hand Flashcards
The transverse retinacular ligament prevents dorsal subluxation of the lateral bands during PIP joint Flexion
The
transverse retinacular ligament prevents dorsal subluxation of the lateral bands during PIP joint extension
The most important pulley in the thump is the oblique pulley and this is a continuation of the abductor pollicis insertion and lies between the two
annular pulleys.
is a continuation of the adductor pollicis insertion and lies between the two
annular pulleys.
Most hand infections are severe
Most hand infections are mild and can be managed in the outpatient
setting,
what The most common infections in the hand ?
The most common infections are a result of inoculation
of tissues by bacteria normally found on human skin. Staphylococcus
and Streptococcus species are by far the most common and should be
covered in initial treatment
what are the indicators of a poor prognosis in hand infection?
Subcutaneous purulence and
digit ischemia on presentation are indicators of a poor prognosis
X-rays is mandatory with fight bites fracture?
X-rays should be performed if there is suspicion
of a retained foreign body or fracture.
In Fight bites the perecentage of the MCP joint is violation is ?
Fight bites require exploration of the wound to rule out jointspace
infection, as the MCP joint is violated in 70% of cases
fascia! flaps and skin grafts are not suitable
in the palmar area why ?
fascia! flaps and skin grafts are not suitable
in the palmar area because scar contracture is likely to occur
Diagnosis of peripheral nerve compression canot be
achieved with history and physical exan1 alone and without
the use of electrodiagnostic or radiologic imaging techniques,
including radiographs, MRI, CT scan, and ultrasound
Diagnosis of peripheral nerve compression may often be
achieved with history and physical exam alone and without
the use of electrodiagnostic or radiologic imaging techniques,
including radiographs, MRI, CT scan, and ultrasound
Dose splinting necessary after nerve decompression ?
Postoperative splinting is generally unnecessary after nerve decompression.
Radiographs ofthe wrist are indicated for carpal tunnel syndrom
Radiographs ofthe wrist are indicated for evaluation ofwrist pain.
Thenar muscles maintain normal strength with PMNE,true or false?
true
whate the early presenting symptoms of PMNE?
muscle weakness while numbness is a relatively late symptom.
does Motor function improve after PMNE surgery?
Weakness of FDP IF and FPL resolves
immediately in the recovery room following surgical release.
Is ther any role for ultrasound,
MRI, in PMNE?
The role of ultrasound,
MRI, and MR neurograms is not defined
What the surgical procedure should don if the pain in the wrist is only in PMNE?
If wrist pain is the main indication for surgery, release of the bicipital aponeurosis under local anesthesia can be highly effective with a quick recovery
can we manage the mild form cupital tunnel syndrome conservatively
Nonoperative management with night splinting, physical therapy, and activity and postural modification is indicated for mild disease and has a 50% rate of efficacy
Radial tunnel syndrome (RTS), is defined as a weakness without pain in the dorsal forearm. true. false?
false. Radial tunnel syndrome (RTS), defined as pain without weakness in the dorsal forearm
can we use Electrodiagnostic studies to differentiate between RTS and epicondylitis?
Electrodiagnostic studies are
not helpful for evaluating the either condition.
Is there are differance between nerve graft versus transfer in axillary nerve injury ?
A metaanalysis of grafting versus nerve transfer outcomes for isolated axillary injuries
showed no significant differences between the two techniques, and most patients achieve M4 or better shoulder abduction.
How many ways can employed to achieve individual finger extension ?
Nerve transfer to the PIN is the only method of achieving
individual finger extension.
the PIN fascicle to supinator should always be excluded to maximize reinnervation of the more critical extensors.
If biceps function is intact, the PIN
fascicle to supinator should be excluded to maximize reinnervation
of the more critical extensors.
Comparison
of grafting versus motor and sensory transfers in proximal ulnar nerve
injuries showed significantly improved sensory rather than motor?
Comparison
of grafting versus motor and sensory transfers in proximal ulnar nerve
injuries showed significantly improved functional outcomes
with nerve transfer(80%) better than nerve graft 22%.
sensory outcomes were not significantly different with only 30% to 40% of patients reaching S3 or better at 2 years of follow-up
Percentage of people whom have an absent EDC of the little finger?
50%
location of posterior intraosseous nerve in the wrist?
on the flower of the fourth compartment
lister tubercle located between the first and second compartments?
false lister tubercle located between the second and third one
EPB insert only to the base of the proximal phalanx?
EPB insert either to proximal phalanx or MPJ extensors hood or terminal phalanx or sometimes absent
how many interosseous in the hand?
7 intraosseous 3 palmers(unipenate) and 4 dorsal (bipennate)
An Esmarch bandage is recommended to fully exsanguinate the limb during hand infection managment ?
No, Gentle gravity exsanguination is
preferred in infected cases to reduce the risk of causing bacteremia.
where is the location of parona space ?
Parona’s space is located in the distal forearm
between the pronator quadratus and the flexor digitorum profundus tendons.
risk factors for a poor outcome of flexor tenosynovitis ?
age over 43 years
the presence of subcutaneous pus
diabetes,
peripheral vascular
renal disease.
presence of digital ischemia.
During extensors tendons injury juncturea tendinae can extend finger to neutral position ,t or f ?
T
What the last muscle innervated by the ulnar nerve?
first dorsal interosseous
The location of the wiound is not important in hand infectoin ?
the location is important as if the wound is at the joint warrants an open joint in a sterile environment while if the wound is at the dorsum of the hand can be manage in side room
Indication of MERSA managment in hand infection?
Presents of necrosis,previous MERSA infection,prevous hospital addmision
hand souked can be used in acute setting only ?
can be used in rehabilitation phase also
Facial flap with skin graft on the dorsum of the hand cause contracture more than the volar side? true
false , dorsum reconstraction with faciocutanous falp plus skin graft showed less contracture rather than faciocutanouse flap in the volar aspect of the hand
what is the presenting complain of nerve compression?
numbness
should patient stop taking anticoagulant befor sugery of nerve cpmression?
patient can keep taking anticoagulant becz expected blood loss is minimum
tourniqate is amost in decomopression surgey ?
no
Most commom cause of carpal tunnel are?
