Hand Surgery Flashcards
Attachments to hook of hamate?
Tranverse carpal ligament
opponens digiti minimi
FDM - transverse carpal Ligament
Pisiform- ADM
Which part of ligaments is thicker - Sc-lunate? Lun-triq?
Sc-Lun - dorsal
Lyn- trip - volar
What is the order of re innervation of the PIN
ECU EDC EDM APL EPL EPB EIP
Where are EIP and EDM tendons in relation to EDC
Ulna side
EIP has most distal muscle belly at wrist 4th dorsal compartment
Where are lumbricals and IO in relation to Deep transverse interMCP ligament .
Lumbricals palmar
IO dorsal
What is the function of the lateral bands and transverse retinacular Ligament
Conjoined lateral bands stabilised by triangular ligament. Prevents VOLAR subluxation
Transverse retinacular ligament prevents dorsal subluxation
General Classifications for wrist instability
Chronicity
Acute 6 weeks
Severity - WATSON
Stage 1 - Predynamic - ligament injury, no malalignment. SL Pain, positive watsons test, normal xray
Stage 2 - Dynamic - carpal malalignment under loading. SL pain and positive stress X-rays
Stage 3 - Static - fixed change in carpal alignment.
Stage 4 - degenerative
Geissler arthroscopic classification
Stage 1 - loss of concavity of SL interval as lig bulges
Stage 2 - SL interval incongruent
Stage 3 - gap in SL interval. Can pass probe
Stage 4 - 2.7mm scope can drive through from mid carpal to radiocarpal
Carpal alignment. DISI - SL angle >60, Cap-Lun angle >20 VISI - SL angle 15 Ulnar translocation Dorsal translocation
CID - Dissociative
CIND - non dissociative
CIC - combined - perilunate dis location
Adaptive - malalignment secondary to issues proximal or distal to carpus ie distal radius malunion
What’s the natural history of scapholunate instability? - classification?
SLAC - Watson classification
1 - scaphoid and radial styloid
2 - scaphoid and entire scaphoid facet
3 - capitate / lunate OA
4 - pan carpal OA
Radio lunate spared
In SNAC - proximal pole and corresponding surface is spared because not loaded
1 - styloidectomy and stabilisation - STT
2 - scaphoid excision and 4CF or PRC or wrist fusion
3 - scaphoid excision and 4CF or wrist fusion
For SNAC, distal pole excision may be enough if wrist in fixed DISI and Scaph-cap joint NOT arthritic
What is the natural history of visi
Not as well known as DISI
Not everyone develops arthritis
Most treated non operatively
How do you assess PA and lateral views of the wrist as ideal?
PA. Groove for EcU radial to mid portion of styloid
Lat - scaphoid tubercle and pisiform maximally superimposed
Operative options for swan neck deformity?
Non-op double ring splint
Nalebuff stages 1) Flexible splint FDS tenodesis of ruptured Lateral band recon - littler
2) Intrinsic tightness
Intrinsic release +/- MCPJ Arthroplasty
3) tight in all ranges of MCPJ
intrinsic release, lateral band recon, dorsal capsular release, volar plate plication
4) OA of PIPJ
arthrodesis or silicone implant
Causes of swan neck
VOLAR plate laxity
Or
Imbalance between forces across PIPJ
Laxity
- Trauma
- ligamentous laxity
- RA
Secondary
- Mallet injury
- Rheumatoid - McPJ volar subluxation
- FDS rupture
- intrinsic contracture
Lateral bands tethered by transverse retinacular ligament from PIPJ hyper extension
Excursion restricted and extension force not transmitted to terminal tendon, instead just to PIPJ
Complications of flexor tendon repair
Tendon adhesions - Tenolysis if passive >active after 3/12 Re rupture- up to 17% Sean neck Trigger finger Lumbrical plus finger Quadrigia
Pathophysiology and associations of trigger finger
Fibrocartilaginous metaplasia of tendon and pulley
RF most common
DM
RA
Amyloidosis
Indications for operative management of scaphoid fractures
Proximal pole Displaced >1mm Trans-scaphoid Peri-lunate dislocation Humpback deformity 15 degrees DISI (radio lunate) > 15 degrees Scapholunate >60 degrees Intrascaphoid angle >35 degrees Comminuted fractures Unstable - vertical or oblique Non-union - either no AVN or AVN (cysts)
Faster return to work/sport
Which approach used for which scaphoid fractures
Dorsal approach -
Proximal pole fractures. Care of blood supply from dorsal carpal branch on dorsal ridge.
