Hand Flashcards
What is the most common type of Ulnar duplication?
Type one, which is a soft tissue nubbin with a skin bridge and small neurovascular bundle
Which thumb is usually removed in reconstruction of duplicated thumb
The one on the pinky side is preserved, and the radial partner is removed to preserve the UCL ligament
What webspace is usually more commonly involved in syndactyly?
The third webspace
Describe the embryological timing of digital separation
The upper limb forms around four weeks of gestation.
Bones begin to appear at five weeks.
Digital rays form at six weeks. Next line rays begin to separate at seven weeks.
By the end of the eighth week digital separation is complete.
What is clinodactyly?
It is a deviated digit can be due to a delta phalanx
What is camptodactyly?
It is a bent digit usually involving the PIP joint of the fifth digit
When is it appropriate to release camptodactyly
Usually patients should be stretched and splinted. Surgical intervention can be used for patients with greater than 70° of flexion contracture
What are the options for opponensplasty in congenital cases?
Typically, the FDS from the fourth digit is transferred. You can also use the abductor digiti minimi which is known as the Huber transfer.
What is the critical period for upper limb development?
24 to 36 days after fertilization
What are the last bones to ossify within their cartilaginous framework?
Carpal
Does sensory or motor innervation occur first
Motor
Sensory uses this as a guide
When is nervous system mylination completed
Two years
What is the fixed unit of the hand?
Distal carpal row and second and third metacarpals
Name the thenar muscles superficial to deep
APB
FPB
OP
Adductor pollicis
What are the muscles of the mobile wad?
ECRB
ECRL
BR
What is the ORL?
Ligament running between the flexor tendon sheath at the proximal phalanx and the terminal extensor tendon which links flexion and extension between the IP joints
What is the transverse retinacular ligament?
Ligaments that span the edge of the flexor tendon sheath to the conjoined lateral bands prevent preventing dorsal shift of the lateral bands, which prevents a swan neck deformity
Where is the epiphysis in the bones of the hand?
Proximally on all phalanges and the thumb metacarpal and distally on the other metacarpals
What compartments is Lister‘s tubercle between?
Second and third
What is an extra octave fracture?
Salter Harris, two fracture of the proximal phalanx of the small finger with ulnar angulation of the small finger
How is the FDP to the index finger unique
It has an independent muscle valley
What is the dominant vascular supply to the hand?
Most commonly is the ulnar artery
What are the landmarks for a ulnar nerve block?
Posterior to the medial epicondyle and 3 to 5 cm proximal
Landmarks for median nerve block
Medial to brachial artery
Medial to biceps
Slightly above the line between the epicondyles
Landmarks for radial nerve block
Anterior aspect of the lateral epicondyle
Lateral to the biceps tendon
Which general anesthetic is most commonly associated with cardiac arrhythmias
Halothane
What is the treatment for a keratoacanthoma?
Surgical excision or intralesional injection using 5-FU or methotrexate
Giant cell tumor
Second, most common tumor of the hand
Histiocytes most dominant cell
Treatment is excision, including stalk
Occurs at the flexor tendon sheath
What is the difference between a neurofibroma and neurilemmoma
Neurofibroma arises from within the nerve fascicles
Neurilemomma is a tumor of Schwann cells on the nerve surface
What is the most common benign nerve tumor in the upper extremity?
Schwanomma
Can be shelled out
What histologic findings are associated with infantile digital fibromatosis?
Interlacing, fibroblast, and intracytoplasmic eosinophilic inclusion bodies which distinguish them from other fibromatosis
What is the most common location of enchondromas?
