Hand Flashcards
What is the pathologic cell type in Dupuytren’s?
Myofibroblasts; abundance of type III collagen
What collagen type is pathologic in Dupuytren’s?
Type III collagen
[…] branch of ulnar nerve lies under the hook
deep motor
[…] view is the best radiograph to see hook of hamate fracture
carpal tunnel view
Hook of hamate excision leads to 5 mm of ulnar displacement of small finger […] tendon
FDP
hook of hamate should be removed […] to avoid damage to motor branch of ulnar nerve
subperiosteally
What is the insertion of ECRL?
base of 2nd metacarpal
What is the insertion of ECRB?
base of 3rd metacarpal
What is the insertion of ECU?
base of 5th metacarpal
What is the insertion of abductor pollicis longus?
trapezium and base of 1st metacarpal
What is the insertion of opponens pollicis
1st metacarpal
What is the insertion of opponens digiti minimi?
medial surface of metacarpal V
Shortening of metacarpals may be prevented by […] ligaments in isolated fracture of the 3rd or 4th metacarpal shafts
transverse intermetacarpal
What is an acceptable shaft angulation for an index or long finger metacarpal fracture?
10-20 degrees
What is an acceptable shaft angulation for a ring finger metacarpal fracture?
30 degrees
What is an acceptable shaft angulation for a small finger metacarpal fracture?
40 degrees
What is acceptable metacarpal shaft shortening for all metacarpal fractures?
2-5 mm
What is an acceptable neck angulation in an index or long finger metacarpal neck fracture?
10-15 deg
What is an acceptable neck angulation in an ring finger metacarpal neck fracture?
30-40 deg
What is an acceptable neck angulation in an small finger metacarpal neck fracture?
50-70 deg
In a middle phalanx fracture with apex dorsal, the fracture is […] to FDS insertion
proximal
In a middle phalanx fracture with apex volar, the fracture […] to FDS insertion
distal
In displacement of proximal phalanx fracture, proximal fragment flexed due to […], and the distal fragment extends due to […]
interossei; central slip
In the blood supply to the fingers, the dominant artery found on […] side of phalanges
median (more midline)
The digital nerves are […] to the digital arteries
volar
A volar middle phalanx base fracture is due to avulsion of […]
volar plate
A dorsal middle phalanx base fracture is due to avulsion of […]
central tendon
Volar middle phalanx fractures are unstable if greater than […] percent articular surface involved
40
Proximal phalanx fractures can be treated with buddy taping if extraarticular fractures with less than […] degrees angulation or less than […] shortening and no rotational deformity
10; 2 mm
Middle phalanx fractures can be treated with buddy taping if extraarticular fractures with less than […] degrees angulation or less than […] shortening and no rotational deformity
10; 2 mm
In treatment of middle phalanx fractures, hemi-hamate arthroplasty has shown to be a successful treatment option in those with great than […] percent articular involvement
50
What is the most common complication following hand phalanx fractures?
loss of motion
In hand phalanx fractures, apex volar angulation effectively shortens extensor tendon and limits extension of […] joint
PIP
Flexor tendon healing occurs via an […] and […] pathway
intrinsic; extrinsic
In intrinsic flexor tendon healing, the healing is produced by […] within the tendon
tenocytes
In extrinsic flexor tendon healing, the healing is stimulated by surrounding […] and inflammatory cells
synovial fluid
Which flexor tendon healing pathway is implicated in scarring and adhesion formation?
Extrinsic
During which phase of tendon healing is linear collagen formation seen?
remodeling
During which phase of tendon healing does the tendon tolerate active range of motion?
remodeling
The remodeling phase of tendon healing occurs during which time frame?
> 28 days
During which phase of tendon healing is disorganized collagen seen on histology?
fibroblastic
What is the innervation of FDS?
Median nerve
What is the most radial structure in the carpal tunnel?
FPL
[…] closest flexor tendon to the median nerve
FCR
What is the insertion of FCR?
base of 2nd metacarpal
What is the insertion of FCU?
pisiform, hook of hamate, and the base of the 5th metacarpal
[…] located at the level of the proximal phalanx where FDP splits FDS
Camper’s chiasm
Which annular pulleys arise from the periosteum?