Idiopathic
Diuretic and oral steriod can be used for managment of CTS?
no role for oral steriod or diuretics
what is the risk factor for cubital tunnel syndrome?
A- male
b- tobacco smoking
c- heavy manual labor
Radial tunnel syndrome are present with weakness and pain true os fals?
Radial tunnel syndrome (RTS), defined as pain without weakness in the dorsal forearm and wrist
What the diffrential dignosis of radial runnel syndrem?
RTS has up to a 41 % overlap with lateral epicondylitis, contributing to the debate.
What the provactive test for superficial radial nerve compression⚡️
Ulanr deviation , wrist flexion, resisted pronation
When i can use compression screws /
This technique is ideal when the fracture length is at least twice the diameter of the bone.
Why Plate fixation is rarely used for phalangeal fractures?
because of the close relationship of the extensor mechanism to the periosteum of the underlying bone; plate fixation in the phalanges frequently leads to tendon scarring and stiffness Conversely, the extensor tendons overlying the metacarpals do not sit directly on bone and, as such, are at low risk for adhesions after plate fixation.
external fixation the definitive solution for hand fracture management?
Rarely is external fixation the definitive solution for hand fracture management
Most common fracture in the hand?
distal phalanx fracture
Tuft fractures often healing has good ptognosis?
Tuft fractures often heal with a malunion
When we use dorsal block with k-wire in distal phalanx frc?
Dorsal block K-wire fixation is recommended for fractures involving more than one-third of the articular surface or in the setting of volar subluxation of the distal fragment
How much the size of screw that use for fracture fixation for phalanx ?
The screw diameter should be less than one-third of the length of the fracture.
In metacarpal fracture xray is sufficient for visualization of the fracture pattern ?
Computed tomography scan may better visualize the fracture pattern and assist in surgical planning
When we should do surgery for metacarpal fracture ?
For fractures with greater articular involvement, > 1 mm articular incongruity, or collateral ligament instability, surgery is warranted.
What the optimum solution for metacarpal head fracture?
Although headless screw fixation is an optimal choice of fixation for metacarpal head fractures, most injuries are comminuted or associated with joint disruption; these injuries may be best treated by dynamic external fixation or acute arthroplasty.
Buried antegrade intramedullary pin are better than k-wire in metacarpal neck fracture?why?
Buried antegrade intramedullary pin application may be
superior because it avoids the extensor mechanism and obviates the
risk for pin tract infection
all nondisplaced fractures in the metacarpal shaft can be treated with closed reduction.
Nondisplaced oblique and spiral
fractures are usually unstable and are often best treated with surgery.
type of stiffness in hand fracture ?
Stiffness with active and passive motion
results from joint contracture, whereas diminished active motion
only is often the result of tendon adhesions
CT scan is the most sensitive
and specific imaging modality for diagnosing scaphoid fractures and
also allows assessment of osseous blood supply and soft tissue injuries.
MRI is the most sensitive
and specific imaging modality for diagnosing scaphoid fractures and
also allows assessment of osseous blood supply and soft tissue injuries.
but CT scan most sensitive in bone detection
Is better with scaphoid fracture to limit the mobility with thump spica including the thump
false,Recently, a randomized trial demonstrated better healing when the thumb is not included
with corneal sensory nerve graft, all patients retained protective sensation? T or F
most patients regained normal sensation, with all patients achieving
protective sensation
In axillary nerve repair radial nerve branches to the medial, lateral, and long heads of the muscle. Originally, the branch to the lateral is preferred ?
branches to the medial, lateral, and long heads of the muscle. Originally, the branch to the long head of the triceps was favored, but others have argued in favor of the medial branch because it has a longer extramuscular course
Is there is difference between nerve graft and nerve transferee in axillary nerve repaire?
A metaanalysis of grafting versus nerve transfer outcomes for isolated axillary injuries showed no significant differences between the two techniques, and most patients achieve M4 or better shoulder abduction.
Wich type of nerve repair can be utilized in musculocutanous in brachial plexus injury?
In the scenario of complete plexus avulsion injuries, the distal spinal accessory or intercostal nerves can be used with an interpositional nerve graft.
In radial nerve palsy if the biceps is functional how we can maximaz the reinnervation
Nerve transfer to the PIN is the only method of achieving individual finger extension. If biceps function is intact, the PIN fascicle to supinator should be excluded to maximize reinnervation of the more critical
In proximal ulnar nerve repair nerve transfer is better than nerve graft in sonsoty recovery only?
In proximal ulnar nerve repair nerve trans better in motor restoration while no defferanc between transferee or graft in sensory outcome .
The triple transfer of spinal accessory to suprascapular, Oberlin transfer, and radial to axillary can get whar type of benefit /
?
The triple transfer of spinal accessory to suprascapular, Oberlin transfer, and radial to axillary shows improved supination and shoulder external rotation compared to grafting
The volar scapholunate ligament is far stronger than its dorsal counterpart and this serves to prevent excessive extension of
the scaphoid relative to the lunate? tor f
F.
The dorsal
scapholunate ligament is far stronger than its volar counterpart and this serves to prevent excessive flexion of
the scaphoid relative to the lunate
wich side is prefferable to harvest left or right phrenic nerve for nerve transfere?
The negative effects on respiratory function seem to be much greater when the right
phrenic nerve is used rather than the left.
what are the contraindication to nerv transferred?
Contraindications to nerve transfer include an extended time interval between injury and transfer (usually more
than 14–18 months is considered too long), where there is no expendable donor, and where the donor nerve has
a motor strength below MRC grade M4
The dorsal root, which contributes to motor and sensory ?T orF
The dorsal root, which contributes sensory nerves only, is thicker and more resistant to avulsion forces.
Most closed injuries of the brachia! plexus are axnotamesis
Most closed injuries of the brachia! plexus are actually mixed in nature {Mackinnon’s sixth degree injury)
When we should do nerve conduction study after suspected brachial plexus injury?
baseline nerve conduction study and EMG should be per formed no earlier than 3 to 4 weeks after trauma,
when shoula we do EMG or NCS after brachial plexus injury?
