Hand

Question 1

H/P

Answer 1

-make a dx; pertinent findings, imaging?
-OR plan and complications?
-Post-op care/therapy
-Assess hand dominance, vocation, duration of onset and mechanism

Question 2

Nerve Anatomy

Answer 2

Radial:
sensation - dorsal radial aspect of hand
motor - extensors

Median:
sensation - volar/radial aspect of hand, radial aspect of RF
Motor - FDS, radial portion of FDP, FCR, FPL, thenar eminence, 1/2 lumbricals

Ulnar
sensation dorsal and solar aspect of small finger
motor - ulnar portion of FDP, FCU, hypothenar M, FPB, all interosseous, 3/4 lumbricals

Test on physical exam:
I would text opposition, extension and ab/adduction
Sensory - sharp/dull

Question 3

Leech therapy

Answer 3

aaeromonas hydrophilic
cipro/cerftriaxone

Question 4

felon

Answer 4

open down the middle of finger pulp, easiest to access

Question 5

why do tendons get infected?

Answer 5

polysaccharide rich synovial sheath and lack of blood flow

Question 6

Kanavel Signs

Answer 6

swlling
flexed posture
tenderness on passive extension
tenderness over flexor tendon sheath

Question 7

Deep space infections

Answer 7

Thenar - trouble bending thumb
Hypothenar - trouble bending sF
midpalmar - trouble bending middle fingers and can extend into carpal tunnel
collar button - between webspace
horshoe - 1st and 5th flexor tendon sheath via midpalmar space

Question 8

septic wrist

Answer 8

WBC>50k
gout - negative birefriengence
pseudo gout - positive birefriengence

Question 9

Nerve compression

Answer 9

alteration of blood flow due to alteration in pressure, breakdown of the blood nerve barrier and secondary physiologic dysfunction

1. Get EMG to establish a saline
2. If intermittent sx try splinting, corticosteroid injection, alteration of lifestyle
3. Operative indications: motor weakness (fasciculations on EMG; persistent sx despite splinting; double crush

Question 10

EMG

Answer 10

-presence of fibrillations, sharp waves abnormal insertional activity with prolonged latency

Operate

Question 11

CTS

Answer 11

-phalen
2pt discrimination

Tx:
CTR, opposition transfer

Post-op splint/elevate, ROM, hand OT

Question 12

Cubital tunnel syndrom

Answer 12

-hx of clumsiness, intrinsic weakness, atrophy of hypothenar

tinnel sign, flexion of elbow and sx (flexion test), 2pt, EMG

Tx with splinting, activity modification, surgical release if refractory to these modifications

Post - op gliding, ROM, elevation, soft dressing, hand OT

for test do insitu release, if subluxation then do anterior sub muscular transposition, medial epicondelectomy, sq transposition with fascial sling

Question 13

sensory vs motor for nerve repair

Answer 13

motor - autograft
sensory allograft for 30mm and less for sure

Question 14

Neuropraxia, axonometesis, neurometesis

Answer 14

neurometesis - no axonal continuity
axonometesis - some degree of continuity

Question 15

Sural nerve harvest

Answer 15

sensory nerve that provides sensation to the lateral leg, foot and small toe

Unilateral harvest can provide up to 40cm

The nerve splits into medial and lateral components on the posterior leg, the medial sural nerve is largest, off the tibial n.
The nerve is found close to but deep to the lesser saphenous vein.

The leg is exsanguinate with a pneumatic tourniquet, the lateral malleolus identified, in the groove between the lateral malleolus and achilles, 2 finger breaths posterior and superior from lateral malleolus, a horizontal incision is made. The small saphenous vein identified, retracted and sural nerve dissected bluntly, a stair step incision is made 10cm superior, the sural nerve identified and mobilized. The sural nerve is transected at the popliteal fossa. 2-3 stair step incisions made and sural nerve mobilized through them.

Question 16

cubital tunnel release

Answer 16

PreoperativeMarkings
1.
Draw a longitudinal line that is equidistant between the tip of the olecranon and the medial epicondyle.
The line should extend proximally 3–4 cm and distally 4–6 cm (incision length will be variable depending on anatomy of individual) over the ulnar nerve course.

Intraoperative Details
(a) Place the patient in supine position with elbow bent at 90°, shoulder externally rotated and abducted on arm table.
(b) Apply well-padded tourniquet as high up the axilla as possible, and place folded stack of towels under the elbow.
(c) Incise a longitudinal line as marked.
(d) Identify and protect the medial antebrachial
cutaneous nerve.
(e) Release from proximal to distal, starting with
the arcade of Struthers, and the medial inter- muscular septum followed by the cubital tun- nel retinaculum and the flexor carpi ulnaris fascia, and ending with the pronator and flexor digitorum superficialis arch fascia.
(f) Test for residual compression sites and ulnar nerve subluxation upon elbow flexion and extension at the end of the decompression.

