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OITE Review Book > Hand > Flashcards

Hand Flashcards

1
Q

SNAC Stage I

A

Arthrosis between scaphoid and radial styloid – treat with radial styloidectomy

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2
Q

SNAC Stage II

A

Arthrosis between scaphoid and capitate – treat w/ PRC, 4 corner fusion or wrist arthrodesis

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3
Q

SNAC Stage III

A

Periscaphoid arthrosis — treat with PRC, 4 corner fusion or wrist arthrodesis

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4
Q

Which joint is usually not involved in a SNAC wrist?

A

radiolunate

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5
Q

Chronic nonunion fx of hook of hamate can cause…

A

rupture of small finger FDP and ulnar neuropathy.

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6
Q

Pisiform is located within…

A

FCU tendon

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7
Q

Treatment of pisiform fracture

A

Acute: immobilize
Chronic: excision of fracture fragment

(same as hook of hamate fx)

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8
Q

Treatment of metacarpal fx shaft

A

CRPP or ORIF if it is intra-articular, rotationally malaligned or multiple MCs

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9
Q

For an oblique MC shaft fx, preferred treatment is…

A

interfragmentary fixation over plate

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10
Q

Bennett fracture

A

intra-articular fracture of the volar lip of the thumb MC base

(the volar oblique ligament holds the fragment in place)

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11
Q

Rolando fracture

A

comminuted intra-articular fracture of the thumb MC base

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12
Q

A thumb CMC dislocation is usually…

A

dorsal due to disruption of the dorsoradial ligament.

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13
Q

What can prevent reduction in a dorsal PIP dislocation?

A

volar plate

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14
Q

Disruption of the volar plate in a PIP dislocation can lead to….

A

swan neck deformity

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15
Q

The most common fracture from a dorsal PIP dislocation is…

A

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.

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16
Q

A volar PIP dislocation can lead to…

A

central sip disruption and ultimately boutonniere deformity.

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17
Q

In a volar PIP fracture dislocation, if less than 40% of the joint is involved, then treat with…

A

extension splinting.

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18
Q

Treatment of a comminuted volar base middle phalanx fracture in a young patient

A

hemi-hamate arthroplasty

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19
Q

Treatment of acute tendon rupture

A

4-strand core repair (placed 1 cm away from edge) with 6-0 epitendinous suture (DONT lock)

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20
Q

Treatment of chronic tendon rupture

A

silastic tendon implant with staged reconstruction

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21
Q

Treatment of partial tendon rupture (<60%)

A

early ROM

BUT if there is triggering, trim the frayed edges (do NOT perform tenorrhaphy)

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22
Q

If there is a FDS rupture in Zone II…

A

repairing only 1 slip improves gliding

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23
Q

Which pulleys are most important to prevent bowstringing?

A

A2 and A4

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24
Q

What happens if you release the oblique pulley of the thumb?

A

bowstringing of FPL

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25
Q

Jersey finger

A

FDP avulsion leading to DIP extension at rest

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26
Q

Treatment of Jersey finger

A

direct repair if acute, 2 stage reconstruction if chronic

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27
Q

Quadrigia effect

A

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

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28
Q

The lumbricals originate from…

A

FDP and insert on the radial lateral bands.

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29
Q

Lumbrical innervation/muscle bellys

A

Lumbricals 1&2: unipennate, median nerve innervated

Lumbricals 3&4: bipennate, ulnar nerve innervated

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30
Q

When FDP is functionally impaired, firing of FDP causes…

A

pull on the lumbricals ultimately leading to paradoxical finger extension (aka lumbrical plus).

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31
Q

Mallet finger

A

disruption of terminal extensor tendon leading to DIP flexion at rest

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32
Q

Mallet finger should be treated operatively when…

A

there is a large bony mallet or with subluxation of the distal phalanx.

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33
Q

Mallet finger can ultimately lead to…

A

swan neck deformity.

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34
Q

Swan neck deformity is most often caused by…

A

volar plate injury/attenuation which leads to PIP hyperextension and DIP flexion.

