Hand & Wrist Flashcards

Question

4 important complications of Dupuytrens surgery?

Answer 1

1. Hematoma - can cause flap necrosis 2. NV injury 3. Flare reaction (like CRPS) 4. Recurrence - up to 50%

Answer 2

Proper: Thumb in flexion (resists valgus in MCP flexion) Accessory: thumb in neutral (resists valgus in extension, along with volar plate)

Answer 3

Dorsal (strongest) Volar Proximal

Answer 4

Adam's technique Radioulnar ligament reconstruction with allograft through bone tunnels in radius & ulna

Answer 5

CMC arthritis with MCP subluxation & adduction/webspace contracture _Treat with:_ LRTI & MCP Fusion MCP fusion indicated when MCP hyperextension \> 40 degrees

Answer 6

Clean wound bed well vascularized Not a war wound (ie crush or blast)

Answer 7

Mechanism of injury: most important Male sex smoker

Answer 8

Dorsally (that's why you get DISI - dorsal is intact)

Answer 9

Cross-sectional area of the muscle belly

Answer 10

Laceration of FDP Congenital absence of FDS 20% of population has absent FDS in small finger If you cut your finger 1 mm proximal to the distal flexion crease and are unable to demonstrate DIP motion, you’ve cut the FDP. However, if you are also unable to demonstrate flexion of PIP with the other fingers held in extension, then you probably have a congenital absence of FDS

Answer 11

Eaton classification Nonoperative: always first option _Operative_ I: volar beak ligament reconstruction II - IV: LRTI

Answer 12

Faster time to healing Faster return to sports and work

Answer 13

FCU: ulnar ulnar 2 FDP: ulnar

Answer 14

Think of it as intrinsic weakness Can also be caused by EDC adherence to MC Effects * MCP extension * IP flexion * PIP flexion causes MCP extension (b/c extrinsic extensors are tight) * MCP flexion causes IP extension (b/c extrinsic extensors are tight) * Unable to perform prehensile grasp * diminished grip and pinch strength Yes, you can still passively flex MCP - no block but the above will occur

Answer 15

1. less than 30 degrees angulation 2. stable joint (CMC)

Answer 16

Soft tissues must have reached equilibrium Joints must be supple Functional recovery must be unlikely

Answer 17

Paradoxical extension of the IP joint while attempting to flex fingers Due to disruption of FDP distal to the origin of the lumbricals

Answer 18

Steindler flexorplasty image transfer common flexor mass proximally on the humerus for a MSK nerve palsy.

Answer 19

Intrinsic minus hand (claw hand) \*\* This is because splinting in MCP extension causes increased tension of the extrinsic finger flexors

Answer 20

**Type 1** * is similar to nonrheumatoid stenosing tenosynovitis, in which the tendons catch at the first annular pulley during flexion secondary to small, localized hyperproliferation of the synovium. **Type 2** * the nodules form in the distal palm and cause the finger to lock in flexion. In **Type 3** * nodules on the flexor digitorum profundus (FDP) tendon near the second annular pulley (over the proximal phalanx) lock the finger in extension. **Type 4** * trigger finger results from generalized tenosynovitis within the fibroosseous canal. Active motion is more restricted than passive motion, and contracture and stiffness result.

Answer 21

Nonoperative: ineffective SL Repair (suture anchor vs. joint pinning) Reconstruction (direct FCR vs. indirect ECRB) Fusion (STT, SLC)

Answer 22

Preiser's disease Scaphoid AVN

Answer 23

Through nail plate No increase in nail defomrities

Answer 24

Less than 94%

Answer 25

Arthroscopy _Geissler classification_ Grade I: * Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space * No incongruity of carpal alignment in midcarpal space Grade II: * Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space * May be a slight gap (less than width of probe) between carpla bones in midcarpal space Grade III: * Incontruity or step-off of carpal alignment as seen from both radiocarpal and midcarpal space * Probe may be passed through gap between carpal bones Grade IV: * Incongruity or step-off of carpal alignment as seen from both radiocarpal and midcarpal space * There is gross instability with manipulation * A 2.7mm arthroscope may be passed through the gap between carpal bones * Drive through sign

Answer 26

LT shuck test Kleinman's shear test LT compression test

Answer 27

Martin-Gruber anastomosis AIN to Ulnar anastomosis. AIN palsy results in loss of some intrinsic hand muscles

Answer 28

EIP --\> EPL

Answer 29

_Repair:_ direct repair _Reconstruction:_ FCR tendon: Brunelli technique ECRB tendon via bony tunne in scaphoid _Fusion:_ STT fusion SLC (scaphoid, lunate, capitate) fusion

Answer 30

Deep arch (radial artery): supplies all fingers (is complete) in 97% of patients vs. Superficial arch (ulnar artery) supplies all fingers (is complete) in 80% of patients Is major supply for digits on ulnar side of hand

Answer 31

Pillar pain Pain adjacent to the TCL release site, where subcutaneous pain of the carpal bones 2nd most common is laceration of the palmar cutaneous branch of the median nerve

Answer 32

Superficial: ulnar It is distal Deep: radial it is proximal

Answer 33

Pronator syndrome or AIN syndrome (2 entities with the same compression sites) _5 sites of compression:_ * Accessory muscle of Gantzer (accessory head of FPL) * **S**upracondylar process * **L**igament of struthers * **L**acertus fibrosis (bicipital aponeurosis) * between 2 heads of **P**T * FD**S** aponeurotic arch "**S**exy **L**adies **L**ove **P**oontang **S**auce"

Answer 34

Make a thumb 80% of contralateral Preserve medial collateral structures to preserve pinch 1 stage

Answer 35

Temporary scaphotrapezial pinning

Answer 36

within 5 days

Answer 37

Volar dislocation Central slip and at least 1 collateral are often ruptured Full time extension splinting x6 weeks for extensor mechanism to heal

Answer 38

1. abductor pollicis longus (PIN) 2. extensor pollicis longus (PIN) 3. adductor pollicis (Ulnar n.)

Answer 39

1. Mesomelic dwarfism 2. Madelungs deformity

Answer 40

Correction of fingers extension only (wrist extension not required) FCR --\> EDC PL --\> EPL

Answer 41

Normal: If \> 35 deg, represents humpback deformity LISA = lateral intrascaphoid angle

Answer 42

central slip + 1 collateral ligament Lateral band is block to reduction

Answer 43

Active flexion lag in fingers adjacent to a digit with a previously injured or repaired FDP Caused by functional shortening of FDP

Answer 44

EIP --\> EPL APL --\> EPL Primary repair Free tendon graft (PL) IP joint arthrodesis

Answer 45

Numbness and tingling in the median nerve distribution Nocturnal numbness Weakness and/or atrophy of the thenar musculature Positive tinel's sign Positive phalen's test Loss of 2 point discrimination

Answer 46

Flexion adduction contracture due to deficient EPL/EPB Congenital Risks: consanguinity

Answer 47

Lumbricals (radial 2) Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis

Answer 48

1. use zig-zag incisions to avoid longitudinal scarring 2. release length mismatched digits first to avoid growth disturbances 3. if both sides of a digit involved release in stages to avoid de-vascularizing the digit

Answer 49

Normal: 30-70 deg Abnormal = VISI/DISI DISI: SL angle \> 60 degrees VISI: SL \<30 deg (they are in line b/c lunate points down in line with scaphoid

Answer 50

Complex dorsal MCP dislocation Volar plate interposed between base of proximal phalanx and MC head Most common in index finger Rare

Answer 51

Sensitive: Durkan: most sensitive clinical test Semmes-Weinstein: most sensitive *sensory* test Specific: Self-administered hand diagram Of Note: EMG is helpful as per JAAOS 2 point discrimination (moving & static) are good for looking at return of function post-op

Answer 52

Arterial thrombus

Answer 53

False. The deep peroneal nerve, ulnar nerve, and brachial plexus lesions had the worst recovery.