Describe position, exsanguination with esmarch, time out, incision, soft tissue dissection protect medial ante brachial cutaneous nerve, proximal dissection to the level of the inter muscular septum where it pierces it, then divide arcade of struthers, attention turned distally, divide the fibroaponeurotic covering, release points of compression at the FCU, pronator teres, care taken not to injure the FCU branches. range elbow, look for subluxation. close, bulky dressing.

Question 17

medial ante brachial cutaneous nerve harvest

Answer 17

Make an incision over cubital tunnel, find basilica vein, MABC has anterior and posterior branch, depending on caliber you can harvest the anterior branch which is superior to basilica vein. This can be taken into axilla like posterior branch pending needs. The median nerve is the larger nerve, and behind the basilica vein, so do not harvest that.

Question 18

Tendon transfers

Answer 18

nerve injury, traumatic loss of tendon, rebalancing congenital, RA, post traumatic deformities

make sure supple joints, adequate strength donor, will decrease by 1 grade regarding function, one tendon, one transfer, synergism, needs to be expendable, supple joints

wrist flexors/extensors of fingers
finger extensor/EPL
finger flexors
interossei
lumbricals

consider patient needs, subjective complaints, assess function, catalogue the available motor donors, match to functional need, pre-op hand therapy

Question 19

Radial Nerve Palsy

Answer 19

remember ECRL and ECRB will work if laceration or injury is above the level of the elbow

Issue: loss of extensor innervation
elbow - tricep
wrist ECRL/ECRB
MCP: EDC, EIP, EDQ
Thumb: EPL, APL, EPB

PIN palsy you have preservation of BR and ECRL

Goal: wrist, finger and thumb extension. In theory will have Ulnar and Median innervated muscles

Classic Transfers:
Wrist-PT(Median) to ECRL/ECRB
Thumb Extension - PL(Median) to EPL
or can do FDS ring finger if no PL
Finger Extension - FCR (Median) to EDC

Only do end to side if you expect some function otherwise end to end

You set the tension half way between as tight as you can and for tenodesis. Do a pulver taft weave to do the transfer

Question 20

Median nerve palsy

Answer 20

Loss of radial and deep flexors, thenar muscles
High injury have extrinsic flexors
Low injury have loss of opposition, and flexion of thumb, loss of FDP to IF and sometimes LF, palmar sensation deficit

GOAL: rector thumb opposition, flexion, and FDP to index and long

Available? Ulnar/Radial

Classic Tx
Thumb opposition - EIP (Radial) to APB (Go around the pisiform to adjust the vector)
Thumb Flexion - BR (radial) to FPL
Index and long finger flexion - FDP 4/5 (ulnar) side to side tenodessis to FDP 2/3

Question 21

ulnar nerve palsy

Answer 21

loss of function: all intrinsics, all linterossei, ulnar lumbricals, hypothenar and adductor pollicis

high ulnar nerve you don’t have as bad of a claw because the FDP is still innervated, low below ulnar nerve you have claw

Need to restore power pinch thumb adduction, MP flexion/IP extension

See what bothers patient and what they need. If the clawing is an issue address with static vs dynamic tendon transfers. Do the Bouvier test which flexes the wrist and extends the fingers. If there is an ability to extend IPJs then do static with FDS Zancoli lasso tenodesis. If there is no extension then do ECRB to ulnar lateral band which is a dynamic

If they need ADDuction then do ECRB to adductor policies
6wks in a splint, 10weeks passive ROM and 6 weeks active???

extrinsic minus is a claw hand

Question 22

High ulnar nerve injury

Answer 22

repair primarily, then to an AIN pronator quadratus to motor portion of ulnar nerve which you can confirm by tracing it to the guyons canal

Question 23

Low ulnar nerve

Answer 23

repair primarily and AIN of pronator quadratus to side of the motor portion of ulnar nerve, through an epidermal window which you can confirm by tracing it to Guyons canal

Question 24

Oberlin Transfer

Answer 24

Ulnar nerve fascicle of FCU to musculocutaneous nerve
goal is to restore bicep function
used in C5/6 plexus palsies

no return of bicep function by 4months

Question 25

Compartment syndrom

Answer 25

>30 or within 20 of diastolic remember to release individual muscle fascia

Question 26

Extensor zones

Answer 26

odd over knuckle, even over the phalynx 7 is carpus and 8 is proximal

Question 27

Zone 1 Extensor Injury

Answer 27

If closed then do 15 degree s of hyperextension for 6 weeks if bony. 8 weeks if just soft tissue envelope involved...then night splints for 6 weeks Operate if open, soft tissue loss, fracture segment between 30-50%, subluxation of DIPJ, occupation requiring frequent use of hands and doesn't tolerate splinting Pin? Block extensor (at an angle) then straight down shaft across DIPJ

