Hand & Wrist Flashcards
Components of the ULC of the Thumb
- Proper Collateral Ligaments - resists valgus with thumb in flexion
- Acessory Collaeral Ligaments - resists valgus with thumb in extension
- Volar Plate - resists valgus with thumb in extension
Indications for Scaphoid Fixation
- Proximal Pole Fractures
- Displacement >1mm
- 15 degrees Humpback Deformity
- Radiolunate Angle > 15 degrees (DISI)
- Interscaphoid Angle >35 degrees
- Associated Perilunate
- Comminuted #
- Unstable vertical or oblique #
Eponymous Name for Idiopathic AVN of the Scaphoid
Presier’s Disease
What is a Stener’s Lesion
Avulsion of the Ulnar Collateral Ligament of the Thumb gets trapped proximally to Adductor Pollicis Tendon
- Prevents healing- surgical indication
- Seen in “Gamekeeper’s Thumb”
Describe Finklestein’s Test
Pain over the first dorsal compartment, with thumb clenched in palm and ulnar deviation of the carpus.
- Sign of DeQuairvain’s Tenosynovitis
- Inflammation/Tendonitis of the 1st Dorsal Compartment
What is the Location of the Two Tendons in the 1st Dorsal Compartment in Relation to Each Other
- Abductor Pollcis Longus - more radial
- Extensor Pollicis Brevis - more dorsal
Eaton’s Classification
Classification of 1st CMC Joint OA
- Normal apperence
- Joint space narrowing, osteophytes <2mm
- Joint space narrowing, osteophytes >2mm
- Pantrapezial arthritis
When is the Distal Radius Shortest Compared to the Ulna?
Shortest in pronation.
- Think: supination is the anatomic position, so the radius has to travel around the ulna to get to pronation.
- Positive ulnar varience is often seen in pronation films.
Position of Greyson’s and Cleland’s Ligaments in Relation to NV Bundle in Fingers
- Grayson’s (Grip)- volar to the NV bundle
- Cleland’s (Ceiling)- dorsal to NV bundle
Where does the Superficial Radial Nerve emerge at the wrist?
Emerges from beneath the brachioradialis ~7-9cm proximal to the radial styloid (Whartenberg’s Point).
Quadregia Effect
- FDP Tendons of 3rd, 4th and 5th digit have a common muscle belly. The excursion of all of them will be equal to the shortest excusion.
- If a tendon is repaired short (>1cm short), will affect the posturing of the other fingers
Boundaries of the Thenar Space
- Radial - thenar eminence
- Ulnar - midpalmar septum
- Dorsal - Adductor Pollicis
- Volar- Flexor Tendons
Lumbricals Plus Finger Sign & Causes (4)
FDP tendon rupture distal to lunbrical origin causes pull through lumbricals and paradoxical PIP extension with finger flexion when making a fist
- Causes
- FDP transection distal to the origin of the lumbrical
- FDP avulsion
- Tendon graft too long
- DIP amputation
Vicker’s Ligament
Aka. Short Radiolunate Ligament
- Implicated in Madelung’s Deformity:
- Disruption of hte volar ulnar physis resuling int increased raidal inclination and radiopalmar tilt.
- Associated with Leri-Weil Dyschonostosis:
- Genetic disorder of SHOX gene
- Dwarfism and Madelung’s Deformity
Anatomic varients of the “Million Dollar Nerve”
- Recurrent branch of the medial nerve
- Varients (in relation to flexor retinaculum):
- Extraligamentous (most common)
- Subligamentous (next)
- Intraligamentous (most rare)
What is the most common place for the palmar cutaneous branch of the median nerve to emerge at the wrist?
Ulnar to FCR tendon
- Travels outside of the carpal tunnel
- Watch out for it when doing a carpal tunnel release
Muscles of the Hypothenar Eminence
- Abductor Digiti Minimi
- Flexor Digiti Minimi
- Opponens Digiti Minimi
* all innervated by ulnar n.
Muscles of the Thenar Eminence
- Flexor Pollicis Brevis
- Deep head innervated by ulnar n.
- Superficial head innervated by recurrent branch median n.
- Abductor Pollicis Brevis - recurrent branch median n.
