Hand Flashcards
What type of collagen for Dupuytren’s contracture tissue?
Type 3 collagen***
Where do A1, A3 and A5 pulley originate from?
Palmar plate***
A2 and A4 arise from periosteum in proximal half of proximal phalanx and midportion of middle phalanx respectively ***
Overlie MP, PIP and DIP respectively
What pulley prevents bowstringing of FPL in thumb?
Oblique pulley*** (also have to have A1 pulley cut to get bowstringing)
Originates at proximal half of proximal phalanx
Which nerve is closest to A1 pulley in thumb?
Radial digital nerve (2.7 mm vs ulnar 5.4 mm)
Two most important pulleys to maintain in fingers?
A2 and A4 - prevent bowstringing
Sequence of pulleys from proximal to distal in fingers?
A1, A2, C1, A3, C2, A4, C3
What supplies superficial arch of hand?
Ulnar artery mainly, minor contribution from superficial branch of radial artery ***
Where are digital nerves vs digital nerves in palm and digits?
Palm: digital arteries are VOLAR to nerves
Digits: Arteries are DORSAL to digital nerves –> NV bundle is volar to Cleland’s ligament
Blood supply for superficial and deep palmar arches?
Superficial: ulnar, give off common digital arteries (main blood supply for digits on the median side of digit/closer to midline)
Deep: radial***
Disruption of SL ligament causes?
Disruption of LT causes?
DISI deformity*** (along with dorsal intercalated segment instability)
VISI deformity*** (along w/ radiotriquetral ligament)
Volar extrinsic ligaments while viewing form 3-4 portal (between EPL and EDC) order from radial to ulnar?
Radioscaphocapitate (most radial)***
Long radiolunate***
Short radiolunate***
Main restraint against ulnar translation of carpus?
Radioscaphocapitate ligament***
What is jersey finger?
FDP avulsion injury from insertin at base of distal phalanx***
Unable to flex DIP***
Generally fix (acutely if retracted to palm vs within weeks if less retracted)***
What is the closest tendon to the median nerve?
FCR***
How far away from flexor tendon injury should suture be placed?
10 mm***
When to consider 2 stage flexor tendon grating?
> 3 months since injury***
How long to cast a kid with flexor tendon injury?
3-4 weeks***
% of flexor tendon cut to repair?
> 60%***
What causes a swan neck deformity
Lax volar plate***
mallet finger - Lesa transfer of DIP extension force into PIP extension force***
FDS rupture - unopposed PIP extension combined with loss of integrity a volar plate
intrinsic contracture - tethering of lateral / collateral bands by transverse retinacular ligament as result of PIP hyperextension. If these are tethered, excursion is restricted in the extension forces not transmitted to terminal tendon and instead transmitted PIP joint
Where do lumbricals originate and insert?
Lumbrical plus?
Originate from FDP and insert onto radial side of extensor expansion***
with FDP laceration, FDP contraction leads to pull on lumbricals –> lumbricals Paula lateral bands leaned PIP and DIP extension of involved digit - can lead to “lumbrical plus” effect –> paradoxical extension of the IP joint when attempting to flex the fingers***
occurs with amputation at the level of the DIP**
Quadrigia?
FDP*** tendons of long, ring and small fingers share common muscle belly –> exucrusion of combined tendon = Shortest tendon
improper shortening of the tendon during repair results and inability to fully flex adjacent fingers***
Who is at risk of trigger finger?
DM patients*
Females >50 y/o*
hypothyroidism***
Caused by stenosing tenosynovitis of the A1 pulley***
What nerve at risk with trigger thumb release?
radial digital nerve***
Elson test?
flex patient PIP joint over a table at 90° in as an to extend against resistance
if central slip is intact, DIP will remain supple***
if central slip is disrupted, DIP will be rigid.***
What causes Boutonniere deformity?
Central slip injury over the PIP joint
causes extrinsic extension mechanism from the EDC to be lost and prevents extension of the PIP joint allows lumbrical pull to become unopposed causing PIP flexion and DIP extension
use Elson test to diagnose**
may do DIP flexion in rehab**
Mallet finger?
Tx?
Disruption of terminal extensor tendon distal to DIP*** (still splint bony avulsions unless volubly subluxated)
Tx: Extension splinting of DIP 6-8 weeks (24 hrs daily)***
Tx surgically if VOLARLY subluxated***
Tx CHRONIC with surgery/reconstruction ***
Sagittal band rupture causes?
Which is disrupted more often?