A2 and A4
Which annular pulleys arise from the volar plate?
A1, A3, A5
The […] pulley is the most important pulley to prevent flexor tendon bowstringing of the thumb
oblique
In Zone […] FDP and FDS are in same tendon sheath
2
In a zone II flexor tendon injury, the tendons can retract if the […] are disrupted
vincula
The carpal tunnel is in which flexor tendon zone?
4
In a zone 4 flexor tendon injury, the transverse carpal ligament should be repaired in a […] fashion if tendon bowstringing is present.
lengthened
Flexor tendon repair and controlled mobilization is indicated in flexor tendon lacerations greater than […] percent of tendon width
60
Flexor tendon laceration can be treated non operatively if the laceration is less than […] percent of the tendon width
60
In flexor tendon repair, the […] is more important than the number of grasping loops
number of core suture strands that cross the repair site
[…] core strands provide adequate strength for early active motion in repair of flexor tendon injuries
4-6
In flexor tendon repairs, circumferential epitendinous sutures improves strength of repair by add […] percent to tensile strength
20
In flexor tendon repairs, the ideal core suture purchase is […] mm from cut edge
10
Pulley management in flexor tendon repairs demonstrates […] percent of A2and […] percent of A4 can be incised with little resulting functional deficit
25; 100
In zone 2 FDS injuries, repair of […] improves gliding compared to repair of […]
one slip; both slips
Flexor tendon repairs are weakest between postoperative days […]
6-12
Flexor tendon repair site gaps greater than […] mm are associated with an increased risk of repair failure
3
What is the safe dose of epinephrine injection in the fingers?
1:400,000 to 1:100,000 is safe; 1:100,000 is used
In timing for tenolysis following flexor tendon repair, wait for soft tissue stabilization (great than […] months) and full passive motion of all joints
3
Tendon adhesions following flexor tendon repairs is highest in zone […] injuries
II
In re-ruptures of flexor tendon repairs, if less than […] of scar is present, resect the scar and perform primary repair
1 cm
What is the most common anatomic location for a scaphoid fracture?
Waist
What is the blood supply to the scaphoid?
dorsal carpal branch (branch of the radial artery)
The dorsal carpal branch enters scaphoid in a nonarticular ridge on the […] surface and supplies proximal 80% of scaphoid via retrograde blood flow
dorsal
A minor blood supply to the scaphoid is the […] (branch of volar radial artery)
superficial palmar arch
Scaphoid fractures managed with immobilization and have less than […] mm displacement have union rate of 90%
1
Scaphoid fixation with percutaneous screw is indicated with displacement greater than […] but without significant angulation or deformity
1 mm
Percutaneous screw fixation of a non displaced scaphoid waist fractures […] time to union
decreases
Percutaneous screw fixation of a non-displaced scaphoid waist fracture […] return to work/play
faster
Percutaneous screw fixation of a non-displaced scaphoid waist fracture has […] cost to casting
equivalent
Open reduction of scaphoid fractures is indicated when there is a […] degree scaphoid humpback deformity
15
A […] approach is best for proximal pole scaphoid fractures
dorsal
A […] approach is indicated in scaphoid waist and distal pole fractures
volar
A […] approach is indicated in scaphoid fractures with humpback flexion deformities
volar
A volar approach to the scaphoid uses the interval between […]
FCR and radial artery
Higher rates of scaphoid nonunion is seen in […] pole fractures
proximal
Scaphoid fracture displacement greater than […] is a risk factor for nonunion
1 mm
A scaphoid humpback malunion is caused by the […] ligament
scapholunate interosseous
What is the innervation of ECU?
