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Anki Import > H&W > Flashcards

H&W Flashcards

1
Q

Indications for Hemi-Resection arthroplasty (DRUJ arthrosis)

A

Painful DRUJ Instability<div>DRUJ contracture<br></br><div>OA DRUJ</div><div>RA DRUJ</div><div>Ulnocarpal Impaction</div></div>

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2
Q

Compression Sites for RTS?

A

Arcade of Froshe (entrance to sup)<div>Fibrous band at distal supinator</div><div>ECRB border</div><div>RC joint</div><div>Leash of henry (Radial Recurrent artery)</div>

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3
Q

Indications for scaphoid OR

A

Displacement >1mm<div>Comminution/Bone Loss</div><div>Perilunate</div><div>RL>15 (DISI)</div><div>Lateral interscaphoid >35 deg</div><div>Proximal Pole</div><div><br></br></div>

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4
Q

RFs for Scaphoid Nonunion

A

Proximal Pole fractures<div>Displacement > 1mm</div><div>Humpback Deformity</div><div>Delay in treatment > 4 weeks</div><div>Height to length ratio > 0.65<br></br></div>

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5
Q

Stages of Mayfield Classification

A

1- disruption of SL ligament complex<div>2 - disrution of LC complex</div><div>3 - disruption of LT complex (carpus separates from lunate; falls dorsally)</div><div>4 - lunate dislocates from radial fossa (volar extrinsic ligaments intact)</div>

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6
Q

“X-ray Findings in Madelung’s”

A

narrow physis on ulnar side of DR<div>increased radial inclination, lunate fossa angle</div><div>increased volar tilt</div><div>anterior bowing of distal radius</div><div>dorsal sublux ulnar head</div><div>ulnocarpal impaction signs</div>

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7
Q

DDx Lytic Lesion in the Hand

A

“infx/non-neo: OM, ABC, UBC, epidermal cyst (intraosseous)<div>benign: enchondroma, GCT, CB, OB</div><div>malignant: chondrosarc, ewing’s, lymphoma, OS</div>”

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8
Q

Non-op Mx of Carpal Tunnel

A

Brace/Splint - strong recommendation<div>Steroid (inj (strong)>oral (mod)>nothing)</div><div>Ketoprofen phonophoresis - moderate recommendation</div>

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9
Q

Compression sites for Median Nerve?

A

Supracondylar Ridge<div>Ligament of Struthers</div><div>Lacertus Fibrosus</div><div>PT (humeral head)</div><div>FDS arch</div><div>FPL</div><div>*AIN syndrome: motor weakness, no pain, neuritis</div>

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10
Q

Compression Sites Ulnar Nerve

A

“Arcade of Str<b><u>u</u></b>thers<div>Medial IM Septum</div><div>Medial Triceps</div><div>Cubital Tunnel (ME, Osbourne Lig)</div><div>FCU heads</div><div>Guyon’s canal</div>”

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11
Q

Principles of Tendon Transfers

A

<div>LOOSE CAST</div>

Donor<div> Minimize functional Loss</div><div> Normal strength (voluntary control)</div><div> One Tendon, One function</div><div>Together</div><div> Excursion</div><div> Vector of pull in line (only cross 1 joint)</div><div> In-phase tendons (synergistic)</div><div>Stable Soft tissue bed that allows gliding</div><div>Full passive ROM of joints</div><div><br></br></div>

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12
Q

Tendon Transfer for Median n. palsy

A

thumb IP flex (FPL): BR, ECRL or ECU<div>thumb opp (AbPB): EIP, FDS ring, PL</div><div>D2 DIP flex (FDP): ECRL</div>

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13
Q

Tendon Transfers for Radial n. Palsy

A

Wrist ext (45 deg): PT to ECRB<div>Finger ext (MCP ext): FCR to EDC</div><div>Thumb Ext: PL to EPL</div>

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14
Q

Order of Neurologic Fxn Return after peripheral nerve injury?

