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Orthopaedics > Hand Surgery > Flashcards

Hand Surgery Flashcards

0
Q

Attachments to hook of hamate?

A

Tranverse carpal ligament
opponens digiti minimi

FDM - transverse carpal Ligament
Pisiform- ADM

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1
Q

Which part of ligaments is thicker - Sc-lunate? Lun-triq?

A

Sc-Lun - dorsal

Lyn- trip - volar

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2
Q

What is the order of re innervation of the PIN

A 
ECU
EDC
EDM
APL
EPL
EPB
EIP
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3
Q

Where are EIP and EDM tendons in relation to EDC

A

Ulna side

EIP has most distal muscle belly at wrist 4th dorsal compartment

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4
Q

Where are lumbricals and IO in relation to Deep transverse interMCP ligament .

A

Lumbricals palmar

IO dorsal

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5
Q

What is the function of the lateral bands and transverse retinacular Ligament

A

Conjoined lateral bands stabilised by triangular ligament. Prevents VOLAR subluxation

Transverse retinacular ligament prevents dorsal subluxation

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6
Q

General Classifications for wrist instability

A

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

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7
Q

What’s the natural history of scapholunate instability? - classification?

A

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

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8
Q

What is the natural history of visi

A

Not as well known as DISI

Not everyone develops arthritis
Most treated non operatively

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9
Q

How do you assess PA and lateral views of the wrist as ideal?

A

PA. Groove for EcU radial to mid portion of styloid

Lat - scaphoid tubercle and pisiform maximally superimposed

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10
Q

Operative options for swan neck deformity?

A

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

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11
Q

Causes of swan neck

A

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

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12
Q

Complications of flexor tendon repair

A 
Tendon adhesions - Tenolysis if passive >active after 3/12
Re rupture- up to 17%
Sean neck 
Trigger finger
Lumbrical plus finger 
Quadrigia
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13
Q

Pathophysiology and associations of trigger finger

A

Fibrocartilaginous metaplasia of tendon and pulley

RF most common

DM
RA
Amyloidosis

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14
Q

Indications for operative management of scaphoid fractures

A 
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

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15
Q

Which approach used for which scaphoid fractures

A

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.

16
Q

What are the bone grafts used for scaphoid fractures

A

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
17
Q

What is the differential for wrist ganglion? 11

A 
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
18
Q

Most common sarcoma In the hand?

A

Epitheloid sarcoma

19
Q

Causes of a lump in the hand - 14

A 
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
20
Q

What is the nalebuff classification for thumb deformities in RA?

A 
1- Boutonnière without CMCJ
2- Boutonnière with CMCJ 
3- Swan neck with CMCJ
4- Gamekeepers thumb
5- Swan neck without CMCJ
6- arthritis mutilans
21
Q

What are rheumatoid nodules?

A

Subcutaneous granulomas consisting of fibrinoid necrosis, cellular debris and monocytes

22
Q

Principles of surgery in Rheumatoid Arthritis?

A

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)

23
Q

Surgical options for Thumb MCPJ in RA?

A

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)

24
Q

What are the aims of surgery in the Rheumatoid hand? - 4

A

⇨ PAIN RELIEF
⇨ IMPROVE FUNCTION
⇨ CORRECT DEFORMITY
⇨ COSMESIS

25
Q

What are the criteria for a diagnose of RA? ACR 1987

A 
Morning stiffness 
Arthritis of at least 3 joints
Arthritis of hand joints
Symmetrical arthritis 
Rheumatoid nodules
Positive serum RF
Radiographic changes - periarticular erosive arthropathy

4 or more for at least 6 weeks

26
Q

What syndrome is associated with complex syndactyly?

A

Apert’s

27
Q

What syndrome is associated with symbrachydactyly?

A

Poland syndrome

Plus absence of chest muscle on that side

28
Q

What did the nalebuff classification for Boutonnière?

A

1- slight deformity / flexible
2- marked deformity / flexible or fixed
3- fixed PIPj arthritis

29
Q

What are the Martin-Gruber anastomoses?

A

1- median to ulna - 10-30% of normal
2- ulna to median - reverse
3- deep median to ulna in FPB Riche-Cannieu
4- digitial in Palm - Berretini

Type 3 - 55-75% of normal

30
Q

Causes of CTs

A

Idiopathic

Traumatic -
Fracture
Malunion
Dislocation
Haemorrhage
Anatomy - 
SoL - lipoma, ganglion, neuroma 
Tumour - 
Anomalous - median artery, palmaris profundis 
Arthritis
Systemic - 
RA
RF / SLE / Scleroderma
Pregnancy / obesity / Alcohol
Thyroid / acromegaly / DM
Vitamin disorder
CRF / CCF
31
Q

Causes of ulna sided wrist pain

A 
Bony - 
Distal radius #
Ulna styloid #
DRUJ
ESSEX-Lopresti
Ulna abutment / OA
Pisiform / Tr OA
Soft tissue - 
ECU / FCU tendinitis
Ulna nerve neuroma 
LT ligament injury - VISI
RA
32
Q

Causes of radial sided wrist pain

A 
Bony - 
Distal radius #
Scaphoid #
Perilunate dislocation 
STT OA
1st CMCJ OA
SLAC / SNAC
OA
Soft tissue -
De Quervain's
Intersection syndrome
SRN neuroma 
FCR tendinitis 
SL lig injury
33
Q

What is the classification for mallet injuries of finger?

A 
Doyle
1- closed mallet
2- open laceration 
3- open skin loss
4- mallet #
4a- p3 physeal
4b - 20-50% articular surface
4c - >50%
34
Q

Indications for replant

A 
Thumb
Multiple digits
Palm, wrist, forearm
Paediatric
Zone 1 distal to FDS
35
Q

Contraindications to replant

A 
Mangled
Crush
Avulsion 
Warm isxhaemia time >12 hrs digit or 6 proxim 
Single border digit
36
Q

What is the goal of Claw hand surgery

A

Prevent MCPJ hyperextension

Contracture release with passive tenodesis or active tendon transfer

Orthopaedics (19 decks)

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