Answer 54

Superficially and towards the midline

Answer 55

Thickened FPL tendon aka: Notta's nodule (vs. trigger finger: thickened tendon sheath)

Answer 56

1. CBC 2. Peripheral blood smear 3. Chromosomal breakage analysis * (Top three are to r/o **FA** which is **life threatening**) 4. Renal U/S 5. Echo

Answer 57

Intersection syndrome (2nd compartment) has pain proximal to the wrist joint De Quervain's has pain distal in 1st dorsal compartment

Answer 58

Number of core strands crossing repair site: * Linear relationship with 4-6 core strands adequate for early mobilization Locking loops (Krakow) \> grasping (Kessler) High calibre suture Core suture placed dorsally Ideal suture purchase is 7-10mm (1cm) from cut edge No gapping between sides Meticulous atraumatic tendon handling minimizes adhesions Circumferential simple epitendinous suture adds 20% of strength * Improves tendon gliding * Improves strength * Allows less gap formation * Simple running suture recommended

Answer 59

Flexion contracture at recipient PIP joint (THINK: it has to stay bent while stuck on the thenar eminence during healing)

Answer 60

FDP: median & ulnar

Answer 61

Pinch: 6 weeks Grip: 12 weeks (3 months)

Answer 62

Syndactyly is fusion of digits due to failure of apoptosis Acrosyndactyly is where distally the digits are fused but they are open proximally * This represents normal apoptosis but something affecting it after (ie constriction band syndrome)

Answer 63

CT: once sclerosis is visible on x-rays, CT scan is the most sensitive to detect fragmentation MRI is only sensitive if there are no early changes (ie stage 1).

Answer 64

Lacertus fibrosis 2 heads of PT FDS Accessory muscle of Gantzer (FPL) Accessory muscles from FDS --\> FDP Abberent muscles: FCRB, palmaris profundus thrombosed ulnar artery

Answer 65

Ulnar It is distal

Answer 66

Goes from worst to best Type I: retraction to palm. Disrupted blood supply. Urgent repair Type II: retracted to PIP. Blood supply intact Type III: Bony avulsion Type IV: double disruption (bony avulsion and tendon avulsion from bony fragment)

Answer 67

Primary: sagittal bands Secondary: juncturae tendinae

Answer 68

2, 3, 4th: ulnar 1st, 5th, radial These are the non-pressure bearing sides of the digit (ie when making pinch - except for 5th, which i don't get, but that's what it says)

Answer 69

**_Clelands and Graysons Ligaments_** 1. tether skin to deeper layers of fascia and bone to prevent excessive mobility of skin and improve grip 2. stabilize the digital neurovascular bundle with finger flexion and extension

Answer 70

Scapholunate less than 30 Radiolunate \> 15 volar capitolunate \> 15 degree

Answer 71

Volar beak ligament keeps he volar-ulnar base fragment reduced to trapezium

Answer 72

Cubital tunnel has: * less clawing * sensory deficit to dorsum of hand * motor deficit to ulnar innervated extrinsic muscles also * Tinel's sign above elbow * positive elbow flexion test

Answer 73

No systemic/medical associations _Orthopaedic:_ * absent ulnar digits * PFFD * fibular hemimeila * scoliosis * Phocomelia

Answer 74

Nail matrix/bed Nail removal, open reduction, nail replacement

Answer 75

Open surgery best Then collaginase Then needle aponeurotomy

Answer 76

DRUJ injury/arhtriits TFCC tear LT tear Pisotriquetral arthritis ECU tendonitis or instability

Answer 77

staph and Strep most common Eikenalla corrodens is the other (gram -)

Answer 78

Boutonniere deformity b/c of concurrent Central slip rupture

Answer 79

PIN syndrome: supinator is usually spared (according to OB RTS is pain only whereas PIN syndrome is weakness as well)

Answer 80

1. DRUJ fusion with creation of pseudoarthrosis proximally in the ulna 2. Younge Labourers with ulnar abuttment syndrome

Answer 81

PT --\> ECRB PL --\> EPL (or FDS 4 --\> EPL) FCR --\> EDC

Answer 82

Nonoperative with extension splinting 6-8 weeks CRPP vs. ORIF Arthrodesis Surgical reconstruction of terminal tendon

Answer 83

Local anesthetic injection

Answer 84

Healing by secondary intention Better outcomes vs. surgical in terms of 2 point discrimination (JAAOS 2013)

Answer 85

Swan-Neck b/c of concurrent volar plate injury

Answer 86

Volarly (that's why you get a VISI with LT disruption - intact volarly)

Answer 87

Complete rupture of ulnar collateral ligament (both proper and accessory parts) and displacement above adductor aponeurosis Requires surgery

Answer 88

_Syndactyly release and digital rotational osteotomy_ * Done at 12-18 months of age _Radial head resection and creation of 1 bone forearm_ * Done in Stage II to provide stability at the expense of forearm motion * There is no good option for restoring elbow motion * Corrective procedures should not be performed until the child is at least 6 months old _Osteotomy of the synosteosis_ * May be required in stage 4 to obtain elbow ROM

Answer 89

AIN: motor only Median nerve palsy & pronator syndrome (which is median nerve compression specifically at SLLPS) witll both have motor and sensory symptoms

Answer 90

**_Early Disease: cure_** _I:_ * nonoperative _I, II, IIIa:_ * temporary scaphotrapezial pinning * joint leveling (ulnar lengthening, radial shortening) * vascularized bone grafts * distal radius core decompression _II, IIIA, IIIB:_ * STT fusion **_Late Disease: salvage_** _IIIB, IV:_ * PRC _IV:_ * wrist fusion * total wrist arthroplasty

Answer 91

Ulnar shortenining osteotomy (most common) wafer procedure (arthroscopic ) Darrach procedure (ulnar head resection) Sauve-Kapandji procedure Ulnar hemi-resectoin Ulnar head replacement

Answer 92

Mechanism of injury: most important Male sex Smoker

Answer 93

Triangular Ligament

Answer 94

Spiral cord It causes contracture of the PIP

Answer 95

repair of vascular damage up to digital pulp \*smoking has NOT been found to be a factor

Answer 96

Notta's nodule = thickened FPL in trigger thumb Leave it after release A1 pulley Just make sure FPL glides well

Answer 97

80% radius 20% ulna

Answer 98

* scapholunate ligament disrupted --\> * disruption of capitolunate articulation --\> * disruption of lunotriquetral articulation --\> * failure of dorsal radiocarpal ligament --\> * lunate rotates and dislocates, usually into carpal tunnel \*volar radiocarpal ligaments usually remain intact