A

SPTTPM<div>Sympathetic</div><div>Pain</div><div>Temp</div><div>Touch - light</div><div>Proprioception</div><div>Motor</div>

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15
Q

Pathophys of Boutonierre Deformity

A

“Central slip disruption at PIP (and triangular ligament)<div>->PIP flexion->volar subluxation of lateral bands–> migrate proximally –> tension on terminal tendon –> DIP hyperextension</div><div><img></img><br></br></div><div> <div> <div><img></img><br></br></div> </div></div>”

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16
Q

Etiologies of Swan Neck in RA?

A

Extrinsic<div> Mallet - disruption of terminal tendon</div><div> Wrist or MP flexion contraction</div><div>Intrinsic</div><div> Instrinsic mm contracture</div><div> Chronic MP volar subluxation</div><div> Tendon adhesion</div><div>Articular</div><div> Volar plat/capsule injury (hyperextension)</div><div> Disruption of FDS</div>

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17
Q

Bunnell Test?

A

For Intrinsic Tightness; positive if: inability to flex PIP with MCP in extension<div><br></br></div><div>basically - cant CLAW (Which is extrinsic tightness)</div>

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18
Q

Lichtman Classification for Kienbock

A

“(1) Normal X-ray; MR has changes –> immob/NSAIDS<div>(2) lunate sclerosis; joint leveling surgery</div><div>(3A) lunate collapse</div><div>(3B) lunate collapse + capitate migration and scaphoid rotation (DISI)–> PRC</div><div>(4) Degenerative intercarpal joints -> wrist fusion</div><div><br></br></div><div><img></img><br></br></div>”

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19
Q

Bennet Fracture Reduction?

A

“Traction<div>Abduction (NOT adduction)</div><div>Extension</div><div>Pronation</div><div><br></br></div><div><br></br></div><div>‘peta’</div><div><br></br></div>”

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20
Q

Treatment options for Dorsal PIP dislocation?

A

“<div><div> <div> <div><img></img></div> </div></div></div>Stable - buddy tapping<div>Tenuous - ie requires 30 deg of flexion post reduction for stability</div><div>Unstable</div><div>-extension block splinting</div><div>-CRPP</div><div>-ORIF</div><div>-dynamic ex fix</div><div>-Volar plate arthroplasty (transosseous fixation)</div><div><b>-hemi-hamate reconstruction arthroplasty (for >50% of articular surface involvement)</b></div>”

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21
Q

Block to reduction of VOLAR PIP dislocation?

A

Lateral Bands<div>Central Slip</div>

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22
Q

Acceptable reduction parameters for MC #s?

A

<div><ul><li>NO Malrotation (RC EXAM)</li> <li> <div> <div></div> <div>Shaft (Deg)</div> <div>Neck (deg)</div> <div>Shaft shortening (mm)</div> <div>D2</div> <div>10</div> <div>20</div> <div>3-5</div> <div>D3</div> <div>20</div> <div>30</div> <div>3-5</div> <div>D4</div> <div>30</div> <div>40</div> <div>3-5</div> <div>D5</div> <div>40</div> <div>50</div> <div>3-5</div> </div> </li></ul></div>

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23
Q

“associations with etiology of Dupuytren’s”

A

Family Hx<div>Northern European descent</div><div>Smoking hx</div><div>EtOH abuse</div><div>Diabetes</div><div>Epileptic medication</div><div>Manual labour <div></div> <div>Less solid answers:</div> Adhesive capsulitis</div><div>Vibration exposure</div><div>?male gender</div><div>hx of peyronies disease<br></br></div>

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24
Q

RA patient unable to extend D4/D5… DDx?

A

Ext tendon rupture (Vaughan-Jackson)<div>Sagittal band rupture</div><div>Volar MCP dislocation</div><div>PIN Palsy (at RC joint)</div><div>Cervical myelopathy</div>

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25
Q

RFs for failure of non-op DR#s?