The baseline nerve conduction study and EMG should be
performed no earlier than 3 to 4 weeks after trauma,
when do we decide to do nerve transfer or tendon transfer?
Delay presentation till 6-9 months considered nerve transfer no proximal construction
mor than 9 month considred tendon transfere
what the factor that effect the type of surgical intervention for brachial plexus injury?
: time since trauma,
surgeon comfort with technique,
the extent of the zone of injury,
and availability of donor nerves or musculotendinous units.
Tendon transfers are always paired with arthrodeses
Tendon transfers are often paired with arthrodeses (shoulder
or wrist) for an enhanced functional result
conventional tendon transfers are viable options for
complete and incomplete brachia! plexus injury,
conventional tendon transfers are only viable options for incomplete brachia! plexus injury,
what type of ERBS palsy needs urgent surgical intervention?
The most common pattern
of injury that necessitates operative exploration is a combination of
root avulsions and extraforaminal ruptures of CS, C6, and C7
when should do a reconstruction procedure for the elbow or wrist joint?
Both shoulder and elbow reconstructions are typically done in the range of 4 to 6 years of age.
Hand and forearm function often accommodates surprisingly well.
Therefore, waiting until age 6 to 13 years before undertaking hand
reconstructive procedures
Is the electro diagnostic study is relatable in erbs palsy?
Electrodiagnosis in infants is notoriously unreliable because of its tendency to overestimate the axonal function that is present
what is the Tetraplegia?
Tetraplegia results from traumatic injuries to the cervical spine causing the loss of upper motor and sensory neurons.
What is the most common level of cervical spine injury?
common levels of the cervical spine
injury are at CS and C6, marked by a loss of elbow extension, wrist flexion, and finger flexion and extension
When I should do surgery for hand fracture ?
■ Articular incongruity
■ Digital malrotation, shortening, or angulation
■ Multiple fractures
■ Open fractures
■ Fractures with soft tissue injury or bone loss
Plate fixation does not use for phalangeal fracture ? why?
Conversely, the extensor tendons overlying the metacarpals
do not sit directly on bone and, as such, are at low risk for adhesions
after plate fixation
are external fixation the
definitive solution for hand fracture?
. Rarely is external fixation the
definitive solution for hand fracture management.
when I should use Dorsal block K-wire fixation?
fractures involving more than one-third of the articular surface or in the setting of volar subluxation of the distal fragment
what type of fixation that can be used for comminuted metacarpal head fracrure?
metacarpal head fractures, most injuries are comminuted or associated with joint disruption; these injuries may be best treated by dynamic external fixation or
acute arthroplasty
Nondisplaced metacarpal spiral fracture best treated with splint and immobilization?
Nondisplaced oblique and spiral fractures are usually unstable and are often best treated with surgery.
how you can assess the outcome after hand fracture managment?
The Jebsen-TaylornHand Function test is one of the most common functional tests
patient-reported outcome measures include the Disabilities of the Arm, Shoulder,
Hand, Short Form-36,
Michigan Hand Questionnaire
Most sensitive imaging techniqe for diagnosis of scaphiod frac?
MRI is the most sensitive
and specific imaging modality for diagnosing scaphoid fractures and
also allows assessment of osseous blood supply and soft tissue injuries
what are the causes of nonunion in scaphoid fracture?
The overall incidence is approximately 10%, but this rate may be elevated by delayed presentation, fracture comminution, smoking, incomplete immobilization, or errors in surgical technique
does epitendinous repair is necessary at zones 3,4,5?
epitendinous sutures may not be necessary because there is more room in
these zones for tendon excursion, which decreases the intensity ofthe
adhesions. Furthermore, multiple structures are cut in these zones,
which require expedient repairs to keep the tourniquet time within
2 hours
can we correct tendons rapture with 3 week of primery intervention ?
Rupture within the first 3 weeks ofthe initial tendon repair
warrants an attempt for repeat repair, which has reasonable success.
Ifthe rupture occurs more than 3 weeks after the primary repair, tendon reconstruction should be considered.
How you manage the closed injury to the extensors tendons?
Acute closed injuries of the digital extensor system are
best treated with splinting
The mainstay of rehabilitation at the digital level (zones
1-4) remains static splinting; however, early motion protocols have shown promising results in more proximal injuries (zones 5-8)
What are the factors that increase the adhesion with extensors tendons injuries?
- The proximity of the tendons to bone,
- the high incidence of associated periosteal stripping
- capsular injuries,
- limited excursion of the extensors
- Furthermore, the mechanical strength of the repair and - status of local soft and hard tissues may not allow early mobilization.
- The stronger opposing action of the flexor system makes early rehabilitation even more problematic
makes repair prone to adherence.
what is the last muscle that receives innervation from the posterior interosseous nerve?
The most distal muscle belly, which occasionally extends beyond the carpus, is the extensor
indicis proprius (EIP). This is the last muscle to receive innervation from the PIN,
They course volar to the deep transverse
metacarpal ligament before attaching to the radial lateral band of the
respective finger,True or false?
T
The interossei course volar to the deep transverse metacarpal ligament and insert into the digital lateral bands
The lumbrical muscles course volar to the deep transverse metacarpal ligament before attaching to the radial lateral band of the respective finger
The interossei course dorsal
The lumbrical muscles course volar
the distal injury of the extensor tendon most commonly a closed injury?
True
What the consequence of the mallet finger ?
within 4 weeks of trauma are considered acute; after
4 weeks, they are chronic. If left untreated, hyperextension of the PIP
joint can develop because of proximal and dorsal migration of the
lateral bands,17 creating the swan-neck deformity
Most injuries are partial IN ZONE 4 extensors tendons ?
TRUE
Most patients should be assessed
for possible ulnar neuropathy with medial epicondylitis
all patients should be assessed
for possible ulnar neuropathy
change in the ECRDL occurs with lateral epicondylitis
Changes within the ECRB tendon
substance represent the sine qua non for lateral epicondylitis
Greater possibility of radial nerve injury with open lateral epicondylitis?
Greater possibility of radial nerve injury
How many of the patients with medial epicondylitis have ulnar neuritis?
Ulnar neuritis is especially
important as 23% to 61% of patients with medial epicondylitis have concurrent ulnar neuropathy.
