hand exam Flashcards
mallet finger surgical indications
> 50% articular surface
subluxation
jersey finger finger predominence
75% ring finger
thumb MCP UCL injury
treat non-op if <2mm articular step-off, no rotation, <20% articular surface
stener lesion is UCL caught over adductor
MCP dislocation
- 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
dorsal PIP dislocation
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
volar PIP dislocation
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.
lateral PIP dislocation treatment
buddy tape
hamate fracture
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)
lunate
Keinbocks MRI T1 marrow bright
pisiform
fall on outstretched hand. pain on palpation. Get CT or MRI of suspected.
scaphoid fracture
nondisplaced, stable: 3 months in short arm cast 95% healing. If young and active surgery may decrease casting time.
scaphoid blood supply
oblique dorsoradial ridge
scaphoid avascular necrosis proximal pole
vascularized bone graft 1,2 ICSRA
medial femoral condyle free graft
T1 marrow should be bright. If not then AVN
thumb CMC ligaments (2 most important)
volar/oblique beak
dorsoradial
if dorsal subluxation then repair dorsoradial ligament with FCR eaton little reconstruction or cast/pin
Roberts view
CMC thumb joint evaluation
thumb CMC dislocation
fracture >30% then pin
closed reduction tracture, abduction, pronation, extension (TAPE)
Similar histology sarcoma
fibrosarcoma, desmoid, MFH
similar histology bone tumor
enchondroma, low-grade chondrosarcoma
similar histology nerve
giant cell tumor of tendon sheath, PVNS
soft tissue sarcomas found in subcutaneous tissues
DFSP, epitheliod sarcoma, MFH (pleomorphic high grade sarcoma), angiosarcoma
soft tissue sarcomas involving aponeurotic, tendon, and bursa
clear cell sarcoma, fibrosarcoma, synovial cell sarcoma
soft tissue sarcomas that metastasize to the lymph nodes
synovial, epitheliod, clear cell, rhabdomyosarcoma
Posterior interosseous artery
- 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
lateral arm flap
- 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
groin flap
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
Medial femoral condyle flap
- descending geniculate artery (off superficial femoral artery just proximal to adductor hiatus). 8cm length.
- rarely superiomedial genicular artery (off popliteal) is dominant
anconeus flap
- 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.
Becker flap
- 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
emboli
- 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.
lunate blood supply
- 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.
distal interosseous membrane
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.
clawing
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.
PIN position
The PIN moves distally with pronation in uninjured forearms, and this excursion is reported to be as high as 2.13 cm.
flexible swan neck deformity treatment
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.
lateral band attachement
radial lateral band
muscle responsible for thumb opposition
APB
brachial plexus anatomy
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,
thoracic outlet syndrome
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
Myoelectric prosthesis
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.
lattisimus transfer for elbow flexion
muscle origin transfered to coracoid process
- this transfer substitutes for the short head of the biceps muscle.
thumb CMC ligaments
Two most important ligaments:
- dorsoradial ligament- if injured get dorsal subluxation with FCR eaton littler reconstruction (or cast/pin)
- anterior oblique ligament (AOL), or “beak” ligament
- saddle joint with a shallow
thumb CMC fractures
- robert xray view
- if metacarpal base fracture >30% need to reduce and pin
- reduction move is traction, abduction, pronation, extension (TAPE)
Bennett fracture
- 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
thumb UCL injury
> 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.
thumb RCL injury
may need to pin the MCP joint to pretct repair due to pull of the APL and EPL.
normal radius measurements
10-12 degree palmar tilt
22 degree radial inclination
11 mm length
operative indication radius
dorsal angulation >10-15 degrees
shortening >5mm
>2mm intraarticular stepoff
radius teardrop
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.
watershed line
distal to PQ where capsule attaches. If plate distal to this may injure FPL.
expected outcomes after distal radius fracture
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
metacarpal fractures
deep transverse intermetacarpal ligament will prevent too much shortening of the metacarpal fracture.
- rotation should be repaired
- dorsal spike can impede extensor tendon excursion
boxers fracture
up to 90 degrees angulation ok if no extensor lag.
may buddy tape or splint.
Palmer classification of acute TFCC injuries
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
DRUJ anatomy
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).
