Hand and Wrist (Updated) Flashcards

Question 1

Q

What are the extensor compartments of the wrist and associated pathology?

Answer

A

EPB + APL = De Quervain’s tenosynovitis
ECRB + ECRL = intersection syndrome
EPL = drummer’s wrist, traumatic rupture with DR #
EDC + extensor indicis = extensor tenosynovitis
EDM = Vaughn-Jackson syndrome
ECU = snapping ECU

Question 2

Q

What are the extrinsic ligaments of the wrist?

[Rockwood and Green 8th ed. 2015]

Answer

A

Volar ligaments (radial to ulnar)

Radial collateral ligament
Radioscaphocapitate
Radioscapholunate
- AKA Ligament of Testut
- Actually a n.v. bundle
- No contribution to carpal stability
Long radiolunate ligament
Short radiolunate ligament
Ulnolunate ligament
Ulnotriquetral ligament
Ulnocapitate ligament
2. Dorsal ligaments
Dorsal radiocarpal ligament (DRC)
Dorsal intercarpal ligament (DIC)

Question 3

Q

What is normal wrist ROM?

[JBJS REVIEWS 2015;3(1):e1]

Answer

A

Flexion = 80^o
Extension = 70^o
Pronation = 90^o
Supination = 90^o

Question 4

Q

What is the differential diagnosis for radial sided wrist pain?

Answer

A

Soft tissue

De Quervains tenosynovitis
FCR tendonitis/rupture

Bone

Radial styloid fracture
Scaphoid fracture

Joint

CMC joint arthritis
Radio-scaphoid arthritis
Scapholunate instability

Question 5

Q

What is the differential diagnosis for ulnar sided wrist pain?

[JAAOS 2017;25:e150-e156]

Answer

A

Soft tissue

Snapping ECU/ECU tendonitis
EDM tendinitis
FCU tendinitis

Bone

Pisiform fracture
Triquetral fracture
Hamate fracture
Ulnar styloid fracture
Base of 5th metacarpal fracture
Kienbock disease
3. Joint
Ulnar impaction syndrome
Ulnar styloid triquetral impaction (USTI)
TFCC tear
Triquetrolunate instability
Pisotriquetral arthritis
DRUJ arthritis
DRUJ instability
LT ligament tear
Ulnotriquetral ligament tear
4. Vascular
Ulnar artery thrombosis
5. Neurologic
Ulnar tunnel syndrome

Question 6

Q

Describe the SL ligament?

[JAAOS 2015;23:691-703]

Answer

A

Intra-articular C-shaped ligament with 3 components

Dorsal – thickest, primary stabilizer
Volar
Proximal - thin, membranous

Question 7

Q

What is the motion of the scaphoid from ulnar to radial deviation ?

[JAAOS 2015;23:691-703]

Answer

A

Position of flexion and radial deviation to extension and ulnar deviation

Question 8

Q

What wrist motion minimizes motion between the scaphoid and lunate and minimizes tension on the SL ligament?

Answer

A

Dart throwers motion

Radial-extension to ulnar-flexion

Question 9

Q

What percentage of patients with a DISI progress to SLAC wrist?

[JAAOS 2015;23:691-703]

Question 10

Q

Describe the Watson Scaphoid Shift test?

[JAAOS 2015;23:691-703]

Answer

A

Examiner provides dorsally directed pressure on the scaphoid tubercle while ranging the wrist from a position of ulnar deviation with slight extension to radial deviation with slight flexion

If SLIL is injured:
- Dorsal pressure subluxates the scaphoid onto the dorsal rim of the radius
- When pressure is released, a palpable clunk and reproduction of dorsal wrist pain occur as the scaphoid relocates into the radioscaphoid fossa.

Question 11

Q

What are the radiographic classifications of SL ligament injury?

[JAAOS 2015;23:691-703]

Answer

A

Static instability
* SL instability evident on plain film
Dynamic instability

SL instability evident on stress views
Stress view = AP clenched fist with 30° ulnar deviation

Predynamic instability
* SL injury evident on advanced imaging or arthroscopy

Question 12

Q

What are the radiographic features of a SL ligament injury?

[JAAOS 2015;23:691-703]

Answer

A

Widened SL distance
Cortical ring sign
Shortening of the scaphoid
Scapholunate angle >70° (normal = 30-60)
Lunate extension
DISI defined by radiolunate angle >15°

Question 13

Q

What arthroscopic portal is the SL ligament best visualized from?

[JAAOS 2015;23:691-703]

Answer

A

Visualized from the radiocarpal space through the 3-4 portal

Probe in the 4-5 or 6R portal

Question 14

Q

What is the arthroscopic classification of SL ligament injury?

[JAAOS 2015;23:691-703]

Answer

A

Geissler Classification

Stage I
- 1mm probe cannot enter SL space from midcarpal joint
Stage II
- 1mm probe can enter SL space from midcarpal joint but not rotate 90°
Stage III
- 1mm probe can enter SL space from midcarpal joint and rotate 90°
Stage IV
- 2.7mm scope can drive through the SL space from the midcarpal and radiocarpal joint

Question 15

Q

What are the surgical options for managing SL ligament injury?

[JAAOS 2015;23:691-703]

Answer

A

Primary repair

Repaired with two horizontal mattress sutures through bone tunnel or suture anchor
Protected with K-wire or screw augmentation
+/- capsulodesis augmentation
Indicated for acute tears
2. Arthroscopic debridement
Indicated for symptomatic partial tears
3. Reconstructive procedures
Indicated for high grade tears with no arthritis
Blatt capsulodesis
- Capsular flap is attached to the distal scaphoid to prevent flexion
  - Recommend using the DIC ligament
- ***Note – does not address the SL gap or lunate extension
Modified Brunelli procedure
- Portion of the FCR from the base of the 2nd metacarpal is passed through the distal scaphoid and attached to the dorsal lunate
Ligament reconstruction
- Most common donor site is retinaculum of the third dorsal compartment of the wrist with bone blocks from the distal radius
RASL
- ‘Reduction and association of the scaphoid and lunate’
- Herbert screw fixes the scaphoid and lunate to create a fibrous union (‘neoligament’)
  1. Salvage Procedures
Indicated for high grade tears with arthritis
Arthroscopic debridement
Radial styloidectomy
Wrist denervation
PRC
4-corner fusion
Limited carpal fusion
Arthroplasty
Total wrist fusion

Question 16

Q

What is the technique for a Blatt capsulodesis?

Answer

A

Original technique

Utilized a strip of dorsal wrist capsule attached to the distal radius and inserted onto the distal pole of the scaphoid preventing scaphoid flexion
Disadvantage
- Wrist flexion limited by ~20° due to crossing of the radiocarpal joint

Modified DIC capsulodesis
* Detaches the proximal portion of the DIC from the triquetrum and after reduction of the scaphoid flexion it is attached to the lunate

Question 17

Q

What is the technique for the Brunelli procedure?

Answer

A

Dual volar and dorsal incisions
A portion of the FCR is passed through the scaphoid tuberosity and sutured to the remnants of the SLIL on the dorsal aspect of the scaphoid.
* The remaining portion of the FCR slip is anchored to the dorsal ulnar corner of the distal radius

Question 18

Q

What is the technique for the modified Brunelli procedure?

Answer

A

Triligament tenodesis described by Garcia-Elias

A strip of FCR tendon is passed from the volar scaphoid tuberosity to the dorsal ridge to reconstruct the scaphotrapezial ligament
The tendon is fixed dorsally to the lunate, passed through a slit in the dorsal radiotriquetral ligament, and sutured back on itself to recreate the SL ligament.

Question 19

Q

What is the most common pattern of wrist arthritis?

Answer

A

SLAC (55%)

Question 20

Q

What is the pathomechanics of SLAC and SNAC wrist development?

Answer

A

In the normal wrist:

Scaphoid links the proximal and distal carpal rows
- Proximal row moves with the scaphoid
Scaphoid has a tendency to assume a flexed posture
Capitate longitudinal load on the lunate is eccentric causing the lunate and triquetrum to extend
These forces are balanced as long as the link between the scaphoid and lunate are intact
2. With SL ligament disruption:
The scaphoid flexes and lunate/triquetrum extend independently
Radiolunate joint remains congruent with lunate extension
- Radiolunate joint preserved
Radioscaphoid joint becomes incongruent with scaphoid flexion
- Radioscaphoid degeneration progresses

With scaphoid nonunion

The distal scaphoid flexes
The proximal scaphoid extends with the lunate and triquetrum

Question 21

Q

What are the radiographic stages of SLAC wrist?

Answer

A

Stage I - radial styloid

Stage II - radioscaphoid joint

Stage III - capitolunate joint

[Stage IV - pancarpal involvment (controversial)]

***Radiolunate typically spared

Initially, degeneration occurs between the radial styloid and radial side of scaphoid near the waist

Degeneration progresses to the proximal pole involving the entire radioscaphoid joint
With scaphoid flexion and loss of the link between the distal and proximal rows increase load occurs in the midcarpal joints (loss of buttress)
Capitolunate degeneration develops with eventual migration of the capitate proximally between the scaphoid and lunate

Question 22

Q

What are the radiographic stages of SNAC wrist?

Answer

A

Stage I - radial styloid

Stage II - proximal scaphocapitate joint

Stage III - capitolunate joint

Initially, degeneration occurs between the radial styloid and radial side of the distal scaphoid fragment

Degeneration does not progress proximally in the radioscaphoid joint because the proximal scaphoid relationship with the lunate is maintained
Degeneration progresses to the midcarpal joint starting with the proximal scaphocapitate joint then the capitolunate joint

Question 23

Q

What are the treatment options for SLAC and SNAC wrist?

Answer

A

Stage I

Radial styloidectomy
Distal pole excision (SNAC)
Wrist denervation (AIN and PIN)

Stage II

Proximal row carpectomy (PRC)
Four corner fusion

Stage III

Four corner fusion
[PRC with capsular flap interposition]

(Stage IV – pancarpal)

Total wrist fusion
Total wrist arthroplasty

Question 24

Q

what are the advantages and disadvantages of PRC and 4 corner fusion

Answer

A

PRC
- advantages - greater postop ROM (flexion, extension, total flexion/extension arc), lower complication rate
- others - earlier ROM no hardware
4 corner fusion
- advantages - greater radial deviation ROM, greater grip strength

Question 25

Q

What is the most common complication following PRC?

[JHS (Eur Vol) 2015,40E(5) 450–457]

Answer

A

Synovitis and significant edema

Question 26

Q

What is the most common complication following 4-corner fusion?

