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Hand exam > hand exam > Flashcards

hand exam Flashcards

1
Q

mallet finger surgical indications

A

> 50% articular surface

subluxation

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2
Q

jersey finger finger predominence

A

75% ring finger

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3
Q

thumb MCP UCL injury

A

treat non-op if <2mm articular step-off, no rotation, <20% articular surface
stener lesion is UCL caught over adductor

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4
Q

MCP dislocation

A
  • most stable in flexion where true collateral ligament taut
  • volar plate can block reduction in dorsal dislocation (or metacarpal neck incarceration between index lumbrical radially and flexor tendons ulnarly)
  • closed reduction: flex wrist to relax flexors and lumbricals
  • generally stable so move early
  • volar plate can be torn off the metacarpal. May need to split if dorsal approach to get reduction.
  • Volar reduction risks injury to the radial digital nerve which is displaced by the dislocation
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5
Q

dorsal PIP dislocation

A

small or no fracture then collateral ligament still attached to middle phalanx so stable. If >40% then unstable (collateral ligament attached to fracture fragement.
buddy tape or extension block 20-30 degrees for 2-3 weeks if stable. extend 10 degrees per week. May get a flexion contracture.
volar plate arthroplasty 30-50% joint surface
hemihamate arthroplasty >50% articular surface or chronic injuries. 50% hemihamate patients get radiographic arthritis but may not be symptomatic

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6
Q

volar PIP dislocation

A

assume central slip injured (can do elson test). Splint PIP in extension 4-6 weeks. If >25% fracture then can pin Can get Boutinnere deformity.

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7
Q

lateral PIP dislocation treatment

A

buddy tape

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8
Q

hamate fracture

A

hook fracture easily missed. racket, baseball, golf mechanism. Need carpal tunnel view or CT scan. Nondisplaced then 6 weeks cast. Excise non-union (protect ulnar motor branch)

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9
Q

lunate

A

Keinbocks MRI T1 marrow bright

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10
Q

pisiform

A

fall on outstretched hand. pain on palpation. Get CT or MRI of suspected.

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11
Q

scaphoid fracture

A

nondisplaced, stable: 3 months in short arm cast 95% healing. If young and active surgery may decrease casting time.

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12
Q

scaphoid blood supply

A

oblique dorsoradial ridge

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13
Q

scaphoid avascular necrosis proximal pole

A

vascularized bone graft 1,2 ICSRA
medial femoral condyle free graft
T1 marrow should be bright. If not then AVN

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14
Q

thumb CMC ligaments (2 most important)

A

volar/oblique beak
dorsoradial
if dorsal subluxation then repair dorsoradial ligament with FCR eaton little reconstruction or cast/pin

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15
Q

Roberts view

A

CMC thumb joint evaluation

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16
Q

thumb CMC dislocation

A

fracture >30% then pin

closed reduction tracture, abduction, pronation, extension (TAPE)

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17
Q

Similar histology sarcoma

A

fibrosarcoma, desmoid, MFH

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18
Q

similar histology bone tumor

A

enchondroma, low-grade chondrosarcoma

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19
Q

similar histology nerve

A

giant cell tumor of tendon sheath, PVNS

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20
Q

soft tissue sarcomas found in subcutaneous tissues

A

DFSP, epitheliod sarcoma, MFH (pleomorphic high grade sarcoma), angiosarcoma

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21
Q

soft tissue sarcomas involving aponeurotic, tendon, and bursa

A

clear cell sarcoma, fibrosarcoma, synovial cell sarcoma

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22
Q

soft tissue sarcomas that metastasize to the lymph nodes

A

synovial, epitheliod, clear cell, rhabdomyosarcoma

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23
Q

Posterior interosseous artery

A
  • identify artery 4 cm distal to the lateral epicondyle. Its trajectory is in a line between the lateral epicondyle and the DRUJ. In the mid-forearm, the pedicle is most often located running between the ECU and EDM.
  • reverse posterior interosseous flap, based on the perforators and intercommunication between the anterior and posterior interosseous artery just proximal to the DRUJ. The axis of the flap is centered over a line drawn from the lateral humeral epicondyle to the ulnar styloid, with the pivot point approximately 2 cm proximal and radial to the ulnar styloid.
  • 5% no communication between the AIN and PIN; and DRUJ trauma and interfere with connection. Must confirm intact for flap to survive
  • 20% necrosis if try to reach PIP
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24
Q

lateral arm flap

A
  • posterior radial collateral artery runs in the intermuscular septum between the triceps and the brachialis muscles.
  • reverse flap based on radial recurrent
  • axis deltoid to lateral epicondyle.
  • must protect radial nerve
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25
Q

groin flap

A

superficial circumflex iliac artery (SCIA). The SCIA is a branch of the femoral artery and runs 2 cm below the inguinal ligament. It pierces the fascia of the sartorius muscle as it crosses the medial border. Mobilization of the pedicle requires dividing the sartorius fascia. The SCIA divides into superficial and deep branches at the medial border of the sartorius muscle.