Proximal phalanx
Metacarpal
Middle phalanx
Olliers disease
Non-hereditary disease of multiple enchondroma that usually present unilaterally
Maffucci
Enchondromas and hemangiomas
Enchondroma
Discovered as pathologic fracture
Treatment is curettage and bone grafting, but you should wait for fracture to heal first
Less than 5% chance of malignant transformation to Conro sarcoma
Periosteal chondroma
Similar to chondroma, it is a benign. Cartilaginous tumor, and most commonly found at the metaphyseal diaphyseal junction of the phalanges
Unicameral bones cyst
Almost exclusively and children
Incidental finding
Non-surgical treatment of steroids
Osteoid osteoma
Pain at night relieved by NSAIDs
On imaging shows up as a sclerotic nidus with a lucent halo less than 1 cm in diameter
Treatment is curettage and bone grafting
Histology is a hypervascular nidus of osteoblast with surrounding cortical reactive bone formation
Osteoblastoma
Same as osteoid osteoma, but bigger than 1 cm and have unlimited growth potential and should be removed
Giant cell tumor of the bone
Presents with gradual swelling pain, and pathologic fracture and is most often in the distal radius
Can be considered a low-grade malignancy because it has the ability to metastasize
Metastasizes to the lungs
On x-ray it looks like lytic lesion without new bone formation and does not penetrate joint surface
Treatment is wide, excision and joint reconstruction
Fibrous dysplasia
Bone marrow of involved bones is filled with noncalcified collagen
On x-ray appears as a ground glass opacity
Usually treatment of the hands is not required
Most common malignant tumor of the hand
Squamous cell carcinoma
When treating melanoma, how is amputation level determined
Amputate proximal to the nearest joint
Synovial cell carcinoma
High-grade sarcoma that grows in proximity to, but not in a joint
Size of the lesion is proportional to mortality
Treatment is wide excision with lymph nodes sampling, and you can consider adjuvant radiation
Epithelioid sarcoma
Similar to synovial cell carcinoma, and seen in the muscle
Especially dangerous when spreading because it spreads proximally along facial plains, tendons, and lymphatics
Where is malignant fibro histiocytoma usually found in the upper extremities
On the deep muscle mass of the adductor policies or other flexor muscles
Osteogenic sarcoma
Most common malignant primary bone tumor in the hands of children and teens
No role for radiation, but chemotherapy does really well
On x-ray, there is bone growth outside the normal skeleton with hazy cloud, bike bone formation into soft tissues
Condrosarcoma
Most common malignant primary bone tumor in adults
Does not respond to radiation or chemotherapy
Ewing sarcoma
Presents with pain, tenderness, swelling, fever, elevated white blood cell or ESR
Onion, skin appearance or sunburst pattern on radiographs
Most commonly on metacarpals and phalanges
Treatment includes surgical, excision, systemic, chemotherapy, and possibly radiation
When primary carcinoma metastasizes to the hand, where does it go?
Distal phalanx
What is the most commonly involved organism in cellulitis of the hand?
Group a beta hemolytic strep
What is the most common infection in the hand of HIV positive patient
Herpes
In what subset of diabetic patients with hand infections is morbidity particularly high
Renal transplant patient
What is the most common algae infection seen in fisherman?
Prototheca wickerhamii
Tx tetracycline
Exposure to what virus causes milkers node in the hand
Pox virus
Interdigital pilonidal cyst
When a foreign piece of hair enters the web space and becomes secondarily infected
Seen in barbers and sheepshearers
Most common location of osteomyelitis in the hand
Distal phalanges
What unique infection can occur in the hands of a patient receiving taxol
Subungal abscess of multiple digits, including the toes with painful nail plate separation
What duration of antibiotics is recommended for septic arthritis of the hand
Between one and four weeks of IV anabiotic’s
What disease diseases are associated with duputryen disease?
Diabetes
HIV
Tobacco consumption
Alcoholism
Anticonvulsant therapy and epilepsy
What is the difference between the collagen and normal fascia and that fascia in dupytrens disease?
Normal fascia has more type one collagen whereas in the disease there is more type three
What causes MCP joint flexion contracture in dupuytren disease
Pre-tendinous cord
Indications for surgery in a patient with Dupeytrens
MCP contractor of 30° or more
Any degree of PIP contractor
Severe adduction, contractor
Possible indications for skin grafting in patients with dupeytrens
Diathesis
PIP flexion contracture, resulting in skin deficiency at closure
Recurrent PIP joint contracture
What is the normal motor latency at the carpal tunnel?
Four MS
What is a clinically significant decrease in velocity at the elbow?
A decrease in velocity of 10 m/s is considered clinically significant
What nerve is affected with thoracic outlets syndrome?
Lower trunk of brachial plexus with symptoms, mimicking cubital tunnel syndrome
What are the contents of the thoracic outlet?
Subclavian vein, subclavian artery and brachial plexus
Adson maneuver
Dampening of radial pulse with neck extension, inhalation and head rotation to the affected side in patients with thoracic outlet syndrome, which is more prevalent in women
WRight maneuver
Reproduction of thoracic outlet syndrome, symptoms, and or damping of radial pulse with arm hyper abducted with the patient’s head positioned in neutral or turned contralateral
Roos maneuver
Both arms are placed 90° abduction and the patient is asked to open and close the hands for three minutes while externally rotated. Patient with thoracic outlet syndrome will have reproduction of symptoms.
