Hand Flashcards
TFCC components
- Triangular fibrocartilage proper (articular disc) 2. Ulnocarpal meniscus homologue 3. Dorsal and volar radioulnar ligs 4. Floor of ECU tendon sheath 5. Volar ulnocarpal ligs
Replant order of operations
B- bone E- extensors F- flexors A- artery V- vein N- nerve S- skin
Indication for replant
Absolutes: Thumb multiple digits amputation at wrist level or proximal any amp in a kid Relative: zone 1 (distal to FDS insertion)
Lumbrical plus finger
Paradoxical extension w/ attempted finger flexion
Intersection syndrome
At the intersection of compartment 1 (APL and EPB) and compartment 2 (ECRL and ECRB)
Radial sided wrist pain
crepitus
Boutonniere
PIP flexion and DIP extension
Pathophys: 1. rupture of central slip
- attenuation of triangular ligament- lumbricals become flexors at PIP and extensor at DIP
- Palmar migration of collateral bands and lateral bands
Tx: Acute (<4 weeks) injuries- 6 weeks PIP extension splint
1o repair
Lateral band relocation
terminal tendon tenotomy (modified Fowler or Dolphin)
tendon (triangular ligament) reconstruction
PIP fusion- RA or arthritic joints
https://www.orthobullets.com/hand/6012/boutonniere-deformity
Finger extensor mechanism
Steps to release PIP flexion contracture
Check progress of passive extension prior to proceeding to next step. Extensor tenolysis if there is no active extension
- takedown flexor pulley and retract flexor tendon
- release check rein ligament
- accessory collateral ligament and volar plate
- proper collateral ligament released off proximal phalanx
Swan neck
PIP hyperextension and DIP flexion
Pathophys- 1o deformity= lax volar plate
2o = extensor force > flexor
Causes= RA (volar MCP subluxation), chronic mallet (DIP extensor force transfers to PIP), FDS laceration (unopposed PIP extension), intrinsic contracture (tethering of lateral bands by transverse retinacular lig)
Tx: double ring splint
Volar plate advancement +/- FDS tenodesis (if ruptured), SORL recon, Fowler tenotomy
preaxial polydactlyly (Thumb duplication)
M> F
White ppl
Tx:
- Type 1 combination procedure (Bilhaut-Cloquet removing central portions of bone and combining the two thumbs to make one digit)
- Types 1-3 deformities
- 20% late deformity
- Type 2 combo procedure- use soft tissue from lesser digit to augment thumb that you’re keeping
- radial digit usually sacrificed
- types 3 & 4
- Type 3 combo procedure (segmental distal transfer “On-top plasty”)- when one digit has better proximal components and the other has better distal components
- types 5-7
https://www.orthobullets.com/hand/6079/polydactyly-of-hand
postaxial polydactylyl (duplication of small finger)
Blacks > white
Classification
- Type A- well-formed digit- type 2 recon procedure (using soft tissue of lesser digit to augment primary digit); keep radial digit usually
- Type B- skin tag- tie-off in nursery or amputate < 1 yo
Central polydactyly
associated w/ syndactyly
can cause angular deformity: osteotomy and lig recon early to prevent angular deformity
PIN syndrome
lose of extensor function except ECRL (radial n proper); intact sensation and no pain
Lipoma= most common cause
Sites of compression (LEAFS):
- vascular Leash of Henry
- ECRB
- Arcade of Froshe
- Fascial band over radial head
- Distal end of supinator
Debridement after 3 mo of non-op
cubital tunnel
Claw hand vs ape hand vs sign of benediction
https://www.youtube.com/watch?v=0AAligXLJ1A&list=TLPQMDkwNzIwMjHFAjc0h4SsRg&index=2
Claw hand (uln n injury) with loss of hand intrinsic leading to EDC4,5 unable to oppose flexors.
- Low uln n injury: Passive position of digs 4 & 5 = MCP, PIP and DIP flexion.
- loss of lumbricals and interossei w/ FDS & FDP intact
- High uln n injury: Passive position of digs 4& 5= MCP, PIP flexion and DIP loose flexion
- Loss of FDP4,5 and loss of intrinsics= balanced loss between extensors and flexors at DIP
Ape hand (med n injury)- unopposed adductor pol pulls the thumb dorsally into the same plane as the rest of the fingers.
Sign of benediction (high med n injury)- happens with attempt to make a fist (active). Digits 4&5 flex, but unable to flex other digits
Double Oberlin n transfer
Brachial plexus injury
FCU (uln.) + FDS/ FCR( med) = biceps and brachialis to restore elbow flexion
High uln n. injury
AIN- uln n
Pronator quad (AIN) to uln n. to restore intrinsic function
High rad n injury
FDS/FCR= PIN/ ECRB
Nerve root avulsion treatment
- Neuroma excision & grafting of intercostal n.
- Transfers
- Spinal accessory ⇒ Suprascap
- Oberlin: FCU ⇒ biceps
- rad branch to triceps ⇒ Ax n. (restore shoulder ER)
- Tendon transfers- lower 1/3rd traps for shoulder ER
- Free gracilis transfer
- Forequarter amputation if complete plexus (C5-T1) avulsed
Tendon Transfer principles
- Excursion (amplitude)= fiber length
- Smith 3-5-7 rule=
- 3 cm excursion of wrist flexors/ extensors
- 5 cm MCP extensors
- 7 cm FDP
- Smith 3-5-7 rule=
- Line of pull should be same
- Force (Strength)= proportional to cross-sectional area
- Functional (no prior reinnervation or tendon repair)
- Expendable or function less necessary that function that was lost
Radial N tendon transfer sets
- High rad n injury
- Wrist ext = PT ⇒ ECRB
- Finger ext = FDS, FCR, FCU ⇒ EDC
- Thumb ext = FDS, FCR, PL ⇒ EPL
Med n tendon transfers
- Low (i.e. thenar atrophy from severe CTS)
- Thumb opposition = Camitz procedure= PL ⇒ OP
- Huber (for congenital thenar absence in kids) takes Abductor digit minimi and transfers to APB
- High
- FDP1-3, FPL
Uln n tendon transfers
- Pinch (+ froment sign)
- ECRB (w/ PL tendon graft augment) ⇒ APB
- FDS ⇒ APB
- Claw (loss of intrinsic and lumbricals) (bouvier test)
- Zancolli (lasso) (FDS looped around A1 pulley) to restore MCP flexion (i.e. Bouvier (-))