  • avoid injury to the lateral femoral cutaneous nerve
  • divide at 3 weeks
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26
Q

Medial femoral condyle flap

A
  • descending geniculate artery (off superficial femoral artery just proximal to adductor hiatus). 8cm length.
  • rarely superiomedial genicular artery (off popliteal) is dominant
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27
Q

anconeus flap

A
  • proximal pedicle is medial collateral artery, a terminal branch of the profunda brachii artery.
  • distal pedicle, the recurrent posterior interosseous artery
  • posterior branch of the radial collateral artery enters in the middle of the muscle.
  • contributes to the terminal 15 degrees of elbow extension and forearm supination.
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28
Q

Becker flap

A
  • dorsal ulnar artery and its ascending branch. The flap is marked on an axis joining the pisiform and the medial epicondyle. The pivot point is on this axis 2-4 cm proximal to the pisiform on the ulnar border of the FCU. -
  • innervated by incorporating the medial antebrachial cutaneous nerve
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29
Q

emboli

A
  • Upper extremity emboli make up only 20% of arterial emboli and 75% originate from the heart.
  • cardiac emboli are large and affect the brachial artery while smaller subclavian emboli affect the wrist level and digital level vessels. Ulnar artery/superficial palmar arch thrombosis tend to embolize to the palm and digits.
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30
Q

lunate blood supply

A
  • The blood supply to the lunate enters through the non-articular palmar and dorsal surfaces. Palmer most important.
  • 10% of lunates have been found to be supplied exclusively by a single palmar vessel.
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31
Q

distal interosseous membrane

A

secondary stabilizer of the distal radio-ulnar joint when the dorsal and palmar radioulnar ligaments of the TFCC are injured.

  • 40% of individuals have a clear fibrous thickening within the distal interosseous membrane known as the distal oblique bundle.
  • This fibrous thickening extends from the distal aspect of the ulnar shaft to the proximal aspect of the sigmoid notch of the radius.
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32
Q

clawing

A

Clawing of the index and long fingers does not occur in a severe ulnar neuropathy, due to function of the lumbricals to the index and long fingers. A branch from the radial digital nerve of the index provides innervation of the lumbrical to the index. The common digital nerve to the long and ring fingers provide innervation to the lumbrical to the long finger. The lumbricals to the small and ring fingers are innervated by the motor branch of the ulnar nerve.

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33
Q

PIN position

A

The PIN moves distally with pronation in uninjured forearms, and this excursion is reported to be as high as 2.13 cm.

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34
Q

flexible swan neck deformity treatment

A

Oblique retinacular ligament reconstruction: take down the ulnar lateral band and passing it deep to Cleland’s ligament (volar to the axis of the PIPJ). The lateral band is then re-inserted into the proximal phalanx or A2 pulley with the joint in slight flexion.

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35
Q

lateral band attachement

A

radial lateral band

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36
Q

muscle responsible for thumb opposition

A

APB

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37
Q

brachial plexus anatomy

A

C5 presents with weakness in the deltoid and biceps, sensory disturbance of the upper lateral arm,
C6 presents with wrist extensor and supination weakness, sensory disturbance in the thumb and index finger,
C7 presents with triceps and wrist flexion and sensory disturbance middle finger
C8 presents with finger flexion weakness, sensory disturbance of the ulnar digits,

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38
Q

thoracic outlet syndrome

A

90% neurgenic caused by scalene muscle hypertrophy, anomalous bands, or soft-tissue tumors or The neurogenic causes can be divided into soft-tissue (70%) and osseous (30%). Neurogenic compression may occur secondary to scalene muscle hypertrophy, anomalous bands, or soft-tissue tumors. Osseous causes of neurogenic compression include a cervical rib, a prominent C7 transverse process, or post-traumatic changes of the clavicle or acromio-clavicular joint.

If vascular most common subclavian vein compression by costoclavacular ligament or subclavius tendon

  • pagett-Schroetter syndrome is subclavian thrombosis
  • provacative manuver is abduction and external rotation
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39
Q

Myoelectric prosthesis

A

elbow flexion by bicepts long head.
Elbow extension by triceps long head.
hand closure, by median motor nerve transferred to biceps short head
Hand opening by transfer of the distal radial nerve to the lateral head of the triceps.

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40
Q

lattisimus transfer for elbow flexion

A

muscle origin transfered to coracoid process

- this transfer substitutes for the short head of the biceps muscle.

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41
Q

thumb CMC ligaments

A

Two most important ligaments:

  1. dorsoradial ligament- if injured get dorsal subluxation with FCR eaton littler reconstruction (or cast/pin)
  2. anterior oblique ligament (AOL), or “beak” ligament
    - saddle joint with a shallow
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42
Q

thumb CMC fractures

A
  • robert xray view
  • if metacarpal base fracture >30% need to reduce and pin
  • reduction move is traction, abduction, pronation, extension (TAPE)
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43
Q

Bennett fracture

A
  • deformed metacarpal position by adductor, APL, and EPL, but fracture fragment stabilized by volar/oblique beak ligament.
  • reduction maneuver: axial traction, direct pressure over the metacarpal base, metacarpal abduction and pronation
  • small fragment then CRPP
  • if larger then ORIF
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44
Q

thumb UCL injury

A

> 35 degrees laxity or >15 degree difference to uninjured side.

  • usually ruptures distally (opposite from the radial side which usually ruptures proximally).
  • if stable cast/splint 4-6 weeks then strengthening at 6 weeks
  • if >2mm displacement or >15 percent articular surface/2mm size fragment then repair.
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45
Q

thumb RCL injury

A

may need to pin the MCP joint to pretct repair due to pull of the APL and EPL.

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46
Q

normal radius measurements

A

10-12 degree palmar tilt
22 degree radial inclination
11 mm length

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47
Q

operative indication radius

A

dorsal angulation >10-15 degrees
shortening >5mm
>2mm intraarticular stepoff

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48
Q

radius teardrop

A

ulnar volar lip is important and can be missed with volar plate. Stryker has a plate that is more ulnar and may help catch these.