[JHS (Eur Vol) 2015,40E(5) 450–457]

Question 27

Q

What are the advantages and disadvantages of a PRC and Four corner fusion?

[JHS (Eur Vol) 2015,40E(5) 450–457]

Answer

A

PRC

Advantages
- Greater postoperative ROM
  - Flexion, extension, total flexion/extension arc
- Lower complication rate
- Others
  - Earlier ROM
  - No hardware
    2. 4-corner fusion
Advantages
- Greater radial deviation ROM
- Greater grip strength

Question 28

Q

What are the technical steps in performing a PRC?

Answer

A

Longitudinal incision centred over Lister’s tubercle
Flaps are elevated off the extensor retinaculum
Extensor retinaculum is opened over the 3rd compartment and EPL is retracted radial
2nd and 4th compartments are elevated off the dorsal capsule
PIN is identified and transected
Ligament-sparing capsulotomy is performed

Longitudinal split of the DRC and DIC
Described by Berger, Bishop and Bettinger 1995

Scaphoid, lunate and triquetrum are excised
Preserve the volar radioscaphocapitate
Capitate is seated in the lunate fossa
Radial styloidectomy is performed if there is impingement noted with radial deviation
Capsule is closed
Extensor retinaculum is closed leaving the EPL subcutaneous

Question 29

Q

What are the technical steps in performing a 4-corner fusion?

Answer

A

Longitudinal incision centred over Lister’s tubercle
Flaps are elevated off the extensor retinaculum
Extensor retinaculum is opened over the 3rd compartment and EPL is retracted radial
2nd and 4th compartments are elevated off the dorsal capsule
PIN is identified and transected
Ligament-sparing capsulotomy is performed
Scaphoid is excised
Lunate, capitate, hamate, triquetrum are prepared for fusion
* Articular cartilage and subchondral bone are removed along the dorsal 75%
Lunate extension is corrected and provisional fixation with K-wires between the carpal bones
Bone graft options include excised scaphoid, local distal radius and ICBG
Definitive fixation options include K-wire, staples, headless compression screws, circular plates

Question 30

Q

What is the DRUJ articulation?

[JAAOS 2012;20:623-632] [The Journal of Hand Surgery (European) 2014, 39E(7) 727–738]

Answer

A

Ulnar head and sigmoid notch of distal radius
Asymmetric

Sigmoid notch has a 4- to 7-mm greater radius of curvature than the ulnar head
Bony contribution to DRUJ stability is 20%
- TFCC primary soft tissue stabilizer

Question 31

Q

What motions does the DRUJ allow?

[JAAOS 2012;20:623-632]

Answer

A

Rotation
Translation (dorsal and volar)

Dynamic translation
- Pronation = 2.8mm of dorsal translation
- Supination = 5.4mm of volar translation
  1. Longitudinal
Dynamic ulnar variance
- Pronation = relative positive
- Supination = relative negative

Question 32

Q

What are the stabilizing structures of the DRUJ?

[JAAOS 2012;20:623-632]

Answer

A

bone contour (sigmoid notch of radius and ulnar head)
TFCC
ulnocarpal ligament complex
ECU
ECU tendon sheath
pronator quadratus
interosseous membrane
DRUJ joint capsule

Question 33

Q

what are the 3 components of the interosseous membrane of the forearm

Answer

A

distal oblique bundle
- present in 40% of individuals
- acts as a 2° stabilizer
- when present, DRUJ is more stable
central band
- AKA interosseous ligament
proximal oblique cord

Question 34

Q

What are the types of DRUJ instability?

[The Journal of Hand Surgery (European) 2014, 39E(7) 727–738]

Answer

A

Pathology

Primary
- Relatively rare
- Usually due to inflammatory/connective tissue disease (eg. RA, Ehlers-Danlos)
Posttraumatic
- Most common (11% of distal radius fractures)
- Worse DRUJ instability with increasing dorsal angulation of distal radius (signif beyond 20^o)
Post-surgical
- I.E. Darrach, Sauve-Kapandji
- Presents with pain/clicking with rotation
  1. Direction
Dorsal
Volar
Bidirectional

Severity
* Asymptomatic
* Symptomatic
Static vs dynamic
Acute vs. chronic

Question 35

Q

What are the associated injuries with DRUJ instability?

Answer

A

Distal radius fracture
Ulnar styloid fracture
Galeazzi fracture
Essex-Lopresti lesion
Both bone forearm fracture
TFFC tear
Capsule/ligament tear

Question 36

Q

What is included in the physical exam when assessing DRUJ instability?

Answer

A

Inspection
* Prominent distal ulna
Palpation
* Ulnar styloid tenderness
ROM

Observe for loss of supination/pronation compared to contralateral side
- Dorsal ulnar dislocation = preferential loss of supination (locked pronation)
- Volar ulnar dislocation = preferential loss of pronation (locked supination)
Pain or subluxation
4. ‘Shuck test’ (Ulnar Ballotment)
Attempt volar and dorsal subluxation of distal ulna with forearm in pronation, neutral and supination
- Compare to contralateral side

‘Press test’

Ask patient to arise from a chair using the wrists
- Focal pain at the distal ulna can indicate a TFCC injury

Question 37

Q

What imaging is indicated when evaulating DRUJ instability

Answer

A

Radiographs with forearm in neutral rotation
CT

***Consider MRI if instability associated with intermittent ulnar neuropathy

DRUJ subluxation can mechanically irritate the ulnar nerve at the wrist
- “Subluxation-related ulnar neuropathy”

Question 38

Q

what is the management of DRUJ instability

Answer

A

nonop
- acute dislocation
  - closed reduction and splinting in stable position for 6 weeks
    - dorsal radioulnar ligament injury - splint midsupination
    - volar radioulnar dislocaiton - splint midpronation
operative
- acute DRUJ instability indications
  - irreducible
    - open reduction +/- DRUJ pinning +/- TFCC repair +/- ulnar styloid fracture fixation
  - associated fractures
    - ORIF of associated fractures often resolves the instability
    - if remains unstable pin in reduced position
  - TFCC tear
    - open or arthroscopic repair
      - open - dorsal interval between 5 & 5 compartment, TFCC repaired to distal ulnar with anchor or suture tunnels
    - reconstruction if repair fails
- chronic DRUJ instability
  - in absence of arthritis
    - distal radius malunion
      - indications for correction = >20° of dorsal angulation (controversial)
      - correct distal radius malunion then assess DRUJ stability
        if still unstable reconstruct the DRUJ
    - reconstruction
      - indications - TFCC or radioulnar ligament repair failure, unrepairable
      - Adams procedure +/- notchplasty (if flat lesser sigmoid)
        
        dorsal approach between 5-6 compartments
        
        L shaped capsulotomy
        
        elevate 4th compartment off distal radius and drill 3.5 from dorsal to volar just radial to lesser sigmoid notch
        
        3.5mm drill hole from ulnar neck to fovea
        
        harvest palmaris longus (alternative plantaris or slip of FCU)
        
        small volar approach between ulnar nerve and flexor tendons
        
        suture passer from dorsal to bolar retrieves graft from volar side
        
        limbs are then passed through ulnar tunnel, wrapped around ulnar neck then sutured to each other
    - bain procedure
      - indication
        
        chronic DRUJ instability with a TFCC foveal tear and stable radial attachment
        
        positive arthroscopic hook and trampoline test
      - technique
        
        dorsal approach via 5th extensor compartment
        
        floor of 5th compartment opened longitudinally
        
        dorsal capsule reflected ulnarly
        
        guide wire advanced from 2cm distal to ulnar styloid to fovea
        
        3.5 or 4mm cannulated drill overreams wire
        
        palmaris longus graft is harvested
        
        graft ends passed through 2 holes in the TFCC from distal to proximal then passed through ulnar drill hole
        
        ulnar graft fixation is variable, anchor proximal to hole recommended
  - in presence of arthritis
    - darrach with ulnar stump stabilization
    - sauve-kapandji

Question 39

Q

What is the effect of forearm rotation on the volar and dorsal radioulnar ligaments?

Answer

A

Pronation = dorsal superficial and volar deep ligaments tighten
Supination = volar superficial and dorsal deep ligaments tighten

superficial radilulnar ligaments
- form acute angle as they converge from radius to ulnar styloid
deep radioulnar ligaments (aka ligamentum subcruentum)
- form obtuse angle as they converge from the radius to ulnar fovea
differential tightening of deep and superficial due to difference in attachment sites and convergence angle

Question 40

Q

What is the effect of neutral, positive and negative ulnar variance on load transmission?

[JAAOS 2012;20:623-632]

Answer

A

Neutral – 20% load through the distal ulna
Positive – lengthening 1mm increases ulnocarpal loading by 50%
* 2.5mm lengthening increases load to 42%
Negative – decrease ulnocarpal load transmission

2.5mm shortening decreases load to 4%
Also increases pressure in DRUJ and stabilizes DRUJ by increasing tension on TFCC

Question 41

Q

What is radioulnar convergence?

[JAAOS 2012;20:623-632]

Answer

A

Ulnar head functions to maintain radioulnar distance during forearm rotation
Loss of ulnar head leads to convergence of the radius and ulna

Question 42

Q

What are the causes of DRUJ arthritis?

[JAAOS 2012;20:623-632]

Answer

A

Post-traumatic

Distal radius malunion
Distal radius fracture with extension into sigmoid notch

Inflammatory arthritis (RA)
Madelung deformity
Tumor
* Osteochondroma

Question 43

Q

What are the surgical management options for DRUJ arthritis?

[JAAOS 2012;20:623-632]

Answer

A

Darrach procedure

Indications
- Low demand and non-reconstructable joint
Technique
- Subperiosteal distal ulna exposure
- Distal ulna resection just proximal to sigmoid notch
- Preserve soft tissue
  - TFCC
  - ECU sheath
  - Periosteum

Hemiresection

Indications
- Requires intact TFCC
Technique
- Classic
  - Resection of articular distal ulna with remainder left insitu including TFCC attachment
- Hemiresection interposition technique (HIT)
  - Resection as classic
  - Soft tissue interposition into void to prevent radioulnar convergence
    - Capsular flap or free tendon

Sauve-Kapandji procedure

Indications
- Young, active patient with nonreconstructable joint
Technique
- Dorsal or ulnar approach preserving soft tissue
- Identify and protect the dorsal cutaneous branch of the ulnar nerve
- Ulnar neck resection just proximal to sigmoid (~10-15mm)
- Sigmoid notch and ulnar head prepared for fusion (cancellous bone)
- DRUJ fusion with 2 k-wires or 3.5mm screw
  - Neutral ulnar variance
- Pronator quadratus interposed in osteotomy site (prevents re-ossification)
- FCU slip can be tenodesed through drill hole in ulnar stump to prevent instability

Partial ulnar head arthroplasty

Indications
- Isolated DRUJ arthritis without instability
- Failed HIT

Total ulnar head arthroplasty

Indications
- Painful instability after failed resection
- Isolated instability
Requires stability from native soft tissues

Total DRUJ arthroplasty

Indications
- Incompetent native soft tissues
- Salvage option after failed distal ulnar resection

Question 44

Q

What are complications of resection arthroplasty (Darrach, HIT, S-K procedure)?

