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Hand Everything Flashcards

1
Q

What is best technique for operative fixation of phalanx fxs?

A

SAE question says lagging the fracture with screws is best treatment to chose in order to allow early ROM (better than pinning)

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2
Q

Dorsal PIP dislocations- how to determine stability and treatment.
What is MC block to reduction?

A
  • MC block to reduction is volar plate
  • Must address stability following reduction, if fracture -> can usually tell by % of articular surface involved:
    • <20%: uniformly stable
    • ~40% want to really carefully examine if stable
    • > 60%: uniformly unstable
  • Treatment:
    • Simple dislocation (no fracture) that is stable and very, very small volar plate avulsion fractures of the base of the middle phalanx-> buddy tape and allow motion x 6 weeks
    • < 40% Articular surface involved or simple dislocation that is unstable-> dorsal extension block splinting (30 degrees) with weekly incremental increase in extension x 4 wks, followed by 3 months buddy taping during during sports activities
    • Dynamic ex-fix
      • When involves >40% and there is comminuted, small pieces
    • Fixation/Pinning
    • Hemi-hamate arthroplasty (graft harvested from dorsal/distal surface). The graft will provide volar buttress to dorsal subluxation of the middle phalanx.
      • If too comminuted for fixation
      • Preferred for ulnar digits where you want to keep motion for power grip
    • Arthrodesis
      • Preferred for radial digits which act more as “posts” in their function of key pinch.
      • If have to fuse RF -> 40 degrees is optimal to allow some power grip ability
    • Acute unstable involvement of > 40% articular surface w/ comminution OR in chronic scenario ->
      • Volar plate arthroplasty of PIPJ (-> must excise the collateral ligaments from the volar plate to allow smooth gliding and advancement of the volar plate to the dorsum of the middle phalanx under the extensor mechanism (SAE question)
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3
Q

Volar PIP dislocation - what can be injured, how do you treat?

A
  • Think about central slip injury!!
  • Treatment:
    • Simple dislocation -> reduction and full time extension splinting x 6 weeks
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4
Q

PIPJ Arthritis treatment in young vs old person

A
  • In a young, active person (typically PTOA or inflammatory dz) - CHOOSE ARTHRODESIS! (Arthroplasty will fail!)
    * Fuse in ~40-55 degrees of flexion and as go more ulnar fuse in even more flexion to optimize function
    • In a older, less active patient WITHOUT rotational deformity with involvement of MF,RF,SF - ARTHROPLASTY (most helpful for pain, doesn’t give great ROM!). In IF consider arthrodesis still bc arthroplasty has higher failure for this digit!
      • Look for presence of rotation deformity in question stem - this will tell you that there is insufficiency of the collateral ligaments
      • Silicone implant with volar approach has best ROM and lowest revision rate
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5
Q

DIP ARTHRITIS - what is seen and what is treatment

A
  • Look for Mucoid cysts on dorsum of finger by DIPJ
  • Treatment options:
    • Surgical excision w/ removal of boney osteophytes
    • Can also perform aspiration, drainage and injection of steroid
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6
Q

Shortening of MC fx -> each 2 mm of shortening results in….how much extensor lag? What else is effected?

A
  • each 2 mm of shortening results in 7 degrees of extensor lag
    • Will also so decrease in grip strength
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7
Q

5th MC neck treatment

A
  • If no malrotation, and < 70 degree angular deformity: buddy tape and optional follow up
    • 5th MC Neck fx (without rotational deformity) can be treated w/ buddy taping vs. splinting and optional follow up (2018 OITE Question!)
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8
Q

Base of 5th MC fx - what is mechanism for injury typically and what is deforming force?

A
  • Injury usually due to punching

* Deforming force ECU

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9
Q

Gamekeepers thumb -
What is injured?
Where does the tear usually occur?
What other “lesion” can be associated with it?

A
  • Due to injury of the PROPER AND ACCESSORY UCL
    • Proper UCL is the primary restraint to radial deviation in MCPJ FLEXION
    • Accessory UCL is the primary restraint to radial deviation in MCPJ EXTENSION (remember “Extension” and “Axcessory”…they kind of sound alike)
  • **Note: the UCL typically tears from its DISTAL insertion (on the proximal phalanx..less common to tear off of the MC)
  • STENER lesion - torn UCL w/ adductor aponeurosis interposed
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10
Q
  • Factor most a/w re-displacement of DR fracture following closed reduction ->
A

initial displacement; most specifically loss of radial height!

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11
Q

What XR should be taken to determine if DRUJ injury following a DR fracture

A
  • Must take a post-reduction true lateral XR of the carpus to assess DRUJ alignment
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12
Q

In splinting DR fracture what position should be avoided?