DRUJ stabilizers
ECU subsheath is static primary stabilizer
PQ, ECU tendon, IOM, articular disk of TFCC, capsule are secondary stabilizers
test ulnar sided wrist pain
- 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
flat sigmoid notch
42% people have this shape
more likely to have unstable DRUJ
TFCC tear diagnosis
MRA more sensitive and specific than MRI. Scope is gold standard.
midcarpal instability
usually neuromuscular, not traumatic.
treat with symptom managment
arthrodesis as salvage
clunk with axial load, pronation and ulnar deviation
midcarpal instability
usually neuromuscular, not traumatic.
treat with symptom managment
arthrodesis as salvage
clunk with axial load, pronation and ulnar deviation
scapholunate ligament injury
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
SL instability grades
- pre-dynamic instability - pain but no xray changes
- dynamic - pain and stress film changes
- static reducible - pain and gap on xray
- static irreducible
- arthritis
LT ligament
strongest palmarly
VISI deformity on lateral view
on exam use compression, shuck or shear to press the triquetrum against the lunate
LT ligament treatment
ECU augmentation 25% complication
repair 40% complication
LT fusion 80% complication
perilunate dislocation
stage 4 only the short radiolunate ligament keeps the lunate tethered to the radius
flexor tendon blood flow
diffusion from intrasynovial imbibition and direct vascular tendon vessels
- avascular zone in zone 2
- peak VEGF at day 7 to promote healing
flexor tendon technical pearls
- 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
pulley preservation
ok to take A4 and 50% of A2 as long as neighboring pulleys intact.
flexor tendon OT protocol
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.
zone III
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
elson test
hold PIP flexed and should not be able to extend DIP against resistance if central slip intact
zone 5 extensor tendon injury
- 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.
zone 6 extensor tendon injury
dorsum of the hand.
- juncturae tendinum may make it look like its intact even if injured
relative motion splint
helpful for rehab for zone 5 & 6 extensor tendon injury and sagittal band injuries
zone 7 extensor tendon injury
within the retinaculum
- may be associated with distal radius fracture and prominent screws
dequervians tenosynovitis
- APL multiple slips
- EPB smaller and dorsal/ulnar
- 33-50% separate subsheath
- steroids help 70-80% patients
intersection syndrome
- 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
ECU tendonitis
- injection, splint, ice, NSAIDS
- tenosynovectomy if fail conservative
ECU subluxation
acute - long arm splint in pronation and radial deviation
chronic - reconstruction
IL-6 mediator
increased in arthritis
DIP arthritis
fusion 12% nonunion
CMC arthritis
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
Eaton stage
1 joint narrowing
2 osteophytes <2mm
3 osteophytes >2mm
4 pantrapezial arthrosis
SLAC progression
- distal pole of scaphoid and radius
- proximal pole of the scaphoid and radius
- mid-carpal (capitate-lunate)
- pan carpal
SNAC similar but spares the proximal scaphoid
PRC
failure rate higher in patients <35 years old
wrist arthroplasty
5 year survival 78%
10 year survival 71%
Keinbocks stage
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
treatment keinbocks
- 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.
psoriatic arthritis
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
gout
- 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)
gout treatment
- 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
pseudogout
- larger joints affected
- older patients
- positive birefringent rhomboid shaped crystals
- intra-articular calcinosis and STT arthrosis
- treat with NSAIDS and steroids
scleroderma
- fibrosis of connective tissue
- 90% have raynauds phenomenon
- ANA+, RF-, Scl-70 antibodies
- treatment: caclium channal blockers, phosphodiesterase inhibitors, periarterial sympathectomy, botox
CREST
calcinosis, raynauds, esophageal dysmotility, sclerodactyly, telangiectasias
hemochromatosis
- diagnose with elevated ferritin (can also elevate with inflammation) and transferrin saturation tests.