[JAAOS 2012;20:623-632]

Answer

A

Pain
Ulnar stump instability
Ulnar translation of carpus
Radioulnar convergence
Re-ossification of resection (S-K procedure)

Question 45

Q

What are surgical options to manage a residual ulnar stump instability?

[JAAOS 2012;20:623-632]

Answer

A

ECU and FCU tenodesis
Tendon allografts

Achilles allograft in interosseous space between radius and ulna
2 slips of BR through distal radius and then around ulna stump

Question 46

Q

What are 3 imaging findings with radioulnar impingement syndrome following distal ulnar resection?

Answer

A

Shortened distal ulna ending proximal to the sigmoid notch
Scalloping of the distal radius along its ulnar border
Radioulnar convergence
* Narrowing between radius and ulna

Question 47

Q

What is the management of DRUJ instability?

[The Journal of Hand Surgery (European) 2014, 39E(7) 727–738][ASSH Manual of Hand Surgery]

Answer

A

Nonoperative

Acute dislocation
- Closed reduction and splinting in stable position for 6 weeks
  - Dorsal radioulnar ligament injury
    - Splint midsupination
  - Volar radioulnar ligament injury
    - Splint midpronation
      2. Operative
Acute DRUJ instability indications
- Irreducible
  - Open reduction
  - +/- DRUJ pinning
  - +/- TFCC repair
  - +/- ulnar styloid fracture fixation
- Associated fractures
  - ORIF of associated fractures often resolves the instability
  - If remains unstable pin in reduced position
- TFCC tear
  - Open or arthroscopic repair
    - Open
      - Dorsal interval between 5+6 compartment
      - TFCC repaired to distal ulna with anchor or suture tunnels
  - Reconstruction if repair fails
Chronic DRUJ instability
- In Absence of arthritis
  - Distal radius malunion
    - Correction indicated if >20° of dorsal angulation (controversial)
    - Correct distal radius malunion then assess DRUJ stability
      - If still unstable reconstruct the DRUJ
  - Reconstruction
    - Indications
      - TFCC or radioulnar ligament repair failure
      - Unrepairable
    - Adams procedure +/- notchplasty (if flat lesser sigmoid) [HAND (2007) 2:123–126]
      - Dorsal approach between 5-6 compartments
      - L-shaped capsulotomy
      - Elevate 4th compartment off distal radius
      - Drill 3.5mm from dorsal to volar just radial to lesser sigmoid notch (distal radius)
      - 3.5mm drill hole from ulnar neck to fovea
      - Harvest palmaris longus (alternative plantaris or slip of FCU)
      - Small volar approach between ulnar nerve and flexor tendons
      - Suture passer from dorsal to volar retrieves graft from volar side
      - Limbs are then passed through ulnar tunnel, wrapped around ulnar neck then sutured to each other
- In Presence of arthritis
  - Darrach with ulnar stump stabilization
  - Sauve-Kapandji

Question 48

Q

What is the management of radioulnar impingement syndrome (failed Darrach or Sauve-Kapandji)?

Answer

A

ECU and FCU tenodesis
Tendon allografts

Achilles allograft in interosseous space between radius and ulna
2 slips of BR through distal radius and then around ulna stump

Ulnar head replacement
* Require some degree of native soft tissue
Total DRUJ replacement
* Does not require native soft tissue
Salvage

One-bone forearm (radioulnar synostosis)
Wide excision (25-50% of distal ulna)

Question 49

Q

What are the patterns of wrist arthritis and causes of each?

[Bone Joint 2015;97-B:1303–8]

Answer

A

Pancarpal arthritis
* Advanced inflammatory or post-traumatic arthritis
Radioscapholunate arthritis

Intra-articular distal radius fractures
Kienbock’s
Inflammatory arthritis

Radioscaphoid arthritis
* SLAC, SNAC
Radiolunate arthritis
* Intra-articular lunate facet fracture

Question 50

Q

What are the treatment options for each pattern of wrist arthritis?

[Bone Joint 2015;97-B:1303–8]

Answer

A

Pancarpal arthritis

Low demand = wrist arthroplasty
High demand = total wrist fusion

Radiolunate arthritis
* Midcarpal joint preserved = radiolunate fusion
Radioscaphoid arthritis

Capitate-lunate preserved = PRC or 4-corner fusion
Capitate-lunate involved = 4-corner fusion

Radioscapholunate arthritis
* Midcarpal joint preserved = radioscapholunate fusion

Question 51

Q

What are the important considerations when performing a radioscapholunate fusion?

[Bone Joint 2015;97-B:1303–8]

Answer

A

Midcarpal is free of arthritis
Distal scaphoid pole excision
* Increases ROM
* Decreases pain
* Rncreases rate of union due to unlocking the midcarpal joint

Question 52

Q

What is the resulting wrist function following total wrist arthrodesis?

[JAAOS 2017;25:3-11]

Answer

A

Loss of flexion, extension, ulnar and radial deviation
Supination and pronation are retained

Question 53

Q

What are the indications for total wrist fusion?

[JAAOS 2017;25:3-11]

Answer

A

Rheumatoid arthritis
Post-traumatic arthritis
Spastic wrist contracture
End stage osteonecrosis

Kienbock disease
Preiser disease

Complete brachial plexus paralysis
Failed wrist arthroplasty
Postinfection degeneration
Failed wrist surgery

PRC
SL reconstruction
Arthrodesis
Silicone synovitis

Question 54

Q

What are the contraindications for total wrist fusion?

[JAAOS 2017;25:3-11]

Answer

A

Active infection
Lack of an adequate soft tissue coverage

Question 55

Q

What are the complications associated with total wrist arthrodesis?

[JAAOS 2017;25:3-11]

Answer

A

Major

Nonunion
Ulnocarpal impaction
Carpal tunnel syndrome
Extensor tenosynovitis
Deep infection
Implant-related problems

Minor

Superficial infection
Carpal tunnel symptoms
Intraoperative fractures
Postoperative fractures
Asymptomatic radiographic loosening

Question 56

Q

What are advantages of wrist arthrodesis vs. wrist arthroplasty?

[JAAOS 2017;25:3-11]

Answer

A

Reliable pain relief
Lower complication rate
Less revision

Question 57

Q

What is the recommended position of wrist fusion?

[JAAOS 2017;25:3-11]

Answer

A

Unilateral wrist arthrodesis

10-15° extension
Slight ulnar deviation

Bilateral wrist arthrodesis

Dominant wrist = slight extension
Nondominant wrist = neutral to slight flexion

Question 58

Q

What are the general principles of total wrist arthrodesis?

[JAAOS 2017;25:3-11]

Answer

A

Adequately prepare the joints

Remove cartilage and expose subchondral bone
Without PRC:
- Radiolunate
- Radioscaphoid
- Scapholunate
- Scaphocapitate
- Lunocapitate
- Triquetrohamate
- 3rd CMC joint
With PRC
- Radiocapitate
- Radiohamate
- 3rd CMC joint
  1. Prepare the distal radius to accept plate
Remove dorsal cortical rim
3. +/- triquetrum excision
Prevents ulnocarpal abutment and provides bone graft
4. Bone graft
Triquetrum
PRC
Olecranon

Precontoured stainless steel locking wrist fusion plate

Fix to 3rd metacarpal shaft
Compression across arthrodesis sites
- Manual compression and compression by design through plate
  1. +/- ECRL and ECRB tendon transfer over plate if finger extensor directly overlying plate
  2. +/- distal ulna resection if DRUJ arthritis present

Question 59

Q

What are the radiographic parameters to assess for distal radius malunion and how do they affect the biomechanics of the wrist?

[JAAOS 2007;15:27-40]

Answer

A

Radial tilt
* Dorsal angulation leads to:
- Loads being shifted dorsal
- DRUJ incongruency
- Tightening of the interosseous membrane
  - Resulting loss in supination-pronation
- Preferential loss of wrist flexion and forearm supination
  * Dorsal angulation causes two forms of wrist instability:
- Dorsal radiocarpal subluxation with maintenance of midcarpal alignment
- Adaptive DISI
  * Volar angulation preferentially decreases extension and pronation
Radial length
Ulnar variance
* Ulnar positive variance leads to ulnocarpal impaction
Radial inclination
* Decrease in inclination shifts loads from the scaphoid fossa to the lunate fossa
Joint congruity

Question 60

Q

What are contraindications to distal radius osteotomy for malunion?

[JAAOS 2007;15:27-40]

Answer

A

Advanced degeneration
Fixed intercarpal malalignment
Severe osteoporosis
CRPS
Inability to comply with postoperative therapy
Serious medical comorbidiities
Very low demand

Question 61

Q

What are the 4 components of surgical management for distal radius malunion?

[JAAOS 2007;15:27-40]

Answer

A

In order:

Osteotomy
Bone grafting
Fixation
Ulnar-side procedure

Question 62

Q

What are the advantages and disadvantages of closing vs. opening wedge osteotomy for correction of distal radius malunion?

[JAAOS 2007;15:27-40]

Answer

A

Closing wedge osteotomy

Advantage
- More stable construct (bone-to-bone contact)
Disadvantage
- Shortening of radius relative to ulna
  - Requires ulnar sided procedure

Opening wedge osteotomy

Advantage
- Restores radial length
- Corrects ulnar variance
- Corrects inclination and tilt
Disadvantage
- Less stable construct
- Increased risk for nonunion or hardware failure

Question 63

Q

What are the bone graft options typically used in osteotomies correcting distal radius malunion?

[JAAOS 2007;15:27-40]

Answer

A

ICBG – corticocancellous
Local distal radius graft
Cancellous autograft or allograft
Bone graft substitute

Question 64

Q

What are the advantages and disadvantages of volar vs. dorsal plating in osteotomy correction of distal radius malunion?

