Hands Flashcards
Classification of Distal Phalanx Fractures
Tuft
Shaft (transverse, longitudinal)
Base (volar, dorsal/mallet)
(Seymour)
Classification of Middle/Proximal Phalanx Fractures
Head
Neck
Shaft
Base
Classification of Proximal phalanx head fractures
Unicondylar (Weiss-Hastings Classification)
- Class I: oblique volar
- Class II: long sagittal
- Class III: dorsal coronal
- Class IV: Volar coronal
Bicondylar
Classification of shaft fractures
Fragments: Simple vs comminuted
Pattern:
- Short oblique
- Long oblique
- Transverse
- Spiral
Displacement:
Clinical and Radiographic features of Bony Mallet
Caused by hyperflexion at DIPJ
Dorsal base fracture or extensor mechanism avulsion fracture
X-ray: fracture displacement, volar subluxation (v-sign), amount of articular surface involved
Management of Bony Mallet
Management:
Non-operative: Extension splint (mallet/zimmer/thermaplast) 6-8 weeks.
- If >50% of articular surface, inadequate reduction, open injury: extension blocking splint (modified Ishiguro k-wire.)
Doyle’s Classification of Mallet Injury
Type I: Closed injury, ± small avulsion fracture
Type II: Open injury with tendon laceration
Type III: Open injury with loss of skin, subcutaneous tissue, and tendon
substance
Type IVA: Transepiphyseal plate fracture in children
Type IVB: Fracture of 20 to 50% of articular surface
Type IVC: Fracture of >50% of articular surface, volar subluxation of distal phalanx
DP tuft fracture - features & management
Commonly caused by crush injury
Associated with sublingual haematoma/nail bed injury
Require removal of nail plate + evacuation of haematoma +/- NBR. Rarely require fixation. Splint immobilisation 3-4 weeks and hand physio follow up.
Seymour fracture - features & management
Paediatric distal phalanx base fracture. Caused by hyperflexion.
Salter Harris I/II
Associated with nail bed injury
Rx:
- Irrigation and debridement
- Antibiotics
- Repair of the lacerated nail matrix
- Fracture reduction (axial k-wire)
Proximal phalanx fractures - features & management
Open vs Closed
Fracture pattern/geometry
Assess for displacement/dislocation, angulation, rotational deformity (scissoring)
Non-operative: buddy strap vs splinting
Operative:
- MUA + splinting
- Cross K-wire
- Lag screw
- Dorsal locking plate
- IM screw
Complications of phalangeal fractures
Malunion (malrotation, volar angulation, lateral angulation, shortening)
Nonunion
Stiffness/loss of ROM
PIPJ extensor lag
Infection
Tendon rupture/entrapment
Indications for operative management of hand fractures
MAOI
Malrotation
Articular fractures
Open fracture
Irreducible fractures
Subcapital fractures (phalangeal)
Segmental bone loss
Polytrauma with hand fractures
Multiple hand or wrist fractures
Fractures with soft tissue injury (vessel, tendon, nerve, skin)
Reconstruction (i.e., osteotomy)
Rates of infection in hand fractures
Swanson et al 1991. Hand fractures distal to carpus.
Type I: 1.4%
a. Clean wounds with minimal delay in treatment
b. No systemic illness
Type II: 14%
a. Gross contamination (bite, grossly dirty, farming injury
b. Delay in treatment >24hrs
c. Major systemic illness
Initial approach to Hand/Digit Amputation
A-E approach ruling out other life or limb threatening injuries.
Focused Hx and Examination.
- Time & Mechanism (crush/incision).
- Level of amputation
- Hand dominance, occupation, hobbies
- Previous hand injuries, PMHx, DHx, allergies, smoking
- Last food & drink
- ICE (replant vs terminalisation)
- Remove rings & Careful examination of other damaged structures.
- Examine amputated part
AATX: Abx, analgesia, tetanus, x-ray: 3 views of hand/finger, X-rays of amputated part(s).
Patient: gentle irrigation to remove gross contamination. Non-adherent dressing, bulky dressings. POP if other fractures.
Amputated parts: gentle irrigation, wrap in NaCl soaked gauze, place in plastic bag or specimen container. Place in slurry of ice water at 4C. Not directly on ICE
Pre-operative approach to attempted hand/digit replantation
NBM.
Mark & Consent.
Discuss with on call consultant. Discuss with theatre coordinator/CEPOD.
Prep theatre/brief: sterile arm tourniquet, microscope, hand set, micro set, hepsal.
Consent for attempted hand/digit replantation
Procedure: replantation RT IF +/- bone/nerve/vein/skin graft
Intended benefits: restore function
Risks:
Pain, bleeding, infection, scarring, stiffness, CRPS
Explanation of expected IP course: prolonged admission/rehab/time off work.