A

Older Age<div>Metaphyseal comminution</div><div>Radial Shortening</div><div><b>not dorsal angulation</b></div>

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26
Q

Transfer for Ulnar nerve palsy

A

Clawing: FDS to lateral bands of ulnar digits<div>Key pinch (thumb adduction): FDS to Add Pollicus</div>

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27
Q

Treatment options for elbow OA

A

Non-op: PT, NSAIDS, steroids<div>Surgical:</div><div>-open vs arthroscopic debridement and capsular release</div><div> -UH arthroplasty or olecranon fossa debridement (Outerbridge Kashiwagi procedure)</div><div>-synovectomy (RA)</div><div>-UH resection with inter-position</div><div>-Arthrodesis (90-110 for hygiene/dominant, 65 for nondominant)</div><div>-TEA</div><div><br></br></div><div><b>consider Ulnar nerve decompression (Esp if <90 deg flex preop)</b></div>

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28
Q

elbow OA presentation

A

weakness, tight capsule, hypertrophic OA<div><b>not loss of joint space</b></div><div><b><br></br></b></div><div><i>characterized by preservation of articular cartilage and maintenance of joint space, but hypertrophic osteophyte formation</i></div>

29
Q

Scaphoid Nonunion Tx algorithm

A

No humpback deformity –> Inlay bone graft (Russe)<div>Humpback deformity –> interposition bone graft (Fisk)</div><div>Osteonecrosis/proximal/revision–> vascularized bone graft</div><div>-Distal radius (1-2 intercompartmental supraretinacular artery)</div><div>-Distal femur (MFC; descending genicular artery pedicle (from the superficial femoral artery))</div><div><br></br></div><div>If Stage 1 SNAC (ie early RS changes) –> can do styloidectomy as well<br></br></div>

30
Q

Order of Flexor Pulleys in Hand?

A

“A1 (MCP) - no useful function<div>A2 - most important</div><div>C1</div><div>A3 (PIP)</div><div>C2</div><div>A4 - most important</div><div>C3</div><div>A5 (DIP)</div><div><br></br></div><div></div><div><img></img><br></br></div>”

31
Q

Volar ulnar approach to Wrist

A

“interval: ulnar NVB and flexor tendons<div><br></br></div><div><img></img><br></br></div><div><img></img><br></br></div>”

32
Q

Avulsion fractures invovled in RC # dislocation?

A

“<div>Three columns:</div>Radial: RSC off radial styloid<div>Intermediate: Short RL off volar lunate facet</div><div>Ulnar: UL and UTq off ulnar styloid</div><div><img></img><br></br></div><div>not a RC Q yet</div><div><br></br></div><div><br></br></div>”

33
Q

Dx criteria for RA?

A

“<img></img>”

34
Q

zones for flexor tendon injuries?

A

“<ul> <li>Anatomic Zones:</li> </ul><ol> <li>Distal to insertion of FDS, injury only to FDP</li> <li>FDS insertion to A1 pulley (““no man’s land””)</li> <li>Carpal tunnel to A1 pulley</li> <ol> <li>Origin of lumbricals from FDP tendon</li> </ol> <li>Carpal Tunnel</li> <li>Tendinous Portion of Forearm</li> </ol><li><div> <div> <div><img></img></div> </div></div></li>”

35
Q

flexor pulley anatomy?

A

“<img></img>”

36
Q

phases of tendon healing

A

“<ul> <li>Inflammatory (0-5 days)</li> <ul> <li>Blood clot and granulation, macrophages and fibroblasts remodel ECM</li> <li>Strength from sutures</li> </ul> <li>Proliferative/Collagen (1-6 weeks)</li> <ul> <li>Proliferation of fibroblasts</li> <li>Rapid synthesis of type 1 collage from epitenon</li> <li>Repair weakest at 10-15 days</li> <li>40% final strength at 4 weeks</li> <ul> <li>Improvement in strength of tendon doesn’t begin until week 3</li> </ul> </ul> <li>Remodeling (up to 1 year)</li> <ul> <li>Longitudinal orientation of collagen along tension lines</li> <li>Normal tendon fibres by 9 months</li> </ul></ul>”

37
Q

Elson Test?