- IF and MF MCP arthritis
- treat with phlebotomy or iron chelation
acute calcific periarthritis
- acute onset
- mono-articular painful swelling and calcification next to joint
- self limited
sarcoidosis
- 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
lyme disease
- borrelia burgdorferi
- knee most common joint
- ELISA testing
- treat with doxy or ampicillin
RA physical exam
- morning stiffness
- subcutaneous nodules
- ulnar drift digits
- wrist with ulnar slide and radial deviation
- boutonniere and swan neck deformity
RA labs
- Rheumatoid factor
- anti-cyclic citrullinate peptide
- ESR, CRP
RA radiology
- PIP spared
- MCP subluxation
- periarticular erosions and osteopenia
differential diagnosis MCP not extend
- extensor tendon rupture
- volar dislocation
- radial sagittal band rupture and ulnar subluxation of extensor
- PIN palsy
- “locked” MCP joint due to osteophyte, boney prominence
MCP silicone implant
fracture rate 65%
caput-ulna syndrome
- 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)
radial deviation of wrist in RA
- early then ECRL to ECU (Clayton) and synovectomy
- intermediate then radiolunate fusion (Chamay)
- advanced then wrist fusion with darrach or arthroplasty
Mannerfelt syndrome
- FPL rupture in carpal tunnel from scaphoid osteophyte .
- treat with FDS ring to FPL transfer, PL graft, BR transfer, or IP fusion
RA nodules
25% aggressive disease
- can excise
trigger finger in RA
clean out pannus and 1 FDS slip but leave A1 pulley intact due to ulnar drift
surgery in RA patients
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
Juvenile RA
- 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).
skin graft survival
<2 days imbibition
2-5 days inoscultation
>5 days revascularization
replant survival rate
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
clenched fist
often IF and thumb not as bad to facilitate pinch
factitious lymphedema
look for “windowpane” where tourniquet was placed
secretans syndrome
striking dorsum of hand to produce swelling (factitious disorder)
elors danlos
AD inheretance
thumb metacarpal lengthening
- can get 3cm and requires webspace deepening
zplasty
60% zplasty results in 75% increase in length
120 degree 4 flap zplasty achieves depth and contour
thumb pulp recon
- littler flap from ulnar aspect MF
- FDMA with sensation from the dorsal radiosensory nerve
- moberg up to 2cm advancement if backcut and 75% have normal sensation
- free toe pulp from dorsal metatarsal artery or plantar system
fingertip anatomy
volar pulp 56% finger tip volume
nerve volar to arteries
at DIP the nerve trifurcates
sensation organs
pacinian (rough touch)
meissner (light touch) - in glaborous skin including FTSG
merkel cell neurite complexes (slowly adapting)
nail injury
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.
steroid injection
glucose elevated in DM 4-5 days
FCR tendonitis
may rupture against scaphoid tubercle and trapezial crest so warn if steroid injection
FCU tendonitis
pain over the pisiform.
- occasional calcification
lumbrical plus deformity
- Amputation at DIP joint and FDP retracts and pulls the lumbricals.
- On exam extend the PIP with attempted flexion.
- treat with intrinsic release
thenar flap
- beware the radial digital nerve to the thumb
- horseshoe shape 1.5 x size of the defect
- divide at weeks
- can get PIP stiffness
V-Y advancement flap
1cm advancement
- must divide the septae
distal amputation
<1cm heal by secondary intension has best sensation
- cold intolerance and numbness normal
- will have maximal improvement at 2 years
trigger finger
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
amyloidosis
- may see in trigger finger in dialysis patients. Remove amyloid deposits
mucopolysaccharidosis
lysosomal storage disease that cases accumulation of glycosaminoglycans.
- may get trigger finger and require tenosynovectomy
pediatric trigger finger
- 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)
vasopessor infiltration
- phentolamine 5-10mg in 10cc saline
- terbutaline
- 2% nitroglycerine paste topically
hydrofluoric acid
- topical calcium gluconate 2.5%
- injectable calcium gloconate 10%
phosphoric acid
copper sulfate solution topically
phenol extravasation
- water lavage then wipe skin with polyethylene or propylene glycol
- maintain urine alkaline and bicarb to decrease hemaglobin precipitation
dopamine extravasation
subcutaneous phentolamine or topical nitroglycerin
doxorubicin (anthracycline) extravasation
dexrazoxane or DMSO (dimethyl solfoxide) adn cold saline
vincristine (plant alkyloid) extravasation
warm compresses and hyluronidase
mechlorethamine (mustard)
sodium thiosulfate and cold compress
vinca alkaloid extravasation
local heat (cold can increase blister formation)
frostbite
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
STSG thickness
0.015”
blister fluid
pro-inflammatory cytokines
integra
bilayer bovine tendon collagen with silicone
apligraft
bovine collagen seeded with fibroblasts for dermis and overlying epidermal keratinocytes for epidermis
electrical burn severity
higher voltage
tissue resistance
bone>fat>tendon>skin>muscle>vessel>nerve
when to excise and graft
anticipate >2-3 weeks for burn to heal
valgus instability (medial or ulnar collateral ligament)
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
posterolateral rotatory instability
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.