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35
Q

Boutonniere deformity is due to…

A

central slip disruption. Normally, the central slip helps EDC extend the PIP.

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36
Q

Disruption of the central slip causes…

A

volar migration of the lateral bands which leads to PIP flexion and DIP extension due to unopposed pull of the lumbricals.

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37
Q

Elson test

A

with the PIP flexed to 90, attempted extension of the PIP leads to DIP hyperextension.

Due to central slip disruption.

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38
Q

Acute central slip injury treatment

A

extension splinting or repair

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39
Q

Chronic central slip injury treatment

A

lateral band relocation

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40
Q

In a perilunate dislocation, if the lunate dislocates volarly into the carpal tunnel, then need to…

A

perform combined dorsal and volar approaches.

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41
Q

Which ligament is normally intact in a perilunate dislocation?

A

short radiolunate

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42
Q

Treatment of chronic perilunate dislocation

A

PRC

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43
Q

Scapholunate ligament deficiency leads to…

A

dorsal intercalated segmental instability (DISI)

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44
Q

DISI

A

Lunate is tilted dorsally (extended).

Acute: SL repair
Chronic: SL reconstruction

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45
Q

Terry Thomas sign

A

scapholunate diastasis > 3 mm with clenched fist xray (sign of DISI)

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46
Q

Lunotriquetral ligament deficiency leads to…

A

volar intercalated segmental instability (VISI).

The lunate is tilted volarly (flexed).

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47
Q

SLAC Stage I

A

arthritis between scaphoid and radial styloid

Treatment: styloidectomy and scaphoid stabilization, PIN/AIN neurectomy

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48
Q

SLAC Stage II

A

arthritis between scaphoid and entire radius

Treatment: PRC, scaphoid excision, 4 corner fusion

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49
Q

SLAC stage III

A

arthritis between capitate and lunate

Treatment: scaphoid excision & 4 corner fusion or radiocarpal arthrodesis

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50
Q

Which joint is not involved in a SLAC wrist?

A

radiolunate joint

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51
Q

Which ligament needs to be preserved during PRC?

A

RSC (in order to prevent ulnar subluxation of the carpus)

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52
Q

Gamekeeper’s thumb (or skier’s)

A

UCL injury

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53
Q

Stener lesion

A

avulsed UCL is displaced above the adductor aponeurosis (which then blocks reduction of the UCL

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54
Q

Proper UCL tear vs Accessory UCL tear

A

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.

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55
Q

Sagittal band rupture leads to…

A

dislocation of the extensor tendon especially during MCP flexion with the wrist flexed.

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56
Q

Which sagittal band ruptures more often?

A

The radial sagittal band leading to tendon dislocation ulnarly.

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57
Q

Tx of acute sagittal band rupture

A

extension splinting of MCPJ

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58
Q

Tx of chronic sagittal band rupture (or in an athlete)

A

direct repair if possible, otherwise extensor centralization procedure

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59
Q

In a rheumatoid hand, sagittal band dysfunction leads to…

A

ulnar deviation of the digits.

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60
Q

Claw hand (intrinsic minus) is…

A

MCP hyperextension (strong EDC) and PIP/DIP flexion (strong FDS/FDP) and is due to ulnar or median nerve palsy (Volkmann’s ischemic contracture).

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61
Q

Extrinsic tightness

A

more PIP flexion with MCP extension than with MCP flexion due to extensor tendon adhesions.

62
Q

Intrinsic plus hand is…

A

weak extrinsics and spastic intrinsics leading to MCP flexion and PIP/DIP extension.