A

“<ul> <li>Most reliable maneuver for diagnosis of Boutonierre</li> <li>Technique</li> <ul> <li>Flex PIP to 90°</li> <li>Extend PIP against resistance</li> <ul> <li>If central slip intact the DIP will remain supple</li> <li>If ruptured DIP will be rigid</li> </ul><li><img></img><br></br></li> </ul><li> <div> <div><br></br></div> </div></li></ul>”

38
Q

Flexor Tendon Reconstruction?

A

“<div> <div> <div> <ul> <div><img></img></div> <div>Flexor Tendon Reconstruction</div> <div>Requirements</div> <ul> <li>supple skin</li> <li>sensate digit</li> <li>adequate vascularity</li> <li>full PROM</li> </ul> <div>Indication</div> <ul> <li>failed primary repair</li> <li>chronic</li> </ul> <div>Technique</div> <ul> <li>often 2 staged</li> <li>Stage I</li> <ul> <li>Hunter rod inserted and sutured distally</li> <li>A2 and 4 pulleys often reconstructed</li> </ul> <li>Stage II</li> <ul> <li>Performed 3 months later </li> <li>Rod removed </li> <li>Tendon autograft is passed through sheath</li> </ul> <li>Extrasynovial grafts</li> <ul> <li>Palmaris</li> <li>Plantaris</li> </ul> <li>Intrasynovial grafts</li> <ul> <li>FDS</li> <ul> <li>Retain gliding surface</li> <li>Heal intrinsically</li> </ul> </ul> <li>Complications</li> <ul> <li>50% tenolysis</li> </ul> </ul> </ul> </div> </div></div>”

39
Q

MCP dislocation:<div>(1) direction</div><div>(2) closed reduction maneuver</div><div>(3) blocks to reduction</div>

A

“(1) dorsal - volar plate avulsion, collaterals torn if rotational component<div>(2) MCP extension, PIP flexion with a distal force on proxial phalanx</div><div><img></img><br></br></div><div>(3) incarcerated volar plate</div><ul> <li>MC head buttoned holed</li> <ul> <li>Flexor tendons ulnar</li> <li>Lumbricals radial</li> <li>Natatory ligaments dorsal</li> <li>Superficial transverse metacarpal displaced proximal</li> </ul> </ul> <div></div> <ul> <li><img></img></li></ul><div><br></br></div>”

40
Q

<div>Mx of Seymour fracture (pediatric physis fracture of distal phalanx)</div>

A

<ul> <li>Juxta-epiphyseal injuries to the distal phalanx with nail bed laceration</li> <li>Crush injuries </li> <li>Technically an open fracture</li> <li>Typically the distal phalanx in a flexed posture (disconnected terminal tendon)</li> <li>Often mistaken for a mallet finger</li> <ul> <li>But physis weaker than the bone</li></ul></ul>

<div><ul> <li>Management:</li> <ul> <li>Closed injuries -> Closed reduction and splint</li> <ul> <li>Due to difficulty with compliance often do operative management</li> </ul> <li>Operative:</li> <ul> <li>Nail plate removed</li> <li>Small oblique incision at junction of paronychial and eponychial folds to expose nail bed laceration</li> <li>Remove soft tissue from fracture site</li> <ul> <li>Can lead to physeal arrest if left</li> </ul> <li>Extend finger to reduce fracture</li> <li>Pin with K-wire across DIP joint</li> <li>Repair nail bed laceration with 6-0 or 7-0 sutures</li> <li>Re-approximate nail</li> <li>Parentral antibiotics x 5-7 days (seems like a lot!)</li> </ul> </ul></ul></div>

41
Q

indications/contraindications for replantation?

