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Huang's Orthopaedic Surgery > Hand & Wrist > Flashcards

Hand & Wrist Flashcards

1
Q

What is a radiocarpal dislocation? How does it differ from perilunate dislocations?

A

Dislocation of the radius from the carpal bones. Differs from perilunate dislocation because the carpal bones are still aligned

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2
Q

Which direction do radiocarpal dislocations commonly occur?

A

Dorsal > volar dislocation (of the carpus on the radius)

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3
Q

What is the primary soft-tissue restraint against volar translation of the carpus?

A

Short radiolunate ligaments

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4
Q

What are the origin and insertions of the short radiolunate ligaments?

A

O: Radius on the ulnar, volar margin of the lunate facet
I: volar surface of the lunate

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5
Q

What is the main restraint of ulnar translation of the carpus?

A

Radioscaphocapitate ligament

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6
Q

What is the classification system of radiocarpal dislocation?

A

Dumontier:
Group 1: radiocarpal fracture-dislocation that is purely ligamentous or involves only a small cortical avulsino fracture off the radius
Group 2: radiocarpal fracture-dislocation associated with a large radiostyloid fracture fragment (involving at least 1/3 of the scaphoid fossa)

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7
Q

Are group 1 or group 2 radiocarpal dislocations harder to treat? Why?

A

Group 1 are harder to treat

  • These represent global ligamentous disruptions resulting in multidirectional instability
  • Unlike group 2’s, they DO NOT have any bony fragments attached to ligaments that will be more easily fixed with surgery
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8
Q

What are the commonly avulsed fracture fragments in radiocarpal dislocation?

A
  • Radial styloid avulsion by the radioscaphocapitate ligament
  • Volar lunate facet by the short radiolunate ligament
  • Ulnar styloid
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9
Q

What are the 3 main groups of wrist ligaments?

A

Palmar radiocarpal ligaments
Ulnar carpal ligaments
Dorsal ligaments

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10
Q

What comprises the palmar radiocarpal ligaments?

A

Radioscaphocapitate ligament
Long radiolunate ligament
Short radiolunate ligament
Radioscapholunate ligament

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11
Q

What comprises the dorsal ligaments of the wrist?

A

Dorsal radiocarpal ligament

Dorsal intercarpal ligament

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12
Q

What comprises the ulnar carpal ligaments of the wrist?

A

Ulnolunate ligamnet
Ulnotriquetral ligament
Ulnocapitate ligament

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13
Q

Describe dorsal versus volar perilunate dislocations:

A

Dorsal: dorsal dislocation of the capitate with respect to the lunate while the lunate stays in good position
Volar: This is the final stage of injury. The capitate has reduced and the lunate is dislocated volarly

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14
Q

What is the classification of perilunate dislocations?

A 
Mayfield Classification
Stage 1: Scapholunate dissociation
Stage 2: + Lunocapitate dissociation
Stage 3: + Lunotriquetral dissociation
Stage 4: Lunate dislocation
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15
Q

What are the common directions of perilunate dislocations?

A

Volar > dorsal

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16
Q

What is the pathomechanical force of perilunate dislocation?

A

Wrist extension, ulnar deviation and intercarpal supination

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17
Q

Which way does a perilunate injury propogate?

A

Ulnarly, with the initial injury coming at the scapholunate interval
- Scapholunate interval -> Space of Poirier/capitolunate articularion -> lunotriquetral articularion -> failure of dorsal radiocarpal ligament

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18
Q

In the final stage of lunate dislocation, where does the lunate dislocate into?

A

Carpal tunnel

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19
Q

What are greater and lesser arc perilunate injuries?

A

Greater arc: Injuries that involve bone

Lesser arc: Injuries that are purely ligamentous

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20
Q

What is a translunate arc injury?

A

Rare injury involving a perilunate dislocation with a fracture of the lunate itself

21
Q

What are the arcs of Gilula?

A

Refers to the curves produced by the anatomic alignment of the carpal row bones

22
Q

Are the volar or dorsal radiocarpal ligament stronger?

A

Volar

This is why most radiocarpal dislocations occur dorsally

23
Q

What does VISI stand for?

A

Volar intercalated segmental instability

24
Q

What is the pathomechanism of VISI?

A

Disruption of the triquetrum, due to distuption in lunotriquetral ligament complex
Leads to hyperflexion of the radio-luno-capitate alignment, where the lunate and capitate have excessive flexion

25
Q

What does DISI stand for?

A

Dorsal intercalated segment instability

26
Q

What is the pathomechanism for DISI?