Are de Quervain patients successfully treated with splinting alone?
Splinting alone was
observed to be less successful, but when combined with corticosteroids, is likely more successful than injections alone
intersection syndrome is an common cause of wrist pain
intersection syndrome is an uncommon cause of wrist pain
intersection syndrome is often diagnosed based on physical exam alone,
True
The percentage of diapetic patients develop trigger finger ?
10٪
In trigger finger splinting should include only the mcp joint ?
Pip can splinted instead of mcp joint with similar effects
what is the Boyes’s rule in tendons transfere?
Boyes’s 3-5-7 rule Flexors
and extensors of the wrist have an average excursion of approximately
3 cm (33 mm); the extensors of the digits (EDC and extensor pollicis longus [EPL]) have an average of 5 cm; and digital flexors have
7 cm of excursion.
In radial nerve palsy radial sensory branch is mandatory to repair?
radial nerve may also be lost. However, this is not a critical sensory loss and typically does not require treatment
wich muscle considred the most important mucsle fro thump aposition ?
The APB is the most
important muscle in thumb opposition
Clawing of the hand is more more with high ulnar nerve palsy ?
, clawing is less severe in high ulnar nerve palsy as the FDP paralysis lessens the flexion forces on the PIP and DIP joints of the ring and small fingers.
Pip joint more staple dorsally?
The extensor system provides the least amount of support, which makes the joint inherently less stable to dorsal forces.
Postinjury stiffness is a substantial problem and is often made worse by improper or prolonged immobilization even within the first 2 weeks after injury. T or F
T
Almost all type I and II PIP J injuries are stable after reduction and can be
treated nonoperatively with buddy straps ? T OR F
T
Forced radial or ulnar deviation of the PIPJ puts stress on the ipsilateral collateral ligament,
Forced radial or ulnar deviation of the PIPJ puts stress on the contralateral collateral ligament,
most common complication of PIP dislocation ?
. Stiffness and flexion contracture
are commonly encountered problems after these injuries
Why DIPJ have added
hyperextensibility compared to the PIPJ?
Due to shorter and
more laterally positioned checkrein ligaments.
Ifan isolated DIPJ dislocation occurs, it is almost
always a volar dislocation.
Ifan isolated DIPJ dislocation occurs, it is almost
always a dorsal dislocation.
why there is mor extension in MCPJ than PIPJ?
Different from the PIPJ, there are no checkrein ligaments on the MCPJ volar plate.
This facilitates some hyperextension of the MCPJ
how you can diagnose the injury of the sagital band ?
Clinicaly ultrasound or MRI can provide confirmation in
unclear cases
The presence of a peripheral pulse exclude impending arterial compromise
The presence of a peripheral pulse may not exclude impending arterial compromise
what the ultimate goals of fixation method ?
the ultimate goals are initiation of range of motion
to provide improved function and minimization of soft tissue stripping to achieve bony healing and union of the fracture
Is it useful to make epitendinous repair in zone 5
he tedious epitendinous sutures are often
not performed to expedite the surgical sequence because of the relative lack of restrictive adhesion formation in this zone
Nerv conduit can give optimum outcome with sensory and motor compared with autologous nerve graft?
Nerve conduits have been shown to
provide sensory recovery but are inferior to autologous nerve grafting
for motor regeneration
Always we need to treat the RCL of the thump surgically in case of complete cut?
Surgical repair of RCL injures will need repair only if there is volar subluxation.1
Lateral or valor dislocation of the little finger pip joint is common?
Lateral dislocations of the little finger PIP joint are more common than volar dislocations, which are rare
What is the contents of the 4th extensor’s compartment ?
The fourth compartment contains the EDC and extensor indicis proprius (EIP). In addition, the posterior interosseous nerve lies in the floor of the fourth compartment.
Does all introsseos are bipennet?
The palmar interossei are unipennate, while the dorsal interossei are bipennate
In boutonniere deformity the surgical option is always an option ?
Specialized surgical repair is usually required only in open injuries.
When we need to take phrenic nerve in nerv transfere wich site is better/
The negative effects on respiratory function seem to be much greater when the right phrenic nerve is used rather than the left
How mach length of the nerve graft that considred with poor outcom/
In cases where nerve grafts greater than 7 cm are required, the outcomes tend to be poor
during replantation, we should tag the flexors and extensors tendons?
Tagging of the extensor tendon is
not usually necessary
does using of heparin effect the replantation outcom?
The use of intravenous heparin does not correlate with higher success rates of replantation but
it may be indicated in cases of intimal damage by crush and avulsion
injuries, intraoperative thrombus, or following successful thrombolysis and arteriosclerotic changes
The muscle that is responsible for Opposition of the thump?
Opposition is the result of the abductor pollicis brevis, opponens pollicis, and superficial head of the flexor pollicis brevis flexing
and rotating the TM and metacarpophalangeal (MP) joints simultaneously.
The advanced imaging technique is useful for thump reconstruction?
Advanced imaging (computerized axial tomography, magnetic resonance imaging) is not indicated in the evaluation ofacute injuries but
may be helpful in patients presenting with complicated injuries for
secondary reconstruction
In the first dorsal metacarpal artery flap, patients may have double-sensitivity, experiencing sensation in the dorsal index finger when using the thumb; however, all patients are able to cortically reorient over time
patients may have double-sensitivity, experiencing sensation in the dorsal index finger when using the thumb; however, some patients are able
to cortically reorient over time
adult accommodate extremely well to pollicization than children
Children accommodate extremely well to pollicization in congenital
and traumatic cases; however, adults may require a prolonged period
of retraining and secondary procedures to optimize the function.
The selection of sensate flaps is essential for thump reconstruction?
T
In proximal trans metacarpal thumb injuries,the patients can not make a thump opposition.
In proximal trans metacarpal thumb injuries,
the opponens pollicis, which inserts on the volar-radial aspect of
the thumb metacarpal may still provide some opposition function
at the TM joint.
In littler flap, the 2PD and cortical orientation are not improved with neuropathy.
Division of the nerve and coaptation to the thumb
digital nerves result in a minimal loss in s2PD (<10 mm) but better
cortical integration.
why routine use of this flap should be limited to use in combination with
other methods for subtotal thumb reconstruction as discussed later?
