Hand and Wrist (Updated) Flashcards

Question

What is the most common complication following PRC? [JHS (Eur Vol) 2015,40E(5) 450–457]

Answer 1

Synovitis and significant edema

Answer 2

1. 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

Answer 3

1. Longitudinal incision centred over Lister’s tubercle 2. Flaps are elevated off the extensor retinaculum 3. Extensor retinaculum is opened over the 3rd compartment and EPL is retracted radial 4. 2nd and 4th compartments are elevated off the dorsal capsule 5. PIN is identified and transected 6. Ligament-sparing capsulotomy is performed * Longitudinal split of the DRC and DIC * Described by Berger, Bishop and Bettinger 1995 7. Scaphoid, lunate and triquetrum are excised 8. Preserve the volar radioscaphocapitate 9. Capitate is seated in the lunate fossa 10. Radial styloidectomy is performed if there is impingement noted with radial deviation 11. Capsule is closed 12. Extensor retinaculum is closed leaving the EPL subcutaneous

Answer 4

1. Longitudinal incision centred over Lister’s tubercle 2. Flaps are elevated off the extensor retinaculum 3. Extensor retinaculum is opened over the 3rd compartment and EPL is retracted radial 4. 2nd and 4th compartments are elevated off the dorsal capsule 5. PIN is identified and transected 6. Ligament-sparing capsulotomy is performed 7. Scaphoid is excised 8. Lunate, capitate, hamate, triquetrum are prepared for fusion * Articular cartilage and subchondral bone are removed along the dorsal 75% 9. Lunate extension is corrected and provisional fixation with K-wires between the carpal bones 10. Bone graft options include excised scaphoid, local distal radius and ICBG 11. Definitive fixation options include K-wire, staples, headless compression screws, circular plates

Answer 5

1. Ulnar head and sigmoid notch of distal radius 2. 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

Answer 6

1. Rotation 2. Translation (dorsal and volar) * Dynamic translation * Pronation = 2.8mm of dorsal translation * Supination = 5.4mm of volar translation 3. Longitudinal * Dynamic ulnar variance * Pronation = relative positive * Supination = relative negative

Answer 7

1. bone contour (sigmoid notch of radius and ulnar head) 2. TFCC 3. ulnocarpal ligament complex 4. ECU 5. ECU tendon sheath 6. pronator quadratus 7. interosseous membrane 8. DRUJ joint capsule

Answer 8

- 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

Answer 9

1. 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 2. Direction * Dorsal * Volar * Bidirectional 3. Severity * Asymptomatic * Symptomatic 4. Static vs dynamic 5. Acute vs. chronic

Answer 10

1. Distal radius fracture 2. Ulnar styloid fracture 3. Galeazzi fracture 4. Essex-Lopresti lesion 5. Both bone forearm fracture 6. TFFC tear 7. Capsule/ligament tear

Answer 11

1. Inspection * Prominent distal ulna 2. Palpation * Ulnar styloid tenderness 3. 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 5. ‘Press test’ * Ask patient to arise from a chair using the wrists * Focal pain at the distal ulna can indicate a TFCC injury

Answer 12

1. Radiographs with forearm in neutral rotation 2. 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"

Answer 13

- 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

Answer 14

1. Pronation = dorsal superficial and volar deep ligaments tighten 2. 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

Answer 15

1. Neutral – 20% load through the distal ulna 2. Positive – lengthening 1mm increases ulnocarpal loading by 50% * 2.5mm lengthening increases load to 42% 3. 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

Answer 16

1. Ulnar head functions to maintain radioulnar distance during forearm rotation 2. Loss of ulnar head leads to convergence of the radius and ulna

Answer 17

1. Post-traumatic * Distal radius malunion * Distal radius fracture with extension into sigmoid notch 2. Inflammatory arthritis (RA) 3. Madelung deformity 4. Tumor * Osteochondroma

Answer 18

1. 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 2. 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 3. 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 4. Partial ulnar head arthroplasty * Indications * Isolated DRUJ arthritis without instability * Failed HIT 5. Total ulnar head arthroplasty * Indications * Painful instability after failed resection * Isolated instability * Requires stability from native soft tissues 6. Total DRUJ arthroplasty * Indications * Incompetent native soft tissues * Salvage option after failed distal ulnar resection