Further procedures.
Failure of replantation. Proceed to terminalisation.
Expected successful outcome: stiffness, reduced sensation, reduced function
GA Risks, VTE, peripheral tissue injury.
Operative plan for replantation
Preparation: Supine, arm board.
Prep whole arm. Sterile arm tourniquet.
Access to leg (vein graft) +/- TEDS/Flowtrons. Catheter. Gel matts. Monopolar plate. Bipolar. Bear hugger.
Procedure:
Digit: washout, surgical prep. ulnar & radial mix axial incisions. Expose and examine neuromuscular bundles. Tag structures. Remove nail plate.
Site:
Warm/Cold Ischaemia time: definitions & principles
Warm ischaemia time: time from avascular and no cooling
Cold ischaemia: time from avascular and cooling
Tolerance of warm ischaemic time is inversely proportional to the amount of muscle. ie more muscle lower tolerance to ischaemia.
Forearm (4-6hours) < hand < digit (12 hours)
Goals of amputation/terminalisation
Maintain length.
Maximize function. Early return to work and recreation.
Stable and durable soft-tissue coverage. Preserve sensation.
Prevent symptomatic neuromas. Prevent adjacent joint contractures
Allow for early prosthetic fitting (if applicable)
Indications for replantation
Thumb amputation
Multiple digit amputation
Any amputation in a child
Hand amputation through palm/wrist
More proximal forearm (sharp, clean injury pattern)
Single-digit amputation distal to flexor digitorum superficialis (FDS) insertion
(zone I injury)
Contraindictions for replantation
Severely crushed or mangled parts
Multilevel amputations
Other severe traumatic injuries or significant medical comorbidities
Prolonged warm ischemia time for proximal amputations
Single-digit amputation proximal to FDS insertion (zone II injury)
* Exceptions: Musician or other person requiring all 10 digits, Children
Thumb opposition score
Kapandji Score:
0: unable to reach IF radial border
1: radial border MP IF
2: radial border DP IF
3: distal tip IF
4: distal tip MF
5: distal tip RF
6: distal tip LF
7: DIPJ crease LF
8: PIPJ crease LF
9: MCPJ crease LF
10: distal palmar crease
Signs of Flexor Sheath Infection
4 Kanaval signs:
1. Fusiform swelling
2. Held in fixed flexion
3. Pain on passive extension
4. Pain on palpation/percussion of the flexor sheath
What are the key history elements to consider when evaluating a patient with Dupuytren’s contracture?
Age, sex, occupation, hand dominance, hobbies, social history, smoking/alcohol status.
Onset and progression of symptoms
Deformity and it’s affect on function, work, social, hobbies
Unilateral or bilateral.
PMHx/DHx: FIT
Q: What should you assess regarding the presenting complaint in Dupuytren’s contracture?
Onset and progression of symptoms, effect on hand function/activities/work, whether it is unilateral or bilateral.
Q: What are the ectopic manifestations of Dupuytren’s disease?
Garrod’s knuckle pads (dorsal fibromatosis of the PIPJ).
Ledderhose disease (plantar fibromatosis).
Peyronie’s disease (penile fibromatosis).
Q: What risk factors are associated with Dupuytren’s contracture?
A: Chronic hand vibrational exposure, diabetes, liver disease, epilepsy, and previous trauma.
FHx
Examination of Dupuytren’s Disease
Look, Feel, Move:
Look: A: Thickening and pitting of the palmar skin, MCPJ/PIPJ contractures, and boutonniere deformity.
Feel: A: Firm, painless nodules fixed to the skin and palmar fascia, and the presence of cords.
Move: ROM
Special tests: “tabletop” test
A functional test to determine if the hand can lie flat on a tabletop, which may indicate contracture severity.
Q: At what contracture angle is intervention typically indicated in Dupuytren’s contracture?
A: Contracture greater than 30 degrees.
Q: Differential diagnoses for Dupuytren’s contracture.
A: Callus, ganglion, and trigger finger. Ulnar nerve palsy and tendon adhesions.
Q: Are investigations usually required for Dupuytren’s contracture?
No, but investigations for underlying conditions like diabetes or liver disease may be considered.
Q: What are the management options outlined by NHS England for Dupuytren’s contracture?
A: Do nothing, needle fasciotomy, fasciectomy, and dermofasciectomy.
Q: What is the recurrence rate of contracture after needle fasciotomy in Dupuytren’s contracture?
85% at 5 years.
Q: What is the recurrence rate of contracture after fasciectomy in Dupuytren’s contracture?
21% at 5 years.
Q: What is the recurrence rate of contracture after dermofasciectomy in Dupuytren’s contracture?
8% at 5 years.
What are the early treatment options for Dupuytren’s contracture with less than 30 degrees contracture?
A: Radiotherapy, corticosteroids, and physiotherapy.