A

“<ul> <li>Indications:</li> <ul> <li>Loss of a thumb</li> <li>Multiple digit amputations</li> <li>Amputations at or proximal to the palm (RC EXAM)</li> <li>Pediatric finger amputations</li> <li>Single digit zone I (Flexor tendon zones)</li></ul></ul> <ul> <li>Relative Contra-indications:</li> <ul> <li>Single digit amputations through zone II</li> <li>Severe crush</li> <li>Mangling</li> <li>Segmental amputation</li> <li>Heavy contamination</li> <li>Prolonged warm ischemia time</li> <li>Medically unsuitable</li> <li>Amputation of single border digit</li> <li>Poor prognosticators:</li> <ul> <li>"”red line sign”” –> red stripe at mid lateral aspect of avulsed digit = hemorrhage along vessel</li> <li>"”Ribbon Sign”” –> tortuous spiraled blood vessels seen = significant intimal injury</li> </ul> </ul> </ul> <div></div> <div><img></img></div><div><br></br></div><div><ul> <li>Warm ischemia time should not exceed 12 hours for digits and 6 hours for amputated parts with substantial muscle</li> <li>Cold ischemia time 24 hours for digits and 10-12 hours for limbs</li></ul></div>”

42
Q

<div>Ddx for base of thumb pain</div>

A

<ul> <li>De Quervain tenosynovitis</li> <li>FCR tendinitis</li> <li>Scaphoid pathology</li> <li>STT arthritis</li> <li>RC arthritis</li> <li>Thumb MCP arthritis</li></ul>

43
Q

approaches for scaphoid and adv/disadv

A

<div> <div></div> <div>Advantages</div><div><br></br></div> <div>Disadvantages</div> <div>Volar (Russe)</div> <div>Good access to waist & distal pole</div> <div>Preserve Dorsal blood supply</div> <div>Extend wrist for OR</div><div><br></br></div> <div>Difficulty with proximal pole</div> <div>Injury to volar ligaments</div> <div>Radial artery at risk</div> <div>Screw placement may require trapezium rongeur</div> <div>Dorsal</div> <div>Proximal Pole</div> <div>Easier screw placement down access</div> <div>Big hole in scaphoid joint surface</div> <div>Increase risk to dorsal blood supply</div> </div>

44
Q

NCS in nerve compression - findings?

A

<ul> <li>Nerve Conduction Studies:</li> <ul> <li>Useful for focal compressive lesions</li> <li>Latency</li><ul> <li>Demyelination --> slower latency, slower velocity, amplitude is the same</li> </ul> <li>Velocity:</li> <ul> <li>Time with respect to the distance</li> </ul> <li>Amplitude:</li> <ul> <li>Strength of response</li> <li>Decreased with axonal loss</li> </ul> </ul></ul>

45
Q

Instrinsic plus/minus?

A

“<div>Intrinsic Plus Hand (Plus = + intrinsics)</div> <ul> <li>Imbalance between spastic intrinsics (interossei/lumbricals) and weak extrinsics (RDS, FDP, EDC)</li> <li>Characterized by MCP flexion and DIP/PIP extension</li> <li>Causes</li> <ul> <li>Trauma: compartment syndrome</li> <li>RA: MCP dislocations/ulnar deviation leads to spastic intrinsics</li> <li>Neuro: TBI, CP, CVA, Parkinson’s</li> </ul> <li>Exam</li> <ul> <li>Weak grip</li> <li>+ Bunnell sign: extend MCP and PIP is tight</li> </ul> <li>Tx</li> <ul> <li>Proximal muscle slide: subperiosteal elevation of interossei lengthens muscle unit</li> <li>Distal intrinsic release (distla to MCP)</li> </ul><li><img></img><br></br></li></ul><div><br></br></div><div><div>Intrinsic Minus Hand (Claw Hand) (Minus = intrinsics weak)</div> <ul> <li>Imbalance between strong extrinsics and deficient intrinsics</li> <li>Characterized by: MCP hyperextension and DIP/PIP flexion</li> <li>Causes</li> <ul> <li>Ulnar nerve palsy: cubital tunnel, ulnar tunnel</li> <li>Median Nerve palsy: Volkmann ischemic contracture</li> <li>CMT</li> <li>Hand Compartment Syndrome</li> </ul> <li>Exam</li> <ul> <li>MCP hyperextension and IP joint flexion</li> <li>Bring MCP joint out of hyperextension–> flexion deformity of DIP/PIP will correct (RC EXAM)</li> </ul> <li>Tx</li> <ul> <li>Contracture release and passive tenodesis vs active tendon transfer</li> <ul> <li>Goal is to prevent MCP joint hyperextension</li> </ul> </ul><li><div> <div> <div><img></img></div> </div></div></li></ul></div>”