A

Disruption of scaphoid leading to excessive dorsiflexion of the luno-triquetral complex.
Either: scaphoid fracture or disruption of scapholunate ligament

27
Q

How do you define a DISI injury (dorsal intercalated segmental instability)?

A

Scapholunate angle >70 deg

28
Q

What is the second most fractured carpal bone?

A

Triquetrum

29
Q

Name the indication for surgery in a scaphoid fracture?

A 
Displacement > 1mm
Radiolunate angle >15 deg
Scapholunate angle >60 deg
Humpback deformity
Nonunion
30
Q

What is the 0 degree capitolunate angle?

A

Straight line drawn 3rd MC shaft, capitate, lunate and radial shaft with the wrist in neutral should be a straight line (0 deg)

31
Q

What is the normal scapholunate angle?

A

45 deg

range 30-70deg

32
Q

What are the ligaments of the wrist?

A

Extrinsic: Bridge the carpal bones from forearm to metacarpal
Intrinsic: Originate and insert in the carpal row

33
Q

What wrist ligaments are stronger, volar or dorsal?

A

Volar

34
Q

What are the most important intrinsic ligaments of the wrist?

A

Scapholunate interosseous ligament
Lunotriquetral interosseous ligament
-Think perilunate injury - these are the first few to be damaged

35
Q

What makes up the volar wrist capsule?

A

Extrinsic wrist ligament

  • That’s why it’s a bad idea to go volar to see the capsule - b/c it destabilizes these ligaments
  • So if you need to see the joint, go dorsal
36
Q

What are the boundaries of the flexor zones of the hand?

A

I: Distal to the FDS
II: Distal to the palmar crease to the FDP
III: Palm
IV: Carpal tunnel
V: Proximal to the carpal tunnel (wrist to forearm)

37
Q

What is No Man’s Land?

A

Flexor zone II

- Historically had poor outcomes, but now better b/c of better movement rehabilitation protocols

38
Q

What are the boundaries of the flexor zones of the thumb?

A

TI:
TII:
TIII:

39
Q

What are the most important pulleys in the fingers/thumb?

A

A2, A4 in fingers

Oblique in thumb

40
Q

What is the most important technical factor in repair of tendons?

A

of stands crossing gap more important than # of grasping loops

  • 4-6 strands crossing gap is adequate for early ROM
  • Epitendinous sutures add 20% strength and also improve gliding
  • Ideal suture purchase is 10mm from tendon edge
  • Core sutures placed dorsally are stronger
41
Q

Name 3 early movement protocols for the hand:

A

Duran:
- Low force, low excursion
- Active finger etension w/ patient assisted passive flexion
Klienert:
- Low force, low excursion
- Active finger extension, dynamic splinting-assisted passive flexion
Mayo synergistic splint:
- Low force, high tendon excursion
- Adds active wrist motion, which increases tendon excursion the most

42
Q

What are the 8 tendon transfer principles?

A
  1. Preoperative correction of contractures
  2. Adequate strength of transferred muscles
    • The transferred muscle will lose one grade of strength
    • Avoid transferring previously denervated muscles
  3. Match donor excursion—may increase amplitude of excursion by increasing the number of joints a transferred tendon crosses or with more dissection of muscle
  4. Straight line of pull
  5. One tendon, one function
  6. Use synergistic muscle groups
    • Like finger flexion and wrist extension
  7. Use expendable donors
  8. Avoid post-operative adhesion formation
    • Delay transfers until wounds are well healed and scars are soft
    • Use natural tissue planes and avoid
43
Q

What are the accepted excursion distances of the wrist flexors and extensors, finger and thumb extensors (EPL) & finger flexors?

A

Wrist flexors & extensors: 33mm
Finger and thumb extensors: 50mm
Finger flexors: 70mm

44
Q

What is the rerupture rate of flexor tendon repair?

A

15-25%

45
Q

What is the management of a re-ruptured flexor tendon?

A

If 1cm of scar, tendon graft

  • If sheath intact & allows passage of a pediatric urethral catheter/vascular dilator: primary tendon grafting
  • If sheath is collapsed, place Hunter rod and perform staged grafting
46
Q

X-rays:
Normal Scapholunate Angle
Normal SL interval
Normal Lunate alignment

A

Normal SL Angle =

47
Q

SLAC wrist classification

A

Watson classification
Stage I: arthritis between radial styloid and scaphoid
Stage II: arthritis extending into scaphoid facet
Stage III: Above + lunocapitate joint involved

48
Q

Scapholunate Disruption Classficiation

A

Geissler classification: based on arthroscopic evaluation
I: attenuation,
II
III
IV: Drive through sign with a 2.7mm scope

Huang's Orthopaedic Surgery (15 decks)

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