Hand Flashcards
Sagittal Band Rupture
Most commonly involved?
Presenation?
Function of SB?
- Radial sagittal band of long finger
- dislocation of extensor tendon during MCP flexion w/ wrist flexed.
- inability to initiate extension, but can hold mcp in extension once placed there.
- PSEUDO triggering
- tx: acute injury splinting of MCP (extension splint/yoke splint for 4-6 weeks); chronic injury or athelete direct repair vs extensor centralization
functions:
* Primary stabilizer of extensor tendon at MCP jt (juncturae tendinum secondary stabilizers)
* resists ulnar deviation of tendon during flexion and bowstringing during extension.
* complete Radial SB sectioning leads extensor dislocation, 50% sectioning of proximal SB leads to extensor tendon subluxation.
complications: MC flexion contracture, from non-op or delayed secondarily intrinsic tightness develops.
RA hand: sagittal band dysfunction leads to ulnar deviation of digits
Diagnosis is made clinically with the inability to initiate MCP extension but the ability to hold MCP in extension once passively extended. In sagittal band rupture, the extensor tendon may subluxate into the valley between the metacarpal heads. The patient will not be able to actively extend the MCP joint from a flexed position with the subluxated tendon, but will be able to maintain MCP extension after it has been passively extended. Extensor lags can have other etiologies other than extensor digitorum communis subluxation such as tendon laceration or rupture, posterior interosseous nerve palsy, but in these conditions, patients cannot maintain MCP extension. Active interphalangeal extension can be achieved with the intrinsic muscles that are not affected by sagittal band rupture.
Scaphoid fractures:
Most common Mechanism of force?
Blood supply?
Imaging: Repeat xrays? Best Xray position? Most sensitive test?
Dorsal approach for?
Volar approach for?
Screw?
AVN rates?
Nonunion rates?
Mechanism: axial load across a hyper-dorsiflexed, pronated and ulnarly-deviated wrist
Blood supply: dorsal carpal branch (radial a.) 80% of blood supply of scaphoid via retrograde blood flow (distal to proximal)
Distally, distal tubercle- superfiscial palmar arch, br of volar radial a.
Repeat xrays 14-21 days if high suspicion,
xray postion: wrist extension & 20 deg ulnar deviation to nuetral PA of wrist. MRI most sensitive less than 24 hrs
CT w/ 1 mm cuts along scaphoid axis to eval for progression of nonunion or union after surgery.
Approaches:
Dorsal: best for proximal pole fxs, higher risk of unrecongnized screw penetration of subchondral bone.
Volar: waist & distal pole, humpback flexion deformitions, avoids jeopardizing scaphoid blood supply. RSC ligament must be incised and repaired.
Rigidity optimized by long screw placed down central axis.
cannulated compression screw in central scaphoid via dorsal approach, biomechanically advantageous and provides greater stability
AVN rates w/o treatment: proximal 5th 100%, proximal 3rd 33%
Union rates of 90-95% with operative treatment.
Scaphoid complications?
Nonunion: incidence risk factors? treatment?
Osteonecrosis?
Malunion?
Subchondral bone penetration w/ arthrosis and prominent hardware?
scaphoid fx
Nonunion in young patient: tx?
typically manifests as?
How to assess?
Rate of success?
Salvage option? contraindication for this?
Hook of hammate fx
xray? RF and mechanism
carpal tunnel view
RF: golf, baseball, hockey
Direct blow to volar palm (grounding a club in golf)
: Patient positioning for carpal tunnel radiograph-wrist is extended 70 degrees, and beam is angled 25-30 deg to the long axis of the hand(arrow).
TFCC
mechanism of injury:
symptoms?
Exam?
What structure is most important restraint of dorsal/palmar translation?
Type 1. Fall on extended wrist in pronation
Type 2. Positive Ulnar variance; ulnocarpal impaction
symptoms: pain w/ door key,
* positive “fovea sign” TTP soft spot b/t ulnar styloid and FCU tendon, between bolcar surface of ulnar head and pisiform
* Pain w/ ulnar deviatin
Tx:
- all traumatic injuries with a stable DRUJ are initially treated with a course of immobilization, NSAIDS, corticosteroid injections, and physical therapy.
- Dorsal and palmar radioulnar ligament: primary restraints to translation of radius on ulna
AAOS: Clinical examination of the distal radioulnar joint is frequently described as translation of the ulnar head in reference to the radius. This description is incorrect, since the ulna is the bone that is fixed in space. Anatomically speaking, the radius moves in relation to the fixed ulna. The triangular fibrocartilage complex is composed of all of the structures listed above. The articular disk is a meniscal-like structure that serves a load-bearing function between the ulnar carpal bones and the ulnar head. About 20% of the load borne across the wrist passes through the disk. It has almost no ligamentous (stabilizing) function. At the dorsal and volar margins of the articular disk are thickened true ligamentous ligaments termed the radioulnar ligaments. They take origin from the foveal area of the ulnar head and styloid and insert into the dorsal and volar margins of the sigmoid notch. These two ligaments serve as primary restraints to dorsal and palmar translation of the radius on the ulna. The ulnolunate ligament, ulnotriquetral ligament, and the subsheath of the sixth extensor compartment are ligaments, but they serve to stabilize the carpus to the ulna and radius. They provide minimal stability to the distal radioulnar joint.
Phalanx dislocation
Dorsal disclocations:
Volar dislocations:
What can happen in a rotatory volar PIP jt dislocation?
Dorsal DIP jt dislocation: prevention of reduction?
Dorsal Dislocations:
* tearing of collateral ligaments and shearing of volar plate
* volar plate and block reduction
* volar plate disruption – swan neck deformity
Volar dislocation: buotonniere deformity
-simple: central slip disruption
-rotatory rupture of one collateral ligament, proximal phalangeal condyle buttonholes between central slip and lateral band
reduction of rotatory: flex mcp and PIP 90 with traction relax volarly displaced lateral band
tx: splint in PIP jt ex, w/ full ROM of mcpj and DIPJ to allow for healing fo central slip.
Dorsal DIP jt dislocatin: volar plate interpositional can prevent reduction
tx:
Buddy taping(splinting):
- adj finger 3-6 weels if dorsal dislocation stable after reduction or lateral dislocation
Extension block splinting if dorsal dislocation unstable
extesnion splinting 6-8 weeks if volar dislocation
Phalanx Fracture dislocation:
Most important determinant of outcome?
Most common fracture and tx?
- maintenance of alignment on of middle phalanx on lateral
- Volar lip of P2:
- less than 40% jt involved or joint stable after reduction: dorsal extension block splint with active flexion and extension
- more than 40% jt involved or joint unstable = crrp orif
Proximal phalanx fx: what kind of deformity?
Oblique proximal phalanx fx?
apex volar deformity (flexion of proximal frament through lumbrical, extension of distal fragment through central slip) extensor lag–> corrective osteotomy to improve active PIP extension
Unstable oblique proximal phalanx fx( scissoring with flexion): K wire?