Due to the issues with donor site morbidity,
significant dissection in the palm, and poor cortical reorientation,
why Osteoplastic Reconstruction of the htump is not prefer?
the bulky appearance, bone graft resorption, need for multiple stages,
and issues with double sensitivity limit the use of this procedure.
in fully functin index Policiczation giv best result than toe to hand transfere?
with a fully functioning index finger, loss of grip strength and the
resulting three-finger hand provide inferior results when compared
to toe-transfer
some of the flaps of the great toe are based on the blood supply to
the first webspace of the foot, usually from the first dorsal metatarsal
artery (FDMtA)
All ofthese flaps are based on the blood supply to
the first webspace of the foot, usually from the first dorsal metatarsal
artery (FDMtA)
what is the drawback of the second toe transfer?
least resemble a normal thumb
in terms of its size and shape. Additionally, the second toe is
prone to clawing
what is the ectopic manifestation of DD?
Ledderhose disease (plantar fibromatosis),
Garrod pads (knuckle pads over the dorsum of the PIPjoints),
and Peyronie disease (fibrotic disease causing curvature of the penis).
In DD the MPJ flexion contracture can easily be corrected rather than the PIP contracture?
isolated MCP contractures are easily corrected by many methods, partially because that the collateral ligaments do not become pathologically shortened when these joints are fixed in flexion for significant periods of time.
However, PIP joints positioned in flexion for long periods of time
develop intrinsic joint contractures
In DD in case of a complete release of the all contacted cord and the contacture is still pressent ,what you can do in this case?
In practice, it may be best to proceed with
PIP joint capsulotomy and/or ligamentous release in select cases
The pain from DD can completely eradicated with imputation ?
Phantom sensation and phantom pain after surgery cannot be predicted easily, and sometimes pain related to complex regional pain syndrome is not eliminated with an amputation of the involved digit.
Most ganglions can be managed conservatively.
True
Most tumour in hand are pianfull
Tumors arising from the hand and wrist usually present as a painless mass
In pIp dislocation how i can know that the reduction is stable ?
As long as the joint exhibits stability at 30° of
flexion or less, it can be considered stable
In case of PIP volar dislocation does all collateral ligament are injured?
If the volar PIPJ dislocation was from a rotatory mechanism, only
one of the collateral ligaments may be injured, whereas a dislocation after a central slip rupture often injures both collateral ligaments.
when i should use surgical intervention in volar PIP dislocation ?
In the setting of a larger intra-articular fracture fragment that is displaced, ORIF may be required. If the deformity
(i.e., boutonniere) is not passively correctable, surgical intervention
is needed.
The most encounter problem with PIP dislocation is ?
Stiffness and flexion contracture are commonly encountered problems after these injuries,
why the DIP is hyperextension mor than PIP?
due to shorter and
more laterally positioned checkrein ligaments. DIPJ/IPJ arc of active
motion is about 60°, with an additional 10° to 15° of passive hyperextension possible for DIPJ
Volar plate arthroplasty is an alternative option for DIP reconstraction , although the potential for flexion contracture is increased with this approach T or F
T
checkrein ligaments on the MCPJ volar plate considered one of the stabilizer of th e MCP joint?
there are no checkrein ligaments on the MCPJ volar plate
there is no role for imaging technique in sagittal band injury?
The diagnosis is usually
made clinically, but ultrasound or MRI can provide confirmation in
unclear cases.
what is the weakest point in thump MCJ ?
Dorsal stability is less stout, provided mostly by the extensor pollicis longus and brevis tendons passing over the joint, along with some strength from the joint capsule itself.
Subungual tumors can cause pain, nail deformities, or bleeding. T :F
T
What is the main modality for evalutaing hand tumor ?
plain radiographs, are main modality for evaluating hand tumors.
What is the main modality for evaluation of complex soft tissue mass?
MRI remains the main modality for imaging complex soft tissues masses
myxoid liposarcomas,can follow up with nuclear study?
myxoid liposarcomas, may not be metabolic and have low 18-FDG uptake, which will limit the utility of these scans.
Almost most of the time you cannot preserve all of the hand with sarcom
Hand preservation is possible for most patients with soft tissue sarcomas of the hand, even those with relatively large tumors
Most common soft tissue tumors of the hand ?
Ganglions are the most common soft tissue tumors seen in the handthey are mucin-filled cysts
At wich age ganglion can occures?
At anny age. 20-40
What is the difference between an open and endoscopic approach in ganglion removal?
Arthroscopic resection, though technically more difficult,
has the advantage of better visualization of the joint and a better surgical scar, with similar recurrence rates to open surgery
why do we prefer to use FDS and extensor indices EIP?
Because they are Independent functions may simplify the postoperative rehabilitation process from a cortical plasticity standpoint.
How much the increase in excertion of the with wrist tenodesis?
the excursion of the transfer can be increased by 2 to 3 cm through the tenodesis effect of wrist flexion or extension.
In radial nerve palsy why the supination is maintained?
maintained because of the Biceps brachii muscle
A patient with a unilateral, nondominant loss of opposition by median nerve palsy may compensate quite well,
how?
Because of the effect of the deep head of flexor polices brevis
how you can correct simple clawing?
osseous blocks on the dorsal metacarpal head
volar (Zancolli) MCP joint capsulodesis
free tendon grafts from the deep intermetacarpal ligament, passed through the lumbrical canal, and secured to the extensor mechanism
Fowler and Tsuge popularized a dynamic tenodesis procedure, where a tendon graft is looped
through the extensor retinaculum of the wrist, and each end is split
in half. The four free ends are then routed along the lumbrical canals
and inserted into the lateral bands to provide MCP joint flex.ion and
IP joint extension with wrist flexion42*43 (Figure 79.6). These procedures are best reserved for patients with a positive Bouvier test (simple clawing)
which ligaments is responsible for PIP contracture?
Small volar checkrein ligaments arising from the
proximal phalanx volar ridges to the VP are thought to contribute
to flexion contractures
in case of extensors, tendon injuries the cut tendon can still be extended, how?
can confuse the diagnosis of tendon disruptions by the ability to extend fingers with ruptured tendons to a neutral posture through the juncturae
tendinae
The DIP can extend with extensors only?
