefit of a ray amputation?

A

To decrease interdigital gap
Supination power is reduced

118
Q

Where is the osteotomy for a ray amputation made?

A

At the base of the metacarpal

119
Q

What tendon inserts onto the base of the little and index fingers?

A

Index: ECRL and FCR
Little: FCU and ECU

120
Q

Which fingers can be transposed in ray amputations?

A

Middle and ring fingers

121
Q

What is the presentation of neuroma vs allodynia following amputation?

A

Allodynia: burning and tingling after light touch, needs desensitization therapy happens around 6 weeks

Neuroma: pinpoint shock or shooting pain, long term issue

122
Q

What causes lumbrical plus deformity?

A

After amputation through the DIP residual FDP tendons attached to the lumbricals pull resulting in flexion of the mcp and extension of the PIP

123
Q

What causes the quadregia effect?

A

It is when one of three FDP tendons are functionally shorter than the rest. This results in the shortest FDP tendon tightening and

124
Q

What is a relative contraindication to digit reimplantation?

A

Zone II Injuries
Outcomes are poor due to stiffness in the long term

125
Q

What is the significance of Tamai zone I?

A

Zone I venous anastomosis is either not possible or extremely difficult would need leech therapy or nailbed bleeding

126
Q

What is the optimal temp for digit storage en route to reimplantation?

A

4 degrees celcius in damp gauze

127
Q

What is the difference between warm and cold ischemia time?

A

Cold ischemia time is time from cold storage during transport

Warm ischemia time is the time from removal of the digit from cold storage

128
Q

What is the order of repair for digital replantation?

A

Bone tendon, nerve vessel
May need to repair vessel before nerve based on ischemia time

129
Q

What does a red line sign mean down the neurovascular bundle?

A

Indicates damage to the vessel and poorer prognosis

130
Q

What is the mechanism of papavarine?

A

Phosphodiesterase inhibitor

131
Q

What organism is associated with leech therapy? What is the ppx?

A

Aeromonas hydrophyla
Cipro or third generation cephalosporin

132
Q

What is the main reason for digit reimplantation failure?

A

Arterial insufficiency

133
Q

Following reimplantation what is the most common secondary procedure needed?

A

Tenolysis

134
Q

What are indications for hand transplant?

A
  1. Dominant hand- if patient still has function of their dominant hand is a contraindication
  2. Bilateral hand amputations, or bilateral arms and legs
135
Q

What are contraindications for hand transplant?

A
  1. Chronic infections HIV
  2. Cancer with high risk of recourrence
136
Q

How is an upper extremity harvested?

A

Fish mouth trans elbow amputation

137
Q

What is the most antigenic tissue?

A

Skin

138
Q

What percentage of hand transplant patients have return of tactile pain and temperature sensation?

A

Over 90 percent

Mid forearm transplants have better prognosis

139
Q

What is a diagnostic finding that is helpful in TMR prognosis?

A

Lidocaine at the suspected neuroma site and seeing if there is resolution of chronic pain

140
Q

Where are motor targets for nerves in BKA?

A

Tibial- gastroc, soleus, tibialis posterior

Deep peroneal- peronial muscles or tibialis anterior

Superficial peroneal: peroneus longis or brevis

Sural- tibialis posterior or soleus

141
Q

What are the motor targets for TMR in AKA?

A

Tibial component of sciatic nerve- biceps femoris

Common peroneal component of sciatic nerves: semitendinosis

Saphenous: gracilis muscle

142
Q

Forequarter amputation TMR targets

A

Median nerve: pec major
Musculocutaneous nerve: clavicular head nerve branch of pec major
Ulnar nerve: pec minor
Radial nerve: thoracodorsal and long thoracic

143
Q

TMR targets for transhumeral amputation

A

MABC: brachialis
LABC: brachialis or brachioradialis
Median: short head of the biceps
Ulnar nerve: brachialis
Musculocutaneous: long head of biceps
Radial: triceps

144
Q

TMR targets for transradial amputation

A

Median nerve: FDS
Ulnar: FCU
Superficial radial: ain, FDS

145
Q

What is the intrinsic plus position?

A

Mcp 90 degrees of flexion
IP joint in 0 degrees of flexion
Wrist in 30 degrees extension

146
Q

What kind of finger splint is used for swan neck deformity?

A

Figure of eight splint

147
Q

What is the postop regimen after flexor tendon injuries?

A

Dorsal blocking splint and early passive range of motion with active range of motion at 6 weeks

148
Q

How are thumb amputations classified?