What anatomic structure must be excised when performing a volar plate arthroplasty of the proximal interphalangeal joint?
The collateral ligament must be excised or released from the proximal phalanx to allow gliding of the middle phalanx on the articular surface of the proximal phalanx. Failure to do so may prevent this gliding motion and make the middle phalanx just hinge on the proximal phalanx.
A 30-year-old woman injured the ring finger of her nondominant hand while playing baseball 5 weeks ago. She now reports pain and limited motion of the proximal interphalangeal (PIP) joint. A lateral fluoroscopy image is shown in Figure 36. Treatment of the PIP joint should consist of
The patient has a neglected PIP joint fracture-dislocation with comminution involving more than 40% of the volar articular surface of the middle phalanx. Volar plate arthroplasty has been advocated for the treatment of acute unstable and chronic dorsal fracture-dislocations. The volar plate is incised laterally and released from the collateral ligaments. The volar fragments of the middle phalanx are removed and a trough is created for advancement of the volar plate, which is secured with sutures secured on the dorsum of the middle phalanx beneath the extensor mechanism.
A 38-year-old man caught his index finger in a volleyball net. He noted an angular deformity of the finger that was reduced when a teammate pulled on his finger. Three weeks later, he now reports trouble extending his finger. A clinical photograph is shown in Figure 55. What anatomic structure is most likely injured?
Central slip
The clinical photograph shows a classic boutonniere deformity. It is likely that the patient sustained a volar dislocation of the proximal interphalangeal joint, with a concomitant rupture of the central slip insertion of the extensor tendon.
Metacarpal fractures
Most important consideration for non op?
ORIF in athlete?
“psuedo clawing”
effect of transverse intermetacarpal ligament?
contributor to extension lag?
what is the effect of shortening of metacarpal fractures?
- no rotational deformity
- most isolated metacarpal fractures can be treated nonsurgically, multiple metacarpal fractures are inherently unstable due to the loss of support that an intact adjacent metacarpal provides; therefore, treatment should consist of surgical fixation of all three metacarpal fractures.
- Athlete w/ metacarpal fx: ORIF, faster return to play, no increase in union, grip strength, or ROM at final follow up
- Dorsal angulation of index and middle finger metacarpal fractures of 30 degrees: is less well tolerated than that of the ring and small fingers, which results in clinical “pseudoclawing” of the affected digit due to metacarpal phalangeal joint (MCPJ) hyperextension
- transverse metacarpal ligament is the primary restraint against the longitudinal shortening of metacarpal shaft fractures.
- Shortening of metacarpal fractures >2-5mm may result in extension lag at the MCP joint as well as reduced grip strength due to loss of tension on the extensor mechanism. 7-degree extensor lag for every 2 mm of metacarpal shortening
angulation less tolerated in shaft than neck fxs, angulation more than 10 should be reduced.
AAOS: effect of shortening Cadaveric models have demonstrated a 7-degree extensor lag for every 2 mm of metacarpal shortening, with the amount of lag increasing in a linear fashion. There was no statistical difference in the amount of lag in regard to the digit involved. Based on muscle length-tension relationships, cadaveric models have also been used to demonstrate an 8% loss of power secondary to decreased interosseous force generation with 2 mm of shortening. Because the intrinsic muscles of the hand contribute anywhere from 40% to 90% of grip strength, decreased interosseous force generation secondary to metacarpal shortening will invariably cause a decrease in grip strength.
Proximal phalanx fx: common deformity?
Indications for buddy taping or splinting phalanx fractures?
- shortened position may lead to an extensor lag at the proximal interphalangeal joint (PIP).Proximal phalanx fractures tend to fall into apex volar angulation due to the proximal fragment being flexed by the interossei (intrinsics) and the distal fragment being extended by the central slip. Extra-articular proximal phalanx fractures with less than 10° angulation, less than 2mm of shortening, and no rotational deformity can be treated non-operatively but those falling outside these parameters may require closed reduction percutaneous pinning vs. open reduction internal fixation (ORIF). If the fracture heals in an angulated or shortened position, this may lead to an extensor lag at the PIP joint due to the effective shortening of the extensor tendon. Soft tissue releases or a corrective osteotomy may be required in this case if symptomatic.
- Indications for buddy taping or splinting include extraarticular fractures with less than 10° angulation, 2mm shortening, no rotational deformity, and non-displaced intraarticular fractures.
- Indications for CRPP vs ORIF include extraarticular fractures with >10° angulation, >2mm shortening, rotational deformity, displaced intraarticular fractures, and unstable or irreducible fracture pattern.
A 47-year-old woman falls and sustains a direct blow to her middle finger. She notes pain and swelling and is unable to move the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. Radiographs are shown in Figures 8a through 8c. Proper management should consist of
The oblique nature of the fracture and extension of the fracture to the condyles implies an unstable fracture. Lag screw fixation provides an excellent chance of union, and the ability to start early range of motion.
Jersey Finger
What’s injured?
exam?
treatment?
- traumatic flexor tendon injury caused by anavulsion injury of the FDP from the insertion at the base of the distal phalanx.
- finger that lies inslight extension at the DIPrelative to other fingers in the resting position.
- during grip ring fingertip is 5 mm more prominent than other digits in ~90% of patients
- tx:
*less than 3 weeks, direct tendon repair or tendon reinsiertion with dorsal button, advancement more than 1 cm risk of DIP flexion contracture or quadrigia - ORIF for avulsion injury
- 2 stage recon for chronic, more than 3 month injuries.
Thumb Collateral ligament injury
Mechanism of Injury?
Presentation?
Stener lesion?
two ligaments and how to test?
Tx?
radially directed force causing hyper abduction moment at mcp jt.
Pain with pinch or grip
Stener lesion: avulsed ligament w/ or without bony attachment is displaced dorsal and superfiscial to** adductor aponuerosis **
Proper U Collateral ligament: resists load in flexion. radial instability at 30 of flexion
Accessory U collateral ligament and volar plate: resists load in extension. radial instability in extension indicates injury to both and/or volar plate
Tx: immobilize 4-6 weeks less than 15 deg of varus/valgus
rcl/ucl repair for stener lesion, 15 deg of varus valgus, 30-35 opening
complications: stiffness most common problem, persistent instability, superfiscial radial neurapraxia
Hand infections
Pyogenic flexorteno:
Most common bug?
iv drug user bug?
human bites?
animal bites?
In the little finger and thumb the sheaths communicate with the?
What is parona’s space where does it lie?
Horse shoe abscess?
Prognosis of kanavel signs:
1 Staph Aureus
IVDU: MRSA (Gram positive cocci)
Human: Eikenella
Animal: Pasteurella (gram negative) tx ampicillin/sulbactam
In the little finger and the thumb, the sheaths usually communicate with the ulnar and radial bursae, respectively.
The potential space of communication,** Parona’s space**, lies between the fascia of the pronator quadratus muscle and flexor digitorum profundus conjoined tendon sheaths.