Answer 99

Paradoxical extension of IP joints while attempting to flex fingers. (FDP is disrupted so when it is activated it still pulls on the lateral bands via the lumbricals, causing MCP flexion with no phalangeal flexion.) * FDP transection * FDP avulsion * DIP amputation * amputation through middle phalanx shaft * "too long" tendon graft

Answer 100

Endoneurium

Answer 101

Syndactyly

Answer 102

Radial nerve

Answer 103

1cm If If \>1cm of scar present: perform tendon graft Is the sheath is intact and allows passage of a pediatric urethral catheter or vascular dilator, perform primary tendon grafting If sheath is collapsed, place Hunter rod and perform staged grafting

Answer 104

Inlay graft (Russe) if undisplaced Interposition (Fisk) graft if humpback present (see picture) Vascularized graft: 1-2 intercopmartmental supraretinacular artery of Zaideberg (branch of radial)

Answer 105

Intrinsic tightness test Positive if PIP flexion less when MCP is in extension vs. flexion b/c intrinsics are tight in extension so will not be able to flex PIP

Answer 106

Sensitive: Durkan or Semmes-Weinstein monofilament Specific Self-administered hand diagram

Answer 107

Congenital radio-ulnar synostosis Usually fixed pronation. Observe unless bilateral and functional deficits.

Answer 108

* Intra-articular fracture * Any malrotation * displaced fracture * failure of non-op (see reduction criteria) * Multiple MC fractures _Acceptable criteria_ * All: 2-5mm shortening * Index: 10 deg angulation * Long: 20 deg angulation * Ring: 30 deg angulation * Small: 40 deg angulation (50 if neck)

Answer 109

natatory ligament Resists hyper-abduction

Answer 110

Carpal instability non-dissociative. Most commonly caused by distal radius mal-union

Answer 111

Full open approach using long midaxial or brunner incision Two small incisions distally at A5 pulley and proximally at A1 pulley and using an angiocatheter

Answer 112

FDP 1 strand of FDS Improves gliding

Answer 113

Floor: transverse carpal ligament relevant b/c if patient has both Guyon's canal syndrome and carpal tunnel syndrome, you only have to release carpal tunnel releasing the TCL will decompress guyon's canal also

Answer 114

1 Leads to better gliding

Answer 115

You can divide the: A2 pulley: 50% A4 pulley: completely (100%) without increasing the amount of the work the tendon needs to do Advantageous in zone II flexor tendon repairs (JAAOS 2014)

Answer 116

CMC resection arthroplasty/LRTI + MCP fusion Indications for MCP fusion * thumb MCP hyperextension exceeds 40° * the deformity is not passively correctable * advanced degenerative changes are noted to affect the articulation

Answer 117

Prevents hyperextension

Answer 118

Diffusion from synovial sheath This occurs for any tendon within a sheath Otherwise, direct vascular supply

Answer 119

Ganglia (most common in zone 2 & overall) ulnar arterial thrombosis (most common in zone 3 - sensory) Lipoma GCT intraneural cysts Dupuytren's Trauma Abnormal muscles: Abnormal palmaris brevis/longus Abn AbDM Abn FDM RA - pannus, edema, bony defomrity Neuropathies (DM, EtOH, CRF, hypothyroid) Iatrogenic

Answer 120

C1, A3, C2

Answer 121

Nonoperative (1st line) CRPP + ligament repair + dorsal capsulodesis LT Fusion (for chronic) Arthroscopic LT debridement and ulnar shortening

Answer 122

Bayne & Klug I: absent distal radial epiphysis (short distally) II: absent distal and proximal radial epiphysis III: Present proximally (partial aplasia) IV: complete absence (most common)

Answer 123

Trick question. The RL articulation is typically **NOT** invovled.

Answer 124

lies between PL and FCR at level of the wrist flexion crease

Answer 125

Terry thomas sign (clenched fist \>3mm SL interval) Signet ring sign SL angle \> 70 deg Radiolunate angle \>15 deg Intrascaphoid angle \> 35 deg

Answer 126

Pre-axial polydactyly Most common: IV 2nd most common: II Most associated with syndromes: VII

Answer 127

Posterior dislocation Short/Bowed Radius Large/Convex Radial Head (also hypoplastic capitellum)

Answer 128

Primary: dorsal carpal branch of radial artery (80%) Secondary: superficial palmar branch of radial artery

Answer 129

Hypertrophic Pulmonary Osteoarthropathy Associated with: Lung Cancer (Bronchogenic Ca \> NSCLC) COPD Treatment: Treat the underlying pathology (Resp)

Answer 130

stretching for all types x 3-6 months

Answer 131

ECRB: PIN vs: ECRL/BR: radial nerve proper ECRB is shorter so gets innervated by the shorter nerve (PIN)

Answer 132

DRUJ Arthrosis

Answer 133

Radial tunnel syndrome THis has pain down the arm vs. lateral epicondylitis, which has point tenderness to lateral epicondyle

Answer 134

\>2cm: first dorsal metacarpal artery flap

Answer 135

Staged, so to avoid vascular compromise b/c you don't want to dissect on both sides of a digit, where the NV bundle is Treat ones with lonest length differences first to avoid growth disturbance

Answer 136

a) Ulnar nerve compression in Guyons canal (Ulnar Tunnel Syndrome) b) 1. ganglion cyst (80% of nontraumatic causes) 2. lipoma 3. repetitive trauma 4. ulnar artery thrombosis or aneurysm 5. hook of hamate fracture or nonunion 6. pisiform dislocation 7. inflammatory arthritis 8. fibrous band, muscle or bony anomaly 9. congenital bands 10. palmaris brevis hypertrophy 11. idiopathic

Answer 137

No It is preferred but may not lead to better clinical outcomes

Answer 138

* Volar ligament reconstruction * LRTI * CMC arthroscopy and debridement * Extension osteotomy of 1st MC * Trapeziometacarpal arthrodesis and fusion * Volar capsulodesis, EPB tendon transfer, sesamoid fusion or MCP fusion * Silicone replacement (not recommended)

Answer 139

1 bone forearm ECU tenodesis Ulnar head arthroplasty (only if SK) Radioulnar resection Pronator quadratus transfer

Answer 140

ORIF Most are intra-articular Vs. *Hook* of hamate fracture: ORIF does not play a role

Answer 141

radiolunate joint

Answer 142

Volar plate and/or Sesamoids

Answer 143

Pronator teres * involves palmar cutaneous branch of median nerve (palmar paresthesia) * has aching over proximal volar forearm * Lacks night symptoms

Answer 144

Supination with wrist in ulnar deviation Relocates with pronation

Answer 145

60% \>60% of the tendon injured: repair

Answer 146

X-ray: carpal tunnel view _Treatment_ * Acute: immobilization * Chronic: surgical excision (ORIF plays no role)

Answer 147

night symptoms short incision relief with steroid injections Not improved with incomplete release of transverse carpal ligament

Answer 148

Post-axial polydactyly in caucasians is worrisome and suggests need for further genetic workup In blacks, it is normal

Answer 149

RA DM Amyloidosis

Answer 150

Deep volar forearm compartment FPL FDP (radial 2) PQ

Answer 151

Abductor pollicis longus Extensor pollicis longus Adductor pollicis _Causes_ * the shaft to be pulled into adduction * The MC base to be supinated

Answer 152

ORIF Hamate autograft Dynamic distraction ex-fix Volar plate arthroplasty Arthrodesis

Answer 153

Any salvageable tissue should be transported with the patient to the hospital Modality: * Keep amputated tissue wrapped in moist gauze in lactate ringers solution * Place in sealed plastic bag and place in ice water * Avoid direct ice or dry ice * Wrap, cover and compress stump with moistened gauze

Answer 154

FDP FDS FPL Median nerve

Answer 155

Structure by structure is best Digit by digit takes the most time

Answer 156

Extraligamentous with recurrnet innervation

Answer 157

IP: midaxial incision MCP: dorsal midline

Answer 158

painless motor weakness AIN is a pure motor nerve

Answer 159

Lunotriquetrial and Dorsal Radiotriquetrial

Answer 160

**_Lumbrical Plus Finger_** He has lost insertion of FDP. When FDP is activated to flex the finger this results in unopposed Lumbrical action beacuse they oriigante on FDP. This paradoxically extends the finger. Treatemnt is FDP repair versus lumbrical release in the palm.