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49
Q

watershed line

A

distal to PQ where capsule attaches. If plate distal to this may injure FPL.

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50
Q

expected outcomes after distal radius fracture

A

3-6 months can progress to unrestricted activity
6-12 months to recover
may continue to have ulnar wrist pain for up to 12 months
may have stiffness worst in supination

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51
Q

metacarpal fractures

A

deep transverse intermetacarpal ligament will prevent too much shortening of the metacarpal fracture.

  • rotation should be repaired
  • dorsal spike can impede extensor tendon excursion
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52
Q

boxers fracture

A

up to 90 degrees angulation ok if no extensor lag.

may buddy tape or splint.

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53
Q

Palmer classification of acute TFCC injuries

A

1A central - rest, immobilize, anti-inflammatories, steroids. Debride. If ulnar positive then wafer or ulnar shortening. inherently stable.
1B Detaced from ulnar fovea - in unstable then repair
1C ulnocarpal ligament tear
1D radial attachment injury - conservative treatment if stable

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54
Q

DRUJ anatomy

A

radius rotates around the ulna (fixed at the elbow).

  • sigmoid notch shallow and arc greater than ulna.
  • pronation increases the load through the ulna (usualy 20% in neutral).
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55
Q

DRUJ stabilizers

A

ECU subsheath is static primary stabilizer

PQ, ECU tendon, IOM, articular disk of TFCC, capsule are secondary stabilizers

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56
Q

test ulnar sided wrist pain

A
  • TFCC fovea test - palpate between FCU and styloid with wrist flexed
  • Nakamura’s ulnar stress test - ulnar deviation of pronated wrist flex and extend while axial loading (basically a grind test)
  • DRUJ ballottment test (most stable in supination)
  • piano key sign
  • press test (ulno-carpal joint) - grasp arms of chair and push up
  • LT ballottment
  • grid pisiform
  • synergy test-resist thumb and MF abduction and point tenderness over ECU
  • ECU subluxation - most stable in pronation and unstable in supination
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57
Q

flat sigmoid notch

A

42% people have this shape

more likely to have unstable DRUJ

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58
Q

TFCC tear diagnosis

A

MRA more sensitive and specific than MRI. Scope is gold standard.

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59
Q

midcarpal instability

A

usually neuromuscular, not traumatic.
treat with symptom managment
arthrodesis as salvage
clunk with axial load, pronation and ulnar deviation

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60
Q

midcarpal instability

A

usually neuromuscular, not traumatic.
treat with symptom managment
arthrodesis as salvage
clunk with axial load, pronation and ulnar deviation

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61
Q

scapholunate ligament injury

A

xray showes SL intervan >3mm, ring sign, SL angle >60 degrees (40 degrees normal)

  • dorsal aspect stronger than volar
  • acute injury then reduce and pin scapholunate and scaphocapitate 8-10 weeks and cast
  • subacute. Can still repair up to 6 weeks or so but still may get palmer flexion of the scaphoid so consider dorsal capsulodesis and/or ligament reconstruction.
  • chronic. No arthritis then SL reconstruction. If arthritis then FCF or PRC or wrist fusion
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62
Q

SL instability grades

A
  1. pre-dynamic instability - pain but no xray changes
  2. dynamic - pain and stress film changes
  3. static reducible - pain and gap on xray
  4. static irreducible
  5. arthritis
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63
Q

LT ligament

A

strongest palmarly
VISI deformity on lateral view
on exam use compression, shuck or shear to press the triquetrum against the lunate

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64
Q

LT ligament treatment

A

ECU augmentation 25% complication
repair 40% complication
LT fusion 80% complication

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65
Q

perilunate dislocation

A

stage 4 only the short radiolunate ligament keeps the lunate tethered to the radius

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66
Q

flexor tendon blood flow

A

diffusion from intrasynovial imbibition and direct vascular tendon vessels

  • avascular zone in zone 2
  • peak VEGF at day 7 to promote healing
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67
Q

flexor tendon technical pearls

A
  • distsal FDS consider modified Becker repair
  • use iced #8 pediatric feeding tube to pass tendon end or can loop wire
  • to get 8 strand repair use looped supramid
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68
Q

pulley preservation

A

ok to take A4 and 50% of A2 as long as neighboring pulleys intact.

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69
Q

flexor tendon OT protocol

A

passive ROM place and hold and tenodesis in extensor blocking splint early
- some increase in strength by 3 weeks but much more at 7 weeks.

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70
Q

zone III

A

central slip injury (boutonniere)

  • early (3-4 weeks) splint PIP if full extension for 3-4 weeks
  • open injury repair primarily to with bone anchor to P2 and pin to keep PIP extended 3-4 weeks then transition to dynamic splint.
  • chronic then curtis staged reconstruction
    1. free up transverse retinacular ligament
    2. cut the transverse retinacular ligament
    3. fowler tenotomy
    4. central slip advancement
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71
Q

elson test

A

hold PIP flexed and should not be able to extend DIP against resistance if central slip intact

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72
Q

zone 5 extensor tendon injury

A
  • sagittal band over the MCP involved
  • fight bite here and 67% penetrate the joint
  • sagittal band injury will be able to hold in extension if put there but not able to actively extend whereas tendon injury cannot do either.
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73
Q

zone 6 extensor tendon injury

A

dorsum of the hand.