Horseshoe: if infection involves the thumb or small fingers (connection b/t sheath at wrist)
Infection tracking through this space presents as a horseshoe abscess
4 Kanavel signs, they found that fusiform swelling was most often present (97% of patients), followed by pain on passive extension (72%), semiflexed digit posture (69%), and tenderness along the flexor tendon sheath (64%).
Game Keepers thumb
What’s a stener lesion?
Valgus Instability in flexion vs extension indicates?
Acute vs chronic injury?
Deep space infections:
what is parona’s space?
Thenar:
Hypothenar:
Midpalmer(central):
Parona’s: connection b/t thumb and SF flexor sheaths; b/t PA and FDP conjoined tendon sheaths.
Thenar (bursa between adductor pollicis and flexor tendons)
Hypothenar
aaos Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.
Hand infection
Collar button abcess: where is it and tx?
abscess in web space b/t fingers, need volar and dorsal incisions for thorough I&D
Nail Bed injuries
Subungual hematoma tx?
Dermabond results?
complications?
- drain hematoma by perforation if less than 50%
- RCT has demonstrated quicker repair time using 2-octylcyanoacrylate (Dermabond) instead of suture with comparable cosmetic and functional result
- complications:
* hook nail: caused by advancement of matrix to obtain coverage without adequate bony support. Tx:** remove nail and trim matrix to level of bone**
* split nail: scarring of matrix following injury to nail bed, tx: excise scar tissue and replace nail matrix.
Seymour fracture
nailbed injury and physeal plate of distal phalanx in peds.
Imblanace: extensor tendon inserts on the epiphysis of distal phalanx and flexor tendon inserts on the metaphysis
subluxated nail plate & interposition of nail matrix blocks anatomic reduction
Acute (less than 24 hrs): close reduction + abx ok (if reduction stable)
If open injury: open reduction, and pinnin across DIP jt and nailbed repair. fewer complications than closed mgmt.
Hyperflexion of digit will permit removal of interposed soft tissue from fracture site
Pressure injuries
PSI of ? are capable of penetrating skin, most industrial pressures are?
Nonop vs Op?
Prognostic variables?
100 PSI, industrial water jet pressures are 8,000 to 12,000 PSI
Nonop: higher complications, 50% treated non op go on to require surgery
Tx: I&D, foreign body removal and broad spectrum I&D
Time to treatment, force of injection, volume injected, composition of material
industrial solvents & oil based paints cause more soft tissue necrosis
grease, latex, chloroflourocarbon & water based paints are less destructive
aaos High-pressure injection injuries are associated with a high risk of amputation. The risk of amputation is highest with organic solvents. The presence of infection and the use of steroids do not impact the amputation rate. Amputation risk is lower if surgical debridement is performed within 6 hours. Elevation and observation would delay necessary care. Neutralizing agents may be used in specific situations, such as hydrofluoric acid exposure or chemotherapeutic agent extravasation, but in high pressure paint thinner injection, the best outcome is achieved through early surgical lavage. This type of injury represents a difficult problem in hand surgery. The factors that most determine outcome after high-pressure injection injuries into the fingertip include: involvement of the tendon sheath, extent of proximal spread of the injected substance, pressure setting, and delay to surgical treatment. The other factor that likely is most important is the type of substance injected. Water and latex-based paints are least destructive. Grease and chlorofluorocarbon-based substances are intermediate, but aggressive surgical debridement can restore reasonable function. Oil-based paints are highly inflammatory and can cause such chronic inflammation such that amputation may be the only reasonable treatment option despite early aggressive surgical treatment.
Frostbite
when to debride?
prevention?
tx?
delay debridement until demarcation
footwear thermal isulation is most important factor for protection
Tx: initial resuscitation with warm IV fluids, tetanus prophylaxis, NSAIDS, silver sulfadiazine ointment or topical antibiotics to open wounds, rapid rewarming
tPA within 24 hrs reduces rate of digital amputations.
escharotomy if circumfrentially constrictive
debrided and clear blisters + aloe vera reduces prostaglandin F2 and thromboxane B2
drain/aspirate hemorrhagic blisters but leave intact, prevents dessication of underlying dermis
Fingertip ampuations and flaps
Goals of treatment?
Healing by secondary intention for?
Revision amp (primary closure)?
Full thickness skin grafting from hypothenar region?
Flap reconstruction?
Goals: sensate tip, durable tip, bone support for nail growth
Healing by secondary intention:
* adults & children w/ non bone or tendon exposed < 2cm of skin
* children with exposed bone
Techniques:
Secondary intension: complete healing takes 3-5 weeks
Revision amp: ablate remaining nail matrix, disarticulate DIP jt if flexor/extensor tendon insertions can’t be preserved, transect remaining tendons as proximal as possible, palmer skin brought over bone and sutured dorsally.
FTSG from hypothenar region:
STSG not useful b/c contractile, tender, less durable
VY advancement flap?
Thenar flap?
cross-finger flap?
Reverse cross finger flap?
Moberg volar advancement?
First dorsal metacarpal artery flap?
- V-Y flap is useful for extending dorsal skin to cover a transverse or dorsally angulated fingertip injury. They are typically used for finger tip amputations which have more dorsal soft tissue loss than palmar loss. Nail bed removal is important to prevent a subsequent hook nail deformity.
- Cross finger flaps are indicated in patients > 30 years of age when the lesion is a volar oblique finger tip lacerations or a volar proximal finger lesions. The advantage is it leads to less stiffness.
- Moberg advancement flaps are indicated for volar thumb defects
- first dorsal metacarpal artery (Kite) flap is the most appropriate flap for defects of the dorsal aspect of the thumb.
first dorsal metacarpal artery (FDMA) arises from the radial artery at the anatomical snuff box.
what type of flap for each region?
what type of injury causes the biggest risk for digital neuroma formation?
Avulsion-type injuries have been shown to pose the most significant risk of digital neuroma formation compared to other mechanisms of injury.
reverse cross finger flap wound best cover?
dorsal fingertip wound involving the eponychial fold or doral PIPJ wound
The RXFF is indicated for reconstruction of: (1) eponychial skinfold and coverage of an exposed extensor tendon near the IP joint, (2) sterile matrix nailbed defects with exposed distal phalanx, (3) contused, repaired, or grafted extensor tendon denuded of paratenon, (4) boutonniere deformity with poor-quality skin over the PIP joint after burn/avulsion injury, (5) complete avulsion of the nailbed, germinal matrix, and surrounding skin of digits
Z plasty for scar contracture lenthening: 40 degree limbs? 60 degrees lengthens by?
50% and 75% lengthening
Replant
Indications and contraindications to replant?