A

Distal third
Middle third A)proximal B) Distal
Proximal third

149
Q

What aids in advancement of the Moberg flap?

A

Release of the skin usually in a v y pattern

150
Q

What aids in deepening first web space when releasing contracture with z plasty?

A

Release of the first dorsal interosseous muscle

151
Q

What is the preferred donor for heterotopic digit transfer for thumb reconstruction when all other digits are uninjured?

A

Ring finger
If injured index finger

152
Q

What are the tendon transfers for pollicization of the index finger?

A
  1. EIP becomes EPL
  2. MCP joint becomes the new cmc joint
  3. FDS becomes Abductor pollicis brevis
  4. FDP becomes the FPL
  5. First palmar interosseous Adductor pollicis
153
Q

Where is the pivot point of the reverse radial forearm flap?

A

Radial styloid

154
Q

What is the blood supply for the scapular flap?

A

Circumflex scapular vessels
Transverse branch- scapular
Descending branch- para scapular

155
Q

What can possibly be injured during a two incision fasciotomy medial incision?

A

Posterior tibial vessels and nerve since dissection continues to the deep compartment through the medial incision

156
Q

What are the two components of the sensory median nerve in the hand and where does the palmar branch originate?

A

Palmar cutaneous branch: innervates the thenar eminence, arises 5 cm from the wrist

Digital cutaneous: arises in the palm, innervates radial fingers

157
Q

What is the most common site of radial nerve compression in radial tunnel syndrome?

A

Arcade of Frohse in the supinator muscle

Wrist extension is preserved

ECRL is preserved since it gets innervation first

158
Q

At what stage does demyelination vs axonal injury happen in nerve compression syndromes?

A

Demylination early
Axonal injury late

159
Q

What is pronator syndrome?

A

Compression of the median nerve in the forearm, sensory not motor

Presents with pain with the resisted FDS contraction (especially in the middle finger)

Compression points:
1. Ligament of Struthers
2. Lacertus fibrosis
3. Arch of the FDS
4. Pronator teres muscle heads

Treat with decompression

160
Q

What is Wartenburgs syndrome? Between which two tendons is sup rad nerve found?

A

Compression of the superficial radial nerve

Found between Brachioradialis and ECRL

No motor weakness

Sup Rad: RL was BRazilian

161
Q

What are the possible points of compression for the radial nerve?

A
  1. Vascular leash of henry (radial recurrent artery)
  2. Medial edge of ECRB
  3. Arcade of Frohse (proximal supinator)
  4. Distal supinator
162
Q

What are the possible compression points of the ulnar nerve?

A

Proximal to distal
1. Medial intermuscular septum
2. Arcade of Struthers
3. Osborne’s ligament
4. Between or within the FCU

163
Q

Where are the sites of compression of Guyons canal?

A

Zone I: mixed sensory and motor
Zone II: deep motor branch only
Zone III: sensory branch only

Can be caused by ulnar artery aneurysm (hypothenar hammer syndrome)

164
Q

What is the presentation of cubital tunnel syndrome?

A

Decreased grip strength
Abducted little finger at all times ( due to unopposed EDM)

165
Q

Where is Erbs point?

A

At the confluence of C5 and C6
Suprascapular nerve arises at this point

166
Q

What nerve roots contribute to the long thoracic nerve?

A

C 5,6,7

167
Q

What is Erbs palsy?

A

Avulsion injury of C5 and 6 nerve roots
Causes waiters tip hand

168
Q

What is found on nerve conduction /EMG of root avulsion injuries of the brachial plexus?

A

Preganglionic injuries

Preserved sensory nerve action potentials

EMG would demonstrate severe injury

May present with horners syndrome

169
Q

What grading classification is used for brachial plexus birth palsy?

A

Waters classification based on glenohumeral joint dysplasia

170
Q

What is the initial management of brachial plexus birth injuries?

A

Physiotherapy and followup in 3 months

Most obstetric palsy’s resolve without surgery

171
Q

Which cord is the thoracodorsal nerve from?

A

Posterior cord

172
Q

What is the Medical Research Council grading system for muscle strength?

A

1: muscle contracts but doesn’t move
2: movement with gravity eliminated (ex when resting on a table)
3: movement against gravity
4: movement against resistance
5: normal strength

Sensory is a 4 point scale

173
Q

What directly surrounds axons in the peripheral nerve?

A

Endoneurium followed by Perineurium

174
Q

What is a Froment-Rauber anastomosis?

A

Rare connection between posterior interosseous nerve and ulnar motor branch

175
Q

What is neurotropism?