What is similar and what is different about the presentation of thoracic outlets syndrome, and cubital tunnel syndrome?
Thoracic outlet syndrome and cubital syndrome have ulnar distribution numbness
TOS also presents with medial forearm numbness and EMG is negative for the nerve, but has positive somatic sensory evoked potentials with arm in offending position
How does the motor examination differ between ulnar compression at the wrist and the elbow?
At the wrist, there is weakness of pinch but not grip
At the elbow, there is weakness and pinch and grip
What are the structures thought to cause effort associated carpal tunnel syndrome?
Lumbrical muscles as they originate from the FDP and reside in the carpal tunnel with gripping
Where is the median nerve located in the proximal forearm?
Between the superficial and deep heads of the pronator teres muscle
How can you test for median nerve compression at the ligament of struthers?
Exacerbated symptoms, when flexing the elbow against resistance
How can the radial nerve be approached in the dorsal forearm?
Between ECRB and EDC
Radial tunnel syndrome
Lateral elbow pain, especially with repetitive extension
Motor findings are absent
What does Volkman’s contracture look like?
Forearm is fixed in pronation. The wrist is flexed. MCP joints are hyperextended and IP joints are flexed.
What is the treatment of choice for a displaced fracture of the dorsal base of the distal phalanges comprising over 25% of the articular surface?
Operative intervention with closed or open reduction and internal fixation
What is the most likely direction of angulation of an unstable transverse metacarpal shaft fracture?
Apex dorsal angulation because of volar interosseous muscle pull
What two structures act as a noose around the MCP head in an irreducible dorsal dislocation of the index MCP joint
Flexor tendon on the owner side and lumbricals radially
In a Bennett fracture, what is the deforming force that causes proximal migration of the thumb metacarpal?
Abductor pollicis longus die die
In a volar dislocation of the PIP joint, what commonly associated injury must be examined for
Rupture of the extensor tendon central slip
What is a lesser arc and greater arc injury?
Lesser arc is purely ligaments around the lunate
Greater arc is disruption around the lunate that involves fractures of some or all of the carpal bones
What x-ray view would be best to visualize a hook ofhamate fx
Carpal tunnel
What x-ray view would be best to visualize the position of a screw in the proximal pole of the scaphoid
An ulnar deviated, PA view and a lateral x-ray
What is the most likely direction of a CMC dislocation of the thumb?
Dorsal
Following repair when does tendon rupture most commonly occur?
Postoperative day, 10
How should a patient be splinted after flexor tendon repair?
Wrist should be in 30° of flexion
MPS in 50 to 70° of flexion
IPS in full extension
How long after a zone to flexor tendon repair should flexor lysis be perform performed if the patient is having limited active range of motion and has not made progress in therapy
At least three months of therapy should be attempted first
What tendon inserts on the second metacarpal the third and the fifth
Second metacarpal is ECRL
Third metacarpal is ECRB
Fifth metacarpal is ECU
What is the intrinsic minus deformity
Extension of the MPS and flexion of the IPS, as in claw deformity scene with ulnar nerve palsies
Good way to remember the function of intrinsics, which is to flex the MPS and extend the IPS
What contributes to the smooth, shiny surface of the nail plate
The dorsal roof of the nail fold
What area of the body has the highest concentration of lymphatic?
Hyponychium
What conditions are thought to cause clubbing?
Family history
Cardiac
Pulmonary disease
G.I. disease like UC chrohns, disease, and liver cirrhosis
Cancer like thyroid, thymus, and CML
Acromegaly and pregnancy
Chromonychia
Induced by renal failure, subungual, hemorrhage, or medication’s
Antineoplastic drugs are associated with this
Adriamycin cyclophosphamide and vinChristine
Associated with AIDS
What causes uncle onycholysis
Abnormalities of the sterile matrix often secondary to traumatic scarring
What medications are associated with the separation of the nail bed and nail plate
Taxane chemotherapeutic’s, including paclitaxel and docetaxel
What causes longitudinal splitting of the nail plate
Abnormalities of the germinal matrix
What causes longitudinal grooving in the nail plate?
Abnormalities in the nail fold
How to treat onychomycosis
Systemic antifungals
Or a topical antifungal with nail plate removal
What are the extra articular manifestations seen in RA?
Vasculitis pericarditis, pulmonary nodules Episcleritis, and subcutaneous nodules
Nodules are the most common
What is the more common direction of sagittal band rupture in RA?