[JAAOS 2007;15:27-40]

Answer

A

Dorsal plating

Advantage
- Easy access for bone graft in dorsal opening wedge osteotomy
Disadvantage
- Hardware irritation and tendon rupture

Volar plating

Advantage
- Less hardware irritation and tendon rupture
Disadvantage
- Difficult access for bone graft
  - May require additional releases

Answer 63

A

Hemiresection-interposition
Ulnar shortening osteotomy
‘Wafer’ resection
Sauve-Kapandji
* DRUJ fusion with proximal pseudoarthrosis)
Darrach
* Complete distal ulna resection
Arthroplasty

Answer 64

A

As soon as possible

Avoids soft tissue contracture

Answer 65

A

Dorsally angulated, extra-articular

Approach – volar or dorsal
- Volar approach requires:
  - Volar locking plate fixation
  - BR Z-lengthening or release
  - Dorsal and radial soft tissue and periosteal release
  - Use of the locking plate as a reduction/correction tool
    - First fix to distal fragment anatomically
      - Can often be done prior to osteotomy
    - Then bring the plate to the shaft correcting inclination, tilt and length
      2. Volarly angulated, extra-articular
Approach – volar
- Less radial and dorsal release required

Intra-articular

Approach – volar or dorsal depending on location of fragment
- Dorsal approach
  - Transverse capsulotomy for direct visualization
- Volar approach
  - Do not perform capsulotomy
  - Reduction may be visualized through osteotomy

Intra-articular and extra-articular deformity

Approach – volar, dorsal or combined
- Typically, the intra-articular malunion is corrected first followed by the extra-articular malunion
- Often a dorsal approach is needed for dorsal capsulotomy and visualization of articular reduction
- Fixation can be volar, dorsal or fragment specific

Answer 66

A

Displacement >1mm
Proximal fracture
Delayed treatment
Inadequate immobilization
Associated carpal instability
Osteonecrosis

Answer 67

A

Radiographic sclerosis
MRI changes
Absence of punctate bleeding intraoperative

Answer 68

A

Scaphoid nonunion with proximal pole osteonecrosis and/or failure of previous grafting

Answer 69

A

Proximal 1/3 nonunion without significant humpback deformity

Recommended
- 1,2 ICSRA (intercompartmental supraretinacular artery) - AKA Zaidenberg
  - Origin
    - Radial artery 5cm proximal to radiocarpal joint
  - Advantages – single approach
  - Disadvantages
    - Unable to correct humpback deformity
    - Vulnerable to kinking and impingement
- Capsule-based (4th extensor compartmental artery)
  - Advantages
    - Simple harvesting technique
    - Short arc of rotation and low risk of kinking
  - Disadvantage
    - Cannot correct humpback deformity
    - Violates dorsal radiocarpal and intercarpal ligaments
Alternatives
- 2,3 ICSRA
- Free vascularized bone graft
  - Medial femoral condyle or iliac crest
    2. Waist nonunion and humpback deformity
Recommended
- Volar radius VBG (AKA Mathoulin)
  - Origin
    - Radial carpal artery
  - Advantages
    - Single incision
      - Preserves dorsal blood supply
    - Simultaneous correction of humpback deformity
    - May preserve wrist flexion (compared to dorsal grafting)
Alternatives
- Free VBG
  - Medial femoral condyle or iliac crest

Answer 70

A

Radiographs

Wrist PA, lateral, scaphoid, 45° pronated and supinated oblique view
Assess for:
- Sclerosis
- Cysts
- Bone resorption at fracture site
- Hardware loosening

CT scan

Assess for:
- Bony union
- Arthritis
- Screw placement
- Fracture reduction
- Proximal pole sclerosis

Answer 71

A

At 3 months if there is inadequate union and evidence of one of the following:

Improper screw placement (at least 3-4 screw threads in each fragment)
Insufficient compression across fracture site (presence of gapping)
Inadequate fixation
Lack of appropriate bone grafting
- Based on OR report or report from surgeon

Answer 72

A

Nonvascularized Bone Graft

Useful when technical error is the primary cause
- IE. Screw malposition, fracture malreduction
Options:
- Distal radius
- Tricortical iliac crest (deformity correction)
Advantages – less technically challenging
Disadvantages
- Heals by creeping substitution and resorption
  - Prolongs time to union and reduces mechanical stability during healing
Union rate = 70%
2. Vascularized bone graft
Union rate = 86%
Options
- Zaidenberg (1,2 ICSRA)
- Mathoulin (Volar branch radial carpal artery)
- Free VBG (Femoral condyle of Iliac crest)

Arterialization
* Direct implantation of the second dorsal intermetacarpal artery into the scaphoid

Answer 73

A

If scaphoid alignment and initial screw position is acceptable and scaphoid is viable:
* Revise with a larger diameter variable pitch screw following the same tract with distal radius bone graft
If screw placement not acceptable:
* Redirect the screw

Answer 74

A

Delayed union (<6 months)
* ORIF with headless compression screw
Established nonunion without humpback
* ORIF with headless compression screw + bone graft (cancellous ICBG or distal radius)
Nonunion with humpback deformity; no AVN
* ORIF via volar approach + corticocancellous bone graft
AVN without humpback deformity
* Vascularized bone graft via volar or dorsal approach
AVN with humpback deformity
* Vascularized medial femoral condyle bone graft via volar approach

Answer 75

A

Volar and dorsal branches from the radial artery
* Volar is dominant and 20% of the time it is sole supply
Gelberman described 3 patterns:
* ‘Y’ = 59%
* ‘I’= 31%
* ‘X’ = 10%
Gelberman hypothesized that a lunate at risk has only one arterial supply or dorsal and volar supply but no anastomoses

Answer 76

A

darrach procedure
- indications
  - preferred for low demand and nonreconstructable joint
- technique
  - subperiosteal distal ulna exposure
  - distal ulna resection just proximal to sigmoid notch
  - preserve soft tissue
    - TFCC, ECU sheath, periosteum
- hemiresection
  - indications -required intact TFCC
  - technique
    - classic -resection of articular distal ulna with remainder left insitu including TFCC attachment
    - hemi-resection interposition technique (HIT)
      - resection as classic
      - soft tissue interposition into void to prevent radioulnar convergence (capsular flap or free tendon)
sauve-kapandji procedure
indications - preferred for young, active patient with nonreconstructable joint
technique
- dorsal or ulnar approach preserving soft tissue
- identify and protect the dorsal cutaneous branch of the ulnar nerve
- ulnar neck resection just proximal to sigmoid (~10-15mm)
- sigmoid notch and ulnar head prepared for fusion (Cancellous bone)
- DRUJ fusion with 2 k-wires or 3.5mm screw (neutral ulnar variance)
- pronator quadratus interposed in osteotomy site (prevents re-ossificaiton)
- FCU slip can be tenodesed through drill hole in ulnar stump to prevent instability
partial ulnar head arthroplasty
- indication - isolated DRUJ arthritis without instability
  - failed HIT
total ulnar head arthroplasty
- indications: painful instability after failed resection, isolated instability
- requires stability from native soft tissues
- total DRUJ arthroplasty
- indications - incompetent native soft tissues, salvage option after failed distal ulnar resection

Answer 77

A

Lichtman Classification

Stage I
- Normal xray
- MRI decreased signal T1
- Bone scan positive
Stage II
- Lunate sclerosis
Stage IIIa
- Lunate collapse (no scaphoid rotation)
- Carpal height maintained
Stage IIIb
- Lunate collapse
- Carpal collapse
- Scaphoid rotation (hyperflexed, RS angle >60^o)
  - Cortical ring sign
  - Capitate migrates proximal
  - Decreased carpal height
Stage IV
- Pancarpal arthritis (Kienbock’s disease advanced collapse)

Answer 78

A

Stage I

Nonoperative (3 months immobilization)

Stage II

Radial shortening osteotomy
- If ulnar negative or neutral
Capitate shortening
- If ulnar positive
(vascularized bone graft)

Stage IIIa

Same as Stage II
Vascularized bone graft (dorsal pedicle)
- 4,5 ECA graft
- Vascularized pisiform
- Free vascularized medial femoral condyle

Stage IIIb

Scaphocapitate fusion
STT fusion
PRC

Stage IV

PRC
Total wrist arthrodesis

Answer 79

A

ulnar head and sigmoid notch of the distal radius
asymmetric -sidmoid notch has a 4-7mm greater radius of curvature than the ulnar head

Answer 80

A

rotation
translation (dorsal and volar)
- dynamic translation
  - pronation - 2.8mm of dorsal translation
  - supination - 5.4mm of volar translation
longitudinal
- dynamic ulnar variance
  - pronation - relative positive
  - supination - relative negative

Answer 81

A

- neutral - 20-33% load through the distal ulna
- positive -lengthening 1mm increases ulnocarpal loading by 50%
- negative - decrease ulnocarpal load transmission
  - also increases pressure in DRUJ and stabilizes DRUJ by increasing tension on TFCC

Answer 82

A

ulnar head functions to maintain raiodulnar distance during foremarm rotation
loss of ulnar head leads to convergence of the radius and ulna

Answer 83

A

post-traumatic
- DR malunion
- DR fracture with extension into sigmoid notch
inflammatory arthritis (RA)
madelung deformity
tumor
- osteochondroma

Answer 84

A

Articular disc
* Extends between the volar and dorsal radioulnar ligaments (hammock)
Meniscus homologue
Volar and dorsal radioulnar ligaments
* Superficial and deep (ligamentum subcruentum)
* Major stabilizers of the DRUJ
Sheath of ECU
Ulnar capsule (ulnar collateral ligament)
* Arises from the ulnar styloid and extends between the ulnotriquetral ligament and the ECU sheath
Ulnolunate and ulnotriquetral ligaments (volar)

Answer 85

A

Stabilize ulnocarpal joint
Stabilize DRUJ
Transmits load from carpus to ulna
Assists with wrist mechanics

Answer 86

A

Peripheral 20% vascularized
Central avascular
supplied by Ulnar artery and anterior interosseous artery
- Palmar and dorsal branches

Answer 87

A

Ulnar nerve
PIN

Answer 88

A

Palmer classification

Type 1 = traumatic
- 1A – central
- 1B – peripheral avulsion from ulnar styloid
- 1C – volar ulnocarpal ligaments
- 1D – radial attachment
Type 2 = atraumatic
- 2A – TFCC wear (no tear)
- 2B – TFCC wear with lunate or ulnar head chondromalacia
- 2C – 2B + TFCC perforation
- 2D – 2C + LT ligament perforation
- 2E – 2D + ulnocarpal arthrosis

