Hand Flashcards
H/P
-make a dx; pertinent findings, imaging?
-OR plan and complications?
-Post-op care/therapy
-Assess hand dominance, vocation, duration of onset and mechanism
Nerve Anatomy
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
Leech therapy
aaeromonas hydrophilic
cipro/cerftriaxone
felon
open down the middle of finger pulp, easiest to access
why do tendons get infected?
polysaccharide rich synovial sheath and lack of blood flow
Kanavel Signs
swlling
flexed posture
tenderness on passive extension
tenderness over flexor tendon sheath
Deep space infections
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
septic wrist
WBC>50k
gout - negative birefriengence
pseudo gout - positive birefriengence
Nerve compression
alteration of blood flow due to alteration in pressure, breakdown of the blood nerve barrier and secondary physiologic dysfunction
- Get EMG to establish a saline
- If intermittent sx try splinting, corticosteroid injection, alteration of lifestyle
- Operative indications: motor weakness (fasciculations on EMG; persistent sx despite splinting; double crush
EMG
-presence of fibrillations, sharp waves abnormal insertional activity with prolonged latency
Operate
CTS
-phalen
2pt discrimination
Tx:
CTR, opposition transfer
Post-op splint/elevate, ROM, hand OT
Cubital tunnel syndrom
-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
sensory vs motor for nerve repair
motor - autograft
sensory allograft for 30mm and less for sure
Neuropraxia, axonometesis, neurometesis
neurometesis - no axonal continuity
axonometesis - some degree of continuity
Sural nerve harvest
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.
cubital tunnel release
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.
medial ante brachial cutaneous nerve harvest
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.
Tendon transfers
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
Radial Nerve Palsy
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
Median nerve palsy
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
ulnar nerve palsy
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
High ulnar nerve injury
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
Low ulnar nerve
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
