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***
Indications for replant?
Thumb at any level*** Multiple digits*** Through palm* Children*** Wrist level or proximal***
Contraindications: Sever vascular disorder Crush injury*** Segmental amputation** Prolonged ischemia time w/ large muscle content (>6 hours)***
Relative: Single digit proximal to FDS (Zone II)***
Bacteria ass’d with leach therapy?
Tx? (1st and 2nd line)
Bacteria: Aeromonos hydrophila***
Tx: Cirpo, then Bactrim
What is Bunnell’s test and how is it done?
To test for INTRINSIC TIGHTNESS***
Patient can passively flex PIP when MCP is flexed but not when MCP is extended***
When to use Moberg flap?
For volar thumb advancement <2 cm***
If larger, then FDMA***
When to use FDMA flap
For volar thumb advancement >2 cm*** (if smaller can use Moberg)
Also use for dorsal thumb***
What to do with clear frostbite blisters?
hemorrhagic blisters?
Clear: Debride***
hemorrhagic: drain but leave in place* (prevents desiccation of underlying dermis*
When to perform amputation for frostbite?
After demarcation –> 1-3 months later***
What is pedicle for:
Free fibula?
Free iliac crest?
Medial gastroc?
Lat?
Gracilis?
Lateral arm flap?
Groin flap?
Free fibula: Peroneal artery
Iliac: deep circumflex iliac vessels
Medial gastroc: sural artery
Lat: perforators off thoracodorsal artery
Gracilis: Medial femoral circumflex
Lateral arm flap: Posterior radial collateral artery –> branch of profound brachii
Groin flap: Superficial circumflex iliac artery (LFCN at risk)***
What is most effective pressure for wound vac?
125 mm Hg***
more granulation tissue, etc vs other pressures
How to distinguish between low and high ulnar nerve palsy?
Low: loss of power pinch, Wartenberg sign and clawing
High: Loss of ring and small finger FDP***
Clawing less pronounced because extrinsic flexors are not functioning
PIN palsy transfer for wrist/hand?
FCR to EDC***
PT to EPL***
What is first function lost and last to be regained after nerve injury?
First to return?
Most reliable PE of nerve returning?
First to be lost and last to be regained: Motor function***
First to return: pain***
Advancing Tinel sign is most reliable indication of recovery***
What layer is cushion against external pressure for a nerve?
What layer provides tensile strength and elasticity?
What portion of the nerve is responsible for regeneration?
Cushion: Epineurium***
Tensile strength and elasticity: Perineurium***
Regneration: Endoneurium*** (must be intact for regeneration)
Neuropraxia vs axonotmesis vs neurotmesis?
Neuropraxia –> focal nerve compression, contusion or stretch leading to REVERSIBLE conduction block w/o Wallerian degeneration (EP studies show conduction velocity decrease or conduction block but NO fibrillations)
Excellent prognosis
Axontmesis –> Incomplete nerve injury
Zxon and myelin sheath disruption –> focal conduction block WITH Wallerian degeneration
EP Studies –> fibrillations and sharp waves on EMG
Unpredictable recovery
Neurotmesis –> complete nerve division with DISRUPTION of ENDONEURIUM
Focal conduction block with
Wallerian degeneration
EMG: fibrillations and sharp waves
No recovery w/o surgery w/ neuroma at proximal end
Which nerves have excellent recovery potential after repair?
Moderate?
Poor?
Excellent***:
Radial
Femoral
Musculocutaneous
Moderate***:
Median, ulnar, tibial
Poor: Peroneal***
Muscles innervated by AIN?
FDP of index and middle fingers
FPL
PQ
What is included in carpal tunnel?
Nine flexor tendons (FDS, FDP, FPL)
Median nerve
FPL is most radial***
Nerve conduction velocity in CTS?
EMG findings?
Outcomes related to electrodiagnostic studies?
NCV –> prolonged latencies (slowing)*
Distal sensory latency of >3.5 ms*
Motor latencies >4.5 ms***
Slower conduction velocities less specific than latencies*** (velocity <52 m/s is abnormal)
EMG: test the electrical activity of individual muscle fibers/motor units
Pathologic findings:
Increased insertional activity *
Sharp waves*
Fibrillations***
Outcomes: Patients with sever findings on electrodiagnsotic study or minimal to no findings tend to improve less than patients with middle range findings***
Role of steroid injxn for CTS?