Answer 19

1. Pain 2. Ulnar stump instability 3. Ulnar translation of carpus 4. Radioulnar convergence 5. Re-ossification of resection (S-K procedure)

Answer 20

1. ECU and FCU tenodesis 2. Tendon allografts * Achilles allograft in interosseous space between radius and ulna * 2 slips of BR through distal radius and then around ulna stump

Answer 21

1. Shortened distal ulna ending proximal to the sigmoid notch 2. Scalloping of the distal radius along its ulnar border 3. Radioulnar convergence * Narrowing between radius and ulna

Answer 22

1. 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

Answer 23

1. ECU and FCU tenodesis 2. Tendon allografts * Achilles allograft in interosseous space between radius and ulna * 2 slips of BR through distal radius and then around ulna stump 3. Ulnar head replacement * Require some degree of native soft tissue 4. Total DRUJ replacement * Does not require native soft tissue 5. Salvage * One-bone forearm (radioulnar synostosis) * Wide excision (25-50% of distal ulna)

Answer 24

1. Pancarpal arthritis * Advanced inflammatory or post-traumatic arthritis 2. Radioscapholunate arthritis * Intra-articular distal radius fractures * Kienbock’s * Inflammatory arthritis 3. Radioscaphoid arthritis * SLAC, SNAC 4. Radiolunate arthritis * Intra-articular lunate facet fracture

Answer 25

1. Pancarpal arthritis * Low demand = wrist arthroplasty * High demand = total wrist fusion 2. Radiolunate arthritis * Midcarpal joint preserved = radiolunate fusion 3. Radioscaphoid arthritis * Capitate-lunate preserved = PRC or 4-corner fusion * Capitate-lunate involved = 4-corner fusion 4. Radioscapholunate arthritis * Midcarpal joint preserved = radioscapholunate fusion

Answer 26

1. Midcarpal is free of arthritis 2. Distal scaphoid pole excision * Increases ROM * Decreases pain * Rncreases rate of union due to unlocking the midcarpal joint

Answer 27

1. Loss of flexion, extension, ulnar and radial deviation 2. Supination and pronation are retained

Answer 28

1. Rheumatoid arthritis 2. Post-traumatic arthritis 3. Spastic wrist contracture 4. End stage osteonecrosis * Kienbock disease * Preiser disease 5. Complete brachial plexus paralysis 6. Failed wrist arthroplasty 7. Postinfection degeneration 8. Failed wrist surgery * PRC * SL reconstruction * Arthrodesis * Silicone synovitis

Answer 29

1. Active infection 2. Lack of an adequate soft tissue coverage

Answer 30

1. Major * Nonunion * Ulnocarpal impaction * Carpal tunnel syndrome * Extensor tenosynovitis * Deep infection * Implant-related problems 2. Minor * Superficial infection * Carpal tunnel symptoms * Intraoperative fractures * Postoperative fractures * Asymptomatic radiographic loosening

Answer 31

1. Reliable pain relief 2. Lower complication rate 3. Less revision

Answer 32

1. Unilateral wrist arthrodesis * 10-15° extension * Slight ulnar deviation 2. Bilateral wrist arthrodesis * Dominant wrist = slight extension * Nondominant wrist = neutral to slight flexion

Answer 33

1. 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 2. 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 5. Precontoured stainless steel locking wrist fusion plate * Fix to 3rd metacarpal shaft * Compression across arthrodesis sites * Manual compression and compression by design through plate 6. +/- ECRL and ECRB tendon transfer over plate if finger extensor directly overlying plate 7. +/- distal ulna resection if DRUJ arthritis present

Answer 34

1. 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 2. Radial length 3. Ulnar variance * Ulnar positive variance leads to ulnocarpal impaction 4. Radial inclination * Decrease in inclination shifts loads from the scaphoid fossa to the lunate fossa 5. Joint congruity

Answer 35

1. Advanced degeneration 2. Fixed intercarpal malalignment 3. Severe osteoporosis 4. CRPS 5. Inability to comply with postoperative therapy 6. Serious medical comorbidiities 7. Very low demand

Answer 36

In order: 1. Osteotomy 2. Bone grafting 3. Fixation 4. Ulnar-side procedure

Answer 37

1. Closing wedge osteotomy * Advantage * More stable construct (bone-to-bone contact) * Disadvantage * Shortening of radius relative to ulna * Requires ulnar sided procedure 2. 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