Volar approach -
Waist and distal pole + humpback fractures
Allows exposure of whole scaphoid
Interval between FCR and radial artery
Plus minus radial styloidectomy if impact ion OA evident.
What are the bone grafts used for scaphoid fractures
Inlay - Russe
Minimal deformity, no adjacent carpal collapse or Flexion humpback deformity
Interposition - Fisk
If adjacent carpal collapse and excessive humpback
Opening wedge to restore length and angulation
Vascular radius bone graft Proximal pole with MRI proven AVN 1-2 intercompartmental supraretinacular artery from dorsal radius - Incision over snuffbox PQ pedicel (volar) 1st dorsal MCP artery graft
What is the differential for wrist ganglion? 11
Epidermoid inclusion cyst Foreign body granuloma Lipoma Tendon sheath GCT Tenosynovitis Intratendinous ganglion Osteophyte DISI/VISI deformity Carpal bossing Aneurysm (dorsal venous, volar radia, volar ulna) Neuroma
Most common sarcoma In the hand?
Epitheloid sarcoma
Causes of a lump in the hand - 14
Ganglion GCT tendon sheath (PVNS) Bone - carpal boss, scaphoid prox pole Heberden or Bouchard nodes Synovial chondromatosis Gouty tophi Inclusion dermoid Foreign body Lipoma Vascular aneurysm Schwannoma Neurofibroma Lipofibromatous hamartoma Anomalous muscle - EDB manus
What is the nalebuff classification for thumb deformities in RA?
1- Boutonnière without CMCJ 2- Boutonnière with CMCJ 3- Swan neck with CMCJ 4- Gamekeepers thumb 5- Swan neck without CMCJ 6- arthritis mutilans
What are rheumatoid nodules?
Subcutaneous granulomas consisting of fibrinoid necrosis, cellular debris and monocytes
Principles of surgery in Rheumatoid Arthritis?
LOWER LIMB SHOULD BE ADDRESS BEFORE UPPER LIMB
SHOULDER & ELBOW PATHOLOGY SHOULD BE ADDRESS FIRST PROXIMAL SURGERY BEFORE DISTAL SURGERY
ADDRESS MCPJ BEFORE IPJ (PIPJ MAY IMPROVE AFTER MCPJ SURGERY)
PERFORM PREDICTABLE WINNER OPERATIONS FIRST
(WRIST STABILISATION & DRUJ SURGERY, FOLLOWED BY MCPJ FUSION, DIPJ FUSION)
STAGE SURGERY (WRIST & FINGER SURGERY SEPARATE / MCPJ & PIPJ CAN BE DONE TOGETHER)
THUMB SURGERY AFTER FINGER SURGERY
CANNOT OPERATE ON BOTH HANDS SIMULTANEOUS PERFORM SURGERY ON JOINT WHERE PAIN ARISES
URGENT SURGERY INVOLVES TENOSYNOVECTOMY & NERVE DECOMPRESSION (PREVENT TENDON RUPTURE)
Surgical options for Thumb MCPJ in RA?
SYNOVECTOMY (EARLY DISEASE)
CAPSULODESIS (SWAN NECK DEFORMITY ONLY – Type 3 or 5)
SILICONE ARTHROPLASTY (BOUTONNIERE DEFORMITY ONLY –Type 1 or 2. NOT Swan neck as joint unstable)
ARTHRODESIS (ALL TYPES)