Yes: thumb, multiple digits, distal to FDS insertion (relative) (zone1), pediatric
No: ribbon sign,
hand proximal to carpal: ischemia time > 6hrs warm, 12 hrs cold
digits: ischemia time >12hrs warm, >24hrs cold
Single digit amputations proximal to the insertion of the flexor digitorum superficialis (FDS), in generally have poor function and severe stiffness following replantation. Replantation between the FDS insertion and the distal palmar crease (zone 2 flexor tendon injuries) has historically led to poor results due to stiffness at the proximal interphalangeal joint, decreased sensation in the finger, and tendon adhesions between the FDP and slips of the FDS
replant
Indications for revision amp?
degloving (need to repair atleast 2 veins), boneinjury w/ neurocascular damage, injury proximal to FDS insetion/PIP
replant
if ray resection vs MCP level amp:
revision amp w/ wider 1st webspace & thus avoids priminent 1st MC head impingement & improve dexterity; revision amp w/ higher satisfaction scores. Some thought that preservation of palmer width with MCP level amp improves grip strength & thus should be done for heavy laborers
replant
order of structures for replant
BEFANV
bones
extensors
flexors
arteries
nerves
veins
replant structure by structure rather than digit by digit
replant
thrombosis at risk post op timing and tx?
arterial (within 12hrs) remove bandage place hand in dependent position, heparin, stellate ganglion block
venous thrombosis after first 12 hrs: elevate hand, leech
replant
leech therapy: risk of ?? ppx with
leech therapy helps with venous congestion,
risk for aeromonas hydrophilla (gram neg rod) infection, ppx with cipro (inhibits DNA gyrase) or tmp-smx (if CKD or FQ resistance)
leeches release hirudin, anticoagulant, heparin soaked pledgets if no leeches.
replant
what causes reperfusion injury?
what drug for reperfusion injury?
mechanism: ischemia induced hypoxanthine conversion to xanthine
allopurinol: inhibits xanthine oxidase= decrease xanthine. Thought to be responsible for reperfusion
distal phalanx amputation what’s a risk if incomplete ablation of germinal matrix?
nail inclusion cyst
Arm Flaps
Lateral arm flap: blood supply?
Lat dorsi myocutaneous flap?
Lateral arm flap: for lateral arm defects, posterior radial collateral
Lat dorsi: thoracodoral artery, branch of subscapular artery, perforators off profunda brachii
free antegrade lateral arm flap (LAF) for soft tissue coverage of the forearm. The flap is based on 3-5 septocutaneous perforators from the posterior radial collateral artery (PRCA), a branch of the profunda brachii. During flap elevation, posterior antebrachial cutaneous nerve is often sacrificed, leading to hypoesthesia of the forearm. During flap elevation, care must be taken to protect the radial nerve, which runs nearby, to prevent transient radial nerve palsy. The flap can also be raised as an osteofasciocutaneous flap (with a vascularized humerus block), as a sensate flap (with posterior brachial cutaneous nerve), musculofasciocutaneous flap (with triceps), or just a fascial flap.
Leg muscle flaps: use and blood supply
Medial Gastroc
Lateral gastroc
Soleus
Gracilis
Free Flap
Groin flap
Bone flaps: use and blood supply
Free iliac
Free fibula
Vascular bone graft radius
index metacarpal
free tissue transfer within ?? for sever trauma?
Free tissue transfer within7 daysfor severe trauma in the upper extremity has been shown to decrease complication rates
groin flap artery and nerve
groin flaps are based on the superficial circumflex iliac artery and place the lateral femoral cutaneous nerve at risk.
Peripheral Nerve Injury and Repair
after injury, first/last to be lost and to recover?
Maximum gap can be bridged by nerve collagen conduit?
What is a nerve conduit made out of?
Best nerve for recover? Worst nerve for recovery?
Median Nerve Lac may require?
indications for nerve autograft?
Peripheral Nerve Injuries
Most important prognostic factor? good prognosis, bad?
- age
- Good: stretch injuries or clean wounds, after direct surgical repair
- Poor: crush or blast, infection, scarred wound, delayed surgical repair
Peripheral Nerve Injuries
Seddon and Sunderland classification:
Neuropraxia?
Axonotmesis?
Neurotmesis?
Neuropraxia: Sunderland 1st degree, “focal nerve compression”
* reversible conduction block w/o wallerian degeneration
* focal temporat demyelination of axon (axon remains intact)
* NC vel slowing or complete conduction block
* no fibrillation potentials
Axonotmesis: Sunderland 2nd-4th degree
- incomplete nerve injury
- Disruption of axons & myelin sheath disruption leading to focal conduction block
- wallerian degen distal to injury
- variable degree of connective tissue disruption
- fibrillation and positive sharp waves on EMG
- neuroma incontinuity may develop
- prognosis: unpredictable
neurotmesis: 5th degree
complete** disruption of endoneurium** (all layers)
focal conduction block w/ wallerian degeneration
fibrillations and positive sharp waves on EMG
neuroma forms proximally
glioma forms distally.
Regeneration process after transection?
distal segment undergoes?
shwann cells?
proximal budding?
Nerve Grafting
approach?
autologous graft?
allograft?
Conduits?
create tension free repair using a graft that is atleat 10% longer than gap
Peripheral nerve repair: Best if procedure is performed ??
* No technique deemed superior.
* Gaps may be addressed with nerve conduit, decellularized nerve allograft, or autograft.
Peripheral nerve repair: Best if procedure is performed** early (less than14 days), repair is tension-free, and wound bed is clean.**
* No technique deemed superior.
* Gaps may be addressed with nerve conduit, decellularized nerve allograft, or autograft.
principles of tendon transfer
tendon transfer for radial nerve palsy?
wrist ext? Finger ext? thumb ext?
For low median nerve palsy?
Testable concepts anatomy
central slip
lateral bands
transverse retinacular ligament
Swann neck
triangular ligament
Boutonniere deformity
Lumbrical muscles
origina, insertion, function, innervation?
Lumbrical muscles: Originate on radial aspect of FDP tendons, and pass volar to transverse metacarpal ligaments (TMLs) to insert on the radial lateral bands (extensor hood)
* Function: IP joint extension, relaxation of extrinsic flexor system
* Innervation: Radial two lumbricals (median n.), ulnar two lumbricals (ulnar n.)
Patient has ulnar nerve injury resulting in intrinsic minus hand or claw hand: describe the test?
Bouvier test guides tendon transfers The Bouvier test is performed by holding the wrist in neutral and blocking full MCP joint extension and seeing if the patient can extend the PIP joints. If the patient is able to extend the PIP joints, then it is considered positive. A positive test indicates simple claw hand and an intact central slip. Tendon transfer procedures are then aimed at re-creating MCP flexion. To correct this, the tendons are either attached to the A1 pulley, A2 pulley or proximal phalanx. However, if the patient is unable to extend the PIP joints, then the test is considered negative. A negative test indicates complex claw hand and tendon transfers must correct both MCP flexion and PIP joint extension via insertion into the lateral bands.
tendon transfer
low median nerve palsy
high median nerve palsy
tendon transfer
Ulnar nerve palsy:
what 3 things do you want to restore?
donor tendon: to?