Diagnostic utility in clinically and EMG equivocal cases***
80% have transient improvement w/ 20% of these symptom free at 1 year***
Failure to respond to injxn = poor prognostic factor w/ surgery less effective***
Outcomes after carpal tunnel release?
Pinch returns in 6 weeks
Grip 100% by 3 months/12 weeks***
Rate of continued symptoms:
2% for moderate CTS
20% for severe CTS***
What occurs if the recurrent motor branch of median nerve is transected during carpal tunnel release?
How to avoid?
Recurrent motor branch innervates ooponens pollicis –> lack of opposition
Also innervates abductor pollicis brevis, and FPB
Avoid by cutting transverse carpal ligament ulnarly***
Sites of compression for ulnar nerve?
Course of ulnar nerve?
Cubital tunnel made up of?
Between two heads of FCU/aponeurosis (most common)**
Arcade of Struthers (hiatus in medial inter muscular septum) *
Between Osborne’s ligament and MCL
Other, less common: Medial head of triceps medial inter muscular septum Medial epicondyle Fascial bands w/in FCU
Anconeus epitrochlearis (anomalous muscle from medial olecranon to medial epicondyle)***
Ulnar nerve course:
Thru intramuscular septum at arcade of Struthers 8 cm prox to medial epicondyle (from anterior to posterior compartment of arm) –> cubital tunnel
Cubital tunnel formed by:
Roof: FCU fascia and Osborne’s ligmament (from medial epicondyle to olecranon)**
Floor: posterior and transverse bands of MCL and capsule
Walls: Medial epicondyle and olecranon***
Intrinsic hand muscles innervated by ulnar
Adductor pollicis
Deep head of FPB
Interossei
Lumbricals 4&5
When to do ulnar nerve transposition?
Failed in situ release
THROWING ATHLETE
Unstable nerve in PEDS patient***
Zones of Guyon’s canal: location, common causes of compression and sx?
Zone 1: Proximal to bifurcation of nerve
Common causes of compression: ganglia and hook of hamate fx
Sx: Mixed motor and sensory***
Zone 2: Surrounds deep motor branch
Common causes of compression: ganglia and hook of hamate fx
Sx: Motor only***
Zone 2: Surrounds superficial sensory branch
Common causes of compression: Ulnar artery thrombosis or aneurysm**
Sx: Sensory only***
How to distinguish cubital tunnel from ulnar tunnel syndrome?
Lack of dorsal ulnar sensory deficit***
Dorsal ulnar cutaneous nerve branches PROXIMAL to Guyon’s canal –> maintained sensation in ulnar tunnel syndrome***
Potential sites of compression of PIN?
Innervation?
Sites of compression:
1 - Fibrous tissue anterior to radiocapitellar joint
2 - Leash of Henry –> recurrent radial vessels that fan out across PIN at level of radial neck
3 - Medial edge of ECRB
4 - Arcade of Frohse –> proximal edge of superficial portion of supinator (MOST COMMON)***
5 - Supinator muscle edge - distal edge of supinator muscle
Innervation
Common extensors: EDC, EDM, ECU
Deep extensors:
Supinator, APL, EPB, EPL, EIP
Sensory fibers to dorsal wrist capsule (terminal branch in floor of 4th extensor compartment
PE: Wrist extension weakness in neutral or ulnar deviation
Wrist WILL extend in radial deviation due to intact ECRL (radial) and absent ECU (PIN)
De Quervain’s tenosynovitis Sx?
where to incise sheath?
Common failure?
Stenosisng condition of the 1st dorsal compartment of wrist (APL, EPB)
Incise sheath dorsally to prevent tendon subluxation**
Common failure: failure to decompress EPB subsheath***
Common complication: superficial radial dysethesias**
Sequence of events to get Boutonniere
1- rupture of central slip –> causes extrenisinc extension block from EDC to be lost and prevents extension at PIP
2- attenuation of triangular ligament –> causes lumbiricals to act as flexors at PIP and extend at DIP w/o opposing/balancing force
3- palmar migration of collateral bands and lateral bands
lumbicjls pull becomes unopposed, pulling thru the base of distal phalanx and volar to PIP –> PIP flexion and DIP extension
Tx of central slip injuries/Boutonneire?
