Hand 2 Flashcards by Lo Kola

What is the dominant feeder for the
Superficial palmar arch
Deep palmar arch / princeps pollicis

Ulnar art -> SPA

Radial art -> DPA, princeps pollicis

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What is hypothenar hammer syndrome
Sx
Dx
Treat

Vs ulnar tunnel syndrome (dx)

Prev traumatic event causes occlusion of the ulnar art at prox palm
Think: catchers, carpenters with hammers

Sx: ischemic pain, +/- Guyon compression

Dx: a-gram

Trt
- If complete arch, can ligate
- If not, reconstruct with reversed vein graft (so valves work for you not against)

vs handlebar palsy aka ulnar tunnel synd - get EMG

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Treat small vessel vaso occlusive disease, examples:
Scleroderma/CREST
Thromboangiitis obliterans (Buerger)

Ca channel blockers
Sympathectomy

Often still progressive = digit ischemia

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Which finger is most likely to affected by embolic disease? Possible sources

Ring finger, PIP
- PIP where vessels narrow
- Ring finger is ulnar dominant so straight shot through Guyon

Causes:
- Embolic - listen for murmur
- Vascular thoracic outlet - get bilateral BPs
- IVDU
- Ulnar art aneurysm

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Describe the 3 stage progression of a claudication even for Raynauds

White digit = spastic cessation flow
Blue = cyanosis 2/2 venous stasis
Red = rebound hyperemia w/ pain

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What is the difference between Raynaud disease vs phenomenon

Disease: w/o underlying cause
- Symmetric

Phenomenon: underlying vaso-occlusive disease
- Asymmetric

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4 absolute indications for replant

1 Thumb
2 Multiple digits
3 Wrist or proximal
4 Child

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CI for replant

Single digit, esp zone 2
Prolonged ischemia
Crush / avulsion
Advanced age / multiple co-morbidities
Polytrauma (aka bigger problems)

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What is the appropriate warm/cold ischemia times for replant:
Prox to wrist
Warm:
Cold:

Digits
Warm:
Cold:

Ischemia time starts at injury

Prox to wrist
Warm: <6hrs
Cold: <12hrs

Digits
Warm: <12hrs
Cold: <24hrs

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Order of replant

BEFANV
Bone
Extensors
Flexors
Art
Nerve (volar to art)
Vein
+/- fasciotomies

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Why do replants fail
<12hrs
>12hrs
>1wk
What is the most common 2ary procedure after successful replant

<12hrs - arterial thrombus
>12hrs - venous congestion
>1wk - infection

2ary procedure = tenolysis

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How do leeches work? What abx do you need for patients with leeches?

Excrete hirudin = anticoag
Cover aeromonas hydrophila - CTX or cipro

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What are the 8 extensor injury zones

ODD = joint / EVEN = bone
1 = DIP
2 = middle phal
3 = PIP
4 = prox phal
5 = MCP jt
6 = MC
7 = wrist joint / carpus
8 = forearm

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Trt extensor tendon lacs

<50% = partial + can extend against resistance
- Early protected ROM

> 50% = suture repair, protected ROM

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Explain difference in treating ST vs bony mallet

Zone 1 extensor injury (DIP)

ST: 6-8wks ext splinting, PIP free

Bony:
- No DIP subluxation = ext splinting
- Frag >50% ORIF
- DIP subluxation = pinning

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Sequelae of missed Mallet
Trt

Swan neck
Central slip doubles force at PIP to hyper extend PIP
Get unopposed flexion at the DIP

Trt: central slip tenotomy
Active DIP ext still possible through oblique retinacular lig

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Zone 3 (PIP)
- Mechanism
- PE test
- Deformity if missed

Zone 3 (PIP) = central slip rupture
Mechanism PIP hyperflex or PIP volar dislocation

Elson test - DIP joint stays flaccid when ask to extend

Missed = boutonniere
- Triangular ligament scars short
- Lateral bands migrate volar
- PIP flexion, DIP hyperext

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Trt Boutonniere closed vs open

Closed - PIP ext splint 6wks, DIP free

Open: central slip repair, same splinting

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What is the most common type of zone 5 (MCP jt) injury? Trt

Sagittal band rupture
Extensor tendon subluxes
Can hold up extension if passively placed there
Cannot actively extend

Trt
- Acute: 4-6wks ext splint
- Chronic: sag band repair/reconstruct

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What is an intrinsic minus hand

MCP hyperext
PIP/DIP flex

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How do you test intrinsic tightness? If the test results are reversed, what is wrong?

Hyperext MCPs - put tension on the intrinsics
- IP little ROM

Flex MCPs - intrinsics relax
- IPs become supple

Extrinsic tightness = opposite
- PIP flexion improves with MP hyperext

Treat intrinsic vs extrinsic tightness

Intrinsic: stretching -> surg release lat bands

Extrinsic: tenolysis

What are the flexor tendon injury zones

1: distal FDS
2: pulleys through the fingers
- No mans land bc tendons are in a sheath - your repair is adding bulk and higher risk scarring
3: palm aka TCL to pulleys
4: carpal tunnel
5: forearm

What flexor tendon gap increases risk for repair re-rupture

> 3mm

Describe ideal suture configuration for flexor tendon repair? Where do repairs usually fail?