The PIP and DIP joints will not extend if the intrinsic
muscles do not contract.
what muscle considered the last mucal innervated by the ulnar nerve ?
The first dorsal interosseous muscle is the last innervated muscle by
the ulnar nerve
Most Civilian shoot gun are managed conservatively T or F
T
Tendon transfers are often paired with arthrodeses in brachial plexus injury
Tendon transfers are often paired with arthrodeses (shoulder
or wrist) for an enhanced functional result
Thrombosis of the radial and ulnar artery following catheterization may occur that lead to ischemia
For T
F. Thrombosis of the radial and ulnar artery following catheterization may occur, but it rarely results in hand ischemia
Aneurysms often present as a painful, palpable, mass with Ischemia
Aneurysms often present as a painless, palpable, pulsatile mass that occasionally is associated with signs of local nerve compression. Ischemia is uncommon unless there is associated thrombosis and embolism.
In hypothenar ulnar syndrome the small finger is always involved.
In some patients, the small finger
is spared because ofthe proper ulnar digital artery to the small finger
arises proximal to the Guyon canal.
what is the corkscrew sign>?
Is an early sign of chronic damage to the intima and media leading to progressive fibrosis with ectasia
Patients with hypothenar hammer syndrome we can harvest the contralateral side radial artery?
the contralateral radial
artery should not be harvested because of the high incidence of
occlusion or ectasia of the ulnar artery seen in the contralateral
asymptomatic extremity in a study of patients with hypothenar
hammer syndrome
In hypothenar syndrom acute attack only we can use fibrinolysis T or F
Fibrinolysis (or thrombolysis) is advocated only for treatment in cases of acute onset of digital ischemia (less than 2 weeks)
In glomus tumor the the diagnosis better don with imaging
Clinical examination alone may be sufficient for diagnosis
Glomus tumour can be occures in the proximal and distal phalanx?
all GVMs were located in the distal phalanx and 59% were in the subungual region
Can we use meshed graft for hand burn?
For patients
who have an evolving burn wound or whose depth and viability
are uncertain at the time of excision, meshed allograft is indicated
why symptoms of radial or ulnar nerve ischemia are not compartment specific.?
The ulnar and radial nerves travel in one compartment first, and then pass through the intermuscular septum into another compartment at the level of distal third of the arm
Which nerve most commonly effected by compartment of the forearm?
The median nerve is the most commonly affected nerve in forearm compartment syndrome
Can hand compartment occures from single metacarpal fracture ?
Hand compartment syndrome can be caused by multiple metacarpal fractures
Closed fracture has mor e incidence of faciatiomy than open fracture ?
patients with open fractures had a higher incidence of fasciotomy than those with closed fractures
What are the rare causes of compartments syndrom?
Rarer etiologies of compartment syndrome include muscle overuse, rhabdomyolysis, and systemic sclerosis.
Pallor and Pulselessness should present in compartments syndromes ?
Pallor and Pulselessness may not present
Radiology and US can be used for compartments syndrome dignosis?
Doppler ultrasound and radiography imaging have been used to evaluate the primary injury and identify the amount of tissue edema, but not helpful for diagnosis of compart-ment syndrome
What the difference between low energy and hight energy brachial plexus injury?
Lower-energy mechanisms tend to produce postganglionic nerve ruptures (breakages within the substance of the peripheral nerve, distal to the dorsal root ganglion) as compared with higher-energy mechanisms which tend to produce more preganglionic root avulsions
The ventral root of spinal cord is thicker or the dorasl root?
The dorsal root, which contributes sensory nerves only, is thicker and more resistant to avulsion forces
Cwphalic traction cuese injury to the lower trunck cuadal traction cause injury to the middle and upper trank. Tor F
T
Which site of cord injury associated with anterior dislocation of shoulder?
Anterior shoulder dislocation and scapular fracture are associated with posterior cord damage
Hourner syndrom came with upper plexus TorF
F. Come with lower plexus because of the proximity of sympathetic system to lower plexus
Allografts can be used in brachial plexus injury ?
Allografts should not be used in this setting.
The majority of inheritance pattern of syndyctyle came with which type of syndrom?
Apert and Poland syndrom
What the method that we can employ to decrees the incidance of using skin graft in syndactytly?
Extended penragonal dorsal flap and defatting of the digits
In type 3 syndactyly in apert syndrom all digits hav complex syndactyly?
False, little finger often doesn’t involve in complex syndactyly only have simple comlete skin only syndactyly
Congenital trigger thump is present at birth is it true or false ?
congenital trigger thumb is also a misnomer because studies of newborns have failed to show its presence at birth, suggesting an acquired etiology.
Dose splinting has role in congenital trigger thump?
Splinting has not been shown to be of any consistent benefit,
Som cases of radial longitudinal deficiency have an associated thumb hypoplasia
F. All cases of radial longitudinal deficiency have an associated thumb hypoplasia
What is the standared study for vascular imaging?
Angiography is the standard study for vascular imaging
What is the best way to distinguish between primary and secondary Rayunuad phenomenon
Capillaroscop
Primary RP considered mor sever than secondary RP
False secondary RP has more sever prognosis with significant morbidity
What is the risk factors for RP?
female gender, family history in a first-degree relative, smoking, and migraines.
Dupeytren disease can diagnose by genetic test?
there is currently no genetic test for DD.
The cortical control
for placing the limb in space and for strong grasping is developed by
3 year.
The cortical control
for placing the limb in space and for strong grasping is developed by
1 year.
percentage of inherited syndactyly?
10% to 40% of cases are familial, inherited
in an autosomal dominant pattern with variable expressivity
When should i seek treatment for clinodactyly?
Treatment for clinodactyly is typically considered when there is more than 20 degrees of deviation
What is the option of teatment of trigger thump?
Observetion or surgery
Splinting can be used with the trigger thump?
Splinting has not been shown to be of any consistent benefit
The most common congenital hand anamoly?
Syndactyly, polydactyly, and camptodactyly are the most frequently encountered disorders
what is the most common web space involved in syndromic syndactyly?
