Hand 2 Flashcards
What is the dominant feeder for the
Superficial palmar arch
Deep palmar arch / princeps pollicis
Ulnar art -> SPA
Radial art -> DPA, princeps pollicis
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
Treat small vessel vaso occlusive disease, examples:
Scleroderma/CREST
Thromboangiitis obliterans (Buerger)
Ca channel blockers
Sympathectomy
Often still progressive = digit ischemia
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
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
What is the difference between Raynaud disease vs phenomenon
Disease: w/o underlying cause
- Symmetric
Phenomenon: underlying vaso-occlusive disease
- Asymmetric
4 absolute indications for replant
1 Thumb
2 Multiple digits
3 Wrist or proximal
4 Child
CI for replant
Single digit, esp zone 2
Prolonged ischemia
Crush / avulsion
Advanced age / multiple co-morbidities
Polytrauma (aka bigger problems)
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
Order of replant
BEFANV
Bone
Extensors
Flexors
Art
Nerve (volar to art)
Vein
+/- fasciotomies
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
How do leeches work? What abx do you need for patients with leeches?
Excrete hirudin = anticoag
Cover aeromonas hydrophila - CTX or cipro
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
Trt extensor tendon lacs
<50% = partial + can extend against resistance
- Early protected ROM
> 50% = suture repair, protected ROM
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
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
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
Trt Boutonniere closed vs open
Closed - PIP ext splint 6wks, DIP free
Open: central slip repair, same splinting
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
What is an intrinsic minus hand
MCP hyperext
PIP/DIP flex
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»_space;> 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
- LF = biceps aponeurosis
AIN - Lig Struthers = medial distal humerus
Medial n - Arcade Froshe = prox supinator
PIN