Answer 161

No improvement in long term outcomes vs. other fingers: early ROM exercises are the gold standard

Answer 162

Cat bites Presentation \>8 hours Immunocompromised (including diabetics) Hand bite Deep bites

Answer 163

Pronator will have: 1. aching pain over proximal volar forearm 2. sensory disturbances over the distribution of palmar cutaneous branch of the median nerve (palm of hand) which arises 4 to 5 cm proximal to carpal tunnel 3. lack of night symptoms

Answer 164

No difference

Answer 165

thumb IP joint flexion in attempted key pinch ulnar nerve palsy

Answer 166

Resist hyper-abduction at MCP

Answer 167

FCR tendon transfer (Brunelli) (direct reconstruction) ECRB Tenodesis (indirect reconstruction) +Blatt capsulodesis (adjunct)

Answer 168

Aeromonas hydrophilia infection from leech therapy Should have been put on gram negative coverage during leech therapy (PO cipro)

Answer 169

Widening of SL interval \> 3mm DISI Loss of colinearity of lunate & capitate & 2nd MC scaphlunate angle \>70 degrees Intrascaphoid angle \>35 degrees (humpback) cortical ring sign Abnormal carpal height ratio: * Carpal height is distance between distal articular surface of capitate to distal radial articular surface * carpal height ratio = carpal height/length of 3rd MC * Normal is 53%

Answer 170

Failed in situ release Throwing athlete patient with poor ulnar nerve bed (from tumour, osteophyte or HO)

Answer 171

Palm: arteries are volar to nerve Digits: * nerve is volar * Entire NV bundle is volar to Cleland's ligament

Answer 172

1. lumbricals 2. extensor indicis 3. dorsal interossei 4. palmar interossei

Answer 173

Apert Syndrome

Answer 174

**_dorsal approach_** * indicated in proximal pole fractures * care must be taken to preserve the blood supply when entering the dorsal ridge by limiting exposure to the proximal half of the scaphoid * percutaneous has higher risk of unrecognized screw penetration of subchondral bone **_volar approach_** * indicated in waist and distal pole fractures and fractures with humpback flexion deformities * allows exposure of the entire scaphoid * uses the interval between the FCR and the radial artery

Answer 175

_Fibrous bands anterior to radiocapetellar joint_ * Between brachialis and brachioradialis _Aka recurrent radial vessels at level of radial neck_ * Leash of Henry _ECRB edge_ _Arcade of Frohse_ * Proximal edge of superficial Supinator _Supinator muscle edge_ * Distal edge

Answer 176

Apert Syndrome Hypertelorism = side set facial features = dysmorphic facies Hand = rosebud hands central 3 fingers share a common nail.

Answer 177

I: mixed II: motor only III: Sensory only Goes from worst to best

Answer 178

10% It will shrink with fibrosis

Answer 179

Tests for Central slip rupture Bend PIP 90° over edge of a table and extend middle phalanx against resistance. **in presence of central slip injury** there will be weak PIP extension the DIP will go rigid **in the absence** of central slip injury DIP remains floppy because the extension force is now placed entirely on maintaining extension of the PIP joint; the lateral bands are not activated

Answer 180

None It is PAIN ONLY

Answer 181

Volar b/c avoids main dorsal supply (dorsal carpal branch of radial artery)

Answer 182

Extensor Zone 5 Must do I&D with exploration of the joint + antibiotics

Answer 183

1) operative = volar plate advancement and central slip tenotomy 2) non-operative = double ring splint (keeps PIP in extension

Answer 184

_Bayne Classification_ 0: deficiencies of the carpus and/or hand only 1: undersized ulna with both growth centers present 2: part of the ulna is missing (Typically distal ulna is absent) 3: absent ulna 4: radiohumeral synostosis _Subtypes based on 1st websace for each type:_ A: normal webspace B: mild deficiency C: Moderate to severe deficiency of webspace D: absent webspace

Answer 185

Should be colinear ± 15 deg ABnormality indicates VISI/DISI

Answer 186

prophylactic antibiotics, systemic or local, are not indicated for patients undergoing a clean, elective carpal tunnel release

Answer 187

Disruption of volar ulnar physis ±Vicker's ligament

Answer 188

Children Stretch injuries Sharp transections that have been repaired within 14 days Clean, well-vascularized wound beds Early, direct surgical repair

Answer 189

Dorsal Even when the MC head is volar Prevents risk of injury to the neurovascular bundle

Answer 190

**_poor prognostic factors for melanoma_** 1. deep lesion 2. male sex 3. lesion on neck or scalp 4. positive lymph nodes and metastases 5. ulceration \*\*Depth is most important (\> 4 mm has

Answer 191

radial usually take off the small, radial one

Answer 192

**_Bunnell test (intrinsic tightness test)_** * differentiates intrinsic tightness and extrinsic tightness * positive test when PIP flexion is less with MCP extension than with MCP flexion

Answer 193

Acute: MRI Chronic (after 3 days): Bone scan (98% specific, 100% sensitive)

Answer 194

Simple: only skin involved Complex: Skin & bone involved (adj. phalanges) Complicated: abnormal bone or soft tissue involve (ie abn phalanges) Complete: extends all the way to tip of finger (vs. incomplete)

Answer 195

Saggital bands

Answer 196

_Absolute:_ * Volar subluxation of distal phalanx _Relative_ * \>50% of joint involved * \>2mm articular gap

Answer 197

Absolute compartment pressure 30-45mmHg Compartment pressure witin 30mmHg of *preoperative* diastolic pressure

Answer 198

Primary lesion: rupture of central slip 1. Rupture of central slip 2. Attenuation of triangular ligaments 3. Palmar migration of collateral bands and lateral bands =all flexion going through

Answer 199

synovial sources \> vascular sources

Answer 200

High index of suspicion Low threshold for surgery Broad spectrum IV antibiotics Leave wounds to heal by secondary intention Early motion Twice daily hand soaks in poviodine or sterile water

Answer 201

Loss of thumb IP flexion (FPL) Loss of index and long DIP flexion (FDP to index & long) Loss of PIP flexion to index, long, ring, little finger (FDS) Thumb opposition (opponens pollicis & APB)

Answer 202

**elevation of the limb (can cause compartment syndrome)** tetanus prophylaxis if needed systemic prophylactic antibiotics analgesia Leave wounds open

Answer 203

same outcomes but higher complications with transposition Mainstay is in-situ

Answer 204

1. is the most sensitive test to diagnose carpal tunnels syndrome 2. performed by pressing thumbs over the carpal tunnel and holding pressure for 30 seconds. 3. onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result.