In syndromic cases, the thumb/index finger
and index/middle finger webspaces are more commonly involved
what is the marker for disease progression in RA?
hand disease progression is often
used as a marker of disease severity
In RA, synovitis affects the midcarpal
joint more than the radiocarpal joint
In RA, synovitis
typically affects the radiocarpal joint more than the midcarpal
joint
patients with RA may be anable to extend their digits why ?
- Attenuation of the radial sagittal band.
- progressive subluxation and volar translation of the proximal phalanx on
the metacarpal head - compression on the posterior interosseous nerve
What are the “checkrein ligaments”?
?
In flexion contracture of the proximal interphalangeal (PIP) joint, the proximal sliding volar plate becomes attached to the firm assembly line structures by fibrous adhesions called the “checkrein ligaments,” which prevent the volar plate from sliding back distally.
Geneticists and pediatricians use the terms malformation, deformation, and
disruption. What do they mean?
In a malformation sequence, poor formation of tissue within the fetus initiates the chain of defects, which may range from minimal to severe. All gradations of radial dysplasia, ranging from absence of the thenar muscles to complete absence of the radius resulting in the club hand posture, are examples. Occurrence rate is in the 5% range. Radial dysplasias also are associated with malformation in other organ systems, such as the VATER association (vertebral anomalies, anal atresia, tracheoesophageal fistula, renal anomalies, and radial dysplasia) and Holt-Oram syndrome (radial dysplasia and congenital heart disease).
• The deformation sequence involves no intrinsic problem with the fetus or embryo; instead, abnormal external mechanical or structural forces cause secondary distortion or deformation. Tethering or constriction of limb parts by anular bands in the constriction ring syndrome is a prime example. The occurrence rate is very low.
• In the disruption sequence, the normal fetus or embryo is subjected to tissue breakdown or injury, which may be vascular, infectious, mechanical, or metabolic in origin. The hand deformities associated with maternal ingestion of thalidomide or alcohol are good examples.
Congenital camptoductyly doese involve the thump
F Congenital camptodactyly does not involve the thumb but should be considered with any flexion deformity of a digit
Secret plus
What is winblown hand?
The hands are often narrow with prominent ulnar drift. Incomplete, simple syndactyly and varying degrees of PIP camptodactyly are often present. The first web space usually is tight. The descriptive term “windblown hand
The most common site for nail melanoma?
The most common site is the thumb, followed by the index finger.
camptodactyly or clinodactyly frequently present with functional deficits.
camptodactyly or clinodactyly frequently present with mild deformities and no functional deficits.
Most cases of congenital hand anomaly are inherited /
Approximately 60% of cases occur spontaneously, 20% are inherited, and 20% are secondary to an environmental cause.
Upper extremity development takes place between 4-6 week of intrauterine life
Upper extremity development takes place between the fifth and eighth weeks of intrauterine growth.
When the apical ectoderml ridg start apoptosis?
apoptosis of specific portions of the AER between 47 and 53 days
The incidence between male and female in sundactly are equal ?
Males are affected twice as often as females.
10% to 40% of syndactyly cases are familial, inherited in an autosomal dominant pattern with variable expressivity, Tor F
T
The most common webspace affected in syndromic syndactyly is the middle/ ring finger. T or false
The most common webspace affected in nonsyndromic syndactyly is the middle/ring finger webspace (57% of cases) followed by the ring/little finger webspace (27% of cases). 9 11 • In syndromic cases, the thumb/index finger and index/middle finger webspaces are more commonly involved
Syndactyly surgery can be don before one year ?
Surgery before 1 year of age is associated with higher rates of scar contracture and potential anesthetic complications.
Syndactyly of the border digits surgical release should be considered earlier, specifically between 3 and 6 months of age.
T
Sequential surgery of syndactyly can be don in 6 between each other
F. 3 month
minimize or avoid the need for a skin graft, in syndactyly how?
minimize or avoid the need for a skin graft, some surgeons advocate recruiting excess dorsal tissue with the design of a dorsal pentagonal flap. This requires more proximal dorsal hand incisions leading to a more conspicuous scar.916• Defatting of the dig
Symbrachydactyly is caused by a disruption in embryonic formation only?
Symbrachydactyly is caused by a disruption in embryonic formation and differentiation
is more common in males, and is often unilateral, affecting the right extremity in two-thirds of cases
is more common in males, and is often unilateral, affecting the left extremity in two-thirds of cases
symbrachydactyly may appear similar to amniotic band syndrome how you differentiate?
Hands with symbrachydactyly often have small nubbins with fingernails, whereas with constriction bands the short digits occur as a result of intrauterine amputation and will lack nails. 18 Furthermore, patients with amniotic band syndrome will not only have a visible band on the hand but also on other locations of the body.
All type of thump polydactyl are inherited in autosomal dominant fashion?
POLYDACTYLY type vll triphalangeal only
Surgery for preaxial polydactyly is generally performed between 15-24 month
Surgery for preaxial polydactyly is generally performed between 9 and 15 months of age, prior to the development of pinch grasp or progressive deviation of the duplicated thumb
Camptoductyly occurs only in pip joints
Yes Although hyperextension of the DIP or MCP joints may occur in camptodactyly, flex.ion contracture of these joints would instead suggest a post-traumatic cause
The delay ed type, which is more common, presents during adolescence, and affects girls and boys equally
The delay ed type, which is more common, presents during adolescence, and affects girls more often than boys
camptodactyly can be transmitted in an autosomal dominant fashion
T
More Advanced case of contradictory. Present with swan neck deformity
boutonniere deformity.
Camptoductyly occures with apert T or F
CLINODACTYLY can occures with apert syndrom
When should considred treatment for clinodactyly
Treatment for clinodactyly is typically considered when there is more than 20 degrees of deviation.
Congenital clasped thump can produce snapping like adult tigger finger
The term tri gg er is a misnomer because it is uncommon to see snapping as in adult trigger finger. Instead, children typically present with a fixed flexion contracture of the IP joint averaging 25 to 35 degrees with inability or difficulty with active or passive thumb extension
The first line treatment for congenital clasped thump is splinting?