63
Q

Intrinsic tightness

A

Less PIP flexion with MCP extended than with MCP flexed

Treat with therapy/distal intrinsic releases

64
Q

Gold standard for dx of hypothenar hammer syndrome

A

arteriography

65
Q

Treatment of ulnar artery thrombosis

A

observation

66
Q

tx of ulnar artery aneurysm (corkscrew artery)

A

excision and reconstruction

67
Q

Raynaud’s disease vs syndrome

A

dz: idiopathic

syndrome/phenomenon: known cause

68
Q

Non-op tx of Raynauds

A

Botox injection decreases pain and improves perfusion via inhibition of presynaptic release of acetylcholine

69
Q

Sx tx of Raynauds

A

periarterial sympathectomy and possible microvascular reconstruction

70
Q

Buerger’s disease (thromboangiitis obliterans)

A

vasculitis in smokers leading to digital ischemia and ulceration due to thrombosis.

Smoking cessation can reverse dx and prevent amputation.

71
Q

Dupuytren’s disease

A

contractures due to myofibroblast activity

DIP contracture: retrovascular cord
PIP contracture: spiral cord
MCP contracture: central cord
Web space contracture: natatory cord

72
Q

Which cord is most important in Dupuytren’s?

A

spiral cord (PIP)

73
Q

Which direction is the NV bundle displaced in Dupuytren’s?

A

centrally and superficially

74
Q

Which ligament is NOT involved in Dupuytren’s?

A

Cleland’s ligament

75
Q

Treatment of ulnocarpal abutment (positive ulnar variance) if fails non-op

A

No arthritis: ulnar shortening osteotomy
Low-demand patient w/ arthritis: Darrach
High-demand patient w/ arthritis: Sauve-Kapandji or ulnar hemiresection arthroplasty w/ TFCC repair/reconstruction

76
Q

Basilar thumb arthritis shows…

A

1st web space adduction contracture, MCP hyperextension

77
Q

Treatment of basilar thumb arthritis

A

trapeziectomy with ligament reconstruction and tendon interposition w/ FCR

(if FCR is compromised, can use ECRL or APL)

78
Q

If there is CMC and STT arthritis, when you perform LRTI, you also have to…

A

address the STT arthritis by excising the proximal trapezoid

79
Q

Heberden’s node

A

DIP arthritis

80
Q

Bouchard’s node

A

PIP arthritis

81
Q

Psoriatic arthritis findings

A
  • pencil in cup deformity
  • nail pitting (onychodystrophy)
  • skin plaques
  • dactylitis (diffuse digital swelling)
82
Q

Brachial plexus injury can be either…

A

pre-ganglionic (proximal to DRG) injury or post-ganglionic (distal to DRG).

83
Q

Examples of pre-ganglionic injury

A
  • Horner’s syndrome (sympathetic chain)
  • medial scapular winging (long thoracic nerve)
  • elevated hemidiaphragm (phrenic nerve)
  • paralysis of rhomboids (dorsal scapular nerve)
  • cervical paraspinals
84
Q

Histamine testing of different brachial plexus injuries

A

Pre-ganglionic: normal histamine (bc of preserved sensory nerve action potentials)

Post-ganglionic: abnormal histamine test

85
Q

Gold standard for diagnosing nerve root injury

A

CT myelogram

86
Q

Post-ganglionic brachial plexus injuries have a better prognosis because…

A

of nerve regeneration (1 mm/day) via wallerian degeneration of the distal segment (phagocytosis by macrophages) and antegrade regeneration of the proximal segment.

87
Q

Best predictor of nerve regeneration

A

tinel sign

88
Q

Oberlin trasnfer

A

transfer fascicles of the ulnar nerve to the motor nerve of the biceps

89
Q

Double nerve transfer

A

transfer (1) fascicles of ulnar nerve to the motor nerve of the biceps and (2) fascicles of the median nerve to the motor nerve of brachialis

90
Q

AIN compression demonstrates…

A

no pain or sensory deficits (motor only)

Motor deficits: FPL, FDP of index and long fingers, pronator quadratus

91
Q

Compression sits of AIN

A

ulnar head of pronator teres, FDS arcade

92
Q

Pronator syndrome compression sites

A
  • supracondylar process
  • ligament of struthers
  • bicipital aponeurosis/lacertus fibrosus
  • FDS aponeurotic arch
  • between ulnar and humeral heads of pronator teres
93
Q

What differentiates pronator syndrome from carpal tunnel?