46
Q

DDX FOR DORSAL WRIST GANGLION

A

<ul> <li>Mobile with tendon sheaths:</li> <ul> <li>Ganglion of tendon sheath</li> <li>Giant cell tumor of tendon sheath</li> <li>Tenosynovitis of inflammatory or infectious origin</li> <li>Extensor digitorum brevis manus muscle belly</li> </ul> <li>Firm </li> <ul> <li>proximal pole of scaphoid (dorsal in DISI, volar in VISI)</li> <li>Osteophytes from STT arthritis</li> <li>CMC arthritis</li> <li>Venous aneurysm</li> <li>Lipoma</li> <li>Neuroma</li> <li>Harmatoma</li> <li>Sarcoma</li> </ul></ul>

47
Q

TFCC Repairability?

A

<ul> <li>Repairable tears can be done all inside, inside out, or outside in</li> <li>Must have a bone tunnel or suture anchor</li> <li>Peripheral tears have improved blood supply and are potentially repairable</li> <ul> <li><b>Ulnar tears most amenable to arthroscopic repair</b></li> <li>Central tears, volardistal, and radial often debrided</li> </ul> <li>Safe to debride 2/3 of TFCC without compromising stability</li></ul>

48
Q

Angles for VISI/DISI?

A

“<img></img>”

49
Q

1st CMC Arthritis tx and MCP

A

<ul> <li>Resection Arthroplasty (Trapeziectomy)+/- LRTI:</li> <ul> <li>Current gold standard</li> <li>Can be combined with ligamentous reconstruction</li> <li>Options for tendon: APL/portion of FCR/PL</li> <li>Gerwin:</li> <ul> <li>20 patients randomized to resection vs interposition</li> <li>No difference at 23 months</li> </ul> <li>Kriegs-Au:</li> <ul> <li>No difference between resection alone and interposition</li> </ul> <li>Wajon Cochrane review:</li> <ul> <li>Simple trapeziectomy had lowest complication rate and best pain relief</li> </ul> </ul> </ul>

<div></div>

<ul> <li>MCP hyperextension deformity</li> <ul> <li>treatment depends on degree of hyperextension</li> <li><10° - no surgical intervention</li> <li>10-20° - percutaneous pinning of MCP in 25-35° flexion x 4wk ± EPB tendon transfer</li> <li>20-40° - volar capsulodesis or sesamoidesis</li> <li>>40° - MCP fusion (20 flex, 20 abd, 20 pro)</li> </ul></ul>

50
Q

indications for ulnar nerve decompression in stiff elbow cases?

A

<ul> <li>Pre-existing ulnar nerve symptoms</li> <li>If contracture > 90o then likely needs release</li> <li>if > 50 deg increase in ROM</li></ul>

51
Q

difference in nerve injuries?

A

“<div> <div> <div><img></img></div> </div></div>”

52
Q

<div>JAAOS 2017 - Differences between ulnar syndrome and cubital tunnel syndrome</div>

A

<ul> <li>ulnar palmer and dorsum of the hand are spared in ulnar syndrome</li> <ul> <li>palmar cutaneous and dorsal cutaneous branches of the ulnar nerve branch off before it enters the ulnar tunnel at the wrist</li> </ul> <li>strength preserved in the FCU and the FDP of the ring and little fingers</li> <li>increased claw hand deformity</li> <ul> <li>FDP preservation increase deformity</li> </ul></ul>

53
Q

Radial nerve syndromes?