Carpal Tunnel testable concents:
Poor prognosis correlates ?
recurrent motor branch exits? innervation?
Most radial structure?
At risk during release?
Grip strenght returns at?
Comparision to non op?
CTS with thenar atrophy?
how many oxy post op?
AAOS clinical practice guidelines (CPGs) for the management of carpal tunnel syndrome, including the following Strong recommendations:
1. Immobilization (brace/splint/orthosis) improves patient-reported outcomes
2. Steroid injections improve patient-reported outcomes
3. Magnet therapy should not be included in the treatment of CTS.
4. Releasing the transverse carpal ligament improves symptoms and function.
5. Surgical treatment of CTS confers a greater treatment benefit at 6 and 12 months as compared to nonoperative management.
6. There is no benefit to postoperative immobilization after carpal tunnel release.
Pronator Syndrome
Compression of the median nerve in arm/forearm:
* sites of compression?
* How to differentiate from CTS?
* Povacative tests
SLAPS
* Pronator syndrome differentiated from CTS by proximal volar forearm pain and sensory disturbances in distribution of palmar cutaneous branch of the median nerve over the thenar region, which comes off the median nerve proximal to the carpal tunnel
* Patients with CTS have normal sensation over the thenar eminence
* Patients with pronator syndrome have decreased sensation over the thenar region
* Provocative tests: Resisted elbow flexion with forearm supinated (bicipital aponeurosis), resisted forearm pronation with elbow extended (pronator teres), and resisted long finger PIP joint flexion (FDS)
Ulnar Nerve
Ulnar nerve signs of motor weakness:
Froment (IP jt flexion during key pinch)
Jeanne (Thumb MCP hyperflexion during key pinch)
Wartenberg (abduction/ext of small digit during attempted adduction)
Masse sign
* Flattening of palmar arch and loss of ulnar hand elevation due to weak opponens digiti quinti and decreased small digit MCP flexion
* Interosseous and/or first web space atrophy
* Ring and small digit clawing due to FDP contraction and paralysis of the intrinsic muscles
Cubital Tunnel
Lowest pressure in cubital tunnel between what ROM?
Test conduction velocities across elbow, normal is ?
Risk factor for in-situ decompression and need for transposition?
Symptoms are due to ?
FCU branches?
Persistent wartenburg sign?
Ulnar nerve crosses IMN ? cm from medial epicondyle?
What atrophy to look for?
Dorsal sensory branch of ulnar nerve leaves?
- Lowest pressure in cubital tunnel between 30-70˚ flexion.
- Test CV across elbow: normal is 50m/s absolute, change less than 10m/s
- Risk factor for failure after in-situ decompression & likely need for transposition: prior trauma & younger age
- Symptoms are due to vascular obstruction of intraneural vessels
- Usually w/ multiple branches to FCU, can sacrifice one prn
- Wartenberg sign due to weak intrinsics (specifically 3rd palmar interosseous muscle) & unopposed pull of ulnar insertion of extensor digiti minimi (radially innervated). If persistent despite decompression: EDM transfer
- Crosses IMS **8cm prox to medial epicondyle **
- First dorsal web space atrophy (dorsal interossei)
- Dorsal sensory branch ulnar nerve (DBUN) leaves 5cm proximal to wrist crease
ulnar tunnel syndrome
most often caused by?
other causes?
imaging necessary?
symptoms?
DDX with cubital tunnel how can you tell?
Guyon’s canal is bordered by the transverse carpal ligament (floor), the volar carpal ligament (roof), the pisiform and abductor digiti minimi muscle (ulnarly), and the hook of the hamate (radially
PIN compression symdrome:
Sites of compression “LEAFS”
Presentation?
How to differentiate it from radial nerve palsy?
Last to recover in a palsy?
- Recurrent Leash of Henry
- Edge of the ECRB
* Arcade of Frohse (most common site, at proximal edge of supinator) and fascial band at the radial head - Distal edge of the supinator
the most common location of spontaneous entrapment is the arcade of Frohse.
distal weakness (no sensory loss; no pain)
Palsy of radial nerve proper (Saturday night palsy) is differentiated from PIN compression by additional weakness of muscles innervated by radial nerve proper (triceps, brachioradialis, ECRL) and sensory disturbances in distribution of SBRN
In PIN palsy, the last muscle to recover is the extensor indicis proprius (EIP).
PIN compression syndrome is a compressive neuropathy of the PIN which affects the nerve supply of the forearm extensor compartment. Diagnosis is made clinically with weakness of thumb and wrist extensors without sensory deficits. Treatment is a course of conservative management with splinting and surgical decompression reserved for persistent cases lasting > 3 months. In PIN palsy, the extensor indicis proprius (EIP) is the last muscle to recover. Surgical decompression of anatomic sites of compression provides good to excellent results for 85% of patient
Radial nerve compression
Radial tunnel syndrome
Wartenberg Syndrome
Radial tunnel syndrome is marked by lateral proximal forearm pain (pain several centimeters distal to lateral epicondyle) rather than distal motor weakness of the hand and wrist
- Sites of compression: Same as in PIN syndrome
- Outcome of surgical decompression less predictable than for PIN syndrome
Cheiralgia paresthetica (Wartenberg syndrome): Compressive neuropathy of SBRN
* Inability to wear wristwatch; pain and paresthesias over dorsoradial hand (SBRN)
Intrinsic plus hand
how is the hand positioned?
What’s the deforming forces causing it?
How to differentiate between intrinsic vs extrinsic tightness
Weak extrinsics & spastic intrinsics → MCP flexion & PIP/DIP extension
Intrinsic tightness: less PIP flexion with MCP extended then with MCP flexed (because intrinsics stretched)
* Bunnell test ddx between intrinsic and extrinsic tightness
* Therapy, distal intrinsic releases
intrinsic minus hand
Whats the deformity?
What causes it?
What’s tight?
Provacative testing?
- MCP hyperextension (strong EDC) & PIP/DIP flexion (strong FDP & FDS)
- Due to ulnar or median nerve palsy (e.g., Volkmann’s ischemic contracture, CMT-PMP22)
- Extrinsic tightness: more PIP flexion with MCP extension than with MCP flexion (would be tough to flex PIPs w/ MPs flexed because tightness puts extrinsics more on stretch)
Imbalance between strong extrinsics and deficient intrinsics is the pathoanatomic process of a claw hand, also called intrinsic minus hand deformity. Intrinsic minus hand posture can result from a variety of causes including ulnar or median nerve palsy, Volkmann’s ischemic contracture, leprosy, hereditary motor-sensory neuropathy, failure to splint a crush-injured hand using intrinsic plus posture, or compartment syndrome of the hand,
Central slip disruption (Boutonniere deformity)
Disruption of the central slip causes?
How to test for it?
Acute injury tx?
Chronic injury tx?
Chronic boutonniere: what’s contracted? tx?