- juncturae tendinum may make it look like its intact even if injured

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74
Q

relative motion splint

A

helpful for rehab for zone 5 & 6 extensor tendon injury and sagittal band injuries

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75
Q

zone 7 extensor tendon injury

A

within the retinaculum

- may be associated with distal radius fracture and prominent screws

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76
Q

dequervians tenosynovitis

A
  • APL multiple slips
  • EPB smaller and dorsal/ulnar
  • 33-50% separate subsheath
  • steroids help 70-80% patients
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77
Q

intersection syndrome

A
  • proximal and ulnar to 1st dorsal compartment
  • treat with steroids and if fail then surgery to release from radial styloid to 6cm proximal
  • rowers get it
  • on exam “footsteps in snow” crepitus and pain with extension
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78
Q

ECU tendonitis

A
  • injection, splint, ice, NSAIDS

- tenosynovectomy if fail conservative

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79
Q

ECU subluxation

A

acute - long arm splint in pronation and radial deviation

chronic - reconstruction

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80
Q

IL-6 mediator

A

increased in arthritis

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81
Q

DIP arthritis

A

fusion 12% nonunion

82
Q

CMC arthritis

A

25% females, 8% males get it

  • if associated STT arthritis then remove 2mm of trapezoid
  • MCP extension deformity >30 degrees then pin or capsulodesis or fuse
83
Q

Eaton stage

A

1 joint narrowing
2 osteophytes <2mm
3 osteophytes >2mm
4 pantrapezial arthrosis

84
Q

SLAC progression

A
  1. distal pole of scaphoid and radius
  2. proximal pole of the scaphoid and radius
  3. mid-carpal (capitate-lunate)
  4. pan carpal
    SNAC similar but spares the proximal scaphoid
85
Q

PRC

A

failure rate higher in patients <35 years old

86
Q

wrist arthroplasty

A

5 year survival 78%

10 year survival 71%

87
Q

Keinbocks stage

A

0 normal xray but abnormal MRI
1 linear or compression fracture
2 increased lunate density but normal shape
3A lunate collapse but scaphoid position ok
3B lunate collapse with scaphoid flexed (SL ligament incompetent)
4 lunate collapse and pan carpal osteoarthritis

88
Q

treatment keinbocks

A
  • radial shortening if ulnar negative
  • vascularized bone graft up to 3B (preferred is the 4,5 ECA)
  • stage 3 or worse PRC or lunate excision with scaphocapitate or STT fusion.
89
Q

psoriatic arthritis

A

scaly cutaneous erythematous plaques

  • can develop staph aureus infections (do not operate through plaques)
  • nail deformities
  • dactylitis “sausage fingers”
  • acro-osteolysis - resorption of the distal phalanx tuft
  • pencil in cup deformity
  • DMARDS for moderate
  • TNF and IL12 antagonists for severe
90
Q

gout

A
  • monosodium urate crystals
  • negative birefringent, needle shaped
  • 1 joint affected at a time
  • serum uric acid normally <7mg/dL but 40% of patients with gout will have normal uric acid
  • high purine foods (red meat, seafood, alcohol) and dehydration bring on attacks
  • tophi at DIP
  • cysts >5mm in carpus (perarticular lytic changes)
  • ligament disruption of the carpus (SL and CT)
91
Q

gout treatment

A
  • acute attack: NSAIDS and colchicine
    • if renal failure then prednisolone
    • anakinra is an interleukin-1 inhibitor
  • chronic:
  • -probenecid enhances renal excretion uric acid
  • -allopurinol and febuxostat reduce uric acid production
92
Q

pseudogout

A
  • larger joints affected
  • older patients
  • positive birefringent rhomboid shaped crystals
  • intra-articular calcinosis and STT arthrosis
  • treat with NSAIDS and steroids
93
Q

scleroderma

A
  • fibrosis of connective tissue
  • 90% have raynauds phenomenon
  • ANA+, RF-, Scl-70 antibodies
  • treatment: caclium channal blockers, phosphodiesterase inhibitors, periarterial sympathectomy, botox
94
Q

CREST

A

calcinosis, raynauds, esophageal dysmotility, sclerodactyly, telangiectasias

95
Q

hemochromatosis

A
  • diagnose with elevated ferritin (can also elevate with inflammation) and transferrin saturation tests.
  • IF and MF MCP arthritis
  • treat with phlebotomy or iron chelation
96
Q

acute calcific periarthritis

A
  • acute onset
  • mono-articular painful swelling and calcification next to joint
  • self limited
97
Q

sarcoidosis

A
  • systemic non-caseating granulomatous disease
  • operative excision leads to recurrance
  • treat with steroids
  • CT chest may show bilateral hilar adenopathy and granulomas in the lungs
98
Q

lyme disease

A
  • borrelia burgdorferi
  • knee most common joint
  • ELISA testing
  • treat with doxy or ampicillin
99
Q

RA physical exam

A
  • morning stiffness
  • subcutaneous nodules
  • ulnar drift digits
  • wrist with ulnar slide and radial deviation
  • boutonniere and swan neck deformity
100
Q

RA labs

A
  • Rheumatoid factor
  • anti-cyclic citrullinate peptide
  • ESR, CRP
101
Q

RA radiology

A
  • PIP spared
  • MCP subluxation
  • periarticular erosions and osteopenia
102
Q

differential diagnosis MCP not extend

A
  1. extensor tendon rupture
  2. volar dislocation
  3. radial sagittal band rupture and ulnar subluxation of extensor
  4. PIN palsy
  5. “locked” MCP joint due to osteophyte, boney prominence
103
Q

MCP silicone implant

A

fracture rate 65%

104
Q

caput-ulna syndrome

A
  • synovitis of the DRUJ
  • volar subluxation of the carpus, ulnar prominent dorsally
  • can cause extensor tendon rupture ulnar
    EDM>EDC4>EDC5>EPL
    Vaughn-Jackson
    reconstruct with EIP to EDC transfer or side to side tenodesis
  • treat with Darrach or Sauve-Kapandji (young patients)
105
Q

radial deviation of wrist in RA

A
  • early then ECRL to ECU (Clayton) and synovectomy
  • intermediate then radiolunate fusion (Chamay)
  • advanced then wrist fusion with darrach or arthroplasty
106
Q

Mannerfelt syndrome

A
  • FPL rupture in carpal tunnel from scaphoid osteophyte .