Radial sagittal band which results ulnar displacement of the extensor tendon
What are contraindications for total wrist arthroplasty
Previous sepsis
Rupture and not fully reconstructable wrist extensor
Absorption of the distal carpal row
Previous wrist arthrodesis
Auto fusion is not a contraindication
Failed silicone wrist implant with fragmentation in particular synovitis
Progressive deformity with advanced arthritis
What is a painless, dorsal wrist mass distal to the extensor retinaculum typically an RA patients
Extensor tenosynovitis
Tenectomy is indicated after 4 to 6 months of medical treatment to prevent rupture of extensor tendon
What is the piano keyboard sign?
Elicited when the prominent on our head is depressed and rebounds as pressure is released
Signifies DRUJ instability
What is the scallop sign in patient with RA
Erosion of the radial sigmoid notch with formation of a sclerotic border it is ominous sign of impending extensor tendon rupture
What is a contraindication in using the superficial flexor tendon for extensor tendon transfer in RA
Presence of swan neck, deformity, and significant flexor teno synovitis
What is the recommended treatment for loss of wrist extensor in RA
Wrist arthrodesis
What is the Clayton procedure in RA?
Transfer of ECRL to ECU to redistribute wrist forces and diminished radial rotation and volar subluxation of carpus at wrist
What is still disease?
Systemic onset of 20% of JRA case cases
Intermittent high fevers
Transient arthritis with associated fevers
Hepatosplenomegaly lymphadenitis uveitis
Lymphocytosis anemia
RF negative
What vascular structure is associated with the C7 root in the exposure of the cervical region of the brachial plexus
Transverse cervical artery
What part of the brachial plexus crosses underneath the clavicle?
The divisions
What muscles are invented by the dorsal scapular nerve
Rhomboid, major and minor
Levator scapula
What is the significance of transverse process fractures on the cervical spine x-rays and brachial plexus patients
Can indicate a root avulsion
What is the Oberlin transfer?
Transfer of selected ulnar nerve bicycles in the upper arm to motor branches of the musculocutaneous nerve to the biceps to restore elbow flexion
What is a common complication due to the internal rotation contracture in children with brachial plexus birth palsy
Posterior shoulder dislocation
What tendon transfer can be used to improve external rotation of the shoulder and prevent the development of internal rotation contracture
Transfer of the LD and Teres major to the humeral greater tuberosity
What deformity of the elbow will frequently develop in children with obstetric brachial plexus palsy?
Posterior radial head dislocation usually by 5 to 8 years
What is a typical finding in the forearm of children with obstetric palsy?
Supination contracture
What are the two functions of EPL?
Thumb IP extension
Thumb adduction
What is the position of immobilization after tendon transfers for wrist, finger and thumb extension?
Elbow flexion at 90°
Neutral forearm rotation
MPJ fully extended
45° wrist extension
IPJ and MJ full extension with thumb abduction
What explains maintained ability of thumb opposition after complete median nerve laceration at the wrist
Variable ulnar nerve innovation of the superficial head of the flexor pollicis brevis
What is the most common tendon transfer for low median nerve palsy?
EIP to APB
What is the disadvantage of the Hubert transfer and thumb hypoplasia
Insufficient tendon for thumb MCP reconstruction
FDS from the long and Ring finger do not have this problem, but they lack bulk
What is the position of a immobilization after opponensplasty
Thumb Spica with opposition of thumb
Slight wrist extension for EIP and ADM
Slight wrist flexion for FDS and PL
What progressive deformity may develop after chronic high median nerve palsy
Swan neck deformity of the small and ring finger because of absent FDS function
What donor muscle is most commonly used for restoration of FPL function
BR
Bouvier maneuver
Blocking the MP hyper extension in a claw hand to allow EDC to extend the PIPNDIP
What tendon transfers are available to restore thumb adduction
ECRB to thumb ADDuctor via intercalated tendon graft
FDS of long ring to thumb adductor insertion
Zancolli lasso
FDP looped around itself at A1 pulley
Provides a dynamic flexion moment at the MPJ
Used to correct claw deformity
Bunnell stiles
ECRL transected, distally and rerouted dorsally
Two slips of Palmaris longus or plantaris tendon are attached to ECRL
Routed through the lumbrical canal volar to the deep transverse metacarpal ligament
The tails are attached to radial lateral bands of the ring and small fingers or to the radial side of proximal phalanges
What deformity can occur after the Bunell styles transfer to the radial lateral bands?