Question 28

Zone 2 extensor injury

Answer 28

OR DIPJ immobilized with k wire 6 weeks AROM and PROM at PIP and MCP allowed Next splint for 6 additional weeks

Question 29

zone 3 extensor injury

Answer 29

Acute - central slip disruption, leads to Boutinnere can see volar PIPJ dislocations Can present with a positive Elson test or mild extensor lag Closed injury - PIPJ extension splint 6 weeks and an additional 6 weeks at night Open injury - go to OR for laceration, avulsion and tendon loss, can reconstruct with lateral band centralization and if loss of central tendon with a proximal end of central tendon that is harvested in the middle and turned down to make a distal tenodesis

Question 30

zone 4 extensor tendon injury

Answer 30

primary repair, usually a laceration with early mobilization

Question 31

zone 5 extensor tendon injury

Answer 31

fight bite, watch for septic joint, if extensor tendon injury do early mobilization and repair if sagittal band injury - almost always the radial sagittal band, you will have ulnar deviation of extensor tendon, will be difficult elevating he finger and resultant extensor lag, pain and tenderness over the sagittal band, if a contusion do a relative motion extension splint (RMES) until contender -if partial injury then do RMES fr 6 weeks If complete subluxation put MCP into extension x6weeks -if above fails then you exhausted non-op management, operate. Also operate on anyone with a delayed presentation 3-4 weeks

Question 32

zones 6-8 for extensor tendons

Answer 32

soft tissue injury, consider primary repair, vs graft vs transfer

Question 33

chronic extensor tendon deformities

Answer 33

Swan Neck - taller injury, PIPJ laxity from valor plate attenuation vs PDS rupture, inflammatory arthritis correct the DIPJ via an arthrodesis. PIPJ do an FDS tenodesis (15-20 degrees of flexion of PIPJ and anchor the FDS to proximal phalanx. Leave PIP in a dorsal blocking splint for 8 weeks, OT after Boutonniere - weakness and loss of extension at PIPJ, hyperextension DIPJ, can occur from disruption f central slip, attenuation of central slip or injury to triangular ligament, volar plate migration to PIPJ. Tx with centralization of lateral bands, PIPJ extension splint AND counsel patient they may have loss of flexion at PIPJ, HAND OT if issues with PIPJ extension can do capsuloligamentous release

Question 34

Zone 2 flexor tendon injury

Answer 34

Describe repair, and therapy remember - kids you rehab in static 6 weeks in splint, same with noncompliant adults, transition to dorsal blocking after and dc splint at 10weeks

Question 35

maximum weakness of tendon

Answer 35

6-18days 2weeks early rupture defined as that within 4weeks late is after 4 weeks What to do? is the tendon sheath ok and tendon? if yes repeat repair. If the sheath ok and tendon is not use a graft (3/4th toe extensor), palmaris or planters. If the sheath is not good, hunter rod and subsequent graft repair within 48-72hrs after rupture, excise FDS, vent pulleys, do not do acute repair if infection, poor compliance, stiffness of joints or soft tissue deficit If we are staging reconstruction, place hunter rod, reconstruct the A2 and 4 pulleys, tack the proximal end to an adjacent tendon, reconstruct at 4-6 months for flexor tendon tenodesis will do so when active ROM is deficient relative to passive, will do so when you can't extend finger For tenolysis need to preserve at least 50% of a2 and a4 pulleys

Question 36

Hand fracture

Answer 36

metacarpal. phalanx, mutilating hand injury, skiers thumb, distal phalanx and nail bed think through presentation what is fractured? what part? intra vs extraarticular?, displaced? comminuted? any associated soft tissue injury? tendon?vessel? nerve? Is there shortening? malrotation and scissoring? edema, echymosis OR plan Rehab

Question 37

Conservative management of fx?

Answer 37

pediatric, minimal displacement, transverse, put into splint and take weekly xrays open reduction if can't reduce, intraarticular or gap deformity indication for internal fixation if unstable pattern, multiple fxs, need to return to work early or sport player, nonunion prone like ulna and scaphoid remember we can tolerate 30-40% angulation of neck and 20% shaft of MC K-wire: MC 0.045, phalanx 0.035, peds use 0.035 remove when not tender, 4 weeks, unless replant then do 6 weeks

Question 38

Bennett Fx

Answer 38

base of thumb MCP, CRPP, thumb spica, pull pins at 4 weeks, hand OT and full activity at 12 weeks

Question 39

multiple MC fxs oblique

Answer 39

K wire, restore length, malrotation, splint, same concept of 4 week pins, hand OR a nd early ROM, full activity at 3 mo