Q: What is Dupuytren’s disease at the pathophysiological level?
A: A benign fibroproliferative disorder of the fascia of the palm and digits.
Q: How does Dupuytren’s disease progress at the cellular level?
A: It begins as fibrous nodules, which develop into longitudinal cords, causing flexion contractures due to increased myofibroblasts, inflammatory cells, and collagen deposition (type III collagen)
What structural deformity can occur in Dupuytren’s contracture?
Boutonniere deformity due to an attenuated central slip
Symptoms of carpal tunnel syndrome
Pain and paraesthesia in the median nerve distribution including the thumb, index, middle fingers, and radial half of the ring finger.
Q: Which red flags indicate severe carpal tunnel syndrome?
A: Persistent paraesthesia, hypoesthesia, objective sensory loss, motor weakness, and thenar muscle wasting.
Q: What is the Boston Carpal Tunnel Questionnaire (BCTQ) used for?
A: Classifying mild to moderate carpal tunnel syndrome symptoms.
Q: What are some key comorbidities and risk factors for carpal tunnel syndrome?
A: Trauma, obesity, osteoarthritis, rheumatoid arthritis, hypothyroidism, diabetes, and pregnancy.
Q: What are common provocation maneuvers for carpal tunnel syndrome diagnosis?
A: Phalen’s test, Tinel’s sign, and Durkan’s test.
Q: Name a differential diagnosis for median nerve compression.
Carpal tunnel, Pronator teres syndrome, anterior interosseous nerve (AIN) syndrome, or cervical radiculopathy.
Thoracic Outlet Syndrome
Wrist/MCPJ OA
RA
Peripheral neuropathy: DM, B12 Def
Management of Carpal Tunnel?
Non-operative: Wrist splints, activity modification, and hand/nerve gliding exercises.
Medical: NSAIDs/steroid injections
Surgical: Carpal tunnel release
Q: What are the boundaries of the carpal tunnel?
Roof: Transverse carpal ligament (flexor retinaculum).
Radial border: Scaphoid and trapezium.
Ulnar border: Hook of hamate and pisiform.
Floor: Carpal bones.
Q: What structures pass through the carpal tunnel?
Tendons: 4 FDS, 4 FDP, 1 FPL.
Nerve: Median nerve.
Persistent median artery (in 3% of cases).
Q: What muscles are innervated by the recurrent branch of the median nerve?
Radial 2 lumbricals.
Opponens pollicis.
Abductor pollicis brevis.
Flexor pollicis brevis
Q: What is the most common upper limb compression neuropathy?
A: Carpal tunnel syndrome, with a prevalence of 3.72%.
Q: How does hypothyroidism contribute to carpal tunnel syndrome?
A: By causing soft tissue swelling that increases pressure in the carpal tunnel
Describe Phalen’s test
flexing the wrist to elicit symptoms of carpal tunnel syndrome
Describe Tinel’s Sign
tapping over the median nerve produces tingling or numbness in carpal tunnel syndrome.
Describe Durkan’s test
Direct pressure on the carpal tunnel to provoke symptoms of carpal tunnel syndrome.
Describe the anatomy of Recurrent branch of median n.
Branch of median nerve
* 50-90% beyond TCL
* 30% below TCL
* 23% through TCL
Supplies: LOAF: Radial 2 lumbricals, opponens policis, abductor policis brevis, flexor policis brevis
AO Principles of Fracture Management
Fracture reduction: Restore the anatomical relationships of the bones
Fracture fixation: Provide stability to the fracture, either absolute or relative
Preservation of blood supply: Maintain the blood supply to the bone and soft tissue
Early mobilization: Safely mobilize the injured part and the patient as soon as possible
Classification of nail bed injuries
Zook et al. (1984)
- Simple lacerations.
- Stellate lacerations.
- Severe crush injury.
- Avulsion.
Describe some classifications of fingertip amputation?
Allen:
I: Only finger pulp is injured.
II: The finger pulp with less than 1/2 of the nail bed and a small amount of the distal phalanx are injured.
III: Entire nail bed and the partial distal phalanx are injured.
IV: Proximal nail fold and distal phalanx are injured
Fassler: (describing injury geometry)
A: Volar oblique (no NB involvement)
B: Volar oblique (NB involvement)
C: Transverse
D: Dorsal oblique
Examination of fingertip amputation
Digit:
Level of amputation
Orientation
Nail bed injury
Exposed bone
FDP and extensor tendon intact
Amputated part:
Soft tissue destruction/crush
Goals of fingertip reconstruction
Provide durable coverage and padding of the fingertip
Preserve length
Preserve sensation
Maintain range of motion
Minimize pain (including prevention of neuroma)
Minimize donor-site morbidity
Minimize time off of work
Provide an aesthetically acceptable appearance
Surgical options for management of fingertip amputations
Reconstructive Ladder:
Primary closure
Healing by secondary intention
Dermal regeneration templates (DRTs)
Skin grafting
Composite grafting
Homodigital flaps: (Atosoy, Kutler, Moberg, Venkataswami)
Heterodigital flaps (cross-finger, Littler, Kite, Quaba)
Regional flaps
Microsurgical replantation/reconstruction
Composite Grafting in Fingertip injuries
Non-microsurgical replantation of amputated fingertip. Typically recommended only for children and young adults.