Answer 89

A

Prominent ulna
Fovea sign

Palpation of the depression volar between ulnar styloid, FCU and pisiform
Tenderness suggests:
- Tear of ulnotriquetral ligament
- Foveal disruption of TFCC
- Chondromalacia of ulnar aspect lunate
  - Suggestive of ulnocarpal impaction

Ulnocarpal stress test
* Ulnar deviation with axial loading in alternating supination and pronation
Positive grind test
* Clicking, crepitus or pain with passive supination and pronation
Lunotriquetral shuck test
* Pain and laxity when examiner grasps the pisiform/triquetrum and lunate with opposite hands and translates volar and dorsal

Answer 90

A

Radiographs

Neutral rotation PA and lateral
PA in ulnar and radial deviation
Pronated PA clenched-fist views

MRI/MRA

Answer 91

A

Trampoline test

Probe is used to test central disc tautness and rebound ability
Laxity suggests detachment from one or more insertion points

Hook test

Traction applied to ulnar-most aspect of TFCC
Ability to pull the TFCC radial and upward suggests foveal attachment disruption

Answer 92

A

Nonoperative
* Most tears are initially treated nonoperative
Operative

Contraindications:
- Severe OA
- Previous infection
- Severe osteoporosis of ulnar head
Open
- Indicated when fixing distal radius fracture or surgeon not familiar with arthroscopy
Arthroscopic
- Palmar 1A – debridement
- Palmer 1B, C, D – repair
  - Transosseous or suture anchor fixation
Ulnar positive wrists
- Perform ulnar shortening osteotomy or wafer procedure at time of TFCC repair
  - Better outcomes

Answer 93

A

Mechanical abutment of the distal ulna with the carpus
Usually associated with positive ulnar variance

Answer 94

A

Congenital

Physiologic
Madelung

Acquired

Distal radius malunion
Radial head excision
Premature physeal closure of radius
Post-wrist fusion

Answer 95

A

Degenerative TFCC tears (Palmer 2A-E)
Chondromalacia of ulnar head
Chondromalacia of ulnar lunate
Chondromalacia of triquetrum
LT ligament perforation

Answer 96

A

Pronation
Grip

[Do pronated grip view to elicit positive ulnar variance]

Answer 97

A

Nonoperative

Rest
Immobilization
Activity modification
NSAIDs
Corticosteroid injections

Operative

Ulnar shortening osteotomy
- Technique
  - Subcutaneous approach to the ulna
  - Osteotomy at junction of distal and middle 1/3
  - Compression plate
    - Volar surface preferred
  - Goal of 0 to -1mm ulnar variance
- Advantages
  - Addresses ulnar styloid carpal impaction concomitantly
  - Decreases dorsal subluxation of distal ulna
  - Larger shortening can be achieved compared to wafer
  - Stabilizes ulnar ligament complex
    - Preferred if associated LT ligament injury
- Disadvantages
  - Nonunion
  - Hardware irritation
Wafer procedure
- Technique
  - Open or arthroscopic
  - Resection of thin wafer of dome of ulnar head
- Advantage
  - Less revision compared to shortening osteotomy (hardware removal)
  - No nonunion
- Disadvantage
  - Limit resection to 2-3mm
  - Does not address associated ulnar styloid carpal impaction
  - Does not improve dorsal ulnar subluxation
  - Does not tighten ulnar ligament complex

Answer 98

A

1-2 portal

Dorsum of the snuffbox just radial to the EPL tendon
Risk = radial artery

3-4 portal

Between the EPL and the EDC, just distal to the Lister tubercle
Risk = EPL or EDC tendons
Main viewing portal

4-5 portal

Between the EDC and EDM, in line with the ring metacarpal, slightly proximal to the 3-4 portal
Risk = EDC or EDM tendon
Main radiocarpal instrumentation portal

6-R portal

Radial side of the ECU tendons
Risk = dorsal sensory branch of ulnar nerve

6-U portal

Ulnar side of the ECU tendons
Risk = dorsal sensory branch of ulnar nerve

Radial midcarpal (MCR)

Radial side of the third metacarpal axis proximal to the capitate in a soft depression between the capitate and scaphoid
Risk = ECRB and EDC tendons

Ulnar midcarpal (MCU)

1 cm distal to the 4-5 portal, aligned with the fourth metacarpal, at the lunotriquetral-capitatehamate joint
Risk = EDC and EDM tendons

STT portal

Midshaft axis of the index metacarpal just ulnar to the EPL at the level of the STT joint
Risk = radial artery and small branches of radial nerve

Volar ulnar portal

Interval between flexor tendons and FCU and the ulnar neurovascular bundle
Risk = ulnar artery

Volar radial portal

Just radial to the FCR tendon at the proximal wrist flexion crease
Risk = radial artery and median nerve

Answer 99

A

Ulnar collateral ligament (UCL)
Radial collateral ligament (RCL)

Answer 100

A

Chronic UCL = gamekeeper’s thumb
Acute UCL = skiers thumb
RCL = reverse gamekeeper’s thumb

Answer 101

A

Proper collateral ligament
* Taut in flexion
Accessory collateral ligament and volar plate
* Taut in extension

Answer 102

A

UCL

Proximal phalanx avulsion (90%)
Midsubstance and metacarpal avulsion less common

RCL
* Variable, more common proximal at metacarpal

Answer 103

A

Distal edge of the avulsed UCL is displaced proximal to the adductor aponeurosis
* Blocked from reapproximation to its insertion on the proximal phalanx
Surgical management is recommended

Answer 104

A

RCL
* Adductor pollicis inserts on the proximal phalanx and ulnar sesamoid creating an ulnar and volar deforming force
Assess with anterior drawer test
* >3mm displacement volar is more common with RCL injury

Answer 105

A

Grade 1

Sprain with no joint instability

Grade 2

Incomplete tear with asymmetric joint laxity
Instability does not meet the criteria for a complete tear
- Characterized by increased laxity with a firm end point, or an incomplete tear

Grade 3

Complete tear with joint instability
- Laxity of >35° in 0° and 30° of flexion
  - Or 15° greater than that of the contralateral side

Answer 106

A

Joint stressed at zero degrees of extension and 30° flexion

Instability = deviation of the proximal phalanx on the metacarpal head of >30-35°

Answer 107

A

Grade 1 and 2

Nonoperative
- Cast or splint x 4 weeks
- Grip and pinch strengthening after 6 weeks

Grade 3

Surgical
- Acute collateral ligament injury = repair
  - Avulsion from proximal or distal insertion
    - Suture anchor repair
  - Midsubstance tear
    - Direct repair
- Chronic collateral ligament injury (>3 weeks)
  - No arthritis
    - Ligament reconstruction with free graft (palmaris longus)
  - Arthritis = arthrodesis

Answer 108

A

Dorsoradial

Answer 109

A

Traction
Abduction
Pronation
Dorsal pressure on the base of the metacarpal (anatomical snuffbox)

Answer 110

A

CRPP

Intermetacarpal pinning
Transarticular pinning

Open/arthroscopic reduction if closed reduction not attained
* Repair capsule/ligament protect with pinning

Answer 111

A

Anteromedial (volar-ulnar) fragment

Smaller (less articular surface area)
Nondisplaced, attached to volar oblique ligament

Metacarpal fragment

Larger (greater articular surface area)
Displaced
- Proximal, dorsal and radial

Answer 112

A

APL = proximal, dorsal, radial
Adductor pollicis = narrowing of 1st web space

Answer 113

A

Traction
Abduction
Pronation
Pressure to the metacarpal base (dorsal to palmer)

**TrAPP/TAPP

Answer 114

A

Wagner approach

Junction of the glabrous and nonglaborus skin
Elevate thenar muscles and perform capsulotomy

Answer 115

A

Large anteromedial fragment
* Open reduction and direct screw fixation
Small anteromedial fragment
* CRPP – transarticular or intermetacarpal
Irreducible or intra-articular gap >2mm [J Hand Surg 2009;34A:945–952.]
* Open reduction

Answer 116

A

‘T’ or ‘Y’ pattern

Extra-articular fracture separating metadiaphysis from epiphysis and a vertical fracture separating the epiphysis into two fragments
Central joint depression may be present

Answer 117

A

Adductor pollicis – metadiaphysis adduction (narrows 1st web space)
APL – dorsoradial displacement of radial articular fragment
Ulnar articular fragment does not displace due to volar oblique ligament

Answer 118

A

Open or arthroscopic reduction

Followed by provisional K-wire fixation and miniplate fixation or definitive k-wire fixation

Answer 119

A

Often regarded as a Rolando fracture, worst stage

Answer 120

A

Intermetacarpal blocked pinning
External fixation

Answer 121

A

Proximal fragment that remains reduced
Metacarpal fragment displaces into adduction

Answer 122

A

<30° of angulation

>30^o results in unacceptable narrowing of the 1st web space

Answer 123

A

<30° of angulation = closed reduction and casting
>30° of angulation = CRPP (intermetacarpal)

Answer 124

A

Apex volar

Proximal fragment flexes due to interosseous attachments
Distal fragment extends due to extensor central slip

Answer 125

A

Apex dorsal if fracture proximal to FDS insertion
Apex volar if fracture distal to FDS insertion

Answer 126

A

No rotation
<10-15° angulation
<2mm shortening

Answer 127

A

Nonoperative (most)
* Stable fractures with acceptable alignment = buddy taping
Operative
* K-wire
* Eaton-Belsky pinning through the metacarpal head
* Screws
* Plates and screws

Answer 128

A

open vs closed
intra-articular vs extra-articular
location - head, neck, shaft, base
pattern - spiral, oblique, transverse, comminuted

Answer 129

A

apex dorsal angulation

Answer 130

A

with the fingers in flexion all should point towards the scaphoid tubercle without overlapping adjacent finger (compare to contralateral side)
for patients who are unable to perform active flexion, the digital cascade can be observed through the tenodesis effect by flexing and extending the wrist
- each degree of rotation at the MC results in 5° of rotation at the fingertip, leading to 1.5cm of digital overlap in the closed fist

Answer 131

A

No articular displacement acceptable

Answer 132

A

metacarpal shaft
1. long oblique/spiral fractures - lag screws
  1. ideally suited for long oblique fractures in which the fracture length is twice the diameter of the bone, enabling accommodation of at least 2 screw
2. short oblique or transverse = dorsal plates or IM pinning
3. comminuted = dorsal plate
metacarpal neck
1. closed reduction and perc pinning
  1. antegrade IM bouquet technique
  2. retrograde IM cross pinning
  3. transverse pinning to adjacent intact metacarpal
2. mini-condylar plate
metacarpal head
1. lag screw or k-wire
metacarpal base
1. CRPP or ORIF with screws +/- plates