Answer 38

1. ICBG – corticocancellous 2. Local distal radius graft 3. Cancellous autograft or allograft 4. Bone graft substitute

Answer 39

1. Dorsal plating * Advantage * Easy access for bone graft in dorsal opening wedge osteotomy * Disadvantage * Hardware irritation and tendon rupture 2. Volar plating * Advantage * Less hardware irritation and tendon rupture * Disadvantage * Difficult access for bone graft * May require additional releases

Answer 40

1. Hemiresection-interposition 2. Ulnar shortening osteotomy 3. ‘Wafer’ resection 4. Sauve-Kapandji * DRUJ fusion with proximal pseudoarthrosis) 5. Darrach * Complete distal ulna resection 6. Arthroplasty

Answer 41

As soon as possible * Avoids soft tissue contracture

Answer 42

1. 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 3. 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 4. 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 43

1. Displacement \>1mm 2. Proximal fracture 3. Delayed treatment 4. Inadequate immobilization 5. Associated carpal instability 6. Osteonecrosis

Answer 44

1. Radiographic sclerosis 2. MRI changes 3. Absence of punctate bleeding intraoperative

Answer 45

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

Answer 46

1. 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 47

1. Radiographs * Wrist PA, lateral, scaphoid, 45° pronated and supinated oblique view * Assess for: * Sclerosis * Cysts * Bone resorption at fracture site * Hardware loosening 2. CT scan * Assess for: * Bony union * Arthritis * Screw placement * Fracture reduction * Proximal pole sclerosis

Answer 48

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 49

1. 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) 3. Arterialization * Direct implantation of the second dorsal intermetacarpal artery into the scaphoid

Answer 50

1. 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 2. If screw placement not acceptable: * Redirect the screw

Answer 51

1. Delayed union (\<6 months) * ORIF with headless compression screw 2. Established nonunion without humpback * ORIF with headless compression screw + bone graft (cancellous ICBG or distal radius) 3. Nonunion with humpback deformity; no AVN * ORIF via volar approach + corticocancellous bone graft 4. AVN without humpback deformity * Vascularized bone graft via volar or dorsal approach 5. AVN with humpback deformity * Vascularized medial femoral condyle bone graft via volar approach

Answer 52

1. Volar and dorsal branches from the radial artery * Volar is dominant and 20% of the time it is sole supply 2. Gelberman described 3 patterns: * ‘Y’ = 59% * ‘I’= 31% * ‘X’ = 10% 3. Gelberman hypothesized that a lunate at risk has only one arterial supply or dorsal and volar supply but no anastomoses

Answer 53

- 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 54

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 55

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 56

- 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 57

- 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 58

- - 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 59

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

Answer 60

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

Answer 61

1. Articular disc * Extends between the volar and dorsal radioulnar ligaments (hammock) 2. Meniscus homologue 3. Volar and dorsal radioulnar ligaments * Superficial and deep (ligamentum subcruentum) * Major stabilizers of the DRUJ 4. Sheath of ECU 5. Ulnar capsule (ulnar collateral ligament) * Arises from the ulnar styloid and extends between the ulnotriquetral ligament and the ECU sheath 6. Ulnolunate and ulnotriquetral ligaments (volar)

Answer 62

1. Stabilize ulnocarpal joint 2. Stabilize DRUJ 3. Transmits load from carpus to ulna 4. Assists with wrist mechanics

Answer 63

1. Peripheral 20% vascularized 2. Central avascular 3. supplied by Ulnar artery and anterior interosseous artery - Palmar and dorsal branches

Answer 64

1. Ulnar nerve 2. PIN

Answer 65

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 66

1. Prominent ulna 2. 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 3. Ulnocarpal stress test * Ulnar deviation with axial loading in alternating supination and pronation 4. Positive grind test * Clicking, crepitus or pain with passive supination and pronation 5. Lunotriquetral shuck test * Pain and laxity when examiner grasps the pisiform/triquetrum and lunate with opposite hands and translates volar and dorsal

Answer 67

1. Radiographs * Neutral rotation PA and lateral * PA in ulnar and radial deviation * Pronated PA clenched-fist views 2. MRI/MRA