A

Chemotactants allowing for distal stump of the nerve to be found

176
Q

What percentage of the motor end plates of a muscle need to be present to retain contractile function?

A

25%

177
Q

What is the sunderland classification?

A

1: axon: return of function days to months
2: axon total with wallarian degeneration: complete return in months
3: axon and endoneureum: mild reduction in function
4 axon, endo and perineurium: moderate reduction in function
5 all structures marked reduction

178
Q

What is the most common bacteria in paronychia?

A

Staph aureus

Infection of soft tissue around nail, pulp space infections are felons

179
Q

How does paronas space infection present?

A

Space between pronator quadratus and FDP

Presents as horseshoe abscess of flexortenosynovitis of little finger and thumb

180
Q

Which animal bites are more likely to be infected?

A

Cat bites

181
Q

What can cause septic arthritis in children?

A

Hematogenous spread

182
Q

What is the criteria for septic arthritis?

A

WBC over 50K

183
Q

What is the treatment for sporotrichosis?

A

Itraconazole or fluconazole

184
Q

Where are ganglion cysts found in children?

A

Volar wrist

185
Q

Where is the most common ligaments associated with ganglion cysts?

A

Sapholunate

186
Q

What is a predisposing factor for ganglion cysts?

A

Previous injury

187
Q

What is the most common malignant bone tumor of the hand and occurs in middle aged patients?

A

Chondrosaecoma

188
Q

What is the presentation of endochondroma?

A

Lyric lesions of the hand with stippled calcifications, presents as pathological fractures

Olliers disease are multiple endochondromas

Maffucci’s disease is with vascular malformations

189
Q

What components make up the spiral cord in dupuytrens?

A

Lateral digital sheet
Spiral band
Graysons ligament
Natatory ligaments
Pretendinous band

Landsmeers ligament is not part of the spiral cord

190
Q

What are the indications for dupuytrens release?

A

Any PIP contracture
MCP above 30

191
Q

What is the general treatment of dupuytrens with collagenase?

A

Two joints can be treated simultaneously

Two office visits, one for injection and one for manipulation

192
Q

When doing fasciectomy where does dissection start and why?

A

It starts in the palm to identify the neurovascular bundles and proceeds distally

193
Q

How is dupuytrens flare treated?

A

Steroids and gabapentin

This is sudden swelling redness and tenderness in the operated hand

194
Q

What is the tissue that is targeted in rheumatoid arthritis?

A

Synovium

195
Q

What are the seven criteria for RA? Need 4 for diagnosis

A
  1. Morning stiffness
  2. Soft tissue swelling of 3 or more joints
  3. MCP PIP or wrist involvement
  4. Symmetrical involvement of joints
  5. Rheumatoid nodules
  6. Positive rheumatoid factor
  7. Typical radiographic findings
196
Q

What are the clinical findings of RA?

A

Radial deviation of the wrist
Ulnar deviation of the MCP

197
Q

Where are early/late sites of RA?

A

Scaphoid waist
Scapholunate ligament
And distal radial ulnar joint

Late is the radio carpal joint

198
Q

What reason is index pIP joint replacement avoided?

A

Instability of the joint soft tissue

199
Q

Which finger deformity is less functional?

A

Swan neck is less functional compared to boutonnière

200
Q

What is the most common thumb abnormality in RA?

A

MCP flexion and IP hyperextension

201
Q

What drug should be stopped on RA patients periop?

A

Biological dmards

202
Q

What is a Mannerfelt lesion?

A

Spontaneous rupture of the FPL tendon caused by osteophytes of the scaphoid

Treat with FDS transfer

203
Q

What is the most common joint affected in OA?

A

DIP

204
Q

Where are heberdens nodes found in OA?

A

DIP joint

Bouchards nodes are over the PIP

205
Q

What are Eatons stages of CMC joint degeneration?

A

1: normal articulations with joint space widening
2: slight narrowing of joint space
3: increase sclerosis and subchondral cysts
4: narrowed scaphotrapezial joint
5: pantrapezial arthritis

206
Q

What is the treatment for CMC joint instability in non OA joints?

A

Using a partial FCR tendon sling for Volar beak and intermetacarpal ligament reconstruction

207
Q

What is the treatment for a young patient with MCP traumatic osteoarthritis?

A

Polycarbon arthoplasty

208
Q

What degree of flexion is the DIP fixed in for OA treatment?

A

0 to 10 degrees

PIP joint is 20 to 40 degrees

209
Q

What is the treatment for loss of pulses after reduction of humeral fracture?

A

Operative exploration

210
Q

What is found on clinical exam for neurological thoracic outlet syndrome?