Answer 205

For flexor pyogenic tenosynovitis 4 signs: * Flexed posture of the involved digit * tenderness to palpation over the tendon sheath * pain with passive extension of the digit * fusiform swelling of the digit Will also have increased warmth and erythema, but these are not technically part of Kanaval's signs

Answer 206

_Absolute_ * Severe vascular disorder * Mangled limb or crush injury * Segmental amputation * Prolonged ischaemia time with large muscle content (\>6 hours) _Relative_: * Single digit proximal to FDS insertion (Zone II) * Medically unstable patient * Disabling psychiatric illness * Tissue contamination * Prolonged ischaemia time with no muscle content (\>12 hours)

Answer 207

Presence of dorsal hand symptoms (numbness) suggest elbow entrapment b/c dorsal ulnar cutaneous branch of ulnar nerve branches proximal to Guyon's canal, therefore Guyon canal entrapment spares dorsal hand

Answer 208

MCP subluxation PIP volar plate attenuation Triangular ligament rupture FDS rupture

Answer 209

Scaphoid AVN Nonoperative Microfracture, revascularization or allograft Scaphoid excision + 4CF or PRC

Answer 210

FDS of ring finger --\> APB tendon (use FCU as pulley) Bunnels Opponensplasty Low Median Nerve Palsy (Other option is EIP to APB)

Answer 211

Full ROM: Tendon repair/transfer Rigid: Fusion

Answer 212

1-2 intercompartmental supraretinacular artery (branch of radial artery)

Answer 213

Low force, low excursion Kleinert or Duran

Answer 214

Finger flexors: 70mm Finger extensors & EPL: 50mm Wrist flexors/extensors: 33mm

Answer 215

open endoscopic Outcomes equivalent

Answer 216

Skin tearing Pruritic rash Lymphadenopathy

Answer 217

_Indication_: Used for coverage of digital tip injuries where there is exposed bone or extensive pulp loss. _Advantages include:_ * More subcutaneous fat than a cross finger flap * Good color and texture match * Primary closure of the donor site _Disadvantages include:_ * Limited flap size (2cm wide and should be 1.5x the width of the defect so it can wrap around it) * Donor site tenderness _Contraindications include_ * RA * Dupuytren’s contracture * advanced age with degenerative disease * These predispose to joint stiffness.

Answer 218

Froment's sign: recruitment of FPL with loss of adductor pollicis Wartenberg sign: little finger abduction due to unopposed pull of EDM (radial) Inability to cross the fingers Ulnar claw hand (if low ulnar nerve palsy) Loss of ulnar sensory distribution

Answer 219

Volar: stable in pronation Dorsal: stable in supination

Answer 220

Between 2 heads of FCU (most common) Arcade of struthers (hiatus in medial intermuscular septum) Cubital tunnel (btw Osborne's ligament (roof) & MCL (floor)) Medial epicondyle Deep flexor/pronator aponeurosis Anconeus epitrochlearis Aponeurosis of FDS proximal edge External sources * Fracture and medial epicondyle nonunions * osteophytes * HO * tumours

Answer 221

Preserved ulnar FDP with loss of hand intrinsics Leads to unopposed flexion of 4th/5th digits

Answer 222

DIP disarticulation and flap (V-Y flap)

Answer 223

Carpal Tunnel View = r/o hook of hamate 30 degree oblique = assess body of hamate

Answer 224

Parsonage-Turner syndrome Viral Brachial plexus neuritis Classic story in question stem

Answer 225

Tsuyuguchi

Answer 226

Anterior oblique (volar beak) ligament This is the "ligament reconstruction" part of the procedure

Answer 227

Volar Dorsal Mobile wad Fasciotomy: Volar: start radial to FCU, curvilinear incision ending at medial epicondyle Mobile wad: over mobile wad, starting 2cm distal to lateral epicondyle, dissecting between EDC & ECRB

Answer 228

Clelands ligament

Answer 229

Clawhand Tight extrinsic extensors Weak intrinsics =MCP hyperextension & DIP/PIP flexion

Answer 230

Wrist extension in radial deviation b/c ECU and ECRB and EDC are gone Only extensor left is ECRL (Radial proper)

Answer 231

_Tendon transfer_ * EIP --\> EPL _Thumb reconstruction with:_ * widening 1st webspace * deepening of 1st webspace * tendon transfer _Arthrodesis_

Answer 232

Elderly Crush/blast injuries Infected wound beds Poorly vacularized wound beds Delayed surgical repair (\>14 days)

Answer 233

Ulnar to median nerve anastomosis

Answer 234

10 compartments of the hand 1x thenar 1x adductor pollicis 1x hypothenar 3x palmar interosseous 4x dorsal interosseous (go dorsal, side with more compartments) Fasciotomy 4 incision technique Dorsal over 2nd & 4th MC to decompress volar/dorsal interossei & adductor Longitudinal midaxial over 1st MC - thenar Longitudinal midaxial over 5th MC - hypothenar

Answer 235

Low palsy. This is because in a low palsy the extrinsic flexors are spared so there is a larger imbalance between extrinsics and intrinsics.

Answer 236

Primary: Sagittal band Secondary: Juncturae tendinum

Answer 237

Volar plate

Answer 238

Closed: volar plate Open: FDP tendon

Answer 239

_Acute_: * extension splinting x 4-6 weeks _Chronic_: * Direct repair * centralization procedure

Answer 240

_0° to 10°_ * Surgical intervention is not necessary when MCP hyperextension is less than 10°. _10° to 20°_ * Percutaneous pinning of the MCP joint in 25° to 35° of flexion for 3-4 weeks may be performed independently or as an adjunct to EPB transfer. _20° to 40°_ * Capsulodesis of the volar aspect of the MCP joint is recommened to provide a check rein for hyperextension and Sesamoidesis has also been investigated as an adjunctive procedure.

Answer 241

FCR most common can use APL or PL

Answer 242

1st: brachioradialis last: extensor indicus proprius (EIP) Last testable muscle: EPL

Answer 243

History of trauma/repetitive trauma Vascular supply pattern (I \> Y \> X) Ulnar negative variance Abnormal lunate geometry

Answer 244

_Proximal to carpus:_ * Warm ischaemia time less than 6 hours * Cold ischaemia time less than 12 hours _Distal to carpus (digit)_ * Warm ischaemia time less than 12 hours * Cold ischaemia time less than 24 hours

Answer 245

Central slip injury prior to development of Boutienniers deformity. * bend PIP 90° over edge of a table and extend middle phalanx against resistance. * in presence of central slip injury there will be * weak PIP extension * the DIP will go rigid

Answer 246

Female obesity pregnancy hypothyroidism RA Diabetes Amyloidosis Age smoking EtOH repetitive motion activities Mucopolysaccharidoses Mucoliposis

Answer 247

In situ release release with transposition medial epicondylectomy

Answer 248

Absence of EPL ± EPB 1st web space contracture Associated with Arthrogyposis Not the same as trigger thumb

Answer 249

Stage 1: scapholunate dissociation Stage 2: +lunocapitate disruption Stage 3: +lunotriquetral disruption = perilunate Stage 4: Lunate dislocated from lunate fossa