PIN
In a 5th carpometacarpal joint (CMCJ) dorsal fracture-dislocation, the 5th metacarpal is displaced dorsally and proximally by the pull of the […] muscle
extensor carpi ulnaris (ECU)
At the DIP and PIP joints, accessory collateral ligament inserts onto the […]
volar plate
At the […], the volar plate forms two checkrein ligaments
PIP joint
At the PIP joint, the volar plate forms two […] ligaments
checkrein
In the hand, the central slip inserts inserts on dorsal base of […] phalanx
middle
The Elson test assess the integrity of the […]
central slip
PIP dorsal dislocations can lead to a […] deformity
swan neck
PIP volar dislocations can lead to a […] deformity
boutonniere
Dorsal PIP dislocations result in shearing off the volar plate from the […] phalanx
middle
In a rotational and volar PIP dislocation, one of proximal phalangeal condyles buttonholes between the […] and […]
central slip; lateral band
In a simple volar PIP dislocation, the […] ruptures
central slip
If a PIP joint dorsal dislocation is unstable after reduction apply a […] splint
extension blocking
For volar PIP dislocations, apply a […] spilnt for 6-8 weeks
extension
In closed dorsal PIP dislocations, reduction is usually prevented by […] interposition
volar plate
In open dorsal PIP dislocations, reduction is usually prevented by […]
FDP tendon
In lateral PIP dislocations, reduction is usually prevented by […] interposition
lateral band
In PIP dislocations, a swan neck deformity occurs secondary to a […] injury
volar plate
In PIP fracture dislocations, if greater than […] percent of of P2 articular surface is involved, the fracture is considered unstable
50
PIP fracture dislocations can be treated with closed reduction and splinting if less than […] percent of the articular surface is involved
40
In closed dorsal DIPJ dislocation, […] interposition is most common block to reduction
volar plate
The […] demarcates the sterile from germinal matrix beneath the nail
lunula
A volar Moberg advancement flap can be used if a volar thumb defect is less than […]
2 cm
A volar thumb soft tissue injury with less than a 2 cm defect can be treated with a […] flap
volar Moberg advancement
Volar thumb injuries with greater than 2 cm defect are treated with a […] flap
FDMA
A FDMA flap is used to treat volar thumb soft tissue defects measuring greater than […]
2 cm
A dorsal thumb soft tissue defect requiring coverage is treated with a […] flap
FDMA
Straight or dorsal oblique finger tip lacerations can be treated with a […] flap
V-Y advancement
A reverse cross finger flap is indicated in adults with […] lacerations
dorsal finger & MCP
Thenar flaps can be used in volar oblique finger tip lacerations to index or middle finger in patients less than […] years
30
Ring finger injuires in zone II have better cosmesis and grip strength with what treatment?
4th ray resection and 5th ray transposition
Ring finger injuires in zone II have better […] and […] with 4th ray resection and 5th ray transposition
cosmesis; grip strength
What is the warm ischemia time distal to the carpus?
12 hours
What is the cold ischemia time distal to the carpus?
24 hours
In replantations, pulse oximetry less […] percent indicates potential vascular compromise
94
In fingertip replantations, […] secondary to vasospasm is most common cause of early replant failure
thrombosis
In leech therapy, what bacterial infection can occur
Aeromonos hydrophila
What prophylactic antibiotics are used in leech therapy?
Ciprofloxacin or Bactrim
What is the MOA of ciprofloxacin?
inhibits DNA gyrase (topoisomerase II and topoisomerase IV)
Replantation failure is most frequently caused within 12 hours by […] from persistent vasospasm
arterial thrombosis
Replanted digits have […] percent of total motion
50
Following finger replantation surgery, […] is most common secondary surgery
tenolysis
In reperfusion injury, the mechanism thought to be related to ischemia-induced […] conversion to […]
hypoxanthine; xanthine
What is the best adjunctive therapy agent to treat reperfusion injury?
allopurinol
What is the antidote to epinephrine vasoconstriction in the digits?
Phentolamine
What approach is used in proximal pole scaphoid fracture ORIF?
dorsal approach
Displaced scaphoid distal pole and waist fractures are typically approached […], especially if there is a humpback deformity;
volarly
A partial laceration (up to 75%) of a flexor tendon has been shown to effectively be repaired without gap formation with […] repair.
an epitendinous only; (ie no core strands)
Volar thumb defect <2 cm can be best covered with a […] flap.