A
  • AVOID THE COTTON-LODER position = extreme flexion/ulnar deviation -> a/w increased risk of acute carpal tunnel syndrome!!!
    • Look for inability to actively oppose the thumb (along with the numb/tingles in median n. Distribution!)
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13
Q

After DR fracture, what can be given to avoid CRPS?

A
  • Give Vit C (500 mg x 50d) to prevent CRPS
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14
Q

Op vs nonop DR fracture outcomes in Pts > 60 yo

A
  • Fixation of DR fx (even unstable fx’s) in older population (>60 yo) vs non-op treatment shows essentially no difference in functional outcome at 1 year (those with fixation have better looking XRs but are roughly doing the same clinically)
    • Fixation does provide better grip strength when compared to nonop
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15
Q

MC tendon rupture after DR fx treated with a volar plate ->

A
  • FPL
    • Also, possible to have EPL rupture after a volar plate due to having a screw that is too long penetrating dorsal cortex.
      • Should use a Flexed Wrist Tangential Axial (Skyline) XR to evaluate screws to make sure they aren’t too long!
      • Note: a lateral and oblique XRs can miss this b/c it may just be behind Lister’s tubercle
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16
Q
  • XR Views to Assess Placement of Fixation:
    • Flexed Wrist Tangential Axial view (Skyline view) -
    • Extended Wrist Tangential view (Sigmoid notch view) -
    • PA anatomic tilt view:
    • Radial Inclination view:
      regular lateral is really only useful for looking at
A
  • Flexed Wrist Tangential Axial view (Skyline view) - best to eval screw length/dorsal penetration
    • Extended Wrist Tangential view (Sigmoid notch view) - best to eval screw in DRUJ
    • PA anatomic tilt view: 11-degree anatomic tilt view that shows the degree of articular congruity
    • Radial Inclination view: 22-degree radially inclined lateral view is best for evaluating intra-articular penetration of screws in radoiocarpal joint.

For comparison a regular lateral without the 23 degree inclination (regular lateral is really only useful for looking at plate placement relative to watershed line):

17
Q

When patient has weakness in first couple weeks with thumb IP flexion after volar plating of DR fx, think about ->

A

scar entrapment, hardware irritation, FPL impingement or ruptures, and injury to AIN

18
Q

When patient has weakness in first couple weeks with thumb IP flexion after volar plating of DR fx, and XR shows:
*well positioned plate
* plate volar to critical line
what is likely cause and how do you manage?

A

*When the lateral XR shows that the plate sits proximal to watershed line (location of origin of volar carpal ligaments, and bone prominence where flexor tendon is closest) and not volar to critical line (ie plate is optimally positioned) -> then FPL rupture is less likely and patient should just be observed b/c weakness will typically resolve with time.
* If persists for 2-3 months -> nerve conduction study (look for AIN injury); if normal then MRI or US to eval for FPL rupture.
* FOR THE TEST LOOK FOR PLATE BEING VOLAR TO THE CRITICAL LINE ( = more volar than most volar aspect of distal radius
If distal to watershed line (which makes plate volar to critical line) then think about FPL rupture!

19
Q
  • After DR is fixed must test the ????stability. And if unstable how to manage?
A
  • After DR fixation - shuck the DRUJ to test stability!
    • This tests the radioulnar ligaments of the TFCC
    • Think about injury to DRUJ when you see an ulnar styloid fracture - otherwise an ulnar styloid does not need to be fixed and a nonunion of it doesn’t matter clinically!! It’s really just a canary in the coal mine
  • If DRUJ unstable and has ulnar styloid fx of reasonable size to fit a pin in it then do this to help with stability.
    • If did this and DRUJ still unstable, or if styloid piece too small, then pin across DRUJ
20
Q

What part of DR fracture has to be looked out for to prevent carpus dislocation?

A
  • Watch out for volar/ulnar corner!! If don’t fix this piece well the whole wrist can dislocate along with this piece
21
Q

After performing ORIF of DR fracture you test stability of DRUJ…what other injury should you look for and if injured how to manage?

A

after DR fx ORIF -> eval for SL widening -> if wide and has injury to SL ligament then after DR ORIF w/ volar plate, use a dorsal incision (dorsal aspect of SL ligament is strongest!) and repair SL ligament + K wire for additional temporary fixation!

22
Q

What tendon should be watched after casting of a DR fracture?
How to manage if injured?