Answer 250

SL less than 30 degrees They are colinear b/c the scaphoid is flexed so they are both pointing down

Answer 251

Bone fixation ± shortening Extensor tendon repair Artery repair Repair second after bone if ischaemic time is \>3-4 hours Venous anastomoses Flexor tendon repair Nerve repair Skin ± fasciotomy (beavfns)

Answer 252

Avoid damage to the recurrent branch of median nerve

Answer 253

**_Urbaniak_** _I: circulation adequate_ * treat with standard bone and soft tissue care _II: circulation inadequate_ * treat with vessel repair _III: complete degloving_ * treat with amputation * Note that inadequate circulation with bone, tendon or nerve injury is a type III

Answer 254

Tendinous edge of deep head of PT (most common) FDS arcade Lacertus fibrosis Accessory head of FPL (Gantzer's muscle) Accessory muscle from FDS to FDP Abberant muscles (FCRB, palmaris profundus) Thrombosed ulnar radial or ulnar artery

Answer 255

Fanconi anemia CBC, blood smear, chromosomal analysis

Answer 256

DISI = no, it is always traumatic VISI = yes, can be seen in hyperlax people without injury

Answer 257

Likely radial sagittal band rupture radial \> ulnar

Answer 258

1. cyst excision and osteophyte resection 2. may need to do local rotational flap for skin coverage

Answer 259

Helps recreate opposition FDS opponensplasty: FDS 4 --\> APB EIP opponensplasty: EIP --\> APB abductor digiti minimi (Huber) transfer: ADM --\> APB PL (Camitz) transfer: PL --\> APB

Answer 260

Stage IV: adjacent intercarpal arthritis * Proximal row carpectomy * wrist fusion * total wrist arthroplasty

Answer 261

Central cord: PIP contracture Lateral cord: PIP & DIP contracture Cords are just pathologic bands/ligaments ie lateral bands normall affect PIP and DIP

Answer 262

Neuritis of superficial **sensory** branch of radial nerve between ECRL & BR (memory tool: the two that are innervated by radial nerve)

Answer 263

Non-dominant | (As it's holding stuff)

Answer 264

Ulnar centralization ± tendon transfers _Done at 6-12 months if:_ * Good elbow ROM & biceps intact _Contraindicated in:_ * older patient with good function * Patient with elbow extension contracture who relies on radial deviation * Proximate terminal condition

Answer 265

AKA intrinsic minus hand Extrinsics overpower intrinsics. Either from ulnar or median nerve injury. EDC, FDP and FDC \>\> Intrinsics Leads to MCP extension and DIp,PIP flexion.

Answer 266

FPL rupture Treatment: FDS --\> FPL transfer

Answer 267

More common in females More common blacks Lunotriquetral most common Often bilateral Due to delay in the natural programmed cell death leading to joint cavitation

Answer 268

MCP arthroplasty Thumb only if there is IP joint involvement

Answer 269

Enlarged FPL tendon Treatment is release of A1 pulley No need to resect nodule Vs. trigger finger: caused by inflammation of tendon sheath

Answer 270

Spiral cord Displaces NV bundle central and superficial

Answer 271

Natatory cords

Answer 272

Volar CIND (volar carpal ligament insuffiency) Dorsal CIND (dorsal carpal ligament insufficiency) Combined CIND (volar & dorsal carpal ligament insufficiency) Adaptive CIND (secondary to fracture malunion (often distal radius))

Answer 273

Symbrachydactyly COmbination of syndactyly and brachydactyly Associated with Polands syndrome

Answer 274

Radial specifically proximal radial

Answer 275

1. weakened grasp * from loss of MP joint flexion power 2. weak pinch * from loss of thumb adduction (as much as 70% of pinch strength is lost) 3. Froment sign * compensatory thumb IP flexion by FPL (AIN) during key pinchcompensates for the loss of MCP flexion by adductor pollicis (ulna n.) * adductor pollicis muscle normally acts as a MCP flexor, first metacarpal adductor, and IP extensor 4. Jeanne sign * compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch * compensates for loss of IP extension and thumb adduction by adductor pollicis (ulna n.) 5. Wartenberg sign * persistent small finger abduction and extension during attempted adduction secondary to weak 3rd palmar interosseous and small finger lumbrical 6. Masse sign * palmar arch flattening and loss of ulnar hand elevation secondary to weak opponens digiti quinti and decreased small finger MCP flexion

Answer 276

Mayfeld classifation I: SL dissociation or scaphoid fracture II: I + lunocapitate dislocation III: II + lunotriquetral injury or triquetral fracture IV: Frank dislocation

Answer 277

Thumb (most important) Long Ring Small Index

Answer 278

_Absolute_: * Thumb at any level * Multiple digits * Through the palm * Wrist level or proximal to wrist * Almost all parts in children _Relative_: * Individual digits distal to the insertion of FDS (Zone I) * Ring avulsion * Through or above elbow

Answer 279

Compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch Compensates for loss of Adductor Policis in Ulnar nerve palsy

Answer 280

+ Tinel's sign in anterior forearm Resisted elbow flexion with forearm in supination (bicipital aponeurosis) Resisted forearm pronation with elbow extended (PT) isolated long finger PIP joint extension (FDS)

Answer 281

Inflammation at the intersection of the 1st/2nd dorsal extensor compartments Pain 6cm proximal to radial styloid

Answer 282

Quadrigia effect. D3 FDP tendon is relatively short, which limits the excursion of D2 and D4 FDP meaning they cant flex all the way. **Could also happen at D4 or D5.**

Answer 283

_Lower limb:_ * Contenital vertical talus * Congenital talipes equinovarus (bilateral) _Upper extremity_ * Flexion defomrities of the 4 fingers _Syndromes_ * Arthrogryposis * Digitotalar dysmorphism * Freeman-Sheldon syndrome * X-linked MASA syndrome

Answer 284

\>1mm displacemenet intrascaphoid angle \>35 degrees (humpback deformity) trans-scaphoid perilunate dislocation Proximal pole fracture (relative)

Answer 285

1. dorsal and volar radioulnar ligaments * deep ligaments known as ligamentum subcruentum 2. central articular disc 3. meniscus homolog 4. ulnar collateral ligament 5. ECU subsheath 6. origin of ulnolunate and ulnotriquetral ligaments

Answer 286

abduction of little finger due to ulnar nerve injury Due to loss of intrinsics and unopposed pull of EDM (radial nerve)

Answer 287

* female sex * obesity * pregnancy * hypothyroidism * rheumatoid arthritis * advanced age * chronic renal failure * smoking * alcoholism * repetitive motion activities * mucopolysaccharidosis * mucolipidosis

Answer 288

Ledderhose disease (plantar fascia) Peyronie's disease (dartos fascia of penis) Garrod disease (Knuckle pads) I.E. Adrians Fetish Triad

Answer 289

Extensor zone 1

Answer 290

Joint to be corrected/must be supple Donor must be expendable Donor must be of similar excursion and power * Finger flexors: 70mm * Finger extensors and EPL: 50mm * Wrist flexors & extensors: 33mm A muscle should not be used for transfer unless it is 85% of normal strength * Ie in the case of muscle reinnervation One transfer should perform 1 function Synergistic transfers if possible (easier to rehab) Maintain a straight line of pull One grade of motor strength will be lost after transfer Attach end-to-end if no recovery of native muscle expected & end-to-side if recovery expected