- Central slip normally helps EDC extend PIP Disruption of central slip causes volar migration of lateral bands → PIP flexion & DIP extension due to unopposed pull of lumbricals
- Elson test: with PIPJ flexed to 90°, attempted extension of PIPJ against resistance leads to DIP hyperextension
- Acute injury: extension splinting of PIP x 6 weeks or CS repair
- Open or fx: fix, avulsion: repair
- Chronic: CS reconstruction +/- triangular ligament reconstruction Triangular ligament prevents volar subluxation of lateral bands (attenuation of this & thus volar subluxation of lateral bands with CS injury)
- Transverse retinacular ligament: prevents dorsal subluxation of lateral bands
- Chronic Boutonniere: ORL contracture ORL links PIP & DIP in motion via lateral bands (from volar A2 to dorsal extensor mechanism past PIP)
Qadrigia effect
why does it happen?
most commonly caused by?
how does it present on exam?
treatment?
- Middle-ring-small FDP tendons have common muscle belly, so advancement of one more than 1 cm compromises flexion of others
- functional shortening of FDP tendon due to
1. over advancement during repair >1cm
2. adhesion; retraction of tendon; “over the top FDP repair of distal phalanc after amp - exam: upon making a fist the fingers adjacent to the injured digit will not reach full flexion
- tx observation vs release of FDP of injured digit for severe symptoms
FDP tendons of long, ring, and little fingers share a common muscle belly
therefore excursion of the combined tendons is equal to the shortest tendon
improper shortening of a tendon during repair results in inability to fully flex adjacent fingers.
Quadriga effect is characterized by an active flexion lag in fingers adjacent to a digit with a previously injured or repaired FDP tendon. The cause is attributable to a common muscle belly among the individual FDP tendons. Unlike the flexor digitorum superficialis, which has independent muscle bellies that are NOT interconnected, the FDP tendons share a common muscle belly proximally, and, in addition, have multiple cross-connections between the tendons distally. Hence if one tendon is shortened during repair, it prevents the others from fully flexing during active flexion (the exception here is that the FDP to the index finger is often independent). Diagnosis is made clinically with the inability to fully flex the fingers of the hand adjacent to the injured finger.
Dupuytren’s disease
Benign fibroproliferative disorder that is sometimes inherited and sometimes sporadic
Dominant cell type on histology?
What ligaments are involved?
PIP joint contracture associated with?
NV bundle at risk during surgery because?
Surgical indications(3) and preferred technique?
Complications? (3)
Use of collaganase injection or NA increasing: what to know (3)
Myofibroblasts: Predominant cell type found on histologic analysis of fascia in Dupuytren disease
* Increase in ratio of type III to type I collagen
* Cleland (dorsal) ligaments are not involved; Grayson (volar) ligaments are involved.
* spiral cord is most clinically relevant and displaces NV bundle centrally/superfiscial
* PIP contracture: Associated with spiral cord
* Neurovascular bundle at risk during surgery from central and superficial displacement
* Surgical indications: Inability to** place hand flat on tabletop (Hueston test), MCP flexion contracture greater than 30 degrees, any PIP flexion contracture**
* Open limited fasciectomy is preferred technique.
* Complications: Recurrence (most common), digital nerve injury, wound breakdown
- Use of collagenase injection or NA is increasing:
- Pooled study results show average** MCP correction up to 85% and PIP correction up to 60%.**
- **Pain, swelling, and bruising **are likely temporary adverse effects of injection.
- Skin tears are more common complication than flexor tendon rupture.
Collagenase Clostridium Histolyticum (CCH), CCH has little effect against type IV collagen, which forms the basement membrane of nerves and blood vessels. : CCH is most effective against types I and III collagen. Pruritic rash and axillary lymphadenopathy is particular only to collagenase injections (CI)
peds trigger thumb and finger
How does peds trigger thumb present? pathognomonic finding? tx?
What’s at risk during release?
Peds trigger finger: whats the pathology? treatment?
Pediatric trigger thumb: Fixed flexion deformity of thumb IP joint; Notta node pathognomonic
* Treatment involves A1 release at 2–4 years of age
* Radial digital nerve is in danger during release.
Pediatric trigger finger (less common than trigger thumb): Aberrant anatomy
* Notta’s node (proximal to A1 pulley), surgery 2-4 years old to prevent contracture
* Treated with A1 pulley release and procedures to address aberrant anatomy (e.g., FDS ulnar slip excision), may need to release FDS slip and A3 pulley
Trigger finger in the child may be associated with a more proximal decussation of the FDS tendon, nodules in either the FDS or FDP tendon, a thickened A-2 pulley, or a tight A-3 pulley. Illustration A shows normal decussation of the FDS tendon near the level of the A2 pulley. The FDS decussation may be found to be more proximal in pediatric trigger fingers, necessitating release.
Intersection syndrome
where does it occur?
who gets it?
exam finding?
tx?
At junction of first and second extensor compartments; rare (less common than deQuervain’s)
rowers, repetitive risk extension
- exam: TTP several centimeters proximal to the wrist joint over the dorsum of the forearm which is worse with resisted wrist and thumb extension. crepitus when flexing and extending the wrist
- Treatment nonoperative in vast majority
- rest, wrist splinting, CSI
- CSI in 2nd dorsal compartment (ECRL, ECRB)
Surgical release 5-6 cm proximal to wrist if non op fails
De Quervain tenosynovitis should be distinguished from the less common intersection syndrome, which causes pain and crepitus proximally and more dorsally between the 1st and 2nd dorsal compartments. Repetitive motion results in friction at the crossover junction of the 1st and 2nd dorsal compartments,
friction leads to and inflammatory response and subsequent tenosynovitis. Repetitive wrist extension tends to worsen symptoms as this causes increased irritation where the 1st compartment tendons (abductor pollicus longus, extensor pollicus brevis) cross under the tendons of the 2nd dorsal compartment (extensor carpi radialis longus/brevis)
Dorsal compartments
Correlating Dorsal compartment pathology that can occur their?
Dorsal compartments radial->ulnar:
1st dorsal compartment (APL—volar in compartment, EPB); De Quervain’s APL & EPB: PIN (branch of radial nerve [C7 & C8) of posterior cord)
2nd dorsal compartment (ECRL, ECRB); 2 dives under 1 at level of wrist; IS
3rd dorsal compartment (EPL); Listers tubercle;Drummer’s wrist, traumatic rupture w/ non op DRFx
4th dorsal compartment (EIP, EDC, PIN), Extensor tenosynovitis
5th dorsal compartment (EDM): Vaughn-Jackson (rupture in RA)
6th dorsal compartment (ECU) : Snapping ECU
DIP arthritis
what are the nodules called?
What are they associated with ? and what’s the treatment?
What’s the best tx for continued pain, instability, or deformity?