- Opponens Pollicis - recurrent branch median n.
Which bone does not contribute to carpal motion?
Pisiform- it is a sesamoid bone of the FCU tendon
Articulations of the Scaphoid
- Radius
- Lunate
- Capitate
- Trapezium
- Trapezoid
Palmar (9) & Dorsal (5) Intrinsic Carpal Ligaments
Palmar
- Scapholunate (SL)
- Lunotriquetral (LT)
- Trequetrohamate
- Trequetrocapitate
- Capitohamate
- Capitotrapezoidal
- Trapeziotrapezoidal
- Scaphotrapeziotrapezoidal (STT)
- Scaphocapitate
Dorsal:
- Scapholunate (SL)
- Lunotriquetral (LT)
- Trapeziotrapezoidal (TT)
- Capitotrapezoid
- Capitohamate
Movement of the proximal carpal row with radial and ulnar deviation.
- Radial Deviation - proximal capal row flexes
- Ulnar Deviation - PCR extends
What is the main function of the midcarpal joint?
Radial and ulnar deviation.
Describes all planes of midcarpal motion.
- Flexion: normal =65 degrees
- 60% is midcarpal
- Can accept 10 degrees functional ROM
- Extension: normal = 55 degrees
- 33% is midcarpal
- Can accept 35 degrees functional ROM
- Radial Deviation: normal = 15 degrees
- 90% is midcarpal
- Can accept 10 degrees functional ROM
- Ulnar Deviation: normal = 35 degrees
- 50% is midcarpal
- Can accept 15 degrees functional ROM
What is the most distal muscle innervated by:
Radial N?
PIN?
Median N?
AIN?
Ulnar N?
- Radial N: ECRL
- PIN: EI
- Median N: 2nd lumbrical
- AIN: PQ
- Ulnar: Adductor pollicis (1st doral interosseus is the most distal, testable muscle innervated)
Vaughn-Jackson’s Sequence
- Rupture of the digital hand extensors from ulnar to radial.
- Pathoanatomy:
- DRUJ instability leads to dosal proninence of the ulnar head which causes attritional ruptures of extensor tendons
- EDM first then proceeds radially.
- Treatments:
- ED4 to EDM, or EIP to EDM
- The more tendons that are ruptured the more transfers that need to be done
- ED4 to EDM, or EIP to EDM
Mannerfelt Lieson. What is it? What are 2 ways to treat it?
FPL Tendon Rupture. Either traumatic or attritional
- Causes:
- Distal pole of scaphoid and trapezium peice through volar wrist capsule causing traumatic rupture
- Attritional rupture of FDP to index due to synovitis in carpal tunnel. Seen in rhematoid hand, causes swelling and pressure.
- Ruptures from radial to ulnar (opposite of Vaughn-Jackson Sequence).
- FLP, FDP index, FDS index, FDP middle
- Treatment:
- FDS from ring transfer - if joint mobile and supple
- Thumb IP fusion
- FPL advancement through FCR or PL
Orientation of Digital A. vs Digital N. in the hand.
- Proximal to the MCP:
- Digital A. Volar, Digital N. Palmar
- Distal to MCP
- Digital N. Volar, Digital A. Palmar
*Digital N is the most volar structure in the hand distal to the MCP
Keinbocks
- Idiopathic AVN of the Lunate
- 7-20% of people have only one major artry supplying lunate
Stages (Litchman Classification):
- I - no changes on xray, only MRI findings
- II - sclerosis of the lunate
- IIIa - lunate collapse, no scaphoid rotation
- IIIb - lunate collapse with fixed scaphoid rotation
- IV - Degenerative ajacent perilunate joints
Blood Supply to the Lunate
- Dorsal Plexus
- Branches of:
- Radial A.
- Anterior Interosseus A.
- Branches of:
- Volar Plexus
- Branches of :
- Radial A.
- Ulnar A.
- Anterior Interosseus A.
- Recurrent vessels of deep palmar arch
- Branches of :
Rich blood supply, which is why you don’t often see AVN of the lunate following perilunate dislocations.
- 7-20% of patients only have one major vessle supplying the lunate, predisposing them to Keinbock’s or posttraumatic AVN