Answer 291

MCP: Central cord PIP: Spiral cord DIP: Retrovascular cord

Answer 292

Lateral bands? Can't find reference but it says so on an old exam

Answer 293

Radiolunate: greater than 15 Scapholunate less than 35

Answer 294

Radiolunate less than 15 degrees Scapholunate less than 60 degrees

Answer 295

DRUJ arthritis

Answer 296

Anstomosis where median crosses to innervate muscles normally innervated by ulnar nerve So Median to Ulnar anastomosis

Answer 297

Allopurinol Due to mechanism being the creation of Xanthine. Allopurinol decreases xanthine production

Answer 298

Dorsal, volar, proximal Dorsal is the strongest

Answer 299

Scapholunate dissociation TFCC tears LT ligament tears Radial shortening from previous Colles fractures

Answer 300

Zone 3 injury with disruption of the central slip

Answer 301

Jahss MCP flexion to 90 deg Reduction of neck by dorsal pressure through PIP while stabilizing MC

Answer 302

Accessory Ligament (stabilizes in extension) Proper Ligament (stabilizes in flexion)

Answer 303

Facultative anaerobe Gram negative Sensitivies: Penicillin (answer to most test questions) 2nd generation cephalosporins tetracycline ampicillin carbenicillin Resistance: Methicillin (naficillin) clinda gent erythromycin chloramphenicol

Answer 304

Hasting's classification Based on amount of P2 articular surface involvement _Type I: stable_ * _Type II: Tenuous_ * 30-50%: treat as type I if reducible _Type III: Unstable_ * \>50%: * ORIF * Hamate autograft volar plate arthroplasty

Answer 305

Greater injection pressure \>1000PSI Presence of secondary infection More distal injection Material injected: industrial solvents and oil based paints cause more necrosis Time to surgery \>10 hours

Answer 306

Distal radius fractures (common) Ulnar styloid and distal ulna fractures TFCC tears Ulnar impaction syndrome Essex-Lopresti injuries Galeazzi fractures

Answer 307

Regional subtotal fasciectomy

Answer 308

1. prevent contracture of DIPJ 2. Prevent violation & extension of infection in flexor sheath

Answer 309

supple skin sensate digit adequate vascularity full passive range of motion of adjacent joints

Answer 310

**_Extrinsic_:** Lead to increased extension force on P2. Causes: Disruption of terminal extensor tendon Wrist of MP joint flexion contracture **_Intrinsic_** Related to tightness of intrinsics or intrinsic plus finger Causes: Chronic MP volar subluxation Ischaemic contracture Tendon adhesion **_Articular_** Include injury to, or degeneration of, the volar structures of the PIP Volar plate/capsule hyperextension injury Disruption of FDS (stabilizer of PIP)

Answer 311

_Froment's sign:_ * Thumb IP flexion during thumb adduction (FDP - AIN) _Jeanne sign:_ * Thumb MCP extension in thumb adduction (EPL - radial) _Wartenburg sign:_ * small finger abduction and extension in attemped adduction (EDM - radial) _Masse sign:_ * palmar flattening and loss of ulnar had elevation (weak opponens digiti minimi)

Answer 312

Wartenberg's: (SRN) tight wristwatches and exacerbated with wrist flex/ex Lateral antebrachial cuntaoues nerve: Tinel's over it De Quervain's: Finklestein positive (may also be positive with Wartenburgs) Radial tunnel: (PIN) Pain distal to lateral epicondylitis. Pain only PIN Compression: Radial tunnel + weakness in radial nerve distribution

Answer 313

Eaton & Littler Classification I: slight joint space *widening* (pre-arthritis) II: slight CMC narrowing with sclerosis & osteophyte III: Marked CMC narrowing with osteophytes \>2mm IV: pantrapezial arthritis (STT involved)

Answer 314

pisiformectomy reliable pain relief without impairment of function

Answer 315

If reducble: immobilize in extension 6-8 weeks to allow for extensor mechanism (central slip) to heal

Answer 316

I: Distal to FDS insertion (only FDP runs in this zone) II: FDS to A1 pulley III: A1 pulley to distal carpal tunnel IV: carpal tunnel V: Wrist T1: Distal to IP T2: Distal to CMC T3: Base of thumb MC

Answer 317

IIIA: lunate collapse, no scaphoid rotation * joint levelling procedure (ulnar legnthening or radial shortening) * radial wedge osteotomy * vascularized bone graft * distal radius core decompression * STT fusion IIIB: lunate collapse with fixed scaphoid rotation * STT fusion * proximal row carpectomy

Answer 318

Webspace contracture treat with flap/graft

Answer 319

Extends PIP and DIP Central slip and Lateral bands

Answer 320

Tight intrinsics (lumbricals, interossei) Weak extrinsics (FDS, FDP, EDC)

Answer 321

Healing by secondary intention in both cases

Answer 322

Crushed or devitalized tissue Foreign body Bites to digital pulp space, nail beds, flexor tendon sheaths, deep spaces of palm ,joint spaces Tenosynovitis Septic arthritis Abscess formation

Answer 323

Stage I: arthrosis in radial styloid & radial side of scaphoid with sharpening of radial styloid Stage II: Scaphocapitate arthrosis, in addition to stage I Stage III: Periscaphoid arthrosis Treatment: Stage I: Radial styloidectomy + scapholunate reduction & stabilization + scaphoid nonunion fixation Stage II/III: PRC vs 4-corner fusion vs. Wrist arthrodesis vs. Wrist arthroplasty Treatment is generally same as SLAC

Answer 324

Can go dorsal or volar Volar more direct but places neurovascular structures at risk

Answer 325

Fight Bite

Answer 326

Adjacent DJD, 70% normal motion 80% grip power

Answer 327

Physiolysis + release of Vicker's ligament Radial corrective **DOME** osteotomy + resection of Vickers + distal ulnar shortening osteotomy DRUJ arthroplasty (controversial)

Answer 328

**_SLEDGE Hammer_** **S**eizures (Epilepsy/Anti-seizure medication) **Li**ver disease **E**tOH **D**iabetes **G**enetics **H**IV

Answer 329

Less than 0.22 is normal (ulnar styloid length - ulnar variance) / width of ulnar head

Answer 330

* Oblique Pulley * Facilitates full excursion of flexor pollicis longus

Answer 331

Improved cosmesis in 16/16 patients (most reliable) Improved function in 14/16 patients Improved grip strength

Answer 332

LT instability (most common) Dorsal radiocarpal ligament injury Volar radiolunate ligament injury May be a normal variant in a patient with ligamentous laxity Associated with TFCC tear

Answer 333

Nonop: splint with elbow in 90 degrees 8-12 weeks (successful in majority and should be cornerstone of treatment (as per JAAOS)) Op: surgical decompression (75% success) consider early OR if definite space occupying lesion

Answer 334

_Neurapraxia_: * mild nerve stretch or contusion * myelin sheath disruption but no Wallerian degeneration * Good prognosis _Axonotmesis_: * Severe but incomplete nerve injury * Focal conduction block exists * Wallerian degenration occurs * guarded prognosis _Neurontmesis_: * Complete nerve injury * Wallerian degeneration occurs * All layers of nerve damaged * Worst prognosis

