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MSK block > Hand Surgery > Flashcards

Hand Surgery Flashcards

1
Q

What is a Bennett’s fracture?

A

A fracture-dislocation of the base of the thumb metacarpal.

Common injury (fall or punch)

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2
Q

How would a Bennett’s fracture appear on X-ray and why?

A
  1. Characteristic intra-articular fragment remains attached to the Beak ligament (anterior oblique ligament) ➞ results in metacarpal fragment articulating with Trapezium
  2. Metacarpal displaced proximally due to pull of AbPL
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3
Q

How is a Bennett’s fracture treated?

A
  1. Reduce the metacarpal back to the fragment
  2. Hold reduction with K wires or small screw
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4
Q

What is Rolando’s fracture

A

Comminuted fracture of the base of the thumb metacarpal (NOT dislocated)

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5
Q

How is a Rolando’s fracture treated?

A

Thumb splint

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6
Q

The Scaphoid is a bean shaped bone which is almost entirely covered in _______.

It articulates with the _______, _______ and _______ and can be palpated in the _______.

It has an unusual blood supply from _______ to _______ which comes from a branch of the _______ artery.

A

articular cartilage

distal radius, lunate, trapezium, anatomical snuffbox

distal, proximal, radial

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7
Q

Most common mechanism of injury of scaphoid fractures?

A

FOOSH injury

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8
Q

Initial investigation for a suspected scaphoid fracture?

A

Scaphoid series of X-rays (4 views)

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9
Q

What are the 4 scaphoid X-ray views?

A
  1. PA
  2. lateral
  3. oblique
  4. Ziter view (PA with wrist in ulnar deviation and beam angulated at 20º)
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10
Q

What is the definitive investigation for a scaphoid fracture?

A

MRI

Should be first-line imaging - but this is not common practice in the UK. It is commonly used second-line when X-rays are inconclusive

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11
Q

What is the biggest danger of a scaphoid fracture?

A

AVN ➞ occurs in the PROXIMAL POLE of the scaphoid

*chance of AVN increases with degree of displacement of fracture

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12
Q

How would a scaphoid fracture present?

A
  1. Pain in the anatomical snuffbox
  2. Pain along the radial aspect of the wrist, at the base of the thumb
  3. Loss of grip / pinch strength
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13
Q

What is a major differential diagnosis of distal radius fracture?

A

Scaphoid Fracture

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14
Q

List the the 4 Scaphoid provocation tests

What do these tell us?

A
  1. Snuffbox tenderness
  2. Pain on telescoping thumb metacarpal
  3. Pain on telescoping index metacarpal
  4. Pain on radial deviation of wrist and palpating distal pole of scaphoid (ulna dev???)

Greater number of positive = more likely fracture

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15
Q

How would you manage the following:

  1. Possible scaphoid fracture
  2. Undisplaced scaphoid fracture
  3. Displaced or proximal scaphoid fracture
A
  1. Immobilise and re-XR 7-10 days
  2. Immobilise in scaphoid cast or splint for 8 weeks
  3. Internal fixation
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16
Q

Position of wrist cast for a scaphoid fracture?

A

Wrist should be placed in the ‘beer glass position’

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17
Q

List 4 complications of a scaphoid fracture

A
  1. AVN
  2. Non union
  3. Post traumatic OA
  4. SNAC wrist (Scaphoid Non-union Articular Collapse)
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18
Q

What forms the roof and base of the carpal tunnel?

A

Roof: Flexor Retinaculum

Base and sides: Carpal Arch

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19
Q

List all structures passing through the carpal tunnel

A

Median nerve + 9 tendons

  • tendon of flexor pollicis longus
  • 4 tendons of FDP
  • 4 tendons of FDS
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20
Q

List 3 symptoms of CTS?

A
  1. Tingling/pain in the first three digits
  2. Worse at night
  3. Relieved by shaking/ hanging out the hand at night
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21
Q

List 2 clinical signs of carpal tunnel syndrome

A

Paraesthesiae in distribution of median nerve ➞ radial 3 and a 1⁄2 digits

Thenar wasting in late disease

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22
Q

What additional muscle wasting may be seen In late carpal tunnel syndrome and why?

A

Abductor Pollicis Brevis as it is located in the Thenar Eminence and is innervated by median nerve

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23
Q

Is Thenar eminence sensation lost in carpal tunnel syndrome? Explain your answer

A

No, it is PRESERVED

This because the palmar cutaneous branch of median nerve does NOT pass through carpal tunnel

24
Q

Differential diagnosis for carpal tunnel syndrome?

A

cervical nerve entrapment (eg C6 or C7 distribution)

25
Q

What 2 tests aid diagnosis of carpal tunnel syndrome

A

Tinel’s test: tapping median nerve at level of volar wrist crease.

Phalen’s test: flexion of the wrist to 90 degrees and compression of the median nerve for 1 minute

26
Q

List 4 risk factors for CTS

A
  1. Diabetes
  2. Pregnancy
  3. Hypothyroidism
  4. Acromegaly
  5. Radial fracture
  6. RA
27
Q

Investigation of choice to diagnose CTS

Explain findings

A

Nerve conduction studies

Characteristic drop in conductance at level of CT ➞ helps differentiate from higher lesion (eg C6)

28
Q

Management of carpal tunnel syndrome (in order)

A
  1. Rest and altered activities
  2. Wrist splints, can be worn at night
  3. Steroid injections
  4. Surgery decompression
29
Q

Explain how a Carpal tunnel decompression is done

A
  1. Day case under local anaesthetic
  2. Can be open (vertical incision at wrist) or endoscopic surgery.
  3. Flexor retinaculum is cut to release pressure on the median nerve
30
Q

What questionnaire can be used to predict liklihood of CTS?