- treat with FDS ring to FPL transfer, PL graft, BR transfer, or IP fusion

107
Q

RA nodules

A

25% aggressive disease

- can excise

108
Q

trigger finger in RA

A

clean out pannus and 1 FDS slip but leave A1 pulley intact due to ulnar drift

109
Q

surgery in RA patients

A 
get C-spine films preop as may have C1-2 subluxation
hold DMARDS one dose preop
consider stress dose steroids
continue methotrexate
DM increases infection risk
110
Q

Juvenile RA

A
  • polyarticular >5 joints
  • pauciarticular <4 joints
  • check for uveitis with slit lamp, especially in ANA+ females because
  • Stills disease is systemic (20%) and presents with fever, anemia, hepatosplenomegaly, RA-
  • wrist flexion contracture, wrist ulnar and MCP radial deviation (opposite normal RA).
111
Q

skin graft survival

A

<2 days imbibition
2-5 days inoscultation
>5 days revascularization

112
Q

replant survival rate

A

88% minimal damage (94% less than 8 hours and 74% longer)
58% avulsion
12% crush
lower survival in kids and epiphysial plates may fuse
ROM about half prior to injury
irreversible injury to muscle by 6 hours

113
Q

clenched fist

A

often IF and thumb not as bad to facilitate pinch

114
Q

factitious lymphedema

A

look for “windowpane” where tourniquet was placed

115
Q

secretans syndrome

A

striking dorsum of hand to produce swelling (factitious disorder)

116
Q

elors danlos

A

AD inheretance

117
Q

thumb metacarpal lengthening

A
  • can get 3cm and requires webspace deepening
118
Q

zplasty

A

60% zplasty results in 75% increase in length

120 degree 4 flap zplasty achieves depth and contour

119
Q

thumb pulp recon

A
  1. littler flap from ulnar aspect MF
  2. FDMA with sensation from the dorsal radiosensory nerve
  3. moberg up to 2cm advancement if backcut and 75% have normal sensation
  4. free toe pulp from dorsal metatarsal artery or plantar system
120
Q

fingertip anatomy

A

volar pulp 56% finger tip volume
nerve volar to arteries
at DIP the nerve trifurcates

121
Q

sensation organs

A

pacinian (rough touch)
meissner (light touch) - in glaborous skin including FTSG
merkel cell neurite complexes (slowly adapting)

122
Q

nail injury

A 
nails grow 0.1mm/day
3-4 nail growths for maximal improvement
subungual hematoma <50% then trephinate
>50% then repair
- bone shortening for distal amp then must keep 2mm past nailbed to prevent hooknail.
123
Q

steroid injection

A

glucose elevated in DM 4-5 days

124
Q

FCR tendonitis

A

may rupture against scaphoid tubercle and trapezial crest so warn if steroid injection

125
Q

FCU tendonitis

A

pain over the pisiform.

- occasional calcification

126
Q

lumbrical plus deformity

A
  • Amputation at DIP joint and FDP retracts and pulls the lumbricals.
  • On exam extend the PIP with attempted flexion.
  • treat with intrinsic release
127
Q

thenar flap

A
  • beware the radial digital nerve to the thumb
  • horseshoe shape 1.5 x size of the defect
  • divide at weeks
  • can get PIP stiffness
128
Q

V-Y advancement flap

A

1cm advancement

- must divide the septae

129
Q

distal amputation

A

<1cm heal by secondary intension has best sensation

  • cold intolerance and numbness normal
  • will have maximal improvement at 2 years
130
Q

trigger finger

A

thumb>RF,MF>IF>SF frequency

  • fibrocartilaginous metaplasia A1 pulley
  • 60-90% steroid improvement
  • if fail to improve with A1 pulley release then vent A2 or FDS slip excision
131
Q

amyloidosis

A
  • may see in trigger finger in dialysis patients. Remove amyloid deposits
132
Q

mucopolysaccharidosis

A

lysosomal storage disease that cases accumulation of glycosaminoglycans.
- may get trigger finger and require tenosynovectomy

133
Q

pediatric trigger finger

A
  • usually thumb, can be bilateral
  • stuck in flexion
  • can splint 3 months and if fail then surgery
  • may feel thickened A1 pulley (notta’s nodule)
134
Q

vasopessor infiltration

A
  • phentolamine 5-10mg in 10cc saline
  • terbutaline
  • 2% nitroglycerine paste topically
135
Q

hydrofluoric acid

A
  • topical calcium gluconate 2.5%

- injectable calcium gloconate 10%

136
Q

phosphoric acid

A

copper sulfate solution topically

137
Q

phenol extravasation

A
  • water lavage then wipe skin with polyethylene or propylene glycol
  • maintain urine alkaline and bicarb to decrease hemaglobin precipitation
138
Q

dopamine extravasation

A

subcutaneous phentolamine or topical nitroglycerin

139
Q

doxorubicin (anthracycline) extravasation

A

dexrazoxane or DMSO (dimethyl solfoxide) adn cold saline

140
Q

vincristine (plant alkyloid) extravasation

A

warm compresses and hyluronidase

141
Q

mechlorethamine (mustard)