PE?
Tx?
Leads to dislocation of extensor tendon* (primary stabilizer of extensor at MCP joint*)
Radial sagittal band more common (radial 9:1 vs ulnar)***
PE: Inability to actively extend MCP but able to maintain after passive extension***
Tx:
Extension splint or yoke splint for 4-6 weeks*** (acute injury)
Fix in professional athlete if chronic (>1 week)***
Realignment if chronic and not able to repair***
Where do peds patients most commonly fracture scaphoid?
Peds: distal 1/3 of scaphoid (ossifies before proximal pole***)
What position is wrist for scaphoid fx?
dorsiflexed, pronated, ULNAR deviation***
Which scaphoid fx’s more likely to have AVN?
proximal pole fx***
Major blood supply = dorsal carpal branch (from radial)*** –> enters in nonarticular dorsal surface and supplies proximal 80% via RETROGRADE flow
minor flow from superficial arch –> enters distally and supplies distal 20%
Approach for scaphoid fx surgery?
Approaches:
Dorsal –> best for PROXIMAL fx (always fix proximal pole fx!)
Volar –> for WAIST fx and DISTAL fx, also humpback fx
Avoids scaphoid blood supply
Interval between FCR and radial artery
Stages of SNAC wrist?
Tx?
Stage I: Arthritis of radial side of scaphoid and radial styloid –> tx with radial styloidectomy + scapholunate reduction and stabilization***
Stage II: scaphocapitate arthritis + stage I –> tx with PRC vs 4CF vs wrist arthrodesis***
Stage III: Periscaphoid arthritis –> tx with PRC vs 4CF vs wrist arthrodesis***
Hook of hamate fx - who gets them?
How to image?
Tx?
Baseball, golf, hockey
Image with CARPAL TUNNEL VIEW or CT or MRI (100%)
Tx:
Immobilization for 6 weeks, but lots of nonunion**
Excision* –> if symptomatic and chronic or high level athlete
Types of TFCC tears?
What makes up TFCC?
Type I: traumatic –> fall on extended wrist in pronation***
Type II: degenerative –> ULNAR POSITIVE***
Components of TFCC:
Dorsal and volar radiounar ligaments, central articular homolog, meniscus homolog, ulnar collateral ligament, ECU SUBSHEATH***, origin of ulnolunate and ulnotriquetral ligaments
What type of finger dislocations are the most common?
What do dorsal dislocations possibly lead to?
What do volar dislocations possibly lead to?
Dorsal dislocations are more common than volar***
Dorsal –> disrupt volar plate –> swan neck***
Volar dislocations –> rupture central slip –> boutonnière***
Tx of simple dorsal PIP dislocation?
Simple volar PIP dislocation?
Dorsal PIP joint fx-dislocation?
Volar PIP fx-dislocation?
Simple PIP dorsal
Buddy tape if stable
Extension block splint if dorsal unstable after reduction
Simple PIP volar: Extension splinting for 6-8 weeks*** (less common than dorsal)
Dorsal PIP fx-dislocation
<40% joint and stable –> extension block splinting*
>40% and unstable –> CRPP vs ORIF*
Volar PIP fx-dislocation
<40% joint and stable –> extension splinting*
>40% and unstable –> CRPP vs ORIF*
How much extensor lag for each 2 mm of shortening in metacarpal?
7 degrees for each 2 mm shortening***
Tx for multiple metacarpal fx?
ORIF***
What type of deformity for fx of proximal phalanx of finger?
Apex VOLAR***
Interossei pull proximal fragment into flexion
Distal fragment into extension from central slip
What type of deformity for fx of middle phalanx of finger?
Apex DORSAL if proximal to insertion of FDS* (more common)
Proximal portion into extension from central slip, distal into flexion due to FDS**
Apex VOLAR if distal to FDS insertion***
Thumb UCL injury testing in flexion and extension?
Flexion (30 deg) –> tests proper collateral ligament ***
Extension –> tests ACCESSORY collateral ligament***
Valgus laxity in both is indicative of complete UCL tear***
Stener lesion?
Muscle and innervation?
Avulsed UCL with or w/o bony attachment displaced above the adductor aponeurosis* –> won’t heal w/o surgery
Muscle: Adductor pollicis, innervation: Ulnar nerve***
Where is Parona’s space?
Why important?
Parona’s space –> between fascia of PQ and FDP conjoined tendon sheaths***
Infection can track through this space from thumb to small finger to present as horseshoe abscess***