Splint PIP in full extension for 6 weeks if acute (<4 wks), encourage active DIP flex/ext in splint to avoid contraction of oblique reticular ligament***
Spiral cord for Dupuytren’s disease
Most important cord –> causes PIP contracture***
Inserts distally into the lateral digital sheet then into Grayson’s ligament
Components: Pretendinous band Spiral band Lateral digital sheet Grayson's ligament
Travels UNDER NV bundle –> displaces central and superficial***
Predictors of NV bundle displacement –> PIP joint contracture and interdigital soft tissue mass
Dupytren’s dz - what causes PIP contracture?
MCP contracture?
DIP contracture?
Web space contracture?
PIP contracture: Spiral cord***
Also displaces NV bundle and places at risk
MCP contracture: Central cord***
Forms palmar nodules and pits between distal palmar crease and planar digital crease
NOT involved w/ NV bundle
DIP contracture: Retrovascular cord***/lateral cord
Dorsal to NV bundle distally
Web space contracture: Natatory cord (from natatory ligament)***
Dupuytren’s tx
Injxn clostridium hisolyticum collagenase (Xiaflex)
LOW ACTIVITY abasing type IV collagen (BM of blood vessel and nerves) –> likely reason of low NV complications
24-48 hrs after injection do manipulation under anesthesia
Repeat at one month if necessary
outcome:
can get MCP/PIP to <5 deg
More successful at MCP than PIP**
PIP recurrence more severe than MCP recurrence
Needle aponeurotomy
22G or 25G needle followed by manipulation
Outcome: more successful for MCP than PIP
Less improvement and higher recurrence than surgery***
Surgical resection
MCP flexion >30 deg*
PIP flexion contracture
Painful nodules NOT indication for surgery
What are nodes over DIP in OA called?
PIP?
DIP: Heberden’s nodules**
PIP: Bouchard’s nodes**
What is primary stabilizer of the CMC joint?
Anterior oblique (volar beak) ligament***
Stages for basilar thumb arthritis?
Stage I –> slight joint space widening (pre-arthhritis)
Stage II: Slight narrowing w/ sclerosis, osteophytes <2 mm
Stage III: marked narrowing with osteophytes >2 mm
Stage IV: Pantrapezial arthritis (STT involved***)
Tx: 1st MT osteotomy, stage I-II, closing wedge dorsal extension
Trapeziectomy +/- ligament recon, stage I-IV (LRTI/ligament recon and tendon interposition, suture suspension, FCR recon)
Expect 25% subsidence*
If subsides and sx, treat with ECRL tendon* or APL if FCR already used***
CMC arthrodesis, stage II-II in young male heavy laborers –> preserves grip strength!
Contra’d w/ STT arthritis
35 deg radial abduction, 30 deg palmar abduction, 15 deg pronation
CMC arthroplasty –> not recommended**
MCP hyperextension deformity in CMC arthritis Tx?
<10 deg: no surgery
10-20: perc pinning of MCP in 25-35 deg flexion x4 weeks + EPB tendon transfer
20-40 deg: volar capsulodesis or sesamoidesis
40+ deg: MCP fusion*****
Trapeziectomy vs trapeziectomy + LRTI?
No difference***
Trapeziectomy does as well as any other technique**
What is Kienbock’s dz?
AVN of lunate***
Risk factors:
Ulnar negative* –> increased radial-lunate contact stress
Decreased radial inclination
Repetitive trauma***
Stages and Tx of Kienbock’s dz?
Stage I: No changes on XR, MRI changes
Tx : immobilization and NSAIDs
Stage II: Sclerosis of lunate
Tx: Joint leveling in ulnar negative*
Radial wedge osteotomy or STT fusion (ulnar neutral pt)*
Distal radius core decompression ***
Stage IIIA: Lunate collapse, no scaphoid rotation
See stage II
Stage IIIB: lunate collapse + scaphoid fixed rotation
Tx: PRC
STT fusion
SC fusion
Stage IV: degenerated adjacent intercarpal joints
Tx: Wrist fusion
PRC
Limited intercarpal fusion
Peds with Kienbock’s tx?
Temporary STT pinning**
Those with evidence of Kienbock’s and progressive wrist pain**
Neutral wrist vs ulnar positive wrist load through radius and ulna?