Answer 68

1. Trampoline test * Probe is used to test central disc tautness and rebound ability * Laxity suggests detachment from one or more insertion points 2. Hook test * Traction applied to ulnar-most aspect of TFCC * Ability to pull the TFCC radial and upward suggests foveal attachment disruption

Answer 69

1. Nonoperative * Most tears are initially treated nonoperative 2. 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 70

1. Mechanical abutment of the distal ulna with the carpus 2. Usually associated with positive ulnar variance

Answer 71

1. Congenital * Physiologic * Madelung 2. Acquired * Distal radius malunion * Radial head excision * Premature physeal closure of radius * Post-wrist fusion

Answer 72

1. Degenerative TFCC tears (Palmer 2A-E) 2. Chondromalacia of ulnar head 3. Chondromalacia of ulnar lunate 4. Chondromalacia of triquetrum 5. LT ligament perforation

Answer 73

1. Pronation 2. Grip [Do pronated grip view to elicit positive ulnar variance]

Answer 74

1. Nonoperative * Rest * Immobilization * Activity modification * NSAIDs * Corticosteroid injections 2. 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 75

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 76

1. Ulnar collateral ligament (UCL) 2. Radial collateral ligament (RCL)

Answer 77

1. Chronic UCL = gamekeeper’s thumb 2. Acute UCL = skiers thumb 3. RCL = reverse gamekeeper’s thumb

Answer 78

1. Proper collateral ligament * Taut in flexion 2. Accessory collateral ligament and volar plate * Taut in extension

Answer 79

1. UCL * Proximal phalanx avulsion (90%) * Midsubstance and metacarpal avulsion less common 2. RCL * Variable, more common proximal at metacarpal

Answer 80

1. Distal edge of the avulsed UCL is displaced proximal to the adductor aponeurosis * Blocked from reapproximation to its insertion on the proximal phalanx 2. Surgical management is recommended

Answer 81

1. RCL * Adductor pollicis inserts on the proximal phalanx and ulnar sesamoid creating an ulnar and volar deforming force 2. Assess with anterior drawer test * \>3mm displacement volar is more common with RCL injury

Answer 82

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 83

Joint stressed at zero degrees of extension and 30° flexion * Instability = deviation of the proximal phalanx on the metacarpal head of \>30-35°

Answer 84

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 85

Dorsoradial

Answer 86

1. Traction 2. Abduction 3. Pronation 4. Dorsal pressure on the base of the metacarpal (anatomical snuffbox)

Answer 87

1. CRPP * Intermetacarpal pinning * Transarticular pinning 2. Open/arthroscopic reduction if closed reduction not attained * Repair capsule/ligament protect with pinning

Answer 88

1. Anteromedial (volar-ulnar) fragment * Smaller (less articular surface area) * Nondisplaced, attached to volar oblique ligament 2. Metacarpal fragment * Larger (greater articular surface area) * Displaced * Proximal, dorsal and radial

Answer 89

1. APL = proximal, dorsal, radial 2. Adductor pollicis = narrowing of 1st web space

Answer 90

1. Traction 2. Abduction 3. Pronation 4. Pressure to the metacarpal base (dorsal to palmer) \*\*TrAPP/TAPP

Answer 91

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

Answer 92

1. Large anteromedial fragment * Open reduction and direct screw fixation 2. Small anteromedial fragment * CRPP – transarticular or intermetacarpal 3. Irreducible or intra-articular gap \>2mm [J Hand Surg 2009;34A:945–952.] * Open reduction

Answer 93

‘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 94

1. Adductor pollicis – metadiaphysis adduction (narrows 1st web space) 2. APL – dorsoradial displacement of radial articular fragment 3. Ulnar articular fragment does not displace due to volar oblique ligament

Answer 95

Open or arthroscopic reduction * Followed by provisional K-wire fixation and miniplate fixation or definitive k-wire fixation

Answer 96

Often regarded as a Rolando fracture, worst stage

Answer 97

1. Intermetacarpal blocked pinning 2. External fixation

Answer 98

1. Proximal fragment that remains reduced 2. Metacarpal fragment displaces into adduction

Answer 99

\<30° of angulation * \>30^o results in unacceptable narrowing of the 1st web space