Question 40

Transverse MC fxs

Answer 40

pin, spint volar, pins 4 weeks, full activity 12 weeks

Question 41

Boxer fx

Answer 41

CRPP, ulnar gutter, pins 4 weeks, full activity 12 weeks.....remember you can tolerate 10, 15, 20, 30 degrees of angulation

Question 42

replantation

Answer 42

ischemia time if its a finger: 6-12hrs warm 12-24 cold hand/forearm warm4-6 cold 6-8 indication - thumb amputation, any amputated digit in a child, multiple digits, distal to FDS insertion, hand replanting a forearm you have better recovery if distal, more proximal motor isn't as good prepare part for replantation - dissect tendon, osseous Wire, prepare arteries, veins, nerves, perform fasciotomies and CTR if needed fix bone, do volar structures like flexor tendon, artery, nerve....then do dorsal structures like extensor and vein do your post op free flap monitoring including beir hugger, elevate, normotensive, Hot, ASA 325

Question 43

Radial and radial forearm anomalies

Answer 43

its a hematopoietic center, need to think and state "prior to proceeding with any congenital hand surgical procedures I would make sure there are no craniofacial, airway, blood, renal or spinal anomalies" surgical timing usually 9-12 mo complete surgeries by 2y/o

Question 44

syndactyly

Answer 44

failure in apoptosis, if syndromic think Aperts vs Poland examine both upper extremities and feet release boarder digits mark your dorsal rectangular flap, alternating zig-zag incisions dorsally and opposing volubly the rectangular flap is 2/3rd length from MCP dimple to PIP dimple

Question 45

polydactyly

Answer 45

preaxial - thumb duplication, 1/3000 births, duplication alone is isolated and sporadic duplication with triphalangeal component is AD, so counsel on genetic testing post-axial - 1/1400 European descent, often syndromic, in african american 1/150 typically sporadic type A is well formed, type b is absence of osseous structures

Question 46

thumb duplication

Answer 46

preserve ulnar duplicate, transfer the RCL from thumb with periosteum, 4-0 or 5-0 ethibond, do so at 9mo

Question 47

polydactyly type a vs b surgical management

Answer 47

a - amputate in office b - ablate the ulnar duplicate and transfer the UCL with periosteum similar to thumb duplication

Question 48

Thumb duplication

Answer 48

Remember your needs; opposition, adequate webspace, good length, stable CMC joint type 1 - minor hypoplasia, no tx type 2 - intrinsic thenar muscle hypoplasia, no opposition so do an opponensplasty, if web space poorly developed do a web space deepening type 3 - have extrinsic muscle and tendon abnormalities a - stable CMC joint, so reconstruct (ADM transfer, web space deepening, UCL reconstruction) b.- unstable CMC joint - politicization type 4 - pollicization

Question 49

pollicization

Answer 49

transpose the IF to the thumb based on its neurovascular pedicles shortened leave on MC head, pronated 130 degrees and tendons shortened EIP to EPL EDC to APL 1st dorsal interosseous to APB 1st palmar interosseous to adductor pollicis metacarpal head to trapexium proximal phalanx to metacarpal middle phalanx to proximal phalynx

Question 50

Constriction bands

Answer 50

excise vs incise - do some cases`

Question 51

tumors of the hand

Answer 51

Benign are the majority: ganglion cyst giant cell tumor hemangioma schwannoma many on exam will be malignant!! so do longitudinal incisions send to path, do culture AFB and fungal

Question 52

steinner lesion

Answer 52

skiers thumb, UCL ligament

Question 53

horners syndrome

Answer 53

ptosis, anhidrosis, miosis indicates a pregangiolinic lesion and nerve root avulsion

Question 54

pan plexus

Answer 54

c5-T1 - flail extremity

Question 55

upper plexus C5/6

Answer 55

loss of shoulder abduction, deltoid and suprasinatus loss of external rotation, infraspinatus loss of elbow flexion biceps and brachialis

Question 56

lower plexus C8-T1

Answer 56

intrinsic weakness of the hand, claw hand, Horners syndrome

Question 57

Imaging for plexus

Answer 57

CT myelogram - gold standard for detecting pseudomenengocele MRI for entire plexus but hard to interpret due to edema do CT 3-4 weeks after EMG 3-4 weeks after injury -loss of sensation with intact sensory nerve action potentials is preganglionic avulsion as the dorsal body in ganglia is preserved -recovery is seen as presence of active motor units, decrease in fibrilations

Question 58

common plexus transfers

Answer 58

1. shoulder stabilization: spinal accessory to suprascapular 2. shoulder abduction: tricep to axillary nerve 3. elbow flexion: fcu to musculocutaneous oberlin