A

palmar cutaneous branch of the median nerve is affected in pronator syndrome

94
Q

Within the carpal tunnel, tendon location…

A

FDS of long and ring fingers are volar to FDS of index and small fingers

95
Q

Injury to the recurrent motor branch of the median nerve during carpal tunnel release leads to…

A

APB weakness

96
Q

When does grip strength return to pre-op strength after carpal tunnel release?

97
Q

Tx of CTS w/ significant thenar wasting

A

transfer EIP around ulnar wrist (opponensplasty) to improve opposition function

98
Q

Froment sign

A

thumb IP flexion (FPL) compensates for weak adductor pollicis during pinch

99
Q

Wartenberg sign is due to..

A

weak intrinsics (specifically palmar interosseous muscle to the LF) and unopposed pull of EDM

100
Q

First dorsal web space atrophy is due to…

A

dorsal interossei atrophy

101
Q

Ulnar tunnel syndrome has similar symptomatology as cubital tunnel syndrome except…

A

there is no sensory deficit to the dorsum of the hand (dorsal cutaneous branch of ulnar nerve spared) and no FCU/FDP weakness

102
Q

Radial tunnel syndrome

A

PIN compression w/ pain but no sensorimotor deficits

  • pain with resisted long finger extension and forearm supination
  • pain 3-4 cm distal to lateral epicondyle over the mobile wad

***if there are sensorimotor deficits, then it is called PIN compression syndrome.

103
Q

Sites of radial nerve compression

A
  • arcade of Frohse
  • leash of Henry
  • ECRB
  • fibrous bands anterior to radiocapitellar joint
104
Q

Wartenberg’s syndrome

A

compression of superficial sensory radial nerve between BR and ERCL w/ forearm pronation

105
Q

Radioulnar synostosis is a failure of…

A

segmentation (typically occurs from distal to proximal).

106
Q

In radioulnar synostosis, the forearm is often fixed in…

A

pronation. The shoulder abducts to compensate for this.

107
Q

When to consider surgery for radioulnar synostosis

A
  • if there is functional impairment or bilateral involvement

- treat with excision and vascularized fat interposition or forearm derotational osteotomy

108
Q

Characteristics of congenital radial head dislocation (compared to traumatic)

A
  • radial head is convex
  • capitellum is hypoplastic
  • bilateral involvement common
  • radial head usually dislocated posteriorly
109
Q

Treatment of congenital radial head dislocation

A
  • usually painless however symptoms can be present at wrist due to ulnar impaction
  • if symptomatic, tx w/ radial head resection after skeletal maturity
110
Q

Madeung’s deformity

A

dyschondrosis of volar and ulnar aspects of distal radial physis leading to increased volar tilt and radial inclination

111
Q

Leri-Weill dyschondrosteosis

A

SHOX mutation

bilateral madelung’s deformity

112
Q

Radial clubhand is due to…

A

defect of apical ectodermal ridge (AER).

113
Q

If radial clubhand is due to thrombocytopenia absent radius (TAR), will find…

A

thumb is present.

114
Q

If radial clubhand is due to Holt Oram, look for…

A

cardial anomaly.

115
Q

If radial clubhand is due to Fanconi anemia, look for…

A

aplastic pancytopenia and chromosomal breakage test.

116
Q

Workup of longitudinal radial deficiency includes…

A
  • renal US
  • echo
  • CBC
117
Q

Treatment of radial clubhand

A

If there is active elbow flexion: ulnar centralization and tendon transfers at 6-12 months of age

118
Q

With thumb hypoplasia, CMC stability determines…

A

thumb reconstruction w/ opponensplasty (stable CMC) vs ablation and pollicization (unstable CMC)

119
Q

Preaxial polydactyly is typically seen in…

A

caucasians (double thumb). Resect the smaller thumb (usually radial).