Answer 100

1. \<30° of angulation = closed reduction and casting 2. \>30° of angulation = CRPP (intermetacarpal)

Answer 101

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

Answer 102

1. Apex dorsal if fracture proximal to FDS insertion 2. Apex volar if fracture distal to FDS insertion

Answer 103

1. No rotation 2. \<10-15° angulation 3. \<2mm shortening

Answer 104

1. Nonoperative (most) * Stable fractures with acceptable alignment = buddy taping 2. Operative * K-wire * Eaton-Belsky pinning through the metacarpal head * Screws * Plates and screws

Answer 105

1. open vs closed 2. intra-articular vs extra-articular 3. location - head, neck, shaft, base 4. pattern - spiral, oblique, transverse, comminuted

Answer 106

apex dorsal angulation

Answer 107

- 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 108

No articular displacement acceptable

Answer 109

1. 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 2. 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 3. metacarpal head 1. lag screw or k-wire 4. metacarpal base 1. CRPP or ORIF with screws +/- plates

Answer 110

- 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 111

1. Index and middle = \<10-15° 2. Ring = \<40° 3. Small = \<60° 4. No rotation

Answer 112

1. Index and middle = \<10° 2. Ring = \<20° 3. Small = \<30° 4. No rotation

Answer 113

1. general indications - polytrauma, severe soft tissue injury, unstable open fractures, segmental bone loss, and multiple hand or wrist fractures 2. shaft fracture indications 1. failure to achieve successful closed reduction (Acceptable alignment paramenters not met) 2. failure to maintain closed reduction 3. neck fracture indications 1. failure to achieve successful closed reduction (Acceptable alignment paramenters not met) 2. failure to maintain closed reduciton 4. head fracture indications 1. step off of >1mm or involvement of more than 25% of the articular surface 5. base fracture inidcations 1. displaced fracture with dislocation or subluxation of the CMC joint

Answer 114

- 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 115

1. 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 2. 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 116

1. Extension (most common) 2. Axial load of a flexed PIP joint

Answer 117

1. Volar plate rupture or avulsion of volar base off middle phalanx 2. Volar avulsion of variable size (loss of buttress effect)

Answer 118

1. Stable * Articular surface \<30% involvement * Clinical stability = stable throughout ROM 2. Tenuous * Articular surface = 30-50% involvement * Clinical stability = Requires ≤30° of PIP flexion to maintain reduction 3. Unstable * Articular surface \>50% involvment * Clinical stability = Requires \>30° of PIP flexion to maintain reduction

Answer 119

1. Stable * Buddy taping 2. 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 3. 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 120

1. Hyperflexion 2. Axial load of an extended PIP joint

Answer 121

1. Central slip rupture or avulsion of dorsal base of middle phalanx 2. Dorsal avulsion of variable size

Answer 122

1. Stable and small minimally displaced fracture * \<50% articular surface and \<2mm displacement * PIP joint splinting 2. Stable and large or displaced fracture * \>50% articular surface and \>2mm displacement * CRPP or ORIF 3. Unstable with minimally displaced fracture * Dynamic distraction and external fixation

Answer 123

Index DIP * 2nd most common = thumb basal joint

Answer 124

Nondominant

Answer 125

1. Trapeziometacarpal (CMC joint) * Most commonly affected articulation 2. Trapeziotrapezoid 3. Scaphotrapezial 4. Scaphotrapezoidal 5. Trapezial-index metacarpal

Answer 126

1. 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 2. Dynamic * Extrinsic * FPL, APL, EPB, EPL * Intrinsic * APB, Adductor pollicis, FPB, opponens pollicis

Answer 127

Anterior oblique ligament

Answer 128

1. Advanced age * 36% \>80y vs. 6.6% 40-49y 2. Female 3. Ligamentous laxity/ higher Beighton score 4. Occupations * Repetitive finger use or heavy manual labour 5. Post-traumatic * Intra-articular fracture * Traumatic ligamentous instability

Answer 129

1. Metacarpal adduction 2. MCP hyperextension

Answer 130

1. CMC grind test * Pain with axial load and rotation around the thumb axis 2. CMC subluxation test * Pain or instability with attempted subluxation 3. Decreased pinch strength