A
  • EPL rupture after a non-displaced DR fx treated w/ a cast should be watched for!!
    • More commonly happens as late finding -> This is thought to be an attritional rupture due to compromised blood flow (can be seen later as well due to callus from healed fx causing restricted blood flow)
      • Since this is an attritional rupture treatment is EIP to EPL transfer (a direct repair won’t work b/c it’s crappy tendon!!).
        • Also, in order to best re-create tension that allows good extension (and doesn’t limit flexion) should perform surgery awake!
    • If happens earlier (less common) it is thought to be due to impingement b/t dorsal aspect of DR and 3rd MC base during the initial hyperextension event/injury
23
Q

Formal PT vs self-directed PT after DR ORIF

A
  • Postop after DR ORIF -> formal PT has no added benefit over self-directed!
24
Q

What is Galeazzi fracture?

What structure is in the way if have difficulty with closed reduction?

A
  • distal 1/3 radial shaft + DRUJ dislocation

* If unable to close reduce DRUJ despite getting distal radius reduced -> ECU interposition is MC cause!!

25
Q

What wrist position is the DRUJ most likely injured in? What PE sign can you see?
What symptoms does DRUJ injury cause?

A
  • Injury occurs due to fall onto extended, pronated wrist
  • With isolated injury that is reducible will see “piano key sign” in which you can push down on the ulna and it will reduce
    • Note: typically clinical examination describes the ulna moving and the radius as fixed; however this is wrong! The radius moves with respect to a fixed ulna!

Symptoms: ulnar-sided wrist pain, reduced ROM, clicking

26
Q
  • Most important restraint to dorsal/ulnar translation of the radius on the ulna in the DRUJ is->
A

dorsal and palmar radioulnar ligaments

27
Q

DRUJ ARTHRITIS:

  • Treatment:
    • In a heavy laborer ->
    • Low-demand, elderly ->
A

DRUJ ARTHRITIS:

  • Treatment:
    • In a heavy laborer -> ulnar hemiresection arthroplasty (literally you just cut off the proximal/radial side of the ulna) + TFCC reconstruction/repair PRN
      • This technique resolves pain and allows them to get back to work sooner
    • Low-demand, elderly -> Darrach procedure = proximal ulnar resection
28
Q

Ulnar Impaction Syndrome:

  • Caused by ulnar head abutment into carpal bones
  • Treatment ->
A
  • Treatment -> Arthroscopic TFCC debridement + Wafer procedure (= ulnar shortening osteotomy -> removal of 2-4 mm of distal ulnar bone) -> indicated in patient with degenerative symptomatic TFCC tear and ulnar positive variance
    • Ulnar shortening osteotomy CONTRAINDICATED if there is also DRUJ arthrosis
29
Q

Scaphoid fracture treatment by location

What fixation type is best biomechanically?

A
  • If proximal 1/3 -> ORIF with central screw, approach DORSAL
    • Note some say scaphoid waist fractures are dealers choice so can do dorsal or volar
  • If middle 1/3 or distal -> ORIF with central screw, approach VOLAR (majority of blood supply is dorsal at this location so want to preserve!!)
  • Best biomechical fixation involves longest, central screw
30
Q
  • Chronic scaphoid waist nonunion w/ proximal pole AVN best treated w/
A

free vascularized femoral bone graft inserted through volar approach
* Taken from the medial femoral condyle

31
Q

Fixation vs nonop for nondisplaced scaphoid fractures…what is benefit of fixing?
If casting, what immobilization is best?

A
  • Fixation of non-displaced scaphoid fractures has resulted in shorter time to union and faster return to work and sports.
  • Studies have shown for nonop treatment immobilization of just the wrist (not also the thumb) is necessary x3 months
32
Q

Capitate fracture -
What is mechanism?
What type of blood supply?
Typical management?

A
  • Think of it like the scaphoid in that, it also has a retrograde blood supply
    • If develops AVN -> like scaphoid, can use free vascularized bone graft from iliac crest or MFC
    • Other risks for AVN other than trauma/missed fx, steroids, vibration expose (ie jack hammer)
  • Fractures are not common, usually high energy injury
  • Fracture typically needs to be fixed
33
Q 
Hook of hamate fx -
What type of athletes?
What symptoms?
What imaging?
Treatment if chronic?
A
  • Symptoms: ulnar-sided wrist pain, tingling in ulnar nerve distribution
    • Think about it especially in golfer or baseball player
  • Eval with carpal tunnel XR
  • Chronic fracture - treat with fragment excision
34
Q

Where is SL ligament strongest?

A
  • Strongest part of the SL ligament complex is DORSAL SL
35
Q

Lunate

A

Stopped here

Hand (6 decks)

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