Hand Flashcards
SNAC Stage I
Arthrosis between scaphoid and radial styloid – treat with radial styloidectomy
SNAC Stage II
Arthrosis between scaphoid and capitate – treat w/ PRC, 4 corner fusion or wrist arthrodesis
SNAC Stage III
Periscaphoid arthrosis — treat with PRC, 4 corner fusion or wrist arthrodesis
Which joint is usually not involved in a SNAC wrist?
radiolunate
Chronic nonunion fx of hook of hamate can cause…
rupture of small finger FDP and ulnar neuropathy.
Pisiform is located within…
FCU tendon
Treatment of pisiform fracture
Acute: immobilize
Chronic: excision of fracture fragment
(same as hook of hamate fx)
Treatment of metacarpal fx shaft
CRPP or ORIF if it is intra-articular, rotationally malaligned or multiple MCs
For an oblique MC shaft fx, preferred treatment is…
interfragmentary fixation over plate
Bennett fracture
intra-articular fracture of the volar lip of the thumb MC base
(the volar oblique ligament holds the fragment in place)
Rolando fracture
comminuted intra-articular fracture of the thumb MC base
A thumb CMC dislocation is usually…
dorsal due to disruption of the dorsoradial ligament.
What can prevent reduction in a dorsal PIP dislocation?
volar plate
Disruption of the volar plate in a PIP dislocation can lead to….
swan neck deformity
The most common fracture from a dorsal PIP dislocation is…
volar lip of P2.
If less than 40% of joint involved or stable joint after reduction, treat with dorsal extension block splint w/ active flex/ext.
If more than 40% or joint is unstable, CRPP vs ORIF.
A volar PIP dislocation can lead to…
central sip disruption and ultimately boutonniere deformity.
In a volar PIP fracture dislocation, if less than 40% of the joint is involved, then treat with…
extension splinting.
Treatment of a comminuted volar base middle phalanx fracture in a young patient
hemi-hamate arthroplasty
Treatment of acute tendon rupture
4-strand core repair (placed 1 cm away from edge) with 6-0 epitendinous suture (DONT lock)
Treatment of chronic tendon rupture
silastic tendon implant with staged reconstruction
Treatment of partial tendon rupture (<60%)
early ROM
BUT if there is triggering, trim the frayed edges (do NOT perform tenorrhaphy)
If there is a FDS rupture in Zone II…
repairing only 1 slip improves gliding
Which pulleys are most important to prevent bowstringing?
A2 and A4
What happens if you release the oblique pulley of the thumb?
bowstringing of FPL
Jersey finger
FDP avulsion leading to DIP extension at rest
Treatment of Jersey finger
direct repair if acute, 2 stage reconstruction if chronic
Quadrigia effect
results if FDP is functionally shortened > 1 cm
FDP to long, ring and small fingers share a common muscle belly –> shortening of one FDP tendon leads to flexion lag to the other two tendons
The lumbricals originate from…
FDP and insert on the radial lateral bands.
Lumbrical innervation/muscle bellys
Lumbricals 1&2: unipennate, median nerve innervated
Lumbricals 3&4: bipennate, ulnar nerve innervated
When FDP is functionally impaired, firing of FDP causes…
pull on the lumbricals ultimately leading to paradoxical finger extension (aka lumbrical plus).
Mallet finger
disruption of terminal extensor tendon leading to DIP flexion at rest
Mallet finger should be treated operatively when…
there is a large bony mallet or with subluxation of the distal phalanx.
Mallet finger can ultimately lead to…
swan neck deformity.
Swan neck deformity is most often caused by…
volar plate injury/attenuation which leads to PIP hyperextension and DIP flexion.
Boutonniere deformity is due to…
central slip disruption. Normally, the central slip helps EDC extend the PIP.
Disruption of the central slip causes…
volar migration of the lateral bands which leads to PIP flexion and DIP extension due to unopposed pull of the lumbricals.
Elson test
with the PIP flexed to 90, attempted extension of the PIP leads to DIP hyperextension.
Due to central slip disruption.
Acute central slip injury treatment
extension splinting or repair
Chronic central slip injury treatment
lateral band relocation
In a perilunate dislocation, if the lunate dislocates volarly into the carpal tunnel, then need to…
perform combined dorsal and volar approaches.
Which ligament is normally intact in a perilunate dislocation?
short radiolunate
Treatment of chronic perilunate dislocation
PRC
Scapholunate ligament deficiency leads to…
dorsal intercalated segmental instability (DISI)
DISI
Lunate is tilted dorsally (extended).
Acute: SL repair
Chronic: SL reconstruction
Terry Thomas sign
scapholunate diastasis > 3 mm with clenched fist xray (sign of DISI)
Lunotriquetral ligament deficiency leads to…
volar intercalated segmental instability (VISI).
The lunate is tilted volarly (flexed).
SLAC Stage I
arthritis between scaphoid and radial styloid
Treatment: styloidectomy and scaphoid stabilization, PIN/AIN neurectomy
SLAC Stage II
arthritis between scaphoid and entire radius
Treatment: PRC, scaphoid excision, 4 corner fusion
SLAC stage III
arthritis between capitate and lunate
Treatment: scaphoid excision & 4 corner fusion or radiocarpal arthrodesis
Which joint is not involved in a SLAC wrist?
radiolunate joint
Which ligament needs to be preserved during PRC?
RSC (in order to prevent ulnar subluxation of the carpus)
Gamekeeper’s thumb (or skier’s)
UCL injury
Stener lesion
avulsed UCL is displaced above the adductor aponeurosis (which then blocks reduction of the UCL
Proper UCL tear vs Accessory UCL tear
Valgus instability when the thumb MCPJ is at 30 degrees of flexion indicates proper tear.
Valgus instability when the thumb MCPJ is at full extension indicates accessory UCL tear.
Sagittal band rupture leads to…
dislocation of the extensor tendon especially during MCP flexion with the wrist flexed.
Which sagittal band ruptures more often?
The radial sagittal band leading to tendon dislocation ulnarly.
Tx of acute sagittal band rupture
extension splinting of MCPJ
Tx of chronic sagittal band rupture (or in an athlete)
direct repair if possible, otherwise extensor centralization procedure
In a rheumatoid hand, sagittal band dysfunction leads to…
ulnar deviation of the digits.
Claw hand (intrinsic minus) is…
MCP hyperextension (strong EDC) and PIP/DIP flexion (strong FDS/FDP) and is due to ulnar or median nerve palsy (Volkmann’s ischemic contracture).