varus posteromedial rotatory instability
gravity assisted varus stress - abduct shoulder to 90 degrees and flex and extend elbow allowing gravity to provide varus stress. + if pain
myofibroblasts
fibroblasts differentiate to myofibroblasts and responsible for delayed contraction. Myofibroblast differentiation includes development of alpha smooth muscle actin.
eccentric loading
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.
Anisotropism
- 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.
hysteresis
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.
thenar space boundaries
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.
os styloideum
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.
carpal os
- 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.
Elson test
test central slip integrity
flex PIP and ask to extend against resistance
DIP should be floppy, if not then central slip injury
Contracture of the oblique retinacular ligament
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
Bunnell intrinsic tightness test
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.
boutonierre vs pseudo-boutonierre
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.
triquetral fracture
- 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
terrible triad
- fracture radial head
- fracture coronoid
- rupture lateral ulnar collateral ligament (most important for joint stability)
leads to posterolateral rotatory instability
palmar midcarpal instability
incompetent:
- dorsal radiotriquetral
- palmar ulnar arcuate ligament
proximal row primary stabilizing ligaments
radioscaphocaptiate and ulnotriquetral ligaments
ulnar carpal translocation
incompetent:
- ulnolunate
- long radiolunate
Thompson approach
- 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
kocher approach
anconeus and ECU
intrinsic anatomy
- 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.
metacarpal fracture shortening
Every 2 mm of shortening results in 7 degrees of extension lag.
20 degrees toleratable since usually have hyper extension
so 6mm shortening acceptable
ehlers-danlos syndrome
- 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
cutis laxa
- skin inelastic and hangs loosely in folds
- appear premature aging
marfan syndrome
- mutation of fibrillin 1
- aortic aneurysm, dislocation ocular lens, arachnodactyly, long bone overgrowth
osteogenesis imperfecta (brittle bone disease)
fractures
short stature
scoliosis
skull deformities
loeys-dietz
connective tissue disorder
aortic and arterial aneurysms
hand contractures
arachnodactyly and long bone overgrowth (similar to marfan syn)
myasthenia gravis
- 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
lambert-eaton syndrome
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.
linberg-comstock anomaly
tendinous interconnections between the flexor pollicis longus (FPL) muscle belly or tendon and the flexor digitorum profundus (FDP), usually of the index
facioscapulohumeral muscular dystrophy
- 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
ECU subluxation position of stability
forearm pronation, wrist radial deviation, and slight wrist extension
steroid injection for trigger finger
- 50-70% initial response but most recur by two years
- less effective if symptoms >4 months, multiple digits, male, DM, younger age
EPL rupture with DRF
- 0.2-5% incidence with DRF
- 5-6 weeks after fracture
- may be from ischemia and/or attrition
complications steroid injection
- 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
treatment elemental earth metal contact (lithium, potassium, sodium)
- 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
white phosphorus particle treatment
use UV light to identify and remove with high flow water decontamination
lymphedema
- 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
true lateral xray
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.
dytelephalangy (Kirners deformity)
volar and radial curvature of distal phalanx. usually small finger, often bilateral. physis deformed with volar widening.
FCU flap
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
thumb flexor pulleys
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.
teardrop angle
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.
elbow stability
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
improve elbow extension
- anterior capsule release
- mobilization/release of brachialis
- excision osteophytes olecranon fossa/process
- removal prominent hardware
DRUJ instability
- 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
flexor tendon pulley in repairs
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.
lasers
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
dorsal metacarpal artery flap (quaba)
pedicle arises distal to juncturae tendinum within the intermetacarpal space
dorsal ulnar artery flap (Becker flap)
dorsal ulnar artery, dorsal to FCU. Can use to cover volar palm.
lateral ulnar collateral ligament
originates from the center of the lateral epicondyle and courses obliquely to its insertion on the crista supinatoris of the proximal ulna