A

“<ul><ul><li>RTS: Same as PIN compression sites but only causes pain with no motor/sensory dysfunction </li> <li>PIN syndrome: pain in forearm and wrist with WEAKNESS</li> <li>Wartenberg’s syndrome: compression of SRN (between BR and ECRL during forearm pronation) leading to PAIN and NUMBNESS</li> </ul></ul>”

54
Q

Diagnostic Criteria (1987 Revised Criteria) for RA

A
  1. Morning stiffness >/= 1 hour<div>2. Swelling in >/= 3 joints</div><div>3. Rheumatoid nodules</div><div>4. Radiographic changes of the hand including bony erosions and decalcification</div><div>5. Symmetric arthritis</div><div>6. Serum RF</div><div>7. Arthritis of the hand (MCP, PIP) and wrist</div><div><br></br></div><div>>/=4 of 7 for a 6 week period</div>
55
Q

Indications for ORIF of the scaphoid (Rockwood and Green)

A

“1. Proximal pole fractures<div>2. Displacement >1mm</div><div>3. Humpback deformity</div><div>- Measurements on sagittal CT scan:</div><div>– Lateral intrascaphoid angle >35o(Normal = 30 +/- 5o)</div><div>– Dorsal cortical angle >160o(Normal = 140o)</div><div>– Height-to-length ratio >0.65 (Normal = 0.6)</div><div>4. DISI</div><div>– Radiolunate angle >15o</div><div>– Capitolunate angle >15<span>o</span></div><div><span>– Scapholunate angle >60o</span></div><div>5. Associated perilunate dislocation</div><div>6. Associated distal radius fracture</div><div>7. Comminuted fracture</div><div>8. Unstable vertical or oblique fractures</div><div>9. Delayed presentation</div>”

56
Q

What are the radiographic views of the scaphoid? (Tornetta)

A
  1. The PA view allows visualization of the proximal pole of the scaphoid<div>2. The semipronated oblique view provides the best visualization of the waist and distal pole regions</div><div>3. The semisupinated oblique view provides the best visualization of the dorsal ridge</div><div>4. The lateral view permits an assessment of fracture angulation, carpal alignment, and carpal instability</div><div>5. PA view with the wrist in ulnar deviation results in scaphoid extension, allowing visualization of the scaphoid in profile</div>
57
Q

What are the advantages of surgical fixation of non-displaced or minimally displaced scaphoid fractures?

A
  1. Earlier union<div>- Surgery 7.1 weeks, Non-op 11.4 weeks</div><div><br></br></div><div>2. Avoid prolonged immobilization</div><div><br></br></div><div>3. Allows earlier return to activity/work</div><div>- Surgery = 6 weeks, non-op = 11 weeks</div><div><br></br></div><div>4. No difference in rate of union</div>
58
Q

What is the preferred non-operative treatment of scaphoid fractures? (JBJS Reviews 2016)

A
  1. Long arm or short arm cast <b>including or not including the thumb, </b>leads to equivalent outcomes in the treatment of scaphoid fractures with immobilization<div>2. Duration ~8-12 weeks</div><div>- Depends on clinical and radiographic union</div><div>- <i>When CT is used to assess union, immobilization is discontinued when >50% union achieved</i></div>
59
Q

What are the indications and advantages of the volar approach for scaphoid fractures? (JAAOS 2012)

A
  1. Distal pole and waist fractures<div>2. Humpback deformity</div><div>3. Preserves dorsal blood supply</div>
60
Q

Describe the volar approach to the scaphoid

A

“1. Interval between FCR and radial artery<div>2. Skin incision can be zig-zag, or at the glabrous/non-glabrous border (Wagner)</div><div>a. Proximal parallel to FCR, distally parallel to the radial aspect of the thenar eminence</div><div>b. ““Standard Russe incision in made along the course of the FCR tendon and extending distally along the border of the glabrous skin of the thenar eminence””</div><div><img></img><br></br></div><div>3. The volar FCR sheath is opened and FCR retracted ulnar</div><div>4. Radial artery is retracted radial (superficial palmar artery crosses the surgical field and may need ligating)</div><div>5. Floor of the FCR sheath and capsule are incised inline with the scaphoid to expose the distal 2/3</div><div>–> RSC and long radiolunate ligaments are incised</div><div><br></br></div><div><img></img><img></img><br></br></div>”

61
Q

What is often required to obtain the start point for the guidewire during volar approach to the scaphoid?

A

Resecting the proximal palmar portion of the trapezium

62
Q

What is the appropriate lenght of screw measurement for scaphoid fixation?