Answer 131

Roberts view * Thumb hyperpronated and flat on the cassette

Answer 132

1. 30% of patients with CTS have thumb basal joint arthritis 2. ≤30% of patients with thumb basal joint arthritis have CTS

Answer 133

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 134

1. Nonoperative * Exercise therapy, heat, education, magnetotherapy, adaptive equipment, orthoses, NSAIDs, corticosteroid injections 2. 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 135

None * No benefit to pain or function * No difference in adverse events [No differences shown between trapeziectomy with or without LRTI]

Answer 136

1. FDS 2. FDP 3. FPL

Answer 137

1. Dorsal portion * Two vinculae supplied by radial and ulnar artery 2. Volar portion * Minimal direct blood supply (synovial diffusion)

Answer 138

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 139

A1 - MCP volar plate Oblique pulley - proximal half of proximal phalanx A2 - IP volar plate

Answer 140

Oblique pulley

Answer 141

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 142

1. Easy placement of sutures in the tendon 2. Secure knots 3. Smooth juncture of the tendon ends 4. Minimal gapping 5. Minimal interference with tendon vascularity 6. Sufficient strength

Answer 143

1. Minimal tendon handling to minimize adhesion 2. Strength of repair is proportional to the number of core sutures and caliber of suture 3. Core sutures should be 7-10mm from tendon edge 4. Dorsal placement is biomechanically advantaged 5. Epitendinous (peripheral) suture improves: * Strength * Minimizes gapping * Reduces CSA * Decreases gliding friction 6. Locking loops increase tensile repair 7. Internal knots have decreased strength

Answer 144

1. Injury to FDP tendon (laceration or avulsion) * Closed avulsion = Jersey Finger 2. 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 145

1. Injury to FDP and/or FDS tendon * FDP injured more often due to superficial nature 2. “No Man’s Land” due to poor outcomes 3. Repair options: * ≤50% = debride to prevent catching at pulleys * \>50% = repair

Answer 146

1. Injury to FDP and/or FDS 2. Good prognosis due to absence of fibrosseous sheath 3. Repair options * Direct surgical repair

Answer 147

1. Often associated with median or ulnar nerve injury 2. “Spaghetti wrist” * Multiple tendons and median nerve involved 3. Repair options: * Carpal tunnel release and direct repair

Answer 148

1. Often associated with nerve or vascular injury 2. Good outcomes

Answer 149

1. Active protocols: * Higher risk of rupture 2. Passive protocols: * Adhesion * Contracture * Decreased ROM * Poor gliding between FDP and FDS

Answer 150

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 151

1. Tendon sheath * Fibrocartilaginous metaplasia * Cartilage degradation * Vascular ingrowth 2. Tendon * Chronic degenerative tears * Absence of inflammatory cells

Answer 152

Ring finger and thumb

Answer 153

1. Female 2. Diabetes 3. RA 4. Crystalline arthropathy 5. Thyroid disease 6. Renal insufficiency 7. Overuse

Answer 154

Carpal tunnel syndrome * \>60% of patients with trigger digits demonstrate clinical or electrodiagnostic evidence of median nerve compression at the wrist

Answer 155

1. Nonoperative * Therapy * Splinting * NSAIDs * Corticosteroid injections * Commonly used firstline 2. Operative * Percutaneous release of A1 pulley * Open release of A1 pulley

Answer 156

1. A0 pulley stenosis * Tight band of superficial palmar aponeurosis proximal to A1 2. FDP entrapment at FDS decussation * In patients with diabetes, RA 3. A3 pulley entrapment

Answer 157

1. Puncture wound (most common) 2. Staph aureus (most common)

Answer 158

1. Symmetric swelling of entire digit 2. Tenderness along course of tendon sheath 3. Semiflexed posture 4. Pain with passive extension of digit

Answer 159

1. Nonoperative * Indication * Early presentation \<48 hours of symptom onset * Initiate empiric antibiotics * If no improvement in 12-24 hours proceed with surgical I&D 2. 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 160

1. Northern European 2. Caucasian 3. Male 4. Family history * Autosomal dominant 5. Advanced age 6. Smoking 7. Alcohol 8. Local trauma 9. Local infection 10. Diabetes (type I \> type II) 11. Epileptic medication 12. Manual labour