DIP joint
* Presentation: Often asymptomatic despite radiographic changes
* Heberden nodes: Marginal DIP osteophytes
* May be associated with symptomatic mucous cyst
* Aspiration (DON’T do) versus excision of cyst and osteophyte if symptomatic ± local rotational skin flap
* Arthrodesis: Kirschner wires or headless cannulated screw (has highest fusion rate (nonunion in 10%))
* fuse 2 &3 in extension
* fuse 4 &5 in 10-20 of flexion
Kienbock’s disease
AVN of Lunate leading to progressive wrist pain and abnormal carpal motion.
Biomechanical Factors?
CT is best for identifying?
Peds tx?
Adult w/ pre-collapse or early collapse?
Adult w/ advanced collapse?
Lichtman classification directs treatment:
- ulnar negative variance (increased radiolunate contact stress), Type I lunate, decreased radial inclination, repititive trauma
- CT for identifying lunate collapse
- Peds: temporary STT pinning
- Adult w/ early collapse:
- negative ulnar variance: radial shortening osteotomy
- normal ulnar variance: distal radius core decompression (thought to activate healing/revascular response in lunate)
- adult with advanced collapse/arthritis: Proximal row carpectomy, limited or total wrist arthrodesis, total wrist arthroplasty
Kienböck disease (idiopathic osteonecrosis of the lunate): Most common in young men; manifests as atraumatic dorsal wrist pain and decreased grip strength
* Unexplained dorsal wrist pain in a young adult with negative ulnar variance should prompt MRI evaluation
Ulnocarpal abutment syndrome
neutral vs postive ulna variance: % load through radius, % ulna?
Increased with what hand movement?
positioning for xrays to assess for variance?
If no DRUJ arthritis, surgery?
If DRUJ arthritis in low demand surgery is?
If DRUJ arthritis in manual laborer, high demand?
- neutral: 80% radius, 20% ulna
- Positive ulnar variance: greater load through ulna (increases up to 40%) →abutment between ulnar & lunate.
- Increases w/ closed fist grip & wrist pronation
- Xrays to assess ulnar variance: forearm in zero rotation by abducting shoulder 90° & flexing elbow 90°
- After failing nonoperative treatment, if there is no DRUJ arthritis: ulnar shortening osteotomy
- If there is DRUJ arthritis:
- Low-demand patient: Darrach (ulnar head resection)
- Manual laborer, high-demand patient: Sauve-Kapandji or ulnar hemiresection arthroplasty with TFCC repair/reconstruction
SLAC: Scapholunate advanced collapse
What is it?
Xray findings?
What jt is no involved?
What ligament provides greatest constraint to translation between scaphoid and lunate?
What ligament needs to be preserved during PRC?
- specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and the lunate.
- Radiolunate joint is usually not involved
- dorsal scapholunate interosseous ligament
- Preserving radioscaphocapitate (RSC) ligament is essential to prevent ulnar subluxation (carpal instability if compromised)
- PRC is contraindicated if there is capitolunate arthritis (stage III)
- Advantage to PRC: no need for as much immobilization, no risk of nonunion or hardware complications
Watson classification
describes predictable progression of degenerative changes from the radial styloid to the entire scaphoid facet and finally to the unstable capitolunate joint, as the capitate subluxates dorsally on the lunate. (1) radial styloid and scaphoid, (2) entire radioscaphoid, (3) capitolunate.
The stability of the scapholunate joint relies on the integrity of the scapholunate interosseous ligament (SLIL). The SLIL has three components, dorsal, proximal, and volar. It is C-shaped, and the dorsal component is the thickest/strongest. Disruption of the SLIL leads to scapholunate dissociation, which causes the scaphoid to flex volarly and the lunate to extend [described as dorsal intercalated segment instability (DISI)]. If left untreated, a DISI deformity can progress into a SLAC wrist.
The radioscaphocapitate ligament is the prime stabilizer between the radius and capitate, preventing ulnar translocation of the carpus. Its oblique orientation prevents the carpus from drifting ulnarly. This stout ligament must be protected when excising the scaphoid.
Radial Club hand
due to defect of ?
most cases are due to what kind of mutuation?
must order?
How to differentiated the causes (3)
if active elbow flexion (intact biceps)?
What do you do for thumb hypoplasia?
peds syndrome
- apical ectodermal ridge
- most due to spontaneous mutation, Sonic Hedgehog gene
- CBC, renal ultrasound, and echocardiogram
- If active elbow flexion (intact biceps function) → ulna centralization & tendon transfers to balance carpus on ulna at 6-12 months of age (Patients born with bilateral radial clubhands may have difficulty getting their hands to their mouth. The centralization procedure would take away that ability if there is a lack of elbow flexion)
- Thumb hypoplasia: CMC stability determines thumb reconstruction with opponensplasty (stable CMC) vs ablation & pollicization (unstable CMC)
pre-axial deficiency usually with complete absence of the thumb. The condition is thought to be caused by an injury to the formation of the apical ectodermal ridge early in embryology. It is not an inherited condition unless it is associated with other syndromic problems. It is not known to be associated with specific teratogens.
TAR- AR, thumb present, thrombocytopenia
Fanconis anemia: AR, aplastic anemia, Fanconi screen, chromosomal breakage test, tx with bone marrow transplant
Holt-Oram: “holter monitor” get echo, “Defib” autosomal Dominant
Madelung’s deformity
what is it?
leads to?
caused by?
what syndrome is it associated with?
tx?
- dyschondrosis (disruption) of volar & ulanr aspects of distal radial physis
- leads to increased volar tilt and radial inclination; ulnar impaction
- Vicker’s ligament: radiolunate ligament (fibrous band DR to Lunate on volar surface)
- abnormal SRL
- Leri-Weill dyschondrosteosis: SHOX mutation; bilateral
- obs if asymptomatic
- surgery: phsysiolysis (bar resection and fat grafting in the physis) with release of vickers ligament for wrist pain or decreased ROM
- radial correcive osteomy +/- distal ulnar shortening osteotomy
asymptomatic until adolescence, symptoms of ulnar impaction, median nerve irritation.
congenital radial ulnar synostosis
- embryology: forearm begins as single carilainous anlage and divides from ? in ? week in utero? This condition is caused by ?
- forearm is often fixed in? how does the shoulder compensate?
- what are the two surgical considerations?
- divides from distal to proximal into the radius and ulna in 7th week
- ** failure of differentiation(segmentation)** results in synostosis
- forearm is fixed in pronation, shoulder abducts to compensate for lack of pronation; shoulder adduction for supination compensation
- consider surgery if functional impairment or bilateral involvement:
*** excision of synostosis with vascularized fat pad interposition ** to restore active forearm roation - excision alone or interposed anconeus muscle results in nearly 100% recurrence of synostosis.
- forearm derotation osteotomy: to place arm in more functional resting position. Perform between 3-6. Unilateral: 0-30 deg pronation. Bilateral finx dominant in 0-15 prnation and nondominant in neutral
familial cases with autosomal dominant inheritance associated with chromosomal abnormalities, particularly duplication of sex chromosomes 20% with positive family history
Klinefelter’s xxy
digital flexion deformity that usually occurs in the PIP joint of the small finger, what’s the dx?
the treatment is based on what exam finding?
most common tx? ie the answer?
whats the operative tx?
what’s the random associated syndrome?