A

Subtract 4mm

63
Q

Indications for dorsal approach to the scaphoid?<div>Describe the dorsal approach.</div>

A

“Proximal pole fracture<div>Complete SL rupture</div><div><br></br></div><div>1. 2-3cm straight dorsal incision starting over Lister’s tubercle, extending distal in line with 3rd MC</div><div>2. Skin flaps raised over the extensor retinaculum</div><div>3. Extensor retinaculum is incised longitudinally distal to Lister’s tubercle along with the dorsal hand fascia</div><div>4. EPL, ECRB and ECRL are retracted radially, EDC retracted ulnarly</div><div>5. Radiocarpal T-capsulotomy performed</div><div>- Transverse limb parallel to the distal radius proximally, longitudinal limb extending directly over the SL ligament</div><div>- Capsular flaps are elevated off SL ligament and scaphoid - avoid disruption of the SL ligament and dorsal scaphoid ridge</div><div><br></br></div><div>Guidewire startpoint: membranous portion of the SL ligament origin</div><div><br></br></div><div>Protect the SRn<img></img></div><div><img></img><img></img><br></br></div><div><br></br></div>”

64
Q

What are the indications for vascularized bone grafting (scaphoid)

A

Scaphoid non-union with proximal pole osteonecrosis and/or failure of previous grafting

65
Q

What are the graft options for scaphoid non-union based on location of fracture and presence of deformity?

A

“<div><ul> <li>Proximal 1/3 non-union without significant humpback</li> <ul> <li>1,2 ICSRA (intercompartmental supraretinacular artery)</li> <ul> <li>Origin: radial artery, 5cm proximal to RC joint</li> <li>Advantages: single approach</li> <li>Disadvantages: unable to correct humpback, vulnerable to kinking</li> <li><img></img></li> </ul> </ul> </ul> <div></div> <ul> <li>Capsule based (4th extensor compartmental artery)</li> <ul> <li>Advantages: simple harvesting technique, short arc of rotation and low risk of kinking</li> <li>Disadvantage: cannot correct humpback, violates dorsal RC and intercarpal ligaments</li> </ul> <li>Alternatives: 2,3 ICRSA, MFC or iliac crest</li> </ul> <ul> <li>With humpback</li> <ul> <li>Volar radius VBG</li> <ul> <li>Origin: radial carpal artery</li> <li>Single incision, preserves dorsal blood supply, simultaneous correction of humpback deformity, may preserve wrist flexion</li> <li><img></img></li> </ul> <li>Alternative: free VBG</li> </ul></ul></div>”

66
Q

What are the indications for re-operation following prior surgical fixation of scphoid fracture? (JAAOS 2013)

A

At <b>3 months</b>if there is inadequate union, and evidence of one of the following<div>1. Improper screw placement (at least 3-4 screw threads in each fragment)</div><div>2. Insufficient compression across fracture sit (presence of gapping)</div><div>3. Inadequate fixation</div><div>4. Lack of appropriate bone grafting (based on OR report or report from surgeon)</div>

67
Q

What is the treatment algorithm for scaphoid non-union based on specific fracture characteristics?

A
  1. Delayed union (< 6 months)<div>- ORIF with headless compression screw</div><div><br></br></div><div>2. Established non-union without humpback</div><div>- ORIF with headless compression screw + bone graft (cancellous ICBG or distal radius)</div><div><br></br></div><div>3. Non-union with humpback deformity; no AVN</div><div>- ORIF via volar approach + corticocancellous bone graft</div><div><br></br></div><div>4. AVN without humpback deformity</div><div>- Vascularized bone graft via volar or dorsal approach</div><div><br></br></div><div>5. AVN with humpback deformity</div><div>- Vascularized MFC via volar approach</div>
68
Q

What are the fundamentals of tendon repair in flexor tendon injuries? (JAAOS 2018)

A
  1. Easy placement of sutures in the tendon<div>2. Secure knots</div><div>3. Smooth juncture of the tendon ends</div><div>4. Minimal gapping</div><div>5. Minimal interference with tendon vascularity</div><div>6. Sufficient strength</div>

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