Splinting has not been shown to be of any consistent benefit the first line is observation
Constricting band syndrom inherited in autosomal dominant fasion ?
with no known autosomal inheritance pattern or genetic predilection.
RADIAL LONGITUDINAL DEFICIENCY result from anteroposterior deficient in zone of polarization
insult to the apical ectodermal ridge during the fourth to seventh weeks of intrauterine development
All the cases of RLD is syndromic?
1/3 of cases is syndromic
Cleft hand patient suffer from sever functional deformity
Although the cleft itself causes little functional limitation,
What the pathological features that occures in cleft hand ?
severe flexion contracture of one or more digits, a malpositioned index finger ray, or syndactyly involving the thumb
In gynicomastia Sometimes, a staged approach is necessary to achieve an ideal result.
T
Neonatal mastauxe, or breast enlargement of the newborn, is directly correlated to circulating maternal estrogens, and is seen in almost 25% of infants
F 70%
All neonates experience a surge of prolactin after birth
some neonates experience a surge of prolactin
Most of of males will have persistent gynecomastia beyond this period( adolescence , defined by breast bud enlargement of greater than 4 cm.
Approximately 4% of males will have persistent gynecomastia beyond this period, defined by breast bud enlargement of greater than 4 cm.٠
Lateral epicondylitis results from microtears at the origin of the common extensor tendon mass, specifically the extensor carpi radialis longus tendon
F. Lateral epicondylitis results from microtears at the origin of the common extensor tendon mass, specifically the extensor carpi radialis brevis tendon
Medial epicondylitis affects the common flexor tendon mass, most often the pronator teres and flexor carpi raclialis.
T
Most of patients should be assessed for possible ulnar neuropathy.
F. all patients should be assessed for possible ulnar neuropathy.
Intersection syndrome results in pain, swelling and often crepitus over the junction on the first and second extensor compartments
T
In trigger finger Corticosteroid injections are not effective in many patients,
F. Corticosteroid injections are effective in many patients,
Atypical conditions include tendinopathy of the extensor carpi ulnaris (ECU), flexor carpi radialis (FCR), and extensor pollicis longus (EPL)
T
lateral epicondylitis may be precipitated by any activity that results in forceful repetitive motion of the forearm flexors
lateral epicondylitis may be precipitated by any activity that results in forceful repetitive motion of the forearm extensors
Manual activities, particularly lifting loads greater than 20 kg, have been associated with the development of lateral epicondylitis
T
Lateral epicondalytis occurs in men mor than female?
F. It is equally common in men and women, and prevalence peaks between the ages of 45 and 54 year
Changes within the ECRL tendon substance represent the sine q ua non for lateral epicondylitis.
F. Changes within the ECRB tendon substance represent the sine q ua non for lateral epicondylitis.
What the hypotheses behind lateral epiocndylates ?
repetitive contact between the capitellum and the ECRB tendon may be the causative problem
Radiographic aid significantly in the diagnosis of lateral epicondylitis. T. F
F. have not been found to aid significantly in the diagnosis of lateral epicondylitis
MRI is often the modality of choice, with a higher sensitivity of 90% to 100% for lateral epicondylates T. F
T
In lateral epicondilytes the severity of disease present on MRI does not necessarily correlate with symptoms,
T
activity modification continues to be the mainstay of treatment for lateral epicondylitis, with up to 90% of patients improving
T
Injections into and around the lateral epicondyle considered the mainstay of treatment
F. Injections into and around the lateral epicondyle remain highly controversial.
With open approach greater possibility of radial nerve injury.in lateral epiconylitis
F. The arthroscopic approach
MEDIAL EPICONDYLITIS less prevalence than lateral epicondylitis
T
In medial epicondylitis The PT and FCR are most frequently affected.
T
Ulnar neuritis is especially important as 23% to 61% of patients with medial epicondylitis
Ulnar neuritis is especially important as 23% to 61% of patients with medial epicondylitis
medial epicondylitis Ultrasound can be used to assist in the diagnosis, as it has been shown to be both specific and sensitive
T
the MCL and the medial antebrachial cutaneous nerves are all key components of this operation.in medial epicondylitis
T
DE QUERVAIN DISEASE occurs in men and female equally. T. F
F. DE QUERVAIN DISEASE six times more common in women than men. In 50-60 %
E QUERVAIN DISEASE. Mor common in hypothyrodism patients. T. F.
F. In pregnant and lactating women
Patients present with a rapid onset of radial-sided wrist pain and tenderness to palpation over the radial styloid.
F. Patients present with a gradual onset of radial-sided wrist pain and tenderness to palpation over the radial styloid.
high success rate of corticosteroid injections alone or in conjunction with splinting in de Quervain patients, that 80% had complete and lasting reliefofsymptoms
T
Splinting alone was observed to be less successful, but when combined with corticosteroids, is likely more successful than injections alone.in de qruvian
T
Studies have shown that a separate subsheath is present in 44% ofnormal cadavers versus 62% in de Quervain disease
T
intersection syndrome is an common cause of wrist pain
F. intersection syndrome is an uncommon cause of wrist pain
Because of the locking or popping sensation noted in trigger finger , it is not uncommon for patients to localize the problem to the proximal interphalangeal (PIP) joint rather than the Al pulley.
T
patients with diabetes, hyp oth yr oidism, rheumatoid arthritis, gout, and renal failure develop trigger fingers at higher rates.
T
patients with diabetes, hyp oth yr oidism, rheumatoid arthritis, gout, and renal failure develop trigger fingers at higher rates.
T
association with specific
occupations has not been found in trigger finger
t
In trigger finger The PIP joint can also be
splinted, instead of the MCP joint, with similar effect
t
Corticosteroid has proven effective in treating trigger fingers and
can be the first line intervention.
t
injection for trigger finger before surgical release in patients without
comorbidities such as diabetes and hypothyroidism is preferable
F Diabetic patients often experience a transient elevation in blood glucose levels after a corticosteroid injection.
trigger finger and de Quervain disease are the most common tendinopathies of the hand and wris
T
treatment of EPL tendinitis is often medical
with complete release of the third dorsal compartment
F treatment of EPL tendinitis is often surgical
with complete release of the third dorsal compartment