- DX: Camptodactyly
- PIP flexion deformity of small finger: progressive stretching & static splinting
- is it a fixed or flexible deformity?
- nonop for most cases, best for PIP contracture less than 30
- FDS tenotomy +/- FDS transfer (to radial lateral band if full active PIP ext can be achieved with MCP flexion): progressive deformities
- camptodactyly-arthropathy-coxavara-pericarditis syndrome (CACP)
most common form: Isolated anomaly of little finger, presents ininfancyand affects males and females equally, tx: stretching/splinting
Poland syndrome
congenital disorder characterized by? theory?
tx?
Peds Syndrome
- unilateral Hypoplasia of hand and forearm
- symbrachydactyly, absent or/and shortening of middle fingers
- unilateral chest wall hypoplasia (pect major)
- theory:disruption of the subclavian artery in utero, causing various hypoplastic anomalies of the upper extremity.
- tx: syndactyly release- produces skin deficiency that requires skin grafting
POland- POHand
hyPOplasia of chest wall (Pect Major) and hand/arm
Apert syndrome
syndrome characterized by?
inheritance, mutation?
* bilateral complex syndactyly of hands and feet
* symphalangism
* premature fusion of sutures (cranial synotosis) flattened skull and broad forehead
* increased distance between eyes (hyperEtolerism)
* glenoid hyperplasia, radioulnar synotosis
Genetics: AD, most new cases are sporadic, FGFr2 gene
symbrachydactyly
tx: surgical release of borer digits at 1 year; digital reconstruction at 1.5 years to convert central 3 digits into two digits
prognosis: Spectrum of normal to moderately disabled cognitive function
The “rosebud” hand is a complex syndactyly that affects the index, middle and ring fingers most commonly. Hypertelorism is exemplified with increased distance between the eyes; additionally, acrocephaly is noted with forehead broadening and skull flattening.
Polydactyly
what are the 3 forms: pre, post, central?
preaxial polydactyly: thumb duplication
* causian
* reconstruction: respect smaller thumb usually radial thumb preserve intrinsic tneond & collateral ligament insertions
postaxial polydactyly: adjacent to smaller finger duplication
* blacks (10X more common), AD inheritance
* post axial polydactyly in whites requires a work up
central polydactyly:
commonly associated with syndactyly, extra digit may lead to angular deformity or impaired motion
post axial: more complex genetics in caucasians
thorough genetic workup should be performed to evaluate for chondroectodermal dysplasia or Ellis-van Creveld syndrome
thumb hypoplasia
congenital underdevelopment of the thumb frequently associated with ?
what anomalies to look at ?
treatment algorithm depens on presence of ?
- congenital underdevelopment of the thumb frequently associated with partial or complete absence of the radius.
- greater than 80% of patients will have associated anomalies including VACTERL Holt-Oram thrombocytopenia-absent radius (TAR) Fanconi anemia
- CMC joint stability must be sufficiently stable to provide resistance during grasp and pinch. This is the main determinant of the feasibility of reconstruction of the hypoplastic thumb.
- If CMC stability is deficient, then ablation and pollicization is preferred
peds trigger thumb
flexion deformity in a kid at the IP jt of the thumb? whats the pathology driving this?
initial treatment?
what if non op fails, at what age do you perform release?
Prognosis/natural history:
- flexor pollicis longus (FPL) tendon is thickened due to abnormal collagen degeneration and synovial proliferation, increased FPL tendon diameter, compared to the A1 pulley, causes disruption of normal tendon gliding
- prominence of the flexor tendon nodule, referred to as “Notta’s node”
- Tx: passive extension exercises, intermittent extension splinting and observation, 30-60% will resolve spontaneoulsy by age 2, only 10% will resolve after 2
- A1 pulley release: indicated for fixed deformed beyond 1 year old and failed conservative therapy
Natural history usually begins with notable thumb triggering that progresses to a fixed contracture spontaneous resolution unlikely after age of 2 years old
hypothenar hammer syndrome
what is it?
what tests?
tx?
- post-traumatic digital ischemia from thrombosis of the ulnar artery at Guyon’s canal.
- occupations using vibrating tools such as carpenters, machinists, mechanics
- Doppler U/S 1st!, digital-brachial index less than 7 needs reconstruction
tx: lifestyle modifications, symptomatic treatment, and vascular consult indications thrombosis without aneurysm > 2 weeks
surgery:
* endovascular fibrinolysis: thombosis w/o aneurysm less than 2 weeks.
* excision of involved segement and reconstruction, if DBI less than 7
* arterial ligation if DBI greater than 7
- Hypothenar hammer syndrome is post-traumatic digital ischemia from thrombosis of ulnar artery at Guyon’s canal and is associated with the use of vibrating tools (e.g. mechanics, construction workers). The hamate hook functions as an anvil, leading to ulnar artery aneurysms, which may cause thrombosis. The digital brachial index (DBI) is a good predictor of outcome and treatment. DBI of 0.85 to 1.25 is normal. If the DBI > 0.7, there are minimal symptoms, the digit is viable, surgery is not warranted. If the DBI < 0.7, arterial reconstruction is suggested. DBI < 0.5 is associated with severe symptoms and digital gangrene.
- Hypothenar hammer syndrome: Most common posttraumatic vascular occlusive condition of the upper extremity; involves the ulnar artery in the proximal palm
- Diagnosis: Noninvasive vascular studies or arteriography
- Treatment: Resection of the thrombosed segment, interposition vein graft or arterial conduit (better patency rate)
what is the allen test?
Allen test is used to determine the presence or absence of a complete arterial arch in the palm.
* Approximately 20% of hands have an incomplete arch.
* Ulnar arch mainly supplies superficial palmar arch, and radial artery mainly the deep palmar arch.
wrist scope
gold standard for dx of?
what’s the first portal?
most common complication?
- Wrist arthroscopy: Gold standard for diagnosis of ulnar-sided wrist pain
- 3,4 ortal just distal 1cm to Lister’s
- Most common complication: Injury to superficial sensory nerves
- dorsal sensory branch to ulnar 6 R portal (8mm)
- Superfiscial sensor branch of radial nerve (16 mm) from 3-4 portal
- 1-2 portal is placed between the ECRB and APL. Care must be taken when accessing this portal, due to reported injuries to the superficial branch of the radial nerve, as well as radial artery.
view of the radiocarpal jt from 34 portal, looking volarly and radially*
The radioscaphocapitate ligament is a volar capsular structure running obliquely from the radial styloid to the scaphoid waist, ultimately inserting on the proximal radial aspect of the capitate.
The radioscaphocapitate ligament is important in preventing ulnar translocation of the carpus.
nerve repair
nerve injury
nerve transfers
electrodiagnostic testing
provacative testing
sensory testing