Moberg advancement volar
Dorsal thumb laceration with exposed tendon would be most appropriately treated with a […] flap
first dorsal metacarpal artery
On NCS, distal sensory latency of greater than […] are abnormal for CTS
3.2 ms
On NCS, motor latencies […] are abnormal for CTS
4.3 ms
Proximal injuries to the ulnar nerve may benefit from […] transfer of the AIN to deep motor branch of ulnar nerve to improve early hand intrinsic function
end-to-side
Proximal injuries to the ulnar nerve may benefit from end-to-side transfer of the […] to deep motor branch of ulnar nerve to improve early hand intrinsic function
AIN
Proximal injuries to the ulnar nerve may benefit from end-to-side transfer of the AIN to […] branch of ulnar nerve to improve early hand intrinsic function
deep motor
In order to improve shoulder abduction and external rotation, a […] nerve transfer to suprascapular nerve can be performed
spinal accessory nerve (CN XI)
A […] branch of radial nerve to axillary nerve transfer can be performed to improve shoulder abduction and flexion.
medial triceps motor
To improve elbow flexion, an Oberlin transfer of […] branch of ulnar nerve to biceps brachii branch of musculocutaneous nerve can be performed
FCU motor
To improve shoulder external rotation, the […] can be transferred to infraspinatus
lower trapezius
To improve thumb opposition in median nerve neuropathy, an […] to APB transfer can be performed
EIP
To improve thumb flexion in a median nerve neuropathy, a […] to FPL transfer can be performed
Brachioradialis
In nerve grafting, create tension-free repair by using a graft that is at least […] percent longer than gap
10
Autologous nerve graft is gold standard for defects greater than […]
5 cm
In nerve grafting, conduits made up of type I collagen rely on […] formation to serve as a scaffold for host cell Schwann cells to build upon
fibrin clot
Free tissue transfer within[…] daysfor severe trauma in the upper extremity has been shown to decrease complication rates
7
Complete disruption of arteriolar flow to the carpal tunnel occurrs at […] mmHg
60-80
Most commoncause of idiopathic CTS is […]
inflamed synovium
Carpal tunnel borders include the […] and […] radially
scaphoid tubercle; trapezium
Carpal tunnel borders included the […] and […] ulnarly
hook of hamate; pisiform
What is the most radial structure in the carpal tunnel?
FPL
On US, increased cross-sectional area (CSA) of the median nerve greater than […] at the level of the pisiform/proximal edge of transverse carpal ligament is associated with CTS
> 10mm²
Long term resultsof endoscopic carpal tunnel release are […] compared to open CTR
equivocal (the same)
In carpal tunnel release, grip strength is expected to return to 100% preoperative levels by […] weeks postop
12
Are prophylactic antibiotics, systemic or local, indicated for patients undergoing a clean, elective carpal tunnel release?
No
Kaplan’s cardinal line approximates the […] arch
superficial palmar
What is the most common complication following carpal tunnel release?
Scar tenderness
Is injury to the recurrent motor branch of the median nerve high in open or endoscopic CTR?
open
What is the most common site of entrapment in cubital tunnel syndrome?
between FCU heads
EMG/NCS with conduction velocity less than […] m/sec across elbow is diagnostic for cubital tunnel syndrome
50
Iatrogenic injury to a branch of the […] nerveduring cubital tunnel release may cause persistent posteromedial elbow pain
medial antebrachial cutaneous
The medial antebrachial cutaneous nerve crosses the field […] cm distal to the medial epicondyle
3
What is the most common etiology of ulnar tunnel (Guyon’s canal) syndrome?
ganglion cyst
What structure makes up the floor of Guyon’s canal?
Transverse carpal ligament
What structure makes up the roof of Guyon’s canal?
Volar carpal ligament
What structure makes up the radial border of Guyon’s canal?
hook of hamate
What structures makes up the ulnar border of Guyon’s canal?
pisiform, pisohamate ligament, abductor digiti minimi muscle
What is the inheritance pattern of Dupuytren’s disease?
autosomal dominant with variable penetrance
What pathologic cells are seen in Dupuytren’s?
myofibroblasts
In Dupuytren’s myofibroblasts differ from fibroblast as the myofibroblast has intracellular […] aligned along long axis of cell
actin filaments
In Dupuytren’s, adjacent myofibroblasts connect via extracellular […] to act together to create contracted tissue
fibronectin
In Dupuytren’s there is an increase in ratio of type […] to type […] collagen
type 3 to type 1
Garrod disease is an ectopic presentation of what disease?