Answer 133

A

with the fingers in flexion all should point towards the scaphoid tubercle without overlapping adjacent finger (compare to contralateral side)
for patients who are unable to perform active flexion, the digital cascade can be observed through the tenodesis effect by flexing and extending the wrist
- each degree of rotation at the MC results in 5° of rotation at the fingertip, leading to 1.5cm of digital overlap in the closed fist

Answer 134

A

Index and middle = <10-15°
Ring = <40°
Small = <60°
No rotation

Answer 135

A

Index and middle = <10°
Ring = <20°
Small = <30°
No rotation

Answer 136

A

general indications - polytrauma, severe soft tissue injury, unstable open fractures, segmental bone loss, and multiple hand or wrist fractures
shaft fracture indications
1. failure to achieve successful closed reduction (Acceptable alignment paramenters not met)
2. failure to maintain closed reduction
neck fracture indications
1. failure to achieve successful closed reduction (Acceptable alignment paramenters not met)
2. failure to maintain closed reduciton
head fracture indications
1. step off of >1mm or involvement of more than 25% of the articular surface
base fracture inidcations
1. displaced fracture with dislocation or subluxation of the CMC joint

Answer 137

A

Jahss Maneuver
- MCP and PIP joints are fully flexed and dorsal force is applied along the long axis of the proximal phalanx and volarly along the MC shaft to reduce the MC head from a flexed position

Answer 138

A

Volar plate

Anatomy
- Volar base of the middle phalanx to the proximal phalanx via swallow-tail extensions called checkrein ligaments
Function
- Primary = resists hyperextension
- Secondary = resists lateral stability
  1. Collateral ligaments
Proper collateral ligament
- Anatomy
  - Pit on lateral side of proximal phalanx head to volar 1/3 of middle phalanx base
- Function
  - Primary = resists lateral displacement in flexion
Accessory collateral ligament
- Anatomy
  - Lateral proximal phalanx head and proper collateral ligament to the volar plate
- Function
  - Primary = resists lateral displacement in extension
    3. Volar base of middle phalanx
Function = resists dorsal displacement

Answer 139

A

Extension (most common)
Axial load of a flexed PIP joint

Answer 140

A

Volar plate rupture or avulsion of volar base off middle phalanx
Volar avulsion of variable size (loss of buttress effect)

Answer 141

A

Stable

Articular surface <30% involvement
Clinical stability = stable throughout ROM

Tenuous

Articular surface = 30-50% involvement
Clinical stability = Requires ≤30° of PIP flexion to maintain reduction

Unstable

Articular surface >50% involvment
Clinical stability = Requires >30° of PIP flexion to maintain reduction

Answer 142

A

Stable
* Buddy taping
Tenuous

Extension block splinting (if no hinging)
- Prevents extension of the PIPJ into the range where it is unstable while permitting motion within the stable range

Unstable

Operative options
- Extension block pinning or transarticular pinning +/- percutaneous pinning of large fracture fragment
  - Indicated when concern for closed reduction failure or digit will not accommodate extension block splint (swollen, short, small digit)
- Dynamic distraction and external fixation (Suzuki splint)
- ORIF
  - Large fragments
- Volar plate arthroplasty
  - Comminuted and impacted volar fragment
  - <50% articular surface involvement
- Hemi-hamate resurfacing arthroplasty
  - Comminuted and impacted volar fragment
  - >50% articular surface involvement

Answer 143

A

Hyperflexion
Axial load of an extended PIP joint

Answer 144

A

Central slip rupture or avulsion of dorsal base of middle phalanx
Dorsal avulsion of variable size

Answer 145

A

Stable and small minimally displaced fracture

<50% articular surface and <2mm displacement
PIP joint splinting

Stable and large or displaced fracture

>50% articular surface and >2mm displacement
CRPP or ORIF

Unstable with minimally displaced fracture
* Dynamic distraction and external fixation

Answer 146

A

Index DIP

2nd most common = thumb basal joint

Answer 147

A

Nondominant

Answer 148

A

Trapeziometacarpal (CMC joint)
* Most commonly affected articulation
Trapeziotrapezoid
Scaphotrapezial
Scaphotrapezoidal
Trapezial-index metacarpal

Answer 149

A

Static

Deep anterior oblique “beak” ligament
- Tightens with thumb abduction, pronation and extension
Dorsal “deltoid” ligaments
- Strong
Volar ligaments
- Weak
Dorsoradial ligament
Ulnar complex
- Ulnar collateral
- Volar TM ligament
- Dorsal TM ligament
  1. Dynamic
Extrinsic
- FPL, APL, EPB, EPL
Intrinsic
- APB, Adductor pollicis, FPB, opponens pollicis

Answer 150

A

Anterior oblique ligament

Answer 151

A

Advanced age
* 36% >80y vs. 6.6% 40-49y
Female
Ligamentous laxity/ higher Beighton score
Occupations
* Repetitive finger use or heavy manual labour
Post-traumatic

Intra-articular fracture
Traumatic ligamentous instability

Answer 152

A

Metacarpal adduction
MCP hyperextension

Answer 153

A

CMC grind test
* Pain with axial load and rotation around the thumb axis
CMC subluxation test
* Pain or instability with attempted subluxation
Decreased pinch strength

Answer 154

A

Roberts view

Thumb hyperpronated and flat on the cassette

Answer 155

A

30% of patients with CTS have thumb basal joint arthritis
≤30% of patients with thumb basal joint arthritis have CTS

Answer 156

A

Eaton-Littler

Stage I
- Normal joint with widening
  - Synovitis, effusion, ligamentous laxity
Stage II
- Mild joint narrowing
- Mild subchondral sclerosis
- Subchondral cysts and/or periarticular debris
Stage III
- Severe joint space narrowing
- Subchondral sclerosis/cysts
- Larger periarticular debris
Stage IV
- Involves scaphotrapezial joint

Answer 157

A

Nonoperative
* Exercise therapy, heat, education, magnetotherapy, adaptive equipment, orthoses, NSAIDs, corticosteroid injections
Operative

Joint preserving options described (Stage I/II)
- 1st metacarpal extension osteotomy
- Arthroscopy and debridement
- Imbrication of the dorsoradial capsule
- Volar beak ligament reconstruction
Joint sacrificing options described (Stage III/IV)
- Trapeziectomy
- Trapeziectomy and ligament reconstruction and tendon interposition (LRTI)
- Distraction hematoma arthroplasty
- Suture suspension arthroplasty
- Prosthesis
- CMC arthrodesis

Answer 158

A

None

No benefit to pain or function
No difference in adverse events

[No differences shown between trapeziectomy with or without LRTI]

Answer 159

A

FDS
FDP
FPL

Answer 160

A

Dorsal portion
* Two vinculae supplied by radial and ulnar artery
Volar portion
* Minimal direct blood supply (synovial diffusion)

Answer 161

A

A1 - MCP volar plate

A2 - proximal phalanx

C1 - between A2-A3

A3 - PIP volar plate

C2 - between A3-A4

A4 - middle phalanx

C3 - between A4-A5

A5 - DIP volar plate

Answer 162

A

A2 and A4

Answer 163

A

A1 - MCP volar plate

Oblique pulley - proximal half of proximal phalanx

A2 - IP volar plate

Answer 164

A

Oblique pulley

Answer 165

A

Zone 1 - distal to FDS insertion

Zone 2 - FDS insertion to proximal A1 pulley

Zone 3 - proximal A1 pulley to distal transverse carpal ligament

Zone 4 - carpal tunnel

Zone 5 - proximal transverse carpal ligament to musculotendinous junction

Answer 166

A

Easy placement of sutures in the tendon
Secure knots
Smooth juncture of the tendon ends
Minimal gapping
Minimal interference with tendon vascularity
Sufficient strength

Answer 167

A

Minimal tendon handling to minimize adhesion
Strength of repair is proportional to the number of core sutures and caliber of suture
Core sutures should be 7-10mm from tendon edge
Dorsal placement is biomechanically advantaged
Epitendinous (peripheral) suture improves:

Strength
Minimizes gapping
Reduces CSA
Decreases gliding friction

Locking loops increase tensile repair
Internal knots have decreased strength

Answer 168

A

Injury to FDP tendon (laceration or avulsion)
* Closed avulsion = Jersey Finger
Leddy classification

Type I - retraction into palm
- Both vincula disrupted
- Repair within 7 days
- Worst prognosis
Type II - retraction to PIP joint
- Repair within 6 weeks
Type III - retraction to distal A4 pulley (bony avulsion)
- Repair within 6 weeks
(Type IV) - fracture and avulsion of FDP tendon from bony avulsion
(Type V) - distal phalanx fracture along with bony avulsion of FDP
3. Repair options
Stump >1cm = primary end-to-end repair
Stump <1cm = suture anchor or pullout buttons
Chronic = consider treating nonoperative or DIP fusion if symptomatic

Answer 169

A

Injury to FDP and/or FDS tendon
* FDP injured more often due to superficial nature
“No Man’s Land” due to poor outcomes
Repair options:

≤50% = debride to prevent catching at pulleys
>50% = repair

Answer 170

A

Injury to FDP and/or FDS
Good prognosis due to absence of fibrosseous sheath
Repair options
* Direct surgical repair

Answer 171

A

Often associated with median or ulnar nerve injury
“Spaghetti wrist”
* Multiple tendons and median nerve involved
Repair options:
* Carpal tunnel release and direct repair

Answer 172

A

Often associated with nerve or vascular injury
Good outcomes

Answer 173

A

Active protocols:
* Higher risk of rupture
Passive protocols:

Adhesion
Contracture
Decreased ROM
- Poor gliding between FDP and FDS

Answer 174

A

Pathways

Intrinsic = tenocytes within the tendon
Extrinsic = inflammatory cells outside the tendon
- Implicated in adhesions/scarring

Phases

Inflammatory (0-72h)
- Strength of repair is equivalent to strength of suture repair
Proliferative (72h-4 weeks)
- Type III collagen laid down
- Strength increases
Remodeling phase (>4 weeks - 112 days)
- Type I collagen laid down
- Strength increases
  - Does not reach preinjury

Answer 175

A

Tendon sheath

Fibrocartilaginous metaplasia
Cartilage degradation
Vascular ingrowth

Tendon

Chronic degenerative tears
- Absence of inflammatory cells

Answer 176

A

A1 pulley

Answer 177

A

Ring finger and thumb

Answer 178

A

Female
Diabetes
RA
Crystalline arthropathy
Thyroid disease
Renal insufficiency
Overuse