Neural wrist
80% through radius, 20% thru ulna
Ulnar positive 2 mm
60% through radius
40% through ulna***
Contraindication to ulnar shortening osteotomy?
Concomitant arthrosis in DRUJ***
Perform in young patients***
Stages of SLAC wrist
Stage I: Arthritis between scaphoid and radial styloid
Tx: Radial styloidectomy and scaphoid stabilization*** vs PIN and IN denervation
Stage II: Scaphoid and entire scaphoid facet of radius
Tx: PRC* –> contra’d in stage III/capitate and lunate arthritis as capitate will articulate w/ radius*
4CF (remove scaphoid and fuse capitate/lunate/hamate/triquetrum)
Stage III: Arthritis between capitate and lunate**
Tx: 4CF vs wrist fusion
Note: Radiolunate joint is SPARED***
Watson shift test - what for and how to do?
Test for SLAC wrist
Firm pressure over the palmar tuberosity of scaphoid –> shift wrist form ulnar to radial deviation
Positive: Scaphoid sublimates out of scaphoid fossa = pain, occurs in SL injury or ligamentous laxity
When pressure removed form scaphoid –> relocates –> snapping or clicking
Compare to contra side
Perform 4CF or PRC for patient with stage II SLAC wrist if patient is a smoker?
PRC –> less complications***
What is primary wrist stabilizer after PRC?
Radioscaphocapitate ligament*** –> must protect when removing scaphoid
What gene defect causes radial clubland?
What other conditions are ass’d w/ radial clubland?
Defect in sonic hedgehog gene***
Ass’d with:
TAR: AR condition with thrombocytopenia + absent radius –> different as THUMB IS PRESENT**
Fanconi’s anemia* –> LETHAL, must test for*
AR w/ aplastic anemia
Get Fanconi screen and chromosomal breakage test*
Tx: BM transplant
Holt-Oram syndorme –> cardiac defects
VACTERL: vertebral anomalies, anal atresia, cardiac abnormalities, tracheoesophageal fistula, renal agenesis, limb defects
Tx:
Hand Centralization**
Requires good elbow motion and biceps function
Perform at 6-12 months*
What is Madelung’s deformity?
Who gets it?
Hypothesis on why?
Ass’d condition?
Congital dyschondrosis of distal radial physis –> partial deficiency of growth of distal radial physis –> excessive radial inclination and volar tilt and ulnar carpal impaction
More in adolescent females
May be due to tethering of VICKERS ligament*
Fibrous band from distal radius to lunate on volar side (radiolunate ligament)*
Associated condition
Leri-Weill dyschondrosteosis*
Rare genetic condition caused by mutation in SHOX (short stature homeobox-containing gene)*
What is genetics of forearm synostosis?
Sx?
Tx?
Autosomal dominant**
Ass’d with chromosomal abnormalities, esp DUPLICATION OF SEX CHROMOSOMES***
Sx: Generally have forearm in pronation**, generally asymptomatic, often found by teachers
Tx: generally nonop
If bilateral and symptomatic, fix dominant arm in 0-15 deg of pronation and non dominant forearm in NEUTRAL
Indication for surgical tx of forearm synostosis?
How to decrease recurrence after surgical treatment of forearm synostosis?
Indication: bilateral involvement***
Decrease recurrence: Interposition of material between radius and ulna**
What is camptodactyly?
Tx?
definition: congenital digital flexion deformity that usually occurs in PIP joint of small finger***
Tx: almost always nonop –> passive stretching/splinting***
Operative: FDS tenotomy +/- FDS transfer –> progressive deformity leading to functional impairment
Can transfer FDS to radial lateral band**
What is Poland syndrome?
Congenital disorder characterized by:
Unilateral chest wall hhypoplcsia –> absence of sternocostal head of pec major*****
HYPOPLASIA of hand and forearm
Symbrachydactyly and shortening of middle phalanx** –> causes absence or shortening of middle phalanx***
Why place volar PIP dislocation in extension after reduction?
Central slip often disrupted, so want to heal so don’t get Boutonniere deformity***
Apert Syndrome
Characterized by:
Bilateral complex syndactyly of hands and feet –> index, middle and ring most commonly affected
Symphalangism
Craniosynostosis –> dysmorphic face with flattened skull and facial features***
Genetics: AD, mutation in FGFR2 gene*** (vs FGFR3 achondroplasia)
Preaxial vs post axial polydactyly?