A

The Kamath and Stothard carpal tunnel questionnaire (CTQ)

31
Q

What is ‘Fight bite’

How does it commonly occur?

A

Extensor tendon rupture

  • Usually due to a punch injury
  • Orthopaedic emergency
  • The tooth penetrates skin at the MCPJ
32
Q

Management of ‘Fite Bite’?

A
  1. Open surgical washout of MCPJ, to prevent septic arthritis
  2. Primary tendon repair and splintage
  3. 5 days course of augmentin
33
Q

Mechanism of a Flexor Tendon Rupture

Which tendon is usually affected?

A

Sudden resisted flexion of finger Eg. gripping a fast moving rugby jersey.

Classically affects FDP on middle finger

34
Q

How does a flexor tendon rupture present?

A
  1. Distal volar tenderness and bruising
  2. Sensation of a mass proximal to the DIPJ
  3. loss of normal finger cascade
  4. Can flex PIPJ when all other fingers immobilised (FDS) but cannot flex DIPJ when PIPJ immobilised
  5. Inability to make fist/flex finger
35
Q

Management of a Flexor Tendon Rupture?

A

Surgical (open repair with suture), followed by prolonged hand therapy and dynamic splinting

36
Q

What is Rheumatoid drop finger?

A

Extensor tendon attrition rupture (at level of the ulnar styloid)

Seen in severe RA patients, as the tendon is degenerate due to synovial damage

37
Q

How does Rheumatoid drop finger present?

A
  1. Sudden inability to extend one, or more, fingers
  2. Starts with little finger, then ring, then middle etc…
  3. Clinically cannot extend the digit on demand
38
Q

Management of Rheumatoid drop finger?

A

Surgery

39
Q

Describe the central slip anatomy of the extensor mechanism

A

Extensor tendon at level of the PIPJ divides into 3 ➞ 2 lateral bands, 1 central slip

The central slip extends the PIPJ and the lateral bands bypass to extend the DIPJ

40
Q

Mechanism of a central slip rupture?

How does it present?

A

Sudden stubbing injury of finger causes rupture of central tendon at PIPJ

Presents as:

  • Pain over the dorsum of PIPJ
  • Swelling and tenderness
  • Can actively extend DIPJ, but struggles to extend PIPJ in isolation
41
Q

If a central slip rupture is missed what is the patient at risk of developing?

Describe this deformity

A

‘Boutonniere’ deformity

Fexed PIPJ and hyperextended DIPJ

42
Q

How do we treat a Boutonniere deformity?

A
  1. Splinting in extension
  2. Surgical repair
43
Q

What is Mallet finger?

What is the characteristic finding?

A

Avulsion of the extensor tendon insertion into the base of the distal phalanx

Characteristic extensor lag of DIPJ

44
Q

What are the 2 types of Mallet finger?

A

Bony or non-bony mallet

  • Bony mallet = flake fracture attached to tendon end
  • Non bony mallet = simple tendon avulsion from distal phalanx, no fracture
45
Q

How do we treat Mallet finger?

List a common long term effect?

A

Immobilisation in a mallet splint for 8 weeks

Long term stiff DIPJ

46
Q

What is Dupuytren’s Contracture?

A

Contracture of the palmer fascia resulting in a fixed flexion deformity of one or more digits

47
Q

List 4 risk factors for Dupuytren’s

A
  1. Age
  2. Family history (autosomal dominant pattern)
  3. Male
  4. Manual labour, particularly with vibrating tools
  5. Diabetes (more with type 1, but also type 2)
  6. Epilepsy
  7. Smoking and alcohol
48
Q

Pathophysiology of Dupuytren’s?

A

Caused by proliferation of myofibroblasts in the palmar fascia.

Results in a progressive deformity with time

49
Q

Medication and condition associated with Dupuytren’s?

A

Epileptic medication and alcoholism

50
Q

Which finger is most often affected in Dupuytren’s?

A

The ring finger

51
Q

How does Dupuytren’s present?

A

Painful palmar nodules and/or knuckle pads over dorsum of MCPJs

Ectopic presentation ie. on feet (aka Ledderhose disease) - this is rare

52
Q

What test can help identify Dupuytren’s?

A

The table-top test

Patient tries to position their hands flat on a table, positive if they cannot

53
Q

When should surgery be considered for Dupuytren’s contracture?

A

When the MCP joints cannot be straightened and thus the hand cannot be placed flat on the table

54
Q

Surgical treatments for Dupuytren’s Contracture?

A
  1. Needle fasciotomy
  2. Limited fasciectomy
  3. Dermofasciectomy
55
Q

What is Skier’s thumb? (Gamekeeper’s thumb)

A

Thumb Ulnar collateral ligament rupture due to forced abduction injury of thumb MCPJ

Most commonly seen after fall when skiing with pole still in hand

55
Q

Treatment for Skier’s thumb? (stable/unstable/fracture).

A

Clinically stable on forced abduction ➞ Thumb splint

Clinically unstable ➞ USS to look for Stener lesion. If present then Surgical repair

If fractured, displaced and unstable ➞ ORIF

56
Q

What is a Stener lesion?

A

When the UCL tears, folds back on itself and gets stuck behind the abductor pollicies brevis tendon

60% of UCL ruptures

MSK block (30 decks)

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