Swan neck
What transfer restores ring and small finger DIP flexion
Side to side transfer of small and ring finger FDP to median innervated index and long finger FDP
What is the carpal height ratio?
Distance from the base of the third metacarpal to the distal, subchondral bone of the radius divided by the length of the third metacarpal
What is the only muscle that inserts onto the carpus?
FCU inserts onto the pisiform
What is the stable bone of the DRUJ?
The ulna is the fixed bone around which the radius rotates
What are the primary stabilizers of the DRUJ?
The Palmer and dorsal radioulnar ligaments
Which extrinsic wrist ligament is felt to be the strongest support in the wrist
Radioscaphocapitate ligament
What is the most common cause of digital replant failure?
Arterial insufficiency
What are the major extrinsic ligaments of the dorsal wrist?
The dorsal radiocarpal ligament and the dorsal intercarpal ligament
What are the measurements of carpal height used for?
To diagnose SL disassociation
Normal ratio is .54
Smaller ratios indicate carpal collapse seen in SL dissociation
What is the definitive diagnostic test for intercarpal pathology?
Rooster arthroscopy
What is a collies fracture?
Distal radius fracture with dorsal angulation, dorsal, commutation, dorsal displacement, and radial shortening, and Apex Voeller angulation with dorsal displacement of the carpus
What is a Smith fracture?
Distal radius fracture with Apex dorsal angulation with volar subluxation of the carpus
What are the functional deficits associated with Ray? Amputation of the index finger?
Decreased pinch and grip strength
Hyper homocystinemia
Associated with chronic renal disease, hypothyroidism, and malignancy
Which digital artery of the toe is more important
Planter digital artery
What is the main advantage of using the second toe in thumb reconstruction?
It can be harvested with a long segment of the second metatarsal, allowing for proximal thumb injury, reconstruction, less donor site morbidity
What tendon is cut when dissecting the FDMA on the foot dorsum
Extensor Hallucis brevis
What are the disadvantages of the great toe wraparound for total thumb reconstruction?
Requires two donor sites
Needs bone from iliac crest for the thumb skeleton and skin graft for the remaining toe
Reconstructed thumb has no IP joint
What layer of the nerve is an extension of the blood brain barrier?
Perineurium
What are clinical measurements of motor nerve injury?
Weakness, loss of function and atrophy
What are clinical measurements of sensory injury?
Moving and static two point discrimination for innervation density and number of fibers
Semmes , Weinstein monofilament and vibration instruments as threshold test for performance levels
Interscalene triangle borders
Anterior scalene muscle anteriorly
Middle scalene muscle posterior
Medial surface of the first rib inferiorly
Surgical treatment of suprascapular nerve entrapment consist of the release of which structure
Transverse scapular ligament
Transax approach for treatment of thoracic outlet syndrome en dangers. What nerve
C8 or T1 nerve root
Supraclavicular approach for thoracic outlet syndrome, endanger what nerve
Phrenic
The motor group of the ulnar nerve at the wrist is located in what position
Ulnar and dorsal
What are the sides of compression of the median nerve that caused pronator syndrome?
Ligament of Struthers
Lacertus fibrosis
Pronation Teres
FDS proximal arch
Borders of the carpal tunnel
Carpal bones are the floor
Transverse carpal ligament is the roof
Scaphoid and trapezium are radial
Pisiform and hook of hamate ulnarly
Tarsal tunnel structures
FHL tendons
FDL muscle
Tibialis posterior muscle
Posterior tibial nerve
Posterior tibial artery
What is the best method for surgical release the first Webb space and what structures need to be released?
Best method for surgical release is a four flap Z plasty
When releasing the first Webb space you must release the tight investing fascia of the first dorsal, interosseous and adductor pollicis muscles
Two most commonly used flaps for reconstruction of a tight first web space are the reverse pedicled radial forearm, and the groin flap
Other options include the reverse pedicled PIA, flat or free facial cutaneous flaps
Hirudin
Binds activated thrombin
Inhibits conversion of fibrinogen to fibrin
Blocks activation of factors five 8 11 and von Willebrand
Decreases activation of TPA protein, C and plasmin
No direct effect on platelets or endothelial cells
Prolonged thrombin dependent coagulation test
Protein C deficiency
One of the most common causes of hereditary thrombophilia
APC in activates factors five and factor eight, which keeps thrombosis and check
Prothrombin 2021A
Relative risk of thrombosis is 2.8
Treatment is Coumadin for 3 to 6 months
If there is a recurrence treatment is indefinite