Landin et al Systematic Review 2021.
Success rates highly variable: 7.7-93.5% Adverse outcomes: 15.6%
Reoperation rates of up to 56.3%
Describe the Atosoy flap, anatomy, indications, technique
Volar V-Y Advancement Flap
Indications: volar oblique/transverse fingertip injuries. Can only be advanced <1cm
Flap Design: match width of nail bed. proximal extent of “V” at DIPJ crease.
Incision: through epidermis and dermis only to avoid NV injury.
Spread through subcutaneous tissue on either side of the flap to divide fibrous attachments while preserving nerves and vessels.
Describe the Kutler flap, anatomy, indications, technique
Lateral V-Y Advancement Flaps
Indications: Transverse, lateral oblique injuries to finger tip
Triangular flaps designed along radial and ulnar aspects of distal tip. Flaps are advanced distally and centrally to cover defect
NOTE: Causes significant scarring of the fingertip; clinical application is limited.
Describe the Moberg flap, anatomy, indications, technique
Volar Advancement Flap
Indications: Thumb tip only
1-1.5cm
Can be V-Y or transverse incision at base to make islanded flap.
Incisions: Radial and ulnar mid-axial incisions are made dorsal to the volar neurovascular bundles, which are both included in the flap. Flap elevation is in plane just volar to the tendon sheath. Base of flap typically located at MCP joint crease
Most common complication: contracture of IPJ/MCPJ due to advancement, tension, and immobilization
Describe the Venkataswami flap, anatomy, indications, technique
Oblique Triangular Neurovascular Island Flap
Indications: Volar oblique injuries <2cm
Unilateral triangular island flap designed as a V-Y advancement based on a single neurovascular bundle. Apex of the flap is located proximal to the PIP joint; can be extended proximally (to web space) for increased advancement
Describe the Cross-finger flap, anatomy, indications, technique
Heterodigital
Indications: Large volar defects
Flap raise: dorsum of MP adjacent to the injured digit. Flap pedicle at the mid-axial line closest to the injured digit. Elevated above the level of paratenon; maintains a vascularized surface for skin grafting of the donor-site defect. Flap division around 2 to 3 weeks.
Complications:
Injured digit often must be flexed to inset flap; may result in PIPJ contracture
Postoperative sensitivity relatively poor
Donor digit frequently bothered by cold intolerance and sensitivity
Aesthetic deformity on dorsum of donor digit
Describe the Littler flap, anatomy, indications, technique
Heterodigital neurovascular pedicled flap
Indications: ulnar thumb pulp defects. Provides stable, sensate coverage
Donor site: ulnar pulp RF/MF
Pulp from donor site harvested along with neurovascular bundle; requires dissection to common digital artery and nerve for adequate mobilization
Large volar access incisions are required to tunnel and inset the flap
Donor site must be reconstructed with skin graft
Describe the Kite flap, anatomy, indications, technique
First Dorsal Metacarpal Artery (FDMA) Flap
Indications: Soft tissue defects of thumb
Pedicled island flap based on the first dorsal metacarpal artery, a branch from the dorsal carpal branch of the radial artery.
Describe the Quaba flap, anatomy, indications, technique
Reverse dorsoradial metacarpal artery flap
Dorsal defects of hand and fingers
Based on palmar dorsal anastomosis between dorsal metacarpal artery and common digital artery. Perforator is found next to metacarpal neck.
Salter Harris Classification
I: Straight across the physis
II: Above into metaphysics/shaft
III: Lower into epiphysis
IV: Through both epiphysis and metaphysis
V: ERase/crush the physis
How does Paediatric bone differ to adults and clinical implications?
Thick periosteum: Heal quickly. Non-union rare. Shorter time frame to make decisions.
Bone more elastic as more collagen: Comminution rare. Buckle fractures.
Growth plate. Can be damaged by metal work.
Classification of sub capital/phalangeal neck fractures in children?
Al-Qattan:
I: Tundisplaced fracture
II: displaced with bone-to-bone contact at the fracture site. Most common type, (70%)
III: displaced with no bone-to-bone contact. Without intervention, type III fractures will not heal properly.
Management of soft tissue mallet
Mallet splint/TP splint holding DIPJ in extension 24/7 for 8 weeks plus at night for 2 weeks.