Preaxial –> thumb duplication**
Postaxial –> small finger duplication**
10x more common in African Americans***
how to determine Tx for thumb hypoplasia?
Treatment depends on stability of CMC joint***
Type I: Minor hypoplasia with all structures present –> No tx
Type II: All bones present but small, MCP ulnar collateral ligament instability –> stabilize MCP, release 1st web space and opponensplasty
Type IIIA: CMC joint intact, soft tissue and osseous structure deficiencies, Tx same as type II
type IIIB: Basal metacarpal aplasia with DEFICIENT CMC JOINT –> thumb amputation and pollicization
Type IV: floating dumb, thumb amputation and pollicization
Tx of congenital trigger thumb?
Nonop with passive extension and observation –> 30-60% resolve spontaneous BEFORE age 2
<10% resolve after age 2 y/o **
Intermittent extension splinting –> first line of Tx***
Operative –> A1 pulley release –> fixed deformity beyond 12 months old, or failed conservative management
Most common locations for epithelial cysts?
Ass’d conditions?
What does biopsy show?
Tx?
Most common: dorsal carpal (70%)–> SL articulation
Volar carpal: radoiocarpal or STT joint (20%) Volar reticular (10%) --> from herniated tendon sheath fluid*** Dorsal DIP joint --> mucous cyst ass/d w/ Heberden's nodes
Ass’d conditions: Median or ulnar nerve compression from volar ganglion***
Biopsy: MUCIN FILLED SYNOVIAL LINED sac*****
Tx:
Observation –> 1st line
75% resolve in kids***
Aspiration: 2nd line in adults –> 50% recurrence but minimal risk so fine to do**
Surgical resection: VOLAR ganglions = higher recurrence***
What to do with kid with ganglion cyst in wrist?
observation***
75% resolve***
Ulnar hypothenar hammer syndrome - what digital-brachial index suggest reconstruction will be required?
What other test to get?
U/S is fist line –> digital-brachial index <0.7 suggest reconstruction necessary***
Angiogram/MRI/CTA required for diagnosis***
Tx of Raynaud’s
Smoking cessation and cold avoidance**
Topical nitrates
Calcium channel blockers**
ASA**
Botulinum toxin A injections-**** If medical management fails Ulcerations not a contraindication "off label" use*** Shown to improve digital perfusion ****
Operative
Digital sympathectomy** –> severe cases that fail conservative Tx
Wrist arthroscopy portals and risks: Radoiocarpal
3-4: distal (1 cm) to Lister, between EPL and EDC, 1st portal primary viewing
Risk: EPL and EDC tendons
4-5: in line w/ 4th metacarpal, EDC and EDM, instrumentation and vixuliaziont of TFCC
Risk: EDC and EDM tendons
6R: radial to ECU, TFCC tears
Dorsal sensory branch of ulnar nerve
6U: ulnar to ECU, for TFCC tears
Dorsal sensory brach of ulnar nerve
1-2: between APL and ECRB, access to radial styloid, rarely used
Risk: superficial brach of radial nerve, radial artery
Midcarpal arthroscopy portals and risks
MCR: 1 cm distal to 3-4 portal (so 2 cm distal to Lister) along radial border of middle finger metacarpal, between ECRB and EDC, to see SL, scaphocapitate and scaphotrapezoid joints
Risk: ECRB and EDC tendons
MCU: 1 cm distal to 4-5 portal along axis of ring finger, between EDC and EDM, to see lunocapitate, lunotriquetral and triquetrohamate joints
Risk: EDC and EDM tendons
STT;: axis of index finger just ulnar to EPL, to see scaphoidtrapezial and scaphotrapezoid joints
Risk : ECRB and ECRL
deforming forces for Bennett fracture?
Adductor pollicis (ulnar n)***
APL and EPB (PIN)*** (1st compartment)
Which way to cast volarly displaced ulna in DRF that is stable after closed reduction (DRUJ now stable)?
Cast in PRONATION –> distal ulna goes volarly in sigmoid notch with forearm in supination* Opposite for pronation (ulna goes dorsally) –> better for cases when ulna is displaced volarly*
If ulna is displaced dorsally to begin with (more common) cast in SUPINATION***