Answer 161

Myofibroblasts

Answer 162

Pretendinous cord [Normal fascial bands become pathologic cords]

Answer 163

1. Transverse ligament of the palmar aponeurosis 2. Cleland ligament

Answer 164

1. Pretendinous cord = MCP contracture 2. Central cord = PIP contracture 3. Lateral cord = PIP or DIP contracture 4. Natatory cord = web space contracture 5. Spiral cord = displaces NV bundle superficial and to midline * MCP and PIP contracture

Answer 165

1. Palmer skin pitting and thickening * Fibrosis of Grapow fibres 2. Painless nodules 3. Cords which may become adherent to overlying skin (resemble flexor tendons) 4. Positive table top test * Unable to place palm flat on table in presence of MCP joint contracture (\>30°)

Answer 166

Ring finger * Followed by: * Small * Long * Index * Thumb

Answer 167

MCP before PIP

Answer 168

Palmer to digital

Answer 169

1. Peyronie disease (penile fibromatosis) 2. Ledderhose disease (plantar fibromatosis)

Answer 170

1. Observation 2. Percutaneous fasciotomy (needle aponeurotomy) 3. 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 171

1. Indications * ≥30° MCP joint contracture * \>15° PIP joint contracture 2. Techniques * Fasciotomy * Limited fasciectomy * Dermofasciectomy * Radical fasciectomy (healthy and diseased fascia)

Answer 172

1. Rheumatoid nodules 2. Caput ulnae syndrome * Dorsal subluxation of the distal ulna * Prominent ulnar head 3. Carpal deformity * Classically, palmar translation, ulnar translation, supination, radial deviation 4. DISI or VISI 5. Arthritis * Usually progression from DRUJ, radiolunate/radioscaphoid, pancarpal arthritis 6. 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 173

1. Darrach procedure * Favoured in low demand, elderly patients * Main concern in RA is ulnar translation of carpus (weak ligamentous support) 2. Sauve-Kapandji * Favoured in active, younger patients * Main concern in RA is less predictable fusion

Answer 174

1. Total wrist arthrodesis (first line) * Plates may be less attractive given tenuous soft tissue 2. Partial arthrodesis if midcarpal preserved * Radiolunate * Scaphoradiolunate 3. Total wrist arthroplasty

Answer 175

1. Early disease (MCP joint reducible) * Synovectomy with cross intrinsic transfer * Ulnar intrinsic lateral band released and transferred radial aspect of adjacent digit (proximal phalanx) 2. 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 176

1. Address the underlying cause * Remove ulnar head (Darrach or SK) and synovectomy 2. 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 177

1. Extensor tendon subluxation between metacarpal heads 2. MCP joint dislocation 3. PIN palsy secondary to elbow joint involvement (rare)

Answer 178

Thumb MCP fusion

Answer 179

1. Young, healthy 2. Sharp mechanism 3. Minimal tissue destruction and contamination

Answer 180

1. Thumb amputation 2. Multiple digit amputation 3. Amputations at or proximal to the palm 4. Pediatric finger amputation at any level 5. Single digit amputation in Zone I (relative)

Answer 181

1. Single digit amputation through Zone II 2. Severe crush, mangled or contaminated amputation 3. Segmental injuries 4. Prolonged warm ischemia time 5. Medically unfit

Answer 182

1. Red line sign * Red stripe along the mid lateral aspect of the avulsed digit * Represents hemorrhage along the vessel 2. Ribbon sign * Tortuous, spiraled blood vessels are seen * Indicates significant intimal injury

Answer 183

1. Avulsion mechanism 2. Smoker 3. Diabetes 4. Prolonged ischemia

Answer 184

1. Wrap in saline-moistened gauze 2. Place in sealed plastic bag 3. Place on ice

Answer 185

1. Digit = 12 hours warm and 24 hours cold 2. Hand and proximal = 6 hours warm and 12 hours cold

Answer 186

1. 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 3. 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 4. 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 187

1. Deformity = flexion of PIP joint and extension of DIP joint 2. 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 3. Mechanism of injury * Blunt trauma * Open laceration * Volar dislocation of PIP joint

Answer 188

1. Hyperextension injury to the PIP joint leading to PIP joint flexion contracture 2. Cause is scarring of volar plate and capsule * Central slip and triangular ligament remain intact 3. Distinguished based on Elson and Boyes tests 4. Treatment differs as it requires aggressive mobilization