A

sodium thiosulfate and cold compress

142
Q

vinca alkaloid extravasation

A

local heat (cold can increase blister formation)

143
Q

frostbite

A

hunting response at 10C with cyclical perfusion to extremities
–2C interstitial ice crystal formation
nucleotide labled perfusion scanning (triple phase bone scan Tc99) correlates with amputation level
intra-arterial tPA may help salvage
Iloprost (prostacycline) and aspirin helps salvage

144
Q

STSG thickness

A

0.015”

145
Q

blister fluid

A

pro-inflammatory cytokines

146
Q

integra

A

bilayer bovine tendon collagen with silicone

147
Q

apligraft

A

bovine collagen seeded with fibroblasts for dermis and overlying epidermal keratinocytes for epidermis

148
Q

electrical burn severity

A

higher voltage

149
Q

tissue resistance

A

bone>fat>tendon>skin>muscle>vessel>nerve

150
Q

when to excise and graft

A

anticipate >2-3 weeks for burn to heal

151
Q

valgus instability (medial or ulnar collateral ligament)

A

valgus stress test - elbow 20-30 flexion, supination, valgus stress. + if pain, opening, no firm end point
milking maneuver - abduction 90 degrees, elbow flexed, pull thumb valgus (posterior). + if pain
moving valgus stress test - abduct 90 degrees, external rotation, flex elbow max and apply vagus stress and extend. + if pain between 120 and 70 degrees flexion

152
Q

posterolateral rotatory instability

A

lateral pivot shift - arm above head and arm supinated. valgus and supinated force as flex. + if pain along outside (radial) elbow and may have radial head clunk
rotatory drawer- anterior posterior force through elbow. + if dislocation of radial head or pain
chair push-up - hold arm of chair with elbow at 90 and forearm supinated and push to extend elbow when stand. + if pain or radial dislocation.
prone push-up - elbow flexed 90 degrees with supination and push up. + of pain or radial head dislocation
table-top relocation - allow elbow to flex while bend over while grabbing edge of table. + if pain if the examiner does not stabilize the radial head.

153
Q

varus posteromedial rotatory instability

A

gravity assisted varus stress - abduct shoulder to 90 degrees and flex and extend elbow allowing gravity to provide varus stress. + if pain

154
Q

myofibroblasts

A

fibroblasts differentiate to myofibroblasts and responsible for delayed contraction. Myofibroblast differentiation includes development of alpha smooth muscle actin.

155
Q

eccentric loading

A

forced lengthening of the muscle-tendon system that occurs while the muscle is contracting. This occurs when a force applied to a muscle exceeds the momentary force produced by the muscle itself, resulting in lengthening of the muscle itself.

156
Q

Anisotropism

A
  • material having different physical properties when stressed in different directions. One example is wood which is easier to split along its grain than across it.
  • viscoelastic - materials demonstrate properties dependent on the rate which force is applied. For example at low loading rates, tendons are compliant but are increasingly stiff with increasing load rates.
  • isotropic - materials behave independent of the direction of applied force.
157
Q

hysteresis

A

retardation of an effect when the forces acting upon a body are changed. A commonly cited example of hysteresis is the difference in the pressure-volume curve between lung inflation and deflation. Hysteresis has been demonstrated in the carpal bones as well. Short et al. described how the amount that the scaphoid was flexed at a particular wrist position was different depending on the direction the wrist was moved to get to that position.

158
Q

thenar space boundaries

A

DORSAL: Fascia of the adductor pollicis, 2nd volar metacarpal, and first volar interosseous fascia.
VOLAR: Tendon sheath of index finger and radial palmar aponeurosis.
RADIAL: Confluence of adductor pollicis fascia and palmar fascia at base of thumb proximal phalanx.
ULNAR: Midpalmar oblique septum.

159
Q

os styloideum

A

accessory carpal ossicle between the trapezoid, capitate and second and third metacarpals. different from boss because rather than boney protuberance at base of metacarpal is is a separate bony ossicle. Associated with NHL players. If symptomatic then activity modification, splint, steroid. Can excise if refractory.

160
Q

carpal os

A
  • os centrale carpi is located between the scaphoid, capitate, and trapezoid, and may be misinterpreted as a scaphoid fracture.
  • os triangulare is situated between the ulnar styloid and triquetrum, and may have the appearance of an ulnar styloid nonunion.
  • os epilunate is located dorsally between the lunate and capitate, and may look like a loose body.
  • os radiostyloideum, adjacent to the radial styloid, may be confused with a radial styloid fracture.
161
Q

Elson test

A

test central slip integrity
flex PIP and ask to extend against resistance
DIP should be floppy, if not then central slip injury

162
Q

Contracture of the oblique retinacular ligament

A

as can occur in a late stage boutonniere deformity, results in DIP extensor posturing. With persistent DIP hyperextension, the ORL tightens from this “shortened” position resulting in a DIP extensor contracture enhanced by passive PIP extension. The ORL tightness test involves checking passive flexion of the DIP with the PIP flexed and extended. If tighter in extension, the ORL is contracted

163
Q

Bunnell intrinsic tightness test

A

passively flexing the PIP joint with the MCP extended and flexed. Increased resistance to flexion in MCP extension that is reduced or eliminated with MCP flexion is a positive test and confirms intrinsic contracture.