A

Normal exam

Neurological cases is from anterior scalene muscles

211
Q

What is Paget Schotter syndrome?

A

Acute venous thrombosis of the subclavian vein from thoracic outlet syndrome

212
Q

What is Beugers disease?

A

Intermittent claudication of the lower limbs in a heavy smoker

Inflammatory thrombi of artery and veins

Treat with smoking cessation

213
Q

What are the 5 ligaments of the cmc joint of the thumb?

A

1: ulnar collateral ligament
2: anterior oblique ligament
3: dorsoradial ligament
4: posterior oblique ligament
5: inter metacarpal ligament

214
Q

What is the ligament of the thumb cmc joint that is injured in dorsal thumb dislocations?

A

Dorsoradial ligament

215
Q

What is the last muscle to be reinnervated after a radial nerve injury?

A

Extensor indicis proprius

216
Q

What muscle is the most common cause of lateral epicondyle pain?

A

ECRB

217
Q

What is the gold standard for diagnosing carpal ligament tears/scapholunate ligament tears?

A

Arthoscopy

218
Q

What is the

A
219
Q

What is the most common muscle involved in lateral epicondylitis?

A

ECRB

220
Q

What can a perilunate dislocation cause?

A

Carpal tunnel syndrome must be decompressed

221
Q

What is the spacing for core sutures?

A

7-8 mm apart

222
Q

What are the functions of Latissimus Dorsi?

A

Adduction
Extension
Internal rotation

223
Q

What are the medial rotators of the arm?

A

MR ST P LAT

Medial rotation: subscapularis, teres major, pec major, latissimus

224
Q

What are the external rotators of the arm?

A

IT

Infraspinatus Teres Minor

225
Q

What is a salvage option in mangled land injuries when free flap is not an option

A

Finger filet flaps to cover soft tissue deficit

226
Q

What toes do the first dorsal metatarsal artery supply?

A

First and second toe 70 percent of cases, can be 20 percent for first plantar metatarsal

Determined by retrograde dissection

227
Q

What view is used to evaluate 5th cmc joint injury?

A
  1. Ap view with 30 degrees of pronation
  2. Lateral view with 30 degrees of pronation
228
Q

What is the function of the vastus lateralis?

A

Knee extension

229
Q

What muscles abduct the hip?

A

TFL and Sartorius

230
Q

What innervates the plantar aspect of the foot?

A

Tibial nerve

Heel

Medial and lateral plantar nerves are from tibial nerve

231
Q

What is the main goal of silicone arthoplasty of digits?

A

Relief of pain, similar outcomes for ROM

232
Q

What is a giant cell tumor and how does it present? Treatment? Path?

A

Benign nodular of the tendon sheath of the hands

Miltinodular tumor of the tendon sheath, second most common soft tissue tumor. Tan in color

Marginal excision

Histicoid mononuclear cells

233
Q

What is the function of the spiral oblique retinacular ligament?

A

Links the PIP joint and the DIP joint in flexion and extension

234
Q

What is reconstruction of the spiral oblique retinacular tendon treat?

A

Swan neck deformity

SORL the swan

235
Q

What is the main benefit of wrist disarticulation vs trans radial amputation?

A

Wrist rotation

236
Q

What are indications for healing through secondary intention for oblique amputations in the fingertips?

A

Less than 1.5 cm² with minimal exposed bone

237
Q

What is the position to evaluate scaphoid on x ray?

A

Ulnar deviation of the wrist and wrist extension

238
Q

What is the treatment for volkman contracture with preserved function just muscle tightness?

A

Flexor pronator slide or tendon lengthening

239
Q

What is the mayfield classification of lunate injuries?

A

Stage I: scaphoid ligament tear
Stage II: midcarpal joint disrupted
Stage III: lunotriquetral ligament torn
Stage IV: lunate dislocation volarly with only short radial ligament intact “spilled teacup”

240
Q

What is the extensor digitorum brevis manus?

A

Anomalous muscle at the distal edge of the extensor retinaculum that presents as a painful mass similar to ganglion cyst

241
Q

What are the tendon transfers for radial nerve palsy?

A

PT to ECRL and ECRB
FCR to EPL and APL or to EDC
FDS-III to EDC (via interosseous membrane)
FDS-IV to EPL and EIP (via interosseous membrane)

242
Q

What is emg evidence of recovering nerve?

A

Nascet potentials

243
Q

What is the treatment of non displaced scaphoid tubercle fractures?

A

Casting 6-12 weeks

244
Q

What is the best way to evaluate scapholunate injuries and how much diastasis is abnormal?