**preserve intrinsic tendon and collateral ligament insertions

120
Q

Postaxial polydactyly is typically seen in…

A

African Americans. (extra digit next to SF)

***If you see this in caucasian, needs genetic workup.

121
Q

Camptodactyly

A

PIP flexion of SF –> tx w/ progressive stretching and splinting

(can be associated with camptodactyly-arthropathy-coxa vara-pericarditis)

122
Q

Syndactyly is due to…

A

failure of apoptosis of digital web space.

123
Q

Poland syndrome

A
  • unilateral chest wall hypoplasia (pec major)
  • unilateral hypoplasia of UE
  • symbrachydactyly (absent/short middle phalanges)
  • associated w/ subclavian artery hypoplasia
124
Q

Apert syndrome

A
  • FGFR2 mutation
  • complex syndactyly
  • craniofacial synostosis
  • symphalangism (fused IP joints)
125
Q

Syndactyly release can be performed at…

A

1 year of age.

Web creep is most common complication.

126
Q

Epiphysiodesis is performed for macrodactyly when…

A

the involved digit reaches normal adult length

127
Q

Tx of amniotic band syndrome (aka Streeter’s dysplasia)

A

excise constriction band and perform Z-plasty

128
Q

Keinbock’s disease

A

avn of lunate

129
Q

Keinbock’s risk factors

A

-negative ulnar variance cuasing increased contract stress between lunate and radius

130
Q

Tx of pediatric Keinbock’s

A

temporary STT pinning

131
Q

Tx of adult Keinbock’s w/ no or minimal collapse

A

Negative ulnar variance: radial shortening osteotomy

Normal ulnar variance: DR core decompression

132
Q

Tx of adult Keinbock’s w/ collapse

A

PRC, arthrodesis or total wrist arthroplasty

133
Q

Indications for digital replant

A
  • multiple digits
  • amputation distal to FDS insertion
  • thumb amputation
  • pediatric patient
134
Q

Contraindications for digital replant

A
  • ribbons sign
  • warm ischemia time > 12 hours
  • cold ischemia time > 24 hours
135
Q

Order of structures for replantation

A 
Bones
Extensors
Flexors
Arteries
Nerves
Veins
136
Q

Treatment of arterial thrombosis w/i first 12 hours of replant

A

remove bandage, place hand in dependent position, heparin, stellate ganglion block

137
Q

Treatment of venous thrombosis after replant (after 1st 12 hours)

A

elevate hand, leech therapy (risk for aeromonas infxn so prophylax w/ Bactrim or Cipro)

138
Q

Reperfusion injury is proposed to be due to…

A

allopurinol inhibits xanthine oxidase which leads to decreased xanthine

139
Q

Fingertip injury

A

Adult w/ no exposed bone: soft dressing

Kid w/ exposed bone: soft dressing

140
Q

VY advancement flap indicated for…

A

transverse or dorsal oblique fingertip injury

141
Q

Thenar flap indicated for…

A

volar fingertip injury (overlying P3) to index or long finger

(risk of PIP contracture)

142
Q

Cross finger flap indicated for…

A

volar injury to digit (overlying P1/P2)

143
Q

Reverse cross finger flap indicated for…

A

dorsal injury overlying P1/P2

144
Q

Moberg volar advancement indicated for…

A

volar thumb injury < 2 cm

145
Q

FDMA flap indicated for…

A

volar thumb injury > 2 cm or dorsal thumb injury

146
Q

Z-plasty lengthening for contracture

A

45 degree limbs –> length increases by 50%

60 degree limbs –> length increases by 75%

147
Q

After peripheral nerve injury, sympathetic activity is…

A

last to be lost and first to recover. Motor function is first to be lost and last to return.

148
Q

What is the maximum gap that can be bridged by a nerve collagen conduit?

149
Q

Tx of hemorrhagic blister

A

drain blister but leave overlying skin intact

150
Q

Treatment of pasteurella

A

gram negative coverage such as ampicillin/sulbactam

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