Answer 335

Stage 2 Kienbock's Joint leveling procedure (ulnar negative patients) Radial wedge osteotomy or STT fusion (ulnar neutral patients) Radial decompression vascularized grafting (4,5 ECA)

Answer 336

Elbow flexion Forearm pronation Wrist flexion Thumb adduction MCP joints in extension IP joints in flexion Pretty much like every other contracture (CP)

Answer 337

Signs of flexor tenosynovitis: * finger held in flexion * fusiform swelling * tenderness along the flexor tendon sheath * pain with passive extension

Answer 338

FDP Zone 1

Answer 339

Release constricting bandages Place in dependent position Consider heparinize Consider stellate ganglion block Early surgical exploration if previous measure unsuccessful

Answer 340

Cleft hand Operate if abnormal thumb webspace Surgical thumb, thumb webspace reconstruction takes precedence (ie over correction of central cleft) **Must counsel family of inheritance (AD, with 70% penetrance) and that each subsequent generation gets worse**

Answer 341

Tests for intrinsic tightness Decreased PIP flexion with MPs held extended is a sign of intrinsic tightness Works b/c intrinsics pass volar to MP joint and dorssl to PIP joint. With the MP extended, they are taught at MP joint, so if they are tight, you won't be able to flex PIP b/c that will tigthen them even more and they wont' have the excursion to do that

Answer 342

Camptodactyly

Answer 343

Dorsal Extrinsic Ligaments Big arrow = Dorsal Intercarpal SMall arrow = Radiotriquetrial

Answer 344

edema contusion pain (from injection & manipulation) Skin laceration lymphadenopathy CRPS (rare) Flexor tendon rupture (Rare)

Answer 345

Pediatric Trigger Finger usually the Ulnar slip May need to release the second slip as well as A3 pulley

Answer 346

Proximal: neuroma Distal: glioma

Answer 347

Any disruption of FDP distal to the origin of the lumbricals FDP Transection FDP avulsion DIP amputation Amputation through middle phalanx shaft Too long tendon graft

Answer 348

* median nerve in distal third of forearm * ulnar nerve in distal third of forearm * sciatic nerve in thigh

Answer 349

1. C1, A3, C2 Pulleys 2. PIP fracture dislocations - for ORIF or hamate autograft

Answer 350

* direct closure after fascial excision * skin excision followed by full-thickness skin grafting (NOT STSG) * open technique in which a portion of the volar skin is left open to close subsequently by wound contraction.

Answer 351

Joint to be corrected/moved must be supple Donor must be expendable Donor must be of similar excursion and power * Smith's 3-5-7 rule * Finger flexors: 70mm * Finger extensors and EPL: 50mm * Wrist flexors & extensors: 33mm Appropriate tensioning A muscle should not be used for transfer unless it is 85% of normal strength * Ie in the case of muscle reinnervation One transfer should perform 1 function Synergistic transfers if possible (easier to rehab) * Wrist extension ↔ finger flexion ↔ thumb adduction * Wrist flexion ↔ finger extension ↔ thumb abduction Maintain a straight line of pull One grade of motor strength will be lost after transfer Usually attach transferred muscle to the tendon of the motor end to end if no native recovery anticipated; end to side if recovery anticipated.

Answer 352

_Lichtman Classification_ I: No xray changes - only MRI changes II: sclerosis of lunate IIIa: lunate collapsed, no scaphoid rotation IIIb: lunate collapsed, fixed scaphoid rotation IV: degenerated adjacent intercarpal joints

Answer 353

Watson Classification Stage I: arthrosis in radial styloid & radial side of scaphoid with sharpening of radial styloid Stage II: Arthrosis of entire radioscphoid joint. Sparing of the radiolunate joint Stage III: Arthrodesis progressing to the capitolunate joint due to proximal migration of capitate _Treatment_ Stage I: radial styloidectomy & scaphoid stabilization Stage II: PRC, scaphoid excision & 4CF * contraindicated if incompetent radioscaphocapitate ligament & stage 3 Stage III: Scaphoid excision & 4CF, wrist arthrodesis Treatment generally same as SNAC ±PIN & AIN denervation at any stage (they only provide sensation and proprioception to wrist capsule)

Answer 354

inflammation of 2nd extensor compartment as it crosses under 1st Occurs 6cm proximal to radial styloid Common in repetitive wrist extension athletes (rowers, weight lifters)

Answer 355

Release both APL and EPB from their subsheaths within the 1st dorsal compartment If you don't, you will have recurrence

Answer 356

Restores pinch _FDS opponensplasty: FDS 4 --\> APB_ * Cannot do if high median nerve palsy b/c FDS will also be knocked out _EIP opponensplasty: EIP --\> APB_ _abductor digiti minimi (Huber) transfer: ADM --\> APB_ _PL (Camitz) transfer: PL --\> APB_ * Cannot do if high median nerve palsy b/c PL will also be knocked out

Answer 357

Ulnar nerve palsy Little pinky abduction due to unopposed pull of EDM

Answer 358

Flexion = radial deviation Extension = ulnar deviation

Answer 359

Yes for aucte and chronic Topical antibiotics + steorids if mild-mod case (no abscess) (acute) Topical antifungal/antibiotics + steroids in chronic This was just as good as gent alone in acute Can also use abx + soaks if no abscess

Answer 360

**Camptodactyly - bent** **Symphalangism - stiff** **Camptodactyly** involves fixed flexion deformity of the proximal interphalangeal joints. The fifth finger is always affected. **Camptodactyly** can be caused by a genetic disorder. In that case, it is an autosomal dominant trait that is known for its incomplete genetic expressivity. Pathophysiology: typically caused by either * abnormal lumbrical insertion/origin * abnormal (adherent, hypoplastic) FDS insertion * other less common causes include * abnormal central slip * abnormal extensor hood * abnormal volar plate * skin, subcutaneous tissue, or dermis contracture **•If full PIP extension can be achieved actively with MCP held in flexion, digit can be explored and abnormal tendon transferred to radial lateral band** * **Type I** * **Isolated anomaly of little finger, presents in infancy and affects males and females equally** * **Most common form** * **Stretching/splinting** * **Type II** * **Same clinical features as Type I, presents in adolescence** * **• Affects girls more often than boys** * **From abnormal lumbrical insertion, abnormal FDS origin or insertion** * **If full PIP extension can be achieved actively with MCP held in flexion, digit can be explored and abnormal FDS tendon transferred to radial lateral band** * **Type III** * **Severe contractures, multiple digits involved, presents at birth** * **Usually associated with a syndrome** * **Non-operative (unless functional deficit exists after skeletal maturity), then consider corrective osteotomy/fusion** * **Kirner's Deformity** * **Specific deformity of small finger distal phalanx with volar-radial curvature (apex dorsal-ulnar)** * **Often affects preadolescent girls** * **Often bilateral** * **Usually no functional deficits** **Symphalangism** Congenital digital stiffness that comes in two forms * hereditary symphalangism * nonherediatry symphalangism **Epidemiology location** * more common in ulnar digits **Pathophysiology** * failure of IP joint to differentiate during development * Genetic inheritance pattern (hereditary type) * autosomal dominant **Associated conditions** * syndactyly (nonhereditary type) * Apert's syndrome (nonhereditary type) * Poland's syndrome (nonhereditary type) * correctable hearing loss (hereditary type)