A

Clenched fist and 5mm of diastasis

245
Q

What is the first line treatment for Raynauds?

A

Oral calcium channel blockers like nifedepine

246
Q

What is the treatment for soft tissue sarcomas?

A

Resection with postop radiation therapy

If involving one or more major nerves, critical structures, consider amputation

247
Q

What are psotop deficits of doing LD flap and recovery?

A

Decreased range of motion of the shoulder, however, improves in one year

248
Q

What is the first line treatment of intermittent hammer syndrome?

A

Intermittent claudication, no soft tissue loss no compressive nerve symptoms

Aspirin and calcium channel blocker such as nifedipine

249
Q

What is the number one risk factor for obstetric brachial plexus injuries?

A

Shoulder dystocia

250
Q

What is the expected post injury course for perilunate lunate fractures?

A

Moderate arthritis
80% grip string

251
Q

What are symptoms associated with amyloidosis?

A

Biceps tendon rupture, carpal tunnel, spinal stenosis, trigger finger

Diagnosed with Congo red stain

252
Q

What is the muscle encountered in the anterior compartment prior to incising the interosseous septum

A

Extensor hallicus longus

253
Q

What length of bone is required proximally and distally to maintain ankle and knee stability in free fibula flap?

A

Proximally: 4-6cm
Distally: 6cm

254
Q

What is the classic presentation of PIN syndrome?

A

Radial deviation on extension due to preservation of the ECRL muscle which is innervated by the Radial nerve

255
Q

What is the preferred reconstruction of a vascular necrosis of the scaphoid? What is the blood supply?

A

Medial femoral condyle flap

Medial superior genicular artery or descending geniculate artery

256
Q

What supplies the posterior interosseous artery?

A

Common interosseous artery (also give anterior interosseous artery)

which is a branch of the ulnar artery

257
Q

What is a reverse pia flap based on?

A

pIA is divided and retrograde flow is based on the dorsal intercarpal arch

258
Q

Between which two tendons is the medial femoral condyle flap found?

A

Between vastus medialis anteriorly

Adductor tendon posterior

259
Q

What is the optimal postoperative course and what repair is needed for early active range of motion?

A

Dorsal blocking splint with at least 4 core sutures and epitendinous repair

260
Q

What is a late deformity of an untreated dip fracture at the base of the distal phalanx?

A

Mallet finger becomes Swan neck deformity

Due to unopposed pull from the FDP leading to hyperextension of the PIP joint

261
Q

If a central slip laceration occurs what can still allow for extension of the PIP joint?

A

Interosseous muscles through the intrinsic extensor mechanism

262
Q

What is the effect of fat grafting after percutaneous dupuytrens release?

A

Decrease in myofibroblasts

263
Q

What is the progression of arthritis in SLAC wrist?

A

Radioscaphoid, scaphocapitate, capitolunate

264
Q

How do you test for fanconi anemia?

A

Chromosome breakage test

Associated with radial longitudinal deficits in the arm

265
Q

What is Bunells test for intrinsic tightness?

A

Flexion of MCP joint with increased ROM at the PIP joint

Extension of MCP joint with decreased ROM at the PIP joint

This is due to the intrinsically having an extensor pull on the PIP joint and flexor pull on the MCP joint and less tension on the intrinsic muscles in mcp flexion

266
Q

Where are the pedicles for propeller flaps found in the lower extremity?

A

Posterior tibial artery (medial leg): FDL and soleus

Anterior tibial: EDL and peroneus longus, or EDL and tibialis anterior

Peroneal: posterior peroneal septum

267
Q

What is the level of nerve injury based on the sunderland classification?

A

1: myelin only
2 and 3: axons causing wallerian degeneration
3: perineurium
4: epineurium
5: complete

268
Q

What is the management of PIP joint fractures based on articular surface and stability?

A

30 percent and below stable

30-50 percent and stable can do dorsal blocking splint or pinning, unstable oRIF

Above 50%: ORIF

269
Q

What is important to evaluate before performing trapeziectomy?

A

MP joint hyperextension, needs to be corrected before surgery

270
Q

What needs to be corrected before tapesiectomy?

A

MP joint hyperextension

271
Q

What is the TMR nerve transfers for hand closure/opening in transhumeral amputation?

A

Closing: Median to short head of the biceps
Opening: radial nerve to lateral head of the triceps
Elbow flexion: proximal radial nerve to long head of the triceps (native)

272
Q

After injecting trigger finger, how long after corticosteroid injection can you perform surgery to avoid infection?

A

12 weeks (80 days)

Hand (1 decks)

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