Answer 189

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 190

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 191

1. 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 2. 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 192

1. Surgical treatment of boutonnière deformities should be done only by experienced hand surgeons 2. Surgical treatment is rarely necessary for supple boutonnière deformities 3. Preoperative and postoperative therapy programs are an essential part of surgical treatment 4. 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 5. If arthritic change is present, tendon rebalancing should be combined with implant arthroplasty or arthrodesis 6. Flexor function should not be jeopardized in an attempt to achieve full extension 7. All procedures involve rebalancing the extensor mechanism to divert force from the DIP joint to the PIP joint

Answer 193

1. Deformity = hyperextension of PIP joint and flexion of the DIP joint 2. 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 194

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 195

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 196

1. Postaxial (ulnar) polydactyly (most common) 2. Preaxial (radial) polydactyly * Involves the thumb 3. Central polydactyly (rare)

Answer 197

Type A * Well-formed digit with osseous connection Type B * Incompletely-formed with soft tissue connection * Nonfunctional

Answer 198

1. Suture ligation 2. Vessel clip 3. Surgical excision * Avoids complications of ligation/clip including neuroma, cyst, residual stump, infection

Answer 199

1. If performed at bedside = as early as feasible 2. If performed in OR = 12 months

Answer 200

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 201

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 202

12-24 months

Answer 203

1. Aligned joints and physis with longitudinal axis 2. Stable joint 3. Balanced tendon pull 4. Prevent nail deformity

Answer 204

1. 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 2. 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 3. 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 205

Addressed on an individual basis

Answer 206

1. Entrapment of the ulnar nerve at the wrist * Guyon's canal 2. Characterized by: * Numbness/paraesthesisa of the small and ulnar half of ring finger * Ulnar palm and dorsum are spared * Intrinsic muscle weakness * Thenar spared 3. 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 4. 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 207

Borders: * Lateral – hook of hamate * Medial – pisiform * Roof – palmar carpal ligament * Floor – transverse carpal ligament Contents * Ulnar nerve and artery/vein

Answer 208

1. Compression of the median nerve at the wrist 2. 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 3. Contents of the carpal tunnel (10): * Median nerve (1) * FPL tendon (1) * FDS tendons (4) * FDP tendons (4) 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 6. Provocative maneuvers: * Phalen test – wrist flexion * Reverse Phalens test – wrist extension * Tinels * Median nerve compression test 7. 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 209

1. Extraligamentous (distal to TCL) – 50% 2. Subligamentous (deep to TCL) – 30% 3. Transligamentous (through TCL) – 20% 4. Ulnar take off (distal to TCL)

Answer 210

1. 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 2. 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 211

1. Pillar pain * Pain along edges of incision at thenar and hypothenar eminences * Most common complication of open 2. Laceration of palmar cutaneous branch of median nerve * 2nd most common complication of open 3. Incomplete release of TCL * Most common complication of endoscopic 4. Injury to motor branch 5. Hypertrophic scar 6. Tendon adhesion 7. Infection 8. Wound hematoma 9. Finger stiffness 10. Recurrence

Answer 212

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

Answer 213

- 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 214

- 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 215

1. ECU and FCU tenodesis 2. 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 3. ulnar head replacement 1. require some degree of native soft tissue 4. total DRUJ replacement 1. does not require native soft tissue 5. salvage 1. one-bone forearm (Radioulnar synostosis) 2. wide excision (25-50% of distal ulna)

Answer 216

- 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 217

- - 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 218

- - 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 219

- 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 220

- 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 221

1. prolonged extension splinting 2. tenodermodesis 3. central slip tenotomy 4. spiral oblique retinacular ligament (SORL) reconstruction 5. DIP joint fusion

Answer 222

- 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 223

- 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 **FREAS** F - Fibrous bands at the elbow R - Radial recurrent vessels (Leash of Henry) E - Extensor carpi radialis brevis (fibrous border of ECRB) A - Arcade of Frohse S - Supinator (fascia and distal border)

Answer 224

1. Compression of the PIN

Answer 225

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

Answer 226

- Wrist extension demonstrates radial deviation - Intact ECRL

Answer 227

* Denervation of PIN innervated muscles