164
Q

boutonierre vs pseudo-boutonierre

A

A “pseudo-boutonierre”, by definition, describes a fixed flexion contracture that results from volar plate injury. Associated soft tissues, i.e., central slip, ORL, lateral bands, terminal tendon, are not contracted and these tissues will test normally. On the other hand, a true boutonniere examines differently. Early after central slip rupture, the PIP contracture is passively correctable. Later, as the lateral bands move palmar through triangular ligament attenuation, and the oblique retinacular ligaments begin to contract, Elson’s test and ORL tightness tests become positive. These findings distinguish the true-boutonniere from the pseudo-boutonniere deformity.

165
Q

triquetral fracture

A
  • second most common after scaphoid (15%)
  • dorsal cortical avulsion fractures immobilize 4-6 weeks. if symptomatic nonunion then fragment excision.
  • body fracture immobilize if nondisplaced or ORIF if displaced
  • pronated oblique view can help diagnose
166
Q

terrible triad

A
  1. fracture radial head
  2. fracture coronoid
  3. rupture lateral ulnar collateral ligament (most important for joint stability)
    leads to posterolateral rotatory instability
167
Q

palmar midcarpal instability

A

incompetent:

  • dorsal radiotriquetral
  • palmar ulnar arcuate ligament
168
Q

proximal row primary stabilizing ligaments

A

radioscaphocaptiate and ulnotriquetral ligaments

169
Q

ulnar carpal translocation

A

incompetent:

  • ulnolunate
  • long radiolunate
170
Q

Thompson approach

A
  • dorsal approach to radius
  • between ECRB and EDC
  • exposes PIN (crosses 5.6cm distal to radiocapatellar joint in pronation)
  • as continue distal transition to between ECRB and EPL
171
Q

kocher approach

A

anconeus and ECU

172
Q

intrinsic anatomy

A
  • The interossei consist of three palmar and four dorsal muscles. These muscles abduct/adduct the digits, and contribute to MCP joint flexion/IP joint extension in combination with the lumbrical muscles. The palmar interossei comprise three unipennate muscles that lie between the metacarpals originating as single muscle bellies from the palmar two-thirds of the metacarpal shafts. The first, second, and third palmar interossei have attachments respectively to the index, ring, and small metacarpals.
  • The dorsal interosseous (DIO) muscles are bipennate, with heads originating from adjacent sides of the thumb through small metacarpals. The DIO originate as two muscle bellies on adjacent metacarpals. As such, the first DIO originates from the thumb and index metacarpals, the second DIO originates from the index and middle metacarpals, the third DIO originates from the middle and ring metacarpals, and the fourth DIO originates from the ring and small metacarpals. The third dorsal interosseous muscle has only one tendon slip, which ulnarly deviates the middle finger through its insertion onto the ulnar dorsal aponeurosis. The remaining dorsal interossei tendons are comprised of two tendon slips. The deep belly inserts onto the dorsal aponeurosis via the lateral tendon. The superficial belly forms a medial tendon that inserts onto the lateral tubercle at the base of the proximal phalanx.
  • The volar interossei (VIO) do not have an insertion to bone. They have a single tendon that inserts into the dorsal aponeurosis. The third VIO originates from the fifth metacarpal, and in ulnar nerve palsy its paralysis is implicated in Wartenberg’s sign.
  • The lumbrical muscles originate from the flexor digitorum profundus tendons. The adductor pollicis originates from the capitate and bases of the index and middle metacarpals.
173
Q

metacarpal fracture shortening

A

Every 2 mm of shortening results in 7 degrees of extension lag.
20 degrees toleratable since usually have hyper extension
so 6mm shortening acceptable

174
Q

ehlers-danlos syndrome

A
  • AD
  • connective tissue affected
  • skin hyper extensibility, joint hypermobility, tissue fragility
  • mutation in gene for fibrillar collagen
  • CMC ligamentous instability resulting in subluxation and arthritis
175
Q

cutis laxa

A
  • skin inelastic and hangs loosely in folds

- appear premature aging

176
Q

marfan syndrome

A
  • mutation of fibrillin 1

- aortic aneurysm, dislocation ocular lens, arachnodactyly, long bone overgrowth

177
Q

osteogenesis imperfecta (brittle bone disease)

A

fractures
short stature
scoliosis
skull deformities

178
Q

loeys-dietz

A

connective tissue disorder
aortic and arterial aneurysms
hand contractures
arachnodactyly and long bone overgrowth (similar to marfan syn)

179
Q

myasthenia gravis

A
  • autoimmune disorder
  • irreversible binding of IgG autoantibodies to the AChR receptors at the motor endplate to prevent skeletal muscle contraction
  • progressive weakness exacerbated by repetitive contracture
  • ptosis
  • associated with hypertrophic thymus
  • diagnose with anticholinesterase test, repetitive nerve stimulation, receptor antibody assay, EMG
180
Q

lambert-eaton syndrome

A

binding of auto-antibodies to the presynaptic voltage-gated calcium channels at the neuromuscular junction, thus preventing impulse transmission and muscle contraction. This condition may be associated with cancer. The presentation involves proximal muscle weakness closer to the trunk. This condition is known for its distinguishing characteristic “Lambert sign” where hand strength will improve with repeated grip dynomometer testing.