Answer 179

A

Carpal tunnel syndrome

>60% of patients with trigger digits demonstrate clinical or electrodiagnostic evidence of median nerve compression at the wrist

Answer 180

A

Nonoperative

Therapy
Splinting
NSAIDs
Corticosteroid injections
- Commonly used firstline

Operative

Percutaneous release of A1 pulley
Open release of A1 pulley

Answer 181

A

A0 pulley stenosis
* Tight band of superficial palmar aponeurosis proximal to A1
FDP entrapment at FDS decussation
* In patients with diabetes, RA
A3 pulley entrapment

Answer 182

A

Puncture wound (most common)
Staph aureus (most common)

Answer 183

A

Symmetric swelling of entire digit
Tenderness along course of tendon sheath
Semiflexed posture
Pain with passive extension of digit

Answer 184

A

Nonoperative

Indication
- Early presentation <48 hours of symptom onset
Initiate empiric antibiotics
- If no improvement in 12-24 hours proceed with surgical I&D

Operative

Open I&D
- Indication
  - Advanced, atypical or chronic cases
- Midaxial or palmer zig-zag incision
Closed tendon sheath irrigation
- Two incisions
  - 1 oblique incision just proximal to A1 pulley and midaxial incision at DIP joint
- Angiocath is threaded into sheath at proximal incision and penrose drain at distal incision
- Irrigation is performed in OR then intermittently at bedside
Continuous closed irrigation
- Same as closed but irrigation is continuous

Answer 185

A

Northern European
Caucasian
Male
Family history
* Autosomal dominant
Advanced age
Smoking
Alcohol
Local trauma
Local infection
Diabetes (type I > type II)
Epileptic medication
Manual labour

Answer 186

A

Myofibroblasts

Answer 187

A

Pretendinous cord

[Normal fascial bands become pathologic cords]

Answer 188

A

Transverse ligament of the palmar aponeurosis
Cleland ligament

Answer 189

A

Pretendinous cord = MCP contracture
Central cord = PIP contracture
Lateral cord = PIP or DIP contracture
Natatory cord = web space contracture
Spiral cord = displaces NV bundle superficial and to midline
* MCP and PIP contracture

Answer 190

A

Palmer skin pitting and thickening
* Fibrosis of Grapow fibres
Painless nodules
Cords which may become adherent to overlying skin (resemble flexor tendons)
Positive table top test
* Unable to place palm flat on table in presence of MCP joint contracture (>30°)

Answer 191

A

Ring finger

Followed by:
- Small
- Long
- Index
- Thumb

Answer 192

A

MCP before PIP

Answer 193

A

Palmer to digital

Answer 194

A

Peyronie disease (penile fibromatosis)
Ledderhose disease (plantar fibromatosis)

Answer 195

A

Observation
Percutaneous fasciotomy (needle aponeurotomy)
Collagenase

Enzymes derived from Clostridium histolyticum
Injection followed by manipulation
Outcomes:
- Good short term results
- Higher recurrence [CORR course]
Complications
- Edema, contusion, pain, skin tear, lymphadenopathy
- Rare – CRPS, flexor tendon rupture

Answer 196

A

Indications
* ≥30° MCP joint contracture
* >15° PIP joint contracture
Techniques
* Fasciotomy
* Limited fasciectomy
* Dermofasciectomy
* Radical fasciectomy (healthy and diseased fascia)

Answer 197

A

Rheumatoid nodules
Caput ulnae syndrome

Dorsal subluxation of the distal ulna
- Prominent ulnar head

Carpal deformity
* Classically, palmar translation, ulnar translation, supination, radial deviation
DISI or VISI
Arthritis
* Usually progression from DRUJ, radiolunate/radioscaphoid, pancarpal arthritis
Extensor tendon

Tenosynovitis
EDQ rupture
EDC rupture
7. Flexor tendon
Tenosynovitis
Carpal tunnel syndrome
FPL rupture over prominent distal scaphoid and trapezium (Mannerfelt syndrome)
FDS and FDP rupture
8. Ulnar drift
9. Volar subluxation of proximal phalanx to MCP joint
10. Swan neck deformity
11. Boutonniere deformity

Answer 198

A

Darrach procedure

Favoured in low demand, elderly patients
Main concern in RA is ulnar translation of carpus (weak ligamentous support)

Sauve-Kapandji

Favoured in active, younger patients
Main concern in RA is less predictable fusion

Answer 199

A

Total wrist arthrodesis (first line)
* Plates may be less attractive given tenuous soft tissue
Partial arthrodesis if midcarpal preserved

Radiolunate
Scaphoradiolunate

Total wrist arthroplasty

Answer 200

A

Early disease (MCP joint reducible)

Synovectomy with cross intrinsic transfer
- Ulnar intrinsic lateral band released and transferred radial aspect of adjacent digit (proximal phalanx)

Late disease

MCP joint arthroplasty
- Silicone arthroplasty with centralization of extensor tendon
  - Imbrication of radial sagittal bands and release of ulnar sagittal bands
Volar plate arthroplasty
- Indicated if MCP joint too small to accept silicone implant

Answer 201

A

Address the underlying cause
* Remove ulnar head (Darrach or SK) and synovectomy
Tendon transfers
* EDM/little EDC rupture
- End-to-side transfer to intact ring EDC
  * Little and ring rupture
- EIP transfer
  * Little, ring and middle rupture
- EIP transfer to little and ring
- End-to-side middle to intact index EDC

Answer 202

A

Extensor tendon subluxation between metacarpal heads
MCP joint dislocation
PIN palsy secondary to elbow joint involvement (rare)

Answer 203

A

Thumb MCP fusion

Answer 204

A

Young, healthy
Sharp mechanism
Minimal tissue destruction and contamination

Answer 205

A

Thumb amputation
Multiple digit amputation
Amputations at or proximal to the palm
Pediatric finger amputation at any level
Single digit amputation in Zone I (relative)

Answer 206

A

Single digit amputation through Zone II
Severe crush, mangled or contaminated amputation
Segmental injuries
Prolonged warm ischemia time
Medically unfit

Answer 207

A

Red line sign

Red stripe along the mid lateral aspect of the avulsed digit
Represents hemorrhage along the vessel

Ribbon sign

Tortuous, spiraled blood vessels are seen
Indicates significant intimal injury

Answer 208

A

Avulsion mechanism
Smoker
Diabetes
Prolonged ischemia

Answer 209

A

Wrap in saline-moistened gauze
Place in sealed plastic bag
Place on ice

Answer 210

A

Digit = 12 hours warm and 24 hours cold
Hand and proximal = 6 hours warm and 12 hours cold

Answer 211

A

3 muscles contribute to finger extension

EDC
Lumbrical
Dorsal interosseous

2.The EDC is stabilized by the sagittal bands at the level of the MCP joint

Radial and ulnar sagittal bands arise from the EDC dorsally and travel volarly to insert on the volar plate and volar periosteum of the proximal phalanx
The sagittal bands help to extend the MCP joint through a ‘lasso’ effect

The EDC tendon trifurcates into a central slip and two lateral slips which join the lumbricals to form the conjoint lateral band

The central slip inserts into the dorsal base of the middle phalanx
The lumbricals arise from the FDP tendons

Distal to the PIP joint, the radial and ulnar conjoint lateral bands are anchored dorsally by the triangular ligament and volarly by the transverse retinacular ligament, preventing volar and dorsal subluxation

Overlying the distal aspect of the middle phalanx, the radial and ulnar conjoint lateral bands come together to form the terminal tendon.
- The terminal tendon inserts into the base of the distal phalanx and extends the DIP joint

Answer 212

A

Deformity = flexion of PIP joint and extension of DIP joint
Etiology

Disruption of central slip and triangular ligament
- Allows the conjoint lateral bands to sublux volarly with PIP joint flexion
- Lateral bands migrate proximally increasing tension on the terminal tendon causing DIP hyperextension
  1. Mechanism of injury
Blunt trauma
Open laceration
Volar dislocation of PIP joint

Answer 213

A

Hyperextension injury to the PIP joint leading to PIP joint flexion contracture
Cause is scarring of volar plate and capsule
* Central slip and triangular ligament remain intact
Distinguished based on Elson and Boyes tests
Treatment differs as it requires aggressive mobilization

Answer 214

A

Elson test

The examiner holds the PIP joint in 90° of flexion and instructs the patient to actively extend the DIP joint
With an intact extensor mechanism, holding the PIP joint in 90° of flexion causes slack in the lateral bands as they are held distally by their attachments to the central slip
- The patient is unable to generate any extension power at the DIP joint
With a boutonnière injury, flexion of the PIP joint does not advance the lateral bands distally secondary to disruption of the central slip
- Tension is generated in the terminal tendon because of the disrupted central slip
- Therefore, the patient is able to generate an abnormal amount of active extension at the DIP joint with the PIP joint held in flexion

Answer 215

A

Burton Classification of Boutonniere Deformity

Stage I
- Supple, passively correctable deformity
Stage II
- Fixed contracture
- Contracted lateral bands
- No joint involvement
Stage III
- Volar plate and collateral ligament contractures
- Intra-articular fibrosis
Stage IV
- Volar plate and collateral ligament contractures
- Intra-articular fibrosis
- Plus proximal interphalangeal joint arthritis

Answer 216

A

Nonsurgical

Burton Stage I
- Extension splinting of PIP joint for 4 to 8 weeks to allow the central slip to heal
- Active DIP flexion exercises are performed multiple times daily
Burton Stage II
- As long as full passive PIP joint extension is achieved
  1. Surgical
Burton Stage I
- If acute and not amenable to splinting
- Pin PIP joint in extension
Open injuries
Large bony avulsions
Chronic injuries
- Proceed with caution
- First, achieve full passive PIP joint extension
- Second, do 1 of 3 options:
  - Terminal tendon tenotomy (simplest) OR
  - Tendon rebalancing technique OR
  - Staged reconstruction
- Alternative option
  - Arthrodesis

Answer 217

A

Surgical treatment of boutonnière deformities should be done only by experienced hand surgeons
Surgical treatment is rarely necessary for supple boutonnière deformities
Preoperative and postoperative therapy programs are an essential part of surgical treatment
Tendon procedures should be done after full passive PIP joint extension has been achieved
* Procedures may need to be staged, with tendon rebalancing following a PIP contracture release
If arthritic change is present, tendon rebalancing should be combined with implant arthroplasty or arthrodesis
Flexor function should not be jeopardized in an attempt to achieve full extension
All procedures involve rebalancing the extensor mechanism to divert force from the DIP joint to the PIP joint