#core strands = strength - Min 4 Dorsal sutures = stronger Locking loop config decreases gap +epitendinous suture = increase strength, decrease gap formation - Running locking > simple running Fail @ suture knots!!!

Why do you do early motion for flexor tendon injuries (3 reasons)? What is the rehab guideline? Who does this not apply to

Positive feedback loop = faster strength at repair site Decrease adhesions Better excursion Rehab: - Dorsal block 6wks - Then 30deg wrist flex - Then 70deg MCP flex - Active motion 4-6wks Doesnt apply KIDS!! Cast 4wks - they'll get it back

What pulleys must stay intact during flexor tendon repair

A2 + 4 Other windows you make through pulleys - dont repair bc sutures will narrow the tunnel / scar

What is a jersey finger? Complication of repair? Trt chronic injury?

Jersey finger = FDP avulsion (zone 1) - Classification based on amt of retraction Complication = overtighten (bc maybe delayed or super retracted) = quadrigia - 1 finger too tight, so the others cant completely flex into the fist Chronic: do not address if FDS is intact

Treatment algorithm for partial flexor tendon lacs <25% 25-50% >50%

<25% - trim 25-50% - epitenon repair >50% - core and epitenon repair Protected mobilization for all Res study Q: <60% debride, >60% epitend only (no benefit to core suture)

What is lumbrical plus finger - Causes - Treat

Flex finger - IP extends - FDP retracted -> tensions the extensor mechanism Causes: loss of FDP insertion - Distal finger amp - Missed lac Trt = lumbrical release

What is quadrigia

FDP has a common muscle belly Because 1 is overtensioned, that sets max tension for all, so the others can't get full flexion Weak grasp - can't make a fist because only 1 finger hits max flexion Forearm pain (common muscle belly) Dont advanced FDP >1cm w/ repair

Hand infections Most common bug: Cat bites + drug Human bites + empiric coverage

Most common bug: S.aureus Cat bites + drug: pasteurella -> augmentin - Cat teeth puncture = worse - Dog bites tear Human bites: eikenella -> IV amp/sulbac or PO augmentin

What are the lab stains for atypical microbacterium? What are the bugs? What do you see on the stains? Trt

Mycobacterium marinum Ziehl Neelsen staining Lowenstein Jensen 28-32deg See NON-case granulomas on biopsy (if TB they are caseating) Trt: clarithromycin, sulfonamides, rifampin, ethambutol, and trimethopriam sulfamethoxazole

What is the lab prep for fungus

KOH prep

What is the lab test for herpes

Tzank smear

How do hand infections move into the forearm/become horseshoe? How might an infection here present?

Parona's space Floor = PG Roof = flexor tendons Infx here can present as acute CTS Forearm: radial or ulnar bursa Wrist: Parona -> carpal tunnel Hand -> digits: Thenar = thumb, index Mid palmar = long, ring Hypothenar spaces = small

Most common bug for cellulitis

Group A beta hemolytic strep Think nec fasc if not improving since same bug!

Herpetic whitlow: Which bug At risk population Test Trt

Which bug - HSV 1 At risk population - kids, dental workers, resp therapists Test - Tzanck prep Trt - acyclovir, don't I&D!

Paronychia: Location of infection Bug

Eponychial fold - extends above/below plate S.aureus (+/- mouth flora)

Felon: Location of infection Bug Trt

Closed space infx = septated digital pulp S.aureus I&D + abx

FTS: Bug

S.aureus

Collar button abscess: Where Trt

Subfascial webspace Presents as dorsal web swelling that spreads the fingers apart I&D w/ dorsal and volar incisions

Treat high pressure injection injuries Name 3 negative prognostic factors

Immediate I&D - often repeat Broad IV abx Amp common Negative prog factors: 1. Late presentation (>10hrs) 2. Higher pressure 3. Oil based paints

What is intersection syndrome Trt

Pain bet 1st/2nd extensor compartments Cause = 2nd compartment stenosis (ECRb/l) Crepitance Inject >>> OR

Keys for adequate DeQuervains decompression

Anatomic variants: Multiple APL slips Separate EPB compartments

What is lateral epicondylitis Trt

ECRB tendinosis (not tendonitis) - No inflam cell infiltrate - Angiofibroblastic hyperplasia - failed attempts at healing microtears Trt: nonop > debridement repair vs aconeus flap

What is medial epicondylitis Trt

Same as lateral but at FCR/PT junction R/o associated cubital tunnel syndrome

Distal biceps - Where does it attach on the bicipital tuberosity - Where does long head vs short head insert vs function - What is the origin and insertion of lacertus

Where does it attach on the bicipital tuberosity : ULNAR Where does long head vs short head insert vs function - Long head PROX - supinates - Short head DISTAL - elbow flexor What is the origin and insertion of lacertus O: short head I: forearm fascia

Pros/cons distal biceps repair 1 vs 2 incision

1 incision - More LABC sx from retractor traction 2 incision - Higher HO - In theory more anatomic repair gets you more supination (debatable)

What is the anatomic site and nerve compressed at each of the following: 1. Lacertus fibrosus 2. Ligament Struthers 3. Arcade of Froshe

1. LF = biceps aponeurosis AIN 2. Lig Struthers = medial distal humerus Medial n 3. Arcade Froshe = prox supinator PIN

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Hand 2 Flashcards

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