Dupuytren’s
What are Garrod’s nodes seen in Dupuytrens?
knuckle pad disease
A spiral cord in Dupuytren’s typically inserts distally into the lateral digital sheet then into […] ligament
Grayson’s
A spiral cord in Dupuytren’s travels […] the neurovascular bundle displacing it central and superficial
under
A spiral cord in Dupuytren’s displaces the neurovascular bundle […] and […]
central (midline); superficial
A central cord in Dupuytren’s causes a […] joint flexion contracture
MCP
Which two fancy hand ligaments in the digits are not involved in Dupuytren’s disease?
Cleland’s and transverse ligament
What injectable can be used in the treatment of Dupuytren’s disease?
collagenase clostridium histolyticum (CCH) injections
Partial palmar fasciectomy for Dupuytren’s is indicated in MCP flexion contracture greater than […] degrees
30
Collagenase injections for Dupuytren’s selectively target collagen types […]
I and III
Collagenase for Dupuytren’s haslow activity against type […] collagen(in basement membrane of blood vessels and nerves) explaining the low neurovascular complication rate
IV
Following partial fasciectomy for Dupuytren’s, early active range of motion starting postoperative day […] is commenced.
5-7
Basilar Thumb Arthritis is caused by attenuation of the […] ligaments
volar beak (aka anterior oblique) and dorsoradial
Concomitant MCP […] deformity can be seen in basilar thumb arthritis
hyperextension
Concomitant carpal tunnel syndrome can be seen in up to […] percent of basilar thumb arthritis
50
What tendon runs through the palmar groove seen on the trapezium?
FCR
The […] ligament is the primary stabilizing static restraint to subluxation of CMC joint
anterior oblique volar beak
Stage I of first CMC arthritis is defined as joint space […]
widening
CMC thumb arthrodesis for CMC arthritis in which patient population?
Stage II-III in young male laborers
[…] tendon most commonly used in LRTI to suspend 1st metacarpal, can also use […] or […] for suspension
FCR; ECRL; APL
In treatment of MCP hyperextension seen in basilar thumb arthritis, fusion is indicated for MCP hyperextension greater than […] degrees
40
Biomechanical factors thought to be associated with Kienbock’s disease include […] ulnar variance and […] radial inclination
negative; decreased
Which imaging modality is most useful once lunate collapse has already occurred?
CT
An adolescent with radiographic evidence of Kienbock’s and progressive wrist pain can undergo temporary […] pinning
scaphotrapeziotrapezoidal
Which vascularized graft provides the greatest arc of motion of the most commonly used arterial pedicles for Kienbock’s disease?
4th + 5th extensor compartmental artery
Chronic SL ligament injury creates a […] deformity
DISI
In a DISI deformity, the scapholunate angle is greater than […] degrees
70
In a SLAC wrist, the first joint affected is the […] joint
radioscaphoid
Which joint is spared in a SLAC wrist?
radiolunate
In a SLAC wrist, initially the radioscaphoid joint is affected and progresses to […] joint
capitolunate
In a SLAC wrist, the capitate subluxates […] on the lunate
dorsally
In a SLAC wrist, PA radiograph will reveal greater than […] diastasis between the scaphoid and lunate
3mm
The […] ligament should be preserved to prevent ulnar subluxation after proximal row carpectomy
radioscaphocapitate
PRC is excision of which bones?
scaphoid, lunate, triquetrum
A PRC is contraindicated with […] arthritis
caputolunate
A scaphoid excision and 4 corner fusion is contraindicated with […] arthritis
radiolunate facet
[…] gives best pain relief and good grip strength at the cost of wrist motion
Wrist fusion
A free antegrade lateral arm flap (LAF) is supplied by […] artery
posterior radial collateral
What is the innervation of adductor pollicis?
deep branch of the ulnar nerve
What is the innervation of opponens pollicis?
recurrent motor branch of the median nerve
Carpal tunnel release (CTR) has shown increased patient-reported outcomes compared to conservative management at […] and […] months.
6; 12
A motor conduction velocity of less than […] m/s is considered abnormal for carpal tunnel
52
Injury to the […] nerve in CTR leads to a lumbrical minus deformity of the index finger due to lumbrical weakness.
proper digital nerve of the index finger