Answer 218

A

Deformity = hyperextension of PIP joint and flexion of the DIP joint
Etiology
* Extrinsic
- Due to excessive extension force on the middle phalanx
  - Eg. terminal tendon rupture, wrist or MCP joint flexion contractures
    - Intrinsic
- Due to intrinsic muscle tightness
  - Eg. chronic volar MCP joint subluxation, ischemic contractures
    - Articular
- Due to injury or degeneration of volar PIP joint structures
  - Eg. post traumatic, inflammatory, generalized laxity, FDS disruptions

***NOTE: treatment differs for inflammatory vs. posttraumatic swan neck deformity

Answer 219

A

Bunnell test

A patient with intrinsic muscle tightness will have a decrease in passive and active flexion of the PIP joint with the MP joint held in extension

Answer 220

A

Type I

Full ROM
No intrinsic tightness
No functional limitations

Type II

Intrinsic tightness

Type III

Stiff PIP in all positions of the MP joint
Joint space preserved

Type IV

Severe arthritic change

Answer 221

A

Postaxial (ulnar) polydactyly (most common)
Preaxial (radial) polydactyly
* Involves the thumb
Central polydactyly (rare)

Answer 222

A

Type A

Well-formed digit with osseous connection

Type B

Incompletely-formed with soft tissue connection
- Nonfunctional

Answer 223

A

Suture ligation
Vessel clip
Surgical excision
* Avoids complications of ligation/clip including neuroma, cyst, residual stump, infection

Answer 224

A

If performed at bedside = as early as feasible
If performed in OR = 12 months

Answer 225

A

Surgical excision

If digit arises from the MCP joint UCL, ulnar capsule and abductor digit minimi are transferred to the base of the proximal phalanx of retained digit

Answer 226

A

Type I

Bifid distal phalanx

Type II

Duplicated distal phalanx (2nd most common)

Type III

Bifid proximal phalanx

Type IV

Duplicated proximal phalanx (most common)

Type V

Bifid metacarpal

Type VI

Duplicated metacarpal

Type VII

Any triphalangeal thumb

Answer 227

A

12-24 months

Answer 228

A

Aligned joints and physis with longitudinal axis
Stable joint
Balanced tendon pull
Prevent nail deformity

Answer 229

A

Excision and reconstruction (most common)

Usually the less developed radial digit is excised, preserving the native UCL
Radial collateral ligament and abductor pollicis longus is transferred to the proximal phalanx

Bilhaut-Cloquet procedure
* Central portions of the duplicated digits are resected and the retained peripheral portions are closed down and combined to form a single thumb
* Wassel type II, III or IV
On-top plasty

Considered when one thumb may be better developed proximally while the other thumb is better developed distally
The well developed portions of each are combined into a single digit

Answer 230

A

Addressed on an individual basis

Answer 231

A

Entrapment of the ulnar nerve at the wrist
* Guyon’s canal
Characterized by:

Numbness/paraesthesisa of the small and ulnar half of ring finger
- Ulnar palm and dorsum are spared
Intrinsic muscle weakness
- Thenar spared

Sites of compression:

Zone I - proximal to bifurcation
- Motor and sensory
Zone II - deep motor branch
- Motor only
Zone III - superficial sensory branch
- Sensory only

Causes of entrapment:

Hook of hamate fracture
Ganglion
Adhesions
Anomalous muscles
Ulnar artery thrombosis or aneurysm
5. Provocative tests:
Tinels at the wrist
6. What are the EMG findings?
Prolonged motor/sensory latencies across wrist but sparing of the dorsal and palmar cutaneous branches and FDP/FCU

Answer 232

A

Borders:

Lateral – hook of hamate
Medial – pisiform
Roof – palmar carpal ligament
Floor – transverse carpal ligament

Contents

Ulnar nerve and artery/vein

Answer 233

A

Compression of the median nerve at the wrist
Borders of the carpal tunnel:
* Ulnar border – hook of hamate and pisiform
* Radial border – scaphoid tubercle and trapezium
* Roof – transverse carpal ligament
* Floor – concave arch of the carpals
Contents of the carpal tunnel (10):
* Median nerve (1)
* FPL tendon (1)
* FDS tendons (4)
* FDP tendons (4)
Characterized by:

Numbness and paraesthesia in median nerve distribution
- Palmar cutaneous branch spared
Night pain
Grip and pinch weakness
Loss of hand dexterity
Thenar atrophy
5. Causes:
Idiopathic
- Women > men
Anatomic
- Trauma
- Persistent median artery
- Infection
- Ganglion cyst
- Tumor
Systemic
- Obesity
- Drug toxicity
- Alcohol
- Diabetes
- Hypothyroidism
- RA
- Primary amyloidosis
- Renal failure
- Pregnancy
Exertional
- Repetitive use of hands and wrists
- Repeated impact to palm
- Operation of vibratory tools
  1. Provocative maneuvers:
Phalen test – wrist flexion
Reverse Phalens test – wrist extension
Tinels
Median nerve compression test

EMG findings:

Distal motor latency >4.5ms
Distal sensory latency >3.5ms
Order electrodiagnostic tests if clinical and/or provocative tests are positive and surgical management is being considered

Answer 234

A

Extraligamentous (distal to TCL) – 50%
Subligamentous (deep to TCL) – 30%
Transligamentous (through TCL) – 20%
Ulnar take off (distal to TCL)

Answer 235

A

Nonoperative

First line
Early surgery is an option when there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment
Options:
- Splinting
- Corticosteroid injections
- Oral steroid
- Ultrasound
  1. Operative
Complete division of the transverse carpal ligament
The wrist should not be immobilized postoperatively
Technical pearls: [JAAOS 2017;25:e194-e203]
- Safest location for a longitudinal incision
  - Long-ring web space axis
- Distal dissection limit
  - Palmar fat pad (found at distal TCL)

Answer 236

A

Pillar pain

Pain along edges of incision at thenar and hypothenar eminences
Most common complication of open

Laceration of palmar cutaneous branch of median nerve
* 2nd most common complication of open
Incomplete release of TCL
* Most common complication of endoscopic
Injury to motor branch
Hypertrophic scar
Tendon adhesion
Infection
Wound hematoma
Finger stiffness
Recurrence

Answer 237

A

pain
ulnar stump instability
ulnar translation of carpus
radioulnar convergence (radioulnar impingement syndrome)
re-ossification of reserction (s-K procedure)

Answer 238

A

ECU and FCU tenodesis
tendon allografts
- achilles allograft in interosseous space between radius and ulna
- 2 slips of BR through distal radius and then around ulna stump

Answer 239

A

shortened distal ulna ending proximal to the sigmoid notch
scalloping of the distal radius along its ulnar border
radioulnar convergence (narrowing between radius and ulna)

Answer 240

A

ECU and FCU tenodesis
tendon allografts
1. achilles allograft in interosseous space between radius and ulna
2. 2 slips of BR through dislta radius and then aorund ulna stump
ulnar head replacement
1. require some degree of native soft tissue
total DRUJ replacement
1. does not require native soft tissue
salvage
1. one-bone forearm (Radioulnar synostosis)
2. wide excision (25-50% of distal ulna)

Answer 241

A

injury of the terminal extensor mechanism resulting in loss of active extension at the level of the DIPJ
injury is characterized by extensor tendon disruption, either isolated or in combination with a distal phalanx avulsion fracture

Answer 242

A

- D.I.P. joint osteoarthritis
- Swan Neck Deformity
- Hyperextension at the level of the PIP joint as a result of proximal retraction of the central slip

Answer 243

A

- Doyle Classification
  1. Type 1-closed injury (with or without a avulsion fracture)
  2. Type 2 - open injury with tendon laceration.
  3. Type 3 - open injury with tendon substance and soft tissue loss.
  4. Type 4 - mallet fracture.
    - Type 4a - no distal interphalangeal joint subluxation
    - Type 4b - hyperflexion injury with involvement of 20-50% of the articular surface
    - Type 4c - hyperentension injury involving more than 50% of the articular surface
- wehbe and schneider
  1. type 1 - no distal interphalangeal joint subluxation
  2. type 2 - DIPJ subluxation
  3. type 3 - physeal or epiphyseal injuries
  4. all injuries are further subdivided based on the involvement of articular surface
    1. subtype A - less than 30%
    2. subtype B - 30-60%
    3. subtype C - >60%

Answer 244

A

nonop
- no associated fracture
- no volar subluxation of the distal phalanx
- fracture involving <30% of the articular surface
operative
- open
- fracture involving >30% of the articular surface
- palmar subluxation of the distal phalanx

Answer 245

A

retrograde pinning of the DIP joint
- indication - pure tendinous or small bony mallets
extension block pinning
- indication - large bony mallet
  - technique
    - involves 2 wires
      - first extension block wire is placed entering at the dorsal middle phalanx just behind the fracture fragment
        keeps the fragment and extensor tendon reduced
      - second wire is placed retrograde across the DIP joint
ORIF (wire, screw, hook plate)
- indication
  - failure to achieve acceptable closed reduction

Answer 246

A

prolonged extension splinting
tenodermodesis
central slip tenotomy
spiral oblique retinacular ligament (SORL) reconstruction
DIP joint fusion

Answer 247

A

EIP

Order of Innervation:

Radial Nerve:
- Triceps
- Lateral 1/3 Brachialis
- Anconeus
- Bradioradialis
- ECRL
PIN:
- ECRB*
- Supinator
- ECU
- EDC
- EDM
- APL
- EPL
- EPB
- EIP
  - Last to return to function after PIN palsy

Answer 248

A

1. Fibrous band at the origin of the lateral head of triceps
2. Lateral intermuscular septum
3. Fascia adjacent to radiocapitellar joint
4. Thickened edge of ECRB
5. Recurrent radial vessels (Leash of Henry)
6. Arcade of Froshe
  - Fibrous arch of the proximal edge of supinator
  - 3-5cm distal to epicondylar axis
7. Supinator fascia (most common)
8. Distal edge of supinator
9. Fascia between ECRL and BR
FREASF - Fibrous bands at the elbowR - Radial recurrent vessels (Leash of Henry)E - Extensor carpi radialis brevis (fibrous border of ECRB)A - Arcade of FrohseS - Supinator (fascia and distal border)

Answer 249

A

Compression of the PIN

Answer 250

A

Weakness of PIN innervated muscles
- Sparing of BR, ECRL
Pain in dorsal radial forearm
no sensory changes

Answer 251

A

Wrist extension demonstrates radial deviation
- Intact ECRL

Answer 252

A

Denervation of PIN innervated muscles