181
Q

linberg-comstock anomaly

A

tendinous interconnections between the flexor pollicis longus (FPL) muscle belly or tendon and the flexor digitorum profundus (FDP), usually of the index

182
Q

facioscapulohumeral muscular dystrophy

A
  • third most common muscular dystrophy
  • AD
  • chromosome 4q35
  • symptoms 1st-2nd decade and progressive
  • shoulder weakness by girdle atrophy with scapular winging
  • facial weakness
  • biceps/triceps weakness, but normal distal to elbow
  • often asymmetric
  • sensation normal
183
Q

ECU subluxation position of stability

A

forearm pronation, wrist radial deviation, and slight wrist extension

184
Q

steroid injection for trigger finger

A
  • 50-70% initial response but most recur by two years

- less effective if symptoms >4 months, multiple digits, male, DM, younger age

185
Q

EPL rupture with DRF

A
  • 0.2-5% incidence with DRF
  • 5-6 weeks after fracture
  • may be from ischemia and/or attrition
186
Q

complications steroid injection

A
  • fat atrophy (1.5-40%)
  • hypopigmentation (1.3-4%)
    usually manifest 2-4 months after injection and resolve 9-12 months later
  • triamcinolone and methylprednisolone are ester containing compounds, making them insoluble and longer acting, whereas betamethasone and dexamethasone are more water soluble. Triamcinolone (Kenalog) is the least soluble and most often implicated in causing hypopigmentation and fat atrophy
187
Q

treatment elemental earth metal contact (lithium, potassium, sodium)

A
  • these undergo exothermic reaction when exposed to water so protect from water and air with mineral oil then remove visible particles. after this then high flow water decontamination
188
Q

white phosphorus particle treatment

A

use UV light to identify and remove with high flow water decontamination

189
Q

lymphedema

A
  • filariasis spread by mosquitos caused by Wuchereria bancrofti
  • lymphedema praecox (meige disease) present at puberty and include both legs
  • lymphedema tarda - due to underdeveloped lymphatic system and slowly progress starting around 35
190
Q

true lateral xray

A

The pisiform is located in the volar ulnar wrist and its location is typically used to identify an appropriately positioned lateral radiograph. The pisiform should overlap the distal pole of the scaphoid on a true lateral view of the wrist.

191
Q

dytelephalangy (Kirners deformity)

A

volar and radial curvature of distal phalanx. usually small finger, often bilateral. physis deformed with volar widening.

192
Q

FCU flap

A

To perform an FCU flap, the FCU tendon is identified and transected distally at the level of the wrist crease. The tendon and muscle are carefully elevated proximally with care to protect the ulnar nerve and ulnar artery (Figure 1). The muscle is supplied by branches of the ulnar artery and posterior recurrent ulnar artery. The dominant proximal vascular pedicle which is capable of supplying the muscle belly after a turnover flap is located on average 5.9 cm (range of 5.2 to 6.8 cm) distal to the tip of the olecranon

193
Q

thumb flexor pulleys

A

Traditionally there have been three pulleys described for the thumb. The A1 pulley lies over the metacarpal phalangeal joint. The oblique pulley is found over the proximal phalanx and runs from proximal ulnarly to distal radially. The A2 pulley lies over the interphalangeal joint. More recently a variable annular (Av) pulley in the thumb has been described which has been found to be present in 93% of cadaveric specimens. Three types have been described, including transverse oblique or continuous with the A1 pulley. Persistent or recurrent triggering may be related to the Av pulley. Complete release of both the A1 and Av pulleys is not recommended as bowstringing may occur.

194
Q

teardrop angle

A

measurement of the volar rim of the lunate facet relative to the long axis of the radius (inclined lateral view). An increase or decrease in this angle (normal 70 degrees) indicates displacement the of the lunate facet.

195
Q

elbow stability

A

Medial Collateral Ligament:
1. anterior - most important for stability
2. posterior - can release to improve elbow flexion
3. transverse
Lateral Collateral Ligament:
1. lateral ulnar collateral ligament - most important for stability. If injured get posterolateral rotatory instability
2. radial collateral ligament
3. anterior lateral collateral ligament
4. annular ligament - stabilizes the radiocaptiellar joint

196
Q

improve elbow extension

A
  1. anterior capsule release
  2. mobilization/release of brachialis
  3. excision osteophytes olecranon fossa/process
  4. removal prominent hardware
197
Q

DRUJ instability

A
  • stabilized by joint capsule, dorsal and palmar radioulnar ligaments, TFCC, interosseous membrane, sigmoid notch.
  • acute then reduce and long arm cast 6 weeks. Volar dislocation then pronation, dorsal dislocation then in supination
198
Q

flexor tendon pulley in repairs

A

Full release of the A-4 pulley does not seem to contribute to bowstringing and the A-2 pulley can be “vented” up to 50% of its length without bowstringing. Bunching of the tendon repair site up to 120-130% of diameter of the tendon results from greater suture tension at the repair site and reduces the likelihood of gapping.

199
Q

lasers

A

carbon dioxide - target water. Enhance pliability, reduce stiffness
pulsed dye - target hemoglobin. tatoos and pigmented lesions
alexandrite - hair removal
intense pulsed light - not laser. Improve pigmented lesions, hair removal

200
Q

dorsal metacarpal artery flap (quaba)

A

pedicle arises distal to juncturae tendinum within the intermetacarpal space

201
Q

dorsal ulnar artery flap (Becker flap)

A

dorsal ulnar artery, dorsal to FCU. Can use to cover volar palm.

202
Q

lateral ulnar collateral ligament

A

originates from the center of the lateral epicondyle and courses obliquely to its insertion on the crista supinatoris of the proximal ulna

Hand exam (9 decks)

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